(wpRlRC44/SRl7)
SUMMARY RECORD OF THE SEVENTH MEETING WHO Conference Hall. Manila Thursday. 16 Sg>tember 1993 at 8.30 a.m. CHAIRMAN: Mr S. NaivaJu (Fiji)
CONTENTS ~
1.
Consideration of draft resolutions ....... ......................... ............................ 1.1 1.2 1.3 1.4 1.5 Eradication of poliomyelitis in the Region .......................................... Report of the Sub-Committee of the Regional Committee on Programmes and Technical Cooperation: Country visits ..... '" ......... .... ... Nutrition in the Western Pacific Region ................ .................. .......... Public health training in the Western Pacific Region ............................. Fiji School of Medicine ............ .............................................. ......
214 214 215 215 216 216
2.
Regional strategy on health and environment, including follow-up of the United Nations Conference on Environment and Development (UNCED) (continued) ................. ........... ............. .... ........... ... ................. ............ WHO Response to Global Change: Report of the Executive Board Working Group ..................................................................................
217 223
3.
- 213 -
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1.
CONSIDERATION OF DRAFT RESOLUTIONS The Committee considered the following draft resolutions:
1.1
Eradication of poliomyelitis in the Region (Document WPRlRC44/Conf. Paper No.3) Dr DURHAM (New Zealand) proposed an additional operative paragraph 5 (4) to provide
for a report on the safety and efficacy of poliovirus vaccine to the Regional Committee in 1994. Dr MONTAVILLE (France) proposed that the final phrase of operative paragraph 3 (1) include a reference to "any other cases". Dr LIN (United States of America) suggested that the proposed amendment to paragraph 3 (I) might read: "to rapidly detect and control imported or any other cases". Dr MONTAVILLE (France) further proposed, with respect to those countries wishing to avail themselves of that possibility, the inclusion of a new operative paragraph 3 (3) to provide for the use of an injectable preparation. Dr ADAMS (Australia) objected that the decision on the appropriate vaccine was best left to a global expert group. The REGIONAL DIRECTOR concurred. The oral vaccine had proved most effective, and a change to an injectable vaccine would have implications for countries outside the Region. The Secretariat would like to be guided by the recommendations of the Global Advisory Group, which were transmitted to it through headquarters. Dr MONTAVILLE (France) suggested that the proposed operative paragraph 3 (3) should include a reference to the advice of the EPI Global Advisory Group on the use of an injectable preparation. In reply to a question from Dr TAPA (Tonga), the REGIONAL DIRECTOR explained that the Global Advisory Group made recommendations to the Director-General, who made the final policy decision. Dr TAPA (Tonga) said he was unhappy with the implication in operative paragraph 2 (1) that immunization should cease in 1995, since the global target was eradication by the year 2000. He would prefer a more flexible wording.
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The REGIONAL DIRECTOR explained that the date 1995 referred only to the national immunization days to prevent local outbreaks. immunization activities well beyond that date. Dr LI Shichuo (China) pointed out that paragraph 4 should include an expression of thanks to the various organizations mentioned therein that had supported poliomyelitis eradication activities in his country. The REGIONAL DIRECTOR said that editorial changes would be made to accommodate the various wishes of the representatives. Decision: The draft resolution, as amended, was adopted (see resolution It would probably be necessary to continue
WPRlRC44.R4).
1.2
Report of the Sub-Committee of the Regional Committee on Programmes and Technical Cooperation: Country visits (Document WPRlRC44/Conf. Paper No.4) Dr SCHUSTER (Samoa) proposed that in operative paragraph 2 (2) the phrase "of the
highest possible quality" be inserted after "comprehensive range of services". Dr LIN (United States of America) commented that, in the view of his delegation, SubCommittee recommendations after country visits should be made in the context of national plans of action for achieving health for all. The REGIONAL DIRECTOR said the draft resolution would be amended to reflect the above comments. Decision: The draft resolution, as amended, was adopted (see resolution
WPRlRC44.R5).
1.3
Nutrition in the Western Pacific Region (Document WPRlRC44/Conf. Paper No.5) Dr DURHAM (New Zealand) proposed that the last line of operative paragraph 3 be
amended to read: "self-reliance, community-based action and, where relevant, the involvement of the food industry".
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It was so agreed. Decision: The draft resolution, as amended, was adopted (see resolution
WPRlRC44.R6).
1.4
Public health training in the Western Pacific Region (Document WPRlRC44/Conf. Paper No.6) Dr MONT AVILLE (France) suggested that operative paragraph 1 (3) should include a
reference to other training opportunities for public health. The REGIONAL DIRECTOR pointed out that the World Directory of Schools of Public Health was a headquarters publication and covered only training institutions specifically concerned with public health. He felt it would be preferable to insert a new operative paragraph 2 (4): "to collect and disseminate all available information on practical training opportunities relating to public health available in the Region" . It was so agreed. Decision: The draft resolution, as amended, was adopted (see resolution
WPRlRC44.R7).
1.5
Fiji School of Medicine (Document WPRlRC44/Conf. Paper No.7) Dr DURHAM (New Zealand) requested clarification of operative paragraph 2 (1). In reply, the REGIONAL DIRECTOR said that the Secretariat was concerned that during
their one-year field internship in their own country - after the first tier of training - primary care practitioner graduates should be appropriately employed as health personnel by their Governments. Another aspect of their status was the proper arrangement of tutorial supervision, so as to enhance their field training. Dr DURHAM (New Zealand) proposed that the operative paragraph concerned be amended to reflect more clearly the need for recognition of the status of trainees by their home countries during the period of field internship. Dr REID (United States of America) proposed that the fourth preambular paragraph be amended by replacing the word "wastage" with "and graduate attrition".
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The REGIONAL DIRECTOR suggested that in addition to the amendment just proposed, operative paragraph 2(1) be amended by replacing the words "their respective health services" with "the health services of their home countries" to meet the concerns of the representll1ive of New Zealand. Decision: The draft resolution, as amended, was adopted (see resolution
WPRlRC44.R8).
2.
REGIONAL STRATEGY ON HEALTH AND ENVIRONMENT, INCLUDING FOLLOW-UP OF THE UNITED NATIONS CONFERENCE ON ENVIRONMENT AND DEVELOPMENT (UNCED): Item 16 of the Agenda (Document WPRlRC44/13) (continued from the sixth meeting, section 3) Dr LI Qingan (China) endorsed the concepts contained in the Regional Director's report
and welcomed the emphasis placed on traditional activities utilizing simple methods for the protection of the environment that were both feasible and practical for developing countries. The control of motor vehicle emissions, covered in section 4.6 of the report, was of great importance in China where, since the policy of reform and opening up of the country, there had been a rapid increase in the number of vehicles in many cities. In Beijing, for example, in 1992 alone the number of vehicles had doubled, with more than 200 taxi companies starting up. Most Chinese people did not own private cars. In his view the number of private cars should not be used in future as an indicator of social development, as the use of public transport should be encouraged. Section 4.7 on coal use took China as an example for the indoor and groundwater pollution caused by the use of coal. However. in most of China there was no natural gas supply so that coal was the major energy source. WHO was currently promoting technology transfer involving appropriate fluoride removal methods in individual households and communities. Traditional methods such as the installation of chimneys and renovation of stoves were also being employed. Urban health development (section 4.8) demanded multisectoral cooperation. authorities should ensure that activities were coordinated. Having developed a sound strategy. the next step was to determine how to put it into practice. China was following guiding principles for the simultaneous programming of construction and urban development on the one hand and environmental protection on the other. Public
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It was also developing legislation to safeguard the environment. responsible for health-related aspects, such as the
The health sector was of a hygiene
establishment
surveillance system, improvement of health legislation and regulations, and the monitoring of drinking water, food safety, occupational health, and sanitation in public places in accordance with health-for-all strategies. Mr HENRY (Cook Islands) commended the report and endorsed the proposed regional objectives and goals and the priority activities highlighted. Cook Islands would be interested to see what benefits would accrue to small island states. His country's main concerns were related to tourism development and economic advancement projects.
It was essential that environmental impact assessment reports were Tourism was the main source of income, and in 1989 a
submitted for all such projects.
commission had been appointed to draw up a ten-year plan for its development. With their fragile environments, small island countries were extremely vulnerable and there was potential for dramatic change in a very short time, for example as a result of contamination of the water supply. Support was needed to help his country fulfil its health-for-aU commitments relating to the environment. Cook Islands had designated the current week "Clean Up the World Week" and many special events had been organized, involving schoolchildren especially. Public employees had been given a one-day holiday to be devoted to cleaning up their villages. The message, coming from children particularly, was that destruction of the environment would mean destruction of the people. He proposed that a World Environment Day be designated so that activities similar to those organized around World Health Day would be encouraged worldwide. Dr ADAMS (Australia) said that the item under discussion was of such importance that it should be retained on the agenda of the Regional Committee for the time being and for as long as was deemed necessary in the future. Australia had put in place a number of initiatives to predict, prevent or minimize the impact of technology on ecosystems and water, air and other environmental resources. Australia was ready and willing to collaborate with other Member States in the implementation of regional strategies to prevent further degradation of the environment. The Secretariat might wish to consider whether it was feasible to draw up a plan of action for environmental health for the Region as a whole.
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Dr ABU BAKAR (Malaysia) welcomed the report and endorsed the goals, objectives and strategies outlined, which were of great relevance to Malaysia. Over the next few years Malaysia would be giving priority to traditional areas of environmental health: community water supply and sanitation in rural and urban areas, and control of environmental health hazards. The Government had privatized the provision of toxic and hazardous waste collection, treatment and disposal; the first treatment plant would become operational in 1994. Similar services for dealing with clinical waste were in the process of being privatized. The Ministry of Health was currently collaborating with the Environmental Health Centre in Kuala Lumpur in developing a national contingency response plan to cope with accidents or pollution of public water supply sources. One of the new areas of importance was the assessment of the impact of development on health. It was now mandatory in Malaysia for an environmental impact assessment to be carried out prior to the implementation of any significant project. However, there was a need to include a health component in such exercises in a meaningful way. There was also a need to improve databases for environmental monitoring and disease surveillance and the relevant parameters and indicators. Malaysia's current drinking-water quality surveillance programme was based on the 1988 WHO guidelines. A review of the programme would be undertaken following publication of the new WHO guidelines later in 1993. In order to strengthen the response mechanisms within the programme and to ensure a reduction in violation rates, a quality assurance programme using specific indicators had been initiated which focused attention on systems with poorer performance using specific indicators. Malaysia was also giving priority to the control of motor vehicle emissions, indoor air quality and urban environmental health and to
human resources development for public health
engineers, health officers and health inspectors. Dr CLARO (Portugal) endorsed the regional strategy on health and environment and the priority areas outlined in the report. Macao was highly urbanized with one of the highest population densities in the world. Furthermore, it was located in the Pearl River delta, an area of rapid industrialization. There was an urgent need to assess the health impact of the latter and it was hoped that a long.term
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comprehensive environmental health plan could be developed with support from the Environmental Health Centre and in close collaboration with China and Hong Kong. Air pollution control, particularly motor vehicle emission control was of high priority. An air quality monitoring programme had been developed since 1988. Data collected showed that air quality was deteriorating. Drinking water quality, assessed under EC standards using WHO recommended methodology, was considered good but the estuarine waters surrounding Macao were becoming heavily polluted. Macao was grateful for the support received from the Environmental Health Centre in undertaking a review of the situation. Construction of a wastewater treatment plant had started. The British Council had sponsored an international workshop on the development of strategies for pollution control in the Pearl River delta, with European Commission support, which had been held in Guangdong, Hong Kong and Macao in February 1993. The three parties had subsequently organized a working group to develop a joint action plan for the area. Food safety was of importance. particularly in view of the high level of tourism and the many restaurants and street food vendors in the city. The limited staff were endeavouring to carry out inspection and food quality surveillance and it was hoped that WHO could provide support for the training of food inspectors. Industrial noise control legislation had been published in July 1993 in the Government Gazette. Scientific knowledge and technical know-how would be needed for its enforcement and WHO support was requested in that area also. The complexity of environmental health issues was such that Member States would require support from the international community. Macao was ready and willing to collaborate with WHO and other countries in the Region in that area. Dr KERE (Solomon Islands), commending the report, said the importance given to health and the environment by Solomon Islands had been reflected in the earlier discussion, during consideration of item 12 of the agenda, on the selection of countries to be visited, and was also reflected in the country's current activities for health promotion, a subject to be discussed under item 18 of the agenda. Dr TAPA (Tonga) commended the report and recalled that Tonga had started its collaboration in the area under discussion with UNICEF and WHO in 1958. The programme. which was still continuing, concentrated on water supplies and sanitation in villages and schools.
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The Government of Australia had assisted Tonga by preparing a 20-year master plan for the period 1990-2010 for water supply, and implementation was under way. As the report indicated, environmental health problems had increased both in magnitude and complexity. Tonga endorsed the regional strategy, and the eight priorities described in the
report, and had noted the future activities outlined. He urged other Member States, other United Nations agencies and WHO to continue their support for the implementation of national plans of action within the regional strategy. Mr UCHIDA (Japan) congratulated the Regional Director on his leadership role in developing the regional strategy outlined in the report before the Committee. Japan had supported WHO activities related to the strategy, including the establishment of the WHO Commission on Health and Environment, WHO's active participation in UNCED and its preparatory processes, the development of the WHO Global Strategy for Health and Environment endorsed by the Health Assembly in resolution WHA46.20 and regional meetings for the preparation of the report before the Committee. Implementation of the global strategy at the regional and country level was extremely important. He endorsed the emphasis on networking more effectively among organizations, as outlined in section 3 of the report, and the need to set priorities. Japan was interested in the outcome of the activities outlined in connection with assessing the impact of environmental health and wished to use that information in implementing its overseas projects for solid waste and treatment disposal. It was hoped that Japan's experience would be taken into account and reflected in the environmental health impact guideline to be elaborated. His Government had participated in the preparation of the new WHO guidelines on drinking-water quality to be published shortly. Japan would be implementing revised national standards based on the new guidelines later in 1993 and would be happy to support WHO in promoting the guidelines in the Region. The inclusion of safety of chemicals and toxic and hazardous wastes as a priority activity (section 4.7 of the report) was an important element of the global strategy and Agenda 21, as 'shown by the endorsement of the expansion of IPCS. He urged the Secretariat to develop project proposals on chemical safety and relevant human resources to be funded from UNDP's Capacity 21 progranune. Such projects should make more effective use of IPCS information.
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The REGIONAL DIRECTOR welcomed the valuable and constructive comments made by representatives. In relation to the comments made by the representatives of Australia and the United States of America, he said that the report outlined a general strategy. The next step was to elaborate the strategy further. The Secretariat had started by identifying the specific environmental concerns most relevant to each Member State; the most common were covered by the priority activities outlined in the report. The aim was to draw up a profile for each country as a basis for the development, in collaboration with Member States, of national plans of action. In reply to the representative of Cook Islands he said that activities for World Health Day, 7 April, were frequently extended beyond the day itself, as determined by Member States themselves. The United Nations agency with responsibility for environmental matters, UNEP, had now designated 5 June as World Environment Day. WHO was willing to collaborate in health-related activities associated with that day. The representatives of Malaysia and Japan had referred to the revised WHO guidelines on drinking-water quality to be published by headquarters shortly. A final draft was available in the Secretariat for consultation by interested Member States prior to the official publication. Collaboration based on the revised guidelines was already being provided, for example in Fiji, for the revision of national legislation on water quality. Japan had expressed interest in collaboration with WHO and would be invited to participate in a meeting on environmental impact assessment, to be held at the Environmental Health Centre in November 1993. Following UNCED, UNDP had developed the Capacity 21 project for implementation of the plan of action of Agenda 21, with a proposed budget of some US$ 5 billion. Contributions totalling some US$ 1.2 billion had been received so far. He had discussed with the Executive Director of the environmental health programme at WHO headquarters the need to approach UNDP to ensure that at least 10% of that large sum would be devoted to health-related projects coordinated by WHO. He urged health officials in Member States to pressure their counterparts in the environmental field in that regard. WHO and Member States should work together to mobilize the necessary resources. The CHAIRMAN requested the Rapporteurs to prepare an appropriate draft resolution.
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3.
WHO RESPONSE TO GLOBAL CHANGE: REPORT OF THE EXECUTIVE BOARD WORKING GROUP: Item 21 of the Agenda (Documents WPRlRC44/18 and Add.l) The CHAIRMAN invited the Regional Director to introduce the item. The REGIONAL DIRECTOR said that, at the eighty-ninth session of the Executive
Board in January 1992, much of the discussion had focused on the profound political, economic and social changes that were affecting the world, and the fact that WHO must respond to such changes in new and more practicable ways if it was to remain effective in international health work. Based on those discussions, it had been proposed that the Board should consider setting up a small sub-committee to take a broad look, in cooperation with the Secretariat, at the Organization and the leadership it should provide in a changing world; the Director-General's new health policy orientations; and the Ninth General Programme of Work. In so doing, it had been suggested that the Board should take into account the roles of and relationships between United Nations agencies, nongovernmental organizations, Member States and others. It had also been proposed that particular emphasis be given to scrutinizing
management and organization, and priorities. Based on those suggestions and subsequent discussion, the Board had decided to convene a working group on the WHO response to global change. The group had been instructed to make preliminary recommendations to the Board's Programme Committee in August 1992 and, through it, to submit final recommendations to the Board at its ninety-first session in January 1993, regarding the Organization's structure, role and mission; its coordinating role with other agencies and organizations; the orientation and preparation of the Ninth General Programme of Work; and the technical quality of programmes. A preparatory group had been set up by the Board to refine the general terms of reference and to develop a work plan for the working group. The Working Group itself had been formed by the Board at its ninetieth session in May 1992, and had subsequently met three times in 1992 and twice in 1993. The final report of the Working Group, before the Committee (Annex 1 to document WPRlRC44/l8) had been submitted to the Board at its ninety-second session, after discussion at the Forty-sixth Health Assembly in May 1993. The report of the Working Group on the WHO Response to Global Change clearly reflected the fact that profound changes - political, economic and social - were affecting the world, and that WHO must respond to them in order to remain effective in international health work.
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The report reviewed the Organization's structure and approach. It highlighted the major issues to be confronted if effectiveness and efficiency were to be improved. Unfortunately, the specific aspects of how to deal with those major issues were not mentioned, nor the source of the additional resources that would be required to bring about "profound change". The report also hardly mentioned the role of regions - an area that the Committee would surely wish to consider carefully. It was not his intention to impose views on the Regional Committee, but he had wondered whether the omission was a signal to Member States to pay careful attention to the role of the regions, to articulate what that role was, and what resources were needed. The Director-General, in his statement on the opening day of the session, had been explicit in his support of a strong role for the regions. World Health Organization". It was reassuring to note that the regions were
considered to be "the very substance of that diversity" which was "one of the major assets of the The reiteration of the prerogative of the Committee to decide upon its own method of work and request to be active in the reform process, was a valuable and timely recognition of the key role that it was to play in shaping the relevance of WHO structures and programmes to the needs of Member States. There was great interest in the document and what it might mean for the future of WHO. The Programme Committee of the Executive Board had spent considerable time at its Iuly 1993 meeting focusing on the Director-General's emerging timetable and workplans for implementation of the Working Group's recommendations; its own appropriate follow-up mechanisms. establishing priorities for early
implementation, particularly those related to the work of the Executive Board; and determining The results of the Programme Committee's Essentially, the Programme deliberations had been provided to the Committee as an addendum (document WPRlRC44/18 Add.l) to the background prepared for that agenda item. Committee had reviewed the recommendations and prioritized them as follows: recommendations already being implemented; recommendations on which a report would be presented at the Executive Board in Ianuary 1994; and recommendations to be implemented during the course of 1994-1995. The Committee had noted that many recommendations required implementation at country and regional levels, and strongly endorsed the proposal that the recommendations of the Working Group should be reviewed by the regional committees with their views being reported to the Executive Board at its ninety-third session in January 1994.
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The Secretariat had thoroughly reviewed the report of the Working Group in preparing the background paper before the Conunittee. While it had tried to indicate which areas might be of greater concern to the Region, that was in no way intended to unduly influence the Conunittee's discussions and he hoped that representatives would see fit to examine the report carefully and discuss its implications for the Region.
\
Although it might be said that, in one way or another, almost all of the Working Group's report had significant implications for the regions, 33 of the 47 recommended "Executive Board actions" were in areas directly requiring response by the Western Pacific Region. Of those 33 actions, 17 involved issues currently being actively addressed by the Region, some of which had more significant regional implications than others. As an example, with respect to the action which requested the Director-General to analyse and define specific objectives and operational targets for the year 2000, the Secretariat was already in the process of doing that in programmes dealing with the reduction in maternal mortality; the eradication of poliomyelitis; the elimination of leprosy as a public health problem; malaria control; and environmental health. Another recommended "Board actiop" focused on influencing other United Nations and external support agencies to include and support the consideration of health as an integral component of development. Over the past year or so, the Secretariat had been quite active with the Asian Development Bank, the World Bank, UNDP, Rotary International and several other bilateral external support agencies in successfully developing collaborative initiatives. Good results had been achieved. Without seeking to prejudice or limit discussions in any way, he wished briefly to highlight a few additional issues considered to be very significant from the Secretariat's perspective. Section 3 of the report, "WHO - Present Organization and Operation". pertinently pointed out that WHO must maintain health sector leadership, but did not indicate how that should be achieved. It highlighted the need to improve the competence, proficiency and capacity of staff and advisers but did not address the question of the resources required to bring that about. Financial constraints were noted only in the context of extrabudgetary resources. The section also introduced the problem of the "seven WHOs" - headquarters and the six regional offices. It appropriately noted that WHO must avoid compartmentalization and fragmentation between headquarters, regions and countries. None the less, he observed that the Region still felt itself to be an integral part of the Organization and that its diversity, which the Director-General himself recognized, was a strength and a resource.
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The WHO regions differed considerably with respect to needs, resources, and approaches. There were three issues that were of immediate importance to the Western Pacific Region. First, while recognizing that "compartmentalization" could occur, the Western Pacific Region had worked very hard to diffuse such situations. Where that type of problem existed, whether at the leadership or technical operations level, it tended to be attributable to the personalities involved rather than to the organizational structure. In the Region, that problem had been dealt with in programmes such as AIDS, environmental health, immunization, information systems, and malaria. regions. Secondly, the Western Pacific Region had, for the most part, been able to harmonize policy and budgetary considerations among the groups mentioned, particularly over the last few years. Considerable efforts had been made to ensure consistency between budget allocation and the specification of priority programme areas. Thirdly, with reference to what the report described as a financial drain on regular budget programmes which must subsidize extrabudgetary administrative activities, until WHO started to operate on a competitive basis, as for instance, with the private sector, it was in no position to request full administrative support cost recovery on a percentage basis from extrabudgetary donors. A more realistic approach that built WHO's actual support and implementation costs into programmes was more pragmatic. Indeed, given the fact that no real increase in regular budget funding could be anticipated, it was essential. A larger question, not stated explicitly in the report, but clearly reflected in what was written, concerned de-emphasizing the role of regional offices and equipping headquarters to deal more directly with a strengthened country representative. That unspoken question shaped a great deal of the report. would not, ultimately, be realistic. Though it might sound With respect to the Working Group report's specific reference to information systems, the Region's experience was proving instructive to other
reasonable in theory, with the added allure of sounding cost-effective, he considered such a step Headquarters' current understanding of regional and national problems was insufficient. That lack could not be met simply by reviewing mission reports and making two-week visits to the field. On the other hand, he fully understood and accepted that, at the regional level, the Organization must improve its operations and
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effectiveness. In that context, the Committee might wish to raise the questions: Had the Region and the regional Secretariat done a good job? Could WHO be more responsive to country needs in the Region if the countries and areas were managed from headquarters? Subsection 4.2, Governing Bodies, concerned the World Health Assembly, the Executive Board, and the regional committees. The temptation would be for regional committees to focus only on the subsection devoted directly to them. He recommended that representatives be guided by the issues raised in the subsections on the World Health Assembly and the Executive Board in examining their own methods of work. Many of the issues, such as consideration of the cost implications, time-limits and reporting associated with resolutions, were equally relevant at the regional level. In carrying out that examination, the Regional Committee might wish to prioritize its activities like the Programme Committee of the Executive Board, and use the Sub-Committee on Programmes and Technical Cooperation in assessing selected issues. A careful consideration of a revised set of terms of reference for the Sub-Committee would be needed, to ensure that that body was clearly directed for that very important task. The areas of special attention in Subsection 4.4, "Regional Offices", had been considered quite appropriate by the regional Secretariat: which to choose); staffing needs and patterns (using the most appropriate level of technical staft); technical consultants (expansion of the population from and communications and collaboration (using modern technology and avoiding duplication of effort among agencies, particularly United Nations agencies). However, the absence in that section of the report (perhaps more than in any other) of any reference to the increased financial resources required to bring about the necessary changes, was a matter for concern, which must be addressed from a regional perspective in some fashion. For example, by keeping consulting fees at a relatively low level, compared with other external support agencies, the pool of available consultants from which a choice could be made would be reduced. That implied that, at times, the Secretariat might have to be more responsive to a consultant's availability and perhaps less responsive to a country's needs with respect to the timing of the implementation of a particular activity. He urged representatives to consider that type of issue, and to confront the long-term implications squarely. Subsection 4.5, "Country offices (WHO Representatives)", highlighted an area in which there was general agreement, namely, the need to strengthen the office of the WHO Representative and, for that matter, in the Region, the Country Liaison Officer.
It
was consistent with the growing trend among external support agencies to try to be more responsive to country needs by taking informed, substantive decisions at the country level. Related to that idea was the need for increased delegation of authority and an emphasis on
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resolving intersectoral and interagency coordination issues at the country level rather than at disparate organization headquarters levels. A review of the profile of skills and qualifications required of highly qualified country representatives (WRs) was suggested. Such a review, if carried out thoroughly, could go a long way toward helping ensure the selection of WRs who were better equipped to deal effectively with the wide range of issues related to health. Those issues and the many others raised in the Working Group's report reflected a spirit of enquiry that was to be applauded and endorsed. Radical change was being considered, and many aspects of the Organization had been opened to question and review. It was essential that the Committee be intimately involved in that process, and that its discussion of the issues should reflect a clear commitment to that involvement. He added that the Regional Committee's discussion would be reported in a preliminary way to the Executive Board's Programme Committee in November 1993 before a final report was drawn up for submission to the Board itself at its ninety-third session in January 1994. The CHAIRMAN invited the Committee to discuss the document section by section. Dr DOl (Japan) commended the Regional Director on the well-prepared documentation, which presented very clearly the regional implications of the Working Group's report. Dr Nakamura of Japan had been a member of the Programme Committee of the Executive Board when it considered in July 1993 the 47 recommendations of the Working Group, which had been classified according to the recommended priority for action. The Programme Committee would meet again in November to consider the response to the Working Group's recommendations, together with the terms of reference for a budget and finance committee proposed by the Health Assembly in resolution WHA46.35 on budgetary reform. At the July meeting of the Programme Committee the Regional Director had expressed his concern about the lack of specific indications for action on the major issues and the resources that would be required to bring about profound change. Japan agreed with those expressions of concern; the feasibility of the Working Group's report in regional terms must be seriously considered, as must the question of how action for change was to be financed. Dr ADAMS (Australia) said that he felt it was no exaggeration to state that WHO's future was at stake. Thus far people's expectations of WHO had been met, but now other organizations were waiting to take its place if it was found wanting. If pride in being associated with WHO was to be upheld, it would be necessary to ensure that WHO remained vibrantly
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active as the supreme organization for health in the world, responsive to changing priorities, flexible, accountable and open in its administration. It must concentrate on results. The role of headquarters and regional offices must, in particular, be clarified, with proper devolution of responsibilities; the administrative and financial aspects of some special programmes seemed thus far to have passed the regions by. Attention should be given to the terms of appointment of the Director-General and regional directors: Australia would favour a limit of two terms of office and the use of search committees for candidates, which had proved effective in the appointment of the Director of International Agency for Research on Cancer. The means of designation of collaborating centres should be examined critically, and methods for increasing the pool of consultants available for work with WHO should be considered as the Regional Director had suggested. It would be hard to finalize pragmatic recommendations in the short time remaining for the Regional Committee; he suggested that the Subcommittee on Programmes and Technical Cooperation might be called upon to help with that task in a special session during the next few weeks. Dr LI Shichuo (China) regarded the item as a particularly important one. The world was undergoing profound political, economic, social changes as well as changes in science and technology, including health. In response to those changes, many countries, including those in the United Nations system, were preparing and implementing reform. Although the approaches were different, encouraging results had been achieved in varying degrees. Reform was the trend of the times - a healthy trend in the process of world development. WHO had set up a Working Group on the WHO Response to Global Change in 1992. The initiative had been a good one and the work done was outstanding. The Executive Board member from China had participated actively in the Working Group. The cooperation of the Director-General and the regional directors, Assistant Directors-General and the staff of the WHO secretariat had been crucial to its work. The World Health Assembly had made positive comments. The report of the Working Group touched upon many major issues relating to WHO's reform, and some suggestions were constructive and feasible. None the less. because of the complexity and difficulty of the task, the varied conditions in each region and country. and the limited size of the Working Group, it had not been possible to make recommendations which
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applied specifically to each country and region.
Some needed to be further discussed.
However, this was an important starting point for WHO's reform and it reflected the conunon aspiration of Member States for more effecti\'e work by WHO. He felt decentralization would be the general trend of reform. offices and Member States were irreplaceable; Headquarters, regional
their roles should be coordinated and
strengthened. It was gratifying to note that WHO had already started its reform. The Regional Office's working efficiency had been spoken of highly by the Member States. As part of the process of reform, more studies should be carried out on such subjects as improvement within the Region, how to do better and more efficient work and how to maintain the high profile. He noted with satisfaction that the Regional Office secretariat had made a sununary of the regional implications of the report by the Working Group with objective and feasible conunents on each of the 47 reconunendations of the Executive Board. The Chinese delegation hoped that with the concerted efforts of the Regional Office and Member States, the reform in the Region could be carried out firmly and practically. Mr BUNE (Fiji) said that his delegation had studied the Report of the Executive Board Working Group with great interest. He believed that reform of the structure and organization of WHO in response to the profound changes taking place was long overdue. He suggested that the Regional Conunittee should review its own method of work and effectiveness. a review on behalf of the Conunittee. With regard to reconunendation (1) on the adequacy of regular budget funding levels (document WPRlRC44I1S, page 15), he endorsed the zero-based budgeting approach as a way to ensure that the Organization operated within its means. He similarly supported reconunendations (2) to (5). He fully endorsed reconunendation (6) relating to the functions and operations of WHO Representatives. Choice of WHO Representatives was a crucial matter, and the process of selecting officials with the most appropriate skills and qualifications should be thoroughly examined, together with opportunities for their training and career advancement. There should be further delegation of powers from headquarters to regional offices, and from regional offices to WHO Representatives - a particularly important matter for the scattered islands in the Pacific .. Referring to the nomination and terms of office of the Director-General and the regional directors, he stressed that health development called for perseverance and continuity. It was based on building up cooperative relations. Frequent changes of the chief executives would cause discontinuity and disruption. However, accountability to Member States was important, The Sub-Conunittee on Progranunes and Technical Cooperation might be requested to carry out such
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so there had to be some flexibility in the duration of tenus of office. Two or three tenus of five years might be an appropriate length of ser.vice for the Director-General and the regional directors. He firmly believed that the momentum to achieve health for all by the year 2000 must be maintained, a prerequisite being continuity and stability of the regional offices, their administrative structure, and programming capabilities. Mr LOVELACE (New Zealand) recognized that the report offered an outstanding opponunity for WHO to build upon past success and ensure its continuing leadership in international health work. He strongly supported the report's emphasis on greater clarity and well-defined goals, increased accountability of WHO structures, and better coordination of global and regional initiatives. He endorsed the suggestion that the report should be reviewed by a sub-committee of the Regional Committee. Ms BLACKWOOD (United States of America) expressed her support for the refonus outlined in the report of the Working Group, which would help WHO to respond more effectively and efficiently to change. Implementation of the recommendations would help to assure WHO's leadership in international health work. The regional offices should playa key role in refonus and undertake the changes needed to ensure that WHO functioned as one body throughout the world. She urged the Regional Director to request headquaners to start the reform process, and to give full attention to implementing the recommendations in the Region. Dr Dong-Mo RHIE (Republic of Korea), commended the report and its excellent analysis of the regional implications. He supported the rationale behind a working group to examine response to change. Human beings survived by adapting to change; so should the Organization. However, changes should be made smoothly so as to
maintain the continuity of health work.
Dr NGO VAN HOP (Viet Nam), referring to the Report of the Executive Board Working Group (document WPRlRC44/18, Annex I), submitted a number of suggestions. With regard to the method of work of the Health Assembly (paragraph 4.2.1.2) he believed that the duration of the Assembly could be reduced to one week in non-budget years and to nine days in budget years by improving the quality of the general debate. Discussion could concentrate on specific points communicated to the participants beforehand. Each country could send in advance a report on its state of health for distribution to participants instead of presenting them in the general debate.
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Concerning the nomination and terms of office of the Director-General and regional directors (paragraph 4.2.2.4), continuity was important for the successful work of the regional directors. Two, or exceptionally three, terms of office were appropriate. On the topic of communications and collaboration (paragraph 4.4.3), where the regions had a specific area of interest, malaria for example, headquarters should devolve responsibility
for that area to the Region. He favoured strengthening the office of the WHO Representative in the countries (paragraph 4.5), suggesting that the post of administrative officer should be filled by local staff. Nationals would be more familiar with their country's administrative procedures and their salaries would be lower than those of international staff. This would be a saving. Mr DURAND-DROUHlN (France) said that his Government considered it absolutely necessary for WHO to adapt rapidly to the major changes taking place. The Executive Board Working Group on the WHO Response to Global Change had done stimulating work. He was satisfied with the report and felt that the recommendations should be followed up. In order to improve WHO's efficiency in health work, the Organization should aim for greater transparency in budgetary and financial matters and in the functioning of the Organization. Better coordination of activities both within the United Nations system and with other partners in the international community was also desirable, as his delegation had made clear during the meeting of the Regional Committee for Europe in Athens. Problems that arose had to be solved. so that WHO could maintain its credibility and means of action as leader in health and health policy. Regional offices and the regional committees had a significant role to play. Since WHO was a single b04y difficulties could only be overcome by involving all in it. The Regional Committee had a responsibility in that process; it therefore had to be rigorous. He endorsed the suggestion that a review of the method of work of the Regional Committee should be placed on the agenda of its forty-fifth session in 1994. In order to improve the efficiency of WHO in the Region, that review should cover the progress of reform as it related to the Region. In particular, it should look at the nomination and terms of office of the Regional Director, personnel matters, and the role and responsibilities of WHO Representatives.
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Dr MILAN (Philippines) expressed her appreciation of the Executive Board's initiative to examine WHO's response to change. Such an initiative ensured that the Organization would adapt to new realities. Given the importance of the subject each issue should be carefully studied. For example, what was actually obtaining in the Region and in Member States? What action did the Committee wish to take? What were the cost implications of that action? She felt that the time allowed was insufficient to deal with matters thoroughly, and therefore endorsed the suggestion that a sub-committee should deal with each question systematically. In general teons she agreed with the analysis, conclusions and recommendations presented in the report. Dr TAPA (Tonga) pointed out that WHO's Constitution contained a chapter on regional arrangements which specifically concerned the Regional Committee, the Regional Office and the offices of WHO Representatives. The Committee should bear that in mind. His Government had views on the regional implications of the Working Group's report, but in order to do justice to the task in hand, he agreed with other speakers that the report should be reviewed by another body. Time constraints prevented the Committee from examining the list of implications contained in Annex 4 of the report, such as those stemming from the proposal to use search committees for the nomination of Regional Directors. Since the Committee had just nominated the Regional Director, who would be in office for five years, was there a need to give an opinion on a search committee immediately? He felt that that could be done during the next four years. There had been no complaints about the method of nominating the previous four Regional Directors. If a search committee were to be set up, how would the members be
selected? What factors might influence them? There were two sides to most questions, and the Committee would not be able to examine all aspects thoroughly. He fully supported the suggestion that a sub-committee of the Regional Committee should examine the report, and would trust its collective wisdom. with, directly connected with its constitutional authority. report carefully, and report at a later date. Mr WAENA (Solomon Islands) fully endorsed the views of the previous speaker. Because of the far-reaching implications of the proposals contained in the Working Group's report, particularly for small island States, he was not in a position to surmise the position of his Government. It would wish to consider those implications closely. Governments should be given the opportunity to reflect upon the issues raised in the report and present their views later, The Committee was required to report to the Executive Board in four months' time, but it had more important matters to deal
It should take its time, study the
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possibly at the Regional Committee in 1994, when they would be able to make a meaningful contribution. The REGIONAL DIRECTOR, noting the suggestion that the Working Group's report should be reviewed by a sub-committee, pointed out that the Committee would have to consider the timeframe for reporting back to the Executive Board. An initial report was required by November, to be completed by January 1994. If a sub-committee were to review the regional implications, it would have to submit its conclusions to the Regional Committee, unless those were accepted a priori. Some representatives had expressed their difficulty in giving concrete and detailed views at the current session. If the Committee felt that it should report at a later date, that opinion should be transmitted to the Executive Board. Possibly the Executive Board had wished to see changes put into effect rapidly. On his side he assured the Committee that any recommendation considered to be constructive would be implemented without delay. As he had mentioned, he had already started to take action on the 17 areas which had more relevant implications for the Region and would pursue that course vigorously.
The meeting rose at noon.