Report of the Regional Director 1 July 2001 – 30 June 2002
SEA/RC55/2
The Work of WHO in the South-East Asia Region
Report of the Regional Director 1 July 2001 – 30 June 2002
World Health Organization Regional Office for South-East Asia New Delhi June 2002
© World Health Organization 2002 Publications of the World Health Organization enjoy copyright protection in accordance with the provisions of Protocol 2 of the Universal Copyright Convention. For rights of reproduction or translation, in part or in toto, of publications issued by the WHO Regional Office for South-East Asia, application should be made to the Regional Office for South-East Asia, World Health House, Indraprastha Estate, New Delhi 110002, India. The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the Secretariat of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Printed in India
Contents Page PREFACE .................................................................................... IX EXECUTIVE SUMMARY ................................................................ XI 1. COMMUNICABLE DISEASES .................................................... 1 Communicable Disease Surveillance ............................................. 1 Communicable Disease Prevention, Eradication and Control ....................................................... 3 Leprosy ........................................................................... 3 Soil-transmitted helminthiasis ............................................... 7 Rabies ............................................................................ 7 Japanese encephalitis .......................................................... 8 Plague ............................................................................ 9 Visceral leishmaniasis ......................................................... 9 Dengue fever/Dengue haemorrhagic fever ............................... 9 Lymphatic filariasis ........................................................... 10 Vector control................................................................. 11 Research and Product Development for Communicable Diseases ...... 12 Roll Back Malaria ............................................................ 13 Tuberculosis ................................................................... 14 HIV/AIDS ...................................................................... 17 Cross-border collaboration on priority communicable diseases........................................... 20 2. NONCOMMUNICABLE DISEASES AND MENTAL HEALTH ................................................................. 23 Surveillance, Prevention and Management of Noncommunicable Diseases ........................................................................ 23 Tobacco ........................................................................ 26 Health Promotion .................................................................. 29 Disability/Injury Prevention and Rehabilitation ............................... 32 Injuries and violence prevention .......................................... 32 Prevention of blindness ..................................................... 32 Prevention of deafness ...................................................... 34 Ageing and health ........................................................... 34 Rehabilitation ................................................................. 34 Mental Health and Substance Abuse .......................................... 35 Suicide prevention ........................................................... 36 Substance abuse and prevention of harm from alcohol.............. 36
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FAMILY AND COMMUNITY HEALTH ....................................... 39 Child and Adolescent Health .................................................... 39 Integrated Management of Childhood Illness ................................ 39 Infant and young child feeding ............................................ 42 Child rights and protection ................................................ 42 Newborn care ................................................................. 42 Children’s environmental health .......................................... 43 Adolescent health and development ..................................... 43 Research and Programme Development in Reproductive Health ........ 45 Making Pregnancy Safer .......................................................... 46 Women’s Health .................................................................... 47 Development of Human Resources for Health............................... 49 Nursing and midwifery ...................................................... 51 Education and training support ........................................... 52 SUSTAINABLE DEVELOPMENT AND HEALTHY ENVIRONMENTS ................................................... 55 Sustainable Development ........................................................ 55 Nutrition ............................................................................. 57 Health and Environment .......................................................... 58 Water supply and sanitation ............................................... 58 Promotion of chemical safety .............................................. 60 Occupational and environmental health ................................. 62 Arsenic poisoning ............................................................ 63 Health impact assessment ................................................. 64 Air pollution .................................................................. 65 Food Safety .......................................................................... 65 Emergency Preparedness and Response ...................................... 66 HEALTH TECHNOLOGY AND PHARMACEUTICALS .................. 71 Essential Medicines: Access, Quality and Rational Use ................................................................... 71 Immunization and Vaccine Development ..................................... 73 Accelerated disease control ............................................... 76 Control of other major vaccine preventable diseases ................ 79 Blood Safety and Clinical Technology.......................................... 81 EVIDENCE AND INFORMATION FOR POLICY ........................... 85 Evidence for Health Policy ....................................................... 85 Health Information Management and Dissemination ............................................................ 87 Research Policy and Cooperation ............................................... 90 WHO collaborating centres ...................................................... 94 Organization of Health Services ................................................ 94 EXTERNAL RELATIONS AND GOVERNING BODIES .................. 97 Governing Bodies .................................................................. 97 World Health Assembly .................................................... 97 Executive Board .............................................................. 97
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Regional Committee ......................................................... 98 Consultative Committee for Programme Development and Management .......................................... 99 Regional Director’s Meeting with WHO Representatives ......... 100 Health Ministers’ Meeting ............................................... 100 Health Secretaries’ Meeting ............................................. 101 Regional Conference of Parliamentarians ............................. 102 Resource Mobilization and External Cooperation and Partnerships... 103 Resource mobilization .................................................... 103 External cooperation and partnerships ................................ 105 8. GENERAL MANAGEMENT................................................... 109 Budget and Management Reform ............................................ 109 Human Resources Development .............................................. 110 Financial Management .......................................................... 112 Informatics and Infrastructure Services ..................................... 113 Procurement Services ........................................................... 115 General Support Services ...................................................... 116 9. REGIONAL DIRECTOR'S DEVELOPMENT PROGRAMME ........... 117 Public Relations and Media .................................................... 117 Regional Office and Country Offices ......................................... 118 Regional Director’s Development Programme ............................ 120 ANNEXES 1. Organizational Structure .................................................. 121 2. Regional Summary of Budgetary Implementation of Activities – 2000-2001 ............................................... 122 3. Budgetary Implementation of Activities – 2000-2001 By Major Programme (2-digit Level) ................................... 124 4. Regional Summary of Budgetary Implementation of Activities – 2002-2003 ............................................... 126 5. Budgetary Implementation of Activities – 2002-2003, By Area of Work ............................................................ 128 6. Regular Budget Reserves 2000-2001 ................................ 130
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PREFACE WHO has continued to work with the Member Countries to help overcome various constraints as well as to address new challenges in health development in the Region. For purposes of programme sustainability and improving the health of the people in the Member Countries, the policies initiated in the previous biennium were pursued. During the period under review, greater emphasis was given to: – integration of programme implementation, particularly in the areas of communicable disease control, and child, women and environmental health. cross-border health problems promotion of healthy lifestyle, and capacity building for health personnel.
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Most countries have been able to handle, on their own, disease outbreaks, which helped to prevent major epidemics of communicable diseases in the Region. Control of major communicable diseases like HIV/AIDS, tuberculosis and malaria, has been progressing well in most Member Countries. For example, during 1998-2002, the DOTS (Directly observed treatment, short-course) coverage in the Region increased from 10 per cent to 58 per cent, with a very high cure rate. With regard to HIV/AIDS, all potential control strategies have been introduced in the national control programmes. Polio is on the verge of eradication with the reported number of cases in the Region during the period July 2001–June 2002 decreasing to only 278. Similar progress is also seen with regard to leprosy elimination.
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The Fifty-fifth World Health Assembly accorded very high priority to NCDs and their risk factors. NCD surveillance and integrated NCD prevention have been initiated in the Member Countries. Community mental health projects and assessment of neuropsychiatric disorders have also been initiated. Injury prevention was selected, for the first time, as a priority area for intercountry programmes. While child health and maternal health have been the main regional focus, adolescent health is now recognized as a very important area in the Region. Greater efforts at integration have been made for more cost-effective implementation. WHO continued to provide support to Member Countries in strengthening their health systems performance. At the same time, countries have been sensitized to the concepts of macroeconomics and health. Through greater coordination with WHO headquarters, regional offices, WHO country offices and the governments, the South-East Asia Region played a leading role in many areas such as preparation of the work plan for 2002-2003, development of proposals for the Global Fund to fight AIDS, Tuberculosis and Malaria (GFATM) etc. Though much has been achieved, we have yet to cover more ground. With these sentiments, I have pleasure in presenting the report on the Work of WHO in the South-East Asia Region covering the period 1 July 2001 – 30 June 2002.
Dr Uton Muchtar Rafei Regional Director
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EXECUTIVE SUMMARY Communicable Diseases The South-East Asia Region witnessed epidemics and outbreaks of communicable diseases such as cholera, acute diarrhoeal diseases, dengue/dengue haemorrhagic fever, malaria and Japanese encephalitis, during the reporting period. WHO extended technical and material support to Member Countries to enhance their capacity to tackle the outbreaks in a timely and effective manner. Considerable progress has been made in controlling tuberculosis. DOTS (Directly observed treatment, short-course) coverage has expanded remarkably over the last three years with nearly 2 million patients receiving treatment with a success rate of around 80 per cent. National and regional medium-term strategic plans have been developed for TB control for the next five years for further enhancing DOTS coverage to achieve the global target by 2005. Member Countries continued to accord high priority to fighting HIV/AIDS. In the SEA Region, more than 95 per cent cases were reported from India, Myanmar and Thailand. HIV/ AIDS prevention and care strategies are being implemented with the involvement of the private sector and nongovernmental organizations. The priorities include scaling up of targeted interventions such as 100 per cent condom use, syndromic management of sexually transmitted infections, prevention of mother-to-child transmission, harm reduction among injecting drug users and provision of care and support for those living with HIV/AIDS. Cross-border spread of the infection is also being addressed in an integrated and coordinated manner. Support was provided to Member Countries in the preparation
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of country coordinated proposals to access resources from the Global Fund to fight AIDS, Tuberculosis and Malaria (GFATM). The re-emergence of malaria in vulnerable areas has posed a formidable problem. In order to reduce case fatality, guidelines on the management of severe malaria for small hospitals have been prepared and shared with the countries to strengthen small hospitals in remote areas. The Roll Back Malaria (RBM) work plan and the country plans of action are being synchronized to ensure effective implementation of RBM. Guidelines have been finalized for the implementation of RBM in the pilot districts during 2002-2003. Increased attention is being paid to the control of crossborder health problems, particularly HIV/AIDS, tuberculosis, malaria and kala-azar in selected cross-border districts, with a multi-disease control approach. This is a major shift from the earlier single disease control approach. While seven countries have already reached the goal of leprosy elimination, efforts to help the remaining countries achieve the target have been increased. Integration of leprosy into the general health services, monitoring of leprosy elimination activities, capacity building, improved management and strengthened surveillance are some of the areas for focused attention. Leprosy Elimination Campaigns are a useful means adopted by the countries. Countries have experienced frequent outbreaks of dengue fever/dengue haemorrhagic fever (DF/DHF). The South-East Asia Region accounts for 52 per cent of the global burden of the disease. There has been a decline in the case-fatality rate. Comprehensive guidelines on prevention and control of DF/ DHF have been developed and distributed to countries. The Region played a significant role in addressing the DF/DHF problem resulting in the adoption of a resolution on DF/DHF by the Fifty-fifth World Health Assembly. In line with the Global Programme for the Elimination of Lymphatic Filariasis by 2020, national plans have been developed by all endemic countries to reach the target by adopting two main strategies to interrupt transmission – mass drug treatment with a combination of two drugs, and disability prevention and alleviation. A population of around 40 million has been covered with mass drug administration. Capacity
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building on comprehensive vector control has been successfully undertaken in the Member Countries. A regional strategic plan for the prevention and control of soil-transmitted helminthiasis is being developed to synchronize with the elimination of lymphatic filariasis (LF), since albendazole used in LF is also a broad spectrum anti-helminthic drug. In regard to rabies control, Member Countries are focusing on phasing out nerve tissue vaccines (NTVs) and replacing them with the modern tissue culture vaccines (TCVs). To combat outbreaks of Japanese encephalitis in the endemic countries, JE vaccine is being procured and distributed by the Regional Office, with technical assistance in developing JE surveillance and rapid response and case management being provided. Support was given to the Government of India in tackling the outbreak of pneumonic plague in 2002. The Region continues to account for a high burden of communicable diseases. However, through WHO initiatives, advocacy and technical support, Member Countries have launched massive efforts to reduce the burden and work towards control, elimination and eradication of communicable diseases.
Noncommunicable Diseases and Mental Health In line with the Global Strategy for Prevention and Control of NCDs, WHO initiated the development of a sustainable surveillance system in all Member Countries. It started with the establishment of NCD surveillance networks in Bangladesh, India, Indonesia, Nepal, Sri Lanka and Thailand. National focal persons from these countries were trained appropriately. The national capacity for NCD prevention in each Member Country was also assessed. Pilot projects on community-based integrated NCD prevention were initiated in Bangladesh, India and Indonesia in order to demonstrate their effectiveness in reducing risk factors of major NCDs. Research activity in the area of NCD prevention and control was also promoted.
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Sentinel prevalence studies on tobacco use were initiated in Bangladesh, Bhutan, India, Indonesia, Myanmar and Sri Lanka. The results of economic analyses of tobacco production and use are being reviewed by WHO headquarters. Research in India to elucidate the implications of chewing tobacco on reproductive health is in its final stage. Global youth surveys on tobacco use were completed in Indonesia, Myanmar, Nepal and Sri Lanka and their results published. Management training modules on tobacco control were developed and are in the process of finalization. As a result of WHO support to the review of health promotion policies and strategies in Bangladesh, Indonesia, Myanmar and Thailand, health promotion has been included in the national health policies of these countries. As a longterm plan for improving health promotion in the countries, the undergraduate curriculum in 27 training institutions in six Member Countries was reviewed and the core curricular content is being developed. Draft guidelines and training modules on “Healthy Districts” were developed and four countries (Bhutan, India, Indonesia and Sri Lanka) have already identified the districts for piloting the concept. Many activities were implemented through healthpromoting schools, health jamborees and life skills education. The theme of World Health Day 2002 was “Move for Health”. The celebrations at the regional and country levels were widely publicized. In this context, five countries were also supported in documenting the national status of healthy lifestyles with particular focus on “physical activity and diet”. Road traffic accidents, burns and work-related injuries are the most common causes of injuries. Injury prevention has been selected as a priority area for intercountry projects in the Region. A regional profile of injuries and regional strategies for injury prevention were developed. Capacity building for health personnel in eye care institutes was initiated in Bangladesh and Indonesia with technical support from Lions Aravind Institute of Ophthalmology, Hyderabad, India. Training of ophthalmological staff in surgical eye care for children in Indonesia was also supported.
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A regional profile on deafness and hearing impairment was prepared. A survey to assess the status of deafness and health infrastructure is being conducted in India, Indonesia, Myanmar, Sri Lanka and Thailand. A profile on health of the elderly in all Member Countries is being prepared. A model for comprehensive community and home-based health care was developed and field-tested. Mental health was the subject of the Technical Discussions at the 38th meeting of CCPDM as well as of a resolution adopted by the 54th session of the Regional Committee in September 2001. Monographs on Alzheimer’s disease, epilepsy, schizophrenia, mental retardation, depression and suicide were issued. Six modules to promote positive mental well-being amongst adolescents and strategies for community neuropsychiatric services were developed and successfully tested in India, Indonesia and Thailand.
Family and Community Health The Task Force on Family and Community Health identified child and adolescent health as one of the 14 priority areas for intercountry collaboration in 2002-2003. The synergy between child and adolescent health has been recognized in the implementation of the programmes. Gender, nutrition, growth and development, and child rights have been taken up as integrated activities on a continuum. Considerable progress has been achieved in the implementation of the Integrated Management of Childhood Illnesses (IMCI) approach in Member Countries with high infant mortality rates. IMCI has also been introduced in pre-service training health professional schools. Attention has been given to the promotion of breast-feeding practices through training and capacity building. Newborn health care, child rights’ protection and environmental health are some of the areas where activities have been carried out. Adolescent health and development was given due attention in the national health policies of the Member Countries. Reduction of maternal mortality and morbidity has been considered as an essential element of health system reform in the Member Countries. Multi-centric operational research on community- and facility-based interventions for Making Pregnancy Safer (MPS) is being implemented in six Member
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Countries. Country profiles on women, health and development are being updated. Health sector reform, enhancing primary health care through the district health system, quality assurance in health care delivery and hospital accreditation were some of the activities in health system development that received attention. As a sub-system in human resources for health (HRH) development, the focus of attention has shifted to quality issues. The emphasis has been on the establishment of an accreditation process for health professional training institutes and networking of public health institutes. Innovations in health professionals’ education continued with WHO technical support. A multidisciplinary Regional Advisory Group was constituted and an in-depth country assessment is being carried out in nursing and midwifery. WHO support for HRH development through fellowships continued.
Sustainable Development and Healthy Environments In the area of sustainable development, promoting intersectoral collaboration through the Health and Environment initiative continued to spearhead the move towards assisting countries to incorporate health concerns in sustainable development. Noteworthy among this was the addition of two national plans of action (PoAs) for Health and Environment to the existing seven PoAs in the Region. With the launching of the report of the Commission on Macroeconomics and Health, the Region has begun advocacy for the setting up of national commissions to activate the recommendations made in the report. In the area of Promotion of Health in Human Environment (PHE), three concerns are being actively addressed. Regarding water supply and sanitation, an approach to household level disinfection of drinking water has been promoted by piloting a methodology in two West Delhi slums. This is in conjunction with the general approach to water quality improvement being promoted by WHO. National-level water supply and sanitation assessments have been initiated. The results should lead to better programming. In the area of Promoting Chemical Safety, xvi THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION
poison control and hazardous waste disposal have been addressed as priorities. WHO has assisted with the setting up or strengthening of poison control centres while hospital waste management strategies have been addressed through advocacy and capacity building. The Occupational Health programme has contributed to assessing the status of environmental impact assessment capacity in Member Countries and the preparation of a protocol for its assessment. The programme has also contributed to arsenic mitigation action by developing a case definition and management protocol. The PHE area being a cross-cutting set of concerns, a significant aspect of programme management has been sought through defining a collaborative approach in what is called Children’s Environmental Health. Action in the Nutrition for Health and Development programme focused primarily on addressing concerns of micronutrient deficiencies and infant and young child feeding practices. The issue of iodine deficiency and vitamin A supplementation has received significant attention. The Food Safety programme has focused on promoting the 10-point strategy developed in 1998. The Regional Office undertook capacity building for better laboratory services and Hazards Analysis and Critical Control Point System (HACCP) training in the countries. In Emergency and Humanitarian Action, the focus has been on promoting preparedness for impending emergencies. Steps have been taken to promote capacity building through training of trainers and emergency focal points for emergency evacuations, and also for linking health as a bridge to peace. Training in Humanitarian Supplies Management System was also undertaken in some countries. The continuing prevalence of occupational and environmental hazards necessitates a concerted environmental epidemiology approach for reducing hazards and associated health risks.
Health Technology and Pharmaceuticals With a view to strengthening blood transfusion services and assure quality, safety and adequacy of blood, guidelines for formulating and implementing country-specific national blood xvii THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION
policies were finalized. Capacity building in the quality management of blood transfusion services in the Member Countries was strengthened. As the Region moves towards the elimination of wild polio virus transmission, efforts are on to ensure that systems are in place for the certification of polio-free status by 2005. WHO continued its partnership with the countries to make essential medicines available to all, particularly the poor and disadvantaged, at affordable prices. WHO support to the Member Countries emphasized the public health provisions of the TRIPS agreement, resulting in five Member Countries supporting the Doha Ministerial Declaration on the primacy of public health over trade. Inter-regional meetings on counterfeit drugs were initiated with the Regional Office for the Western Pacific .
Evidence and Information for Policy The WHO collaborative programme as well as the intercountry programme in this area focused on collecting, validating, analysing, synthesizing and disseminating evidence-based information on health situation and trends. National capacity in the Member Countries was strengthened in the areas of (a) data management for evidence-based decisionmaking; (b) implementation and assessment of ICD-10 coding; (c) knowledge on methods and issues related to the conduct of health systems performance assessment; (d) preparation of national health accounts; (e) preparatory activities for the conduct of a world health survey and burden of disease methodology; (f) strengthening the quality of morbidity and mortality statistics, and (g) improving the health information systems in the countries, with the focus on monitoring and evaluation mechanisms and transformation of data into information for evidence-based decision-making. This was achieved by conducting appropriate workshops and consultations at the country and intercountry levels. The main activities of the Information Management and Dissemination programme included the production and distribution of documents and publications, translation of WHO
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publications into national/local languages, as well as marketing and promotion activities for WHO publications. Improvement of scientific communication through updating of the Documents web site with the inclusion of the latest periodicals, bibliographies and publications was also undertaken. The library is the portal to WHO information in the Region. It has established “base stations” at WHO country office libraries for direct provision of WHO information to respective Member Countries. In addition, the library has direct access to over 800 international medical journals in full text. The library implements several technical support activities in the management of information resources of Member Countries. The 2001 updated regional health research strategy views health research as a system which acts as the “brain” for health system development. The countries of the Region used the strategy as a generic framework to analyse the existing situation of health research systems. In the area of health research management, WHO continues to support Member Countries in specific areas of priority setting in health research and promotion of health research culture. Capacity strengthening in health research was conducted through collaboration with the WHO collaborating centres and national centres of excellence in implementing commissioned research as well as principal investigation-developed research. A series of training workshops were conducted to improve the awareness of national ethical review board members and to develop national ethical guidelines. The Regional Office continued to concentrate on, and promote ethical issues in health research. Some countries have started mapping the profiles of national and institutional ethical review boards. In the area of health research information, the Regional Office developed a database for tracking managerial and technical aspects of research proposals seeking WHO funding as well as a database on WHO collaborating centres and on expert advisory panels.
External Relations and Governing Bodies In view of the growing importance of and the need for external resources for health activities in the Region, the Regional Office has geared up its efforts by developing its own resource xix THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION
mobilization strategy, providing support to national authorities and WHO country offices with necessary tools and information. The increase in extrabudgetary resources in the last biennium (2000-2001) over the 1998-1999 biennium was almost 62 per cent. The Regional Office has also stepped up its efforts in forging productive partnerships with civil society organizations in the area of health development. Collaboration and coordination with other UN agencies, intergovernmental and nongovernmental organizations, and regional organizations and bodies were strengthened and enhanced to integrate health dimensions in economic, social and environmental development at regional and country levels. With strong advocacy in partnership with Member Countries, international agencies, nongovernmental organizations and civil society organizations to ensure that trade agreements do not adversely affect public health, a “Declaration on TRIPS Agreement and Public Health” was adopted at the WTO Conference, held in Doha (Qatar) in November 2001.
General Management An approach unique to the SEA Region was adopted for the development of detailed work plans for the supplementary intercountry programme for the 2002-2003 biennium, ensuring greater participation by the Member Countries in its formulation. A high-level task force for intercountry collaboration, comprising representatives from Member Countries, identified 14 areas and finalized work plans reflecting regional and global priorities. In the spirit of “One WHO”, the Regional Office continued to collaborate with WHO headquarters in the development of the Programme Budget 2004-2005. The Region-specific Part-II of Programme Budget 2004-2005 was developed through intensive consultations with the Member Countries. As part of the Organization-wide performance evaluation, Member Countries and the Regional Office analysed the quality and relevance of WHO’s collaborative programme implemented in the 2000-2001 biennium. xx THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION
Regional Director’s Development Programme During the reporting period, the Regional Office continued to maintain high-level media relations. Active provision of technical information to mediapersons by WHO helped stem rumours and panic, particularly regarding bio-terrorism following the 11 September 2001 tragedy in the USA and the plague outbreak in India. The media was provided special technical briefings at the National Leprosy Programme Officers’ meeting and the Global Alliance for Elimination of Lymphatic Filariasis. Support for producing information materials was provided to all technical units as well as the newly-established WHO offices in DPR Korea and East Timor. The Regional Director’s Office played a vital role in monitoring and facilitating programme implementation. Uncommitted funds for the 2000-2001 biennium were pooled and reallocated through the intercountry mechanism, which speeded up programme implementation. In August 2001, the Director-General inaugurated the WHO Representative’s office in DPR Korea.
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1 COMMUNICABLEDISEASES CommunicableDiseaseSurveillance During the reporting period, countries in the Region witnessed epidemics or outbreaks of communicable diseases including cholera, acute diarrhoeal disease, a mysterious disease (possible atypical measles), dengue/DHF, malaria, Japanese encephalitis, anthrax, rabies, hand, foot and mouth disease (HFMD) and plague (see Figure 1.1). Member Countries were supported with technical, material and human resources to enable them to effectively respond to the outbreaks. Stockpiling by the Regional Office of essential reagents and diagnostic test kits as part of epidemic preparedness helped in responding rapidly to disease outbreaks. In the aftermath of the terrorist act in the USA in September 2001, the countries in the SEA Region reiterated the need to upgrade the preparedness of the health sector towards potential emergencies resulting from terrorism. The capacity of the health services in the Member Countries to prepare for and respond to any public health emergency, be it from natural or manmade causes, is generally inadequate. WHO played a proactive role in the preparation and dissemination of information on possible biological/chemical agents through fact sheets, frequently-asked questions on how to deal with suspicious letters or packages, guidelines on prophylaxis/treatment on exposure to anthrax, guidelines on smallpox vaccination etc. Laboratory support was provided and an intercountry Workshop on Laboratory Diagnosis of Anthrax was held in Bangkok in December 2001. WHO also provided timely technical support to the Government of India in controlling the outbreak of plague in February 2002. A consultant assisted the national authorities in analysing the data, identifying any gaps and making recommendations for future prevention and
WHO supported Member Countries with technical, material and human resources in dealing with disease outbreaks
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Figure 1.1: Major outbreaks of diseases in the SEA Region DPR Korea Japanese Encephalitis
Bhutan Bangladesh Nepa l Meningitis Dengue/DHF Malaria
India Myanmar Plague, Cholera Acute Diarrhoeal Disease Measles Atypical Dengue/DHF Leptospirosis Dengue Acute Diarrhoeal Disease Anthrax Leptospirosis
Thailand Anthrax Rabies Dengue/DHF
Sri Lanka Maldives Hand, Foot & Mouth Disease Dengue/DHF Japanese Encephalitis Hand, Foot & Mouth Disease
n
I
d
o
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es ia
Source: WHO/SEARO
control of plague outbreaks. This included drafting of specific guidelines for outbreak management and precautions to be taken at the hospital. Technical support was provided to the countries in establishing or strengthening rapid response teams (RRTs) at national, provincial and district levels to enable them to detect early and respond rapidly to disease outbreaks and epidemics. To improve the quality of surveillance data, the countries were encouraged to adopt the standardized case-definition guidelines for priority communicable diseases based on the document “WHO Recommended Surveillance Standards”. Support was provided to strengthen national and regional surveillance of communicable diseases through further strengthening of regional training institutes in India, Indonesia and Thailand for capacity building in epidemiology and training in the management of priority communicable diseases and using these institutes for developing a critical mass of skilled epidemiologists and paramedical staff. WHO also organized four intercountry workshops on Epidemic Preparedness and
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Response at the National Institute of Epidemiology (NIE), Chennai (India) in November 2001 and January 2002 where more than 80 medical officers were trained. WHO is developing two training manuals for managing priority communicable diseases, one for health workers and the other for doctors at the PHC level. These manuals use a systems approach to integrate management. The manual for health workers was peer-reviewed and field-tested in India, Myanmar and Nepal and is ready for printing. The manual for the first contact doctor was reviewed at an informal consultation, held in Bangkok in December 2001, and is being finalized. At the request of the Member Countries, the Regional Office is developing training modules with the help of a Delhibased NGO, for a five-day course on Epidemic Preparedness and Response for the first contact doctor, with a facilitator’s guide. To evaluate the teaching package, an intercountry course was held in Agra (India) in January 2002 in the presence of experienced observers, with the aim of getting a feedback from both observers and participants before its finalization. WHO assisted the Government of India in developing a Project Implementation Plan for the Integrated Disease Surveillance Programme (IDSP). IDSP will provide essential data to monitor the progress of disease control programmes, help in the allocation of resources and will be crucial in obtaining political and public support for the programmes. The plan will help to identify areas of health priority as well as resources from the World Bank and USAID for strengthening the surveillance system. Outbreak Verification Lists (OVLs) continued to be provided to the countries in the Region to share information on outbreaks and encourage timely action. The establishment of web sites by some countries and the Regional Office has helped in speedy retrieval of relevant information.
CommunicableDiseasePrevention, Eradication and Control Leprosy 3
The Region accounts for 75 per cent of the global leprosy caseload. Nine out of the ten Member Countries of the Region
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Figure 1.2: Prevalence of leprosy in the SEA Region by country, as of June 2002 4.50 4.2 4.00 3.4
3.50 Cases per 10,000 population 3.00 2.50 2.00 1.50 1.00 0.50 0.00 0.85 0.66 0.61 0.56
1.8
Global Goal Global Goal
0.83 0.36
BAN
BHU
IND
INO
MAV
MMR
NEP
S R L
THA
Source: WHO/SEARO
are endemic for leprosy. Currently, India accounts for 90 per cent of the regional and 66 per cent of the global caseload. Bangladesh, Bhutan, DPR Korea, Indonesia, Maldives, Sri Lanka and Thailand have already reached the elimination goal (prevalence rate <1 per 10 000 population) at the national level. Myanmar, Nepal and India are targeted to reach this goal by 2005 (Figure 1.2). In India, the prevalence of leprosy is high in the states of Bihar, Jharkhand, Uttar Pradesh, Madhya Pradesh, Chhattisgarh, Orissa, West Bengal, Andhra Pradesh, Maharashtra, Karnataka and Tamil Nadu. WHO provided technical support for the integration of leprosy into the general health services as well as for systematic monitoring of leprosy elimination activities. State-level periodical reviews and Partners Meetings were also supported in all the endemic states. A Guide to Eliminate Leprosy, published in English and 13 Indian languages, was distributed to all the affected districts. As part of the IEC activities, posters and diagnostic cards in Hindi, Oriya, Bengali and English were distributed to all primary
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health centres and sub-centres during the Modified Leprosy Elimination Campaigns (MLEC) during October-December 2001. A total of 132 083 new cases were detected during MLEC and put on MDT treatment. WHO has supported capacity building and management as well as monitoring and surveillance of the implementation of leprosy elimination in India through the National Institute of Health and Family Welfare (NIHFW). In May 2002, training programmes were held for 360 state and district leprosy officers and chief medical officers in 12 endemic states where leprosy elimination monitoring (LEM) has been carried out. WHO supported the clinical trial for the treatment of pauci-bacillary (PB) leprosy cases with a single dose of rifampicin, obloxacin and microcydine (ROM), undertaken by the National Institute of Epidemiology, Chennai, India (WHO Collaborating Centre for Leprosy). To advocate and enhance political commitment to leprosy elimination, an Intercountry Meeting of National Leprosy Programme Managers was held in New Delhi in December 2001. The meeting enabled updating of knowledge and experiences in the march towards the goal of leprosy elimination. In Myanmar, WHO supported the assignment of three national consultants for the Leprosy Programme. Support was also provided for leprosy elimination campaigns (LECs) in 151 townships as well as for strengthening supervision at the township level. In Nepal, WHO supported the development of electronic mass media, printing of a Guide to Eliminate Leprosy in the local language, LECs in 16 endemic districts, provision of transport for supervision and monitoring, and recruitment of six National/Regional Coordinators for the Leprosy Elimination Programme. In October 2001, following leprosy elimination campaigns, 5 803 new cases were detected and put on MDT treatment. The Second Global Alliance for Leprosy Elimination was held in Brasilia (Brazil) in January 2002. Staff from the Regional Office, the WHO country office in India as well as from the
5 THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION
Figure 1.3: Trend of leprosy cases in the SEA Region, 1985-2002 12000000
10000000
Number of cases
8000000
6000000
4000000
2000000
0 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2002
Prevalence
Newly Detected
Cumulative cured with MDT
Source: WHO/SEARO
national programmes in India, Indonesia, Myanmar and Nepal attended. Leprosy elimination monitoring (LEM) was completed in Sri Lanka. Since 1985, over 10 million persons have been cured with multidrug therapy (MDT) (Figure 1.3). It is estimated that around 1.5 million additional patients in the Region will have to be detected and put under MDT treatment by the end of 2005 to achieve the target of elimination. Strategies are based on improving access to treatment, early detection and change in the societal perception of leprosy. WHO will further intensify its technical support and provide MDT drugs to Member Countries. WHO is continuing intensive work with partners, including The Nippon Foundation, Novartis, NGOs, the World Bank, DANIDA and others to attain the goal of leprosy elimination in the three remaining countries, viz. India, Myanmar and Nepal, by the end of 2005 and to sustain elimination levels and progress towards sub-national elimination in other countries.
6 THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION
Soil-transmitted helminthiasis At any given time, more than one billion people, mostly in developing countries, are infected with soil-transmitted helminths with about 300 million having severe morbidity. It is a major public health problem in all countries of the Region. Significant reduction in the burden of these diseases can be achieved through regular treatment of those at highest risk of morbidity with a single dose of an anthelminthic drug which costs less than three US cents. This strategy was endorsed by the Fifty-fourth World Health Assembly in May 2001. The target is to treat 75 per cent of school-aged children at risk by 2010. A draft regional strategic plan for the prevention and control of soil-transmitted helminthiasis was prepared and reviewed in WHO headquarters. This draft will be further discussed at a regional meeting with national authorities and experts. Member Countries identified national focal points for coordinating activities related to the control and prevention of these diseases. Meanwhile, deworming activities were carried out in many countries of the Region. WHO also played a mediatory role in getting donor assistance for deworming activities. Myanmar implemented a new programme to cover deworming of 100 000 school aged children in 350 schools with technical and logistical support from WHO. Technical assistance was also provided to countries to assess the burden of the diseases. Maldives, Sri Lanka and Thailand showed a decline in the prevalence of helminthic infections among some sectors of the population. Under the WHO programme for the elimination of lymphatic filariasis, mass drug administration, with a combination of two drugs which includes albendazole, an effective anthelminthic drug, provides significant deworming benefits to the community. WHO sponsored a study to assess the impact of this intervention on soil-transmitted helminthiasis in Sri Lanka.
Rabies 7
Ninety per cent of the approximately 50 000 human deaths due to rabies worldwide occur in Asia. In addition, the majority
THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION
of the 10 million rabies cases receiving post-exposure treatment worldwide are in Asia. The disease, which is caused mainly by infected dog bites, is fatal but preventable through an effective vaccine. It is a disease of poverty affecting vulnerable peri-urban and rural populations and currently kills more people than yellow fever, dengue or Japanese encephalitis (JE). The disease is endemic in seven of the ten countries of the Region. WHO is encouraging the Member Countries to pay increasing attention to rabies. Though the WHO Expert Committee on Rabies in 1992 had recommended discontinuation of the nerve tissue vaccines (NTVs) and replacement with the modern tissue culture vaccines (TCVs), four of the seven endemic countries, viz. Bangladesh, India, Myanmar and Nepal, are still producing and using NTVs. Except Sri Lanka and Thailand, the other countries do not have an effective rabies control programme. In order to address these lacunae, WHO organized two meetings in December 2001 at New Delhi - Joint WHO/NICD workshop on promoting TCVs in India and the First Steering Committee Meeting on Rabies Control in Asia. Bangladesh, India, Myanmar and Nepal have agreed in principle to phase out NTVs and replace them with TCVs. WHO will provide technical support to these countries in developing strategic plans of action and assist in the development of the required infrastructure, procurement of equipment/reagents, and developing capacity building to produce TCVs.
Japaneseencephalitis Outbreaks of Japanese encephalitis (JE) are reported annually from India and Nepal with high case-fatality rates. JE is a public health problem in Sri Lanka and Thailand; sporadic outbreaks occur in Indonesia and Myanmar. WHO is supporting initiatives by India and Nepal in procuring JE vaccine and providing technical assistance to Member Countries in developing JE surveillance and rapid response and in the development of guidelines for case management.
8 THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION
Plague There was an outbreak of pneumonic plague in India in February 2002, which occurred in two clusters – one in the state of Himachal Pradesh and the other in Chandigarh. WHO provided technical support to the Government of India in successfully containing the outbreak.
Visceralleishmaniasis With WHO support, the three countries reporting kala-azar (visceral leishmaniasis) in the Region, viz. Bangladesh, India and Nepal, agreed to tackle this common problem through collaborative action. A plan of action for cross-border control of kala-azar has been developed jointly by the three countries for implementation in selected border districts in 2002-2003. A WHO intercountry meeting, held in Kathmandu in February 2002, decided to expand target diseases for crossborder collaboration to include HIV/AIDS, tuberculosis and malaria. Trials on oral treatment with the new drug, miltefosine, conducted in India with WHO support, have been completed. The Drug Controller of India finalized the registration of the drug in March 2002. WHO will support the introduction of this drug at the village level during 2002-2003.
Dengue fever/Dengue haemorrhagic fever Forty per cent of the global population (2.5 billion) in at least 100 countries are exposed to dengue fever/dengue haemorrhagic fever (DF/DHF). The South-East Asia Region contributes 52 per cent or 1.3 billion cases to this total. Seven countries – Bangladesh, India, Indonesia, Maldives, Myanmar, Sri Lanka and Thailand – regularly report incidences of DF/DHF outbreaks. Bhutan and Nepal have not reported any case while DPR Korea has not reported transmission of DF/DHF. All endemic Member Countries have experienced frequent outbreaks cyclically. The last major epidemic occurred in 1998 with 218 959 reported cases. The number of reported cases up to September 2001 is 119 707. However, the case-fatality rate,
9 THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION
which fluctuates between 2 and 5 per cent, has shown a downward trend and now ranges between 1 and 2 per cent. The notable achievements in dengue prevention and control in the Region were: (1) development of comprehensive guidelines on prevention and control of DF/DHF; (2) development of guidelines for the treatment of DF/DHF in small hospitals; and (3) publication of the annual Dengue Bulletin in collaboration with the Regional Office for the Westrn Pacific. Further, in collaboration with Queen Sirikit National Institute of Child Health (QSNICH), Bangkok (WHO Collaborating Centre for Case Management of DF/DHF/DSS), guidelines for the diagnosis and management of DF/DHF are being developed for use by physicians. WHO had developed regional strategies for the prevention and control of dengue in 1995. These strategies were revised at the Meeting of Programme Managers of DF/DHF, held in Batam (Indonesia) in July 2001. The six elements of these regional strategies are: (1) establishing effective disease and vector surveillance; (2) ensuring early recognition and effective case management; (3) undertaking disease prevention and control through integrated vector management with community and intersectoral participation; (4) undertaking activities to achieve sustainable behavioural changes and partnerships; (5) establishing emergency response systems to control outbreaks, and (6) strengthening regional and national capacities for the prevention and control of dengue and to undertake research.
Lymphatic filariasis Lymphatic filariasis (LF) is endemic in eight countries of the Region. Over 700 million people at risk of infection live in filaria-endemic areas with 60 million already affected. This represents 60 per cent of the global burden of the disease. In line with the Global Programme for the Elimination of LF by 2020, a Regional Strategic Plan was developed in 2000. Subsequently, all endemic countries developed national plans aimed at reaching the goal of elimination. The two main strategies are: (1) reducing the spread of infection by
10 THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION
interrupting transmission through mass drug administration with a combination of two safe and effective drugs (diethylcarbamazine and albendazole) to all those living in the endemic areas, and (2) disability alleviation through morbidity management and relieving and preventing suffering. WHO facilitated the free supply of albendazole by donors for mass drug administration in the endemic countries. These countries were divided into two groups to be separately reviewed by two Sub-Regional Programme Review Groups with regard to the progress made in the elimination of LF and to review applications for free supply of albendazole. The MekongPlus Programme Review Group, which was established in collaboration with the Western Pacific Region and the group for the Indian sub-continent, had its first meeting in January 2002. WHO also arranged a training workshop for programme managers, a workshop for mapping of LF cases, and an international workshop on morbidity management of lymphoedema as part of WHO technical support to Member Countries. In 2001, Bangladesh conducted mass drug administration (MDA) covering a population of 808 697, while India covered a population of 14.2 million, Myanmar 1.9 million and Sri Lanka 1.7 million. In 2002, Bangladesh will be extending MDA from one district to three to cover 5.4 million people. India increased its coverage to 21 million. Nepal has planned to commence mass drug administration in 2002 covering a population of 250 000. Indonesia conducted a round of MDA with combination drugs covering one million people. In June 2002, Sri Lanka extended MDA with combination drugs to cover the entire population at risk (9 million) living in endemic areas. Thailand covered a population of 200 000.
Vector control Vector-borne diseases are a major cause of morbidity and mortality in the Region and hence, vector control assumes importance in the prevention and control of these diseases. Selective transmission control of malaria has been emphasized and practised resulting in a reduction in the use of 11 THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION
Vector control assumes importance in the prevention and control of vector-borne diseases, which are a major cause of morbidity and mortality in the Region
DDT in the Member Countries by approximately 50 per cent. India and Thailand are phasing out DDT for indoor residual spraying while many countries have introduced pyrethroids for the control of vectors. Countries have been urged to revive and strengthen their insecticide policy for public health use for the guidance of decision-makers. Countries are also encouraged to use WHO specifications for insecticide use in public health and to establish and further strengthen quality control of insecticides and dispensing equipment. A WHO Regional Training Course on Comprehensive Vector Control (CVC), was organized at the Vector Control Research Centre (VCRC), in Pondicherry (India), in August-September 2001. Considering the importance of vector control, countries have now started sending additional participants for training in CVC at their own cost. In addition, WHO assisted Myanmar in conducting a course on CVC for its nationals in SeptemberOctober 2001. The CVC training course in Pondicherry, would be an annual feature, with WHO providing technical support. Member Countries need to be further sensitized regarding bio-environmental aspects when taking up major development projects like dams and hydroelectric schemes to ensure minimum disturbance to the ecology and vector balance in the area. Collaborative studies to evaluate the operational impact of insecticide-treated bednets on malaria control have been planned through the RBM Technical Support Network to be implemented in 2002. Bangladesh, India, Indonesia, Myanmar and Thailand will carry out these studies.
ResearchandProductDevelopmentfor CommunicableDiseases The Tropical Disease Research (TDR) Programme was established in 1975 with two interdependent objectives: (1) to undertake research and development of new and improved tools for the control of major groups of tropical diseases (malaria, schistosomiasis, lymphatic filariasis, onchocerciasis, leishmaniasis, Chagas disease, African trypanosomiasis and leprosy), and (2) to strengthen research capabilities where these diseases are endemic. Now, dengue and tuberculosis have also been included in TDR activities.
12 THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION
The TDR programme continued to support activities and research focused on malaria (Bangladesh, India, Myanmar, Nepal, Sri Lanka, Thailand); lymphatic filariasis (India, Myanmar, Nepal, Sri Lanka); leprosy and tuberculosis (India); and kala-azar (Bangladesh, India, Nepal); studies on drug resistant malaria (Myanmar, Thailand); vaccine development (India, Thailand); vector control (Sri Lanka); monitoring of drug efficacy (Indonesia, Myanmar, Sri Lanka); and new drug regimen (Bangladesh, Thailand). The studies on kala-azar, undertaken in India, focused on the development of an animal model and clinical studies with aminosidine and miltefosine.
Roll Back Malaria Malaria continues to challenge national economies and the health of the people in the Region. While resources continue to be limited, the recent economic crisis in some countries has further affected control programmes and consequently caused the re-emergence of endemicity in vulnerable areas. WHO, in collaboration with partners, mobilized emergency support and assigned experts to provide technical assistance for the control of malaria in two Member Countries. To reduce case fatality, WHO, in collaboration with experts from Member Countries, developed Guidelines on Management of Severe Malaria for Small Hospitals. The guidelines will be disseminated to Member Countries to strengthen small
13 WHO advocates the use of insecticide-treated nets for malaria control THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION
hospitals in remote areas. Guidelines on Implementation of RBM at the District Level have been finalized for adaptation by the countries to be used in the RBM pilot districts during 20022003. Support was provided to countries in translating the documents into respective national languages. Realizing the importance of collaboration among six countries in the Mekong region, WHO assigned a consultant to coordinate efforts by the countries and to work with partners in addressing the problems of multidrug resistance. Following the Meeting on Technical Support Networks, held in Chiang Mai (Thailand) in March 2000, WHO supported 21 proposals developed jointly by control programmes and scientists to solve operational problems in their respective countries. In view of the spread of multidrug resistant malaria in the Region, WHO, in collaboration with Member Countries and partners, has established surveillance networks for drug resistance monitoring in the Mekong region (six countries) and in Bangladesh, Bhutan, India, Nepal and Myanmar. WHO provided technical support to Member Countries in collecting data on the therapeutic efficacy of first and second line antimalarial drugs. The work will be completed in October 2002 for use by the countries in formulating their antimalarial drug policy. An Intercountry Consultative Meeting of National Malaria Programme Managers was held in Yogyakarta (Indonesia) in November 2001. As a follow up, the countries developed a Malaria Strategic Plan which was later used to respond to a call from the Global Fund to fight AIDS, TB and Malaria (GFATM). WHO provided technical support to five countries in submitting proposals for malaria to the GFATM Secretariat.
The recent economic crisis in some countries has affected malaria control programmes resulting in the re-emergence of endemicity in vulnerable areas
Tuberculosis The Region accounts for nearly 38 per cent of the world’s burden of TB (Figure 1.4), with 3 million new cases and nearly 750 000 deaths reported every year. The incidence of the disease is highest in the 20-45 age group, thus seriously affecting economic development. The spread of HIV in the Region and the emergence in recent years of multidrug-resistant strains of tuberculosis pose additional threats.
14 THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION
Figure 1.4 : Distribution of global TB burden, by WHO region (Percentages)
Source: WHO/HQ: WHO Report 2002, Global Tuberculosis Control
DOTS coverage now extends to 56 per cent of the Region’s population (Figure 1.5). Under the DOTS strategy, nearly 2 million patients have been treated with a success rate of around 80 per cent in areas where the strategy has been applied. The quality of diagnosis has been good; however, the number of cases detected is still low at fewer than 40 per cent of the estimated cases. The Regional Office has developed guidelines and assisted countries in developing plans for the implementation of TB control activities in the next five years. A Regional Strategic Plan for TB Control has been prepared and a Regional Partners’ Forum to mobilize commitment and resources to intensify and further extend coverage with DOTS in the Region is planned in the near future. Joint plans of action for initiating disease
Figure 1.5 : DOTS coverage in the SEA Region,1997-2001 60 50 45 27 18 10 56
Percentage
40 30 20 10 0 1997 1998 1999 2000 2001
15 THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION
Source: WHO/SEARO
Tuberculosis can be cured and transmission interrupted through the DOTS strategy
WHO has developed guidelines and assisted countries in developing plans for the implementation of TB control activities in the next five years
control in the adjoining border districts of Bangladesh, Bhutan, India, and Nepal have been drawn up and will be carried forward in 2002. The Thai-Myanmar border programme for disease control is already in place. Assistance was provided to develop a network of laboratories for smear microscopy in several Member Countries and mechanisms to establish quality assurance of microscopy services and for drug resistance surveillance have been identified. Several Member Countries, including India will receive assistance through the Global Drug Facility (GDF) to ensure regular supplies of quality drugs; Myanmar was among the first countries to benefit from this facility. A number of regional training courses on various aspects of TB control were held during 2001-2002: annual comprehensive training course on TB control; on laboratory methods for the diagnosis of TB including drug resistance surveillance, and on data management to facilitate recording and reporting at the country level. A course on Leadership and Strategic Management for national and intermediate level staff of national TB programmes is being developed. In addition, a number of technical and training materials have been developed and widely disseminated.
16 THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION
There is a strong commitment in the Region for achieving the global target and nationwide DOTS coverage by 2005. Nearly 58 per cent or 875 million of the Region’s population
now have access to DOTS services compared with less than 10 per cent in 1997; however, case detection needs to be enhanced. Though the quality of DOTS implementation has been good, it is necessary to intensify and extend DOTS coverage to increase the number of those successfully treated and cured. The required key interventions have been identified and built into the five-year plans of the Member Countries. The resources required have also been identified and some commitments from donors/partners already obtained. Resource gaps, however, remain and must be urgently met. Given the current impetus and the additional resources expected, the Region will reach the global target by 2005.
HIV/AIDS The AIDS epidemic continued to spread in the Region, which is the second most affected region in the world, after sub-Saharan Africa. Of the 40 million persons estimated by WHO and UNAIDS to be living with HIV/AIDS at the end of 2001, more than 5 million are in the SEA Region. As of March 2002, 216 443 cases of AIDS were reported from the Member Countries (Table 1.1). This is considered to be a gross underestimate of the actual situation because of reporting deficiencies. More than 99 per cent of the cases were reported from three countries – India, Myanmar and Thailand; the prevalence of HIV in these countries is much higher than in the other countries of the Region. There is a potential for rapid spread of HIV in all countries as risk behaviours and vulnerabilities, which fuel the spread of infection, exist in all countries. Indonesia and Nepal are already experiencing a rapid increase in HIV prevalence among injecting drug users. Thus, the epidemic in the Region is highly dynamic and evolving rapidly. Member Countries continued to give high priority to fighting the AIDS epidemic and attendant problems. They are implementing the national strategic plans with the involvement of a number of government, private sector and nongovernmental organizations. Priority is being given to targeted interventions and scaling up of effective interventions, such as 100 per cent condom use in sex work, syndromic management of sexually transmitted infections, prevention of mother-tochild transmission and harm reduction among injecting drug
17 THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION
Table 1.1: Reported AIDS cases and estimated HIV infections in the SEA Region, as of March 2002 Country Bangladesh Bhutan DPR Korea India Indonesia Maldives Myanmar Nepal SriLanka Thailand Total Source : Country reports
Reported AIDS cases 19 3 0 29 007 671 8 4 598 536 117 181 484 216 443
Estimated HIV infections 13 000 <100 <100 3 860 000 100 000 <100 510 000 34 000 7 300 770 000 ~ 5 294 600
users. Many countries are undertaking behavioural surveillance in order to monitor risk behaviours among selected groups. As a result of these effective interventions, the number of new HIV infections in Thailand is estimated to have decreased from 143 000 in 1990 to 25 800 in 2002. Increasing attention is also being given to cross-border spread of the infection with the preparation of joint plans of action for cross-border interventions. The participation of NGOs and the private sector is steadily increasing. The Member Countries have given high-level commitment to the control of AIDS. The Ministers of Health of the countries of the Region accorded high priority to HIV, and on their recommendations, WHO formed a Regional Task Force on HIV/AIDS with the objective of mobilizing resources required to combat the epidemic. The Regional Office continued to play a leading role in providing support to all aspects of HIV/AIDS, such as surveillance, STI prevention and care, blood safety, counselling and care of affected persons. The members of the Regional Task Force on HIV/AIDS were regularly briefed on matters related to GFATM. The first meeting of the Task Force, held in the Regional Office in January 2002, updated the participants on GFATM, determined the terms of reference of the Task Force
18 THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION
and proposed actions to be taken for resource mobilization to fight the three diseases. The Regional Office kept the WHO country staff informed about GFATM and provided technical support in various activities related to the Fund. It provided expertise at the regional consultations held in connection with the Fund in Bangkok (November 2001) and Beijing (February 2002). The South-East Asia Region, in collaboration with the Western Pacific Region, organized an Asia-Pacific meeting on Global Health Sector Strategy on HIV/AIDS in Bangkok in January 2002. The meeting reviewed the implications of HIV/AIDS on the national health system and the health sector response. It also discussed the global health sector strategy for strengthening response to HIV/AIDS, identified the essential components of the Asia-Pacific response strategy and the areas and mechanisms for bi-regional collaboration in this area. In order to improve national capacity in STI management, the Regional Office organized an intercountry workshop in Yangon in July 2001. Apart from updating the participants on STI prevention and care, the workshop reviewed and finalized the guidelines for conducting an STI prevalence study and the generic protocol for preparing the study proposal.
Care of HIV/AIDS patients at the community level requires partnerships between government, the private sector and nongovernmental organizations
19 THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION
Two intercountry training courses, each of two weeks’ duration, were conducted in Bangkok: one on Clinical Management of HIV/AIDS in October 2001 and the other on Voluntary Counselling and Testing, in November 2001. The objective of the training courses was to build national capacities in providing counselling and care to persons with HIV. The Regional Office continued to provide technical support to Member Countries through country visits and correspondence. It produced and distributed various publications, such as guidelines and a protocol for the STI prevalence study, the information package for World AIDS Day and the regular newsletter, AIDSWatch. Identifying effective interventions, increasing such interventions and mobilizing resources for filling funding gaps are the major challenges. GFATM is a welcome initiative to fill the gap in funding. Active involvement of NGOs and the private sector is very important for successful implementation of the interventions. Sustained political commitment and adequate resource allocations at the national level are vital issues for the Member Countries. While prevention should be the primary aim, people with HIV/AIDS also need adequate counselling and care. The role of antiretroviral drugs in preventing motherto-child transmission and in the care of infected persons needs to be studied.
Cross-border collaboration on priority communicable diseases Realizing the importance of intercountry collaboration in ensuring effective response to cross-border health problems, WHO organized an Intercountry Meeting on Cross-border Initiatives on Priority Communicable Diseases in New Delhi in July 2001. The meeting, attended by representatives from Bangladesh, Bhutan, India and Nepal, reached a consensus on effective strategies for the control of HIV/AIDS, tuberculosis, malaria and kala-azar in selected cross-border districts. There has been a major shift in the approach to cross-border health problems. Realizing that targeting a single disease has been ineffective in solving cross-border health problems, the
20 THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION
countries have jointly developed multi-disease control action plans with WHO technical support and through consensus building at the border district meetings for implementation at pilot districts in an integrated and coordinated manner. WHO will support capacity building, monitoring and evaluation components of these pilot projects. WHO continues to support similar cross-border collaborative programmes initiated by Myanmar and Thailand.
21 THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION
22 THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION
2 NONCOMMUNICABLE DISEASES AND MENTAL HEALTH Surveillance, Prevention and Management of Noncommunicable Diseases Noncommunicable diseases (NCDs) are increasingly becoming a major cause of morbidity, mortality and disability. The World Health Report 2001 had indicated that NCDs account for 51 per cent of deaths and 44 per cent of the disease burden in the Region. The major NCDs include: cardiovascular diseases, cancers, diabetes mellitus, and chronic obstructive pulmonary disease. To address these problems, the framework of a regional strategy for NCDs was developed based on the Global Strategy for Prevention and Control of NCDs that was endorsed by the Fifty-third World Health Assembly. It identifies major diseases, viz. cardiovascular diseases, cancer and diabetes mellitus for integrated surveillance, community-based prevention and primary health care-based cost-effective management. The strategy targets major risk factors like tobacco and alcohol consumption, physical inactivity, imbalanced diet, obesity and high blood pressure for standardized surveillance and integrated community-based interventions. The Regional Office initiated activities aimed at developing an affordable and manageable surveillance system for all countries of the Region. One of the activities undertaken in 23 THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION
NCDs are increasingly becoming a major cause of disability, morbidity and mortality in the Region
this context was to collect information from each Member Country on major noncommunicable diseases and their risk factors. Data as reported by the principal investigators from Bangladesh, Bhutan, DPR Korea, India, Indonesia, Myanmar, Nepal, Sri Lanka and Thailand were compiled and analysed in the publication, Noncommunicable Diseases in South-East Asia – A Profile. Although the data collected are of very limited epidemiological value, this is the first publication of its kind issued by the Region. As such, it may contribute to the ongoing discussion on the role of NCD surveillance and also prompt the countries to establish sustainable databases for NCDs and their risk factors. To help strengthen NCD surveillance activities, the development of national NCD surveillance networks in Bangladesh, India, Indonesia, Nepal, Sri Lanka and Thailand was supported. The activities included a series of national workshops that facilitated the development of national consensus on the objectives, strategy, scope and methods of sustainable surveillance of major NCDs and their risk factors. Based on the experiences and recommendations made by national networks in the six Member Countries, it is planned to establish a Regional Network for NCD Surveillance to facilitate exchange of information and experiences and in developing a regional strategy for NCD surveillance.
24 THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION
WHO has developed guidelines and a methodology to support Member Countries in developing sustainable, standardized NCD risk factor surveillance. A step-wise approach based on both standardized data collection and sufficient flexibility, which would be appropriate in a variety of country settings, has been proposed. It emphasizes that small amounts of good quality data are more valuable than large amounts of poor quality data. The approach and methodology tested recently in selected demonstration areas is being advocated for widespread implementation in the Region. WHO and national networks of NCD surveillance that have been developed/strengthened are facilitating training and planning activities aimed at integrating this NCD risk factor surveillance approach into national health information systems in a sustainable way. The step-wise approach to NCD risk factor surveillance was incorporated into the Indonesian Health survey ( Surkesnas) and, through it, into the Indonesian Health Information System (Siknas) in 2001. The first regional Steps Planning Workshop was held in Bangkok in April 2002 to support seven Member Countries in capacity building for incorporating standardized NCD risk factor surveillance into national health information systems. Pilot projects were initiated in demonstration suburban areas of the capitals of three regional mega countries (Dhaka, Jakarta and New Delhi) in 2001 to collect evidence on the effectiveness of community-based prevention programmes aimed at reducing NCD risk factor levels in the population. After completing the pilot phase, long-term NCD intervention targeting major risk factors in an integrated way and incorporating appropriate mechanisms for monitoring and evaluation will be continued with WHO support. Recognizing the importance of cardiovascular diseases which contribute to 29 per cent of the deaths in the Region, the SEA Advisory Committee on Health Research (SEA/ACHR) addressed the problem at its 27th session in April 2002. The Committee identified priorities in CVD research and proposed measures to strengthen collaborative research in the area. WHO supported many research studies, including health system research, focusing on priority NCD prevention and control and assisting Member Countries in strengthening health care for people with
Pilot projects were initiated to collect evidence on the effectiveness of community-based prevention programmes
25 THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION
established NCDs. It facilitated the development and implementation of cost-effective secondary prevention interventions, with emphasis on primary health care and community-based participation. To support this work, a new WHO collaborating centre for diabetes research and prevention was designated in Chennai (India) in 2002. Using a global WHO questionnaire, the national capacity for NCD prevention and control was assessed in all the ten countries of the Region. The exercise provided valid information that helped in identifying constraints and needs, and in setting priorities for technical support. In addition, it helped in planning, implementation and evaluation of NCD prevention and control programmes. National NCD prevention and control programmes have been initiated in a majority of Member Countries since 1975. They are however vertical, disease-specific and most often tertiary care-focused rather than integrated and oriented on population-based primary prevention targeting common NCD risk factors. There is a need to build up on the experience of other WHO regions (EUR, AMR, and AFR) that have initiated regional NCD prevention and control networks and integrated them with the Global Forum for NCD Prevention and Control in order to more effectively address international and global dimensions and challenges, including coordinated advocacy, resource mobilization and training. There is also a need to strengthen political commitment on developing the network by the Member Countries and to identify appropriate resources to facilitate planning, implementation, monitoring, evaluation and coordination of its activities.
Tobacco The Regional Committee, at its 53rd session, urged Member Countries to use regional mechanisms and associations, such as SAARC and ASEAN, to actively promote the Framework Convention on Tobacco Control (FCTC), and tobacco control in general. In response, with WHO support, representatives from Member Countries continued to participate in the FCTC process at the global and regional levels. 26 THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION
To provide a forum for an in-depth analysis of FCTC, two intercountry consultations were organized in Thimphu
(Bhutan) and Jaipur (India) respectively. These meetings have incrementally helped Member Countries to clarify and strengthen their positions on the various sections of the Convention. The participation of delegates from Member Countries was supported at the 3rd and 4th meetings of the Intergovernmental Negotiation Body on FCTC. Regional positions on FCTC and region-specific proposals on the Global Fund for the implementation of FCTC by developing countries were forcefully articulated at these meetings. Development of a scientifically sound database on tobacco control continued to be a critical component of the regional technical support to Member Countries. Sentinel prevalence studies on tobacco use were initiated in Bangladesh, Bhutan, India, Indonesia, Myanmar and Sri Lanka and have been completed in all these countries except India. The studies provide a sound basis for target-specific intervention development and advocacy for intensified tobacco control activities. Economic analyses of tobacco production and use as well as health and other costs related to tobacco use have been conducted in Bangladesh, Bhutan, Indonesia, Maldives, Myanmar, Nepal, Sri Lanka and Thailand. The results of these studies are being reviewed by WHO headquarters and would help strengthen fiscal and legislative policies of countries to reduce tobacco consumption, particularly among children, the youth, women and the poor. While the adverse effects of smoking on reproductive health are widely known, that of chewing tobacco has not been sufficiently researched. In most parts of the Indian subcontinent, tobacco use among women is predominantly in the chewing form. Research to elucidate the implications of chewing tobacco on reproductive health is at its final stage in India, while it has just started in Bangladesh. Based on the results of these studies, countries can formulate antenatal and community-based interventions focusing on tobacco use by pregnant women and women in general. WHO continued to support the Global Youth Survey on Tobacco Use being spearheaded by WHO headquarters. The initiative focuses on collecting data on tobacco use among the youth with a view to having a global database for evolving effective country-specific tobacco control interventions. So far, Indonesia, Myanmar, Nepal and Sri Lanka have completed national surveys and published results.
Representatives from Member Countries participated in the FCTC process at the global and regional levels
27 THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION
The regional launch of the second round of the SEAAT flame was held in conjunction with World No-Tobacco Day 2002
To support tobacco control activities at the country level, the Indian Institute of Health Management and Research, Jaipur (India) was contracted to develop management training modules on tobacco control. The first training for focal points using the module took place in August 2001. It is planned to strengthen these modules further by incorporating country-specific case studies through pilottesting at the national level. To strengthen the advocacy capacity of NGOs, the NGO Alliance for Tobacco Control in India was supported to develop, print and distribute a media kit on tobacco. Copies of the kit have been shared regionwide to support NGOs in their advocacy efforts. To support advocacy and educational programmes through World No-Tobacco Day at the country level, information kits and T-shirts were produced and distributed to all the countries. The theme for 2002 was “Tobacco Free Sports: Play it Clean”. The Regional Director briefed the media on the focus of the celebration and WHO’s position on tobacco and sports. The second round of the South-East Asia Anti-Tobacco (SEAAT) Flame was launched. 28 THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION
The publication of the regional quarterly newsletter, Lifeline, continued; three issues were brought out. The newsletter provides a useful forum for countries to share experiences.
Health Promotion WHO supported the review of health promotion policies and strategies in Bangladesh, Indonesia, Myanmar and Thailand. The objective was to identify an entry point to intensify advocacy for political commitment for strengthened health promotion policies and implementation. Advocacy to use health promotion strategies as an important tool for health development was found to be successful in that health promotion has been included in the health policies of these countries. The review results however highlighted the urgent need for political commitment for implementing health promotion activities. The lack of a proper understanding of the concept and the tendency to equate health promotion with behavioural change communications as well as the weak intersectoral partnerships of health promotion were also noted. To secure a regionwide overview of health promotion implementation, the review is being expanded to cover the remaining six countries. The availability of adequately qualified human resources is critical to the successful implementation of health promotion interventions which are sensitive to the needs of Member Countries. With rapid changes in the epidemiological and demographic patterns in the Region, health promotion needs to focus more on the health determinants and risk factors. A review of the health promotion curricular content of 27 training institutions in six Member Countries was conducted to ascertain the level of health promotion inputs and the capacity of such institutes to offer health promotion courses. The review results formed the basis of an intercountry consultation held in Madurai (India) in September 2001, which defined the core training curricular content for the various levels of health promotion training. A network of health promotion training institutions was initiated at the consultation to help operationlize the core curricular content at the national level. The Regional Committee, at its 53rd session, urged countries to pilot the concept of healthy districts at the country level. The development and concept of the Healthy Districts Programme was extensively discussed among participants from nine Member Countries of the Region at an intercountry consultation, held in May 2001 in Gurgaon (India). The
The availability of adequately qualified human resources is critical to the successful implementation of health promotion interventions
29 THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION
outcome of the meeting included definition of a healthy district, guiding principles, goal and objectives as well as criteria for identifying the district for piloting the concept. As a followup, Bhutan, India, Indonesia and Sri Lanka have already identified districts for the programme, while Maldives and Nepal are in the process of doing so.
WHO supported Member Countries to introduce life skills education into school curricula as a health promotion methodology to improve lifestyles of school children
To create a better understanding of the concept and practice of healthy settings, an advocacy package has been developed and distributed to all countries. This encapsulates the origins of the concept and experiences at the district level as an umbrella setting for coordinated and cooperative action for health. The Regional Concept and Strategies paper and the operational guidelines that have been developed would help strengthen the capacity of Member Countries in developing healthy districts. The guidelines have been pretested in Indonesia and India. To support the management of the Healthy District Programme, a training module on the management of integrated healthy settings at the district level has been finalized. Technical support continued to be provided to Member Countries in the area of health promoting schools, hospitals and workplaces. Operational guidelines for the development of health promoting hospitals have been finalized for pretesting. Schools are strategic settings for fostering good health, not only for students but also school personnel and the community. The health promoting schools initiative in the Region supports schools to adopt policies that empower them to create supportive environments for healthy living. In this context, schools can be effective advocates to promote health within and outside schools. Member Countries were supported to introduce life skills education into school curricula as a health promotion methodology to improve lifestyles of school children. An effort to make students themselves health promotion activists culminated in an intercountry Health Jamboree in Maldives in September 2001. The Jamboree highlighted the objectives of health as a holistic concept, sharing observations, experiences of students on prevalent health problems, discussing existing school health programmes in the respective countries and outlining strategies to help countries improve the health of adolescents in school.
30 THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION
A regional health jamboree, organized for students in Maldives, highlighted the objectives of health as a holistic concept
The outcome of the Jamboree included an oath taken by students in the presence of the President of Maldives as well as recommendations for follow-up actions. Modules prepared for the Jamboree have been revised with additional subjects included on adolescent health. The facilitators guide that was developed will help teachers and students to conduct a successful Health Jamboree at the national level. This would strengthen the efforts of Member Countries in promoting adolescent health as well as expanding the activities of health promoting schools at the country level. Member Countries were supported in celebrating World Health Day 2002 on the theme of physical activity, with the slogan, “Move for Health”. Information kits with emphasis on the prevention and control of noncommunicable diseases were developed and shared with all Member Countries. Promotional materials were made available to countries to motivate schools, youth and sports groups as well as communities on physical activity programmes. Five countries were supported to document country programmes on healthy lifestyles with emphasis on physical activity and diet. The Regional Office is working with the remaining five countries to undertake similar documentation. This would help define strategies to strengthen physical activity at various levels and for specific age groups.
31 THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION
Disability/Injury Prevention and Rehabilitation Injuries and violence prevention Based on the estimates of World Health Report 2001, the SouthEast Asia Region has reported the largest burden of injuries among all WHO regions. An estimated 1.4 million people are reported to have died due to injuries in 2000 and about 70 million people are estimated to have sought emergency treatment owing to injuries. Acknowledging a large burden of injuries and violence in the Region, a number of regional and national activities were initiated during the period under review. The high-level task force, constituted by the Regional Director, has identified injuries as a priority activity for intercountry projects. A regional profile of injuries has been prepared. Road traffic injuries, burns, work-related injuries, suicide and violence are reported to be among the more common injuries. An intercountry consultation, held in Bangkok in January 2002, developed a regional strategy for injury prevention. Advocacy for strengthening national programmes, injury surveillance, pre-hospital care and emergency care are the key approaches adopted. A regional training programme for trauma epidemiology and injury surveillance has also been identified as a priority and a curriculum for the same is under development. At the national level, research activities on the epidemiology of injuries are being supported in India, Indonesia and Sri Lanka. Assistance was provided to the countries for the development of national plans of action on injury prevention. Ground work has been completed for piloting injury surveillance and pre-hospital care in three countries.
Prevention of blindness Following the regional launch of Vision 2020: The Right to Sight, the Prevention of Blindness Programme has taken new strides. Many countries have launched national Vision 2020 campaigns while some of them have developed national programmes. Considering the high prevalence of blindness in Bangladesh (1 per cent) and Indonesia (1.5 per cent), a capacity building programme is being piloted in one institution in each country with expertise from the Lions Aravind Institute of
32 THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION
Prevention of Blindness programmes in the Region have received an added thrust with the launch of the Vision 2020 : the Right to Sight
Ophthalmology in India. This project aims at increasing the productivity of each of these centres and improving the outcome of services to serve as models. A team consisting of an ophthalmologist, an anaesthetist and an ophthalmic nurse is being trained to provide surgical eye care to children to address the problem of childhood blindness in eight countries of the Region. A team from the Cicendo Eye Hospital in Bandung (Indonesia) has already been trained. Participants from other countries will be trained in batches. Under this process, about 32 nationals will be trained in paediatric eye care and eight countries will have one paediatric eye care centre each. Training is being provided at L.V . Prasad Eye Institute in Hyderabad (India). Preparations are at an advanced stage to initiate an intervention study for the prevention of traumatic corneal ulcer in Bhutan, India and Myanmar. For long, management deficiencies have been recognized as key obstacles in implementing prevention of blindness and Vision 2020 programmes. To improve the situation, training in management and systems development has been provided to 16 heads of eye hospitals, 17 eye care programme managers as well as 7 hospital administrators. October 20, 2001 was observed as World Sight Day in all the countries of the Region. An advocacy kit, developed by the Regional Office, was distributed in the Region.
33 THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION
Prevention of deafness To assess the extent of the problem, a survey on hearing impairment and ear diseases using the WHO protocol was completed in India, Indonesia, Myanmar and Sri Lanka. A regional profile of deafness and hearing impairment has been prepared. Chronic otitis media, noise-induced hearing impairment, the use of ototoxic drugs and congenital diseases have been identified as the main conditions causing deafness and hearing impairment in the Region. A survey is being carried out to assess the infrastructure to deal with deafness and ear disease in India, Indonesia, Myanmar, Nepal, Sri Lanka and Thailand. A regional strategy to reduce the impact and burden of deafness and hearing impairment will shortly be developed once baseline data are available. Support was provided to the countries for training primary health care workers in primary ear care and for conducting mobile ear camps.
Ageing and health The population of those 60 and above is rapidly increasing in the Region. The current estimated number of this population is 120 million which is expected to increase to 493 million by 2050. Health systems in the Member Countries have been slow to respond to the needs of this rapidly increasing section of the population. A regional situation analysis on ageing and health has been prepared by analysing the available information. A Manual on Health Care of the Elderly at Family and PHC levels has been developed with WHO support, for use in DPR Korea. A profile on health of the elderly in all the ten countries of the Region is under preparation. This will provide the much-needed evidence base for developing a regional strategy. A regional model for Comprehensive Community and Home-based Health Care has been developed and is being fieldtested in Bhutan, Myanmar, Nepal and Thailand.
The proportion of the elderly population is increasing rapidly in the Region
Rehabilitation Increased longevity and the growing incidence of injuries have led to a rapid increase in the number of disabled persons requiring rehabilitation services in the Member Countries. Community-based rehabilitation (CBR), promoted by WHO, has been implemented in many countries. Significant efforts
34 THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION
have been made to remove barriers and improve access for the disabled. Home-based long-term care is being promoted as a supplementary strategy. A new International Classification of Functioning, Disability and Health has been adopted by the World Health Assembly. The countries of the Region participated in its development over the last six years.
Mental Health and Substance Abuse Mental health was the subject of a resolution adopted by the 54th session of the Regional Committee, as well as of discussions during the Regional Parliamentarians Meeting in New Delhi. The Regional Office developed several intercountry projects and programmes on topics related to mental health and on substance abuse. A series of monographs covering Alzheimer’s disease, epilepsy, schizophrenia, mental retardation, depression and suicide were also issued. Professional neuropsychiatric services are scarce in Member Countries, particularly in rural and remote areas. Thus patients with neuropsychiatric disorders are deprived of even the basic minimum level of service. An Intercountry Consultation on Development of Strategies for Community-based Neuropsychiatric Services, held in Bangkok in November 2001, recommended that strategies be developed for training general practitioners and other lay health workers in the identification and management of two disorders (epilepsy and psychosis). This project is at an advanced stage of development and fieldtesting is scheduled for the second half of 2002. Projects are being developed in rural and remote areas for the rehabilitation of children with mental retardation. Similar urban-based projects will include training programmes for rehabilitation workers which can be implemented in all Member Countries. In addition, models for the rehabilitation of patients with long-term stay in hospitals are being developed. To promote positive mental well-being amongst adolescents, six modules entitled Coping with Stress, Conflict Resolution, Strengthening Bonds with Others, Handling Peer Pressure, Selfesteem Enhancement and Dealing with Emotions were
35 THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION
developed. These modules have been tested in India, Indonesia and Thailand and found to be very useful. An Intercountry Workshop on Development of Methodology for assessment of the magnitude of neuropsychiatric disorders in the community was conducted. As a follow-up, surveys will be conducted in Member Countries in collaboration with WHO headquarters. Thus, reliable, community-based and internationally comparable data on the magnitude of neuropsychiatric disorders in the Member Countries will be available. These data will assist in prioritization and programme development for mental health and substance abuse. Representatives from all the Member Countries participated in project development workshops conducted by the Regional Office. Bhutan, Indonesia, Maldives and Sri Lanka were supported in the development of several community mental health projects, adolescent mental health, neuropsychiatric disorders survey and community-based neuropsychiatric management. Support was provided to India in initiating projects in the areas of management of epilepsy, psychosis and rehabilitation of mentally challenged persons.
Suicide prevention India and Sri Lanka record the highest number of suicide rates and occupy the 45th and 7th positions globally respectively. Moreover, the classical risk factor applicable to suicide in the western countries usually cannot explain most of the suicides in the Region. An intercountry study on the subject has been initiated by WHO headquarters in which India, Sri Lanka and Thailand are participating. The results of this study should lead to the identification of unique local factors which predispose a person to committing suicide. A WHO monograph entitled Suicide Prevention: Emerging from Darkness was issued by the Regional Office.
Substance abuse and prevention of harm from alcohol 36 THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION
The Regional Office, in collaboration with WHO headquarters, is developing programmes aimed at adolescents for addressing diverse issues related to substance abuse, including volatile
substance abuse, which is an increasing problem and has not been addressed effectively. Alcohol abuse, particularly among the poor, remains a major problem in the Region. Innovative programmes for the prevention of harm from alcohol are being developed. A booklet entitled Mental Health and Substance Abuse including Alcohol in the South-East Asia Region was issued. Another monograph on Alcohol Use and Related Problems is under preparation. A Technical Experts Consultation on Development of a project for Prevention of Harm from Alcohol Abuse was held in Bali (Indonesia) in June 2002. The consultation finalized the draft regional strategy to address the multi-faceted issues relating to alcohol abuse in the Region and to identify unique solutions to reduce the harm due to alcohol use in the community.
37 THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION
38 THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION
3 FAMILY AND COMMUNITY HEALTH Child and Adolescent Health In line with WHO headquarters, the Regional Office also brought under one head the various programmes relating to child and adolescent health (CAH) and development (integrated management of childhood illness, including newborn health, breast-feeding and infant feeding, adolescent health and the rights of children). The objective is to recommend a one-stop service for children and adolescents using a life-cycle approach.
Integrated Management of Childhood Illness Integrated management of childhood illness (IMCI) is a costeffective strategy which emphasizes prevention of disease, promotion of child health and development, besides provision of standard case management of childhood illness. The IMCI strategy was first implemented in Nepal and Indonesia in 1997. Since then it has been implemented in all the countries with high infant and under-five mortality. Different countries of the Region are at different phases of implementation – introduction, implementation or expansion (Figure 3.1). The main focus of IMCI is on: (a) capacity building, (b) improving family and community practices, and (c) preservice training. Considerable progress has been made in the area of capacity building of human resources and institutions in the Member 39 THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION
Figure 3.1: Implementation of IMCI in the SEA Region DPR Korea Nepal
Bhutan
Bangladesh
Expansion
India
Myanmar
Implementation Introduction
Thailand
Sri Lanka Maldives n
I
d
o
n e s i a
Source: WHO/SEARO
Countries. Eight national and intercountry training courses were conducted. The noticeable change is that all the facilitators are now drawn from the countries of the Region. Through these courses, the Regional Office has also contributed to capacity building of human resources for WHO headquarters and other WHO regions. In addition to providing training to health care providers in developing skills to manage the main childhood illnesses as described in the IMCI strategy, the focus in capacity building has been on the training of staff to undertake the tasks of facilitators, course directors, clinical instructors and adaptation consultants. Programme managers, staff from WHO collaborating centres, NGOs and national training institutes have been trained in IMCI. As capacity building is a continuous process, efforts are being made to strengthen national-level training institutes in selected countries to provide in-service training on an ongoing basis and thus ensure sustainability. Regional and country capacity on follow-up after training has been strengthened. In order to achieve substantial reductions in under-five mortality, it is important that health care be provided within the village, thereby bringing the IMCI strategy closer to the community. The SEA Region has done pioneering work in the
40 THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION
development of a package for the training of basic health workers (BHWs), which has been shared with other regions of WHO. The package, developed in collaboration with CARE and the Government of India, has been adapted, translated and used in the training of different types of basic health workers in different countries of the Region (India, Indonesia, Myanmar and Nepal). A demonstration course was held in Bangladesh in March 2002. The Region is now incorporating the management of malaria and the young infant into the package. A substantial impact of the IMCI strategy is likely to come through people’s participation in improving family and community practices. The key family and community practices were reviewed and consolidated in a book, IMCI: In the hands of families. Following the review, which incorporates the work done so far in the countries of the Region, the 12 key practices that strengthen family and community practices have been consolidated into 30 messages in an illustrated guide for use by and guidance of volunteers and the community. Training and orientation on the IMCI strategy has been introduced in 15 medical schools in Indonesia and five each in Nepal and India. In Indonesia, steps have been initiated to introduce IMCI in nursing schools. The IMCI chart booklet and key information on the strategy are already included in the textbook of paediatrics, which is a widely-used reference textbook for medical students in the Region.
Integrated management of childhood illness: reaching out to the community to improve child health
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Infant and young child feeding Breast-feeding practices continue to be eroded in the countries of the Region. To tackle this problem, training courses to promote breast-feeding counselling were organized in Nepal and Maldives during the period. India and Bangladesh had organized similar courses earlier. National capacity was strengthened in a few countries in the area of lactation management and policy. IMCI is considered an important strategy to improve health, nutrition and development of under-five children. In this context, the Regional Office participated in the meeting on the development of the national nutrition strategy in Maldives. The global strategy on infant and young child feeding has been accepted by the Fifty-fifth World Health Assembly. WHO is providing technical support to countries to adapt the strategy at the national level.
Child rights and protection The Regional Office has pioneered the promotion of child rights and protection. Following the first Regional Orientation Workshop on the Convention of the Rights of Child (CRC), the Regional Office has prepared advocacy material on CRC. The National Institute of Public Cooperation and Child Development (NIPCCD) organized the first National Workshop on Child Rights for policy-makers of different ministries in the Government of India. Regional and district-level workshops are proposed to be organized with support from WHO and UNICEF in India. The Regional Office prepared a Manual on How to Recognize Child Abuse addressed to medical officers in Member Countries.
Newborn care Newborn mortality is one of the world’s most neglected health problems. Worldwide, more than eight million babies are stillborn or die every year, before they reach the age of one month. Most of these deaths occur in developing countries. In the SEA Region, mortality rates among babies one month old and above have significantly declined over the past decade; the mortality rates among newborns have shown no such decline. As a result, neonatal (especially early neonatal) deaths now represent a much larger proportion of the overall total infant
42 THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION
Figure 3.2: Perinatal and neonatal mortality rates in the SEA Region, 1999 100 90 80 70 Mortality rate 60 50 40 30 20 10 0 MMR BAN BHU MAV NEP IND DPRK World
85
80 60
75 55 55
75
70 50 35
70 60 45 45 52 40 31 25 30 15 20 10
INO
SRL
THA
Perinatal mortality rate (per 1000 total births) Source: WHO Geneva, Department of Reproductive Health and Research, Perinatal and Neonatal mortality : Global, Regional and Country estimates, second edition, Draft 5, November 2001
Neonatal mortality rate (per 1000 live births)
mortality rate (Figure 3.2). Further reduction in infant and child mortality will now depend on improving the care of newborns. The Regional Office is working with governments and development partners to respond to this situation and is helping countries develop evidence-based strategies and interventions.
Children’s environmental health A Conference on Environmental Threats to the Health of Children: Hazards and Vulnerability was organized by the Children’s Environmental Health Task Force in WHO headquarters in collaboration with Chulalongkorn University and the Regional Office in Bangkok in March 2002. The conference discussed new research results with a view to promoting awareness among different sectors on children’s environmental health.
Adolescent health and development The regional strategy on adolescent health and development (AHD), finalized in 1998, was widely shared with Member 43 THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION
Countries. Nepal was the first country in the Region to develop and finalize its own national strategy on AHD in 2001. Other countries, including Bangladesh, India, Indonesia and Myanmar, are actively pursuing the development of a comprehensive national policy and strategy on AHD. WHO continues to provide technical support towards the realization of this important step. As part of the strategy, the need to develop adolescentfriendly services (AFHS) by linking and building upon the existing facilities has been recognized. In India, WHO is supporting the implementation of AFHS as part of the SHAHN (Safdarjung Hospital Adolescent Health Network) project in New Delhi. In Indonesia, WHO is supporting an operational study on the development of adolescent health services in Tebet Health Centre, Jakarta. In Nepal, Bir Hospital has been identified as a centre to provide adolescent-friendly health services. Technical support was also provided for a set of modules developed by the Nepal Society of Obstetrics and Gynaecology for the training of health workers in providing AFHS. In Thailand, technical assistance is being provided to monitor and evaluate the “Friends Corner” (an AFHS initiative) project being undertaken by the Ministry of Public Health. Under the UN Inter-agency Working Group (IAWG), India, WHO supported the development, field-testing and finalization of a set of modules on Life Skills Education (LSE) for out-ofschool adolescents. The focus is on building specific skills on important health-related issues. Developmental efforts have been mounted to prepare LSE modules for school-going adolescents in Sri Lanka and Bangalore (India). A package on “Peer Group Counselling” has been field-tested and finalized. The Regional Office is working, in coordination with WHO headquarters, on a project “Working with Street Children: A training Package on Substance Use, Sexual and Reproductive Health including HIV/AIDS and STDs”, which will be implemented with NGOs in Bangladesh, India and Indonesia. Adolescent health has been successfully mainstreamed with the programmes of other departments. Health and Behaviour (H&B) has developed modules on Mental Health which have been field-tested in three countries. HIV-STB has commissioned two situation analyses on “Communication strategies on HIV/AIDS for adolescents” and “Review of HIV/AIDS school
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curriculum”. Nutrition for Health and Development (NHD) is in the process of preparing an analysis on “Adolescent nutrition in the SEA Region”.
Research and Programme Development in Reproductive Health Reproductive health is a crucial part of general health and is central to human development. Awareness of the burden of reproductive ill-health has been growing during the past decade in the Region. The unacceptably high level of MMR in seven out of ten Member Countries prompted the 53rd session of the Regional Committee to urge Member Countries to accord high priority to the reduction of maternal mortality. As operational research is an important tool for generating evidence-based innovative approaches and for policy formulation as well as strengthening of the programme, the Regional Office has been promoting operational research in maternal and newborn health. A multi-centric operational research on community and facility-based interventions for maternal and newborn health is ongoing in six high MMR countries (Bangladesh, Bhutan, India, Indonesia, Myanmar and Nepal). This research proposes to study the effectiveness of interventions aimed at addressing the three delays, i.e. delay in deciding to seek care;
45 Special attention is given to enhancing accessibility to and improving the quality of community health services in reproductive health THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION
delay in reaching a health facility; and delay in receiving treatment at the facility. The study findings are expected to provide an evidence-based model for reducing maternal deaths in the countries. India and Nepal have expressed interest in implementing the health sector strategy for reducing MMR. With a view to reducing maternal deaths, India has initiated activities to address the problem of unsafe abortion. Nepal has initiated similar activities as well and expanded the National Safe Motherhood Programme to 25 districts. A variety of activities in the broad area of reproductive health have been conducted in the Region. WHO supported the training of programme managers in reproductive health from India and Indonesia. Quality improvement of family planning services and prevention/control of STD/HIV/AIDS were the major activities conducted in Bangladesh and Indonesia. In Bhutan, the quality of training of paramedical health workers in reproductive health was improved. Activities to prevent and control cervical cancer were initiated. In India, the quality of reproductive and child health services in disadvantaged districts was improved by enhancing the capacity of the system for grassroot planning, implementing innovative interventions and involving NGOs.
Making Pregnancy Safer The maternal mortality ratio (MMR) in the countries of the Region except in DPR Korea, Sri Lanka and Thailand is extremely high. The Region contributes almost 40 per cent of the global maternal deaths. These deaths occur despite affordable technologies available to prevent them. One important reason is that a large number of women, particularly the poor and the marginalized, do not always have effective access to such life-saving technologies. The Declaration on “Health Development in the South-East Asia Region in the 21st Century” identified maternal mortality reduction as one of the foremost challenges advocated for public health actions. “Making Pregnancy Safer” is a new strategy to revitalize WHO’s commitment to ensure women’s right to life by reducing maternal and perinatal morbidity and mortality,
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within the broader context of safe motherhood and reproductive health. A joint statement by WHO, UNFPA, UNICEF and the World Bank has been issued in support of the MPS strategy. At the regional level, an “information kit on Making Pregnancy Safer” has been developed, published and disseminated to Member Countries and to all regional offices. A package for improving family and community practices for MPS has been developed and is ready for field-testing. The use of tools/ manuals on Making Pregnancy Safer has been initiated in some Member Countries. Worldwide, ten spotlight countries has been chosen as Making Pregnancy country in 2001. countries have been identified as global for “Making Pregnancy Safer”. Indonesia one of them. A national strategic plan on Safer was developed and launched in the
Improvement of the quality of basic midwifery services, especially delivery care, has been an ongoing activity, and conducted in collaboration with other agencies and professional organizations. Several tools have been re-evaluated, revised and adapted. The manual on Managing Complication in Pregnancy and Childbirth was adapted in Bahasa Indonesia and printed. Training of midwives and doctors in basic emergency obstetric and neonatal care has been initiated. Indonesia has initiated partnership with NGOs and other stakeholders in implementing the MPS initiative as well as in the adaptation of technologies related to family planning and protection of health of women and the newborn. Among others, adaptation of post-abortion care at the primary care level, adaptation of the integrated essential reproductive health package, improvement of the quality of family planning services, development of IEC materials and prevention of maternal anaemia were the main features of the MPS initiative.
Making Pregnancy Safer is a new strategy to revitalize WHO’s commitment to ensure women’s right to life by reducing maternal and perinatal morbidity and mortality
Women’s Health WHO’s focus on women’s health and its multiple determinants now includes a gender dimension intensified through collaboration with various WHO technical areas for gender mainstreaming in all health programmes. This is in harmony 47 THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION
Member Countries have accorded a high priority to the reduction of maternal mortality
with the thrust across the UN system that integration of gender considerations and gender mainstreaming must become standard practice in all policies and programmes. Strategies for gender mainstreaming have been developed and adopted by Member Countries along with gender mainstreaming tools. A draft training package for gender mainstreaming in health for health programme managers, health professionals and the community has been developed and pretested in India. The modules are meant to be tools for initiating gender mainstreaming in health with contents and use adapted to the country situation. Adaptation of the training package and its field-testing are under way in Bhutan, India, Indonesia, Myanmar, Nepal and Thailand. Maldives and Sri Lanka have also initiated steps for field testing of the training package for gender mainstreaming in health. A Regional Consultation of Gender Focal Points has been planned for October 2002 to discuss action plans for mainstreaming gender concerns into health policies and programmes. A variety of initiatives on women’s health have been undertaken in collaboration with professional organizations in the Region. The process of updating the country profiles on women, health and development has been initiated in most of the Member Countries. Project proposals pertaining to incorporation of prevention of violence against women in gender mainstreaming in health; health promotion and anti-
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TB drives in slum clusters catering predominantly to women and adolescent girls of Delhi and improvement of quality of materials for training programmes in Indonesia, incorporating gender sensitivity, Making Pregnancy Safer, and domestic violence issues were initiated and achieved. The situation in regard to the girl child in India and interventions provided by the government and NGOs have been analysed in collaboration with WHO headquarters in a document, Windows of Opportunity: The Girl Child in India. Preparation for its publication as a document and a policy paper is under way.
Development of Human Resources for Health Emphasis was laid on quality assurance and accreditation standards for institutions of higher education and on issues related to health personnel education and training. Innovative strategies in the education and training of health professionals, including competency-based and problem-based learning continued to be implemented. Clinical decision analysis and evidence-based medicine are new areas in medical education. A Regional Consultation on Development of Accreditation Guidelines for Educational/Training Institutions and Programmes in Public Health was held in Chennai (India) in January-February 2002. Steps are being taken to develop national standards for the accreditation of public health training programmes. Continuing education (CE) for health professionals has been taken up in Sri Lanka and India. Although CE or Continuing Professional Development (CPD) has been discussed and professional bodies conduct a few programmes, more attention is now focused on the subject due to globalization and re-certification of health professionals in some countries. Data in two countries to assess the situation are being collected to institutionalize continuing education in Member Countries. The pilot phase is under completion in Sri Lanka. In India, preliminary work on a situation analysis of continuing education of health professionals has been undertaken.
WHO provided support for human resources planning and training for the development of the health sector and a HRH Master Plan in East Timor
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Technical support was provided to Bangladesh, Bhutan, DPR Korea, East Timor, India, Indonesia, Maldives, Myanmar and Sri Lanka in the area of HRH. In Bangladesh, technical support was extended to Bangabandhu Sheikh Mujib Medical University, the Centre for Medical Education for postgraduate programmes and health professionals training as well as for accreditation of educational institutions for health professionals. Bhutan was supported in the area of HRH planning and production. Telemedicine/ Health Telematics and Research were considered on a pilot basis. Assistance was provided to DPR Korea for the revision, publication and distribution of a book on paediatric pharmacology. Health services in East Timor are in a state of transition. Support was provided for human resources planning and training for the development of the health sector and a HRH Master Plan. In India, issues on accreditation of medical education programmes, educational innovations in Indian medical education and quality of medical education were discussed with the Vice-Chancellors of five health sciences universities Karnataka, Tamil Nadu, Andhra Pradesh, Maharashtra and Baba Farid. These universities are responsible for more than 50 per cent of the 155 (recognized) medical schools. The discussions highlighted the need for WHO to address the theory–practice gap of university/teaching hospitals, to increase quality services in the catchment areas as well as the need to initiate more community-oriented programmes to improve social accountability. In Indonesia, assistance was provided to Padjadjaran University, Bandung, for formulating an international short course on public health for executives and for development of the MPH programme. An assessment of the current HRH situation and development of HR policies and future projections were recommended. Technical assistance was provided to Maldives to complete the primary phase of the development of the HRH Master Plan. An HR projection model has been prepared; this lists projections for a ten-year period based on existing and planned health
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facilities. HR projections have been made in Indonesia, Nepal and Sri Lanka. However, in most instances, Member Countries are not using the computer-derived figures in HR planning. Technical advice was also given on the development of basic and mid-level educational programmes. Production of HRH is being undertaken in the local context for all levels of the health work force in all the countries except Bhutan and Maldives. At the regional level, attempts are being made to integrate the training activities of different technical units with support from HRH. Sustainability and effectiveness of HRH has to be secured through high-level political commitment, ownership of plans by the country, sound and reliable data, and securing sufficient financial resources. Following the WHO headquarters organized Consultation on Imbalances in Health Work Force, held in Ottawa (Canada) in March 2002, countries will be encouraged to collect and document data on HRH for decisionmaking on health system development. The Regional Office was represented at the ASEAN Workshop on GATS Agreement and its impact on health services, held in Jakarta in March 2002. The workshop discussed the implications of GATS on the human resources aspect of the health system. Training in management, health insurance schemes and health financing, and implications of migration of health workers are areas that have to be carefully explored. Attempts are being made to strengthen WHO collaborating centres in the areas of education and training of health professionals.
Nursing and midwifery Countries of the Region are striving to enhance the contribution of nursing and midwifery personnel to national health development. Technical assistance was continued to countries to strengthen their nursing and midwifery education for producing competent and motivated personnel. Concerted efforts were also made to improve the quality of nursing and midwifery care and to strengthen nursing and midwifery service management for the provision of quality health care.
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WHO has a high commitment to address the problem of continuing shortage and maldistribution of the nursing and midwifery work force as well as the inappropriate professional skill mix in many countries of the Region
WHO has a high commitment to address the problem of continuing shortage and maldistribution of the nursing and midwifery work force as well as the inappropriate professional skill mix in many countries of the Region. A multidisciplinary Regional Advisory Group on Management of Nursing and Midwifery Work Force has been constituted to address the issue. The first meeting of the Group was convened in December 2001 to develop the conceptual framework and the essential actions required for effective management of the work force. Consequently, an in-depth assessment of nursing and midwifery work force management is being carried out in all the countries of the Region. The outcomes of this assessment will be used as inputs for developing guidelines for effective management of the nursing and midwifery work force. Special attention was also given to improving the accessibility and quality of community health services as well as enhancing the productivity of nursing and midwifery personnel at the peripheral levels. A model for comprehensive community and home-based care has been developed. It was critically reviewed for its relevance and practicality in the regional context at a regional consultation held in August 2001. The model is currently being field-tested in Bhutan, Myanmar, Nepal and Thailand.
Education and training support Human resource development has always provided a thrust to capacity building in Member Countries and WHO has consistently been supporting the education and training of health personnel. Currently, this consists of fellowships, study tours and inter- and intra-country training. There has been an increasing trend of short-term practical training in specialized fields with greater use of regional and in-country training resources. Presently, such training is in the areas of primary health care, field epidemiology, vector biology, community health care and research, malaria control and nursing. There is an upward trend in regional training as compared to the earlier emphasis on extra-regional fellowships. Efforts are constantly being made to assess the in-country training needs of the Region in terms of the number, duration and areas of study under the WHO collaborative programme.
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During the period under review, 408 fellowship proposals were received. Of these, letters of award in respect of 186 fellowships were issued. These awards covered 98 fellowships of the previous biennium and 88 from the current biennium. Of the 98 fellowships awarded last year, Fellowship Termination of Studies Reports in respect of 71 were received. Table 3.1 gives a broad picture of fellowship implementation in the countries of the Region. Further, the SEA Region offered services to other regions such as the Western Pacific (WPR) and Eastern Mediterranean (EMR) Regions in the implementation of their fellowships programme. Forty-one such fellowships from the Western Pacific Region and seven from the Eastern Mediterranean Region were assisted. Applications for 49 study tours were processed for implementation by the technical units. During the review period, 55 meetings/group educational activities (GEAs) were held, of which 7 were policy meetings, 7 were advisory meetings and 41 were intercountry technical meetings.
Table 3.1: Distribution of fellowships in the SEA Region 1 July 2001 to 30 June 2002 Countries Bangladesh Bhutan DPR Korea India Indonesia Maldives Myanmar Nepal Sri Lanka Thailand Total 1
Number of applications received 1 17 25 124 55 4 23 77 19 53 11 408
Number of fellowships awarded 15 23 63 36 4 8 10 9 11 7 186
Number of fellowship termination of studies reports received 12 10 0 22 2 3 7 4 7 4 71
98 from the previous biennium and 310 of the current biennium
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Source: WHO/SEARO
In order to streamline and strengthen fellowships operations in the Regional Office, a Documents Management System (DMS) has been taken up for implementation in the ETS Unit. As of now, the records relating to two biennia, viz. 1998-1999 and 2000-2001, have been scanned, stored and indexed. From the biennium 2002-2003 onwards, online work will be undertaken to reach the goal of a “paperless” office. The main benefits and features would include, among others, electronic storage, retrieval, access, speedy action, indexing and CD back-up. The staff of the Unit will be given training and orientation on various aspects of this system.
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4 SUSTAINABLE DEVELOPMENT AND HEALTHY ENVIRONMENTS Sustainable Development In 1983, the World Commission on Environment and Development (Brundtland Commission) defined sustainable development as “a development that meets the needs of the present generation without compromising the ability of future generations to meet their own needs”. Sustainable development encompasses economic, ecological and social dimensions, all of which have implications for human health. Agenda 21, the product of UNCED in 1992, stated as its first principle that “human health is the centre of concern for sustainable development”. Since 1993, WHO has been functioning as task manager for implementing Chapter 6 of this Agenda. The rapid pace of urbanization and population pressure exposes large numbers to health risks associated with lack of clean water and basic sanitation, industrial and agro-chemical pollution, crowded housing and a variety of other risks. While environmental standards are being developed and their enforcement strengthened in the countries, the conflict between economic growth and environmental protection continues unabated. In the South-East Asia Region, it is the poor who suffer disproportionately from unsafe environment conditions and food insecurity. Just as poverty is both a cause and a
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consequence of ill-health, poverty is also caused by growing environmental risks - both modern and traditional - and, in turn, it aggravates those risks. It must be emphasized that most environmental interventions are cost-effective in achieving positive health outcomes. As specified vividly in the report of the Commission on Macroeconomics and Health, the proper application and financing of a few well-targeted health interventions could save the lives of around 8 million people per year. Globally, this would generate yearly economic benefits of more than $360 billion by 2015-2020. The focus on understanding health in a broad development context and on making health a force for poverty reduction and economic growth is a crucial area of work for WHO. One of the important roles of WHO is to engage in the development process and put health on top of the national sustainable development agenda making poverty reduction an essential focus. More multidisciplinary interactions at both institutional and programme fronts are needed to enhance national capacity for action. The mechanisms for intersectoral planning and action are weak in most Member Countries and need to be appropriately strengthened. Accordingly, the need to develop action plans on health and environment has been highlighted in recent years. Through the health and environment (H&E) initiative, WHO assisted the countries in identifying and assessing health hazards and issues in such sectors as agriculture, industry and environment. Priority areas, such as clean water and air, food safety and safe use of chemicals, have been taken up for coordinated planning and intersectoral action. Macro development plans in several countries are laying increasing emphasis on these areas. Since 1993, nine countries have initiated/developed H&E programmes and adopted or drafted plans of action involving intersectoral partnerships. During the reporting period, WHO assisted Bhutan in developing a national health and environment action plan with the focus on food safety. It is noteworthy that the overall situation analysis covering health and environment as also specific issues in the priority areas were conducted by the national authorities. An action plan has also been developed. WHO facilitated the processes involved
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and provided the requisite support. Specifically, during the reporting period, WHO assisted in the development of national environment and health action plans for Myanmar and Thailand. With regard to the focus on poverty, WHO supported seminars for the development of national strategies on health and poverty reduction in Sri Lanka and Nepal.
Nutrition Despite population pressures, notable progress has been made in the area of health and nutrition. National plans of action for nutrition are implemented using a multisectoral approach. Simultaneously, interventions are being redesigned keeping in view past experiences and future needs. Household food insecurity remains a major concern. Severe forms of protein-energy malnutrition (PEM) and nutritional blindness have declined substantially, but the reduction in mild and moderate degrees of malnutrition has been negligible in most countries. While several nutritional disorders, such as beriberi and pellagra, have virtually disappeared, nutritional disorders of public health concern like PEM and deficiencies of micronutrients, such as iron, iodine and vitamin A, persist. On the other hand, the prevalence of obesity and diet-related chronic noncommunicable diseases (NCDs), such as diabetes, cardiovascular diseases and certain cancers are increasing, imposing a burden on the health services and causing death and disability. With increasing urbanization, changing dietary habits and lifestyles, this alarming situation is bound to become even more severe if preventive measures are not undertaken soon. Many countries have low rates of exclusive breast-feeding as well as inconsistent feeding policies. There appears to be considerable variation among and within the countries with respect to complementary feeding. The age of initiation of complementary feeding generally varies from 4-9 months in the countries of the Region. The proportion of infants receiving complementary foods at 6-9 months of age ranges from 2986 per cent. This shows that in South-East Asia complementary
National plans of action for nutrition are implemented using a multisectoral aproach. Simultaneously interventions are being redesigned keeping in view past experiences and future needs
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feeding is untimely - either too late or too early. The feeding frequency, amount and micronutrient content are also inadequate. DPR Korea, Indonesia, Maldives and Myanmar are yet to adopt the International Code for the Marketing of Breastmilk Substitutes. The following are some of the activities carried out during the past year: l A document entitled “Guidelines for the in-patient
treatment of severely malnourished children” was developed. l Member Countries of the Region were involved with the
international WHO Multicentric Growth Reference Study that aims at constructing new growth reference curves for children aged 0 to 5 years. l WHO was involved in close monitoring of the
implementation of national plans of action in nutrition as per the recommendations of the International Conference on Nutrition (ICN). l Technical assistance for research and training activities
is being provided to the four WHO Collaborating Centres in Nutrition. At the same time, technical assistance is being provided to individual countries according to their research needs.
Health and Environment Water supply and sanitation During the period under review, an initiative was launched to improve the information base on water, sanitation and health in the Region. This was done through country-level assessments of water supply and sanitation while simultaneously strengthening national drinking water quality surveillance programmes. The country-level assessments are being implemented as a follow-up to the joint WHO/UNICEF Global Water Supply and Sanitation Assessment 2000 report. Data from the report (Table 4.1) demonstrate that some 14 per cent of the total
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Table 4.1: Water supply and sanitation coverage in the SEA Region, 1990-2000 Country Bangladesh Bhutan DPR Korea India Indonesia Maldives Myanmar Nepal Sri Lanka Thailand Year Urban 1990 2000 1990 2000 1990 2000 1990 2000 1990 2000 1990 2000 1990 2000 1990 2000 1990 2000 1990 2000 109 466 129 155 1 696 2 124 20 461 24 039 850 785 1 013 662 182 812 212 108 216 286 40 520 45 611 18 772 23 931 17 046 18 827 55 595 61 399
Population (in thousands) Rural 21 090 31 665 87 152 11 946 14 481 217 254 288 283 55 923 86 833 56 75 9 984 12 628 1 680 2 844 3 625 4 435 10 410 13 252
Percentage of water supply coverage Total 88 376 97 490 1 609 1 972 8 515 9 558 633 531 725 379 126 889 125 275 160 211 30 536 32 983 17 092 21 087 13 421 14 392 45 185 48 146
Percentage of sanitation coverage Urban 78 82 – 65 – 99 58 73 76 87 100 65 65 68 75 93 91 97 97
Urban 98 99 – 86 – 100 92 92 90 91 100 88 88 96 85 90 91 83 89
Rural 89 97 – 60 – 100 73 86 60 65 100 56 60 63 80 59 80 68 77
Total 91 97 – 62 – 100 78 88 69 76 100 64 68 66 81 66 83 71 80
Rural 27 44 – 70 – 100 8 14 44 52 41 38 39 16 20 79 80 83 96
Total 37 53 – 69 – 99 21 31 54 66 56 45 46 21 27 82 83 86 96
population in the countries of the Region lack access to improved water supply and 62 per cent lack access to improved sanitation facilities. Only Africa has a lower coverage for water supply, while no region of the world has a lower coverage for sanitation. These assessments will help in formulating specific recommen-dations for national policy reform initiatives and may support countries in their efforts to mobilize national and extrabudgetary resources. The Regional Office has been concerned about the quality of drinking water in Member Countries for many years. During the period under review, attention continued to be given to the strengthening of national drinking water quality programmes. A regional situation analysis of drinking water quality surveillance programmes, conducted by the Regional Office, highlighted the need to strengthen national institutions and to develop innovative approaches to water quality monitoring. Similar recommendations had been made at the Intercountry Consultation on Quality Assurance in Water Supply Systems,
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Strengthening of national drinking water quality programmes in the Member Countries is receiving increasing attention
Bangkok (January 2002) and the Regional Office followed this up in the period under review by developing innovative projects for monitoring chemicals in drinking water in Bangladesh, Indonesia, Nepal and Thailand; and community-based water quality improvement projects in Bangladesh, India and Nepal. Since June 2000 and continuing through the period under review, the Regional Office has been developing practical guidelines on the prioritization of chemical risks in drinking water. The guidelines were submitted for international peer review and will be published later this year. Related to the area of water, sanitation and health, the theme of Healthy Cities has been incorporated in the broader theme of Healthy Districts. An assessment of the Healthy Cities initiatives in five countries was initiated and is expected to result in better orientation of this programme. One option is to focus on basic needs in urban settings. Preliminary findings of the ongoing country-level assessments of water supply and sanitation indicate the need to focus efforts on sanitation for high-risk communities in urban slums.
Promotion of chemical safety 60 THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION
In the area of Promotion of Chemical Safety (PCS), the focus has been on injection safety and safe disposal of health care waste, and establishing poison control centres.
Countries in the Region also recognized that the deliberate use of biological and chemical agents can become a major threat to human health. Though no such incident has taken place in the SEA Region, it is felt that the potential requires urgent action from WHO. Responding to these needs, the Regional Office has set up an interdepartmental committee to address accidental or deliberate atomic, biological, chemical incidents (ABC Committee) to provide national partner institutions with support and guidance. A SEARO special web site gives technical information on “ABC” threats and other related information. A Workshop on the Management of Anthrax was held in Bangkok in December 2001 which was attended by epidemiologists and public health bacteriologists from all the Member Countries of South-East Asia and some from the Western Pacific Region. Guidelines to include ABC responses within the national emergency preparedness plans were prepared and disseminated through the EHA focal points in the Region.
Increased attention is being given to injection safety and safe disposal of health care waste and establishment of poison control centres
Injection safety and health care waste Each year, about 12 billion preventive and curative injections are administered worldwide. This means 14 million injections per day. Concerns about injection safety, primarily through reuse of syringes, have become a major public health priority. Of the 240 million injections given each year in the Region for the primary series of childhood immunization, 90 per cent are with reusable syringes and needles. While this practice reduces the volume of waste, the risk of health workers being exposed to needle pricks is substantial. With the objective of all countries of the Region achieving the use of auto-disable (AD) syringes for all immunizations by 2005, the shift from sterilizable immunization injection to AD syringes represent a major challenge in terms of financial investment and management of increased waste. Weak infectious waste management, particularly disposal of “sharps”, represents a real risk of transmission of blood-borne pathogens. The Regional Office has initiated a study on the existing health care waste technological pathways that have been developed in India. The results will be presented at a meeting of the Global Alliance for Vaccines and Immunization (GAVI) in July 2002.
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Management of poisonings The Regional Office promoted the INTOX system which enables users to record data relating to poisoning systematically and to respond quickly to emergency enquiries about poisons. It is also the gateway to a global electronic network of poison centres and other users of the system. Thirty professionals from the Region successfully completed an intensive five-day inter-regional training course in INTOX system software, held in Bangkok in March 2002. A three-day symposium on networking was also held in December 2001 in New Delhi, with more than 200 health professionals agreeing to launch a poison information network in India. Agreement was also obtained to support the upgrading of six centres to regional poison treatment centres. A Training Manual on Promotion of Chemical Safety for Health Workers at the PHC Level was developed.
Occupational and environmental health The Region has an estimated work force of 580 million. Eighty per cent of this work force is in the informal sector, including small-scale industries, home industries, self-employed, services, farms and fisheries. The Region continues to face major environmental health problems, including arsenic contamination of ground water in some countries, exposing at least 30 million people to drinking water containing arsenic above the WHO guideline value of 50 ug/ml. Increased health risks are also associated with air pollution and developmental projects. The occupational and environmental health programme is an integral component of sustainable development to mitigate health risks associated with environmental hazards by using environmental epidemiological tools that focus on reduction of environmental morbidity and mortality, reduction of environmental risk factors, strengthening of the health system for improving environmental human health, and promoting the inclusion of the health sector in impact assessment of developmental projects. 62 THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION
The major achievements during the reporting period are outlined below.
Occupational health In order to assess the policy basis, administration of occupational health as well as the extent of risk of hazardous conditions and unsafe work practices in the Region, a survey was carried out using a structured questionnaire and guidelines. The survey has been completed in Bangladesh, Bhutan, India, Indonesia, Maldives, Nepal, Sri Lanka and Thailand. The data are being analysed for trends that will be useful for advocacy by policy-makers in implementing risk reduction intervention measures in occupational diseases and injuries. Work on the preparation of regional guidelines for surveillance of occupational injuries and diseases has been initiated. A computer database has been developed for regional monitoring of occupational diseases. The combined use of the guidelines and the database will strengthen occupational disease surveillance and contribute to a reliable estimate of occupational disease burden. The survey questionnaire and guidelines developed for the above situation analysis has been adopted as a model by the Global Network of Collaborating Centres on Occupational Health to be used for similar surveys in other regions.
The SEA Region continues to witness major environmental health problems, including arsenic contamination of ground water
Arsenic poisoning As arsenic poisoning is a priority area, a concept paper has been developed for arsenic mitigation focusing on exposure assessment, risk determination and risk management. As a first step towards harmonizing case detection in the Region, the Regional Office has formulated a regional casedefinition algorithm, for use as a tool in developing national protocols. As a first application of this tool, technical support was provided to Bangladesh in developing a case definition and case management algorithm during the International Workshop on Arsenic Mitigation, organized by the Government of Bangladesh in January 2002. Furthermore, a national workshop in Thailand, also using the regional algorithm, was technically and financially supported in February 2002. In order to effectively manage information on the extent of arsenic contaminated tubewells and the prevalence of arsenicrelated diseases, a geographical information system for 63 THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION
monitoring the prevalence of arsenic contamination and arsenic diseases is being developed. A case-control research study on the risk of skin lesions associated with arsenic contaminated drinking water and the role of nutritional co-factors was supported by the Regional Office in collaboration with the International Centre of Cholera and Diarrhoeal Diseases, Bangladesh (ICDDR, B). The protocol is being finalized and pilot testing of the study questionnaires has been initiated. A position paper summarizing the extent of arsenic contamination of ground water in the Region, the existing gaps in epidemiological knowledge, and the past, present and future normative activities of WHO was prepared. This was used as a basis for discussions at the 54th session of the Regional Committee in September 2001, which adopted a resolution calling for intensified arsenic mitigation activities in the Region. Further, a position paper summarizing the gaps between research conducted and research needs in the Region was prepared for the scientific debate at the 27th session of the SEA Advisory Committee on Health Research, held in Dhaka in April 2002. The session focused, among other topics, on research on arsenic poisoning. A scientific paper entitled “Case studies on the Impact of understanding bio-availability and bio-acessibility: arsenic” and another entitled “Lessons learnt from investigation of heavy metals” were prepared. The regional plan of action and a critical epidemiological assessment of arsenic contamination were presented at the South-East Asia Congress of Epidemiology, sponsored by the International Epidemiology Association at Jhansi (India) in February 2002.
Health impact assessment WHO assistance on health impact assessment focuses on providing policy and advocacy support, technical assistance and fostering partnership. In order to gauge information on the prevailing health impact assessment situation in the Region, a structured questionnaire was used in a survey on the status
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of health impact assessment and practices. The quesionnaire addressed policy and framework, existing infrastructure, capacity building mechanisms and size of the environmental problem in Bangladesh, Bhutan, India, Indonesia, Maldives, Nepal, Sri Lanka and Thailand.
Air pollution With technical assistance from WHO headquarters and based on the assessment of the air pollution situation in India, Bangladesh and Nepal, a concept paper was formulated for mitigating air pollution in the Region. This paper focuses on providing policy, advocacy and technical directions as well as on fostering partnership. The situation analysis survey on health impact assessment, conducted by the Regional Office, also contains relevant air pollution data. An analysis of the data indicated that air pollution is widely prevalent in the Region and there is little or no intersectoral collaboration between health and non-health sectors. The Thailand-specific data were presented to the Environmental Health Division of the Ministry of Public Health for strategizing their environmental plan of action in September 2001.The regional findings were presented at an international Workshop on Transportation, Land Use and the Environment, organized by the Harvard School of Public Health, the World Bank and the Asian Development Bank in Pune (India) in December 2001. In order to effectively manage information on the extent of air pollution and the prevalence of air-related diseases, a computer database and a geographical information system for monitoring the prevalence of air pollution and lung diseases was developed. These tools will facilitate estimation of disease burden and identify areas where interventions may be warranted.
The situation analysis on health impact assessment, conducted by the Regional Office, indicated that air pollution is widely prevalent in the Region
Food Safety Foodborne diseases are common in most countries of the Region. Mortality and morbidity due to diarrhoea, however, is largely preventable if microbial contamination of food and water is controlled. The increasing use of chemicals in 65 THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION
agriculture and food processing has added new concerns for health. A number of countries have entered the international food trade and are exporting and/or importing food. While several countries in the Region have food legislation, welldefined national food safety policies and strategies have yet to be developed in many. In addition to developing and implementing the ten point Regional Strategy on Food Safety, adopted at the 53rd session of the Regional Committeee, a regional consultation was held in August 2001, which made a number of recommendations for action. The consultation recognized the importance of research in identifying priority foodborne hazards and devising means for their prevention and control and recommended that all Member Countries consider undertaking appropriate studies. The following activities are notable: WHO support was extended to Member Countries to evaluate and review food safety programmes and to follow up the implementation of the regional strategy on food safety. Training workshops on hazard analysis and critical control points system (HACCP) were conducted in Bangladesh and Nepal. The existing situation of nutrition and food safety was reviewed and recommendations made emphasizing the need for consumer awareness on safe food and surveillance of foodborne diseases. WHO support was provided to East Timor to review and analyse the existing situation on food safety and identify resource and infrastructure requirements for a food safety programme.
Emergency Preparedness and Response The Region continues to be affected by natural disasters and complex emergencies leading to a severe impact on the health situation of the affected populations. Estimates suggest that 38 per cent of the population affected and 57 per cent of the persons killed by natural disasters during the last decade were from South-East Asia. Rapid industrialization and urbanization is taking place in the Region, where large groups of people still live in poverty, and armed conflicts continue to affect several countries. The result is a complex environment with severe public health consequences.
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WHO, in active partnership with other UN agencies, international organizations, NGOs and donors, ensures technical support to institutional focal points in ministries of health. Dissemination of material on best public health practices in emergencies and training, support to the use of emergencies, hazard and vulnerability mapping, promotion of operational research on disaster and emergency response in the Region, and development of effective response measures to improve administrative mechanisms is also carried out. Apart from direct interventions in a number of countries affected by the humanitarian crisis, the Regional Office is also working on preparedness activities in various countries, including Bangladesh, India, Indonesia and Nepal. WHO (South-East Asia and Western Pacific Regions) and the Asian Disaster Preparedness Centre (ADPC), in collaboration with Japan International Cooperation of Welfare Services, organized the first Inter-Regional Training Course on Public Health and Emergency Management in Asia and the Pacific in March 2002 at ADPC, Bangkok. This course was designed for national health emergency officers, health coordinators, WHO focal points, representatives of academic institutions and experts. The Regional Office provided technical inputs on emergency and humanitarian action, hospital disaster preparedness and mass casualty management, nutrition and food safety, environmental health, essential drugs policy and information and media management. In Nepal, significant results were achieved in the areas of emergency planning, mass casualty management, seismic vulnerability assessment, training and production of information material. The Regional Office provided computerbased simulation exercises and training seminars on mass casualty management to medical and paramedical staff. A structural assessment of 15 hospitals in the Kathmandu Valley was also conducted in collaboration with the National Society for Earthquake Technology (NSET), Nepal. The United Nations Disaster Response Preparedness Plan for Nepal is an important tool to prepare and ultimately achieve readiness. The Prime Minister of Nepal launched the first part of the plan on UN Day in October 2001. WHO contributed significantly to the development of this document and ensured that it is based on the best public health practices during emergencies. Assistance
Natural disasters and complex emergencies have led to a severe impact on the health situation of the affected populations in the Member Countries
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was also provided to UN Nepal in dealing with a major earthquake that affected the Kathmandu Valley and in the development of the Emergency Preparedness and Disaster Response Plan for the Health Sector in Nepal. In Sri Lanka, the armed conflict lasting nearly two decades has had a severe impact on the population in the north and north-eastern parts of the country. WHO provided technical inputs for Health as a Bridge for Peace (HBP) to help equip a pool of resource people with the tools, skills and training methods to run the HBP programme. In Indonesia, emergency response and management activities were continued in Maluku and other locations experiencing large population displacement. A workshop on Health as a Bridge for Peace was conducted in January 2002 in Ambon (Maluku Province). The Regional Office provided financial support in meeting the flood situation in Jakarta in February 2002. In East Timor, WHO continued to develop and strengthen health systems and resource mobilization. Technical assistance covered areas such as disaster preparedness, communicable disease surveillance, environmental sanitation, human resource development, strengthening of laboratory services, health policy legislation and IMCI. In India, WHO continued to support the Government of Gujarat in strengthening the disease surveillance system, water and sanitation and health sector coordination in Bhuj, which was the most affected district in the earthquake in January 2001. WHO activities have since expanded to other districts, apart from Bhuj, and a WHO office was established in Gandhi Nagar in December 2001. The European Commission has provided financial assistance to the Government of Gujarat to strengthen disease surveillance and emergency preparedness activities in seven additional districts with technical inputs by WHO. The EHA office in DPR Korea continued its operations till late 2001 when the WHO Representative’s office was opened. A UN appeal for funds for DPR Korea was launched in November 2001 for community health services, TB, essential drugs and control of communicable diseases. In Bangladesh,
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disaster preparedness activities, such as mass casualty management, were conducted. WHO also supported other intercountry activities along the Thailand-Myanmar border. These included the strengthening of coordination of health activities along the border, assessment of the health situation of migrant populations, dissemination of health information to the relevant authorities and specific support to prevent and control HIV/AIDS, TB, malaria and sexually transmitted diseases.
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5 HEALTH TECHNOLOGY AND PHARMACEUTICALS Essential Medicines: Access, Quality and Rational Use The mission of WHO’s Medicines Strategy is, in partnership with the countries, “to help save lives and improve health by closing the huge gap between the potential that essential drugs have to offer and the reality that for millions of people particularly for the poor and disadvantaged - medicines are unavailable, unaffordable, unsafe or improperly used”. This is to be done through the four objectives of Policy, Access, Quality and Safety, and Rational Use. Workshops held in the countries of the Region focused on rational drug use, initiation and management of drugs and therapeutics committees, and in pharmacoeconomics. The next step would be to have workshops in the countries organized by the participants themselves with WHO support to enhance national capacity. DPR Korea, Nepal and Sri Lanka made use of fellowships in the manufacture and regulation of pharmaceuticals to increase their national capability. An assessment of the Drug Regulatory Authority in Indonesia was carried out in November 2001 which provided useful feedback. Technical assistance was provided to Nepal in drug financing, to DPR Korea in essential drugs and to Sri Lanka in the evaluation of a computerized drug registration system.
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The nineteenth meeting of Ministers of Health of the countries of SouthEast Asia identified bulk purchase of quality generic essential drugs as a priority for the Region
The nineteenth meeting of Ministers of Health, held in August 2001, identified bulk purchase of quality generic essential drugs as a priority for the Region, especially for the smaller countries. Pre-qualification of manufacturers is an essential part of this process. The initial work of identifying manufacturers through verifiable criteria has been undertaken and a scheme for purchase is being developed. The majority of these manufacturers would be from India but manufacturers from Indonesia and Thailand too are being assessed. Countries in the Region were concerned about the access to drugs and the effect of the agreement on Trade Related Intellectual Property Rights. WHO support to the countries emphasized the public health provisions of the agreement. This resulted in Bangladesh, India, Indonesia, Sri Lanka and Thailand supporting the successful Doha Ministerial declaration on the primacy of public health over trade. A bi-regional meeting (with the Western Pacific Region) on counterfeit drugs was held in Cambodia in August 2001. The complexity of the problem was identified and the ground work for follow-up was initiated. Another bi-regional activity was the training course on Emergency Management for Health Ministry officials in Bangkok in March 2002. The recentlyrevised WHO Drug Donation Guidelines were presented here and helped to reinforce the Essential Drugs Concept for the countries. The ASEAN cooperation in pharmaceuticals had Indonesia as a reference country for GMP and Thailand as the one for reference standards. Both countries contributed in their respective field to increasing the capabilities of the countries of the Region that were not members of ASEAN. The considerations in traditional medicine are the same as in essential medicines: policy, access, quality and safety, and rational use. The WHO Traditional Medicine Strategy 20022005, published in May 2002, provides a map for future work in this area. An informal consultation was held in November 2001 with participants from five countries to develop guidelines on Panchakarma in Ayurveda. This was the first consultation in Ayurveda in a technical area, the previous meetings having focused on the role of Ayurveda in the health care system. The output from the meeting would be useful for encouraging good practice as well as regulation. The capacity of the countries of the Region is being assessed as part of the survey on complementary and traditional medicines, in collaboration with the WHO Kobe Centre, Kobe (Japan).
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Immunization and Vaccine Development The period under review has been particularly significant for the Vaccines and Biologicals programme. As the Region moves towards the elimination of wild polio virus transmission, efforts are being made to ensure that systems are in place for the certification of polio-free status by 2005. The result of this ongoing commitment to surveillance and laboratory networks is becoming evident. In order to get maximum benefit - and to ensure that lessons are learnt - from the polio eradication initiative, WHO has been examining ways to use the well-established polio immunization infrastructure to introduce high quality immunization services for other vaccine preventable diseases. With funding from the Global Alliance for vaccines and Immunization (GAVI), 2002 will see a series of new initiatives, including the phased introduction of hepatitis B vaccine and auto-disable (AD) syringes across the Region. Work in the past year also addressed the needs of national services that support the Expanded Programme on Immunization (EPI). In particular, WHO has invested considerable effort in supporting national regulatory authorities in their role of guardians of the quality of vaccine supply, preparing strategies for adverse events following immunization (AEFI) and improving the standards of injection safety and waste management.
73 WHO assisted Member Countries in obtaining funds from the Global Alliance for Vaccines and Immunization THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION
During the last two years, WHO has assisted eight eligible countries in the Region to successfully apply for funding by the Children’s Vaccine Fund (CVF) of GAVI for innovations in immunization activities. Over the next five years, approximately $ 200 million will be provided from the Fund to countries in the Region for activities in three areas: immunization services, injection safety and introduction of new vaccines (see Table 5.1). Within the framework of EPI, four countries, viz. Bhutan, Indonesia, Maldives and Thailand, have introduced hepatitis B vaccine into their routine immunization programme prior to 2001. With funding from CVF, all the remaining countries of the Region will introduce hepatitis B vaccine in a phased manner during 2002 and 2003. Through the Regional Working Group on Immunization for South-East Asia, WHO will be providing technical support to these countries in the training, advocacy and monitoring necessitated by this innovation. The longerterm challenge will be to develop financial sustainability plans to ensure that this vital vaccine programme is continued. WHO has committed itself to assisting in additional training, public education and improvements in cold chain management to make this new vaccine regimen work. Strengthening of the national regulatory authorities (NRA) to oversee quality control has been a high priority in the Region. Between May 2001 and June 2002, the Regional Office, in collaboration with WHO headquarters, completed assessments of NRAs in Myanmar, India, Bangladesh, Nepal and Indonesia. Before the end of 2002, assessments will be completed in Bhutan and Maldives. As a result of these assessments, new development plans are being elaborated in accordance with the procurement procedures of the country. In India, for example, with WHO technical support, NRA developed an activity plan to conduct good manufacturing practices (GMP) inspections covering 11 vaccine manufacturers. This plan will utilize the 20 inspectors scheduled to receive WHO-sponsored training on GMP in 2002. Additional efforts were made to ensure that technicians from the Central Drug Laboratories, Kasauli, and national vaccine manufacturers received adequate training in July 2001 to ensure the standardization of testing procedures for vaccine potency.
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Table 5.1: Proposal for GAVI funding from SEAR countries Strengthening of immunization services Approved 2001 Not eligible, DPT3 > 80% Conditional approval 2001 Not eligible Not eligible, DPT3 > 80% Approved 2002 Approved 2001 Not eligible, DPT3 >80%) Injection safety Approved 2001 Application not submitted Conditional approval 2001 Approved 2002 Pending Approved 2002 Approved 2001 Approved 2001 for 2003 Introduction of new vaccines Approved 2001 Approved 2000 Conditional approval 2001 Approved 2002 Approved 2002 Conditional approval 2002 Approved 2001 Approved 2001 for 2003
Country Bangladesh Bhutan DPR Korea
Comments Two instalments already released Funding will start in 2003 Conditions: (1) Prove DPT is < 80% and (2) Show cold chain capacity Will launch introduction in July 2002 Birth-dose of hepatitis B vaccine in UniJect Condition: Show cold chain capacity Needs to update hepatitis B plan of action Funding requested for 2003
India Indonesia Myanmar Nepal Sri Lanka Source: WHO/SEARO
Each country’s NRA and EPI programme manager is responsible for monitoring AEFI and particularly to promptly detect and respond to these occurrences. Through the WHO Global Training Network (GTN) a workshop on AEFI surveillance was held in Kathmandu in November 2001. Twenty-three participants from nine countries of the Region and the Philippines from the Western-Pacific Region participated. At this workshop, participants reviewed the components of AEFI systems and developed national activity plans to establish and strengthen their surveillance and response systems. As immunization systems are expanded and additional vaccines added to EPI, injection safety becomes an even more critical issue. In 2001, WHO provided technical assistance to Nepal for a national assessment of immunization safety. Similar
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assessments are planned for Bangladesh and India in 2002; other countries will follow. The results of these studies will be used to develop new training material on injection practices and other safety improvements. However, the sustainability of this effort depends mainly on two factors: the availability of AD syringes at low cost and the capacity of the countries to deal with the waste generated by the introduction of single use injection devices. WHO has encouraged technology transfer for local production of AD syringes and medical waste treatment solutions in India and Myanmar on a pilot project basis. In early 2002, the Regional Office initiated a Vaccine Management Project in Myanmar. The aim is to pilot a fivestep integrated approach that assesses, monitors and suggests improvements to the entire vaccine supply and logistics process, from cold chain to delivery.
Accelerated disease control Polio eradication In 2001, the Region accounted for 49.9 per cent of the global burden of virus-positive polio (268 out of 537 virus positive cases globally as of 18 March 2002) with India being the only country in the Region that had polio virus circulation. India reported 268 cases in 2001. Although this is an increase over the 265 cases reported in 2000, the data show that tremendous progress was made (Figure 5.1). Despite house-to-house campaigns during 2001, it is apparent that a susceptible pool of children under 24 months of age remains unreached in some underserved communities. Till May 2002, 41 cases had been detected in the Region, all in India. Ninety-three per cent of these cases were from Uttar Pradesh and Bihar. Bangladesh, Myanmar and Nepal have been polio-free since 2000, as borne out by good AFP surveillance. Bhutan, DPR Korea, Indonesia, Maldives, Sri Lanka and Thailand have all been polio-free for more than four years. Although Indonesia has been polio-free since 1995, the deteriorating economic situation and civic unrest in some provinces have made the implementation of both routine EPI and supplementary polio
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Figure 5.1: Wild polio virus cases in the Region, by month, 1999-2002 450 400 350 300
Cases
250 200 150 100 50 0 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
1998
1999
2000
2001
2002
Source: WHO/SEARO
immunization activities problematic. Therefore, Indonesia is at increased risk of wild polio virus. Progress indicates that eradication is an achievable target in India even by the end of 2002 or shortly thereafter, provided that the strategies are implemented with a consistent degree of quality across all strata of communities in the three endemic foci in Uttar Pradesh and Bihar. During the last year, all countries in the Region conducted supplementary OPV immunization rounds, with Bangladesh, DPR Korea India, Myanmar and Nepal conducting National Immunization Days (NIDs) or mop-up operations in highrisk areas. Bhutan, Indonesia, Maldives, Sri Lanka and Thailand conducted sub-national immunization days in high-risk areas and provinces. The NIDs were synchronized as far as possible. National Polio Immunization Days are also increasingly being used to deliver vitamin A to children in the Region. During 2001-2002, Bangladesh, DPR Korea and Myanmar integrated vitamin A distribution with NIDs. Over 35 million children between 6 and 59 months of age received one high dose of vitamin A. All countries in the Region switched to using the virological classification scheme in 2001. This permits sensitive as well 77 THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION
Significant progress has been made in polio eradication and the goal of interrupting transmission is within reach
as specific identification of polio and provides programme managers with specific virological information which they can use to accurately target areas for mopping-up activities. Till mid-2002, Bangladesh, India, Myanmar, Nepal, Sri Lanka, and Thailand have sustained their non-polio AFP rate of at least 1 per 100 000 children aged less than 15 years. In response to Indonesia’s decline in AFP surveillance in the previous two years, WHO assisted the countries to recruit and train an additional 34 surveillance medical officers and 10 supervisory surveillance officers. By mid-2002, the rate of non-polio AFP had increased to 0.86 per 100 000 children in Indonesia. In order to ensure that countries conduct certification standard surveillance, WHO commissioned independent joint national and international reviews of AFP surveillance in Bangladesh, DPR Korea, India, Myanmar and Nepal during 2001 and 2002. These reviews have verified the quality of the surveillance data in these countries and highlighted opportunities for further strengthening of surveillance. All 17 laboratories in the Polio Laboratory Network in the Region are fully accredited, including the Global Reference Laboratory in Mumbai, India. The laboratories provide timely and accurate information to allow a targeted and appropriate response. WHO has developed regional guidelines for implementation of laboratory containment of wild polio viruses and convened the 1 st Regional Containment Meeting in Colombo
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in February 2002. As of November 2001, eight countries had finalized plans of action for containment. Table 5.2 summarizes the estimated resource requirements for all polio eradication activities during 2002, at approximately $ 151 million. Contributions in the past have come from a wide variety of bilateral and multilateral sources, including AusAID, the Bill and Melinda Gates Foundation, CDC, DFID, DANIDA, EC, Italy, Japan, KfW Germany, NORAD, Rotary International, UN Foundation, the World Bank, UNICEF and WHO among others. Until the Region is certified polio free, bridging the funding gap and maintaining the level of donor commitment will be a major challenge for polio eradication.
Table 5.2: Estimated resource requirements in 2002 for polio eradication in priority countries of the SEA Region US $ in million
Country Bangladesh DPR Korea* India Indonesia Myanmar Nepal Total *Based upon UN Appeal
OPV 9.80 0.55 56.30 5.30 1.87 3.17 76.99
Operational 3.05 0.68 44.04 4.50 1.64 2.38 56.29
AFP and laboratory 1.70 0.64 10.09 4.15 0.76 0.96 18.29
Total requirements 14.55 1.86 110.43 13.95 4.27 6.51 151.57
Commitment 12.49 0.62 108.95 2.86 1.75 5.38 132.05
Shortfall 2.06 1.25 1.48 11.09 2.53 1.13 19.52
Control of other major vaccine preventable diseases Measles and neonatal tetanus In an effort to build on polio, the SEAR Technical Consultative Group meeting in October 2001 focused on the strengthening of routine immunization. There is consensus among Member Countries and partner agencies on the goals of reducing measles mortality and eliminating maternal and neonatal tetanus (MNT). The challenge ahead for the Region is underscored by the fact that measles accounts for an estimated 202 000 deaths/ year and five countries (Bangladesh, India, Myanmar, Nepal and DPR Korea) have not yet eliminated MNT. A meeting of EPI managers from all the Member Countries, held in Delhi in February 2002, focused on these topics.
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While polio supplementary immunization activities continue until global certification is achieved, renewed emphasis is being placed on routine EPI. In 2001, Bangladesh and Bhutan took advantage of mass mobilization efforts and included measles and tetanus antigens in successful polio campaigns. In early 2002, the Regional Office provided technical assistance to India in using polio micro-planning techniques to strengthen routine EPI as part of a national routine immunization planning exercise.
Issues and challenges Can polio virus transmission be interrupted in India and by when? Transmission can be interrupted in the next 18 months provided the programme achieves the highest possible quality in implementing the strategies. A blueprint of supplementary immunization activities has been developed. The challenges lie in overcoming programme fatigue and in sustaining government and partner commitment. How long must polio-free countries continue to do NIDs? Until India is polio free, the other countries of the Region are at risk of importation of wild polio virus. Additionally, in countries with low or poor routine immunization coverage and/or in those that have not conducted NIDs for more than three years, there is a risk of children being paralysed by mutant strains of the polio virus. Will there be adequate funding? The current funding shortfall for the Region up to 2005 amounts to about $200 million. The Regional Office is working closely with WHO headquarters and partners to cover this shortfall. Will polio eradication benefit EPI? The Regional Office has begun addressing the issue of strengthening EPI through polio eradication by building on the foundations and lessons learnt from the polio initiative. Two meetings, one in October 2001 in Delhi and one in February 2002, have put in place plans to halve measles mortality (compared to 1998) and eliminate MNT.
Blood Safety and Clinical Technology 80 THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION
Safe blood is one of the priority areas for WHO. Strengthening of blood transfusion services to assure quality, safety and
adequacy of blood in developing countries warrant national commitment and a sustainable national plan. Most of the Member Countries in the Region lack these. Accordingly, guidelines for formulating and implementing country-specific blood policies were finalized at a WHO intercountry meeting, held in Yangon in November 2001. In consonance with the priority accorded to safe blood by WHO, efforts for capacity building in Member Countries through various activities were continued. Following a regional quality management training course in blood transfusion services, national training courses for capacity building in quality management were organized in India, Indonesia, Myanmar and Sri Lanka. These have resulted in the creation of 107 trained managers in quality management in Member Countries. Their distribution in the Region is shown in Figure 5.2. To provide continuous technical support to trained quality managers and to monitor their progress in implementing quality in their respective blood transfusion programme, the National Blood Centre of the Thai Red Cross Society, Bangkok, has been designated as a Regional Quality Centre. This centre maintains continuous liaison with the trainees of the first regional Quality Management Training (QMT) course and provides the required technical support as well as undertakes
Figure 5.2: Distribution of trained managers in quality management in the SEA Region, as of June 2002 30 25 24 22 21 27
Number of trained managers
20 15
10 5 3
2
2
2
2
2
0 BAN BHU DPRK IND INO MAV MMR NEP SRL THA
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Source: WHO/SEARO
WHO continues to support capacity building in Member Countries to improve the quality, safety and adequacy of blood
follow-up of the action plan developed by the participants during the course. The expertise and infrastructure available at this centre will also be utilized for conducting courses in the future. An independent assessment of quality is an essential component of any quality programme. Two centres under the Ministry of Public Health, Thailand, have been identified as organizers of the external quality assessment scheme for blood group serology as well as screening for HIV and hepatitis B in the Region. The first cycle of this scheme commenced in January 2002 for participants of the regional QMT. To undertake a situation analysis of quality assurance in HIV/AIDS and viral hepatitis in blood banks in both the private and public sectors, a common evaluation format has been developed. On-site assessment was undertaken in Bangladesh, DPR Korea, Indonesia, Maldives, Myanmar and Sri Lanka. The assessment was also followed by hands-on training to nationals in areas that needed strengthening. Sri Lanka has commenced an ambitious project with support from WHO for revamping its entire blood transfusion services with aid from the Japanese Bank of International Cooperation (JBIC). Technical support is being provided by WHO. The project activities were reviewed in August 2001. The next review is planned for July 2002. Technical support was provided to Bangladesh, India, Nepal and Sri Lanka to strengthen their blood transfusion services. WHO has been promoting quality in health laboratories for several years, providing technical support to all the Member Countries. A review of quality assurance activities was carried out in Bangladesh, DPR Korea, Maldives and Thailand and short orientation courses were organized in Bangladesh, Nepal and DPR Korea to overcome commonly-encountered problems. The generation of quality results by health laboratories requires the use of quality diagnostic reagents. Realizing that the regulatory mechanisms for diagnostic kits and reagents were practically non-existent in the Member Countries, an intercountry meeting was organized to develop policy guidelines for quality assurance of diagnostic reagents.
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Bangladesh, Indonesia, and India were provided technical support to strengthen antimicrobial resistance monitoring. An intercountry meeting to review the Gonococcal Antimicrobial
WHO promotes quality assurance in health laboratories in the countries of the Region
Susceptibility Programme (GASP) in Bangladesh, India, Nepal and Sri Lanka was organized. Issues impeding the successful implementation of GASP were identified and appropriate recommendations made to strengthen the programme. Bioterrorism, especially due to anthrax bacilli, became a topical issue during 2001. A bi-regional workshop was organized at Bangkok in collaboration with CDC Atlanta, USA, for various countries to upgrade their skills in epidemiological and laboratory aspects of management of anthrax. Practical and simple guidelines for laboratory diagnosis of anthrax were developed and distributed to all countries in the Region. A rapid, user-friendly and economical diagnostic kit, developed by the Defence Research and Development Establishment of India, was evaluated by a regional panel of experts and found to be useful for screening and diagnosis of anthrax. Hospital-associated infections have emerged as an important problem in the Region. To create awareness and implement effective surveillance and control mechanisms, guidelines were developed and published for the prevention and control of hospital-associated infections for use in the Member Countries. In order to strengthen quality assurance and radiation safety in diagnostic imaging, as well as for capacity building in this area, technical support was provided to Maldives, Bangladesh and Thailand through the WHO Collaborating Centre in Radiology at the All India Institute of Medical Sciences, New Delhi.
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Capacity building in analytical toxicology was supported in Indonesia in collaboration with the Medical Toxicology Unit, London. Technical support was also provided to India, Myanmar and Sri Lanka to develop their programmes for strengthening analytical toxicology. Newsletters on quality assurance in health laboratory services and blood transfusion services (QA News) and on Gonococcal Antimicrobial Susceptibility Programme (GASP Newsletter) were regularly published and information disseminated on these issues to all Member Countries. Guidelines on laboratory diagnosis of opportunistic infections in HIV/AIDS were also developed to support efforts by the countries in strengthening their infrastructure and expertise in combating the challenge of opportunistic infections.
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6 EVIDENCE AND INFORMATION FOR POLICY Evidence for Health Policy The WHO collaborative programme in the Region as well as the intercountry programme in this area focused on collecting, validating, analysing, synthesizing and disseminating evidencebased information on the health situation and trends. National capacity in the Member Countries was strengthened in the areas of (a) data management for evidence-based decision making; (b) implementation and assessment of ICD10 coding; (c) knowledge on methods and issues related to the conduct of health systems performance assessment; (d) preparation of national health accounts; (e) preparatory activities for the conduct of world health survey and burden of disease methodology; (f) strengthening of the quality of morbidity and mortality statistics, and (g) improving the health information systems (HISs) in the countries, with the focus on monitoring and evaluation mechanisms and transformation of data into information for evidence-based decision-making. This was achieved by conducting appropriate workshops and consultations at country and intercountry levels. To further improve the quality of ICD-10 coding and overall validity and reliability of morbidity and mortality statistics, an Intercountry Training Workshop for Trainers on the Assessment of ICD-10 Coding was organized in Yangon in July 2001. Health professionals from Member Countries were trained on the concept and actual application of the Australian
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Coding Benchmark Audit (ACBA) for assessment of ICD-10 coding in the countries. As an outcome of this workshop, a curriculum for ICD-10 is being developed by the Regional Office in collaboration with experts from the Region for use in medical and paramedical institutes. In order to strengthen the performance of health information systems and their contribution to national planning, the Regional Office is finalizing a generic protocol for monitoring and evaluation of health information systems, in collaboration with experts from the Region. In this context, in order to achieve more responsive, dynamic and user-friendly HISs to serve the needs of the countries, an Intercountry Consultation on Strengthening Health Information Systems was organized in the Regional Office in October 2001 to review the framework, data transmission system, existing monitoring mechanism and performance indicators of the health information system and its sub-systems. During the last several years, WHO has undertaken many activities to strengthen HISs and medical records in the Member Countries and thus contribute to improving the collection of morbidity and mortality statistics. Many intercountry and national training courses were conducted on medical records procedures, health information management and ICD-10 for medical records staff of the Member Countries. An evaluation of these activities showed that in some countries transformation of data into information for evidence-based decisionmaking still needs improvement. There are a number of constraints that are common to many countries of the Region in terms of data collection, transmission and presentation and analysis. In order to strengthen this area, an Intercountry Workshop on Data Management for Evidence-Based DecisionMaking was organized in Bangkok in December 2001 to promote critical thinking in the application of data and analytical skills in data management for evidence-based decision-making. Thirty-five health professionals from nine Member Countries were trained in this workshop. As a followup, many countries have planned similar workshops with technical assistance from WHO. In the first phase, national workshops were conducted in Indonesia, Maldives, Myanmar and Nepal in 2002.
Strengthening of information systems and medical records in the Member Countries has contributed to improving the collection of morbidity and mortality statistics
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World Health Report 2000, which generated widespread interest among governments, set in motion public debates and led to increased focus on the strengths and weaknesses of the national health systems. As a follow-up to the report, the regional offices, in collaboration with WHO headquarters, supported the strengthening of capacity building in Member Countries for better assessment of their health systems performance through the global Enhancing Health Systems Performance Initiative (EHSPI). India, Indonesia, Myanmar, Nepal, Sri Lanka and Thailand from the SEA Region are participating in this initiative. WHO headquarters initiated regional consultations in all the six regions to review the framework and methodology of health systems performance assessment (HSPA). A Regional Consultation and Technical Workshop on Health Systems Performance Assessment was organized jointly by the Regional Office and WHO headquarters in June 2001 in the Regional Office. Fifty-three high-level health officials at policy and programme levels, senior public health officials, social scientists and other technical experts from the countries of the Region attended this meeting. This resulted in a better understanding of the methodological issues related to HSPA, which may be very useful in conducting assessments in the countries. The output of these regional consultations has to be reviewed by the peer review group, formed by the Director-General, to outline the methodology for health systems performance assessment. This subject was also discussed at the 109th session of the WHO Executive Board in January 2002. The peer review group submitted its final report on the assessment of health systems performance to the 110th session of the Executive Board in May 2002.
Health Information Management and Dissemination The main activities of the Information Management and Dissemination programme included the production and distribution of documents and publications, translation of WHO publications into national/local languages, marketing and promotion of WHO publications and improvement of scientific communication.
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Volume 5, Nos.1 and 2 (2001) and Volume 6, No.1 (2002) of the Regional Health Forum were published. This publication serves as a forum for the exchange of views and sharing of experiences on health development in the Region. New publications covering such areas as traditional medicine, nutrition, dengue and tuberculosis were brought out. Non-priced documents, including reports, monographs, guidelines and advocacy material on different subjects continued to be printed and distributed. Documentation of the WHO South-East Asia Regional Committee, including the report of the 54th session and of the Technical Discussions, were issued and distributed. Documents pertaining to the meetings of the World Health Assembly and the Executive Board were also disseminated to the Regional Office staff as well as the national authorities in the Member Countries. With a view to making WHO publications easily available and accessible to staff, a number of books and periodicals were uploaded to the SEARO Intranet Reports and Documents web site. Several cover pages of recent books, along with their comprehensive bibliographical descriptions, were published in the web site. The latest issues as well as archives of the Regional Health Forum and SEARO News are now available online. Efforts are under way to make the web site more comprehensive. The Regional Office participated in the Book Fairs held in Nagpur, Ranchi, Chennai, New Delhi (India), Colombo (Sri Lanka), Frankfurt (Germany), and Kathmandu (Nepal), giving visibility to WHO publications. In addition to sales of publications and books, a large number of subscriptions and reprint rights were also negotiated at these fairs. A large number of books, documents and pamphlets advocating changes in the areas of health and WHO’s activities were disseminated free of cost, while many others were sold at reduced prices. Copies of subscription leaflets and the WHO publications catalogue were distributed extensively. WHO publications were displayed on the occasion of World Water Day 2001 and 2002, to bring information about WHO to the notice of health professionals, paramedical workers, information scientists as well as the general public. During the period under review, the sales turnover was approximately $ 246 000. The entire
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activities of the Sales sub-unit have now been computerized using in-house software. With a view to reducing production costs and enabling wider distribution, reprint rights were granted to commercial publishers for low-cost local editions of 46 publications. The translation of 39 WHO titles was negotiated by offering translation rights in various regional and local languages to promote access to WHO information. The languages included Bahasa Indonesia, Bangla, Korean and Thai as well as several major Indian languages. The Regional Office library continued to function as the focal point for providing information support to staff members in the Regional Office as well as in the country offices. It also plays a central role in the provision of information support to health professionals, policy-makers, administrators, scientists and researchers in the Region. The library adopted an “activity-oriented strategy” in providing information services to staff members and member libraries of Health Literature, Library and Information Services (HELLIS) Network in the Region. Library services were reorganized into “information support packages”, developing several new services, whenever necessary, to provide effective information support. The library also serves as the portal to WHO information in the Region. It now has a comprehensive collection of WHO publications and documents in digital format. Using “decentralized dissemination” as the key strategy, the library has been setting up “base stations” at WHO country office (WCO) libraries for direct provision of information to Member Countries. An auto-install CD-ROM-based information package “WEBLIB-WR” has been developed and distributed to the WCO libraries to assist in the establishment of the base stations. By participating in both the United Nations System Electronic Information Acquisition Consortium, led by the Dag Hammar skjold Library at UN headquarters in New York, and the WHO Libraries Network Project on Global Information Full-Text (GIFT), led by the library at WHO headquarters, the library has direct access to over 800 international medical journals in full text. The service has now been expanded to WCO libraries. Staff members at these offices with Internet
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facility can now have direct access to these information resources which are also available to health personnel in the Member Countries through the WCO libraries. Under the Health Inter-Network Access to Research Initiative (HINARI) launched by the UN Secretary-General and led by WHO, Bhutan, Myanmar and Nepal now receive free electronic access while Maldives has access to discounted prices for over 1 500 major international journals in full text. The library serves as a focal point for coordination of activities and provision of technical support to “HINARI Enabled” libraries and institutions in the Member Countries. One of the most important areas in information management in developing countries is that of National Information Resource Management (NIRM). Much of the resources are not properly managed in several Member Countries and a significant portion of these resources are lost over time. The Regional Office library therefore has been laying special emphasis on NIRM in the Member Countries and provides awareness and support to NIRM activities in the Region. Several NIRM activities have been undertaken in Bangladesh, Bhutan, DPR Korea, Indonesia, Myanmar, Nepal and Sri Lanka with technical support from the Regional Office. The activities focus on priority information items such as National Index Medicus, research reports and Directory of Health Manpower. Technical support was provided to the National Health Research Council Library in Nepal for strengthening information management and dissemination. DPR Korea was supported in strengthening itsmedical university libraries.
Research Policy and Cooperation The Regional Research Policy and Cooperation (RPC) Programme continued to focus on the following strategic directions: (1) to advocate for and facilitate research promotion and development in the Member Countries by providing support for drawing up and implementing the health research agenda, (2) to build and strengthen national research capability through collaboration with medical/health research councils and analogous bodies and other health research-related institutions,
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including national, regional and international NGOs, (3) to elucidate and foster public debates on the social and ethical implications of science and health development in their social, economic, medical and cultural environments, (d) to strengthen analytical capability and to devise common approaches to analytical reporting within the Organization, and (5) to further develop and maintain health research information systems. The 27th session of the Advisory Committee on Health Research (SEA-ACHR), held in Dhaka in April 2002, deliberated on important issues such as national health research systems development; ethics in health research, health impact assessment and health research in cardiovascular diseases. Health research on arsenic poisoning was the subject chosen for the scientific debate during the session. The 54th session of the Regional Committee in 2001 endorsed the updated Regional Health Research Strategies. All Member Countries have accepted the updated regional strategies as the framework for analysing their national health research systems. Simultaneously, the Indian Council of Medical Research has developed the final draft of the national health research policy envisaging a national health system as the approach for integrating multi-disciplinary efforts. The National Institute of Health Research and Development, Indonesia, developed a draft national health research agenda which would serve as a tool for streamlining the coordination of health research studies in the country within the next five years. The Ministry of Public Health, Thailand, developed a national strategic plan of health research in 1999, which became the basis for assisting researchers to fulfil evidence-based needs of the national health programmes. In order to empower health researchers in managing and coordinating health research, the Regional Office continued to support the strengthening of health research management in the countries. Nepal, Myanmar and India carried out activities in priority setting in health research using the conceptual framework developed by the Regional Office. Sri Lanka developed a draft legislative provision for a National Health Research Council. Bangladesh, Myanmar and Nepal assessed the complementarity between the national health research policy and the existing health research projects. India, Indonesia, Myanmar, Sri Lanka and Thailand have taken initiatives to
WHO supported various studies, including the involvement of private medical practitioners in implementing the DOTS strategy, malaria, traditional medicines and reproductive health
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develop national systems of health research information as part of health literature and library development. An assessment of the health research infrastructure and health research scenario was commissioned in Thailand. Representing another facet of managerial relevance, astudy on development of a generic monitoring system for health research projects was commissioned in Myanmar. To study how training in research methodology is imparted in a formal educational setting, a “review of curricula on research methods and research related-issues used in medical and paramedical institutes” was conducted with WHO support in Bangladesh, Indonesia, Myanmar, Nepal and Sri Lanka. WHO supported a national workshop on “Strengthening Health Research Culture”, organized by the Myanmar National Academy of Medical Sciences as well as a workshop on managing health research for health research managers at the township level. In India, WHO supported various studies including the involvement of private medical practitioners in implementing the DOTS strategy, malaria, traditional medicine, reproductive health and emergency contraceptives, mental health, and the development of cancer registries in 14 cancer institutes. Three health research studies in the area of tobacco use are in progress: economics of tobacco use involving Bangladesh, Bhutan, Indonesia, Maldives, Myanmar, Nepal, Sri Lanka and Thailand; sentinel prevalence of tobacco use in Bangladesh, Bhutan, India, Indonesia, Myanmar and Sri Lanka; and the influence of tobacco use on pregnancy outcomes, in Bangladesh and India. In view of the high incidence of iodine deficiency in some parts of the country, Myanmar undertook a study on the variation of iodine content in salt at factory outlets and wholesalers/retailers. Another study on chemical carcinogens in street foods in Yangon city is in progress. Many Member Countries have utilized other means to strengthen the capacity of researchers, such as supporting health researchers/research managers to attend relevant national or international conferences, congresses, training workshops and/or seminars.
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Following the scientific debate on regional perspectives on genomics and health at the 26th session of SEA-ACHR, held in Thimphu (Bhutan) in 2001, a WHO inter-regional consultation was held in Bangkok in July 2001. The outcome of the consultation has been transmitted to WHO headquarters for inclusion in the Director-General’s report on Genomics and World Health. The Regional Office continued to promote ethical issues in health research. Following the South-East Asia Health Ethics Network (SEAHEN) study on baseline situation in health ethics in seven Member Countries, draft teaching guidelines for health ethics in medical schools were developed to be tested in 10 medical institutions. At the end of 2001, Indonesia conducted a study on “Mapping and profiling ethical review board”. The results provided valuable inputs to move forward with plans for strengthening the capacity of national and institutional ethical committee members in reviewing biomedical research proposals involving human subjects. The ethics core group of the National Institute of Health Research and Development is also in the process of finalizing the National Ethical Guidelines by involving health professional societies, scientists, lawyers, researchers and chairmen of eminent institutional ethical review committees. India and Nepal have developed their National Ethical Guidelines and are now moving to enact legislation. Keeping in view the recommendations of the Scientific Working Group on Management of Health Research Information, India, Indonesia, Myanmar, Sri Lanka and Thailand have taken initiatives to strengthen their national health research information systems as part of health literature and library development. Nepal, Myanmar and Bhutan now have free access to international journals under a project, Health InterNetwork, initiated by WHO. There are a total of 137 experts on different Expert Advisory Panels from the Region, of which 54 are from India, 31 from Thailand and 22 from Indonesia. The rest are from Bangladesh, Myanmar, Nepal and Sri Lanka.
With a view to promoting ethical issues in health research, WHO has developed teaching guidelines for health ethics in medical schools
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WHO collaborating centres WHO collaborating centres are a very important mechanism for promoting the Organization’s research policy and cooperation and for strengthening capacity in the area of health research. In consonance with the Fiftieth World Health Assembly resolution and subsequent discussions at the Executive Board, a review of the rules and regulations relating to WHO collaborating centres was carried out and a new set of rules and regulations has been framed and put into effect. The new rules enunciate the criteria for selection and the procedures for designation of WHO collaborating centres as well as their management, evaluation and monitoring. As of May 2002, there are a total of 86 WHO collaborating centres in the Region representing 7.2 per cent of the 1187 WHO collaborating centres existing globally. Within the Region, 43 centres are within the designation period and 43 are overdue for redesignation while 22 institutions are awaiting designation.
Organization of Health Services The ninth round of the International Practical Training on District Health System based on the Primary Health Care approach was held in India, Myanmar and Thailand in July/ August 2001. Twenty-five participants, including 7 from Uganda, who attended the India leg of the course only, benefited by attending the training in which efforts were made to describe the integration of essential health care services into the district health system for children, adolescents, men and women of reproductive age, the elderly, displaced persons, people with disabilities, chronic diseases, emerging and re-emerging diseases, as well as to identify new approaches/techniques for improving the PHC approach. Maldives and Nepal were assisted in initiating/strengthening their quality assurance programme through advocacy, workshops and training, and developing generic training modules on quality assurance in health care delivery, in collaboration with the Indian Institute of Health Management Research, Jaipur (India). An expert assisted Maldives in assessing the current status of management of health care delivery at
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the Indira Gandhi Memorial Hospital (IGMH) and in identifying priority areas that require urgent attention in terms of improving the quality of health care delivery. WHO supported the Member Countries by arranging their participation at the International Conference on Health Systems Reform under the theme of “Strategy and Process for Health System Reform”, held in Chiang Mai (Thailand) in December 2001. Two participants each from Bangladesh, Bhutan, Indonesia, Maldives, Myanmar, Nepal and Thailand attended. The objective of this conference was to provide the forum for international health policy and health systems researchers to share their knowledge and experience of health systems reform in their respective countries with special emphasis on structure and process. While most countries have embarked on the process of health sector reforms, some have achieved more success than others. There are beneficial lessons that could be learned from both what has worked and what has not worked in the countries and the reasons for the same. It was recommended that WHO should continue to support Thailand and other Member Countries of the Region in promoting the health systems reform process. There was a special session to discuss the “Thirty Baht Scheme” in Thailand for hospital care aimed at improving access, particularly for the poor.
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7 EXTERNAL RELATIONS AND GOVERNING BODIES Governing Bodies World Health Assembly The Fifty-fifth World Health Assembly was held in Geneva from 13-18 May 2002. Discussions took place on important issues, e.g. mental health, health and sustainable development, ensuring accessibility of essential drugs, destruction of variola virus stocks, global public health response to natural occurrence, accidental release or deliberate use of biological and chemical agents or radionuclear material that affect health, quality of care, patient safety, diet, physical activity and health, the need for increased representation of developing countries in the Secretariat and in Expert Advisory Panels and committees and infant and young child nutrition.
Executive Board The 109th session of the WHO Executive Board was held in Geneva from 14 to 21 January 2002. Among the important issues discussed were: health strategy matters, interactions for health: WHO’s involvement; role of contractual agreements in improving health systems performance; programme budget priorities for 2004-2005; amendments to the Financial Regulations; and use of languages in WHO. The technical and health matters discussed related to expanding access to essential drugs; updating WHO’s Model 97 THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION
list of Essential Drugs; health of children and adolescents; food safety and health; diet, physical activity and health; quality of care: patient safety; infant and young child nutrition; violence and health; dengue prevention and control; and deliberate use of biological and chemical agents to cause harm. The 110th session of the Executive Board was held in Geneva on 20-21 May 2002. Among the technical matters discussed were: the Global Fund to Fight AIDS, Tuberculosis and Malaria, International Nonproprietary Names, and Assessment of health systems’ performance. It also reviewed staffing and management matters.
Regional Committee The 54th session of the Regional Committee for South-East Asia was held in Yangon from 3-6 September 2001. It was attended by representatives of all the ten Member countries, the DirectorGeneral and representatives of other UN agencies, intergovernmental organizations, and international and local nongovernmental organizations. The Committee discussed the biennial report of the Regional Director for the period July 1999 to June 2001. It noted that significant improvement had been made in the prevention and control of major communicable diseases. The SEA Region was certified to be free of guineaworm disease and a regional strategy to eliminate lymphatic filariasis in eight endemic
Picture to be placed
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The 54 session of the Regional Committee for South-East Asia was held in Yangon, Myanmar th
countries had been formulated. The report also noted the WHO support provided to strengthen national and international programmes on Roll Back Malaria initiative; dengue and dengue haemorrhagic fever; HIV/AIDS, tuberculosis; tobacco control; health systems and community health; adolescent health; childhood illnesses; food safety; arsenic contamination of drinking water; substance abuse; national drug policies and natural disasters and complex emergencies. The polio eradication initiative continued to receive priority support. WHO was working with Member Countries in the collection, validation, analysis and dissemination of information on the health situation and trends. WHO’s partnership with other UN agencies and inter-governmental organizations had helped to bring health to the centre of the development agenda. Close monitoring of implementation of programmes had resulted in efficiency savings.
WHO worked with Member Countries in the collection, validation, analysis and dissemination of information on the health situation and trends
Consultative Committee for Programme Development and Management The 38th meeting of the Consultative Committee for Programme Development and Management (CCPDM) was held in Yangon from 30 August to 2 September 2001. The Committee, inter alia , critically reviewed the implementation of the WHO collaborative programmes at country and regional levels, including the intercountry programme. It was noted that the amount and percentage of surrendered reserves had been declining. The CCPDM took note of reports by country representatives on their attendance at the meetings of the coordinating bodies of the WHO global programmes and reviewed the regional implications of the decisions and resolutions of the World Health Assembly and the Executive Board. The CCPDM reviewed the detailed work plans for country and intercountry programmes for the 2002-2003 biennium and made recommendations to the 54th session of the Regional Committee for noting. The implementation targets for the 2002-2003 biennium proposed by CCPDM were 85 per cent by 31 December of the first year and 100 per cent by 30 June of the second year. As part of the meeting, Technical Discussions were held on Mental Health and Substance Abuse, including Alcohol.
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The CCPDM also reviewed the findings of a joint evaluation of two intercountry programmes, viz. (1) Tobacco Free Initiative, and (2) Improving the Health of marginalized and vulnerable groups, by country representatives and the Regional Office staff, conducted in five countries and the Regional Office. Its recommendations were forwarded to the 54th session of the Regional Committee for noting. The CCPDM recommended that such exercises should continue. The Committee stressed the need for and importance of sustainability of traditional medicine in the countries of the Region. It emphasized continued support for traditional medicine with special emphasis on the use of plant-based drugs and integration of alternative/traditional medicine with the national health care systems.
Regional Director’s Meeting with WHO Representatives The 50th meeting of the Regional Director with the WHO Representatives was held in November 2001 in the Regional Office. Country-specific issues concerning implementation of programme budget 2000-2001 and formulation of programme budget 2002-2003, collaboration between the Regional Office and other organs of the Organization and technical updates on priority health issues in Member Countries of the Region were among the topics discussed, in addition to other managerial issues.
Health Ministers’ Meeting The 19th Meeting of Health Ministers of the countries of the Region was held in August 2001 in Maldives. The meeting reviewed the actions taken on the recommendations of the 18th meeting of Health Ministers. It also reviewed the high-level policy meetings in the Region and decided that future meetings of Health Ministers should be held in conjunction with the sessions of the Regional Committee to enable the Health Ministers to participate in both the meetings. It was also decided that the Health Secretaries’ Meetings should be rescheduled from February to April enabling the Health Secretaries to discuss issues to be addressed at the World Health Assembly in May of that year.
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The 19th Meeting of Ministers of Health of the countries of the WHO South-East Asia Region was held in Maldives
The meeting reviewed the health problems in the Region and recommended various actions for improving the health status of the people. Inter alia, it recommended that the Member Countries, in collaboration with WHO, should develop a regional proposal for funding by the Global Fund for Tuberculosis and Malaria HIV/AIDS. The meeting also deliberated upon the Essential Drugs and Medicines Policy in the regional perspective and noted that while manufacturing essential drugs is a technical issue, making them available was a political issue that required political commitment. It recommended, inter alia , that WHO should offer technical support and facilitate activities such as bulk purchase schemes for essential drugs by generic name, and drug quality control systems, especially for the smaller countries in the Region. The meeting also provided the regional inputs into Organization-wide priorities for the 2004-2005 biennium.
Health Secretaries’ Meeting The 7th meeting of Health Secretaries of the countries of the SEA Region was held in April 2002 in New Delhi. It reviewed the implementation of the programme budget 2000-2001; status of implementation of the programme budget 2002-2003 and Part II of the Proposed Programme Budget 2004-2005. Among the various items included in the provisional agenda of the Fifty-fifth World Health Assembly,
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the meeting broadly deliberated on risks to health; report of the WHO Commission on Macroeconomics and Health; the Global Fund to fight AIDS, TB and Malaria and WHO’s Medicines Strategy.
Regional Conference of Parliamentarians The Regional Conference of Parliamentarians on HIV/AIDS and Mental Health was held in December 2001 in New Delhi. The global magnitude of the HIV/AIDS problem, the lessons learnt in responding to HIV/AIDS, and the strategies needed in the new millennium were highlighted. The Parliamentarians expressed grave concern about the HIV/AIDS situation unfolding in the Region and the impact it would have on the health of the people and on economic development. The conference stressed that national programmes should focus on HIV prevention as a matter of priority since the HIV/AIDS epidemic was still at an early stage. It was agreed that parliamentarians should set up a task force in each country to provide a forum to law makers to articulate their concern regarding the HIV/AIDS epidemic and to mobilize support from governments, NGOs, international agencies and development partners, the private sector as well as the community in combating HIV/AIDS. They also agreed to take a lead in establishing effective and rational policies and strategies in their countries to make the AIDS programme a people-oriented one. Discussions on mental health focused on World Health Report 2001, which aims at raising public and professional awareness regarding the real burden of mental disorders and their costs in human, social and economic terms. It was noted that mental disorders are caused by a complex interaction between genetic, biological, psychological and socio-cultural factors. The scarcity of qualified manpower in the areas of mental health and neurosciences in the countries of the Region was highlighted. It was indicated that mental health has to be seen from the intersectoral perspective as other sectors, such as education, welfare, the criminal justice system, housing and labour, can benefit from mental health interventions as well as contribute to mental health care. It was also recommended that parliamentarians in each country should set up a task force to provide a forum on mental health and to mobilize appropriate support in combating mental disorders.
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Resource Mobilization and External Cooperation and Partnerships Resource mobilization In view of the persistent zero real growth budget and absence of any donor in the SEA Region, the issue of mobilizing external resources has assumed significant importance in carrying forward WHO’s activities geared to health development. In order to address this issue, the Regional Office has developed a resource mobilization strategy based on WHO’s Global Resource Mobilization Policy Guidelines and the Organization’s corporate entity. The goal of the strategy is to place health at the centre of overall development in partnership with Member States, UN agencies, regional intergovernmental organizations, multilateral and bilateral organizations, foundations, civil society organizations and others. The strategy was shared with all country offices in July 2001 and tested in Sri Lanka as a case study. Currently, voluntary contributions constitute over 60 per cent of WHO’s total budget. Despite the absence of any donors in the Region, the amount of extrabudgetary funds has shown a significant increase - almost 62 per cent in the biennium 2000-2001 totalling over $ 114 million. The major recipient areas during the reporting period were polio eradication, TB, HIV/AIDS, EHA and malaria. The countries that received most of these resources are India ($52 million), Indonesia ($10 million), Bangladesh ($10 million) and Nepal ($8 million). USAID/CDC, DFID and DANIDA were the major government contributors, while UNF was the highest contributor among the foundations. Given the increasing importance of foundations in mobilizing voluntary contributions for health, the issue of mobilizing resources from other global funds, such as the Global TB Fund, UN Fund, the Bill and Melinda Gates Foundation, etc. featured in the agenda of the 50th Meeting of the Regional Director with the WHO Representatives, in November 2001. The discussion on this issue centred mainly on ways and means of mobilizing funds from these organizations.
In view of the persistent zero real growth budget, mobilization of external resources has assumed significant importance
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The Regional Office played an active role in organizing the Meeting of Interested Parties (MIP) that would be built around the strategic programme budget with the participation of Member Countries, donors, civil society organizations and others. For the first time, the MIP meeting this year would be held in October instead of its regular schedule in June; also the duration will be shortened from two weeks to one week. The Regional Office underlined the need for an overall review of resource mobilization achievements and bottlenecks with special emphasis on the regional situation and resource mobilization. In line with global policy guidelines, the Regional Office has been trying to forge meaningful partnerships with NGOs. Collaboration with NGOs has generated a significant amount of voluntary contributions in areas like polio eradication, prevention of blindness and leprosy elimination. Among NGOs, Rotary International and Sasakawa Foundation contributed most in a number of countries. In order to promote and consolidate partnerships with NGOs, the Regional Office is currently engaged in exploring the possibility of setting up a WHO-NGO Consultative Forum between government, NGOs and WHO, both at regional and country levels. As part of this initiative, country studies in Bangladesh, India, Maldives, Nepal, Sri Lanka and Thailand on NGO activities were undertaken and completed. The process of undertaking follow-up activities based on the findings of these studies is under way. The Regional Office continued to support countries in their efforts to mobilize external resources for health. Apart from providing the latest information to countries on donors on a regular and “as and when” basis, including the possibility of getting funds from them, it technically supported the national authorities as well as donors in appraisal and programme formulation missions, programme monitoring and evaluation and monitoring of the progress of implementation of projects. The submission of proposals for funds as well as concluding agreements with donors and implementing agencies in a number of projects in India, Myanmar and Nepal was also facilitated. Further, support was provided to Sri Lanka for organizing a national aid negotiation workshop and a workshop for skill development.
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External cooperation and partnerships WHO continued to promote the integration of health dimensions in social, economic and environmental development with enhanced partnerships with UN system agencies, intergovernmental organizations, regional agencies and associations. In collaboration with other UN system agencies, WHO country offices actively participated in the preparation of a Common Country Assessment (CCA) and the United Nations Development Assistance Framework (UNDAF). The CCA has been completed in Bhutan, Bangladesh, India, Indonesia, Myanmar (country paper in place of CCA), Nepal, Sri Lanka, Thailand and UNDAF in Bhutan, India and Sri Lanka. In most countries, WHO is the lead agency for health in the inter-agency coordination mechanisms within the UN Resident Coordinator System, such as Inter-agency Working Groups, Theme Groups and Task Forces on Primary Health Care, Reproductive Health, HIV/AIDS, and Water Supply and Sanitation. Together with other agencies, WHO country offices have been providing support for the preparation of the Millennium Development Goals Report (MDGR). This activity has been completed in Nepal. WHO has strengthened its collaboration with the Economic and Social Commission of the United Nations (ESCAP). It contributed to the discussions on policy issues relating to the implications of the recent economic and social development in the ESCAP region, emerging issues relevant to health and regional preparations for the Special Session of the UN General Assembly on HIV/AIDS and the World Summit for Sustainable Development at the 57th and 58th sessions of ESCAP , held in Bangkok, in April 2001 and May 2002 respectively. It also collaborated with ESCAP on poverty alleviation, policies and programmes on social safety, human resources development, and regional inter-agency coordination. WHO has appointed a Coordinator for the Public Health Cooperation Programmes with respect to Greater Mekong subregional collaboration. It has also established an RBM Mekong office for Roll Back Malaria at the ESCAP office to follow up the ECOSOC resolution (2000/5) on the Decade of Greater Mekong Subregional Development Cooperation, 2000-2009.
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Close coordination was maintained with UNAIDS intercountry teams in Bangkok and New Delhi and the UN Task Force on HIV/AIDS Care and Support for Asia. The Regional Office also supported the development of HIV databases in selected countries as well as projects on prevention and control of HIV/AIDS in some countries of the Region.
As part of its collaborative activities with SAARC, WHO convened an intercountry meeting to discuss crossborder initiatives in the areas of HIV/ AIDS, TB, malaria and Kala-azar
WHO continued its collaboration and coordination with UNICEF on the Expanded Programme on Immunization (EPI) through the Technical Consultative Group (TCG) for EPI, the Regional Inter-agency Coordinating Committee (ICC) and the Regional Working Group on Immunization for South-East Asia (RWG-SEA). RWG-SEA provided support to Member Countries in the application process to GAVI and conducted joint field visits to Nepal and Bangladesh. In Bangladesh, DPR Korea, India, Nepal, Myanmar and Sri Lanka, RWG-SEA provided technical assistance for the conduct of EPI and hepatitis B burden reviews, development of action plans for strengthening routine EPI, financial sustainability of EPI, and injection safety and introduction of hepatitis B vaccine into routine immunization programmes. WHO continued to maintain close cooperation with the Association of South-East Asian Nations (ASEAN) for the improvement of health. The meeting of the ASEAN Subcommittee on Health and Nutrition, held in Hanoi (Vietnam) in October 2001, reviewed the progress on the implementation of the MoU between WHO and ASEAN. Technical support was provided for the 6th ASEAN Health Ministers’ Meeting, held in Vientiane (Laos) in March 2002. Here a Conceptual Framework for Promoting Healthy ASEAN Lifestyles was considered and Work Programmes on Healthy ASEAN and the Ministerial Declaration were adopted. WHO continued to assist Member Countries in dealing with health-related issues emanating from several multilateral trade agreements of the World Trade Organization (WTO). In view of the growing trend of international trade in health services, country case studies have been undertaken in India, Indonesia and Thailand to review and analyse the implications of foreign hospital operations on national health policy and development in the respective countries. Technical and financial support was also provided for the ASEAN Workshop on General Agreement
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on Trade in Services (GATS) of WTO and Impact Assessment of Trade in Health Services on the Health Sector in Jakarta in March 2002. With strong advocacy in partnership with Member Countries, other international agencies, nongovernmental organizations and civil society organizations to ensure that international trade agreements do not adversely affect public health, a “Declaration on TRIPS Agreement and Public Health” was adopted at the WTO Ministerial Conference, held in Doha (Qatar), in November 2001. This was the first time in WTO history of more than 50 years that a separate declaration on public health was adopted. The declaration provides flexibility in the use of the intellectual property system for better public health. WHO continued its collaboration with the South Asian Association for Regional Cooperation (SAARC) and convened an intercountry meeting in Kathmandu in March 2001 to discuss cross-border initiatives in the areas of HIV/AIDS, TB, malaria, and kala-azar. Discussions have been initiated between the two agencies to follow up on the MoU between WHO and SAARC concluded in August 2000.
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8 GENERAL MANAGEMENT Budget and Management Reform The 2000-2001 biennium was a success in terms of financial implementation. Regular and intensive programme monitoring by WHO country offices and technical units in the Regional Office, with the active participation of the national authorities concerned, resulted in full implementation of the programme budget 2000-2001. Departmental Directors and the Advisory Committee on Policy and Programmes (ACP) reviewed and monitored the financial and technical aspects of programme implementation during the biennium. Accelerated financial implementation also led to the Region having lower reserves at the end of 2000-2001, which should result in smaller unspent funds being surrendered than in the previous biennium. The ACP also reviewed programmatic and technical issues and made appropriate recommendations to the Regional Director. Detailed work plans for the 2002-2003 country and intercountry programmes were finalized and noted by the 54th session of the Regional Committee. The supplementary intercountry programme was developed with the full involvement of a high-level task force for intercountry collaboration, established by the Regional Director. The Regional Committee set an implementation target of 85 per cent of the planned budget by the end of the first year of the biennium and 100 per cent by June 2003. Accordingly, the Member Countries and WHO rescheduled some of the planned activities in their respective work plans to ensure accomplishment of the target.
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Intensive consultations took place between the Regional Office and WHO headquarters as part of the Organizationwide efforts to develop the programme budget 2004-2005. The formulation of Part II (region specific) of the programme budget 2004-2005 was initiated with inputs provided by the Health Secretaries at their seventh meeting, held in New Delhi in April 2002. Based on the decision taken by the 53rd and 54th sessions of the Regional Committee, an evaluation of the supplementary intercountry programme for 2002-2003 was conducted; its findings will be reported to the 55th session of the Regional Committee in September 2002. Inputs were provided to WHO headquarters for the development of Organization-wide guidelines for conducting programme evaluation. As part of the global evaluation on the quality of programme implementation of the programme budget 20002001, Member Countries and the Regional Office conducted an end-of-the-biennium analysis. The lessons learnt will be effectively used in the current biennium.
Human Resources Development The current organizational structure of the Regional Office is at Annex 1. Human Resources Management continues to provide administrative and management support to the technical programmes in the Regional and field offices. The Organization must adapt itself to rapidly changing health development needs. This can be achieved by attracting and retaining skilled, committed and well-motivated people that the Organization needs. For this reason, the current recruitment and selection procedures are under review. Initiatives have been taken to attract highly qualified people. Training and development opportunities are being provided to enhance the capacity of staff members. The policy on performance management and development system (PMDS) is in the process of being introduced to enhance motivation and commitment of staff members. 110 THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION
Staff development is aimed to provide staff members with learning opportunities in order to develop their capacities.
Table 8.1: Gender and geographical distribution of recruitment of professional staff in the SEA Region, July 2001 – June 2002 a Total recruitments 14 (9) a
Women 6 (2)
Percentage 56 (22)
Unrepresented/ under-represented nationalities 3 (6)
Percentage 43 (67)
Figures in parentheses relate to the previous 12-month period.
Furthermore, it provides training and development opportunities to increase the capacity of management to make a significant contribution to achieving WHO’s goals. In this context, a workshop on negotiation skills for all staff in the Professional and higher categories and selected GS staff members in the Regional and country offices was organized. Among other training opportunities, an orientation programme on PMDS was organized. As part of staff health promotion activities, presentations on various topics, such as heart care and tobacco use, have been periodically organized. The Regional Office, moreover, has arranged regular yoga/aerobics classes for staff. With the participation of all UN agencies, a hardship survey was conducted in August 2001 for the classification of duty stations in India. Furthermore, preparations have started for a comprehensive salary survey scheduled for this year. The factfinding phase will begin in August 2002. Table 9.1 provides information on the progress in gender and geographical distribution in relation to recruitment: During the reporting period, 171 short-term consultants/ short-term professionals (leading to 272 assignments) were recruited. Some 882 SSA holders were in position as of 30 June 2002. As of 30 June 2002, the Regional Office had 133 established professional posts as compared to 127 posts as of 30 June 2001. A total of 6 new posts of coordinators were established in order to bring about fruitful programme implementation. Out of 84 professional staff in position as of 30 June 2002, 41 (49%) were nationals of the SEA Region and 25 (30%) were women. 111 THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION
One area of expansion at the country level is the National Programme Officer category. Nineteen posts of National Professional Officer were established, of which 12 have been filled. Action is in progress to establish another three posts in Bangladesh.
Financial Management The target of 75 per cent implementation for the first year of the 2000-2001 biennium was largely unmet. However, with the decision to pool and redistribute funds that remained uncommitted after 30 June 2001, nearly every country in the Region has achieved 100 per cent implementation.
Highlights of Programme Budget Implementation 2000-2001 l The Region fully obligated its $95.4 million Regular
Budget (activities $60.4). No funds were left uncommitted at the end of the biennium (Annexes 2 and 3). l The liquidation (expenditure) rate was 87 per cent,
compared with 83 per cent in 1998-1999. l Among the countries, Myanmar (95 per cent), Sri Lanka
(93 per cent), and Maldives (92 per cent) had the highest rates of liquidation (and consequently, the lowest reserves).
Table 8.2 : Regular budget reserves established vs. surrendered 1994-1995 to 2000-2001 Biennium 1994-1995 1996-1997 1998-1999 2000-2001 Allocation 84 543 200 95 920 300 96 220 000 95 388 800 Reserves established 23 863 006 16 339 909 15 977 905 12 689 292 Percentage of allocation 28 17 17 13 Reserves surrendered 4 404 277 4 271 522 3 763 620 371 263* Expressed as percentage of allocation surrendered 5.2 4.5 3.9
* As of 30 June 2002. Final figures will be known after 31 December 2002
l The Region ended 2000-2001 with a reserve of $12.7
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million compared with $16 million in the last biennium, an improvement of 20 per cent (Table 8.2 and Annex 6).
l Extrabudgetary (EB) funds from donors increased
dramatically and surpassed Regular Budget funds for the first time in 2000-2001. Polio accounted for 65 per cent of Extrabudgetary Funds. The pace of implementation of programme activities during the first six months of the biennium 2002-2003 is higher in comparison with the same period of 2000-2001 (Figure 8.1 and Annexes 4 and 5).
Figure 8.1: Implementation of Regular Budget – 2000-01 and 2002-03 (Activities) 120 100 Percentage 80 60 40 20 0 Mar Yr 1 June Yr 1 2002-03 Sep Yr 1 31 Dec Yr 1 30 June Yr 2 2000-01 12 33 21 60 37 85 59 100
Informatics and Infrastructure Services Country offices have been further strengthened with state-ofthe-art Information and Communication Technologies (ICT). Currently, seven country offices have dedicated Internet connectivity. The Global Private Network (GPN) services between the regional offices and WHO headquarters was extended to some country offices, including the full GPN access in the country office in India. The South-East Asia Regional Office is the first among the regional offices to establish Internet and data connectivity through GPN. Selected GPN services have also been made available to Maldives, Nepal and Thailand, using the Virtual Private Networking (VPN). The Local Area Networks (LAN) in the country offices in DPR Korea, India and Sri Lanka were upgraded with the latest technology.
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The software standards for the Region, established in 1998, have been substantially upgraded. The implementation of the four-year ICT training plan for the Regional Office was successfully completed. A new training plan to reorient the staff to the upgraded software standards is being developed.
The Activity Management System has been remodelled by developing user-friendly web-based interfaces incorporating global and regional business requirements
Major efforts have been made to improve the information system in the Region. A web-based Proposal Tracking System (PTS) was developed to facilitate electronic clearance of proposals, tracking their status and electronic filing. Regionwide implementation of this system is expected to improve efficiency in the clearance of proposals and in programme implementation. A web-based system to manage all regional address lists was developed. The system will provide direct interfacing with the telephone system to allow dialling of numbers through the computer. A sales monitoring information system for WHO publications has been developed. The Activity Management System (AMS) has been remodelled by developing user-friendly web-based interfaces that incorporate global and regional business requirements. In addition to technical and financial monitoring, linkages have been provided to allow access to various allied systems such as Supplies and Equipment system, Proposal Tracking System etc. This will enable the country offices to get up-to-date, consistent and complete programme implementation information online through a single regional database. Electronic information dissemination has been further strengthened through continuous updating of the SEARO web site. Web sites have been developed for all areas of work and departments. A web site builder tool is under development. This tool will facilitate easy development of web sites at the country level and ensure coherent standards and a corporate look for all regional web sites. Bhutan and Sri Lanka were provided ICT support for establishing pilot Health Telematics Projects. A need assessment for Health Telematics services was carried out in Maldives as well. Technical support was continued to several projects in India. These include: the electronic connectivity project for the Tuberculosis Programme; a web-based system for the dissemination of health-related statistical data for the Central Bureau of Health Intelligence, an information management
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system for the National Institute of Communicable Diseases; a web-based Health Research Information System for the Indian Council of Medical Research (as part of the Health InterNetwork Project); computerization of the International Health Division of the Ministry of Health and Family Welfare and the Gujarat Earthquake Relief Programme.
Procurement Services For effective implementation of WHO’s collaborative programme, procurement and related services were provided to all the Member Countries. Requisitions received from projects, Member Countries and country offices as well as the Regional Office resulted in total procurement of the value of 9.4 million covering drugs, biologicals, contraceptives, medical and hospital supplies, office automation and informatics equipment, vehicles, medical literature, etc. Supplies-related logistic support was made available to national health activities being implemented with WHO collaboration and funded by extrabudgetary resources or donors. At the request of Member Countries or United Nations agencies, the Medical Supply Unit extended administrative and logistic support in procuring, on a reimbursable basis, essential drugs, vaccines, etc. to meet their needs. As part of WHO’s global programme of polio eradication, OPV and other vaccines, laboratory supplies and equipment, and promotional material for social mobilization and training, were provided to the Member Countries engaged in polio eradication. For successful implementation of the DOTS strategy, anti-TB drugs were supplied to India and DPR Korea. Logistic support continued to be provided to the leprosy containment programme by arranging clearance, transportation and distribution of medical supplies, including drugs received as donations. Similar assistance was rendered in respect of purchase of albendazole tablets for the lymphatic filariasis programme in India. The Regional Office rushed emergency health kits and other supplies to India, Bangladesh and DPR Korea to meet earthquake, floods, disasters or disease outbreaks. Assistance
115 THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION
is continuing in the rehabilitation work following the earthquake that struck Gujarat state in India and the floods in Bangladesh last year. To contain and prevent waterborne diseases among the populations and to facilitate surveillance by the WHO relief missions, water quality testing equipment and other supplies were provided for the earthquake victims in Gujarat. Assistance was also rendered in processing supplies for East Timor. The stipulation of early deadlines for submission by projects and country offices of requisitions for the procurement of supplies and equipment in the previous biennium facilitated faster and timely procurement. As a result, a major portion of the “supplies” component of the biennial budget was utilized in the first year of the biennium.
General Support Services In DPR Korea, accommodation for the newly-established office of the WHO Representative was identified, refurbished and equipped. New office premises adjacent to the Ministry of Health were identified for the WHO staff in Indonesia who were spread out in many locations. This brought the WHO staff under one roof, which contributed to greater efficiency and security of the staff. Renovation of some offices in the Regional Office was carried out and landscaping of the lawn in front of the Annexe completed. In line with WHO’s theme for World Health Day 2002 and to provide facilities for improving the health of staff members, a fitness room was constructed and exercise equipment is being installed. The area available outside World Health House has been modified to provide extra parking space. Security in the building was strengthened and tighter control of visitors introduced following the events of 11 September 2001. Incoming mail is now screened in a self-contained location to ensure the safety of staff. 116 THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION
9 REGIONALDIRECTOR'S DEVELOPMENTPROGRAMME PublicRelationsandMedia Relations with the media continued to be maintained at a high level during the reporting period. National and international media turned to WHO with increasing frequency for information on technical matters and the Regional Office was able to ensure timely and efficient response. Press events organized by WHO saw a very large turnout, especially during the launch of the World Health Report, World Health Day 2002, and the Parliamentarians Conference. There were two major health-related events that attracted media attention. The first was the anthrax scare in the aftermath of the 11 September 2001 tragedy in New York, which was felt in this Region as well. The second was an outbreak of plague in India, when media and public attention globally was fixed on this country. To begin with, the Regional Office had to clearly articulate WHO’s position on both the issues and to keep the Member Countries well informed. This was done through information sheets written in simple and clear language. During this period, journalists regularly turned to WHO for urgent information and clarification. The Task Force approach worked very well as WHO briefings and press interviews provided clarification and reassurance and helped to stem any sense of panic and fear. While the Information Unit supported the work of all the technical units, special mention must be made of two meetings: viz. (1) Global Alliance for Elimination of LF, and (2) National 117 THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION
Representing WHO on the occasion of the independence of East Timor, the Regional Director, Dr Uton Muchtar Rafei, signed the instruments of agreement with the President, Mr Xanana Gusmao
Leprosy Programme Officers’ Meeting. A special effort was made to provide media persons with technical briefing on the subjects and to elicit their interest to report on these issues. Besides supporting requests from WHO headquarters and countries, this year the Regional Office also provided special support to the newly-established WHO Representative’s Office in DPR Korea as well as the WHO office in East Timor to develop and produce information materials. These highlighted health issues and WHO’s role in supporting these Member Countries. Several new features were added at the 54th session of the Regional Committee in Yangon to help focus the spotlight on health issues in the Region. Two photo/poster exhibitions were developed and displayed and a special edition of the SEARO newsletter, “Window on SEAR” was developed highlighting success stories from each of the Member Countries. Country offices are seeing the usefulness of having regular contact with the news media, and this year, two of them have media professionals working with their offices. This is helping cement relationship with the media, an extremely useful investment for long-term cooperation between the health sector and the media.
Regional Office and Country Offices 118 THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION
The period under review marked the transition from completing programme implementation in respect of the 2000-2001 biennium to the preparation for and implementation of the
programme budget 2002-2003. The Regional Director’s Office played a vital role in monitoring and facilitating implementation of both intercountry and country programmes through close collaboration with the Department Directors and the WHO Country offices. During the second half of 2001, the uncommitted funds from the regional and country programmes relating to the 2000-2001 biennium were pooled and reallocated for regional and country proposals through the intercountry mechanism. This mechanism was found to be very effective in speeding up programme implementation as well as in improving the quality of the proposals. Since joining WHO in 1973 as a Member Country of the South-East Asia Region, the Government of DPR Korea decided to establish a permanent WHO Representative’s Office in Pyongyang. The WHO Representative to DPR Korea was appointed in August 2001 and the new office was inaugurated by the Director-General in November 2001. Two meetings of the Regional Director with the WHO Representatives were held, the 50th meeting in November 2001 and the 51st meeting in June 2002. The meeting of the Regional Director with the WHO Representatives, usually held in November, was advanced to June this year to enable the Representatives to review the progress in programme implementation at an early stage so as to allow sufficient time
119 Dr Gro Harlem Brundtland, Director-General, WHO, visited Pyongyang to inaugurate the WHO office in DPR Korea THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION
for taking corrective measures; to be briefed on decisions taken and resolutions adopted by the World Health Assembly and the Executive Board; and equip them with sufficient information to brief country delegates to the ensuing session of the SEA Regional Committee. The countries of the SEA Region had finalized their Country Cooperation Strategies (CCS) in 2000. In order to review progress in their implementation, an evaluation was conducted in India, Indonesia, Myanmar and Nepal in December 2001, in collaboration with WHO headquarters. The results of the evaluation indicated a need for standardization and implementation in the process of preparation of CCS.
RegionalDirector’sDevelopmentProgramme During the reporting period, several initiatives and health emergency relief measures were supported in the Member Countries through the Regional Director’s Development Fund (RDDF). These included: (1) organization of (a) Workshops on Community Health Care; (b) Management of Anthrax; (c) GATS Agreement and its Impact on Health Services; (d) Guidelines for Prevention and Control of Hospital Associated Infections; (e) Community Deafness Survey; (f) Prevention and Control of DF/DHF, (g) Links between Mental Health Promotion, Prevention and Treatment of Mental Illnesses; and (h) Peace Building in Sri Lanka; and (2) fellowships and study tours in the areas of (a) Skills for the new world of health care, and (b) cataract management, and (3) establishment of a HELLIS electronic library in Myanmar. Health emergency relief during the floods in India (West Bengal and Orissa), Myanmar and the Eastern Provinces of DPR Korea and drought in Sri Lanka were also supported.
120 THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION
Annexes
Annex 1
Organizational Structure
Regional Director Director Regional Regional Cabinet (RCT) Regional Director’s Office (RDO) VAB ERO INA
Deputy Regional Director/ Director, Programme Management (DRD/DPM)
Director, Administration and Finance (DAF)
Communicable Diseases (CDS)
Promotion of Health, Environment and Development (PED)
Evidence and Information for Policy (EIP)
Family and Community Health (FCH)
WHO Representatives WHO Country Offices WHO Field Staff
121 THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION
Annex 2
Budgetary Implementation of Activities by Country – 2000-2001 REGULAR BUDGET ( As of 31 December 2001) (Expressed in US $)
Country
Allotted 6 563 279 1 719 863 2 978 271 155 203 13 415 979 7 010 256 1 027 629 5 597 756 4 548 759 3 403 720 3 825 482 50 246 197 10 138 392 60 384 589
Disbursement 5 106 748 (78%) 1 424 808 (83%) 2 627 842 (88%) 125 050 (81%) 10 171 406 (76%) 6 001 329 (86%) 878 383 (85%) 5 229 625 (93%) 3 369 912 (74%) 3 129 916 (92%) 2 924 832 (76%) 40 989 851 (82%)
Unliquidated obligation 1 456 531 (22%)
Total obligation 6 563 279 (100%) 1 719 863 (100%) 2 978 271 (100%) 155 203 (100%) 13 415 979 (100%) 7 010 256 (100%) 1 027 629 (100%) 5 597 756 (100%) 4 548 759 (100%) 3 403 720 (100%) 3 825 482 (100%) 50 246 197 (100%) 10 138 392 (100%) 60 384 589 (100%)
Earmarking 0 (0%) 0 (0%) 0 (0%) 0 (0%) 0 (0%) 0 (0%) 0 (0%) 0 (0%) 0 (0%) 0 (0%) 0 (0%) 0 (0%) 0 (0%) 0 (0%)
Total committed 6 563 279 (100%) 1 719 863 (100%) 2 978 271 (100%) 155 203 (100%) 13 415 979 (100%) 7 010 256 (100%) 1 027 629 (100%) 5 597 756 (100%) 4 548 759 (100%) 3 403 720 (100%) 3 825 482 (100%) 50 246 197 (100%) 10 138 392 (100%) 60 384 589 (100%)
Uncommitted balance 0 (0%) 0 (0%) 0 (0%) 0 (0%) 0 (0%) 0 (0%) 0 (0%) 0 (0%) 0 (0%) 0 (0%) 0 (0%) 0 (0%) 0 (0%) 0 (0%)
Bangladesh Bhutan DPR Korea East Timor India Indonesia Maldives Myanmar Nepal Sri Lanka Thailand Country total Intercountry (including IX) SEAR
295 055 (17%) 350 429 (12%) 30 153 (19% ) 3 244 573 (24%) 1 008 927 (14%) 149 246 (15%) 368 131 (7%) 1 178 847 (26%) 273 804(8%) 900 650 (24%) 9 256 346 (18%) 2 150 759 (21%) 11 407 105 (19%)
7 987 633 (79%) 48 977 484 (81%)
122 THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION
EXTRABUDGETARY FUNDS (As of 31 December 2001) (Expressed in US $)
Country
Allotted 10 052 698 88 823 3 850 842 3 082 188 51 886 654 10 214 026 4 648 188 8 651 544 432 572 310 128 93 217 663 21 159 396 114 377 059
Disbursement 8 000 457 (80%) 74 901 (84%) 2 889 988 (75%) 1 988 788 (65%) 37 914 702 (73%) 6 184 120 (61%) 2 629 658 (57%) 4 614 546 (53%) 62 745 (15%) 122 426 (39%) 64 482 331 (69%) 12 325 941 (58%) 76 808 272 (67%)
Unliquidated obligation 1 133 341 (11%) 8 806 (10%) 512 612 (13%) 374 927 (12%) 2 901 416 (6%) 372 117 (4%) 644 221 (14%) 719 765 (8%) 43 583 (10%) 4 802 (2%) 6 715 590 (7%) 1 796 096 (8%) 8 511 686 (8%)
Total obligation 9 133 798 (91%) 83 707 (94%) 3 402 600 (88%) 2 363 715 (77%) 40 816 118 (79%) 6 556 237 (65%) 3 273 879 (71%) 5 334 311 (61%) 106 328 (25%) 127 228 (41%) 71 197 921 (76%) 14 122 037 (66%) 85 319 958 (75%)
Earmarking 40 850 (0%) 0 (0%) 0 (0%) 0 (0%) 628 010 (1%) 192 948 (1%) 461 913 (9%) 228 041 (4%) 39 000 (9%) 0 (0%) 1 590 762 (2%) 373 938 (3%) 1 964 700 (2%)
Total committed 9 174 648 (91%) 83 707 (94%) 3 402 600 (88%) 2 363 715 (77%) 41 444 128 (80%) 6 749 185 (66%) 3 735 792 (80%) 5 562 352 (65%) 145 328 (34%) 127 228 (41%) 72 788 683 (78%) 14 495 975 (69%) 87 284 658 (77%)
Uncommitted balance 878 050 (9%) 5 116 (6%) 448 242 (12%) 718 473 (23%) 10 442 526 (20%) 3 464 841 (34%) 912 396 (20%) 3 089 192 (35%) 287 244 (66%) 182 900 (59%) 20 428 980 (22%) 6 663 421 (31%) 27 092 401 (23%)
Bangladesh Bhutan DPR Korea East Timor India Indonesia Myanmar Nepal Sri Lanka Thailand Country total Intercountry SEAR
123 THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION
Annex 3
Budgetary Implementation of Activities – 2000-2001 By Major Programme (2-digit Level) REGULAR BUDGET (Including IX) ( As of 31 December 2001) (Expressed in US $)
Prog number 01.1 01.2 01.3 01.4 02.1 02.2 02.3 03.2 03.3 03.4 04.1 04.2 04.3 04.4 05.1 05.2 05.3 05.4 06.1 06.2 06.3 07.1 07.2 07.3 07.4 08.2 08.3 09.1 10.1 10.3
Prog code CSR CPC CEE CRD NCS NCP NCM CAH RHR WMH HSD NHD PHE EHA HPR DPR MNH SAB EDM VAB BCT GPE IMD RPC OSD RMB ECP BMR DGO DDP
Programme title
Allotted 1 143 638 6 587 584 679 944 88 486 339 262 4 311 073 711 842 2 518 683 4 733 823 336 768 2 023 625 802 332 4 514 201 574 193 2 323 858 1 857 433 815 665 203 734 3 359 370 2 298 220 1 696 488 1 103 395 293 576 2 049 133 11 640 615 230 115 2 464 201 10 743 244 589 428 000 60 384 589
Obligated
Total 1 143 638 6 587 584 679 944 88 486 339 262 4 311 073 711 842 2 518 683 4 733 823 336 768 2 023 625 802 332 4 514 201 574 193 2 323 858 1 857 433 815 665 203 734 3 359 370 2 298 220 1 696 488 1 103 395 293 576 2 049 133 11 640 615 230 115 2 464 201 10 743 244 589 428 000 60 384 589
% 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100
Communicable Disease Surveillance and Response Communicable Disease Prevention and Control Communicable Disease Eradication and Elimination Communicable Disease Research and Development (including TDR) Noncommunicable Disease Surveillance Noncommunicable Diseases Prevention Noncommunicable Diseases Management Child and Adolescent Health and Development Reproductive Health and Research Women’s Health Health in Sustainable Development Nutrition for Health and Development Protection of Human Environment Emergency and Humanitarian Action Health Promotion Disability/Injury Prevention and Rehabilitation Mental Health Substance Abuse Essential Drugs and Other Medicines Vaccines and Other Biologicals Blood Safety and Clinical Technology Evidence for Health Policy Health Information Management and Dissemination Research Policy and Cooperation Organization of Health Services Delivery Resource Mobilization External Cooperation and Partnerships Budget and Management Reform Director-General’s and Regional Director’s Offices Director-General’s and Regional Director’s Development Programme and Initiatives Total
124 THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION
EXTRABUDGETARY FUNDS (As of 31 December 2001) (Expressed in US $)
Prog Number 01.1 01.2 01.3 02.2 02.3 03.2 03.3 04.1 04.2 04.4 05.3 05.4 06.1 06.2 06.3 07.2 07.3 07.4 08.3 09.2
Prog Code CSR CPC CEE NCP NCM CAH RHR HSD NHD EHA MNH SAB EDM VAB BCT IMD RPC OSD ECP HRS
Programme Title
Allotted 633 409 14 110 738 7 285 759 10 500 3 705 2 220 360 3 584 419 18 505 31 070 9 202 382 74 973 105 700 417 393 74 491 088 250 000 133 455 28 572 128 318 1 615 638 31 075 114 377 059
Obligated
Total 495 826 7 276 312 3 796 029 0 3 705 1 916 110 2 232 299 15 443 31 070 6 895 054 26 971 67 288 318 033 60 765 717 10 170 600 376 125 509 1 312 371 31 075 85 319 958
% 78 52 52 0 100 86 62 83 100 75 36 64 76 82 4 0 1 98 81 100 75
Communicable Disease Surveillance and Response Communicable Disease Prevention and Control Communicable Disease Eradication and Elimination Non-communicable Disease Prevention Non-communicable Disease Management Child and Adolescent Health and Development Reproductive Health and Research Health in Sustainable Development Nutrition for Health and Development Emergency and Humanitarian Action Mental Health Substance Abuse Essential Drugs and Other Medicines Vaccines and Other Biologicals Blood Safety and Clinical Technology Health Information Management and Dissemination Research Policy and Cooperation Organization of Health Services Delivery External Cooperation and Partnerships Human Resources Services Total
125 THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION
Annex 4
Budgetary Implementation of Activities by Country – 2002-2003 REGULAR BUDGET (As of 30 June 2002) (Expressed in US $) $) (Expressed in US
Country
Allotted 5 303 800 1 178 800 2 077 400 9 679 100 4 190 900 802 700 4 191 000 4 091 900 2 381 300 3 058 700 36 955 600 5 610 400
Disbursement 403 783 (8%) 198 872 (17%) 24 538 (1%) 666 798 (7%) 538 749 (13%) 160 364 (20%) 248 766 (6%) 305 264 (7%) 345 156 (14%) 218 380 (7%) 3 110 670 (8%) 777 163 (14%) 3 887 833 (9%)
Unliquidated obligation 969 796 (18%) 248 717 (21%) 469 753 (23%) 1 929 372 (20%) 467 626 (11%) 134 042 (17%) 472 963 (11%) 852 371 (21%) 371 543 (16%) 675 832 (22%) 6 592 015 (18%) 707 909 (13%) 7 299 924 (17%)
Total obligation 1 373 579 (26%) 447 589 (38%) 494 291 (24%) 2 596 170 (27%) 1 006 375 (24%) 294 406 (37%) 721 729 (17%) 1 157 635 (28%) 716 699 (30%) 894 212 (29%) 9 702 685 (26%) 1 485 072 (27%) 11 187 757 (26%)
Earmarking 122 100 (2%) 16 050 (1%) 891 927 (43%) 86 150 (1%) 36 600 (1%) 56 008 (7%) 664 316 (16%) 49 940 (1%) 104 561 (4%) 196 100 (6%) 2 223 752 (6%) 834 175 (14%) 3 057 927 (7%)
Total committed 1 495 679 (28%) 463 639 (39%) 1 386 218 (67%) 2 682 320 (28%) 1 042 975 (25%) 350 414 (44%) 1 386 045 (33%) 1 207 575 (29%) 821 260 (34%) 1 090 312 (35%) 11 926 437 (32%) 2 319 247 (41%) 14 245 684 (33%)
Uncommitted balance 3 808 121 (72%) 715 161 (61%) 691 182 (33%) 6 996 780 (72%) 3 147 925 (75%) 452 286 (56%) 2 804 955 (67%) 2 884 325 (71%) 1 560 040 (66%) 1 968 388 (65%) 25 029 163 (68%) 3 291 153 (59%) 28 320 316 (67%)
Bangladesh Bhutan DPR Korea India Indonesia Maldives Myanmar Nepal Sri Lanka Thailand Country total Intercountry SEAR Total
42 566 000
126 THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION
EXTRABUDGETARY FUNDS As of 31 December 2001 (Expressed in US $)
Country
Allotted 3 931 402 5 116 2 062 356 718 472 30 052 911
Disbursement 554 067 (14%) (8 806) (-172%) 60 864 (3%) 192 409 (27%) 5 859 924 (20%) 2 343 172 (33%) 618 705 (21%) 956 419 (15%) 67 882 (16%) 102 355 (16%) 10 746 991 (20%) 1 002 407 (9%) 11 749 398 (18%)
Unliquidated obligation 783 289 (20%) 9 395 (184%) 587 146 (28%) 220 981 (31%) 10 023 960 (33%) 1 545 281 (21%) 749 824 (26%) 1 642 663 (27%) 82 656 (20%) 137 997 (21%) 15 783 192 (29%) 3 774 198 (34%) 19 557 390 (30%)
Total obligation 1 337 356 (34%) 589 (12%) 648 010 (31%) 413 390 (58%) 15 883 884 (53%) 3 888 453 (54%) 1 368 529 (47%) 2 599 082 (42%) 150 538 (36%) 240 352 (37%) 26 530 183 (49%) 4 776 605 (43%) 31 306 788 (48%)
Earmarking 63 947 (2%) 0 (0%) 0 (0%) 126 390 (18%) 925 313 (3%) 307 102 (4%) 418 (0%) 10 570 (0%) 0 (0%) 34 233 (5%) 1 467 973 (3%) 487 867 (4%) 1 955 840 (3%)
Total committed 1 401 303 (36%) 589 (12%) 648 010 (31%) 539 780 (76%) 16 809 197 (56%) 4 195 555 (58%) 1 368 947 (47%) 2 609 652 (42%) 150 538 (36%) 274 585 (42%) 27 998 156 (52%) 5 264 472 (47%) 33 262 628 (51%)
Uncommitted balance 2 530 099 (64%) 4 527 (88%) 1 414 346 (69%) 178 692 (24%) 13 243 714 (44%) 3 031 109 (42%) 1 512 296 (53%) 3 535 563 (58%) 266 494 (64%) 376 241 (58%) 26 093 081 (48%) 5 899 085 (53%) 31 992 166 (49%)
Bangladesh Bhutan DPR Korea East Timor India
Indonesia Myanmar Nepal Sri Lanka Thailand Country total Intercountry SEAR
7 226 664 2 881 243 6 145 215 417 032 650 826 54 091 237 11 163 557 65 254 794
127 THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION
Annex 5
Budgetary Implementation of Activities – 2002-2003, By Area of Work REGULAR BUDGET (As of 30 June 2002) Expressed in US$
AOW number 01.1 01.2 01.3 01.4 01.5 02.1 02.2 02.3 02.4 02.5 03.1 03.2 03.3 03.4 03.5 04.1 04.2 04.3 0.4.4 04.5 05.1 05.2 05.3 06.1 06.2 06.3 06.4 08.1 09.2
AOW code CSR CPC CRD MAL TUB NCD TOB HPR DPR MNH CAH RHR MPS WMH HIV HSD NUT PHE FOS EHA EDM IVD BCT GPE IMD RPC OSD BMR DDP
Area of work
Allotted 2 094 200 1 121 700 99 000 1 400 800 959 400 2 905 600 1 714 800 1 250 100 1 155 900 1 174 400 1 645 100 298 500 1 621 489 580 811 1 287 400 1 310 700 919 500 2 522 100 812 900 718 200 2 336 500 1 286 000 1 062 000 1 354 100 39 200 964 800 9 278 300 224 500 428 000 42 566 000
Committed
Total 933 879 554 540 352 577 114 353 428 1 012 247 540 681 368 571 531 518 283 582 688 041 46 513 355 038 202 290 378 741 460 924 159 800 606 436 303 749 315 834 745 002 355 182 390 058 399 450 25 446 356 111 3 020 855 68 760 211 542 14 245 684
% 45 49 0 41 37 35 32 29 46 24 42 16 22 35 29 35 17 24 37 44 32 28 37 29 65 37 33 31 49 33
Communicable Disease Surveillance Communicable Disease Prevention, Eradication and Control Research and Product Development for Communicable Diseases Malaria Tuberculosis Surveillance, Prevention and Management of Noncommunicable Diseases Tobacco Health Promotion Disability/Injury Prevention and Rehabilitation Mental Health and Substance Abuse Child and Adolescent Health Research and Programme Development in Reproductive Health Making Pregnancy Safer Women’s Health HIV/AIDS Sustainable Development Nutrition Health and Environment Food Safety Emergency Preparedness and Response Essential Medicines: Access, Quality and Rational Use Immunization and Vaccine Development Blood Safety and Clinical Technology Evidence for Health Policy Health Information Management and Dissemination Research Policy and Promotion Organization of Health Services Budget and Management Reform Director-General’s and Regional Director’s Development Programme and Initiatives Total
128 THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION
EXTRABUDGETARY FUNDS (As of 30 June 2002) Expressed in US$
AOW number 01.1 01.2 01.4 01.5 02.1 02.2 02.3 02.4 02.5 03.1 03.2 03.5 04.1 04.3 04.5 05.1 05.2 05.3 06.1 06.2 06.3 06.4 07.2
AOW code CSR CPC MAL TUB NCD TOB HPR DPR MNH CAH RHR HIV HSD PHE EHA EDM IVD BCT GPE IMD RPC OSD REC
Area of work Communicable Disease Surveillance Communicable Disease Prevention, Eradication and Control Malaria Tuberculosis Surveillance, Prevention and Management of Noncommunicable Diseases Tobacco Health Promotion Disability/Injury Prevention and Rehabilitation Mental Health & substance Abuse Child and Adolescent Health Research and Program Development in Reproductive Health HIV/AIDS Sustainable Development Health and Environment Emergency Preparedness and Response Essential Medicines : Access, Quality and Rational Use Immunization and Vaccine Development Blood Safety and Clinical Technology Evidence for Health Policy Health Information Management and Dissemination Research Policy and Promotion Organization of Health Services Resource Mobilization and External Cooperation and Partnerships Total
Allotted 1 027 482 6 080 182 1 579 187 9 766 971 81500 233 200 88 129 34 748 177 202 643 606 193 058 3 516 374 3 062 417 375 4 221801 239 321 35 905 999 239 830 98 690 132 855 238 196 32 759 303 267 65 254 794
Committed Total 243 353 2 395 080 751 993 5 127 443 9 376 87 200 10 139 3 998 42 991 487 262 45 188 604 496 352 17 940 2 146 569 124 408 20 711 467 107 547 28 261 101 435 13 021 13 862 189 247 33 262 628 % 24 39 48 52 12 37 12 12 24 76 23 17 11 5 51 52 58 45 29 76 5 42 62 51
129 THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION
Annex 6
Regular Budget Reserves 2000-2001 (As of 30 June 2002*) Expressed in US$
Country
Opening balance 1 514 788 304 490 489 530 31 432 3 327 433 1 194 476 166 358 386 266 1 313 958 338 572 965 315 10 032 618 2 656 674 12 689 292
Disbursed 910 707 (60%) 150 724 (50%) 427 072 (87%) 20 721 (66%) 1 311 230 (39%) 586 599 (49%) 101 763 (61%) 247 811 (64%) 662 324 (50%) 203 988 (60%) 401 309 (42%) 5 024 248 (50%) 1 438 798 (54%) 6 463 046 (51%)
Unliquidated 464 248 (31%) 148 392 (49%) 77 985 (16%) 2 810 (9%) 1 898 807 (57%) 704 383 (59%) 63 895 (38%) 129 956 (34%) 509 517 (39%) 103 347 (31%) 581 900 (60%) 4 685 240 (47%) 1 169 743 (44%) 5 854 983 (46%)
Total (Disb.+ULO) 1 374 955 (91%) 299 116 (99%) 505 057 (103%) 23 531 (75%) 3 210 037 (96%) 1 290 982 (108%) 165 658 (99%) 377 767 (98%) 1 171 841 (89%) 307 335 (91%) 983 209 (102%) 9 709 488 (97%) 2 608 541 (98%) 12 318 029 (97%)
Total surrendered 139 833 (9%) 5 374 (1%) (15 527) 3% 7 901 (25%) 117 396 (4%) (96 506) 8% 700 (1%) 8 499 (2%) 142 117 (11%) 31 237 (9%) (17 894) 2% 323 130 48 133 371 263
Bangladesh Bhutan DPR Korea East Timor India Indonesia Maldives Myanmar Nepal Sri Lanka Thailand Country Total ICP (including IX) SEARO
*Final Figures will be known after 31 December 2002
130 THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION