Cover : Regional O ffice fo r Europe, Copenhagen, Denmark THE WORK OF WHO IN THE EUROPEAN REGION 1979 THE WORK OF WHO IN THE EUROPEAN REGION 1 9 7 9 A n n u a l R e p o r t o f t h e R e g i o n a l D i r e c t o r W O R LD H E A L T H O R G A N IZ A T IO N Regional O ffice fo r Europe CO PEN HAGEN 1980 ABBREVIATIONS The abbreviations used in this report include the following: AMEE - Association for Medical Education in Europe ASPHER - Association o f Schools o f Public Health o f the European Region CE - Council of Europe CEC — Commission o f the European Com munities СМЕА - Council for Mutual Economic Assistance DA NI DA - Danish International Development Agency EACMR - European Advisory Committee for Medi cal Research ECE - Economic Commission for Europe EEC - European Economic Community F'AO - Food and Agriculture Organization of the United Nations IAEA - International Atomic Energy Agency IARC - International Agency for Research on Cancer ICC International Children’s Centre IFLA - International Federation o f Library As sociations and Institutions ILO - International Labour Organisation <Of fice) OECD - Organisation for Economic Co-operation and Development UNDP - United Nations Development Programme UNDRO - Office of the United Nations Disaster Relief Coordinator UNDSA - United Nations Division for Social Affairs UNEP - United Nations Environment Programme UNESCO - United Nations Educational, Scientific and Cultural Organization UNFPA United Nations Fund for Population Activities UNICEF - United Nations Children’s l und USAID United States Agency for International Development WFP World Food Programme IS B N 929020 198 3 © W orld Health Organization 1980 Publications o f the WHO Regional Office fo r Europe enjoy copyright protection in accordance w ith the provisions o f Protocol 2 o f the Universal Copyright Convention. For rights o f reproduction or translation, in part or in tuto, o f this publication application should be made to the WHO Regional Office fo r Europe, Scherfigsvej 8, D K-2100 Copenhagen Ç). Denmark. The Regional Office welcomes such applications. The designations employed and the presentation o f the material in this publication do not imply the expression o f any opinion whatsoever on the part o f the Secretariat o f the World Health Organiz ation concerning the legal status o f any country, te rrito ry, city or area or o f its authorities, or con cerning the delim itation o f its frontiers or boundaries. Where the designation “ country or area” appears in the heading o f tables, it covers countries, territories, cities or areas. The mention o f specific companies or o f certain manufacturers' products does not im ply that they are endorsed or recommended by the World Health Organization in preference to others o f a similar nature that are not mentioned. Errors and omissions excepted, the names o f proprietary products are distinguished by in itial capital letters. PR IN T E D IN D EN M A RK ISSN 1014-4323 EUR/RC30/2 C O N T E N T S Page Introduction ........................................................................................................... 1 1.... Policy organs.................................................................................................... 5 2. General programme development, management and coordination. . . . 7 2.1 General programme development................................................................. 7 2.2 Country health programming........................................................................ 9 2.3 In form ation systems p ro g ra m m e ................................................................. 10 2.4 External coordination for health and socioeconomic development.............. 11 2.5 Emergency relief operations........................................................................ 15 2.6 Research prom otion and development..................................................................... 16 2.7 Publications................................................................................................. 17 3. Development o f comprehensive health services....................................... 19 3.1 General........................................................................................................ 19 3.2 Family hea lth ............................................................................................... 30 3.3 Mental health............................................................................................... 36 3.4 Prophylactic, diagnostic and therapeutic substances..................................... 39 4. Disease prevention and c o n tro l................................................................... 43 4.1 Communicable disease prevention and con tro l............................................ 43 4.2 Noncommunicable disease prevention and control....................................... 48 5. Promotion o f environmental health............................................................ 55 5.1 General........................................................................................................ 55 5.2 Environmental health planning and management.......................................... 56 5.3 Provision of basic sanitary measures............................................................ 59 5.4 Recognition and control of environmental hazards....................................... 61 5.5 Food safety................................................................................................. 65 5.6 Environmental tox ico lo g y .......................................................................................... 6 6 5.7 Country a c tiv it ie s ........................................................................................................ 67 6. Health manpower development................................................................... 71 6.1 General........................................................................................................ 71 6.2 Continuing education................................................................................... 74 6.3 Communication and collaboration.............................................................. 75 6.4 Fellowships and courses............................................................................... 76 6.5 Nursing........................................................................................................ 79 6.6 Country activities........................................................................................ 80 7. Health in fo rm a tio n ........................................................................................ 83 7.1 General........................................................................................................ 83 7.2 Health statistics............................................................................................ 85 7.3 WHO publications and documents.............................................................. 86 7.4 Health legislation.......................................................................................... 87 7.5 Health literature services............................................................................... 88 7.6 Health information of the public................................................................. 88 8. General services and support programmes................................................. 91 8.1 Programme planning and general support..................................................... 91 8.2 Staff development and training................................................................... 92 8.3 Personnel...................................................................................................... 92 8.4 Supplies........................................................................................................ 92 8.5 Conference, office and building services....................................................... 92 8.6 Budget and finance...................................................................................... 94 Annex 1. Active and non-active Member States o f the World Health Organization, European Region, 31 December 1979................ 97 Annex 2. Professional staff in the European Region, 31 December 1979 .......................................................................... 99 Annex 3. Organizational chart o f the Regional Office, 31 December 1979 .......................................................................... 101 Annex 4. Intercountry meetings convened by the Regional Office for Europe in 1979 .......................................................................... 103 Annex 5. European response to the study o f WHO’s structures in the light o f its functions (résumé)................................................. 109 Annex 6. Activities o f the WHO Regional Office fo r Europe, in cooperation w ith Member States and other international organizations, in the field o f environmental health - Dr R.J.H. Kruisinga..................................................................... 121 vi
INTRODUCTION This is the second annual report o f the Regional Director to cover a com plete calendar year. The first o f these, for the year 19 78, was very well re ceived at the twenty-ninth session o f the Regional Committee in Helsinki. The Committee made several suggestions fo r improvement, and most o f these have been taken into consideration in the preparation o f this volume. This year, the collection o f summary reports on meetings convened by the Regional Office is issued as a companion volume. The latest recommenda tions on technical subjects in the various programme areas, which appear in these reports, may be used to supplement the information provided here. The period under review was a somewhat difficult time for the Regional Office from the budgetary point o f view, owing to the unstable international monetary situation. However, most o f the planned and approved programme was carried out with the help o f voluntary contributions and other arrange ments. In the implementation o f the programme, full account was taken o f the mandate given by the World Health Assembly and the Executive Board to reorient activities so that they are directly relevant to WHO's goal o f health fo r all by the year 2000 (HFA/2000). At the end o f 1979, the General Assembly o f the United Nations adopted resolution A /R E S/34/58 dealing with “health as an integral part o f develop m ent” which will, it is hoped, lead to even closer collaboration within the United Nations system in support o f WHO's long-term aims. At the regional level, regular contact was maintained with the United Nations Centre for Social Development and Humanitarian Affairs, UNDP, UNFPA, UNICEF the World Bank, FAO. ILO, ICC and OECD, as well as with the many related programmes within the Economic Commission fo r Europe. During 1979 possibilities were created fo r closer collaboration with the Council for Mutual Economic Assistance (CMEA). At the European level WHO is now in full cooperation with several intergovernmental organiza tions, the most important being, in addition to CMEA, the Commission o f the European Communities and the Council o f Europe. The detailed programme o f WHO in the European Region followed the approved programme budget for 1978-79. In addition, the Regional Com mittee at its twenty-ninth session analysed three major areas that are par ticularly important if the concept o f H FA/2000 is to be achieved: family health, primary health care and the Office's contribution to the international programme on chemical safety, which in the industrialized countries o f Europe is o f the utmost importance. Proposals in these areas, which were reviewed in detail and endorsed by the Regional Committee, have influenced the 1980-81 programme and will be followed up and included in the proposed programme for 1982-83. The Regional Office has continued to develop its capabilities fo r hand ling information, which is rapidly increasing owing to the new responsibil ities o f the Office in the field o f regional research promotion and coordina tion. In addition to the meeting o f the European Advisory Commit tee for Medical Research and its sub-planning groups, a very important consultation involving the Regional Office, Member States and their medical research councils or academies o f science was held in October in Copenhagen, at which the need was expressed for an interregional research programme on health care problems related to hypertension. Following the International Conference on Primary Health Care held in Alma-Ata in 1978, my report on the situation in Europe was published by the Regional Office and has received considerable attention. The book let also lists documents and publications that European governments had prepared fo r the Conference. In various parts o f Europe, primary health care is now seen as an approach to alleviating the problem o f over-sophisticated, hospital-based health services. It is also seen as a means o f bringing the health services closer to the family and making it possible fo r people to solve their own health problems: self-reliance and self-care are now considered more and more acceptable by what, up to now, has been a very professionally oriented health care system. The Regional Office has followed this develop ment with keen interest and cooperates with many intergovernmental and nongovernmental organizations, governments, universities and other bodies concerned with primary health care. One o f the highlights o f the year in the field o f environmental health, to which WHO contributed, was the High-level Meeting within the frame work o f the ECE on the Protection o f the Environment, held in Geneva in November. The Meeting adopted the Convention on Long-range Transboundary Air Pollution, which was signed on behalf o f 33 governments, and the Declara tion on Low- and Non-waste Technology and Re-utilization and Recycling o f Wastes. Owing to the considerable support provided during 1978 and 19 79 by a large number o f organizations and European countries, the malaria situation in Turkey has improved, but will need continuous vigilance fo r several years to come. In this connexion, WHO will be the executing agency fo r a project financed by UNDP to intensify epidemiological surveillance systems in south east Europe. Cooperation involving the European and Eastern Mediterranean regions o f WHO and other international organizations continued on the control o f pol lution in the Mediterranean Sea. Initiatives were also taken by WHO and UNDP in establishing a zoonoses control programme in the Mediterranean area. A new feature in this report are the lists o f expenditure for each pro gramme area, which will be found at the end o f each chapter. In addition to showing the regular budgetary allocation, these lists provide a breakdown o f extrabudgetary funds by source. Finally, the work in the Region during 1979 benefited greatly from the active participation o f leading health administrators and scientists who, through the various consultative groups and advisory committees, have given a great deal o f their time to the Organization. I should like to acknowledge their very important contribution to the development o f the programme and in keeping it relevant to the needs o f the Member States. Leo A. Kaprio Regional Director 3 Chapter 1 POLICY ORGANS The planning and implementation o f the Regional Office programme con tinued to reflect im portant resolutions o f the Executive Board and the World Health Assembly, which are carefully analysed and commented on each year fo r the Regional Committee. In response to resolution WHA32.30, and the resolution adopted by the twenty- ninth session o f the Regional Committee (EUR/RC29/R6), a Regional Health De velopment Advisory Council (RHDAC) was established by expanding the Con sultative Group on Programme Develop ment (CGPD) to include experts in dis ciplines outside the health sector, such as sociology, political sciences and econ omics. The first task o f the RHDAC will be to advise the Regional D irector on establishing regional strategies to meet the target o f attaining, by the year 2000, a level o f health that would permit every one to lead a socially and economically productive life (HFA/2000). The impact o f these strategies on the Regional O f fice programme w ill be taken in to ac count and consideration given to the specific needs o f the European Region which, in contrast to most other re gions, is composed mainly o f indus trialized countries. Three programmes were discussed in detail by the Regional Committee in the light o f their importance and relevance to HFA/2000. These were: fam ily health, where special attention would be paid to perinatal problems, the role o f women in society, and psychosocial problems o f adolescents; chemical safety and the re gional contribution to the worldwide programme: and primary health care and its relevance to all the programmes o f the Region. Similarly, the research aspects in all programmes and the development o f health services research in the Region, at both the national and the regional level, are playing an increasingly im port ant role (resolution WHA32.15). Ap propriate medical technology to meet the needs o f individual countries and the problems o f oversophisticated technol ogy, characteristic o f the European Re gion, w ill be the theme o f the technical discussions at the th irtie th session o f the Regional Committee in 1980, when both the economic and ethical aspects o f medi cal technology w ill be examined. In reviewing the regional report on the study o f WHO’s structures in the light o f its functions, the twenty-ninth ses sion o f the Regional Committee for Europe recognized the importance o f 5 the provisions o f the Constitution (A r ticles 61-63), stressing that there was a need to ensure implementation o f the decisions o f the global and regional gov erning bodies and that better use could be made o f the provisions o f the Consti tution. Member States were therefore urged to report on national health devel opment, an essential element in the ex change o f inform ation for the establish ment o f criteria and indices fo r further action to achieve HFA/2000. The fu ll report and minutes o f the twenty-ninth session o f the Regional Committee were sent as usual to Member States and to other international organ izations. Changes in demographic structure and the trend towards an older popula tion between now and the year 2000, both in developing and developed coun tries, have led to a marked interest in the possible effect on socioeconomic devel opment and its consequences fo r health care. The designation o f the Regional O f fice fo r Europe as the focal point fo r the global programme on health care o f the el derly has intensified collaboration with other WHO regions, Member States throughout the world, and other organiza tions both w ith in and outside the United Nations system (resolution WHA32.25). Activities related to the preparation for the World Assembly on the Elderly in 1982 are being given special attention. The form ulation o f medium-term programmes in all programme areas great ly facilitated the preparation o f the Eu ropean programme budget proposals for 1982-83 and the preliminary work fo r the Seventh General Programme o f Work. The trend towards intensifying the participation o f Member States in the work o f WHO, and the awareness o f the value o f standardizing as far as possible the agendas o f meetings o f the global and regional governing bodies, have contri buted to the strengthening o f regional committees in general and considerably improved the relationship between the Regional Committee, the Executive Board and the World Health Assembly. POLICY ORGANS Expenditure (US$) Regular funds 59 677 Host government’s contribution 31 800 UN funds Voluntary funds a Being 0.57% of total expenditure. 91 477° 6 Participants in the twenty-ninth session o f the Regional Committee posing in Finlandia Hall, Helsinki President LJrho Kekkonen of Finland speaking at the inaugural ceremony of the twenty-ninth session of the Regional Committee In the Town Hall of Helsinki the Lord Mayor, Mr Teuvo Aura, receives participants in the Regional Committee îventy-five meetings were arranged by the Regional O ffice fo r Europe during 1979. One of these (above) as the f if th session o f the European Advisory Committee fo r Medical Research held in Prague, another >elow) was the Technical Group on Protective Devices and Restraint Systems in Road T ra ffic Accidents •evention held in Meknes, Morocco Officers o f the tw enty-n inth session o f the Regional Committee fo r Europe. Seated from le ft to right: Dr G. Martii France (Rapporteur), Dr T. lonescu, Romania and Mr O. Jennane, Morocco (Vice-Chairmen), Professor E. Kivali Finland (Chairman), Dr Leo A. Kaprio, WHO Regional D irector fo r Europe, Dr H. Mahler, WHO Director-Gener. and Dr J.E. Asvall, D irector, Programme Management, WHO Regional O ffice fo r Europe Dr Halfdan Mahler, WHO Director-General, being interviewed on his arrival at Helsinki a irport Chapter 2 GENERAL PROGRAMME DEVELOPMENT, MANAGEMENT AND COORDINATION 2.1 G ENERAL PROGRAMME DEVELOPMENT On 1 February 1979 Dr J.E. Asvall, previously Regional O fficer fo r Country Health Programming, took over as Direc tor, Programme Management. He suc ceeded Dr F.A. Bauhofer, who died on 15 March 1979 following a long and severe illness. In an effort to make the Regional Office programmes more relevant to the European situation and to ration alize and integrate the d ifferent plan ning exercises, it was decided that the Office should embark on a syn chronized medium-term planning exer cise fo r all programme areas fo r the remaining part o f the Sixth General Programme o f Work. This would be done by producing in one document a medium-term programme for this period (i.e., 1980-83), a programme bud get for 1982-83, and a tentative pro jection o f future trends during the period o f the Seventh General Pro gramme o f Work (1984-89) fo r each programme o f the Regional Office. This planning process took place between March and October, when the individual programmes were presented to the Regional Programme Committee for review. On this basis the consultation letter covering the period 1982-83 was subsequently prepared, and this was sent to all Member States fo r review. The third meeting o f the Consulta tive Group on Programme Development (CGPD) was held in April. The Group felt that a more systematic evaluation o f the Regional Office programmes was called for to ensure a thorough review, including external evaluation o f past achievements, before embarking on any new activities. One possibility proposed was that the CGPD should review selected programme areas follow ing the programme evaluation guidelines recently produced by WHO headquarters. One aspect o f this evaluation would be to assess the impact o f Regional Office programmes on Member States, and one means to this end would be an analysis o f the follow-up given to resolutions adopted by the Regional Committee and the World Health Assembly. The CGPD proposed that a system be established whereby Member States would be asked on a regular basis what action had been taken at the national level to implement resolutions o f WHO governing bodies and to carry out activities recommended by the Organization. 7 The increasing need for voluntary contributions to Regional Office pro grammes owing to the fall in purchasing power caused by monetary fluctuations was raised. It was suggested that more extensive use be made o f collaborating centres and that governments be asked to pay fo r national participation at WHO meetings. The subject o f support for Regional Office programmes would be taken up in more detail by the CGPD during its jo in t session w ith the Con sultative Group on Budgetary Questions in March 1980. The CGPD also reviewed various documents prepared for the twenty- ninth session o f the Regional Com m it tee: a draft medium-term programme in fam ily health, a report on the Regional O ffice’s contribution to the International Programme on Chemical Safety, and a draft document on activities to be car ried out in the field o f primary health care as a part o f comprehensive health services, as a follow-up to the Alma- Ata Conference. The CGPD had before it an analysis o f the replies received from Member States, the staff o f the Regional Office and the International Children's Centre to the questionnaire prepared in con nexion with the Director-General’s docu ment on the study o f WHO’s structures in the light o f its functions. This analy sis was subsequently presented to the twenty-ninth session o f the Regional Committee which, in general, felt that caution was required in deciding whether to m odify structures that seemed satis factory on the whole. Any required improvement would be related more to working methods than to structures, bearing in mind the need to make better use o f the potential o f the Member States. It was unanimously agreed that there was no need for a revision o f the WHO Constitution at that stage. (F o ra résumé o f the European response to the study see Annex 5.) In the CGPD’s discussions on the preparation o f the Seventh General Programme o f Work (1984-89), it was noted that an underlying factor would be the attainment o f the goal o f “ health for all by the year 2000” (HFA/2000) in line w ith the World Health Assembly document on this subject (A32/8) and resolution WHA32.30. The CGPD decided that some o f its members should meet w ith Professor J.J.A. Reid, Chair man o f the sixty-th ird session o f the Executive Board, to assist the Regional Director in preparing for the preliminary discussions on strategies at the twenty- ninth session o f the Regional Committee. This ad hoc group met in July and drafted a questionnaire which was circulated to Member States. The Re gional Committee recognized that the formulation o f regional and national strategies would be a continuing, long term process and took note o f the Re gional D irector’s intention to establish a Regional Health Development Ad visory Council (RHDAC) to study the formulation o f such strategies. It was agreed that Member States should revise their health development in the light o f HFA/2000, as applicable to the Euro pean Region, and should promote an intersectoral approach to activities for the achievement o fth a t goal. A more detailed questionnaire on the subject was then prepared by the Secre tariat and circulated to Member States with the request that it be returned to the Regional Office in February 1980, for review by the first meeting o f the 8 RHDAC in March 1980 and fo r the prep aration o f a document on the subject for the th irtie th session o f the Regional Committee. The value o f WHO publications was repeatedly referred to by the CGPD and their importance as a means o f inform a tion transfer and o f assisting govern ments in the development o f their own programmes was emphasized. It was vital that publications reach as many people and institutions as possible, and con tinuous efforts should be made to pub lish results o f activities in a way that would make them easily applicable at the national level. In this connexion, the Regional Director submitted to the Glo bal Programme Committee (GPC) in May proposals fo r making the best use o f translation staff on an interregional basis for the preparation o f documents and publications in various languages. He was subsequently requested by the GPC to analyse the situation in quantifiable terms and to make proposals to other Regional Directors and to headquarters concerning practical interregional ar rangements for making documents and publications available to Member States in the relevant working languages. A review o f current decision-making and administrative functions was begun, aiming at sim plifying office procedures, clarifying managerial responsibilities, im proving the utilization o f professional and general service staff, and increasing job satisfaction. Representatives from Algeria, the Federal Republic o f Germany, Romania and Sweden paid offic ia l visits to the Re gional Office during the year to discuss jo in t programme development, w ith emphasis on areas o f special interest such as fellowships and publications. The Director, Programme Manage ment visited Algeria in November to finalize the country programme budget fo r 1980-81. In meeting national health development priorities, the jo in t pro gramme w ill stress the principles o f primary health care. 2.2 COUNTRY H EALTH PROGRAMMING Regional Office activities in this field were restricted during the year owing to the lack o f a Regional O fficer fo r Country Health Programming (CHP). Two con sultants were, however, recruited for a tota l o f five months to assist the Re gional Office in this field. The main activity was the Workshop on Country Health Programming in European Health Planning and Manage ment Education, organized in June in cooperation w ith the Austrian Federal M inistry o f Health and Environmental Protection and the Department o f Hos pital Adm inistration in Vienna. This was the first forum to consider CHP in the context o f industrialized countries. Four European case studies were presented from Algeria, Portugal, Scotland and Spain where CHP or project systems analysis had been carried out. The Work shop recommended CHP as a useful ap proach fo r European countries but stressed that the existing WHO guide lines on CHP should be amended to cor respond better to the problems and needs o f European health planners. This idea o f region-specific CHP guidelines (in addition to the guidelines for world wide use) was subsequently supported by the second interregional seminar on 9 CHP (organized by WHO headquarters and supported by D AN ID A) held in Dubrovnik in November 1979, where case studies on the adaptability o f CHP to national health planning in Portugal, Turkey and Yugoslavia were presented. Country activities Algeria. A consultant reviewed, with the national authorities, the possibility o f further developing primary health care by means o f country health pro gramming. Denmark. The Danish Hospital Insti tute, in collaboration w ith a WHO con sultant, studied methodology based on country health programming for de veloping cancer services and for compre hensive planning at the county level. Portugal. A consultant assisted in the preparation o f a country health pro gramming seminar and in conducting the subsequent p ilo t CHP exercise in the north o f the country. Yugoslavia. It was proposed that CHP methodology could be used to plan the rebuilding o f the health infrastructure following the destruction caused by the earthquake in Montenegro in April. 2.3 IN FO R M ATIO N SYSTEMS PROGRAMME In 1979 the Regional Office became the p ilo t demonstration and training cen tre fo r implementing at the regional level the automated technico-administrative procedures to be used by WHO w orld wide. For this purpose the Regional Office acquired in November a small computer as an interim solution. The automation o f budget and f i nance operations had priority in 1979. O f the four components planned bud get control, expenditure accounting, general accounting, and processing o f claims - the first was implemented and made operational. Computer programs were developed to facilitate storage and retrieval o f directories o f health special ists and institutions collaborating with the Regional Office. The range o f computer services avail able to the Regional Office was expanded by using the International Computing Centre (ICC) and the Northern European University Computing Centre (NEUCC). Application programs, e.g., for fellow ship awards and placements and travel by staff members or temporary advisers, have been developed, allowing for easy transfer o f data to the internal com puter. The processing and analysis o f country data from national studies or surveys coordinated by the Regional Office was initiated at NFUCC, e.g., for the programme on health care o f the elderly, fo r which the Office has global responsibility. The word processing equipment ac quired in 1978 proved most useful for the work in the Regional Office. Addi tional equipment was purchased to in crease the number o f work stations from 4 to 14. This equipment can now handle the English, French and German lan guages, and the addition o f Russian is foreseen in the near future. In July a questionnaire on the organ ization and management o f health re search in the WHO European Region was 10 sent to all Member States, and 18 coun tries replied. These replies were discussed at the Third Meeting o f the Planning Group on Inform ation Systems for the Biomedical Research Promotion and De velopment Programme, held in London in September. They showed that most o f the countries had some mechanism for planning and coordinating health ser vices research programmes, although in a large proportion o f these countries this mechanism applied only to research sponsored by central bodies such as the health services and research and scienti fic funds or organizations. Inform ation on such research is usually published; however, since the international ex change o f information depends on the availability o f easily comparable data, it would be desirable to establish a basic data set fo r each country. The Planning Group recognized that there were two main problems, namely for countries to establish complete na tional inventories o f health services re search and fo r international organiza tions to improve the exchange o f in form ation on national health services research activities. Several groups were working on the development o f similar systems, e.g., in UNESCO and EEC, and the need fo r close international cooperation was emphasized. 2.4 EXTER N AL COORDINATIO N FOR HEALTH AND SOCIOECONOMIC DEVELOPMENT An analysis o f health activities o f relevance to the Regional Office that are the responsibility o f intergovernmental organizations was made fo r the meeting o f the Consultative Group on Programme Development in April. The information thus obtained is now maintained system atically in the Regional Office to avoid duplication and overlapping o f activities. A t the same time, it is realized that a more dynamic approach to coordination is desirable, by which the Regional O f fice w ill act to ensure that health prob lems are not left unsolved simply because various other organizations are poten tia lly involved. The new Head o f the Public Health Division o f the Council o f Europe (CE), Mr F. Marziale, visited the Office in March, at the invitation o f the Regional Director, as part o f the preparation for a long-term programme in the field o f public health. O f particular interest to the Regional Office was the decision o f the Com m it tee o f Ministers o f CE to accept the pro posal o f the Spanish Minister o f Health to hold a European conference o f minis ters responsible fo r public health in the spring o f 1981 in Spain, as was the de cision to restore the original membership o f the Committee o f Experts on Legal Problems in the Medical Field. The par ticipation o f the Regional Office in the exploratory meeting o f the latter con cerned the defin ition o f patients’ rights and compensation for damage caused by medical intervention. The Regional Office was represented at a number o f CE meetings. The meeting o f the European Public Health Commit tee o f CE in November marked the tw enty-fifth anniversary o f CE and the main subjects discussed were: blood transfusion and immunohaematology ; problems related to death: the patient as an active participant in his own treatment ; 1 1 drug dependence; the medical fellow ships programme for 1980; expec tations from health education pro grammes; and the cost o f health care both inside and outside hospital. Rep resentatives o f the Regional Office attended meetings o f the Select and Expert Committees on hospital in fection prevention, the role o f school health services, and m ortality and mor bid ity, and the Coordinated Medical Research Programme meeting on the cost o f health care in the Member States o f CE and in Finland. Following the Exchange o f Letter signed by the Council for Mutual Econ omic Assistance (CMEA) on 7 July 1978 and by WHO on 7 March 1979, dis cussions were held w ith officials o f CMEA to elaborate the details o f the agreement between the two organiza tions and to redefine certain selected areas in various public health fields, e.g., occupational health, for future collaboration. Contacts were established w ith the National Institute o f Pharmacy, Hungary, which is a coordinating institute for CMEA. In connexion w ith WHO coopera tion w ith the Commission o f the Euro pean Communities (CEC) it was agreed that CEC would be invited to send observers to future sessions o f the World Health Assembly. The Regional Director attended a meeting o f the Chief Medical Officers o f the European Economic Community (EEC) in Cologne in March and the Director, Programme Management at tended a similar meeting in Lyons in October. During these meetings WHO activities were reported and the roles o f EEC, WHO and CE discussed. It was accepted that WHO’s role is that o f providing technical and scientific ex pertise on health problems and that the Directorate-General fo r Social Affairs o f the CEC is the centre for the coordina tion o f health-related activities in the EEC. The Directorate-General w ill there fore be kept fu lly informed o f any ques tionnaire dealing w ith health that WHO sends to its Member States. As regards technical cooperation w ith CEC at the project level, the Re gional Office was represented at a sym posium organized by CEC on technical innovations in the service o f the elderly and disabled, as well as at a meeting on the Study o f the Nutritional Status o f Infants, the Regional Office being a member o f the special committee for this Study. Cooperation with the Organisation for Economie Co-operation and Develop ment (OECD) was maintained in the tie Ids o f air pollu tion, solid waste and. in particular, road tra ffic accidents. The Regional Office was represented at the annual plenary session o f the Nor dic Council’s Committee on Medical Statistics (NOMF.SCO), during which in formation on the O ffice ’s current activ ities in health statistics was provided and further cooperation envisaged. The O f fice was also represented at the Confer ence on Primary Health Care in Remote Areas, arranged by the Nordic Council o f Ministers, the recommendations o f which are o f particular interest to WHO. A presentation on the Regional Office programme on prophylactic, diagnostic 1 2 and therapeutic substances was made at the tenth meeting o f the Nordic Council. 2.4.1 Col laboration with the United Nations system and other organi zations Following WHO assistance to the Economic Commission fo r Europe (ECE) in preparing the Convention on Long- range Transboundary A ir Pollution, the Regional D irector represented the Director-General at the signing o f the Convention during the High-level Meeting on the Protection o f the En vironment held in Geneva in November. The Regional O fficer for Coordina tion participated in the th irty -fo u rth session o f ECE in Geneva in March. The Regional Office expressed its support in principle fo r the ECE programme o f work fo r 1979-83, and the relationship between ECE and the Regional Office in the field o f environmental health was underlined. Cooperation continued, es pecially in relation to transboundary air and water pollution, toxic chemicals and waste, and environmental impact assess ment. Links were established w ith ECE in respect o f the programme on the pre vention o f road tra ffic accidents and the Regional Office participated in the th irty-s ixth session o f the Expert Group on Road Safety, which dealt w ith statis tics on road traffic accidents. The Re gional Office expressed the interest o f WHO in participating in the UNDP/ECE trans-European north-south motorway project. During the period under review the Regional Office fo r Europe was the executing agency for 41 projects financed by the United Nations Development Pro gramme (UNDP), 28 o f which concerned the environment, including food safety. Most o f the other projects dealt w ith health manpower development. The Regional Office was represented at the UNDP Country Programme Re view in Turkey in May and the Mid-Term Country Programme Review in Yugo slavia in December. A meeting was held in Copenhagen in March w ith representatives o f UNDP, UNDSA, UNFPA, UNICEF and UNEP, at which WHO country programmes, jo in t procedures and programme matters were discussed. The global activities o f UNEP were presented; those on toxic chemicals, the Mediterranean Plan and the GEMS projects were o f particular relevance to the programme o f the Re gional Office. A report on this meeting was also sent to all the UNDP resident representatives. The UNDP resident repre sentative in Algeria visited the Regional O ffice in September. Two WHO/UNDP consultations were held at the Regional O ffice: one on re gional cooperation in environmental health aspects o f the control o f chemi cals, in August, and the other on regional cooperation on food safety services in Europe, in October. The Regional Office is the executing agency for the UNDP Intercountry Pro ject fo r the Control o f Malaria in South- East Europe, the first meeting o f which w ill be held in Sofia in March 1980. An intercountry project to study and assess the water quality o f the River Danube is at present being negotiated 13 with the governments concerned and UNDP. A meeting was also held in Geneva w ith representatives o f the United Nations Environment Programme (UNEP) regarding the development o f a water quality project in the Danube basin. In October, the Office was repre sented at the second meeting o f the “ National Blue Plan Focal Points” , con vened by UNEP in Cannes, and in July at the UNEP Interagency Meeting on Regional Seas, during which it was agreed that WHO should act as the leading agency for environmental impact assess ment. An urgent investigation related to mercury levels in Mediterranean fish is to start, involving WHO and FAO. The very close working relationship with UNFPA, both at headquarters and in the Held, was further intensified. In addition to the four country and two intercountry projects that this Office was already carrying out for UNFPA, two more were started in Bulgaria. During a visit to FAO it was agreed that jo in t programming meetings should be held periodically to harmonize activ ities and make the best use o f resources. The Office was represented at the thirteenth session o f the Codex A li- mentarius Commission in December. Dame Judith Hart visited the Office in November, in her capacity as a special UNICEF envoy, in order to become ac quainted w ith WHO’s policies and pro grammes related to children in Europe. Discussions were held with UNICEF on possible future collaboration in primary health care. The Office also collaborated with UNICEF on the International Year o f the Child. UNICEF provided five vehicles for use in the Turkish malaria pro gramme. The Office participated in the jo in t UNICEF/WHO meeting on infant and young child feeding in Geneva in October. Close collaboration continued w ith the International Children’s Centre (ICC) in Paris through the jo in t planning and evaluation o f courses in family health, fam ily planning and teaching. In addi tion, development continued in the documentation o f family health and family planning. A book, published under the jo in t sponsorship o f the Re gional Office and ICC in English and French, comprised a selection o f papers distributed to participants during the above-mentioned courses since 1973. The Regional Office was represented at the fifty -s ix th session o f the ICC Technical Consultative Committee in December. C ooperation w ith IEO made progress. In June the Chief o f the Occupational Safety and Health Sector assured the O f fice o f the participation o f ILO in the Working Group on Evaluation ol Occupa tional Health and Industrial Hygiene Services. An ILO representative attended the Working Group on Health Aspects o f Wellbeing in Working Places in Prague in September, and the Office was repre sented at the Third ILO European Con ference in October. Following the transfer o f the United Nations Division for Social Affairs (IJNDSA) from Geneva to Vienna and its integration with the United Nations Centre for Social Development and Humanitarian Affairs, the United Nations Office in Geneva requested comments on an aide-mémoire concerning the future 14 o f the European social development pro gramme. The possibility o f involving the European Centre for Social Welfare Training and Research in Vienna in this programme was indicated. A fte r the Regional Office had made its comments, the Regional O fficer fo r Coordination attended the sixth Annual General Meeting o f the Board o f Directors o f the European Centre and the Director, Comprehensive Health Services attended the third meeting o f the UN Standing Working Group on Social Development, both o f which were held in Vienna in December. As a result o f jo in t efforts by UNDP in Ankara and the Regional O ffice, a mission from the World Bank was sent to Ankara in January to ascertain the correlation between the malaria re surgence in Turkey and the irrigation network in the Çukurova area. Contacts w ith the Economic Com mission for Africa and the Organisation o f African Unity were made at the first meeting o f the plenipotentiaries o f the Multi-national Programming and Opera tional Centre for North Africa in Tangiers in March. 2.4.2 Col laboration with multilateral and bilateral programmes An im portant DANIDA/W HO Joint Programming Review Meeting fo r 1980/ 81 was convened in Geneva in February. It was devoted to courses, seminars and projects, and problems o f policy and general administration were discussed. 2.4.3 Nongovernmental and other or ganizations Regular collaboration was main tained with some 30 nongovernmental organizations. During the year, agree ments were signed w ith five, namely the European Federation fo r the Welfare o f the Elderly, the International Center o f Social Gerontology, the International Federation on Ageing, the Interna tional Medical Association for the Study o f Living Conditions and Health, and the International Federation o f Telephonic Emergency Services. Details o f current activities may be found in the sections on the relevant technical programmes. In particular, attention is drawn to the creation in 1979 o f the European Committee on Clinical Laboratory Standards (see p. 29) and to the support received from the In ternational Union for Health Education. 2.5 EMERGENCY RELIEF OPERATIONS On the occurrence o f the earthquake in Montenegro in April, a jo in t Regional Office/WHO headquarters mission visited Yugoslavia to make a rapid assessment o f the situation. The Regional Office sub sequently appealed to certain Member States for funds, and both the Regional Office and headquarters made small sums available for re lief equipment. Fol lowing a visit to Copenhagen by the liaison o fficer appointed by the Y ugoslav Government, it was recommended that further assessment o f the epidemiological situation be carried out. including a study on the facilities then available for the prevention o f communicable diseases. In November a follow-up visit to the coun try was made by the Director, Programme Management to discuss the situation with the health authorities. 15 A Memorandum o f Understanding was signed by W H O and the United Nations Disaster R e lie f Organization (U N D R O ) defining the responsibilities o f the two organizations for disaster re lief operations and pre-disaster planning. This will in future guarantee more rapid coordination o f activities in emergency situations. 2.6 R E S E A R C H P R O M O T I O N A N D D E V E L O P M E N T Despite the adverse financial situa tion during the year, the Regional O f fice was able in many instances, thanks to additional assistance from various Member States, to implement not only the activities foreseen under the research development programme but also new ones. Thus, four o f the E A C M R sub groups in five priority research areas (standardization o f methods, measure ments, and term inology in biomedical and health services research; evaluation o f drugs and other therapeutic and diag nostic substances; prevention, prophy laxis and early detection; and economic aspects o f health care) held fo llow-up meetings and made a number o f recom mendations (see under the relevant technical programmes). The first three groups also examined the problem o f hypertension in preparation for the Consultation on Hypertension Research related to Health Care in October. The planning group on information systems for the research promotion and development programme held its third meeting in London in September. The discussions centred on the answers to a questionnaire sent to all Member States in order to prepare a survey o f current health research. (See also section 2.3.) A workshop on health economics research was convened in The Hague in September. The meeting reviewed existing research into the degree to which the growth in health resources, budget and finance systems and new technology was responsible for the growth in health services. The meet ing concluded that there was a need to control the numbers o f health per sonnel and to review the financing arrangements, and made a number o f recommendations for future re search. Fo llow ing the Regional C om m it tee’s endorsement o f the E A C M R recommendation to promote coordina tion with European research bodies particularly concerned with health ser vices research, a liaison meeting on research coordination was held in Helsinki in September. The partici pants suggested an increase in dialogue by holding regularly, every one or two years, similar consultative meet ings. Interest was expressed in par ticipating in WHO meetings and in contributing to the resulting initia tives through the technical poten tial and resources available to them. O f particular interest was the con tact established with the International Federation o f Pharmaceutical Manu facturers Associations and its willing ness and interest in cooperating with WHO in the field o f research. In order to focus health services research efforts on more specific issues, arterial hypertension, being o f general concern to all Member States, was 16 singled out fo r special consideration. A Consultation on Hypertension R e search related to Health Care took place at the Regional O ff ice in October, and proved to be a significant event in the initiation o f this new thrust o f the European research programme. The recommendations adopted stressed the public health importance o f re search on the subject, defined priority areas fo r study and coordination, and outlined a programme o f future activ ities. E fforts to provide adequate funds fo r the proposed activities are being actively pursued by the Regional O f fice. A t its fifth session in Prague in October, the E A C M R reviewed the progress o f the programme and dis cussed the reports o f three o f the plan ning groups in research priority areas, as well as the recommendations o f the meetings mentioned above. It recommended, inter alia, a further study o f questions such as the extent to which health services are being used in terms o f primary health care, the rationalization o f prevention activ ities, the coordination o f clinical trials o f drugs by the Regional O ff ice , and research on diagnostic aspects o f drugs. The E A C M R also called for a real istic attitude towards coordination. While agreeing that health services research was not only a priority issue per se but an essential means o f health services development, the E A C M R be lieved that health services research should be highlighted as an interdis ciplinary activity, and also that it was necessary to consider how research policy in this area could be promoted; there was an increasing need to analyse national research structures in view o f the lack o f information on systems that included health services research. Consultant studies were undertaken on management structure and on the dynamics o f health research at the national level. Contacts continued to develop with many research institutes and coord i nating bodies, not on ly in Europe but also in Canada and the USA. This was achieved through exchange o f information, attendance at meetings by Regional O ff ice staff, visits, and further development o f personal con tacts at the technical level. Discus sions were held with the National Center for Health Services Research, Hyattsville, USA, on possibilities for cooperation, and with the Institute o f Medicine, National Academ y o f Sciences, Washington DC, on inter national perspectives in health re search planning. The Regional O f fice was represented at the biannual meetings o f the European Research Medical Councils in Bethesda (U S A ) and Obernai (near Strasbourg), at which such topics as mental illness re search, tox ico logy , human reproduction, biomedical research and health econ omics were reviewed. 2.7 P U B L I C A T I O N S Research on simulation models for health management: report on a W H O Working Group. E U R O R e ports and Studies, No. 20. 17 G E N E R A L P R O G R A M M E DEVELOPMENT, M A N A G E M E N T A N D COORDINATION Expenditure (US$) 6 3 0 295 33 7 6 9 6 6 4 0 6 4 ° a Being 4.15% o f total expenditure. Regular funds U N funds Voluntary funds 18 Chapter 3 D E V E L O P M E N T OF C O M P R E H E N S IV E H E A L T H SE RV ICES 3.1 G E N E R A L During 1979 the development o f health services in the countries o f the European Region continued. The means o f reaching the goal o f “ health fo r all by the year 2000” were seen as being the development o f primary health care, the improvement o f appropriate technol ogy for health, and the intensification o f e f fort, not only in respect o f the phy sician but also through collaboration with other institutions and services. The principles enunciated in the Declaration o f A lma-Ata, namely that primary health care is not an isolated approach but the most local part o f a comprehensive health system, that health care should be related to the needs o f the population, that consumers should participate individually and collectively in the planning and implementation o f health care, and that the fullest use must be made o f available resources, are already influencing the development o f health services in the Region and the current programmes o f the Regional Office. More attention has recently been paid to establishing closer cooperation with individual health institutions in the Member States. The results o f three years o f jo in t activities with Bulgaria are cur rently being evaluated and courses in Bulgaria in the fields o f primary health care and maternal and child health, or ganized for developing countries on the basis o f the Gabrovo pilot area, are being supported. Closer contact in the develop ment o f different areas o f the health services was established between the Re gional O ff ice and several Member States. A lthough strategies for the achieve ment o f “ health for all by the year 2000 ’ ’ are still being formulated, a sig nificant contribution has been made by the Regional O ff ice in conjunction with the International Epidemiological Asso ciation in the publication o f Measure ment o f levels o f health (WHO Regional Publications. European Series. No. 7). “ Measurement o f levels o f health” is taken to include the incidence and pre valence o f specific diseases and syn dromes and measurements o f physical and mental conditions, as well as the social function o f individuals and popu lation groups and their behaviour or attitudes towards health and health- related activities. Demographic phe nomena are taken into consideration on the one hand, and availability and 19 utilization o f health services on the other. Measurable variables are grouped under the headings: measurements o f ill health; measurements o f need and demand fo r medical care; measure ments o f the use o f health services; and measurements o f effectiveness and e ff ic iency o f health services and pro grammes. The interface between the health and social services is also ex amined. The wish expressed by Member States for research components in certain programmes o f the Regional O ff ice led to the preparation o f a re port on the content, organizational arrangements and priority research prob lems o f WHO activities in health ser vices research and on suggested future activities. The report drew attention to the dearth o f publications on the management o f health services and terminology in this field, and sug gested that the Regional O ff ice might consider preparing a publication on the measurement o f health services, along the lines o f Measurement o f levels o f health. The new Portuguese National Health Service Law, No. 56/79, dated 15 Sep tember 1979, designates the primary health care department as one o f the three main departments o f the central health administration. The new law is the result o f intensive efforts on the part o f the Portuguese Government since 1975 in which it has enlisted the help o f the Regional O ff ice at all stages. 3.1.1 Health services planning and man agement The Study on Health Care o f the Elderly progressed well. In most o f the participating countries the field work was completed, and data sent to the Regional O ff ice fo r processing and analysis. Fo r some o f the centres processing o f data was completed and preliminary tabulations were made. The editorial board for the report on the Study met in Tampere, F in land, in December 1979 to discuss and approve the outline and content o f the First report, to be issued in the first quarter o f 1981. Further preparation was made for the Study on the Development o f Systems fo r the Epidemiological Sur veillance o f Long-Term Environmen tal Health Effects. Sixteen countries expressed interest in participating and nominated institutions and research workers responsible fo r the imple mentation o f the project in their coun tries. The steering group fo r the Study met in Copenhagen in Novem ber to prepare outlines o f draft protocols for surveillance systems and to recom mend steps to be taken for setting up pilot schemes based on the draft protocols. In March the Planning Group on Standardization o f Methods, Measure ments and Term ino logy in B iomedi cal and Health Services Research met in Copenhagen to review existing know ledge in the field o f health care out come measurements and the present use o f these measurements in various countries; to consider the possible unification and standardization o f out come measurements; and to recommend steps to be taken to achieve these aims. In addition, the Group examined the methodological and terminological aspects o f arterial hypertension control, 2 0 this having been selected as one o f the ch ief problems for research in the European Region. The Group found that there are certain prerequisites for the use o f outcome measurements in a standard ized, unified way, such as a common approach to setting objectives for health services and a comm on ap proach to measurements. Accordingly , the Group made proposals on a frame work fo r setting objectives for health service interventions and programmes and for the measurement o f particular outcomes, and provided examples o f health outcome measures related to particular objectives. In the recom mendations concerning future work the Group stressed the need to develop concepts, criteria and methods fo r the measurement o f disability, discomfort and dissatisfaction. The emphasis o f the health econ omics programme during the year under review, besides support to other programmes o f the Regional O ffice , was on research. The Planning Group on Economic Aspects o f Health Care, at its second meeting in Copenhagen in November, recommended three additional topics for national and international research, namely (a) econom ic and social im plications o f routine clinical decisions; (h) cost-effectiveness o f the shifting o f care towards primary health care; and (c ) the influence o f the econom y on health and o f health policies on the econom y. The Group also ex panded the scope o f two earlier recom mendations concerning the development o f indicators o f health care performance and the development o f techniques for evaluating innovations in treatment and other procedures. The Workshop on Health Econ omics Research, held in The Hague in September, reviewed the available evidence that health services tend to grow, owing to (a) the higher avail ability o f health care resources; (b) in centives inherent in certain budget and finance systems; and ( c ) new health technology. The evidence was con vincing fo r (a), with obvious conclu sions fo r limiting unnecessary growth o f health resources; supportive for (/?); and plausible but incomplete fo r (c ) . The Group considered the most urgent need was for research on the supply o f health facilities, and especially the crucial role o f the physician as an agent acting on behalf o f the patient. A number o f smaller studies and sur veys were carried out: surveys were started on existing research, training and advisory activities in health econ omics in selected countries, and studies on national health accounts and the cost o f viral hepatitis were continued. Country activities Portugal. The Regional O ff icer for Epidemiology served as faculty member at a seminar on “ health policy: the con tribution o f ep idem io logy and health services research” , organized by the National School o f Public Health. Publications Measurement o f levels o f health. W HO Regional Publications, Euro pean Series, No. 7. 21 Programme development made a good start fo l low ing the discussions o f the twenty-ninth session o f the Regional Com m ittee on the document Primary health care as a part o f com prehensive health services (E U R /R C 29/10), which resulted in resolution EUR/RC29/R5. The ideas advanced by the Regional Comm ittee were incorporated in the medium-term programme fo r primary health care (P H C ), which emphasizes the fo llow ing programme areas: promoting favourable attitudes towards PHC; inte gration o f health with other related services; community involvement in the planning and administration o f PHC ser vices; self-care; appropriate technology fo r PHC ; the use o f secondary and tertiary level facilities and specialized personnel in the support o f PHC; and research in PHC. The activities launched initially deal with primary medical services; this is intentional, because such services are available and easily recognizable in all Member States. Gradually, the activities will be expanded to cover the more comprehensive primary health services as envisaged in the Declaration o f Alma-Ata. The first activity to be launched under the new medium-term programme was a study on the management needs o f primary health care, which is expected to result in a descriptive analysis o f the situation in Europe and in suggestions fo r remedial action, such as educational programmes specifying objectives, con tents and methods, and organizational changes. Another major activity was related to the preparation o f a publica tion on a number o f salient issues that have to be faced when developing PHC 3,1.2 Primary health care in industrialized countries. Preparations were also begun to establish a consulta tive comm ittee fo r PHC. The report o f the Regional D irector to the A lma-Ata Conference was pub lished during the year under the title Primary health care in Europe. In this booklet the Regional D irector reviews the present situation in Europe, the problems that must be overcom e in implementing the PHC approach, and some o f the developments that are taking place. Annexes to the publica tion comprise the Declaration o f Alma- A ta and lists o f publications and docu ments on PHC issued by the Regional O ff ice and by Member States. One o f the areas into which PHC is expected to move is circumpolar health. The Working Group on Health Problems o f Local and Migrant Popula tions in A rct ic Regions, which met in September, and an ensuing consulta tion, made recommendations concerning possible W H O involvement and activities in this field. Country activities Algeria. A major project on the de velopment o f PHC, comprising the estab lishment o f demonstration areas and the creation o f a national health deve lop ment centre, was designed in collabora tion with the health authorities. Given the favourable conditions in Algeria, this project may provide an example for other countries. Publications Primary health care in Europe, by Leo A . Kaprio. EU RO Reports and Studies, No . 14. Mechanization, automation, the crea tion o f new technologies and other developments have changed the nature o f work in the European Region, lead ing to new patterns o f morbidity related to working conditions. A reduction in the incidence and severity o f occupa tional diseases and an increase in psycho somatic disorders and others such as neurosis, diseases o f the cardiovascular system, and disorders o f the digestive and locom otor systems have been observed. A Working Group on Health Aspects o f Wellbeing in Working Places was held in Prague in September. Factors influ encing the wellbeing o f workers in w ork ing places were identified and particular attention was paid to psychological factors. A definition o f wellbeing in work places was established and the humanization o f work was considered. The prevention o f harmful effects o f occupational hazards on workers ’ health is based on knowledge o f the biological aspects o f these factors. The use o f epidemiological methods provides basic and reliable information for studying the effects o f long-term exposure to low levels o f occupational hazards. In order to stimulate the application o f epidemi o logy to occupational health, a Consulta tion on Epidemiology o f Occupational Health was held in Copenhagen in July 1979. The need for a manual on m ethodology was emphasized and the outlines o f such a manual were drafted during the Consultation. The report o f a study on periodical health examinations o f workers exposed to industrial hazards was issued; the 3.1.3 Workers’ health study covered experience gathered in five countries on the protection o f workers ’ health. During the period under review particular attention was paid to the protection o f health in workers exposed to vegetable dusts. As a fo llow-up to the WHO programme on the early detection o f health impairments in occupational exposure to health hazards, a joint HQ/EURO Task Group on Health Cri teria o f Respiratory Diseases due to Vegetable Dusts met in Copenhagen in July. National programmes o f occupational health are required to set up methodology and to evaluate its e ff ic iency and e f fec tiveness. T w o working documents were prepared on this subject for a working group to be convened in Stockholm in April 1980. Country activities Denmark. A consultant assisted in the development o f modern occupational health services and the Institute o f Occupational Health. National legislation on occupational health was prepared and published. The Institute o f Occupational Health was o ffic ia lly opened. Post graduate training courses were organized, with lectures by specialists from different countries o f the Region. Finland. Three Kuropean Member States sent participants to the Sixth International Advanced Course in Epi dem iologic Methods, an interregional activity held at the Institute o f Occupa tional Health o f Helsinki. Poland. The WHO/UN DP project on the evaluation o f tox ic ity o f new 23 technologies and substances used in in dustry made progress, and tw o consul tant missions were carried out within the framework o f this project. The Inter national Course on Industrial T o x ic o lo gy was convened by the Institute o f Occu pational Medicine (W H O Collaborating Centre fo r Occupational Health) in Lodz. S ta ff members from the Regional O f fice and W H O headquarters participated and gave lectures. O f the 15 participants in this course 8 came from developing countries. Portugal. A consultant mission was provided as a fo llow-up to advice in the organization o f occupational health ser vices and training. Yugoslavia. T w o European Member States sent participants to the Third In ternational Training Course in Occupa tional and Environmental Tox ico lo gy , an interregional activity held in Belgrade. 3.1.4 Care o f the aged, disability pre vention and rehabilitation The Regional O ff ice is now respon sible for the global as well as the re gional programmes dealing with health care o f the elderly and the prevention o f road traffic accidents. Only the regional programmes are reported on be low; details o f activities concerning the global programmes appear in the report o f the Director-General. Health care o f the elderly Reorientation o f services fo r the el derly in Member States, and o f the Organization ’s programme in this field, received an impetus from the Declaration o f A lma-Ata, which calls for soundly- based and socially acceptable services delivered to the individual and the family within the community. Current pro gramme activities are directed at defining the needs o f the elderly as established by population-based data, comparing the ways by which countries meet these needs, and re-examining the technology used. For example, the editorial board fo ran international epidemiological study on the elderly met in Tampere, Finland in December 1979, a consultant visited Czechoslovakia, Denmark and Switzer land in preparation fo r an ad hoc tech nical group on services and systems o f care fo r the elderly to be hosted by the Government o f Finland in 1980, and another consultant began the prepara tion o f documentation for an ad hoc group on the use o f pharmacological substances in old age, which the Govern ment o f Switzerland will host in 1980. A major stimulus to the programme was provided in 1979 by United Nations resolution A33.52 and the related World Health Assembly resolution W HA32.25 concerning a world assembly on the el derly to be held in 1982. The programme is closely linked with the mental health and nursing pro grammes. both o f which issued reports concerning the elderly in 1979. The departments o f community medicine and geriatric medicine o f the University o f Edinburgh, in collabora tion with the Regional O ff ice , organized a two-week course on the planning and provision o f services for the elderly. Fig. 1 and 2 show, respectively, the percentage o f the population in countries o f the European Region aged 65 years and over in 1977 and a forecast o f that percentage fo r the year 2000. 2 4 Prevention o f road traffic accidents A fte r cardiovascular diseases and can cer, road traffic accidents are the third most important cause o f death in most industrialized countries. Trends in road traffic accidents in four European coun tries are shown in Fig. 3. Large invest ments have been made to make the traffic environment safer and any further im provement will probably be small in comparison. A technical group on re straint systems met in June in M orocco to review the existing measures used after a crash to minimize the severity o f injuries. It concluded that existing know ledge was sufficient for e ff ic ient measures to be formulated and made concrete recommendations in this respect. In accordance with the stated pro gramme objectives, a review o f major issues was pursued. In general, emphasis was placed on the identification o f pub lic health consequences o f traffic acci dents, as well as on the better use o f public health resources and expertise in this field. Intersectoral coordination and cooperation have been fundamental to programme development at both the na tional and international levels. Links be tween several medical and traffic safety research institutes were strengthened, and intersecretariat meetings with govern mental organizations concerned with transport are now well established. The planning and evaluation o f pro grammes on road accident prevention depend on the quality o f the data col lected. One important d if f icu lty in introducing preventive measures and evaluating their effectiveness is that the necessary data are collected through d i f ferent governmental channels. The health sector is the key source o f morbidity and disability data, which are particularly necessary fo r assessing injury protective measures. On the whole, basic national accident data systems do not produce satisfactory results because o f the weak ness o f the health data collecting systems. Fo llow ing the meeting o f a technical group on road traffic statistics in 1978, the project on the medical monitoring o f road accidents has been continued, and six national centres are involved in preparing guidelines in this field. Traff ic trauma now represents an important proportion o f overall mor bidity. Services fo r the care o f the in jured involve the highest level o f medical technology and countries are devoting more and more resources to improving their quality. In February a group met in France to discuss the organization o f emergency medical services. This meeting gave the various countries involved the opportunity to share their experience, and in particular the group considered the problem o f planning and assessing the various alternatives in use. Changing the behaviour o f popula tions is a long process. Education is con sidered one o f the priorities in traffic safety, and transport and police depart ments are usually responsible for the formulation o f programmes in this field. In order to explore the role that health personnel could play, a group met in Novem ber in the Federal Republic o f Germany to discuss education in traffic safety. One o f the group’s con cerns was to study the methods used in traffic safety and health education with the aim o f considering how health education could contribute more actively to road safety education. The jo int WHO/ICC Documentation Centre on Accidents in Childhood became 2 5 F i g . 1 . P e r c e n t a g e o f t h e p o p u l a t i o n a g e d 6 5 y e a r s a n d o v e r i n 1 9 7 7 Source: Demographic yearbook, 1977. New York, United Nations, 1978. F i g . 2 . E s t i m a t e d p e r c e n t a g e o f t h e p o p u l a t i o n a g e d 6 5 y e a r s a n d o v e r i n t h e y e a r 2 0 0 0 Source: World population trends and prospects by country, 1 9 5 5 -2 0 0 0 : summary report o f the 1978 assessment. New York, United Nations. 1979 (S T/ES A /S ER . R /33 ). 27 Fig. 3. Trends in road traffic accidents involving persons killed in four European countries, 1955-77 Denmark Hungary Italy Netherlands 1955 1960 1965 1970 1975 Year Source: Statistics o f road traffic accidents in Europe, 1977. New York, United Nations Economic Commission for Europe, 1978. operational in 1979 and the first bib liographic bulletin was issued. Publications Road traffic accident statistics: re port on a W HO Ad hoc Technical Group. E U R O Reports and Studies, No. 19. 3.1.5 Appropriate technology fo r health The present state o f the art in the Field o f medical and other related technologies in the European Region was reviewed at several meetings and through national contacts. The new programme on appropriate technology for health was developed and will deal with three sectors: (a ) laboratory dis ciplines: ( b ) radiation medicine; and (c ) bio-instrumentation. In these three sectors, the pro gramme will consider two dimensions: the one concerned with the technical aspects o f equipment and its evalua tion and cost, and the other with the appropriate utilization o f the d i f fe r ent types o f equipment and m ethod o logy in individual health care pro grammes. T w o meetings took place during the period under review. One, a W ork ing Group on Appropriate Technol ogy in Health Laboratories held in London, discussed in great detail ap propriate technologies and methods in the various laboratory disciplines and several guidelines fo r the use o f laboratory technologies were developed. The second, a Working Group on Quality Control in Health Laboratories held in Brussels, dealt with quality con trol as a too l to improve laboratory results. Important aspects o f the lat ter meeting were the identification o f the role o f quality control in the laboratory disciplines and the provi sion o f guidelines for national quality control programmes. In the field o f radiation medicine and bio-instrumentation, the present trends were reviewed and several w ork ing groups were planned. Sponsorship and input were again provided fo r the annual meeting o f the European Public Health M icro bio logy Services Directors in Oslo in September. Input was provided to several ac tivities associated with the creation o f the European Com m ittee on Clini cal Laboratory Standards (E C CLS ). This new nongovernmental organization is intended to facilitate the selection o f rational and reliable laboratory tech niques compatible with international standards. Country activities Albania. Standard reagents were supplied. Algeria. During a visit, the Regional O ff icer for Appropriate Technology fo r Health reviewed the present state o f the public and hospital laboratories and fo llowed the progress o f the new Pasteur Institute and the planned Na tional Institute o f Public Health. A project to develop laboratory ser vices at the local and intermediate levels was initiated. Malta. During a visit, the laboratory services, particularly those for tox i co logy, were evaluated and recommenda tions made on the organization o f a clinical tox ico logy unit. Morocco. The Regional O f f ice r for Appropriate Technology for Health visited the country to discuss the or ganization o f a postgraduate course in m icrob io logy and an operational study o f laboratory technology at the local level. Portugal. At the request o f the na tional authorities, the present state o f the health care support services (laboratories, radiology and bio-instrumentation) was reviewed and, after field visits, recom mendations for future action were proposed. Sweden. Close collaboration with the Swedish Planning and Rational ization Institute in the field o f medi cal technology was initiated and fo l lowed up. Documents The role o f the hospital labora tory in public health: report on a Working Group. Document 1СР/ A T H 004. 2 9 3.2 F A M I L Y H E A L T H 3.2.1 Maternal and child health The maternal and child health programme continued to seek solu tions to the problems o f mothers and children in industrialized society. The medium-term programme in family health was presented to and approved by the Regional Com m it tee in September. This medium-term programme focuses on the family as the most important resource in pri mary health care, so that primary health care services in the Region will gradually incorporate this resource to an even greater extent. The emphasis on the family has two important aspects: the evalua tion o f health problems and the gen eration o f solutions to those prob lems. The family is the most import ant determinant o f lifestyle and be haviour, especially for children. In formulating solutions to health prob lems it is becoming increasingly clear that the family, as the basic function ing unit in society, is also the basic health unit. A lthough more research and know ledge concerning childhood and ado lescence are certainly needed, deci sions on policy and programmes o f action are required immediately be cause existing services for the 5 - 18-year age group are inadequate and/or in appropriate fo r solving the problems created by the rapid socioeconom ic development and industrialization now taking place in the Region. Im port ant changes are occurring in the role o f wom en and in behavioural patterns with regard to human reproduction, as shown by falling birth rates, the increasing em ploym ent o f wom en and the rise in the number o f unwanted adolescent pregnancies. While perinatal and infant mortality rates are falling appreciably, greater emphasis is being placed on infant morbidity and the quality o f care. N ew trends in the industrialized countries are leading to new forms o f malnutrition among children and adolescents, o ften char acterized by overnutrition. Further more, air pollution, the use o f food additives and overmedication are giving rise to chronic diseases in children (cancer, allergies, respiratory diseases), and new patterns o f morbid ity are appearing. The development o f the medium- term programme, which had the strong support o f the International Children ’s Centre and the International Pediatric Association, was part o f the Regional O f f ic e ’s comm itm ent to the Inter national Year o f the Child, together with the publication o f the report on the Conference on the Child and the Adolescent in Society. The Regional O ff icer for Mater nal and Child Health explained to Dame Judith Hart, during her visit to the O ff ice in Novem ber as a special U N IC K F envoy, what might be achieved in Europe i f U N IC E F were to express more interest in family health. A Working Group on the Early Detection o f Handicap in Children was 3 0 held in Faro, Portugal in May. Recom mendations were made fo r the compre hensive management o f relevant pro grammes, based on the health and socio econom ic determinants and consequences o f the early detection o f handicap in children. Family planning The main thrust o f the intercountry family planning projects was directed to wards the training o f national cadres in family health/family planning and the provision o f technical information and support fo r project development and im plementation. Some countries were as sisted in formulating projects, which were then submitted by the respective govern ments to U N F PA . T w o additional international courses in family planning were successfully con ducted in collaboration with specialized institutions, bringing the total number o f such courses since 1973 to 11, with an attendance o f 228 fellows from the European, African and Eastern Mediter ranean Regions. One o f these two courses was conducted in Spain in collaboration with the International Children ’s Centre ( IC C ) for a multidisciplinary team o f health and social workers; it was fo llowed by a national session for maternal health specialists for the purpose o f involving them in family planning activities in Spain. The other course was conducted in Poland with the National Research Institute for Mother and Child for instructors in nursing/midwifery. A c cording to subsequent evaluation, this course met with its participants’ ex pectations in terms o f its applicability to the home situation. It is worth noting that o f 45 fellows who attended the two courses, 40 were women. A n evaluation o f past WHO/ICC courses on family health/family planning was conducted. Based on the answers re ceived to a questionnaire sent to the par ticipants and their governments, it can be stated that this teaching has a positive impact and countries wish to see it con tinued. Fo llow ing this evaluation, plans were drawn up fo r the future, taking into account the comments and sug gestions o f both the participants and their governments. Studies on the outcom e o f early adolescence (Tu rk ey ) and on the МСН/ family planning home-based records (Portugal) are being conducted. Plans were also made for the organization o f a working group on research needs and approaches in relation to adolescent re productive health in the developing countries o f the Region, to be held in Portugal in August 1980. A study on family planning legisla tion in m idwifery services and education was carried out jo intly with the Nursing unit. On the basis o f this study, a W ork ing Group on Legislation concerning Nursing/Midwifery Services and Educa tion was organized in Hamburg in December. Intercountry family planning pro grammes continued to receive U N F P A support. The Regional O ff ice was rep resented at the U N F P A interagency meeting held in Geneva to formulate strategies for future U N F P A support in regional population activities. Table 1 shows some aspects o f government policy on family planning in 30 European countries. 31 T a b l e 1. F a m i l y p l a n n i n g p o l i c i e s in E u r o p e Country Population in millions (m id -197 8 ) Num ber of children per wom an (1 9 7 5 -8 0 )3 I Governm ent perception o f fe rtility level II Governm ent policy to influence fe rtility I I I Governm ent position on contraceptive services Albania 2.7 4 .5 □ □ X Algeria 18.5 7.1 □ X О Austria 7.6 2 .2 □ X 0 Belgium 10.0 2 .2 □ x □ Bulgaria 9 .0 2 .2 Д Д О Czechoslovakia 15.0 2.2 □ □ О Denmark 5.1 1.9 □ x О Finland 4.7 1.6 □ □ О France 54 .3 2.4 Д Д О German Dem. Rep. 17.3 2.1 Д Д О Germ any, Fed. Rep. of 61 .9 1.7 Л x о Greece 9.0 2 .3 Л Д д Hungary 10.7 2 .0 □ □ о Ireland 3.2 3.4 □ □ д Italy 55.8 2 .2 □ X о Luxembourg 0.3 2 .0 Л «_к Д □ Malta 0.3 2.1 □ x д Morocco 19.2 6 .7 о о о Netherlands 13.9 2.1 □ X о Norway 4.1 2 .3 □ X о Poland 34.7 2 .0 □ □ о Portugal0 8.9 2 .5 □ X о Romania 21.7 2 .5 □ □ X Spain 36 .5 2 .8 □ X □ Sweden 8.4 2.1 □ X о Switzerland 6.7 1.9 □ X □ Turkey 43.1 5 .6 о о о USSR 262.8 2.4 □ □ о United Kingdom 57.1 2 .4 □ X о Yugoslavia* 21 .9 2 .3 □ □ о Key: I □ — acceptable О — I I □ — to m aintain О — too high to reduce Д — too low Д — to raise X - no intervention II I □ — some support О — active support Д — restrictions X — по support 3 Total fertility rate. ^ Family planning is a constitutional right in these countries. Source: Family planning policies: a 1979 People wallchart. People, 6 (2 ) (1979). 32 Algeria. Progress in the project on birth spacing and the development o f a maternal and child health infrastructure continued with efforts to attain wider geographical and population coverage, the regionalization o f the retraining courses fo r health personnel in birth spacing, planning fo r the organization o f in formation days on contraception and o f a jo in t publication on this project, and the development and procurement o f documentation and audiovisual material on family health and family planning. A consultant in evaluation was recruited for this project fo r four months, starting in December. Bulgaria. A short-term consultant was recruited to analyse existing re sources in connexion with tw o project requests to U N F P A in the Field o f human genetics. In May, the Regional O ff ice be came the executing agency fo r these two UNFPA-funded projects, one dealing with remedies fo r sterility and the other with screening o f the newborn and at- risk families for birth-related diseases. The placement o f fellows abroad was be gun and the equipment requested for 1979 purchased. T w o fellows attended the WHO/ICC international course on family health/ family planning in Spain. Czechoslovakia. Fo llow ing a U N F P A mission, a short-term consultant visited the country twice, in March and June, in connexion with family planning-related activities, mainly to assist in the prepara tion o f project documents. German Democratic Republic. A short-term consultant paid a visit in May Country activities to discuss with representatives and specialists from the Ministry o f Health the possibility o f w idening cooperation and collaboration with the Regional O f f ice in family planning activities with U N F P A support, mainly with regard to a course in Rostock fo r participants from developing countries. Hungary. A short-term consultant visited the country in March to dis cuss matters related to family planning activities. Plans were made to involve Hungary in the study o f pilot applica tion to family planning o f programme evaluation guidelines to be carried out in 1980. Ireland. The Regional O ff ice was represented at the International Seminar on Natural Family Planning organized by the Ministry o f Health in October. Morocco. Development o f the na tional family planning programme in the field o f public health and the improve ment o f living conditions fo r women continued. The Regional O ff ice provided placement abroad for medical and other health personnel, some for training in family health/family planning and others to examine the availability o f audiovisual material fo r the strengthening o f the health education programme. Planning was begun fo r the WHO/ICC international course on family health/family planning to be held in M orocco in 1980. Four fellows attended the WHO/ICC inter national course on family health/family planning held in Madrid. Poland. A short-term consultant visited the country in June to assist the Child Health Centre in the elabora tion o f a project request to U N F P A in the field o f MCH. Books were supplied 3 3 to the Council fo r Family Matters, M in istry o f Labour and Social Affairs. Portugal. There was steady develop ment o f the project o f assistance to the national family planning programme. The Regional O ff ice proceeded with the placement o f fellows abroad and with the purchase o f contraceptives and equipment. Assistance was given with a seminar held in Funchal on MCH and family planning organized by the Directorate-General o f Population Planning, Lisbon and the Regional Secretariat o f Madeira. In formation seminars and retraining courses for health personnel were conducted by national sta ff throughout the country, and documentation on family health and family planning was developed. Seven fellowships were financed: six to attend the WHO/ICC course on family health/family planning held in Madrid and one fo r a part-time member o f the family planning team o f the Directorate- General o f Health to study family planning for tw o months in Belgium and Switzerland. The project carried out by the Uni versity o f Lisbon on family planning training and services provided weekly consultations on family planning and infertility and initiated research activ ities in this field. The manager o f this project spent seven weeks in Denmark and Sweden studying aspects o f family planning. Romania. A short-term consultant paid a visit to the country in May to dis cuss with the Ministry o f Health the possi bility o f widening collaboration with the Regional O ff ice in family planning activities with U N F P A support. The consultant also attended the Seminar on the Access o f You th to Work and Partici pation in Public L ife held in Costineçti, which was organized by the United Nations Division o f Social A ffa irs in co operation with the Romanian Research Centre on You th Problems. Spain. The WHO/ICC international course on family health and family planning was held in Madrid and Talavera de la Reina in Novem ber and was fo l lowed by a national session at which the Regional O f f ice was represented. Plans were made fo r the active involvement o f the Family Planning unit in the Tenth World Congress on Fertility and Steril ity, to be held in Spain in 1980, and for the involvement o f Spain in the study o f pilot application to family planning o f programme evaluation guidelines. Turkey. The development o f inte grated family planning services con tinued. The Regional O ff ice organized a study tour in selected European coun tries fo r Turkish officials from both the General Directorate o f Population Plan ning and the General Directorate o f Professional Training to observe family planning education and services. Various retraining courses in family planning for provincial nurse/midwives and their instructors were conducted and training material was developed. A master plan and an assessment o f the needs for refresher training o f health personnel in М СН/family planning was elaborated with the assistance o f the Regional O f fice and W H O headquarters. This is meant to form a basis fo r the General Directorate o f Population Planning pro ject proposal to U N F P A . A seminar on primary health care implementation and health personnel 34 education in Turkey was held in Ankara in June. It stressed the high priority to be given to М С Н /family planning and to the basic role and use o f midwives at the local level. Four Turkish fellows attended the two international courses on family health/family planning organized by the Regional O ffice. Yugoslavia. The Regional O ff ice made technical comments on three pro ject requests to U N F P A in the field o f family health and family planning, at the request o f U N F P A . Publications Service-oriented research in adoles cent fertility: report on a W HO M eet ing. F U R O Reports and Studies, No. 1. The child and the adolescent in society: report on a W H O Confer ence. F U R O Reports and Studies, No . 3. Family health and family planning. Paris, International Children ’s Centre and Copenhagen, W HO Regional O f fice for Europe, 1979. 3.2.2 Nutrition As a follow-up to the jo in t UNICEF/ WHO meeting on infant and young child feeding in Geneva, Member States have been enjoined to hold meetings at na tional level to encourage breastfeeding. Fo llow ing the recommendations o f the meeting, a code o f ethics fo r exporting and importing countries o f baby food and baby food technology is being drafted at headquarters, and Member States will be requested to review this code and to o f fe r their input towards its finalization before the next World Health Assembly. In cooperation with the Federal Cen tre for Health Fducation, Cologne, the third survey on smoking and health in the W H O European Region, covering the period 1975-77, was initiated. It was hoped that the report would be published by the end o f the year, but by that time many Member States had still not replied to the questionnaire. The survey covers eight areas: ( 1 ) demographic character istics o f smokers and their consumer habits; (2 ) the import, manufacture and sale o f tobacco products and tobacco taxation; (3 ) the consumption o f to bacco products and information on their tar, nicotine and carbon monoxide con tent; (4 ) restrictions on the manu facture and sale o f tobacco products: (5 ) restrictions on the consumption o f tobacco products; (6 ) restrictions on to bacco advertising; (7 ) measures to in form the public o f the health hazards o f smoking; and (8 ) research on the subject o f smoking and health, and the influence o f research findings. On the basis o f the data so far avail able, it is not possible to draw firm conclusions as to trends and develop ments in the anti-smoking field. It is, however, possible to say that anti smoking measures and legislation are most highly developed in the eastern European countries and in Finland, Norw ay and Sweden. Tobacco taxation is still an important source o f income in many countries and this may account fo r a certain reluctance on the part o f governments to take anti smoking measures. There is cause to wonder why the control o f tobacco products has not developed along the same lines as that o f foods and beverages, 3.2.3 Health education 0 3 5 including drinking-water, which are care fully controlled by state agencies as to their quality and the presence o f poss ibly harmful additives. The Director-General, the Regional Director and four staff members attended the Fourth World Conference on Smoking and Health in Stockholm in June. The Regional Director and the Re gional O ff ice r for Health Education and Social Sciences attended the Tenth Inter national Conference on Health Educa tion in London in September, at which the top ic “ Health education in action - achievements and priorities” covered the integration o f health education in public policy, health education in youth , and methodologies o f health education. The opening address delivered by Dr U. Kekkonen, President o f the Re public o f Finland, at the inaugural ceremony o f the twenty-ninth Regional Committee was subsequently published in the International journal o f health education. The address, entitled “ The importance o f personal initiative” , high lighted the prom otion by WHO o f pri mary health care as the means to a higher level o f health throughout the world and the importance o f the en vironment and personal lifestyles in health, particularly in Europe. The speaker stressed that education in such subjects as smoking, physical exercise and nutrition could do much to promote a healthier lifestyle. An experimental postgraduate train ing course in health education (German language), supported by the Regional O ffice , was held at the Academ y o f Public Health in Düsseldorf, Federal Republic o f Germany. Turkey. A consultant studied exist ing training programmes in health educa tion and made proposals fo r strengthening both the training programmes and health education manpower and services. Publications Education pour la santé : tabagisme, alcoolisme et drogues, par K. Vuyl- steek. E U R O Reports and Studies, No . 10. Health education: smoking, alcohol ism, drugs, by K. Vuylsteek. E U R O Reports and Studies, No. 10 (English translation). Principles and methods o f health education: report on a WHO W ork ing Group. EU RO Reports and Studies, No . 1 1. Country activities 3.3 M E N T A L H E A L T H The rapid changes and growing com plexity o f present-day civilization, par ticularly in industrialized countries, have made mental health problems more im portant and have brought to light new issues that justify a thorough considera tion o f the methods and techniques to be applied. The general trend now is for the establishment o f community-oriented programmes o f prevention, care and rehabilitation. Mental health is thus seen as a broad combination o f health and social measures rather than as a narrow specialty made available in closed insti tutions. N ew subjects for study include the consequences o f certain attitudes 3 6 and behavioural patterns, psychological factors, and changes in lifestyle. The mental health component is still too o ften neglected in country health programming and in intersectoral coor dination and planning. The traditional tendency to isolate care in a hospital environment persists: more than 1 mil lion mental patients in the European R e gion are still kept in institutions, a third o f which have more than 1000 beds. There is a noticeable lack o f f lexible and innovative programmes fo r high-risk population groups such as the elderly. Since 1950 the consumption o f al cohol has increased dramatically, in some countries by over 300% (Table 2), with predictable consequences as far as accidents, delinquency, suicide and fam ily problems are concerned. Similar trends are found with regard to psycho tropic drugs. These different problems highlight the need to train administra tors responsible fo r developing compre hensive and integrated community-based mental health services. The inadequacy o f knowledge and in formation about effective primary prevention calls for more efforts by national research councils and fo r better coordination w ith public health research as a whole. Primary men tal health care programmes should aim at increasing the involvement o f general practitioners, self-help groups, educators and families. Intercountry activities Great care has been taken to base the mental health programme on national pro gramme profiles. Representatives from 20 Member States and from 5 nongovern mental organizations, together with the Director, Division o f Mental Health, WHO headquarters, met in the first regional meeting o f national mental health advisers in Bielefeld, Federal Repub lic o f Germany in Novem ber, at which national mental health programme pro files that will form the basis o f the regional medium-term programme in mental health were presented. The meet ing, while endorsing the regional mental health programme as well as the recom mendations o f the Technical Advisory Com m ittee on the European Mental Health Programme, held in Copenhagen in February, recommended: 1. Transition from custodial forms o f care, based on large institutions, to a system o f comprehensive community mental health care covering well-defined populations. A lthough the fundamental principles o f comm unity care have been accepted and emphasized by a number o f W H O working groups, development is slow and should remain the main objec tive o f the W H O mental health pro gramme in Europe. 2. Im proved health education o f the public; better undergraduate and post graduate medical education in psy chiatry and mental health; and im proved understanding o f mental health issues by nonmedical professional groups and voluntary agencies. 3. Specific activities within the context o f the family aimed at target groups including, most importantly, the young, the aged, the alcoholic and the drug dependent. 4. Im provem ent o f in formation systems to assist planning, operational and clinical research, and the evaluation o f services and changes in them. Surveys on mental health services in Europe have resulted in the collection o f 3 7 T a b l e 2 . Per capita c o n s u m p t i o n o f p u r e a l c o h o l , 1 9 5 0 - 5 2 a n d 1 9 7 5 - 7 6 Heaviest consumption 1950-52 1975-76 Country Litres Country Litres France 17.6 France 16.5 Portugal 12.9 Portugal 14.1 Italy 9.4 Spain 14.0 Spain 8.1 Luxembourg 13.4 Luxembourg 6.8 Italy 12.7 Belgium 6.6 Germany, Fed. Rep. of 12.5 Switzerland 6.6 Austria 11.2 Austria 5.4 Hungary 10.7 Czechoslovakia 4.9 Switzerland 10.3 United Kingdom 4.9 Belgium 10.2 Country Per capita consumption in 1975-76 (litres) Increase over 1950-52 (%) Sharpest increase Netherlands and German Dem. Rep. 8.3 337 Germany, Fed. Rep. of 12.5 247 Iceland 3.7 236 Yugoslavia 8.9 230 Least increase France 16.5 - 6.2 Portugal 14.1 + 9.3 Italy 12.7 +35.0 Belgium 10.2 +55.0 Switzerland 10.3 +56.0 Source: Produktschap voor gedestillerde dranken. Schiedam, Netherlands, 1977. 3 8 a large amount o f information. N ine teen pilot study areas in 16 Member States are now participating in the project on mental health services in pilot study areas to develop data col lection and processing techniques for improving the planning and assess ment o f community mental health care. T h ey carry out or prepare de tailed studies o r activity analyses, direct cost-accounting, and assessment o f the effectiveness o f mental health care. The programme is implemented in conjunction with several national institutions, for instance the Finnish Foundation for A lcoho l Studies, with which close collaboration has been maintained fo r several years; with a network o f technical counterparts and experts, advisory panels, and pilot study areas; and with other units in the Regional O ff ice , including those responsible for family health, nursing, health education, care o f the elderly, and primary health care. Active con tacts are maintained with the Council o f Europe, the Commission o f the European Communities and a number o f nongovernmental organizations. Country activities Italy. Technical and administrative advice was given to the national auth orities on planning a seminar on epi dem iology and psychiatric services evalu ation. Romania. The project document fo r the UNDP-supported project on rehabilitation o f the handicapped was signed, and consultations took place at the Regional O ffice with the Romanian coordinator and the W H O consultant involved with this project. It is fore seen that seven temporary advisers will lecture at a training course to be held in Romania in 1980 and will assist in the placement o f Romanian fellows after the course. Publications and documents Psychogeriatric care in the com munity. Public Health in Europe, No . 10. Crisis admission units and emerg ency psychiatric services: report on a Study, by J.E. Cooper. Pub lic Health in Europe, No . 1 1. Objectives o f youth advisory ser vices: report on a Working Group. Document ICP/MNH 035 111. Public health aspects o f alcohol and drug dependence: report on a W HO Conference. E U R O Re ports and Studies, No . 8. 3.4 P R O P H Y L A C T I C , D I A G N O S T I C A N D T H E R A P E U T I C S U B S T A N C E S A new unit for coordination o f the programme was established in April, its main concerns being: (a ) to prom ote the exchange o f information on drug evaluation and control to avoid overlapping and dupli cation o f work in national drug regula tory agencies; 3 9 ( b ) to cooperate in the formulation o f national drug policies and to foster cooperation between national drug regu latory agencies and international organ izations active in the drug field; (c) to stimulate drug utilization re search at the national level and to coor dinate the work o f the W HO Drug U til ization Research Group in which scien tists from 14 European countries are collaborating; (d) to prom ote the concept o f essential drugs and collaborate with Member States, the pharmaceutical in dustry and other interested organizations in defining drugs required fo r basic health needs; and (e ) to collect and exchange in form a tion on undergraduate and postgraduate training o f pharmaceutical personnel in the European Region. The programme is generally becoming more oriented towards the coordination o f activities at the country and inter country levels and towards the p rom o tion o f an exchange o f in formation among drug regulatory agencies, manu facturers o f drugs, prescribers, distribu tors and allied health personnel and, not least, the consumers. The formulation o f national drug policies has an international impact; there is wide concern that there should be better harmonization o f drug regula tory policies and procedures taking into account d ifferent laws, econom ic and political systems, internal capabilities, and national priorities. The eighth in the series o f symposia on clinical pharmacological evaluation in drug control was held in Cologne in November, and took the form o f an expert group fo l low ed by a steering committee. The recommendations o f previous symposia were evaluated, and plans were developed for the future, in cluding main themes fo r three symposia: (a) drugs and the elderly and drugs fo r long-term treatment; ( b ) drug in formation; and (c ) drugs fo r children and drugs during pregnancy and lactation. The Drug Utilization Research Group (D U R G ) held its annual meeting in Prague in August. Research protocols, fo r example covering antihypertensive drugs, the harmonization o f classifica tion o f drugs, and m ethodo logy in measuring drug use, were discussed. The new publication Studies in drug utiliza tion was presented at the meeting. Studies in drug utilization represents the outcom e o f the activities o f the members o f D U R G since its foundation in 1969. It deals with drug utilization studies mainly from the point o f view o f prescribing patterns and touches briefly on questions o f distribution and marketing. Its aim is to stimulate the gathering o f information on drug utiliza tion studies, with particular emphasis on international comparisons. The greater part o f the book is devoted to descrip tions o f national sources o f information that are available and the uses to which they have been put in the various coun tries that participated in the project. The addresses o f institutions in the European Region where further in formation on drug utilization studies can be obtained are listed. The Planning Group on Evaluation o f Drugs and other Therapeutic and Diagnostic Substances, established under 4 0 the priority area identified by E A C M R , met in March. This meeting dealt with the development o f further links with other E A C M R research programmes, as well as with the main research components in the programmes o f the Regional O ffice. Guidelines for clinical trials o f antihyper tensive drugs, which had been drafted by the Working Group on the Harmonization o f Guidelines for Clinical Trials o f Drugs — Antihypertensive Drugs, in Uppsala in April 1978, and subsequently dis cussed at the Seventh European Sym posium on Clinical Pharmacological Evaluation in Drug Control held in Deidesheim in Novem ber o f that year, were adopted by the Planning Group and issued as a document. The guide lines cover early studies in man (first administration/pharmacodynamic studies and pilot therapeutic trials/dose-finding studies); controlled therapeutic trials (methods o f observation, criteria for admission o f patients and types o f controlled therapeutic trial); and drug interactions. A survey on under- and postgraduate training and the number o f pharma cists and pharmacy technicians in the Region, and the updating o f the Directory o f O ffic ia l Drug Control Agencies in Europe, originally pub lished by the Regional O ff ice in 1974, were started. In the biologicals field, the provision o f training for W H O fellows from the European and other regions continued. Country activities Albania. A t the request o f the health authorities, the Regional O f ficer for Coordination visited the country in December. A plant for the industrial production o f antibiotics had been built in Tirana but was not functioning owing to a lack o f expertise. The Regional O f fice later assisted the authorities in find ing an expert in the industrial production o f antibiotics to help in making the plant operational. Publications and documents Studies in drug utilization. W HO Re gional Publications, European Series, No. 8. Clinical pharmacological evaluation in drug control: report on a Sym posium. Document ICP/PHA004 . Clinical pharmacological evaluation in drug control: report on the Seventh European Symposium. E U R O R e ports and Studies, No . 13. 41 D E V E L O P M E N T OF COMPREHENSIVE H E A L T H SERVICES Expenditure (US$) 1 541 156 795 482 92 220 2 428 858* a Including Funds-in-Trust. * Being 15.19% of total expenditure. Regular funds U N funds Voluntary funds" 42 A severe earthquake struck Yugoslavia, especially the Republic of Montenegro, where a number of casualties and damage to houses and public buildings occurred. The Regional Office took part in assessing ie damage and in assisting with the rehabili tation efforts of the Yugoslav Government The Regional Office for Europe has taken a greate interest in circumpolar health. In the USSR rafts, sma boats, helicopters and other appropriate means с transport and communication are used to serve arcti populations D ISEASE P R E V E N T IO N A N D C O N T R O L Chapter 4 4.1 C O M M U N I C A B L E DIS E A S E P R E V E N T I O N A N D C O N T R O L 4.1.1 General In general, activities planned fo r the period under review were carried out, despite serious financial difficulties. This was made possible, to a large extent, by voluntary donations and the mobiliza tion o f other external resources. Close ties were maintained with WHO global programmes, including ep idem io logical surveillance, the Expanded Pro gramme on Immunization and the Programme on Diarrhoeal Diseases Con trol. The malaria epidemic in Turkey was successfully contained, although trans mission continued at lower levels in several foci. Generous financial support from various European countries and international bodies contributed to this achievement. Meetings were arranged among the Mediterranean countries with a view to preventing the réintroduction o f malaria into areas where transmission had been halted. These meetings involved collaboration between the W HO Regional O ffices fo r Europe and the Eastern Mediterranean. A second meeting o f the Global Commission for Certification o f Small pox Eradication was held in Geneva. Countries o f the European Region had returned signed statements confirming that there had been no case o f smallpox during the previous tw o years. Turkey expressed willingness to co operate in the W HO Expanded Pro gramme on Immunization, and in this connexion a headquarters sta ff member paid a visit to Turkey to discuss the problems and procedures involved. As a result, Turkey nominated two partici pants to attend an interregional course fo r planning and management o f im munization programmes, held in Dam ascus at the end o f the year. 4.1.2 Epidemiological surveillance A meeting o f representatives from 13 Mem ber States was held on the Sur veillance Programme fo r Control o f F o o d b o m e Infections and Intoxications in Europe, at which the draft o f a manual on the surveillance o f foodborne diseases was reviewed and recommendations re garding fo llow-up action agreed on. 43 An Ad hoc Consultation on C om municable Diseases was held in Copen hagen at which future Regional O ff ice activities in the field o f communicable disease control were discussed and a checklist o f priorities was drawn up. The report was sent to national technical counterparts in communicable diseases fo r their comments and suggestions. As part o f the programme on econ omic aspects o f communicable diseases, the second study phase on econom ic aspects o f viral hepatitis is under way. The aim is to assess the cost-effectiveness or cost-benefit o f specific measures in hepatitis prevention and control. Country activities Algeria. The visit by three consul tants in 1978 was fo llowed up with visits by four consultants, who prepared tech nical documents fo r the second phase o f the project concerned (a) with setting up a centre fo r research on the Sahara in order to carry out health and socioecon omic studies, and (b) with possible ad verse effects, in particular the transmis sion o f communicable diseases that may be caused by use o f the Trans-Saharan Highway. They concluded that the com municable diseases requiring special sur veillance were above all malaria, fo llowed by schistosomiasis, cholera and the haemorrhagic fevers. Detailed recom mendations were made on strengthening laboratory infrastructure. Morocco. A t the request o f the Government the W H O microbiologist has been asked to continue ( f o r a further two years) his collaboration with national experts in the training o f laboratory technicians, in epidemiological studies o f communicable diseases, and in the organ ization o f laboratory services. The programme was carried out ac cording to plan and progress has been achieved in the malaria emergency in Turkey in spite o f many difficulties (financial, political, staffing, transport, technical and operational, such as resis tance to some insecticides). The number o f reported cases was only 29 324 in 1979, compared with 115 512 in 1977 and 87 867 in 1978. This improvement was evident throughout the country, as can be seen from Fig. 4 and 5. The G ov ernment is considering integrating the malaria services into the PHC services and the W H O team will provide the necessary support. The total budget allocated by the Turkish Government to the national malaria eradication service in 1979 amounted to U S$35 099 236, represent ing 6.4% o f the total budget o f the Ministry o f Health, and exceeding the amount foreseen for 1979. A number o f problems remain, some o f which are o f a research nature (e.g., the danger o f development o f resistance in A. sacharovi to malathion). A W H O en tomologist was assigned to Turkey at the beginning o f 1980 and his main function will be the training o f entomological sta ff and constant monitoring o f suscepti bility to insecticides. The Com m ittee o f Food A id Policies and Programmes provided financial assist ance to the malaria eradication and con trol programme in Turkey; this is an in centive to the assistants in community health prom otion to participate regularly in the antimalaria campaign in order to assist and support the national malaria eradication and primary health care services. 4.1.3 Malaria and other parasitic diseases 44 F i g . 4 . T u r k e y : e p i d e m i o l o g i c a l st r at a r^jStratum l-a # Foci in 1977 r]Stratum l-b B F o c i in 1978 QjStratum II [^Stratum III © Foci in 1979 jffiStratum IV F i g . 5 . T u r k e y : p a r a s i t e i n c i d e n c e Stratum I-a 0.004 0.001 1975 1976 1977 1978 1979 Stratum l-b Stratum II Stratum III Stratum IV A W HO multidisciplinary evaluation team, together with national counter parts, carried out an evaluation o f the programme, and the team ’s conclusions were used as a basis fo r discussions at an evaluation meeting held in Ankara, in November. International participation was ensured by representation from EEC, U N D P, W FP, Finland and Y u go slavia. Both countries pledged further support to the programme. In January the World Bank spon sored a mission in Turkey to study the role o f the irrigation system in the re surgence o f malaria in the Çukurova 4 6 Plain. This was fo llowed by a World Bank/WHO/FAO meeting in Ankara in September. Consideration was given to possible support by the World Bank for a mosquito abatement unit based on helicopters and equipment fo r main taining drainage canals, combined with sta ff training fo r such activities. Contacts were made with the health authorities o f Bulgaria, Greece and Yugoslavia in order to establish lines o f collaboration and exchange o f in forma tion on the present epidemiological situation with regard to malaria, and in this connexion it is planned to hold a series o f meetings, the first in Bulgaria at the beginning o f 1980. As a follow-up to a previous meeting in Izmir, a Coordination Meeting on the Prevention o f the Réintroduction o f Malaria in the Countries o f the Western Mediterranean was held in Erice, Italy in October, to which the Italian Govern ment gave a substantial contribution. The stimulus fo r convening the meeting was concern over, on the one hand the increasing number o f cases o f malaria imported from A frica into Europe and the dangers connected with the Trans- Saharan Highway, and on the other hand the reduction o f government interest in malaria due to the progress achieved by the malaria control programmes and/or absence o f local transmission at present. The Meeting was attended by participants from seven countries (A lger ia , France, Italy, M orocco, Portugal, Spain and Tunisia) and by a representative o f the Regional O ff ice fo r the Eastern M edi terranean. Many recommendations were made on control measures and the train ing o f personnel. A need was felt fo r an annual WHO-sponsored seminar with participants from Algeria, Libya, Mali, M orocco , Niger and Tunisia, for periodic meetings o f the coordinating committee o f the north African countries under W HO sponsorship, and fo r an annual meeting o f the countries present at the meeting. Country activities Algeria. A t the request o f the G ov ernment, three consultants helped to m on ito r entomological development, to evaluate the eradication programme and to prepare a plan o f action fo r 1980. Th ey concluded that the programme continued to require strong central tech nical direction, and that the entom ologi cal service required continuous interna tional support, and recommended that investigations into the compatibility o f Algerian vectors and imported Plas modium strains should be undertaken without delay. Morocco. Several new foci were re ported from Khemisset; this prompted the Government to organize a workshop fo r an antimalaria action programme for 1980 and intensification o f work in the future. 4.1.4 Bacterial and virus diseases The Ministry o f Health in Turkey is preparing to participate in the W HO Pro gramme on Diarrhoeal Diseases Control. It is hoped to produce the oral rehydra tion powder locally. Training will be provided for laboratory sta f f and for workers in primary health care; health education o f the public will also be necessary. A Meeting on the Surveillance and Control o f Zoonoses and Foodborne Diseases was held in Pendik/Istanbul and 47 was attended by participants from the countries o f the Mediterranean Basin. This was fo llowed immediately by the Second Meeting o f the Joint Coordinating Comm ittee , the purpose o f which was to discuss national activ ities and the activities o f the Medi terranean Zoonoses Control Centre in 1980 and 1981. This Centre was opened in Athens in February, and an inter country programme coordinator was appointed. Representatives visited a number o f western Mediterranean coun tries to discuss their potential partici pation in or support for a comprehen sive zoonoses control project. The need fo r simple guidelines on the management o f sexually trans mitted disease fo r physicians in gen eral practice has been apparent fo r some years. In Europe, no less than in other parts o f the world, the ma jo r ity o f patients suffering from sex ually transmitted diseases are treated in general medical practice by phys icians who have not received adequate training in the management o f this group o f diseases and who, as a con sequence, pay insufficient attention to correct laboratory diagnosis and contact tracing. The Symposium on the Surveil lance and Control o f Sexually Trans mitted Diseases, organized in conjunc tion with the Government o f Austria in 1976, recommended that WHO should prepare a practical manual on the management o f sexually trans mitted diseases that would contribute to their improved control through the more e ffective treatment o f the many cases that occur each year. Dr R.R. Will- cox undertook the task on behalf o f the Regional O ff ice , and the guide was published in 1979 (see below ). Country activities Greece. In conjunction with the Greek veterinary and health services, a consultant studied the rabies situ ation and advised on strengthening the rabies surveillance system. Turkey. A consultant visited Tur key in October to assist the Govern ment in its leprosy control programme, i.e., to assess the extent o f the disease and advise on the organization o f the leprosy service, training, routine treat ment and the possibility o f external assistance. 4.1.5 Publications Receptibility to malaria and other parasitic diseases: report on a WHO Working Group. E U R O Reports and Studies, No. 15. The management o f sexually trans mitted diseases: a guide fo r the general practitioner, by R.R. Will- cox. E U R O Reports and Studies, No . 12. 4.2 NONCOMMUNICABLE DISEASE PREVENTION AND CONTROL 4.2.1 General During the year a particular e ffort was made to strengthen ties with na tional authorities, institutes, professional groups and collaborating centres fo r the 4 8 implementation o f activities o f mutual in terest. Similarly, contacts with interna tional, intergovernmental and nongovern mental organizations and international professional associations were intensified, and mutual support established, in order to utilize available resources to the maxi mum extent possible. Collaboration with other programmes o f the Regional O ff ice was intensified to mutual benefit. In particular, the com munity control programmes in pilot study areas in the fields o f cardiovascular dis eases and mental health are relevant to the primary health care and care o f the elderly programmes. Other aspects covered were appropriate technology fo r health, health manpower development, health in forma tion, and applied research. A comprehen sive approach was adopted for chronic diseases with comm on risk factors ( f o r example, the association o f smoking with lung cancer, cardiovascular diseases and chronic respiratory diseases) and with com m on aspects o f care delivery at the community level. Deeper interest was developed in the epidemiological aspects o f chronic dis eases and behaviour (nutrition, alcohol consumption, smoking and other habits) which, together with environmental fac tors, create conditions favourable fo r the development o f chronic diseases and acci dents, particularly road traffic accidents. Research applied to health services attracted greater attention, and a new venture — health care-related research in hypertension — was pursued. 4.2.2 Cancer With a view to strengthening coord i nation between the cancer programmes o f the Regional O ff ice and IA R C , a jo int Study Group on Cancer Screening was convened in Copenhagen in Decem ber. Experience in cervical screening in Canada, Norway, Sweden, the United Kingdom and the U SA over the past decade was reviewed, and the value o f well organized screening programmes was unanimously recognized. A need was felt fo r further research into the defi nition o f age groups, the frequency o f screening, the quality o f smears, non-response and high-risk groups, and cost-benefit relationships. It was decided that an attempt would be made to pool analysed data from the various national programmes. 4.2.3 Cardiovascular diseases The cardiovascular diseases (C V D ) programme gained momentum through renewed interest in C V D problems and W H O ’ s role in tackling them. This new in terest was spurred by such controversies as hospital versus home care o f acute m y o cardial infarction, by-pass surgery, and reasons fo r the decline in mortality from ischaemic heart disease ( IH D ). This favourable attitude was reflected by prog ress in the projects on comm unity con trol o f C V D , and the successes attained in the established pilot study areas. In some countries, however, it is still d i f f i cult to concentrate the best skills, man power and resources in one suitable geo graphic area. Another indicator o f prog ress is the fact that the time allotted to the WHO symposium to be held during the European Congress o f Cardiology in Paris in June 1980 is twice that o f the symposium in Amsterdam in 1976, In spite o f financial difficulties, the overall development o f the programme was maintained, and some new activities 4 9 were added, such as the project on m oni toring IHD incidence, in which at least eight centres are ready to participate. During a meeting o f a working group in Rome in May, the principal investiga tors in the European Collaborative Study on Primary Prevention o f Ischaemic Heart Disease evaluated the progress made. As the Study was still going on in a few centres, it was decided to wait until 1981 to publish the final results, including incidence data. The Study on Primary Prevention o f Ischaemic Heart Disease by Lowering Blood Cholesterol (A trom id Trial) con firmed the original hypothesis that lower ing b lood cholesterol results in a lower in cidence o f coronary heart disease in the high-cholesterol intervention group. H ow ever, a thorough mortality fo llow-up has been initiated, covering the whole period since the closure o f the trial in 1977, and the results are now ready for publication. A Working Group on the D eve lop ment o f Coronary Care in the Community was held in Brussels in February. The Group emphasized the concept o f com prehensive care, starting with primary pre vention and care in the community for those suffering a heart attack, prior to admission to hospital. Training o f an adequate number o f people in cardio pulmonary resuscitation, reduction o f the delay in reaching skilled medical assistance, proper but not overly sophis ticated care in the coronary care unit, early rehabilitation, and secondary pre ventive measures emerged as the most important issues contributing to better outcome. Analysis o f the results o f the Study on Effects o f Rehabilitation and Second ary Prevention in Patients with C V D was begun at the Cancer Research Centre in Heidelberg. Concom itantly, some o f the participants in the Study started to prepare a monograph on the present state o f the art in coronary heart dis ease, and a meeting o f the editorial board was held in Heidelberg in June. The directors o f the pilot areas for the Study on Comprehensive Cardiovas cular Com m unity Control Programmes, together with experts in health educa tion, met in August in Novi Sad. In none o f the centres had the programmes proceeded far enough in data analysis or data collection to permit an assessment o f the results o f the intervention activ ities. Nevertheless, there was evidence o f an intense e f fo r t being made to establish the risk factor status o f the populations over time, and to institute preventive measures through various methods o f health education and promotion in the collaborating communities. The principal investigators in the Study on Chronic Lung Diseases leading to Pulmonary Hypertension met in Novem ber in Strasbourg. The publica tion o f the results o f the retrospective study (covering more than 800 patients) is foreseen for the second half o f 1980. The protocol and record forms o f the prospective study have been finalized and the recruitment o f patients started. The E A C M R selected health care- related hypertension research as one o f its first priorities. A consultation was held in Copenhagen in October with representatives from 25 European Mem ber States. The main areas where it was felt there was a need for WHO- coordinated research included: the role o f sodium intake in causation and pre vention; genetic markers; the natural 50 history o f high blood pressure in children and adolescents; the role o f psychosocial factors; monitoring effects o f screening and long-term treatment; evaluation o f hygienic, psychogenic, and pharmaco logical treatment in the comm unity; the role o f general practitioners and health personnel in the management o f hyper tension; public attitudes towards preven tion; and compliance with treatment. Accord ingly , a health care-related re search programme in hypertension is now being developed, in close collabora tion with W H O headquarters. As part o f the Regional O ff ice pro gramme on appropriate technology for health, a study was undertaken on the role and utilization o f ECG in health care. Three consultants collected in for mation from 11 countries and their report concluded with a number o f con crete recommendations. In collaboration with WHO head quarters, tw o consultations were held to develop a protoco l fo r a study on monitoring systems for the incidence o f C V D . This study w ill provide in formation on trends in mortality and morbid ity from and the incidence o f coronary heart disease, together with changes in risk-factor levels and health service indices. Country activities Italy. The Regional O ff ice r for Chronic Diseases gave a lecture at the Symposium on Preventive Cardio logy at the National Institute o f Health, Rom e, in May, attended the National Meeting o f the Associations o f Italian Centres for Preventive Cardiology, Perugia, in Decem ber, and visited the Istituto Superiore di Sanità in December. Morocco. The Regional O ff ice r for Chronic Diseases lectured at the 8th Con gress o f French-speaking Cardiologists, Agadir, which was organized by the Moroccan Association o f Cardiology. Portugal. Discussions were held with the President o f the Portuguese Heart Foundation, during which advice was given on the development o f a national programme to control C V D in general, and hypertension in particular. 4.2.4 Oral health The increasing interest in oral health should be seen in the light o f the fact that dental caries and peri odontal diseases continue to be a pub lic health problem o f concern to most European countries. There are, how ever, great variations in the prevalence o f dental caries within the European Region, being high to very high in northern Europe, moderate to high in central Europe and low to moder ate in southern Europe. Unfortunately, there are now clear signs o f an alarming increase in dental caries in those coun tries in which the prevalence hitherto has been low to moderate. In certain parts o f Europe, where effective mass preventive measures have not yet been implemented, the average number o f decayed, missing and filled permanent teeth (D M F T ) is in the order o f 8 - 1 2 at 12 years o f age. This means that at this age 2 5 -4 0 % o f the permanent teeth are already diseased. Since dental caries is an irreversible disease, the signs will accumulate with age. A t 3 5 -4 4 years o f age the D M F T index in many highly developed countries is in the order o f 15-25 , with 5 -3 5 % o f the population being complete ly edentulous. 51 Only in those countries in which e f fe c tive mass preventive measures have been introduced is there evidence o f an im provement in oral health in children and young adults. With the increasing cost o f comprehensive treatment and rehabilita tion, which will prove prohibitive fo r even the richest o f countries, it is imperative that top priority be given to prevention. The oral health programme is and will continue to be aimed at collaborating with countries in an attempt to increase the use o f comprehensive mass preventive meas ures, and to expand the use o f dental aux iliaries according to the need and health policy o f the Mem ber States in the Euro pean Region. The promotion o f rational management o f dental health services by developing eff ic ient information systems and by stimulating research related to practical needs will be an important com ponent o f the oral health programme. The publication Oral health services in Europe by J. Kostlan, which appeared in 1979, consists o f a general review o f oral health care in Europe and a country- by-country description o f national oral health services, their origins, organiza tion and problems. The number o f countries participating in the W HO International Collaborative Study on Dental Manpower Systems was extended, with the inclusion o f the Ger man Democratic Republic and Ireland. The Oral Health unit cooperated in the planning o f drinking-water fluoridation projects in Portugal and Greenland. A d visory services were provided to a num ber o f Member States and an ever- increasing number o f requests for co l laboration and information on oral health matters reflects a growing aware ness o f the importance o f improving oral health in Europe. 4.2.5 Other noncommunicable diseases The planned shift towards a compre hensive chronic disease control approach was accepted with interest by leading experts and is gaining support from a number o f collaborating institutes. Close collaboration with WHO headquarters and the relevant professional societies was the mainstay o f progress in this new approach. A Study on M ethodology and Evalua tion o f Behavioural Changes in Children and Adolescents in Relation to Non communicable Diseases was started, in volving three centres in the Federal Republic o f Germany, Finland and N o r way. This Study is closely linked with the W HO headquarters study on athero sclerosis precursors in children. The report o f the Study on the Long term Health Effects o f A ir Pollution was finalized. The study clearly showed a strong association between air pollu tion and various respiratory indices in children. The findings suggest that initial effects on respiratory indices in children should be sought at annual mean con centrations o f sulfur dioxide and smoke below 200/oig/m3 and, i f further studies are to be conducted, this should be done in countries with annual mean concentra tions o f sulfur d ioxide and smoke be tween 50 and 200/ug/m3. Country activities United Kingdom. The Regional O f ficer for Chronic Diseases lectured at a combined scientific meeting o f the Heberden Society and the British Asso ciation fo r Rheumatology and Rehabilita tion, organized by the University o f Manchester in July. 52 Oral health services in Europe, by J. Kostlan. W HO Regional Publica tions, European Series, N o . 5. 4.2.6 Publications The role and function o f national institutes o f ophthalmology : report on a WHO Meeting. E U R O Reports and Studies, N o . 5. DISEASE PREVENTION A N D C O N T R O L Expenditure (USS) Regular funds 1 483 486 (285 423)a U N funds 164 410 ( 78 047)“ Voluntary funds* 1 103 873 (989 906)° 2 751 769c a Figures in parentheses refer to funds allocated to malaria control activities (total USS 1 353 376). * Including Funds-in-Trust. c Being 17.21% of total expenditure. 53 Chapter 5 PROMOTION OF ENVIRONMENTAL HEALTH 5.1 G E N E R A L A considerable shift o f emphasis took place in the environmental health activities o f the Regional O ff ice during the year. Since the goals o f the first long-term programme have been pro gressively attained, e fforts are now being focused on tw o major activities that are occupying the attention o f W HO, both at headquarters and through out the various regions, namely the International Drinking-Water Supply and Sanitation Decade and the W H O Inter national Programme on Chemical Safe ty. Fo r the report o f a WHO senior adviser on the role o f the Regional O f f ice in the field o f environmental health, see Annex 6. A lthough most countries o f the Region have adequate community water supplies and urban sanitation, there are many deficiencies in rural areas; in a small number o f countries substantial investment and technical development will need to take place i f satisfactory services are to be provided to all com munities by the end o f the Decade. Such facilities are, o f course, an essen tial component o f primary health care and a high priority o f the Regional O ff ice during the next few years will be technical cooperation with Member States (a) to stimulate the necessary investment and ( b) to ensure cost- effectiveness by encouraging the use o f appropriate technology and the develop ment o f adequately trained manpower at all levels and, particularly in the case o f small rural communities, by helping to secure community participation. In order to facilitate the attainment o f the Decade objectives, the Regional O ff ice will endeavour to have an experienced W HO engineer resident in each o f the countries o f the Region with the greatest water supply and sanitation needs; the engineer will assist the government in developing a strategy fo r the Decade, and will collaborate with the Resident Representative o f U N D P in securing coordinated international technical co operation. With over half o f the w or ld ’s chemi cal industry concentrated in the Euro pean Region, the International Chemical Safety Programme is o f particular im portance to the Regional O ff ice , and preparatory work was completed to wards the end o f the year for substantial regional activities concerned with poten tially tox ic materials in air, water, food and the working environment. 55 Emphasis is also being placed on the training o f toxicologists and associated personnel and on legislative and adminis trative considerations in the safeguarding o f human health from exposure to tox ic chemicals. Collaboration w ith govern ments is also taking place in relation to contingency planning and response to in dustrial emergencies concerning the re lease o f harmful chemicals, such as took place at Seveso in 1976. In view o f the proliferation o f chemicals in the environ ment, the Regional O ff ice , together with W HO headquarters, has commenced a complete revision o f the WHO standards for drinking-water, and it is anticipated that this work will be completed by the end o f 1981. Increased attention is being paid to the environmental health effects o f changing patterns o f energy production and utilization. A Working Group on Health Aspects related to Indoor A ir Quality, convened in Bilthoven in April, demonstrated the potential hazards o f air pollution in buildings. Work is now proceeding on the public health aspects o f housing and settlements, both in northern Europe and in the Mediter ranean countries. It is clearly impossible to separate the effects on human health and well being o f environmental hazards from those resulting from the lifestyles o f individuals and communities; work is therefore commencing within the field o f human eco logy in an endeavour to link a number o f such factors in indus trialized societies. This should facilitate the process o f assessing relative risk and help governments to develop national priorities in relation to environmental health. Effective environmental health man agement at the national level can be achieved only by satisfactory institu tional arrangements. Unfortunately, in many countries o f the Region there has been a proliferation o f government de partments or agencies dealing with d i f ferent aspects o f environmental protec tion, and this has sometimes led to a neg lect o f considerations relating to human health, and to a sectoral approach that makes it d iff icult fo r decision makers to take a holistic view. An important part o f the work o f the Regional O ff ice is therefore related to the design o f e f fective environmental health services. 5.2 E N V I R O N M E N T A L HEALTH PLANNING A N D M A N A G E M E N T Fo llow ing the establishment o f the new unit o f Environmental Health Plan ning and Management in February, a start was made on the task o f organizing and developing environmental health policies and manpower studies in the environmental field in collaboration with Member States and training institutes. A t the same time, several activities started in 1978 were further developed, under both the regular programme and the jo in t collaborating programme with other United Nations agencies, particu larly U N D P and UNEP. In this con nexion, whenever possible, links were established between the two programmes. For instance, the results o f the seminars on environmental impact assessment held in Greece and Czechoslovakia promoted the interest o f other countries in the development o f this powerful too l in planning strategies and policies having environmental consequences. 56 The main thrust o f the intercoun- try programme was directed towards the training o f personnel and the de velopment o f professional profiles. A three-country survey o f environmen tal services was also undertaken and completed in collaboration w ith WHO headquarters. As in previous years, the postgradu ate course on environmental sciences and technology (in English) held in Delft, Netherlands o ffered an 11-month study programme, including lectures, laboratory exercises, workshops, pro ject work and field studies in a great variety o f subjects. It was attended by biologists, chemists and engineers. T w o lecturers were recruited by WHO and 13 students from 6 different coun tries participated in the course as WHO fellows. A meeting was held in the Netherlands in May to discuss coopera tion between institutes and the R e gional O ff ice , keeping in mind the growing need to train environmental specialists in the European Region and fo r a periodical updating o f the cur ricula to meet the challenge o f very rapid sociocultural, technological and econom ic changes. T o formalize rela tions between the Regional O ffice and the International Institute for Hydraulic and Environmental Engineer ing in Delft, negotiations are under way on the designation o f that Insti tute as a WHO collaborating centre fo r manpower development in environ mental health. The postgraduate course in en vironmental engineering (in French) at the Federal Polytechnic in Lausanne, Switzerland continued to be supported. One lecturer was funded by the Regional O ff ice and seven fellows, three from the European Region and four from other W H O regions, attended the course to specialize in such subjects as basic sanitation, industrial hygiene, occupa tional health and air pollution. The Regional O ff ice continued to support the training programme o f the Sanitary Engineering Centre in Rabat, and the first teachers trained fo r the Centre under W H O fe l low ships abroad were employed. A t the beginning o f the academic year in September only two W H O sta ff mem bers still held teaching positions at the Centre, the rest being occupied by Moroccan nationals. Collaboration with the European Centre for Human Eco logy in Geneva continued. As a result, the O ff ice was represented at a seminar in Le Mesnil Saint-Denis, France at which a medium- term programme on health and the environment, including the establish ment o f “ health observatories” in se lected areas in France, was discussed. In formation was collected by a consultant fo r the preparation o f an inventory o f institutions in the Euro pean Region where facilities for train ing in environmental health are avail able, giving details o f the content and duration o f courses and the type o f dip loma or certificate obtainable. A meeting was held at the Insti tute o f Environmental Engineering in Warsaw in Novem ber, to discuss the professional profiles o f sanitary and environmental engineers, including cur ricula, training facilities, recognition o f certificates/degrees and em ployment opportunities. 57 Three countries were selected for a survey o f environmental services in collaboration with W HO headquarters: Czechoslovakia, the Federal Republic o f Germany, and Yugoslavia. The rap porteurs from these countries described the environmental services within the existing governmental structure and paid particular attention to the problem o f coordination. A W H O collaborating cen tre in the field o f water research is prepared to take part in the survey as far as the water component o f the environ mental services is concerned. A Consultation on Professional Pro files fo r the Environmental Health O ff icer in an Industrialized Society was held in Copenhagen in Novem ber, to fo l low up the work o f the Consultation on the Role, Functions and Training Require ments o f Environmental Health Officers (Sanitarians) held in December 1977. As there has been a shift o f emphasis from traditional sanitation problems to the new hazards associated with intensive industrialization, the professional profile o f the environmental health o f f icer is expected to reflect the importance o f his preventive role in controlling environ mental factors hazardous to health. The report on the Consultation on Manpower Development in T ox ico lo gy , issued during the year, helped in clari fy ing the type o f knowledge and skills required from the professional to x i cologist, as well as training requirements. It was also agreed that there was an urgent need to promote international recognition o f tox ico logy as an inde pendent science, with wider under standing o f the training methods used in the various Member States. As a follow-up to the Seminar on En vironmental Health Impact Assessment held in Greece in 1978, a Seminar on Environmental Impact Assessment in relation to Environmental Protection and Physical Planning was held in Bratis lava at the end o f August. It was agreed that strategies fo r environmental protec tion should reflect the current and emerging problems o f industrialized society, with priority given to industrial pollution in general and the effects o f tox ic chemicals in particular. The environmental impact analysis system has emerged as one o f the most powerfu l planning tools fo r the preven tion o f environmental pollution and degradation. Environmental impact analysis is growing in importance and is likely to assume an even greater significance in the future, as potentially conflicting demands are made for an improvement in the quality o f life on the one hand and continuous econom ic growth on the other. Environmental impact analy sis will be o f considerable importance in helping governments to achieve rational solutions to these short-term conflicts. One o f the most important com po nents o f any environmental impact as sessment system is health. The Regional O ff ice has made persistent e fforts to assist in the development o f the skills, attitudes, in formation and tools needed fo r full and adequate treatment o f the health com ponent o f environmental impact assessment systems. The results o f environmental health impact assessment must be communi cated to decision makers and to the pub lic in a form that will allow them to grasp the essential conclusions. In an e f fo r t to develop a method o f effective 5 8 communication the Regional O ff ice , in collaboration w ith the Technical University o f Copenhagen, has de veloped computerized techniques for translating emission inventories, environ mental dispersion models and health effect in formation into coloured three- dimensional maps. This process facili tates the rapid manipulation o f data and visual demonstration o f probable health effects o f the various alterna tives o f the proposed action, over a range o f probable circumstances. The maps shown in Fig. 6 were produced to test the m ethodology ; they are based to a large extent on hypothetical data, and therefore do not represent a real-life situation. Publications Environmental health impact as sessment: report on a W H O Semi nar. E U R O Reports and Studies, No . 7. 5.3 PROVISION OF BASIC SANITARY MEASURES The persistence in the European Region o f communicable diseases re lated to poor basic sanitation was reflected in the occurrence o f enteric diseases, including cholera, in several countries during the year. The report on the Meeting on En vironmental Health Problems in Tourist Areas, held in Montpellier in Septem ber 1978, was published in French (see be low ). The participants in the Meeting studied the e ffec t o f large seasonal fluctuations in population, climatic constraints, and unsanitary or hazardous econom ic activities on essential services responsible fo r en vironmental health. They also discussed the impact o f these factors on the administration o f municipal technical services, on the management o f water resources, and on the maintenance o f the ecological balance and the con trol o f tox ic chemicals that could be dispersed in tourist areas. The consolidated report on the rapid assessment o f the drinking-water supply and sanitation situation in Europe was sent to all Member States for review before finalization. A Planning Consultation on the European Study on Public Health As pects o f Housing took place in Copen hagen in December to design a proposed study protocol fo r a comm on exercise among collaborating institutes in several European countries. In May, a planning meeting was held in Copenhagen to prepare for a workshop on environmental health problems in arctic and subarctic areas, to take place in the USSR in 1981. Publications La salubrité de l'environnement dans les zones touristiques européennes : rapport sur la réunion d ’un groupe de travail. E U R O Reports and Studies, No. 18. 5 9 Fig. 6 . Mapping of environmental impacts and health effects Green: no noticeable health effect. Yellow: increased m orbidity — reduction of pulmonary function, higher incidence of chronic bronchitis and other pulmonary diseases. Red/orange: higher mortality among the most susceptible sectors of the population. A. Section of a coastal metropolitan area. The contours represent average yearly levels of S02 from a variety of area, line and point sources. B. The same area and the same background levels as in map A. Two additional large pointsources (e.g., a power station and a large chemical plant) located on the axis parallel to the prevailing wind “2 ж 6 0 F i g . 6 . ( c o n t d ) C. The same area and the same sources as in map B, but with the two large point sources located on the axis perpendicular to the prevailing wind. 5.4 RECOGNITION A N D C O N T R O L OF E N V I R O N M E N T A L H A Z A R D S 5.4.1 Water pollution control Water quality management o f the Danube U N D P financed preliminary discus sions with the governments concerned to enable W H O staff and consultants to draw up detailed project proposals. A representative o f the Regional O f fice and a U NEP consultant visited Yugoslavia in Novem ber to discuss proposed project activities. The Govern ment expressed full support fo r the project and indicated its readiness to participate. A temporary adviser attended a meeting o f the Danube Commission in Budapest in December on behalf o f the Regional O ffice. It is expected that a large-scale UNDP/W HO project, in collaboration with UNEP, F A O , UNESCO and IA E A , will commence during 1980. Water quality monitoring system — GEMS ( Wa ter) Collaboration w ith Member States continued within the framework o f the UNEP-sponsored Global Environmental Monitoring System (G E M S ), aiming at the prom otion o f an exchange o f infor mation on levels and trends o f water pollution. Ten o f the eleven countries participating in this exercise have signed agreements with W HO and four (Belgium, Spain, Turkey and the United K ingdom ) have been approached to provide data on a pilot basis for the W HO collaborating 61 centre on surface and ground water quality in Canada. Operational guides (in English) were sent to the national centres/stations in each o f the partici pating countries: Belgium, Finland, Hun gary, Malta, Monaco, Netherlands, N o r way, Portugal, Spain, Turkey and the United Kingdom. The GEMS programme is carried out in close collaboration with W HO headquarters. Joint WHO/UNEP Coordinated Pilot Project on Coastal Water Quality Con trol in the Mediterranean (MED VII) Follow ing the decision o f the inter governmental review meeting o f M ed i terranean coastal states and the First meeting o f the contracting parties to the Convention for the Protection o f the Mediterranean Sea against Pollution and its related protocols, the pilot project, along with other similar activities, was extended for two more years. T w o M ED V I I meetings on coastal quality monitoring o f recreational and shellfish areas were organized by WHO and U N E P and attended by the principal investigators o f the collaborating insti tutes. The subjects discussed included m ethodology o f monitoring, selection and identification o f parameters, labora tory quality control, comparability o f results, their analysis and evaluation, environmental quality criteria, and ep i demiological studies on dose-response relationships. The document Principles and guide lines fo r discharge o f wastes into the marine environment was finalized and distributed during a meeting o f technical and legal experts for the adoption o f a protocol on pollution from land-based sources, organized by U NEP in Geneva. W H O consultants and, on occasion, staff o f the Regional O ff ice , represented the Organization at nine different meet ings organized by U NEP in connexion with the Mediterranean Act ion Plan. Other activities Reports on four working groups held at the end o f 1977 and during 1978 were published (see be low ). These reports will serve as an essential contribution to the present revision o f the WHO standards fo r drinking-water and to the prepara tion, together with W HO headquarters, o f new guidelines. Agreement was reached with Per gamon Press in the United K ingdom on the publication o f the handbook Exam ination o f water for pollution control, on behalf o f the O ffice . The three vol umes will cover: sampling, data analysis and laboratory equipment; physical, chemical and radiological examinations; and biological, bacteriological and vir- ological examinations. Publication is planned fo r 1980. The report on the pilot-scale inter comparison studies o f methods for water analysis, comprising three studies on anionic detergents, heavy metals (cadmium, copper, iron and zinc), and oxygen demand and organic carbon, was finalized by the Water Quality Institute, Denmark. It was distributed on behalf o f the Regional O ff ice to all collabor ating laboratories in Europe and North America. Preparations started for a meeting o f a working group on health implications o f the use o f drinking-water reservoirs for recreation, to be hosted by the Hun garian authorities in 1981. 62 Sodium, chlorides and conductivity in drinking-water: report on a WHO Working Group. E U R O Reports and Studies, N o . 2. Health effects o f the removal o f substances occurring naturally in drinking-water, with special refer ence to demineralized and desal inated water: report on a WHO Working Group. E U R O Reports and Studies, No . 16. Radiological examination o f drinking- water: report on a W H O Working Group. E U R O Reports and Studies, No. 17. Coastal quality monitoring o f rec reational and shellfish areas (MED VII): report o f a Workshop jo in t ly convened by W HO and UNEP. Document ICP/RCE 206 (9 ). 5.4.2 A ir pollution control During the High-level Meeting w ith in the framework o f the ECE on the Protection o f the Environment, held in Geneva in November, the Regional Director represented the Director-General at the signing o f the Convention on Long-range Transboundary A ir Po l lution. Air quality monitoring system - GEMS ( A ir) By the end o f the year, 18 coun tries o f the Region were participating Publications and documents in the GEMS air quality monitor ing programme, namely: Algeria, Bel gium, Czechoslovakia, Denmark, F in land, France, Federal Republic o f Germany, Greece, Italy, Netherlands, Poland, Portugal, Spain, Sweden, Swit zerland, Turkey, United K ingdom and Yugoslavia. Bulgaria and M orocco have also expressed interest in jo in ing the project, which is carried out in close collaboration with WHO headquarters. Experts were recruited fo r country visits, lectures, or advice on setting up m onitoring equipment, fellowships were granted fo r attending specialized courses, and standard equipment for monitoring stations was provided for five countries (A lgeria, Poland, Portu gal, Switzerland and Turkey ). An inter calibration exercise fo r the determina tion o f sulfur d ioxide from selected samples was performed, fo l low ing the recommendations o f the Workshop on A ir Pollution Reference Measurement Methods and Systems held in March. The proceedings o f the Interregional Seminar on A ir Quality Management, held in Sofia at the end o f 1978, have been prepared. W ork on the Manual on ambient air pollutants from industrial sources continued and the second draft was almost completed. A Working Group on Health As pects related to Indoor A ir Quality took place in Bilthoven in April. The Group discussed the effects o f soil surfaces and building materials that emit radioactive radon gas, asbestos- containing materials that can release asbestos fibres, and insulation materials and processed w ood that release formal dehyde to the indoor atmosphere. 63 The Group also considered the wide range o f current consumer products such as personal hygiene products, cleaning agents, biocides, air fresh eners, solvents, adhesives, and hob by and handicraft materials, all o f which can discharge harmful con taminants to the indoor environ ment. The Working Group reviewed cer tain aspects o f indoor air quality that have always been o f concern but which are even more serious with drastic ally reduced ventilation, such as body odours and those produced by cook ing and tobacco smoking. The health consequences o f increased levels o f particulates and carbon m onox ide from tobacco smoke and o f increased levels o f nitrogen d ioxide, carbon monoxide and aldehydes from the use o f un- vented gas appliances during cook ing and water heating were also dis cussed. Throughout the discussions o f the Working Group, a consistent finding was the extreme scarcity o f data on health effects specific or even appli cable to the indoor environment. A l most all considerations o f the Group with respect to the health effects o f specific contaminants had to be based on research data obtained in the study o f ambient air pollutants, or on data obtained from studies on places o f work. The Third Intersecretariat M eet ing on A ir Pollution Problems in Europe took place in Geneva in January. The invitations fo r the Fourth Meeting in May 1980, at IL O headquarters in Geneva, have been despatched. Health aspects related to indoor air quality: report on a W HO W ork ing Group. E U R O Reports and Studies, No . 21. 5.4.3 Solid waste management The chapters on animal waste, petrochemical waste, mining waste and ferrous metal waste, which form part o f the manual on solid waste man agement, were issued separately as documents in English only. The chap ter on composting is being revised. By the end o f the period under re view there had been no clear response from U N E P regarding financial sup port fo r this project. 5.4.4 Radiation protection Work on the manual on nonion izing radiation protection was almost completed. The chapter on m icro wave and radio frequency radiation was finaUzed, fo l low ing a revision and review by a group o f over 20 experts. This revision was made with strong support from the WHO collaborating centre at the US Bureau o f Rad io logical Health. A number o f meet ings were held among and with the experts involved in finalizing the chap ter on microwave radiation and in evaluating the questionnaires, to dis cuss various details. Replies to the two questionnaires on legislation and institutions continued to arrive. The finalization o f the manual was de layed because o f the essential re vision o f the microwave chapter, and because o f the late arrival o f some Publications 64 replies from Member States to the questionnaires. The manual will be published in 1980. The French and Russian trans lations o f the report on the Working Group on Health Implications o f N u clear Power Production were distrib uted. The second meeting within this project, on health aspects o f trans uranium elements (neptunium, p luto nium, americium and californium) took place in Brussels in November, during which a planning meeting was con vened to prepare for the third meet ing on health implications from high- level radioactive waste disposal, planned fo r June 1980 in Bruges. 5.5 F O O D SAFETY The level o f general food hygiene in a country depends more on resources for inspection and control and on the standard and training o f the food inspectors than on the legal regula tions in force. Most countries in the European Region have a reasonably good system o f food laws, aiming at the protection o f consumers’ health and giving various requirements for the composition, quality, presentation and control o f food . International agreements, in particular those made under the jo in t F AO/WHO Codex Alimentarius system, give guidance to countries on national legislation. Im plementation and enforcement, how ever, need to be improved; the work o f the O ff ice on food safety during the year therefore emphasized the provision o f assistance and advice on aspects o f implementing food law. and on the optimum use o f resources for field food inspection and labora tory investigations. Standardization o f food becomes increasingly important when trade grows and food production becomes more specialized and concentrated in larger production units. This fact is also being recognized by countries in which it has not yet been possible to give formal acceptance to the standards elaborated under the Codex Alimentarius system. The standards are being used as models and guidelines when national laws are amended or changed. A number o f gov ernments are now prepared to allow free circulation in their countries o f food that complies with the Codex standards. Even the most comprehensive regu lations can be ineffective i f they are not accompanied by proper control. Sufficient resources for surveillance must be made available. Cooperation within countries among the d ifferent authorities concerned is being en couraged, as well as the exchange among countries o f experience and informa tion on food problems. A survey o f fo od safety and hygiene services in Europe was completed and will be published in the series Public Health in Europe. Outbreaks o f food poisoning caused by bacterial contamination outnumber by far those caused by chemical contamina tion. Efforts should be concentrated on cleaning up systems o f food handling and increasing public awareness o f the importance o f food hygiene. Efforts were made to give more attention to the relationship between 65 environmental hygiene and food hygiene. In addition to the traditional work on safeguarding food by providing lists o f ad ditives, licensing food premises, inspec tion, and sampling systems, consideration should also be given to the risks to food and drinking-water from environmental pollution. Continuous efforts are being made to promote teamwork among toxicologists, sanitary engineers, veterin arians, physicians and environmental health officers. An example o f such team work is the plan in connexion w ith the jo int F AO/UNEP/W HO work in the M ed i terranean area to study viral o r parasitic infection o f foods and drinking-water originating from the disposal o f solid o r liquid wastes, e.g., infectious hepatitis from shellfish, viral infections caused by fertilizing vegetables with sludge, and parasitic disease problems in connexion with fish farming near sewage outlets. A Working Group on Health Exam ination fo r Food-Handling Personnel was convened in November. Again, the im portance o f maintaining the highest standards o f hygiene in all food handling was stressed. The Group concluded that, in the prevention o f foodborne disease, medical examinations fo r food handlers are o f limited value compared with training in hygienic practice. L imited re sources in time and m oney are better spent on educating food handlers in basic food hygiene, as well as their supervisors, administrators and others responsible fo r food safety. 5.6 E N V I R O N M E N T A L TOXICOLOGY The Regional O ff ice took a lead ing role in the development o f the International Programme on Chemi cal Safety, especially in the fields o f manpower development, contingency planning and response to emergen cies, and in technical cooperation with Member States on specific prob lems. A Consultation on Regional C o operation on Environmental Health Aspects o f the Control o f Chemicals was held in Copenhagen in August to discuss the outline project docu ment fo r a proposed UNDP/WHO project on European cooperation, and to establish priorities fo r action. A revised draft project document was developed and discussed with UNDP. The preliminary activities phase o f this project is expected to be approved early in 1980, and operations will commence forthwith . The voluntary contributions that have been promised by some Mem ber States will permit integration o f the UNDP-supported project, in which 11 countries are expected to participate, with the pan- European programme o f the Regional O ff ice . The Italian Government requested the assistance o f the Regional O ff ice in dealing with the consequences o f the industrial accident, involving dis charge o f tox ic chemicals into the environment, at Seveso in 1976. An ad hoc meeting o f experts was con vened in Seveso to develop recom mendations fo r remedial action and fo r the necessary epidemiological sur veillance. The Regional O f f ice was subsequently invited to designate a staff member to act as chairman o f the Consultative Committee on the T ox ic o lo gy o f TC D D ( 2,3,7,8-tetra- chlorodibenzo-p-dioxin), to be established 66 by the Italian authorities to m oni tor the situation and to advise the Government. Fo llow ing an episode o f ground water pollution b y potentially tox ic chemicals in Vicenza Province the Italian authorities, in collaboration with the Regional O ff ice , organized a W ork ing Group on Criteria and Guidelines fo r Halogenated Arom atic Compounds, which was held in Venice in Septem ber. The meeting reviewed the avail able information on the chemistry, environmental occurrence and tox ic ity o f toluenes, benzenes and phenols, and evaluated the possible health hazards associated with their presence in the environment. Recommendations on ap propriate guidelines for health protec tion were developed. Within the framework o f the pilot project on the assessment o f human exposure to air pollutants, a m eet ing was held in Geneva, attended by staff from W HO headquarters and the Regional O ff ice and experts from the Institute for Medical Research and Occupational Health in Zagreb, to formulate a plan o f work for initial activities on this project. It is expected that a subcontract with the Institute will be signed early in 1980. The UNEP/WHO/GEMS pilot pro ject on assessment o f human e x p o sure to pollution through b io log i cal monitoring, with particular ref erence to organochlorine compounds, was discussed at a meeting convened by the Swedish National Food A dm in istration in Uppsala in December. Manpower development in toxicol ogy: report on a W H O Consultation. E U R O Reports and Studies, No . 9. Publications 5.7 C O U N T R Y ACTIVITIES Algeria. The Regional O f f ice con tinued to assist the Environmental Health Department o f the National Public Health Institute, particularly in the train ing o f sanitarians. The O ff ice also as sisted in the training o f sanitary en gineers, and in preparations for the International Drinking-Water Supply and Sanitation Decade, as well as in waste disposal technology, especially fo r toxic industrial solid waste. A training course on this last subject took place in Algiers in December. Greece. The UNDP-supported pro ject on environmental pollution control in the metropolitan area o f Athens was terminated in 1979. A tripartite review meeting was held in Athens in Decem ber, at which the Government, U N D P and WHO expressed their satisfaction with the achievements o f the project, which reached substantially all its objec tives. E ffic ient operation o f the pro ject produced savings o f approximately U S$ 300 000 from the U N D P contri bution. A new project was approved, the purpose o f which is to assist the Govern ment in establishing a country-wide en vironmental protection service and in introducing the environmental impact assessment procedures fo r various types 67 o f development activity. The formal project document was signed b y the Government, U N D P and W H O ; imple mentation is expected early in 1980. Italy. The Regional O ff ice collab orated with the Regional Government o f Lombardia on the consequences o f the industrial accident in Seveso, and with the Regional Government o f Veneto fo llow ing an incident o f ground water contamination in the Province o f Vicenza. Malta. The Regional O ff ice coop erated in the new project on sewer ex tension, maintenance and repair. Morocco. The large-scale WHO- assisted urban water supply preinvest ment project is now terminating, but the Regional O ff ice has started a new project on the control o f eutrophica tion in reservoirs and is preparing a future project on preinvestment studies fo r rural water supplies. The World Bank granted a second loan o f US$ 49 mil lion to the National O ff ice fo r Water Supply fo r investments studied during former WHO-assisted projects. Poland. Environmental protection activities in the Upper Silesia industrial region came to a close after six years o f collaboration between the Government and the Regional O ffice . One result o f the project was the establishment o f the Environmental Pollution Abatement Cen tre in Katow ice , which has as its main task the preparation o f a comprehensive plan for the protection o f the environ ment in an area consisting o f four tow n ships in the District o f Katow ice , cover ing about half the Upper Silesia industrial region and about 43% o f its population. Progress was made in the W HO/UNDP project on the evaluation o f tox ic ity o f new technologies and substances used in industry. T w o consultant mis sions were provided within the frame work o f this project. The International Course on Indus trial T o x ic o lo g y was convened by the Institute o f Occupational Medicine (W H O collaborating centre for occupational health) in Lodz . Headquarters and R e gional O f f ice sta ff participated and lectured at this course. O f the 15 par ticipants, 8 were from developing countries. A new environmental health protec tion project was formulated, negotiated and approved during the year. Environ mental impact assessment studies will be carried out in three pilot areas in Poland and the experience thus gained used to introduce a country-wide en vironmental impact assessment system. The workplan has been elaborated and project operations commenced in the autumn. The industrial tox ico logy project in Lod z was extended until the end o f the year to cover the costs o f training abroad for sta ff o f the Institute o f Occupational Medicine, the cost o f supporting foreign experts at the Institute, and the purchase o f supplementary and replacement equip ment. Portugal. A W HO consultant visited the country to fo l low up advice provided on organization and training in occupa tional health. W H O continued to assist the Govern ment in developing a basic sanitation programme, and a planning meeting for 68 the International Drinking-Water Supply and Sanitation Decade took place in Lisbon in early November. The Regional O ff ice also continued to assist with the drinking-water fluoridation project and a training course, involving W H O lecturers, took place in Lisbon in November. The air pollution control project also re ceived assistance, and W HO contributed actively to the Te jo Estuary ecological study project. Spain. Regional O ff ice cooperation in the Huelva air pollution control project, which is financed entirely by the Government, was completed. Turkey. W H O continued to assist research and training in environmen tal health at four universities; this project was the subject o f an evalua tion meeting in Novem ber, at which time an extension was suggested. As sistance with projects related to epi demiological studies on air pollution, water quality standards development, and the Porsuk river basin water qual ity management was completed. C o operation was started on the manage ment and disposal o f solid waste in the Istanbul metropolitan area and in preparations for a solid waste dis posal programme in Ankara. The R e gional O ff ice continued assisting the Water Supply and Sewerage Depart ment o f the Bank o f Municipalities in charge o f urban areas. With regard to the International Drinking-Water Supply and Sanitation Decade, new WHO-assisted activities are under dis cussion fo r the rural sector. A UNDP/W HO project on the strengthening o f food control services in Turkey started in March. A sem inar, with about 200 participants, was held in Ankara to evaluate the present situation in the field o f food safety in Turkey. A m ong the problems men tioned by many participants were the need for better field food inspec tion, integration o f food control with other public health services, and edu cation o f the public in food hygiene. Several training courses for food in spectors were held in Turkey, the assistance o f a consultant was pro vided, and fellowships were awarded in Denmark, the Federal Republic o f Germany and the United Kingdom. Yugoslavia. The first phase o f the project on river pollution control in the Republic o f Bosnia and Herzego vina was completed after tw o years o f activity. The results produced a number o f proposals to reduce the pollution o f the Jala-Spreca water basin caused by urban, and especial ly industrial, wastewater from various sources in the neighbourhood o f the city o f Tuzla. The Third International Training Course in Occupational and Environ mental T o x ic o lo gy was held in Bel grade. The water supply and waste dis posal project for K osovo continued during 1979 and is expected to be com pleted early in 1980. 69 PR OMOTION O F E N V I R O N M E N T A L H E A L T H Expenditure (US$) Regular funds U N funds Voluntary funds 796 590 1 712888 44 573 2554051° a Being 15.97% of total expenditure. Chapter 6 HEALTH MANPOWER DEVELOPMENT 6.1 G E N E R A L Dr A. Wojtczak took over as Direc tor, Research, Planning and Human Re sources at the Regional O ff ice on 1 Jan uary 1979. The European component o f the global medium-term programme on health manpower development, as ap proved by the Thirty-first World Health Assembly, focused during the year on a few influential and important areas, such as: national teacher training activ ities; support for training in health man agement and administration; and stimu lating the development o f continuing education programmes fo r the medical and health professions. Emphasis was placed on developing a strong line o f communication and co operation with various professional as sociations and national centres involved in the education o f health personnel, educational research, and training in health management. The need fo r close collaboration between those responsible for health development and fo r the edu cation and training o f medical and health personnel, to provide for educational planning according to the health needs o f the community, was also stressed. The Regional O ff ice signed a con tractual agreement with the Association fo r Medical Education in Europe (A M E E ), the aim o f which is the preparation o f comprehensive information on admis sion procedures to medical schools in Member States. In some countries there is no limit on admissions, which creates a diff icult situation for the proper organ ization o f medical education and has an impact on the quality o f the education and consequently on that o f the gradu ates. It is hoped that, by obtaining an accurate picture o f the situation, it will be possible to help Member States gradually to introduce admission quotas, reorientate medical education more towards community needs, and con sequently improve the level o f health care. Fig. 7 shows the number o f people to each physician in the countries o f the Region. During the A M E E meeting an A s sociation o f Medical Deans in Europe was established, which will collaborate closely with the Regional O ff ice and AM EE. The first official meeting o f the Association will take place in Groningen in September 1980 when the topic “ Responsibility o f medical schools for teaching hospitals and the provision o f clinical services” will be discussed. Deans 71 Fig. 7. Number of people per physician in the countries of the European Region Source: W o rld h e a lth s ta tis tic s a n n u a l, 1979 . Geneva, WHO, 1979. 72 o f medical schools or faculties in the European Region have been invited and ministries o f health have been informed about the activities and aims o f the Association. The Sixth General Assembly o f the Association o f Schools o f Public Health in Europe (A S P H E R ) took place in Lon don in September. Five areas o f possible cooperation between A S P H E R and the Regional O ff ice were identified: ex change o f in formation; com m on activ ities o f Member States; elaboration o f European standards; introduction o f new training courses; and health services re search. The implementation o f these five areas was discussed in detail when the Secretary-General o f A S P H E R visited the Regional O ff ice in December. During the period under review the Regional O ff ice organized a study tour fo r a group o f Chinese medical educators to study the organization and manage ment o f medical education in Denmark, Finland, the Netherlands, N orw ay and the United Kingdom. The tour was con cluded by a visit to the Regional O ff ice , where a programme on the work o f the various units was arranged. This was arranged fo llow ing an agreement signed in 1978 on technical cooperation in the health field between W HO and the M in istry o f Health o f the Peop le ’s Republic o f China. The main activity o f the teacher training component o f the medium- term programme was the Seminar on Planning and Implementation o f Teacher Training Programmes that took place at the British L ife Assurance Trust (B L A T ) Centre fo r Health and Medical Educa tion, London, in May. The Seminar was convened to discuss the organization and management o f teacher training centres and to exchange in formation on the planning and implementation o f teacher training programmes as part o f W H O ’s medium-term programme in health man power development in the European Region. The participants examined prob lems and trends in the training o f teachers for the health professions, with special reference to integrated services and staff development. The importance o f recruit ing suitable teachers fo r training and the need to give them adequate incentives was emphasized. S ta ff development pro grammes might include formal courses, distance learning, self-assessment and audit. Considerable experience and ex pertise is available in the European Re gion and this should be shared among the d ifferent countries and universities. The participants supported the Regional O ff ice in its e fforts to set up a network o f W HO collaborating centres in teacher training, and negotiations with different Member States have started. A lso organized at the B L A T Centre in 1979, under the auspices o f the R e gional O ff ice , was the Second Course on Modern M ethodo logy fo r Teachers o f Health Sciences. This was a very success ful course attended by 23 participants, 13 o f whom were from the W HO Euro pean Region. The second version o f the Inventory o f Teacher Training Facilities, listing 71 institutes in 17 European countries, became available at the end o f the year. The Regional O ff ice intends to bring this inventory up to date in 1982 and to include additional Member States. Within the framework o f the agree ment signed in 1978 between the Insti tute fo r Research in Medical Education 7 3 and Evaluation, Bern and the Regional O ffice , a Workshop on Curriculum Planning (in German) was held in Bern in March. As in the past, the O ff ice continued to support the courses fo r public health administrators (in English and Russian), which are held annually at the Central Institute fo r Advanced Medical Studies, Moscow. The programme o f the English course was changed to take into account the recommendations o f the Second Joint Com m ittee o f the courses in 1978, which placed emphasis on objectives and has increased the practical work o f the course through workshops, sem inars and travel to different countries to study the health services. In 1980 the Regional O ff ice will provide sup port to the F ifth Scientific Session o f the courses in Budapest. As a fo llow-up to one o f the recom mendations o f the Working Group on Training o f Senior Public Health Adm in istrators in Moscow in 1978, the Pro- Rector o f the Central Institute for A d vanced Medical Studies, Moscow, visited France, the Federal Republic o f Ger many and the United K ingdom to obtain information on the training programmes used in d ifferent schools o f public health. This information will be used to improve the programme o f the Moscow courses for public health administrators. A study on the dep loym ent o f gradu ates from schools o f public health in the U SA was carried out by Dr J. Evans, now Director, Department o f Population Health and Nutrition at the World Bank, under the auspices o f the Rockefe ller Foundation. Fo r the European part o f his study he was briefed at the Regional O ff ice , where a meeting was arranged with members o f the University o f Copen hagen and the Nord ic School o f Public Health, Gothenburg. Dr Evans also at tended the Sixth General Assembly o f A S P H E R in London in September. A Working Group on the Design o f Training in Health Planning and Manage ment, convened in Berlin (West) in July, investigated the feasibility o f developing and using training programmes to in tensify training in health management. The Regional O ff ice assisted the Division o f Health Manpower Development at W HO headquarters in collecting in forma tion from European Member States on regular training programmes in health planning, administration and manage ment; this information will appear in a world directory or inventory on train ing programmes in health management, which is intended to assist governments in their e fforts to provide national health management. 6.2 CONTINUING EDUCATION In an e f fo r t to supply Mem ber States with pertinent information on the educa tion and training o f health personnel, an updated report in French o f the WHO Capacity Study on Graduate Medical Education in the European Region was distributed. The participants in the technical discussions at the twenty-ninth session o f the Regional Com m ittee considered the definition o f continuing education, noting that it includes basic o r specialist training and any education that takes place thereafter, and that it embraces all the health professions. T h ey described a 74 wide range o f programmes through out the European Region fo r medical practitioners (especially primary medi cal care practitioners), dentists, nurses and midwives, environmental health professionals and social workers. There are also courses fo r medical labora tory technicians, physiotherapists, radio graphers, pharmacists, dietitians, chiro podists and opticians. The methods used are equally varied but it was agreed that, wherever possible, continuing education must be provided at the place o f work and be relevant to the needs both o f professionals and o f the community they serve. The value o f breaking down communication barriers and promoting a spirit o f interprofes sional collaboration was stressed. It was felt that continuing education had succeeded i f it imparted new know ledge, skills and attitudes, but had failed i f it drew the professional away from patient care. The evaluation o f con tinuing education required coordinated research on an international basis. It was suggested that the Regional O ffice should stress evaluation in all relevant publications and meetings, that all pro grammes should be evaluated, and that all new teaching techniques should be assessed in relation to the possibilities they o ffered for evaluation. Finally, it was recognized that the greatest need fo r continuing education o f ten arose among those who had the great est d iff icu lty in obtaining it, i.e., isolated and single-handed professionals who were heavily overworked and had relatively low status and remuneration. The challenge would be First to provide better status and remuneration fo r those who served where they were most needed. Continuing education o f health per sonnel as a factor in career develop ment: report on a W HO Working Group. E U R O Reports and Studies, No . 6. Publications 6.3 C OMMUNICATION A N D COLLABORATION A matter o f major concern for the Regional O ff ice is the improvement o f communication and collaboration within the various health professions and between health and educational systems and social components. More careful jo in t planning in the field o f health services and education might help to provide more e f fect ive and relevant services and thus meet health needs more successfully. A consultative group met in Copen hagen in December to prepare for the Working Group on Communication and Collaboration between and within Health and Educational Systems, to be held in 1980. Case studies on existing formal and informal communication patterns and mechanisms will be carried out by members o f the consultative group. The case studies, involving coun tries with d ifferent systems o f education and health care administration, will demonstrate existing mechanisms o f communication and point out d iff icul ties, obstacles and constraints, as well as functional solutions and e ffective mech anisms. A lso , on the recommendation o f the consultative group, a critical review o f all recommendations in this field will be undertaken. 75 The report o f the W H O Study Group on Communication and Collaboration between Health Systems and Education in the Health Professions, organized by the federal and cantonal authorities and the Institute fo r Research in Medical Education and Evaluation, Bern, in 1977 and 1978, under the auspices o f the Re gional O ff ice , was published in English and German. It will be used as a back ground document fo r the communica tion and collaboration working group. 6.4 FELLOWSHIPS A N D COURSES The fellowships programme o f the Regional O f f ice continued to be sup ported strongly by the Member States. In 1978 and 1979 no voluntary funds could be obtained to organize the Meeting o f National Fellowships Officers o f the European Region. However, in view o f the importance o f the top ic a voluntary contribution has been made which, although insufficient to finance the meeting complete ly, will enable the O ff ice to proceed further with its prep aration. It is hoped that Member States will further support this activity and thereby contribute to its success. The subjects studied by the W HO fellows reflect the health problems o f the countries o f origin and the emphasis placed by W H O programmes on the solu tion o f those problems. Table 3 shows the distribution o f fellowships by sub ject and Fig. 8 shows, fo r each Member State o f the Region, the number o f fe l lows that came to that country to study and the number from that country that studied elsewhere. As in the past, a small number o f countries together received the greatest number o f fellows. T w o courses concerned with health services took place during the year. 1. The sixth University o f Leeds/ W HO Summer Course on the British Health Services, which was attended by two fellows from the European Region and four from other W HO regions. It is felt that a change o f emphasis would be appropriate fo r future courses, with more consideration being given to coun try health programming; this will reflect current W H O thinking on health plan ning and will fill a real and increasing need fo r in formation and understanding on this subject. 2. The University o f Oslo Interna tional Summer Course on the Norwegian Health Services. Only one W HO fe llow attended this course, although the Uni versity provided nine half-fellowships. It is hoped that Member States will take greater advantage o f future courses. Fo l low ing negotiations with the G ov ernment o f the German Democratic R e public, a course on the health services in that country is being planned fo r Sep tember 1980. A l l Member States in the European Region w ill be in formed o f the possibility o f sending fellows to the course. During the year the Fellowships unit maintained close contact with all the re gions o f W H O , and sta f f members assisted at meetings organized by other regional offices, such as the Conference on R e gional Cooperation in the Fellowships Programme in Manila, the Conference on the Implementation o f the W H O Fe l low ships Programme in N e w Delhi, and the Biennial National Fellowships Officers 76 L L P E R C E N TA G E O F T O T A L I T O T A L 33 > 2 5 S f f 1 П Î - 5 Î- : i а П ä ! i ï 1 î I f * 1 ! 1 " 1 s i * 1 1 1 ! i t 1 i I ° 1 О О 3J l g O J > S m f 8 î l ? § f ? s ! 8 ? 1 а | 5 . 3 з - 2 | i 1 * 1 1 f i i s 1 f = § ? 5 8- Г о = 2 2 * $ 8 t I c o- f 5 a 1 E ? S 2 1 5 ° S ubject of stu dy (mam groups) « Ы K» AI hart i a 1 2 8 £ - 5 16119 101 Algeria Z - - Austria ° - - Belgium £ - - - - - _ (O Bulgaria S «*» - - Czech oiiovakia 2 u> - - Denmark œ Ы - - Finland z - - - France œ U> - - German Dem. Rep - o> - Germany, Fed. Rep. of L) ю - M - « » « Greece - - - Hungary s - - Iceland - - - - Ireland - - - - Ita ly - Luxembourg s - - Malta О ° Monaco s S - - 14512 Morocco £ 00 Netherlands £ o> - Norway £ - 2831021 s Й - - - ~ Portugal s - - Romania s <o - - - Spam - OS - - - Sweden iD - - - Switzerland о 0. - 27102111 Turkey s - - - - USSR - * - - United Kingdom <л 5 Yugoslavia 97 8 8 - - - * <Л * O' « О» « - 4 * - 104652818 17 15 14 13 11 TO TAL FOR EUROPEAN REGION œ « TO TAL OTHER REGIONS 8 360 I - - - - M * СЛ tf> U> tf> 0> CT> (7> -~J 00 — 104 6528181715141311 G RAND TO TAL 0 3 0 3 0 3 3.1 2 2 1 9 1.7 1.7 1.7 1 7 1 4 1 4 1 4 1 1 0.6 0.3 28 9 18.1 7.8 5 0 4.7 4 2 3 9 3 6 3 1 PERCENTAGE OF TOTAL Table 3. Fellow ships aw arded in 1979 by the R egional O ffice to fellow s from the European Region and other regions, by subject F i g . 8 . D i s t r i b u t i o n b y c o u n t r y o f f e l l o w s i n t h e E u r o p e a n R e g i o n 3 0 Number of fellows received in the country. 0 Number o f fellows from the country studying elsewhere. 3 These figures refer only to those fellows who started their fellowships in 1979. 78 Meeting in Amman. Close contact was also maintained with national fellowships counterparts in all Member States. 6 .5 N U R S IN G The medium-term programme in nursing/midwifery in Europe continued to develop. The number o f nursing re search centres collaborating directly with the programme increased from five to seven with the addition o f those in Utrecht and Lyons. The country networks o f partici pating centres continued to grow. In terest in developing Type I centres,“1 which will participate directly in the standardized studies, was expressed by 20 countries. The link between col laborating centres and Type I partici pating centres was better identified. In some countries, networks are already well established; in others, plans for the development o f networks are still in preparation. Interest in participating in the programme as Type II participating centres* was expressed by representa tives o f a number o f hospitals and health centres. a Type I participating centres: centres form ally associated with the program m e and agreeing to conduct controlled studies using standard program m e pro to cols. Such centres should also agree, as part o f the study, to experim ent with alternative patterns in the organization and m anagem ent o f nursing services. * Type I I participating centres: centres form ally associated with the program m e and agreeing to partici pate actively in such areas as field testing o f designs, nonspecific im plem entation o f the nursing process m ethod, exchange o f inform ation , continuing educa tion , and provision o f participants for working and/or technical advisory groups. Work was started on the devel opment o f designs for the standard ized studies that will be conducted as part o f components I (nursing pro cess) and II (organization and manage ment o f nursing/midwifery services) o f the medium-term programme. Col laborating centres worked jointly on the designs, which will include methods and schedules to be used in the assess ment o f patient/client needs for nurs ing care, criteria for selecting priority needs and relating needs to resources, methods and schedules for planning to meet selected needs, implementa tion o f care recording schedules, and evaluation methods and recording forms. Work also commenced on the data recording and management system for the studies. Preparations were begun on the production o f a teaching/learning pack age which, although for use specifi cally in Type I participating centres, will consist o f seven interrelated mod ules, some o f which will contain in formation directed at a wider audience. The modules cover: WHO and its role in health care; health services in Europe; nursing and nurses in the European Region; the medium-term programme in nursing/midwifery in Europe; the nursing process; and nursing research in general. Multinational research in nursing, research designs and their application in direct patient/client care, and alternative patterns for managing nursing services will also be covered in the package. The first meeting on national legis lation controlling the practice and educa tion o f nurses and mid wives in the Region was held. As working documents for this meeting, reviews were prepared o f 79 legislation related to nursing in 25 o f the 32 European Member States and to midwifery in 24 countries. The updating o f bibliographies in the workbooks on the nursing process and on the organiza tion o f nursing/midwifery services was completed. The second in a series o f meetings related to the management o f nursing/ midwifery services at national, regional and local levels was held at the end o f the year. This meeting again empha sized the need for appropriately quali fied nurses to be represented at all levels o f management. The role o f nurses in health planning in general was em phasized, as was the need for better preparation o f nurses for all types o f management post in such areas as cost accounting, communication skills and personnel management. The survey on nursing personnel and their education in nine countries o f the Region developed steadily, and a form for collecting information was tested in five countries. This form will be revised and retested in additional countries in due course. Considerable financial support was received from Member States for con ducting meetings o f relevance to the medium-term programme, and for the salary o f staff and support services in four o f the seven collaborating centres. Publications Evaluation o f inpatient nursing prac tice: report on a WHO Working Group. EURO Reports and Studies, No. 4. 6.6 C O U N T R Y A C T IV IT IE S Algeria. WHO and UNDP continued to support two projects in Algeria. 1. The Institute o f Health Technol ogy, Constantine, where preparations are being made for a final evaluation. 2. Training o f teachers fo r deaf children. This project, which received high priority from the Algerian Gov ernment, developed satisfactorily. The Regional Office continued to send ex perts to conduct training in different parts o f the country, and fellowships were awarded in Belgium, France and Yugoslavia. Future activities in Algeria will emphasize an integrated approach to primary health care and suitable training for health personnel. Belgium. Through its country pro gramme “ Lecturers and fellowships” , the Government continued to request ex perts from European countries and the USA to lecture at different schools o f public health. A short-term consultant assisted at the University o f Leuven with staff training and the teaching o f students as part o f the WHO-assisted funds-in-trust project on training programmes for nurs ing leaders. Later in the year a second consultant (nursing professor) continued the programme and carried out the final evaluation of the project. A Belgian nurse from this project is currently com pleting her doctoral degree dissertation. Denmark. The Regional Officer for Nursing conducted a one-day seminar on nursing research for teaching staff at the 80 Danish Nurses’ High School, University of Aarhus. The Danish Nurses’ Organiza tion provided the services o f a nursing research consultant. Federal Republic o f Germany. Close collaboration continued with the Acad emy o f Public Health, Düsseldorf. A workshop was convened to establish postgraduate training courses in health education (in German) with the close collaboration o f the Regional Office. Hungary. Two WHO staff visited Hungary in August to discuss the train ing o f students from developing coun tries and the possibility o f closer collab oration between the Regional Office and the Medical Faculty o f Semmelweis University in the field o f teacher training. Agreement was reached that the Office would assist in developing a programme o f research in medical education over the next three years. After that time the Department could be considered a can didate for the status o f WHO partici pating centre in teacher training. Iceland. A short-term consultant was assigned to the University o f Iceland for six weeks to teach community health nursing and assist with staff training. One Icelandic nurse studied in the USA for a master’s degree, and another was appointed junior instructor at the College o f Nursing, University o f Saskatchewan, Canada for the academic year 1979-80. Italy. A consultant continued to as sist the funds-in-trust project in the Re gion of Tuscany on education and train ing o f nursing and related health person nel. Collaboration continued with the Italian Centre for Medical Education, San Remo in teacher training and con tinuing education. Regional Office staff took part in discussions held by the Uni versity o f Perugia with the support o f the Italian Government, following the regionalization of health services in Italy, in order to assist in the establishment of concepts for health services and health manpower development. Portugal. In July an evaluation was made o f the Workshop on Medical Edu cation organized at the School o f Public Health, Lisbon in 1978. Spain. Officials from the Ministry o f Public Health visited the Regional Of fice to request assistance in the field o f medical education and nursing, and the Regional Officer for Nursing later visited the country for further discus sions. Two WHO staff (one from the Re gional Office and one from headquarters) participated in the meeting o f the Spanish Society o f Medical Education in Sala manca and one o f them also attended a meeting on “ Interaction between health services and education in medicine and related professions” in Madrid. Both meetings were attended by deans and members o f the faculty o f all the medi cal schools in Spain. Sweden. Close contact continued with the Nordic School o f Public Health, Gothenburg. A group o f students at tending the course in social medicine visited Copenhagen in March for briefing on the different programmes of the Of fice, including health manpower develop ment, the medium-term programme in nursing, country health programming, the incidence and prevalence o f chronic disease, and primary health care. Another visit to the Regional Office was made by the Committee for Inte grated Medical and Health Education 81 from Linköping, the aim o f which was to discuss the setting up o f a Health Science Faculty at Linköping where medical students would study in close contact with nursing and other profes sions. Turkey. Together with a staff mem ber from the Regional Office, a WHO consultant visited Turkey in March to discuss the implementation o f Phase II of the UNDP/WHO project on health manpower development. A draft project was drawn up by the Regional Office and submitted to the Government. Close contact was maintained with the German Agency for Technical Cooperation (GTZ) in support o f this project. The Centre for Medical Education Technology (СМЕТ) continued to develop, but true integration o f СМЕТ into the School o f Public Health in Ankara has yet to be achieved. Three programme areas were selected for Phase II: strengthening o f the School o f Public Health; teacher training; and development o f field training areas. United Kingdom. The Regional Of ficer for Nursing delivered the inaugural address at the Annual Conference of the British Health Visitors’ Association, in Brighton in October. H E A L T H M A N PO W ER D E V E L O P M E N T E x p e n d itu re (U S $ ) 1 6 8 9 6 8 8 9 6 2 7 9 9 9 7 1 2 1 8 8 5 6 7 9 * a Including Funds-in-Trust. * Being 11.79% o f total expenditure. R egu lar funds U N fu n d s V o lu n ta ry fu n d s0 82 ,. -Cüs :'i AäüiAte H o s p t a l ac< in to c t io n s : t( ) la b o r a t o i asssa S jP * m . Ши: Подготовка 1 и использование Щ вспомогательного 9 зубоврачебного персонала . ш ш ж Ш M easurem ent of Levels o f Health variety of subjects are covered by Regional Office publications in the four working languages 3 new word processing equipment acquired by the Regional Office will speed up office procedures and improve nmunication with the Member States o f the Region '4'/■ /* Щ Я Modem office equipment and techniques w „ e introduced In .he Regional Office, such « t h . connpute, (above) and video equipment for staff briefing and general information work Chapter 7 HEALTH INFORMATION 7.1 G E N E R A L The consolidation o f the different programmes o f the Regional Office dealing with the handling, analysis and dissemination o f information, which took place at the end o f 1978 with the creation o f a Health Information service, continued throughout 1979. The growing cost o f health care, on which many developed European countries spend more than one twelfth o f their gross national product, has become a major concern to health planners and administrators, health ser vice personnel, and the general public. All require more detailed information on the services provided through health care programmes, and the assurance that these programmes are adequate, acceptable and cost-effective. Yet, in spite o f spiralling costs, most o f the indices o f health developed over the last 100 years, which revealed a great in crease in the health o f the population during the first half o f the century, are levelling o ff or even showing an apparent or a real reduction in health. The Regional Office is therefore focusing its programmes o f collaboration with national information services on the search for more relevant data on the functioning o f health services, with emphasis on: quality o f life as a supple ment to the classical morbidity rate; better measures o f social disability (as opposed to sickness); and the recogni tion o f the effects o f lifestyle and en vironmental hazards on health. The growing recognition that health is no longer the prerogative o f the medi cal profession, but that every member of society is responsible for and should be actively engaged in promoting a more healthy life, is giving a new dimension to the health information programme of the Regional Office, as well as to those o f the Member States. Not only should more accurate, up- to-date, relevant and easily available in formation be promoted, but it should also be made more widely available through the Regional Office publica tions programme in as many languages as necessary to ensure wide dissemination throughout the Region. Fig. 9 shows the number o f copies o f publications requested during the year, and their distribution by language and region. 83 Fig. 9. Copies of publications requested in 1979 by language, and their distribution by region □ English □ German в French H Russian O)ГО4-* С 8 L_0) CL 100 90 80 70 60 50 40 30 20 1 0 0 EUR AMR OTHER Region 84 Attention will be paid to ensuring that the mass media play an even greater role so that every member o f society is adequately informed about the dangers o f poor environment and adverse life style, and is made aware o f the costs and the consequences o f ill health. The health literature services o f the Office are using new and more ef ficient documentation and communica tion methods to inform research workers, health professionals, teachers and stu dents o f developments in medical knowledge. The facilities acquired in 1979 for data storage and processing, and for text processing, which are mentioned elsewhere in this report (p. 91) will play an important role in the development o f the Regional Office health information programme. 7 .2 H E A L T H S T A T I S T I C S A major event during the year was the Fourth European Conference on Health Statistics, held in Luxem bourg in August, which considered the needs for health information in the planning and management o f health services. The Conference stressed the need to extend health information, which is still based mainly on mortality statistics, to cover a wider range o f health measurements, including environ mental indicators and those related to the cost o f health care. It also empha sized the urgent need to improve, both in scope and content, information on primary health care. A preliminary review o f the health statistics programme was made, with a view to improving its capacity to meet the requirements o f the move ment towards health for all by the year 2000, which is likely to gain mo mentum after the first meeting o f the Regional Health Development Ad visory Council in 1980. The use o f data collected by other United Nations agencies and intergovernmental organ izations in the Region, as well as data provided by the Member States them selves, should make it possible for the Regional Office to support its own programmes as well as to pro vide assistance to Member States. It is also expected that the Office’s fore casting capacity will be increased and the development o f positive health indicators facilitated. An important part o f the develop ment o f the Regional Office health in formation system will be the standard ization o f the data contained in it. Although mortality data are reasonably well standardized owing to the Inter national Classification o f Diseases, now in its ninth revision (ICD-9), other health-related information is not. Close collaboration in this field is maintained with the Division o f Health Statistics at WHO headquarters and with other interested bodies such as the Economic Commission for Europe and the Council o f Europe. Much use was made o f the facilities o f the Northern European University Computing Centre, especially in the field o f data presentation. The coloured maps o f Europe that appear in this report are an example o f the type of presentation available. 85 7.3 WHO P U B L I C A T I O N S A N D D O C U M E N T S During the period under review, publications continued to play a sig nificant role in the health information programme of the Regional Office. One major development was the introduction o f a new series o f publica tions: EURO Reports and Studies. The final reports on meetings, which were hitherto issued as documents, are now published in this series and are made widely available through the network o f WHO sales agents. The series is also used to publish the results o f studies and occasionally other suitable material. Particularly important was No. 14, en titled Primary health care in Europe, based on the report o f the Regional Director to the Alma-Ata Conference in 1978. Twenty-two issues in the new series appeared during the year. The period under review saw the publication o f No. 7 and No. 8 in the WHO Regional Publications, European Series, these being entitled, respec tively, Measurement o f levels o f health and Studies in drug utilization. The lat ter presents the outcome o f drug util ization studies in a number o f European countries, particularly from the point o f view o f prescribing patterns. The former publication was the result o f col laboration between the Regional Office and the International Epidemiological Association. The book explores the prevalence and incidence o f specific diseases and syndromes, and measure ments o f physical and mental condi tions, as well as the social function o f individuals and population groups and their behaviour or attitudes towards health and health-related activities. Two issues in the series Public Health in Europe appeared, No. 10 entitled Psychogeriatic care in the community and No. 11, Crisis admission units and emergency psychiatric services. The for mer publication explores ways in which the care o f elderly people who are men tally ill may be undertaken within the framework o f the comprehensive com munity health services that are evolving in most European countries; the latter presents the results o f a study of 15 crisis admission units in 8 countries. French editions o f four publications already available in English appeared: Energie nucléaire et santé (OMS, Publi cations régionales, Série européenne, No. 3), and Nos 6, 7 and 8 in the series La Santé publique en Europe entitled, respectively, La coordination des services de santé et des services sociaux dans quatre pays : Autriche, Italie, Pologne et Suède; Formation et emploi des auxiliaires dentaires; and Santé et en vironnement. The first Russian editions o f publica tions under the agreement between the Regional Office and the Moscow pub lishing house “ Medicina” appeared during the year. Both were in the series WHO Regional Publications, European Series: No. 3, Health implications o f nuclear power production and No. 4, Hospital- acquired infections: guidelines to lab oratory methods. Efforts were continued to encourage translation o f the Office's publications into non-working languages. A well- known Spanish publishing firm applied for the translation rights o f Measure ment o f levels o f health. A number of requests for the translation rights o f final reports on meetings were received from 86 Japanese institutions, and other re quests were received from Italy and Poland. Certain countries have expressed a wish to widen the dissemination of Regional Office publications to appropriate institutions to ensure that they reach the persons for whom they are intended. The Office is anxious to support such efforts in all coun tries o f the Region. A request for the regular distribution o f publications was received from the Canadian health authorities. The Office has strengthened its relations with two publishing houses in the United Kingdom who have shown willingness to publish manuscripts that exceed the capacity o f the Office to produce internally. The first publi cation resulting from this arrange ment appeared in 1979: Hospital util ization: an international study, by R.F. Bridgman. As part o f the effort to provide accurate, up-to-date, relevant and easily available information and, at the same time, to improve project delivery, the production o f short-term consul tant reports was made more system atic. This included the summarizing of recommendations in a standard form which should make it possible for both national authorities and the Regional Office to evaluate their im pact, both in the short and in the long term. It is greatly appreciated that, wherever possible, Member States per mit the derestriction o f these tech nical reports and thus allow wider dissemination o f information and the consequent sharing o f experience. 7 .4 H E A L T H L E G I S L A T I O N The consultant in health legisla tion at the Regional Office, whose employment is financed by a volun tary contribution from the Govern ment o f Belgium, continued to build up the health legislation programme for the European Region. The intro duction or updating o f legislation is becoming vital for an increasing num ber o f health programmes, and this is a matter o f concern not only for national authorities but for intergovern mental organizations in the Region. Technical cooperation continued with Member States, with the consultant visiting authorities in Denmark, Greece, Morocco, Portugal, the USSR and the United Kingdom (Scotland). The net work o f correspondents was extended from 11 to 18 and another 5 potential participating institutes were visited. Eight countries were provided, at their own request, with advice on improving their legislation on such matters as: the health professions (general practitioners, ophthalmologists, dentists); communi cable diseases (rabies in urban areas, compulsory immunization); food hy giene; abortion; care o f the dying; and the legal and social protection o f minors. In 1979 particular attention was paid to developing collaboration with non governmental organizations specializing in legislation relevant to Regional Office programmes, such as the World Associa tion for Medical Law, the International Commission o f Jurists, the Interna tional Council o f Environmental Law, and the International Federation for Information Processing. Work also con tinued in support o f other Regional 87 Office programmes such as workers’ health, health education and social sciences, accident prevention, family planning, and research promotion and development. The consultant was par ticularly involved in the Working Group on Legislation concerning Nursing/Mid wifery Services and Education, held in Hamburg in December. 7.5 H E A L T H L I T E R A T U R E S E R V I C E S The main concern during the year was the improvement o f library services in direct support o f Regional Office pro grammes. Assistance continued to be given to country projects through pur chasing literature and supplying refer ences and photocopies. As a first step towards a European exchange o f information on health planning, collaboration was begun with institutes participating in HECLINET (Health Care Literature Information Network) and with the US National Health Planning Centre. HECLINET records the entire European litera ture on hospital planning and manage ment; all reports on meetings and other publications issued by the Re gional Office are indexed at the Danish Hospital Institute and included in HECLINET. Contacts were made with the Bio logical and Medical Sciences Section o f the International Federation o f Library Associations and Institutions (IFLA ), with a view to coordinating projects and activities in the European Region. 7.6 H E A L T H I N F O R M A T IO N O F T H E P U B L IC The Declaration o f Alma-Ata marked a turning point for public information in the European Region. Before that, there was no overall mandate for such activ ities, beyond giving support to resolu tions adopted by the World Health As sembly and to activities organized by the Regional Office. The Declaration con sists o f solemn engagements by the world health community, including the 32 Member States o f the European Re gion, to promote the goal o f “ health for all by the year 2000” , and a new rela tionship has thus been established be tween the governments and the Regional Office which, as far as public informa tion goes, implies a much better co ordinated effort from both sides than was previously the case. The fact that the Declaration may be interpreted in different ways, according to the needs and priorities o f each country concerned, suggests that close consultation is es sential to avoid misunderstanding on the part o f the public. Much o f the public information work continued to reflect the Organization’s activities and interests. Thus World Health Day, the theme o f which was “ a healthy child, a sure future” , was cele brated jointly with UNICEF/UNIPAC in Copenhagen and visits were exchanged between the staff o f both organizations. Progress towards the global eradication o f smallpox was publicized through the distribution o f kits, posters and other material and by assisting WHO head quarters in organizing a travelling ex hibition to various airports in the Euro pean Region. 88 Environmental protection was an other subject that was emphasized by the Public Information unit. Chemical safety in particular was highlighted at a press conference at the Regional Office and at a press luncheon organized by the Government o f Finland during the twenty-ninth session o f the Regional Committee. By the end o f the year it was already apparent that the theme o f “ health for all by the year 2000” could not be publicized through general philosophical statements but needed to be based on concrete situations relevant to the European Region. Various meetings, among which nursing and appropriate technology in health laboratories were prominent, offered excellent opportun ities to explain the new concept to journalists in Brussels, Hamburg and London. In each case it was stressed that the concern o f WHO was not limited to the developing world but included the industrialized areas as well. Queries from the media were fre quently received to ascertain the latest WHO policy on such topics as tradi tional medicine, essential drugs and schistosomiasis. There was therefore close contact with the Division of Pub lic Information at headquarters to keep abreast o f new developments. In that connexion the Public Information Of ficer attended the Nordic Journalist Encounter organized by the Norwegian Agency for International Development (NORAD) in Oslo on the subject o f in fant foods in the developing countries. He also took part in the Joint United Nations Information Committee annual meeting o f information officers in Helsinki, which gave him an opportunity to meet counterparts from national development agencies. H E A L T H IN F O R M A T IO N E xp en d itu re (U S $ ) 1 4 9 4 6 5 3 3 8 158 1 5 3 2 8 1 1 ° a Being 9 .59% o f to ta l expenditure. R egu lar fun ds UN fu n ds V o lu n tary fun ds 89 GENERAL SERVICES AND SUPPORT PROGRAMMES Chapter 8 8.1 P R O G R A M M E P L A N N I N G A N D G E N E R A L S U P P O R T As proposed by the Consulta tive Group on Programme Develop ment in its third meeting in April, a meeting o f the Consultative Group on Budgetary Questions will be con vened in March 1980. Towards the end o f the period under review prep arations were made, in collaboration with the Executive Management o f the Regional Office, for one day to be spent discussing topics o f mutual interest with the Consultative Group on Programme Development and one day discussing some o f the practical and budgetary implications. Reorganization in the Regional Of fice resulted in a new unit, Text Pro cessing and Secretarial Training, being added to the support programme. This involved the purchase o f new electronic word processing equipment as well as the relocation o f staff through out the Regional Office’s various build ings to make room for staff and equip ment. In addition to text processing, the gradual changeover to computer ization throughout the Organization made particular demands on the sup port programme. At the Regional Office, the support programme is par ticularly involved (a) with that part o f the introductory stage o f com puterization already in use for bud get and finance tasks; (b) with the planned eventual incorporation o f per sonnel and supply applications; and (c) with the fact that the introduc tion o f these facilities constitutes a pilot study with a view to the event ual extension o f computerization to the other regional offices. The shortage o f space became even more acute, owing not only to the re organization described above but also to the Regional Office’s new responsibility for global programmes and the intro duction o f German as a working lan guage. Discussions with the Danish Government on the possible financing and construction o f an extension to the main building were initiated late in the year. Currency fluctuations stabilized to wards the end o f the period and, owing 9 1 to the allocation o f additional funds from headquarters and to considerable voluntary contributions from several Member States, the Regional Office was able to implement its programme for 1979. 8 .2 S T A F F D E V E L O P M E N T A N D T R A I N I N G The Regional Office maintained an interest in the development and training o f its staff in the necessary technical skills, as well as in manage ment and teamwork for staff at all levels. A course on management in health services development and an other on teamwork in office manage ment were attended by staff members, with encouraging results. A general review was carried out during the year and a medium-term programme for staff development and training was drawn up. 8.3 P E R S O N N E L During the period under review three professional posts were abol ished, one at the Regional Office and two in the field. One o f the field staff posts had been financed by UNDP. Three new professional posts were established at the Regional Office, one o f which was financed by UNDP. At its sixty-third session the Execu tive Board adopted resolution EB63.R25, approving the Director-General’s pro posal to set a specific target o f 20% for the recruitment o f women to the professional and higher grades. Fig. 10 shows the numbers o f men and women employed at the Regional Office and in the field in 1979; 18.7% o f the posts in the professional and higher grades were held by women. 8 .4 S U P P L IE S The work o f the Supplies unit in connexion with the malaria emerg ency in Turkey continued, the major items being insecticides, chloroquine tablets, and spraying equipment. The provision o f laboratory equip ment for projects dealing with a range o f subjects from cardiovascular diseases to environmental pollution was also a feature o f the work in 1979. 8.5 C O N F E R E N C E , O F F I C E A N D B U I L D I N G S E R V I C E S Some 1650 persons attended the 75 WHO-sponsored meetings held during the year, 32 o f which took place at the Regional Office. The number o f non- WHO meetings held on Regional Of fice premises continued to increase; 113 such meetings attended by 2824 per sons took place during the period under review. 92 N um be r of st af f F i g . 1 0 . N u m b e r s o f m e n a n d w o m e n e m p l o y e d a t t h e R e g i o n a l O f f i c e a n d i n t h e f i e l d i n 1 9 7 9 40 30 20 10 И m t ■ М я М й п P1 P2 P3 P4 P5 P6 D1 Professionals and higher men CO 4— О к.Q)-Q E и m r~i D2 UG General service 8.6 B U D G E T A N D F IN A N C E A total o f US$ 11 588 072 was ex pended, representing 99.98% o f the regu lar budget allocation. Under other funds, which included UNDP, UNFPA, UNEP, the Voluntary Fund for Health Promotion, Funds-in- Trust, the Special Account for Servicing Costs and the Real Estate Fund, a total of U S$4 371 554 was disbursed. In ad dition, U S $ 3 1 8 0 0 was contributed by the Government o f Finland towards the cost o f the twenty-ninth session o f the Regional Committee in Helsinki. Member States have provided con siderable assistance by covering the local costs o f WHO meetings and o f the at tendance o f national experts at meetings abroad. The collaboration o f institutes in Member States in the research pro gramme o f the Regional Office is another form o f assistance which is not easily expressed in monetary terms. A breakdown by source o f voluntary contributions received during the year is shown in Table 4. Table 4. Voluntary contributions, including Funds-in-Trust, received during 1979 (US$) Austria 163859 Belgium 116 494 Denmark 109 328 Finland 24 888 Germany, Federal Republic of 268 489 Ireland 2 500 Luxembourg 7 882 Netherlands 25 363 Norway 123546 Saudi Arabia 100000 Sweden 41 809 Switzerland 90 361 Japan Shipbuilding Industry Foundation 15000 Imperial Chemical Industries 9 126 USAID 66 400 1 165 045 3 Of which US$452 739 was provided for malaria control. 94 G E N E R A L S E R V IC E S A N D SU PPO R T PROGRAM M ES Expenditure (U S $ ) Regular funds Real estate funds Special account for servicing costs UN funds Voluntary funds a Being 25.53% o f to tal expenditure. 3 8 9 2 5 2 7 1 0 6 0 1 1 33 000 51 179 4 0 8 2 7 1 7 a 95 A n n e x 1 ACTIVE AND NON-ACTIVE MEMBER STATES OF THE WORLD HEALTH ORGANIZATION, EUROPEAN REGION 31 December 1979 At 31 December 1979 the European Region o f the World Health Organization had 32 active Member States and 2 non-active Member States. They are listed below with their date of entry to the Organization. Albania 26 May 1947 Algeria 8 November 1962 Austria 30 June 1947 Belgium 25 June 1948 Bulgaria 9 June 1948 Byelorussian S S R fl 7 April 1948 Czechoslovakia 1 March 1948 Denmark 19 April 1948 Finland 7 October 1947 France 16 June 1948 German Democratic Republic 8 May 1973 Germany, Federal Republic o f 29 May 1951 Greece 12 March 1948 Hungary 17 Jun e 1948 Iceland 17 Jun e 1948 Ireland 20 October 1947 Italy 11 April 1947 Luxem bourg 3 Jun e 1949 Malta 1 February 1965 Monaco 8 Ju ly 1948 Morocco 14 May 1956 Netherlands 25 April 1947 Norway 18 August 1947 Poland 6 May 1948 Portugal 13 February 1948 Romania 8 June 1948 Spain 28 May 1951 Sweden 28 August 1947 Switzerland 2 6 March 1947 Turkey 2 January 1948 Ukrainian S S R a 3 April 1948 U S S R 24 March 1948 United Kingdom 22 Ju ly 1946 Yugoslavia 19 November 1947 a Non-active Member State. 97 A n n e x 2 PROFESSIONAL STA FF IN THE EUROPEAN REGION 31 December 1979 R E G I O N A L O F F I C E Executive M anagement (O ffice o f the Regional Director and the Director, Programm e M anagement) Regional Director Dr Leo A. Kaprio Ms C. Celinder D irector, Programm e M anagement Dr J.E. Asvall (attached units and supporting staff) Coordination with Other Organizations Dr C. Guttuso Ms N. Humbert Country Health Programming Vacant Programme Monitoring Ms V.S. Pedersen Research Prom otion and Developm ent Dr B.Z. Nizetic Developm ent o f Com prehensive Health Services Director Dr D.K. Sokolov A ppropriate Technology for Health DrA.H. Wahba Epidem iology Dr Z.J. Brzezinski Mr A.J. Ester man Fam ily Planning Ms W. Haddad Health Care o f the Elderly Dr D.M. Macfadyen Ms F.A. Palmera Health Econom ics Dr H.F.K. Zöllner Maternal and Child Health Dr M.O. Wagner Primary Health Care Dr H. V. Vuori Prophylactic, Diagnostic and Therapeutic Substances Mr A. Grimsson W orkers’ Health Dr M.I. Miheev Disease Prevention and Control Director Dr M. Postiglione Accident Prevention Dr C.J. Römer Ms F.A. Palmera Chronic Diseases Dr G. Lamm Com m unicable Diseases (including Malaria) Dr B. Velimirovic Mr Y.H.R.R. Timmermansa General Preventive Services Vacant a Half-time. Disease Prevention and Control (con td) Mental Health Dr A.E. Baert Mr J. U. Hannibal Oral Health Dr I.J. Miller0 Prom otion o f Environm ental Health Director Mr J.I. Waddington Basic Sanitary M easures Mr E.R.J. Giroult Environm ental Health Planning and Management Mr C.A. Ferullo Environm ental System s M anagement Dr A. Gilad* Food Safety Programme Ms B. Blomberg R ecognition and Control o f Environm ental Hazards Dr M.J. Suess Toxicology Vacant Health Manpower Developm ent Director Dr A.M. Wojtczak Educational Developm ent and Support Dr L.A. Judin Fellow ships Adm inistration Mr E.C. Fricke Ms E. Miklikova Mr Y.H.R.R. Timmermansc Mr I. Tolstoy Fellow ships and Prom otion o f Training Dr R. Manrique de Lara Health Education and Social Sciences Dr A.P. Woudenberg Health Manpower Planning and M anagement Dr W.E.P. Fritsche Nursing Dr D.C. Hall Ms M.O. Abbottd Ms E. Stussi a Paid by WHO headquarters, working part-time for EU R O . b Paid by UNDP. c Half-time. ^ Paid by WHO headquarters. 99 Health Inform ation Director Health Literature Services Inform ation System s Programm e D r A .A . Weber Ms A. Mercier Vacant Mr I. Vinther-Jtfrgensen Publications Vacant M r F .E . Theakston Public Inform ation M rJ.M . van Gindertael R eports Ms C .F. Murphy Translation and Editorial (Chief) Mr J.-M . D eram at (English) Mr P .J. Boyle Vacant Translation and Editorial (contd) (French) (Germ an) (R ussian ) Su pport Programm e Director Adm inistrative Services Budget and Finance Conference Services Personnel Vacant Vacant M sM .A . Chevreau D r M .T .L .F . L o r ion D r J .E . Raeder-Roitzsch Mr V.M. Sorokine Mr E .B . Mezevitinov Mr A.N . Grigoriev Mr R .S. Weil Mr C. G. Chatelier Mr G. Y. Derweduwen M r J.P . T. Mulvaney D r U.B. Rem itz FIELD STAFF Algeria A L G /E H P 0 0 1 (UNDP) - Training o f Sanitary Engineers, Algiers Sanitary engineer Dr J. Schulm ann A L G /E H P 0 0 2 (UNDP) - Training o f Sanitarians a t the In stitu te o f Health Technology, Algiers Sanitary engineer Mr D. Popovic Greece G R E /R C E 001 (UNDP) - Environm ental Pollution Control, A thens Adm inistrative A ssistant Mr J . N em fakos M orocco M O R /ESD O O l - Surveillance an d C ontrol o f Com m unicable D iseases, R ab at Biologist Dr F .Ä . G atti ICP/PTR 005 - San itary Engineering Centre, R abat Sanitary engineer Mr T.B .A. Zeribi Sanitary engineer D r N.O. Akm anoglu Turkey TUR /B SM 001 - Environm ental San itation , Ankara Sanitary Engineer Vacant Sanitary T utor Mr P. W. Jo lly TUR/EHPOOI (UNDP) - Urban Water Supply and Sew erage, A nkara Senior Technical Adviser Dr G. Watters T U R /E H P 0 0 3 (UNDP) - Environm ental Training an d Research in F o u r Universities, Istanbul Sanitary Engineer Mr S .J . Arceivala ICP/M PD 005 - Intercountry M alaria Team, Ankara Field O peration Manager Mr J O. Espinoza Cajina Adm inistrative O fficer Mr J .F . Bugge ICP/M PD 0 0 7 - Intercountry Project f o r Control o f Malaria in South-East E urope (UNDP/W HO) M alariologist Dr K. Lassen 100 Annex 3: Organizational chart o f the Regional Office , 31 D ecem ber 1979 Coordination w ith Other Organizations Country Health Programming E X E C U TIV E M A N A G E M E N T ' Programme M onitoring Research Promotion and Development D EV E LO P M E N T OF C O M PR EH EN SIVE H E A L T H SERVIC ES Appropriate Technology for Health Epidemiology Family Planning Health Care o f the E lderly^ Health Economics Maternal and Child Health3 Primary Health Care Prophylactic, Diagnostic and Therapeutic Substances Workers' Health D ISEASE P R E V E N T IO N A N D C O N T R O L Accident Prevention4 Chronic Diseases Communicable Diseases (including Malarial General Preventive Services Mental Health Oral Health P R O M O T IO N OF E N V IR O N M E N T A L H E A L T H Basic Sanitary Measures Environmental Health Planning and Management Environmental Systems Management Food Safety Programme Recognition and Control o f Environmental Pollution Hazards Toxicology H E A L T H M AN PO W ER D EV E LO P M E N T Educational Development and Support Fellowships Adm inistration Fellowships and Promotion o f T raining Health Education and Social Sciences Health Manpower Planning and Management Nursing H E A L T H IN F O R M A T IO N Health L iterature Services Info rm ation Systems Programme Publications Public Inform ation Reports Translation and Editorial SUPPORT PR O G R A M M E Adm inistrative Services Budget and Finance Conference Services A n n e x 4 INTERCOUNTRY" MEETINGS CONVENED BY THE REGIONAL O FFICE FOR EUROPE IN 1979 ICP/RCE 206(9) ICP/ADR 001(4) ICP/MNH 038 I ICP/CVD 003(9) ICP/SPM 004(4) ICP/ADR 040 ICP/RPD 006(2) ICP/RPD 004(2) ICP/RCE 304(1) Workshop on Monitoring o f Recreational Coastal Water Quality and Shellfish Culture Areas within the Framework o f WHO/UNEP Pilot Project MED VII, Rome, 17-19 January (English) Fourth Liaison Meeting on the Prevention and Control o f Road Traffic Accidents, Copenhagen, 29-31 January (English) Technical Advisory Committee on the European Mental Health Programme, Copenhagen, 6 -9 February (English) Working Group on the Development o f Coronary Care in the Community, Brussels, 12-14 February (English) Second Meeting o f Steering Group for the Study on Health Care o f the Elderly, Copenhagen, 2 2 -2 3 February (English) Technical Group on Planning and Organization o f Emergency Services, Toulouse, 2 4 -2 8 February (English, French) Planning Group on Evaluation o f Drugs and other Therapeutic and Diagnostic Substances, Copenhagen, 13-15 March (English) Planning Group on Standardization o f Methods, Measurements and Terminology in Biomedical and Health Services Research, Copenhagen, 19-21 March (English) Working Group on Health Aspects related to Indoor Air Quality, Bilthoven, 3 -6 April (English) a Several other meetings held during the year were financed through country project funds. Som e o f these, although not listed here, were o f considerable interest to more than one country. ICP/GPD 001(3) ICP/MCH 012 ICP/CVD 002(15) ICP/EDS 001 ICP/MPM 025 IC P/A D R 0 2 7 ICP/RPD 005(2) ICP/SPM 003 ICP/CVD 005(15) ICP/ESD 005 ICP/ADR 010 ICP/SPM 010 ICP/WKH 004 104 Interregional Planning and Coordination Committee on Pre vention of Road Traffic Accidents, Copenhagen, 24-25 April (English) Consultative Group on Programme Development, Copenhagen, 2 4 -2 6 April (English, French, German, Russian) Working Group on the Early Detection o f Handicap in Children, Faro (Portugal), 15-18 May (English) Working Group on the Prevention o f Ischaemic Heart Disease, Rome, 16-18 May (English) Seminar on Planning and Implementation o f Teacher Training Programmes, London, 23-25 May (English, Russian) First Meeting o f Researchers from Collaborating and Selected Participating Centres associated with the Medium-Term Pro gramme in Nursing/Midwifery in Europe, Copenhagen, 28 May — 1 June (English) Planning Group on Prevention, Prophylaxis and Early Detection, Brussels, 6 -8 June (English, French) Workshop on Country Health Programming (CHP) in European Health Planning and in Management Education, Vienna, 10- 15 June (English) Study on Effects o f Rehabilitation and Secondary Prevention in Patients with Cardiovascular Diseases — Meeting o f the Editorial Board, Heidelberg, 18-21 June (English) Ad hoc Consultation on Communicable Diseases, Copenhagen, 26-27 June (English) Technical Group on Protective Devices and Restraint Systems in Traffic Accident Prevention, Meknès (Morocco), 26 -28 June (English, French) Working Group on the Design o f Training in Health Planning and Management, Berlin (West), 3 -6 July (English) Joint HQ/EURO Task Group on Health Criteria o f Respiratory Diseases due to Vegetable Dusts, Copenhagen, 3 -9 July (English) ICP/WKH 001 ICP/RCE 903 ICP/CVD 018(5) ICP/HST 002 ICP/MPM 026 ICP/RCE 904 ICP/RPD 301 ICP/WKH 002(1) ICP/RPD 002(3) ICP/RPD 801 ICP/PHC 010 ICP/PHC 010 ICP/ADR 013 ICP/CV D 0 0 2 (1 6 ) Informal Meeting o f the Principal Investigators in the Study on Primary Prevention o f Ischaemic Heart Disease, London, 5-7 July (English) Consultation on Epidemiology o f Occupational Health, Copen hagen, 10-12 July (English) Consultation on Regional Cooperation on Environmental Health Aspects o f the Control o f Chemicals: Proposed UNDP/WHO Project, Copenhagen, 2 0 -2 2 August (English) Meeting on Comprehensive Community Cardiovascular Control Programmes, Novi Sad, 2 7 -3 0 August (English) Fourth European Conference on Health Statistics, Luxembourg, 28-31 August (English, French, German, Russian) Meeting o f Programme Managers from Collaborating Centres associated with the Medium-Term Programme in Nursing/Mid wifery in Europe, Copenhagen, 3 -5 September (English) Working Group on Criteria and Guidelines for Halogenated Aro matic Compounds, Venice, 3 -7 September (English) First Liaison Meeting on Health Research Coordination in the WHO European Region, Helsinki, 6 September (English) Working Group on Health Aspects o f Wellbeing in Working Places, Prague, 18-20 September (English) Third Meeting o f Planning Group on Information Systems for the Biomedical Research Promotion and Development Programme, London, 19-21 September (English) Workshop on Health Economics Research, The Hague, 24 - 27 September (English) Working Group on Health Problems o f Local and Migrant Popula tions in Arctic Regions, Copenhagen, 25-27 September (English) Consultation to Prepare the Outline o f a MTP on Arctic Medicine, Copenhagen, 28 September (English) Technical Group on Education in Traffic Safety, Essen, 2 -4 Octo ber (English) 105 ICP/CV D 0 2 2 Consultation on Hypertension Research related to Health Care, Copenhagen, 2 - 4 October (English, French, German, Russian) ICP/ATH 001 ICP/RPD 001(5) ICP/RCE 903(2) ICP/MPD 008 ICP/ADR 020 ICP/SPM 013(1) ICP/FSP 007 ICP/RCE 802(2) ICP/PHB 006 ICP/EHP 005 Working Group on Appropriate Technology in Health Labora tories, London, 2 -5 October (English) European Advisory Committee for Medical Research, Fifth Session, Prague, 17-18 October (English, French, German, Russian) Consultation on Proposed UNDP/WHO Project for Regional Co operation on Food Safety Services in Europe, Copenhagen, 2 3 - 25 October (English) Coordination Meeting on the Prevention o f the Réintroduction o f Malaria in the Countries o f the Western Mediterranean, Erice (Trapani, Italy), 23 -27 October (French) Interregional Planning and Coordination Committee on Health Care o f the Elderly, Copenhagen, 29-31 October (English) Meeting on the Development o f Health Economics, Aberdeen, 29-31 October (English) Working Group on Health Examination for Food-Handling Personnel, Copenhagen, 5 -7 November (English) Working Group on Health Aspects related to Actinides and their Decay Products, Brussels, 6 -9 November (English) Eighth European Symposium on Clinical Pharmacological Evalu ation in Drug Control, Cologne, 2 0 -2 2 November (English, German) Consultation on Study o f Professional Profiles — “ The Environ mental Health Officer in an Industrialized Society”, Copenhagen, 2 0 -2 3 November (English) ICP/RCE 206(10) Meeting on Shellfish and Recreational Coastal Water Quality Monitoring, Rome, 20-23 November (English, French) ICP/CVD 019(5) Study on Chronic Lung Diseases leading to Pulmonary Hyper tension - Meeting o f Investigators, Strasbourg, 22 -23 November (English, French) 106 ICP/MNH 054 ICP/RPD 008(2) ICP/SPM 008(1) ICP/CAN 012 ICP/ATH 005 ICP/BSM 002(4) ICP/SPM 021 ICP/ADR 029 ICP/SPM 004(5) ICP/SPM 015(2) ICP/SPM 007(1) ICP/CVD 002(17) ICP/CV D 0 2 3 Meeting o f National Mental Health Advisers, Bielefeld, 26 - 30 November (English, French, German, Russian) Planning Group on Economic Aspects o f Health Care, Copen hagen, 2 7 -2 9 November (English) Meeting o f the Steering Group for the Study on the Develop ment o f Systems for the Epidemiological Surveillance o f Long- Term Environmental Health Effects, Copenhagen, 2 8 -3 0 Novem ber (English) EURO/IARC Study Group on Cancer Screening, Copenhagen, 3 -5 December (English) Working Group on Quality Control in Health Laboratories, Brussels, 4 - 7 December (English) Planning Consultation on the European Study on Public Health Aspects o f Housing, Copenhagen, 4 -7 December (English) Working Group on Nursing/Midwifery in the Context o f Health Care Delivery Systems, Brussels, 4 -7 December (English, French, German) Second Preparatory Meeting for Conference on Road Traffic Accidents in Developing Countries, Paris, 6 -7 December (English) First Meeting o f the Editorial Board for the Report on the Study on Health Care o f the Elderly, Tampere (Finland), 10-12 Decem ber (English) Meeting on National Health Accounts, Leidschendam, 11- 13 December (English) Working Group on Legislation concerning Nursing/Midwifery Services and Education, Hamburg, 11-14 December (English, French, German, Russian) Meeting o f Principal Investigators o f the Primary Prevention of IHD by Reducing Blood Cholesterol-Atromid Trials, Geneva, 12-14 December (English) Meeting o f Investigators on New Monitoring Systems for the Incidence o f IHD in the Population, Geneva, 17-19 December (English) 107 Annex 5 European response to THE STUDY OF WHO’ S STRUCTURES IN THE LIGHT OF ITS FUNCTIONS (Résumé) Twenty countries o f the Euro pean Region supplied the Regional Office with replies to the questionnaire concerning the study on WHO’s struc tures in the light o f its functions. Staff in the Region and the Director-General o f the International Children’s Centre were also asked to comment. Docu ment EU R/RC29/5, containing an analy sis o f the replies, was then discussed at the twenty-ninth session o f the Regional Committee. Although the study carried out in the European Region was based mainly on the Director-General’s document DGO/78.1, it also took into account other sources o f information or appraisal, including the Declaration o f the New International Economic Order, the Final Act o f the Helsinki Conference on Security and Cooperation in Europe, the report o f the Executive Board on technical cooperation between develop ing countries, the Declaration o f Alma- Ata on primary health care, and the report to the Executive Board by its Pro gramme Committee on the formulation o f strategies leading to health for all by the year 2000. Analysis o f the replies received produced a fairly general consensus on a number o f points. With regard to the role o f WHO, it is recognized that, while in principle all Member States have equal rights, the Organization’s activities should vary according to need and to the level o f economic and social development. Europe is in a privileged position, which enables it to play a pioneering role in several fields. It would be advantageous for the Regional Office to achieve better coordination between its activities and those o f other regions that include coun tries with the same high level o f techni cal expertise. In this connexion, while WHO’s efforts should be directed chiefly at the developing countries, the special problems o f the industrialized countries should not be ignored. Replies vary concerning the possibil ity o f WHO playing a more “ political” role. It is generally acknowledged that, although WHO is primarily a technical organization, health is also a political problem. However, the countries are vir tually in full agreement that a develop ment o f this nature should not entail basic changes in the functions o f the Director- General and the regional directors. They all agree that the WHO Constitution has not exhausted its possibilities and does not need to be changed. There is broad approval o f the prin ciple o f interdependence between WHO programmes and national programmes, but practical difficulties are still being 109 encountered too frequently. Most coun tries believe that their collaboration with the Regional Office is satisfactory, in cluding that in the field o f research, but consultation procedures could be im proved. Practically all countries have a unit or service responsible for liaison with WHO, as well as health advisory councils, and only one-third feel that their ministries o f health should be strengthened politically and technically. However, other ministries having some kind o f responsibility for health should be included in mechanisms for closer coordination with WHO. With regard to the governing bodies o f the Organization, the main emphasis is on the need to ensure better liaison between regional committees, the Execu tive Board and the Assembly, to avoid excessive proliferation o f committees and working groups, and to exercise more rigorous control over the large number of resolutions. Nevertheless, no signifi cant changes are suggested in existing structures, and most countries favour a retention o f the present frequency o f sessions. Concerning the interrelationships among the different operational levels o f the Secretariat, the majority o f countries are in favour o f increasing the responsi bilities o f the regional offices. Neverthe less, they stress that any decentralization should be carried out with prudence and that headquarters should, in any event, remain the brain-centre o f the Organiza tion and the guarantor o f its unity. There is room for closer and better defined cooperation, and every effort should be made to avoid duplication, both with other United Nations bodies and with European organizations. Comments by countries reveal a gen eral desire to retain a structural system that has proved itself and achieved no table results. More systematic coordina tion o f the preparation, implementation and evaluation o f programmes should un doubtedly be sought, while information systems should be promoted and recip rocal links between various groups at the global, regional and national levels should be broadened. However, as one country emphasizes, “ efforts should mainly be concentrated not on internal organizational problems but on the most effective and active solution o f world health problems” . T H E R O L E O F WHO The role o f WHO worldwide It is unanimously recognized that, while in principle all Member States have equal rights, WHO cannot and should not play the same role in all regions and in all countries. The Organization’s activ ities must necessarily be oriented to the needs o f the various countries, which will vary according to the stage o f devel opment reached in the economic, social and health fields. Health should be regarded as an in trinsic element o f economic and social development. In pursuing the measures that stem from the New International Economic Order, the aim should be to reduce the gap between the level o f health in developed countries and that in de veloping countries. In this respect WHO has two essential functions: the coordi nation o f international health activities (developing health principles, collecting 110 and disseminating information, strength ening interregional collaboration and adapting activities to regional character istics); and technical collaboration with Member States (transfer o f resources from some countries to others). Doubts are expressed as to whether WHO should have a more “ political” role. It is generally believed that WHO is, above all, a technical organization within the United Nations system. It should remain so, in the interests o f maintaining its authority, by con centrating its efforts on the technical aspects and economic consequences o f health problems. Nevertheless, its technical orientation should not pre vent WHO from entering the political field in special cases where, for example, risks to the health o f a population could not be overcome simply by “ recommendations” . In fact, it is a mat ter o f agreeing on the meaning o f the word “ political” . WHO should, on no account, impose its own political opinions on a country, any more than it should impose those expressed by a majority o f Member States; on the other hand, under the terms o f Article 2 o f its Constitution, it does have the task o f calling the attention o f political leaders and public opinion to the high priority that should be accorded to health matters. The role o f WHO in the European Region The European Region is in a special situation since, on the one hand, it pos sesses considerable scientific and tech nical potential — to date insufficiently utilized by WHO - and, on the other hand, it is the only WHO region where developing countries are not in the majority. Transfer o f technology, knowledge and information can take place either by direct technical cooperation between countries, or by using the Regional Office as an intermediary, or through various regional institutions (the Council of Europe, the European Economic Com munity, the Nordic Council, the Council for Mutual Economic Assistance, etc.), with which WHO closely coordinates its activities. It is really at the intercountry level that the Regional Office finds its raison d ’être. In addition to the role o f catalyst, the Regional Office also fulfils a pioneering role in a number o f fields. The European Region would thus ap pear to be an ideal testing ground for health technologies capable o f being ap plied in developing countries around the year 2000. Nevertheless, such orientation and responsibilities must not be unilateral. Industrialized countries themselves have serious health problems, and at the twenty-ninth session o f the Regional Committee the Regional Office was seen to have a special responsibility towards in dustrialized society in general. Moreover, in Europe, the slogan “ health for all by the year 2000” should emphasize certain groups, for example the elderly, migrant workers, and isolated populations such as those living in arctic regions. IN T E R A C T I O N B E T W E E N WHO A N D M E M B E R S T A T E S IN P R O G R A M M E D E V E L O P M E N T , WITH P A R T I C U L A R R E F E R E N C E T O E U R O P E A N C O N D IT IO N S There is widespread acceptance of the principle o f interdependence in the planning o f WHO programmes and 1 1 1 national programmes, in other words integrated programme planning. The programming procedure should take place from the periphery towards the centre — global programmes resulting from regional programmes and regional programmes resulting, in turn, from national programmes. However, it is recognized that this principle o f interaction and inter dependence may be largely theoret ical. Representatives o f countries may adopt resolutions in WHO assemblies without always appreciating the con sequences o f implementing them. In addition, ministries other than the ministry o f health may formulate plans that are not necessarily in accord with health programming. While it is clear that priority must be given to decisions and options at the national level, WHO should use its tech nical competence and influence to in volve countries in programmes, the need for which may not be evident to them. The Organization should also encourage countries to rationalize and coordinate the planning o f those programmes, not only with WHO but also with UNDP and other institutions and sources o f assistance. Moreover, programmes o f na tional scope should not conceal the value o f limited pilot projects, which have a far-reaching effect. It is suggested that the consultation procedures used in the European Region for the preparation o f programme bud gets be expanded and strengthened, especially with regard to medium-term planning. When establishing priorities, more consideration should be given to countries’ financial means and budgetary arrangements. Universally applicable solutions to the problem o f ensuring that governments apply in their own countries the policies they adopt in various WHO assemblies, and that their requests for technical co operation comply with those policies, cannot be envisaged: conditions, possi bilities and the opinions o f governments vary from one country to another; governments themselves change; and rep resentatives at WHO assemblies return home to find themselves faced with new requirements. However, the Executive Board could conduct a study on methods of implementing and applying WHO recommendations at the national level, the results o f which would then be sub mitted to the Assembly. Generally speaking, ministries o f health and other national institutions, but not parliamentarians, are made aware o f WHO resolutions, recommenda tions, reports, etc. WHO documents are taken into consideration in the health planning process. Efforts to keep the general public informed deserve to be intensified. Most countries believe that collab oration between the Regional Office and Member States is satisfactory. The Euro pean Region, which contains a large majority o f developed countries, could with advantage increase its collaboration with other regions such as the Western Pacific Region, where there are several industrialized countries with problems similar to those in Europe. With regard to cooperation between the developed and developing countries, there could also be value in calling up on the resources o f countries at an inter mediate level o f development. The trans fer to developing countries o f technology 1 1 2 used by the most highly developed coun tries should take the necessary adapt ations into account. There should be adequate support for regional and national training centres by making available technical person nel to instruct teachers, and by pro viding the necessary equipment. It is suggested that more information be provided on achievements likely to in terest developing countries, that a pre cise list be drawn up o f the health prob lems faced by those countries between now and the end o f the century and o f the links between them, and that de veloping countries be given responsibil ity from the beginning. With regard to technical cooperation among developing countries (TCDC), opinions differ as to the need for struc tural changes in regional offices. Plans for cooperation between two or more countries (with WHO participation) might be envisaged, or annual meetings could be held to evaluate the results o f past activities, establish new prior ities and compare experience. Efforts should clearly include the exchange o f scientific experts, the development o f specific teaching, training and research programmes and an increase in the number o f seminars. Attention is drawn to the fact that, apart from official collaboration, both multilateral and bilateral, there are wide possibilities in the private sector. Initia tives in the latter are often more adaptable than activities in the public sector to the requirements o f national health planning. Coordination o f TCDC in the health field is clearly within the scope o f WHO, in consultation and liaison with UNDP, where specific health-related programmes are concerned. Such coordination falls within the overall responsibility o f UNDP, in consultation and liaison with WHO, when the problems relate more to economic and social development. N A T I O N A L S T R U C T U R E S T O S U P P O R T C O O P E R A T IO N WITH WHO In order to reflect systematically the technical advice o f WHO in the national health planning process, it would appear that the governments consulted have in formation resources and administrative machinery that are, on occasion, inad equate. Such machinery is more difficult to set up in states with a federal struc ture. More often than not, organized controls do not exist. Some countries indicate the role played in this connexion by their higher health councils; others mention that there are various consulta tive committees, seminars and working groups to apply the policies adopted by WHO assemblies, and in addition greater attention is paid to the selection o f na tional representatives at the World Health Assembly and the Regional Committee. Countries are concerned to improve these mechanisms by providing better informa tion and wider publicity services, and by developing a proper plan o f technical co operation with WHO. Only one-third o f the countries consulted acknowledge that their minis tries o f health need strengthening either politically or technically. Personnel re sources are generally insufficient in rela tion to the volume and complexity o f the tasks involved. Technical and admin istrative functions should be developed 113 simultaneously, and not some at the ex pense o f others. One country considers that the need for strengthening ministries o f health differs among countries. In in dustrialized countries, the resources for public health are often distributed among several ministries, many problems have al ready been solved, and less need is felt for a “ political strengthening” o f ministries o f health. In developing countries, the gap between needs and resources is more marked. The ministry o f health may run the risk o f being in competition with or inferior to other ministries, which are able to furnish in the short term more convincing statistically based proof o f their activities and efficiency. However, it is pointed out that the developing countries do not have to cope with the burden o f tradition and acquired situa tions, which is frequently the case in industrialized countries. In almost all the countries consulted, the ministry o f health has one or several health advisory councils. Generally these are made up o f the most competent per sons in the sector concerned, together with representatives o f the ministry, and thus there is a dialogue between techni cians and administrators. They give their opinions on the various problems submit ted to them, as well as on legislative and statutory texts. In certain countries they set up permanent committees. The estab lishment o f such councils in all Member States is strongly recommended. As regards contacts with WHO, al most all ministries o f health have a unit, section or service dealing with interna tional relations. However, the ministry o f health is not necessarily the only agency concerned with the WHO programme in a country, and coordination between all those concerned could be improved. Conversely, there is often a need for interministerial coordination o f the pro grammes o f all international organizations in a country. The question of WHO programme co ordinators is not o f direct concern to the European Region. Their abolition in the developing countries is viewed favour ably, but this can only take place gradual ly, depending on the rate at which such countries are able to develop their own administrative and coordinating struc tures, not only within the country, but also within the region as a whole and at the global level. WHO programme co ordinators need not necessarily be physicians. National institutions could be better and more fully utilized in the develop ment o f WHO programmes and in train ing and research activities. This calls, above all, for improved information, a widening o f contacts and field visits, and better coordination among national insti tutions dealing with subjects o f direct interest to WHO. However, the reverse is also true: it is necessary to ascertain not only how WHO can make better use o f national institutions but also what the Organization, in its turn, can offer them. It is emphasized, nevertheless, that while it is advisable to entrust experi mentation in new programme concepts to countries themselves, it might prove injudicious to pass the responsibility for whole programme areas to WHO collab orating centres, since this would entail the risk o f their exceeding their advisory role. Similarly, greater dependence on nongovernmental organizations is not without some risk to the independence o f WHO, and a prudent approach in this field is advocated. 114 WHO S T R U C T U R E S : G O V E R N I N G B O D I E S Regional committees (Regional Commit tee for Europe) The WHO Regional Committee for Europe is generally seen as fulfilling an essential role, in that it comple ments and possibly amends the role o f other regional institutions. The participation o f Member States should be still further increased and intensi fied. However, the suggestion that governments should send the same representatives to the Assembly and the Regional Committee, to ensure continuity and coherence in their relations with WHO, is regarded by some countries as difficult to institute because the Assembly has a broader and more international mandate. The staff recommend that the Regional Committee meet more often in Copen hagen to facilitate contacts between themselves and country representatives. One country stresses the import ance o f the Consultative Group on Programme Development, which has shown itself to be not only a useful tool for providing advice to the Re gional Director but also an integrating force within the Regional Commit tee. Membership o f the Group should be on the basis o f rotation, although continuity should be ensured. Improvements in relations between regional committees, the Executive Board and the Assembly depend mainly on the provision o f better reciprocal in formation at the various levels. There is insufficient liaison between the regional committees themselves, and interregional cooperation should be further developed. There is a case to be made for strengthening the influence o f the regional committees in the prepara tory work on problems for discus sion in the Executive Board and the Assembly, and in the drawing up of their agendas. With regard to resolutions, it is largely agreed that the present system of presentation does not provide guarantees on such factors as applicability, duplica tion and unforeseen financial develop ments. Opinion is almost equally divided on whether all or certain resolutions should be submitted to the relevant regional committee before they are sub mitted to the Executive Board or the Assembly. It is admitted that this would be a good method of facilitating the selection and processing o f resolutions, but administratively it would be very cumbersome. Representatives o f countries should retain their right to submit draft res olutions during the Assembly. On the other hand, it would be useful if, without the delegates’ right o f initi ative being limited, the Assembly could decide to postpone certain resolu tions until its next session or to have them discussed beforehand by the regional committees concerned. As regards the regional affiliation o f certain countries, it is generally agreed that bringing the WHO regions into conformity with the structures o f the United Nations system would be a logical and effective move, especially as the existing delineation o f the WHO regions does not always correspond with criteria purely related to health. Nevertheless, to certain countries a new division, and above all a multi plication o f regions, seems o f doubt ful value. The Executive Board Opinion is divided on the ques tion o f strengthening the work o f the Executive Board still further. Li aison with other organizations o f the United Nations system should be in tensified; on the other hand, the setting up o f subgroups or subcommittees o f the Executive Board should not be excessive, and should not result in duplication. The Board should not interpose itself between the regional committees and the Assembly but, on the contrary, should give more attention and time to the reports o f regional committees. Documents should be submitted to the Board sufficiently far in advance. The duration o f the session following the As sembly should be extended and the agenda made more detailed. One country considers that Executive Board members could play a greater part in the prepara tion o f important documents, for ex ample those relating to medium-term programmes. It is generally felt that the number of members o f the Executive Board should not be increased. However, one country considers that there could be wider representation o f disadvantaged regions. Another queries whether the system whereby Executive Board members make interventions in a personal capacity should be retained. The work o f the Assembly would be facilitated if the preparatory docu ments were distributed sufficiently early to be examined in good time and if there were stricter selection o f topics for discussion, thus enabling certain matters to be considered by the Ex ecutive Board or subgroups and ad hoc committees. One country considers it advisable to limit the time devoted to statements in plenary session, while another feels that in recent years the Assembly has spent time on matters having no direct link with the basic objectives o f WHO. There are too many resolutions, often uselessly re peated from year to year. It would be preferable to monitor the implementa tion o f resolutions already adopted rather than concentrate on adopting new resolutions. There are different opinions on the frequency o f Assembly sessions; they centre on shorter annual sessions or sessions every two years. It is suggested that a survey might be undertaken to ascertain what economies would be made from holding biennial sessions, and what difficulties and additional work would be imposed on the Ex ecutive Board. The timetables o f the three governing bodies should, in any case, be re-examined and better co ordinated. The idea that the Assembly should make greater use o f conventions (Ar ticles 19 and 20 o f the Constitution) is received with some reservations. It is feared that the two-thirds majority provision would lead to compromises that would improve neither the work nor the prestige o f the Assembly. The World Health Assembly WHO STRUCTURES: THE SECRETARIAT Regional offices (Regional Office for Europe) and their relations with WHO headquarters Distribution o f tasks and authority between WHO headquarters and the Regional Office The Director-General’s objective of “ health for all by the year 2000” , which makes health a fulcrum for economic and social development and a spring board for peace, does not seem to imply major changes in the structures o f the Secretariat. It is generally thought that the Director-General has no need o f an additional support group to ensure his “ political” role concerning which, as already noted above, some doubts are expressed. There should be no essential changes in the functions o f the Director-General. He is the guardian o f the rights o f Mem ber States, he is entrusted with imple menting the guiding principles o f WHO, and he ensures collaboration between WHO and all those organizations that, in one way or another, are working to achieve solutions to the problems con fronting mankind. The interrelationships between dif ferent operational levels in the Secre tariat require, as a first essential, an adequate and rational flow o f informa tion, systematic mechanisms o f com munication and consultation, and broader national participation. Decentralization is the logical con sequence o f the priority accorded to country health programming. In the case o f the developing countries, it guarantees their greater independence. In the Euro pean Region, it should arouse greater interest in the programmes and strengthen action at the national level. However, a distinction should be made between genuine decentralization and the mere transfer o f activities from headquarters to the regional offices, as is the case with certain programmes for which the Re gional Office for Europe is at present responsible. WHO headquarters should remain the brain-centre o f the Organization and the guarantor o f its unity by con tinuing to centralize certain specific activities (for example, international classifications, standards and norms). Any lessening o f the authority o f the Assembly and the Executive Board to the benefit o f regional committees could result in the creation o f six sep arate health organizations. There is room in WHO programmes for closer cooperation with other United Nations agencies and for the use o f their experts, particularly in such fields as population problems, environmental health, nutrition, education and train ing, and social questions. Several ex amples o f duplication are cited, not only with United Nations bodies (FAO in nutrition, UNESCO in training, ILO in industrial medicine, UNFPA in maternal and child health, UNEP in environmental sanitation, etc.) but also in some instances with European or ganizations, both intergovernmental and nongovernmental. WHO and the various organizations concerned should strive for a better understanding o f their respective functions, and possibly have 117 recourse to the assistance o f the United Nations Joint Inspection Unit, Structure o f the Regional Office In so far as regional directors might be required to assume a greater pol itical role it is thought that, as in the case o f the Director-General, there would be no need for a new consulta tive group to provide them with “ politi cal protection” . It is generally agreed that the Or ganization could profitably use ex ternal specialists to study its manage ment procedures and structures. One country notes that it would be use ful to call upon the services o f the United Nations Joint Inspection Unit in this connexion. Consultative bodies The question was raised as to whether a network o f national experts would be preferable to panels o f regional experts in the European Region. If such experts are requested, perhaps on a rotation basis, to work outside their own countries, they become regional experts and there is no con flict between the two categories. It would even be possible to envisage panels o f “ subregional” experts who would work in countries neighbour ing on their own with similar prob lems and linguistic affinities. One country considers that it would be generally desirable for WHO to broaden its scientific base, while respect ing the essential geographical balance as far as countries o f origin o f experts are concerned. P R A C T I C A L C O N S E Q U E N C E S O F P R O P O S E D C H A N G E S Changes in the WHO Constitution It is unanimously agreed that the WHO Constitution does not require to be changed and that its possibilities have not yet been exhausted. Nevertheless, one country believes that more system atic use should be made o f certain points in the Constitution. Another reply re lates to Article 13 and the possibility o f biennial Assembly sessions to coincide with biennial budgeting. Concerning the appointment o f regional directors, one country notes that Article 52 does not indicate the procedure to be followed in the case o f disagreement between the Executive Board and the regional com mittee. Finally, one country suggests that regional directors could be nom inated by the Director-General; this would increase their independence o f Member States. It is also suggested that their term o f office should be renewed only once. Changes in the rules Several countries express some scep ticism regarding the need for basic changes in the rules; changes should occur, rather, in the working methods. One country, however, considers that changes would be appropriate on the following points: the unwieldiness o f current procedures (one country gives as an example cancer research and the anti cancer campaign where, within WHO it self, over 12 different organs are active, not counting the collaborating centres and the regional meetings on the sub ject); the often illogical division o f activities at WHO headquarters; the 118 growing number o f committees and working groups; and the inadequacy of horizontal communications, which have not been improved to the same degree as vertical communications. Changes in personnel policies Recruitment policy Several countries stress the need to observe adequate geographical distribu tion in selecting personnel, while others believe that, in so doing, the search for the best technical qualifications should not be adversely affected. One country considers that the tendency in regional offices to recruit staff almost exclusively from countries o f the region itself might jeopardize the unity, universality and efficiency o f the Organization. The staff would like to be represented at selection committees for posts o f all levels. One country proposed that contracts should not exceed a period of five to seven years: five years for public health physicians (those whom the Director- General’s document refers to as general practitioners) and shorter periods, o f one to two years, for experts in specific techniques. Such short-term contracts could, by a system o f rotation, make it possible to recruit highly qualified, competent and motivated persons in countries that are still under-represented. In any case, long-term recruitment plans should be formulated in conjunction with Member States. S ta ff training There is a generally favourable reac tion to the suggestion that the Regional Office for Europe be used as an in- service training centre for national personnel, but the ways and means o f implementing such a project need to be defined. Finance Many countries note that all struc tural changes, even if they seem justi fied, inevitably involve new expenditure, and they should not be brought about unless they are o f indisputable value, do not depart from established bud getary procedures, and do not place regions and Member States in unequal positions. Evaluation o f proposed changes There is unanimity on the need for such evaluation, which should establish a permanent and definite procedure, including time-scales. The elements to be considered are the following: — the economies achieved; - the cost-benefit study o f new measures; - the speed and effectiveness o f WHO action in the Member States; and — the satisfaction felt by Member States and the Secretariat as a whole. Such evaluation could be carried out on a trial basis in certain sectors or in a pilot region, in comparison with other regions. However, opinions differ on who should conduct this evaluation; a whole range o f authorities is men tioned in that connexion, from the Mem ber States themselves to regional com mittees, the Executive Board and the Assembly. One country suggests that the Executive Board, assisted by quali fied former members o f staff, should carry out the evaluation. 119 D I S T R I B U T I O N O F R E P L I E S T O K E Y Q U E S T I O N S Answer Yes No ° ther opinions Q u est ion 4.1 Should WHO play the same role in all regions and for all Member States? 13 5 9.1 Do you agree that no change is needed in the WHO Constitution? 17 1 21.1 Are WHO resolutions submitted to the appropriate legislative com missions, ministerial departments and other agencies involved in health policy formation? 17 1 21.2 Is WHO technical advice, as expressed in resolutions, recommendations by WHO expert committees, working groups, etc., systematically fed into the health planning system in your country? 15 3 25.1 Do you feel that your Ministry o f Health (or its equivalent) needs to be strengthened politically and/or technically? 5 10 3 26.1 Does your country have a national health advisory council? 13 3 2 32.1 Are you satisfied with the present arrangements for cooperation among Member States in the European Region? 13 2 3 36.1 Are you satisfied with the consultation procedures in the European Region for programme budget preparation? 9 2 7 37.1 Are you satisfied with the steps taken so far by the Regional Office for Europe in the field o f health services research? 14 1 3 40.1 Is there a need to strengthen the Executive Board? 7 6 5 43.1 Should the Assembly make more use o f conventions (see Articles 19 and 20 o f the Constitution)? 4 6 8 46.1 Should the Assembly be held annually? 10 6 2 48.2 Should all resolutions first be submitted to the regional committee of the region where they originate before going to the Board and the Assembly? 9 9 48.3 Should all or only certain types of resolutions be discussed by all the regional committees before being submitted to the Board and the Assembly? 4 8 6 53.1 Should the Regional Office for Europe be used more extensively for in-service training of national staff (at Member States’ expense and for periods o f several months to two years)? 8 7 3 58.1 Is there a specific unit in your Ministry o f Health (or its equivalent) for handling WHO matters? 15 3 66.2 Is there a need for any additional group to advise the Regional Director? 3 11 4 N.B. Tw o Member States made general comments that did not follow the order of the Director- General’s document or o f the questionnaire. 120 A n n e x 6 ACTIVITIES OF THE WHO REGIONAL OFFICE FOR EUROPE, IN COOPERATION WITH MEMBER STATES AND OTHER INTERNATIONAL ORGANIZATIONS, IN THE FIELD OF ENVIRONMENTAL HEALTH by Dr R.J.H. Kruisinga WHO Senior Adviser At the twenty-eighth session o f the Regional Committee for Europe, the Re gional Director reported that in line with the emphasis given to environmental questions by the Belgrade meeting, fol lowing the Helsinki Conference, the ser vices o f a senior adviser had been retained to study the role that the Regional Of fice could play in such matters. During the period of the writer’s assignment, undertaken on that basis, several meetings and discussions were held with intergovernmental organiza tions and government authorities in the Member States o f the European Region, and the findings are reflected in the present report. The assignment was completed in July 1979. The main finding is that the action taken in implementing the decisions o f WHO headquarters and the Regional Office, in relation to Member States, United Nations agencies and other organizations, has been marked by a cer tain lack o f consistency between the content o f the decisions and their practical implementation. Included in this report are brief descriptions o f the WHO global and regional medium-term programmes for the promotion o f environmental health in the period 1978-83; an account o f the activities undertaken by other organ izations and the Regional Office in co operation with Member States; an assess ment o f the action taken by the Regional Office in implementing the recommenda tions o f the Regional Committee at its twenty-eighth session; and a list o f mat ters for consideration. WHO G L O B A L A N D R E G I O N A L M E D IU M - T E R M P R O G R A M M E S Global programme The global programme was formu lated in accordance with the directives o f WHO’s governing bodies at global and regional level. Stress is laid on the ex pressed priorities and needs o f Member States in respect o f technical coopera tion with WHO, on the principle that environmental health must be taken into account in the formulation o f poli cies, plans and programmes for socio economic development at all levels o f government. Priority is given to the 121 provision o f services for underserved populations in rural and urban areas, the enhancement o f community par ticipation, and the strengthening of national institutions in the management and solution o f environmental health problems. Two major fields o f activity have emerged: (a) the strengthening o f technical cooperation in basic sanitation, in accordance with the targets o f the Inter national Drinking-Water Supply and Sanitation Decade 1980-90 ; and (b ) the assessment o f new en vironmental hazards arising from socio economic development and their pre vention to safeguard the benefits o f such development. Regional programme The medium-term programme for the promotion o f environmental health in the European Region was elaborated in accordance with the principles and ob jectives o f the global programme and with the provisions o f several resolutions o f the Regional Committee, reflecting the particular needs o f the European Region. The priorities are based on the view that, in spite o f a slower rate o f economic expansion due to the energy crisis, in dustrial activities are expected to develop in the chemical sector. Thus an important focus o f cooperation between the Re gional Office and the Member States will be the International Programme on Chemical Safety. The regional programme has four components. 1. Environmental health planning and management, with emphasis on insti tutional development, implementation of national environmental health pro grammes, and manpower development. 2. Basic sanitary measures, with em phasis on the solution o f problems re lating to smaller communities, industrial areas on the urban fringes o f large cities, high-rise blocks, recreational facilities, and tourist activities. 3. Recognition and control o f en vironmental hazards, with emphasis on development o f the International Pro gramme on Chemical Safety in which the European Region will play a major role; on environmental impact assessment; on health risks from accidents in industries and nuclear power plants; and on pre vention and control of chemical, bio logical and physical hazards, including food toxicity, occupational hazards and those due to harmful substances in build ing materials, textiles, cosmetics and household utensils. In dealing with such hazards, attention will be paid to their long-term and chronic effects, including allergic effects and those o f combined exposure to more than one hazard. UNDP will continue to support the country and intercountry programmes for environ mental quality surveillance and control. Collaboration with UNEP in air and water quality monitoring under the GEMS pro gramme is expected to continue. The Re gional Office will continue to play a major role in implementing the UNEP Action Plan for the Mediterranean. Simi lar activities may be undertaken in rela tion to the Baltic and Black seas and the Danube river. 4. Food safety, with emphasis on aspects o f the protection o f consumers of food, including food contamination, surveillance systems, hospital and mass catering, health examinations o f food handlers, and the hazards o f food addi tives, especially those not covered by the FAO/WHO Codex Alimentarius. In this connexion, it should be noted that the Codex Alimentarius Commission has adopted and sent to governments for ac ceptance some 150 food standards, cover ing a wide range o f products, about 1000 maximum limits for pesticide residues and other contaminants, and codes o f practice on matters such as food hygiene. However, progress as regards acceptance o f standards and codes o f practice still leaves much to be desired. On several occasions the developing countries have expressed the wish that developed countries should make greater efforts towards practical accomplishment o f the aims o f the Commission. Implementation o f the four pro gramme components will require opti mal use o f the overall resources, and strengthening o f the WHO regional resources through voluntary contribu tions from the more industrialized coun tries o f the Region. A C T I V I T I E S O F I N T E R N A T I O N A L O R G A N I Z A T I O N S The field o f environmental protection is broad and there are clearly no sharp limits to the areas in which the health and wellbeing o f man are predominant, compared to other factors such as the conservation o f flora and fauna. A number o f international organiza tions are concerned with the various aspects o f environmental protection and it is important that their efforts be har monized, with optimal utilization o f overall resources and avoidance o f all unnecessary overlapping. In the Euro pean Region, some progress has been made in recent years in accomplishing this objective, particularly since regular interagency coordination meetings were instituted by UNEP and ECE. The Re gional Office has taken a major role in this effort, often providing the secretariat for the meetings. Some rationalization of the environmental work o f international organizations has been achieved and the total picture appears more cohesive than in the past. There has, for instance, been effective interagency cooperation in im plementing the UNEP Action Plan for the Mediterranean, under which different activities are carried out by WHO, FAO, IMCO, IOC and other bodies in collab oration with Member States. ECE has a programme o f environ mental measures that should be, but are not always, coordinated with its other economic and development activities. Under ECE auspices, senior advisers to governments meet to discuss a range of environmental problems, but not specifi cally in relation to human health. FAO studies the environmental aspects o f food production and fisheries. UNESCO deals with a variety ofenvironmental activities, particularly under its “ man and the bio sphere” programme, but is not directly concerned with matters affecting human health. UNIDO has programmes on in dustrial pollution, and IAEA is clearly concerned with health physics in relation to nuclear technology. ILO has long been involved in matters o f occupational health and has joint programmes with WHO in this sphere. Oil pollution from ships is a major concern o f IMCO. OECD 123 has been involved in several studies, in cluding a programme on toxic chemicals. Most o f the activities o f these and other organizations are, surprisingly, not o f direct relevance to the environmental health concerns o f WHO, which there fore still has important tasks in this field. UNEP, o f course, has an umbrella func tion in matters o f environmental pro tection. It is not primarily an executing agency, but has cooperated in a number o f activities o f other international organ izations, including WHO. The two major economic groups in the European Region, namely EEC and CMEA, have important functions for co ordination among their member govern ments in relation to environmental pro tection. EEC, for example, is currently formulating directives in an endeavour to standardize environmental goals with in its member countries. These organiza tions, o f course, are concerned to a con siderable extent with environmental pro tection in relation to economic develop ment. Moreover, the geographical limits o f their respective areas o f influence are meaningless from the environment and health standpoints, as neither o f these factors can be confined within national boundaries. There is an urgent need for better coordination. For instance, ac ceptances o f the recommended Codex standards and maximum limits for pesti cide residues continue to be received from the various governments, but major progress would be made if EEC orCMEA decided to adopt the Codex standards as standards for their members. In the case o f EEC, it is true that several Com munity directives are very close in sub stance to the corresponding Codex stan dards, but there are also instances where there are significant differences. It seems wasteful o f resources for EEC to be engaged in the same work at Com munity level as the Codex Alimentarius Commission at global level. Any idea that Community standards, which are also international standards, could be sig nificantly different from the Codex standards should be discouraged. A C T I V I T I E S O F T H E R E G I O N A L O F F I C E It seems evident that there is an im portant and quite broad field o f environ mental work that should logically be carried out by WHO, which is not bound by the artificial limits o f the major econ omic groups in the European Region. Moreover, up to now insufficient atten tion has been paid to the human health aspects o f environmental protection. For instance, community water supply and sanitation is both an environmental con cern and a task o f major importance in primary health care. For this reason, WHO’s work in relation to the Inter national Drinking-Water Supply and Sanitation Decade has high priority, and it is clear that there is still much to be done for this purpose, particularly in rural areas, in many parts o f the Region. The public health aspects o f housing and settlements are logically also a con cern o f WHO and, whereas this work does not at present have high priority globally, many problems are faced in the European Region; for example, the design of high apartment blocks often takes no account o f the requirements o f young families and special groups such as the aged and the handicapped. Health problems also arise from city centre 1 2 4 decay and uncontrolled development on urban fringes. In this respect the import ance o f mental health for social wellbeing is often overlooked. The Regional Office undertakes activ ities in relation to pollution o f surface, ground and coastal water, which are har monized with those o f other organiza tions as far as possible. Similarly, urban air pollution and the disposal o f solid wastes have important public health im plications in an industrialized society and receive due emphasis in the WHO programme. Although IAEA has numer ous activities in the field o f radiation, it seems appropriate that WHO should make recommendations on the health implications o f nuclear power produc tion and o f various uses o f nonionizing radiation, and propose guidelines for subsequent health surveillance and evalu ation. In the area o f food safety, WHO has always endeavoured to work closely with FAO and in view o f the widespread use o f food additives and the disquieting trends in microbiological contamination o f foods, particularly in mass catering establishments, it is felt that the Regional Office should have an active programme to provide guidance on such matters, taking into account the specific condi tions in the Region. A problem o f major concern to Member States o f the Region is that o f the increasing hazards in the production, use and final disposal o f toxic chemicals, and their synergistic relationship with other environmental perturbations and with aspects o f lifestyle, e.g., diet and smoking. WHO is now launching the International Programme on Chemical Safety and, since much of the world’s chemical production and use is con centrated in the European Region, it is o f great importance that the Regional Office should play an active role in this effort. The work o f the Regional Office must be closely harmonized with that o f WHO headquarters and the form o f the global programme is appropriate in this respect. It is essential that there be fre quent consultation between headquarters and the regions to ensure maximum ef fectiveness in the use o f resources, as these are clearly going to be inadequate in the next few years, although it is hoped that substantial assistance will be made available through extrabudgetary funds. A major problem in providing ad equate environmental health protection in the Region is the number o f different ministries and authorities involved. Al most every country has a different set o f administrative arrangements for the purpose and in many cases the health ministry does not play the role it should. However, notwithstanding these difficul ties, WHO is enjoined by its Constitution to place great emphasis on environmental health, particularly in the European Re gion where this factor is in many ways becoming predominant in health protec tion and will be o f crucial importance in achieving the goal o f “ health for all by the year 2000” . It is therefore proposed that the Regional Committee should consider setting up an environmental health forum, with the involvement o f all Member States. The deliberations o f such a forum would not only be important for the Regional Committee but would also be appreciated by other European organizations, especially ECE. In the terms o f the Alma-Ata Declaration and the Final Act o f the Conference on Security and Cooperation in Europe, WHO has an obligation to take a lead 125 in this field and, as the problems o f the next few years are likely to be o f great magnitude and complexity, early steps should be taken to set up the necessary machinery. In conclusion, the question o f whether the Regional Office is fulfilling its functions in the field o f environ mental health should be examined in relation to three fundamental considera tions: (a) the goal o f “ health for all by the year 2000” in the context o f the deteriorating environment in the Euro pean Region; (b) the consequences o f environ mental change, not only from the physi cal but also from the mental point o f view, bearing in mind that social well being, both individual and community, is a major concern o f WHO under its Constitution; and (c) the implications for health co operation o f the Conference on Security and Cooperation in Europe, as stated in resolution EUR/RC25/R1 1. M A T T E R S F O R F U T U R E C O N S I D E R A T IO N Programme 1. Strengthening o f scientific and technical collaboration between insti tutions concerned with research and practice in the field o f toxic chemicals, with a view to establishing a regional network o f such institutions. 2. Promotion o f geographically- based epidemiological research in order to determine the health effects on in dividuals and communities o f changes in environmental conditions, whether physical or psychosocial. 3. Encouragement o f the Member States in conducting studies on the con sequences o f environmental change for health and welfare. 4. The cost o f economic growth in relation to its effects on the health of individuals and communities. 5. Environmental health problems in relation to primary health care. 6. The consequences o f environ mental deterioration in achieving the goal o f “ health for all by the year 2000” in the European Region. 7. Definition o f the role o f the European Region in implementing the programme o f the International Drinking- Water Supply and Sanitation Decade. 8. Clearer definition o f the effects o f architecture, housing, human settle ments and land use on the health o f in dividuals, families and communities. 9. Study o f lifestyle as a factor o f environmental protection and health. Organization 10. Identification o f the ministries or organizations in each Member State that have responsibility for environmen tal changes affecting human health, and determination o f the scope o f such responsibility. 12 6 11. Means for promoting discussion and cooperation among intergovernmen tal organizations in relation to environ mental health policy and programmes in the Region. 12. The role to be played by the Regional Office in promoting and stimu lating contacts with and between non governmental organizations in the field of environmental health, in order to optimize the effectiveness o f their work in relation to that o f WHO. 13. Definition o f areas for continued collaboration between WHO headquarters and the Regional Office in the field o f environmental health as the regional programme expands. 14. More precise definition o f the respective responsibilities for environ mental health o f WHO, United Nations agencies, and other intergovernmental organizations. 15. The functions o f the Regional Office health information service in rela tion to environmental health. Budget 1 6. Determination o f the budgetary requirements o f the regional programme and means o f encouraging voluntary contributions for this purpose. Policy 17. Determination o f the health implications o f the Conference on Security and Cooperation in Europe, and formulation o f a plan o f regional action to implement the programmes envisaged in the Final Act o f the Con ference. 1 8. Realistic appraisal o f the situa tion in the Region by representatives in the Regional Committee when making proposals and recommendations, so as to ensure their proper and timely imple mentation. 19. The advisability o f establishing a forum o f environmental health ad visers, with the involvement o f all Mem ber States o f the Region. 127
REFERENCE COPY NOT TO BE REMOVED FROM TRE Cover : Regional O ffice fo r Europe, Copenhagen, Denmark THE WORK OF WHO IN THE EUROPEAN REGION 1979 THE WORK OF WHO IN THE EUROPEAN REGION 1 9 7 9 A n n u a l R e p o r t o f t h e R e g i o n a l D i r e c t o r W O R LD H E A L T H O R G A N IZ A T IO N Regional O ffice fo r Europe CO PEN HAGEN 1980 ABBREVIATIONS The abbreviations used in this report include the following: AMEE - Association for Medical Education in Europe ASPHER - Association o f Schools o f Public Health o f the European Region CE - Council of Europe CEC — Commission o f the European Com munities СМЕА - Council for Mutual Economic Assistance DA NI DA - Danish International Development Agency EACMR - European Advisory Committee for Medi cal Research ECE - Economic Commission for Europe EEC - European Economic Community F'AO - Food and Agriculture Organization of the United Nations IAEA - International Atomic Energy Agency IARC - International Agency for Research on Cancer ICC International Children’s Centre IFLA - International Federation o f Library As sociations and Institutions ILO - International Labour Organisation <Of fice) OECD - Organisation for Economic Co-operation and Development UNDP - United Nations Development Programme UNDRO - Office of the United Nations Disaster Relief Coordinator UNDSA - United Nations Division for Social Affairs UNEP - United Nations Environment Programme UNESCO - United Nations Educational, Scientific and Cultural Organization UNFPA United Nations Fund for Population Activities UNICEF - United Nations Children’s l und USAID United States Agency for International Development WFP World Food Programme IS B N 929020 198 3 © W orld Health Organization 1980 Publications o f the WHO Regional Office fo r Europe enjoy copyright protection in accordance w ith the provisions o f Protocol 2 o f the Universal Copyright Convention. For rights o f reproduction or translation, in part or in tuto, o f this publication application should be made to the WHO Regional Office fo r Europe, Scherfigsvej 8, D K-2100 Copenhagen Ç). Denmark. The Regional Office welcomes such applications. The designations employed and the presentation o f the material in this publication do not imply the expression o f any opinion whatsoever on the part o f the Secretariat o f the World Health Organiz ation concerning the legal status o f any country, te rrito ry, city or area or o f its authorities, or con cerning the delim itation o f its frontiers or boundaries. Where the designation “ country or area” appears in the heading o f tables, it covers countries, territories, cities or areas. The mention o f specific companies or o f certain manufacturers' products does not im ply that they are endorsed or recommended by the World Health Organization in preference to others o f a similar nature that are not mentioned. Errors and omissions excepted, the names o f proprietary products are distinguished by in itial capital letters. PR IN T E D IN D EN M A RK EUR/RC30/2 ISSN 1014-4323 (print) Reissued under ISBN: 9789289023320 (print) in 2024. Originally published under ISBN-10: 9290201983. C O N T E N T S Page Introduction ........................................................................................................... 1 1.... Policy organs.................................................................................................... 5 2. General programme development, management and coordination. . . . 7 2.1 General programme development................................................................. 7 2.2 Country health programming........................................................................ 9 2.3 In form ation systems p ro g ra m m e ................................................................. 10 2.4 External coordination for health and socioeconomic development.............. 11 2.5 Emergency relief operations........................................................................ 15 2.6 Research prom otion and development..................................................................... 16 2.7 Publications................................................................................................. 17 3. Development o f comprehensive health services....................................... 19 3.1 General........................................................................................................ 19 3.2 Family hea lth ............................................................................................... 30 3.3 Mental health............................................................................................... 36 3.4 Prophylactic, diagnostic and therapeutic substances..................................... 39 4. Disease prevention and c o n tro l................................................................... 43 4.1 Communicable disease prevention and con tro l............................................ 43 4.2 Noncommunicable disease prevention and control....................................... 48 5. Promotion o f environmental health............................................................ 55 5.1 General........................................................................................................ 55 5.2 Environmental health planning and management.......................................... 56 5.3 Provision of basic sanitary measures............................................................ 59 5.4 Recognition and control of environmental hazards....................................... 61 5.5 Food safety................................................................................................. 65 5.6 Environmental tox ico lo g y .......................................................................................... 6 6 5.7 Country a c tiv it ie s ........................................................................................................ 67 6. Health manpower development................................................................... 71 6.1 General........................................................................................................ 71 6.2 Continuing education................................................................................... 74 6.3 Communication and collaboration.............................................................. 75 6.4 Fellowships and courses............................................................................... 76 6.5 Nursing........................................................................................................ 79 6.6 Country activities........................................................................................ 80 7. Health in fo rm a tio n ........................................................................................ 83 7.1 General........................................................................................................ 83 7.2 Health statistics............................................................................................ 85 7.3 WHO publications and documents.............................................................. 86 7.4 Health legislation.......................................................................................... 87 7.5 Health literature services............................................................................... 88 7.6 Health information of the public................................................................. 88 8. General services and support programmes................................................. 91 8.1 Programme planning and general support..................................................... 91 8.2 Staff development and training................................................................... 92 8.3 Personnel...................................................................................................... 92 8.4 Supplies........................................................................................................ 92 8.5 Conference, office and building services....................................................... 92 8.6 Budget and finance...................................................................................... 94 Annex 1. Active and non-active Member States o f the World Health Organization, European Region, 31 December 1979................ 97 Annex 2. Professional staff in the European Region, 31 December 1979 .......................................................................... 99 Annex 3. Organizational chart o f the Regional Office, 31 December 1979 .......................................................................... 101 Annex 4. Intercountry meetings convened by the Regional Office for Europe in 1979 .......................................................................... 103 Annex 5. European response to the study o f WHO’s structures in the light o f its functions (résumé)................................................. 109 Annex 6. Activities o f the WHO Regional Office fo r Europe, in cooperation w ith Member States and other international organizations, in the field o f environmental health - Dr R.J.H. Kruisinga..................................................................... 121 vi
INTRODUCTION This is the second annual report o f the Regional Director to cover a com plete calendar year. The first o f these, for the year 19 78, was very well re ceived at the twenty-ninth session o f the Regional Committee in Helsinki. The Committee made several suggestions fo r improvement, and most o f these have been taken into consideration in the preparation o f this volume. This year, the collection o f summary reports on meetings convened by the Regional Office is issued as a companion volume. The latest recommenda tions on technical subjects in the various programme areas, which appear in these reports, may be used to supplement the information provided here. The period under review was a somewhat difficult time for the Regional Office from the budgetary point o f view, owing to the unstable international monetary situation. However, most o f the planned and approved programme was carried out with the help o f voluntary contributions and other arrange ments. In the implementation o f the programme, full account was taken o f the mandate given by the World Health Assembly and the Executive Board to reorient activities so that they are directly relevant to WHO's goal o f health fo r all by the year 2000 (HFA/2000). At the end o f 1979, the General Assembly o f the United Nations adopted resolution A /R E S/34/58 dealing with “health as an integral part o f develop m ent” which will, it is hoped, lead to even closer collaboration within the United Nations system in support o f WHO's long-term aims. At the regional level, regular contact was maintained with the United Nations Centre for Social Development and Humanitarian Affairs, UNDP, UNFPA, UNICEF the World Bank, FAO. ILO, ICC and OECD, as well as with the many related programmes within the Economic Commission fo r Europe. During 1979 possibilities were created fo r closer collaboration with the Council for Mutual Economic Assistance (CMEA). At the European level WHO is now in full cooperation with several intergovernmental organiza tions, the most important being, in addition to CMEA, the Commission o f the European Communities and the Council o f Europe. The detailed programme o f WHO in the European Region followed the approved programme budget for 1978-79. In addition, the Regional Com mittee at its twenty-ninth session analysed three major areas that are par ticularly important if the concept o f H FA/2000 is to be achieved: family health, primary health care and the Office's contribution to the international programme on chemical safety, which in the industrialized countries o f Europe is o f the utmost importance. Proposals in these areas, which were reviewed in detail and endorsed by the Regional Committee, have influenced the 1980-81 programme and will be followed up and included in the proposed programme for 1982-83. The Regional Office has continued to develop its capabilities fo r hand ling information, which is rapidly increasing owing to the new responsibil ities o f the Office in the field o f regional research promotion and coordina tion. In addition to the meeting o f the European Advisory Commit tee for Medical Research and its sub-planning groups, a very important consultation involving the Regional Office, Member States and their medical research councils or academies o f science was held in October in Copenhagen, at which the need was expressed for an interregional research programme on health care problems related to hypertension. Following the International Conference on Primary Health Care held in Alma-Ata in 1978, my report on the situation in Europe was published by the Regional Office and has received considerable attention. The book let also lists documents and publications that European governments had prepared fo r the Conference. In various parts o f Europe, primary health care is now seen as an approach to alleviating the problem o f over-sophisticated, hospital-based health services. It is also seen as a means o f bringing the health services closer to the family and making it possible fo r people to solve their own health problems: self-reliance and self-care are now considered more and more acceptable by what, up to now, has been a very professionally oriented health care system. The Regional Office has followed this develop ment with keen interest and cooperates with many intergovernmental and nongovernmental organizations, governments, universities and other bodies concerned with primary health care. One o f the highlights o f the year in the field o f environmental health, to which WHO contributed, was the High-level Meeting within the frame work o f the ECE on the Protection o f the Environment, held in Geneva in November. The Meeting adopted the Convention on Long-range Transboundary Air Pollution, which was signed on behalf o f 33 governments, and the Declara tion on Low- and Non-waste Technology and Re-utilization and Recycling o f Wastes. Owing to the considerable support provided during 1978 and 19 79 by a large number o f organizations and European countries, the malaria situation in Turkey has improved, but will need continuous vigilance fo r several years to come. In this connexion, WHO will be the executing agency fo r a project financed by UNDP to intensify epidemiological surveillance systems in south east Europe. Cooperation involving the European and Eastern Mediterranean regions o f WHO and other international organizations continued on the control o f pol lution in the Mediterranean Sea. Initiatives were also taken by WHO and UNDP in establishing a zoonoses control programme in the Mediterranean area. A new feature in this report are the lists o f expenditure for each pro gramme area, which will be found at the end o f each chapter. In addition to showing the regular budgetary allocation, these lists provide a breakdown o f extrabudgetary funds by source. Finally, the work in the Region during 1979 benefited greatly from the active participation o f leading health administrators and scientists who, through the various consultative groups and advisory committees, have given a great deal o f their time to the Organization. I should like to acknowledge their very important contribution to the development o f the programme and in keeping it relevant to the needs o f the Member States. Leo A. Kaprio Regional Director 3 Chapter 1 POLICY ORGANS The planning and implementation o f the Regional Office programme con tinued to reflect im portant resolutions o f the Executive Board and the World Health Assembly, which are carefully analysed and commented on each year fo r the Regional Committee. In response to resolution WHA32.30, and the resolution adopted by the twenty- ninth session o f the Regional Committee (EUR/RC29/R6), a Regional Health De velopment Advisory Council (RHDAC) was established by expanding the Con sultative Group on Programme Develop ment (CGPD) to include experts in dis ciplines outside the health sector, such as sociology, political sciences and econ omics. The first task o f the RHDAC will be to advise the Regional D irector on establishing regional strategies to meet the target o f attaining, by the year 2000, a level o f health that would permit every one to lead a socially and economically productive life (HFA/2000). The impact o f these strategies on the Regional O f fice programme w ill be taken in to ac count and consideration given to the specific needs o f the European Region which, in contrast to most other re gions, is composed mainly o f indus trialized countries. Three programmes were discussed in detail by the Regional Committee in the light o f their importance and relevance to HFA/2000. These were: fam ily health, where special attention would be paid to perinatal problems, the role o f women in society, and psychosocial problems o f adolescents; chemical safety and the re gional contribution to the worldwide programme: and primary health care and its relevance to all the programmes o f the Region. Similarly, the research aspects in all programmes and the development o f health services research in the Region, at both the national and the regional level, are playing an increasingly im port ant role (resolution WHA32.15). Ap propriate medical technology to meet the needs o f individual countries and the problems o f oversophisticated technol ogy, characteristic o f the European Re gion, w ill be the theme o f the technical discussions at the th irtie th session o f the Regional Committee in 1980, when both the economic and ethical aspects o f medi cal technology w ill be examined. In reviewing the regional report on the study o f WHO’s structures in the light o f its functions, the twenty-ninth ses sion o f the Regional Committee for Europe recognized the importance o f 5 the provisions o f the Constitution (A r ticles 61-63), stressing that there was a need to ensure implementation o f the decisions o f the global and regional gov erning bodies and that better use could be made o f the provisions o f the Consti tution. Member States were therefore urged to report on national health devel opment, an essential element in the ex change o f inform ation for the establish ment o f criteria and indices fo r further action to achieve HFA/2000. The fu ll report and minutes o f the twenty-ninth session o f the Regional Committee were sent as usual to Member States and to other international organ izations. Changes in demographic structure and the trend towards an older popula tion between now and the year 2000, both in developing and developed coun tries, have led to a marked interest in the possible effect on socioeconomic devel opment and its consequences fo r health care. The designation o f the Regional O f fice fo r Europe as the focal point fo r the global programme on health care o f the el derly has intensified collaboration with other WHO regions, Member States throughout the world, and other organiza tions both w ith in and outside the United Nations system (resolution WHA32.25). Activities related to the preparation for the World Assembly on the Elderly in 1982 are being given special attention. The form ulation o f medium-term programmes in all programme areas great ly facilitated the preparation o f the Eu ropean programme budget proposals for 1982-83 and the preliminary work fo r the Seventh General Programme o f Work. The trend towards intensifying the participation o f Member States in the work o f WHO, and the awareness o f the value o f standardizing as far as possible the agendas o f meetings o f the global and regional governing bodies, have contri buted to the strengthening o f regional committees in general and considerably improved the relationship between the Regional Committee, the Executive Board and the World Health Assembly. POLICY ORGANS Expenditure (US$) Regular funds 59 677 Host government’s contribution 31 800 UN funds Voluntary funds a Being 0.57% of total expenditure. 91 477° 6 Participants in the twenty-ninth session o f the Regional Committee posing in Finlandia Hall, Helsinki President LJrho Kekkonen of Finland speaking at the inaugural ceremony of the twenty-ninth session of the Regional Committee In the Town Hall of Helsinki the Lord Mayor, Mr Teuvo Aura, receives participants in the Regional Committee îventy-five meetings were arranged by the Regional O ffice fo r Europe during 1979. One of these (above) as the f if th session o f the European Advisory Committee fo r Medical Research held in Prague, another >elow) was the Technical Group on Protective Devices and Restraint Systems in Road T ra ffic Accidents •evention held in Meknes, Morocco Officers o f the tw enty-n inth session o f the Regional Committee fo r Europe. Seated from le ft to right: Dr G. Martii France (Rapporteur), Dr T. lonescu, Romania and Mr O. Jennane, Morocco (Vice-Chairmen), Professor E. Kivali Finland (Chairman), Dr Leo A. Kaprio, WHO Regional D irector fo r Europe, Dr H. Mahler, WHO Director-Gener. and Dr J.E. Asvall, D irector, Programme Management, WHO Regional O ffice fo r Europe Dr Halfdan Mahler, WHO Director-General, being interviewed on his arrival at Helsinki a irport Chapter 2 GENERAL PROGRAMME DEVELOPMENT, MANAGEMENT AND COORDINATION 2.1 G ENERAL PROGRAMME DEVELOPMENT On 1 February 1979 Dr J.E. Asvall, previously Regional O fficer fo r Country Health Programming, took over as Direc tor, Programme Management. He suc ceeded Dr F.A. Bauhofer, who died on 15 March 1979 following a long and severe illness. In an effort to make the Regional Office programmes more relevant to the European situation and to ration alize and integrate the d ifferent plan ning exercises, it was decided that the Office should embark on a syn chronized medium-term planning exer cise fo r all programme areas fo r the remaining part o f the Sixth General Programme o f Work. This would be done by producing in one document a medium-term programme for this period (i.e., 1980-83), a programme bud get for 1982-83, and a tentative pro jection o f future trends during the period o f the Seventh General Pro gramme o f Work (1984-89) fo r each programme o f the Regional Office. This planning process took place between March and October, when the individual programmes were presented to the Regional Programme Committee for review. On this basis the consultation letter covering the period 1982-83 was subsequently prepared, and this was sent to all Member States fo r review. The third meeting o f the Consulta tive Group on Programme Development (CGPD) was held in April. The Group felt that a more systematic evaluation o f the Regional Office programmes was called for to ensure a thorough review, including external evaluation o f past achievements, before embarking on any new activities. One possibility proposed was that the CGPD should review selected programme areas follow ing the programme evaluation guidelines recently produced by WHO headquarters. One aspect o f this evaluation would be to assess the impact o f Regional Office programmes on Member States, and one means to this end would be an analysis o f the follow-up given to resolutions adopted by the Regional Committee and the World Health Assembly. The CGPD proposed that a system be established whereby Member States would be asked on a regular basis what action had been taken at the national level to implement resolutions o f WHO governing bodies and to carry out activities recommended by the Organization. 7 The increasing need for voluntary contributions to Regional Office pro grammes owing to the fall in purchasing power caused by monetary fluctuations was raised. It was suggested that more extensive use be made o f collaborating centres and that governments be asked to pay fo r national participation at WHO meetings. The subject o f support for Regional Office programmes would be taken up in more detail by the CGPD during its jo in t session w ith the Con sultative Group on Budgetary Questions in March 1980. The CGPD also reviewed various documents prepared for the twenty- ninth session o f the Regional Com m it tee: a draft medium-term programme in fam ily health, a report on the Regional O ffice’s contribution to the International Programme on Chemical Safety, and a draft document on activities to be car ried out in the field o f primary health care as a part o f comprehensive health services, as a follow-up to the Alma- Ata Conference. The CGPD had before it an analysis o f the replies received from Member States, the staff o f the Regional Office and the International Children's Centre to the questionnaire prepared in con nexion with the Director-General’s docu ment on the study o f WHO’s structures in the light o f its functions. This analy sis was subsequently presented to the twenty-ninth session o f the Regional Committee which, in general, felt that caution was required in deciding whether to m odify structures that seemed satis factory on the whole. Any required improvement would be related more to working methods than to structures, bearing in mind the need to make better use o f the potential o f the Member States. It was unanimously agreed that there was no need for a revision o f the WHO Constitution at that stage. (F o ra résumé o f the European response to the study see Annex 5.) In the CGPD’s discussions on the preparation o f the Seventh General Programme o f Work (1984-89), it was noted that an underlying factor would be the attainment o f the goal o f “ health for all by the year 2000” (HFA/2000) in line w ith the World Health Assembly document on this subject (A32/8) and resolution WHA32.30. The CGPD decided that some o f its members should meet w ith Professor J.J.A. Reid, Chair man o f the sixty-th ird session o f the Executive Board, to assist the Regional Director in preparing for the preliminary discussions on strategies at the twenty- ninth session o f the Regional Committee. This ad hoc group met in July and drafted a questionnaire which was circulated to Member States. The Re gional Committee recognized that the formulation o f regional and national strategies would be a continuing, long term process and took note o f the Re gional D irector’s intention to establish a Regional Health Development Ad visory Council (RHDAC) to study the formulation o f such strategies. It was agreed that Member States should revise their health development in the light o f HFA/2000, as applicable to the Euro pean Region, and should promote an intersectoral approach to activities for the achievement o fth a t goal. A more detailed questionnaire on the subject was then prepared by the Secre tariat and circulated to Member States with the request that it be returned to the Regional Office in February 1980, for review by the first meeting o f the 8 RHDAC in March 1980 and fo r the prep aration o f a document on the subject for the th irtie th session o f the Regional Committee. The value o f WHO publications was repeatedly referred to by the CGPD and their importance as a means o f inform a tion transfer and o f assisting govern ments in the development o f their own programmes was emphasized. It was vital that publications reach as many people and institutions as possible, and con tinuous efforts should be made to pub lish results o f activities in a way that would make them easily applicable at the national level. In this connexion, the Regional Director submitted to the Glo bal Programme Committee (GPC) in May proposals fo r making the best use o f translation staff on an interregional basis for the preparation o f documents and publications in various languages. He was subsequently requested by the GPC to analyse the situation in quantifiable terms and to make proposals to other Regional Directors and to headquarters concerning practical interregional ar rangements for making documents and publications available to Member States in the relevant working languages. A review o f current decision-making and administrative functions was begun, aiming at sim plifying office procedures, clarifying managerial responsibilities, im proving the utilization o f professional and general service staff, and increasing job satisfaction. Representatives from Algeria, the Federal Republic o f Germany, Romania and Sweden paid offic ia l visits to the Re gional Office during the year to discuss jo in t programme development, w ith emphasis on areas o f special interest such as fellowships and publications. The Director, Programme Manage ment visited Algeria in November to finalize the country programme budget fo r 1980-81. In meeting national health development priorities, the jo in t pro gramme w ill stress the principles o f primary health care. 2.2 COUNTRY H EALTH PROGRAMMING Regional Office activities in this field were restricted during the year owing to the lack o f a Regional O fficer fo r Country Health Programming (CHP). Two con sultants were, however, recruited for a tota l o f five months to assist the Re gional Office in this field. The main activity was the Workshop on Country Health Programming in European Health Planning and Manage ment Education, organized in June in cooperation w ith the Austrian Federal M inistry o f Health and Environmental Protection and the Department o f Hos pital Adm inistration in Vienna. This was the first forum to consider CHP in the context o f industrialized countries. Four European case studies were presented from Algeria, Portugal, Scotland and Spain where CHP or project systems analysis had been carried out. The Work shop recommended CHP as a useful ap proach fo r European countries but stressed that the existing WHO guide lines on CHP should be amended to cor respond better to the problems and needs o f European health planners. This idea o f region-specific CHP guidelines (in addition to the guidelines for world wide use) was subsequently supported by the second interregional seminar on 9 CHP (organized by WHO headquarters and supported by D AN ID A) held in Dubrovnik in November 1979, where case studies on the adaptability o f CHP to national health planning in Portugal, Turkey and Yugoslavia were presented. Country activities Algeria. A consultant reviewed, with the national authorities, the possibility o f further developing primary health care by means o f country health pro gramming. Denmark. The Danish Hospital Insti tute, in collaboration w ith a WHO con sultant, studied methodology based on country health programming for de veloping cancer services and for compre hensive planning at the county level. Portugal. A consultant assisted in the preparation o f a country health pro gramming seminar and in conducting the subsequent p ilo t CHP exercise in the north o f the country. Yugoslavia. It was proposed that CHP methodology could be used to plan the rebuilding o f the health infrastructure following the destruction caused by the earthquake in Montenegro in April. 2.3 IN FO R M ATIO N SYSTEMS PROGRAMME In 1979 the Regional Office became the p ilo t demonstration and training cen tre fo r implementing at the regional level the automated technico-administrative procedures to be used by WHO w orld wide. For this purpose the Regional Office acquired in November a small computer as an interim solution. The automation o f budget and f i nance operations had priority in 1979. O f the four components planned bud get control, expenditure accounting, general accounting, and processing o f claims - the first was implemented and made operational. Computer programs were developed to facilitate storage and retrieval o f directories o f health special ists and institutions collaborating with the Regional Office. The range o f computer services avail able to the Regional Office was expanded by using the International Computing Centre (ICC) and the Northern European University Computing Centre (NEUCC). Application programs, e.g., for fellow ship awards and placements and travel by staff members or temporary advisers, have been developed, allowing for easy transfer o f data to the internal com puter. The processing and analysis o f country data from national studies or surveys coordinated by the Regional Office was initiated at NFUCC, e.g., for the programme on health care o f the elderly, fo r which the Office has global responsibility. The word processing equipment ac quired in 1978 proved most useful for the work in the Regional Office. Addi tional equipment was purchased to in crease the number o f work stations from 4 to 14. This equipment can now handle the English, French and German lan guages, and the addition o f Russian is foreseen in the near future. In July a questionnaire on the organ ization and management o f health re search in the WHO European Region was 10 sent to all Member States, and 18 coun tries replied. These replies were discussed at the Third Meeting o f the Planning Group on Inform ation Systems for the Biomedical Research Promotion and De velopment Programme, held in London in September. They showed that most o f the countries had some mechanism for planning and coordinating health ser vices research programmes, although in a large proportion o f these countries this mechanism applied only to research sponsored by central bodies such as the health services and research and scienti fic funds or organizations. Inform ation on such research is usually published; however, since the international ex change o f information depends on the availability o f easily comparable data, it would be desirable to establish a basic data set fo r each country. The Planning Group recognized that there were two main problems, namely for countries to establish complete na tional inventories o f health services re search and fo r international organiza tions to improve the exchange o f in form ation on national health services research activities. Several groups were working on the development o f similar systems, e.g., in UNESCO and EEC, and the need fo r close international cooperation was emphasized. 2.4 EXTER N AL COORDINATIO N FOR HEALTH AND SOCIOECONOMIC DEVELOPMENT An analysis o f health activities o f relevance to the Regional Office that are the responsibility o f intergovernmental organizations was made fo r the meeting o f the Consultative Group on Programme Development in April. The information thus obtained is now maintained system atically in the Regional Office to avoid duplication and overlapping o f activities. A t the same time, it is realized that a more dynamic approach to coordination is desirable, by which the Regional O f fice w ill act to ensure that health prob lems are not left unsolved simply because various other organizations are poten tia lly involved. The new Head o f the Public Health Division o f the Council o f Europe (CE), Mr F. Marziale, visited the Office in March, at the invitation o f the Regional Director, as part o f the preparation for a long-term programme in the field o f public health. O f particular interest to the Regional Office was the decision o f the Com m it tee o f Ministers o f CE to accept the pro posal o f the Spanish Minister o f Health to hold a European conference o f minis ters responsible fo r public health in the spring o f 1981 in Spain, as was the de cision to restore the original membership o f the Committee o f Experts on Legal Problems in the Medical Field. The par ticipation o f the Regional Office in the exploratory meeting o f the latter con cerned the defin ition o f patients’ rights and compensation for damage caused by medical intervention. The Regional Office was represented at a number o f CE meetings. The meeting o f the European Public Health Commit tee o f CE in November marked the tw enty-fifth anniversary o f CE and the main subjects discussed were: blood transfusion and immunohaematology ; problems related to death: the patient as an active participant in his own treatment ; 1 1 drug dependence; the medical fellow ships programme for 1980; expec tations from health education pro grammes; and the cost o f health care both inside and outside hospital. Rep resentatives o f the Regional Office attended meetings o f the Select and Expert Committees on hospital in fection prevention, the role o f school health services, and m ortality and mor bid ity, and the Coordinated Medical Research Programme meeting on the cost o f health care in the Member States o f CE and in Finland. Following the Exchange o f Letter signed by the Council for Mutual Econ omic Assistance (CMEA) on 7 July 1978 and by WHO on 7 March 1979, dis cussions were held w ith officials o f CMEA to elaborate the details o f the agreement between the two organiza tions and to redefine certain selected areas in various public health fields, e.g., occupational health, for future collaboration. Contacts were established w ith the National Institute o f Pharmacy, Hungary, which is a coordinating institute for CMEA. In connexion w ith WHO coopera tion w ith the Commission o f the Euro pean Communities (CEC) it was agreed that CEC would be invited to send observers to future sessions o f the World Health Assembly. The Regional Director attended a meeting o f the Chief Medical Officers o f the European Economic Community (EEC) in Cologne in March and the Director, Programme Management at tended a similar meeting in Lyons in October. During these meetings WHO activities were reported and the roles o f EEC, WHO and CE discussed. It was accepted that WHO’s role is that o f providing technical and scientific ex pertise on health problems and that the Directorate-General fo r Social Affairs o f the CEC is the centre for the coordina tion o f health-related activities in the EEC. The Directorate-General w ill there fore be kept fu lly informed o f any ques tionnaire dealing w ith health that WHO sends to its Member States. As regards technical cooperation w ith CEC at the project level, the Re gional Office was represented at a sym posium organized by CEC on technical innovations in the service o f the elderly and disabled, as well as at a meeting on the Study o f the Nutritional Status o f Infants, the Regional Office being a member o f the special committee for this Study. Cooperation with the Organisation for Economie Co-operation and Develop ment (OECD) was maintained in the tie Ids o f air pollu tion, solid waste and. in particular, road tra ffic accidents. The Regional Office was represented at the annual plenary session o f the Nor dic Council’s Committee on Medical Statistics (NOMF.SCO), during which in formation on the O ffice ’s current activ ities in health statistics was provided and further cooperation envisaged. The O f fice was also represented at the Confer ence on Primary Health Care in Remote Areas, arranged by the Nordic Council o f Ministers, the recommendations o f which are o f particular interest to WHO. A presentation on the Regional Office programme on prophylactic, diagnostic 1 2 and therapeutic substances was made at the tenth meeting o f the Nordic Council. 2.4.1 Col laboration with the United Nations system and other organi zations Following WHO assistance to the Economic Commission fo r Europe (ECE) in preparing the Convention on Long- range Transboundary A ir Pollution, the Regional D irector represented the Director-General at the signing o f the Convention during the High-level Meeting on the Protection o f the En vironment held in Geneva in November. The Regional O fficer for Coordina tion participated in the th irty -fo u rth session o f ECE in Geneva in March. The Regional Office expressed its support in principle fo r the ECE programme o f work fo r 1979-83, and the relationship between ECE and the Regional Office in the field o f environmental health was underlined. Cooperation continued, es pecially in relation to transboundary air and water pollution, toxic chemicals and waste, and environmental impact assess ment. Links were established w ith ECE in respect o f the programme on the pre vention o f road tra ffic accidents and the Regional Office participated in the th irty-s ixth session o f the Expert Group on Road Safety, which dealt w ith statis tics on road traffic accidents. The Re gional Office expressed the interest o f WHO in participating in the UNDP/ECE trans-European north-south motorway project. During the period under review the Regional Office fo r Europe was the executing agency for 41 projects financed by the United Nations Development Pro gramme (UNDP), 28 o f which concerned the environment, including food safety. Most o f the other projects dealt w ith health manpower development. The Regional Office was represented at the UNDP Country Programme Re view in Turkey in May and the Mid-Term Country Programme Review in Yugo slavia in December. A meeting was held in Copenhagen in March w ith representatives o f UNDP, UNDSA, UNFPA, UNICEF and UNEP, at which WHO country programmes, jo in t procedures and programme matters were discussed. The global activities o f UNEP were presented; those on toxic chemicals, the Mediterranean Plan and the GEMS projects were o f particular relevance to the programme o f the Re gional Office. A report on this meeting was also sent to all the UNDP resident representatives. The UNDP resident repre sentative in Algeria visited the Regional O ffice in September. Two WHO/UNDP consultations were held at the Regional O ffice: one on re gional cooperation in environmental health aspects o f the control o f chemi cals, in August, and the other on regional cooperation on food safety services in Europe, in October. The Regional Office is the executing agency for the UNDP Intercountry Pro ject fo r the Control o f Malaria in South- East Europe, the first meeting o f which w ill be held in Sofia in March 1980. An intercountry project to study and assess the water quality o f the River Danube is at present being negotiated 13 with the governments concerned and UNDP. A meeting was also held in Geneva w ith representatives o f the United Nations Environment Programme (UNEP) regarding the development o f a water quality project in the Danube basin. In October, the Office was repre sented at the second meeting o f the “ National Blue Plan Focal Points” , con vened by UNEP in Cannes, and in July at the UNEP Interagency Meeting on Regional Seas, during which it was agreed that WHO should act as the leading agency for environmental impact assess ment. An urgent investigation related to mercury levels in Mediterranean fish is to start, involving WHO and FAO. The very close working relationship with UNFPA, both at headquarters and in the Held, was further intensified. In addition to the four country and two intercountry projects that this Office was already carrying out for UNFPA, two more were started in Bulgaria. During a visit to FAO it was agreed that jo in t programming meetings should be held periodically to harmonize activ ities and make the best use o f resources. The Office was represented at the thirteenth session o f the Codex A li- mentarius Commission in December. Dame Judith Hart visited the Office in November, in her capacity as a special UNICEF envoy, in order to become ac quainted w ith WHO’s policies and pro grammes related to children in Europe. Discussions were held with UNICEF on possible future collaboration in primary health care. The Office also collaborated with UNICEF on the International Year o f the Child. UNICEF provided five vehicles for use in the Turkish malaria pro gramme. The Office participated in the jo in t UNICEF/WHO meeting on infant and young child feeding in Geneva in October. Close collaboration continued w ith the International Children’s Centre (ICC) in Paris through the jo in t planning and evaluation o f courses in family health, fam ily planning and teaching. In addi tion, development continued in the documentation o f family health and family planning. A book, published under the jo in t sponsorship o f the Re gional Office and ICC in English and French, comprised a selection o f papers distributed to participants during the above-mentioned courses since 1973. The Regional Office was represented at the fifty -s ix th session o f the ICC Technical Consultative Committee in December. C ooperation w ith IEO made progress. In June the Chief o f the Occupational Safety and Health Sector assured the O f fice o f the participation o f ILO in the Working Group on Evaluation ol Occupa tional Health and Industrial Hygiene Services. An ILO representative attended the Working Group on Health Aspects o f Wellbeing in Working Places in Prague in September, and the Office was repre sented at the Third ILO European Con ference in October. Following the transfer o f the United Nations Division for Social Affairs (IJNDSA) from Geneva to Vienna and its integration with the United Nations Centre for Social Development and Humanitarian Affairs, the United Nations Office in Geneva requested comments on an aide-mémoire concerning the future 14 o f the European social development pro gramme. The possibility o f involving the European Centre for Social Welfare Training and Research in Vienna in this programme was indicated. A fte r the Regional Office had made its comments, the Regional O fficer fo r Coordination attended the sixth Annual General Meeting o f the Board o f Directors o f the European Centre and the Director, Comprehensive Health Services attended the third meeting o f the UN Standing Working Group on Social Development, both o f which were held in Vienna in December. As a result o f jo in t efforts by UNDP in Ankara and the Regional O ffice, a mission from the World Bank was sent to Ankara in January to ascertain the correlation between the malaria re surgence in Turkey and the irrigation network in the Çukurova area. Contacts w ith the Economic Com mission for Africa and the Organisation o f African Unity were made at the first meeting o f the plenipotentiaries o f the Multi-national Programming and Opera tional Centre for North Africa in Tangiers in March. 2.4.2 Col laboration with multilateral and bilateral programmes An im portant DANIDA/W HO Joint Programming Review Meeting fo r 1980/ 81 was convened in Geneva in February. It was devoted to courses, seminars and projects, and problems o f policy and general administration were discussed. 2.4.3 Nongovernmental and other or ganizations Regular collaboration was main tained with some 30 nongovernmental organizations. During the year, agree ments were signed w ith five, namely the European Federation fo r the Welfare o f the Elderly, the International Center o f Social Gerontology, the International Federation on Ageing, the Interna tional Medical Association for the Study o f Living Conditions and Health, and the International Federation o f Telephonic Emergency Services. Details o f current activities may be found in the sections on the relevant technical programmes. In particular, attention is drawn to the creation in 1979 o f the European Committee on Clinical Laboratory Standards (see p. 29) and to the support received from the In ternational Union for Health Education. 2.5 EMERGENCY RELIEF OPERATIONS On the occurrence o f the earthquake in Montenegro in April, a jo in t Regional Office/WHO headquarters mission visited Yugoslavia to make a rapid assessment o f the situation. The Regional Office sub sequently appealed to certain Member States for funds, and both the Regional Office and headquarters made small sums available for re lief equipment. Fol lowing a visit to Copenhagen by the liaison o fficer appointed by the Y ugoslav Government, it was recommended that further assessment o f the epidemiological situation be carried out. including a study on the facilities then available for the prevention o f communicable diseases. In November a follow-up visit to the coun try was made by the Director, Programme Management to discuss the situation with the health authorities. 15 A Memorandum o f Understanding was signed by W H O and the United Nations Disaster R e lie f Organization (U N D R O ) defining the responsibilities o f the two organizations for disaster re lief operations and pre-disaster planning. This will in future guarantee more rapid coordination o f activities in emergency situations. 2.6 R E S E A R C H P R O M O T I O N A N D D E V E L O P M E N T Despite the adverse financial situa tion during the year, the Regional O f fice was able in many instances, thanks to additional assistance from various Member States, to implement not only the activities foreseen under the research development programme but also new ones. Thus, four o f the E A C M R sub groups in five priority research areas (standardization o f methods, measure ments, and term inology in biomedical and health services research; evaluation o f drugs and other therapeutic and diag nostic substances; prevention, prophy laxis and early detection; and economic aspects o f health care) held fo llow-up meetings and made a number o f recom mendations (see under the relevant technical programmes). The first three groups also examined the problem o f hypertension in preparation for the Consultation on Hypertension Research related to Health Care in October. The planning group on information systems for the research promotion and development programme held its third meeting in London in September. The discussions centred on the answers to a questionnaire sent to all Member States in order to prepare a survey o f current health research. (See also section 2.3.) A workshop on health economics research was convened in The Hague in September. The meeting reviewed existing research into the degree to which the growth in health resources, budget and finance systems and new technology was responsible for the growth in health services. The meet ing concluded that there was a need to control the numbers o f health per sonnel and to review the financing arrangements, and made a number o f recommendations for future re search. Fo llow ing the Regional C om m it tee’s endorsement o f the E A C M R recommendation to promote coordina tion with European research bodies particularly concerned with health ser vices research, a liaison meeting on research coordination was held in Helsinki in September. The partici pants suggested an increase in dialogue by holding regularly, every one or two years, similar consultative meet ings. Interest was expressed in par ticipating in WHO meetings and in contributing to the resulting initia tives through the technical poten tial and resources available to them. O f particular interest was the con tact established with the International Federation o f Pharmaceutical Manu facturers Associations and its willing ness and interest in cooperating with WHO in the field o f research. In order to focus health services research efforts on more specific issues, arterial hypertension, being o f general concern to all Member States, was 16 singled out fo r special consideration. A Consultation on Hypertension R e search related to Health Care took place at the Regional O ff ice in October, and proved to be a significant event in the initiation o f this new thrust o f the European research programme. The recommendations adopted stressed the public health importance o f re search on the subject, defined priority areas fo r study and coordination, and outlined a programme o f future activ ities. E fforts to provide adequate funds fo r the proposed activities are being actively pursued by the Regional O f fice. A t its fifth session in Prague in October, the E A C M R reviewed the progress o f the programme and dis cussed the reports o f three o f the plan ning groups in research priority areas, as well as the recommendations o f the meetings mentioned above. It recommended, inter alia, a further study o f questions such as the extent to which health services are being used in terms o f primary health care, the rationalization o f prevention activ ities, the coordination o f clinical trials o f drugs by the Regional O ff ice , and research on diagnostic aspects o f drugs. The E A C M R also called for a real istic attitude towards coordination. While agreeing that health services research was not only a priority issue per se but an essential means o f health services development, the E A C M R be lieved that health services research should be highlighted as an interdis ciplinary activity, and also that it was necessary to consider how research policy in this area could be promoted; there was an increasing need to analyse national research structures in view o f the lack o f information on systems that included health services research. Consultant studies were undertaken on management structure and on the dynamics o f health research at the national level. Contacts continued to develop with many research institutes and coord i nating bodies, not on ly in Europe but also in Canada and the USA. This was achieved through exchange o f information, attendance at meetings by Regional O ff ice staff, visits, and further development o f personal con tacts at the technical level. Discus sions were held with the National Center for Health Services Research, Hyattsville, USA, on possibilities for cooperation, and with the Institute o f Medicine, National Academ y o f Sciences, Washington DC, on inter national perspectives in health re search planning. The Regional O f fice was represented at the biannual meetings o f the European Research Medical Councils in Bethesda (U S A ) and Obernai (near Strasbourg), at which such topics as mental illness re search, tox ico logy , human reproduction, biomedical research and health econ omics were reviewed. 2.7 P U B L I C A T I O N S Research on simulation models for health management: report on a W H O Working Group. E U R O R e ports and Studies, No. 20. 17 G E N E R A L P R O G R A M M E DEVELOPMENT, M A N A G E M E N T A N D COORDINATION Expenditure (US$) 6 3 0 295 33 7 6 9 6 6 4 0 6 4 ° a Being 4.15% o f total expenditure. Regular funds U N funds Voluntary funds 18 Chapter 3 D E V E L O P M E N T OF C O M P R E H E N S IV E H E A L T H SE RV ICES 3.1 G E N E R A L During 1979 the development o f health services in the countries o f the European Region continued. The means o f reaching the goal o f “ health fo r all by the year 2000” were seen as being the development o f primary health care, the improvement o f appropriate technol ogy for health, and the intensification o f e f fort, not only in respect o f the phy sician but also through collaboration with other institutions and services. The principles enunciated in the Declaration o f A lma-Ata, namely that primary health care is not an isolated approach but the most local part o f a comprehensive health system, that health care should be related to the needs o f the population, that consumers should participate individually and collectively in the planning and implementation o f health care, and that the fullest use must be made o f available resources, are already influencing the development o f health services in the Region and the current programmes o f the Regional Office. More attention has recently been paid to establishing closer cooperation with individual health institutions in the Member States. The results o f three years o f jo in t activities with Bulgaria are cur rently being evaluated and courses in Bulgaria in the fields o f primary health care and maternal and child health, or ganized for developing countries on the basis o f the Gabrovo pilot area, are being supported. Closer contact in the develop ment o f different areas o f the health services was established between the Re gional O ff ice and several Member States. A lthough strategies for the achieve ment o f “ health for all by the year 2000 ’ ’ are still being formulated, a sig nificant contribution has been made by the Regional O ff ice in conjunction with the International Epidemiological Asso ciation in the publication o f Measure ment o f levels o f health (WHO Regional Publications. European Series. No. 7). “ Measurement o f levels o f health” is taken to include the incidence and pre valence o f specific diseases and syn dromes and measurements o f physical and mental conditions, as well as the social function o f individuals and popu lation groups and their behaviour or attitudes towards health and health- related activities. Demographic phe nomena are taken into consideration on the one hand, and availability and 19 utilization o f health services on the other. Measurable variables are grouped under the headings: measurements o f ill health; measurements o f need and demand fo r medical care; measure ments o f the use o f health services; and measurements o f effectiveness and e ff ic iency o f health services and pro grammes. The interface between the health and social services is also ex amined. The wish expressed by Member States for research components in certain programmes o f the Regional O ff ice led to the preparation o f a re port on the content, organizational arrangements and priority research prob lems o f WHO activities in health ser vices research and on suggested future activities. The report drew attention to the dearth o f publications on the management o f health services and terminology in this field, and sug gested that the Regional O ff ice might consider preparing a publication on the measurement o f health services, along the lines o f Measurement o f levels o f health. The new Portuguese National Health Service Law, No. 56/79, dated 15 Sep tember 1979, designates the primary health care department as one o f the three main departments o f the central health administration. The new law is the result o f intensive efforts on the part o f the Portuguese Government since 1975 in which it has enlisted the help o f the Regional O ff ice at all stages. 3.1.1 Health services planning and man agement The Study on Health Care o f the Elderly progressed well. In most o f the participating countries the field work was completed, and data sent to the Regional O ff ice fo r processing and analysis. Fo r some o f the centres processing o f data was completed and preliminary tabulations were made. The editorial board for the report on the Study met in Tampere, F in land, in December 1979 to discuss and approve the outline and content o f the First report, to be issued in the first quarter o f 1981. Further preparation was made for the Study on the Development o f Systems fo r the Epidemiological Sur veillance o f Long-Term Environmen tal Health Effects. Sixteen countries expressed interest in participating and nominated institutions and research workers responsible fo r the imple mentation o f the project in their coun tries. The steering group fo r the Study met in Copenhagen in Novem ber to prepare outlines o f draft protocols for surveillance systems and to recom mend steps to be taken for setting up pilot schemes based on the draft protocols. In March the Planning Group on Standardization o f Methods, Measure ments and Term ino logy in B iomedi cal and Health Services Research met in Copenhagen to review existing know ledge in the field o f health care out come measurements and the present use o f these measurements in various countries; to consider the possible unification and standardization o f out come measurements; and to recommend steps to be taken to achieve these aims. In addition, the Group examined the methodological and terminological aspects o f arterial hypertension control, 2 0 this having been selected as one o f the ch ief problems for research in the European Region. The Group found that there are certain prerequisites for the use o f outcome measurements in a standard ized, unified way, such as a common approach to setting objectives for health services and a comm on ap proach to measurements. Accordingly , the Group made proposals on a frame work fo r setting objectives for health service interventions and programmes and for the measurement o f particular outcomes, and provided examples o f health outcome measures related to particular objectives. In the recom mendations concerning future work the Group stressed the need to develop concepts, criteria and methods fo r the measurement o f disability, discomfort and dissatisfaction. The emphasis o f the health econ omics programme during the year under review, besides support to other programmes o f the Regional O ffice , was on research. The Planning Group on Economic Aspects o f Health Care, at its second meeting in Copenhagen in November, recommended three additional topics for national and international research, namely (a) econom ic and social im plications o f routine clinical decisions; (h) cost-effectiveness o f the shifting o f care towards primary health care; and (c ) the influence o f the econom y on health and o f health policies on the econom y. The Group also ex panded the scope o f two earlier recom mendations concerning the development o f indicators o f health care performance and the development o f techniques for evaluating innovations in treatment and other procedures. The Workshop on Health Econ omics Research, held in The Hague in September, reviewed the available evidence that health services tend to grow, owing to (a) the higher avail ability o f health care resources; (b) in centives inherent in certain budget and finance systems; and ( c ) new health technology. The evidence was con vincing fo r (a), with obvious conclu sions fo r limiting unnecessary growth o f health resources; supportive for (/?); and plausible but incomplete fo r (c ) . The Group considered the most urgent need was for research on the supply o f health facilities, and especially the crucial role o f the physician as an agent acting on behalf o f the patient. A number o f smaller studies and sur veys were carried out: surveys were started on existing research, training and advisory activities in health econ omics in selected countries, and studies on national health accounts and the cost o f viral hepatitis were continued. Country activities Portugal. The Regional O ff icer for Epidemiology served as faculty member at a seminar on “ health policy: the con tribution o f ep idem io logy and health services research” , organized by the National School o f Public Health. Publications Measurement o f levels o f health. W HO Regional Publications, Euro pean Series, No. 7. 21 Programme development made a good start fo l low ing the discussions o f the twenty-ninth session o f the Regional Com m ittee on the document Primary health care as a part o f com prehensive health services (E U R /R C 29/10), which resulted in resolution EUR/RC29/R5. The ideas advanced by the Regional Comm ittee were incorporated in the medium-term programme fo r primary health care (P H C ), which emphasizes the fo llow ing programme areas: promoting favourable attitudes towards PHC; inte gration o f health with other related services; community involvement in the planning and administration o f PHC ser vices; self-care; appropriate technology fo r PHC ; the use o f secondary and tertiary level facilities and specialized personnel in the support o f PHC; and research in PHC. The activities launched initially deal with primary medical services; this is intentional, because such services are available and easily recognizable in all Member States. Gradually, the activities will be expanded to cover the more comprehensive primary health services as envisaged in the Declaration o f Alma-Ata. The first activity to be launched under the new medium-term programme was a study on the management needs o f primary health care, which is expected to result in a descriptive analysis o f the situation in Europe and in suggestions fo r remedial action, such as educational programmes specifying objectives, con tents and methods, and organizational changes. Another major activity was related to the preparation o f a publica tion on a number o f salient issues that have to be faced when developing PHC 3,1.2 Primary health care in industrialized countries. Preparations were also begun to establish a consulta tive comm ittee fo r PHC. The report o f the Regional D irector to the A lma-Ata Conference was pub lished during the year under the title Primary health care in Europe. In this booklet the Regional D irector reviews the present situation in Europe, the problems that must be overcom e in implementing the PHC approach, and some o f the developments that are taking place. Annexes to the publica tion comprise the Declaration o f Alma- A ta and lists o f publications and docu ments on PHC issued by the Regional O ff ice and by Member States. One o f the areas into which PHC is expected to move is circumpolar health. The Working Group on Health Problems o f Local and Migrant Popula tions in A rct ic Regions, which met in September, and an ensuing consulta tion, made recommendations concerning possible W H O involvement and activities in this field. Country activities Algeria. A major project on the de velopment o f PHC, comprising the estab lishment o f demonstration areas and the creation o f a national health deve lop ment centre, was designed in collabora tion with the health authorities. Given the favourable conditions in Algeria, this project may provide an example for other countries. Publications Primary health care in Europe, by Leo A . Kaprio. EU RO Reports and Studies, No . 14. Mechanization, automation, the crea tion o f new technologies and other developments have changed the nature o f work in the European Region, lead ing to new patterns o f morbidity related to working conditions. A reduction in the incidence and severity o f occupa tional diseases and an increase in psycho somatic disorders and others such as neurosis, diseases o f the cardiovascular system, and disorders o f the digestive and locom otor systems have been observed. A Working Group on Health Aspects o f Wellbeing in Working Places was held in Prague in September. Factors influ encing the wellbeing o f workers in w ork ing places were identified and particular attention was paid to psychological factors. A definition o f wellbeing in work places was established and the humanization o f work was considered. The prevention o f harmful effects o f occupational hazards on workers ’ health is based on knowledge o f the biological aspects o f these factors. The use o f epidemiological methods provides basic and reliable information for studying the effects o f long-term exposure to low levels o f occupational hazards. In order to stimulate the application o f epidemi o logy to occupational health, a Consulta tion on Epidemiology o f Occupational Health was held in Copenhagen in July 1979. The need for a manual on m ethodology was emphasized and the outlines o f such a manual were drafted during the Consultation. The report o f a study on periodical health examinations o f workers exposed to industrial hazards was issued; the 3.1.3 Workers’ health study covered experience gathered in five countries on the protection o f workers ’ health. During the period under review particular attention was paid to the protection o f health in workers exposed to vegetable dusts. As a fo llow-up to the WHO programme on the early detection o f health impairments in occupational exposure to health hazards, a joint HQ/EURO Task Group on Health Cri teria o f Respiratory Diseases due to Vegetable Dusts met in Copenhagen in July. National programmes o f occupational health are required to set up methodology and to evaluate its e ff ic iency and e f fec tiveness. T w o working documents were prepared on this subject for a working group to be convened in Stockholm in April 1980. Country activities Denmark. A consultant assisted in the development o f modern occupational health services and the Institute o f Occupational Health. National legislation on occupational health was prepared and published. The Institute o f Occupational Health was o ffic ia lly opened. Post graduate training courses were organized, with lectures by specialists from different countries o f the Region. Finland. Three Kuropean Member States sent participants to the Sixth International Advanced Course in Epi dem iologic Methods, an interregional activity held at the Institute o f Occupa tional Health o f Helsinki. Poland. The WHO/UN DP project on the evaluation o f tox ic ity o f new 23 technologies and substances used in in dustry made progress, and tw o consul tant missions were carried out within the framework o f this project. The Inter national Course on Industrial T o x ic o lo gy was convened by the Institute o f Occu pational Medicine (W H O Collaborating Centre fo r Occupational Health) in Lodz. S ta ff members from the Regional O f fice and W H O headquarters participated and gave lectures. O f the 15 participants in this course 8 came from developing countries. Portugal. A consultant mission was provided as a fo llow-up to advice in the organization o f occupational health ser vices and training. Yugoslavia. T w o European Member States sent participants to the Third In ternational Training Course in Occupa tional and Environmental Tox ico lo gy , an interregional activity held in Belgrade. 3.1.4 Care o f the aged, disability pre vention and rehabilitation The Regional O ff ice is now respon sible for the global as well as the re gional programmes dealing with health care o f the elderly and the prevention o f road traffic accidents. Only the regional programmes are reported on be low; details o f activities concerning the global programmes appear in the report o f the Director-General. Health care o f the elderly Reorientation o f services fo r the el derly in Member States, and o f the Organization ’s programme in this field, received an impetus from the Declaration o f A lma-Ata, which calls for soundly- based and socially acceptable services delivered to the individual and the family within the community. Current pro gramme activities are directed at defining the needs o f the elderly as established by population-based data, comparing the ways by which countries meet these needs, and re-examining the technology used. For example, the editorial board fo ran international epidemiological study on the elderly met in Tampere, Finland in December 1979, a consultant visited Czechoslovakia, Denmark and Switzer land in preparation fo r an ad hoc tech nical group on services and systems o f care fo r the elderly to be hosted by the Government o f Finland in 1980, and another consultant began the prepara tion o f documentation for an ad hoc group on the use o f pharmacological substances in old age, which the Govern ment o f Switzerland will host in 1980. A major stimulus to the programme was provided in 1979 by United Nations resolution A33.52 and the related World Health Assembly resolution W HA32.25 concerning a world assembly on the el derly to be held in 1982. The programme is closely linked with the mental health and nursing pro grammes. both o f which issued reports concerning the elderly in 1979. The departments o f community medicine and geriatric medicine o f the University o f Edinburgh, in collabora tion with the Regional O ff ice , organized a two-week course on the planning and provision o f services for the elderly. Fig. 1 and 2 show, respectively, the percentage o f the population in countries o f the European Region aged 65 years and over in 1977 and a forecast o f that percentage fo r the year 2000. 2 4 Prevention o f road traffic accidents A fte r cardiovascular diseases and can cer, road traffic accidents are the third most important cause o f death in most industrialized countries. Trends in road traffic accidents in four European coun tries are shown in Fig. 3. Large invest ments have been made to make the traffic environment safer and any further im provement will probably be small in comparison. A technical group on re straint systems met in June in M orocco to review the existing measures used after a crash to minimize the severity o f injuries. It concluded that existing know ledge was sufficient for e ff ic ient measures to be formulated and made concrete recommendations in this respect. In accordance with the stated pro gramme objectives, a review o f major issues was pursued. In general, emphasis was placed on the identification o f pub lic health consequences o f traffic acci dents, as well as on the better use o f public health resources and expertise in this field. Intersectoral coordination and cooperation have been fundamental to programme development at both the na tional and international levels. Links be tween several medical and traffic safety research institutes were strengthened, and intersecretariat meetings with govern mental organizations concerned with transport are now well established. The planning and evaluation o f pro grammes on road accident prevention depend on the quality o f the data col lected. One important d if f icu lty in introducing preventive measures and evaluating their effectiveness is that the necessary data are collected through d i f ferent governmental channels. The health sector is the key source o f morbidity and disability data, which are particularly necessary fo r assessing injury protective measures. On the whole, basic national accident data systems do not produce satisfactory results because o f the weak ness o f the health data collecting systems. Fo llow ing the meeting o f a technical group on road traffic statistics in 1978, the project on the medical monitoring o f road accidents has been continued, and six national centres are involved in preparing guidelines in this field. Traff ic trauma now represents an important proportion o f overall mor bidity. Services fo r the care o f the in jured involve the highest level o f medical technology and countries are devoting more and more resources to improving their quality. In February a group met in France to discuss the organization o f emergency medical services. This meeting gave the various countries involved the opportunity to share their experience, and in particular the group considered the problem o f planning and assessing the various alternatives in use. Changing the behaviour o f popula tions is a long process. Education is con sidered one o f the priorities in traffic safety, and transport and police depart ments are usually responsible for the formulation o f programmes in this field. In order to explore the role that health personnel could play, a group met in Novem ber in the Federal Republic o f Germany to discuss education in traffic safety. One o f the group’s con cerns was to study the methods used in traffic safety and health education with the aim o f considering how health education could contribute more actively to road safety education. The jo int WHO/ICC Documentation Centre on Accidents in Childhood became 2 5 F i g . 1 . P e r c e n t a g e o f t h e p o p u l a t i o n a g e d 6 5 y e a r s a n d o v e r i n 1 9 7 7 Source: Demographic yearbook, 1977. New York, United Nations, 1978. F i g . 2 . E s t i m a t e d p e r c e n t a g e o f t h e p o p u l a t i o n a g e d 6 5 y e a r s a n d o v e r i n t h e y e a r 2 0 0 0 Source: World population trends and prospects by country, 1 9 5 5 -2 0 0 0 : summary report o f the 1978 assessment. New York, United Nations. 1979 (S T/ES A /S ER . R /33 ). 27 Fig. 3. Trends in road traffic accidents involving persons killed in four European countries, 1955-77 Denmark Hungary Italy Netherlands 1955 1960 1965 1970 1975 Year Source: Statistics o f road traffic accidents in Europe, 1977. New York, United Nations Economic Commission for Europe, 1978. operational in 1979 and the first bib liographic bulletin was issued. Publications Road traffic accident statistics: re port on a W HO Ad hoc Technical Group. E U R O Reports and Studies, No. 19. 3.1.5 Appropriate technology fo r health The present state o f the art in the Field o f medical and other related technologies in the European Region was reviewed at several meetings and through national contacts. The new programme on appropriate technology for health was developed and will deal with three sectors: (a ) laboratory dis ciplines: ( b ) radiation medicine; and (c ) bio-instrumentation. In these three sectors, the pro gramme will consider two dimensions: the one concerned with the technical aspects o f equipment and its evalua tion and cost, and the other with the appropriate utilization o f the d i f fe r ent types o f equipment and m ethod o logy in individual health care pro grammes. T w o meetings took place during the period under review. One, a W ork ing Group on Appropriate Technol ogy in Health Laboratories held in London, discussed in great detail ap propriate technologies and methods in the various laboratory disciplines and several guidelines fo r the use o f laboratory technologies were developed. The second, a Working Group on Quality Control in Health Laboratories held in Brussels, dealt with quality con trol as a too l to improve laboratory results. Important aspects o f the lat ter meeting were the identification o f the role o f quality control in the laboratory disciplines and the provi sion o f guidelines for national quality control programmes. In the field o f radiation medicine and bio-instrumentation, the present trends were reviewed and several w ork ing groups were planned. Sponsorship and input were again provided fo r the annual meeting o f the European Public Health M icro bio logy Services Directors in Oslo in September. Input was provided to several ac tivities associated with the creation o f the European Com m ittee on Clini cal Laboratory Standards (E C CLS ). This new nongovernmental organization is intended to facilitate the selection o f rational and reliable laboratory tech niques compatible with international standards. Country activities Albania. Standard reagents were supplied. Algeria. During a visit, the Regional O ff icer for Appropriate Technology fo r Health reviewed the present state o f the public and hospital laboratories and fo llowed the progress o f the new Pasteur Institute and the planned Na tional Institute o f Public Health. A project to develop laboratory ser vices at the local and intermediate levels was initiated. Malta. During a visit, the laboratory services, particularly those for tox i co logy, were evaluated and recommenda tions made on the organization o f a clinical tox ico logy unit. Morocco. The Regional O f f ice r for Appropriate Technology for Health visited the country to discuss the or ganization o f a postgraduate course in m icrob io logy and an operational study o f laboratory technology at the local level. Portugal. At the request o f the na tional authorities, the present state o f the health care support services (laboratories, radiology and bio-instrumentation) was reviewed and, after field visits, recom mendations for future action were proposed. Sweden. Close collaboration with the Swedish Planning and Rational ization Institute in the field o f medi cal technology was initiated and fo l lowed up. Documents The role o f the hospital labora tory in public health: report on a Working Group. Document 1СР/ A T H 004. 2 9 3.2 F A M I L Y H E A L T H 3.2.1 Maternal and child health The maternal and child health programme continued to seek solu tions to the problems o f mothers and children in industrialized society. The medium-term programme in family health was presented to and approved by the Regional Com m it tee in September. This medium-term programme focuses on the family as the most important resource in pri mary health care, so that primary health care services in the Region will gradually incorporate this resource to an even greater extent. The emphasis on the family has two important aspects: the evalua tion o f health problems and the gen eration o f solutions to those prob lems. The family is the most import ant determinant o f lifestyle and be haviour, especially for children. In formulating solutions to health prob lems it is becoming increasingly clear that the family, as the basic function ing unit in society, is also the basic health unit. A lthough more research and know ledge concerning childhood and ado lescence are certainly needed, deci sions on policy and programmes o f action are required immediately be cause existing services for the 5 - 18-year age group are inadequate and/or in appropriate fo r solving the problems created by the rapid socioeconom ic development and industrialization now taking place in the Region. Im port ant changes are occurring in the role o f wom en and in behavioural patterns with regard to human reproduction, as shown by falling birth rates, the increasing em ploym ent o f wom en and the rise in the number o f unwanted adolescent pregnancies. While perinatal and infant mortality rates are falling appreciably, greater emphasis is being placed on infant morbidity and the quality o f care. N ew trends in the industrialized countries are leading to new forms o f malnutrition among children and adolescents, o ften char acterized by overnutrition. Further more, air pollution, the use o f food additives and overmedication are giving rise to chronic diseases in children (cancer, allergies, respiratory diseases), and new patterns o f morbid ity are appearing. The development o f the medium- term programme, which had the strong support o f the International Children ’s Centre and the International Pediatric Association, was part o f the Regional O f f ic e ’s comm itm ent to the Inter national Year o f the Child, together with the publication o f the report on the Conference on the Child and the Adolescent in Society. The Regional O ff icer for Mater nal and Child Health explained to Dame Judith Hart, during her visit to the O ff ice in Novem ber as a special U N IC K F envoy, what might be achieved in Europe i f U N IC E F were to express more interest in family health. A Working Group on the Early Detection o f Handicap in Children was 3 0 held in Faro, Portugal in May. Recom mendations were made fo r the compre hensive management o f relevant pro grammes, based on the health and socio econom ic determinants and consequences o f the early detection o f handicap in children. Family planning The main thrust o f the intercountry family planning projects was directed to wards the training o f national cadres in family health/family planning and the provision o f technical information and support fo r project development and im plementation. Some countries were as sisted in formulating projects, which were then submitted by the respective govern ments to U N F PA . T w o additional international courses in family planning were successfully con ducted in collaboration with specialized institutions, bringing the total number o f such courses since 1973 to 11, with an attendance o f 228 fellows from the European, African and Eastern Mediter ranean Regions. One o f these two courses was conducted in Spain in collaboration with the International Children ’s Centre ( IC C ) for a multidisciplinary team o f health and social workers; it was fo llowed by a national session for maternal health specialists for the purpose o f involving them in family planning activities in Spain. The other course was conducted in Poland with the National Research Institute for Mother and Child for instructors in nursing/midwifery. A c cording to subsequent evaluation, this course met with its participants’ ex pectations in terms o f its applicability to the home situation. It is worth noting that o f 45 fellows who attended the two courses, 40 were women. A n evaluation o f past WHO/ICC courses on family health/family planning was conducted. Based on the answers re ceived to a questionnaire sent to the par ticipants and their governments, it can be stated that this teaching has a positive impact and countries wish to see it con tinued. Fo llow ing this evaluation, plans were drawn up fo r the future, taking into account the comments and sug gestions o f both the participants and their governments. Studies on the outcom e o f early adolescence (Tu rk ey ) and on the МСН/ family planning home-based records (Portugal) are being conducted. Plans were also made for the organization o f a working group on research needs and approaches in relation to adolescent re productive health in the developing countries o f the Region, to be held in Portugal in August 1980. A study on family planning legisla tion in m idwifery services and education was carried out jo intly with the Nursing unit. On the basis o f this study, a W ork ing Group on Legislation concerning Nursing/Midwifery Services and Educa tion was organized in Hamburg in December. Intercountry family planning pro grammes continued to receive U N F P A support. The Regional O ff ice was rep resented at the U N F P A interagency meeting held in Geneva to formulate strategies for future U N F P A support in regional population activities. Table 1 shows some aspects o f government policy on family planning in 30 European countries. 31 T a b l e 1. F a m i l y p l a n n i n g p o l i c i e s in E u r o p e Country Population in millions (m id -197 8 ) Num ber of children per wom an (1 9 7 5 -8 0 )3 I Governm ent perception o f fe rtility level II Governm ent policy to influence fe rtility I I I Governm ent position on contraceptive services Albania 2.7 4 .5 □ □ X Algeria 18.5 7.1 □ X О Austria 7.6 2 .2 □ X 0 Belgium 10.0 2 .2 □ x □ Bulgaria 9 .0 2 .2 Д Д О Czechoslovakia 15.0 2.2 □ □ О Denmark 5.1 1.9 □ x О Finland 4.7 1.6 □ □ О France 54 .3 2.4 Д Д О German Dem. Rep. 17.3 2.1 Д Д О Germ any, Fed. Rep. of 61 .9 1.7 Л x о Greece 9.0 2 .3 Л Д д Hungary 10.7 2 .0 □ □ о Ireland 3.2 3.4 □ □ д Italy 55.8 2 .2 □ X о Luxembourg 0.3 2 .0 Л «_к Д □ Malta 0.3 2.1 □ x д Morocco 19.2 6 .7 о о о Netherlands 13.9 2.1 □ X о Norway 4.1 2 .3 □ X о Poland 34.7 2 .0 □ □ о Portugal0 8.9 2 .5 □ X о Romania 21.7 2 .5 □ □ X Spain 36 .5 2 .8 □ X □ Sweden 8.4 2.1 □ X о Switzerland 6.7 1.9 □ X □ Turkey 43.1 5 .6 о о о USSR 262.8 2.4 □ □ о United Kingdom 57.1 2 .4 □ X о Yugoslavia* 21 .9 2 .3 □ □ о Key: I □ — acceptable О — I I □ — to m aintain О — too high to reduce Д — too low Д — to raise X - no intervention II I □ — some support О — active support Д — restrictions X — по support 3 Total fertility rate. ^ Family planning is a constitutional right in these countries. Source: Family planning policies: a 1979 People wallchart. People, 6 (2 ) (1979). 32 Algeria. Progress in the project on birth spacing and the development o f a maternal and child health infrastructure continued with efforts to attain wider geographical and population coverage, the regionalization o f the retraining courses fo r health personnel in birth spacing, planning fo r the organization o f in formation days on contraception and o f a jo in t publication on this project, and the development and procurement o f documentation and audiovisual material on family health and family planning. A consultant in evaluation was recruited for this project fo r four months, starting in December. Bulgaria. A short-term consultant was recruited to analyse existing re sources in connexion with tw o project requests to U N F P A in the Field o f human genetics. In May, the Regional O ff ice be came the executing agency fo r these two UNFPA-funded projects, one dealing with remedies fo r sterility and the other with screening o f the newborn and at- risk families for birth-related diseases. The placement o f fellows abroad was be gun and the equipment requested for 1979 purchased. T w o fellows attended the WHO/ICC international course on family health/ family planning in Spain. Czechoslovakia. Fo llow ing a U N F P A mission, a short-term consultant visited the country twice, in March and June, in connexion with family planning-related activities, mainly to assist in the prepara tion o f project documents. German Democratic Republic. A short-term consultant paid a visit in May Country activities to discuss with representatives and specialists from the Ministry o f Health the possibility o f w idening cooperation and collaboration with the Regional O f f ice in family planning activities with U N F P A support, mainly with regard to a course in Rostock fo r participants from developing countries. Hungary. A short-term consultant visited the country in March to dis cuss matters related to family planning activities. Plans were made to involve Hungary in the study o f pilot applica tion to family planning o f programme evaluation guidelines to be carried out in 1980. Ireland. The Regional O ff ice was represented at the International Seminar on Natural Family Planning organized by the Ministry o f Health in October. Morocco. Development o f the na tional family planning programme in the field o f public health and the improve ment o f living conditions fo r women continued. The Regional O ff ice provided placement abroad for medical and other health personnel, some for training in family health/family planning and others to examine the availability o f audiovisual material fo r the strengthening o f the health education programme. Planning was begun fo r the WHO/ICC international course on family health/family planning to be held in M orocco in 1980. Four fellows attended the WHO/ICC inter national course on family health/family planning held in Madrid. Poland. A short-term consultant visited the country in June to assist the Child Health Centre in the elabora tion o f a project request to U N F P A in the field o f MCH. Books were supplied 3 3 to the Council fo r Family Matters, M in istry o f Labour and Social Affairs. Portugal. There was steady develop ment o f the project o f assistance to the national family planning programme. The Regional O ff ice proceeded with the placement o f fellows abroad and with the purchase o f contraceptives and equipment. Assistance was given with a seminar held in Funchal on MCH and family planning organized by the Directorate-General o f Population Planning, Lisbon and the Regional Secretariat o f Madeira. In formation seminars and retraining courses for health personnel were conducted by national sta ff throughout the country, and documentation on family health and family planning was developed. Seven fellowships were financed: six to attend the WHO/ICC course on family health/family planning held in Madrid and one fo r a part-time member o f the family planning team o f the Directorate- General o f Health to study family planning for tw o months in Belgium and Switzerland. The project carried out by the Uni versity o f Lisbon on family planning training and services provided weekly consultations on family planning and infertility and initiated research activ ities in this field. The manager o f this project spent seven weeks in Denmark and Sweden studying aspects o f family planning. Romania. A short-term consultant paid a visit to the country in May to dis cuss with the Ministry o f Health the possi bility o f widening collaboration with the Regional O ff ice in family planning activities with U N F P A support. The consultant also attended the Seminar on the Access o f You th to Work and Partici pation in Public L ife held in Costineçti, which was organized by the United Nations Division o f Social A ffa irs in co operation with the Romanian Research Centre on You th Problems. Spain. The WHO/ICC international course on family health and family planning was held in Madrid and Talavera de la Reina in Novem ber and was fo l lowed by a national session at which the Regional O f f ice was represented. Plans were made fo r the active involvement o f the Family Planning unit in the Tenth World Congress on Fertility and Steril ity, to be held in Spain in 1980, and for the involvement o f Spain in the study o f pilot application to family planning o f programme evaluation guidelines. Turkey. The development o f inte grated family planning services con tinued. The Regional O ff ice organized a study tour in selected European coun tries fo r Turkish officials from both the General Directorate o f Population Plan ning and the General Directorate o f Professional Training to observe family planning education and services. Various retraining courses in family planning for provincial nurse/midwives and their instructors were conducted and training material was developed. A master plan and an assessment o f the needs for refresher training o f health personnel in М СН/family planning was elaborated with the assistance o f the Regional O f fice and W H O headquarters. This is meant to form a basis fo r the General Directorate o f Population Planning pro ject proposal to U N F P A . A seminar on primary health care implementation and health personnel 34 education in Turkey was held in Ankara in June. It stressed the high priority to be given to М С Н /family planning and to the basic role and use o f midwives at the local level. Four Turkish fellows attended the two international courses on family health/family planning organized by the Regional O ffice. Yugoslavia. The Regional O ff ice made technical comments on three pro ject requests to U N F P A in the field o f family health and family planning, at the request o f U N F P A . Publications Service-oriented research in adoles cent fertility: report on a W HO M eet ing. F U R O Reports and Studies, No. 1. The child and the adolescent in society: report on a W H O Confer ence. F U R O Reports and Studies, No . 3. Family health and family planning. Paris, International Children ’s Centre and Copenhagen, W HO Regional O f fice for Europe, 1979. 3.2.2 Nutrition As a follow-up to the jo in t UNICEF/ WHO meeting on infant and young child feeding in Geneva, Member States have been enjoined to hold meetings at na tional level to encourage breastfeeding. Fo llow ing the recommendations o f the meeting, a code o f ethics fo r exporting and importing countries o f baby food and baby food technology is being drafted at headquarters, and Member States will be requested to review this code and to o f fe r their input towards its finalization before the next World Health Assembly. In cooperation with the Federal Cen tre for Health Fducation, Cologne, the third survey on smoking and health in the W H O European Region, covering the period 1975-77, was initiated. It was hoped that the report would be published by the end o f the year, but by that time many Member States had still not replied to the questionnaire. The survey covers eight areas: ( 1 ) demographic character istics o f smokers and their consumer habits; (2 ) the import, manufacture and sale o f tobacco products and tobacco taxation; (3 ) the consumption o f to bacco products and information on their tar, nicotine and carbon monoxide con tent; (4 ) restrictions on the manu facture and sale o f tobacco products: (5 ) restrictions on the consumption o f tobacco products; (6 ) restrictions on to bacco advertising; (7 ) measures to in form the public o f the health hazards o f smoking; and (8 ) research on the subject o f smoking and health, and the influence o f research findings. On the basis o f the data so far avail able, it is not possible to draw firm conclusions as to trends and develop ments in the anti-smoking field. It is, however, possible to say that anti smoking measures and legislation are most highly developed in the eastern European countries and in Finland, Norw ay and Sweden. Tobacco taxation is still an important source o f income in many countries and this may account fo r a certain reluctance on the part o f governments to take anti smoking measures. There is cause to wonder why the control o f tobacco products has not developed along the same lines as that o f foods and beverages, 3.2.3 Health education 0 3 5 including drinking-water, which are care fully controlled by state agencies as to their quality and the presence o f poss ibly harmful additives. The Director-General, the Regional Director and four staff members attended the Fourth World Conference on Smoking and Health in Stockholm in June. The Regional Director and the Re gional O ff ice r for Health Education and Social Sciences attended the Tenth Inter national Conference on Health Educa tion in London in September, at which the top ic “ Health education in action - achievements and priorities” covered the integration o f health education in public policy, health education in youth , and methodologies o f health education. The opening address delivered by Dr U. Kekkonen, President o f the Re public o f Finland, at the inaugural ceremony o f the twenty-ninth Regional Committee was subsequently published in the International journal o f health education. The address, entitled “ The importance o f personal initiative” , high lighted the prom otion by WHO o f pri mary health care as the means to a higher level o f health throughout the world and the importance o f the en vironment and personal lifestyles in health, particularly in Europe. The speaker stressed that education in such subjects as smoking, physical exercise and nutrition could do much to promote a healthier lifestyle. An experimental postgraduate train ing course in health education (German language), supported by the Regional O ffice , was held at the Academ y o f Public Health in Düsseldorf, Federal Republic o f Germany. Turkey. A consultant studied exist ing training programmes in health educa tion and made proposals fo r strengthening both the training programmes and health education manpower and services. Publications Education pour la santé : tabagisme, alcoolisme et drogues, par K. Vuyl- steek. E U R O Reports and Studies, No . 10. Health education: smoking, alcohol ism, drugs, by K. Vuylsteek. E U R O Reports and Studies, No. 10 (English translation). Principles and methods o f health education: report on a WHO W ork ing Group. EU RO Reports and Studies, No . 1 1. Country activities 3.3 M E N T A L H E A L T H The rapid changes and growing com plexity o f present-day civilization, par ticularly in industrialized countries, have made mental health problems more im portant and have brought to light new issues that justify a thorough considera tion o f the methods and techniques to be applied. The general trend now is for the establishment o f community-oriented programmes o f prevention, care and rehabilitation. Mental health is thus seen as a broad combination o f health and social measures rather than as a narrow specialty made available in closed insti tutions. N ew subjects for study include the consequences o f certain attitudes 3 6 and behavioural patterns, psychological factors, and changes in lifestyle. The mental health component is still too o ften neglected in country health programming and in intersectoral coor dination and planning. The traditional tendency to isolate care in a hospital environment persists: more than 1 mil lion mental patients in the European R e gion are still kept in institutions, a third o f which have more than 1000 beds. There is a noticeable lack o f f lexible and innovative programmes fo r high-risk population groups such as the elderly. Since 1950 the consumption o f al cohol has increased dramatically, in some countries by over 300% (Table 2), with predictable consequences as far as accidents, delinquency, suicide and fam ily problems are concerned. Similar trends are found with regard to psycho tropic drugs. These different problems highlight the need to train administra tors responsible fo r developing compre hensive and integrated community-based mental health services. The inadequacy o f knowledge and in formation about effective primary prevention calls for more efforts by national research councils and fo r better coordination w ith public health research as a whole. Primary men tal health care programmes should aim at increasing the involvement o f general practitioners, self-help groups, educators and families. Intercountry activities Great care has been taken to base the mental health programme on national pro gramme profiles. Representatives from 20 Member States and from 5 nongovern mental organizations, together with the Director, Division o f Mental Health, WHO headquarters, met in the first regional meeting o f national mental health advisers in Bielefeld, Federal Repub lic o f Germany in Novem ber, at which national mental health programme pro files that will form the basis o f the regional medium-term programme in mental health were presented. The meet ing, while endorsing the regional mental health programme as well as the recom mendations o f the Technical Advisory Com m ittee on the European Mental Health Programme, held in Copenhagen in February, recommended: 1. Transition from custodial forms o f care, based on large institutions, to a system o f comprehensive community mental health care covering well-defined populations. A lthough the fundamental principles o f comm unity care have been accepted and emphasized by a number o f W H O working groups, development is slow and should remain the main objec tive o f the W H O mental health pro gramme in Europe. 2. Im proved health education o f the public; better undergraduate and post graduate medical education in psy chiatry and mental health; and im proved understanding o f mental health issues by nonmedical professional groups and voluntary agencies. 3. Specific activities within the context o f the family aimed at target groups including, most importantly, the young, the aged, the alcoholic and the drug dependent. 4. Im provem ent o f in formation systems to assist planning, operational and clinical research, and the evaluation o f services and changes in them. Surveys on mental health services in Europe have resulted in the collection o f 3 7 T a b l e 2 . Per capita c o n s u m p t i o n o f p u r e a l c o h o l , 1 9 5 0 - 5 2 a n d 1 9 7 5 - 7 6 Heaviest consumption 1950-52 1975-76 Country Litres Country Litres France 17.6 France 16.5 Portugal 12.9 Portugal 14.1 Italy 9.4 Spain 14.0 Spain 8.1 Luxembourg 13.4 Luxembourg 6.8 Italy 12.7 Belgium 6.6 Germany, Fed. Rep. of 12.5 Switzerland 6.6 Austria 11.2 Austria 5.4 Hungary 10.7 Czechoslovakia 4.9 Switzerland 10.3 United Kingdom 4.9 Belgium 10.2 Country Per capita consumption in 1975-76 (litres) Increase over 1950-52 (%) Sharpest increase Netherlands and German Dem. Rep. 8.3 337 Germany, Fed. Rep. of 12.5 247 Iceland 3.7 236 Yugoslavia 8.9 230 Least increase France 16.5 - 6.2 Portugal 14.1 + 9.3 Italy 12.7 +35.0 Belgium 10.2 +55.0 Switzerland 10.3 +56.0 Source: Produktschap voor gedestillerde dranken. Schiedam, Netherlands, 1977. 3 8 a large amount o f information. N ine teen pilot study areas in 16 Member States are now participating in the project on mental health services in pilot study areas to develop data col lection and processing techniques for improving the planning and assess ment o f community mental health care. T h ey carry out or prepare de tailed studies o r activity analyses, direct cost-accounting, and assessment o f the effectiveness o f mental health care. The programme is implemented in conjunction with several national institutions, for instance the Finnish Foundation for A lcoho l Studies, with which close collaboration has been maintained fo r several years; with a network o f technical counterparts and experts, advisory panels, and pilot study areas; and with other units in the Regional O ff ice , including those responsible for family health, nursing, health education, care o f the elderly, and primary health care. Active con tacts are maintained with the Council o f Europe, the Commission o f the European Communities and a number o f nongovernmental organizations. Country activities Italy. Technical and administrative advice was given to the national auth orities on planning a seminar on epi dem iology and psychiatric services evalu ation. Romania. The project document fo r the UNDP-supported project on rehabilitation o f the handicapped was signed, and consultations took place at the Regional O ffice with the Romanian coordinator and the W H O consultant involved with this project. It is fore seen that seven temporary advisers will lecture at a training course to be held in Romania in 1980 and will assist in the placement o f Romanian fellows after the course. Publications and documents Psychogeriatric care in the com munity. Public Health in Europe, No . 10. Crisis admission units and emerg ency psychiatric services: report on a Study, by J.E. Cooper. Pub lic Health in Europe, No . 1 1. Objectives o f youth advisory ser vices: report on a Working Group. Document ICP/MNH 035 111. Public health aspects o f alcohol and drug dependence: report on a W HO Conference. E U R O Re ports and Studies, No . 8. 3.4 P R O P H Y L A C T I C , D I A G N O S T I C A N D T H E R A P E U T I C S U B S T A N C E S A new unit for coordination o f the programme was established in April, its main concerns being: (a ) to prom ote the exchange o f information on drug evaluation and control to avoid overlapping and dupli cation o f work in national drug regula tory agencies; 3 9 ( b ) to cooperate in the formulation o f national drug policies and to foster cooperation between national drug regu latory agencies and international organ izations active in the drug field; (c) to stimulate drug utilization re search at the national level and to coor dinate the work o f the W HO Drug U til ization Research Group in which scien tists from 14 European countries are collaborating; (d) to prom ote the concept o f essential drugs and collaborate with Member States, the pharmaceutical in dustry and other interested organizations in defining drugs required fo r basic health needs; and (e ) to collect and exchange in form a tion on undergraduate and postgraduate training o f pharmaceutical personnel in the European Region. The programme is generally becoming more oriented towards the coordination o f activities at the country and inter country levels and towards the p rom o tion o f an exchange o f in formation among drug regulatory agencies, manu facturers o f drugs, prescribers, distribu tors and allied health personnel and, not least, the consumers. The formulation o f national drug policies has an international impact; there is wide concern that there should be better harmonization o f drug regula tory policies and procedures taking into account d ifferent laws, econom ic and political systems, internal capabilities, and national priorities. The eighth in the series o f symposia on clinical pharmacological evaluation in drug control was held in Cologne in November, and took the form o f an expert group fo l low ed by a steering committee. The recommendations o f previous symposia were evaluated, and plans were developed for the future, in cluding main themes fo r three symposia: (a) drugs and the elderly and drugs fo r long-term treatment; ( b ) drug in formation; and (c ) drugs fo r children and drugs during pregnancy and lactation. The Drug Utilization Research Group (D U R G ) held its annual meeting in Prague in August. Research protocols, fo r example covering antihypertensive drugs, the harmonization o f classifica tion o f drugs, and m ethodo logy in measuring drug use, were discussed. The new publication Studies in drug utiliza tion was presented at the meeting. Studies in drug utilization represents the outcom e o f the activities o f the members o f D U R G since its foundation in 1969. It deals with drug utilization studies mainly from the point o f view o f prescribing patterns and touches briefly on questions o f distribution and marketing. Its aim is to stimulate the gathering o f information on drug utiliza tion studies, with particular emphasis on international comparisons. The greater part o f the book is devoted to descrip tions o f national sources o f information that are available and the uses to which they have been put in the various coun tries that participated in the project. The addresses o f institutions in the European Region where further in formation on drug utilization studies can be obtained are listed. The Planning Group on Evaluation o f Drugs and other Therapeutic and Diagnostic Substances, established under 4 0 the priority area identified by E A C M R , met in March. This meeting dealt with the development o f further links with other E A C M R research programmes, as well as with the main research components in the programmes o f the Regional O ffice. Guidelines for clinical trials o f antihyper tensive drugs, which had been drafted by the Working Group on the Harmonization o f Guidelines for Clinical Trials o f Drugs — Antihypertensive Drugs, in Uppsala in April 1978, and subsequently dis cussed at the Seventh European Sym posium on Clinical Pharmacological Evaluation in Drug Control held in Deidesheim in Novem ber o f that year, were adopted by the Planning Group and issued as a document. The guide lines cover early studies in man (first administration/pharmacodynamic studies and pilot therapeutic trials/dose-finding studies); controlled therapeutic trials (methods o f observation, criteria for admission o f patients and types o f controlled therapeutic trial); and drug interactions. A survey on under- and postgraduate training and the number o f pharma cists and pharmacy technicians in the Region, and the updating o f the Directory o f O ffic ia l Drug Control Agencies in Europe, originally pub lished by the Regional O ff ice in 1974, were started. In the biologicals field, the provision o f training for W H O fellows from the European and other regions continued. Country activities Albania. A t the request o f the health authorities, the Regional O f ficer for Coordination visited the country in December. A plant for the industrial production o f antibiotics had been built in Tirana but was not functioning owing to a lack o f expertise. The Regional O f fice later assisted the authorities in find ing an expert in the industrial production o f antibiotics to help in making the plant operational. Publications and documents Studies in drug utilization. W HO Re gional Publications, European Series, No. 8. Clinical pharmacological evaluation in drug control: report on a Sym posium. Document ICP/PHA004 . Clinical pharmacological evaluation in drug control: report on the Seventh European Symposium. E U R O R e ports and Studies, No . 13. 41 D E V E L O P M E N T OF COMPREHENSIVE H E A L T H SERVICES Expenditure (US$) 1 541 156 795 482 92 220 2 428 858* a Including Funds-in-Trust. * Being 15.19% of total expenditure. Regular funds U N funds Voluntary funds" 42 A severe earthquake struck Yugoslavia, especially the Republic of Montenegro, where a number of casualties and damage to houses and public buildings occurred. The Regional Office took part in assessing ie damage and in assisting with the rehabili tation efforts of the Yugoslav Government The Regional Office for Europe has taken a greate interest in circumpolar health. In the USSR rafts, sma boats, helicopters and other appropriate means с transport and communication are used to serve arcti populations D ISEASE P R E V E N T IO N A N D C O N T R O L Chapter 4 4.1 C O M M U N I C A B L E DIS E A S E P R E V E N T I O N A N D C O N T R O L 4.1.1 General In general, activities planned fo r the period under review were carried out, despite serious financial difficulties. This was made possible, to a large extent, by voluntary donations and the mobiliza tion o f other external resources. Close ties were maintained with WHO global programmes, including ep idem io logical surveillance, the Expanded Pro gramme on Immunization and the Programme on Diarrhoeal Diseases Con trol. The malaria epidemic in Turkey was successfully contained, although trans mission continued at lower levels in several foci. Generous financial support from various European countries and international bodies contributed to this achievement. Meetings were arranged among the Mediterranean countries with a view to preventing the réintroduction o f malaria into areas where transmission had been halted. These meetings involved collaboration between the W HO Regional O ffices fo r Europe and the Eastern Mediterranean. A second meeting o f the Global Commission for Certification o f Small pox Eradication was held in Geneva. Countries o f the European Region had returned signed statements confirming that there had been no case o f smallpox during the previous tw o years. Turkey expressed willingness to co operate in the W HO Expanded Pro gramme on Immunization, and in this connexion a headquarters sta ff member paid a visit to Turkey to discuss the problems and procedures involved. As a result, Turkey nominated two partici pants to attend an interregional course fo r planning and management o f im munization programmes, held in Dam ascus at the end o f the year. 4.1.2 Epidemiological surveillance A meeting o f representatives from 13 Mem ber States was held on the Sur veillance Programme fo r Control o f F o o d b o m e Infections and Intoxications in Europe, at which the draft o f a manual on the surveillance o f foodborne diseases was reviewed and recommendations re garding fo llow-up action agreed on. 43 An Ad hoc Consultation on C om municable Diseases was held in Copen hagen at which future Regional O ff ice activities in the field o f communicable disease control were discussed and a checklist o f priorities was drawn up. The report was sent to national technical counterparts in communicable diseases fo r their comments and suggestions. As part o f the programme on econ omic aspects o f communicable diseases, the second study phase on econom ic aspects o f viral hepatitis is under way. The aim is to assess the cost-effectiveness or cost-benefit o f specific measures in hepatitis prevention and control. Country activities Algeria. The visit by three consul tants in 1978 was fo llowed up with visits by four consultants, who prepared tech nical documents fo r the second phase o f the project concerned (a) with setting up a centre fo r research on the Sahara in order to carry out health and socioecon omic studies, and (b) with possible ad verse effects, in particular the transmis sion o f communicable diseases that may be caused by use o f the Trans-Saharan Highway. They concluded that the com municable diseases requiring special sur veillance were above all malaria, fo llowed by schistosomiasis, cholera and the haemorrhagic fevers. Detailed recom mendations were made on strengthening laboratory infrastructure. Morocco. A t the request o f the Government the W H O microbiologist has been asked to continue ( f o r a further two years) his collaboration with national experts in the training o f laboratory technicians, in epidemiological studies o f communicable diseases, and in the organ ization o f laboratory services. The programme was carried out ac cording to plan and progress has been achieved in the malaria emergency in Turkey in spite o f many difficulties (financial, political, staffing, transport, technical and operational, such as resis tance to some insecticides). The number o f reported cases was only 29 324 in 1979, compared with 115 512 in 1977 and 87 867 in 1978. This improvement was evident throughout the country, as can be seen from Fig. 4 and 5. The G ov ernment is considering integrating the malaria services into the PHC services and the W H O team will provide the necessary support. The total budget allocated by the Turkish Government to the national malaria eradication service in 1979 amounted to U S$35 099 236, represent ing 6.4% o f the total budget o f the Ministry o f Health, and exceeding the amount foreseen for 1979. A number o f problems remain, some o f which are o f a research nature (e.g., the danger o f development o f resistance in A. sacharovi to malathion). A W H O en tomologist was assigned to Turkey at the beginning o f 1980 and his main function will be the training o f entomological sta ff and constant monitoring o f suscepti bility to insecticides. The Com m ittee o f Food A id Policies and Programmes provided financial assist ance to the malaria eradication and con trol programme in Turkey; this is an in centive to the assistants in community health prom otion to participate regularly in the antimalaria campaign in order to assist and support the national malaria eradication and primary health care services. 4.1.3 Malaria and other parasitic diseases 44 F i g . 4 . T u r k e y : e p i d e m i o l o g i c a l st r at a r^jStratum l-a # Foci in 1977 r]Stratum l-b B F o c i in 1978 QjStratum II [^Stratum III © Foci in 1979 jffiStratum IV F i g . 5 . T u r k e y : p a r a s i t e i n c i d e n c e Stratum I-a 0.004 0.001 1975 1976 1977 1978 1979 Stratum l-b Stratum II Stratum III Stratum IV A W HO multidisciplinary evaluation team, together with national counter parts, carried out an evaluation o f the programme, and the team ’s conclusions were used as a basis fo r discussions at an evaluation meeting held in Ankara, in November. International participation was ensured by representation from EEC, U N D P, W FP, Finland and Y u go slavia. Both countries pledged further support to the programme. In January the World Bank spon sored a mission in Turkey to study the role o f the irrigation system in the re surgence o f malaria in the Çukurova 4 6 Plain. This was fo llowed by a World Bank/WHO/FAO meeting in Ankara in September. Consideration was given to possible support by the World Bank for a mosquito abatement unit based on helicopters and equipment fo r main taining drainage canals, combined with sta ff training fo r such activities. Contacts were made with the health authorities o f Bulgaria, Greece and Yugoslavia in order to establish lines o f collaboration and exchange o f in forma tion on the present epidemiological situation with regard to malaria, and in this connexion it is planned to hold a series o f meetings, the first in Bulgaria at the beginning o f 1980. As a follow-up to a previous meeting in Izmir, a Coordination Meeting on the Prevention o f the Réintroduction o f Malaria in the Countries o f the Western Mediterranean was held in Erice, Italy in October, to which the Italian Govern ment gave a substantial contribution. The stimulus fo r convening the meeting was concern over, on the one hand the increasing number o f cases o f malaria imported from A frica into Europe and the dangers connected with the Trans- Saharan Highway, and on the other hand the reduction o f government interest in malaria due to the progress achieved by the malaria control programmes and/or absence o f local transmission at present. The Meeting was attended by participants from seven countries (A lger ia , France, Italy, M orocco, Portugal, Spain and Tunisia) and by a representative o f the Regional O ff ice fo r the Eastern M edi terranean. Many recommendations were made on control measures and the train ing o f personnel. A need was felt fo r an annual WHO-sponsored seminar with participants from Algeria, Libya, Mali, M orocco , Niger and Tunisia, for periodic meetings o f the coordinating committee o f the north African countries under W HO sponsorship, and fo r an annual meeting o f the countries present at the meeting. Country activities Algeria. A t the request o f the G ov ernment, three consultants helped to m on ito r entomological development, to evaluate the eradication programme and to prepare a plan o f action fo r 1980. Th ey concluded that the programme continued to require strong central tech nical direction, and that the entom ologi cal service required continuous interna tional support, and recommended that investigations into the compatibility o f Algerian vectors and imported Plas modium strains should be undertaken without delay. Morocco. Several new foci were re ported from Khemisset; this prompted the Government to organize a workshop fo r an antimalaria action programme for 1980 and intensification o f work in the future. 4.1.4 Bacterial and virus diseases The Ministry o f Health in Turkey is preparing to participate in the W HO Pro gramme on Diarrhoeal Diseases Control. It is hoped to produce the oral rehydra tion powder locally. Training will be provided for laboratory sta f f and for workers in primary health care; health education o f the public will also be necessary. A Meeting on the Surveillance and Control o f Zoonoses and Foodborne Diseases was held in Pendik/Istanbul and 47 was attended by participants from the countries o f the Mediterranean Basin. This was fo llowed immediately by the Second Meeting o f the Joint Coordinating Comm ittee , the purpose o f which was to discuss national activ ities and the activities o f the Medi terranean Zoonoses Control Centre in 1980 and 1981. This Centre was opened in Athens in February, and an inter country programme coordinator was appointed. Representatives visited a number o f western Mediterranean coun tries to discuss their potential partici pation in or support for a comprehen sive zoonoses control project. The need fo r simple guidelines on the management o f sexually trans mitted disease fo r physicians in gen eral practice has been apparent fo r some years. In Europe, no less than in other parts o f the world, the ma jo r ity o f patients suffering from sex ually transmitted diseases are treated in general medical practice by phys icians who have not received adequate training in the management o f this group o f diseases and who, as a con sequence, pay insufficient attention to correct laboratory diagnosis and contact tracing. The Symposium on the Surveil lance and Control o f Sexually Trans mitted Diseases, organized in conjunc tion with the Government o f Austria in 1976, recommended that WHO should prepare a practical manual on the management o f sexually trans mitted diseases that would contribute to their improved control through the more e ffective treatment o f the many cases that occur each year. Dr R.R. Will- cox undertook the task on behalf o f the Regional O ff ice , and the guide was published in 1979 (see below ). Country activities Greece. In conjunction with the Greek veterinary and health services, a consultant studied the rabies situ ation and advised on strengthening the rabies surveillance system. Turkey. A consultant visited Tur key in October to assist the Govern ment in its leprosy control programme, i.e., to assess the extent o f the disease and advise on the organization o f the leprosy service, training, routine treat ment and the possibility o f external assistance. 4.1.5 Publications Receptibility to malaria and other parasitic diseases: report on a WHO Working Group. E U R O Reports and Studies, No. 15. The management o f sexually trans mitted diseases: a guide fo r the general practitioner, by R.R. Will- cox. E U R O Reports and Studies, No . 12. 4.2 NONCOMMUNICABLE DISEASE PREVENTION AND CONTROL 4.2.1 General During the year a particular e ffort was made to strengthen ties with na tional authorities, institutes, professional groups and collaborating centres fo r the 4 8 implementation o f activities o f mutual in terest. Similarly, contacts with interna tional, intergovernmental and nongovern mental organizations and international professional associations were intensified, and mutual support established, in order to utilize available resources to the maxi mum extent possible. Collaboration with other programmes o f the Regional O ff ice was intensified to mutual benefit. In particular, the com munity control programmes in pilot study areas in the fields o f cardiovascular dis eases and mental health are relevant to the primary health care and care o f the elderly programmes. Other aspects covered were appropriate technology fo r health, health manpower development, health in forma tion, and applied research. A comprehen sive approach was adopted for chronic diseases with comm on risk factors ( f o r example, the association o f smoking with lung cancer, cardiovascular diseases and chronic respiratory diseases) and with com m on aspects o f care delivery at the community level. Deeper interest was developed in the epidemiological aspects o f chronic dis eases and behaviour (nutrition, alcohol consumption, smoking and other habits) which, together with environmental fac tors, create conditions favourable fo r the development o f chronic diseases and acci dents, particularly road traffic accidents. Research applied to health services attracted greater attention, and a new venture — health care-related research in hypertension — was pursued. 4.2.2 Cancer With a view to strengthening coord i nation between the cancer programmes o f the Regional O ff ice and IA R C , a jo int Study Group on Cancer Screening was convened in Copenhagen in Decem ber. Experience in cervical screening in Canada, Norway, Sweden, the United Kingdom and the U SA over the past decade was reviewed, and the value o f well organized screening programmes was unanimously recognized. A need was felt fo r further research into the defi nition o f age groups, the frequency o f screening, the quality o f smears, non-response and high-risk groups, and cost-benefit relationships. It was decided that an attempt would be made to pool analysed data from the various national programmes. 4.2.3 Cardiovascular diseases The cardiovascular diseases (C V D ) programme gained momentum through renewed interest in C V D problems and W H O ’ s role in tackling them. This new in terest was spurred by such controversies as hospital versus home care o f acute m y o cardial infarction, by-pass surgery, and reasons fo r the decline in mortality from ischaemic heart disease ( IH D ). This favourable attitude was reflected by prog ress in the projects on comm unity con trol o f C V D , and the successes attained in the established pilot study areas. In some countries, however, it is still d i f f i cult to concentrate the best skills, man power and resources in one suitable geo graphic area. Another indicator o f prog ress is the fact that the time allotted to the WHO symposium to be held during the European Congress o f Cardiology in Paris in June 1980 is twice that o f the symposium in Amsterdam in 1976, In spite o f financial difficulties, the overall development o f the programme was maintained, and some new activities 4 9 were added, such as the project on m oni toring IHD incidence, in which at least eight centres are ready to participate. During a meeting o f a working group in Rome in May, the principal investiga tors in the European Collaborative Study on Primary Prevention o f Ischaemic Heart Disease evaluated the progress made. As the Study was still going on in a few centres, it was decided to wait until 1981 to publish the final results, including incidence data. The Study on Primary Prevention o f Ischaemic Heart Disease by Lowering Blood Cholesterol (A trom id Trial) con firmed the original hypothesis that lower ing b lood cholesterol results in a lower in cidence o f coronary heart disease in the high-cholesterol intervention group. H ow ever, a thorough mortality fo llow-up has been initiated, covering the whole period since the closure o f the trial in 1977, and the results are now ready for publication. A Working Group on the D eve lop ment o f Coronary Care in the Community was held in Brussels in February. The Group emphasized the concept o f com prehensive care, starting with primary pre vention and care in the community for those suffering a heart attack, prior to admission to hospital. Training o f an adequate number o f people in cardio pulmonary resuscitation, reduction o f the delay in reaching skilled medical assistance, proper but not overly sophis ticated care in the coronary care unit, early rehabilitation, and secondary pre ventive measures emerged as the most important issues contributing to better outcome. Analysis o f the results o f the Study on Effects o f Rehabilitation and Second ary Prevention in Patients with C V D was begun at the Cancer Research Centre in Heidelberg. Concom itantly, some o f the participants in the Study started to prepare a monograph on the present state o f the art in coronary heart dis ease, and a meeting o f the editorial board was held in Heidelberg in June. The directors o f the pilot areas for the Study on Comprehensive Cardiovas cular Com m unity Control Programmes, together with experts in health educa tion, met in August in Novi Sad. In none o f the centres had the programmes proceeded far enough in data analysis or data collection to permit an assessment o f the results o f the intervention activ ities. Nevertheless, there was evidence o f an intense e f fo r t being made to establish the risk factor status o f the populations over time, and to institute preventive measures through various methods o f health education and promotion in the collaborating communities. The principal investigators in the Study on Chronic Lung Diseases leading to Pulmonary Hypertension met in Novem ber in Strasbourg. The publica tion o f the results o f the retrospective study (covering more than 800 patients) is foreseen for the second half o f 1980. The protocol and record forms o f the prospective study have been finalized and the recruitment o f patients started. The E A C M R selected health care- related hypertension research as one o f its first priorities. A consultation was held in Copenhagen in October with representatives from 25 European Mem ber States. The main areas where it was felt there was a need for WHO- coordinated research included: the role o f sodium intake in causation and pre vention; genetic markers; the natural 50 history o f high blood pressure in children and adolescents; the role o f psychosocial factors; monitoring effects o f screening and long-term treatment; evaluation o f hygienic, psychogenic, and pharmaco logical treatment in the comm unity; the role o f general practitioners and health personnel in the management o f hyper tension; public attitudes towards preven tion; and compliance with treatment. Accord ingly , a health care-related re search programme in hypertension is now being developed, in close collabora tion with W H O headquarters. As part o f the Regional O ff ice pro gramme on appropriate technology for health, a study was undertaken on the role and utilization o f ECG in health care. Three consultants collected in for mation from 11 countries and their report concluded with a number o f con crete recommendations. In collaboration with WHO head quarters, tw o consultations were held to develop a protoco l fo r a study on monitoring systems for the incidence o f C V D . This study w ill provide in formation on trends in mortality and morbid ity from and the incidence o f coronary heart disease, together with changes in risk-factor levels and health service indices. Country activities Italy. The Regional O ff ice r for Chronic Diseases gave a lecture at the Symposium on Preventive Cardio logy at the National Institute o f Health, Rom e, in May, attended the National Meeting o f the Associations o f Italian Centres for Preventive Cardiology, Perugia, in Decem ber, and visited the Istituto Superiore di Sanità in December. Morocco. The Regional O ff ice r for Chronic Diseases lectured at the 8th Con gress o f French-speaking Cardiologists, Agadir, which was organized by the Moroccan Association o f Cardiology. Portugal. Discussions were held with the President o f the Portuguese Heart Foundation, during which advice was given on the development o f a national programme to control C V D in general, and hypertension in particular. 4.2.4 Oral health The increasing interest in oral health should be seen in the light o f the fact that dental caries and peri odontal diseases continue to be a pub lic health problem o f concern to most European countries. There are, how ever, great variations in the prevalence o f dental caries within the European Region, being high to very high in northern Europe, moderate to high in central Europe and low to moder ate in southern Europe. Unfortunately, there are now clear signs o f an alarming increase in dental caries in those coun tries in which the prevalence hitherto has been low to moderate. In certain parts o f Europe, where effective mass preventive measures have not yet been implemented, the average number o f decayed, missing and filled permanent teeth (D M F T ) is in the order o f 8 - 1 2 at 12 years o f age. This means that at this age 2 5 -4 0 % o f the permanent teeth are already diseased. Since dental caries is an irreversible disease, the signs will accumulate with age. A t 3 5 -4 4 years o f age the D M F T index in many highly developed countries is in the order o f 15-25 , with 5 -3 5 % o f the population being complete ly edentulous. 51 Only in those countries in which e f fe c tive mass preventive measures have been introduced is there evidence o f an im provement in oral health in children and young adults. With the increasing cost o f comprehensive treatment and rehabilita tion, which will prove prohibitive fo r even the richest o f countries, it is imperative that top priority be given to prevention. The oral health programme is and will continue to be aimed at collaborating with countries in an attempt to increase the use o f comprehensive mass preventive meas ures, and to expand the use o f dental aux iliaries according to the need and health policy o f the Mem ber States in the Euro pean Region. The promotion o f rational management o f dental health services by developing eff ic ient information systems and by stimulating research related to practical needs will be an important com ponent o f the oral health programme. The publication Oral health services in Europe by J. Kostlan, which appeared in 1979, consists o f a general review o f oral health care in Europe and a country- by-country description o f national oral health services, their origins, organiza tion and problems. The number o f countries participating in the W HO International Collaborative Study on Dental Manpower Systems was extended, with the inclusion o f the Ger man Democratic Republic and Ireland. The Oral Health unit cooperated in the planning o f drinking-water fluoridation projects in Portugal and Greenland. A d visory services were provided to a num ber o f Member States and an ever- increasing number o f requests for co l laboration and information on oral health matters reflects a growing aware ness o f the importance o f improving oral health in Europe. 4.2.5 Other noncommunicable diseases The planned shift towards a compre hensive chronic disease control approach was accepted with interest by leading experts and is gaining support from a number o f collaborating institutes. Close collaboration with WHO headquarters and the relevant professional societies was the mainstay o f progress in this new approach. A Study on M ethodology and Evalua tion o f Behavioural Changes in Children and Adolescents in Relation to Non communicable Diseases was started, in volving three centres in the Federal Republic o f Germany, Finland and N o r way. This Study is closely linked with the W HO headquarters study on athero sclerosis precursors in children. The report o f the Study on the Long term Health Effects o f A ir Pollution was finalized. The study clearly showed a strong association between air pollu tion and various respiratory indices in children. The findings suggest that initial effects on respiratory indices in children should be sought at annual mean con centrations o f sulfur dioxide and smoke below 200/oig/m3 and, i f further studies are to be conducted, this should be done in countries with annual mean concentra tions o f sulfur d ioxide and smoke be tween 50 and 200/ug/m3. Country activities United Kingdom. The Regional O f ficer for Chronic Diseases lectured at a combined scientific meeting o f the Heberden Society and the British Asso ciation fo r Rheumatology and Rehabilita tion, organized by the University o f Manchester in July. 52 Oral health services in Europe, by J. Kostlan. W HO Regional Publica tions, European Series, N o . 5. 4.2.6 Publications The role and function o f national institutes o f ophthalmology : report on a WHO Meeting. E U R O Reports and Studies, N o . 5. DISEASE PREVENTION A N D C O N T R O L Expenditure (USS) Regular funds 1 483 486 (285 423)a U N funds 164 410 ( 78 047)“ Voluntary funds* 1 103 873 (989 906)° 2 751 769c a Figures in parentheses refer to funds allocated to malaria control activities (total USS 1 353 376). * Including Funds-in-Trust. c Being 17.21% of total expenditure. 53 Chapter 5 PROMOTION OF ENVIRONMENTAL HEALTH 5.1 G E N E R A L A considerable shift o f emphasis took place in the environmental health activities o f the Regional O ff ice during the year. Since the goals o f the first long-term programme have been pro gressively attained, e fforts are now being focused on tw o major activities that are occupying the attention o f W HO, both at headquarters and through out the various regions, namely the International Drinking-Water Supply and Sanitation Decade and the W H O Inter national Programme on Chemical Safe ty. Fo r the report o f a WHO senior adviser on the role o f the Regional O f f ice in the field o f environmental health, see Annex 6. A lthough most countries o f the Region have adequate community water supplies and urban sanitation, there are many deficiencies in rural areas; in a small number o f countries substantial investment and technical development will need to take place i f satisfactory services are to be provided to all com munities by the end o f the Decade. Such facilities are, o f course, an essen tial component o f primary health care and a high priority o f the Regional O ff ice during the next few years will be technical cooperation with Member States (a) to stimulate the necessary investment and ( b) to ensure cost- effectiveness by encouraging the use o f appropriate technology and the develop ment o f adequately trained manpower at all levels and, particularly in the case o f small rural communities, by helping to secure community participation. In order to facilitate the attainment o f the Decade objectives, the Regional O ff ice will endeavour to have an experienced W HO engineer resident in each o f the countries o f the Region with the greatest water supply and sanitation needs; the engineer will assist the government in developing a strategy fo r the Decade, and will collaborate with the Resident Representative o f U N D P in securing coordinated international technical co operation. With over half o f the w or ld ’s chemi cal industry concentrated in the Euro pean Region, the International Chemical Safety Programme is o f particular im portance to the Regional O ff ice , and preparatory work was completed to wards the end o f the year for substantial regional activities concerned with poten tially tox ic materials in air, water, food and the working environment. 55 Emphasis is also being placed on the training o f toxicologists and associated personnel and on legislative and adminis trative considerations in the safeguarding o f human health from exposure to tox ic chemicals. Collaboration w ith govern ments is also taking place in relation to contingency planning and response to in dustrial emergencies concerning the re lease o f harmful chemicals, such as took place at Seveso in 1976. In view o f the proliferation o f chemicals in the environ ment, the Regional O ff ice , together with W HO headquarters, has commenced a complete revision o f the WHO standards for drinking-water, and it is anticipated that this work will be completed by the end o f 1981. Increased attention is being paid to the environmental health effects o f changing patterns o f energy production and utilization. A Working Group on Health Aspects related to Indoor A ir Quality, convened in Bilthoven in April, demonstrated the potential hazards o f air pollution in buildings. Work is now proceeding on the public health aspects o f housing and settlements, both in northern Europe and in the Mediter ranean countries. It is clearly impossible to separate the effects on human health and well being o f environmental hazards from those resulting from the lifestyles o f individuals and communities; work is therefore commencing within the field o f human eco logy in an endeavour to link a number o f such factors in indus trialized societies. This should facilitate the process o f assessing relative risk and help governments to develop national priorities in relation to environmental health. Effective environmental health man agement at the national level can be achieved only by satisfactory institu tional arrangements. Unfortunately, in many countries o f the Region there has been a proliferation o f government de partments or agencies dealing with d i f ferent aspects o f environmental protec tion, and this has sometimes led to a neg lect o f considerations relating to human health, and to a sectoral approach that makes it d iff icult fo r decision makers to take a holistic view. An important part o f the work o f the Regional O ff ice is therefore related to the design o f e f fective environmental health services. 5.2 E N V I R O N M E N T A L HEALTH PLANNING A N D M A N A G E M E N T Fo llow ing the establishment o f the new unit o f Environmental Health Plan ning and Management in February, a start was made on the task o f organizing and developing environmental health policies and manpower studies in the environmental field in collaboration with Member States and training institutes. A t the same time, several activities started in 1978 were further developed, under both the regular programme and the jo in t collaborating programme with other United Nations agencies, particu larly U N D P and UNEP. In this con nexion, whenever possible, links were established between the two programmes. For instance, the results o f the seminars on environmental impact assessment held in Greece and Czechoslovakia promoted the interest o f other countries in the development o f this powerful too l in planning strategies and policies having environmental consequences. 56 The main thrust o f the intercoun- try programme was directed towards the training o f personnel and the de velopment o f professional profiles. A three-country survey o f environmen tal services was also undertaken and completed in collaboration w ith WHO headquarters. As in previous years, the postgradu ate course on environmental sciences and technology (in English) held in Delft, Netherlands o ffered an 11-month study programme, including lectures, laboratory exercises, workshops, pro ject work and field studies in a great variety o f subjects. It was attended by biologists, chemists and engineers. T w o lecturers were recruited by WHO and 13 students from 6 different coun tries participated in the course as WHO fellows. A meeting was held in the Netherlands in May to discuss coopera tion between institutes and the R e gional O ff ice , keeping in mind the growing need to train environmental specialists in the European Region and fo r a periodical updating o f the cur ricula to meet the challenge o f very rapid sociocultural, technological and econom ic changes. T o formalize rela tions between the Regional O ffice and the International Institute for Hydraulic and Environmental Engineer ing in Delft, negotiations are under way on the designation o f that Insti tute as a WHO collaborating centre fo r manpower development in environ mental health. The postgraduate course in en vironmental engineering (in French) at the Federal Polytechnic in Lausanne, Switzerland continued to be supported. One lecturer was funded by the Regional O ff ice and seven fellows, three from the European Region and four from other W H O regions, attended the course to specialize in such subjects as basic sanitation, industrial hygiene, occupa tional health and air pollution. The Regional O ff ice continued to support the training programme o f the Sanitary Engineering Centre in Rabat, and the first teachers trained fo r the Centre under W H O fe l low ships abroad were employed. A t the beginning o f the academic year in September only two W H O sta ff mem bers still held teaching positions at the Centre, the rest being occupied by Moroccan nationals. Collaboration with the European Centre for Human Eco logy in Geneva continued. As a result, the O ff ice was represented at a seminar in Le Mesnil Saint-Denis, France at which a medium- term programme on health and the environment, including the establish ment o f “ health observatories” in se lected areas in France, was discussed. In formation was collected by a consultant fo r the preparation o f an inventory o f institutions in the Euro pean Region where facilities for train ing in environmental health are avail able, giving details o f the content and duration o f courses and the type o f dip loma or certificate obtainable. A meeting was held at the Insti tute o f Environmental Engineering in Warsaw in Novem ber, to discuss the professional profiles o f sanitary and environmental engineers, including cur ricula, training facilities, recognition o f certificates/degrees and em ployment opportunities. 57 Three countries were selected for a survey o f environmental services in collaboration with W HO headquarters: Czechoslovakia, the Federal Republic o f Germany, and Yugoslavia. The rap porteurs from these countries described the environmental services within the existing governmental structure and paid particular attention to the problem o f coordination. A W H O collaborating cen tre in the field o f water research is prepared to take part in the survey as far as the water component o f the environ mental services is concerned. A Consultation on Professional Pro files fo r the Environmental Health O ff icer in an Industrialized Society was held in Copenhagen in Novem ber, to fo l low up the work o f the Consultation on the Role, Functions and Training Require ments o f Environmental Health Officers (Sanitarians) held in December 1977. As there has been a shift o f emphasis from traditional sanitation problems to the new hazards associated with intensive industrialization, the professional profile o f the environmental health o f f icer is expected to reflect the importance o f his preventive role in controlling environ mental factors hazardous to health. The report on the Consultation on Manpower Development in T ox ico lo gy , issued during the year, helped in clari fy ing the type o f knowledge and skills required from the professional to x i cologist, as well as training requirements. It was also agreed that there was an urgent need to promote international recognition o f tox ico logy as an inde pendent science, with wider under standing o f the training methods used in the various Member States. As a follow-up to the Seminar on En vironmental Health Impact Assessment held in Greece in 1978, a Seminar on Environmental Impact Assessment in relation to Environmental Protection and Physical Planning was held in Bratis lava at the end o f August. It was agreed that strategies fo r environmental protec tion should reflect the current and emerging problems o f industrialized society, with priority given to industrial pollution in general and the effects o f tox ic chemicals in particular. The environmental impact analysis system has emerged as one o f the most powerfu l planning tools fo r the preven tion o f environmental pollution and degradation. Environmental impact analysis is growing in importance and is likely to assume an even greater significance in the future, as potentially conflicting demands are made for an improvement in the quality o f life on the one hand and continuous econom ic growth on the other. Environmental impact analy sis will be o f considerable importance in helping governments to achieve rational solutions to these short-term conflicts. One o f the most important com po nents o f any environmental impact as sessment system is health. The Regional O ff ice has made persistent e fforts to assist in the development o f the skills, attitudes, in formation and tools needed fo r full and adequate treatment o f the health com ponent o f environmental impact assessment systems. The results o f environmental health impact assessment must be communi cated to decision makers and to the pub lic in a form that will allow them to grasp the essential conclusions. In an e f fo r t to develop a method o f effective 5 8 communication the Regional O ff ice , in collaboration w ith the Technical University o f Copenhagen, has de veloped computerized techniques for translating emission inventories, environ mental dispersion models and health effect in formation into coloured three- dimensional maps. This process facili tates the rapid manipulation o f data and visual demonstration o f probable health effects o f the various alterna tives o f the proposed action, over a range o f probable circumstances. The maps shown in Fig. 6 were produced to test the m ethodology ; they are based to a large extent on hypothetical data, and therefore do not represent a real-life situation. Publications Environmental health impact as sessment: report on a W H O Semi nar. E U R O Reports and Studies, No . 7. 5.3 PROVISION OF BASIC SANITARY MEASURES The persistence in the European Region o f communicable diseases re lated to poor basic sanitation was reflected in the occurrence o f enteric diseases, including cholera, in several countries during the year. The report on the Meeting on En vironmental Health Problems in Tourist Areas, held in Montpellier in Septem ber 1978, was published in French (see be low ). The participants in the Meeting studied the e ffec t o f large seasonal fluctuations in population, climatic constraints, and unsanitary or hazardous econom ic activities on essential services responsible fo r en vironmental health. They also discussed the impact o f these factors on the administration o f municipal technical services, on the management o f water resources, and on the maintenance o f the ecological balance and the con trol o f tox ic chemicals that could be dispersed in tourist areas. The consolidated report on the rapid assessment o f the drinking-water supply and sanitation situation in Europe was sent to all Member States for review before finalization. A Planning Consultation on the European Study on Public Health As pects o f Housing took place in Copen hagen in December to design a proposed study protocol fo r a comm on exercise among collaborating institutes in several European countries. In May, a planning meeting was held in Copenhagen to prepare for a workshop on environmental health problems in arctic and subarctic areas, to take place in the USSR in 1981. Publications La salubrité de l'environnement dans les zones touristiques européennes : rapport sur la réunion d ’un groupe de travail. E U R O Reports and Studies, No. 18. 5 9 Fig. 6 . Mapping of environmental impacts and health effects Green: no noticeable health effect. Yellow: increased m orbidity — reduction of pulmonary function, higher incidence of chronic bronchitis and other pulmonary diseases. Red/orange: higher mortality among the most susceptible sectors of the population. A. Section of a coastal metropolitan area. The contours represent average yearly levels of S02 from a variety of area, line and point sources. B. The same area and the same background levels as in map A. Two additional large pointsources (e.g., a power station and a large chemical plant) located on the axis parallel to the prevailing wind “2 ж 6 0 F i g . 6 . ( c o n t d ) C. The same area and the same sources as in map B, but with the two large point sources located on the axis perpendicular to the prevailing wind. 5.4 RECOGNITION A N D C O N T R O L OF E N V I R O N M E N T A L H A Z A R D S 5.4.1 Water pollution control Water quality management o f the Danube U N D P financed preliminary discus sions with the governments concerned to enable W H O staff and consultants to draw up detailed project proposals. A representative o f the Regional O f fice and a U NEP consultant visited Yugoslavia in Novem ber to discuss proposed project activities. The Govern ment expressed full support fo r the project and indicated its readiness to participate. A temporary adviser attended a meeting o f the Danube Commission in Budapest in December on behalf o f the Regional O ffice. It is expected that a large-scale UNDP/W HO project, in collaboration with UNEP, F A O , UNESCO and IA E A , will commence during 1980. Water quality monitoring system — GEMS ( Wa ter) Collaboration w ith Member States continued within the framework o f the UNEP-sponsored Global Environmental Monitoring System (G E M S ), aiming at the prom otion o f an exchange o f infor mation on levels and trends o f water pollution. Ten o f the eleven countries participating in this exercise have signed agreements with W HO and four (Belgium, Spain, Turkey and the United K ingdom ) have been approached to provide data on a pilot basis for the W HO collaborating 61 centre on surface and ground water quality in Canada. Operational guides (in English) were sent to the national centres/stations in each o f the partici pating countries: Belgium, Finland, Hun gary, Malta, Monaco, Netherlands, N o r way, Portugal, Spain, Turkey and the United Kingdom. The GEMS programme is carried out in close collaboration with W HO headquarters. Joint WHO/UNEP Coordinated Pilot Project on Coastal Water Quality Con trol in the Mediterranean (MED VII) Follow ing the decision o f the inter governmental review meeting o f M ed i terranean coastal states and the First meeting o f the contracting parties to the Convention for the Protection o f the Mediterranean Sea against Pollution and its related protocols, the pilot project, along with other similar activities, was extended for two more years. T w o M ED V I I meetings on coastal quality monitoring o f recreational and shellfish areas were organized by WHO and U N E P and attended by the principal investigators o f the collaborating insti tutes. The subjects discussed included m ethodology o f monitoring, selection and identification o f parameters, labora tory quality control, comparability o f results, their analysis and evaluation, environmental quality criteria, and ep i demiological studies on dose-response relationships. The document Principles and guide lines fo r discharge o f wastes into the marine environment was finalized and distributed during a meeting o f technical and legal experts for the adoption o f a protocol on pollution from land-based sources, organized by U NEP in Geneva. W H O consultants and, on occasion, staff o f the Regional O ff ice , represented the Organization at nine different meet ings organized by U NEP in connexion with the Mediterranean Act ion Plan. Other activities Reports on four working groups held at the end o f 1977 and during 1978 were published (see be low ). These reports will serve as an essential contribution to the present revision o f the WHO standards fo r drinking-water and to the prepara tion, together with W HO headquarters, o f new guidelines. Agreement was reached with Per gamon Press in the United K ingdom on the publication o f the handbook Exam ination o f water for pollution control, on behalf o f the O ffice . The three vol umes will cover: sampling, data analysis and laboratory equipment; physical, chemical and radiological examinations; and biological, bacteriological and vir- ological examinations. Publication is planned fo r 1980. The report on the pilot-scale inter comparison studies o f methods for water analysis, comprising three studies on anionic detergents, heavy metals (cadmium, copper, iron and zinc), and oxygen demand and organic carbon, was finalized by the Water Quality Institute, Denmark. It was distributed on behalf o f the Regional O ff ice to all collabor ating laboratories in Europe and North America. Preparations started for a meeting o f a working group on health implications o f the use o f drinking-water reservoirs for recreation, to be hosted by the Hun garian authorities in 1981. 62 Sodium, chlorides and conductivity in drinking-water: report on a WHO Working Group. E U R O Reports and Studies, N o . 2. Health effects o f the removal o f substances occurring naturally in drinking-water, with special refer ence to demineralized and desal inated water: report on a WHO Working Group. E U R O Reports and Studies, No . 16. Radiological examination o f drinking- water: report on a W H O Working Group. E U R O Reports and Studies, No. 17. Coastal quality monitoring o f rec reational and shellfish areas (MED VII): report o f a Workshop jo in t ly convened by W HO and UNEP. Document ICP/RCE 206 (9 ). 5.4.2 A ir pollution control During the High-level Meeting w ith in the framework o f the ECE on the Protection o f the Environment, held in Geneva in November, the Regional Director represented the Director-General at the signing o f the Convention on Long-range Transboundary A ir Po l lution. Air quality monitoring system - GEMS ( A ir) By the end o f the year, 18 coun tries o f the Region were participating Publications and documents in the GEMS air quality monitor ing programme, namely: Algeria, Bel gium, Czechoslovakia, Denmark, F in land, France, Federal Republic o f Germany, Greece, Italy, Netherlands, Poland, Portugal, Spain, Sweden, Swit zerland, Turkey, United K ingdom and Yugoslavia. Bulgaria and M orocco have also expressed interest in jo in ing the project, which is carried out in close collaboration with WHO headquarters. Experts were recruited fo r country visits, lectures, or advice on setting up m onitoring equipment, fellowships were granted fo r attending specialized courses, and standard equipment for monitoring stations was provided for five countries (A lgeria, Poland, Portu gal, Switzerland and Turkey ). An inter calibration exercise fo r the determina tion o f sulfur d ioxide from selected samples was performed, fo l low ing the recommendations o f the Workshop on A ir Pollution Reference Measurement Methods and Systems held in March. The proceedings o f the Interregional Seminar on A ir Quality Management, held in Sofia at the end o f 1978, have been prepared. W ork on the Manual on ambient air pollutants from industrial sources continued and the second draft was almost completed. A Working Group on Health As pects related to Indoor A ir Quality took place in Bilthoven in April. The Group discussed the effects o f soil surfaces and building materials that emit radioactive radon gas, asbestos- containing materials that can release asbestos fibres, and insulation materials and processed w ood that release formal dehyde to the indoor atmosphere. 63 The Group also considered the wide range o f current consumer products such as personal hygiene products, cleaning agents, biocides, air fresh eners, solvents, adhesives, and hob by and handicraft materials, all o f which can discharge harmful con taminants to the indoor environ ment. The Working Group reviewed cer tain aspects o f indoor air quality that have always been o f concern but which are even more serious with drastic ally reduced ventilation, such as body odours and those produced by cook ing and tobacco smoking. The health consequences o f increased levels o f particulates and carbon m onox ide from tobacco smoke and o f increased levels o f nitrogen d ioxide, carbon monoxide and aldehydes from the use o f un- vented gas appliances during cook ing and water heating were also dis cussed. Throughout the discussions o f the Working Group, a consistent finding was the extreme scarcity o f data on health effects specific or even appli cable to the indoor environment. A l most all considerations o f the Group with respect to the health effects o f specific contaminants had to be based on research data obtained in the study o f ambient air pollutants, or on data obtained from studies on places o f work. The Third Intersecretariat M eet ing on A ir Pollution Problems in Europe took place in Geneva in January. The invitations fo r the Fourth Meeting in May 1980, at IL O headquarters in Geneva, have been despatched. Health aspects related to indoor air quality: report on a W HO W ork ing Group. E U R O Reports and Studies, No . 21. 5.4.3 Solid waste management The chapters on animal waste, petrochemical waste, mining waste and ferrous metal waste, which form part o f the manual on solid waste man agement, were issued separately as documents in English only. The chap ter on composting is being revised. By the end o f the period under re view there had been no clear response from U N E P regarding financial sup port fo r this project. 5.4.4 Radiation protection Work on the manual on nonion izing radiation protection was almost completed. The chapter on m icro wave and radio frequency radiation was finaUzed, fo l low ing a revision and review by a group o f over 20 experts. This revision was made with strong support from the WHO collaborating centre at the US Bureau o f Rad io logical Health. A number o f meet ings were held among and with the experts involved in finalizing the chap ter on microwave radiation and in evaluating the questionnaires, to dis cuss various details. Replies to the two questionnaires on legislation and institutions continued to arrive. The finalization o f the manual was de layed because o f the essential re vision o f the microwave chapter, and because o f the late arrival o f some Publications 64 replies from Member States to the questionnaires. The manual will be published in 1980. The French and Russian trans lations o f the report on the Working Group on Health Implications o f N u clear Power Production were distrib uted. The second meeting within this project, on health aspects o f trans uranium elements (neptunium, p luto nium, americium and californium) took place in Brussels in November, during which a planning meeting was con vened to prepare for the third meet ing on health implications from high- level radioactive waste disposal, planned fo r June 1980 in Bruges. 5.5 F O O D SAFETY The level o f general food hygiene in a country depends more on resources for inspection and control and on the standard and training o f the food inspectors than on the legal regula tions in force. Most countries in the European Region have a reasonably good system o f food laws, aiming at the protection o f consumers’ health and giving various requirements for the composition, quality, presentation and control o f food . International agreements, in particular those made under the jo in t F AO/WHO Codex Alimentarius system, give guidance to countries on national legislation. Im plementation and enforcement, how ever, need to be improved; the work o f the O ff ice on food safety during the year therefore emphasized the provision o f assistance and advice on aspects o f implementing food law. and on the optimum use o f resources for field food inspection and labora tory investigations. Standardization o f food becomes increasingly important when trade grows and food production becomes more specialized and concentrated in larger production units. This fact is also being recognized by countries in which it has not yet been possible to give formal acceptance to the standards elaborated under the Codex Alimentarius system. The standards are being used as models and guidelines when national laws are amended or changed. A number o f gov ernments are now prepared to allow free circulation in their countries o f food that complies with the Codex standards. Even the most comprehensive regu lations can be ineffective i f they are not accompanied by proper control. Sufficient resources for surveillance must be made available. Cooperation within countries among the d ifferent authorities concerned is being en couraged, as well as the exchange among countries o f experience and informa tion on food problems. A survey o f fo od safety and hygiene services in Europe was completed and will be published in the series Public Health in Europe. Outbreaks o f food poisoning caused by bacterial contamination outnumber by far those caused by chemical contamina tion. Efforts should be concentrated on cleaning up systems o f food handling and increasing public awareness o f the importance o f food hygiene. Efforts were made to give more attention to the relationship between 65 environmental hygiene and food hygiene. In addition to the traditional work on safeguarding food by providing lists o f ad ditives, licensing food premises, inspec tion, and sampling systems, consideration should also be given to the risks to food and drinking-water from environmental pollution. Continuous efforts are being made to promote teamwork among toxicologists, sanitary engineers, veterin arians, physicians and environmental health officers. An example o f such team work is the plan in connexion w ith the jo int F AO/UNEP/W HO work in the M ed i terranean area to study viral o r parasitic infection o f foods and drinking-water originating from the disposal o f solid o r liquid wastes, e.g., infectious hepatitis from shellfish, viral infections caused by fertilizing vegetables with sludge, and parasitic disease problems in connexion with fish farming near sewage outlets. A Working Group on Health Exam ination fo r Food-Handling Personnel was convened in November. Again, the im portance o f maintaining the highest standards o f hygiene in all food handling was stressed. The Group concluded that, in the prevention o f foodborne disease, medical examinations fo r food handlers are o f limited value compared with training in hygienic practice. L imited re sources in time and m oney are better spent on educating food handlers in basic food hygiene, as well as their supervisors, administrators and others responsible fo r food safety. 5.6 E N V I R O N M E N T A L TOXICOLOGY The Regional O ff ice took a lead ing role in the development o f the International Programme on Chemi cal Safety, especially in the fields o f manpower development, contingency planning and response to emergen cies, and in technical cooperation with Member States on specific prob lems. A Consultation on Regional C o operation on Environmental Health Aspects o f the Control o f Chemicals was held in Copenhagen in August to discuss the outline project docu ment fo r a proposed UNDP/WHO project on European cooperation, and to establish priorities fo r action. A revised draft project document was developed and discussed with UNDP. The preliminary activities phase o f this project is expected to be approved early in 1980, and operations will commence forthwith . The voluntary contributions that have been promised by some Mem ber States will permit integration o f the UNDP-supported project, in which 11 countries are expected to participate, with the pan- European programme o f the Regional O ff ice . The Italian Government requested the assistance o f the Regional O ff ice in dealing with the consequences o f the industrial accident, involving dis charge o f tox ic chemicals into the environment, at Seveso in 1976. An ad hoc meeting o f experts was con vened in Seveso to develop recom mendations fo r remedial action and fo r the necessary epidemiological sur veillance. The Regional O f f ice was subsequently invited to designate a staff member to act as chairman o f the Consultative Committee on the T ox ic o lo gy o f TC D D ( 2,3,7,8-tetra- chlorodibenzo-p-dioxin), to be established 66 by the Italian authorities to m oni tor the situation and to advise the Government. Fo llow ing an episode o f ground water pollution b y potentially tox ic chemicals in Vicenza Province the Italian authorities, in collaboration with the Regional O ff ice , organized a W ork ing Group on Criteria and Guidelines fo r Halogenated Arom atic Compounds, which was held in Venice in Septem ber. The meeting reviewed the avail able information on the chemistry, environmental occurrence and tox ic ity o f toluenes, benzenes and phenols, and evaluated the possible health hazards associated with their presence in the environment. Recommendations on ap propriate guidelines for health protec tion were developed. Within the framework o f the pilot project on the assessment o f human exposure to air pollutants, a m eet ing was held in Geneva, attended by staff from W HO headquarters and the Regional O ff ice and experts from the Institute for Medical Research and Occupational Health in Zagreb, to formulate a plan o f work for initial activities on this project. It is expected that a subcontract with the Institute will be signed early in 1980. The UNEP/WHO/GEMS pilot pro ject on assessment o f human e x p o sure to pollution through b io log i cal monitoring, with particular ref erence to organochlorine compounds, was discussed at a meeting convened by the Swedish National Food A dm in istration in Uppsala in December. Manpower development in toxicol ogy: report on a W H O Consultation. E U R O Reports and Studies, No . 9. Publications 5.7 C O U N T R Y ACTIVITIES Algeria. The Regional O f f ice con tinued to assist the Environmental Health Department o f the National Public Health Institute, particularly in the train ing o f sanitarians. The O ff ice also as sisted in the training o f sanitary en gineers, and in preparations for the International Drinking-Water Supply and Sanitation Decade, as well as in waste disposal technology, especially fo r toxic industrial solid waste. A training course on this last subject took place in Algiers in December. Greece. The UNDP-supported pro ject on environmental pollution control in the metropolitan area o f Athens was terminated in 1979. A tripartite review meeting was held in Athens in Decem ber, at which the Government, U N D P and WHO expressed their satisfaction with the achievements o f the project, which reached substantially all its objec tives. E ffic ient operation o f the pro ject produced savings o f approximately U S$ 300 000 from the U N D P contri bution. A new project was approved, the purpose o f which is to assist the Govern ment in establishing a country-wide en vironmental protection service and in introducing the environmental impact assessment procedures fo r various types 67 o f development activity. The formal project document was signed b y the Government, U N D P and W H O ; imple mentation is expected early in 1980. Italy. The Regional O ff ice collab orated with the Regional Government o f Lombardia on the consequences o f the industrial accident in Seveso, and with the Regional Government o f Veneto fo llow ing an incident o f ground water contamination in the Province o f Vicenza. Malta. The Regional O ff ice coop erated in the new project on sewer ex tension, maintenance and repair. Morocco. The large-scale WHO- assisted urban water supply preinvest ment project is now terminating, but the Regional O ff ice has started a new project on the control o f eutrophica tion in reservoirs and is preparing a future project on preinvestment studies fo r rural water supplies. The World Bank granted a second loan o f US$ 49 mil lion to the National O ff ice fo r Water Supply fo r investments studied during former WHO-assisted projects. Poland. Environmental protection activities in the Upper Silesia industrial region came to a close after six years o f collaboration between the Government and the Regional O ffice . One result o f the project was the establishment o f the Environmental Pollution Abatement Cen tre in Katow ice , which has as its main task the preparation o f a comprehensive plan for the protection o f the environ ment in an area consisting o f four tow n ships in the District o f Katow ice , cover ing about half the Upper Silesia industrial region and about 43% o f its population. Progress was made in the W HO/UNDP project on the evaluation o f tox ic ity o f new technologies and substances used in industry. T w o consultant mis sions were provided within the frame work o f this project. The International Course on Indus trial T o x ic o lo g y was convened by the Institute o f Occupational Medicine (W H O collaborating centre for occupational health) in Lodz . Headquarters and R e gional O f f ice sta ff participated and lectured at this course. O f the 15 par ticipants, 8 were from developing countries. A new environmental health protec tion project was formulated, negotiated and approved during the year. Environ mental impact assessment studies will be carried out in three pilot areas in Poland and the experience thus gained used to introduce a country-wide en vironmental impact assessment system. The workplan has been elaborated and project operations commenced in the autumn. The industrial tox ico logy project in Lod z was extended until the end o f the year to cover the costs o f training abroad for sta ff o f the Institute o f Occupational Medicine, the cost o f supporting foreign experts at the Institute, and the purchase o f supplementary and replacement equip ment. Portugal. A W HO consultant visited the country to fo l low up advice provided on organization and training in occupa tional health. W H O continued to assist the Govern ment in developing a basic sanitation programme, and a planning meeting for 68 the International Drinking-Water Supply and Sanitation Decade took place in Lisbon in early November. The Regional O ff ice also continued to assist with the drinking-water fluoridation project and a training course, involving W H O lecturers, took place in Lisbon in November. The air pollution control project also re ceived assistance, and W HO contributed actively to the Te jo Estuary ecological study project. Spain. Regional O ff ice cooperation in the Huelva air pollution control project, which is financed entirely by the Government, was completed. Turkey. W H O continued to assist research and training in environmen tal health at four universities; this project was the subject o f an evalua tion meeting in Novem ber, at which time an extension was suggested. As sistance with projects related to epi demiological studies on air pollution, water quality standards development, and the Porsuk river basin water qual ity management was completed. C o operation was started on the manage ment and disposal o f solid waste in the Istanbul metropolitan area and in preparations for a solid waste dis posal programme in Ankara. The R e gional O ff ice continued assisting the Water Supply and Sewerage Depart ment o f the Bank o f Municipalities in charge o f urban areas. With regard to the International Drinking-Water Supply and Sanitation Decade, new WHO-assisted activities are under dis cussion fo r the rural sector. A UNDP/W HO project on the strengthening o f food control services in Turkey started in March. A sem inar, with about 200 participants, was held in Ankara to evaluate the present situation in the field o f food safety in Turkey. A m ong the problems men tioned by many participants were the need for better field food inspec tion, integration o f food control with other public health services, and edu cation o f the public in food hygiene. Several training courses for food in spectors were held in Turkey, the assistance o f a consultant was pro vided, and fellowships were awarded in Denmark, the Federal Republic o f Germany and the United Kingdom. Yugoslavia. The first phase o f the project on river pollution control in the Republic o f Bosnia and Herzego vina was completed after tw o years o f activity. The results produced a number o f proposals to reduce the pollution o f the Jala-Spreca water basin caused by urban, and especial ly industrial, wastewater from various sources in the neighbourhood o f the city o f Tuzla. The Third International Training Course in Occupational and Environ mental T o x ic o lo gy was held in Bel grade. The water supply and waste dis posal project for K osovo continued during 1979 and is expected to be com pleted early in 1980. 69 PR OMOTION O F E N V I R O N M E N T A L H E A L T H Expenditure (US$) Regular funds U N funds Voluntary funds 796 590 1 712888 44 573 2554051° a Being 15.97% of total expenditure. Chapter 6 HEALTH MANPOWER DEVELOPMENT 6.1 G E N E R A L Dr A. Wojtczak took over as Direc tor, Research, Planning and Human Re sources at the Regional O ff ice on 1 Jan uary 1979. The European component o f the global medium-term programme on health manpower development, as ap proved by the Thirty-first World Health Assembly, focused during the year on a few influential and important areas, such as: national teacher training activ ities; support for training in health man agement and administration; and stimu lating the development o f continuing education programmes fo r the medical and health professions. Emphasis was placed on developing a strong line o f communication and co operation with various professional as sociations and national centres involved in the education o f health personnel, educational research, and training in health management. The need fo r close collaboration between those responsible for health development and fo r the edu cation and training o f medical and health personnel, to provide for educational planning according to the health needs o f the community, was also stressed. The Regional O ff ice signed a con tractual agreement with the Association fo r Medical Education in Europe (A M E E ), the aim o f which is the preparation o f comprehensive information on admis sion procedures to medical schools in Member States. In some countries there is no limit on admissions, which creates a diff icult situation for the proper organ ization o f medical education and has an impact on the quality o f the education and consequently on that o f the gradu ates. It is hoped that, by obtaining an accurate picture o f the situation, it will be possible to help Member States gradually to introduce admission quotas, reorientate medical education more towards community needs, and con sequently improve the level o f health care. Fig. 7 shows the number o f people to each physician in the countries o f the Region. During the A M E E meeting an A s sociation o f Medical Deans in Europe was established, which will collaborate closely with the Regional O ff ice and AM EE. The first official meeting o f the Association will take place in Groningen in September 1980 when the topic “ Responsibility o f medical schools for teaching hospitals and the provision o f clinical services” will be discussed. Deans 71 Fig. 7. Number of people per physician in the countries of the European Region Source: W o rld h e a lth s ta tis tic s a n n u a l, 1979 . Geneva, WHO, 1979. 72 o f medical schools or faculties in the European Region have been invited and ministries o f health have been informed about the activities and aims o f the Association. The Sixth General Assembly o f the Association o f Schools o f Public Health in Europe (A S P H E R ) took place in Lon don in September. Five areas o f possible cooperation between A S P H E R and the Regional O ff ice were identified: ex change o f in formation; com m on activ ities o f Member States; elaboration o f European standards; introduction o f new training courses; and health services re search. The implementation o f these five areas was discussed in detail when the Secretary-General o f A S P H E R visited the Regional O ff ice in December. During the period under review the Regional O ff ice organized a study tour fo r a group o f Chinese medical educators to study the organization and manage ment o f medical education in Denmark, Finland, the Netherlands, N orw ay and the United Kingdom. The tour was con cluded by a visit to the Regional O ff ice , where a programme on the work o f the various units was arranged. This was arranged fo llow ing an agreement signed in 1978 on technical cooperation in the health field between W HO and the M in istry o f Health o f the Peop le ’s Republic o f China. The main activity o f the teacher training component o f the medium- term programme was the Seminar on Planning and Implementation o f Teacher Training Programmes that took place at the British L ife Assurance Trust (B L A T ) Centre fo r Health and Medical Educa tion, London, in May. The Seminar was convened to discuss the organization and management o f teacher training centres and to exchange in formation on the planning and implementation o f teacher training programmes as part o f W H O ’s medium-term programme in health man power development in the European Region. The participants examined prob lems and trends in the training o f teachers for the health professions, with special reference to integrated services and staff development. The importance o f recruit ing suitable teachers fo r training and the need to give them adequate incentives was emphasized. S ta ff development pro grammes might include formal courses, distance learning, self-assessment and audit. Considerable experience and ex pertise is available in the European Re gion and this should be shared among the d ifferent countries and universities. The participants supported the Regional O ff ice in its e fforts to set up a network o f W HO collaborating centres in teacher training, and negotiations with different Member States have started. A lso organized at the B L A T Centre in 1979, under the auspices o f the R e gional O ff ice , was the Second Course on Modern M ethodo logy fo r Teachers o f Health Sciences. This was a very success ful course attended by 23 participants, 13 o f whom were from the W HO Euro pean Region. The second version o f the Inventory o f Teacher Training Facilities, listing 71 institutes in 17 European countries, became available at the end o f the year. The Regional O ff ice intends to bring this inventory up to date in 1982 and to include additional Member States. Within the framework o f the agree ment signed in 1978 between the Insti tute fo r Research in Medical Education 7 3 and Evaluation, Bern and the Regional O ffice , a Workshop on Curriculum Planning (in German) was held in Bern in March. As in the past, the O ff ice continued to support the courses fo r public health administrators (in English and Russian), which are held annually at the Central Institute fo r Advanced Medical Studies, Moscow. The programme o f the English course was changed to take into account the recommendations o f the Second Joint Com m ittee o f the courses in 1978, which placed emphasis on objectives and has increased the practical work o f the course through workshops, sem inars and travel to different countries to study the health services. In 1980 the Regional O ff ice will provide sup port to the F ifth Scientific Session o f the courses in Budapest. As a fo llow-up to one o f the recom mendations o f the Working Group on Training o f Senior Public Health Adm in istrators in Moscow in 1978, the Pro- Rector o f the Central Institute for A d vanced Medical Studies, Moscow, visited France, the Federal Republic o f Ger many and the United K ingdom to obtain information on the training programmes used in d ifferent schools o f public health. This information will be used to improve the programme o f the Moscow courses for public health administrators. A study on the dep loym ent o f gradu ates from schools o f public health in the U SA was carried out by Dr J. Evans, now Director, Department o f Population Health and Nutrition at the World Bank, under the auspices o f the Rockefe ller Foundation. Fo r the European part o f his study he was briefed at the Regional O ff ice , where a meeting was arranged with members o f the University o f Copen hagen and the Nord ic School o f Public Health, Gothenburg. Dr Evans also at tended the Sixth General Assembly o f A S P H E R in London in September. A Working Group on the Design o f Training in Health Planning and Manage ment, convened in Berlin (West) in July, investigated the feasibility o f developing and using training programmes to in tensify training in health management. The Regional O ff ice assisted the Division o f Health Manpower Development at W HO headquarters in collecting in forma tion from European Member States on regular training programmes in health planning, administration and manage ment; this information will appear in a world directory or inventory on train ing programmes in health management, which is intended to assist governments in their e fforts to provide national health management. 6.2 CONTINUING EDUCATION In an e f fo r t to supply Mem ber States with pertinent information on the educa tion and training o f health personnel, an updated report in French o f the WHO Capacity Study on Graduate Medical Education in the European Region was distributed. The participants in the technical discussions at the twenty-ninth session o f the Regional Com m ittee considered the definition o f continuing education, noting that it includes basic o r specialist training and any education that takes place thereafter, and that it embraces all the health professions. T h ey described a 74 wide range o f programmes through out the European Region fo r medical practitioners (especially primary medi cal care practitioners), dentists, nurses and midwives, environmental health professionals and social workers. There are also courses fo r medical labora tory technicians, physiotherapists, radio graphers, pharmacists, dietitians, chiro podists and opticians. The methods used are equally varied but it was agreed that, wherever possible, continuing education must be provided at the place o f work and be relevant to the needs both o f professionals and o f the community they serve. The value o f breaking down communication barriers and promoting a spirit o f interprofes sional collaboration was stressed. It was felt that continuing education had succeeded i f it imparted new know ledge, skills and attitudes, but had failed i f it drew the professional away from patient care. The evaluation o f con tinuing education required coordinated research on an international basis. It was suggested that the Regional O ffice should stress evaluation in all relevant publications and meetings, that all pro grammes should be evaluated, and that all new teaching techniques should be assessed in relation to the possibilities they o ffered for evaluation. Finally, it was recognized that the greatest need fo r continuing education o f ten arose among those who had the great est d iff icu lty in obtaining it, i.e., isolated and single-handed professionals who were heavily overworked and had relatively low status and remuneration. The challenge would be First to provide better status and remuneration fo r those who served where they were most needed. Continuing education o f health per sonnel as a factor in career develop ment: report on a W HO Working Group. E U R O Reports and Studies, No . 6. Publications 6.3 C OMMUNICATION A N D COLLABORATION A matter o f major concern for the Regional O ff ice is the improvement o f communication and collaboration within the various health professions and between health and educational systems and social components. More careful jo in t planning in the field o f health services and education might help to provide more e f fect ive and relevant services and thus meet health needs more successfully. A consultative group met in Copen hagen in December to prepare for the Working Group on Communication and Collaboration between and within Health and Educational Systems, to be held in 1980. Case studies on existing formal and informal communication patterns and mechanisms will be carried out by members o f the consultative group. The case studies, involving coun tries with d ifferent systems o f education and health care administration, will demonstrate existing mechanisms o f communication and point out d iff icul ties, obstacles and constraints, as well as functional solutions and e ffective mech anisms. A lso , on the recommendation o f the consultative group, a critical review o f all recommendations in this field will be undertaken. 75 The report o f the W H O Study Group on Communication and Collaboration between Health Systems and Education in the Health Professions, organized by the federal and cantonal authorities and the Institute fo r Research in Medical Education and Evaluation, Bern, in 1977 and 1978, under the auspices o f the Re gional O ff ice , was published in English and German. It will be used as a back ground document fo r the communica tion and collaboration working group. 6.4 FELLOWSHIPS A N D COURSES The fellowships programme o f the Regional O f f ice continued to be sup ported strongly by the Member States. In 1978 and 1979 no voluntary funds could be obtained to organize the Meeting o f National Fellowships Officers o f the European Region. However, in view o f the importance o f the top ic a voluntary contribution has been made which, although insufficient to finance the meeting complete ly, will enable the O ff ice to proceed further with its prep aration. It is hoped that Member States will further support this activity and thereby contribute to its success. The subjects studied by the W HO fellows reflect the health problems o f the countries o f origin and the emphasis placed by W H O programmes on the solu tion o f those problems. Table 3 shows the distribution o f fellowships by sub ject and Fig. 8 shows, fo r each Member State o f the Region, the number o f fe l lows that came to that country to study and the number from that country that studied elsewhere. As in the past, a small number o f countries together received the greatest number o f fellows. T w o courses concerned with health services took place during the year. 1. The sixth University o f Leeds/ W HO Summer Course on the British Health Services, which was attended by two fellows from the European Region and four from other W HO regions. It is felt that a change o f emphasis would be appropriate fo r future courses, with more consideration being given to coun try health programming; this will reflect current W H O thinking on health plan ning and will fill a real and increasing need fo r in formation and understanding on this subject. 2. The University o f Oslo Interna tional Summer Course on the Norwegian Health Services. Only one W HO fe llow attended this course, although the Uni versity provided nine half-fellowships. It is hoped that Member States will take greater advantage o f future courses. Fo l low ing negotiations with the G ov ernment o f the German Democratic R e public, a course on the health services in that country is being planned fo r Sep tember 1980. A l l Member States in the European Region w ill be in formed o f the possibility o f sending fellows to the course. During the year the Fellowships unit maintained close contact with all the re gions o f W H O , and sta f f members assisted at meetings organized by other regional offices, such as the Conference on R e gional Cooperation in the Fellowships Programme in Manila, the Conference on the Implementation o f the W H O Fe l low ships Programme in N e w Delhi, and the Biennial National Fellowships Officers 76 LL PERCENTAGE OF TO TAL I TOTAL 33 > 2 5 S f f 1 П Î - 5 Î- : i а П ä ! i ï 1 î I f * 1 ! 1 " 1 s i * 1 1 1 ! i t 1 i I ° 1 О О 3J l g O J > S m f 8 î l ? § f ? s ! 8 ? 1 а | 5 . 3 з - 2 | i 1 * 1 1 f i i s 1 f = § ? 5 8- Г о = 2 2 * $ 8 t I c o- f 5 a 1 E ? S 2 1 5 ° Subject of study (mam groups) « Ы K» A I h ar t i a 128 £ - 5 16 1 1 9 10 1 A lg er ia Z - - A us tr ia ° - - B el gi um £ - - - - - _ (O B ul ga ria S «*» - - C ze ch o iio va ki a 2 u> - - D en m ar k œ Ы - - F in la nd z - - - F ra nc e œ U> - - G er m an D em . R ep - o> - G er m an y, F ed . R ep . o f L) ю - M - « » « G re ec e - - - H un ga ry s - - Ic el an d - - - - Ir el an d - - - - It a ly - Lu xe m bo ur g s - - M al ta О ° M on ac o s S - - 14 5 1 2 M or oc co £ 00 N et h er la nd s £ o> - N or w ay £ - 28 3 10 2 1 s Й - - - ~ P or tu ga l s - - R om an ia s <o - - - Sp am - OS - - - S w ed en iD - - - S w itz er la nd о 0. - 27 10 2 1 1 1 T ur ke y s - - - - U S S R - * - - U ni te d K in gd om <л 5 Y ug os la vi a 97 8 8 - - - * <Л * O ' « О» « -4 * - 104 65 28 18 17 15 14 13 11 T O T A L F O R E U R O P E A N R E G IO N œ « T O T A L O T H E R R E G IO N S 8 360 I - - - - M * СЛ tf> U> tf> 0> CT> (7> -~J 00 — 104 65 28 18 17 15 14 13 11 G R A N D T O T A L 0 3 0 3 0 3 3.1 2 2 1 9 1.7 1.7 1.7 1 7 1 4 1 4 1 4 1 1 0.6 0.3 28 9 18.1 7.8 5 0 4.7 4 2 3 9 3 6 3 1 P E R C E N T A G E O F T O T A L Table 3. Fellowships awarded in 1979 by the Regional Office to fellows from the European Region and other regions, by subject F i g . 8 . D i s t r i b u t i o n b y c o u n t r y o f f e l l o w s i n t h e E u r o p e a n R e g i o n 3 0 Number of fellows received in the country. 0 Number o f fellows from the country studying elsewhere. 3 These figures refer only to those fellows who started their fellowships in 1979. 78 Meeting in Amman. Close contact was also maintained with national fellowships counterparts in all Member States. 6 .5 N U R S IN G The medium-term programme in nursing/midwifery in Europe continued to develop. The number o f nursing re search centres collaborating directly with the programme increased from five to seven with the addition o f those in Utrecht and Lyons. The country networks o f partici pating centres continued to grow. In terest in developing Type I centres,“1 which will participate directly in the standardized studies, was expressed by 20 countries. The link between col laborating centres and Type I partici pating centres was better identified. In some countries, networks are already well established; in others, plans for the development o f networks are still in preparation. Interest in participating in the programme as Type II participating centres* was expressed by representa tives o f a number o f hospitals and health centres. a Type I participating centres: centres form ally associated with the program m e and agreeing to conduct controlled studies using standard program m e pro to cols. Such centres should also agree, as part o f the study, to experim ent with alternative patterns in the organization and m anagem ent o f nursing services. * Type I I participating centres: centres form ally associated with the program m e and agreeing to partici pate actively in such areas as field testing o f designs, nonspecific im plem entation o f the nursing process m ethod, exchange o f inform ation , continuing educa tion , and provision o f participants for working and/or technical advisory groups. Work was started on the devel opment o f designs for the standard ized studies that will be conducted as part o f components I (nursing pro cess) and II (organization and manage ment o f nursing/midwifery services) o f the medium-term programme. Col laborating centres worked jointly on the designs, which will include methods and schedules to be used in the assess ment o f patient/client needs for nurs ing care, criteria for selecting priority needs and relating needs to resources, methods and schedules for planning to meet selected needs, implementa tion o f care recording schedules, and evaluation methods and recording forms. Work also commenced on the data recording and management system for the studies. Preparations were begun on the production o f a teaching/learning pack age which, although for use specifi cally in Type I participating centres, will consist o f seven interrelated mod ules, some o f which will contain in formation directed at a wider audience. The modules cover: WHO and its role in health care; health services in Europe; nursing and nurses in the European Region; the medium-term programme in nursing/midwifery in Europe; the nursing process; and nursing research in general. Multinational research in nursing, research designs and their application in direct patient/client care, and alternative patterns for managing nursing services will also be covered in the package. The first meeting on national legis lation controlling the practice and educa tion o f nurses and mid wives in the Region was held. As working documents for this meeting, reviews were prepared o f 79 legislation related to nursing in 25 o f the 32 European Member States and to midwifery in 24 countries. The updating o f bibliographies in the workbooks on the nursing process and on the organiza tion o f nursing/midwifery services was completed. The second in a series o f meetings related to the management o f nursing/ midwifery services at national, regional and local levels was held at the end o f the year. This meeting again empha sized the need for appropriately quali fied nurses to be represented at all levels o f management. The role o f nurses in health planning in general was em phasized, as was the need for better preparation o f nurses for all types o f management post in such areas as cost accounting, communication skills and personnel management. The survey on nursing personnel and their education in nine countries o f the Region developed steadily, and a form for collecting information was tested in five countries. This form will be revised and retested in additional countries in due course. Considerable financial support was received from Member States for con ducting meetings o f relevance to the medium-term programme, and for the salary o f staff and support services in four o f the seven collaborating centres. Publications Evaluation o f inpatient nursing prac tice: report on a WHO Working Group. EURO Reports and Studies, No. 4. 6.6 C O U N T R Y A C T IV IT IE S Algeria. WHO and UNDP continued to support two projects in Algeria. 1. The Institute o f Health Technol ogy, Constantine, where preparations are being made for a final evaluation. 2. Training o f teachers fo r deaf children. This project, which received high priority from the Algerian Gov ernment, developed satisfactorily. The Regional Office continued to send ex perts to conduct training in different parts o f the country, and fellowships were awarded in Belgium, France and Yugoslavia. Future activities in Algeria will emphasize an integrated approach to primary health care and suitable training for health personnel. Belgium. Through its country pro gramme “ Lecturers and fellowships” , the Government continued to request ex perts from European countries and the USA to lecture at different schools o f public health. A short-term consultant assisted at the University o f Leuven with staff training and the teaching o f students as part o f the WHO-assisted funds-in-trust project on training programmes for nurs ing leaders. Later in the year a second consultant (nursing professor) continued the programme and carried out the final evaluation of the project. A Belgian nurse from this project is currently com pleting her doctoral degree dissertation. Denmark. The Regional Officer for Nursing conducted a one-day seminar on nursing research for teaching staff at the 80 Danish Nurses’ High School, University of Aarhus. The Danish Nurses’ Organiza tion provided the services o f a nursing research consultant. Federal Republic o f Germany. Close collaboration continued with the Acad emy o f Public Health, Düsseldorf. A workshop was convened to establish postgraduate training courses in health education (in German) with the close collaboration o f the Regional Office. Hungary. Two WHO staff visited Hungary in August to discuss the train ing o f students from developing coun tries and the possibility o f closer collab oration between the Regional Office and the Medical Faculty o f Semmelweis University in the field o f teacher training. Agreement was reached that the Office would assist in developing a programme o f research in medical education over the next three years. After that time the Department could be considered a can didate for the status o f WHO partici pating centre in teacher training. Iceland. A short-term consultant was assigned to the University o f Iceland for six weeks to teach community health nursing and assist with staff training. One Icelandic nurse studied in the USA for a master’s degree, and another was appointed junior instructor at the College o f Nursing, University o f Saskatchewan, Canada for the academic year 1979-80. Italy. A consultant continued to as sist the funds-in-trust project in the Re gion of Tuscany on education and train ing o f nursing and related health person nel. Collaboration continued with the Italian Centre for Medical Education, San Remo in teacher training and con tinuing education. Regional Office staff took part in discussions held by the Uni versity o f Perugia with the support o f the Italian Government, following the regionalization of health services in Italy, in order to assist in the establishment of concepts for health services and health manpower development. Portugal. In July an evaluation was made o f the Workshop on Medical Edu cation organized at the School o f Public Health, Lisbon in 1978. Spain. Officials from the Ministry o f Public Health visited the Regional Of fice to request assistance in the field o f medical education and nursing, and the Regional Officer for Nursing later visited the country for further discus sions. Two WHO staff (one from the Re gional Office and one from headquarters) participated in the meeting o f the Spanish Society o f Medical Education in Sala manca and one o f them also attended a meeting on “ Interaction between health services and education in medicine and related professions” in Madrid. Both meetings were attended by deans and members o f the faculty o f all the medi cal schools in Spain. Sweden. Close contact continued with the Nordic School o f Public Health, Gothenburg. A group o f students at tending the course in social medicine visited Copenhagen in March for briefing on the different programmes of the Of fice, including health manpower develop ment, the medium-term programme in nursing, country health programming, the incidence and prevalence o f chronic disease, and primary health care. Another visit to the Regional Office was made by the Committee for Inte grated Medical and Health Education 81 from Linköping, the aim o f which was to discuss the setting up o f a Health Science Faculty at Linköping where medical students would study in close contact with nursing and other profes sions. Turkey. Together with a staff mem ber from the Regional Office, a WHO consultant visited Turkey in March to discuss the implementation o f Phase II of the UNDP/WHO project on health manpower development. A draft project was drawn up by the Regional Office and submitted to the Government. Close contact was maintained with the German Agency for Technical Cooperation (GTZ) in support o f this project. The Centre for Medical Education Technology (СМЕТ) continued to develop, but true integration o f СМЕТ into the School o f Public Health in Ankara has yet to be achieved. Three programme areas were selected for Phase II: strengthening o f the School o f Public Health; teacher training; and development o f field training areas. United Kingdom. The Regional Of ficer for Nursing delivered the inaugural address at the Annual Conference of the British Health Visitors’ Association, in Brighton in October. H E A L T H M A N PO W ER D E V E L O P M E N T E x p e n d itu re (U S $ ) 1 6 8 9 6 8 8 9 6 2 7 9 9 9 7 1 2 1 8 8 5 6 7 9 * a Including Funds-in-Trust. * Being 11.79% o f total expenditure. R egu lar funds U N fu n d s V o lu n ta ry fu n d s0 82 ,. -Cüs :'i AäüiAte H o s p t a l ac< in to c t io n s : t( ) la b o r a t o i asssa S jP * m . Ши: Подготовка 1 и использование Щ вспомогательного 9 зубоврачебного персонала . ш ш ж Ш M easurem ent of Levels o f Health variety of subjects are covered by Regional Office publications in the four working languages 3 new word processing equipment acquired by the Regional Office will speed up office procedures and improve nmunication with the Member States o f the Region '4'/■ /* Щ Я Modem office equipment and techniques w „ e introduced In .he Regional Office, such « t h . connpute, (above) and video equipment for staff briefing and general information work Chapter 7 HEALTH INFORMATION 7.1 G E N E R A L The consolidation o f the different programmes o f the Regional Office dealing with the handling, analysis and dissemination o f information, which took place at the end o f 1978 with the creation o f a Health Information service, continued throughout 1979. The growing cost o f health care, on which many developed European countries spend more than one twelfth o f their gross national product, has become a major concern to health planners and administrators, health ser vice personnel, and the general public. All require more detailed information on the services provided through health care programmes, and the assurance that these programmes are adequate, acceptable and cost-effective. Yet, in spite o f spiralling costs, most o f the indices o f health developed over the last 100 years, which revealed a great in crease in the health o f the population during the first half o f the century, are levelling o ff or even showing an apparent or a real reduction in health. The Regional Office is therefore focusing its programmes o f collaboration with national information services on the search for more relevant data on the functioning o f health services, with emphasis on: quality o f life as a supple ment to the classical morbidity rate; better measures o f social disability (as opposed to sickness); and the recogni tion o f the effects o f lifestyle and en vironmental hazards on health. The growing recognition that health is no longer the prerogative o f the medi cal profession, but that every member of society is responsible for and should be actively engaged in promoting a more healthy life, is giving a new dimension to the health information programme of the Regional Office, as well as to those o f the Member States. Not only should more accurate, up- to-date, relevant and easily available in formation be promoted, but it should also be made more widely available through the Regional Office publica tions programme in as many languages as necessary to ensure wide dissemination throughout the Region. Fig. 9 shows the number o f copies o f publications requested during the year, and their distribution by language and region. 83 Fig. 9. Copies of publications requested in 1979 by language, and their distribution by region □ English □ German в French H Russian O)ГО4-* С 8 L_0) CL 100 90 80 70 60 50 40 30 20 1 0 0 EUR AMR OTHER Region 84 Attention will be paid to ensuring that the mass media play an even greater role so that every member o f society is adequately informed about the dangers o f poor environment and adverse life style, and is made aware o f the costs and the consequences o f ill health. The health literature services o f the Office are using new and more ef ficient documentation and communica tion methods to inform research workers, health professionals, teachers and stu dents o f developments in medical knowledge. The facilities acquired in 1979 for data storage and processing, and for text processing, which are mentioned elsewhere in this report (p. 91) will play an important role in the development o f the Regional Office health information programme. 7 .2 H E A L T H S T A T I S T I C S A major event during the year was the Fourth European Conference on Health Statistics, held in Luxem bourg in August, which considered the needs for health information in the planning and management o f health services. The Conference stressed the need to extend health information, which is still based mainly on mortality statistics, to cover a wider range o f health measurements, including environ mental indicators and those related to the cost o f health care. It also empha sized the urgent need to improve, both in scope and content, information on primary health care. A preliminary review o f the health statistics programme was made, with a view to improving its capacity to meet the requirements o f the move ment towards health for all by the year 2000, which is likely to gain mo mentum after the first meeting o f the Regional Health Development Ad visory Council in 1980. The use o f data collected by other United Nations agencies and intergovernmental organ izations in the Region, as well as data provided by the Member States them selves, should make it possible for the Regional Office to support its own programmes as well as to pro vide assistance to Member States. It is also expected that the Office’s fore casting capacity will be increased and the development o f positive health indicators facilitated. An important part o f the develop ment o f the Regional Office health in formation system will be the standard ization o f the data contained in it. Although mortality data are reasonably well standardized owing to the Inter national Classification o f Diseases, now in its ninth revision (ICD-9), other health-related information is not. Close collaboration in this field is maintained with the Division o f Health Statistics at WHO headquarters and with other interested bodies such as the Economic Commission for Europe and the Council o f Europe. Much use was made o f the facilities o f the Northern European University Computing Centre, especially in the field o f data presentation. The coloured maps o f Europe that appear in this report are an example o f the type of presentation available. 85 7.3 WHO P U B L I C A T I O N S A N D D O C U M E N T S During the period under review, publications continued to play a sig nificant role in the health information programme of the Regional Office. One major development was the introduction o f a new series o f publica tions: EURO Reports and Studies. The final reports on meetings, which were hitherto issued as documents, are now published in this series and are made widely available through the network o f WHO sales agents. The series is also used to publish the results o f studies and occasionally other suitable material. Particularly important was No. 14, en titled Primary health care in Europe, based on the report o f the Regional Director to the Alma-Ata Conference in 1978. Twenty-two issues in the new series appeared during the year. The period under review saw the publication o f No. 7 and No. 8 in the WHO Regional Publications, European Series, these being entitled, respec tively, Measurement o f levels o f health and Studies in drug utilization. The lat ter presents the outcome o f drug util ization studies in a number o f European countries, particularly from the point o f view o f prescribing patterns. The former publication was the result o f col laboration between the Regional Office and the International Epidemiological Association. The book explores the prevalence and incidence o f specific diseases and syndromes, and measure ments o f physical and mental condi tions, as well as the social function o f individuals and population groups and their behaviour or attitudes towards health and health-related activities. Two issues in the series Public Health in Europe appeared, No. 10 entitled Psychogeriatic care in the community and No. 11, Crisis admission units and emergency psychiatric services. The for mer publication explores ways in which the care o f elderly people who are men tally ill may be undertaken within the framework o f the comprehensive com munity health services that are evolving in most European countries; the latter presents the results o f a study of 15 crisis admission units in 8 countries. French editions o f four publications already available in English appeared: Energie nucléaire et santé (OMS, Publi cations régionales, Série européenne, No. 3), and Nos 6, 7 and 8 in the series La Santé publique en Europe entitled, respectively, La coordination des services de santé et des services sociaux dans quatre pays : Autriche, Italie, Pologne et Suède; Formation et emploi des auxiliaires dentaires; and Santé et en vironnement. The first Russian editions o f publica tions under the agreement between the Regional Office and the Moscow pub lishing house “ Medicina” appeared during the year. Both were in the series WHO Regional Publications, European Series: No. 3, Health implications o f nuclear power production and No. 4, Hospital- acquired infections: guidelines to lab oratory methods. Efforts were continued to encourage translation o f the Office's publications into non-working languages. A well- known Spanish publishing firm applied for the translation rights o f Measure ment o f levels o f health. A number of requests for the translation rights o f final reports on meetings were received from 86 Japanese institutions, and other re quests were received from Italy and Poland. Certain countries have expressed a wish to widen the dissemination of Regional Office publications to appropriate institutions to ensure that they reach the persons for whom they are intended. The Office is anxious to support such efforts in all coun tries o f the Region. A request for the regular distribution o f publications was received from the Canadian health authorities. The Office has strengthened its relations with two publishing houses in the United Kingdom who have shown willingness to publish manuscripts that exceed the capacity o f the Office to produce internally. The first publi cation resulting from this arrange ment appeared in 1979: Hospital util ization: an international study, by R.F. Bridgman. As part o f the effort to provide accurate, up-to-date, relevant and easily available information and, at the same time, to improve project delivery, the production o f short-term consul tant reports was made more system atic. This included the summarizing of recommendations in a standard form which should make it possible for both national authorities and the Regional Office to evaluate their im pact, both in the short and in the long term. It is greatly appreciated that, wherever possible, Member States per mit the derestriction o f these tech nical reports and thus allow wider dissemination o f information and the consequent sharing o f experience. 7 .4 H E A L T H L E G I S L A T I O N The consultant in health legisla tion at the Regional Office, whose employment is financed by a volun tary contribution from the Govern ment o f Belgium, continued to build up the health legislation programme for the European Region. The intro duction or updating o f legislation is becoming vital for an increasing num ber o f health programmes, and this is a matter o f concern not only for national authorities but for intergovern mental organizations in the Region. Technical cooperation continued with Member States, with the consultant visiting authorities in Denmark, Greece, Morocco, Portugal, the USSR and the United Kingdom (Scotland). The net work o f correspondents was extended from 11 to 18 and another 5 potential participating institutes were visited. Eight countries were provided, at their own request, with advice on improving their legislation on such matters as: the health professions (general practitioners, ophthalmologists, dentists); communi cable diseases (rabies in urban areas, compulsory immunization); food hy giene; abortion; care o f the dying; and the legal and social protection o f minors. In 1979 particular attention was paid to developing collaboration with non governmental organizations specializing in legislation relevant to Regional Office programmes, such as the World Associa tion for Medical Law, the International Commission o f Jurists, the Interna tional Council o f Environmental Law, and the International Federation for Information Processing. Work also con tinued in support o f other Regional 87 Office programmes such as workers’ health, health education and social sciences, accident prevention, family planning, and research promotion and development. The consultant was par ticularly involved in the Working Group on Legislation concerning Nursing/Mid wifery Services and Education, held in Hamburg in December. 7.5 H E A L T H L I T E R A T U R E S E R V I C E S The main concern during the year was the improvement o f library services in direct support o f Regional Office pro grammes. Assistance continued to be given to country projects through pur chasing literature and supplying refer ences and photocopies. As a first step towards a European exchange o f information on health planning, collaboration was begun with institutes participating in HECLINET (Health Care Literature Information Network) and with the US National Health Planning Centre. HECLINET records the entire European litera ture on hospital planning and manage ment; all reports on meetings and other publications issued by the Re gional Office are indexed at the Danish Hospital Institute and included in HECLINET. Contacts were made with the Bio logical and Medical Sciences Section o f the International Federation o f Library Associations and Institutions (IFLA ), with a view to coordinating projects and activities in the European Region. 7.6 H E A L T H I N F O R M A T IO N O F T H E P U B L IC The Declaration o f Alma-Ata marked a turning point for public information in the European Region. Before that, there was no overall mandate for such activ ities, beyond giving support to resolu tions adopted by the World Health As sembly and to activities organized by the Regional Office. The Declaration con sists o f solemn engagements by the world health community, including the 32 Member States o f the European Re gion, to promote the goal o f “ health for all by the year 2000” , and a new rela tionship has thus been established be tween the governments and the Regional Office which, as far as public informa tion goes, implies a much better co ordinated effort from both sides than was previously the case. The fact that the Declaration may be interpreted in different ways, according to the needs and priorities o f each country concerned, suggests that close consultation is es sential to avoid misunderstanding on the part o f the public. Much o f the public information work continued to reflect the Organization’s activities and interests. Thus World Health Day, the theme o f which was “ a healthy child, a sure future” , was cele brated jointly with UNICEF/UNIPAC in Copenhagen and visits were exchanged between the staff o f both organizations. Progress towards the global eradication o f smallpox was publicized through the distribution o f kits, posters and other material and by assisting WHO head quarters in organizing a travelling ex hibition to various airports in the Euro pean Region. 88 Environmental protection was an other subject that was emphasized by the Public Information unit. Chemical safety in particular was highlighted at a press conference at the Regional Office and at a press luncheon organized by the Government o f Finland during the twenty-ninth session o f the Regional Committee. By the end o f the year it was already apparent that the theme o f “ health for all by the year 2000” could not be publicized through general philosophical statements but needed to be based on concrete situations relevant to the European Region. Various meetings, among which nursing and appropriate technology in health laboratories were prominent, offered excellent opportun ities to explain the new concept to journalists in Brussels, Hamburg and London. In each case it was stressed that the concern o f WHO was not limited to the developing world but included the industrialized areas as well. Queries from the media were fre quently received to ascertain the latest WHO policy on such topics as tradi tional medicine, essential drugs and schistosomiasis. There was therefore close contact with the Division of Pub lic Information at headquarters to keep abreast o f new developments. In that connexion the Public Information Of ficer attended the Nordic Journalist Encounter organized by the Norwegian Agency for International Development (NORAD) in Oslo on the subject o f in fant foods in the developing countries. He also took part in the Joint United Nations Information Committee annual meeting o f information officers in Helsinki, which gave him an opportunity to meet counterparts from national development agencies. H E A L T H IN F O R M A T IO N E xp en d itu re (U S $ ) 1 4 9 4 6 5 3 3 8 158 1 5 3 2 8 1 1 ° a Being 9 .59% o f to ta l expenditure. R egu lar fun ds UN fu n ds V o lu n tary fun ds 89 GENERAL SERVICES AND SUPPORT PROGRAMMES Chapter 8 8.1 P R O G R A M M E P L A N N I N G A N D G E N E R A L S U P P O R T As proposed by the Consulta tive Group on Programme Develop ment in its third meeting in April, a meeting o f the Consultative Group on Budgetary Questions will be con vened in March 1980. Towards the end o f the period under review prep arations were made, in collaboration with the Executive Management o f the Regional Office, for one day to be spent discussing topics o f mutual interest with the Consultative Group on Programme Development and one day discussing some o f the practical and budgetary implications. Reorganization in the Regional Of fice resulted in a new unit, Text Pro cessing and Secretarial Training, being added to the support programme. This involved the purchase o f new electronic word processing equipment as well as the relocation o f staff through out the Regional Office’s various build ings to make room for staff and equip ment. In addition to text processing, the gradual changeover to computer ization throughout the Organization made particular demands on the sup port programme. At the Regional Office, the support programme is par ticularly involved (a) with that part o f the introductory stage o f com puterization already in use for bud get and finance tasks; (b) with the planned eventual incorporation o f per sonnel and supply applications; and (c) with the fact that the introduc tion o f these facilities constitutes a pilot study with a view to the event ual extension o f computerization to the other regional offices. The shortage o f space became even more acute, owing not only to the re organization described above but also to the Regional Office’s new responsibility for global programmes and the intro duction o f German as a working lan guage. Discussions with the Danish Government on the possible financing and construction o f an extension to the main building were initiated late in the year. Currency fluctuations stabilized to wards the end o f the period and, owing 9 1 to the allocation o f additional funds from headquarters and to considerable voluntary contributions from several Member States, the Regional Office was able to implement its programme for 1979. 8 .2 S T A F F D E V E L O P M E N T A N D T R A I N I N G The Regional Office maintained an interest in the development and training o f its staff in the necessary technical skills, as well as in manage ment and teamwork for staff at all levels. A course on management in health services development and an other on teamwork in office manage ment were attended by staff members, with encouraging results. A general review was carried out during the year and a medium-term programme for staff development and training was drawn up. 8.3 P E R S O N N E L During the period under review three professional posts were abol ished, one at the Regional Office and two in the field. One o f the field staff posts had been financed by UNDP. Three new professional posts were established at the Regional Office, one o f which was financed by UNDP. At its sixty-third session the Execu tive Board adopted resolution EB63.R25, approving the Director-General’s pro posal to set a specific target o f 20% for the recruitment o f women to the professional and higher grades. Fig. 10 shows the numbers o f men and women employed at the Regional Office and in the field in 1979; 18.7% o f the posts in the professional and higher grades were held by women. 8 .4 S U P P L IE S The work o f the Supplies unit in connexion with the malaria emerg ency in Turkey continued, the major items being insecticides, chloroquine tablets, and spraying equipment. The provision o f laboratory equip ment for projects dealing with a range o f subjects from cardiovascular diseases to environmental pollution was also a feature o f the work in 1979. 8.5 C O N F E R E N C E , O F F I C E A N D B U I L D I N G S E R V I C E S Some 1650 persons attended the 75 WHO-sponsored meetings held during the year, 32 o f which took place at the Regional Office. The number o f non- WHO meetings held on Regional Of fice premises continued to increase; 113 such meetings attended by 2824 per sons took place during the period under review. 92 N um be r of st af f F i g . 1 0 . N u m b e r s o f m e n a n d w o m e n e m p l o y e d a t t h e R e g i o n a l O f f i c e a n d i n t h e f i e l d i n 1 9 7 9 40 30 20 10 И m t ■ М я М й п P1 P2 P3 P4 P5 P6 D1 Professionals and higher men CO 4— О к.Q)-Q E и m r~i D2 UG General service 8.6 B U D G E T A N D F IN A N C E A total o f US$ 11 588 072 was ex pended, representing 99.98% o f the regu lar budget allocation. Under other funds, which included UNDP, UNFPA, UNEP, the Voluntary Fund for Health Promotion, Funds-in- Trust, the Special Account for Servicing Costs and the Real Estate Fund, a total of U S$4 371 554 was disbursed. In ad dition, U S $ 3 1 8 0 0 was contributed by the Government o f Finland towards the cost o f the twenty-ninth session o f the Regional Committee in Helsinki. Member States have provided con siderable assistance by covering the local costs o f WHO meetings and o f the at tendance o f national experts at meetings abroad. The collaboration o f institutes in Member States in the research pro gramme o f the Regional Office is another form o f assistance which is not easily expressed in monetary terms. A breakdown by source o f voluntary contributions received during the year is shown in Table 4. Table 4. Voluntary contributions, including Funds-in-Trust, received during 1979 (US$) Austria 163859 Belgium 116 494 Denmark 109 328 Finland 24 888 Germany, Federal Republic of 268 489 Ireland 2 500 Luxembourg 7 882 Netherlands 25 363 Norway 123546 Saudi Arabia 100000 Sweden 41 809 Switzerland 90 361 Japan Shipbuilding Industry Foundation 15000 Imperial Chemical Industries 9 126 USAID 66 400 1 165 045 3 Of which US$452 739 was provided for malaria control. 94 G E N E R A L S E R V IC E S A N D SU PPO R T PROGRAM M ES Expenditure (U S $ ) Regular funds Real estate funds Special account for servicing costs UN funds Voluntary funds a Being 25.53% o f to tal expenditure. 3 8 9 2 5 2 7 1 0 6 0 1 1 33 000 51 179 4 0 8 2 7 1 7 a 95 A n n e x 1 ACTIVE AND NON-ACTIVE MEMBER STATES OF THE WORLD HEALTH ORGANIZATION, EUROPEAN REGION 31 December 1979 At 31 December 1979 the European Region o f the World Health Organization had 32 active Member States and 2 non-active Member States. They are listed below with their date of entry to the Organization. Albania 26 May 1947 Algeria 8 November 1962 Austria 30 June 1947 Belgium 25 June 1948 Bulgaria 9 June 1948 Byelorussian S S R fl 7 April 1948 Czechoslovakia 1 March 1948 Denmark 19 April 1948 Finland 7 October 1947 France 16 June 1948 German Democratic Republic 8 May 1973 Germany, Federal Republic o f 29 May 1951 Greece 12 March 1948 Hungary 17 Jun e 1948 Iceland 17 Jun e 1948 Ireland 20 October 1947 Italy 11 April 1947 Luxem bourg 3 Jun e 1949 Malta 1 February 1965 Monaco 8 Ju ly 1948 Morocco 14 May 1956 Netherlands 25 April 1947 Norway 18 August 1947 Poland 6 May 1948 Portugal 13 February 1948 Romania 8 June 1948 Spain 28 May 1951 Sweden 28 August 1947 Switzerland 2 6 March 1947 Turkey 2 January 1948 Ukrainian S S R a 3 April 1948 U S S R 24 March 1948 United Kingdom 22 Ju ly 1946 Yugoslavia 19 November 1947 a Non-active Member State. 97 A n n e x 2 PROFESSIONAL STA FF IN THE EUROPEAN REGION 31 December 1979 R E G I O N A L O F F I C E Executive M anagement (O ffice o f the Regional Director and the Director, Programm e M anagement) Regional Director Dr Leo A. Kaprio Ms C. Celinder D irector, Programm e M anagement Dr J.E. Asvall (attached units and supporting staff) Coordination with Other Organizations Dr C. Guttuso Ms N. Humbert Country Health Programming Vacant Programme Monitoring Ms V.S. Pedersen Research Prom otion and Developm ent Dr B.Z. Nizetic Developm ent o f Com prehensive Health Services Director Dr D.K. Sokolov A ppropriate Technology for Health DrA.H. Wahba Epidem iology Dr Z.J. Brzezinski Mr A.J. Ester man Fam ily Planning Ms W. Haddad Health Care o f the Elderly Dr D.M. Macfadyen Ms F.A. Palmera Health Econom ics Dr H.F.K. Zöllner Maternal and Child Health Dr M.O. Wagner Primary Health Care Dr H. V. Vuori Prophylactic, Diagnostic and Therapeutic Substances Mr A. Grimsson W orkers’ Health Dr M.I. Miheev Disease Prevention and Control Director Dr M. Postiglione Accident Prevention Dr C.J. Römer Ms F.A. Palmera Chronic Diseases Dr G. Lamm Com m unicable Diseases (including Malaria) Dr B. Velimirovic Mr Y.H.R.R. Timmermansa General Preventive Services Vacant a Half-time. Disease Prevention and Control (con td) Mental Health Dr A.E. Baert Mr J. U. Hannibal Oral Health Dr I.J. Miller0 Prom otion o f Environm ental Health Director Mr J.I. Waddington Basic Sanitary M easures Mr E.R.J. Giroult Environm ental Health Planning and Management Mr C.A. Ferullo Environm ental System s M anagement Dr A. Gilad* Food Safety Programme Ms B. Blomberg R ecognition and Control o f Environm ental Hazards Dr M.J. Suess Toxicology Vacant Health Manpower Developm ent Director Dr A.M. Wojtczak Educational Developm ent and Support Dr L.A. Judin Fellow ships Adm inistration Mr E.C. Fricke Ms E. Miklikova Mr Y.H.R.R. Timmermansc Mr I. Tolstoy Fellow ships and Prom otion o f Training Dr R. Manrique de Lara Health Education and Social Sciences Dr A.P. Woudenberg Health Manpower Planning and M anagement Dr W.E.P. Fritsche Nursing Dr D.C. Hall Ms M.O. Abbottd Ms E. Stussi a Paid by WHO headquarters, working part-time for EU R O . b Paid by UNDP. c Half-time. ^ Paid by WHO headquarters. 99 Health Inform ation Director Health Literature Services Inform ation System s Programm e D r A .A . Weber Ms A. Mercier Vacant Mr I. Vinther-Jtfrgensen Publications Vacant M r F .E . Theakston Public Inform ation M rJ.M . van Gindertael R eports Ms C .F. Murphy Translation and Editorial (Chief) Mr J.-M . D eram at (English) Mr P .J. Boyle Vacant Translation and Editorial (contd) (French) (Germ an) (R ussian ) Su pport Programm e Director Adm inistrative Services Budget and Finance Conference Services Personnel Vacant Vacant M sM .A . Chevreau D r M .T .L .F . L o r ion D r J .E . Raeder-Roitzsch Mr V.M. Sorokine Mr E .B . Mezevitinov Mr A.N . Grigoriev Mr R .S. Weil Mr C. G. Chatelier Mr G. Y. Derweduwen M r J.P . T. Mulvaney D r U.B. Rem itz FIELD STAFF Algeria A L G /E H P 0 0 1 (UNDP) - Training o f Sanitary Engineers, Algiers Sanitary engineer Dr J. Schulm ann A L G /E H P 0 0 2 (UNDP) - Training o f Sanitarians a t the In stitu te o f Health Technology, Algiers Sanitary engineer Mr D. Popovic Greece G R E /R C E 001 (UNDP) - Environm ental Pollution Control, A thens Adm inistrative A ssistant Mr J . N em fakos M orocco M O R /ESD O O l - Surveillance an d C ontrol o f Com m unicable D iseases, R ab at Biologist Dr F .Ä . G atti ICP/PTR 005 - San itary Engineering Centre, R abat Sanitary engineer Mr T.B .A. Zeribi Sanitary engineer D r N.O. Akm anoglu Turkey TUR /B SM 001 - Environm ental San itation , Ankara Sanitary Engineer Vacant Sanitary T utor Mr P. W. Jo lly TUR/EHPOOI (UNDP) - Urban Water Supply and Sew erage, A nkara Senior Technical Adviser Dr G. Watters T U R /E H P 0 0 3 (UNDP) - Environm ental Training an d Research in F o u r Universities, Istanbul Sanitary Engineer Mr S .J . Arceivala ICP/M PD 005 - Intercountry M alaria Team, Ankara Field O peration Manager Mr J O. Espinoza Cajina Adm inistrative O fficer Mr J .F . Bugge ICP/M PD 0 0 7 - Intercountry Project f o r Control o f Malaria in South-East E urope (UNDP/W HO) M alariologist Dr K. Lassen 100 Annex 3: Organizational chart o f the Regional Office , 31 D ecem ber 1979 Coordination w ith Other Organizations Country Health Programming E X E C U TIV E M A N A G E M E N T ' Programme M onitoring Research Promotion and Development D EV E LO P M E N T OF C O M PR EH EN SIVE H E A L T H SERVIC ES Appropriate Technology for Health Epidemiology Family Planning Health Care o f the E lderly^ Health Economics Maternal and Child Health3 Primary Health Care Prophylactic, Diagnostic and Therapeutic Substances Workers' Health D ISEASE P R E V E N T IO N A N D C O N T R O L Accident Prevention4 Chronic Diseases Communicable Diseases (including Malarial General Preventive Services Mental Health Oral Health P R O M O T IO N OF E N V IR O N M E N T A L H E A L T H Basic Sanitary Measures Environmental Health Planning and Management Environmental Systems Management Food Safety Programme Recognition and Control o f Environmental Pollution Hazards Toxicology H E A L T H M AN PO W ER D EV E LO P M E N T Educational Development and Support Fellowships Adm inistration Fellowships and Promotion o f T raining Health Education and Social Sciences Health Manpower Planning and Management Nursing H E A L T H IN F O R M A T IO N Health L iterature Services Info rm ation Systems Programme Publications Public Inform ation Reports Translation and Editorial SUPPORT PR O G R A M M E Adm inistrative Services Budget and Finance Conference Services A n n e x 4 INTERCOUNTRY" MEETINGS CONVENED BY THE REGIONAL O FFICE FOR EUROPE IN 1979 ICP/RCE 206(9) ICP/ADR 001(4) ICP/MNH 038 I ICP/CVD 003(9) ICP/SPM 004(4) ICP/ADR 040 ICP/RPD 006(2) ICP/RPD 004(2) ICP/RCE 304(1) Workshop on Monitoring o f Recreational Coastal Water Quality and Shellfish Culture Areas within the Framework o f WHO/UNEP Pilot Project MED VII, Rome, 17-19 January (English) Fourth Liaison Meeting on the Prevention and Control o f Road Traffic Accidents, Copenhagen, 29-31 January (English) Technical Advisory Committee on the European Mental Health Programme, Copenhagen, 6 -9 February (English) Working Group on the Development o f Coronary Care in the Community, Brussels, 12-14 February (English) Second Meeting o f Steering Group for the Study on Health Care o f the Elderly, Copenhagen, 2 2 -2 3 February (English) Technical Group on Planning and Organization o f Emergency Services, Toulouse, 2 4 -2 8 February (English, French) Planning Group on Evaluation o f Drugs and other Therapeutic and Diagnostic Substances, Copenhagen, 13-15 March (English) Planning Group on Standardization o f Methods, Measurements and Terminology in Biomedical and Health Services Research, Copenhagen, 19-21 March (English) Working Group on Health Aspects related to Indoor Air Quality, Bilthoven, 3 -6 April (English) a Several other meetings held during the year were financed through country project funds. Som e o f these, although not listed here, were o f considerable interest to more than one country. ICP/GPD 001(3) ICP/MCH 012 ICP/CVD 002(15) ICP/EDS 001 ICP/MPM 025 IC P/A D R 0 2 7 ICP/RPD 005(2) ICP/SPM 003 ICP/CVD 005(15) ICP/ESD 005 ICP/ADR 010 ICP/SPM 010 ICP/WKH 004 104 Interregional Planning and Coordination Committee on Pre vention of Road Traffic Accidents, Copenhagen, 24-25 April (English) Consultative Group on Programme Development, Copenhagen, 2 4 -2 6 April (English, French, German, Russian) Working Group on the Early Detection o f Handicap in Children, Faro (Portugal), 15-18 May (English) Working Group on the Prevention o f Ischaemic Heart Disease, Rome, 16-18 May (English) Seminar on Planning and Implementation o f Teacher Training Programmes, London, 23-25 May (English, Russian) First Meeting o f Researchers from Collaborating and Selected Participating Centres associated with the Medium-Term Pro gramme in Nursing/Midwifery in Europe, Copenhagen, 28 May — 1 June (English) Planning Group on Prevention, Prophylaxis and Early Detection, Brussels, 6 -8 June (English, French) Workshop on Country Health Programming (CHP) in European Health Planning and in Management Education, Vienna, 10- 15 June (English) Study on Effects o f Rehabilitation and Secondary Prevention in Patients with Cardiovascular Diseases — Meeting o f the Editorial Board, Heidelberg, 18-21 June (English) Ad hoc Consultation on Communicable Diseases, Copenhagen, 26-27 June (English) Technical Group on Protective Devices and Restraint Systems in Traffic Accident Prevention, Meknès (Morocco), 26 -28 June (English, French) Working Group on the Design o f Training in Health Planning and Management, Berlin (West), 3 -6 July (English) Joint HQ/EURO Task Group on Health Criteria o f Respiratory Diseases due to Vegetable Dusts, Copenhagen, 3 -9 July (English) ICP/WKH 001 ICP/RCE 903 ICP/CVD 018(5) ICP/HST 002 ICP/MPM 026 ICP/RCE 904 ICP/RPD 301 ICP/WKH 002(1) ICP/RPD 002(3) ICP/RPD 801 ICP/PHC 010 ICP/PHC 010 ICP/ADR 013 ICP/CV D 0 0 2 (1 6 ) Informal Meeting o f the Principal Investigators in the Study on Primary Prevention o f Ischaemic Heart Disease, London, 5-7 July (English) Consultation on Epidemiology o f Occupational Health, Copen hagen, 10-12 July (English) Consultation on Regional Cooperation on Environmental Health Aspects o f the Control o f Chemicals: Proposed UNDP/WHO Project, Copenhagen, 2 0 -2 2 August (English) Meeting on Comprehensive Community Cardiovascular Control Programmes, Novi Sad, 2 7 -3 0 August (English) Fourth European Conference on Health Statistics, Luxembourg, 28-31 August (English, French, German, Russian) Meeting o f Programme Managers from Collaborating Centres associated with the Medium-Term Programme in Nursing/Mid wifery in Europe, Copenhagen, 3 -5 September (English) Working Group on Criteria and Guidelines for Halogenated Aro matic Compounds, Venice, 3 -7 September (English) First Liaison Meeting on Health Research Coordination in the WHO European Region, Helsinki, 6 September (English) Working Group on Health Aspects o f Wellbeing in Working Places, Prague, 18-20 September (English) Third Meeting o f Planning Group on Information Systems for the Biomedical Research Promotion and Development Programme, London, 19-21 September (English) Workshop on Health Economics Research, The Hague, 24 - 27 September (English) Working Group on Health Problems o f Local and Migrant Popula tions in Arctic Regions, Copenhagen, 25-27 September (English) Consultation to Prepare the Outline o f a MTP on Arctic Medicine, Copenhagen, 28 September (English) Technical Group on Education in Traffic Safety, Essen, 2 -4 Octo ber (English) 105 ICP/CV D 0 2 2 Consultation on Hypertension Research related to Health Care, Copenhagen, 2 - 4 October (English, French, German, Russian) ICP/ATH 001 ICP/RPD 001(5) ICP/RCE 903(2) ICP/MPD 008 ICP/ADR 020 ICP/SPM 013(1) ICP/FSP 007 ICP/RCE 802(2) ICP/PHB 006 ICP/EHP 005 Working Group on Appropriate Technology in Health Labora tories, London, 2 -5 October (English) European Advisory Committee for Medical Research, Fifth Session, Prague, 17-18 October (English, French, German, Russian) Consultation on Proposed UNDP/WHO Project for Regional Co operation on Food Safety Services in Europe, Copenhagen, 2 3 - 25 October (English) Coordination Meeting on the Prevention o f the Réintroduction o f Malaria in the Countries o f the Western Mediterranean, Erice (Trapani, Italy), 23 -27 October (French) Interregional Planning and Coordination Committee on Health Care o f the Elderly, Copenhagen, 29-31 October (English) Meeting on the Development o f Health Economics, Aberdeen, 29-31 October (English) Working Group on Health Examination for Food-Handling Personnel, Copenhagen, 5 -7 November (English) Working Group on Health Aspects related to Actinides and their Decay Products, Brussels, 6 -9 November (English) Eighth European Symposium on Clinical Pharmacological Evalu ation in Drug Control, Cologne, 2 0 -2 2 November (English, German) Consultation on Study o f Professional Profiles — “ The Environ mental Health Officer in an Industrialized Society”, Copenhagen, 2 0 -2 3 November (English) ICP/RCE 206(10) Meeting on Shellfish and Recreational Coastal Water Quality Monitoring, Rome, 20-23 November (English, French) ICP/CVD 019(5) Study on Chronic Lung Diseases leading to Pulmonary Hyper tension - Meeting o f Investigators, Strasbourg, 22 -23 November (English, French) 106 ICP/MNH 054 ICP/RPD 008(2) ICP/SPM 008(1) ICP/CAN 012 ICP/ATH 005 ICP/BSM 002(4) ICP/SPM 021 ICP/ADR 029 ICP/SPM 004(5) ICP/SPM 015(2) ICP/SPM 007(1) ICP/CVD 002(17) ICP/CV D 0 2 3 Meeting o f National Mental Health Advisers, Bielefeld, 26 - 30 November (English, French, German, Russian) Planning Group on Economic Aspects o f Health Care, Copen hagen, 2 7 -2 9 November (English) Meeting o f the Steering Group for the Study on the Develop ment o f Systems for the Epidemiological Surveillance o f Long- Term Environmental Health Effects, Copenhagen, 2 8 -3 0 Novem ber (English) EURO/IARC Study Group on Cancer Screening, Copenhagen, 3 -5 December (English) Working Group on Quality Control in Health Laboratories, Brussels, 4 - 7 December (English) Planning Consultation on the European Study on Public Health Aspects o f Housing, Copenhagen, 4 -7 December (English) Working Group on Nursing/Midwifery in the Context o f Health Care Delivery Systems, Brussels, 4 -7 December (English, French, German) Second Preparatory Meeting for Conference on Road Traffic Accidents in Developing Countries, Paris, 6 -7 December (English) First Meeting o f the Editorial Board for the Report on the Study on Health Care o f the Elderly, Tampere (Finland), 10-12 Decem ber (English) Meeting on National Health Accounts, Leidschendam, 11- 13 December (English) Working Group on Legislation concerning Nursing/Midwifery Services and Education, Hamburg, 11-14 December (English, French, German, Russian) Meeting o f Principal Investigators o f the Primary Prevention of IHD by Reducing Blood Cholesterol-Atromid Trials, Geneva, 12-14 December (English) Meeting o f Investigators on New Monitoring Systems for the Incidence o f IHD in the Population, Geneva, 17-19 December (English) 107 Annex 5 European response to THE STUDY OF WHO’ S STRUCTURES IN THE LIGHT OF ITS FUNCTIONS (Résumé) Twenty countries o f the Euro pean Region supplied the Regional Office with replies to the questionnaire concerning the study on WHO’s struc tures in the light o f its functions. Staff in the Region and the Director-General o f the International Children’s Centre were also asked to comment. Docu ment EU R/RC29/5, containing an analy sis o f the replies, was then discussed at the twenty-ninth session o f the Regional Committee. Although the study carried out in the European Region was based mainly on the Director-General’s document DGO/78.1, it also took into account other sources o f information or appraisal, including the Declaration o f the New International Economic Order, the Final Act o f the Helsinki Conference on Security and Cooperation in Europe, the report o f the Executive Board on technical cooperation between develop ing countries, the Declaration o f Alma- Ata on primary health care, and the report to the Executive Board by its Pro gramme Committee on the formulation o f strategies leading to health for all by the year 2000. Analysis o f the replies received produced a fairly general consensus on a number o f points. With regard to the role o f WHO, it is recognized that, while in principle all Member States have equal rights, the Organization’s activities should vary according to need and to the level o f economic and social development. Europe is in a privileged position, which enables it to play a pioneering role in several fields. It would be advantageous for the Regional Office to achieve better coordination between its activities and those o f other regions that include coun tries with the same high level o f techni cal expertise. In this connexion, while WHO’s efforts should be directed chiefly at the developing countries, the special problems o f the industrialized countries should not be ignored. Replies vary concerning the possibil ity o f WHO playing a more “ political” role. It is generally acknowledged that, although WHO is primarily a technical organization, health is also a political problem. However, the countries are vir tually in full agreement that a develop ment o f this nature should not entail basic changes in the functions o f the Director- General and the regional directors. They all agree that the WHO Constitution has not exhausted its possibilities and does not need to be changed. There is broad approval o f the prin ciple o f interdependence between WHO programmes and national programmes, but practical difficulties are still being 109 encountered too frequently. Most coun tries believe that their collaboration with the Regional Office is satisfactory, in cluding that in the field o f research, but consultation procedures could be im proved. Practically all countries have a unit or service responsible for liaison with WHO, as well as health advisory councils, and only one-third feel that their ministries o f health should be strengthened politically and technically. However, other ministries having some kind o f responsibility for health should be included in mechanisms for closer coordination with WHO. With regard to the governing bodies o f the Organization, the main emphasis is on the need to ensure better liaison between regional committees, the Execu tive Board and the Assembly, to avoid excessive proliferation o f committees and working groups, and to exercise more rigorous control over the large number of resolutions. Nevertheless, no signifi cant changes are suggested in existing structures, and most countries favour a retention o f the present frequency o f sessions. Concerning the interrelationships among the different operational levels o f the Secretariat, the majority o f countries are in favour o f increasing the responsi bilities o f the regional offices. Neverthe less, they stress that any decentralization should be carried out with prudence and that headquarters should, in any event, remain the brain-centre o f the Organiza tion and the guarantor o f its unity. There is room for closer and better defined cooperation, and every effort should be made to avoid duplication, both with other United Nations bodies and with European organizations. Comments by countries reveal a gen eral desire to retain a structural system that has proved itself and achieved no table results. More systematic coordina tion o f the preparation, implementation and evaluation o f programmes should un doubtedly be sought, while information systems should be promoted and recip rocal links between various groups at the global, regional and national levels should be broadened. However, as one country emphasizes, “ efforts should mainly be concentrated not on internal organizational problems but on the most effective and active solution o f world health problems” . T H E R O L E O F WHO The role o f WHO worldwide It is unanimously recognized that, while in principle all Member States have equal rights, WHO cannot and should not play the same role in all regions and in all countries. The Organization’s activ ities must necessarily be oriented to the needs o f the various countries, which will vary according to the stage o f devel opment reached in the economic, social and health fields. Health should be regarded as an in trinsic element o f economic and social development. In pursuing the measures that stem from the New International Economic Order, the aim should be to reduce the gap between the level o f health in developed countries and that in de veloping countries. In this respect WHO has two essential functions: the coordi nation o f international health activities (developing health principles, collecting 110 and disseminating information, strength ening interregional collaboration and adapting activities to regional character istics); and technical collaboration with Member States (transfer o f resources from some countries to others). Doubts are expressed as to whether WHO should have a more “ political” role. It is generally believed that WHO is, above all, a technical organization within the United Nations system. It should remain so, in the interests o f maintaining its authority, by con centrating its efforts on the technical aspects and economic consequences o f health problems. Nevertheless, its technical orientation should not pre vent WHO from entering the political field in special cases where, for example, risks to the health o f a population could not be overcome simply by “ recommendations” . In fact, it is a mat ter o f agreeing on the meaning o f the word “ political” . WHO should, on no account, impose its own political opinions on a country, any more than it should impose those expressed by a majority o f Member States; on the other hand, under the terms o f Article 2 o f its Constitution, it does have the task o f calling the attention o f political leaders and public opinion to the high priority that should be accorded to health matters. The role o f WHO in the European Region The European Region is in a special situation since, on the one hand, it pos sesses considerable scientific and tech nical potential — to date insufficiently utilized by WHO - and, on the other hand, it is the only WHO region where developing countries are not in the majority. Transfer o f technology, knowledge and information can take place either by direct technical cooperation between countries, or by using the Regional Office as an intermediary, or through various regional institutions (the Council of Europe, the European Economic Com munity, the Nordic Council, the Council for Mutual Economic Assistance, etc.), with which WHO closely coordinates its activities. It is really at the intercountry level that the Regional Office finds its raison d ’être. In addition to the role o f catalyst, the Regional Office also fulfils a pioneering role in a number o f fields. The European Region would thus ap pear to be an ideal testing ground for health technologies capable o f being ap plied in developing countries around the year 2000. Nevertheless, such orientation and responsibilities must not be unilateral. Industrialized countries themselves have serious health problems, and at the twenty-ninth session o f the Regional Committee the Regional Office was seen to have a special responsibility towards in dustrialized society in general. Moreover, in Europe, the slogan “ health for all by the year 2000” should emphasize certain groups, for example the elderly, migrant workers, and isolated populations such as those living in arctic regions. IN T E R A C T I O N B E T W E E N WHO A N D M E M B E R S T A T E S IN P R O G R A M M E D E V E L O P M E N T , WITH P A R T I C U L A R R E F E R E N C E T O E U R O P E A N C O N D IT IO N S There is widespread acceptance of the principle o f interdependence in the planning o f WHO programmes and 1 1 1 national programmes, in other words integrated programme planning. The programming procedure should take place from the periphery towards the centre — global programmes resulting from regional programmes and regional programmes resulting, in turn, from national programmes. However, it is recognized that this principle o f interaction and inter dependence may be largely theoret ical. Representatives o f countries may adopt resolutions in WHO assemblies without always appreciating the con sequences o f implementing them. In addition, ministries other than the ministry o f health may formulate plans that are not necessarily in accord with health programming. While it is clear that priority must be given to decisions and options at the national level, WHO should use its tech nical competence and influence to in volve countries in programmes, the need for which may not be evident to them. The Organization should also encourage countries to rationalize and coordinate the planning o f those programmes, not only with WHO but also with UNDP and other institutions and sources o f assistance. Moreover, programmes o f na tional scope should not conceal the value o f limited pilot projects, which have a far-reaching effect. It is suggested that the consultation procedures used in the European Region for the preparation o f programme bud gets be expanded and strengthened, especially with regard to medium-term planning. When establishing priorities, more consideration should be given to countries’ financial means and budgetary arrangements. Universally applicable solutions to the problem o f ensuring that governments apply in their own countries the policies they adopt in various WHO assemblies, and that their requests for technical co operation comply with those policies, cannot be envisaged: conditions, possi bilities and the opinions o f governments vary from one country to another; governments themselves change; and rep resentatives at WHO assemblies return home to find themselves faced with new requirements. However, the Executive Board could conduct a study on methods of implementing and applying WHO recommendations at the national level, the results o f which would then be sub mitted to the Assembly. Generally speaking, ministries o f health and other national institutions, but not parliamentarians, are made aware o f WHO resolutions, recommenda tions, reports, etc. WHO documents are taken into consideration in the health planning process. Efforts to keep the general public informed deserve to be intensified. Most countries believe that collab oration between the Regional Office and Member States is satisfactory. The Euro pean Region, which contains a large majority o f developed countries, could with advantage increase its collaboration with other regions such as the Western Pacific Region, where there are several industrialized countries with problems similar to those in Europe. With regard to cooperation between the developed and developing countries, there could also be value in calling up on the resources o f countries at an inter mediate level o f development. The trans fer to developing countries o f technology 1 1 2 used by the most highly developed coun tries should take the necessary adapt ations into account. There should be adequate support for regional and national training centres by making available technical person nel to instruct teachers, and by pro viding the necessary equipment. It is suggested that more information be provided on achievements likely to in terest developing countries, that a pre cise list be drawn up o f the health prob lems faced by those countries between now and the end o f the century and o f the links between them, and that de veloping countries be given responsibil ity from the beginning. With regard to technical cooperation among developing countries (TCDC), opinions differ as to the need for struc tural changes in regional offices. Plans for cooperation between two or more countries (with WHO participation) might be envisaged, or annual meetings could be held to evaluate the results o f past activities, establish new prior ities and compare experience. Efforts should clearly include the exchange o f scientific experts, the development o f specific teaching, training and research programmes and an increase in the number o f seminars. Attention is drawn to the fact that, apart from official collaboration, both multilateral and bilateral, there are wide possibilities in the private sector. Initia tives in the latter are often more adaptable than activities in the public sector to the requirements o f national health planning. Coordination o f TCDC in the health field is clearly within the scope o f WHO, in consultation and liaison with UNDP, where specific health-related programmes are concerned. Such coordination falls within the overall responsibility o f UNDP, in consultation and liaison with WHO, when the problems relate more to economic and social development. N A T I O N A L S T R U C T U R E S T O S U P P O R T C O O P E R A T IO N WITH WHO In order to reflect systematically the technical advice o f WHO in the national health planning process, it would appear that the governments consulted have in formation resources and administrative machinery that are, on occasion, inad equate. Such machinery is more difficult to set up in states with a federal struc ture. More often than not, organized controls do not exist. Some countries indicate the role played in this connexion by their higher health councils; others mention that there are various consulta tive committees, seminars and working groups to apply the policies adopted by WHO assemblies, and in addition greater attention is paid to the selection o f na tional representatives at the World Health Assembly and the Regional Committee. Countries are concerned to improve these mechanisms by providing better informa tion and wider publicity services, and by developing a proper plan o f technical co operation with WHO. Only one-third o f the countries consulted acknowledge that their minis tries o f health need strengthening either politically or technically. Personnel re sources are generally insufficient in rela tion to the volume and complexity o f the tasks involved. Technical and admin istrative functions should be developed 113 simultaneously, and not some at the ex pense o f others. One country considers that the need for strengthening ministries o f health differs among countries. In in dustrialized countries, the resources for public health are often distributed among several ministries, many problems have al ready been solved, and less need is felt for a “ political strengthening” o f ministries o f health. In developing countries, the gap between needs and resources is more marked. The ministry o f health may run the risk o f being in competition with or inferior to other ministries, which are able to furnish in the short term more convincing statistically based proof o f their activities and efficiency. However, it is pointed out that the developing countries do not have to cope with the burden o f tradition and acquired situa tions, which is frequently the case in industrialized countries. In almost all the countries consulted, the ministry o f health has one or several health advisory councils. Generally these are made up o f the most competent per sons in the sector concerned, together with representatives o f the ministry, and thus there is a dialogue between techni cians and administrators. They give their opinions on the various problems submit ted to them, as well as on legislative and statutory texts. In certain countries they set up permanent committees. The estab lishment o f such councils in all Member States is strongly recommended. As regards contacts with WHO, al most all ministries o f health have a unit, section or service dealing with interna tional relations. However, the ministry o f health is not necessarily the only agency concerned with the WHO programme in a country, and coordination between all those concerned could be improved. Conversely, there is often a need for interministerial coordination o f the pro grammes o f all international organizations in a country. The question of WHO programme co ordinators is not o f direct concern to the European Region. Their abolition in the developing countries is viewed favour ably, but this can only take place gradual ly, depending on the rate at which such countries are able to develop their own administrative and coordinating struc tures, not only within the country, but also within the region as a whole and at the global level. WHO programme co ordinators need not necessarily be physicians. National institutions could be better and more fully utilized in the develop ment o f WHO programmes and in train ing and research activities. This calls, above all, for improved information, a widening o f contacts and field visits, and better coordination among national insti tutions dealing with subjects o f direct interest to WHO. However, the reverse is also true: it is necessary to ascertain not only how WHO can make better use o f national institutions but also what the Organization, in its turn, can offer them. It is emphasized, nevertheless, that while it is advisable to entrust experi mentation in new programme concepts to countries themselves, it might prove injudicious to pass the responsibility for whole programme areas to WHO collab orating centres, since this would entail the risk o f their exceeding their advisory role. Similarly, greater dependence on nongovernmental organizations is not without some risk to the independence o f WHO, and a prudent approach in this field is advocated. 114 WHO S T R U C T U R E S : G O V E R N I N G B O D I E S Regional committees (Regional Commit tee for Europe) The WHO Regional Committee for Europe is generally seen as fulfilling an essential role, in that it comple ments and possibly amends the role o f other regional institutions. The participation o f Member States should be still further increased and intensi fied. However, the suggestion that governments should send the same representatives to the Assembly and the Regional Committee, to ensure continuity and coherence in their relations with WHO, is regarded by some countries as difficult to institute because the Assembly has a broader and more international mandate. The staff recommend that the Regional Committee meet more often in Copen hagen to facilitate contacts between themselves and country representatives. One country stresses the import ance o f the Consultative Group on Programme Development, which has shown itself to be not only a useful tool for providing advice to the Re gional Director but also an integrating force within the Regional Commit tee. Membership o f the Group should be on the basis o f rotation, although continuity should be ensured. Improvements in relations between regional committees, the Executive Board and the Assembly depend mainly on the provision o f better reciprocal in formation at the various levels. There is insufficient liaison between the regional committees themselves, and interregional cooperation should be further developed. There is a case to be made for strengthening the influence o f the regional committees in the prepara tory work on problems for discus sion in the Executive Board and the Assembly, and in the drawing up of their agendas. With regard to resolutions, it is largely agreed that the present system of presentation does not provide guarantees on such factors as applicability, duplica tion and unforeseen financial develop ments. Opinion is almost equally divided on whether all or certain resolutions should be submitted to the relevant regional committee before they are sub mitted to the Executive Board or the Assembly. It is admitted that this would be a good method of facilitating the selection and processing o f resolutions, but administratively it would be very cumbersome. Representatives o f countries should retain their right to submit draft res olutions during the Assembly. On the other hand, it would be useful if, without the delegates’ right o f initi ative being limited, the Assembly could decide to postpone certain resolu tions until its next session or to have them discussed beforehand by the regional committees concerned. As regards the regional affiliation o f certain countries, it is generally agreed that bringing the WHO regions into conformity with the structures o f the United Nations system would be a logical and effective move, especially as the existing delineation o f the WHO regions does not always correspond with criteria purely related to health. Nevertheless, to certain countries a new division, and above all a multi plication o f regions, seems o f doubt ful value. The Executive Board Opinion is divided on the ques tion o f strengthening the work o f the Executive Board still further. Li aison with other organizations o f the United Nations system should be in tensified; on the other hand, the setting up o f subgroups or subcommittees o f the Executive Board should not be excessive, and should not result in duplication. The Board should not interpose itself between the regional committees and the Assembly but, on the contrary, should give more attention and time to the reports o f regional committees. Documents should be submitted to the Board sufficiently far in advance. The duration o f the session following the As sembly should be extended and the agenda made more detailed. One country considers that Executive Board members could play a greater part in the prepara tion o f important documents, for ex ample those relating to medium-term programmes. It is generally felt that the number of members o f the Executive Board should not be increased. However, one country considers that there could be wider representation o f disadvantaged regions. Another queries whether the system whereby Executive Board members make interventions in a personal capacity should be retained. The work o f the Assembly would be facilitated if the preparatory docu ments were distributed sufficiently early to be examined in good time and if there were stricter selection o f topics for discussion, thus enabling certain matters to be considered by the Ex ecutive Board or subgroups and ad hoc committees. One country considers it advisable to limit the time devoted to statements in plenary session, while another feels that in recent years the Assembly has spent time on matters having no direct link with the basic objectives o f WHO. There are too many resolutions, often uselessly re peated from year to year. It would be preferable to monitor the implementa tion o f resolutions already adopted rather than concentrate on adopting new resolutions. There are different opinions on the frequency o f Assembly sessions; they centre on shorter annual sessions or sessions every two years. It is suggested that a survey might be undertaken to ascertain what economies would be made from holding biennial sessions, and what difficulties and additional work would be imposed on the Ex ecutive Board. The timetables o f the three governing bodies should, in any case, be re-examined and better co ordinated. The idea that the Assembly should make greater use o f conventions (Ar ticles 19 and 20 o f the Constitution) is received with some reservations. It is feared that the two-thirds majority provision would lead to compromises that would improve neither the work nor the prestige o f the Assembly. The World Health Assembly WHO STRUCTURES: THE SECRETARIAT Regional offices (Regional Office for Europe) and their relations with WHO headquarters Distribution o f tasks and authority between WHO headquarters and the Regional Office The Director-General’s objective of “ health for all by the year 2000” , which makes health a fulcrum for economic and social development and a spring board for peace, does not seem to imply major changes in the structures o f the Secretariat. It is generally thought that the Director-General has no need o f an additional support group to ensure his “ political” role concerning which, as already noted above, some doubts are expressed. There should be no essential changes in the functions o f the Director-General. He is the guardian o f the rights o f Mem ber States, he is entrusted with imple menting the guiding principles o f WHO, and he ensures collaboration between WHO and all those organizations that, in one way or another, are working to achieve solutions to the problems con fronting mankind. The interrelationships between dif ferent operational levels in the Secre tariat require, as a first essential, an adequate and rational flow o f informa tion, systematic mechanisms o f com munication and consultation, and broader national participation. Decentralization is the logical con sequence o f the priority accorded to country health programming. In the case o f the developing countries, it guarantees their greater independence. In the Euro pean Region, it should arouse greater interest in the programmes and strengthen action at the national level. However, a distinction should be made between genuine decentralization and the mere transfer o f activities from headquarters to the regional offices, as is the case with certain programmes for which the Re gional Office for Europe is at present responsible. WHO headquarters should remain the brain-centre o f the Organization and the guarantor o f its unity by con tinuing to centralize certain specific activities (for example, international classifications, standards and norms). Any lessening o f the authority o f the Assembly and the Executive Board to the benefit o f regional committees could result in the creation o f six sep arate health organizations. There is room in WHO programmes for closer cooperation with other United Nations agencies and for the use o f their experts, particularly in such fields as population problems, environmental health, nutrition, education and train ing, and social questions. Several ex amples o f duplication are cited, not only with United Nations bodies (FAO in nutrition, UNESCO in training, ILO in industrial medicine, UNFPA in maternal and child health, UNEP in environmental sanitation, etc.) but also in some instances with European or ganizations, both intergovernmental and nongovernmental. WHO and the various organizations concerned should strive for a better understanding o f their respective functions, and possibly have 117 recourse to the assistance o f the United Nations Joint Inspection Unit, Structure o f the Regional Office In so far as regional directors might be required to assume a greater pol itical role it is thought that, as in the case o f the Director-General, there would be no need for a new consulta tive group to provide them with “ politi cal protection” . It is generally agreed that the Or ganization could profitably use ex ternal specialists to study its manage ment procedures and structures. One country notes that it would be use ful to call upon the services o f the United Nations Joint Inspection Unit in this connexion. Consultative bodies The question was raised as to whether a network o f national experts would be preferable to panels o f regional experts in the European Region. If such experts are requested, perhaps on a rotation basis, to work outside their own countries, they become regional experts and there is no con flict between the two categories. It would even be possible to envisage panels o f “ subregional” experts who would work in countries neighbour ing on their own with similar prob lems and linguistic affinities. One country considers that it would be generally desirable for WHO to broaden its scientific base, while respect ing the essential geographical balance as far as countries o f origin o f experts are concerned. P R A C T I C A L C O N S E Q U E N C E S O F P R O P O S E D C H A N G E S Changes in the WHO Constitution It is unanimously agreed that the WHO Constitution does not require to be changed and that its possibilities have not yet been exhausted. Nevertheless, one country believes that more system atic use should be made o f certain points in the Constitution. Another reply re lates to Article 13 and the possibility o f biennial Assembly sessions to coincide with biennial budgeting. Concerning the appointment o f regional directors, one country notes that Article 52 does not indicate the procedure to be followed in the case o f disagreement between the Executive Board and the regional com mittee. Finally, one country suggests that regional directors could be nom inated by the Director-General; this would increase their independence o f Member States. It is also suggested that their term o f office should be renewed only once. Changes in the rules Several countries express some scep ticism regarding the need for basic changes in the rules; changes should occur, rather, in the working methods. One country, however, considers that changes would be appropriate on the following points: the unwieldiness o f current procedures (one country gives as an example cancer research and the anti cancer campaign where, within WHO it self, over 12 different organs are active, not counting the collaborating centres and the regional meetings on the sub ject); the often illogical division o f activities at WHO headquarters; the 118 growing number o f committees and working groups; and the inadequacy of horizontal communications, which have not been improved to the same degree as vertical communications. Changes in personnel policies Recruitment policy Several countries stress the need to observe adequate geographical distribu tion in selecting personnel, while others believe that, in so doing, the search for the best technical qualifications should not be adversely affected. One country considers that the tendency in regional offices to recruit staff almost exclusively from countries o f the region itself might jeopardize the unity, universality and efficiency o f the Organization. The staff would like to be represented at selection committees for posts o f all levels. One country proposed that contracts should not exceed a period of five to seven years: five years for public health physicians (those whom the Director- General’s document refers to as general practitioners) and shorter periods, o f one to two years, for experts in specific techniques. Such short-term contracts could, by a system o f rotation, make it possible to recruit highly qualified, competent and motivated persons in countries that are still under-represented. In any case, long-term recruitment plans should be formulated in conjunction with Member States. S ta ff training There is a generally favourable reac tion to the suggestion that the Regional Office for Europe be used as an in- service training centre for national personnel, but the ways and means o f implementing such a project need to be defined. Finance Many countries note that all struc tural changes, even if they seem justi fied, inevitably involve new expenditure, and they should not be brought about unless they are o f indisputable value, do not depart from established bud getary procedures, and do not place regions and Member States in unequal positions. Evaluation o f proposed changes There is unanimity on the need for such evaluation, which should establish a permanent and definite procedure, including time-scales. The elements to be considered are the following: — the economies achieved; - the cost-benefit study o f new measures; - the speed and effectiveness o f WHO action in the Member States; and — the satisfaction felt by Member States and the Secretariat as a whole. Such evaluation could be carried out on a trial basis in certain sectors or in a pilot region, in comparison with other regions. However, opinions differ on who should conduct this evaluation; a whole range o f authorities is men tioned in that connexion, from the Mem ber States themselves to regional com mittees, the Executive Board and the Assembly. One country suggests that the Executive Board, assisted by quali fied former members o f staff, should carry out the evaluation. 119 D I S T R I B U T I O N O F R E P L I E S T O K E Y Q U E S T I O N S Answer Yes No ° ther opinions Q u est ion 4.1 Should WHO play the same role in all regions and for all Member States? 13 5 9.1 Do you agree that no change is needed in the WHO Constitution? 17 1 21.1 Are WHO resolutions submitted to the appropriate legislative com missions, ministerial departments and other agencies involved in health policy formation? 17 1 21.2 Is WHO technical advice, as expressed in resolutions, recommendations by WHO expert committees, working groups, etc., systematically fed into the health planning system in your country? 15 3 25.1 Do you feel that your Ministry o f Health (or its equivalent) needs to be strengthened politically and/or technically? 5 10 3 26.1 Does your country have a national health advisory council? 13 3 2 32.1 Are you satisfied with the present arrangements for cooperation among Member States in the European Region? 13 2 3 36.1 Are you satisfied with the consultation procedures in the European Region for programme budget preparation? 9 2 7 37.1 Are you satisfied with the steps taken so far by the Regional Office for Europe in the field o f health services research? 14 1 3 40.1 Is there a need to strengthen the Executive Board? 7 6 5 43.1 Should the Assembly make more use o f conventions (see Articles 19 and 20 o f the Constitution)? 4 6 8 46.1 Should the Assembly be held annually? 10 6 2 48.2 Should all resolutions first be submitted to the regional committee of the region where they originate before going to the Board and the Assembly? 9 9 48.3 Should all or only certain types of resolutions be discussed by all the regional committees before being submitted to the Board and the Assembly? 4 8 6 53.1 Should the Regional Office for Europe be used more extensively for in-service training of national staff (at Member States’ expense and for periods o f several months to two years)? 8 7 3 58.1 Is there a specific unit in your Ministry o f Health (or its equivalent) for handling WHO matters? 15 3 66.2 Is there a need for any additional group to advise the Regional Director? 3 11 4 N.B. Tw o Member States made general comments that did not follow the order of the Director- General’s document or o f the questionnaire. 120 A n n e x 6 ACTIVITIES OF THE WHO REGIONAL OFFICE FOR EUROPE, IN COOPERATION WITH MEMBER STATES AND OTHER INTERNATIONAL ORGANIZATIONS, IN THE FIELD OF ENVIRONMENTAL HEALTH by Dr R.J.H. Kruisinga WHO Senior Adviser At the twenty-eighth session o f the Regional Committee for Europe, the Re gional Director reported that in line with the emphasis given to environmental questions by the Belgrade meeting, fol lowing the Helsinki Conference, the ser vices o f a senior adviser had been retained to study the role that the Regional Of fice could play in such matters. During the period of the writer’s assignment, undertaken on that basis, several meetings and discussions were held with intergovernmental organiza tions and government authorities in the Member States o f the European Region, and the findings are reflected in the present report. The assignment was completed in July 1979. The main finding is that the action taken in implementing the decisions o f WHO headquarters and the Regional Office, in relation to Member States, United Nations agencies and other organizations, has been marked by a cer tain lack o f consistency between the content o f the decisions and their practical implementation. Included in this report are brief descriptions o f the WHO global and regional medium-term programmes for the promotion o f environmental health in the period 1978-83; an account o f the activities undertaken by other organ izations and the Regional Office in co operation with Member States; an assess ment o f the action taken by the Regional Office in implementing the recommenda tions o f the Regional Committee at its twenty-eighth session; and a list o f mat ters for consideration. WHO G L O B A L A N D R E G I O N A L M E D IU M - T E R M P R O G R A M M E S Global programme The global programme was formu lated in accordance with the directives o f WHO’s governing bodies at global and regional level. Stress is laid on the ex pressed priorities and needs o f Member States in respect o f technical coopera tion with WHO, on the principle that environmental health must be taken into account in the formulation o f poli cies, plans and programmes for socio economic development at all levels o f government. Priority is given to the 121 provision o f services for underserved populations in rural and urban areas, the enhancement o f community par ticipation, and the strengthening of national institutions in the management and solution o f environmental health problems. Two major fields o f activity have emerged: (a) the strengthening o f technical cooperation in basic sanitation, in accordance with the targets o f the Inter national Drinking-Water Supply and Sanitation Decade 1980-90 ; and (b ) the assessment o f new en vironmental hazards arising from socio economic development and their pre vention to safeguard the benefits o f such development. Regional programme The medium-term programme for the promotion o f environmental health in the European Region was elaborated in accordance with the principles and ob jectives o f the global programme and with the provisions o f several resolutions o f the Regional Committee, reflecting the particular needs o f the European Region. The priorities are based on the view that, in spite o f a slower rate o f economic expansion due to the energy crisis, in dustrial activities are expected to develop in the chemical sector. Thus an important focus o f cooperation between the Re gional Office and the Member States will be the International Programme on Chemical Safety. The regional programme has four components. 1. Environmental health planning and management, with emphasis on insti tutional development, implementation of national environmental health pro grammes, and manpower development. 2. Basic sanitary measures, with em phasis on the solution o f problems re lating to smaller communities, industrial areas on the urban fringes o f large cities, high-rise blocks, recreational facilities, and tourist activities. 3. Recognition and control o f en vironmental hazards, with emphasis on development o f the International Pro gramme on Chemical Safety in which the European Region will play a major role; on environmental impact assessment; on health risks from accidents in industries and nuclear power plants; and on pre vention and control of chemical, bio logical and physical hazards, including food toxicity, occupational hazards and those due to harmful substances in build ing materials, textiles, cosmetics and household utensils. In dealing with such hazards, attention will be paid to their long-term and chronic effects, including allergic effects and those o f combined exposure to more than one hazard. UNDP will continue to support the country and intercountry programmes for environ mental quality surveillance and control. Collaboration with UNEP in air and water quality monitoring under the GEMS pro gramme is expected to continue. The Re gional Office will continue to play a major role in implementing the UNEP Action Plan for the Mediterranean. Simi lar activities may be undertaken in rela tion to the Baltic and Black seas and the Danube river. 4. Food safety, with emphasis on aspects o f the protection o f consumers of food, including food contamination, surveillance systems, hospital and mass catering, health examinations o f food handlers, and the hazards o f food addi tives, especially those not covered by the FAO/WHO Codex Alimentarius. In this connexion, it should be noted that the Codex Alimentarius Commission has adopted and sent to governments for ac ceptance some 150 food standards, cover ing a wide range o f products, about 1000 maximum limits for pesticide residues and other contaminants, and codes o f practice on matters such as food hygiene. However, progress as regards acceptance o f standards and codes o f practice still leaves much to be desired. On several occasions the developing countries have expressed the wish that developed countries should make greater efforts towards practical accomplishment o f the aims o f the Commission. Implementation o f the four pro gramme components will require opti mal use o f the overall resources, and strengthening o f the WHO regional resources through voluntary contribu tions from the more industrialized coun tries o f the Region. A C T I V I T I E S O F I N T E R N A T I O N A L O R G A N I Z A T I O N S The field o f environmental protection is broad and there are clearly no sharp limits to the areas in which the health and wellbeing o f man are predominant, compared to other factors such as the conservation o f flora and fauna. A number o f international organiza tions are concerned with the various aspects o f environmental protection and it is important that their efforts be har monized, with optimal utilization o f overall resources and avoidance o f all unnecessary overlapping. In the Euro pean Region, some progress has been made in recent years in accomplishing this objective, particularly since regular interagency coordination meetings were instituted by UNEP and ECE. The Re gional Office has taken a major role in this effort, often providing the secretariat for the meetings. Some rationalization of the environmental work o f international organizations has been achieved and the total picture appears more cohesive than in the past. There has, for instance, been effective interagency cooperation in im plementing the UNEP Action Plan for the Mediterranean, under which different activities are carried out by WHO, FAO, IMCO, IOC and other bodies in collab oration with Member States. ECE has a programme o f environ mental measures that should be, but are not always, coordinated with its other economic and development activities. Under ECE auspices, senior advisers to governments meet to discuss a range of environmental problems, but not specifi cally in relation to human health. FAO studies the environmental aspects o f food production and fisheries. UNESCO deals with a variety ofenvironmental activities, particularly under its “ man and the bio sphere” programme, but is not directly concerned with matters affecting human health. UNIDO has programmes on in dustrial pollution, and IAEA is clearly concerned with health physics in relation to nuclear technology. ILO has long been involved in matters o f occupational health and has joint programmes with WHO in this sphere. Oil pollution from ships is a major concern o f IMCO. OECD 123 has been involved in several studies, in cluding a programme on toxic chemicals. Most o f the activities o f these and other organizations are, surprisingly, not o f direct relevance to the environmental health concerns o f WHO, which there fore still has important tasks in this field. UNEP, o f course, has an umbrella func tion in matters o f environmental pro tection. It is not primarily an executing agency, but has cooperated in a number o f activities o f other international organ izations, including WHO. The two major economic groups in the European Region, namely EEC and CMEA, have important functions for co ordination among their member govern ments in relation to environmental pro tection. EEC, for example, is currently formulating directives in an endeavour to standardize environmental goals with in its member countries. These organiza tions, o f course, are concerned to a con siderable extent with environmental pro tection in relation to economic develop ment. Moreover, the geographical limits o f their respective areas o f influence are meaningless from the environment and health standpoints, as neither o f these factors can be confined within national boundaries. There is an urgent need for better coordination. For instance, ac ceptances o f the recommended Codex standards and maximum limits for pesti cide residues continue to be received from the various governments, but major progress would be made if EEC orCMEA decided to adopt the Codex standards as standards for their members. In the case o f EEC, it is true that several Com munity directives are very close in sub stance to the corresponding Codex stan dards, but there are also instances where there are significant differences. It seems wasteful o f resources for EEC to be engaged in the same work at Com munity level as the Codex Alimentarius Commission at global level. Any idea that Community standards, which are also international standards, could be sig nificantly different from the Codex standards should be discouraged. A C T I V I T I E S O F T H E R E G I O N A L O F F I C E It seems evident that there is an im portant and quite broad field o f environ mental work that should logically be carried out by WHO, which is not bound by the artificial limits o f the major econ omic groups in the European Region. Moreover, up to now insufficient atten tion has been paid to the human health aspects o f environmental protection. For instance, community water supply and sanitation is both an environmental con cern and a task o f major importance in primary health care. For this reason, WHO’s work in relation to the Inter national Drinking-Water Supply and Sanitation Decade has high priority, and it is clear that there is still much to be done for this purpose, particularly in rural areas, in many parts o f the Region. The public health aspects o f housing and settlements are logically also a con cern o f WHO and, whereas this work does not at present have high priority globally, many problems are faced in the European Region; for example, the design of high apartment blocks often takes no account o f the requirements o f young families and special groups such as the aged and the handicapped. Health problems also arise from city centre 1 2 4 decay and uncontrolled development on urban fringes. In this respect the import ance o f mental health for social wellbeing is often overlooked. The Regional Office undertakes activ ities in relation to pollution o f surface, ground and coastal water, which are har monized with those o f other organiza tions as far as possible. Similarly, urban air pollution and the disposal o f solid wastes have important public health im plications in an industrialized society and receive due emphasis in the WHO programme. Although IAEA has numer ous activities in the field o f radiation, it seems appropriate that WHO should make recommendations on the health implications o f nuclear power produc tion and o f various uses o f nonionizing radiation, and propose guidelines for subsequent health surveillance and evalu ation. In the area o f food safety, WHO has always endeavoured to work closely with FAO and in view o f the widespread use o f food additives and the disquieting trends in microbiological contamination o f foods, particularly in mass catering establishments, it is felt that the Regional Office should have an active programme to provide guidance on such matters, taking into account the specific condi tions in the Region. A problem o f major concern to Member States o f the Region is that o f the increasing hazards in the production, use and final disposal o f toxic chemicals, and their synergistic relationship with other environmental perturbations and with aspects o f lifestyle, e.g., diet and smoking. WHO is now launching the International Programme on Chemical Safety and, since much of the world’s chemical production and use is con centrated in the European Region, it is o f great importance that the Regional Office should play an active role in this effort. The work o f the Regional Office must be closely harmonized with that o f WHO headquarters and the form o f the global programme is appropriate in this respect. It is essential that there be fre quent consultation between headquarters and the regions to ensure maximum ef fectiveness in the use o f resources, as these are clearly going to be inadequate in the next few years, although it is hoped that substantial assistance will be made available through extrabudgetary funds. A major problem in providing ad equate environmental health protection in the Region is the number o f different ministries and authorities involved. Al most every country has a different set o f administrative arrangements for the purpose and in many cases the health ministry does not play the role it should. However, notwithstanding these difficul ties, WHO is enjoined by its Constitution to place great emphasis on environmental health, particularly in the European Re gion where this factor is in many ways becoming predominant in health protec tion and will be o f crucial importance in achieving the goal o f “ health for all by the year 2000” . It is therefore proposed that the Regional Committee should consider setting up an environmental health forum, with the involvement o f all Member States. The deliberations o f such a forum would not only be important for the Regional Committee but would also be appreciated by other European organizations, especially ECE. In the terms o f the Alma-Ata Declaration and the Final Act o f the Conference on Security and Cooperation in Europe, WHO has an obligation to take a lead 125 in this field and, as the problems o f the next few years are likely to be o f great magnitude and complexity, early steps should be taken to set up the necessary machinery. In conclusion, the question o f whether the Regional Office is fulfilling its functions in the field o f environ mental health should be examined in relation to three fundamental considera tions: (a) the goal o f “ health for all by the year 2000” in the context o f the deteriorating environment in the Euro pean Region; (b) the consequences o f environ mental change, not only from the physi cal but also from the mental point o f view, bearing in mind that social well being, both individual and community, is a major concern o f WHO under its Constitution; and (c) the implications for health co operation o f the Conference on Security and Cooperation in Europe, as stated in resolution EUR/RC25/R1 1. M A T T E R S F O R F U T U R E C O N S I D E R A T IO N Programme 1. Strengthening o f scientific and technical collaboration between insti tutions concerned with research and practice in the field o f toxic chemicals, with a view to establishing a regional network o f such institutions. 2. Promotion o f geographically- based epidemiological research in order to determine the health effects on in dividuals and communities o f changes in environmental conditions, whether physical or psychosocial. 3. Encouragement o f the Member States in conducting studies on the con sequences o f environmental change for health and welfare. 4. The cost o f economic growth in relation to its effects on the health of individuals and communities. 5. Environmental health problems in relation to primary health care. 6. The consequences o f environ mental deterioration in achieving the goal o f “ health for all by the year 2000” in the European Region. 7. Definition o f the role o f the European Region in implementing the programme o f the International Drinking- Water Supply and Sanitation Decade. 8. Clearer definition o f the effects o f architecture, housing, human settle ments and land use on the health o f in dividuals, families and communities. 9. Study o f lifestyle as a factor o f environmental protection and health. Organization 10. Identification o f the ministries or organizations in each Member State that have responsibility for environmen tal changes affecting human health, and determination o f the scope o f such responsibility. 12 6 11. Means for promoting discussion and cooperation among intergovernmen tal organizations in relation to environ mental health policy and programmes in the Region. 12. The role to be played by the Regional Office in promoting and stimu lating contacts with and between non governmental organizations in the field of environmental health, in order to optimize the effectiveness o f their work in relation to that o f WHO. 13. Definition o f areas for continued collaboration between WHO headquarters and the Regional Office in the field o f environmental health as the regional programme expands. 14. More precise definition o f the respective responsibilities for environ mental health o f WHO, United Nations agencies, and other intergovernmental organizations. 15. The functions o f the Regional Office health information service in rela tion to environmental health. Budget 1 6. Determination o f the budgetary requirements o f the regional programme and means o f encouraging voluntary contributions for this purpose. Policy 17. Determination o f the health implications o f the Conference on Security and Cooperation in Europe, and formulation o f a plan o f regional action to implement the programmes envisaged in the Final Act o f the Con ference. 1 8. Realistic appraisal o f the situa tion in the Region by representatives in the Regional Committee when making proposals and recommendations, so as to ensure their proper and timely imple mentation. 19. The advisability o f establishing a forum o f environmental health ad visers, with the involvement o f all Mem ber States o f the Region. 127