Proceedings of the fifth meeting of WHO representatives, Alexandria, 7-11 June 1987

EM/WR/~-E

D i s t r : KESTKXCTED

PROCEEDINGS OF THE FIFTH MEETING OF WHO REPRESENTATIVES Alexandria, 7-11 June 1987

The c o n t e n t s o f t h i s r e s t r i c t e d document may n o t be d i v u l g e d t o persons o t h e r than t h o s e t o whom i t has been or1 g i n a l l y a d d r e s s e d . I t may n o t b e f u r t h e r d i s t r i b u t e d nor reproduced i n any manner, and should n o t b e r e f e r e n c e d i n b i b l i o g r a p h i c a l matter o r c i r e d .

WORLD HEALTH ORGANlZATION REGIONAL OFFXCE FOK

THE EASTERN MEDITERRANEAN

1987

DISTRIBUTION LIST

Eastern Mediterranean Region All WHO Representatives Participants from the field Programme Directors and Regional Advisers Heads of Administrative Units Regional Director's Office Library Hepor t s Conference Officer AU/UPM

Headquarters

Eastern Mediterranean Special Programme (EMS) ~irector-~eneral's office ADGS Participants

from Geneva

CONTENTS

I .

INTRODIJCTORY ADDRESS MANAGEMENT OF IMPLEMENTATION OF WHO'S COLLABORATING

11. 1

PROGRAMME WITH COUNTRIES 11-1. Presentation 11-2. Regional Director's comments 11-3. Discussions

11-4. Recommendations 111. BRIEFING ON DISTRICT HEALTH SYSTEMS

111-1. Presentation 111-2. Discussions IV.

FINANCIAL AUDIT IN POLICY AND PROGRAMME TERMS

IV-1. Presentation IV-2. Discussions IV-3. Recommendations V. PROCRAMME MANAGEMENT INFORMATION FOR WHO PROGRAMME

DEVELOPMENT

V-l. V-2. V-3. VI.

Presentation Discussions Recommendations JOINT-GOVERNMENT/WHO

PROCUMME REVIEW MISSIONS ( JPRMS)

VI-1. Presentation VI-2. Regional ~irector'scomments VII. VII-1.

PROGRESS REPORTS Acquired i u u u u n o d e f i ~ i e n c ~ syndromc (AIDS)

VII-1.1 Presentation VII-1.2 Discussion VII-2. Information and education for health VII-2.1 Presentation VII-3. Health for All leadership development VLX-3.1 Presentation VII-3.2 Dr figott's comments VII-3.3 Recommendations VII-4. School health curriculum VII-4.1 Presentation VII-4.2 Recommendations VII-5. Staff development and training VII-5.1 Recommendations VIIL. CLOSING SESSION

. Programme Annex I Annex 11. List of participants Annex III Agenda

I. 1.

INTRODUCTORY ADDKES S

G e z a i r y , welcomed t h e WHO R e p r e s e n t a t i v e s P i g o t t and D r J . D . M a r t i n , t o t h e m e e t i n g . He f e l t t h a t r e l a t i o n s h i p s w i t h Member S t a t e s were improving, l a r g e l y b e c a u s e o f t h e e f f o r t s of WHO R e p r e s e n t a t i v e s . T h e r e was more u n d e r s t a n d i n g of t h e r o l e of W H O and how t o make b e s t u s e o f WHO'S f i n a n c i a l and o t h e r r e s o u r c e s t o p r o v i d e t h e maximum s u p p o r t Co c o u n r r i e s . However, t h e e x c e n r of t h i s u s e depended on how WHO c o u l d e d u c a t e o t h e r s t o a p p r e c i a t e i t s r o l e a s a t e c h n i c a l agency, not i n competition with o t h e r o r g a n i z a t i o n s a b l e t o provide much greater sums of money. For e x a m p l e , t h e e n t i r e Reginnal WHO hurlget w n t l l d n o t s u f f i c e t o meet t h e h e a l t h n e e d s o f o n e s i n g l e c o u n t r y . Member S t a t e s had f o r WHO, not just based on o u r t o r e a l i z e t h a t t h e r e was a need s e l £-judgement, b u t from e x p e r i e n c e w i t h WHO'S a b i l i t y t o p r o v i d e s e r v i c e s making optimum u s e o f i t s meagre r e s o u r c e s . and the H ~ a d q ~ ~ a r t e r ps a'r t i c i p a n t s ,

The R e g i o n a l D i r e c t o r , D r H.A.

Dr W.J.

2.

The World H e a l t h Assembly d i s c u s s i o n s had s t r e s s e d t h a t WHO'S s u c c e s s o r on w h e t h e r Member States

failure depended

paid

their

a s s e s s e d contributions;

e v e n d e l a y s i n payment c o u l d have a n a d v e r s e e f f e c t . However, many Member S t a t e s were s u f f e r i n g h a r d s h i p from f l u c t u a t i o n s i n c u r r e n c y r a t e s a n d , i n d e v e l o p i n g c o u n t r i e s , r e d u c e d p r i c e s f o r t h e i r p r o d u c t s . F o r example, ~ g y p'ts c o n t r i b u t i o n s i n E g y p t i a n pounds had d o u b l e d t o meet i t s d o l l a r commitment, a f t e r devaluation. 3. Despite improvements there w e r e still a n ~ ~ m b e rof administrative p r o b l e m s , which would b e r a i s e d by WHO R e p r e s e n t a t i v e s , i n c o o p e r a t i o n between t h e R e g i o n a l O f f i c e and t h e f i e l d , c a u s i n g d e l a y s and w a s t a g e o f t i m e and e f f o r t . He c i t e d a n example o f a f e l l o w s h i p a p p l i c a t i o n r e t u r n e d t o a c o u n t r y s e v e r a l t i m e s f o r c l a r i f i c a t i o n b e f o r e t h e c o u n t r y was informed t h a t t h e f e l l o w s h i p was n o t i n l i n e w i t h WHO p o l i c y . He f e l t t h a t a d v a n t a g e was t o b e g a i n e d from d i s c u s s i n g a l l s u c h problems i n open m e e t i n g s and t h a t t h i s s h o u l d not b e rcgardcd as

o reflection

on

individualo.

Efforts were

being

made

to

overcome d e l a y s i n c o r r e s p o n d e n c e by u s e o f t h e f a c s i m i l e s y s t e m , which w a s l e s s e x p e n s i v e and more e f f e c t i v e t h a n t e l e x e s and t e l e p h o n e c a l l s .

D r G e z a i r y reviewed t h e q u e s t i o n s r a i s e d on page 2 o f t h e Report of t h e F o u r t h Meeting of WHO R e p r e s e n t a t i v e s ( E M / W R C / ~ - E ) , some o f which were o f a g e n e r a l n a t u r e , o t h e r s were t e c h n i c a l , a d m i n i s t r a t i v e o r r e l a t e d t o t h e r o l e o f t h e WHO R e p r e s e n t a t i v e . H e had n o t e x p e c t e d t o r e c e i v e a n s w e r s d u r i n g t h e f o u r t h m e e t i n g , b u t was t h r o w i n g l i g h t on i s s u e s and a r e a s which h e e x p e c t e d p a r t i c i p a n t s t o s t u d y s i n c e t h e m e e t i n g and t h i s time h e would be l o o k i n g f o r w a r d t o r e s p o n s e s and examples o f improvements made and d e f i c i e n c i e s c o r r e c t e d . I n p a r t i c u l a r , h e would l i k e t o know what s t e p s had b e e n t a k e n t o R s had improve WHO'S image i n t h e c o u n t r y of a s s i g n m e n t and t o what e x t e n t W been i n v o l v e d i n d e v e l o p i n g t h e v a r i o u s programme a r e a s . He f u r t h e r a s k e d f o r c o a a l l r r ~ t s an the u s e f u l n e s s of the present t y p e of WRs' meeting, or- s h u u l d a n o t h e r mechanism b e s o u g h t ?

4.

5. He had emphasized during that meeting that it was essential for the cuur~triss L u s t r ~ r~aliullal a n n u a l targets for each programme. IIe cxpcctcd that W R s had played an active role to make this happen. He would, therefore, like to hear during the present meeting to what extent WRs had been successful in this area and if not what were the reasons for fai2ure. 6. During the fourth meeting, there had also been various recommendations. He would like to know to what extent these recommendations were being implemen~edaL cuuntry aurl Regional level. The outcome of W R s ' meetings should be used as a tool for improvement of the managerial system and support to countries, but he also looked at it as a tool for evaluating the performance of the WHO Representative at country level and he intended to u s e it f o x this purpose.

7. Since the fourth WRs' meeting, the Regional Consultative Committee had met twice, in Kuwait and in Khartoum, Sudan. The Regional Committee held its Thirty-third Session in Kuwait in October 1986, and he had recently attended the Seventy-ninth Session of the Executive Board and the Fortieth World Health Assembly. He w i . s h ~ dt o hear from W R s what action had been taken to ensure that resolutions and decisions of all these meetings were being implemented and to what extend WRs had been supporting countries in so doing.

8 . During the same period there had been certain developments in the Regional Office. The third round of the Programme Review Missions had been concluded, various posts had been filled and the overall managerial system was n o w oriented towards targeting for H ~ a l t h For All through concentrating on major priority primary health care actions and building up health services in a manageable geographic health area, which may be a district. Activities in areas supportive to the achievement of the Health for All (HFA) goal, such as training of national health otticials in international health, leadership development, promotion of a healthy life-style, strengthening coordination with Regional and international agencies and accelerating various priority programmcc, were being increased.

9.

The present meeting would look at: (a) (b)

the progress achieved at country level in implementing recommendations, decisions and resolutions already referred to; menagemtnt and

the

implementation of all collaborative programmes with

countries: district health system, financial audit, programme management information and WNO programme development, as well as progress reports and follow-up related to the Joint Programme ~ e v i e w Missions, acquired immunodeficiency syndrome (AIDS), HFA leadership, school health curriculum, staff development and training. During individual meetings of WRs with the technical units, problems and success stories could be expanded.

1 0 . WHO field and Regional Office staff had been asked to give ideas and proposals which would strengthen or support countries and the various health programmes. He asked WRs once more to e x t r a c t frnm their experience innovative ideas and approaches towards the improvement of Regional services. certainly, there should be awareness of World Health Assembly, Executive Board and Regional Committee resolutions and he strongly recommended that the HFA series publications should be closely studied. WKO staff should be aware of new developments in medicine in order to respond to enquiries and he felt that field staff should be given the opportunity to attend meetings of experts to ~ future trends. update their technical k n o w l ~ d gof 11. He referred to a few observations which had previously been brought up, some of which still continued to be problem areas. (a)

The Regional Office still received correspondence and/or requests from governments which had not been scrutinized nor commented upon by WRs. On some of these t h e W R should have taken the ncccssary steps locally. In the area of health manpower development there were still problems resulting from lack of careful examination of the fellowship application forms; sometimes the fellowship policy was not adhered to. The Regional Office had not heard from WRs what efforts they had put into identifying potential candidates and potential leaders to be trained. In the area of environmental health, more evidence was expected that the WRs were playing an effective role in strengthening intersectoral and interagency coordination in water and sanitation programmes. As regards disease prevention, p r o b l ~ m n still continued in relation to accurate r e p o r t i n g and in overall surveillance systems. Some diseases which had been well under control in the past were emerging as major problems; malaria and tuberculosis were two of the most important examples.

(b)

12. All the points raised tempted the Regional Director to start looking into the staff appraisal system. WHO was committed to noble goals and Member States had entrusted WHO with thc responsibility of making t h e s e liealtl~ g o a l s a fact. WHO should be able to justify its existence and he intended to see that the presence of each staff member was justified by his performance and the impact of his activities. Everyone should develop a positive attitude and exercise self-judgement in carrying out his duties, but at the same time remain convinced that what he was doing was worthwhile. Failure in any one area should be taken as a lesson to learn from and not as a depressant hindering progress.

13. way. 14.

We should develop the will and if there was a will there was always a

Dr Aref El Yafi was elected Chairman of the meeting and took the chair.

11.

MANAGEMENT OF COUNTRIES

IMPLEMENTATION OF

WHO'S

COLLABORATIVE

PROGRAMME WITH

Presentation 15. Dr A. Khogali, Director, Programme Management, introducing the Agenda item, stated that the Global Programme Committee (GPC) had asked the Programme Development Working Group (PDWG) to review the management of programme dudit L ~ ~ r e p o r t s and (b) implementation on rhe basis of findiugs uS (a) ~ I ~ L K L L financial audits in policy and programme terms carried out in 20 countries selected from all WHO regions, with a view to corrective action. The Regional O f f i r e had instituted its own audit of programme budget policy implementation in Somalia this year. The newly introduced financial audits in policy and programme terms determined how decisions to use WHO resources are made, to what extent government/~~O activities comply with WHO policy and what these activities have achieved. The reason for introducing this type of audit, which is not always understood at country level, is the concern with the gap between the theory reflected in the collectively agreed policies and the practice as s e e n in the way WHO resources are actually used. commented that WHO had a good record in planning, and evaluation but that support to implementation of national cuuntry ' S was weaker. A t counrry level, planning of ten exceeded L ~ K capacity in order to have access to resources, which naturally to under-implementation and evaluation "Overload", i.e. time and e f f o r t spent t n e x p l a i n rhines which already in the first place were not going to work as planned. The PDWG felt that some of the twenty countries used might not be adequate to make generalizations. However, the results hais not revealed any really new findings but constituted the first internal documentation of managerial constraints which allows better tocus on issues; also self-appraisal was preferable to having faults pointed out by external auditors. 17. The PDWG endorsed the EMRO approach of linking audits to Joint WH~/~rogramme Review Missions as an input to reprogramming for the nexr biennium. It also felt that in addition to auditing the use of some 70% of WHO resources at country level, the remaining 30% used at Headquarters and Regional offices level should also be audited. 18. Tllr

16. The monitoring programmes absorptive gave rise

PDWG had

issues addressed

related

to

(1)

programme

design

and

budgeting

process: (a) government/WHO dialogue, (b) country planning figures (CPFS), (c) planning of intercountry activities and ( d ) the slow rate of implementation; and (2) managerial issues in programme implementation: ( a ) WR's function, ( b ) utilization of resources, and (c) the Administration and Finance Intonnation ( A F I ) system. 19. The audits showed that g o v c r n m e n t / ~ ~ dialogue ~ was not based on a systematic review and monitoring of health development activities and was not preceded by a programme evaluation. There were difficulties in following supporting documentation, poor coordination between the health and other sectors and inadequate attention was paid to the need for long-term commitment

and national resources. The PDWG recommended that Joint Government/WHO Programme Review Missions should follow the criteria contained in ~ ~ 0 / 8 3 . 1 (Rev.1) Managerial framework for optimal use of WHO resources at country level as well as DG0/85.1 and the Regional Programme Budget Policy. Cnv~rnments would thus be better informed, leading to better intra- and intersectoral coordination. Identification of insufficient and ineffective use of resources should be the basis of reprogramming in the next biennium. These recommendations should be enforced through a forceful and confident WR, with an intimate knowledge of policy, strategy and programming.

-

-

The audits revealed that the budgetary process was administrative rather managerial and that there was extensive reprogramming during implementation. Countries still think in rerms U S ownership of CPFs. A t present, in establishing CPFs, the country's absorptive capacity, previous record of programme implementation and relative achievements with the health status of the population are not taken into account. The PDWG recommended two alternatives for action: ( a ) abolition of CPFs in favour of budgeting according to needs, or (b) the development of criteria including those mentioned ahnve for gradual redistribution of CPFs to be submitted to the Regional Committee for approval. It was also recommended t h a t the cost of the WR's Office be excluded from the CPF. than

20.

21. Intercounrry a c i i v i t i c s w e r c not confined to meetings and were intended to link elements of WHO activities in several countries and form a cost-effective managerial tool. The PDWG recommended that the criteria in the Seventh General Programme of Work and the Regional Programme Budget Policy for planning intercountry activities be applied. Countries s h o u l d be encouraged to use their CPF resources for intercountry activities, as is being done in the malaria programme in three countries (Democratic Yemen, Somalia and yemen) through sharing of long-term staff. 22.

The audit found that more

funds

were obligated in the last quarter of

1985 than in the first three quarters, mostly for supplies and equipment,

local costs, special service agreements, etc. Also tlre funds u o e d for these categories exceeded one-third of the total amount obligated for the full biennium 1984/85. Corrective measures taken by Regional Offices included the use of plans of work/workplans, more effective technical and financial programme management information, earlier programming for consultants, supplies and equipment and fellowships, as well as regular monitoring by the Regional Programme Committee and Joint Government/WHO Programme Review Missions. The PDWG recommended preparation of plans o f action for a11 collaborative activities in the last s i x months of the preceding biennium and introduction of a follow-up system to enable staff awareness of responsibility in the chain UL implementation and regular reporting of the budgetary situation. This will allow management to identify where and by whom deadlines are not met. 23. Audit findings on managerial issues relared to t h e W R function showed a need for application of selection criteria. Ten per cent of WR posts globally had been vacant in the last three years. Training in negotiation and management was weak, there was a lack of systematic record-keeping and a need

for a more structured work system. Some WRs were reluctant to use the authority delegated to them for action at country level. The WR was the representative of the Director-General and the Regional Director at country level and should be able to advise countries on the need to act in accordance with the collectively agreed WHO policy. The PDWG recommended that special attention continue to be paid to selection and training of WRs. Administration and management, including office management, should be emphasized in training and adequate relevant information support provided. WRs should be encouraged to take decisions in accordance with agreed policies and to call on Regional and global levels for support. Day-to-day administrative management of offices requires increased support.

24. With regard to Direct Financial Cooperation (DFc), the PDWG recommended Joint Government/WR selection of appropriate programmes, which the WR should monitor closely through timely reports, periodic visits and review of records and accounts. The Regional Ottice should also monitor activities. To overcome delays in submission of certified financial statements for local cost subsidies, rigorous application of the WHO Manual was recommended - no advances should be made where statemenrs w P r e three months

overdue and there

should be a total embargo after s i x months' delay. Local cost subsidies should not exceed the normal 10% limit.

25.

The PDWG recommended strict adherence to selection criteria for fellowship candidates; no fellowships should be awarded for undergraduate studies; there should be systematic evaluation of the fellowship programme

during Joint G o v e r n m e n t / W ~ OProgramme Rcvicw ~ i o e i o n s .

26. In view of difficulties in recruitment of consultants, it was recommended that each Region analyse its problems in consultant utilization, including the use of Regional Office and Headquarters staff and nationals, and modify procedures to speed up the response to requests. Consultants should be properly briefed and their recommendations followed up, with greater use of y r r v i u u s c o n s u l t a n t s ' reports.

27. The Regional Office had instituted measures to improve procurement of supplies and equipment, including early submission of requests after Joint Government/WHO Programme Review Missions, scrutiny of requests by the WR and the Regional Office, and a weekly status report. The PDWG recommended that adherence to criteria be evaluated and a detailed analysis carried out in a lew cuu~~lrie us l: p ~ o l l e n i s i n selection, ordering and delivery of equipment.

28. With regard to research, the PDWG recommended that an effective follow-up system be instituted a t Regional level to overcome problems such as lack of reporting on research grants, both on the financial status and research results. 29. Publications issued by countries with WHO support can be below standard as regards relevance and content and can duplicate existing works. The PDWG recommended Regional mechanisms to provide valid in£ormation to countries, including WHO-supported publications and the use of .Joint Government/tJHO Programme Review Missions to inform governments of available publications.

30. It was found that while the Administration and Finance Information Syscem provided accounts and r e c u r d s fur overall financial and b u d g e t a r y management, it did not reflect the technical status of implementation. Possible solutions should be proposed. It was suggested that funds might be ~ n r m a r k ~ fd n r each activity to permit them to be monitored. 11-2,Regional Directorts Comments

31. The Regional Director commented that a lot of work had been done in the Regional Programme Budget Policy to combine directives from various resolutions and documents. It was available in English and Arabic. He expected WR3 and other staff to read it c r t r ~ f ~ r l l y and almost know it by heart. It should be made known to nationals, so that dialogue would be greatly facilitated. CPFs were a sensitive issue, but the Regional Committee had already approved a number of actions whereby not all countries received the same increase in CPF, some being given a differential increase due to their absorptive capacity and actual needs. A "points" system in the allocation of resources had also been tried out. It was hoped that in a few years' time the CPFs would become more realistic. 32. He emphasized that it: was WHO policy to replace long-term staff by consultants, but the best solution would be to use suitable national capabilities where possible, covered by Special Service Agreements. The question of the WRs' functions needed to be further discussed. It t o delegate more a u t h o r i t y to t h e WRn, although this would entail greater responsibility, particularly if governments tried to persuade R to use his authority for approval of incorrect action. the W was

33.

important

11-3. Discussions 34. WRs,

In the following discussions, various points were raised by a number of uutably with

regard

to

oupplice

and

equipment,

fellowships

and

consultants. It was felt that Programme Review Missions could result in delays, for example, in ordering supplies and equipment. The Regional Director pointed out that there was no need to await the final Mission report before ordering, since the supplies and equipment required would have been agreed on in principle. 35. Several WRs y o i t ~ t e d uut the importance of supplies and equipment to governments and the need for speedy procurement. A main cause of delay arose from badly presented orders and the length of time taken by countries in providing clarifications. The Regional Office sent catalogues of supplies yearly to WRs to help in preparing orders, but price lists were difficult to prepare due to dollar and price fluctuations. UNICEF catalogues were recommended as a useful guide. There was, however, a need for specialist lists of standard supplies and equipment: for p r o j e c t s . Unavoidable delays w e r e caused by the need for technical screening of long lists, usually greatly in excess of the budgetary allocation, by the WR and the Regional Adviser, and for processing in Headquarters. However, it would be possible to send a status report on orders to WRs, possibly every two months, so that they would be aware of the stage of processing of orders.

36. There were a number of comments on the usefulness and ability of s i t 1 1 access to a pool of short-term consulcancs, especially in c u u ~ ~ L r i e w technical excellence, both in the ministry of health and in institutions such as universities. 37. While the use of national experts as consultants was advocated, this could raise the difficulty that, while technically competent, there was no guarantee that they would conform with WHO policy. When Regional Office staff are to undercake consultantsl~iysin c o u n t l - i e s , the Regional Director felt it might be useful, in certain cases, to recruir a long-term consultant who would ensure continuity of the adviser's work during his absence. This could be considered a s part of the intercountry portion of the country's programme support. 38. With regard to fellowships, the main difficulty with training institutions abroad continued to be che requiremenz: for proficiertcy ~ I English, which few candidates could meet. Attention was called to the directory of training facilities available in the Region. 11-4. Recommendations I

Recommendat ion 1 Su~~lie and s eaui~ment T e c h n i c a l advisers should prepare s t a n d a r d lists of equipment and supplies needed for projects in their area with, if possible, an indication of cost, which could be used as a model by WRs when advising national authorities on the suitability of supplies and equipment requested. This would serve to shorten the time taken in technical screening ot orders in the Kegional Office.

Recommendation 2 Consultants

2.1. A follow-up report on implementation of previous consultants' recommendations should be submitted by the government when requesting a further consultancy in the same field. 2 . 2 . Where

national expcrts are used

as

consultants

in

their awn country,

they should be thoroughly briefed by the WR. The terms of reference for both national and external consultants should be spelt out in detail. 2.3. External consultants should be thoroughly briefed in the Regional Office. They should work closely with the WR and s i t with him and the national authorities to prepare the report on the consultancy.

2.4. As a learning experience and to develop a future resource for the country, a suitable national might accompany an external consultant during all or part of his assignment.

Recommendation 3 Fellowships 3.1. WRs should explain to governments the preferability of placing fellows in training inst itucfons within t h c Region, w h i rh would overcome the difficulty of proficiency in English. 3.2. WRs should play a clear role in the screening of candidates for fellowships, refusing for example multiple fellowships for the same candidate.

3.3. WRs should advise the government when the field of study requested for a fellowship is not in line with t h e national strategy for Health for All. WRs should try to enforce the policy, agreed to by governments, whereby fcllow should work in the area of competence acquired during his fellowship on return to his country.

3 . 4 .

a

3.5. There should be more intensive follow-up and evaluation of the results of fellowships and their impact on the development of health in the fellow's country. Transverse evaluation of the programmes

39. Dr A. Rahmani presented an example of a "transverse evaluation" carried out in Somalia, where common elements of eight programmes were evaluated together. The results were presented to the Financial Audit in Programme and Recommendations were made to the Joint Programme Review Policy Terms. Mission, resulting in a cut in allocations for supplies and equipment, consul~a~lts and fellowships, and the bulk of the 1988f1989 Budget going to strengthening of essential health services. III.

BRIEFING ON DISTRICT HEALTH SYSTEMS

111-1. Presentation Dr 3.D. Martin, Responsible Officer, District Health System ( D H S ) , WHO Headquarters, Geneva, introducing the subject, stated that while che DHS programme at the moment was sited in the Division of Strengthening of Health Services, coordination with other WHO programmes was assured by a steering committee drawn from six ocher programmes, chaired hy the Assistant Director-General, Dr F. Partow, to which the DHS core group reported. 40.

41. DHS activities could only succeed with the support of WRs and with their leadership in their countries of assignment. The concept was not new, but the organization of DHS based firmly on primary health care, with emphasis on equity, full community involvement, as well as that of other sectors with an influence on health, was new in many countries. It was an opportunity to stress operational difficulties which many countries were experiencing in implementing national Health for A11 strategies. By focusing on intermediate levels it might be possible to analyse difficulties and find solutions which WHO could pass on and share with other countries.

page 10

The programme was acting on a stimulus from Member States, which had said clearly rhar: country problems a l i u e f r o r n weak infrastructure and poor management in districts, as shown in the evaluation which led to the Seventh A DHS dealt with a geographical area Report on the World Health Situation. which m i g h t have a population varying from less than 100 000 up to half a million or more; its boundaries usually conform to those of local government administrations. It was close enough to the national level to be aware of national policies and to the communities to be aware of local needs. The health system within this boundary comprised people rhernselves; ocher sectors such as education, agriculture or industry; health centres and health posts; the district hospital and institutions governed privately or by non-governmental organizations. All of these, linked by common objectives and targets, were what is meant by DHS.

42.

43. In many countries, hospitals and health centres operated in isolation. Health workers waited for sick people and made little effort: 10 go ouc and analyse the health needs of the people, or to use chis information to provide a balance between curative care, preventive care and promotive activities. 44. The district level often suffered from weak organization and management coupled with vertical management of certain areas, leading to separate allocation of resources, including medical supplies, and separate training opportunities. More could be done with resources if fhere were a focus on local needs rather than on national targets, which did not always apply to the varying situations found in parts of the same country. Better health could be arrived at by better health care, aiming at improved accessibility for people, especially those most at risk; by seeking to integrate preventive, promotive and curative services in health At the same time, people institutions; as well as by reducing health risks. should know more about their health problems and what they could do about them. Communities should get together in a concerted way to coordinate their activities with those of local health workers to fight their problems, Priorities for action had to be defined and targets refined according to groups most at risk.

45.

46. The organizational principles for DHS were, therefore: (1) equity in health and health care, (2) the need to improve access, (3) the need to focus on health risks and more efforts in promotion and prevention, not as tools for L l i e 11ealLli s e c t u r alone but for intersectoral and community action. The district must have support in policy and managerial terms from the national level, which must take responsibility for greater decentralization and facilitating greater integration. Better management at district level had to be complemented by better management at national level and the national level should ensure that there was equity in resource allocation between districts. An Interregional tlccting would be held i n Harare, Z i m b a b u c , in t h c firct Many industrialized week of August 1987, for 20 countries from all Regions. The Global countries, as well as developing ones, welcomed the DHS concept. Programme Committee in its meeting on 28 June 1987 was to make a prior review of progress and the information gathered so far would be made known to other 47.

EM/WR/ 5-E page 11

countries. Lur

It was hoped that the meeting would result in securing resources t l ~ ~ u u g the h pal-ticipation of UNDI',

t l ~ ryruglralulile

UNICEF, thc World Bank,

DANIDA, the Netherlands, SIDA and USAID. The participating countries would then work with WHO, primarily the ~egional Offices, to formulate plans of action capable of attracting resources, so that by 1988 a worldwide network should emerge. 48. Apart from providing technical staff, helping to promote the concept and providing relevant rraining opprotunities, Regional Off ices could pru~tlutt-: research and development at local level. T3f-2.

Discussions

49. In the discussions, it was pointed out that the Regional Office, in fact gave priority to the concentration of WHO resources on community health development at all levels up to and including the district hospital and, in some countries, at least half of WHO allocations was being devoted to ~rimary health care up to district level a district being defined as a manageable hcalth area. It was clarified that "district" health s y s t e m was being used in its generic sense, but the situation varied in different countries. For example, a "district" in one country might correspond to a "region" or to a "health area" in another. It was Eully agreed that health development could not be separated from overall development in other sectors, but rather than ask sectors to work towards health goals, better coordination might be achieved by asking how these sectors were working towards their own objectives, including their responsibility for health-related aspects. nauhts were expressed as to whether emphasis on the district level would create confusion or possible contradiction with the focus of primary health care. It was also stated that, in certain countries, planning and setting of priorities was done at central, regional, provincial or other levels rather than at district level. A further difficulty would be an overload of responsibility on the the district medical officer who would require guidance and support.

-

50. Finally, Dr Martin stressed that programme action would be taken in close consultation with Regional Offices and countries. Wis visit to the Regional Office was part of this process. He hoped that by establishing better linkages with the Regional Office and some Regional countries, starting with Pakistan, Somalia and Sudan, these experiences could be built into the programme to help provide a full assessment of what had been achieved. I V * FINANCIAL AUDIT IN POLICY AND PROGRAMME TERMS

IV-1. Presentation

Mr P i e 1 reported on the first Regional Programme Budget (EMRPB) Policy 51. Audit which was carried out in Somalia, 7 - 14 February 1987. The EMR audit was based on the guidelines for monitoring use of WHO'S resources (IAU/M.Pw/86.1 and EMR/MPW/~~.~). It was an "audit of theory versus practice'' in carrying out the Regional Programme Budget Policy (WHO-EM/RC33/7) governing programme development, implementation and financing, and the audit was directly 1inked to the f01 low-on Joint Programme Review Mission in Somalia, 15*--25 February 1987. Beginning as an "external" audit by Regional Off ice staff, including FIN as "acting Auditor", and WR, Somalia, with participation of WR, Sudan, the audit converged and conli~lued w i t h the J P W with national participation.

EM/WK/5-E

page 12

52. Commenting on the EMRPB Policy Audit and JPKM reports, Mr W.W. Furth, ADG/RQ, has written: "I think that these documents are the two most refreshing ones to come out of a WHO region in a long time. I find the idea of a regional programme budget policy audit in a given country, modelled upon the headquart ers-organized financial audit in policy and programme terms particulary noteworthy. The format, with its emphasis on findings and recommendations, appears to me to be excellent. Most impressive also is the tact that the usual question arising after such an a u d i ~ - w l r a L tu do about its findings and how to implement its recommendations - has been answered by having the audit immediately followed by and in fact merged with the Joint ~ n v ~ r n m e n t / W H Programme O Review Mission ( J P R M ) . The audit is thus not merely an interesting exercise; it is in fact the evaluation upon which the programming is based. I really think that EMRO has found the right mechanism for which we have been groping for a long time."

53. The main finding of the EMPRB Policy Audit was that the use of WHO'S resources was thinly spread over too many programmes, and mainly at central level. The task w a s l e f t to t h e JPRM t n reorient and t o reprogramme resources for 1986-87 and 1988-89, focusing on planning and implementation of the integrated PHC approach to social development at community level, with district and regional referral and support, in accordance with the Regional Programme Budget Policy. The Somalia audrt confirmed what 1 s probably the case in a number of other developing countries, where the future emphasis of WHO support should be on integrated PHC from community to district level, without

losing

sight

of

WJ4Ote

role

in

overall

national

health

policy

and

programme development.

54. The EMRPB Policy Audit reviewed the national AFA policy development, coordination, programme budgeting, decision-making, monitoring and evaluation process. As other external and internal audits and evalution had shown, it was often difficult to reconstruct and to document past programme budget decision-making during the financial p c r i o d , particularly t h e ad-hoc decicione made outside the formal reprogramming exercises. To remedy this EMRO proposed to establish a streamlined "programme budget decision tracking system", using a one-page "programme budget change request form" to reflect the nature, justification and programme effect of budget changes (including A draft form is under consideration by the EMR effect on source programme). Programme Committee

.

55. The EMRPB Policy Audit: particularly reviewed JNSP, CWS, CLR, EPI, CDD and MAL. These were followed up by the JPRM. "Transverse evaluation" was carried out on certain common items, such as fellowships, meetings, training Due to the low courses, supplies and equipment (as mentioned on page 7 ) . return rate of fellows, the general fellowship provision for 1988-89 was reduced by 75% and a training and fellowship review committee procedure was established. Use of supplies and equipment and transportation was more tightly controlled. Programme and office management procedures were recommended. Advice was provided on imprest accounts and other financial matters. The audit findings and recommendations were discussed with national and WHO staff, and action was taken on all items.

page 13

56. A f t e r r e c e i v i n g t h e EMRPB P o l i c y A u d i t r e p o r t s , t h e D i r e c t o r - G e n e r a l commended t h e R e g i o n a l D i r e c t o r , EMR, and s e n t c o n f i d e n t i a l c o p i e s t o a l l o t h e r R e g i o n a l D i r e c t o r s , u r g i n g a d o p t i o n of t h i s a p p r o a c h i n a l l r e g i o n s . The D i r e c t o r - G e n e r a l encouraged EMR t o c a r r y o u t f u r t h e r RPB P o l i c y A u d i t s . Although a v a i l a b l e r e s o u r c e s ( t i m e , manpower and money) i n EMR were l i m i t e d and a l l 3PRMs f o r 1987 were c o m p l e t e d , M r P i e l s a i d t h a t s u c h a u d i t s , o r a t l e a s t some form of programme e v a l u a t i o n , s h o u l d p r e c e d e or be p a r t of a l l For example, a n i n - d e p t h r e v i e w of PHC had p r e c e d e d t h e JPRM JPRMs i n 1989. i n Sudan t h i s y e a r . P e r h a p s a "mini a u d i t " c o u l d be Lacked on the f r u ~ ~ l - r r i d of f u t u r e JPRMs. I d e a s from W R s on how b e s t t o go a b o u t t h i s were s o u g h t . DSP a g r e e d w i t h t h e v i e w e x p r e s s e d t h a t t h e r o l e of t h e WR i n c l u d e d a continuous programme budget p o l i c y a u d i t f u n c t i o n . IV-2. Discussions

57. I n t h e e n s u l n g d i s c u s s i o n s , q u e s t i o n s were posed w i t h r e g a r d c o rhe u s e f u l n e s s o f t h e one-page w o r k p l a n / p l a n of a c t i o n form, s i n c e a d e t a i l e d p r o j e c t p l a n o f o p e r a t i o n was s t i l l r e q u i r e d . It was concluded t h a t t h e one-page plan of a r r i n n forms p a r t o f an o v e r a l l p l a n of o p e r a t i o n , and s e r v e s a u s e f u l p u r p o s e i n t h a t i t s p e c i f i e s who would t a k e what a c t i o n and when, and t h u s c o n s t i t u t e s a good p r o j e c t management t o o l . The number of p r o j e c t s h a v i n g a p l a n of a c t i o n had r i s e n from 30% t o 100% s i n c e i t s introduction. V a r i o u s c h a n g e s s u g g e s t e d i n t h e format, r ~ u t a b l y regrouping o f t h e i t e m s t o b e completed i n t o s e c t i o n s which c o u l d b e completed by t h e p e r s o n r e s p o n s i b l e , were welcomed by t h e R e g i o n a l D i r e c t o r . The EMR Programme Committee w i l l r e v i e w t h e s e s u g g e s t i o n s and f i n a l i z e t h e form. I t was s t r e s s e d t h a t even i f a government and WHO had a g r e e d on c e r t a i n a c t i o n s , e s p e c i a l l y a s r e g a r d s s u p p l i e s and equipment and h o l d i n g of m e e t i n g s , Manual i n s t r u c t i o n s s t i l l had t o be r e s p e c t e d b e f o r e procurement c o u l d commence o r funds could be obligated.

58.

countrico propoccd a u d i t s in Afghanistan, ~ j i b o u t iand Yemen

The n e x t f i n a n c i a l a u d i t would be u n d e r t a k e n i n Sudan; t h e WRs i n t h e s e i E t h e respective

governments a g r e e d . The r e s t of t h e c o u n t r i e s o f t h e Region would c a r r y o u t a u d i t s a s soon a s f e a s i b l e and a s s t a t e d some form of a u d i t o r e v a l u a t i o n would p r e c e d e o r b e p a r t o f e v e r y JPRM i n 1989. IV-3. Reconmrendations

Rccommcndation 4

The EMRPB P o l i c y A u d i t s s h o u l d examine t h e p o s s i b i l i t y of p h a s i n g o u t a c t i v i t i e s which have b e e n i n o p e r a t i o n f o r a l o n g p e r i o d and o u t l i v e d t h e i r usefulness, t h u s f r e e i n g r e s o u r c e s f o r new, h i g h e r p r i o r i t y programme a c t i v i t i e s s u c h a s s u p p o r t t o d i s t r i c t h e a l t h s y s t e m development. Recommendation 5 WRs might u n d e r t a k e a n a u d i t t h e m s e l v e s , b a s e d on w o r k p l a n s / p l a n s of Such a n a u d i t s h o u l d be done t o g e t h e r w i t h a a c t i o n , p r i o r t o t h e JPRM. n a t i o n a l s o t h a t t h e reasons f o r suggested changes a r e understood. National views on c o s t / e f f e c t i v e n e s s should b e taken i n t o account.

EM/WK/S-E

page 14

V. PROGRAMME MANAGEMENT INFORMATION FOR WHO PROGRAMME DEVELOPMENT V-1. Presentation 59. T ~ agenda P item was introduced by Dr E. Hammoud, acting Director, Health System Infrastructure, and Dr A. Amini, WRY ~emocratic Yemen. DT Hammoud stated that the study resulted from the "Managerial Framework for Optimal Use of WHO'S Resources in Direct Support to Member States" (Document DG0/83.1) and a report on "Updatxng the Masterplan for Informa~ics Support to WHO", prepared by ISS/WHO, on the basis of which the Director-General requested the PDWG and HPC to work out a Programme Management Information (PMI) system for trial in countries in each r e g i o n and in a few selected WHO programmes at all levels of the Organization. A Task Force was set up, of which Dr Amini was a The study comprised two member, and met in New Delhi in February 1985. stages; (1) the country/WHO interface and ( 2 ) the part of the system reaching in from the country to the Regional Office, to the global level and back again through the preceding levels. 60. He r l d t u ~ a t e d on the a c o p c o f thc otudy and the T a s k Force's proposals

for implementation, including responsibilities at the different levels. Principles were defined for the country studies, each step of which would require, and in turn generate, information, which should be available, adequate, reliable, timely and in an appropriate form. The PDWG agreed that the informatics support requirements of WRs, particularly to meet new A managerial arrangements, should be regarded as a matter of urgency. protocol for a WR information study focused on the WRs four major functions as described in the managerial approach DG0/85.1: (1) to provide the government with information on agreed HFA policies; (2) to support the government in planning and management of national health programmes; ( 3 ) to identify, plan and manage WHO collaboration and 4 to identify and coordinate external resources. The protocol was tested in Indonesia, Papua New Guinea, Somalia, Sri Lanka, Togo and Zambia. The results were analysed and regrouped by the PDWG before f i e l d - l e b t i l t p , in Democratic Y e m e n in January 1987. A revised framework was sent to WRs in April 1987. 61. The Health Manpower Development and Community Water Supply Sanitation programmes were selected for the secono phase of the study. and

62. Dr Amini further elaborated on the methodology and outcome of the study, notably Phase 1 dealing w i t 1 1 the WH0/country interface through the WR. V-2.

Discussions

63. A number of WRs commented on the suitability of the WR information framework, Difficulties arose in obtaining the required information on the policies and resources of multi- and bilateral agencies working in As with health-related areas, not always available in ministries u f health. the PMI system, in some countries there appeared to be doubt that this information should be provided to WHO. In one country this had been overcome by initiating a cnnrdinatinn system with all external partners, who provided information on their support, including project progress reports. The Country Health Resource Utilization Reviews (CRUs) were cited as an important source of information in countries where these had been carried out.

EM/WR/5 -E page 15

A further major difficulty arose in providing names of officials at national, subnational and discrict levels, in view o f frequent o t a f f changes64. 65.

Mr Pie1 commented on three of the constraints which had emerged from the in Somalia and testing in Democratic Yemen: (1) lack of storage facilities for information and its organization in WRs offices, (2) the need for automation support to WRs and (3) difficulties in communication between Additional library the country, the Regional Office and WHO Headquarters. space was being negotiated with national focal p o i l i t libraries. A review a £ automation needs was ready for follow-up and it was cleax that equipment, such as a simple personal computer capable of undertaking word processing, was an advantage which c o u l d even cut staff costs. The Regional Office was ready to respond to WRs' requests. Reports on the Administrative and Finance Information system could be provided to WRs every three months. study

V-3.

Recommendations

Recommendation 6 WBs should collect and store information in the most appropriate way, but if possible nationals should be involved in its collection, so that they utilize better what information is available. In addition, a11 information, from whatevex source, should be made known freely L u l l a t i o n a l o f f i c i a l c .

Recommendation 7

The in£o m a t ion available in national collections in universities and other institutions should be utilized, and formation of an integrated cell of information at the Ministry of Health, using trained nationals to collect information, might be envisaged. Recommendation 8 The Regional Committee might be asked to discuss the attitude of governments of certain countries which feel that part of the information called for under the PMI system should not be provided to WHO.

VI

. JOINT GOVERNMENT/WHO

PROGRAMME REVIEW MISSIONS (JPRM)

VI-1. Presentation

65. The agenda item was presented by Dr 0. Sulieman, Regional Adviser, Health Programme Development and Mr A. Piel, Director, Support Programme. DrnSulieman stated that experience with 3PRMs had shown t h a t they lead to improved communications, a greater understanding of WHO'S role, an increased tendency toward priorization, introduction of innovative approaches, emphasis on health systems research, linking of fellowships to programme requirements and training of nationals in health leadership. Problems had arisen in the methodology of implementation, mainly resulting from a lack of review of programmes, inadequate preparation, discrepancies in data between text and tables and the lack of participation of other seccors w i ~ hali i u l p a c t on health development.

page 16

G7. I t was i r n p o r t a i ~ t t o know t h c rcasons f o r dclay i n implcrncntation of health strategies; some countries were even still asking for support in developing health plans at this late stage.

68. It has also been found that some presentations by programme managers were inadequate. Furthermore, Dr Sulieman felt that the importance o f the Centre for Environmental Health Activities (CEHA) should be stressed to governments, so that they would make suitable allocarions. Various proposals were put forward, including the possibility of tabulating JPRM reports for ease of reference. In general, it was felt that the success of a JPRM depended largely on the degree of preparation by the WR and nationals. It was requested that the note for the record on the visit of nationals to the Regional Office in 1986 be sent to WRs.

69.

70. Mr Piel agreed that there had been problems but that results had been Not all useful; EMR leads all Regions in the effectiveness of its Reviews. countri-es had studied the Regional Programme Budget Policy and WRs should try to overcome this lack. 71. Country allocations were frequently questioned; usually more resources were requested and, furthermore, affluent countries which had relinquished part of their allocations, with changing conditions were now requesting their full share of resources. CPFs were a complex and sensitive issue, which only the Director-General (and t h p Regional Director as his alter ego) could decide. CPFs should not be discussed or renegotiated during JPRMs. The Regional Director could decide to exclude the costs of the WR's office from the CPF when advising countries of their allocations, and this would be discussed by the Regional Committee in October 1981. Another recommendation under consideration was that a portion, perhaps 10%, of the CPF should be uncommitted and/or, in countries which do not have a primary-health-care-based system, perhaps 50% bc cct aside for integrated ~rimary health care development at community through district level.

72. Islamic Republic of Iran had raised the question of paying all or portion of its assessed contribution in local currency, but the Executive Board, World Health Assembly and the Legal Section ruled that contributions must be paid in US dollars. However, their suggestion of paying the local parL uf c u s t s o f t h e WR's

office i n local currency might b e met t o a c e r t a i n

extent by use of the Revolving Fund for external purchase of supplies and equipment in local currency - the 3% handling charge is waived in the case of learning materials. 73. EMRO statistics showed that the effect of PRMs in 1987 had been to accelerate the process of purchase of supplies and equipment in 1986/87. As regards purchases for 1988/89, t h c JPRMs has already i d e n t i f i e d the supplies and equipment needed for action plans and WRs could forward requests to the Regional Office for review during the second half of 1987, for early delivery in 1988. Obligations would be made from October/November 1987 when allotments for 1988-89 will be available.

EM/WR/S-E page 17

VI-2. Regional Director's comments 74. The Regional Director, in summing up, stated that learning from the JPRMs would take time. We would consider the suggestion of participation of Directors and Advisers from the Regional Office. If a WR were involved from the early stages of preparation of a Review, he should not consider himself solely as either belonging to the national or to the WHO team and should not take sides in the discussions. The suggestion to use WRs from countries which had received a JYKM as consultants for J P m s in other countries would be considered. VXI. PROGRESS REPORTS

VII.1.

Acquired Immunodeficiency Syndrome (AIDS)

VII-1.1. Presentation

75.

Dr M.H.

Wahdan, Regional Focal Point the

for Acquired

Immunodeficiency grmlp

Syndromc (AIDS), made a

in which h e reviewed w i t h t h e

?he

epidemiological situation of Regional situation.

disease, with

special emphasis

on

the

76. It was stressed by the Regional Director that probably the disease has already been introduced into all countries of the world, that the situation is serious and that in the coming few years the world may be facing a situation which has not been seen since the Middle Ages with any infectious disease. Technical aspects of AIDS were presented and discussed, particularly diagnosis, and prevention and control measures. It was highlighted that, with the absence of vaccines or effective treatment, the only possible approach is through health education, which should be planned for individual countries separately, depending on the national situation with respect to transmission of the disease and high-risk behaviour groups. The role of uational health authorit icc w a s discussed, particularly their role in making available balanced information to the public, in ensuring surveillance activities and making sure of the safety of blood and blood products. Xt was emphasized that there is no justification for certification ot freedom from AIDS for international travellers which, in addition to complex and serious logistical, epidemiological, legal, political and ethical aspects, is very costly a ~ i d could only b r i e f l y r e t a r d the spread of the virus in the community concerned. The Regional programme of collaboration with national authorities in AIDS was presented. ICs essential elements included training of nationals through the Regional Collaborating Centres on Laboratory Diagnosis. The Regional Office has succeeded during 1986 in training at least two nationals for each Member State on the ELISA technique. Training on a further laboratory test is starting this month and will hopefully be provided to cover a11 MerriLer States before 19-38, 77.

78. 1.

Future areas for collaboration in which WHO can extend support include: Organization of national initial assessment surveillance to determine whether the virus is circulating and identify high-risk behaviour groups. This is considered a prerequisite for any proper approach to WHO is ready to provide the drafting a national control yroglanxne. necessary consultancy and diagnostic support for such a survey.

EM/WK/ 5-E

page 18

2.

To support planning of national health education in communities iurr w l i i c l ~ would addressing Che essential elemenLs of loodes of trarls~iliss appear as a result of the survey. Exchange of information. The Regional Office is ensuring that WRs and national authorities will receive copies of all publications and information on AIDS. Discussions

3.

VII-1.2.

79.

The WHO Representatives requested the Regional Office to send them

copies of background papers which are discussed in technical meetings in

WHO,

in order to keep them abreast of developments in the field of AIDS. VII-2. Information and education for health VIL-2.1. 80.

Presentation the agenda item, Professor J .

In presenting

Ling stated that humankind

has struggled to communicate since time immemorial. Songs, gestures, sounds, pictures, smoke signals and drums were followed by words and writing as means of sending messages from one to another. The invention of printing in China first and then in Germany by Gutenberg made mass dissemination of ~ntormation a reality. Printing remained the principal instrument of mass communication. Then, exploding technological advances in communication in t h e 20th c c n t u r y altcrcd aubctnntislly patterns of information dissemination and knowledge sharing. This in turn has had a profound effect on the promotion of public health and the practice of medicine. 81. Radio, the telephone and television have radically changed the speed and reach of information dissemination, and they have also had an impact on social behaviour. These realities of modern communication are coupled with systeruatic studies o f interpersonal communication, which has bccomc an effective tool for commercial and political pursuits. Communication scholars in recent decades have emphasized the importance of two-way dialogue for any social endeavour. As far back as the 6th century BC, a military strategist, Sun Tse, advocated "knowing us and them, a hundred battles, a hundred victories": stripped of its military motive, Sun Tse had unwittingly laid down the principle of modern marketing. Seen in another light, "knowing your autlie~lces''involved the p r a c t i c e of empathy.

82. Founders of WHO recognized the linkage between health and an informed public ' s involvement and made specific reference to it in the Organizations's Constitution. The architects of Alma-Ata also identified education of the public as the first of the eight essential elements of PHC, which stresses equity, access, prevention, intersectoral cooperation and community action, all requiring various mixes 01 m e d i a and i n t e r p e r sonal communication. 83. The President of the World Health Assembly in 1983 complained in his address that "life-styles are no longer conditioned by climate and culture; they are initiated as soon as communications speed information from one country to another." He, in effect, identified a new category of communicable diseases related to life-styles, communicated by words and images. The

page 19

Seventh General Programme of Work (7GPW) responded to the communication changes by integrating public information and i t o media orientation with health education which focuses on community education and action. The new IEH programme has a framework that ranges from advocacy and information d i s s e m i - n a t ;.on, mobilizing political, legislative, financial and other support to community education involving groups and individuals for health action. The communication continuum runs through the entire range of IEH activities, employing various media mixes and interpersonal communications to suit specific audiences and particular purposes.

84. The 8GPW reaffirms this 7GPW thrust, which emphasizes the strengthening of national IEH capacity and the IEH components of health programmes, mobilizing connnunity resources, health promotion of specific population groups, human resource development and research. Health education for children is also stressed and advocacy for health is listed as a distinct I E H target. While many leaders in health are serious about IEH and communication, Old habits die hard. Znrellectual commitment to PHC is not often followed by emotional and behavioural commitment. In. the culture of science, dissemination of information and relations with the public are not part of basic scientific training. Reform in health training curricula is needed, and change of attitude among health workers is absolutely essential. the rank and file of the health sector is less so.

85.

86. Intersectoral cooperati on, which received much attention, will not be possible if the health sector does not learn to communicate with other sectors. Use the languages of others, practice empathy, and listen to Sun Tse. The lay public can absorb only limited details and, therefore, it is wise to stick to the absolutely essential. Recognize thar scientific truth has two ends: the originating end and the receiving end. IEH really matters at the country level, where t h e WR r n l l s t be rhe key point. IEH must be part of policy and strategy, an operational arm of HFA. At Headquarters, IEH is now directly supervised by the Director-General.

87.

88. Health should work hand-in-hand in partnership with the media sector, which is intersectoral by definition, Try to understand the priorities and agenda of other sectors, such as education and agriculture, and involve them; health should b e an integral part of their rcepcctive tasks.

89. WRs should take on IEH as their responsibility. Be aware of communication needs, call for technical help when necessary. Take on national talents on a part-time or full-time basis, using special service agreements, at manageable cost. WRs need to be assertive and proactive, using success stories of PHC for replication elsewhere and to enhance the image of healrh and WHO. Alsu, do not confuse the dictum of "no advertising for doctors" with going public on health issues. It is part of a WR's job to "hustle" for public support. Good deeds do not speak loudly enough for themselves. There is fierce competition for public attention and the health sector pays a high price for being late.

EM/WR/ 5-E

page 20

90. JCHP has now adopted a new policy on Information, Education and Communication, calling for joint action in the field, including training of staff in communication, in which Staff Development and raining is involved. WHO will observe its 40th anniversary in 1988. The theme is: All for Health, Health for All: it will be a tremendous challenge for the role of WRs in IEH work.

91. For development work to be successful, to quote a development communFcarion specialisr remember the five 1's; InfurmaLion, I r i s ~ r u c t i o r l (guidance) , Inspiration (high quality to inspire), Insistence (repetit ion) and finally Involvement. Also, in communication never assume too much and d i a1 o g t l ~with the audience. 92. The Regional Director, referring to lack of knowledge of WHO, even among health professionals, urged WRs and other staff to make use of every opportunity to convey health messages. Television time could be easily secured, free o f charge, in developing countries, to report on interesting health action, and television can convey information even to illiterates.

VII-3. Health for All leadership development VII-3.1. presentation

93. Dr O.I.H. Omer, Director, Health Manpower Development, explained that in 1985 the Director-General had launched an initiative to develop a critical mass of people i n support of Health for AIL in countries and in W H O , t o meet the problem of the gap between Health for All policies and strategies and their implementation. It was felt that the gap could be narrowed if leaders understand more fully national, regional and global policies, strategies and plans of action, towards Health for All.

94. A Task Force in WHO Headquarters, in which the Director, Programme Management, and later t h e Director, Hcolth Monpowcr Development participated, prepared a plan of action for 1986187. Initially activities on a global basis were to define what was meant by Health for All leadership; to identify leaders in WHO and in countries; to identify roles in relation to Health for All and to discuss ways to teach or develop leadership. A series of colloquia were held in five countries in 1985186 to discuss Health for All issues and a d i a l o g u e L e t w r r ~ il e a d e r s i l l N e w D e l l i i i t 1 1906, in which Pakistan participated. 96. Action has proceeded at a greater pace in the Region than at Headquarters. In 1985, the Regional Committee approved a recommendation of the Regional Consultative Committee asking for development of courses for senior officials in ministries of health. The Regional Director formed a Regional Task Force comprising the Directors of Health Manpower Development, Managerial Process for National Health Development and Health Programme Development, the programme manager of Education Development and Support and the Personnel Officer. Consultants prepared guidelines on approaches to be used and issues and problems to be addressed, as well as five modules for colloquia.

95.

EM/WR/ 5-E page 21

97. In Sudan, five districts have been selected for development of health leadership in suypvrt o f p r i ~ n a s - y health care. The district mcdical officcro, local government inspectors and senior Ministry of Health officials were to pay an observation visit to Thailand in July 1987, to be joined by the Ministers n f Health, Local Government, Finance and planning for the last three I t was planned that similar groups from ~emocraticYemen, days of the visit. Islamic ~epublicof Iran, Pakistan, Somalia and Yemen would participate in the Colloquium in Thailand in July. The Regional Director and Director, Programme Management will attend the last three days of che Colloquium and travel with the Ministers of Health of the five countries to Indonesia to observe Primary Health Care. 98. It is planned to develop colloquia in countries in the Region and form a network of institutions for collective activities in training, exchange and dissemination of information and conduct of colloquia. To develop WHO capacity in supporting this action, W R s , regional advisers and other WHO staff should receive training in leadership. This is envisaged to bring nationals into the Regional Office to work with WHO staff and learn by doing. They will also be attached to WRs' offices and country projects to gain practical experience. 99. The initiative is financed in 1988/89 by allocation of 10% of general country fellowship funds and support from Headquarters.

VII-3.2.

Dr Pigott's comments

100. Dx W.J. Pigott, Secretary of the Headquarters Task Force, stated that WRs would be a target group for involvement in action. It was confirmed that national colloquia were expected to be an outcome of participation in intercountry colloquia. It was hoped that eventually all countries will be given the opportunity to participate in such meetings. It was also hoped that the use of demonstration areas for colloquia in the countries of the Re8iu1l would serve to prove that dclivcry of health care at low cost can provide total population coverage.

VII-3.3.

Recommendations

Recommendation 9 WRs, as well as other WHO staff visiting countries, should try identify potential leaders. to

VII-4. School Health Curriculum VII-4.1. Presentation 101. DL 0. Sulieman, Regional Adviscr, Health Programme Development, introducing the subject, referred to a school health curriculum being developed in the Region. The curriculum is action-oriented and does not entail the use of additional textbooks. Integration of instruction on health matters relevant to the local situations in the teaching of other subjects, could trigger off health action by both the teacher and the pupils. One

EN/WR/ 5-E

page 22

example might be that, after instruction on transmission of schistosomiasis, pupils would be sent out to dig up and destroy the host snails. The curriculum will be provided to countries as a working paper, from which they will develop their own materials and curricula. It was envisaged first to introduce the curriculum in the national school system, but the material was suitable also for Koranic schools. 102. A situation analysis carried out in the Region had shown that there was a real need for such a curriculum. A workshop of eminent educators pruduced a plan of action and consultants prepared material, which was currently being revised. This material was sent to all ministries of health, training institutions, Regional organizations and United Nations agencies for comments. Four institutes in Sudan, Sweden, the United Kingdom and the United States were employed on a contractual basis to provide comments. Professor J. Ling was to lead the group a s from 1 July in incorporating all cormnents received and it was hoped that the material would be completed by AugustlSeptember 1987. 103. There had been disappointingly little reaction from countries and those comments received did not contain much substance. Attempts to involve UNESCO had proved unsuccessful; UNICEF will provide a consultant and 10% of required resources and will be cited as partner in the programme. 104. Professor Ling mentioned the importance which Headquarters attached to the programme. The Centers for Disease Control, Atlanta, USA had expressed a w i s h to learn from i t s experienceEMR w a s t a k i n g a f i r s f step in a void and he hoped that priority attention would be given to the programme.

VII-4.2. Recommendations 0 Recommendat ion 1 WRa should urgc m i n i c t r i c e of health, and others i n t h e i r country o f assignment who had received the material, to provide comments, even if these should be negative.

Recommendation 11 WRs should, if necessary, visit all relevant ministries and agencies to Nationals employcd on a Standard Service Agreement basis to support WHO could be asked to effect the necessary introductions. explain the c u u ~ e p t o f t h e school h e a l t h curriculum.

VII-5 Staff Development and

raining

105. In introducing the programme, Dr W. J. Pigott, Programme Manager, Staff Development and Training (SDT), stated that it was a privilege to be involved in the WRs' meeting, which in itself had been rich in opportunities for individuals to learn and develop.

106. SDT has at least two components: what the individual can do for himself The values and and what SDT and others can do to facilitate development. principles inherent in HFA and PHC such as equity, self-reliance,

page 2 3

p a r t i c i p a t i o n a n d maximum use of a v a i l a b l e r e s o u r c e s , must be r e f l e c t e d i n SDT activities. SUT and, i n f a c t , t h e staff member's r o l e , i s r e f l e c t e d i l l the S u f i s t o r y of t h e melon h u n t e r emphasizing t h e need t o l i s t e n and tune i n t o where people a r e , working with them t o b r i n g about change r a t h e r than f r i g h t e n i n g them w i t h a q u i c k o r powerful answer.

-

107. The i n d i v i d u a l performance: 1. 2.

has

a

big

role

to

play

in

the

three

aspects

of

3.

r e l a t e d t o o n e ' s own g o a l s and a b i l i t i e s . r e l a t e d t o o n e ' s p e r c e p t i o n of o n e ' s r o l e , priorities and w h a t thar role m i g h t s c h i e v e . This a l s o depends on rhe e x t e n t t o which one i s p r o a c t i v e r a t h e r t h a n r e a c t i v e o r p a s s i v e . Being allowed t o do i t - r e l a t e d t o o n e ' s p e r c e p t i o n of t h e c o n s t r a i n t s o r o p p o r t u n i t i e s (whether something i s viewed a s an o p p o r t u n i t y r a t h e r t h a n a c o n s t r a i n t ) and i s r e f l e c t e d i n t h e d e g r e e of i n i t i a t i v e one shows.

Being a b l e t o do something Being w i l l i n g t o d o it

-

-

108. The i n d i v i d u a l can bc hclpcd by o t h e r s t o m a k e changes in t h e three a r e a s , b u t t h e changes have t o s t a r t from w i t h i n . SDT i s committed t o f a c i l i t a t i n g t h e s e changes, u s i n g t h e above t h r e e a r e a s a s s t a r t i n g p o i n t s .

1 . The o b j e c t i v e of t h e SDT programme i s t o h e l p s t a f f a t a l l l e v e l s t o b e f u l l y p r e p a r e d t o provide support t o c o u n t r i e s i n a c h i e v i n g t h e i r HFA strategy, through b e t t e r u n d e r s t a n d i n g and a p p l i c a t i o n of WHO'S p o l i c y , programmes and managerial p r o c e s s . Supporting and d e v e l o p i n g t h i s a b i l i t y i n WRs i s g i v e n h i g h p r i o r i t y . 120. The SDT programme i s o u t l i n e d i n t h e Manual 11.8 and t r a i n i n g f o r WRs i n the Manual 1.2:190. The approach t o WR development h a s been o u t l i n e d i n a band-out. WRs have been i d e n t i f i e d a s a key group, b o t h i n terms of need and their p o t e n t i a l r o l e i n t h e work of t h e O r g a n i z a t i o n . The i s s u e h a s been discussed at l a ~ l g t li~ n PDWGs and G P C s and has been g i v e n a high p r i o r i t y . h t r a i n i n g programme f o r WRs h a s commenced w i t h f u r t h e r development: planned i n terms of follow-up and ongoing e d u c a t i o n f o r WRs. T r a i n i n g i s , however, but a p a r t of a n o v e r a l l approach t o improving t h e performance of t h e 90-or-so WRs, which i n c l u d e s : improved s e l e c t i o n , so t h a t the b e s t a v a i l a b l e p e r s o n s a r e i d e n t i f i e d and s e l e c t e d ; b e t t e r p r e p a r a t i o n , t r a i n i n g and ongoing e d u c a t i o n , t o i n v o l v e t o t h e maximum e x i s t i n g and new WRs, b u i l d i n g on t h e i r strengrhs and drawing out their innate a b i l i t i e s , so that t h e i r skills and e x p e r i e n c e r a n be f u l l y used f o r KFA; s t r e n g t h e n i n g of mechanisms t o p r o v i d e t h e ongoing s u p p o r t r e q u i r e d by WRs. T b i s i m p l i e s improving the a b i l i t y of s t a f f a t a l l l e v e l s t o p a r t i c i p a t e i n t h e p r o c e s s of s u p p o r t i n g WHO'S m i s s i o n at c o u n t r y l e v e l , through t h e WR.

111. The o v e r a l l aim i s t o e n a b l e WRs t o m o b i l i z e and maximize t h e i r own r e s o u r c e s and t h o s e of t h e people wirh whom t h e y work, and a L he s a m e t i m e demonstrate and f a c i l i r a t e t h e key p r i n c i p l e s of HFA. The SDT programme f o r WRs and o t h e r s t a f f encompasses b r i e f i n g , s k i l l development i n managemenr, r n m m l i n i r a t i o n and language, s u p p o r t t o i n d i v i d u a l s , support t o t h e Region, c o n t i n u i n g e d u c a t i o n and i n - s e r v i c e t r a i n i n g .

page 24

112. Teamwork is an important aspect, firstly as part of training and development of skills in working together, but more importantly in SDT. All are responsible for contributions to the overall development of the people and the organization they belong to in their self-development and in their encouragement of learning and change in others. SDT'S role is to facilitate this process.

-

113. SDT is but one component of personal growth and development. There is SDT goes strong c o n u ~ ~ i l m e r l tLu l i l i k i r ~ g tlris w i t h u i g a n i z a t i o n a l change. beyond courses and workshops and includes a variety of activities and work assignments such as some which already occur in EMRO (participation in HFA leadership activities, in Joint Programme Review Missions and the use of STCs to allow Regional Office staff to participate in country level activities). 114. Dr Khogali pointed out that EMR would training seminar for WRs as part of SDT. be hosting an interregional

115. In reply to a comment on the need for refresher training for staff posted for long periods in hardship posts, the Regional Director repeated that, as stated in the ~ntroduction,he favoured the attendance of field staff at meetings of experts for this purpose. Ilb. A number of participatns queried the usefulness of SU'L', when on return from training a staff member was still subject to unchanged restrictive In reply, the Regional Director gave his supervision at a number of levels. o p i n i o n t h a r SDT s h o l ~ l dh~ n p p l i ~ dat levels of the Organization.

VII-5.1. Recommendations Recommendat ion 12 The need for involvement of long-term field staff in SDT was endorsed; WRs

should

identify

their

needs

for

refresher

training

to

update

their

technical capabilities. VIII. C L O S I N G S E S S I O N Dr 0 . Sulieman submitted the draft report of the meeting and asked for comments and amendments to it, as -well as suggestions for future meetings. Suggestions included:

-

that WRs might be allowed to meet alone together for 1 or 2 hours before the meeting to elect a chairman, discuss their mutual problems and constraints and list the main points to guide discussions in the open meeting ; that future WRs' meetings might be held in countries with a WR'S office, so that the actual situation could be studied on the spot, although this could be more costly than using the Regional Office;

EM/WK/S-E

page 25

t h a t each WR might s e l e c t onc programme i n h i s country o f

crceignment

to

present a situation report, followed by a technical assessment by the relevant Regional Adviser; the entire country programme should be presented;

that the Sixth Meeting might be devoted to health resource mobilization, in collaboration with Headquarters; that the presence of the WRs might be used activities, such as the use of the computer; for specific training

that the subject of the image of WHO might be included in the Sixth Meeting, WRs to provide innovative ideas of how to make WHO better known, using the occasions of the 40th anniversary of WHO, the 10th anniversary o t the Alma-ATa Declaration and World Health (NO s m o k i n g ) Day. WRs should commence work on this subject without delay. The Chairman, Dr Aref El Yafi, thanked the Regional Director for the personal support and guidance extended to him during the sessions. He also thanked the Director, Programme Management, the WRs and all EMRO staff who participated in the meeting for their collaboration. W e emphasized that WHO had a good image and reputation at country level in this Region, as well as in other regions, which depended to a large extenc on t h e performance and c o n d t l r t n f WHO field staff, including WRS. and on their seriousness and sincerity in discharging their duties, as well as on their unlimited tolerance and their success in day-to-day contacts with national partners. These qualities were supported by the technical and administrative guidance of the Regional Office, leading to a two-way understanding and collaboration between the field and the Office.

The c o n t i n u i n g development and t r a i n i n g o f WHO s t a f f in the field should be maintained at the highest standard possible. They should be given access to more ~egional Office activities, intercountry meetings, workshops and training courses, so that they will be able to match, and even surpass, the rapid development and training of nationals. Otherwise nothing could prevent the image and the reputation of WHO from being jeopardized.

EM/WK/S-E

page 2 6

ANNEX I PROG RAMME Sunday, 7 June 1987 08.30 a.m.09.00 a.m.

Address by Dr Hussein A. Gezairy, Regional Director Management of Implementation of WHO'S Collaborative Programme with Countries, by Dr A. Khogali, Director, Programme Management Briefing on District Health Systems, by Dr J.U. Martin, Kesponsible Ufficer, ~istrictHealth Systems, WHO/HQ

Transverse Evaluation of the Programmes, Country Example by Dr A. Rahmani, A/WR Somalia. Discussion of major problems faced and proposed solutions

Monday, 8 June 1987 Financial Audit in Policy and Programme Terms, by Mr A . Piel, Director, Support Programme. Discussions Programme Management Information for WHO Programme Development, WR Framework,by Dr E. Hammoud, Acting Director, Health S y s t e m Infrastructure and D r

A. Amini,

WR, Democratic Yemen.

Discussions

*

Coffee Break: 10.30 - 11.00 a.m.

EM/WR/S-E page 27

Monday, 8 June 1987 (Cont'd) Joint Government/WO Programme Review Missions: Experiences from and followup to the last round of JPRMs (including plans of action/workplans and timely requests for consultants, supplies and equipment, fellowhsips, etc.), by Dr 0. S u l i e ~ o a n , R t i g i u a a l Advisei-, I l e a l t h Programme Development, and Mr A. Piel, Director, Support Programme. Discussions Tuesday, 9 June 1987 08.30 a.m. - 14.00 p.m. Progress reporLs OZI;

-

Acquired Immunodeficiency Syndrome (AIDS), by Dr M.H. Wahdan. Director, Disease Prevention and Control by Prof. J. Ling

- Information and Education for Health,

-

HFA Leadership Development, by Dr O . I . W . h e r , ~irector, Health Manpower Development.

School Health Curriculum, by Dr 0. Sulieman, Regional Adviser,Health Programme Development Staff Development a n d Training, by

-

Dr W.J. Pigott, Programme Manager, Staff Development and ~raining,WHO Headquarters. Discussions ~ r e o e n t a t i o nof films.

Meetings with technical programmes and administrative units

Thursday, 11 June 1987 , 07.30 a . m .

-

12.30 p.m.

Meetings with technical programmes and

administrative units Final Report and Closing Session.

page 28

ANNEX I1 L I S T OF PARTICIPANTS Dr M. Rahman WHO Representative Kabul AFGHAN ISTAN

Aden DEMOCRATIC YEMEN

WHO

Dr A. Arnini Representative

Dr R. Wassef WHO ~epresentative Djibouti DJ IBOUT1 .. Dr Ashfaq Alam Khan WHO Representative Teheran LSLAMIG REPUBLIC OF I R A N

Dr J. Jirous WHO Representative

Dr P.L. Giacometti WHO Representative Muscat OMAN

Dr Nabil S. A1 Tawil WHO ~e~resentative Islamabad PAKISTAN Dr M. A r e £ El Yaf i W f 3 0 Representative

Riyadh SAUDI ARABIA Dr A.M. Rahmani WHO ~epresentative,Lebanon a n d Acting WHO Rcprcscntntive, Somalia

Mogadishu SOMALIA Dr Mohammed Jarnil Khan WHO Representative Khartoum SUDAN

page 29

Dr Abdul Majid Abdul Hadi WHO Representative for Jordan

and Syrian Arab Republic Damascus SYRIAN ARAB REPUBLIC Dr Zamil A. A1 Alawy WHO ~epresentative Saua ' a

YEMEN Dr H.J.H. Hiddlestone Director of Health and WHO Representative UNRWA Vienna AUSTRIA

WHO REGIONAL OFFICE AND HEADQUARTERS

Dr Hussein A. Gezaixy, Regional Director Dr A. Khogali, Director, Programme Management Dr 3.D. Martin, Responsible officer, District Health Systems, Geneva Mr A. Piel, Director, Support Programme Dr M.H. Wahdan, Director, Disease Prevention and Control Dr O . 1 . H . Omer, Director, Healrh Manpower DevelopmrnL Dr M.H. Khayat, Director, Health Protection and Promotion Dr E. Hamoud, Acting Director, Health System Infrastructure Dr M.L. Sheikh, Chief, Environmental Health Programme Development Dr W . J . Pigott, Programme Manager, Staff Development and Training, Geneva Professor J. Ling, WHO Consultant Regional Advisers and administrative assistants also attended.

EM/WR/5-E'

page - 30 ANNEX I I I AGENDA

Address by Regional Director Management of implementation of WHO'S collaborative programme with countries

-

isc cuss ion of major problems faced and proposed solutions

Programme Management Information for WHO Programme Development Joint Government/WHO Programme Review Missions:

-

Experiences from and follow-up to the last round of JPRMs (including plans of actions/workplans and timely requests for S T C s , Supplies and Equipment, Fellowships, e t c . )

Briefing on District Health Systems Progress reports on: -'

School Health Curriculum AIDS

-

HFA Leadership Development

Scarf Development and Training

Any other business