WORLD HEALTH ORGANIZATION REGIONAL OFFICE FOR SOUTH-EAST ASIA 19th Meeting of Ministers of Health Bandos Island Resort, Maldives, 20-22 August 2001 SEA/HMM/Meet.19/4 Update on Health Problems in the Region
CONTENTS Page 1. INTRODUCTION................................................................................................. 1 2. PROGRESS ........................................................................................................ 1 3. OPPORTUNITIES ............................................................................................... 4 4. DECENTRALIZATION AND LOCAL ACTION..................................................... 4 5. LOCAL ACTION – PEOPLE’S PARTICIPATION ................................................ 5 6. PROPOSED ACTION BY THE HEALTH MINISTERS ........................................ 5 7. CONCLUSION..................................................................................................... 6
SEA/HMM/Meet.19/4 Page 1 1. INTRODUCTION Numerous health problems are directly or indirectly affecting the economic growth and development of the countries of South-East Asia Region of WHO which includes five least developed countries with a population of more than 1.5 billion. Comprising nearly a fourth of the world’s population, the Region has a high proportion of poor people (about 35%). The countries continue to reel under the burden of communicable diseases (estimated 38%). In addition, the problems of noncommunicable diseases, mental health and injuries are increasingly challenging the already overstretched health systems. The vital link between ill health, low productivity and poor development is now understood more than ever before. Leaders and governments are recognizing that good health is the key to development and progress. The debate on issues relating to health and development is now leading to global consensus. Evidence shows that by using cost- effective tools and strategies, it is possible to reverse the adverse impact of existing and emerging threats even in the poorest countries. However, more resources are needed and existing resources have to be utilized more effectively with a focus on outcomes. Interventions require scaling up for widespread application. At the same time, efforts have to be made in accelerating research and development to meet emerging threats and new challenges. 2. PROGRESS In the countries of the SEA Region of WHO, the infant mortality rates are declining and life expectancy is increasing. Guinea-worm disease has been eradicated. This was a historical landmark and a major public health achievement after the eradication of smallpox some 25 years ago. Polio will soon be eradicated, leading to a reduction in the number of disabled persons and a lot of savings in terms of cost of immunizing all children with the polio vaccine. The success in the polio eradication programme is related to the use of simple low- cost oral vaccine, using the strategy of national immunization days combined with effective disease surveillance. In addition, the approach using cross-border collaboration was adopted through intercountry cooperation. The achievements in polio eradication are a tribute to national leadership and partnerships, which mobilized resources on an unprecedented scale. Leprosy is an ancient scourge associated with stigma and poor development. Since the inception of Multi-drug Therapy (MDT), more than 9.5 million cases have been successfully treated with MDT in the Region. This represents about 90% of the cases treated world over. The national elimination targets of prevalence rate of 1/10000 population have been reached in seven countries in the Region. India, Myanmar and Nepal, which had a high burden of leprosy, have successfully reduced the prevalence rates to 3-4/10000. The elimination efforts have to be intensified and accelerated to achieve the national targets by the year 2005. Measles and neonatal tetanus are the other diseases, which can be eliminated. This can be accomplished through vaccination, which is a cost-effective intervention of proven value. SEA/HMM/Meet.19/4 Page 2 The pandemic of HIV/AIDS arrived late in the countries of SEA Region. To date, there have been more than 170000 people reported with AIDS and an estimated 6 million people who are HIV positive in South and SE Asia. Since there is a latent period of 7-10 years between HIV infection and AIDS development, the adverse impact of the disease will increase in the years to come. HIV continues to spread in the Region except in Thailand where the prevalence level in various population groups is declining. In the Region, about 95 % of the problem of HIV/AIDS is in India, Myanmar and Thailand. In the other countries, vulnerability for HIV/AIDS is a matter of serious concern. Control of HIV/AIDS requires political commitment, intersectoral cooperation, partnerships, people’s participation and adequate resources. Urgent scaling up of prevention and care interventions is needed before the HIV/AIDS epidemic reverses the past achievements in health and development. Tuberculosis (TB) is of serious concern since it affects mostly young adults in the most productive period of their life. The direct and indirect costs of TB are estimated at about US$4 billion annually for India alone. Multi-drug resistance and HIV/TB co-infection are emerging as serious concerns. DOTS strategy, recommended by WHO is proven to be effective wherever it has been applied. Remarkable progress has been achieved in the implementation of DOTS strategy in the Region. From a meagre 10% coverage in 1998, the coverage has increased to about 50% now. Maldives has already reached the global targets, while Bhutan, Bangladesh and Sri Lanka are very close to reaching the WHO targets. All the countries propose to reach the targets by 2005. The adverse health and economic effects from malaria are well known. Malaria is of serious concern due to problems of multi-drug resistance of the parasite and insecticide resistance of vectors. P. falciparum is increasing and focal outbreaks are becoming frequent. The problem of malaria has persisted without any significant decline during the last decade with about 3 million reported cases and 21 million estimated cases per year. The vulnerability of the population and retardation of socioeconomic development are strong reasons for effective control of malaria. WHO is spearheading Roll Back Malaria (RBM) initiative for early diagnosis and prompt treatment, widespread use of impregnated bed nets and maximizing people’s participation. Although countries have accepted RBM initiative, scaling up of efforts are urgently needed. Childhood diseases such as diarrhoea, pneumonia, malaria and undernutrition are common, serious and preventable life-threatening problems in young children, which cause high mortality and affect adversely their growth and development. The strategy of Integrated Management of Childhood Illness (IMCI) developed by WHO and partners is a cost-effective approach. The Regional Office has developed tools for use in the community and health outposts so that the strategy can be applied everywhere. This is a successful strategy adopted by all target countries with high infant and child mortality. National scaling up of efforts is required to produce impact. The countries in the Region are going through epidemiological transition. Socioeconomic changes are taking place at a rapid pace. Adoption of unhealthy lifestyles such as tobacco use, decreased physical activity, increased intake of fat and energy-dense foods and increased alcohol consumption is on the rise. Noncommunicable diseases including cancer, diabetes and cardiovascular diseases are becoming a serious concern. According to estimates, these account for about 38% of disease burden and 52% deaths. It is estimated that about 0.5 million deaths occur every year as a result of cancer. The most common cancers affect the lungs, breast and cervix followed by oral cavity, oesophagus and SEA/HMM/Meet.19/4 Page 3 liver. Nearly 40 million people had diabetes mellitus in the countries of the Region in 1998. Tobacco-related health problems and deaths are a challenge. Increasing tobacco use plays a significant role in heightened incidence of cancer, cardiovascular disease and chronic respiratory disorders. The impact of second-hand smoke on non-smokers in the causation of bronchitis, pneumonia and asthma is profound. Injuries and disabilities are increasing the existing burden on health systems. Of every four persons seeking health services, at least one is troubled by mental or neurological disorder or suffering from psychosocial problems or ill-effects of alcohol or drug abuse. There are widespread misconceptions, stigma and discrimination associated with mental ill health. While undernutrition is common amongst the poor and the marginalized, obesity is emerging as a serious problem of people in higher strata in the society. To improve health (including mental health), individuals have to be enabled to change their lifestyles but actions must also be directed at improving the social and living conditions, which interact to produce and maintain these lifestyles. Physical activity has to be woven into the culture and lifestyle of majority of people for widespread adoption. This will help reduce stress, anxiety, high blood pressure and improved psychological well being. Promoting healthy lifestyles demands intensive education to promote a favourable change in individual and social perception of self-responsibility for health and at the same time emphasizing the tremendous health and economic benefits of healthy lifestyles. For this to succeed, illiteracy and poverty, which influence lifestyles, must be eliminated. Strong policy and legislative measures to address risk factors and advocacy are needed. Increased investment in health- promoting schools activities which focus on life skills education is a critical entry point for future health of the population. Focus on workers, occupational groups is a good entry point. The health of the elderly should also be a priority entry point for increased investment in managing and controlling most of the life-threatening chronic noncommunicable diseases. The powerful link between health problems and poverty cannot be broken by health sector alone. These must be identified as priority by all ministries, local self-governments, civil society and the people. It has to be an all out war. The battle against ill health and poverty must be fought by according social issues such as education and health a high priority (by providing safe water and sanitation, primary education for all, safe environment and basic health care). Health must be viewed in the development paradigm as an essential concern for all the sectors. Discrimination on the basis of gender is common in many countries of SE Region. The persistent high maternal death rates and the problem of low birth weight have continued to haunt us. There has been little progress during the past couple of decades. The strategy to tackle these problems – through integrated management of pregnancy and childbirth (IMPAC) is available. It is awaiting implementation. The rapid pace of globalization has brought numerous challenges. The risk of spread of infectious diseases is increasing as a result of increased and rapid travel, migration and displacement of people. During the last two years more than 40 epidemics were brought to attention in the Region. Trade and economic implications resulting from epidemics are well known. The outbreak of plague in India lead to huge economic losses. Food safety concerns are becoming prominent. Advertisement and widespread sharing of information is changing lifestyles negatively in the form of increased use of tobacco, and alcohol, and consumption of unhealthy foods. This is changing the disease profile rapidly. Although globalization is SEA/HMM/Meet.19/4 Page 4 increasing the expectations of the people, they are not able to use the services because of economic and other constraints, leading to frustration and poor utilization of available services. 3. OPPORTUNITIES Globalization has helped in developing consensus on priority health concerns and establishing targets for tackling them. Liberalization, economic reforms, trade agreements and democratization have created new vistas for international cooperation. The unprecedented progress made in information technology has brought people closer, through e-mail, computer, cell phones, and satellite TV. Information technology has opened up excellent opportunities to inform and involve people. In order to tackle priority health concerns and accelerate national socioeconomic development, resources (both human and financial) are needed on a sustained basis. The political climate for mobilization of new external resources is excellent at present, as evidenced from the various commitments made at the G-8, Okinawa, and other forums. The special session of the UN General Assembly on HIV/AIDS held in New York in June 2001 called upon the countries to wage an all out war against the HIV/AIDS pandemic. A global HIV/AIDS and health fund is proposed to be set up. While the case of Sub- Saharan Africa merits full support, Asia’s case is strong because of the magnitude, poverty and vulnerability of its population. Asian solidarity can go a long way in convincing the global community of Asia’s case for deployment of resources to fight HIV/AIDS and other problems like malaria, TB and childhood diseases for which cost- effective interventions are available. Individual and collective leadership from countries in Asia should stake evidence-based claim for mobilizing the required resources to meet the challenge. At the same time countries must demonstrate the capacity to absorb the funds with demonstration of the expected outcomes. National policy should place health high on the national development agenda by recognizing the vital link between health and development. The policy should provide for resources on a sustained basis with a wider base, with health explicitly expressed as a concern of many ministries and not the Ministry of Health alone. For effective control of priority health problems, for which cost-effective, evidence-based interventions are available, the national policy should promote nationwide implementation. The poor, vulnerable and the marginalized should be given priority while formulating national policy. For priority health problems, accessibility, availability and affordability of medicines, commodities and knowledge should be ensured. The national policy needs to widen the distribution of resources by adopting an increasingly regulatory and stewardship role for the government. Decentralization deserves serious consideration in the national policy to enhance participation by the local governments and the people for ensuring local relevance. Strengthening of the health system and widening of the knowledge base have to be an integral part of the policy. 4. DECENTRALIZATION AND LOCAL ACTION Decentralization and local action are becoming an imperative for successful countrywide implementation of major public health interventions. This is especially relevant to large countries in the Region. It provides an excellent opportunity for provinces and districts to take SEA/HMM/Meet.19/4 Page 5 on the responsibility for the health of the people. In addition to national and international resources, decentralization can contribute local resources for public health good. Decentralization will encourage local adaptation based on local evidence before implementation of interventions. This can maximize people’s decision-making and participation, since local self-governments have the responsibility for implementation. Effective decentralization can also enhance the participation of private providers and civil society. For the scaling up of efforts, strengthening of health system is a pre-requisite. Capacity in the districts and provinces has to be enhanced to collect, analyze and use health information for planning, implementation and monitoring. Private sector and civil society have to be an integral part of health system strengthening provided they keep the public health approach as the priority and do not exploit the poor people. An effective health system can be used to bridge the existing health divide. It can remove barriers in the provision of essential medicines, knowledge, and commodities. 5. LOCAL ACTION – PEOPLE’S PARTICIPATION For reduction of excess mortality, controlling the risk factors and major determinants of health, the enormous potential of the people must be recognized. People can be effectively mobilized by local action in the decentralized system. Paramedics and health volunteers can be mobilized to act as a vital interface between health system and the people. They should demystify technology and information for wide adoption and acceptance by the people in the local cultural context. People’s power can be harnessed to rationalize appropriate and timely utilization of health care from health system, enhance compliance to treatment, adoption of favourable lifestyle measures including safe sex, ensuring availability of basic water and sanitation, food safety and participation in vaccination programmes. People’s participation is vital for success in the control of social evils like alcohol, drug abuse, violence, tobacco use and gender discrimination. 6. PROPOSED ACTION BY THE HEALTH MINISTERS (1) The ministers of health of the countries of the Region could play a critical role in convincing the Heads of Governments of their countries to stake their claim to avail benefits from the Global HIV/AIDS and Health Fund. Asian solidarity would help in maximizing our share from the Fund. (2) Focus should be maintained on priority health problems, i.e., HIV/AIDS, TB, malaria, and childhood illnesses, through cost-effective, evidence-based interventions (3) Intercountry cooperation with a focus on disease surveillance (communicable, noncommunicable) and cross-border collaboration needs to be strengthened. (4) Commitment to strengthen health systems to increase accessibility and affordability of medicines, commodities and knowledge should be sustained as a response to tackle priority health problems. SEA/HMM/Meet.19/4 Page 6 (5) Broad-based partnerships at all levels (including private sector and NGOs) for promoting widespread local action should be encouraged. 7. CONCLUSION It is possible to solve many priority health problems in the countries of the South-East Asia Region with the knowledge and technology that is available and by using cost-effective, evidence-based approaches, provided there is commitment and adequate resources, which are used in a focused manner. The pace of implementation has to be rapidly accelerated and health has to be a people’s programme and a priority concern for other sectors. This is the imperative need of the hour to launch a frontal attack on poverty. The windows of opportunity are closing and, therefore, there is no room for complacency. The current political climate and global consensus should be fully utilized in bringing about a rapid change in health in the countries of South-East Asia. This requires effective articulation of disease burden and risk factors, the potential socioeconomic impact of continued ill health for making a difference through scaling up of effective and rational disease control interventions. Let us take action now before it is too late!