(WPR/RC36/SR/8)
SUMMARY RECORD OF THE EIGHTH MEETING WHO Conference Hall, Manila Thursday, 19 September 1985, at 2.30 p.m. CHAIRMAN: Dr Terepai Maoate (Cook Islands) CONTENTS
1.
International Drinking Water Supply and Sanitation Decade - Review of progress (continued)
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Mental health •••. _ ..••• · ·......................................
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Prevention and control of cardiovascular diseases ••••••••••••• Urban primary health care
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5.
"Towards future health and medical manpower: New strategies in education for the XXIst century" Report of the meeting held in Tokyo in April 1985 •••••••••••••
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1.
INTERNATIONAL DRINKING WATER SUPPLY AND SANITATION DECADE - REVIEW OF PROGRESS: Item 18 of the Agenda (Document WPR/RC36/13) (continued)
Dr VERMEULEN (Samoa) asked for information on the developments since the report by a WHO consultant on the feasibility of setting up a training centre in Fiji to train health inspectors for the South Pacific. The report had envisaged a full curriculum with the possibility of ct>ntinuing to a master's degree in environmental health, so that staff entering the field could be offered a proper career structure. Samoa would be very interested in joining such a venture. Mr TIXIER (Cook Islands) welcomed the Regional Director's report, which showed the . s ituation in different parts of the Region and out lined constraints, needs and future plans. Reporting on the water supply situation in his country, he noted that in Rarotonga, which was considered urban, present coverage was almost 100%. Projects were under way to improve quality and to treat water by chlorination on a trial basis. In the Southern Group of islands, coverage was 7 5% and should be close to 100% by 1986. In the Northern Group, covera~e was 70%. Rain water was the main source of supply. As to sanitation, coverage in Rarotonga, mostly linked to septic tanks, was 95%. The absence of a pub 1 ic sludge disposal area was a problem, and dumping at sea had been proposed. Coverage in the Southern Group was 90%; the conversion of dry pit latrines to at least pour-flush types should be completed by 1987. In the Northern Group, coverage was 80%. Close to 100% coverage with pour-flush toilets for each home was expected by 1987. Mr FUNIFAKA (Solomon Islands) said that WHO's support to his country's water supply and sanitation programme had begun some years after the programme's approval by the Government. Some 68% of people in rural areas were now served with potable water supplies. In sanitation, where implementation had lagged because of such factors as attitudes and customs, coverage was about 28%. He thanked the Australian and New Zealand Governments for providing funding. His own country's input included substantial c01111unity participation, together with about a third of the funding of each project. Problems were foreseen in the maintenance of installations. The Ministry of ·Health would welcome a survey to determine what impact the achievement of 68% coverage with safe water had had on health. His country had discussed the training of health inspectors with the Secretariat. It was planni.n g a two-year course at the Solomon Islands College of Higher Education, and would need information and support from WHO.
Dr WONG FAT (France) said that French Polynesia had given particular attention to drinking water supply and sanitation as part of the Decade activities. With regard to drinking water, the absence of mandatory quality standards prevented the health authorities from intervening effectively to ensure that water supplies were safe. In the higher islands, supplies were drawn from the rivers; that water was turbid in the rainy season but had a low level of mineralization and organic pollution.
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Because of the cost of drilling, and despite its high quality, groundwater was used only in the dry season or when the river water was extremely turbid. Supplies in the low-lying islands came from rain water, which could deteriorate rapidly if the storage tanks were not adequately maintained. Fresh water from underground lenses was being used, but required treatment and disinfecting. Such lenses were highly vulnerable to chemical and microbiological pollution. Two atolls in the Tuamotus had communal supplies from that source pumped by solar power and treated by slow sand filtration before distribution. For the future, the higher islands were developing the treatment of surface water in the dry season and the tapping of groundwater during rains. On the low-lying islands, rain water storage tanks were being improved and the use of freshwater lenses developed. Some US$3.75 million had been earmarked in 1985 for studies and operations, while a three-year programme costing US$6 million to install 1300 individual tanks on the inhabited islands of the Tuamotu-Gambier archipelago was being prepared. Sanitation was governed by outdated legislation, which covered only individual independent installations. As there was no collective communal sanitation, the number of independent systems was increasing substantially, and difficulties were being encountered in urban areas. Studies were in progress with a view to installing communal sewerage and finding sites for sea outlets. The problems were considerable, and WHO's cooperation was needed to ensure that they did not hold back progress in other fields. Dr BIUMAIWAI (Fiji) said that in his country the bulk of national resources were being used for the urban areas, while most external funding served to finance Decade act1.v1t1.es in the rural and underserved communities. In collaboration with WHO, a number of workshops for the training of community workers had been conducted and a further workshop was to be held in 1985 in line with the Government's grassroots approach and its determination to achieve 100% coverage by 1990. Some of the developed water sources had been seriously affected by the hurricanes of 1983 and, although most of them had been brought back to normal, the droughts that had followed had shown up the inadequacy of current facilities. There was a shortage of trained staff both for carrying out projects and for operation and maintenance activities~ An evaluation of hvman resources in water supply and sanitation was to be carried out in 1986. Appropriate technologies were being disseminated in the rural areas through the Divisional Public Health network and it was hoped in future to make greater use of the potentialities of the Fiji Institute of Technology in that respect. Funds for new rural water supply and sanitation projects were proving hard to come by and the reprogrammed WHO funds that had been made available were highly appreciated. In the next few years emphasis would be on the sanitation sector, which was lagging behind, and WHO collaboration would be needed for developing Fiji's national sanitation programme.
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In the following three years Fiji's Decade plans would continue to be focused on developing community projects based on the application of appropriate technologies, including modular water tanks with roof catchments, water-sealed prefabricated sanitation facilities and solar-powered pumps for isolated communities. Dr VOCCOR (Vanuatu) said that the increase from less than 50% coverage of the rural population with water supplies before Independence to the current 80% had shown the effectiveness of WHO collaboration. About 60% of the rural population had some form of pit latrine available but customary beliefs were proving an obstacle to the Ministry of Health's plan for a substantial increase in coverage. Dr WELCH (Australia) said that experience in the drinking water and sanitation projects in which Auatralia was involved, both in the Region and elsewhere, had shown that the provision of human resources was of paramount importance. Trained manpower was becoming increasingly scarce as progress was made towards Decade goals. Inadequate finance was obviously a further constraint. WHO's efforts to promote a better supply of trained manpower in the Region seemed the most effective way of ensur1ng the further development of Decade activities. Dr CATI (Kiribati) said that the failure of 66% of the hand-pump installations mentioned on page 7 of document WPR/RC36/13 had occurred in Kiribati. Efforts were now being made to retrieve the situation and a maintenance system had been devised under which pumps could be properly maintained by village welfare groups. A total of 300 pumps had already been installed, providing 30% coverage, which would be brought up to 45% by the planned installation of a further 120 pumps. Dr SIALIS (Papua New Guinea) said that his country had had the benefit of WHO technical cooperation and financial and technical support from the Asian Development Bank and other organizations. The Government had committed funds to cover Decade activities in the period 1984-1988. In view of the financial constraints, much more emphasis was to be placed on community involvement. Dr CARTIER (Regional Adviser in Environmental Health), in reply to a question by the representative of New Zealand concerning proposed training activities in the Region, said that their main efforts were being directed to the training of appropriate manpower through the training of trainers, who passed on to others the theoretical knowledge and practical skills they had acquired. It was hoped 1n that way to alleviate many of the operational and maintenance problems mentioned in the Committee's discussions. A considerable number of tra1n1ng and other programmes concerned with Decade activities were planned. .Regarding the comments of the representative of France, the Secretariat was well aware of the importance of ground-water location, the exploration of new underground lenses and the prevention of brackish-water intrusion. Dr CHRISTMAS (New Zealand) hoped that the resolution would reflect their appreciation and strong support of the Programme, with particular emphasis on staffing and training.
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Dr KHALID (Malaysia) was pleased to note that the Regional Centre for the Promotion of Environmental Planning and Applied Studies in Malaysia had diversified its activities and was providing training programmes for essential staff. He thought that these activities should be intensified and that trainees should be invited from other countries in the Region. In the absence of further comments, the CHAIRMAN requested the Rapporteurs to prepare a suitable draft resolution. (For considerat,ion of the draft resolution, see the ninth meeting, section 2.1). 2. MENTAL HEALTH: Item 19 of the Agenda (Document WPR/RC36/14) the and the of and
The REGIONAL DIRECTOR said that, during the previous two years, regional mental health programme had been significantly broadened reoriented. It included three sub-programmes: psychosocial factors in promotion of health and human development; prevention and control alcohol and drug abuse; and prevention and treatment of mental neurological disorders.
Document WPR/RC36/14 reviewed the situation 1n the Region and described some of the achievements of the regional mental health programme in recent years. Section 4 of the document defined future directions for WHO activities in the field of mental health and neurosciences as proposed by the second meeting of the Regional Coordinating Group on the Mental Health Programme. Dr PHAM SONG (Viet Nam) said that his country was making great efforts to rehabilitate drug addicts. A special centre had been set up in Ho Chi Minh City; it provided vocational tra1.n1.ng, particularly in handicrafts, and had facilities for sports and other leisure activities. Acupuncture was used to alleviate withdrawal symptoms. Many drug addicts, who were kept under constant monitoring and control, had thus been enabled to return to a normal productive life. Dr HASEGAWA (Japan) said that one neuropsychiatric problems was the increasing as the proportion of elderly people in the would be very grateful for intensified WHO problem. of his country's greatest incidence of senile dementia population increased. They programme activity on that
Dr CHRISTMAS (New Zealand) also felt that more attention should be paid to the problema of senile dementia. Child mental health programmes should also be intensified. The plight of the mentally handicapped and the need to develop services for them should also be recognized. Dr ZHANG LI (China) said that an epidemiological survey on mental he a 1 th in China had shown an incidence ranging from 3. 57 to 11.8 per 1000 in different areas. There was a total of six million patients. Various measures were being taken to strengthen the prevention, diagnosis and treatment of mental disorders and to integrate mental health control programmes into the primary health care services. Priority was being given to the establishment of mental health establishments at the grassroots level (community mental health services). T)le integration of a mental health component into the general maternal and child health services, as advocated by WHO, was having good results and much attention was being paid
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to child mental health. Eight workshops and a seminar had been organized. With changes 1n the population structure, it was expected that the incidence of mental disorders would increase. China was eager to collaborate with WHO and its Member States in the Region with a view to facilitating the solution of common problems. Dr DURAYAPPAH (Brunei Darussalam) said her delegation considered that mental health problems were not of much significance in Brunei Darussalam, but it foresaw that psychosocial problema might become of some concern in the future, especially among young people. A drug training survey was currently being carried out in schools. Mental health services were hospital-based, but rehabilitative services in home surroundings were being developed within the co111111unity. The Government also took responsibility for the care and rehabilitation of the mentally handicapped, particularly of the younger age group. The Ministry of Education and Health and the Ministry of Sports, Youth and Welfare worked in close collaboration to provide those services. Dr KHOO (United Kingdom of Great Britain and Northern Ireland) said that the steep rise in the population of Hong Kong over the last two decades, the rapid sociocultural changes and increased affluence, resulting in increased stress, together with an aging population, were associated with a rising trend in psychosomatic and mental disturbances. Chronic schizophrenia accounted for 70% of the inpatient population of psychiatric hospitals; the remainder of that population consisted of senile and presenile organic psychotic conditions, unspecified mental retardation, affective psychosis, and paranoid states. Hong Kong subscribed to the modern trend in mental health care whereby a distinction was made between primary care (prophylaxis), secondary care (treatment) and tertiary care (rehabilitation), and planning and provision of services were based on that approach. It was accepted that there were certain essential needs common to the whole spectrum of mentally ill patients, and those needs formed the basis of mental health provision 1n Hong Kong. Services ranged from institutional care. outpatient clinics and day hospitals to community accommodation and domiciliary services such as lorag-term care homes and half-way houses, and various support services such as sheltered workshop and social clubl to maintain and rehabilitate patients in the community. Increasing emphasis was also being placed on the development of community mental health programmes with community involvement and participation. He therefore fully supported the priority areas for WHO proposed by the Regional Coordinating Group on the Mental Health and urged that countries should give serious consideration adequate measures to deal with the public health problems posed illness in the Region. activities Programme, to taking by mental
Mr DEL ROSARIO (United States of America) commended the Regional Director for an excellent report. There was in Guam a very high incidence of amyotrophic lateral sclerosis (ALS) and Parkinsonism-type dementia (PD). He did not know whether in other countries of the Region the number of cases approached that of Guam, and he would like the Committee to give
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some at tent ion to the problem. Recent research seemed to point to the presence of trace elements, especially aluminum, in the water and soil of southern Guam. The question had been under investigation for some time by the National Institute of Neurological Diseases and Stroke in Washington, D.C. Recently, a Canadian team of investigators had visited Guam with the aim of finding a solution to the problems of Alzheimer's disease, and had concluded that investigation of the ALS and PD problem might help in the search for that solution. Dr SUNG WOO LEE (Republic of Korea) also praised the quality of the report, and said his delegation was satisfied with the action taken on the resolutions, as set out in section 3. The Republic of Korea was looking forward to attending the mental health workshop in Singapore, and also the national workshop on mental health policy, to be held in Seoul in November 1985. Mr TIXIER (Cook Is lands) also expressed appreciation of the report. He was interested to note the developments in the regional situation, and the priorities listed under section 4. In particular, Cook Islands found priority (3) (development of programmes in specific mental health/neuroscien.ces areas of public health importance) relevant to its needs. Mental health had not been a problem until some ten years ago, but recently the situation had changed, which was perhaps not unexpected in a constantly evolving small population, since economic change was probably the main factor needed for mental illness to become of significance in morbidity. Alcohol consumption, which was also a problem in Cook Islands, also contributed, directly or indirectly, to mental ill-health. Health services development had to be redirected to meet that need. Although certain measures had been taken, Cook Islands now intended to take a more long-term approach, with the intention of formulating programmes in the area of preventive services. Dr SHINFUKU (Regional Adviser in Mental Health) thanked members for their encouraging comments, which would be used as a basis for the further development of the programme with respect to mental, neurological and psychosocial problems in the Region. He was particularly grateful for the appreciation expressed of WHO's collaboration in the field of mental health and the neurosciences. He also expressed gratitude for the endorsement by the representatives of Cook Islands and the United Kingdom of the priorities set out in the report. He welcomed the comments made by the representatives of China, Japan and New Zealand on the development of programmes for senile dementia and child mental health. It was true that the plight of patients in those categories had often been neglected. On the point raised by the United States regarding mental illnesses prevalent in Guam. similar disorders were thought to exist in parts of Japan. The relationship between Parkinsonism and types of senile dementia should be further explored, since at the moment there was no scientific basis for assuming such a relationship.
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In the absence of further coments, the CHAIRMAN asked the Rapporteurs to prepare an appropriate draft resolution. (For consideration of the draft resolution, see the ninth meeting, section 2.2).
3.
PREVENTION AND CONTROL .OF CARDIOVASCULAR DISEASES: Agenda (Document WPR/RC36/15)
Item 20 of the
The REGIONAL DIRECTOR recalled that, during its thirty-fourth session, the Regional Committee had adopted a resolution on the prevention and control of cardiovascular diseases. The subject had also been extensively discussed during the review of ~he report of the Sub-Committee on Technical Cooperation among Developing Countries, when it was suggested that cardiovascular disease control would be an appropriate subject for the Technical Discussions. It had therefore been put forward as one of the proposed topics for discussion in 1985. However, as this did not materialize, it had been proposed that the subject of cardiovascular disease control should be included as an item on the agenda of the thirty-sixth session of the Regional Committee. Cardiovascular diseases were a very serious public health problem not only in developed countries but also in many developing countries of the Region. According to available information, the most important of the cardiovascular diseases in the Region were hypertension and stroke, ischaemic heart disease etc. However, with the progress of research on the etiology of the diseases, substantial knowledge had now become available for the initiation of preventive measures. Activities had recently been intensified in that prograDDDe area, particularly with regard to epidemiological surveys in China and the South Pacific countries, which had been carried out with WHO collaboration. Although it was regretted that no reference was made 1.n the document, rheumatic fever/rheumatic heart disease problems existed in French Polynesia and New Caledonia and collaboration had been extended to French Polynesia in 1985 in setting up a control centre. The Regional Director said that he firmly believed that it was time to strengthen regional cardiovascular disease control activities. Dr DE SOUZA (Australia), welcoming the Regional Director's report, said it was recognized that in many countries in the Region the major public health priorities must continue to be in the area of communicable disease control and prevention. At the same time, the report clearly indicated that, in many developing countries, morbidity and mortality from cardiovascular diseases were rapidly increasing. He noted that in Samoa and Tonga such diseases now represented the most commonly certified causes of death and were already a major public health problem, and that hospital deaths from cancer and cardiovascular diseases in Tonga had increased more than fivefold in 25 years. The report outlined the main constraints in the development of the regional and national cardiovascular disease control programmes and also the need for manpower training and development, and public education and prevention through lifestyle modification.
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On page 5 of the report. three proposals for action were recommended for consideration by Member States. No one imagined that the task would be easy. Apart from the lack of resources, the promotion of cardiovascular health did not rest with governments alone, but strong government support was necessary for any such social issue programme to gain momentum. There were a number of constraints. The attainment of cardiovascular health necessarily involved prevention, and prevention involved social engineering and legislation as well as education. Governments to some extent reflected community values. People valued health but were much more prepared to pay for cure. Some people resisted intrusion into their lifestyles. Governments could use that attitude to justify inaction and they were under constant pressure from vested interests not to focus on health measures that might have an impact on the sales of their products and on their profitability. It was encouraging to note that WHO was approaching the problem in a positive manner despite all those constraints. Dr KOINUMA (Japan) said that in his country there had been a significant increase in cardiovascular diseases and a marked decrease in communicable diseases such as tuberculosis. The three main causes of death in Japan were cancer, cardiovascular diseases and heart diseases. A characteristic of cardiovascular diseases was their chronicity and there was a strong link between those diseases and the accumulating effects of daily habits. With a view to preventing the so-called degenerative diseases, including cardiovascular diseases, comprehensive measures had been initiated in February 1983 in line with the Act on Health and Medical Services for the Aged, in which preventive activities other than medical care were stressed. The activities consisted of the issue of health notebooks to all inhabitants over 40 years old, health education, health consultation, check-up of the circulatory organa, rehabilitation training in the community and visiting guidance for bedridden elderly patients. Those services were mainly operated by municipalities but their costs were shared equally by the central Government, prefectural governments and municipalities. Those undergoing check-up of the circulatory organs in 1983 represented 20.2% of total residents. The Ministry of Health and Social Welfare was endeavouring to raise the proportion to 50% and to intensify periodical medical check-ups and visiting guidance. His delegation hoped that WHO would be able to strengthen the cardiovascular diseases programme still further though it realized that it took time to obtain good results. Dr FOLIAKI (Tonga) said that the representative of Australia had rightly mentioned that cardiovascular diseases constituted a public health problem for Tonga. It could be seen from the report that deaths from such diseases had increased some five- or sixfold during the past twenty-five years and were now the second most common cause of hospitalization of both males and females over 40 years of age. In 1973, Tonga had undertaken a project on cardiovascular diseases, in conjunction with WHO, which had been aimed at conducting surveys on the incidence of such diseases with a v1ew to setting up screening and surveillance programmes.
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Early in 1985, a workshop on noncommunicable diseases had been organized with the primary aim of developing an integrated programme on the subject, the emphasis being on cardiovascular diseases, hypertension, rheumatic fever and rheumatic heart diseases, in association with the diabetes control programme. His country appreciated the support received from WHO in establishing the surveillance programme and welcomed Tonga's inclusion in the fifteen Member States involved in the intensified programme on rheumatic fever and rhematic heart disease. It had noted with interest the efforts WHO had put into the control of cardiovascular diseases and it strongly supported the various action programmes and proposals outlined on page 5 of the report. Dr DURAYAPPAH (Brunei Darussalam) said that mortality and morbidity caused by cardiovascular diseases in her country were a matter of serious public health concern, particularly in view of their increase in recent years, though the incidence of rheumatic fever was not significant. Cardiovascular diseases ranked highest among the causes of death in the country. Of 768 deaths reported in 1984, 105 had been due to cardiovascular diseases. The country also had a high percentage of deaths recorded under the WHO classification of ill-defined conditions, some of which might well be due to cardiovascular diseases. The incidence of hypertension in the country was also increasing, probably due to changing life-styles and food habits, though one of the reasons for the apparent increase was thought to be the better utilization of health services due to the increased concern of the population for their health. Promotion of the prevention of the conditions concerned would be one of her country's priorities in planning its health promotion activities in 1986, when it hoped to screen the at-risk population for hypertension, carry out local area monitoring in two districts and intensify health education and the involvement of the people in all promotion activities. Her country would appreciate WHO cooperation in those areas. Dr CHRISTMAS (New Zealand) said that his country was conscious of the need to establish an effective programme for the prevention of cardiovascular disease and his Department hoped to launch such a programme in the coming year. In preparation for doing so, it proposed to establish a small expert committee, which would examine in terms of local application the recommendations in the technical report of the WHO Expert Committee (Technical Report Series No. 678, 1982). Two workshops on rheumatic fever control had been conducted at which the criteria for identification and notification of the disease, regimes for surveillance and long-term secondary prophylaxis and the setting up of rheumatic fever registers on a national basis had been studied. A number of studies on hypertension, sponsored by the Medical Research Council, had been undertaken and it was hoped to review them and to develop a long-term lifestyle prograliDlle. His delegation recognized cardiovascular diseases as an important problem and fully supported the recommendations made in the report of the Regional Director. Hr TIXIER (Cook Islands), noting that the representative of Australia had highlighted the points made in the Regional Director's report, said that Cook Islands would like to conclude that promotion and encouragement of the action proposed in that report would be carried out in such a manner as to maintain the link with his country, where prevention prograliDlles had
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been in operation for some time in the field of health education in order to create awareness of the need for weight control through diet and physical exercise. His country had achieved some results in controlling the disorder but there was still room for further development and it would welcome active programmes by WHO on the subject. Dr BIUMAIWAI (Fiji) said that, from being a relatively rare disease thirty years earlier, cardiovascular diseases, diabetes mellitus and other noncommunicable diseases had now become the major health problems in Fiji. Several clinical and cOIIIDunity-based studies carried out during the past two decades, including the major national cardiovascular diseases and diabetes survey carried out 1n 1980, showed that those diseases were reaching almost epidemic proportions. Prevalence and incidence were high and morbidity and mortality excessive and the diseases were putting an undue strain on the country's health care resources. Following the 1980 cardiovascular diseases and diabetes survey, several discussions had been held between the Ministry of Health, WHO consultants and the South Pacific Commission regarding the prospect of planning and obtaining funding for an intervention programme by establishing a national noncommunicable diseases centre in order to control the rapidly increasing trends in the diseases concerned. Diabetes and cardiovascular disease problems 1n the developing countries had already reached large proportions, which might become gigantic unless timely action was initiated. The establishment of special centres in developing countries to promote and in,tegrate care, learning and research 1n cardiovascular diseases and diabetes was desirable. Following seminars for health care professionals on diabetes mellitus and cardiovascular diseases held in the three main hospitals in Fiji in 1983, a proposal to establish a centre had been accepted by the Ministry of Health and the National Centre for Noncommunicable Diseases had been opened 1n Suva in September 1984. Dr CATI (Kiribati) said that cardiovascular diseases were not considered a problem in his country, possibly because of existing life-styles. It was nevertheless comforting to know that, because of the seriousness of the condition in other countries, guidelines existed in section 4 of the Regional Director's report (Action proposed) which would help Kiribati to monitor its people at intervals with a view to preventing a serious situation from arising. Dr VOCCOR (Vanuatu) said that, while acknowledging that noncommunicable diseases were not yet a major health problem, his Government was concerned to have up-to-date information on the current extent of some of those diseases. A survey had recently been carried out by WHO in three main areas (rural, semi-rural and urban) and little difference had been observed among them. Life-styles were likely to change in the future. He welcomed the forthcoming establishment of a committee to work in the field concerned and would be happy to assist in its work.
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Dr DEL ROSARIO (United States of America) said that his Government continued to have a strong interest in cooperative results concerning cardiovascular diseases in the Region. There was a need to improve the accuracy of morbidity and mortality data in several countries. By doing so, it might be possible to standardize the available data by age, sex, ethnic group, etc. so that the real trends could be examined. It was suggested that registers might be developed for myocardial infarction and stroke. Where there were gaps in existing information it might be possible to fill them in with available data.
The continuing need to encourage the development of programmes 1n cardiovascular disease research was of prime importance. Since 1934, the Trust Territories of the Pacific Islands had been involved in surveys that had included risk factors in cardiovascular diseases. The ability accurately to assess those surveys in order better to understand and combat the risk factors had been greatly hampered by the lack of standardized measurement techniques and the need for capably trained public health specialists in that area. In order to strengthen regional capability and to carry out the research objectives of some of the institutes of the National Institutes of Health in the United States, the institutes might offer consultants to the Region to develop research on cross-sectional studies and to train public health specialists from the Region in such activities as lipid measurements. They would also be willing to provide available training materials. There might also be a follow-up of the 1982 national heart-lung workshops in the Region and a development of research studies in areas of mutual interest such as diet and coronary risk changes. Dr TERAO (Regional Adviser in Noncommunicable Diseases) thanked the representatives for their views, which would be reflected 1n future activ1.t1es. He welcomed the request from the representative of Brunei Darussalam and would be communicating with her Government with a view to initiating collaboration. He was pleased to hear from the representative of the United States of America that the agencies of the National Institutes of Health, incl~ding the National Heart, Lung and Blood Institute, were ready to collaborate with WHO 10 the field of noncommunicable diseases. He thanked the Governments of Australia and Japan for their generous financial contributions to the WHO programme. The Japanese Shipbuilding Industry Foundation had also given valuable financial support. According to the available information, the most important cardiovascular disease in the Region was hypertension/stroke, followed by coronary heart disease, rheumatic fever and rheumatic heart disease. The most practical approach to the last two was by secondary prevention. Primary prevention was possibe for hypertension/a troke and coronary heart disease. He reiterated the importance of public education, including that for schoolchildren, on changing life-styles. He drew attention to the importance of evaluating traditional food habits in developing countries. Recent research had shown that blue fish such as tuna, sardine and mackerel contained a fat, eicosapentaenoic acid, which helped to prevent thrombosis in human blood vessels. In line with resolution WHAJ8.30, Tonga, in collaboration with WHO, had introduced an integrated approach to cardiovascular disease and diabetes mellitus in its noncommunicable disease programme. He was pleased
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to announce that a regional seminar on the epidemiology and community control of cardiovascular diseases, including diabetes mellitus was planned for the South Pacific in 1987. He recalled that the 1980 prograiiiDe "Smoking or health - the choice is yours" had been popular. In an effort to strengthen anti-smoking activities, the Regional Office had proposed to Headquarters that a global meeting be held. A meeting of operational officers had been held in April 1985, as a result of which efforts were being made to promote national programmes, focusing on education and information dissemination to the public, legislation, and operational research. The challenge to develop successful programmes was difficult, but worthwhile. Some excellent ongoing activities were being undertaken by governments in Guam, Hong Kong, Malaysia, and Singapore. The first regional meeting on smoking and health would be held 1n conjuction with the Sixth International Conference on Smoking and Health 1n Japan in 1987. The CHAIRMAN requested the Rapporteurs to prepare an appropriate draft resolution taking account of the views expressed. (For consideration of the draft resolution, see the ninth meeting, section 2.3). 4. URBAN PRIMARY HEALTH CARE: (Document WPR/RCJ6/16) Item 21 of the Agenda
The REGIONAL DIRECTOR recalled that, at the Regional Conference on Primary Health Care in Manila in 1977, the attention of the participants had been drawn to the need to introduce primary health care not only in rural areas but in urban areas as well. The same message had been conveyed in the very first recommendation of the International Conference on Primary Health Care, held in Alma-Ata in 1978. The Regional Office for the Western Pacific had conducted a regional seminar in Manila in 1981 for the promotion of urban primary health care. While that promotion effort had had some impact, he believed that much more needed to be done. The urbanization trend was still at a high level. Urbanization had quite often proceeded in an uncontrolled manner, resulting in a deterioration of the health status and social problems. It was important, therefore, that Member States should be able to fully meet the challenge with well-formulated programmes. He believed that the principles of primary health care were equally applicable to both urban and rural areas in spite of the differences in conditions. He cited as an example the promotion of colllllunity involvement in health activities, which was essential in any setting. However, greater efforts and perhaps different approaches might have to be employed in the urban areas compared with the rural areas because of the different attitudes and ways of life of the population. The same applied to intersectoral coordination where one might have to work with a larger number of agencies in the urban centres than in the rural areas. In spite of that, coordination still needed to be promoted. Certain health technologies could also be more readily acceptable to the rural population than the urban population and vice versa, yet the fact remained that appropriate technology must be promoted in both areas.
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Dr DEL ROSARIO (United States of America) thanked the Regional Director for his excellent report. He drew attention to a further docuQlent entitled "Primary health care in urban areas: reaching the urban poor of the developing countries" (document JC/25/UNICEF/WH0/85.5), which had been presented to the UNICEF/WHO Joint Committee on Health Policy in January 1985. Many of the findings of the report and the recommendations of the Joint Committee were relevant to the debate and might be of interest to representatives. Dr DURAYAPPAH (Brunei Darussalam) thanked the Regiona 1 Director for his report. The subject was of relevance to her country as some 60% of the population lived in or around the capital city. Owing to the pace of socioeconomic development and urban migration from both within and outside the country, there was a need to strengthen existing preventive and promotional health activities, and to intensify intersectoral activities and community involvement. She requested WHO's support in developing appropriate technology for those activities. Dr ZHANG LI (China) said that, since 80% of China's population lived 1.n rural areas, the People's Republic had always stressed the development of rural health services. Great importance was also attached to the development of urban primary health care, which served some 200 million people. A number of urban grassroots organizations had been set up, forming a network of urban health care, with the aim of providing urban health care for every neighbourhood. China's cities were divided into districts, sub-districts and residents committees, and the urban health care network was based on that structure. In addition, enterprising colleges, universities and large factories had their own hospitals, health stations and clinics, which were part of the network. Each sub-district had a hospital providing outpatient care, and more than half of them also had hospital beds. Such hospitals treated 30% of urban outpatients and also undertook some emergency treatment, preventive work, maternal and child health care, and family planning. Recently, a new way of hospitalization had been introduced, each sub-dis tr ic t hospital managing 80-120 family beds. Since 1980, private practice had been permitted by the Central Committee, and there were currently some 8000 private practitioners helping to meet the deficiencies of primary health care. In order to develop urban primary health care, it would be necessary to set up and consolidate a network of prevention and health care centres, strengthening coordination with the various departments concerned. Propaganda was equally important to make people use health resources and participate in the development of primary health care. In 1986, in cooperation with WHO , a district 1.n Shanghai had been selected as a model for urban primary health care development. The experiences in the project would be disseminated in order to assist others. Rural primary health care had been extensively discussed at previous sessions of the Regional Committee and it was therefore most timely to discuss urban primary health care. The Philippines and several other countries had undertaken valuable work in the field and he would be interested to learn of their experiences.
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Dr KHALID (Malaysia) thanked the Regional Director for his informative report. The report stated that the private health sector operated as a completely separate section of health care in most countries - although it consumed considerable resources, it served only a minority of the population - and there was thus a need to integrate that section in the total health care system. In most urban populations, facilities for the private sector formed a considerable proportion of the health services provided. However, those facilities were only available to those able to pay. Integration of the public and private health sectors, especially for primary health care, was worthy of study. In Malaysia, one third of the doctors were centred in or around Kuala Lumpur, with access only to those who could pay. Further, their activities were largely restricted to diagnosis and treatment. Even emergency cases were taken with reluctance owing to the need for follow-up and the possible implications of taking on such cases. He hoped WHO would look at systems where the private and public health sectors had been integrated, particularly as regards primary health care, as he would be interested to know how it could be done. Malaysia's own experience was limited and little information was available 1n the literature. If there was insufficient existing experience, it might be worth considering the possibility of pilot projects. In Malaysia, the health care financing study had shown a complete separation of public and private health care in many sectors. It was an important matter in view of the serious problems of the urban poor. Dr BAYAN (Philippines) said that her Ministry of Health had been instrumental in initiating collaboration between WHO and the city of Manila concerning the introduction of urban primary health care in Metropolitan Manila. A conference had been held with the participation of most of the Philippines' 61 city health officers. Nationwide workshops had also been held with the aim of translating national primary health care policies into the development and implementation of urban primary health care. The workshops had stimulated the active involvement of the city health officers. A reorganization within the Ministry of Health, which had placed city health officers and their assistants under an integrated provincial health office, had facilitated the development of urban primary health care. She would provide the representative of China with report on the workshop on urban primary health care. a
copy
of
the
Dr SIAL IS (Papua New Guinea) commended the Regiona 1 Director for his informative report. Papua New Guinea was experiencing increasing urban migration, with semi-urban and squatter settlements. The latter, with limited health services, were naturally experiencing more health problems. Although Papua New Guinea was developing rural primary health care, it lacked experience in urban primary health care. His Government would therefore be asking the Regional Office for help in that area. Papua New Guinea was also looking at the possibility of encouraging large private organizations to institute their own primary health care services. Mr TIXIER (Cook Islands) thanked the Regional Director for his report. Cook Islands was experiencing inward migration and would need some Primary health care in the urban community was provided by the help.
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Government, with a limited impact from the private sector. Urban child welfare clinics were built by commun1t1es with government assistance, through the Ministry of Health, with materials and personnel. Although the situation in Cook Islands was slightly different from elsewhere, he would view any planned programme with interest. Care) Dr NUGROHO (Medical Officer, Primary Health thanked representatives for their views. WHO would · be happy to collaborate 1n urban primary health care in Brunei Darussalam and Papua New Guinea. In reply to the representative of Malaysia, he said that he knew of one publication concerning the integration of the private health sector with some form of community health insurance scheme in Seattle, United States of America, which had some 2 7 3 000 members. The scheme was unique in that it was run by the members who determined the premiums and decided which facilities would be developed. He would be happy to make copies of the publication available. The CHAIRMAN requested the Rapporteurs to prepare an appropriate draft resolution taking account of the points raised during the discussion. (For consideration of the draft resolution, see the ninth meeting, section 2.4). 5. "TOWARDS FUTURE HEALTH AND MEDICAL MANPOWER: NEW STRATEGIES IN EDUCATION FOR THE XXIST CENTURY" - REPORT OF THE MEETING HELD IN TOKYO IN APRIL 1985: Item 22 of the Agenda (Document WPR/RC36/17)
The REGIONAL DIRECTOR said that the document now before the Committee described the very significant conference which had been convened in Tokyo in April 1985 to review the fundamental question of the relevance of health manpower to the present and future health needs of society. There had been an impressive gathering of more than sixty participants, including policy makers, scholars, health administrators, educationists, parliamentarians, and others, at that historic meeting. The Conference had recognized that, if the health services were to be reoriented towards primary health care based on changing community needs, an adequate number of suitably qualified health manpower would be needed, and that the planning, training and utilization of such manpower would in turn require fundamental changes. The Conference had reviewed those factors which influenced the introduction and implementation of changes in health manpower development. As not only technical, but also political, social, cultural, financial and administrative factors were involved, it had been strongly felt that a reorientation of health manpower in the direction of primary health care called for innovative work with mul tisectora l dimensions. Training institutions in particular would have to carefully review their mission in order to anticipate and respond to rapidly changing life styles and socioeconomic conditions. Other institutions and bodies which had an impact on the training and utilization of health manpower must also critically examine their roles in that regard. One of the important outc6mes of the Conference had been the Declaration of Tokyo, which expressed deep concern about the future health manpower and urged immediate action by institutions and persons concerned
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with health manpower development. The Conference had also adopted a series of recommendations directed at governments, training institutions and WHO. One of the important recommendations referred to the constitution of regional task forces to advise on and promote the implementation of strategies to introduce changes in accordance with the Declaration of Tokyo. The Committee would wish to study and, he hoped, endorse and follow up the recommendations of the Tokyo Conference as well as the Declaration of Tokyo. Dr FURUICHI (Japan) said that the Tokyo Conference had been a most timely and historic meeting. The Western Pacific Region was the first of WHO's six regions to focus attention on the special efforts needed 1n reorienting health manpower development since the Declaration of Alma-Ata. The Conference was a first step and he thanked the Regional Director for the endeavour he had initiated and developed. He looked forward to the future activities of the Regional Office in health manpower development in the light of the primary health care concept. He requested the Regional Director to gather information concerning the current education situation in Member States, and to evaluate and follow up the Tokyo Conference, which, he hoped, would lead to the development of new manpower strategies in the Region. Dr LIU XIRONG (China) said that he had read the report with great interest. The Tokyo Conference was a very important meeting at which all aspects of health manpower development had been discussed. Its recommendations were excellent. He commended the Regional Director and the sixty participants who had contributed to the success of the meeting. China was actively improving its health services, and Chinese health workers were seriously implementing national strategies for health for all by the year 2000. There was still much to do. of which manpower development - the training of large numbers of personnel for future health work - was perhaps the most important. With high-quality personnel, the work would be advanced and the difficulties gradually overcome. China stressed the importance of primary health care to all its medical students to make them willing to engage in primary health care work after graduation. His Government and the medical colleges were studying the recommendations of the Tokyo Conference and were implementing them in the light of China's needs. He hoped the Regional Director would continue to organize seminars on In collaboration with WHO, China planned to sponsor manpower training. similar seminars in China. Dr DE SOUZA (Australia) said that the Declaration of Tokyo was an affirmation of the priorities of primary health care and the commitment of countries to support it. His own country was committed to primary health care as a principal vehicle for health care and was acting accordingly. Current activities related to primary health care in Australia included: a policy document entitled "Advancing Australia's health", which focused attention on needs for community and preventive care as priorities 1n the future development of hea 1 th services; a proposal for a major
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review and reorientation of medical education starting in 1986; a recent ANZSERCH meeting at which high-level representatives of the Department of Health and academics had discussed the major issues of primary health care; support for academic development in community medicine; and a study of the possible establishment of a college of general practice. Among activities to assist in the development of primary health care elsewhere in the Region, he referred to the link between Queensland University and Shanghai Medical School; the Asian and Pacific Centre for Clinical Epidemiology in Newcastle for the tra1n1ng of graduates for South-East Asia; and a number of other manpower development and planning programmes. Australia was increasingly involved in the manpower development of neighbouring countries through the WHO fellowship programme. In addition, negotiations were under way with a view to expanding the role of the Regional Teacher Training Centre for Health Personnel of the University of New South Wales. Dr CAT! {Kiribati) commended the Declaration of Tokyo and the recommendations, which identified appropriate structures for the training of staff for primary health care progranunes. Kiribati was able to train personnel at basic level, but still needed other countries' help for other aspects of tra1n1ng. With WHO's cooperation, it was participating 1n training programmes in Australia and Malaysia. Dr FOLIAKI (Tonga) said that the Tokyo meeting had been far-reaching in its proposals for the reorientation of health manpower development for the implementation of primary health care programmes. He endorsed the Declaration and recommendations, and proposed that the Committee adopt a resolution on the subject. Dr KHALID (Malaysia), congratulating WHO on its initiative in holding the Conference, said that, if the Declaration of Alma-Ata provided the framework, the Declaration of Tokyo provided vital input for its realization, sounding a clarion call for the reorientation of health manpower to achieve health for all. In addition to the quality and effectiveness of health manpower, atcount must also be taken of the cost. He pointed also to the long time span needed to train staff in new ways; if the wrong type of manpower was produced, much time was wasted. He agreed that a suitable resolution should be adopted, and suggested that the Declaration and the recommendations should be transmitted to the Executive Board, since the issues raised were relevant to all regions. Mr FUNIFAKA (Solomon Islands) attached importance to the document because, without manpower trained in the appropriate skills, no strategy could succeed. He welcomed the remarks of the representative of Australia about that country's present approach. Health institutions needed to review the standards they demanded in relation to the role health staff were to play; some of them overtrained their students in subjects irrelevant to primary health care. He believed that the Tokyo meeting was bearing fruit and would benefit his and other similar countries 1n the Region.
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Mr TIXIER (Cook Islands) said that his country fully supported the recommendations of the Tokyo Conference. He hoped that they would be widely disseminated. Dr BOELEN (Regional Adviser in Health Manpower Development) said that the health system could not be reoriented towards primary health care unless there was a corresponding reorientation of health manpower. That would require fundamental changes not only in the way health manpower was trained but also in the way its development was planned and the way it was utilized. Those changes were not taking place at the expected rate or to the expected extent and one aim of the Tokyo Conference had been to find out why. Anticipatory thinking was needed, together with skilled management of change. To date, little had been done along those lines and the Regional Office was endeavouring, in parallel with its current activities in health manpower development, to meet those two key requirements by holding meetings, organizing task forces and devising appropiiate sets of methods. The REGIONAL DIRECTOR. replying to the representative of China and other representatives, said that follow-up measures were being planned in consultation with certain Member States concerned with future health manpower development. particularly in the field of medical education. If the medical and allied health professions were to keep their leadership in community development, they must change and adopt a different approach, in the spirit of the Declaration of Tokyo. Seminars would be held in the different sub-regions, with international part1c1pation and necessarily bringing together the ministries of health, ministries of education, the universities and . schools. When a firm commitment to participation along those lines had been obtained, a seminar or symposium would be organized, using intensive case studies, by the participants, of current health manpower development, with the collaboration of WHO and international experts, as the basis for discussing how to change or reorient health manpower development towards the needs of the twenty-first century. There must be changes by the year 2000, under the increasing impetus of health-for-all activities, not only in the structure of the professions themselves but also in professional skills and attitudes. In the absence of further comments, the CHAIRMAN invited the Rapporteurs to prepare an appropriate resolution. (For consideration of the draft resolution, see the ninth meeting, section 2.5).
The meeting rose at 5.45 p.m.