SEA-RDO-1 Distribution: General
Summaries of Lunchtime Seminars (2010-2011)
Food for Thought:
Regional Office for South-East Asia
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Contents Page Abbreviations .........................................................................................................v From GNP to GNH: How necessary is this shift?.................................................... 1 Tuberculosis and poverty in the South-East Asia Region......................................... 5 Strategic health communication – evolution and management .............................. 8 Financing for universal coverage in public health................................................. 12 Benefits of opioid substitution therapy for drug users........................................... 16 Integrating the Tobacco-Free Initiative into noncommunicable diseases programmes: Experiences from the SEA Region................................................... 18 Risk assessment for outbreaks .............................................................................. 22 Rational use of drugs ........................................................................................... 26 “One health” for avian influenza – How it came about and where we are now ......................................................................................................... 31 Routine immunization in the SEA Region: Synergizing with primary health care .......................................................................................................... 35 Evidence-based policy-making: the challenge of making difficult operational decisions........................................................................................... 39 Challenges to community participation in clinical trials: Lessons from the field ...................................................................................................... 47 Ecological sanitation and health........................................................................... 50 Innovative training of human resources for health: A focus on staff retention: The Step-Ladder Curriculum, School of Health Sciences, University of Philippines...................................................................................... 54 Increasing health literacy using health learning materials...................................... 59
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Food for Thought: Summaries of Lunchtime Seminars (2010-2011)
Empowerment for self-care ................................................................................. 63 Obesity: Confronting a new epidemic in the SEA Region..................................... 66 Integrated disease surveillance and data management system, Maldives .............. 69 Childhood obesity ............................................................................................... 71 Establishing an injury surveillance system in Egypt: Challenges and successes....... 76 Pulse polio campaigns: Adverse events following immunization........................... 79 Collaborative planning in WHO: Breaking rigid boundaries................................. 83 Yaws elimination: A useful investment................................................................. 87 Keeping health facilities safe from disasters.......................................................... 91 Life after WHO: Preparing for a peaceful retirement ........................................... 95 WHO’s work in Timor-Leste: Past, present and future......................................... 99 Returning to the fold: Assisting the recovery of drug users back into mainstream society............................................................................................ 104 Adolescent health promotion – engaging with parents ...................................... 107 Life in the country office: Baptism by fire - Learning the hard way..................... 114 To clinical governance through clinical audit ..................................................... 118 Waist and hip circumferences as risk factors ...................................................... 124 Risk management .............................................................................................. 127
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Abbreviations AI AIDS BCC BMI CBA CME DHS DRR FAO FCTC GNH GNP HIV HTA IDD IEC IHR IMR MCH MDG MOH NCD NGO NTD OIE OST PH PHC RBM RCT avian influenza acquired immune deficiency syndrome behaviour change and communication basal metabolic index or body mass index cost-benefit analysis continuing medical education demographic and health survey disaster risk reduction Food and Agriculture Organization Framework Convention on Tobacco Control Gross National Happiness Gross National Product human immunodeficiency virus health technology assessment iodine deficiency disorder information, education and communication International Health Regulations infant mortality rate maternal and child health Millennium Development Goal Ministry of Health noncommunicable disease nongovernmental organization neural tube defect World Organization for Animal Health opioid substitution therapy public health primary health care Roll Back Malaria randomized controlled trial
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Food for Thought: Summaries of Lunchtime Seminars (2010-2011)
RRP RUM SDE SEA SEARO SHS SO TB TFI UNFPA UNICEF UPCM VAT WC WHO WHR WR
risk reduction plan rational use of medicines Sustainable Development and Healthy Environments South-East Asia South-East Asia Regional Office School of Health Sciences Strategic Objectives tuberculosis Tobacco-Free Initiative United Nations Population Fund United Nations Children’s Fund University of Philippines College of Medicine visceral abdominal tissue waist circumference World Health Organization waist-to-hip ratio WHO Representative
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From GNP to GNH: How necessary is this shift?1 Gross National Product (GNP) is the broad indictor that measures economic development. However, it is now generally understood that this is not a measure of social equity. Given that economic development is the direction all nations are aspiring towards, and that this is now seen as one of major contributors to global warming and resulting climate change, a life-as-usual world will not secure a sustainable future for coming generations. The economic behemoth is bound to founder in the not-so-distant future if our mindless production and growth policies continue unabated. And human health will suffer. Bhutan is now famous for an alternative paradigm termed Gross National Happiness (GNH). This is a major shift in perspective to growthbased development and modernization, given that the purpose of life is to serve each other towards peace and harmony on earth. This can be achieved through having for ourselves happiness and wellbeing. That economic wealth and materialistic progress will not give us happiness is patently known. Our lives are full of examples that attest to this. The stress of modern living drives up the prevalence of diabetes, cardiovascular diseases, cancers and asthma, and various other morbidities, both newly named and nameless, abound. New emerging infections take a toll on our populations in untreatable diseases, death and fear. Politically and culturally induced conflicts kill and maim on the one side, even as we promote disease protection and prevention through magic bullets and other technological innovations on the other. Yet we continue to amass wealth in quantities that we don’t even use. In our current victimized state, the overambitious ego drives us to want ever more just so it can survive. We are the prisoner. Curiously, the economic development paradigm that is supposed to liberate us keeps us a prisoner of the mind instead. With more wealth than we can use in our lifetime and with none of it available for us to take it with us when we do depart, it just seems an experience in futility. Even purely from an economic point of view, a range of international surveys show that beyond an annual income level of US$ 15 000 per head,
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Dr Abdul-Sattar Yoosuf, Assistant Regional Director, WHO-SEARO August 2010 1
Food for Thought: Summaries of Lunchtime Seminars (2010-2011)
life satisfaction barely changes between countries with quite different levels of GDP (2). Thus there appears to be a clear point beyond which extra income does not deliver extra wellbeing. So how can we stop this seemingly inexorable drive towards the precipice of life’s destruction? The only way is to adopt a shift of paradigm for development. The GNH is one such possibility. Cynics and pessimists and die-hard consumerists will always disagree, even when the waters will threaten to consume us in a watery grave. But we need to start thinking of possibilities to get out of this morass if we want our progeny to survive on this earth. In an argument for another paradigm shift, it is worthwhile to look at the principles behind the GNH and the GDP paradigms to see how these relate to the survival-related realities of today. The GNP is the child of the industrial revolution where the measure of output was the litmus test of productivity and development. And so our whole life was based on that principle of want and gain and greed. The more we had, the better we seemed we were, and so we worked to get still more. And so life continued –our schools nurtured us to be successful in life, to get out of school and get a job to make money and be better off and thus better than the other person. So the three Rs of the modern-day education system (reading, writing and ‘rithmatic) became the leading edge of our classroom lessons. This was good for the industrializing world, and has been the benchmark now for the whole world that is running after the same concept of development in the postcolonial age. The values that went with this system of education were also the plastic attitudes of the personality ethic that guided us to be good with our customers rather than with our community. Leaving school and getting a job was the goal here. The GNH in contrast is about love and social harmony. The new schooling thus is recommended to change from the three Rs to the four Hs3. The Hs stand for head, hand, heart and home. The nurturing of the head here no longer means just a repertoire of banked information, but using this information for creativity and innovation. The hand is for learning to do things with our own hands, and learning life skills that will make us survive on earth even without too much money or hired help. The heart is 2 3
Ecology and Growth, by Nick Robins, in Resurgence, July/August 2010, No.261 Richard Louv
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for nurturing love and caring and compassion, and the home is for placing all the above in the context of the practice of everyday life. The schools of tomorrow need this approach for the society of tomorrow to be more caring and compassionate and thus learn to be happy, content and conflictfree. The search for a definition of development away from the present growth-dependent ideas will need a complete de-linking of our mind to the multiple possibilities of how happiness and wellbeing can be achieved. In particular, it will not be possible to re-conceptualize equity without recovering the diversity of prosperity. Linking the desire for equity to economic growth has been the conceptual cornerstone of the development age, whereas now the linking of equity must be to community and culturebased notions of wellbeing in the post-developmental age.4 Dismantling the culture of consumerism will require major curtailment of advertising to stall the greed-generation process, or the establishment of a 21-hour work-week that will break the cycle of work and spending and liberate that most nonrenewable of resources – time, for family and friends and sheer enjoyment.5
Discussion The presentation was followed by a rich discussion. Initially, GNH was seen as nebulous concept that defies real definition in tangible terms. But discussion revealed that definitions can also be subjectively framed. In the case of GNH, certain criteria that are seen as contributing to happiness, such as having meaningful social relationships, a safe environment, good governance all can contribute to being happy. But it was also felt that even with these kinds of enabling conditions for happiness, the context of a person’s mental make-up, culture, etc. may make varying contributions to the strength of the joy or happiness one perceives along each of these variables. Bhutan’s example of qualifying development through happiness indicators was an attempt at being visionary towards the potential pitfalls of growth-based development, as we increasingly witness by the encroaching issues of global conflict, corruption, and disruptive climate change, both economic and environmental. GNH would bring out the more affective
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Dismantling development, by Wolgang Sachs, Resurgence, July/August, 2010, No261 The Spirit Level: why more equal societies almost always do better, by Richard Wilkinson and Kate Pickett. 2009. 3
Food for Thought: Summaries of Lunchtime Seminars (2010-2011)
nature of society than catering to efficiency and effectiveness of the individual as put forth by the growth model. Another point was the acceptance that money will not bring happiness, but that a certain level of wealth is necessary to be happy – those that cater at least to the basic needs of food, clothing, shelter, schooling and job security that will ensure a flow of disposable income. Happiness was also thought to be in the mind of the beholder. Pleasure is from material things and so prone to wear out soon and the seeker seeks more and more. This is different to happiness that can be more lasting and doesn’t have a material basis. Pleasure is linked to ego so the modern person’s ego is fueled by materialism that will not provide happiness that is lasting; ill health may also set in. The act of “giving” is linked to happiness, whereas “taking” is related to pleasure. So GNH strives to keep that sharing concept alive. The coexistence of want and giving is difficult to balance. But a balance is needed for future generations to survive. Unlimited growth is apocalyptic. We also discussed happiness in the office environment. How can we be happier at work? There is always scope to being happier in any work environment. In the case of the South-East Asia Regional Office (SEARO), we agreed to first take a happiness interview. Those attending this session would contribute to framing a questionnaire to assess this initially. Based on its acceptability, we could have an in-house survey, and then see how we can bring about a happier environment at SEARO. The Regional Director’s concern for promoting a positive psychosocial environment at SEARO was mentioned. The strength of the organizational bureaucracy, quality of internal communication, perception of belongingness and job satisfaction, etc. are concerns that may, among others, be included. Some of us felt that we should cause the change ourselves by following the 4Hs (head, heart, hands and home) paradigm at the office and in our homes. If we can improve the situation at the office, we would have contributed not only to our own happiness but also the happiness of all members of this community.
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Tuberculosis and poverty in the South-East Asia Region6 Globally, one billion people – one sixth of humanity – live on less than one dollar a day. In our cities, two billion people live in live in slums and difficult circumstances of lodging and terrain. Environmental conditions, overcrowding, poor ventilation and poor nutrition characterize the life of slums everywhere. Affliction with tuberculosis (TB) can cause job loss or time away from work and affects social relationships also. Presently, 95% of TB-related deaths occur in the South-East Asia (SEA) Region. Poverty is both a cause and consequence of TB. When a poor person has TB, he/she spends his money and time to get well. And during this period, he loses his livelihood because of having to spend excessive time away from work, resulting in less money earned and less spent on food and nutrition. Consequently, nutritional deficiency further erodes health, and increases the potential for re-infection. Other opportunistic infections may then invade the body. This doesn’t have to be nutritional deficiency. Other diseases also can bring on TB. Acquired immune deficiency syndrome (AIDS) is a classic example of a disease that invites TB into an immunecompromised body. The barriers to effectively addressing the issues of TB of the poor are several and severe in many of our countries. On the side of treatment, access is of paramount difficulty. Finding the poor and providing treatment poses both cultural and logistical concerns for TB programmes. It requires persuasion and awareness creation. But this may not be enough. The mere physical logistics of getting to the places where the patient resides is often a major impediment. The determinants of TB are both biological and environmental. While the role of environment is generally understood, it is difficult to mainstream this into TB programme actions. This is because of the non-health sector nature of the determinants and thus the health sector’s traditionally reticent attitude in dealing with others. Housing, overcrowding, social habits of sanitation and personal hygiene with respect to respiratory disease
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Dr Khurshid Alam Hyder, Regional Adviser- Tuberculosis Control, WHO-/SEARO 12 August 2010 5
Food for Thought: Summaries of Lunchtime Seminars (2010-2011)
prevention, and nutrition and food security are both beyond the authority and purview of the health sector and also often alien to the communication and negotiation skill base of the health sector. The key to getting other sectors to pitch in is to work assiduously with the policy-makers and programme-managers of these sectors to instil the necessity of involvement. This is major shift in the working of health sector staff, yet a necessary one for succeeding in TB control. In seeking solutions, we must focus on good poverty analysis to identify the distribution of this population group within our communities so that we can make focused input to future programme implementation. We must address the barriers mentioned above with innovative solutions to access the unreached poor and get other development sectors involved in a cooperative programme on TB control – with the private medical sector also effectively brought into this engagement. Programmatically, the poor need to be focused on, not merely for treatment with DOTS, but also with attempts to address related social determinants such as housing, personal hygiene, nutrition, livelihood, and food security. This will require health sectors to move beyond their regular schemes of action. So far there has been low emphasis on the above aspects in the ongoing TB programmes in most of our countries. Perhaps a stronger intersectoral emphasis needs to be made in the planning of TB programmes, and more regular analysis of programme progress would need to be carried out with more enthusiasm and emphasis on this aspect. Such assessments will contribute to future iterations of programme cycles that will make for success. This is also a way to assess the effectiveness of how the social determinants of TB are being taken into account within an integrated programme structure. The medical practitioners must also be brought into this fold of an integrated programme concept for future success.
Discussion on the presentation (1) The necessity to promote the integrated approach. There is inadequate effort on this aspect as the health sector is not geared to working in partnership with others. National health authorities and even World Health Organization (WHO) need to work more holistically. The example of the WHO programme on drugs harm reduction working with the police was cited as a success example.
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(2)
Community empowerment is necessary so that the holistic nature of the effort can be practiced in a controlled setting. For example, the health settings idea can be used, and the TB programme needs to reach out to the other programmes within WHO to capitalize on mutual strengths of those programmes. Actively seeking a common objective such as the Millennium Development Goals (MDGs) and Social Determinants of Health (SDH) in a programmatically integrated way will also help the streamlining process and will be an example to countries too. We need to put the economic argument to countries, reflecting on how much money countries can save by using an integrated approach. This may help policy makers and politicians pay some productive attention. But this would need more health economists engaged in the work of national health sectors; presently there is a very sparse commodity of health staffing in our health infrastructure. Having other disciplines incorporated into the fold of health-sector expertise, and learning to work effectively with other sectors will be truly a productive sea change for the future of the health sector, and the effectiveness of our programmes. Donors also need to be shown good examples of intersectoral programmes and multi-disciplinary programmes so that they maybe inspired to direct their policy away from their present insistence of funding only the vertical type of health investments.
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Food for Thought: Summaries of Lunchtime Seminars (2010-2011)
Strategic health communication – Evolution and management7 Communication is to generate demand. The idea of communication as promotion began in the agricultural sector in the early days. This was done as agricultural extension work. Later, public health work used that approach also, promoting health though community-based or visiting health extension workers. This was in the 1960s, and was basically a one-sided approach to communication, to make the recipient aware of what was available and what could be done about improving their condition (crop production or human health, respectively). This approach was characterized by posters and pamphlets and one-way talks. Then in the late 1960s and 1970s came the idea of IEC – the information-education-communication model promoted by the Harvard and Johns Hopkins groups. Here too the communication component was weak in that it was not very evidence-based. Here was also the birth of “branding”. Branding gave symbolism and provided the target masses a mental pop-up from the graphic design of a logo or picture. Thus, the “Red Triangle” signified India’s family planning programme. The “Green Umbrella” was that of the Bangladesh family planning programme. But while this branding provided a mass view of the programme and perhaps an idea of the content, it still did not move the behaviour-change dimension. Because IEC programme were primarily inefficient and government-driven, acceptance was low. The marginal show on behaviour change was often because of the low level of services provided to stimulate that behaviour change. The IEC approach also brought in the idea of the “campaign”, where mass mobilization was the objective and thus the reach and exposure focus was the main effort. It could not, however, effectively push the understanding of what needed to be done by the people and thus could not effect changes in behaviour. After this came a new age in communication associated with the work in human immunodeficiency virus (HIV) and AIDS through coalitions and alliances. Here, there were greater reach and behaviour change through risk-factor analyses and target-specific analyses. There came into this also 7
Mr Deepak Gupta, Temporary International Professional – Communication, CDS/SEARO 8 September 2010
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Food for Thought: Summaries of Lunchtime Seminars (2010-2011)
the human rights issues and thus the push towards more socially inclusive programmes and relevant research as integral aspects of the programme. This new strategic/development communication model operationalized through a Behaviour change and communication (BCC) approach set a new milestone for public health promotion. Other programmes such as for maternal and child health (MCH) also took this approach of risk factor analyses and focus groups for social mobilization. Four key defining aspects of this process are that communication is results-driven, socially inclusive and focused, client- and service-driven, and research-oriented. The programmes are directed at the individual level for behaviour change, also at the family level, at the community level, and at the social level, each having its own specific messages and communication objectives, well defined. This BCC approach had islands of success in some countries of the SEA Region, e.g. the Youth Café programme in Maldives, and the Bangladesh programme on MCH. The limiting factor for replication and scale-up of this success has been the reticence of the health sector, which still prefers to use the IEC process of posters, charts, pamphlets etc. for health promotion. A set of several issues underlie this lack of application by national health sectors: lack of resources, lack of awareness of the usefulness of this strategic approach, lack of technical skills to apply the process, and the nonexistence or non-functionality of the departments that house these programmes. For future success to reap the gains from health promotion, there needs to be a paradigm shift towards this BCC approach and to move further toward replication of successes by ministries of health.
Discussions (1) A major weakness of our communications programmes is the lack of well-defined communication objectives. There is also the lack of communication research to document outcomes. This area is very weak in our programmes. Most of our public health (PH) programmes don’t have a coherent communications component. Presently in most of our
(2)
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Food for Thought: Summaries of Lunchtime Seminars (2010-2011)
countries, mere information dissemination appears to be the major target of our promotional strategies. (3) There needs to be a better method mix for increased success of our health promotion programmes. These need to be tailormade communications that will fit respective programmes. The importance of counselling was noted and much more needs to be done. Counselling is about listening and sharing and not telling or prescribing. Bad news spreads fast whereas good news does not fan out that fast. It was felt that the media need to be taken on board and made our friend, and they should be fed with information that they can use quickly when there is a newsworthy situation. If the media don’t already have such information at hand, they will report what will carry best as news. And often these reports can be detrimental to health programmes, as in cases of polio vaccination cases or mass drug administration where unintended reactions can happen and these negatives are reported rather than the good that the programme does for the community. The question was raised of when BCC was best deployable in programme promotion. HIV programmes and helping to rationalize differing viewpoints between the Commercial Sex Workers (CSW) and the client on the issue of compulsory condom use, or coaxing the drug user in a harm reduction programme to use new needles in the face of the police who would take this as abetting a criminal act, are two cases cited as examples for when BCC approach would come in very useful. With the small island of successes as the basis, how can we expand this success further?. The consensus was that persistent and sustained advocacy with the government is the best approach. Nongovernmental organizations (NGOs) alone cannot accomplish this scale-up done as it would be the government officials and politicians who have to take this up as policy for such investments to be made available. It was also noted that the government officials’ job turnover will be a challenge. Continuous orientation would be needed to keep the knowledge and skills base from dwindling. Advocacy with the government must not be just event-based but comprehensive and sustained over time.
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Food for Thought: Summaries of Lunchtime Seminars (2010-2011)
(8)
Where IEC or BCC are soft interventions, the outcomes would be difficult to measure. But it was agreed that there could be good indicators crafted that could measure outputs and outcomes of programmes, especially defined at the communication programme design stage. Also, communication must be given much more priority in our health programmes. Our health programmes are fraught with too many programmespecific terminologies. For example the dengue, HIV, TB programmes have their own terms for their specific advocacy, such as IEC, BCC, COMBI, etc. We can actually call for a comprehensive umbrella title such as “Strategic Health Communication” for all our WHO programmes. This will take care of both the “mediated” communication aspects as well as the “personal” communication aspects –- the former being the mass communication type that calls for large social awareness, and the latter focusing on the human touch through counselling and behaviour change (empowerment skills).
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Food for Thought: Summaries of Lunchtime Seminars (2010-2011)
Financing for universal coverage in public health8 In our day-to-day discussion of health systems performance, the real meaning of the words “access” and “coverage” has been generally masked by ambiguity. Why the confusion? What is the difference? Access denotes a sense of intended equality as, for example, to aspire for 100% access which denotes the sense of everyone having a part of what is being available. But coverage denotes what is actually done programmatically and so with it bringing a sense of lack, deprivation, or inequity. Though we aspire to greater coverage, there always appears to be, for various reasons, inadequacy of reaching the unreached, or the mention of the poor and marginalized which never seem to be bridged. In our health systems lexicon, these are not the only confusing terms used interchangeably. Others are “carry-over” vs “carry-forward”, where carry-over usually denotes the channelling of funds to the future due to bad implementation performance, whereas carry-forward may be due to the arrival of new funds, or donor priorities that necessitate carrying forward funds to a future time; “primary health care” (PHC) vs “primary care”; and the interchangeably used terms relating to PHC, such as principle, pillar, strategy and approach. In the context of financing for universal coverage, coverage is mostly related to health insurance to reduce the proportion of direct payment or out-of-pocket expenditures. The principle adopted in health insurance is pre-payment and risk pooling. A large pool is needed (i.e. law of big numbers) to allow cross-subsidization from the rich to the poor and from the healthy to the sick. If well accessed by the poor, this is a way to avoid the catastrophic expenditures that the poor would be otherwise subjected to. Catastrophic expenditure is generally defined as at least 40% of a person’s disposable income (income minus food expenditure). Health insurance is of several types: tax-based, social health insurance, community-based and private health insurance. If we don’t mince words, health insurance really is a medical insurance, because most of the resources go for paying curative and rehabilitative costs. But public health insurance also, when available to all, can be a difficult thing to really manage because of our lack of frugality in its use. No one would seem to
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Dr Nyoman Kumara Rai, Adviser to the Regional Director, WHO-SEARO 20 January 2011
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care because the government is usually providing public health (health promotion and disease prevention) for free, so we would not be paying for it. Public health as it is, is seen as a public good, and so only the government will take it up. The private sector would not be interested in it, except for perhaps some philanthropic reason. A good example of a public good, for clarity of the concept, is the metaphor of a lighthouse. The lighthouse on the coast or in treacherous waters is something available for everyone to use with no cost to the consumer. Similarly, the ambient air we breathe is also a public good – available to everyone – but by contrast, the air-conditioned breathing environment is a private good, only available to those who can pay for that comfort. A public good thus has no rival, as there is no competition created for it. Thus one can make use of it as much as one wants without paying for it. An individual with good health awareness can make use of a public good with little cost if at all. So the government is left to clean up the air, or make our environment safe to live in, while the private sector will gladly take care of the curative and rehabilitative aspects of health because there is a private benefit. Unfortunately, the budgets of most health ministries are skewed towards medical care, even though their plans are made along the dictates of PHC, with improper allocations that lead to allocative inefficiency and for over-sophisticated treatment and medical technology, resulting in technical inefficiency. This is the case even in Thailand, where a lot of effort has gone toward providing universal coverage through the introduction of the 30 Baht scheme (that is now abolished), and other arrangements have made the populace more financially irresponsible in the seeking of health care, towards a viewpoint that what is availed must be taken, and also that health means medical. The anecdote is told of the person who asked the doctor “to cure his teeth” as opposed to being inclined to take preventive measures to protect his teeth. Thailand despite, almost achieving universal coverage, still faces some public health problems. Notable among these is iodine deficiency disorder (IDD). What is to be done for the future? This may be in the form of truly working on health sector reform based on PHC, with a good understanding of what this revival of PHC means; promoting equitable access by being aware of the real priorities in our health systems, and focusing on putting the right amount of resources there; the building of a health system that is people-centered, with community involvement, and intersectoral collaboration. Health insurance will not be a panacea for the health-related ills of our society. Financing public health in wise ways can get us out of the woods. We have to understand and assess well the unserved quantum of 13
Food for Thought: Summaries of Lunchtime Seminars (2010-2011)
society by identifying the difference between what we gauge as access and our measure of coverage. Discussions that followed were exciting and worthy of note: The feeling was that we should be starker in our mention of health insurance to be deprived-centered and not just marginalized. A bigger gamut of the needy would thus be captured. Funding for coverage derived from general taxation was a good thing some time ago, but with present cost escalations, this may not be sufficient. The prevention of moral hazard of the health service providers (defined as the irresponsible use of the health insurance funds) was a major thing to aspire for while providing the most equitable benefits. The various methods of purchasing by the health insurance – through fee for service, co-payments, deductibles, capitation, diagnosis related Groups (DRG), reimbursement and, of late, performance-based, were all currently in use. The methods chosen must be very context-specific, and each has its own pros and cons. There were views expressed on the need to find more homegrown or hybrid approaches that may take into consideration local values and capacities better than imported models can. The weak governance of our health systems needs greater focus; no amount of insurance will give us health unless it is provided along with other public health measures. Often the benefits of government health expenditures go to the middle class and hardly to the poor. Governments now seem to have a short-term perspective with immediate and visible monuments established that are concrete and visible in the short term rather than what would be good for the future and sustainable. The World Wide Web is a breakthrough in providing information to the public. With such access, the future of a more health-aware society is assured. It will transform the way health care is provided and sought.
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Food for Thought: Summaries of Lunchtime Seminars (2010-2011)
In Thailand too, with government subsidizing, a regressive approach is emerging in that provider institutions may want to cut costs and save the disbursements received from the insurance system in such a way that the patient does not get the full benefit of what is due. In the past, the inefficiencies of the government’s health-care system with its long waiting times resulted in reduced cost by putting off many who did not want to go through that hassle – even the poor. But now with private systems, when there is copayment, etc. the poor may not be getting the care they should receive. In capitation and DRG schemes, doctors, with a cost-saving business mindset, are reluctant to recommend further care, because that would be additional cost to the provider. With different types of insurance systems in one country, there is bound to be fragmentation of the risk-pooling system, resulting in higher transaction costs and inefficiency. There is a need to establish a community-based, universal coverage method that is home-grown, or a hybrid method that is good for the context in question. In general, due to the small size of community-based health insurance, sustainability is at risk. We need to do local-level equity studies routinely alongside or as part of various household survey such as Demographic and Health Survey (DHS), Family Life Survey or socioeconomic surveys that are already being conducted regularly. Ministries of health and finance and social security should share this responsibility rather than the Ministry of Health (MOH) alone. Government health spending on public health needs drastic changes to accommodate health-system reforms based on PHC and within the recommendations of the Paris Declaration on donor effectiveness financing through better alignment and harmonization.
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Food for Thought: Summaries of Lunchtime Seminars (2010-2011)
Benefits of opioid substitution therapy for drug users9 A documentary film from the Ukraine called “Returning Home” was screened followed by a discussion. The focus of the film is to widen access to opioid substitution therapy (OST) and provide additional social and medical services for female injecting drug users in Ukraine. The film explores the issues of (1) How and why does a woman become a drug addict? (2) In what way does her life change? (3) How to overcome this dependence from drugs? (4) How to learn to be happy again? The 20minute film outlines the life, problems and needs of a young woman with a child, who has become an OST client. The film shows the positive influence of the OST programme on the quality of life of the main character and her child; and it contains comments of the leading Ukrainian experts, physicians and OST programme clients regarding the effectiveness of OST. The film raised a number of issues among the viewers. It was highlighted that OST involves replacing the illicit drug a drug user is taking with another similar-acting drug. A key difference is that OST is prescribed by a doctor, and that OST does not provide the “high” that is experienced by consumption of illicit drugs. It was emphasized that there is no euphoric effect with substitution drugs as the pharmaceutical effects are markedly different. A key focus of OST is to address physical dependency and reduce the various adverse health, social and economic consequences that arise from the use of illicit drugs. OST has its best effect when it is prescribed for at least 12 months before the client is weaned off the medicine. For some drug users OST can be prescribed for 1-10 years or even longer depending on the needs of the drug user. Problematic drug dependency is a chronic relapsing medical condition and as result, it is more beneficial to have a drug user stabilized on a prescribed medicine than using unsafe drugs that are commonly found on the streets. The duration of time for taking OST is best determined between the doctor and the drug user. OST can only be beneficial to those that have a dependency on opioids and will be of no value for those that are dependent upon other drugs such as cocaine, amphetamine-type substances or cannabis. Not all drug users are ready to commence OST as they may not consider their drug use as a problem. In
9
Dr Gary Reid, Technical Officer, Harm Reduction, HIV/AIDS, WHO-SEARO 3 February 2011
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these circumstances it is important that other harm reduction measures such as provision of clean injecting equipment, information and communication messages and materials about various drugs and their effects and of ways to minimize the harms of consuming drugs are made available. Participants in the session were informed of the two most commonly prescribed treatments in the area of OST, which are methadone and buprenorphine. Methadone, first developed in the mid-1960s, is the most widely researched in the OST family of drugs. It is mainly supplied as syrup. Buprenorphine gained wide popularity in many countries in the early 1990s and is prescribed as a tablet. It is taken sub-lingual (under the tongue). Overall, methadone is the more widely used OST in the Asia region. In South-East Asia OST is gaining greater popularity but its use is still limited: fewer than 5% of all injecting drug users in the region have access to OST. Increased advocacy efforts to inform and assist governments in the Asia region are essential to ensure a scale-up of OST takes place.
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Integrating the Tobacco-Free Initiative into noncommunicable diseases programmes: Experiences from the SEA Region10 Collaboration among programmes in SEARO is a policy direction the RD frequently alludes to for greater programme efficiency, from both financial and time considerations. There are opportunities for working together within the wide array of programmes we have in our organization. The presentation focused mainly on the collaboration of the Tobacco Free Initiative (TFI) with the Noncommunicable disease (NCD) programme unit. Clearly, heart disease, diabetes, cancer, and chronic obstructive pulmonary disease (COPD) are related to tobacco use, unhealthy diets, physical inactivity and the harmful use of alcohol. And thus, tobacco was a stark point of commonality of interest of both programmes. But clear as such a common programme intersection maybe, there are other facets of programme implementation that often hinder collaboration. These may relate to personalities of programme managers, or the lack of clarity on pros and cons for necessary collaboration in programme planning, or approaches to financing individual technical units. Mostly however, having to share funds becomes the critical hindrance. In the case of TFI, which has more financial resources than the NCD programme, the offer of funds by the TFI to NCD was an incentive, but ultimately it was the commonality of the tobacco issue that bound this collaborative horizontal relationship. In contrast, however, in the case of the health promotion function in the office, while there was a clear need for advocacy for reducing tobacco use, and thus the overt niche for cooperation, such an approach was not taken. This indicates a gap in our perception of programme coherence and programmatic arrangements. There are several other such potential partnerships. The technical units dealing with health systems, adolescent health, MCH, TB control etc. are all good candidates for partnering or integrated programming with TFI. TFI now partners with NCD in a Regional meeting of programme managers and country focal points of NCD and tobacco control, and this may be considered a success. The other area of convergence is that of 10
Dr Dhirendra Sinha, Regional Adviser – Surveillance (Tobacco Control), WHO-SEARO
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surveillance. However, there is great potential for collaboration or partnership in the areas of research, training, advocacy etc. In our effort to promote this togetherness, the TFI unit regularly shares write-ups or reports with other technical units. But the response is quite dismal. Surveillance platform is the common denominator between TFI and NCD, and there has been effective integration of TFI survey questions into the STEPS process of the NCD programme. To come to a win-win situation of both parties achieving their own objectives in the process of this collaboration, there has been the sharing of funds also – from TFI. However, the sustainability factor must also be considered for the longer run. TFI’s provision of US$ 20 000 to country surveys that STEPS did (in Maldives, Myanmar and Nepal) is good for now. But when the money dries out, there must be an institutionalization that will carry the process forward. Unless organizational-level enablement happens, in whatever innovative ways, partnerships cannot be sustained. Ultimately, sustainability depends on the availability of resources for operationalizing the partnership – whether for short- or long-term goals. A new approach TFI has taken to reduce the expenditure of so great resources is to have a shorter questionnaire (from Global Adult Tobacco Survey based on MPOWER Indicators) included in future STEPS surveys. This contains 20-standard Tobacco Survey Questions (TQS) for the national survey including STEPS NCD risk-factor survey. This sharing of resources is specifically for including these questions into the survey instrument, and not just as additional resources for NCD activities. Such specific niches for collaboration must be clarified before resourcesharing can be effectively done. More countries such as Maldives and Sri Lanka are now online for this collaborative sharing with TFI. Thus, three main aspects signify the niches for funding: technical review, human resources, and funding of activities. As a next step, now that Sustainable Development and Health Environments (SDE) is a bigger department with the inclusion of health promotion and NCD also included in it, the opportunities for sharing of programme objectives among SDE units become more of a possibility. Flexibility of the within-department structure and management can be harnessed to make teamwork approaches more possible. A constraint for interdepartmental sharing is the difference in the policies, technical unit sensitivities and sensibilities, which need hard work to persuade and align. There needs to be more priority given to the Framework Convention on Tobacco Control (FCTC) in all our offices; at the Global level this has a very strong place of presence; in WHO Geneva, the Director-General’s Office houses the FCTC Secretariat. 19
Food for Thought: Summaries of Lunchtime Seminars (2010-2011)
To effect collaboration, we need to be flexible in our programming and management approach too. To find common ground will require deep thinking and shared vision, and good planning once these ideas have been clarified and firmed up in the minds of the partners. Perhaps this sharing/combining/collaborating should be the way to think in the planning for the next biennium 2012-2013. In our TFI and NCD case, we may need to think of other intersections of our programme objectives such as a focus on smokeless tobacco use in our countries (with 206 million smokeless tobacco users in Bangladesh, India and Thailand), and the issue of secondhand smoke, which research indicates is as injurious to human health as direct smoking itself. In the case of second-hand smoke, the global mortality rate is 9 million. Clearly, these are issues that must draw our critical attention.
Discussion (1) There was consensus on the need for horizontal collaboration and teamwork in WHO programmes. We need to think of ways to share our money among programmes so that the collective strength of a big chunk of money can be maximized rather than spreading it thinly and wasting it. Divisions in our programmes are artificial. It does not have to be like this. A better restructuring can bring about greater programme efficiencies in money and time. But we need to define our outcome objectives better. Given that tobacco use is an overarching concern that will find a place in any health programme, the discussion noted that in the case of the TFI programme, it may not need to be a separate programme with so many staff. All programmes should consider the risks from smoking when planning for health problem reduction for any group of people – youth, women, elderly, the poor, etc. We must close this artificial divide we have created in our programming structure and seek out the synergies. We can work towards reducing donor-driven programmes in innovative ways. Many feel that the divisions we see in our programmes are due to the exigencies of donor funding being given to increasingly smaller aspects of our programmes, thus creating the divide within our otherwise cohesive programmes.
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(5)
The government of India is apparently working on health programme reforms that bring similar programmes together through more comprehensive strategies, a mass media plan, and pooling of money. TB centres are doing tobacco cessation work. This is relevant in India where a fifth of women use smokeless tobacco, and where unfortunately doctors are not asking any questions on tobacco use during the captive MCH check-up moments. ASHA training in the Rural Health Mission is also seriously considering a similar approach. Even in the Indian bureaucracy, there is an effort toward a more comprehensive system. There is a concept note moved to reduce vertical programmes and increase horizontal programmes, to reduce the number of joint secretaries looking into a given project, and also have more multitasking focal points that will save on manpower. Although it may take a while, tobacco cessation is to be also integrated into the work of the PHC units. While explicit tobacco advertising is very much under control, surrogate or indirect advertising is still rampant and very difficult to control as the tobacco companies are very savvy in their marketing and can more than match the meagre resources countries can put into stalling this. Still, cinema and sports use this in very covert ways. The next biennial planning exercise needs to look into making horizontal planning a reality in WHO SEA Region programmes. We need to identify cross-cutting programmes in the WHO collaborative programme and seek to find horizontal operational mechanisms where a team of technical units partner. At the moment we are not quite aware of what even the technical unit next to us does, and the inherent technical skills and capacities in our staff to do shared work beyond the call of duty in our post descriptions. We need more flexibility in our programmes and in our minds, with Directors playing a bigger role in directing. Also need to understand the win-win opportunities we have in sharing. And there must be generated, organizational interest to promote collaboration.
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Food for Thought: Summaries of Lunchtime Seminars (2010-2011)
Risk assessment for outbreaks11 Risk assessment is a systematic process for gathering, assessing and documenting information in order to assign an overall level of risk for a potential public-health event. This information is then also used to prioritize interventions and guide communications to decision-makers and the general public. It is actually something we unconsciously do every day of our lives, for example in crossing the road we may consider the following: What kind of traffic is there: are there bicycles, motorbikes, cars or lorries? How busy and how fast is the traffic? How do drivers “behave” in relation to pedestrians in this sociocultural context? Is it day or night (can I see well and accurately estimate the speed of the traffic)? If I make a bad judgement and get into trouble half-way across, can I run to the other side? Are accidents known to happen regularly in this spot? We might even have at the back of our minds what the health services are like if we have an accident.
In making this assessment, what we are subconsciously doing is to identify the type of hazard, taking into account the context and also thinking about our vulnerability. Then, based on this assessment, we estimate how likely an accident is and what the consequences would be. Then, based on all this information, we decide what we think is the overall level of risk and what to do to achieve our aim while reducing the likelihood of a bad outcome. At present, normal practice for public-health practitioners when making decisions about outbreaks and other “public-health events” is usually just to apply some basic epidemiological principles and then use
11
Dr Richard Brown, Regional Adviser – Disease Surveillance and Epidemiology (DSE), WHO-SEARO, 10 February 2011
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“common sense” to decide what to do. We can surely do much better than this: so the rationale for the current WHO initiative to produce a guideline for risk assessment of public-health events is to apply a more systematic approach based on the kind of logical approach inferred above. There are other clear benefits to following this approach. Firstly, demonstrating and documenting that a rational approach has been followed makes any decision more defensible and supports accountability. It also increases the likelihood that the right interventions are applied more rapidly. Therefore, the process that will be followed in the guidelines is first to think clearly about what the potential hazard is. Sometimes it may be very clear that people are falling unwell because of a specific infectious disease or exposure to a chemical, but sometimes it can be extremely difficult to be sure of the cause, especially when we are often faced with assessing limited information contained in rumours and media reports. Similarly, at the early stages of an outbreak/event, it can be very difficult to know what is happening. In this situation, it may be necessary to consider a number of different possible hazards and rank their likelihood based on the clinical/epidemiological features and the context. The next steps (as implied above) are to assess the degree of exposure to the hazard and to assess the context. When considering the overall possible impact of an event, the evaluation of the context should be broad and might include aspects such as the ability of the surveillance system to capture (or miss) cases and the relative strength of the clinical-care infrastructure. The next step is to characterize the risk, which involves using the information obtained above to estimate the likelihood of the hazard being what you think it is, estimating and documenting your levels of confidence/certainty and assessing the potential consequences. Taking all this information into account will give the measure of the overall risk.
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In making these judgments it may be useful to consider some very specific issues. The most useful process is to identify ”risk questions” such as “What would be the likelihood of further spread of the disease if I apply (or do not apply) intervention ‘x’?” It is also important to appreciate that risk assessment should be an iterative process: it may be best described as a risk management cycle (see below). Risk management cycle
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Clarification was sought on the terminology and the definitions that will be used in the guidelines. Risk assessment is an established discipline in other contexts (including laboratory biosafety, complex emergencies and in business) and the terminology is a bit different. The specific problems associated with risk assessment of public-health events, such as the frequent difficulty in identifying a hazard and the dynamic nature of an infectious disease outbreak, make it necessary to adopt a different approach, and the terminology has been adapted to reflect this. However, a comprehensive glossary of terms will be included, which is aimed at reducing the potential for confusion. Discussion also ensued about the application of risk assessment in relation to the International Health Regulations (IHR 2005). The IHR do require Member countries to report any potential Public Health Event of International Concern to WHO and to assist in this process, and an algorithm exists in Annex II of the document. However, although the application of this algorithm could be described as a limited form of risk assessment, the tool is more accurately described as a decision instrument.
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Food for Thought: Summaries of Lunchtime Seminars (2010-2011)
Rational use of drugs12 This presentation was to inform staff about the irrational use of medicines and what we can do about it. The presentation covered the evidence, global and Regional, showing extensive irrational use of medicines and what we can do to improve the use of medicines. According to WHO (1985), rational use of medicines (RUM) requires that patients receive medications appropriate to their clinical needs, in doses that meet their own individual requirements for an adequate period of time, and at the lowest possible cost to them and their community. Unfortunately, many low- and middle-income countries do not monitor drug consumption or prescription. Therefore, WHO/HQ created a database of drug-use information at primary care from surveys, using standard indicators, done in developing and transitional countries from 1990 to 2009. The studies were identified through the bibliography of the International Network of the Rational Use of Drugs, PUBMED and the WHO archives. Data concerning drug use, methodology, interventions and demographic details were systematically extracted from all the studies and entered into the database. The data shows very serious irrational use of medicines, with less than 50% compliance with clinical guidelines in all regions, but only 15% compliance in the SEA region and no improvement over the past 20 years. Data from all the regions show that drug use is worse in the private-for-profit sector as compared to the public sector and that nurses prescribe just as well as doctors for simple infections. In the SEA Region, for diarrhoea, while 70% of patients receive oral rehydration salts as recommended, 69% receive antibiotics and 21% antidiarrhoeals – both of which are not recommended. For acute respiratory tract infection, while only 64% of patients receive an appropriate antibiotic for pneumonia, 47% receive an antibiotic inappropriately for a viral upper respiratory tract infection. Promoting RUM is a cyclical, iterative process. The first step is to measure drug use, the second step to investigate the reasons underlying irrational use, the third step to develop and implement interventions to correct the drug use problems, and the fourth step to re-measure drug use to see if the intervention has had any impact and also to monitor that the 12
Dr Kathleen Holloway, Regional Adviser – Essential Drugs and other Medicines (EDM), WHO-SEARO, 24 February 2011
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Food for Thought: Summaries of Lunchtime Seminars (2010-2011)
interventions have indeed been implemented. The factors underlying irrational drug use were discussed and include lack of knowledge, prescriber habit, social and cultural factors, economic and legal factors, issues of authority and supervision, workload and infrastructure (e.g. oneminute consultations), the influence of the pharmaceutical industry and access to unbiased information. Unless these underlying factors are addressed by the interventions, improvement in drug use is unlikely to occur or be sustained. There are four types of intervention: educational, to inform and persuade; managerial, to guide decision-making; economic, which offer incentives; and regulatory interventions, which restrict choices. Intervention impact by type of intervention, as extracted from the WHO database on medicines use, was shown. Impact was judged in each study by the drug use variable showing the largest change with the intervention. Only those studies which were randomized controlled trials, pre–post with control or time series were included. The data show that use of printed materials alone is least effective (8% improvement) while multicomponent interventions including elements of face-to-face education for providers and consumers, supervision and drug supply are most effective (28%-40% improvement). The policy framework influences drug use greatly. WHO sends a questionnaire to ministries of health (MOHs) once every four years on what policies they have in place. According to what MOHs stated in 2003 and 2007, only 25%-60% of countries were implementing any one of the policies recommended by WHO, and no country was implementing all policies. Thus, many countries did not have updated essential medicines or clinical guidelines, Drug and Therapeutic Committees in their hospitals, continuing medical education (CME) for doctors, training on the essential-medicines concept for medical students, a drug information centre for prescribers, public education on medicines use, antibiotic non-availability without a prescription, a national strategy to contain antimicrobial resistance, nor any information from recent drug use surveys or monitoring. Results from Europe, showing decreased antibiotic use after national public education campaigns and the implementation of coordinated national strategies, demonstrated that large changes in drug use are possible with government commitment and investment. Many of these results were presented at the Second International Conference on Improving the Use of Medicines in 2004 which recommended that countries implement national programmes to promote RUM, that successful local interventions be scaled up and that much more
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Food for Thought: Summaries of Lunchtime Seminars (2010-2011)
work be done on improving the use of medicines in the private and informal sectors, which are particularly prominent sectors in the SEA Region. Following this, WHA Resolution 60.16 on RUM was adopted in 2007 and a SEA Regional meeting in July 2010 recommended having a Regional Committee Resolution in 2011. WHO activities include Regional advocacy and training programmes, conducting country situational analyses to inform future health planning and WHO technical support, promoting the essential medicines concept, and monitoring progress through the databases on drug use and policy. It was concluded that while much is known about what should be done to improve medicines use, little is actually being done and it is not a priority with countries. If a fraction of the money spent on medicines was spent on promoting their rational use, much could be achieved.
Discussion (1) It was emphasized that the issue of irrational use of medicines should not be viewed by itself in an isolated manner, but that it should be addressed in the whole health system development and strengthening. Notable viewpoints shared were: Noting the results of the impact of various interventions, it was argued that more needs to be done on awareness of providers, especially through the professional associations. The data on the low clinical guideline compliance rate in primary-care facilities need to be compared with that of hospitals, which unfortunately are not available because they were not part of the study and there are fewer standardized indicators allowing comparison across studies; however, the speaker mentioned that there are many studies showing that guideline compliance in hospitals is not any better than in primary-care facilities. The audience, while appreciating the many factors that determine use of drugs by providers, noted that providers generally are defensive of their practice and they cite their reasons as “valid” – for the good of the patient and not wanting to take risks, workload that does not allow time to examine every case fully, demands from the patients.
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(5)
Notwithstanding these reasons, it was also recognized the economic incentive is a major factor, especially in private practice. Therefore an approach is to improve the nexus and dynamics of the relationships between industry and providers, especially doctors, in such a way as to promote RUM. While the study did not specifically assess the influence of coverage by health insurance, there is anecdotal evidence that being able to make claims through insurance can indeed influence drug use. However this has another (positive) side to it that can be taken advantage of – policies can be designed in such a way that reimbursements from insurance should factor in “penalties” for irrational use and rewards for rational use, for example, by reimbursing essential medicines and not nonessential ones. One of the options for national policies is obligatory CME. This can open up vast opportunities, especially for countries where this is already in place, for example, minimum CME points required for annual renewal of licence to practice. Such CME could be fine-tuned to include RUM, although care should be taken that the CME on rational prescribing is not undertaken by the pharmaceutical industry. National public education campaigns targeting consumers and prescribers, as successfully done in Europe, are urgently needed and should be undertaken by governments. Another option to improve antibiotic use is drug scheduling to ensure that some new antibiotics are not available over the counter without prescription.
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(10) It was mentioned that the lack of action with regard to irrational use of medicines was one of the biggest public health scandals of the 21st century. It was reiterated that the degree of irrational use of drugs, especially use of unnecessary antibiotics and antidiarrhoeals in children in many countries, is harming children in a big way and needs to be urgently addressed. (11) The point made by the speaker on the relatively large quantum of expenditure on purchase of drugs by governments as compared to the small quantum on advocating and ensuring RUM has great relevance. This huge disproportion can be used
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as an argument to advocate to governments that if they put in place policies and strategies for RUM, there will be cost savings in the purchase of drugs. (12) Finally it was suggested that within all health programmes in WHO, all programme directors and managers should include RUM in their programmes wherever possible, so resulting in an integrated approach, which is what WHO advocates.
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Food for Thought: Summaries of Lunchtime Seminars (2010-2011)
“One health” for avian influenza – how it came about and where we are now13 The presentation was an exposure to the idea of “One Health” promoted for the control of avian influenza (AI). It aimed to familiarize participants with the One Health concept and its importance in prevention and control of emerging infectious diseases at the animal–human–ecosystem interfaces, and also to reflect on the scope of using the One Health approach in WHO programme implementation. As in all health concerns, humanity faces many challenges that require global solutions. One of these challenges is the spread of infectious diseases that emerge (or re-emerge) from the interfaces between animals and humans and the ecosystems which we all inhabit. It is clear that no one discipline or sector of society has enough knowledge and resources to prevent the emergence or resurgence of diseases in the modern globalized world. The outbreak of avian influenza (H5N1) since 2003 has clearly demonstrated the need for close collaboration between human-health and animal-health sectors, i.e. adopting a coordinated “One Health” approach. The need for a “One World One Health” approach originated at the International Ministerial Conference on Avian and Pandemic Influenza held in New Delhi in December 2007. Later, the ministerial conference in Sharm-Al-Sheikh, Egypt, in October 2008, endorsed the strategic framework for reducing risks of infectious diseases at the animal-humanecosystems interface, termed “Contributing to One World, One Health”. The US Centre for Disease Control, in close collaboration with FAO, OIE and WHO hosted the expert consultation in Atlanta (USA) from 4-6 May 2010 to further develop the framework for reducing the health risks from zoonotic and other Emerging Infectious Diseases at animal–human– ecosystem interface and to promote actions and policies that will advance the One Health concept at national and global levels. There is now a growing acceptance of One Health concepts and usage of the approach in recent years, and countries would need to adopt
13
Dr Gyanendra Gongal, Scientist – Veterinary Public Health (VPH), WHO-SEARO 3 March 2011 31
Food for Thought: Summaries of Lunchtime Seminars (2010-2011)
this according to each country requirements and situation. It has been realized, however, that different groups see One Health in different ways. The objectives of One Health must be clearly defined and this approach must be cost-effective enough to achieve the objectives. While there is growing recognition of One Health, it has to be translated from concept into actions through country-level activities.
Discussion The discussion focused on practical implementation of the One Health concept in real-world situations. (1) It was pointed out that coordination and collaboration between animal-health and human-health sectors works well during times of crisis time, but it is not functional during peaceful periods. In an emergency situation our common concerns converge easily and the desire to cooperate is easily kindled. But when the emergency is no more, the team frays as our interests dwindle differentially. Even a simple two-party partnership requires a continuous redefinition of common interests. In the case of avian flu, the scare of the epidemic jump-started the partnership between the health and the agriculture sector, with WHO, the Food and Agriculture Organization (FAO) and World Organization for Animal Health (OIE) being very serious about it to continue. But now that the issue is at a low ebb, the partnership appears hard to maintain. There is the issue of interests. Partnering is always best when we can figure out the common benefits. Rabies is an old case in point. Since the disease is an acute and serious condition, the health sector has always given it priority because it relates to people getting sick. But the municipal sector had played an inconsistent role, perhaps due to competing priorities. Nevertheless, the health sector needs this partnership sustained through making the municipal sector see a critical commonality in the importance of human health. Or alternatively, this could be done by influencing the municipal sector to link the importance of eliminating stray dogs to achieve another important piece of their mandate. The differing implementation success of the One Health approach to AI in India, Indonesia,
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Italy and Thailand was also cited, and there was concern about the priority and mindset of professionals working in the health and agriculture sectors. Sometimes there is a conflict of interest, i.e. economic versus human health. It is a challenging task to find common interests to work together unless we can find justifications in our comparative advantages rather than looking at our differences. There are in fact a lot of good things to share. For example, WHO’s field epidemiology in public-health practice, FAO and OIE’s high-quality laboratory diagnosis in animal health. These can create win-win situations to working together and will make it cost-effective and efficient to achieve results. There has to be much better donor and agency understanding too, looking beyond the myopic concerns of their own mandates and priorities to those of the global. (3) There was also the aspect of addressing antimicrobial resistance in public-health issues related to animal health. In our discussion, three types of animals are to be considered – agriculture- and food-related (like cattle, pigs, chickens etc.), companion animals (dogs, birds, etc.) and wildlife. Using the One Health approach requires the varying constituencies to come together and iron out their differences to find common ground. This can be much more complex than just two partners getting together to address an issue. In the case of antibiotics in animal feed, while this will help keep animals healthy, overuse and indiscriminate use will result in the emergence of resistance, and so the implications for disease spread. Economic interest cannot be a sustainable concept in the case of health-related partnerships. Promoting partnerships should begin early. The divide between medical and veterinary education was discussed. It was suggested that academic institutions should be involved and medical and veterinary curricula should be revised to include and promote the One Health concept. Country-level activities should be launched to implement the One Health approach at animal, human and ecosystem interfaces. Joint training of different professionals, establishment of mechanisms for sharing epidemiological information and networking of animal-health and public-health institutions will enhance understanding and cooperation among stakeholders which will lead to promotion of One Health. 33
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(5)
Behaviour change is a key issue, and holistic multidisciplinary approaches demand interdepartmental collaboration and joint activities among professionals even within the WHO system. It was concluded that this approach can be translated into serious action by utilizing real joint planning for the WHO 2012-2013 biennial workplan, linking relevant strategic objectives and proposing joint activities for implementation. Repositioning must take place. Donors will reposition when WHO shows the way, repositioning its policies and stands to be more inclusive of veterinary health as an integral part of health actions, and making each other take responsibility through an awareness of this holism of health and of approaches to addressing health.
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Routine immunization in the SEA Region: Synergizing with primary health care14 The presentation focused on the notion that linking routine immunization with PHC in countries was a good way to improve coverage. It is estimated that in 2009, 23.515 million children globally did not receive DPT3 vaccination during their first year of life. Almost 10 million – about 43% – of these vulnerable children were living in the SEA Region. Furthermore, the DPT3 coverage trend in the Region appears to be stagnant with only a marginal 7% increase in coverage from 2000 to 2009. Thus, while seven countries in our Region have 90% or more coverage, others are at less than 80%; this is a chronic and continuing problem. There are critical geographical concerns in coverage due to the specific features of certain countries. The biggest challenge is in India due to its size and varying geographical locations. Here, 90% of the children who do not receive DTP3 reside in 11 states (Uttar Pradesh, Bihar, Rajasthan, Madhya Pradesh, Maharashtra, West Bengal, Assam, Jharkand, Gujarat, Andhra Pradesh, and Chhattisgarh). Madhya Pradesh and Uttar Pradesh are notable in this regard, with coverage hovering around only 25%. The reasons for this are issues of access: distance, terrain and culture are critical factors. There is also the lack of capacity for resource use; the money that is still unused at end-of-plan periods and is returned to the centre attests to the low managerial capacity of mid-level health workers. There are also in some cases the concerns of availability of uninterrupted supply of vaccines and related logistics. There is also weak informational support, and even when such support exists, it is not used effectively. Risk communication in management of adverse events following immunization also needs strengthening. Staff motivation meted out from policy and supervisory levels is needed to give more impetus to local-level programme action. Policy officials themselves also need a greater push through advocacy with them not to ignore requests for preparing good local-level strategies. At
14
Dr Nihal Abeysinghe, Regional Adviser – Vaccine Preventable Diseases (VPD), WHO-SEARO 10 March 2011 WHO/UNICEF - Best Estimates 2009 35
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the partner level, we need to have the GAVI and other support systems pay greater attention. Operationally, in future, we may need to select a geographical region for specific focus with collaborative programming. There will be issues of cold chain (strategies should be inclusive of coldchain expansion), social mobilization (through campaigns) and better mapping of neglected areas in every country, and then kick-starting the PHC process under which the Immunization and Vaccine Development (IVD) action can function within the PHC principles, and wisely using PHC functional levels to good advantage. The “health for all” idea must be used to reach everyone, remove of obstacles, and contribute to and promote national economic development. But many areas are beyond the immunization portfolio, and so there is a need to reach out to other sectors such as maternal care, safe delivery, postpartum care, polyclinics, growth monitoring, networking, and the commercial sector to push coverage. There is a need for support to top management to engender teamwork and find the common ground for the partners to contribute to. We can't work alone any more.
Discussion (1) Most health ministries don't have a dedicated department for concentrating on PHC and PHC work is done by different departments and units. This means we have a lot of difficulty integrating and coordinating activities. It was felt that in the case of immunization-related action, most effort is expended on the supply side and thus there is a passiveness in promoting the behaviour of active demand. However, in situations that have focused on the demand side there is more chance of programme sustainability. Some of this demand-side action is seen in the Bangladesh programme and in the Bihar programme in India. Bihar’s other health indicators are also commensurately good, perhaps because of its greater health consciousnesses overall. This is seen in their relatively higher health-seeking behaviour, whether they go to the private sector or to traditional practitioners. Presently there is a dwindling of the demand-side action overall in our Regional immunization programme. More demand-side
(2)
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advocacy is needed. Given that the DTP3 push is most needed for India, we need more interest created in other states of India. (3) Immunization coverage is a good indicator of the proactive nature of public health measures in a setting that is often commensurate with other health indicators. PHC can best be invoked in practice at the local levels rather than at the central levels. The importance of cutting our programme according to our acceptability was a concern expressed. In the deep south of Thailand, religious leaders’ efforts made a difference in coverage. This indicates the specificity of intervention methods in varying situations and conditions. We often think of public ignorance as the cause of low coverage, but it maybe better termed as lack of acceptance. This is a more positive approach that recognizes the value-based lives of our populations and the imperative to craft our programmes according to such parameters. Given the multifactorial implementation nature of our programmes – even in a vertical programme such as immunization – it was felt that we can increase coverage working together and the approach of PHC is still relevant. The difference between universal access and universal coverage was noted. Routine immunization is more voluntary on perception of needs. Health education requires that the different language requirements are considered. Education should be part of a package rather than an individual programme. Thus health education needs to be an overarching exercise. We must look for approaches to promoting at local contexts – thus cultural specificities. So we have to work across our departments and with other UN agencies too such as the United Nations Children’s Fund (UNICEF) and the United Nations Population Fund (UNFPA). We must build a health system based on PHC. But donor, sectoral and turf issues pose hindrances. But there are positives also in having multipurpose health workers at the local level, the common logistics all can help provide a collaborative work environment. The ASHA system in India is expected to help in this too. There is a great need for this as many countries are 37
(4)
(5)
(6)
(7)
Food for Thought: Summaries of Lunchtime Seminars (2010-2011)
being decentralized in governance. In countries like Indonesia also there is a huge need for local capacity-building. (8) The IVD programme's special model activities that will be planned at the local level in Punjab, India, will hopefully provide a good example for scaling up in other parts of the country and the Region.
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Evidence-based policy-making: the challenge of making difficult operational decisions16 Evidence is central to the work of the World Health Organization. Thus, one of the most significant normative roles of WHO is the generation of evidence, and using this evidence to develop standards, norms, guidelines and tools. These are shared with countries and other interested parties such as institutions for adoption and use, with or without adaptation, to make both clinical and public-health decisions. While the experience of translating such evidence into standards and tools can be considered satisfactory, the translation of these tools to policy and practice is not often optimal, for several reasons that go beyond the technical into the realms of social, political and cultural correctness or appropriateness. The 1990s is considered as the decade of quality, and in medical practice, one of the many quality improvement initiatives was promoting evidence-based medicine. The Ministry of Health of Malaysia went to great lengths to achieve this, including the formulation of a policy that any new intervention, especially if it implies high costs (the equivalent of USD 25 000 or more) must, before approval, be subjected to a health technology assessment (HTA) which entailed conducting meta-analyses and systematic reviews on the particular intervention. The HTA used the universally accepted levels in the hierarchy of evidence from 1 to 4, based on the strength or robustness of the evidence (randomized controlled trials or RCTs being the gold standard), and these were to be followed by a recommendation graded from A to D. Level of evidence 1a 1b 2a 2b 3 4 Nature/strength of evidence Systematic reviews or meta-analyses of RCTs At least one RCT At least one well-designed controlled study without randomization At least one other type of well-designed quasiexperiment type of study Well designed non-experimental study Expert opinion, respected individual’s view Grade of recommendation A A B B C D
16
Dr Narimah Awin, Regional Adviser – Making Pregnancy Safer and Reproductive Health (MRH), WHO-SEARO, 24 March 2011 39
Food for Thought: Summaries of Lunchtime Seminars (2010-2011)
These concepts and principles are easily applied to clinical medicine, such as deciding to introduce a new treatment modality for a disease. However, in public health practice, especially in policy-making, by its very nature and scope, these criteria are not as easily applicable; policy-makers’ questions go beyond whether an intervention merely works. They also address among other things whether it will work in a particular setting, how much it will cost and what consequences it brings. In other words, while RCTs and other types of studies focus largely on efficacy, the public-health practitioner often has to make decisions based also on effectiveness and efficiency. Cervical cancer prevention offers a good example; secondary prevention by cytological screening such as Pap smear is efficacious but is ineffective in many settings because it is difficult to translate into a national programme. Or in the case of the human papillomavirus vaccine, it is extremely efficacious for primary prevention and is likely to be relatively easy to be made into a national programme, but it is limited by its high cost. Public health looks at the question “What works?” from different practical aspects. Thus, there have been instances when “evidence” has to be presented (and defended for acceptance and approval) based on criteria which are different from (but not necessarily less stringent than) what is used in the above hierarchy. Some examples/case studies from my personal experience as a policy-maker at national level in the Ministry of Health of Malaysia are given below
Case study 1: To formulate policy on newborn screening of congenital hypothyroidism (1990) While a study was being conducted in two districts to assess the burden of disease (which was anyway known to be very low, but the study would have detected subclinical and borderline cases), argument was put forth not to wait for the results but to implement the screening programme on the following evidence: (a) the severity of congenital hypothyroidism (imbecility or any degree of lowered intelligence) and the extreme ease of treatment (thyroxin), thus it was argued that even if one case was
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saved, any amount of cost would justify it, and there were already RCTs to establish efficacy; (b) the screening test is cheap, and so is the treatment; (c) it is easy to do, nurses and midwives can take blood by heel prick as soon as the baby is delivered; and they were already doing this to screen for G6PD since the 1980s.
The screening programme was approved based on the above evidence.
Case study 2: To introduce Hib (Haemophilus influenza B) vaccine into EPI (1997) There was already convincing evidence from the USA (among Native Americans, where Hib disease was prevalent) that the vaccine had markedly reduced the incidence of Hib disease. Studies were conducted in Malaysia in 1991-1995 to establish the burden of disease, and these justified the vaccine, but the constraint for nationwide introduction was financial since it was then very costly. The arguments put forth as evidence for introduction were: (a) the vaccine was already being given by private doctors, and it was a matter of time before there would be a public outcry on the lack of caring by the government to withhold a vaccine for such a serious disease only on the basis of cost; the country was spending a lot of money on mega-projects which had world attention such as the Twin Towers, which was then the tallest building in the world; from experience of hepatitis B vaccine which was introduced in 1988, it was just a matter of time before costs would come down drastically.
(b)
(c)
Notwithstanding this evidence, a cost-benefit analysis (CBA) was required, and this showed that the vaccine was cost-beneficial with a costbenefit ratio of 1.3. Approval was given after the compelling CBA.
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Case study 3: Government should provide free chelation treatment to thalassaemia-major patients (mostly children) who are transfusion-dependent (2004) Until this time, these patients (numbering about 2 400) were provided free blood transfusion as a lifesaving management, but they were not given free chelating agent (desferoxamine) because of the exorbitant cost, and therefore they suffered the consequences of iron overload. Thus there was a clear differential between the children from rich and poor families. Evidence on efficacy had been established globally, based on the gold standard of RCTs, effectiveness was also not an issue since the treatment did not need complex programme management, but costeffectiveness/efficiency was the issue, and the arguments used for this were: (a) iron overload as a consequence of blood transfusion is a complication from a treatment, and therefore it can be seen as iatrogenic; the fact that blood transfusion saves life does not mitigate this reality; the rich–poor divide is unacceptable, it is social injustice, especially when these children “compare notes” with one another; the rich have a future, while the poor face complications of iron overload. with possible death; even though the cost per patient was high, the number needing treatment was small (2 400) compared to more than 10 000 HIV patients who were offered free treatment; and thalassaemia is a genetic disease, not a lifestyle disease.
(b)
(c)
Approval was given on condition that efforts on prevention were also developed.
Case study 4: Prevention of thalassaemia major (prenatal screening, population screening, termination of pregnancy – 2004) Approval of the above policy for free chelating agents has a serious social implication – patients who would have died before they reach adulthood will now live longer, get married and have children, and if they marry 42
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another thalassaemia patient or carrier they are likely to increase the pool of carriers and patients. Therefore there was a need for an evidence-based prevention programme, which was developed using the experiences of Cyprus, Greece and Italy. The success of these countries came in spite of major social and religious implications that compromised the feasibility and acceptability of their programmes, especially termination of pregnancy following prenatal diagnosis in a Muslim community, and the ethics of screening young boys and girls for carrier status and then counselling the carriers not to marry another carrier. This very difficult programme was gradually developed by pursuing the following evidence: (a) Prenatal screening: when subjected to HTA using meta-analyses and systematic reviews, the evidence showed that this was not appropriate, which made termination of pregnancy not an accepted choice. Population screening: population screening in the abovementioned successful countries (all of which are majority-Roman Catholic) had been carried out with no serious consequences of a political or religious nature. In these countries, it was found that young people tested positive rarely (less than 5%) and would change their minds about choosing a life partner who was also a carrier, even when they were counselled not to have children. In Malaysia, the existing school health programme offers an opportunity for screening teenagers before they choose their life partners. Termination of pregnancy: due to ambiguity of Islamic edicts on termination of pregnancy, a review of fatwa (religious rulings) has begun in some Muslim countries with high carrier rate (Iran, Pakistan).
(b)
(c)
Approval was given for (b) while for (c) discussions are still ongoing with the fatwa council, in the event that in future, newer prenatal diagnostic methods are able to diagnose the condition very early in pregnancy, and this will be in line with the current fatwa.
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Case study 5: Prenatal screening of genetic diseases and inborn errors of metabolism (2004) Since the above issue of thalassaemia prevention required an HTA, it was decided to simultaneously conduct systematic reviews for other genetic diseases including Down’s syndrome, congenital conditions and inborn errors of metabolism. The reviews concluded that none of these conditions justified a prenatal screening programme, and such a programme was thus not approved based on current evidence.
Case study 6: Folic acid for prevention of neural tube defect (2006 – unfinished) Neural tube defect (NTD) can be prevented by giving women adequate doses of folic acid before they become pregnant. But this has to be given four months before pregnancy, which makes supplementation almost impossible unless all women of reproductive age are given the supplement. Food fortification is the logical answer, which provides for mandatory fortification of a commonly consumed food substance, usually wheat flour. But because most Malaysians eat rice instead of wheat, and rice having to be washed before cooking, it is not suitable. Food fortification implies an added cost for the food item, which requires advocacy and wide public education. Efforts are still being made to gather evidence on the possible means of addressing these complex technical, economic and cultural challenges. These real-life experiences in policy-making provide three lessons: (1) The practice of public health which looks at population and not at individual health requires approaches different from those of clinical medicine, including the use of evidence. To this end, public-health practitioners and policy-makers often face difficulties in trying to use evidence optimally and convincingly. The hierarchy of evidence used for clinical medicine is often not appropriate in public health; other pieces of evidence that are pragmatic but still remain scientific are needed.
(2)
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(3)
The use of these other types of evidence can be made more compelling by using social, emotional and political arguments. Also, in the above examples this aspect may be shown by: highlighting the tragedy associated with the consequence of congenital hypothyroidism, which is low intelligence (which can be as serious as imbecility), for which a very effective and affordable treatment exists; appealing to the sense of social justice as in offering chelating agents to poor thalassaemia patients (mostly children) who are dependent on blood transfusions to remain alive; pointing to the need for consistency in policy objectives; reminding the government that if a country has resources to have prestigious large-scale development projects, resources for health should not be compromised; finding the meeting point of cultural and technical win-win; addressing the difficulty of NTD prevention because of the cultural issue related to food fortification in a rice-eating community.
Discussion (1) The settings-specific nature of many scientific studies from which evidence is generated constrains their extrapolation to general policy. And settings-specific scientific research also costs money and effort that may not always generate outputs enticing enough to policy-makers, who look at the rationality of policy-making from several angles, the technical/scientific being just one of their considerations. Funding for research is generally in short supply. However, even when available, funding for a programme may not always concur with the direction of interest of the project manager or management, and so, research may often be done for the sake of the research interest of a donor or other party rather than for programme improvement objectives. Thus, evidence is often not fully utilized to make policies.
(2)
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(3)
Public-health problems, unlike clinical interventions, take time to solve, and thus this element of temporality may militate against the political objectives of a programme that is bent on showing quick results – thus there may be a divergence in the technical and political objectives of a programme. Advocating for translating evidence into policy requires excellent communication, negotiation and practical leadership skills of those who mediate between research and policy; this relates particularly to public-health practitioner/policy officials who have to use the benefit of scientific research to persuade political leaders to enact health policy, laws and regulations that make public-health sense. The discussion also made specific note of the need for a high degree of passion and commitment in both the service provider and policy-makers to ensure that public-health programmes are truly aligned with the real public-health needs of our communities.
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Challenges to community participation clinical trials: Lessons from the field17 The presentation is about a large-scale community clinical trial for typhoid and cholera vaccine conducted in a Kolkata slum area, where the public health condition was very poor. It was crowded, congested and a tube well provided the water used by the whole community for washing, bathing, and drinking. The hygiene situation in the slum was dismal. Very often, these kinds of trials that involve the community in the process pose huge challenges for implementation, and many approaches must be used attract and persuade community members to take part. In this case, the community was readied for the trial by educating them through focus group discussions, exposing them to persuasive views of general practitioners, imams, and local political and social leaders. Leaflets were distributed describing the objectives of the trial, permission taken from local state government and municipal council, and information was given to the human rights commission and local police. Scientific and ethical reviews were also done to ensure adherence to such principles. However, even with all this, during the trial some people refused to take the vaccine for several reasons, the prime one being their wish to know exactly what they were getting. It was a double-blind randomized trial, and so when some participants wanted to know what vaccine they were actually getting, we could not disclose this, and yet we could not also insist on them to take the vaccine. Thus we had to forego some. Follow-up in these areas can also be a problem. In randomized control trials, when large numbers of volunteers are used, some adverse event occurrences are possible. While in this case none was detected, some pockets of residents (minority groups) refused to take on the basis of a fear that the vaccines might make them impotent. Later on, some good counselling by the Imam persuaded many to change their mind and take the vaccine.
17
Dr Sujit M. Bhattacharya, Temporary International Professional – Tropical Diseases and Research, WHO-SEARO, 31 March 2011 47
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After the trial was over, cross-vaccination was done and attempts were made to make these available at a lower cost.
Discussion Non-acceptance and community resistance to oral polio vaccine in north Nagaland and Uttar Pradesh; even one death is a big issue for the parents. During the trial, it’s a scare. That is very difficult to address. Blind trials present delicate yet huge challenges. Which is the placebo and which the real drug? Many a time the volunteers want to know what the real vaccine is. This is a significant technical issue, yet an ethical one also. We can always give ad hoc responses, but serious consideration must be given to crafting these well enough to maintain the critical ethical standards needed. This must perhaps be done at the trial’s planning stages so that we can be ready with possible mishaps that can happen during the trial and those possible responses we can give. Then there is the situation of what to do about those who find out that they were given a placebo? As such revelations may be very few, a possible approach could be to vaccinate them later if such exigencies arise. The price of the vaccine is often very high and the logical question would be how affordable this is for the poor person. The standard response given is that the price will come down when the demand for the vaccine rises later, but even later, the prices don’t seem to come down and thus continue to be beyond the poor’s affordability. Yet, the poor are the ones who need this most as they live in the most vulnerable conditions. Other excuses such as intellectual property rights arguments also may be put forth, manifesting the tug-of-war between the drug companies and the health sector. However, the issue of access needs to be addressed and this onus of responsibility needs to be passed onto the international community, for the risk is now beyond national boundaries. No doubt that this type of research is needed if we are to find remedies for the illnesses of our developing countries, and in such circumstances we may be seen as the hapless victims of unfortunate circumstances orchestrated by the wealthy. The ethical dimension drew queries. The issue of getting healthy volunteers for the trial was a case in point; how was this done? This can often be a family decision and there must be incentives built into the process. In the case of the Calcutta typhoid and cholera vaccine trial, 48
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towels, soaps and toothbrush, toothpaste, and orange juice were distributed. Learning to be in sync with local culture -- habits and behaviours, or dressing up like them so as not to seem alien may also be tactics to make the connect with the community and persuade the youth to participate. In this Calcutta case, there had to be several meetings with community leaders and parents to persuade and influence consent for engaging in the trial. There were occasion when the human rights commission was also informed to get a go-ahead so as to make the process as legitimate as possible. There was also the experimental versus control group dilemma of ethics. What happens when the team leaves after their work was done? Who would address unintended consequences? Firstly, a reward system that may bridge this perceived discriminatory divide needs to be taken by giving something back of benefit to the community. For instance, in the cholera vaccines case, the government promised to provide vaccines to the community in the years that followed as a special consideration for their participating as a community. Managing adverse effects was another point of discussion. The cases of other trials were also alluded to. In a case of mass drug administration, there was the incident of two deaths in one Regional country and six in another. In such situations, adverse effects investigation guidelines can come to the rescue. In both cases the deaths were found not related to the mass drug administration. In the case of lymphatic filarial in 1992 and 1997 some adverse effects were detected and investigated; here too they were found not to be related. The 2000 Assam vitamin-A administration incidents also brought to the fore the question of related child death, that were later found to be not related but coincidental. The positive role of the press in such situations can be very important, and by using them assiduously, possible negative political and social repercussions can be averted. We may need to orient the press continuously for them to be wise to these possibilities and report incidents responsibly. They can also play a key role in bringing the public into confidence about impending clinical trials so that communities are more ready with greater awareness. It was felt that if adverse events were found they must be communicated to the community leadership and to the community tactfully, with as much transparency as possible, backed by evidence, and conveyed through a programme spokesperson for imparting a consolidated voice.
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Ecological sanitation and health18 The importance of sanitation to public health cannot be overemphasized. And this does not mean only toilets. Although in our everyday jargon, we have come to associate this word with that of toilets and toileting, sanitation is a broad term that incorporates the management of human excreta, grey water, solid wastes, storm water, industrial waste, medical, chemical and other hazardous wastes. The lunchtime seminar focused on human excreta management. In this modern world, toilets constitute a “flush and forget” solution. We don’t think beyond toilets – how and where the flushed water goes and the burden it puts on the environment which eventually puts ourselves at risks from waterborne diseases. Much more needs to be done to bring about a comprehensive and holistic solution. Water flush latrines developed in the West and coupled with good solid-waste (garbage) management were the beginnings of health improvement in that part of the world. And more recently, some laud the discovery of oral rehydration salts in the therapy of diarrhoeal diseases as one of the most innovative remedies of the twentieth century. While these have immensely benefited developing countries, we too have in our own way developed culturally appropriate methods of waste disposal as evident in the movement of expanding the idea of improved sanitation where safety from contact with human waste is the central paradigm. Furthermore, the Sulabh movement in India (among others) has also revolutionized the “nocontact with faeces” movement with their pour-flush and VIP latrines. While at least 60% of our population now use such improved latrines, more than 300 million still continue to relieve themselves in open spaces, sustaining the threat of exposure to related infections. Such lack of sanitation deprives women particularly, as they are constrained only to the morning hours and the dangerous and dark hours of the night. At least 8% of our population lack family toilets and have to share toilets with strangers. The issue of loss of fresh treated water to flush toilets is a major concern in this day and age of environmental austerity and saving the planet. Still, about 80% of our toilets are of the water flush type, with at 18
Ms Payden, Regional Adviser – Water, Sanitation and Health, WHO-SEARO 21 April 2011
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least 20 000 litres per person per year used to flush human excreta. This is a huge waste treatment regime for the municipalities of the world. But only a small fraction of this waste is in fact treated. The rest goes untreated to pollute our rivers and streams. The pristine Ganges emerging from Gongotri is but a sewer when it reaches the Bay of Bengal, exposing the countries on its meandering path to the threat of all kinds of infections. It is ironic that we forget that the water that leaves our homes costs the nation billions to treat; but as it is “flush and forget”, no one really associates this cost with the behaviours that we ourselves engender. One solution is ecological sanitation or eco-sanitation, which is not just a way to dispose of our waste, but a way of using this as a resource. This is indeed a sustainable alternative. But the caveat of acceptability remains. In comparison with water-flush latrines, this pales in attractiveness by comparison with the surroundings and the mindset about cleanliness that we have grown up with (the “no contact with faeces” mentality). The first impression of eco-sanitation to many may be that of a messy process, yet it is also a no-contact solution. The difference is that in the case of the water flush, it is “flush and forget” whereas in the eco-model, it is retention for other purposes. Perhaps the retention of waste “under us” is repulsive to some; but it is still no-contact. So a mental shift is needed to value this benefit. The double-vault urine diversion dehydrating toilets being experimented with in Bhutan and Nepal are good examples of clean and neat structures that embody this process and the use of the urine collected to fertilize backyard patches into verdant fields of vegetables. The faeces is also kept for 6-12 months in the vault to biodegrade into useful compost that can then be used as fertilizer for the fields. These experiences in Bhutan, India and Nepal have benefited households to live with less hardship; no need to keep the toilet away from the house any more, and also generate a resource which avoids the extra cost of buying chemical fertilizers for home gardens. The simple drip irrigation systems being developed in these countries make life easier still as the direct application of the urine in dilution can be now done from a stand-post with propped-up large containers and the perforated pipes laid in the home garden plot continuously feeding the ground with the liquid. The market is expanding also for various designs of squat-plates and even sit-on toilet seats with the urine-diversion principle. Even a water 51
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saving design is available that has provision for a flushing out the faeces and collecting the urine. This design is particularly useful when we are making a transition in our habits. But it provides a windfall in the saving of water for flushing as we in this case need to flush only a couple of times a day and save the flushes we would otherwise do each time we empty our bladders.
Discussion (1) Most of the discussion revolved around questions of practicality and up-scalability of the eco-sanitation approaches. How we may do this in congested urban areas such as in Delhi or other big cities was a concern raised. Or why has this idea not blossomed over these several years? Perhaps the issues are about getting a critical mass of people persuaded, and a few projects in a few countries are not visible enough. There is also the issue of retrofitting existing toilets or making such a system structurally amenable in urban environments with high-rises and people with different mindsets. For this kind of a new thinking in the midst of already-accepted behaviour of flush toilets will take a lot of convincing. And it is this conviction that will make people really want to change – and an ultimate necessity perhaps is what will tilt to action. In urban settings, we are no more the community-leader governed systems, but a mix of ethnicity and modernity; no more a homogenous lot as in the past. Furthermore, we live in rented apartments which we do not own and so the ownership factor that makes people responsible is also not evident in urban settings. If accepted, ecosanitation can be a very cost-effective option; an economic saving and a wise investment in family agriculture. Even in urban conditions, rooftop gardens which many grow can use eco-fertilizing as a sustainable option. SEARO could also begin this as a showcase example. A good place for us to visit is the toilet museum at the Sulabh Center in the Delhi suburbs. There, sanitation has been carried to a real practical end, and their advocacy has reached millions. Perhaps we should learn from that. (Incidentally, it was WHO’s sanitation-related documents of the 1960s that inspired Sulabh’s founder Dr Pathak to begin his work on the pour-flush doublevault latrine).
(2)
(3)
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(4)
Universal coverage can be attempted with eco-sanitation also. As with other health programmes, in this case too, with the support of Ministry of Health, we must try to promote these ideas with local governments for action. The ecocentre examples from Nepal, and the pilots from Bhutan should be showcased. But municipal corporations will have to be the source of continuous motivation. Therefore, municipal officials and technical staff would need to be educated and have demonstrated to them the comparative benefits and the application of these methods in everyday community life practice, and how these make a difference. Encourage and/or commission research on the energy equation (the carbon footprint) and write advocacy papers promoting the eco-sanitation idea and share widely, yet strategically.
(5)
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Innovative training of human resources for health: A focus on staff retention - The StepLadder Curriculum, School of Health Sciences, University of the Philippines19 Background The School of Health Sciences (SHS) of the University of the Philippines was established in 1976, in Leyte Province of the Philippines. It was an experiment in medical education, aimed at developing a range of community-oriented health workers. The SHS represents a bold strategy to counteract the twin problems of the “brain drain” and mal-distribution of human resources for health available in the Philippines. The exodus of Filipino medical professionals to affluent countries such as the United States had been alarming – about 50% of medical graduates left the country annually up to 1970. Within the country, the concentration of doctors in urban areas had left the 70% of Filipinos who lived in rural areas without adequate health and medical services. Many medical educators had dismissed these problems as being caused by economics and, therefore, insoluble. However, this was more a post facto rationalization than a true assessment of the situation. Crucial factors other than money contributed to doctors’ desire to go abroad or practice only in urban areas. Foremost among them was the orientation of the curriculum towards the Western system of health care which was followed by all medical and allied educational institutions in the Philippines. Many features of this education were not relevant to health practice in rural areas. Consequently, most graduates developed skills, knowledge and attitudes which were not oriented towards the health needs or resources of rural Philippines. An Extraordinary Curriculum Committee was created by faculty members of the University of Philippines’ College of Medicine (UPCM) in 1974 to prepare a medical curriculum geared towards health-care delivery in underserved rural areas. These socially concerned medical educators 19
Dr Sumana Barua, Team Leader – Global Leprosy Programme (GLP), WHO-SEARO 28 April 2011
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were joined by faculty members from other units of the university such as the Colleges of Arts and Sciences and of Engineering. They were headed by the dean of UPCM at that time. The Committee generated “counter-culture” ideas for development of human resources for health that departed radically from traditional training programmes in curriculum design and admission policies. They followed educational principles that emphasized community relevance rather than academic excellence. The SHS was conceived as a joint venture of the University of the Philippines, MOH, the Ministry of Local Government and Community Development and the province of Leyte. WHO Western Pacific Regional Office provided technical support for the research and development component of SHS during its pilot phase. The venture was an attempt to develop an alternative form of health personnel education which would overcome the existing problems of medical education and services within the Philippines, and which would address the needs of PHC in rural communities. The SHS was originally housed in a new two-classroom building. It also made extensive use of existing Department of Health facilities and personnel for all academic training needs.
Objectives This experimental venture has two primary objectives: (1) to produce a broad range of health professionals who will serve in depressed and underserved rural communities of the country; and (2) to design and test programme models for development of human resources for health that would be replicable in various parts of the country, and hopefully, other countries similarly situated as the Philippines.
Philosophy SHS believes in: (1) health as a universal right; (2) universal educability; and (3) Relevance of training to community needs
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Academic programme The School offers an innovative “stepladder” curriculum where each student starts at a single point and exits at various levels with varying competencies, first as Community Health Worker or midwife, then sequentially as Bachelor of Science in Nursing, and eventually as Doctor of Medicine. Through its democratized admissions policy, the school provides scholarships and admits deserving high-school graduates coming from remote and largely inaccessible rural communities of target municipalities and provinces. The scholars are bound by a “social contract” and are committed to return to serve their communities after completion of a programme. Since it is intended to benefit the local community, selection of scholars is determined in consultation with the community. Students do not apply on their own but are nominated by their communities of origin. Hence, the client of the School is primarily the community in need of the services of a health worker. Two guiding principles were considered the primary determinants for curriculum development and for selection of teaching and learning methods: (1) Learning was to take place not only in classrooms and in clinical and laboratory settings, but, more importantly, in the settings of future practice – the communities. Thus, while three days each week are spent learning theories and concepts in the classroom, the next three days are spent in communities and clinical settings to enable the students to apply their new knowledge to the actual work setting; (2) Teaching and learning methods were also to accommodate and be supportive of the kind of students the democratized admissions process brought to the SHS. There are only two scores/grading system, either P (pass) or NT (needs tutorial) and each student is given time to learn, as necessary, through the tutorial scheme.
Summary of contributions Since 1976, there have been 35 annual batches and around 2 300 scholars enrolled from 71 provinces all over the Philippines and one from Bangladesh. At least 85% of graduates returned to their respective communities and most of them have been serving as midwives and nurses in the remote and largely inaccessible rural communities of the Philippines. 56
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A total of 90 scholars have gone through all the steps of the ladder curriculum and been licensed as medical doctors; of these, 81 remained to serve rural communities of the country, while 8 left for affluent countries and one of the graduates has been serving at SEARO. The SHS process has remarkably influenced the integration and restructuring of the country’s health-care delivery system. It has also provided educational and work opportunities to many disadvantaged people in rural areas who would have never dreamed of pursuing a course in the health professions because of the cost. The innovative stepladder curriculum has given the privilege, to many disadvantaged rural young people, of being educated in the country’s premier health sciences institution and has contributed towards developing the Philippines’ human potential and alleviating poverty. SHS laboratory-communities are where the students are given exposure to the communities served as the principal field experience for the Health for All policy and the PHC policy of the Philippines & for WHO Western Pacific Region. SHS and its laboratory-communities also served as the training venue for a Japan International Cooperation Agency training for prospective PHC experts who are now working in more than 20 developing countries.
Replication/expansion of SHS There are two new extension campuses: in 2008 the Baler, Aurora campus was opened, and in 2010 one in Koronadal City, South Cotabato. Both are in the Philippines where retention of health personnel is a dire need. Discussions are underway for possible replication of the programme in other countries, including Timor-Leste.
Recognitions The SHS has earned numerous recognitions and awards for its innovative approach for training of human resources for health who stay and serve the inaccessible rural communities where their services are needed most. In 2008, SHS was awarded the Presidential Lingkod Bayan Award by the 57
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President of the Philippines for its public service contribution to the country. At the end of June 2011, SHS will celebrate its 35th Foundation Anniversary with a grand reunion of graduates, when many of them will be receiving recognitions and awards for their services to the communities for 5, 10, 20 or even more than 30 years.
Discussion (1) Given that globally there are 57 countries with a critical shortage of trained health workers, an estimated one billion people have no access to essential health-care services. The issue of brain drain is weakening developing countries’ public-sector human resource capacity to a level of veritable inaction. This is on the one hand sapping the strength of the public sector overall, yet even within the country it is creating a dual system of publicand private-sector demarcation – one of quality, and the other with none or very little. We will need innovative approaches to turn the tide of this brain exodus. To address this crisis and with a view to implementing the WHO Global Policy Recommendations on “Increasing access to health workers in remote and rural areas through improved retention”, Member countries of the SEA Region face a crucial challenge. This sustainable community approach provides a reminder about relevance and community ownership and partnership in promoting community health at a time when we are seeing the need for revitalizing PHC. The new generation of health workers who seek a profession in public health has a lot to learn from this prominent community success. Lessons may be learned from the SHS stepladder curriculum and such other innovative approaches for training of human resources for health who would stay and serve the inaccessible rural communities of our Region. The group noted the power of the social contract within a democratized recruitment process; it is such processes that would put back the responsibility for health in the community’s lap – as it should be, so as to engender a greater sense of responsibility and cost benefit. Graduate retention of 80%-85% was a grand achievement.
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Increasing health literacy using health learning materials20 The issue of self-care is a very pertinent topic in our attempt at empowering our communities to make wise health decisions. Everyone needs to be responsible for their own health. If they have the ability to obtain and process knowledge, then they will make better health-promoting decisions. What difference does that make? A lot would be the answer. Especially in a world that is moving towards more chronic health conditions, the ability to manage our health by ourselves is imperative. Such knowledge and intelligence will ultimately relate also to increasing coverage and access to services by the very fact of our being able to know where to look for support. Consequently, this also relates to health system strengthening and promotes the demand side of health care and the road to a healthy life. Promoting self-care is about real empowerment of community, and for this we need to know how to improve health literacy. While in our part of the world little work has been done to study the health effects of a health literacy empowered public, evidence from industrialized countries, particularly the USA, shows that improving public information by removing health literacy related barriers leads to health system improvements. In the US, 50% of adults don’t go beyond the reading skills of highschool graduates. Simplified material made the difference. When health education material is written in sophisticated language, it is beyond the real comprehension of the general public, and thus of limited use. We will need to re-examine the reading and comprehension skills of the public and align our educational material with such findings so that optimum benefit is derived from our learning material. Learning from health education material and being an active listener to those who tell us about our health are also important habits to nurture. Many of us are often too quick to give answers, even before a question is asked. This restlessness must give way to active listening.
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Dr Ilsa Nelwan, Regional Adviser – Health Systems Strengthening, WHO-SEARO 5 May 2011 59
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Active listening and understanding is the basis for improving our knowledge base. Methods such as reformulating and reframing the words of the speaker will help us gain more focus on the intended message. For health educators too, being more aware of the audience’s level of awareness and educational level will help to engage the discussion at a level that can ensure optimal absorption of the message and using good techniques of wrapping up and recapping methods will ensure effective delivery of the message. “Let me be sure if you have understood everything” or “Have I covered everything?” are some such questions the speaker may ask of the audience to reiterate the importance of feedback to know if the message reached home. Self-care and prudent use of available health services are the focus we need to establish as the objective of increased health literacy. In order to practice self-care in the context of PHC, it is pertinent to be aware of the general dichotomy within it of medical public health, and preventive public health. A continuum of health care in an integrated manner is the better approach. The medical being the domain demarcated by the areas of preventive medical health, disease prevention and disease control, and that of preventive public health being demarcated by the areas of environmental protection, self-medication and rehabilitation. And selfcare can be practised in all these areas very effectively by being armed with the health knowledge that health literacy provides. While access and availability may be there, the actual act of availing of such services depends on our awareness – at the individual, family, and community levels. How to communicate this to the community? Both interpersonal and mass media methods are available. The written media and the audiovisual are those that have been available for a long time. But more recently, digital and computer-aided methods are on the increase. Social media such as the mobile phone, Facebook, Twitter and Youtube etc. are being used by increasing swathes of our populations – particularly the younger generation. But we can also think of reviving the older methods such as posters, street theatre, and even the blue-trunk library approach. The blue-trunk library is a carry box (blue colour for WHO) of essential health books delivered to health facilities that have no reference books.
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Discussions (1) SEARO can work on reviving the blue-trunk library method by experimenting with it online as a switchover to modern methods. The blue- trunk library is still popular in Africa, but we are now thinking of a “cyber library” where we supply health facilities with laptops to use the audiovisual health messages so that community health workers may use this in their health promotion work with the community. Information Management and Dissemination (IMD) group can help replacing with new publications of relevance. This can be piloted in Indonesia at a WHO collaborating centre that can be identified by the health communications department of the MOH (this would be coordinated by Ilsa in cooperation with the WHO office in Jakarta). There were questions about whether this discussion was about empowering the health workers or the community. While the main focus of the presentation was on health literacy, that is primarily the domain of the public; it was felt that there was a need to empower health workers also with more tools so that this public health literacy for self-help can be enhanced. Various new methods should be used to empower the community; for this to be done, we need to use innovative methods of display and reach the audience. Much more needs to be done to use the captive opportunity of visitors to hospitals and health centres to convey such messages as they wait for their consultations in emergency rooms and also in hospital rooms for inpatients. This requires good organization and coordination by the private sector. Private sector needs to be brought in partnership to promote prevention and self-help. However, it was noted that this would not be easy as the objective of the private sector would be the maximizing of profit. Given that this may be so, there would be innovative approaches that can be win-win situations of benefit to both the private and public health sectors, used to enhance public health literacy and thus community health empowerment. The challenge of catering to multiple languages, disciplines, and cultures in the SEA Region in the crafting of health literacy is 61
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immense. Most of us agreed that there should be similar messages, but the medium of delivery need to be varied to fit the culture of the populations considered. (7) As a result of the increasing health-care industry dominance in many countries, and due to their declining role as medical caregivers in local settings, PHC workers were losing the respect they held in the past. This poses a big challenge to the needed expansion of community health literacy, for such literacy is not in the interest of the industry, and conversely, the loss of social position of PHC workers in their communities means they find fewer takers of their advice. The use of multimedia and publichealth campaigns, and the use of mothers and peer groups to learn from each other, may help to rectify this loss of healthworker interpersonal communication capacity. Being discerning to the media market blitz on healthy behaviours and health products is also very necessary. The vast array of messages by the private sector on TV and other media to sell their products needs to be countered with consumer education processes that are credible and pervasive enough to generate the health literacy needed for the public to make wise health choices. WHO may need to make its health guidelines less technical for the benefit of the general public’s better comprehension. We need to make these simple enough without feeling that expert advice needs to be esoteric to be respected.
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Empowerment for self-care21 Dr Mahler says self-care is necessary for health for all. We need to empower ourselves to be able to make our own choices. People must empower themselves, not others. Simply put, empowerment must come through the effort of the individual who wants to be empowered. No one can empower another person. We can increase the resources for health information, and small groups to help themselves. They must learn to be sensitive to their own needs and define these in behavioural terms – practical and operational terms. Wellness and sickness are at the extremes of a continuum. And that revolves around a cycle of sickness, health care, rehabilitation and wellness. Self-care does not mean that it is about taking care of only ourselves at the individual level, but of the community we live in too and this could still be expanded even to a nation. And why not to the whole world also? This means the basic building block that we all have control of is ourselves – that aspect of self-care. Health is ultimately a reciprocity between what we give to a community and what it gives back to us in a good and enabling environment that nurtures our health. Nature is always giving, but unfortunately, we always seen to be taking – and too often more than what we need – and too niggardly or selfish to give anything back. We don't reciprocate nature's love. So by self-care we are demonstrating the reciprocity of that love the universe gives us. Health promotion advocates prevention and a big part of that is from self-awareness which leads to self-treatment. The everyday situation of us taking some medication when we start feeling a bit "under the weather" is a situation calling for self-care and most of us oblige ourselves with an aspirin for a headache or oral salts for diarrhoea to say the least. But this can be more elaborate also as what a chronic diabetic or a hypertensive may do to continuously be aware of the vital signs and be mindful of keeping up the actions that will keep one alive. We may perhaps know even more than our own physician about such particular afflictions because in such a situation, our senses have become so attuned.
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Dr Boosaba Sanguanprasit, Temporary International Professional – Primary and Community Health Care, WHO-SEARO, 9 June 2011 63
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So we take simple home remedies to a certain degree and go the doctor when we feel our self-care may not help beyond a certain point. The self-efficacy theory of motivation states that a person is motivated not just by the knowledge that one may have of a given cause and effect, but by the confidence that his/her action, through the exercise of a given skill that one may have, will result in success. It is the power of that motivation that moves action towards a stated goal. So we need the knowledge, skills, and also the confidence in ourselves that we can apply that skill effectively. We need a good dose of risk perception for us to be able to practice self-care, and the confidence of an outcome expectancy (what is the value added in achieving the particular goal/outcome under consideration) for being self-efficacious. Risk perception would embody the understanding of the outcome with respect to susceptibility, severity, benefits if achieved, the alternatives etc. This knowledge must be imparted in consonance with the target audience and factors such as their social and cultural values, the age or educational status etc. This is why health promotion uses so effectively the group approaches such as mothers’ groups, peer groups, religious groups etc. to move the message. The peer approach helps to communicate in this pervasive social bandwidth – enhancing mutual understanding through the homogeneity of their language, dialogue and values. Often, discussions in group settings are fun too, and creative ideas also will emerge in relaxed and informal discussions that encourage participation and autonomy of decision-making. This is the best context for problem-solving and community planning. It is common knowledge also that people learn best from their own problems and attempts to solve their own problems. The approach would be to set achievable and measurable goals in a progressive way so that the goals may not seem too daunting. This will also be a way to cope with problems as the group will have empathy among each other and peer support factors will help them cope.
Discussion (1) The question of whether or not someone else can empower another was raised. This presentation dwelled on this premise. But the group felt that people can indeed empower others too by their support and encouragement. Perhaps this was not
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negated by the presentation's premise. Health education can condition the person to be aware of the risks and opportunities for self-care and through a change of the person's mental awareness to be thus moved towards greater self-empowerment. The role of the health educator or health leadership will be to facilitate the process by providing information and skill development. (2) Empowered means the ability to make a change but this comes from inspiration and encouragement of leaders in the system. Empowering to self-help can be easier when people are afflicted with NDC conditions because, in a sense, they are compelled to be aware of their condition. Whereas in the case of self-help for public health objectives, because it is healthy people that need to be motivated, the approaches to do so may differ. Here, there is a necessity to impart more inspiration than the knowledge only. The need to engage the right brain or the left, as the case may be. True empowerment is achieved when we have internalized the need for our action. It has to be not just an intellectual understanding of the issue, but rather an awareness that this is necessary for the person's very being, and the dawning of a feeling of "Yes, I can", and a belief in themselves. Economic necessities also may motivate people for self-care due to the need to save on disposable income. With the charges of the heath-care industry reaching deep into people's pockets, there is that incentive too to be frugal. Reduced hospital stays necessitate people to be caring longer for themselves in their homes now. Even the dwindling nature of the extended family compels people towards cost-conscious behaviour and to practice self-care.
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Obesity: confronting a new epidemic in the SEA Region22 Globally, in 2008, 1.5 billion adults were deemed overweight. One third of these fell into the category of being obese (over 200 million men and nearly 300 million women), and globally, obesity rates have more than doubled since 1980, from 5% to 10% in men, and from 8% to 14% in women. As a result of this overweight and obese condition, at least 2.8 million people die each year globally. In the SEA Region, about 300 000 people die annually as a result of being overweight or obese. As for children, nearly 40 million of those under the age of 5 years were reported as overweight in 2010. The prevalence of being overweight in countries across the SEA Region ranges from 7.6% in male adults in Bangladesh to 53% in female adults in Maldives. And for the SEA Region, obesity has doubled in the past decade, with at least 3 million dying from direct causes; an increase of about 30% in diabetes, and about a 7% increase in cancers. In Thailand also, overweight and obesity has doubled in the past decade. Globally, the prevalence of obesity is highest in the Americas Region; in the SEA Region it is still comparatively low; but even in places such as Maldives, obesity is on the rise – 53% of women and 30% of men. Perhaps women, being more concerned about reducing wastefulness, eat up and do not throw away leftover food from the family table so as not to waste; perhaps they do not also exercise regularly! Among children, obesity is higher among boys than girls, especially in the higher socioeconomic stratum of society. Obesity is indeed a public health problem of huge proportions. Globalization and its ramifications have contributed to this epidemic. The export and ubiquity of the fast-food and soft-drinks culture, the superior preservation and packaging technology of the food industry and its savvy marketing practices all contribute to this. Unfortunately, at the end of the line, the health sector is the ultimate recipient of all these costs of obesity in the national accounts in escalating health-care bills. So, what can be done
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Dr Renu Garg, Regional Adviser – Noncommunicable Diseases, WHO-SEARO 17 June 2011
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to tackle obesity as a public health problem? The following are some of the thoughts that emerged in the group’s discussions.
Discussion (1) We strived to understand the measures of obesity. Who decides who is obese? Usually it is the basal metabolic index (BMI), but there are other tools that are becoming popular. Having these as common knowledge will help individuals to keep themselves under check for keeping within healthy limits. We need to keep the government responsible. But others feel that this should be the individual’s responsibility. But it is very difficult not to be swayed by the marketing savvy of big business. There is a contribution to this also from the expansion of the junk food revolution and food industries. We need to work on promoting greater sensitivity of policymakers on this emerging epidemic and the need to target the food industries. We need awareness development in schools and practice of good food habits there, that can then be taken to the home. Can we have warning labels on foods? We should not try to separate obesity and related diseases; they go together as the disease is the consequence. Otherwise, obesity is only looked at as a feel-good and look-good factor. We need to know how this affects our health. It will be more penetrating for lasting behaviour change if we are able to make that persuasion. We need to create awareness and a culture that junk food is bad and not a fad that is glamorous. Knowledge is one thing, but doing something about obesity in the light of that knowledge is another thing altogether. Obesity may be related to the stress of life – social and lifestyle. There are environmental factors also that can prevent the ability for self-control. There is, however, a need to make the environment more conducive to making our lifestyle behaviour wiser. 67
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(10) Our ability to use exercise facilities is also dependent on their management – timings for opening and the supportive facilitation they provide. Even in SEARO, we need the gym to be open at more flexible hours so staff can use their time more flexibly. (11) Schools also need to have more play space to help children to be healthy. Also, programmes must be organized in this way. Schools can influence very easily such values that will leave a lasting impression on young minds. In Singapore, school health programmes are being reduced over a three-year period. Children should be taught the value of taking care of the body and these values be taken home for practice. So parents also need to be empowered, particularly women should be made aware of this in knowledge and practice. Thirty minutes of physical exercise per day may reduce the risk of cancer. (12) There are consumer demands for safe foods but the market focus on our lives entices and persuades us to use even substandard products in the market. There should be much more effort on consumer awareness on the health value of processed foods in the market. (13) Industries may be made to self-regulate through innovative mechanisms – perhaps also by making it a duty of the government to provide subsidies to those industries that comply. Why not more subsidies for the necessary items of foods – fruits and vegetables at least? Barriers to this in the way industry engages are: soda vending machines, the culture of perceiving health issues as aesthetics rather than concerns of improving wellbeing.
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Integrated disease Surveillance and Data Management System, Maldives23 In 2005, the Republic of Maldives initiated the application of a WHOSEARO- supported web-based data analysis system (SIDAS) that serves as a single integrated tool for epidemiological surveillance, data collection, updating, analysis and dissemination of data on health and related indicators. The system was first customized to the needs of Maldives for data to be entered at the lowest health-care level and be aggregated at higher levels to provide information about diseases, including distribution by age, sex, and location. Aggregated information can thus be displayed with summary tables, graphs, charts, and maps as appropriate. In 2006, training for central and atoll staff was conducted, and preparations including installation of software, piloting and testing were implemented. In January 2008, the system was fully launched with daily surveillance data reported on-line from atolls. Data from islands were reported manually and using phones to the atoll level, where data were entered into the system. The system has been generating daily reports for information and action by senior public-health officials and weekly data analysis to monitor disease situations. Furthermore, a biweekly epidemiological report is also produced for wider dissemination to all stakeholders. The flow chart of the functions of the system is as below: Online Mode
Online Data Entry by the user Atoll Users
Data submission
Internet
Validation Data Upload Enter data in Offline Excel Templates Atoll Users Filled Templates Upload Data templates
Application & Database Server at WHO
Data Analysis
Offline Mode DPH Users and Atoll users
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Dr Rakesh M. Rastogi, Technical Officer – Surveillance, Monitoring and Evaluation (SME), WHO-SEARO, 7 July 2011 69
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The results show that SIDAS is functioning very well at all levels. Eighty percent of atolls enter data online on a daily basis and analyse their data using the tool. The remaining atolls cannot enter the data online because of the non-availability of internet facilities. However, they send their daily report to central level by fax and data is then entered daily at the centre. At every level, the system was found to be easy to operate, maintain, and user-friendly. Its use is noted for getting signals on outbreaks, useful data for media alerts, providing inputs for the statistical year book, providing input for advocacy, and reducing the workload of staff at all levels. Recognizing the relevance of the system, the Ministry of Health and Family has committed to continue the use of SIDAS and to expand its scope so that it incorporates other diseases of public health importance. It was observed that there is ample scope to enhance the system for other diseases as it offers opportunity to include other indicators with a few programming changes. This is a good example of WHO country cooperation and partnership in which the WHO country office played a key role in providing technical input and being a facilitator.
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Childhood obesity24 This presentation was inspired by a previous lunchtime seminar, “Obesity in South-East Asia” held by my internship supervisor, Dr Renu Garg, RA-NCD, SEARO. The purpose of my presentation was to focus on obesity in children and raise awareness of, as well as provoke thoughts and discussion on, the increasing rates seen on a global, Regional, and national scale. Since the topic itself is very broad, the presentation was narrowed down to answer three fundamental questions: What is childhood obesity? Why is it increasing? How do we cope? It aimed to do so by briefly outlining the causes of childhood obesity, the dangers associated with the condition, and its impact on the individual and society. The presentation then briefly considered the case studies of the USA and Europe before focusing on the increasing rates found in the SEA Region, particularly India. The presentation ended on a slightly more positive note by discussing strategies available to governments, communities, and families which can halt and reverse the currents trends. The purpose of this report is to highlight some of the important points raised in the presentation. Childhood obesity occurs when excess body fat negatively affects a child’s physical and mental health, and it is regarded as a growing health concern worldwide. In 2010, WHO reported that 43 million children under five years were overweight globally; 35 million of these children were in developing countries. Obesity has been portrayed in the media and by various health organizations as an “epidemic” due to its rapidly increasing prevalence. However, most health professionals and experts agree that it is not a “disease” but rather caused by a complex interaction of several factors: genetic, environmental, and behavioural. It has been proven that children with obese parents are more likely to be obese; heredity contributes approximately 5%-25% of the risk for obesity. Modern lifestyles in the West involve people consuming an increasing amount of “junk” food which is energy-dense and low in nutritional value. These habits are also increasingly seen in developing countries. The global consumption of cola has increased by 300% in the last 20 years, a symbol of progressively more unhealthy diets in modern society. This is coupled with a predominantly sedentary lifestyle in children due to widely available access to television, video games, and forms of entertainment that don’t require physical 24
Ms Emma Sjokvist, Summer Intern, SDE, WHO-SEARO 14 July 2011 71
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activity. In short, obesity in children is increasing due to an imbalance between the amount of energy consumed and the amount expended. There are many dangers associated with childhood obesity which make it an important health concern. There are direct consequences consisting of various physical and risk factors which include, but are not limited to: raised blood pressure, high cholesterol, high blood sugar, excess abdominal fat, difficulties breathing, sleep apnoea, type-2 diabetes, hormone imbalances, and an increased risk of fractures. It is important also to note the psychological risk factors which can affect an obese child, such as low self-esteem, eating disorders, depression, and discrimination due to the stigma surrounding the condition. Indirect consequences are also important to think about: since obese children have a high risk of growing into obese adults, they carry a high risk for NCDs such as cardiovascular diseases, type-2 diabetes and cancers, as well as disabilities and premature death. The impact of childhood is twofold: firstly we must consider the impact on the personal sphere with all the physical and psychological health risks imposed on the child. Secondly, societal costs must be taken into account. An increase in type-2 diabetes and NCD risk factors causes an enormous burden on health systems, many of which are simply not designed to treat these adult conditions in children and adolescents, particularly in developing countries. Children suffering from health consequences of overweight and obesity are more likely to have trouble concentrating in school, and in the long term this may lead to loss of productivity in school and potentially in adult labour if childhood obesity continues to increase. According to WHO, an estimated 10% of children of 5-17 years of age globally are overweight. In the USA, obesity is a well-documented public health concern and the data on childhood obesity are daunting; nearly one third of children and adolescents are overweight/obese! From 1980-2000, this number became double in children and tripled among adolescents. It is important to remember the potential damage that this causes to these children’s health, a fact that is proven by studies revealing that 70% of overweight children in the USA are affected by at least one cardiovascular disease risk factor, and 39% reportedly suffer from two or more. One study showed that in the USA an average of $147 billion is spent per year directly treating obesity, amounting to 9% of all medical spending. There is also a lower recorded age at which NCDs become apparent. Europe is catching up to America on obesity rates and medical
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spending, and children are increasingly showing symptoms of this health burden. In these developed countries, studies have shown a link between poverty and lower education levels and obesity. This can be explained by the fact that junk food is often cheaper than healthier foods in Europe and North America, as well as a gradual shift in education to focus on the negative impact of fast food and sedentary lifestyles. Traditionally a burden of the rich, obesity is now on the rise in lowand middle-income countries as well. The SEA Region is experiencing aggressive economic and social development which is causing a rapid change in diet, lifestyle and the physical activity levels of urban populations. This economic transition is leading to higher disposable incomes coupled with wider availability of high-fat, high-sugar processed food. In contrast with Europe and the USA where poverty is linked with obesity, it is the upper-income levels and the growing middle class which are showing the highest rates of childhood obesity in Asia. The onset of diabetes is occurring at a younger age, and obesity among Asian children is rising by 1% each year, the same as in developed countries. In India there are particular factors to consider in assessing the increasing rates of childhood obesity. Culturally, there is often a general misconception that an obese child is a healthy child, perhaps due to the previous prevalence of malnutrition as the dominant health problem among children. Also, academic competitiveness among school adolescents has led to a severe decrease in physical activity, especially among girls. In concentrated urban environments there is also a lack of physical space for playgrounds, parks, and other venues for physical activity. Combined with rapid economic growth and its associated lifestyle changes, these factors have contributed to increasing obesity rates in Indian children. A survey among 14-18 year olds found that the prevalence of overweight/obesity was 25% in private schools and 9% in public schools. Type-2 diabetes is already a public health concern in India, and among children this condition is increasing in prevalence. India is at risk of facing similar problems as the USA and Europe as childhood obesity becomes a rising health burden. There are many strategies available in tackling and preventing obesity in children. These include, but are not limited to: banning unhealthy foods and drinks in educational institutions, enforcing mandatory physical education, banning/placing limits on advertising junk food on television during the daytime, promoting and/or subsidizing fruits and vegetables, and launching programmes to raise nutrition awareness. The environment also
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plays an influential role in a child’s physical activity levels; ensuring adequate and safe parks/playgrounds in schools and communities would be a good start. The family unit can do much to influence a child’s physical health. By limiting media time for children at home and encouraging physical activities, the negative cycle of a sedentary lifestyle can be broken. Also, eating healthier food at home will shape the way that a child views nutrition and food. As a parent, the best thing one can do is to be a good role model by practising what one preaches. By promoting and encouraging healthy eating and physical activity at the government, community, and family levels, we can most effectively ensure that our children have the best possible start to a long and healthy life. In sum, this presentation raised the importance of childhood obesity awareness since it is increasing in prevalence globally, Regionally, and nationally. It is important that the SEA Region and India take note of the problems faced in North America and Europe in order to prevent childhood obesity from reaching similar epidemic proportions. Preventative measures need to be enforced on a state and community level as well as within the family unit in order to encourage healthy diets and lifestyles in children. They are our future! The discussion which followed the presentation was lively and constructive. Some important and interesting points that were raised were: (1) Whether there has been any evaluation of the success of interventionist strategies in schools? – There has indeed been evaluation. Studies in Australia have shown that in schools where soda drinks have been removed and healthier foods introduced, physical activity levels have increased and the average weight has decreased compared to control groups. In some countries, junk foods are cheaper than healthy foods. This is a large contributor to the structurally unequal prevalence of obesity found in developed countries. Poverty and obesity are interlinked. Obesity could be seen more in higher-income group in developing countries as opposed to the reverse in developed countries. During the H1N1 outbreak, there was a greater mortality rate in obese people. It is easier to treat lean people than obese people.
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International agencies play a role in the increasing rates of obesity in developing countries. These states are often coerced/ encouraged to lift trade regulations and invite in fast-food corporations such as McDonalds and KFC which sell high-calorie foods. There is a need to change policy at global level. Cultural factors, as in India, also play a vital role in obesity as every mother wants to see her children hefty like “baby Krishna”. In the USA, the army has recommended to the president to declare child obesity a national emergency, as it is finding it increasingly difficult to recruit fit citizens. In Delhi, boarding schools are more responsible in providing healthy foods and encouraging physical exercise than day schools, which do not have space for playgrounds. There is a need to develop a communications package targeting family, society and schools. Organizations such as WHO need to take nutrition more seriously and launch an attack similar to the tobacco campaigns.
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(10) There should be restriction of timing in advertisement of junk food, as it is difficult for parents to control external influences. (11) Satellite TV has intruded in the lives of people, discouraging physical exercise – a cultural problem of the twenty-first century! (12) Behavioural change could play a vital role in the prevention of obesity. There is a need for attitude change in society as a whole!
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Establishing an injury surveillance system in Egypt: Challenges and successes25 As in most other countries of the world, injuries are a big part of the morbidity and mortality concerns of Egypt. Within the complicated structure of Egypt’s health-care system, the true incidence of injuries is hard to assess. This presentation tracks a painfully slow but evolving system of injury surveillance constituted by the MOH. In 1993, with the help of WHO,26 a national review was done to assess Egypt’s problem of injuries through an in-depth review by a technical workgroup from the MOH’s occupational health department and emergency care department, several academics, and which also had collaboration from experts of the United States Centers for Disease Control. Consequent to this, in 1996 the occupational health department of the MOH was nominated as the potential stakeholder for a national injury surveillance system. A ministerial decree (#156) in 1996 gave the department full responsibility for this system and directed it to operate the injury prevention unit from within the infrastructure of the department. The department was also given the mandate to act in the capacity of main facilitator for the injury prevention advisory committee. In 1997, an external evaluation to address the gaps in the system revealed that the coverage was very low, with only a third of injury-related mortality being reported. In 2007, a national review of injury burden and impact was carried out based on the review of national injury surveillance data collected by the department in combination with a review of other available literature in the national public domain, to identify the total national injury burden, its pattern and distribution. It was discovered that coverage was low and only one third of the institutions were reporting, and these were mainly government institutions which noted all injured patients visiting the emergency department (and thus not a sample reporting). In these reports of road-traffic injuries and deaths, car occupants outnumbered other
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Dr Rania Hamada Saad, Temporary International Professional – Regional Data Coordinator (Disability Prevention and Rehabilitation), WHO-SEARO, 4 August 2011 Dr Gujuraj, et al.
26
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categories of road users. However, independent studies revealed that pedestrians were at greater risk. Even though the facilities reporting continued to be low (55%), the surveillance system showed its resilience by its continued functioning for a decade or so. It was in 2008 that a major programme overhaul took place to fine-tune programme quality. During this phase, the system was nationally reclassified to use an internationally recognized classification method for simple data exchange nationally and internationally and for including more data categories such as attempted suicides, rapes, assaults etc. Since 2007, quality training has also been imparted using TEACH-VIP. In the period March-June 2009, a national community survey was carried out in five governorates, covering 11 118 households and 47 797 individuals to measure the burden of injuries. It showed that road-traffic injuries are indeed a leading cause of both deaths and hospitalisations in Egypt. There were nearly 21 000 deaths (65% of these due to road-traffic injuries) every year, most being men. Among women, falls are the leading cause of injuries, followed by road-traffic injuries. In 2008-2009, as a quality validation tool for assessing causes of death in the national health information system, a survey of national newspapers was also conducted. Road-traffic death comes up high here too. It is felt that the use of international classification, strengthening data quality, and multiple data source validation will further help strengthen this injury surveillance system. However, national policy-makers, in spite of these surveillance system developments and refinements, still believe police reports that show low traffic death incidence, and dismiss this Egyptian reality of injuries and fatalities in their overt preference and continued emphasis on communicable diseases and the usual slate of NCDs. Thus, this will continue to be a big hurdle for the injury prevention profession to take on.
Discussion (1) Classification of injuries was an issue. There could be multiple reporting resulting in bad statistics. The use of internationally recognized methods would allay this. The inadequacy of police reporting which only indicates death on the spot. Those dying in hospitals and within four weeks may
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not be seen here. How do we address these hidden cases? But as the police voice is louder, their reports tend to get the attention and credibility too. With motor cycles increasing, related injuries and deaths are also increasing, and many go unreported. (3) There is a need to make way for institutionalizing any such important venture (such as the establishment of a surveillance system etc.) in as short a time as possible because the enthusiastic perpetrator may not be around after a few years at best and if there is no other enthusiast around, even a good programme can just be forgotten when new people and new leadership come on board. The continuity can only happen if institutionalization takes place. This means inserting or integrating the activity as a part of the regular programme system of the institution rather than its continuing to be a stand-alone project. WHO needs to help in training in reporting and recording. Data entry staff should be well versed with ICD10 and chapter 20.
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Pulse polio campaigns: Adverse events following Immunization27 In the pulse polio programme in India, a single day’s work entails immunizing about 172 million children. So an eventless day is very rare. One telling adverse event that the presenter experienced in Kerala in 1998 was the report of a death in Malappuram district after oral polio vaccine immunization. He was asked by the authorities to go to this particular household and investigate. The newspapers reported very blatantly that the child struggled and died in anguish after receiving the vaccine. This event reported during the particular polio campaign had a significant impact on vaccine acceptance and coverage in the community. As was to be expected, the child's family received Dr Madhav with some hostility and harsh words. Fortunately, the post mortem was done and it was proven that the child died due to breast milk aspiration. This was concluded because milk was found in the child’s trachea. The next day this was "reported" in the papers too, but this time only an obscure one-squareinch back-page column of text carried this new conclusion. There are many other such events being reported after immunization, but the point to remember is that such events are a minuscule proportion of those immunized. Such risks may wane when compared with the opportunity cost of not vaccinating and the child being at the mercy of another impending health risk that can effectively drain a poor family’s monthly disposal income. Unfortunately, what the media write or report is believed by the public, perhaps because our antennae are always naturally tuned, for whatever evolutionary reason, to wanting to hear more about adversities and less about successes. That is perhaps what catches our attention by the very fact that the death or infirmity of a child is an emotional distress to any parent and makes for riveting headlines in the media. So mothers and caregivers naturally go to the next logical question of querying whether this vaccination stuff is really safe. A possible decline in acceptance of immunization may result if good investigation and allaying these fears are not addressed with urgency. A gulf
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Dr Madhav Ram Balakrishnan, Temporary Internatinal Professional – Medical Officer (Surveillance), WHO-SEARO, 11 August 2011 79
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between perceived adverse events and actual events can result in loss of confidence by the people and vaccine rates can drop, and epidemics can result. The significant decline in acceptance of oral polio vaccine in 2005, when rumours spread that sterility as a result of vaccination was being spread in Nigeria, resulted in a global outbreak that spread first across Africa, later affecting children in the Middle East and finally spreading as far off as Indonesia. Strong advocacy that stresses the point that an adverse event following vaccination is not equal to an adverse effect caused by the vaccine i.e. "event is not effect" are slogans that are now being used. But no doubt, we must not underestimate the logical and psychological dimension of people’s perceptions. A medical event that takes place after an immunization is naturally a cause for concern. And we do have to acknowledge that there are several types of potential events that occur following our vaccination programmes. Some are isolated, solitary events while some are clusters of adverse events due to vaccine reaction or injection reaction, which are unavoidable. Avoidable programme errors occur as a result of bad strategic planning, inadequate training, transportation and storage inadequacies, carelessness of providers etc. Efforts at investigation of these events can also be difficult sometimes due to health workers hiding the event and even destroying evidence. Vaccine-specific reactions including contra-indications need special attention by the immunizer, and in case of such events, one must be prepared for clinical management. In the present day and age, we can confidently say that vaccines are good – they are safe, stable and provide long-term protection. There are vaccine vial monitors that help to maintain precise quality and reliable storage methods. With eradication as the vision now, polio programmes are being redesigned. There are new methods and routes of administration being tried out, such as an inhalable measles vaccine, and new additives that aid in more stabilization and preservation of sensitive vaccines. Overall, one could confidently say that vaccine quality is generally safe. But vaccinator training is to be continued especially to orient and empower vaccinators about these new developments as they arise, and about quicker and better means of adverse-event recognition and investigation.
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Discussion (1) The issue of the media not reporting the real truth about adverse events following immunization. The recently held WHO High evel Meeting on improving routine immunization, attended by ministers from seven of our Regional countries, had media participants too and the seriousness of these issues was conveyed to them. At national level these stories are what makes news and so the negatives take precedence over the success stories – unfortunately. So we need to give more training to the media on health awareness and also what setbacks their unsubstantiated stories can have on vaccine programmes. Several training sessions have been given by WHO and categorically by UNICEF media spokespersons before the start of most campaigns when the microplanning process for the campaigns is done. But for reporters, perhaps their vocation comes ahead of their avocation. There are many success stories, even in a state like Bihar, with routine immunization rising to over 60% now and still continuing to successfully conduct pulse polio events. The media would do well to raise public confidence by reporting on these very positive developments by crafting attention-grabbing news. On a pulse-polio day India immunizes over 170 million children and that requires a gigantic effort of logistics and so one can imagine the precision that needs to be there for risk-free performance. But often media blows up adverse events based on hearsay. Many adverse health incidents upon investigation are found related to other concomitant causes. We need to find other avenues to spread our message of vaccine safety to the community – through schools and through advocacy to parents in forums where their attention can be held as a captive audience. Since health is a state subject, there is disagreement between the state and central government on several fronts on the issue of vaccination programmes. An issue was also raised as to the possible downgrading of attention given to another prevalent community disease or 81
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condition because of the inordinate attention being given to vaccination programmes. The case of rubella was raised as an example. Pointed out was the fact that rubella prevalence has nothing to do with the provision of polio immunization. This seeming neglect of rubella has come to the forefront as an artefact. Because of the improved and intensive surveillance of vaccine-preventable diseases of the present, we are detecting the background rubella that is there anyway. This would be there even in the absence of a polio campaign. Rubella infections have always been there but not detected. Its presence is not because more attention is given to polio and less given to rubella.
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Collaborative planning in WHO: Breaking rigid boundaries28 Why do we see WHO planning as rigid? The following viewpoints prevailed. Country office experience says the strategic objectives (SOs) are good inventions, but now without the resources to get the work carried out, this is no more seen as an advantage. Perhaps the separations are too specific. Perhaps the non-communicable diseases and communicable disease programs could be combined so that there is more flexibility in the use of resources. How have these boundaries been created? There was concern about process too, in that we spend too much time doing the planning and refining. This also relates to the rigidity, as there is no opportunity to change when one truly needs to take another route than what was planned. We seem to be forced to move along that planned path even when we have better opportunities opening up that are more efficient. The choice of jargon is too complex and ambiguous. In a perverse way this can be taken as flexibility as we can assume this jargon to have a range of meanings. But that would be fooling ourselves and ultimately furthering the confusion. The so-called flexibility provided by the system allows for a certain degree of changes. But if this is resulting in programme changes that amount to 70% of the planned activities being changed, this says something about the quality of the planning. Why plan so stringently when we know we cannot hold onto even 50% of the planned activities? Could we not think of another way to set our goals? Therefore, some see this planning as just a way of legitimizing the securing of funds. And programme changes help to share the funds even if these are within the limitations of some business rules.
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Dr Thushara Fernando, Planning Officer, WHO-SEARO 18 August 2011 83
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Our planning process can be perceived as if we are just trying to fit our perception of Regional and country needs into a set of planning jargon and a prefabricated planning matrix. Is this the way to plan? It seems that if we can successfully fill in this matrix by cleverly engineering the process of input that fits with the business rules, the planning is complete and thus appropriate. At the country level too, sometimes we do a theoretical exercise in planning at the country office rather than really engaging the national programme managers and officials in a ground-level, bottom-up process that can enunciate real health needs. We prepare a good-fit matrix with needs that are only our WHO staff perceptions of country need. The planning terminology or jargon that we use is also not in sync with what others use in the government or other UN agencies. So naturally there are misunderstandings. We have a two-year operational plan. Should we have a longerterm plan (perhaps five years) that will build in some flexibility? At present our plans, being short-term, are also very vertically oriented and with little space for overlaps to be collaboratively functional. Here each RA looks at his/her own interests.
The speaker reflected on the above with a metaphor in planning of going from a point A to a point B. The point A is where the situational analysis will be taking place, and if done well it will chart a good journey that will lead to point B. Planning is about how to go to that destination, perceiving the possible obstacles we may face and readying ourselves to overcome those along our journey. Thus, all planning will be fraught with risks and so it is our job to do a realistic risk analysis and anticipate what these might be and be ready with some alternatives paths to take, just in case. Sometimes we make this analysis very complicated and find that moving forward is made difficult right away. But, if we analyze the risks we may face in a simpler way, the journey maybe easier to take. Most of our effort is spent in fitting into the process rather than really thinking hard about the relevance of the outputs we hope to achieve. Also we are using more of a top-down process than one that is bottom-up, even though we say we are being results-based. In the WHO context, SOs are actually not meant to be rigid structures, but a classification of activities that are being carried out in our
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countries. Perhaps the issue is not about structure, but about why we are unable to work together across the SOs and share our resources – why we are unable to make our activities collaborative activities. Some questions that lead to why this collaboration is not happening relates to how our pooled funds are being used for sharing among the set of 13 such pools; how Global Management System (GSM) is going to cope with this sharing; how budget ceilings hinder collaboration etc. Actually, there are many strategies for the sharing of co-voluntary contributions (CVC) funds by shifting between CVC and assessed contributions (AC) funds – i.e. shifting to AC so that AC can be spent; use of expenditure batches where two “Awards” agree to shift place and make space for another allotment to come in; raising ceilings through innovative approaches such as recruiting under an allotment that has no ceiling and getting the work of the other allotment carried out, etc. While this may seem manipulations that may slightly complicate the budgetary process, being aware of these opportunities by all RAs can help in finding ways to manoeuvre -- at least for this next biennium. Beyond 2014, a new strategic framework for WHO may take a different route to addressing the planning process using lessons from the issues of those past several biennia. The real issue everyone seems to point to is the concern of integration. This is not happening within this planning framework. Or even if possible, it is a labyrinth of manoeuvring and informal inter-RA and interdirector relationships that will make this happen. For example, reducing the infant mortality rate (IMR) is so much about reducing diarrohea and so addressing this will require the partnerships of units such as that on water, sanitation and health (WSH) which is at the moment not considered in the IMR reduction strategy. This is a matter for operational planning and this leeway needs to be available in the structuring of our plans. Planning has to be an inclusive process with good problem analysis that uses tools such as problem tree and fishbone methods etc. to track causes and find comprehensive ways to address strategic causes in an integrated way. Such approaches need to be coupled with a change in our organizational culture also: how we have been used to working in the past and how the country programmes are structured, and how ready we are to move to another culture of collaborative planning. Our organization needs to be motivating and facilitating this process. Should we move from one where we “don’t talk to each other” to one that encourages the “sharing of 85
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resources with one another”? However, for now it is only informal relationships that drive sharing; we need a formalized approach of having teams (rather than individual RAs) to be moving our deliverables – one that focuses more on the results to be achieved in countries, than on the dollars we get into our programmes. Mental flexibility is often inversely proportional to bureaucratic and technical divisions in an organization. There are positives for collaborative planning that can take some of the pain out of our planning right away: RD wants people to collaborate together, so right away we have the policy endorsement to move in that direction. There are ways to navigate through the rules to find berth for your office-specific expected result (OSER) Go across SOs: place your product in another SO, after convincing the SO coordinator of the win-win benefits. However, you may not own that product anymore. Making your OSER in another SO (after consultation with SO coordinator and related RAs – and this way you will own that OSER) Creating multiple PTAEOs for a given OSER that can be then shared. Don’t constrain your thinking due to limited budgetary ceilings
With these opportunities in sight, we need now to look into ourselves and ask if we are really willing to change our past individualized approach of programme implementation, and begin a fresh new approach of sharing our tasks with our colleagues in the true spirit of creating WHO teams.
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Yaws elimination: A useful investment29 Yaws is a non-venereal disease still found in remote and accessible pockets in some countries in the world where people live in extremely poor conditions. It has been referred to as “a disease that starts where the road ends”. It has no extra-human sources but is disseminated by direct contact – in unhygienic and crowded housing, in playgrounds, schools and cramped living conditions of very poor households. More than 50% of those affected are children. This is an easily treatable and curable disease with just one dose of Benzthine penicillin. In the 1950s, when the first concerted effort on this disease began, yaws prevailed in many countries of the tropical belt from South Pacific islands to South-East Asia, Africa and South and Central America. In the SEA Region, yaws was prevalent in India, Indonesia, Myanmar, Thailand and Sri Lanka. In 1948, WHO accorded priority to endemic treponematosis (Yaws, endemic syphilis-bejel and pinta) and implemented a global Treponema Control Programme (TCP) jointly with UNICEF. In 1954, the World Health Assembly passed a resolution to eradicate yaws. By 1964, the intensive efforts of endemic countries with the support of WHO and UNICEF had reduced the prevalence by 95% through treating 50 million cases in 46 countries. This reduced the numbers affected to just 2.5 million, three quarters of them children. In 1970, with the advent of PHC systems, there was an attempt at integrating yaws elimination with other programme activities with a hope that the few prevailing cases of yaws could now be quickly mopped up, and a costly vertical programme would thus not be necessary. However, this plan did not go as hoped, resulting in a resurgence of yaws in isolated pockets of many countries. Even by 1990, the needed political will was not there to give sufficient attention to the disease as a priority public-health problem. This meant that the benefits of modern development did not also reach these isolated communities.
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Dr C.R. Revankar, Temporary International Professional – Neglected Tropical Diseases (NTD), WHO-SEARO, 25 August 2011 87
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It was again in 1995 that renewed efforts at elimination began in the SEA Region, which harboured an estimated 50 000 out of the global estimated caseload of 460 000. In the SEA Region, India, Indonesia and Timor-Leste remained endemic in isolated pockets. The effots were flanked by intensive case-finding, treatment and follow-up and a focus on mopping up new cases. By 2006, India had claimed elimination of yaws as a disease by reaching zero new cases. Currently, India is moving towards declaring “India Free from Yaws”. For India, this was yet another success story after the eradication of smallpox and declaring India free from guinea-worm disease. India’s success story would be very useful for the remaining endemic countries to move forward. Since then, Indonesia and Timor-Leste have been making efforts. Some reflection on the reasons behind this disease’s persistence indicates very simply that the political interest was not sustained to promote the objective of elmination. Other priority diseases, including national development objectives, took attention away from the resources that were needed to sustain the yaws elimination programme. Moreover, the silent voice of the affected isolated communities had no chance of rallying any power over the louder voices. As the poorest of the poor, they were truly neglected by the system in general, including overall developmental activities. It may have also seemed that their inclusion in the workforce of a nation, or a lack of it, would not have made any perceptible dent in these nations’ economic growth. From a health programmatic point of view too, this decline in attention to yaws may have been due to the programme integration decisions and other competing diseases. Lack of importance given to yaws elimination vis-à-vis other competing programmes resulted in yaws losing out to the other prevailing diseases that garnered more political and social attention. The most recent formal decision taken was at the WHO-SEARO Bali meeting in 2006 which resolved to consider yaws as one of the priority diseases for elimination in SEA Region by 2012. The strategies decided upon were strong advocacy, active case-finding and treatment including contacts, health education for personal hygiene, and community mobilization with a strong effort at disease surveillance. 88
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For Indonesia, the programme poses real challenges due to the vastness of the country and the issue of lack of access to these communities. However, there is again added political will and commitment to eliminate yaws by 2015. The programme is making its best efforts to mobilize resources. For Timor-Leste too, the picture is not bleak. While yaws is believed to be endemic in six of the country’s 13 districts, the availability of health outposts all over the country signals the promise of the programme to reach these poor communities. Timor-Lester is reviving its interest through an integrated programme approach. Using school health, multisectoral partnerships and the mobilization of the community into an inclusive partnership, the potential for programme success seems high. WHO-SEARO will be organizing an informal consultation on elimination of yaws in Timor-Leste in October 2011, where participants of India, Indonesia and Timor-Leste will discuss how to move forward.
Discussion (1) The lessons we gather from the above is that we need strong political will to sustain such programmes, demonstrated by commensurate investment by the government, and the requisite national implementation mechanisms such as focal points, taskforces, operational programmes that include sensitization of the district governance systems through their political leaders and communities etc. Being a disease of the poor, better socioeconomic development in general in the yaws-endemic pockets may eliminate the disease anyway in the future. Such development will make available water, sanitation, environmental hygiene etc. that will improve health in many ways including by addressing yaws. In the interim period, the government must make continued efforts to address yaws elimination given the wide distribution of health service outlets in the country. An intensive one-time investment can help to eliminate this disease in the background of developmental activities. 89
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For a disease such as yaws or any health condition that draws trivial attention yet harbours an enormous human burden and neglect for the community concerned, it may be best to take a health and human rights approach to advocacy to draw the attention of policy-makers. Yaws prevalence could be a marker for social development of neglected people, just as lack of water, sanitation and poor hygiene are. Through a programme such as yaws elimination, we should capitalize on the opportunities that open up to search for other neglected health interventions such societies are subject to, such as nutritional, immunization, education etc. rather than looking at these again separately and vertically.
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Keeping health facilities safe from disasters30 The concept of keeping health facilities safe from disasters began after the 1975 Mexico earthquake, when most of the health facilities collapsed in Mexico City and there was no way to provide needed health services to the mass of casualties. This presentation is a reflection on what, why, where, what context, what challenges and what contributions or directions are needed for the future of such an event in our Region. A basic question in this regards is what constitutes a safe health facility? We can perhaps say that it is some place that provides clinical and public-health services. Another such question is what makes for its safety? This should be about structures that are able to withstand the traumas typically those experienced in those geographic locations; and non-structurals, which consist of equipment that will not fail, such as constant supply of electricity, water backup and related contingencies. Then we should also have the conventional aspects such as trained staff skilled according to our disaster preparedness plans and who are aware of the consequences of disasters and brave enough that they do not run away at times of disasters leaving patients abandoned. Having prepared, functional evacuation plans is also one of the other conventional dimensions that makes for a safe facility. Having health facilities functional and available in a disaster is both an economic and a political concern. People can harbour disastrous impressions of a governance system that cannot deliver or was no prepared for the consequences and also because of such a loss, the opportunity costs of resources that could have been there become starkly apparent. As it is, health service outlets are not the priority items for governments and donors to fund, whether in peacetime or in disaster time. Besides these losses, the social loss is also an important one. In a post-emergency situation, the hospital is a veritable meeting place for all to come together and feel a sense of shared plight and mutual comfort, or a sojourn for those whose homes have been destroyed. If the hospital remains standing, it can give access to telephone and other basic services such as water, sanitation, electricity backups, and other social security measures. And most of all, it houses the field hospital that will take care of the urgent and salvageable casualties of the early hours of the disaster. When a health facility is lost, it is a huge loss in investment, not just because of the absolute amount of 30
Dr Roderico Ofrin, Regional Adviser – Emergency and Humanitarian Action (EHA), WHO-SEARO, 1 September 2011 91
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money lost, but also because of the lack of opportunities to attract public or donor funds to such investments. The health sector is not the first priority of such investors or investments. Especially in times of disasters, funds pooled go elsewhere, to seemingly more visible items such as housing, roads, bridges etc. In the scheme of governance, health is very underfunded. So it is all the more important and reason enough to help protect these investments a priori. Usually, the health sector will receive at most only about 5% percent of such investments. Retrofitting is a high-cost item no doubt, but nevertheless this has to be done if we are to protect our health facilities and keep them standing for the post-disaster benefits they will accrue. During the last decade, nearly 60% of deaths from disasters were in the SEA Region. We have had several emergencies in these few years – the Asian tsunami, cyclones Cidr and Nargis, the Kosi river floods in Nepal, the West Sumatra earthquake and other complex emergencies such as the conflict in Sri Lanka. Health workers risk their lives through all this and although all health services are supposed to be neutral even in times of war, there are crossfire causalities or collateral damage, as it is now sometimes called. Lack of investment for keeping health facilities intact may have its basis in the lack of emotional attachment people have for these facilities. In the case of a school, for instance, direct emotional attachment is apparent because people’s children are going there every day and its continuity is critical for the future of their children, so people are more willing and ready to invest to keep a school intact rather than a health facility to which one goes only when one is sick. Thus, health facilities do not have the backing or demand for protection as these other entities. Thus such a request is difficult to put into the realm of public opinion. Perhaps it is also a fact that hospitals do not have too many good feelings attached to them anyway because we prefer happy memories to the often gloomy memories of our illnesses. Structurally too, hospitals can be a difficult thing to plan consistently across all cultures and national boundaries. Neither do all countries have the same health systems nor risk reduction systems. And not all countries have similar architectural designs or constructional typologies. Therefore, an all-encompassing systemic programme is difficult to craft. There have to be national-level adaptations, and these take meticulous attention and time.
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So how do we address these challenges? The MOH and other sectors, including the private sector, and the general public need the benefit of a comprehensive approach that would bring everyone together. Instruments such as the Kathmandu Declaration made at the Twenty-seventh Meeting of Ministers of Health can help to bring the idea of collaboration to the fore. It can be used as an advocacy tool with which we can promote training such as Public Health and Emergency Management in Asia and the Pacific and the like in Regional countries. There is a lot going on even at the moment in Bangladesh, Indonesia and Thailand. Standards and guidelines and benchmarks need to be established. Good work in this area is going on in Indonesia and Nepal. Also, developing system mechanisms within health and across other sectors to bring about a comprehensive approach is very much needed. Increasingly, all UN programmes also have a component. Since the 2009 campaign to promote the movement for keeping health facilities safe in disasters, a lot of effort since the “click a brick” on Facebook has happened. There were a lot of hits on this, and now global ambassadors such as the Chinese actor Jet Li, and Heikki Kovalainnen, the F-1 speed ace, have endorsed the campaign. WHO has published a very popular pocket guide to disasters. The private sector also has contributed through the growth of health-care providers, such as medical tourism, new health facilities such as the Max and Apollo chains that endorse this movement. In India, next month (October 2011) the CII will be involved in the discussions at a national conference on disaster risk reduction (DRR). In Nepal, the Nepal Consortium for Disaster Risk Reduction will engage districts and communities for their contributions in the tasks of retrofitting for schools initially, and which can then be rolled over to hospitals too – an important feature of this campaign being also the push for reducing the acceptance of bribes in granting building permits.
Discussion (1) Is SEARO included in this kind of activity? Does SEARO have adequate health facilities and training to meet such situations? ASO needs to be probably brought into this discussion. In SEARO some action has been taken such as replacing the ventilation ducts with more flexible joints so that strong vibrations will not damage these. Also, there was a seismic assessment of the building done some time ago. It was felt that we should be doing more preparedness drills and imbuing staff with relevant skills so that we can set an example to others. Four of our Country offices that seem of greater potential for disasters 93
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are much better prepared with skills development and equipment such as satellite phones is available. (2) It would be good to have our weaknesses assessed so that we can direct our training in a focused way and be better prepared. A good example is Indonesia where such assessments were done and retrofitting also carried out in some hospitals, and that has withstood the onslaught of a disaster a second time around. Urban dwellers must be taught the skills of how to respond in an emergency. This is the place where most casualties will be recorded if an emergency should strike. There are disaster risk reduction actions being taken in several cities now. The Gujarat pilot project is one that uses the community in programme planning, drills and response plans. The Kathmandu valley also has a better plan now that will be more effective on these fronts. The Hospitals Preparedness in Emergencies programme in Nepal has engineers involved in the training course, and a similar project will also soon be rolled out in India. Furthermore, in India, there is an urban disaster preparedness initiative happening already. Risk mitigation and personal protection in schools and communities are included in this. There is a two-city simulation exercise also now being planned for Mumbai and Delhi, which would require that all new hospitals be seismically resistant. But quality professionals are also needed for assessing and reconstructing. These are unfortunately hard to come by, which may delay the work somewhat. Private sector regulation is also a huge issue that must be addressed. With so many providers and hospitals, they must be also made to abide by building regulations. However, this will need strong legal backing. The Clinical Establishments Act that is in force unfortunately relates only to central-government establishments. This needs to be enacted at the state levels too, to be implemented and facilities accredited for safety features. WHO can be a voice of advocacy for all this, but the action must be for partners to take. The International Union of Architects is now getting involved in the programme. But we need not only architects but structural engineers involved too. For such dual input and a new culture of partnerships, this needs to be integrated into teaching in engineering and architectural university programmes.
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Life after WHO: Preparing for a peaceful retirement31 Life after WHO continues to support our heath and well-being. And so, retired life should be one free of hassles and annoyances – a time for relaxing and enjoying the things we could not do when we were on the job. To be able to meet old friends and visit places we did not have the pleasure of seeing. To maximize this potential, one should be well prepared, and that needs proactive and early planning for retirement. Some say that the day after your retirement is a moment that sticks in your mind as a momentous shift from what we have been for the past decades. Waking up and not having to go to work is both exhilarating and yet sad. On the one hand there is a sense of freedom to do what you want, but on the other, a sense of loss for now not knowing what to do. This is why prudent planning is necessary for retirement so that we are actively prepared for that moment when otherwise we are at a loss for what to do. This situation of post-retirement bliss or blues can be different from place to place, and even within each Region, cultural differences can also alter the attitudes one sustains after retirement. For example, in our Region, retirees visiting the Regional Office just to see friends are a regular sight – to have a cup of coffee with a colleague, and drink in the nostalgia of the past. Even though the physical space may have changed in our offices, the aura still remains. At other locations, social culture may dictate a lesser nurturing of such warmth or social proximity. Perhaps, in our case, still the extended family values of our Region for example may seem to extend into the psychological environment of our offices and thus the manifestation of that cordiality. So to cater to both the above problems, planning is most important. Alex indicated that while he had not proactively planned for his retirement, however, his having worked in the human resources department of WHO in those days gone by, and the contact-wisdom of other retired friends, made him realize that planning was important. So in this regard, his conscious effort for planning did indeed begin perhaps five years before retirement. The benefits are clearly perceptible to him given that he is fully
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Mr Alexander Woode, Temporary International Professional – Personnel Officer, WHO-SEARO, 13 September 2011 95
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functional in his retirement, still giving the benefit of his expertise and past experience to the Organization. It is also important that we talk about these things with our families before this eventual day arrives. WHO’s retirement benefits and other entitlements are well described in a little green booklet and supporting information papers prepared and available at personnel. Alex elaborated a few points of relevance and importance. Choosing our country of residence after retirement. When we choose the country of residence, we need to carefully study the liveability conditions that prevail in that country. For example, issues such as taxation, social and physical security, cost of living etc. For example, some countries impose taxation even on retirement benefits. We also need to consider the nation’s political stability that will reflect the potential for living a safe and stress-free life there. These considerations may not apply, however, if one is settling down in one’s own country. Having a safe and comfortable house to live in. An important issue for many of us is to have a secure abode of our own to move into right away as we return. It could be that some of us, while we had the WHO job, rented out our houses. Without the lease being closed on time, one would face a truly difficult situation when our goods arrive and we have no place to put them, or consequently having to rent out another place in the interim period. This awkward and irksome situation can be avoided if we plan ahead. In the case of the home, repairs and upgrading that may need to be done due to damages during the lease period will have to be taken care of and that also takes time to get done. For yet others, it would be a new buy, and this may involve several months of savings or acquiring substantial loans. Having a car that will not break down. A good car that will not break down is an important investment for retirement. Having a car in retirement that would give hassle-free service for at least 10 years will give us peace of mind. The contrary can cause a substantial drain on pension receipts. In some countries, the pensioners’ associations have tie-ins with car manufacturers to facilitate procuring vehicles at ex-factory prices.
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Schooling for kids who have not quite finished even though we have. For some, family responsibilities of school-age children are not yet over even at the time of our retirement. Is the school system in the country of residence suitable for the my children’s studies, and do I have the resources to keep up the fees at the present rate etc. are questions we have to ask ourselves. Timely decisions need to be taken on such matters for peace of mind to prevail at retirement. Ensuring that nothing is pending from us to the Organization. Being clear of any financial advances taken, duty travels not claimed for, or materials and equipment that have to be returned such as books, computers, telephones well before retirement. The clearance certificate we are entitled to fill out before leaving should be thoroughly completed so that our final month’s pay will not have any deductions. Selecting a pension. There are three general options. These include: full pension; a reduced pension with a lump-sum option; and a final settlement with no further payments. Usually, the reduced pension with the lump-sum option seems the most popular, and is availed of by the vast majority of staff members across the United Nations system. Balancing pleasure with some indulgence in professional work. Unless of course we are totally committed to a relaxed life, a bit of engagement and tethering to our professional mind gives good balance to our life and keeps us refreshed. So doing some technical work on and off, or renewing our professional association membership, giving lectures, and taking some of this as a hobby will keep us mobile, and living a life that is healthy in body and mind.
Discussion A few additional points given below were also discussed: (1) Should its finances dwindle or some catastrophe should occur, would all the member Organizations come to the rescue of the UNJSPF to help meet their obligation of paying regular pensions? It was clarified that the Pension Fund is independent of any UN 97
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Organization and the funds are generated through contributions both by staff members and the Organizations. This money is usually kept in very safe investments and thus very secure, and mostly kept in sure and safe accounts. However, it was also mentioned that while such a situation may not occur, the fund situation could get tight as the number of pensioners rises over the years. (2) Another query was whether early retirement was possible without a financial benefits loss. It was explained that while early retirement can be taken, there will be no immediate statutory benefits from doing so. Retirement benefits kick off when a certain age limit is reached. But an early retiree can avail the pension benefits only if that remaining gap to the 55-year or 57year retirement threshold age is covered by active payments by the retired staff member to the pension fund during the interim period. This does not automatically happen. Unless extraordinary conditions prevail, it is in the overall interest of each staff member to complete the full service period. Is there a plan for increasing the retirement age to 65? None as yet, but there is a move to have the 62-year retirement age limit be applicable to all staff regardless of post-1992 appointment or not. This issue is being tabled at the next January 2012 Executive Board meeting. Any benefits from Voluntary Group Life Insurance after retirement? This is not valid after retirement. However, as this is done by a private agency, this benefit can be continued by the staff member by paying premiums even after retirement as a personal enrolment rather than something orchestrated by WHO, as was the case during pre-retirement.
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WHO’s work in Timor-Leste: Past, present and future32 The health indicators in Timor-Leste are similar to other less-developed countries, with priority areas being communicable diseases, childhood illnesses, under-nutrition and maternal health. It has a very high fertility rate, hovering around 7, which is consistent with the extremely short birth intervals observed. A DHS indicated very low contraceptive acceptance also. The maternal mortality rate is also high with a figure of around 800 deaths per 100 000 live births, with less than a third of the deliveries having trained birth attendance. A compromised physical state of the majority of expectant mothers stems from a combination of malnutrition, close-spaced births, malaria and possibly other diseases or conditions. Accidents and acute trauma also remain high. A number of key determinants contribute to the continuation of poor health: education levels are extremely low which impact on the knowledge, skills and behaviours of the community; limited trained health workforce at the subdistrict level; housing is basic, unregulated and conducive to harbouring disease; lack of water and sanitation influences inappropriate behaviours and hygiene practices; limited infrastructure including roads, transport, communication etc; public security, law and human rights remain fragile and impact on health and well-being. The period 2006-2007 was the most turbulent with a humanitarian crisis in the country, with socio-political uncertainty and increased violence despite continuing support by United Nations and donor communities. However, the process of development of the health sector continued and MOH staff demonstrated dedicated hard work. During this recent crisis period, the MOH was still able to supervise and direct public-health interventions as well as undertake preventive and curative health services for the internally displaced populations. This could be attributed to the training of the national health personnel vigorously supported by WHO during the past few years in the process of capacity-building.
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Dr Alexander G. Andjaparidze, Temporary International Professional – Technical Officer (Viral Hepatitis), WHO-SEARO, 15 September 2011 99
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In addition to day-to-day activities, during 2006-2007, with the help of partners, some of the major achievements of the MOH were: healthsector policy developed and associated legislation published; national and district output indicators established; district health plans elaborated annually as basis for MOH plan and budget; autonomous Medical Supply Store established; Health Sector Human Resource Development Plan adapted; and various national strategies developed and published. Timor-Leste’s PHC approach is based on essential concepts such as universal coverage; a balanced mix of services; effectiveness of services; cultural acceptability; and maximum community involvement and effective intersectoral collaboration. Health-care delivery in Timor-Leste consists of one National Hospital, four Referral Hospitals, 65 Community Health Centres, and 174 Health Posts and Mobile Clinics, supplemented by other nongovernmental support structures. Most Community Health Centres and Health Posts are newly constructed and more than 80% of the population live within 70 minutes’ walk from health facilities. For those who live far from health facilities, service is provided twice a week by mobile clinics. A major emphasis of the MOH is capacity development of the national health workforce with special attention to public health within a decentralized policy. In the process of decentralization, major emphasis is on the involvement of community, although community involvement at this stage is still very limited. Cuba has been a major provider of human resource assistance. In addition to the deployment of about 300 doctors in the post-2006 period, more than 900 high-school graduates were also sent to Cuba to study medicine. It is expected that the number of doctors by 2013 will be around 1000. Timor-Leste stands to gain significantly from oil and gas revenues of over US$ 1 billion during the period 2005-2009. Though this expected windfall will provide much-needed resources for the implementation of the National Development Plan, it poses an important set of challenges to the government in how to distribute these in a strategic way. The current annual budget of the MOH is US$ 25.7 million. The Health Sector Strategic Plan 2007-2012 was completed in April 2007, and consists of a Basic Package of Services, Hospital Service Package and Public Health. 100
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Discussion (1) The forerunner of the WHO office in Timor-Leste was established in November 1999 and the Interim Administration of the UNTAET managed all administrative activities of the country. A full-fledged WHO country office was established in January 2000 and Dr Alex, the speaker, remained the WHO Representative to Timor-Leste until his reassignment (2008) as WHO Representative to Nepal. International donors and NGOs dictated everything in the early stages from 1999 to 2001. The MOH was fledgling and had two sides to listen to, i.e. the UNTAET administration and WHO, and some confusion ensued. WHO’s initial closeness to the MOH was perceived as lessening over time as other advice was also offered by other partners. This WHO-centric opinion maybe not be quite authentic when viewed from the government side, for this perception may have been a consequence of the effort by the government to assert some independent thinking. The Independence of Timor-Leste was accomplished in 2002. The nationals would like to call it the handover of administration to the nationals. The local belief is that they had independence since 1976, and that the 2002 event was a restoration of their independence. In 1999 there were only 16 local medical doctors left in the country, and so for a new nation, this was a big health challenge. There was no medical plan; only the activities of the international NGOs dominated the whole scope of health services delivery. With the handing-over of independence, this approach needed to be overhauled towards national control of the health system, and so in 2001, the government began, with the help of WHO, to reclaim the system for the nationals. This was done based on a good assessment of the resident international NGOs’ comparative capabilities. But as expected, there was too much conflict of interest to be forfeited in a change of the status quo. There was a strong petition by the international NGOs against this proposed change, which was
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ultimately rejected. The leadership was thus given to the Timorese. Once this change was done, health centres were established all over the country for public health-care services and five regional hospitals were established, and the Word Bank helped refurbish and upgrade the national hospital. (5) In 2002, there was high health-staff turnover. There were educational and training opportunities opening up to local health staff, and so they were let go for the sake of a better future for them and the country – with the hope that they will return after training. It was thus a very lean system then with the few people available taking on leadership of multiple tasks, and chairing many working groups. The crisis of 2006 resulted in both political and economic setbacks for Timor-Leste and saw the emergence of a huge number of internally displaced people and attendant health and security issues. It was during this period also that the per diem of the health workers was increased as a matter of new government policy of post-2006, and so given the increased costs, some programmes were shelved. The arrival of about 300 Cuban doctors in the country in the post-2006 period changed the map of relationships that the government had with WHO, particularly a change toward an increase in the clinical based health services and somewhat a setback to the public-health approach WHO tried to advocate. The previous nurse- and midwife-based systems began to be more physician-based, with public-health actions being increasingly relegated to only campaign types of action. Portuguese becoming the lingua franca also signalled some practical setbacks as regards the implementation of health activities, due primarily to the language issue. Case definitions for prescribing, and health bulletins for health information all needed changing. Yet, the future call would be for more coherence and the national health workforce to be acting as one national team with a common vision, and the need for the
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application of systematic and rational planning approaches to prevail. (9) Many lessons have been learned from this experience of TimorLeste: Have to take control of the local system from expatriates as soon as possible. Need to measure your capacity, including money, material and staffing. Make optimal use of the international presence. Let NGOs have a rational niche to work from, under national control. Train national staff under a rational human resources plan for capacity development.
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Returning to the fold: Assisting the recovery of drug users back into mainstream society33 It is very difficult for many recovering drug users to come back in the fold of normal life due to endemic stigma and discrimination as a result of past behaviours. To test the possibility of assisting recovering drug users, a project funded by UNESCO was tried to assist drug users to get back to the community through vocational education, skills-building and broader aspects of education. The first step was to identify an NGO in India to undertake this pilot project. A Kolkata-based NGO called Society for Community Intervention and Research was identified and the NGO accepted the challenge to participate in what became a social experiment. The NGO’s mission was to assist those who had fallen into the lowest rung of society and through various means to help their client group to reach higher. With low literacy and no regular job to hold onto and earn a living, many had fallen between the cracks of society, remaining deeply impoverished and marginalized. Lacking skills, dependent on drugs and experiencing numerous problems, many also became unemployed. To move from unemployment to employment and then address all the issues of dealing with recovery from drug use would require long-term commitment from many stakeholders. There has been inadequate emphasis upon vocational education and skills-building as being a critically important contribution to the recovery process. There have been increased efforts upon the need to introduce drug substitution therapy. But full recovery from a history of drug use (whether short- or long-term) is more than simply providing medicine. For many drug-dependent users, finding the money to sustain their habit becomes a full-time job. Only providing medicine and not the other supplementary aspects for a full-person recovery often results in multiple relapse episodes. Data collected from the NGO indicated that 90% of the clients on OST, or those who had sought a package of harm reduction services for being abstinent from drug use, had relapsed.
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Mr Gary Reid, Temporary International Professional – Harm Reduction (HIV/AIDS), WHOSEARO, 22 September 2011
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Part of the process was to meet various potential agencies in Kolkata to support this innovative project, and a common tagline used in all of the discussions was “can we prove that society is forgiving?” when helping recovering drug users to return to society. Gary approached many organizations that had worked on training programmes primarily for poor people or the disadvantaged, but none had worked on training and assisting those that were recovering drug users. Many of the agencies were uncertain that the drug users could recover and become useful members of society. In the end all agencies approached came forward with support and contributed to the programme. A set of basic criteria for selecting candidates was developed, such as not taking drugs for the past six months, regularly taking OST for five months, self-motivation, recommendations from counselling etc. With these basic criteria, about a thousand persons applied. UNESCO provided $60 000 of funding for 200 persons for a skillsdevelopment programme for 30 months. To better understand the target population a study was undertaken involving 143 participants. Of the 143 ex-users, 15% had no schooling and 45% had studied only up to grade 4. Forty percent could not read and 31% could not write. Only 27% had a regular employment but the majority of these were peer educators with the NGO. Ninety percent had employment prior to becoming drug-dependent. Ninety percent believed vocational education would help them to earn an income. Over time, 42 training agencies were lined up to assist. As part of the project to improve literacy among recovering drug users, classes were conducted inside the premises of the NGO which also had a school established for children from the nearby slum. Many of those enrolled in the project required counselling and the NGO offered this service. Some of the recovered drug users took on the role of being taught how to teach others and it fuelled their self-esteem that they were also able to contribute to the potential success of the programme. Sixty-one of those enrolled completed vocational courses, and 34 of them got employment. Sixty-three were still in training programmes. Skills included being taxi drivers, mobile phone repairs, computer repairs etc. Twenty-eight were enrolled to read and write better. Ten enrolled into teaching literacy. Twenty-two received microcredit and loans that ranged from 5000-10 000 rupees. Most of those that received microcredit had not been able to get loans as they did not have bank accounts. Only three of those receiving microcredit relapsed. 105
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A key message is that prior to the project, 90% of drug users accessing the service of the NGO relapsed into drugs. For the 196 beneficiaries of the project the relapse rate was 11%. The programme ended in May 2011. The Joint United Nations Programme on HIV and AIDS was very impressed by the result of the pilot programme and with some donors a 10-month extension has been obtained. Assisting drug users not to re-enter the high-risk environment of injecting drugs is viewed as an HIV prevention approach. Ultimately ownership of such work should be by the government. It is hoped that this model is a template for others to be experimented with in other parts of the country and in the Asian context. This experiment indicated that if people are given a chance with support, change is possible for those dealing with their drug dependency. The big challenge is how to sustain the momentum of what has been achieved. Society’s mindset is also still not geared to fully accept these rehabilitated drug users into its fold. Stigma still persists. We need to continue this effort and see how policy-makers can be brought into the dialogue. Ideas and mindsets will have to evolve and with new evidence, many ministries may feel that this area may also be taken up as part of social development; currently ministries are more financially comfortable than they used to be, and they may be encouraged to take part in this exercise which will have a telling effect on society.
Discussion and comments Drug dependency is a medical condition. While the taking-up of drugs may relate to experimentation and teenage fancy, thinking that this is only a temporary or a passing phase is a fallacy. The deeper issues of social caring need to be visited. How caring and forgiving is our society? How demanding should we be of our loved ones so that the so-called social pressures and expectations don’t overextend mental capacity that drives the not-so resilient ones among us down to the “comfort” or anaesthetic that drugs provide? Consuming drugs for some is a sure way to leave the pain of the world behind! To walk away from this discussion and related actions would be a travesty of society’s ethical and moral responsibility. Are we a forgiving society?
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Adolescent health promotion – engaging with parents34 35 One fifth of the world’s population, a total of 1.2 billion people, are adolescents, and 85% of them are in the developing world. Adolescence is a time of unprecedented promise – and peril. During the second decade of life, young people can encounter a rapidly widening world of opportunities, as they gradually take on adult characteristics in size, sexual characteristics, thinking skills, identity and economic and social roles. Too often, however, the widening world also exposes adolescents to serious risks before they have adequate information, skills and experience to avoid or counteract them. Their level of maturity and social status is no match for some challenges, unless they are provided with support, information and access to resources. Without help, the consequences of health-risk behaviours in adolescence can be life-threatening and lifelong. Nearly two thirds of premature deaths and one third of the total disease burden in adults can be associated with conditions or behaviours that begin in youth. To protect and preserve our subsequent generations, no better investment can be made in the developing world than to foster promotion of adolescent development and prevention of health-risk behaviours among adolescents. In 1997, a Study Group on Programming for Adolescent Health jointly convened by WHO, UNFPA and UNICEF issued a technical report, Programming for adolescent health and development,36 that proposed a framework with five major intervention areas to promote healthy development and prevent and respond to health problems: creating a safe and supportive environment; providing accurate information; building skills; providing counselling; and improving health services. The framework cites “home” as the first intervention setting and “family” as key players for intervention delivery. The importance of the 34
Dr Rajesh Mehta, Temporary International Professional – Child and Adolescent Health, WHO-SEARO 35 Dr Neena Raina, Regional Adviser – Child and Adolescent Health, WHO-SEARO 27 October 2011 36 Programming for adolescent health and development. Geneva, World Health Organization, 1999 (WHO Technical Report Series No. 886). 107
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family environment was clearly affirmed as central to healthy adolescent development and to the prevention and treatment of health problems. The report notes that the family: provides support and love; promotes moral development and a sense of responsibility; provides role models and education about culture; sets expectations; negotiates for services and opportunities; and filters out or counteracts harmful or inconsistent influences from the social environment. Parents’ roles can be organized into five dimensions, each of which has specific influences on adolescent health outcomes: 1. Connection – love; 2. Behaviour control – limit; 3. Respect for individuality – respect; 4. Modelling of appropriate behaviour – model; 5. Provision and protection – provide. These parenting roles, building on those earlier in childhood, are played out in daily interactions with adolescents. Parents are usually unconscious of the individual roles and of their potential consequences on health and development. Here are some details on the roles: Connection: A positive, stable emotional bond between parents and adolescents is an important protective factor for adolescent heath and development. Connection is made up of behaviours that convey to adolescents that they are loved and accepted. It is a dimension of the parent–adolescent relationship that is otherwise called warmth, affection, care, comfort, concern, nurture, support or love. It is also important to consider the adolescent’s contribution to the bond. The empirical evidence shows that this sense of connectedness to the primary caregiver (parent or another significant adult in the family) is vital to successful adolescent development. In the United States, adolescents who reported feeling connected to their parents were less likely to consider or attempt suicide, be involved with interpersonal violence, smoke cigarettes, use alcohol or have sexual intercourse at a young age. These conclusions were repeated again in the Caribbean where adolescents aged 13-15 years who were connected to a parent were less likely to have had sexual intercourse, to experience rage or to be involved with interpersonal violence. Up until the age of 18 years, those who were connected to parents reported less depression and fewer suicide attempts.37
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Blum RW et al. Adolescent health in the Caribbean: Risk and protective factors. American
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Adolescents’ perceptions of feeling loved and of feeling supported are very important. Frequently conceptualized as “warmth”, this relates to the quality of the affective bond between parents and children and includes physical, verbal and symbolic behaviours parents use to express these feelings. One end of the continuum of “warmth” is represented by parental acceptance. The other end is marked by parental rejection, which can refer to the absence or significant withdrawal of these feelings or behaviours. Programmes to improve this aspect of parental and family connection and thus the mental health of children would do well to focus on improving their self-esteem and social competence. Behaviour control: This is described or otherwise referred to as regulation, monitoring, structure and limit-setting, and encompasses parents’ actions aimed at shaping or restricting adolescents’ behaviours. These actions include supervising and monitoring adolescents’ activities, establishing behavioural rules and consequences for misbehaviour, and conveying clear expectations for behaviour. Because of urbanization, the nuclearization of families and both parents going to work, supervision of adolescents in present times has decreased, both in well-to-do families as well as the those engaged in labour in the cities. Empirical evidence indicates that parental monitoring/knowledge is associated with a decreased risk of drug and alcohol use, decreased sexual activity, later age of pregnancy, decreased depression, decreased school problems, decreased victimization and delinquency and decreased negative peer influences. Monitoring was significantly predictive of lower antisocial behaviour.38 Programmes could focus on improving parents’ ability to play the behaviour control role on establishing rules, communicating expectations, and learning to exercise consistent and effective monitoring of adolescents’ behaviours. Respect for individuality: This involves allowing the adolescent to develop a healthy sense of self. Acknowledging and permitting this sense of individual worth (self-esteem) and identity is important for all adolescents, regardless of whether cultural expectations ultimately put more emphasis on being part of a collective, as in parts of Asia, Africa and Latin America, or Journal of Public Health, 2003, 93:456–460 38
Barber BK, Stolz HE, Olsen JA. Parental support, psychological control, and behavioural control: Relevance across time, culture, and method. Monographs of the Society for Research in Child Development, 2005, 70, No. 4. 109
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on establishing personal autonomy, as in parts of Europe and North America.39 40 41 Adolescents who feel that parents have consistently violated their individuality through disrespectful, controlling, manipulative or intrusive behaviours (referred to in the research literature as “psychological control”) have significantly higher rates of problem behaviours. Specifically, parents need to guard against being excessively critical of adolescents, invalidating their feelings, constraining their self-expression, and using guilt or withdrawal of love to manipulate compliance. Evidence indicates that adolescents (and younger children) who perceive their parents to be psychologically controlling (i.e. disrespectful of their individuality) have higher rates of internalized problems (e.g. depression, eating disorders) as well as externalized problems (e.g. risky sexual behaviour, substance use). Programmes need to help parents focus on respecting the individuality of their adolescents such as avoiding the intrusive behaviours of parental psychological control. Modelling of appropriate behaviour: “Social norms” are a set of idealized attitudes and behaviours that are considered acceptable in a culture or society. For adolescents, there are various sets of norms that influence their actions, depending on the social domain. For example, there may be one set of norms at school, another related to religious affiliations, and another set among friends. Most importantly, there are norms that exist at home. As individuals with enormous influence in all aspects of development, parents establish these norms within the household by their own behaviour and attitudes as well as interpreting the norms of the wider society. Adolescents consciously or subconsciously follow or adapt themselves to the behaviour and attitudes the parent has established within the home. Parents become role models - their behaviours and attitudes providing examples of how to behave in relation to many areas of daily life, including health.
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Greenfield PM et al. Cultural pathways through universal development. Annual Review of Psychology, 2003, 54:461–490. Kagitcibasi C. Autonomy and relatedness in cultural context: Implications for self and family. Journal of Cross- Cultural Psychology, 2005, 36:403–422 Spiro ME. Is the Western conception of the self “peculiar” within the context of the world cultures? Ethos, 1993, 21:107–153.
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Evidence indicates that parents who make healthy choices themselves are linked to better skills and attitudes around the academic achievement, employment, health habits, relationships, communication, coping and conflict resolution of their children. The evidence is particularly strong to indicate that, when it comes to major issues involving morality, adolescents are likely to hold opinions and attitudes similar to their parents. Much of the research relevant to parents’ attitudes and behaviours influencing subsequent behaviour by adolescents focuses on substance use, and the correlation is high and repeatedly documented. Programmes can aim to encourage parents to adopt attitudes and behaviours that are supportive of health (e.g. non-smoking) and also reflect prevailing social norms. Provision and protection: The provision and protection role of parenting refers to parents’ provision of the resources that they are able to provide, and seeking out resources when they cannot do so. It entails efforts by parents to seek out relationships and opportunities within the community that can supplement what the family is able to provide. New research indicates that adolescents from developing countries associate this parental role with being loved.42 Examples include participating in school functions, and identifying opportunities for their adolescent to develop the competencies necessary for adulthood, that could contribute to eventual income-earning and/or civic functions. Sometimes this role is akin to creating “social capital,” enlisting the support of other caring adults, such as teachers, extended family members, village elders and coaches, who can supplement what parents provide in the way of support, guidance, information and opportunities that adolescents need to fulfil adult roles. Research linking this role to adolescent behaviours and/or health outcomes is limited. An exception is the area of parental academic involvement, such as helping children with homework and participating in school activities, which, in the United States, has been shown to increase adolescents’ academic aspirations, and, in affluent families, also achievement. Further work has found that parents of poor families were less likely to be involved in their child’s academic activities due to the cost of transportation and difficulty in rearranging work schedules. Another aspect of the protection and provision role is closeness with which a family is
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McNeely, Clea, Barber BK. How do Parents Make Adolescents Feel Loved? A Cross Cultural Comparison; Paper prepared for the conference Reducing Adolescent Risk Behaviour through Strengthening Families, Bellagio, Italy, 2006 111
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linked with outside institutions. As many countries are in the midst of rapid urbanization, the traditional bonds that existed in rural societies based on historical connections are breaking down. Poor parents have much less resources than the rich to engage in such protection. But in consideration of the United Nations Convention on the Rights of the Child, the responsibility for the provision and protection of all children rests with the state. Therefore programmatically, the best place to intervene would be in promoting poverty reduction and income security programmes for a lasting solution. Community-level programmes can also assist parents in identifying their adolescents’ needs, and resources outside of the family that could help to meet them. In the setting of the home environment, all five of these parental roles are interconnected in that parents perform them all, simultaneously, to one degree or another. However, given limited time, funds and parental willingness or ability to participate in programming efforts, it is sensible to focus on the key roles that have been identified in the research findings as they relate to specific domains of adolescent health and development. Existing programmes presently offer parents the following: Information: on the overall project objective, such as information on sexual and reproductive health, signs of substance use, or the availability of community resources. Some also offer general information on adolescent development, with the aim of assisting parents to have reasonable expectations of their adolescents. Skills: Enhanced, especially on communication skills, such as talking with adolescents about sex, listening to adolescents’ concerns, or talking without shouting. Support: Parents’ need for emotional and/or logistical support, either providing it or referring parents to community organizations/individuals for support.
If there is one consistent message – from research and from programmatic experience – it is that parents are important for promoting adolescent health. Assisting parents to assume their roles is feasible and leads to results in developing countries.
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Discussion (1) In the lunchtime seminar an interactive presentation was used based on the above technical contents and professional experiences of the author. The presentation included multimedia clippings available from various sources to illustrate key parenting behaviours. The participants took keen interest and were able to relate to their personal experiences in dealing with their own adolescents at home. They agreed that parents are an important resource for promoting healthy behaviours and preventing or reducing risky behaviours among children and adolescents. Major adolescent health challenges at present include eating behaviours (responsible for both under-nutrition and over-nutrition), decreased physical activity (leading to obesity and NCDs), injuries (sports and automobile accidents), violence (including self-harm and suicide, and hurting others), unsafe sexual behaviour (sexually transmitted infections, HIV and unwanted pregnancy) and mental health issues including substance use (like alcohol, tobacco and illegal drugs). For preventing such behavioural conditions a multisectoral approach would be very effective and necessitates collaboration among various units within WHO to develop strategies for reaching out to adolescents directly as well as indirectly through their parents and families for promoting/reinforcing healthy behaviours and minimizing risky behaviours. (Further Reading: Helping parents in developing countries improve adolescents’ health: World Health Organization 2007)
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Life in the country office: Baptism by fire — learning the hard way43 Mine was an unplanned journey into the work of WHO in general and to Myanmar in particular. Getting to WHO has been a meandering process that did not have at its basis a specific drive to be a staff member of the Organization. It was a culmination of several propitious events. It was just by chance that I worked for the malaria control programme in my country and later on in WHO. Early in my career in the 1980s I worked in remote rural areas without malaria. In 1988 a professorresearcher from a research institute for tropical medicine visited the place where I worked to investigate the potential source of malaria infection of a Western tourist who was diagnosed with malaria in a medical centre in Metro Manila. She apprised me of the importance of malaria as a publichealth problem. She told me that working in malaria research would be a stream that would help me chart a future. That event opened to me the “malaria world”. In hindsight this seemed so prescient, for the prediction did indeed come to pass. After further coaxing by that professor-researcher, I joined her team as clinical monitor in malaria research. Later on I transferred to the malaria control programme in a province. After that I immersed myself in this programme, moved up the ladder and ultimately I became the Division Chief, Malaria Control Services, Department of Health. The launch of Roll Back Malaria (RBM) in 1998 by WHO, UNICEF, the United Nations Development Programme and the World Bank opened up more opportunities to work in WHO. I did not know about it until a colleague from the research institution informed and encouraged me to apply for Global Health Leadership Fellowship to be assigned to the RBM Department in WHO Geneva. I did so with no anxiety about whether I would be accepted or not. The application was quite out of my mind since I was too busy being the Programme Manager, with numerous added responsibilities including
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Dr Leonard Ortega, Regional Adviser – Malaria Control, WHO-SEARO 17 November 2011
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chair of the technical working group for re-organization of public health programmes at central level of the Department of Health. With massive reorganization underway and being a good soldier, I was the first to volunteer to be assigned to a regional office where I thought I would become the regional director in a few years’ time. It would also give me a chance to easily visit my aging parents during weekends. I was almost ready for re-assignment when one Friday afternoon my office received a call from WHO Geneva. I returned the call the following week, and after several exchanges of emails, I went to Bangkok for the interview. A few weeks later, I got my contract as a technical officer and not as a fellow in RBM Department. Here was my entry into WHO! I spent three years in HQs initially at P3 and later at P4 level. My supervisor appreciated my contribution so much that she did not let me go to a P4 post in WHO-Indonesia. It was a good time in Geneva, but something told me that country-based work would be more rewarding. My supervisor fully supported me when the opportunity to work in WHOMyanmar as P5 came up. The eight-and-a-half years I spent in the Myanmar country office are unforgettable, as it was there I grew more as a staff member and as a person. I grew as a politically savvy individual who learned to discern and work through the social nuances of culture and political sensibilities. From the first moment of entry into the country at the Yangon airport to the days spent in the office, contact with officials and friends on the job, and the management of work in office and outside it, I learned the ropes of how to survive and be productive in an environment very different to mine. In WHO, it is about getting things done, not making excuses about the customs of a system or people. There are always avenues where work can be made to move and get things done. At the office my first shock was the discovery that at the country office, we don’t only do those things that are in the post description. Given the shortage of staff, our plates will be served with much more than we are officially expected to do. However, unlike getting more food, getting more work can be distressing. But soon we learn that this is a necessity and learn to accept and adapt by proactively learning about these other responsibilities. A thoughtful and knowledgeable WHO Representative (WR) with good PR qualities and empathetic attitude helps to inspire the sense of moral responsibility that WHO must exercise to the nations it 115
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serves. My WR was such a person who took me sensibly through the administrative and political hurdles and tripwires I might encounter on the way, with a clear notion that all countries have their own peculiarities, and it is our role as staff members to be vigilant and aware. For example, before writing a report, we need to anticipate the nuance of what is expected and work towards framing our recommendations that will be in sync with the ways such requests and suggestions are made and thus be accepted. For understanding such nuances and what is to be expected, there is a need to spend time getting to know our counterparts to understand the culture and mores. A sixth sense is necessary to understand the local mindsets of officials in any government more closely as a person, and how they would react to programme activities. We need to assume an attitude of flexibility even as we hold onto WHO’s rules of procedures. The way we use our funds for programme support can be a tricky aspect of our work. Being aware of the realism of the WHO budget -- who owns it and how can we maximize our ownership without hurting national sensibilities – is an important diplomatic skill to be learned. Certainly, we cannot sacrifice our role of accountability. Yet, we can work towards being politically correct in our effort to be productive and effective. Every culture has its preferred words and phrases that can anger or endear. Thus the need for using the right words and the right language/phrases cannot be overemphasized. This is needed to reap the most of our proposals and recommendations. So there is no excuse for not learning the local culture, particularly those that differ from your own sensibilities. Overall, WHO country office success depends on how well we build trust with the MoH, which is our port of entry to the country. Lobbying and working behind the scenes on requests so that we are in line with national needs is important. Sometimes, key decisions maybe made by the time we come to the table, where there can be little substantive discussion, and the asking may just be a formality. In situations of emergencies, there has to be some relaxation of the rules, but for most of the time we must work within the dictates of a national system. In the cases of SARS, the tsunami and Nargis, different ground rules for WHO support did apply, however, when these emergencies were no more, we had to revert to regular working procedures. 116
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WHO is well respected in the country. They count on WHO to provide the closeness of a friend which countries never get from another agency. WHO is unique in this as we deal with less rigid business rules, and because MOH is our partner in all we do. All country experiences are enriching and it is a goldmine of experience. But unfortunately, with the transfer of staff members from the country postings, much of the lessons we gather in our country office experiences are lost to other incumbents, for these are not logged as inputs to new staff orientations. We need to keep a log of our experiences as lessons for others. At the least, these lessons could be reflected in our assignment reports rather than just reporting the technical work we did. Social life in the country is also so much more rewarding than RO or HQ. There is the sense of camaraderie in the country office and work seems more integrated to give a sense of team. There is more interaction and collaboration with other UN colleagues. Also more common exposure to social life together by way of eating together, travelling to common places together, and just even having parties on weekends, helps to build and strengthen these links. It may be right to say that this type of interaction is comparatively very little in RO and HQ staff relationships.
Recommendations: (1) (2) Must have a career development advisor in WHO. National staff need to be made aware of other cultures too so that they can work best with the different nationalities that work in WHO. Do more at country offices to build rapport with the national authorities, and build trust, for transparency and pro-activeness.
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To clinical governance through clinical audit44 Background and History The medical or health audit is a concept developed to evaluate health outcomes for the purpose of improving service quality. It is by now accepted widely that medical or clinical audits are a necessary part of modern health-care management. It was during the time of the Crimean War of the nineteenth century that one of the first medical audits was undertaken by none other than Florence Nightingale, who linked the high mortality among injured and ill soldiers to the appalling conditions of sanitation in the barracks. It was her method of good hygiene and sanitation coupled with meticulous recordkeeping that unravelled the connection and made doubting British doctors of that time believers in her methods of outcome management. The next reference is to the work of Dr Ernest Codman (1869-1940), a Boston surgeon whose “end result idea” kept him recording and following-up for surgeon’s errors of all patients who underwent surgeries. This led to the establishment of the American Hospital Standardization Programme. The UK white paper on working for patients (1989) was the first move in UK to apply standardized clinical audits as part of professional health care.
Definitions Medical audit is “a systematic critical analysis of the quality of medical care including the procedures used for diagnosis and treatment, the use of resources and the resulting outcome and quality of life for the patient." Clinical audit is “a quality improvement process that seeks to improve patient care and outcomes through systematic review of care against explicit criteria and the implementation of change.”
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Dr Sunil Senanayake, Regional Adviser – Health System Management (HSM), WHO-SEARO 1 December 2011
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Clinical governance is the term used to describe a systematic approach to maintaining and improving the quality of patient care within a health system. This definition was adopted by NHS UK as follows: “A framework through which NHS organizations are accountable for continually improving the quality of their services and safeguarding high standards of care by creating an environment in which excellence in clinical care will flourish” Figure: Framework for clinical governance
Clinical governance is the confluence of the supportive elements of education and training, clinical audit, clinical effectiveness, research and development, openness, and risk management. Clinical audit is a tool to improve quality of clinical care given to patients which ultimately supports the framework for clinical governance. Patients, hospitals, care givers as well as community are benefitted by clinical auditing and it needs to be implemented in the SEA Region as a continuous routine programme of hospitals. In the governance idea, four concerns were looked at: evaluating the use of resources, hospital service design, protecting patients, and security of service to the public. All these needed to be done to improve quality of care, and subsequently in the UK, led to hospital accreditation and CME, the keeping of clinical records, and providing of national awards for quality of care as incentive. 119
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Discussion (1) The implication of not having these standards was a concern raised. There are no “Asian standards” for hospital accreditation, and so we use Western/European standards. But perhaps because these are not enforced, there is non-use, nonacceptance, lack of ownership, and several other necessary factors uncoordinated resulting in medical audit or clinical governance not happening effectively in many Asian countries. To make audits beneficial, other factors of the system, such as good medical record-keeping practices, accountability and medical ethics need to converge. Research has shown that 80% of clinical diagnosis errors and clinical care errors can be reduced by enforcing clinical audits. Aren’t clinical audit and quality assurance the same thing? Are these just differences in jargon? It was felt that clinical audit was a tool for quality assurance. The asymmetry of information available from all providers hinder assurance of harmony in the system, and many times the lack of accountability of the provider can stymie the system. Bad clinical practice will be revealed if clinical audit is enforced, and so in health systems that don’t value accountability high on the agenda, weak recordkeeping may be used as an excuse to refuse auditing and hide the offences of bad practice. Sometimes, when enforcement is lax, the record-keeping can be just lip service and records can be doctored to show good performance when in fact it may not be so. In our culture where the doctor is king, there is a lack of sharing information with the patient just because it is the accepted social hierarchy that is being played out and both doctor and patient are sometimes accepting of this dichotomy with the patient accepting this superior physician behaviour as what it is meant to be – and the patient having little recourse to a rights process in case of negligence. But with the information age, and the pervasive internet, patients are questioning the relevance of what is prescribed. Thus, developing countries are at the crossroads to a changing of attitude in the doctor–patient contact relationship. In the West, this is well on the way towards acceptance, but in developing countries, it still has a long way to
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go, for the conventional wisdom of our traditional societies still stands in the way. But patient charters being advocated will add more to the need for doctors to be more accountable to the patient and to the integrity of professionalism they would need to maintain to be accepted as credible. Litigation is also on the rise, as more cover needs to be built by physicians, they may order relevant but not necessarily important tests/investigations to manage the case, which may inflate the hospital bill. But we need to remember quality always has a cost and there should be ways to cover it. (4) (5) There needs to be a strong accountability system built into the system of accreditation. The medical records are not written by the doctor, and so the question is why they don’t do it themselves. Maybe the legislation or requirement is very lax. And the medical councils are not strict on this? Perhaps there has to be stricter licensing to make it compulsory and mandatory. Otherwise the audit will not be useful or enforceable. For this, minimum standards need to be maintained. What is the incentive for institutions to be accredited? For clinicians to comply, they must have an incentive to do so. In most of the developing countries, out-of-pocket expense is the rule and so without strict regulation, there is no incentive to stop the flow of this money into the clinics. So who will have to steward this control? Who will have to set, for instance, the minimum patient time as standard practice, so that physicians will not take patient consultations as a crowd-clearing exercise? But in the situation of a patient–physician contact, social contexts are also different, and presenting medical conditions may be also different in different patients with the same ailment. How will provision for such differences be accommodated in the standard procedures that are framed? Will the government (MOHs) or medical associations take the challenge? In the meantime, the poor get poorer, having to paying the exorbitant bills as out-of-pocket payments that exhaust their meagre disposable income. How can WHO help countries to see the importance of medical audit as a tool to promote health-service quality? This question is
(6)
(7)
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very important as we pursue our effort to assist health-systems strengthening. We need to promote advocacy for this, with a good grounding of the arguments for the benefits of audits, this will help in introducing the tools needed to implement them. Other departments and technical units in WHO should also be involved in this area of medical audit, for the subject is so crosscutting. (8) What are the effects and side effects of audits in our Region? Will people change behaviour, or what other associated factors must be streamlined for this behaviour to be seriously adopted? At present, the fact that in most instances the errors that occur in clinical care do not get logged into the maintained records indicates the practice of evasion. In such a situation, how could we have, for instance, a count of how many mistakes are made in a year as a measure of performance? But then, even if mistakes are found, the question of who will enforce – take action – remains. The record-keepers are physicians’ subordinates anyway, and they will not report any faults for fear of their supervisor’s action. There has to be a lot of advocacy and getting the medical councils on board. Such a step would reduce the bargaining power of the provider. But without some separation and immunity from penalty built in, record-keepers won’t touch the controversial areas just so stakeholders are kept happy.
(9)
(10) Why are Western countries able to do this and not developing countries? The answer may be the maturation process. In Europe, medical audits have been on the table since the middle of the nineteenth century (as Florence Nightingale’s story depicts) and the governments there spend a lot of money to establish standards and protocols so providers are compelled to comply. Negligence is investigated and action followed up. This is done not to blame, but to have accountability to be the right thing for the people that are served. Governments of developing countries have no seriousness on this, so little money is spent. This is perhaps the weakness of developing countries’ incentives to push forth this agenda. Or could it be that we just import a foreign tool or concept and we are reluctant to own it? Perhaps we need to grow our own methods in this Region. Or perhaps we are trying to introduce these tools too fast without 122
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understanding that this can only happen as a gradual process. Perhaps there should be a much better understanding and awareness of the system of associated factors that will enable audits to work, and emphasis on the establishment or resolution of these factors before the core concern of quality of care will change for the better. Thus clinical governance is the confluence of all this, the workings of which seems still a long way from our reach. (11) Patient education on patient rights need to be done – even with a patient charter available, this has to be the promotional process that needs to continue. (12) Medical schools must include this as a subject in the undergraduate education. Could a peer review audit process be established taking random cases of real situations? This needs to be used in health-care institutions and in teaching institutions, without implying this activity to be an inquisition process but rather as efforts toward learning and reform. (13) Leadership in health institutions need to be very serious about this topic in the future. In a globalizing world, this can have implication for the quality of practitioners who are now increasingly crossing borders also, especially in the expanding area of international trade in health services and health providers, protecting the export quality of this resource to other countries – just like other goods and services.
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Waist and hip circumferences as risk factors45 Over the past decade or so, due to the availability of a rich variety of foods, the technology to enhance its maintenance of quality, and the increasing purchasing power of people, diets and lifestyles have rapidly transformed with significant impact on the health and nutritional status of populations. Along with this change comes an increased consumption of energy-dense diets high in fat, particularly saturated fat, and low in unrefined carbohydrates. There is also a decline in energy expenditure associated with a more sedentary lifestyle, enhanced by the increase in motorized transport, home labour-saving devices, the phasing out of physically demanding manual tasks in the home and workplace, and more at-home leisure and physically undemanding pastimes that make us less outdoor and less active. Thus, obesity has become a major worldwide epidemic affecting more than 300 million people. WHO has established ranges of population nutrition intake goals. For example, total fat should range between 15%-30% of total dietary energy, while saturated fat should provide less than 10% of the total dietary energy. Total carbohydrates should provide between 55%-75% of the total dietary energy while the goal for protein intake should be between 10%-15% of total energy intake. Based on available statistics, there has been an overall increase in per capita dietary energy consumption between 1990 and 2007. Cereal continues to provide the major portion of the dietary energy intake in most SEA Region Member countries. Obesity reflects the accumulation of potentially harmful levels of excess body fat. It is also an important risk factor for type-2 diabetes mellitus (chronic disorder of carbohydrate, fat, and protein metabolism). In the “pear-shaped” form of obesity, there is greater lower-body fat, primarily observed among women; in the “apple-shaped” form of obesity, primarily noticed in men, there is greater upper-body (android) type of fat distribution. Several SEA Region countries show a gradual increase in the prevalence of overweight/obesity in children and adults.
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Dr Kunal Bagchi, Regional Adviser – Nutrition and Food Safety, WHO-SEARO 8 Decvember 2011
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Surveillance to quantify and track chronic diseases and their risk factors is a key component of any NCD/chronic disease action plan. Body Mass Index (BMI) is used as a tool to classify degrees of generalized obesity: overweight/obesity. BMI is defined as weight in kilogrammes divided by the square of height in metres (kg/m2). BMI remains the most popular measure used to assess overweight and obesity; it does not separate fat mass from muscle mass and is highly correlated with both adipose and muscle mass. WHO has developed a classification of overweight and obesity in adults based on BMI. Asian populations generally have a higher percentage of body fat than Caucasians of the same age, sex and BMI. The proportion of Asians with risk factors for type-2 diabetes and cardiovascular disease is substantial even below the existing BMI cut-off of 25 kg/m2 for defining overweight. BMI cut-off points for different Asian populations have been suggested as: observed risk from 22-25 kg/m2 and high risk from 26-31 kg/m2. Additional intermediate cut-off points as trigger points for public-health action against overweight and obesity along the BMI continuum are: 23.0/27.5/32.5/37.5 kg/m2. Several types of charts using different standards are available for individuals to identify their BMI values. Abdominal obesity reflects increased amount of intra-abdominal fat including visceral abdominal tissue (VAT). Measures of VAT are strongly correlated with numerous cardiovascular disease risk factors. Abdominal obesity is generally assessed by either the waist circumference (WC) or waist-to-hip ratio (WHR) measures. Increase in WC and WHR likely reflect increased VAT and hepatic fat. Even with “normal” BMI those with increased WC or WHR can have a several fold increase in cardiovascular disease risk and premature death. Asians have an increased metabolic risk at lower WC and WHR than Caucasians, probably because of higher body fat and visceral adipose tissue. Clinical evidence suggests that the association of diabetes with central obesity is stronger than the association with general fat. WC cannot distinguish abdominal subcutaneous fat, total abdominal fat and total body fat. Other indicators of body fat are: sub-scapular/triceps skin-fold ratio has been used to describe central versus peripheral obesity; WHR and the waist-to-thigh ratio have been used to identify upper versus lower body obesity; waist-to-height ratio, and abdominal to mid-thigh girth have been developed on the basis of a variety of criteria. These ratios are difficult to
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interpret biologically, are less sensitive to weight gain, and have statistical limitations. Techniques to measure waist and hip circumferences were demonstrated and several WC and WHR values were presented.
Discussion The presentation provided information on various food groups and tips on healthy eating along with nutrition information on common food items available at the Regional office. We need to use more dietary energy consumption, not from sugars and condensed stuff. Vegetables and cereals are good for chronic disease control. WHO standards say it’s ok to have 15%-30% fat in our diets. Carbohydrates about 55%-75%, salt 5 g, fruits and vegetables 400 g per day, and protein 10%-15%. 7200 cal are equal to 1 kg of weight, and that is achieved by consuming just 20-30 calories more per day for a year. Physical exercise is not enough to lose weight; there must be reduction in diet. It’s a math equation ultimately of balancing the calories taken in versus those burned off. Good general advice would be: Use whole grains and eat a variety of foods and eat little portions each time, and learn to eat slowly. We must be more aware and more responsible. Portion size is different in different countries. So we must be aware of this.
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Risk management46 From the day we are conceived until the day we pass away, we all have risk. There is no risk-free place around us and no risk-free time in our lives. We are living either in low-, medium- or high-risk situations. Even if we are in the same place at the same time and doing similar things, the risk imposed on each one of us is different. As risk became the centre of our lives, we all are somewhat managing it on a daily basis. We are assessing and finding ways to reduce, minimize and manage it to have more positive and less negative impacts. Thus, risk becomes the first priority for us to manage it to be alive, survive and live peacefully. Knowing this basic logic and concept, risk becomes the basic principle in developing programmes and operational plans in the field of emergencies and disaster management. If we do not manage risk well, we may expose ourselves to it without being aware of the affects. It is important to understand first what we mean by risk? The logical explanation of risk in a simple term is “a potential level or degree of impact imposed as the potential or direct affect of hazards, depending on vulnerability and capacity to cope with it in a giving condition and situation”.
Risk Risk Capacity Hazard Developed Vs Developing Vulnerability
Global Warming Climate/ Planets Changes
Risk = Hazard x Vulnerability ----------------------------Capacity
Risk is directly proportionate to three major components – hazards, vulnerability and capacity – and can be calculated mathematically in a 46
Dr Vijaynath Kyaw Win, Technical Officer – Emergency and Humanitarian Action (EHA), WHO-SEARO, 15 December 2011 127
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formula to compare and find its degree/level of impact. The graphic is used to explain risk for easy understanding. The mouse wants to have the cheese placed in the mousetrap, which means taking the cheese and doing so safely. The trap is a hazard for the mouse as he could be killed if the action of taking the cheese is not well managed. If the mouse decides not to take the cheese, the trap – hazard – remains as neutral and not harmful. Vulnerability here is the proximity to the hazard. As the mouse approaches nearer to the trap, the vulnerability increases, and when the mouse moves away from the hazard, the vulnerability decreases. The capacity is the knowledge, skill and practice in preparedness and ability to manage the challenging situation. The mouse has a helmet to protect its head in case something goes wrong while taking the cheese. In addition, if the mouse has quickness skills in getting the cheese from the trap, then its capacity can be seen as high. But if the mouse is a novice having little experience in grabbing the cheese from the trap, then its capacity is deemed low. Combing the three major components, hazard, vulnerability and capacity, one can calculate the risk for the mouse. In this scenario, depending on the vulnerability and capacity, the hazard can be changed, from no effect/neutral to the deadliest harmful effect on the mouse. For example, on a scale of 1 to 10, the mousetrap as hazard is given 10 points because it has potential harmful affect – a death sentence. The vulnerability increases as the mouse moves towards the hazard: if the mouse decides to get the cheese and approach the mousetrap, then 10 points can be given to vulnerability as the mouse has reached the point of hazard. Now it is the capacity of the mouse that will determine the level of risk. Since the mouse has a helmet, it has something to prevent it from the harm. So, one can consider giving 5 points for capacity. If the mouse has good skills in getting the cheese, then 10 points can be given for capacity. With these figures, the risk ratio can be calculated. There are many other factors influencing the risk in a DRR programme. Major factors are climate change, global warming and the effects of development. Climate change and global warming impose changes in weather. As development kicks in, there are demands for more urbanization and people’s demand for higher standards of living that depends on increasingly sophisticated technology. By contrast, underdevelopment seen in many parts of the world relates to poverty and
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poor living conditions. All these contribute to changes in risk imposed on the population. After understanding the logic behind the risk, we can now look at hazards. In logical simple terms, hazard is seen as different types of harmful affects. In the real world, anything around us, human, animals, microorganisms, plants, objects, structures, geographic settings and even ourselves can changed into hazards depending on the situations and conditions. In time of an earthquake, damaged buildings become hazards; if a plane has engine problem and has to make an emergency landing, it can change into a major hazard to the passengers inside; micro-organisms that cause diseases can become a hazard to human beings and animals when infected. Even a friend who may change his behaviour and attacks can also become a hazard. All things we see and feel as normal in our daily lives can change into hazards at many time. That is why we can say we all are living in a risky world. Hazards can be natural or human-made; some are caused by a combination also. These can be classified also by type such as geology, meteorology, biology, technology, environmental, or social and political. Vulnerability can be explained as an exposure to the harmful effects that are known as hazards. The closer we are to the hazards, our vulnerability increases, like the mouse approaching the trap. Also, there are times that hazards can move towards us and we can have unwanted impacts from them, as in the case of earthquakes and tsunamis. And even we ourselves can increase or decrease our vulnerabilities, as for example when we drive a car slowly (low vulnerability) compared with driving at break-neck speed and increasing our vulnerability to having a crash and dying. To reduce and manage risk, the most important component is capacity. Capacity is the knowledge, skill and practice of people to understand, prevent, be prepared for and know how to manage challenging situations, especially in times of emergencies and disasters, by minimizing the impacts of hazards and reducing the vulnerability. The main focus of risk reduction and management in our daily lives and in developing programmes is to build our capacities through formal and non-formal education programmes. Under the DRR programme, there are two main terminologies that we need to clarify. One is “emergency” and the other is “disaster”. An 129
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emergency situation is when the risk can be managed using existing resources and support in a given condition and situation. And a disaster situation is when the risk can be managed only with the support of external resources in a given condition and situation. To manage the risk in a DRR programme, risk assessment, analysis and mapping are important to start the process. In reality, we do this consciously or unconsciously in our daily lives. Risk assessment, analysis and mapping is “where potential hazards, vulnerability of population, essential facilities, structures and existing capacity to manage risk are identified, analyzed and mapped out in a geographic map.” To start with, we can do hazard mapping. Then we can add the vulnerable population and structures, and at the end, add the capacity that exists. From this, we can analyse strengths, weaknesses and gaps for DRR programme implementation. No 1 2 3 Area District 1 District 2 District 3 Hazard 10 10 10 Vulnerability 5 10 5 Capacity 5 5 10 Risk Index 10 20 5
For simple example, in the table below, three scenarios are posted. In this case all three districts have similar hazards in a same geographic location, but the risk index is different based on the vulnerability and capacity. Detailed calculation based on indicators can be used and the riskindexing method allows for comparing different programme interventions using standard weights. This method helps programme managers to strategize, standardize and prioritize programme activities. Since it is based on facts and indicators, it is easy to monitor and evaluate the programme implementation. Every programme needs a plan to start with. In DRR programming, a risk reduction plan (RRP) is the starting point. This is also known as Emergency and Disaster Preparedness Plan. Based on experiences and lessons learned, RRP has laid down four major interventions to be developed. These are as follows: risk assessment, analysis, mapping and indexing; contingency planning; operational planning; preparing standard operating procedures.
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Risk Reduction Plan Components Risk Mapping, Analysis and Indexing
Contingency Plan Check List
Operational Plan
Standard Operating Procedure
In the history of disasters that have hit the world, the first wake-up call to all countries and professionals was the 2004 Indian Ocean earthquake and tsunami that imposed a high risk on many countries. Over 240 000 lives were lost, many people were displaced and there was major damage to infrastructures. No government or organizations were prepared to manage the risk at that time, and the disaster made it the first wake-up call to the world to concentrate on early warning and preparedness. Major lessons were learned, billions of dollars were spent on relief and recovery interventions. When the world realized that it should work together, coordination becomes the key area to be strengthened especially in times of disasters to manage the risk effectively. Why do we need to coordinate during disasters? Because the host country has to respond and manage many challenges imposed during the disaster period and to manage the risk. At the same time, many external resources came to help and if not well coordinated, it could end up in another disaster leading towards waste of resources and of the usefulness of the interventions. It is crucial to have good information from rapid assessment to make requests for specific needs. The coordinators need to know: who are coming in? Why are they coming? How can they help? When can they do it? Where can they go? How can the host manage them? If it is well coordinated, the affected communities will have the benefit of the synergistic effects of help and support from many organizations. If not, one can even create conflict among the humanitarian actors and communities. This is known as double disaster. UN cluster approach was developed based on the experiences gained and lessons learned during the coordination process that took place in Aceh during the Indian Ocean earthquake and tsunami in 2004.
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