The work of WHO in the South-East Asia Region: Report of the Regional Director 1 July 2004 - 30 June 2005

Report of the Regional Director 1 July 2004 – 30 June 2005

SEA/RC58/2

The Work of WHO in the South-East Asia Region

Report of the Regional Director 1 July 2004 – 30 June 2005

World Health Organization Regional Office for South-East Asia New Delhi June 2005

The rainbow on the cover vividly illustrates the feeling of hope and confidence in the Region. It also heralds the period of reconstruction and of rehabilitation of thousands of lives that were so suddenly shattered by the devastating tsunami of December 2004.

© World Health Organization 2005 Publications of the World Health Organization enjoy copyright protection in accordance with the provisions of Protocol 2 of the Universal Copyright Convention. For rights of reproduction or translation, in part or in toto, of publications issued by the WHO Regional Office for South-East Asia, application should be made to the Regional Office for South-East Asia, World Health House, Indraprastha Estate, New Delhi 110002, India. The designations employed and the presentation of material in this publication do not imply the expression of any opinion whatsoever on the part of the Secretariat of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. iv THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION

Printed in India

Contents Page PREFACE ............................................................................................. vii EXECUTIVE SUMMARY ......................................................................... ix 1. COMMUNICABLE DISEASES .......................................................... 1 Emerging Disease Surveillance and Response ..................................... 1 Communicable Disease Prevention and Control .................................. 5 Diseases Targeted for Eradication/Elimination ................................... 16 Immunization and Vaccine Development .......................................... 23 Blood Safety and Laboratories ......................................................... 26 Research and Development ............................................................ 29 NONCOMMUNICABLE DISEASES AND MENTAL HEALTH ................................................................ Surveillance, Prevention and Management of Noncommunicable Diseases ....................................................... Tobacco ....................................................................................... Health Promotion .......................................................................... Injuries, Violence and Disabilities ................................................... Mental Health and Substance Abuse ................................................ FAMILY AND COMMUNITY HEALTH............................................. Child and Adolescent Health .......................................................... Reproductive Health ...................................................................... Making Pregnancy Safer ................................................................. Women’s Health ........................................................................... Nursing and Midwifery .................................................................. Nutrition ..................................................................................... SUSTAINABLE DEVELOPMENT AND HEALTHY ENVIRONMENTS .................................................. Sustainable Development .............................................................. Health and Environment ................................................................. Food Safety .................................................................................. Emergency Preparedness and Response ...........................................

2.

31 31 34 36 38 39 43 43 46 48 50 51 52

3.

4.

55 55 56 67 70

v THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION

5.

HEALTH SYSTEMS DEVELOPMENT ............................................... Organization of Health Services ...................................................... Evidence for Health Policy .............................................................. Research Policy and Cooperation ..................................................... Essential Drugs and Medicines ....................................................... Knowledge Management and Dissemination .....................................

77 77 82 85 89 93

6.

PROGRAMME PLANNING AND MANAGEMENT .......................... 97 Governing Bodies ......................................................................... 97 Resource Mobilization, and External Cooperation and Partnerships ............................................................................... 105 General Management .................................................................. 108 WHO’s Presence in Countries ...................................................... 118 Public Relations and Media ........................................................... 119 Regional Director’s Development Fund ......................................... 122

ANNEXES 1 Organizational Structure ............................................................... 123 2 Budgetary Implementation, 2004-2005, by country/ intercountry (RB) .................................................................... 124 3 Budgetary Implementation, 2004-2005, by area of work (RB) ............ 125 4 Budgetary Implementation, 2004-2005, by country/ intercountry (EB) .................................................................... 126 5 Budgetary Implementation, 2004-2005, by area of work (EB) ............ 127

vi THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION

PREFACE In the global quest for better health, the South-East Asia Region of WHO can set or mar the pace. With its 11 Member States and nearly a fourth of the world’s population, the Region faces the double burden of communicable and noncommunicable diseases as well as the threat of emerging and re-emerging diseases. In addition, six Member States of the Region were devastated by the worst ever, earthquakegenerated tsunamis on 26 December 2004. This unprecedented event also brought forth an overwhelming and spontaneous response from the world community. In collaboration with the Member States and development partners, WHO played a vital role in coordinating the health sector response and in providing emergency health care to the affected population. Steps were also taken to ensure that health facilities were restored as quickly as possible. As a result of these coordinated efforts, no major outbreaks of any diseases were reported from the devastated areas. This was commendable indeed, reflecting the resilience and inherent strength of health systems in the respective Member States. While the tsunami certainly overshadowed most other activities, important areas of health development were, however, given due attention. These included efforts to eliminate or eradicate certain communicable diseases, prevent and control noncommunicable diseases, promote family and community health as well as sustainable development and healthy environments, strengthen health systems development and to streamline programme planning and management.

vii THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION

This report provides details of such collaborative efforts. It also highlights the achievements, the challenges and the strategies adopted to achieve the desired results. What stands out vividly is that, despite the formidable odds facing the Region, concerted efforts are being made to reach the set targets. This is particularly so with reference to the Millennium Development Goals. As the tsunami and the epidemics of SARS and avian influenza clearly showed, both Member States and WHO have to be ever vigilant and prepared to effectively respond to such situations. WHO stands committed, as always, to support Member States in their efforts to create a healthier future for their people. It is with this assurance that I present my Report on the Work of WHO in the South-East Asia Region during the period 1 July 2004 – 30 June 2005.

Samlee Plianbangchang, M.D., Dr.P .H. Regional Director

viii THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION

EXECUTIVE SUMMARY Communicable Diseases Communicable diseases cause a large number of deaths and disability in the South-East Asia (SEA) Region, which suffers disproportionately from this burden. Each year, 750 000 adults in the Region die of TB and 250 000 children of measles. More than six million people are living with HIV/AIDS and 250 million are at risk of contracting a severe form of malaria. In addition, the Region faced epidemics of emerging infectious diseases, adding to the burden of the health systems. Severe acute respiratory syndrome (SARS) and avian influenza are recent examples of such diseases which caused enormous health and socioeconomic hardship and posed a major threat to health security across countries, and beyond national borders. Dengue/DHF, the Nipah virus and the new strain of cholera (V.cholera 0139 Bengal) are spreading to new areas, while ageold diseases like leprosy, kala-azar and lymphatic filariasis continue to cause considerable suffering and psychosocial disruption. Moreover, drug resistance is a serious and emerging problem. In order to effectively deal with these threats to human health, good progress has been made in systematically approaching the problem. In the aftermath of avian influenza and SARS, the Regional Office developed a “vision paper on emerging diseases in the SEA Region”, which provides a strategic and policy framework for combating the new, emerging and re-emerging diseases. Assessment of surveillance and response capacity has been carried out in many countries and national epidemic preparedness plans are being developed. Risk communication, strategic stockpiling of essential drugs, vaccines and diagnostics, and research are being strengthened. A strategic health operations centre (SHOC) is being established in the Regional Office. While a communicable disease

ix THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION

surveillance and response sub-office is being established in the WHO Representative’s office in Thailand. In this regard, three examples of the Regional Office’s proactive role in communicable disease control stand out. The first relates to the tsunami which struck on 26 December 2004; the second, in facilitating the revision of the International Health Regulations, and the third, in achieving lowest-ever levels of polio transmission in the Region. Following the unprecedented tsunami crisis, the response from Member States, WHO and other partners was swift. The Regional Office mobilized and coordinated Organization-wide technical support to all affected countries. This included the establishment of an emergency surveillance and early warning system, verification of and response to outbreaks, mobilization and rapid deployment of more than 200 experts and WHO staff from within and outside the Region, provision of nearly 90 technical guidelines and best practices, and ensuring stockpiling of life-saving drugs and vaccines, as well as of diagnostics. The fact that no major communicable disease epidemics occurred in the Region following the tsunami is proof of the commendable work done by public health professionals in Member States, in close collaboration with WHO and other partners. WHO also played a key role in mobilizing opinions and views in Member States which ultimately led to the development of a consensus on new regulations for managing public health emergencies of international concern, adopted by the World Health Assembly in May 2005. The revised International Health Regulations (IHR) replace the current regulations, which were adopted in 1969. The purpose is to ensure maximum protection of people against the international spread of diseases while causing minimum interference to world travel and trade. During the period under review, the Region achieved the lowest levels ever recorded for polio transmission. In 2004, only 134 cases were detected in India, and in 2005, only 15 cases as of 31 May. All other countries in the Region have been free from indigenous polio since 2000. However, as a recent contact case in Nepal and an imported case in Indonesia demonstrate, all countries continue to be at risk until wild polio is finally eradicated. The key challenge is to end polio

x THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION

transmission in India while continuing to maintain high-level acute flaccid paralysis (AFP) surveillance in the rest of the Region. WHO will continue to provide direct technical support for surveillance as well as assist in expanding AFP surveillance to include other vaccine-preventable diseases where appropriate. Routine immunization services have been improving steadily throughout the Region, as evidenced by the increase in DTP3 coverage rates. While countries are using auto-disable syringes, further work is necessary to ensure safe disposal of all sharps waste. Leprosy is expected to be eliminated as a public health problem at the national level, except possibly in Timor-Leste, by the end of 2005. In a significant move, the Director-General decided to shift the Global Leprosy Programme to the SEA Region and, since March 2005, the Programme is located in and managed by the Regional Office. The Region has embarked on two new initiatives – Kala-azar Elimination by 2015 in three endemic countries, namely Bangladesh, India and Nepal; and Yaws Eradication from India, Indonesia, and Timor-Leste. A regional strategy and national plans of action for kala-azar elimination have been developed. Political commitment and regional solidarity were demonstrated by the signing of a Memorandum of Understanding by Bangladesh, India and Nepal during the World Health Assembly in May 2005. Soon, yaws could become a thing of the past. Good progress is also being made in the elimination of lymphatic filariasis. HIV/AIDS is a major concern not only for health development but also for socioeconomic development in the Region. Recognizing the multisectoral determinants of HIV, the response also requires a multidisciplinary approach. Thus, on the recommendation of WHO, countries have mainstreamed HIV prevention, care and treatment into their ongoing national programmes within health systems, such as adolescent health, reproductive health, nursing, and TB control. Remarkable progress in TB control has been achieved in the Region. Commendable DOTS expansion, especially in India, Indonesia and Myanmar, without compromising on quality, is widely acknowledged. Three countries, namely DPR Korea, India, and Maldives, have already achieved the global target of 70% case detection and 85% treatment success, while others are expected to achieve these targets. It is clear that the global progress in TB control is now driven by the efforts being made in the Region.

xi THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION

With regard to malaria, the Region reports very high morbidity with its associated human suffering and economic hardship. Moreover, the increasing trend of malaria caused by Plasmodium falciparum and the emergence and possible spread of drug resistance are causing grave concern. WHO has established a Regional Technical Advisory Group (RTAG) to advise on the technical and operational aspects of the programme. In this context, a new policy and strategic framework which looks beyond the traditional approach is being developed in consultation with experts from RTAG and Member States. Besides technical support, WHO has continued to assist Member States in the preparation of good quality proposals to the Global Fund to fight AIDS, TB and malaria (GFATM), as well as in their implementation and technical monitoring and evaluation. In the first four rounds, all countries except Maldives had their proposals approved by the GF Board. In the fifth round, specific attempts have been made to build health system capacity and technical support components as an integral part of the proposals. Collaboration and partnership with the Regional Office for the Western Pacific (WPRO) is also gaining strength in many areas of communicable disease control. For example, an AsiaPacific strategy on emerging diseases was developed jointly, a document articulating the TB situation in Asia and the Pacific was prepared and a meeting of programme managers held.

Noncommunicable Diseases and Mental Health The progressive increase in the prevalence and incidence of noncommunicable diseases (NCDs) is the consequence of the rapid demographic changes and unhealthy lifestyles in the Region. Over the last few decades, firm scientific evidence has become available on the role of risk factors such as tobacco consumption and alcohol abuse, unhealthy diets, physical inactivity as well as indoor and outdoor air pollution. The role of elevated blood pressure, overweight, and high levels of cholesterol and sugar in triggering major NCDs is also unequivocal. These largely modifiable risk factors contribute to an estimated 42% of all deaths occurring in the Region. Diabetes, cardiovascular diseases and cancer stand out as the most prevalent causes of morbidity and mortality.

xii THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION

A Regional NCD control programme has been developed within the framework of the Global Strategy. Also, a regional network for prevention of chronic diseases, SEANET-NCD, has been established with the involvement of national NCD networks. Through this network, NCD risk factor prevention and health promotion activities have been undertaken. WHO is currently working closely with nine Member States in the development of a national NCD InfoBase on risk factors and case prevalence/incidence, in order to strengthen the surveillance and control of NCDs. With intensive advocacy by WHO and its partners during the last few years, tobacco control activities in countries have been intensified. All countries in the Region, except one, have signed the WHO Framework Convention on Tobacco Control (FCTC) and nine have ratified it. The countries that have ratified the Convention are either developing new, or amending existing legislation, in line with the provisions of the Convention. In order to facilitate the sharing and exchange of information on tobacco control, a Regional Online Database System has been developed, linking it to a global portal managed by the Tobacco Free Initiative (TFI) programme at WHO headquarters. National action programmes for reduction of tobacco use among youth were initiated using the findings of the Global Youth Tobacco Survey (GYTS) carried out in nine countries in the Region. Since the adoption of the Ottawa Charter on health promotion, WHO has worked closely with Member States to make health promotion programmes a leading and vital component of public health. However, progress in the implementation of major strategies such as creating healthy settings, and promoting healthy lifestyles, has been slow. The results of a regional exercise in “Mapping of capacity to promote health” undertaken in 2003-2004, revealed that most countries still lacked human and financial capacity, particularly leadership and sustainable financial mechanisms, in developing and implementing comprehensive health promotion programmes. To respond to these challenges, a regional strategy on comprehensive health promotion was developed with the full involvement of national focal points for health promotion.

xiii THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION

Injuries and violence kill 5.1 million people worldwide, of which more than a quarter are from the SEA Region. Blindness and deafness constitute two of the most important disabilities in the Region. Regional strategies for prevention of injuries and violence, as well as for prevention and control of blindness and hearing loss have been developed. They are focused on strengthening service delivery, improving human resources and enhancing advocacy through generation of evidence. A challenge for Member States is to guard against the tendency to take a disease-based psychiatric model for mental health services rather than a broad-based view of mental wellbeing. The regional mental health promotion strategy, developed in 2004, was based on the identification of determinants of risk factors for mental illness and interventions for ensuring good mental health. These strategies include mental health promotion in schools using the lifeskills approach and development of a model for the use of traditional methods such as meditation as a public health strategy. WHO is working closely with Member States in implementing these strategies, as part of community-based mental health care. WHO is also helping Member States in developing and implementing appropriate and updated mental health legislation and the related regulatory framework. This will help enhance community-based mental health promotion programmes and provide legal recourse and protection to mentally-ill individuals. Harm from alcohol abuse is a serious issue affecting some countries. Of particular relevance is the linkage between poverty and rural alcoholism using home-brewed and illicit alcohol. Substance abuse is assuming multiple dimensions, such as the use of amphetamines in some countries and injecting drug use in others. WHO is working with other development partners, UN agencies and NGOs in implementing WHO’s strategy for empowerment of the community through information and knowledge to reduce the demand for, and harm from, alcohol and other substances of abuse.

Family and Community Health xiv THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION

The Region accounts for over one third of the global child mortality. Policy support was provided to Member States for

incorporating evidence-based child health initiatives. The Integrated Management of Childhood Illness (IMCI) strategy addresses major causes of child mortality. Technical support to countries and regional capacity for implementing IMCI was enhanced. The Regional Office continued to assist in scaling up IMCI in countries. Neonatal survival is a major challenge in the Region which accounts for 1.4 million deaths. Countries are in different stages of finalizing strategies for neonatal health with technical support from WHO. Adolescents represent almost one fourth of populations in countries of the Region. Collation of epidemiological data on adolescents has been initiated. A Regional Technical Advisory Group on Adolescent Health and Development has been constituted to guide the work in this area. The SEA Region has been identified among the WHO regions to focus on HIV and young people. The adolescent health and HIV/AIDS programmes are working closely in this endeavour. The challenge in the Region is to ensure the widest achievable range of safe and effective reproductive health services across the health system and their integration into primary health care. Efforts are being focused to support countries in ensuring skilled care at every birth. Evidence-based norms, standards and tools continued to be promoted to improve the quality of care in maternal and newborn health, family planning, unsafe abortion and control of RTIs/STIs. Work in this area has been carried out in close collaboration with Member States, UN agencies, development partners and NGOs. The impact of gender inequities on women’s health is an area of concern in the Region. WHO-supported capacitybuilding programmes focused on reshaping medical education to ensure that gender issues were integrated into the planning and delivery of services and public health core competencies. Capacity of health workers and policy-makers was strengthened through stand-alone courses covering HIV/AIDS, sexuality and applied research in gender. Attention was given to strengthen nursing and midwifery workforce management in the Region. Guidelines for strengthening nursing and midwifery workforce were disseminated. Capacity building of nurses and midwives through regional training of trainers programmes on nursing and midwifery management in HIV prevention, care and

xv THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION

support, and preparation of educational modules on malaria and injury prevention were undertaken. Although there has been a decrease in its prevalence, malnutrition – both protein energy malnutrition and micronutrient deficiencies – continues to be a major public health problem. Member States are implementing the Global Strategy on Infant and Young Child Feeding and the Global Strategy on Diet, Physical Activity and Health.

Sustainable Development and Healthy Environments Member States have responded positively to the Report of the Commission on Macroeconomics and Health (CMH) published in 2002 which highlighted that investment in health yields high economic returns, stimulates economic growth and contributes to poverty reduction. While three countries developed national plans for scaling up essential health interventions, three others are in the process of doing so. The Region can achieve the Millennium Development Goals for safe water supply if two countries where this is a major challenge are able to meet their targets. With regard to sanitation, major strides have been made by several countries following the South Asia Conference on Sanitation held in Dhaka in 2003. Two countries – Bangladesh and India – have committed themselves to Total Sanitation by 2010 and 2012 respectively. WHO continued to produce norms and guidelines that can be introduced in country programming for water supply and sanitation. The Guidelines for Drinking Water, published in 2004, boosted country-level interest in water quality and related health risk assessments. The launch of the UN International Decade for Action, “Water for Life”, in March 2005 helped to raise awareness in most countries of the Region. Following the tsunami of 26 December 2004, support for water and sanitation capacity was mobilized throughout WHO and its partner network. Experts were provided at site to support governments with information, restoration of water supplies and sanitation facilities for displaced populations. xvi THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION

Healthy settings initiatives as an effective approach to supplement capacity building were successfully demonstrated in Maldives and Sri Lanka.

A field guide for the detection, management and surveillance of arsenicosis was finalized and used for training. Risk assessment and research on treatment modality and pathogenesis of arsenicosis were supported in several countries. To mitigate arsenic poisoning in the Region, a multicountry initiative focusing on risk mitigation, capacity building and infrastructure strengthening was launched. A regional occupational health strategy has been formulated. The available information is being reviewed for curriculum development for capacity building. Many Member States are developing national action plans for chemicals management. Some are also in the process of becoming parties to four international agreements on sound management of chemicals. Support was extended for the preparation of documents and guidelines for infection control. A distance learning course was facilitated and the development of policies and systems to deal with immunization campaigns and hospital wastes in Bangladesh, Bhutan, India and Nepal were supported. WHO also promoted a comprehensive approach to address vector control management through the use of integrated vector management principles. To boost environmental protection to safeguard children’s health, three research studies on children and environmental health and two pilot studies on indoor air quality were supported in Bangladesh, Bhutan, Indonesia, Maldives, Nepal and Timor-Leste. School-based environmental health models promoting educational games were used in the studies. Bhutan and Timor-Leste initiated sur veillance and prevention of foodborne health hazards. Countries were encouraged to get more involved in the work of the FAO/ WHO Codex Alimentarius Commission.

Health Systems Development To meet the major challenges in the delivery of health services, the ‘South-East Asia Public Health Initiative: 2004-2008’ was launched. It includes the formation of the South-East Asia Public Health Educational Institutes Network (SEAPHEIN) and xvii THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION

initiation/facilitation of faculty exchange among countries of the Region. Public health legislation and assessment of public health functions were undertaken. Extensive technical guidance was provided to Member States in patient safety and quality assurance. WHO is actively promoting curriculum reform in medical schools. Issues such as gender and women’s health were also addressed. A regional core curriculum for laboratory technicians was developed. Information is the basis for evidence-based decision-making in health policy and health systems analysis. The main regional strategy for management of data and policy analysis requires strengthening of national health information systems for monitoring the progress relating to MDGs. Health profiles were prepared to provide information on the health system framework in each country. The Regional Office collaborated with the Regional Office for the Western Pacific (WPRO) in strengthening health information to identify issues and challenges in the collection, compilation, analysis and dissemination of core indicators including MDGs. A dataset of core health indicators (CHI) was created for monitoring health status and health system performance. A 2005 Core Health Indicators Brochure for Asia and the Pacific was published. WHO-supported training activities were carried out in regard to the International Classification of Diseases. The Regional Office also collaborated with the Regional Office for the Western Pacific in developing a bi-regional strategy on health care financing. In view of the outbreaks of SARS and avian influenza, the SEA Advisory Committee on Health Research (SEA/ACHR) discussed ‘Emerging Infectious Diseases’, at its 29th session in June 2004. It recommended stronger political support for health research; improvement of surveillance; development of new diagnostics as well as new vaccines and drugs; strengthening of laboratories, and analysis of the socioeconomic impact on health systems. Member States were urged to develop a national policy on emerging diseases. A high-level Ministerial Summit on Health Research, held in Mexico in November 2004, was attended by ministers of health and science and technology from the Region. One of the recommendations of the summit was that Member States should set aside 2% of their national budgets for research.

xviii THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION

Teaching guidelines on medical ethics were tested in seven medical schools of the Region while some schools reviewed their existing medical ethics curriculum. To provide safe, effective and good quality drugs to people, Sri Lanka prepared a draft policy, India amended its national patent legislation to be in line with the TRIPs agreement, and Bangladesh started work on the enactment of a Patent Legislation by 2016. India and Sri Lanka initiated work on the WHO-Health Action International (HAI) project on Medicine Prices with a view to contributing to the Global Database. India, Indonesia and Thailand are already producing anti-retrovirals (ARVs). Simple monitoring for adverse drug reactions has now advanced to pharmacovigilance. The Region, with increasing expertise in the manufacture of medicines, contributed to international consultation, as well as international standards-setting. Fruitful collaboration among countries of the Region was observed in the areas of combating counterfeit medicines and in the procurement of medicines for HIV/AIDS. “Guidelines for Regulation of Herbal Medicines in the SEA Region” were published and were being used also by other regions. Information materials were digitized and knowledge management activities, e.g. Global Health Library, e-health and Health InterNetwork Access to Research Initiatives (HINARI) pursued actively. Product-oriented technical support was provided through the HELLIS Network. Cost-effective access to international scientific literature in health was also provided. Staff members were trained in identification, accessing, sharing and dissemination of information.

Programme Planning and Management As recommended by the forty-first meeting of the Consultative Committee for Programme Development and Management (CCPDM), the Regional Director established a Working Group to develop guiding principles for distribution of WHO funds to the Region. The Group was also requested to provide guidance on horizontal collaboration and intercountry activities since the ICP II mechanism will be phased out from the 2006-2007 biennium. The Group recommended that the guiding principles for budget allocations to the Region, as well

xix THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION

as to countries, should be based on health needs by using objective and internationally-accepted health indicators, which take into account a country’s population. The Working Group also concluded that the criteria currently guiding multicountry initiatives should continue and recommended that at least 5.35% (current ICP II) of each country budget should be reserved for multi-country activities. Efforts at mobilization of voluntary contributions in the Region have been significantly intensified and enhanced through a number of regional and country initiatives. The Regional Office developed and implemented a Strategic Action Plan for Resource Mobilization for 2004-2005 and organized a number of consultations and meetings with development partners which provided a good forum to apprise partners of WHO’s activities and identify funding opportunities. Country offices worked closely with development partners and concluded a number of project agreements and Memoranda of Understanding on funding support to WHO at country level. The close collaboration and coordination within WHO was maintained and strengthened. The Regional Office provided technical support to Member States in the preparation of proposals for the Global Fund to fight AIDS, TB and Malaria. Several regional and country workshops on skill development for resource mobilization were held to strengthen technical capacity. As a result, resource mobilization during the period under review reached the highest level in recent years: as of 30 March 2005, the total allocation of voluntary contributions to the Region was US$ 193 million (including tsunami funding of US$ 31 million) – well over the biennium target of US$ 191.5 million. Strengthened WHO coordination and collaboration with partners at regional and country levels contributed to bringing health into the multisectoral development agenda. The United Nations Economic and Social Commission for Asia and the Pacific (UNESCAP) adopted a landmark resolution on Regional Call for Action to Enhance Capacity for Public Health in May 2005.

xx THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION

WHO developed a Strategic Framework for Collaboration with the Association of South-East Asia Nations (ASEAN) and had a number of discussions with the South Asian Association of Regional Cooperation (SAARC) to further improve partnerships. Following active coordination and collaboration of WHO country offices with governments, UN system agencies and development partners, new versions of United Nations Development Assistance Framework (UNDAF) were developed in Bangladesh and Sri Lanka. In the area of public information and advocacy, the Region faced many challenges. Prime among these were the overwhelming media demands for WHO expert comments following the tsunami, and the return of avian iInfluenza in the Region. In collaboration with WHO headquarters, communications professionals were mobilized and placed in the tsunami-affected countries. A draft communications/media strategy was developed for the Region, in additon to a special tsunami communication strategy. Regular media training for professional staff, with the focus on “risk communications”, was also initiated.

xxi THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION

1

COMMUNICABLE DISEASES Emerging Disease Surveillance and Response Emerging infectious diseases are a growing threat to health security worldwide, particularly in the South-East Asia Region. Hitherto unrecognized infectious diseases continue to emerge, challenging the health systems in Member States. The pandemic of SARS and the outbreak of avian influenza, which were both unprecedented in their scale and pace of spread, caused significant economic losses. These emerging diseases highlight the Region’s inherent vulnerability and pose a significant threat to health and socioeconomic development. During the reporting period, there were outbreaks of a number of infectious diseases in the Region including those of avian influenza, encephalitis caused by Nipah virus, dengue fever, meningococcal disease, and leptospirosis. Moreover, dengue/dengue haemorrhagic fever and a new strain of cholera

Figure 1.1: Cumulative number of confirmed human cases of avian influenza A (H5N1) in Asia reported to WHO (as of 26 May 2005)

Source: FAO/OIE/WHO, Country reports

(Vibrio cholera 0139 Bengal) are spreading to new areas. The outbreak of avian influenza led to 97 cases among human beings, with 53 deaths – a case fatality rate of 54.6% in three countries of Asia, namely Vietnam, Thailand and Cambodia from December 2003 up to the end of May 2005 (Figure 1.1). The avian influenza H5N1 virus, with its potential to cause a pandemic, therefore continues to be a major source of concern. The main challenges in combating emerging diseases include weak health systems, limited resources and inadequate preparedness. Therefore, building national capacity to recognize early and contain such threats through a strong national surveillance and early warning and response system should be considered a long-term investment. While there has been encouraging progress in advocacy and mobilization of additional resources, efforts must be enhanced to ensure sustained technical and logistic support to Member States, particularly to improve epidemic preparedness, and to verify and mobilize rapid response to disease outbreaks. This applies also to emergency and crisis situations such as post-tsunami. WHO, through its “vision paper on emerging infectious diseases in the SEA Region” emphasizes the need for regional partnerships and measures for improving capacity for surveillance and outbreak response through application of

2 THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION

proper public health tools. This vision document, developed in consultation with experts from the Region, provides the policy and strategy framework for action at regional and country levels. Within this context, an assessment of national surveillance systems was carried out in Bangladesh, India, Indonesia, Maldives, Myanmar and Sri Lanka. In addition, many countries have established outbreak verification and response systems to monitor reports and rumours of outbreaks, and to mobilize technical and logistics support. Epidemic preparedness plans are being developed in order to strengthen surveillance and laboratory capacity, risk communication, strategic stockpiling of essential drugs, vaccines and diagnostics and research capacity. Thailand has already developed an influenza pandemic preparedness plan while Indonesia is finalizing the draft. Other countries are in the process of developing epidemic preparedness plans. A Strategic Health Operations Centre is being established in the Regional Office, with a help desk and other communication facilities to improve information exchange during outbreaks and other crises. Technical guidelines on outbreak investigation and case management have been developed. The Regional Office prepares and distributes a “Daily Outbreak Update” and a quartely “Communicable Disease Newsletter”. An Asia-Pacific strategy on emerging diseases has been developed in collaboration with the Regional Office for the Western Pacific and in consultation with experts from the Region. A communicable disease surveillance and response sub-office is being established in the WHO Representative’s office in Thailand. The field epidemiology training programme (FETP) is being strengthened. Over the past years, officials from Member States attended FETP courses at the WHO Collaborating Centre for Epidemiology Training, National Institute of Communicable Diseases (NICD), Delhi, India and at the Bureau of Epidemiology, Ministry of Public Health, Thailand. Additionally, selected paramedical personnel from Bhutan, Maldives, Myanmar and Sri Lanka attended a four-week training course on prevention and control of communicable diseases at NICD, Delhi. Communicable diseases surveillance and response will be further strengthened through implementation of the revised 3 THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION

An Asia-Pacific strategy on emerging diseases has been developed in collaboration with the Regional Office for the Western Pacific

A success stor y fr om A ceh from Aceh An early warning system for targeted epidemic-prone diseases was established jointly by WHO’s Epidemic Alert and Response team and the Provincial Ministry of Health in Aceh, Indonesia by the first week of January 2005. WHO established excellent collaboration and coordination with all operational agencies providing health care to the affected populations. This resulted in weekly reporting on syndromes and immediate alerting of suspected cases for a rapid response to epidemic-prone diseases, including field case investigations and institution of appropriate interventions. The fact that so far no epidemics have occurred in the tsunami-affected province of Aceh where there are approximately 400 000 internally-displaced persons living in temporary housing, is a testament to this remarkable accomplishment.

International Health Regulations (IHR). The Regional Office facilitated consultations among countries leading to the adoption by the World Health Assembly of the new International Health Regulations. These regulations will help manage public health emergencies of international concern, such as outbreaks of avian influenza, severe acute respiratory syndrome (SARS), polio and Marburg haemorrhagic fever. They replace the current regulations, which were adopted in 1969. The purpose of the new regulations is to ensure maximum protection of people against international spread of diseases while causing minimum interference to world travel and trade. On 26 December 2004, when the tsunami struck suddenly causing severe devastation in six countries of the Region, the response by WHO was swift. With the massive international outpouring of concern and offers of support including from the Global Outbreak Alert and Response Network (GOARN) and from other partners, the Regional Office coordinated and facilitated Organization-wide technical support to all affected countries. This included the establishment of an emergency surveillance and early warning system (see an example in the box), verification of and response to outbreaks, mobilization and rapid deployment of more than 200 experts and WHO staff from within and outside the Region, provision of nearly 90 technical guidelines and best practices, and ensuring stockpiling of life-saving drugs and vaccines, as well as of diagnostics. The fact that no major communicable disease epidemics occurred in the Region following the tsunami is proof of the commendable work done by public health professionals in Member States, in close collaboration with WHO and other partners.

4 THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION

Communicable Disease Prevention and Control HIV/AIDS According to WHO estimates, there are 6.2 million people living with HIV/AIDS in the South-East Asia Region, the second most affected in the world after sub-Saharan Africa (Figure 1.2). The adult HIV prevalence rate in the Region varies from 1-2% in Myanmar and Thailand; to 0.1-1% in India, Indonesia and Nepal, and to below 0.1% in other countries of the Region, namely, Bangladesh, Bhutan, DPR Korea, Maldives, Sri Lanka and Timor-Leste. Commercial sex and injecting drug use are the two main factors driving the HIV/AIDS epidemic in the Region. “Bridging” populations such as migrant workers, truck drivers, rickshaw pullers, sailors, fishermen, and manual labourers in border areas who are more likely to become clients of commercial sex workers are spreading the infection to lowrisk populations (such as spouses and children). Although effective inter ventions to prevent HIV transmission and to provide effective care and treatment are currently being implemented, the HIV epidemic is yet to be reversed in the Region, with the exception of Thailand. This is because countries are faced with numerous challenges, such as inadequate health systems, lack of trained human resources,

Figure 1.2: Estimated number of people living with HIV/AIDS, WHO regions, 2004

South-East Asia Region has the second highest burden of HIV/AIDS

5 Source: WHO/SEARO, HIV/AIDS Unit - 2004 THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION

limited strategic information, and high costs of drugs and reagents that prevent access to prevention and care for people with HIV/AIDS. In accordance with the Global Health Sector Strategy, the Regional Office is taking the lead in the health sector’s response to HIV and working towards the Millennium Development Goals of halting and reversing the spread of HIV/AIDS by 2015. The national AIDS programmes, with support from WHO and other partners, are accelerating HIV prevention, care and treatment interventions. The Regional Office continued to expand its role of providing technical and programmatic support, advocating scale-up of prevention, care and treatment services, collecting adequate strategic information to monitor programme progress and surveillance, supporting capacity building, and providing normative guidance to Member States. Other activities included resource mobilization and recruitment of additional staff and consultants for intensified country support. The situation of HIV/AIDS and programmatic experiences in the Region were articulated in a book entitled “AIDS in Asia”. With WHO support, surveillance activities are being strengthened. In particular, the second generation surveillance system has been established in most countries of the Region. As part of the efforts to build capacity for data collection, analysis and use at the country level, guidelines on HIV, STIs, as well as behavioural surveillance have been prepared and widely disseminated for use by the national programmes. The Regional Office has played a pioneering role in preparing monitoring and evaluation tools in support of the “3 by 5” initiative. Efforts of Member States towards management of STIs, particularly in the private sector, have been reinforced. Efforts to scale up interventions for preventing mother-to-child transmission are under way in India, Indonesia, Myanmar and Nepal. A bi-regional strategy for harm reduction was developed in 2004, in collaboration with the Regional Office for the Western Pacific. However, interventions addressed towards injecting drug use such as substitution treatment for harm reduction are still in the pilot project stage in most countries. 6 THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION

There is considerable interest and commitment to the “3 by 5” initiative in the Region, reflected in the rapid scale-

up of anti-retroviral treatment (ART). The number of people in the Region on ART increased from 37 500 in January 2004 to 90 000 by April 2005 (Figure 1.3). Although it is still too low compared to the target of 400 000 in the Region, the experience provides a firm basis for scaling up ART access at a faster rate. There is also an increase in the number of sites offering voluntary counselling and testing (VCT) services which are entry points to care and treatment. Resources have been mobilized from the Global Fund to fight AIDS, Tuberculosis and Malaria (GFATM) for Bangladesh, India, Indonesia, Maldives, Myanmar and Nepal.

Figure 1.3: Number of people on ART in the South-East Asia Region

On ART Source: WHO/SEARO, HIV/AIDS Unit - 2005

Target

The TB/HIV collaborative projects ongoing in many countries are following the regional TB/HIV strategic plan developed in consultation with experts from the Region. WHO, the Centers for Disease Control (CDC) Atlanta, and the Research Institute of Tuberculosis, Japan, jointly developed training materials on TB/HIV to build capacity for implementation of the regional strategic plan.

Tuberculosis Significant progress has been made in the implementation of Directly Observed Treatment, Short course (DOTS), the recommended strategy for TB control. The goal is to sustain and then surpass the case detection and treatment success

7 THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION

targets set for end-2005, in order to reduce by half, TB prevalence and mortality, as per the MDGs, in all countries in the Region by 2015. Due to rapid expansion in the coverage with DOTS in all Member States, almost 90% of the Region’s population lived in areas with access to DOTS services by the end of 2004 (Figure 1.4). The first of the two global targets, that of achieving 85% treatment success among all new smear-positive TB cases registered under DOTS, has already been achieved in the Region, while progress is rapid in achieving the second target – 70% case detection. While DPR Korea, India and Maldives have already surpassed the 2005 global targets, Myanmar and Nepal are within reach of the target. Other countries are making steady progress. The overall case-detection rate in the Region has shown a steep increase from 15% in 1999 to nearly 55% in 2004, getting progressively closer to the target of 70% set for end-2005 (Figure 1.5). This is largely attributable to a significant increase in case-detection rates in India, which alone accounted for 39% of the global increase in cases detected under DOTS in 2003. A wide range of issues, however, need to be addressed in order to continue to expand the reach of DOTS, sustain achievements made and to improve the current quality of services. The most important is the need to develop adequate technical and managerial expertise, at all levels of national programmes, particularly in countries where health care has

Figure 1.4: DOTS implementation in the South-East Asia Region, 1997-2004

8 THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION

Source: WHO/SEARO, TB Unit - 2005

Figure 1.5: Trend in case detection in the South-East Asia Region, 1995-2004

* Data from National TB Programmes in the SEA Region (as of May 2005) Note: The circles indicate the number of new smear-positive cases notified under DOTS, expressed as a percentage of the estimated cases for each year. The dotted line is an extrapolation, based on the current annual increment.

been decentralized. Necessary infrastructure and logistics support are required to ensure uninterrupted supplies of high quality drugs and laboratory consumables to provide qualityassured diagnostic and treatment services for TB. Ensuring that all cases of TB diagnosed and registered for treatment are then effectively reported on by national TB control programmes (NTPs) continues to be a major challenge. Greater collaboration with other health care providers including the private health sector, medical schools, NGOs and business and industry, is needed to ensure that all TB patients receive care under DOTS, and are also reported to the national programme. Effective advocacy, communication and social mobilization approaches are equally essential to overcome the continuing low community awareness of TB and the traditional stigma attached to the disease. The parallel epidemic of HIV/AIDS and the emergence of multidrug resistant TB (MDR-TB) necessitate the adoption and urgent implementation of comprehensive and feasible approaches to address HIV-related TB and drug resistance. While most countries are benefiting from the increased resources made available through international initiatives such as GFATM, the Global Drug Facility (GDF) and through bilateral agreements at country level, concerns remain regarding disbursement and long-term financing of TB control . The four previous rounds of country proposals to activities.

9 THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION

There has been remarkable progress in the implementation of the DOTS strategy in the Region.

GFATM have generated financial commitments totalling US$ 228 million over five years to nine Member States in the Region for TB control. The Global Drug Facility, through grants or direct procurement mechanisms, is assisting in ensuring quality TB drugs in Bangladesh, DPR Korea, India, Indonesia, Maldives, Myanmar, Nepal, Sri Lanka and TimorLeste. Regional and national-level coordination and collaboration are essential for optimal planning, implementation and evaluation of the utilization of current resources and to ensure sustained and adequate financing in the longer term. The Regional Office and country offices continued to provide strategic direction and enhanced technical support to NTPs in Member States during the period under review. The focus of work was guided by four key strategies aimed at improving TB control interventions in the countries. These were: (a) sustaining and improving the quality of DOTS implementation; (b) scaling up and strengthening effective intersectoral partnerships for DOTS; (c) improving community awareness and utilization of DOTS; and (d) addressing HIVrelated TB and anti-TB drug resistance, under programme conditions. WHO continued to work closely with Member States to raise the profile of TB on policy and development agendas through advocacy at the highest policy levels. Assistance was extended to countries in mobilizing increased

10 THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION

funding through multilateral and bilateral donors and development partners. During the period under review, WHO deployed long-term technical staff in Bangladesh, India, Indonesia, Myanmar and Nepal. Technical missions were fielded to countries to provide assistance in specific areas based on country needs, with special emphasis on quality assurance mechanisms, surveillance, drug procurement and logistic systems. Bangladesh, India, Indonesia, Myanmar and Sri Lanka were assisted in the preparation of proposals for submission to GFATM during the fifth round of applications. Comprehensive reviews of progress made with DOTS implementation were undertaken in Bangladesh, Indonesia, Maldives, Myanmar, Sri Lanka and Timor-Leste during the previous two years. WHO also provided assistance in developing initial proposals as well as in the implementation and monitoring of activities supported through GFATM and other agencies such as CIDA, DfID, KNCV Tuberculosis Foundation, USAID, and the World Bank. India, Indonesia and Myanmar received additional support under the multi-donor-funded Intensified Support and Action for Countries. In collaboration with the Regional Office for the Western Pacific, a bi-regional report on the TB situation was prepared. Intercountry training on TB control, leadership and strategic management, surveillance, monitoring and evaluation, and on the management of TB/HIV, have contributed to capacity building. Similar training was supported in several Member States. The annual meetings of the Region’s NTP managers and the technical working group on TB continued to provide a very useful forum for exchange of information and experience. They also facilitated joint decisions on future steps for improved implementation of TB control activities in the Region. Support for research aimed at increasing the utilization and acceptance of DOTS, to reach poor and vulnerable populations, to ensure gender equity, and to develop an evidence base for new policies, particularly in the context of health sector reform in several Member States, is equally essential. The three WHO collaborating centres for TB control in the Region have been actively involved in research and in several national and intercountry activities such as training, technical workshops

Intercountry training on TB control, leadership and strategic management have contributed to capacity building

11 THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION

and consultations and in providing technical assistance through missions to countries in the Region.

Malaria Malaria remains a serious public health problem, with nearly 290 million people estimated to be at high risk. Although reported morbidity and mortality showed a declining trend (Figure 1.6), the proportion of Plasmodium falciparum cases has increased significantly over the past many years. They now constitute nearly 50% of all reported malaria cases (Figure 1.7). Of the reported cases, India accounts for 77% of the regional total, while 54% of all deaths are reported from Myanmar. Maldives remains malaria-free, but the disease is on the increase in Myanmar and Nepal. A decline in reported malaria cases has been observed in Bhutan, DPR Korea, Indonesia, India, Sri Lanka, and Thailand. The malaria situation in Timor-Leste, however, remains unchanged since 2002. Under-reporting of malaria cases and deaths is one of the major challenges in the Region, mainly due to shortage of laboratory facilities to confirm cases and weak surveillance systems. Against the 2.4 million cases reported in 2003, nearly 20 million cases were estimated to have occured during the same period. The number of deaths estimated was 80 000 compared to 4 500 reported in 2003. There is an urgent need

Figure1.6: Reported malaria cases and deaths in the South-East Asia Region, 1993-2003

12 THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION

Source: WHO/SEARO, Malaria Unit - 2004

Figure 1.7: Proportion of reported malaria cases due to P . falciparum and P. vivax in the South-East Asia Region, 1977-2003

Source: WHO/SEARO, Malaria Unit - 2005

to improve disease surveillance and conduct special surveys to better estimate the actual disease burden. In 2004, a review of drug resistance was carried out to provide evidence-based information for policy revision. An increase in drug resistance was observed in Bangladesh, Bhutan, India (particularly the north-eastern states), Indonesia, Myanmar and Thailand. As a result, Bangladesh, Bhutan, Myanmar and Thailand revised their national treatment policies and adopted artemisinin-based combination therapy (ACT) to treat drug-resistant P falciparum. Thailand introduced ACT nation-wide, while India initiated it in some areas. The coverage of indoor residual spraying (IRS), with insecticides remains low (42%). Insecticide-treated nets (ITNs) have been introduced in almost all countries to supplement IRS efforts, but the coverage of ITN remains extremely low. Preparation of a revised strategic plan to control malaria is under way, representing a shift from the traditional approach to that which emphasizes ecological, social, behavioural and environmental aspects; with priority given to intersectoral cooperation, social mobilization in scaling up effective interventions such as ITN, indoor residual spraying, and early diagnosis and prompt treatment with artemisinin-based combination therapy. In most countries, the resource gap is being bridged with proposals supported by the Global Fund. Eight countries, 13 THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION

namely Bhutan, India, Indonesia, Myanmar, Nepal, Sri Lanka, Thailand and Timor-Leste, have had their proposals approved by the Fund in the first four rounds. Technical support was provided to develop proposals as well as for implementation of Global Fund-sponsored projects, particularly in Bangladesh, Bhutan, Myanmar and Timor-Leste. In April-May 2005, Bangladesh, India, Indonesia, Sri Lanka and Thailand, in collaboration with SEAMEO-TROPMED and with technical assistance from WHO, developed a multi-country proposal on networking and monitoring of drug resistance, drug quality and insecticide resistance for some selected countries for onward submission to the Global Fund. Bi-regional collaboration between the countries of the South-East Asia and the Western Pacific regions helped in coordinating activities in malaria control, especially in the area of monitoring drug resistance, drug quality and programme implementation. With involvement of experts from Member States, the Regional Offices for the Western Pacific and SouthEast Asia developed a regional strategy for improving and upgrading the quality of malaria microscopy. Significant progress was made in fighting outbreaks of vivax malaria at international borders between the Republic of Korea and the Democratic People’s Republic of Korea. Bi-regional collaboration in the control of vivax malaria was further strengthened by improved information sharing among countries and through efforts in establishing the Asia vivax network. In 2004, a Regional Technical Advisory Group on malaria was established to advise on policies and strategies that are crucial for scaling up malaria control in the Region.

Approximately 1.3 billion people in the Region are considered to be at risk for dengue

Dengue fever/dengue haemorrhagic fever (DF/DHF) Approximately 1.3 billion (86% of the population) people in the Region are considered to be at risk for dengue. The disease is reported every year from Bangladesh, India, Indonesia, Maldives, Myanmar, Sri Lanka and Thailand. During 2004, 151 676 cases with 1 232 deaths were reported. In addition, dengue outbreaks occurred in Bangladesh, Indonesia and Sri Lanka. An outbreak also occured in Bhutan for the first time in 2004, followed by one in Timor-Leste in 2005. 14 THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION

WHO is promoting disease and vector surveillance, early recognition and effective case management, vector control with community participation, sustainable behavioural changes and

partnership, and strengthening of regional and national capabilities as strategies for dengue control. Technical assistance was provided to Bhutan and Timor-Leste for outbreak investigations and management through vector control measures and clinical management of cases. In 2004, a Regional Technical Advisory Group on Dengue, consisting of experts to advise on policy and strategy, was established. WHO headquarters, together with the Regional Office, expanded the internet-based global surveillance system for dengue and DHF called “DengueNet”, to countries in the SEA Region, as part of the central data management system to collect and analyse standardized information. Bilateral cooperation between the South-East Asia and the Western Pacific regions is planned through the Asia Pacific Dengue Forum supported by the Ministry of Health, Labour and Welfare, Japan. The Dengue Bulletin, Volume 28 (2004) was published jointly with the Regional Office for the Western Pacific and distributed widely.

Soil-transmitted helminthiasis (STH) About 500 million people are chronically infected with soiltransmitted helminthiasis (STH) in the Region. All countries are endemic, with school-age children and women of childbearing age at maximum risk. De-worming, once or twice a year, is a highly cost-effective intervention being promoted by WHO through appropriate advocacy and technical support. Five countries – Bhutan, Maldives, Myanmar, Sri Lanka and Thailand – are targeting the entire school-age children population for regular schoolbased de-worming. The focus in future will be on DPR Korea, India and Indonesia. The goal is to reduce morbidity and mortality caused by STH by 50% and to achieve a target of regular treatment to cover at least 75% of all school-age children at risk by 2010. The objectives are to reduce the prevalence and the intensity of the infections of STH among the high-risk groups in the population, and reduce anaemia and other clinical complications caused by STH. Partnerships have been forged with several agencies in the de-worming programme. These include: CARE and the World 15 THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION

Food Programme in Nepal; the German Pharma Health Fund in Bhutan and Myanmar; JICA in Myanmar and Thailand; UNICEF in Nepal, Maldives and Bangladesh and the Sasakawa Memorial Health Foundation in Timor-Leste. WHO is also collaborating with the Asian Centre for International Parasite Control (ACIPAC), Bangkok, for training personnel for capacity building in the countries.

Diseases Targeted for Eradication/Elimination Polio Due to the magnitude of the challenges and the resources needed, partnerships in polio eradication have created an unprecedented level of cooperation. The Regional Office is striving to build on, and broaden, these partnerships to ensure support for all programme areas. During 2004-2005, polio eradication activities in the Region were focused on India. Following concerted efforts, case numbers remain the lowest ever (see Box). Polio cases in India continue to be geographically restricted, with more than 90% occurring in a small cluster of districts in western Uttar Pradesh (UP) and central Bihar. The reduction in case numbers has occurred against a background of significantly improved sur veillance sensitivity in 2004-2005 through major

16 THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION

WHO is assisting Member States to enhance implementation of high quality supplementary immunization programmes.

Photograph: Sephi Bergerson for WHO

Polio eradication status and strategies In 2004, only 134 wild polio cases were found in India, the lowest total ever recorded. As of 31 May 2005 only 15 cases were found. However, another 65 polio cases were discovered in Indonesia as well by end-June 2005. The source of this outbreak was traced to an imported virus from the North of Africa. Ending wild polio transmission by closing the immunity gap in India, while continuing to maintain polio-free status in the rest of the Region remains one of the main challenges. With the final push to end polio transmission, Member States will require increased assistance in preparing for the rigours of the containment and certification process. Advocacy support to ensure that the political commitment required for polio eradication in India, and, for maintaining certification standard surveillance in polio-free countries remains strong, will also be needed. Once the polio eradication programme moves from the eradication phase to certification, the countries have to ensure that AFP surveillance system strategies and capacities to enhance immunization activities are adapted to support national routine immunization programmes. This, in turn, would lead to improved detection of and response to other vaccine-preventable diseases.

improvements in acute flaccid paralysis (AFP) case-detection rates and specimen collection rates, particularly in UP and Bihar. There has been no significant high season spread from known reservoir areas, indicating that general levels of immunity among children in non-reservoir areas are high. This is consistent with data on supplementary immunization activity (SIA) quality and immunization status of AFP cases, which showed steady improvement in most areas in 20042005. Quality gaps remain, however, in critical high-priority districts in Uttar Pradesh, Bihar and Maharashtra. WHO provided extensive support to India and other countries to enhance their capacity to implement high quality supplementary immunization, to boost routine immunization and to strengthen surveillance. In 2004, AFP surveillance in India, especially in the polioinfected areas, was overall of a high standard. Though reported AFP cases increased sharply in India, surveillance was below certification levels in Maldives and Timor-Leste. While the risk of polio virus circulating in these countries is minimal, both countries have taken steps to strengthen surveillance. During the reporting period, the Regional Office conducted AFP surveillance reviews in Bangladesh and Thailand. The reviews concluded that surveillance systems were sufficiently sensitive to detect any polio cases. Other countries, i.e. Bangladesh, Indonesia, Myanmar and Nepal, with a WHO-supported surveillance network, have 17 THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION

conducted integrated vaccine-preventable disease surveillance. At the request of the government, the WHO network in Nepal also expanded its responsibility to include communicable disease surveillance and outbreak investigation of Japanese encephalitis (JE). The polio laboratory network performed at an optimal level across the Region.

Leprosy The Region is steadily moving towards achieving the goal of elimination of leprosy as a public health problem, i.e. a prevalence of less than 1 case per 10 000 population by December 2005. To bolster regional efforts towards leprosy elimination, the Director-General, in a significant move, decided to relocate the Global Leprosy Programme to the SEA Region. Since March 2005, the Programme is housed in and managed by the Regional Office. Currently, all countries except India, Nepal and Timor-Leste have achieved national-level elimination (Figure 1.8). It is expected that all countries except, possibly, Timor-Leste, will eliminate leprosy as a public health problem by the end of 2005. A significant decline in both overall prevalence and new case detections was seen in India, the country with the highest leprosy burden. This was mainly due to efforts at

Figure 1.8: Leprosy prevalence in the South-East Asia Region (as of March 2005)

18 THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION

Source: WHO/SEARO, Leprosy Unit (country reports) - 2005

Early detection and treatment play a vital role in the elimination of leprosy.

minimization of various ‘operational factors’ such as wrong diagnosis, re-registration of cases, better treatment compliance and regular updating of registers. The eight countries in the Region which had achieved national-level elimination sustained their elimination levels and further reduced the burden of leprosy. A 10-member Regional Technical Advisory Group was established to provide policy and technical advice on all aspects of leprosy elimination in the Region. WHO continued to provide free supply of MDT drugs and assisted countries in drug management and monitoring. The Novartis Foundation for Sustainable Development has assured free supply of MDT drugs through WHO until 2010. The sustained financial and advocacy support of the Nippon Foundation and the Sasakawa Memorial Health Foundation of Japan continued to provide vital support for leprosy elimination in the Region. The visits of Mr Yohei Sasakawa, President of the Sasakawa Memorial Foundation and the WHO Goodwill Ambassador for leprosy elimination, to India and Nepal during 2004 were very valuable for advocacy at the highest political levels. WHO will continue to provide technical support to achieve national and sub-national elimination, to further reduce the burden of leprosy, continue the free supply of MDT drugs and assist Member States in mobilizing the required resources and in strengthening international and local partnerships.

19 THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION

Visceral leishmaniasis (Kala-azar) There are around 147 million people living in areas threatened with kala-azar in countries of the Region, especially in Bangladesh, India and Nepal (Figure 1.9). The border districts in Bhutan are also at risk. The disease occurs among the poorest of the poor and in marginalized communities. Nearly 2.4 million disability-adjusted life years (DALYs) are lost each year due to kala-azar globally of which the Region accounts for 400 000 DALYs. WHO established a Regional Technical Advisory Group (RTAG) to accelerate efforts towards the elimination of kalaazar. The group comprises independent experts selected on the basis of their expertise in kala-azar and related fields, including epidemiology, entomology, communications and social mobilization. At their first meeting in December 2004, the regional strategic framework on elimination of kala-azar by 2015 was endorsed by RTAG. The regional strategy includes early diagnosis with dipstick rk39 and complete treatment with effective oral medicine; disease and vector surveillance, with an efficient, inbuilt management information system linking all reporting facilities; integrated vector management with the focus on indoor residual spraying (IRS), insecticide treated nets (ITN) and environmental management; social mobilization and

Figure 1.9: Kala-azar distribution in the South-East Asia Region, 2004

20 THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION

Source: WHO/SEARO, VBC Unit - 2004

Elimination of kala-azar from the Region received a boost by the signing of a Memorandum of Understanding by the three endemic countries at the World Health Assembly in May 2005.

behavioural change interventions, and clinical and operational research to support the elimination programme. During the Health Ministers’ meeting in September 2004, the Ministers of Health of Bangladesh, India and Nepal agreed to intensify their efforts to expand intercountry cooperation and collaboration to eliminate kala-azar. Their commitment to kala-azar elimination is exemplified by a Memorandum of Understanding signed by the three countries at a ceremony during the Fifty-eighth World Health Assembly in May 2005.

Lymphatic filariasis Nine endemic countries in the Region account for 64% of the global burden of lymphatic filariasis (LF). The strategies adopted to eliminate LF by 2020 include (1) Mass Drug Administration (MDA) with annual single-dose, co administration of diethylcarbamazine (DEC) and albendazole to the entire population at risk over a five to six-year period and (2) the alleviation of disability associated with LF. One of the pre-requisites prior to MDA implementation is mapping to determine LF endemicity in the country. Over the past year, Bangladesh completed mapping of LF case distribution for the entire country. Other countries that have completed mapping include Maldives, Sri Lanka, Thailand and Timor-Leste. Mapping is expected to be completed in other countries by the end of 2005.

21 THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION

During 2004, 51.3 million people in nine endemic countries were covered under MDA-2 drug administration, compared to 103 million globally. This effectively gave possible protection against LF to about 64 million people living in those endemic areas for a significant part of the year. In addition, India covered 360 million endemic population under the “DEC alone” strategy. However, large geographic areas and a large number of people living in those endemic areas are yet to be reached. Raising resources, especially funds, for scaling up elimination activities, is the biggest challenge in the Region. While continuing support to the endemic countries in their efforts to eliminate LF, WHO will also endeavour to mobilize donor support including the free supply of albendazole. Technical assistance was provided to a national-level donor mobilization meeting in Bangladesh and to community-based pilot projects on disability prevention in Indonesia, Sri Lanka and Timor-Leste. The SEA Regional Programme Review Group (RPRG) for Elimination of LF was established in 2004. Its first meeting was held in New Delhi in May 2005, followed by the LF Programme Managers’ Meeting. The meetings reviewed the progress of elimination, planned future activities and discussed the way forward.

Yaws Yaws is a non-venereal treponematosis caused by Trepenoma pertenue and is restricted to a few endemic pockets in three countries – India, Indonesia and Timor-Leste. Indonesia, with about 4 000 annual cases, carries the highest burden of disease. The disease is poverty-related as it occurs predominantly in children and young adults from the marginalized groups. The people at risk are poor tribal populations living in remote areas, where there is a general lack of clean water, sanitation and personal hygiene. The disease though generally not fatal, causes deformities and contributes to economic loss among already poor populations. The eradication of yaws is a regional priority and an achievable goal, with the availability of a safe and cost-effective intervention – a single injection of long-acting Benzathine Penicillin. To support the eradication programme, a Regional Strategic Plan and an advocacy document highlighting the

22 THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION

disease burden, the needs and challenges are being finalized. WHO will, in addition, assist the countries in timely procurement of Benzathine Penicillin; in strengthening active search and treatment of injection cases and family contacts; capacity building; monitoring/evaluation; mobilization of required resources; building partnerships and promoting eradication of yaws as an achievable goal.

Immunization and Vaccine Development Within the current routine immunization programmes, the greatest challenge for Member States is to ensure equitable improvements in immunization coverage and reductions in immunization drop-out rates. Another specific challenge for routine immunization in the Region is achieving the 80/80 goal1 set by the Global Alliance for Vaccines and Immunization (GAVI).

The eradication of yaws is an achievable goal in the Region.

As increasingly more vaccines are produced in the Region, technical capacity for quality assurance will need to be strengthened. Additionally, though Member States have adopted the use of auto-disable syringes, tremendous challenges remain for sharps-waste disposal and injection safety training. Moreover, the Region will be at the forefront for both developing and testing new vaccines over the next 5-10 years. The regional vaccine strategy, developed in 2003, is helping to set the agenda for the Region and to assist countries in making vital decisions regarding introduction of new vaccines. The regional vaccine strategy, as contained in the Strategic Plan for 2002-2005 for IVD, is based on approaches that seek to ensure the provision of safe, quality protection against vaccine-preventable diseases for people of the Region. The primary approach is two-fold: to increase the national capacity of Member States and to prioritize interventions where WHO has a comparative advantage. WHO continues to support the provision of high quality AFP surveillance in the Region. Surveillance is the key to Ensure that all districts (or equivalent administrative unit) in 80% of developing countries achieve 80% DTP3 coverage, by 2005 1

23 THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION

interrupting polio transmission as well as in providing data to guide immunization programme planning. WHO also provides technical assistance for a wide range of activities, including EPI programme management and development, supplemental immunization planning, vaccine quality assurance, injection safety, and surveillance. Member States were supported to build the technical and management capacity of national immunization programmes by providing international training opportunities as well as in developing local training institutions, organizing national workshops and curriculum development. WHO provided technical assistance as well as direct support to a variety of activities to monitor and evaluate immunization programmes, including development of programme monitoring tools such as the Data Quality Assessment (DQA) and Data Quality Survey (DQS).

Measles Member States are giving high priority to strengthen measles surveillance by building on the surveillance infrastructure established for polio eradication. Efforts in this regard included, among others, the establishment of a regional measles laboratory network (14 national laboratories and one regional reference laboratory). In addition to improving measles surveillance, the laboratory network also detected rubella outbreaks previously unidentified in Bangladesh, Bhutan, Indonesia and Nepal. All countries of the Region include a dose of measlescontaining vaccine (MCV) in their routine vaccine schedules. During the period under review, several countries updated their national plans for routine immunization and attempted to improve the routine coverage. In addition, Myanmar and Nepal conducted measles supplementary immunization activity (SIA) in order to increase population immunity and reduce the incidence of measles. Nepal carried out a measles catch-up campaign and succeeded in vaccinating 9.5 million children against the disease. Sri Lanka also conducted a similar campaign. Additionally, the post-tsunami measles efforts in Aceh and North Sumatra in Indonesia reached 5.2 million children. The WHOinitiated South-East Asia Measles Partnership, formed in 2004, provided resource mobilization and technical support to all countries in their efforts to control measles.

24 THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION

Strengthening of immunization systems Efforts were made to improve routine immunization by encouraging the drafting and use of revised immunization policies; multi-year plans and operational guidelines; assisting in planning for financial sustainability, strengthening servicesprioritized target districts, as well as enhancing the quality and coordination of training practices. Bangladesh, Bhutan, DPR Korea, Indonesia, Myanmar, Nepal and Sri Lanka submitted their immunization financial sustainability plans, while India drafted its plan for 2005-2010. While these efforts resulted in some improvements in routine immunization as indicated by the DTP3 coverage in Member States (Figure 1.10), additional efforts are needed to ensure a more comprehensive impact. These include: increasing management capacity at the district level and focusing more on the underserved areas.

Introduction of new vaccines GAVI has committed over US$ 180 million to the nine countries in the Region which are eligible for support from the Vaccine Fund. Apart from Timor-Leste, all eligible countries received funding to introduce hepatitis B (HepB) vaccine as part of their national immunization programme and three years’ supply of auto-disable syringes for all antigens. Ten of the 11 Member States now have HepB vaccine integrated

Figure 1.10: DTP3 coverage rates in the South-East Asia Region, 2001-2003

25 Source: WHO/UNICEF estimated coverage 2001-2003 THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION

into their routine immunization programmes. As of 31 December 2004, more than US$ 28 million were disbursed as cash grants to support the strengthening of immunization services. These countries will also receive additional support to further strengthen immunization coverage.

Vaccine quality All Member States except Timor-Leste completed assessments on the functioning of their National Regulatory Authority (NRA) for vaccine quality control, in 2004-2005. Timor-Leste has yet to establish a NRA. The establishment of appropriate centres as part of the Global Training Network (GTN) in the Region on vaccine management, vaccine procurement and lot release is currently in process. Additionally, a global NRA network, the Developing Countries’ Vaccine Regulation (DCVR), was established in 2004. The NRAs of three regional vaccine-producing countries (India, Indonesia and Thailand) are members of the sub-network for evaluation of vaccine clinical trials.

Blood Safety and Laboratories Blood transfusion services are in varying stages of development in Member States of the Region. According to 2004 WHO estimates, every year 9.3 million units of blood are collected in the Region against an estimated annual requirement of 15 million. Only 61% of collected blood is from voluntary donors. DPR Korea, Maldives, Nepal and Thailand have more than 90% of their collection from voluntary donors. Only 50% of the six million units collected annually in India come from voluntary donors. Bangladesh collects 27% of its 160 000 units from voluntary donors and another 18% from professional paid donors. Screening of donated blood is universal only for HIV and hepatitis B but the quality of screening needs strengthening. It is critical because of the large number of carriers of HIV (6 million), hepatitis B (85 million) and hepatitis C (25 million) in the Region. Almost three fourths of collected blood is utilized as whole blood. Facilities for production of blood components and awareness of their use among clinicians are inadequate. 26 THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION

The WHO Global Strategy for Safe Blood, accepted by all Member States, comprises five key elements: establishment

Concerted efforts are being made to create awareness for safe blood and voluntary donation among the general public.

of nationally-coordinated blood transfusion services; collection of blood only from non-remunerative blood donors; transfusion of blood that has been screened for infectious markers and processed for immunohaematological parameters; appropriate clinical use of blood or blood components, and integration of quality systems in all spheres of blood transfusion services. While India, Nepal and Thailand already have national blood policies, Bangladesh, Bhutan, and Sri Lanka, with WHO’s assistance, formulated their respective policies which are awaiting legislative approval. WHO provided technical support to Bangladesh, DPR Korea and Sri Lanka in externally-funded projects on strengthening nationally coordinated blood transfusion services and assisted Nepal and Timor-Leste in developing proposals for mobilizing resources. The Central Blood Bank in Dili, Timor-Leste, was initiated with WHO’s support. There has been a steady increase in blood units collected, from 8 million in 2002 to 9.3 million in 2004 in the Region, as well as in contributions by volunteers. Several activities to create awareness among the general public for safe blood and voluntary donation of blood were supported. To further augment voluntary blood donation, the World Health Assembly in May 2005 adopted a resolution designating 14 June as World Blood Donor Day every year.

27 THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION

Quality management skills of technical staff from Bhutan and Nepal were upgraded. A Regional External Quality Assessment Scheme for blood grouping and screening of infectious markers is in operation and regularly provides assessment of the quality of laboratory services as well as technical support for their improvement. The National Blood Centre, Thailand, has been designated as a WHO Collaborating Centre on Blood Safety to provide training and act as a resource centre for strengthening quality systems. Guidelines for establishing production units for blood components were developed to facilitate their production and utilization. Public health laboratories in the Region require strengthening for supporting efficient disease surveillance and management of various outbreaks. At present, many outbreaks remain undiagnosed. The capacity of public health systems in diagnosing new and emerging infectious diseases is limited. While national networks of public health laboratories are operational in almost all countries, the noninclusion of academic and research institutes as well as laboratories from the private and veterinary sectors in these networks reduces their effectiveness. Except in countries like India, Indonesia and Thailand, modern laboratory services in other countries of the Region are inadequate, especially those for virology and molecular biological studies. Non-availability of quality diagnostic reagents for emerging infectious diseases hampers early and accurate diagnosis of outbreaks. Although an HIV diagnostic infrastructure is in place in all Member States, efficient laboratory support for monitoring of antiretroviral therapy in high-burden countries needs rapid expansion. WHO has been advocating strengthening of national networks by harnessing expertise available within the country and participation of national laboratories in regional or global networks. Indigenous development and production of reagents for epidemic-prone diseases and integration of quality systems are encouraged. WHO worked closely with the 16 national laboratories as part of the networks of poliomyelitis and measles laboratories in the Region. There are 71 laboratories participating in the WHO Global Salmonella Surveillance Network. Six countries were also sensitized to participate in DengueNet.

28 THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION

During the reporting period, a mobile public health laboratory was established in Aceh, Indonesia to provide critical support to disease surveillance in the tsunami-affected areas. Rapid diagnostic kits for leptospirosis and anthrax were evaluated and disseminated to all Member States. Regional Guidelines for Diagnosis of HIV and Monitoring of Antiretroviral Therapy were developed and disseminated through an intercountry workshop. Furthermore, an external quality assessment scheme for CD4 enumeration was initiated for selected laboratories to promote quality in laboratory results.

Research and Development Research is a crucial part of the response to communicable diseases. Forward-thinking operational research enables to uncover the weak links in the armoury of emerging microbes, create novel ways to identify and fight infections and evaluate the preventive impact of new approaches. To combat communicable diseases, the Regional Office supports the renewal and expansion of research on the epidemiology and biology of microbes, vectors and intermediate hosts, the transmission patterns, and in creating awareness that new epidemics can, and will emerge in unexpected places. Research on the behavioural aspects and on the socioeconomic impact of communicable diseases are being undertaken, as are studies relevant to the scaling up of interventions in the control, elimination and eradication of infectious diseases. Similarly, other programmes such as HIV and TB have identified priority research areas for implementation. These include the role of the private sector in STI and HIV treatment seeking behaviour among clients, enhancing access to and utilization of services such as DOTS, and the role of the community in scaling up prevention and control interventions. WHO collaborating centres are being used increasingly in taking the research agenda forward. In addition, the Regional Office is working closely with the UNICEF/UNDP/World Bank/WHO Special Programme for Research and Training in Tropical Diseases (TDR), which gives priority to operational and basic research on tropical diseases prevention and control. Support was provided to facilitate and strengthen control-oriented operational research in tropical and communicable diseases in selected countries of the Region (Bhutan, DPR Korea, Maldives and Timor-Leste). Applications

Non-availability of quality diagnostic reagents for emerging infectious diseases hampers early and accurate diagnosis of outbreaks

29 THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION

for the Joint Small Grants Programme for Operational Research in Tropical Diseases were invited from these selected countries in 2005. Workshops on Research Capacity Strengthening were conducted in Bhutan and Maldives in 2004, to strengthen proposal writing skills and on computerized literature search, record-keeping and data entry. Training materials and TDR proposal guidelines were used, and three research proposals were initiated at these workshops. TDR continued to support research activities on malaria, kala-azar, lymphatic filariasis, leprosy, tuberculosis, vaccine development and vector control in a number of countries in the Region. A special collaborative relationship has been established with TDR in initiating and implementing kala-azar elimination in the Region.

30 THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION

2

NONCOMMUNICABLE DISEASES AND MENTAL HEALTH Surveillance, Prevention and Management of Noncommunicable Diseases Noncommunicable Diseases (NCDs) account for 44% of the disease burden and 51% of deaths in the Region. The four major NCDs, namely cardiovascular diseases, cancer, chronic pulmonary disease and diabetes are among the dominant causes of mortality and morbidity. Large segments of populations in the countries of the Region are being exposed to physical and socioeconomic environments that adversely affect their health. Preserving individual behaviours that are conducive to the protection of health is therefore becoming increasingly important. Well-defined risk factors contributing to NCDs include high tobacco and alcohol consumption, unhealthy diets and physical inactivity, low fruit and vegetable intake, indoor and

31 THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION

outdoor air pollution, elevated blood pressure, overweight, high levels of cholesterol and sugar in blood. All these risk factors contribute to an estimated 40% of all deaths occurring in the Region. Tobacco use alone accounts for an estimated 1.1 million deaths every year. There are an estimated 41 million diabetics in the Region, with India alone having around 29 million (69% of the total cases in the Region) (Figure 2.1). Simple and cost-effective preventive and curative interventions targeting risk factors are well established. Moreover, the application of population-based, high-risk-prevention strategies has proved to influence public and individual health outcomes positively.

Figure 2.1: Country-wise distribution of estimated diabetes cases in the South-East Asia Region (%)

Source: SEAR NCD profile, 2003

Thus, in addition to communicable diseases, NCDs have also become a major public health challenge in the Region. However, NCD control efforts in countries especially in expanding national prevention and control activities beyond the pilot phase remain fragmented and compartmentalized. There are gaps in translating the existing knowledge and evidence into large-scale public health inter ventions. Consequently, many national programmes still target expensive case management of NCDs through modern medical technologies that are confined to the affluent and privileged segments of the population. 32 THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION

In order to address these issues, some Member States are adjusting their policies, strategies and legislation to set up an integrated and comprehensive health promotion and NCD

prevention platform, and to provide cost-effective care at primary health care level. Thailand, and recently Indonesia, have developed comprehensive national policies for the prevention and control of NCDs. The process of developing national NCD programmes has been initiated in India, Maldives and Nepal. Adjusting the health system management infrastructure in Bhutan, India, Myanmar, Nepal, Sri Lanka and Thailand has facilitated the process of developing and amending national NCD strategies. In addition, a few countries have started developing national plans to implement the “WHO Global Strategy on Diet, Physical Activity and Health.” WHO worked closely with Member States, in 2004, to develop a regional network called SEANET-NCD in order to facilitate the exchange of information and promote the adoption of strategic approaches for NCD control. The regional network is coordinating activities of national NCD networks established in Indonesia, Maldives, Sri Lanka and Thailand. In addition to sharing information and expertise, the network is involved in capacity building, advocacy, policy development and research. WHO also provided technical support in assessing the feasibility of expanding community-based NCD prevention projects. This was following the completion of baseline surveys in Bangladesh, India, Indonesia, Maldives and Sri Lanka. Limited availability of and accessibility to epidemiological information on major NCDs and their risk factors, and poor utilization of data are among the main barriers in advancing the NCD programme. To address these challenges, the Regional Office is assisting Member States in conducting epidemiological surveillance of major NCDs, with the initial focus on building national capacity for systematic collection and utilization of core, standardized information on NCD risk factors. In 2004, eight countries conducted risk factor surveys using the WHO standard methodology. Data were collected on tobacco and alcohol use, fruit and vegetable consumption, physical activity, body mass index and blood pressure. Results of the surveys are being extensively used for development of national NCD programmes, and to monitor and evaluate local community-based NCD prevention projects. Building on the

Limited availability of and accessibility to epidemiological information on major NCDs are among the main barriers in advancing the NCD programme

33 THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION

experience of these surveys, India is planning to incorporate the NCD Risk Factor Module into the National Integrated Disease Surveillance Project. National and regional NCD InfoBase systems have been established and are functioning since 2004. The InfoBase is also accessible on the WHO Regional Office web site.

Tobacco Currently, tobacco kills an estimated one million people every year in the Region, which is unacceptably high. The tobacco epidemic in the Region is complex because some countries are among the biggest producers and consumers of tobacco products. Several countries feel that the tobacco industry provides substantial revenue as well as employment to the people. Evidence, however, shows that the share of the government revenue generated by tobacco products varies (Figure 2.2). A wide range of measures addressing a broad array of issues related to tobacco control therefore need to be taken simultaneously. Some countries of the Region do demonstrate a deep commitment to control the epidemic, despite the compulsions of the economics of tobacco production. WHO is working closely with Member States to strengthen capacity for integrating the WHO Framework Convention on Tobacco Control (FCTC) provisions into the national tobacco legislation and related activities. The major focus for the next

Currently, tobacco kills an estimated one million people every year in the Region

Figure 2.2: Share of government revenue from tobacco products in the South-East Asia Region

34 THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION

Source: WHO and World Bank, HNP Discussion Paper, No.11, 2003

four to five years will therefore be to build capacity on development and implementation of national comprehensive tobacco control policies and strategies, in conformity with FCTC. In order to effectively deal with the tobacco epidemic in the Region, Member States have agreed to implement regional strategies aimed at preventing people from using tobacco; protecting nonsmokers from second-hand smoke; promoting tobacco cessation; and regulating tobacco products through measures calling for reduction of both the demand and supply of tobacco products. Member States have initiated a number of activities to promote One key strategy is to strengthen the tobacco control. capacity of countries to comply with the FCTC provisions. The Regional Office is also working closely with governments in the area of surveillance of the tobacco epidemic, and in monitoring and evaluation of existing tobacco control programmes. Partnership has been built with NGOs for creating public support in favour of effective tobacco control measures. In order to facilitate exchange of tobacco control information, an Online Database System has been developed in the Regional Office. This is part of the Tobacco Free Initiative (TFI) web site, which is linked to the global portal managed by WHO headquarters. National tobacco control programmes were reviewed in mid-2004 and activities initiated to raise awareness and understanding of the legal and technical aspects of FCTC. National programme activities for tobacco control were revised based on priority areas for future intercountry programmes as well as on the research findings. Pilot Global Health Professional Surveys (GHPS) were conducted in Bangladesh and India in 2004. The results of the surveys were used during the observance of World NoTobacco Day 2005 with the theme, “Health Professionals against Tobacco”. Participation by Bangladesh, Bhutan, DPR Korea, Indonesia, Myanmar and Timor-Leste at the second meeting of the 35 THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION

WHO Framework Convention on Tobacco Control Following the adoption by the Fifty-sixth World Health Assembly of the Framework Convention on Tobacco Control (FCTC) in May 2003, Member States of the Region were quick to sign and ratify the Convention. By June 2004, all Member States except Indonesia had signed the Convention. Until May 2005, except Nepal, all signatory countries had ratified the Convention and thus become a party to it. In order to take the Convention forward, WHO and Member States are developing national tobacco control legislation and related programmes in line with the provisions of FCTC. By the end of May 2005, three countries – Bangladesh, India and Thailand – had enacted comprehensive national tobacco control legislation. Other countries are in the process of drafting and enacting similar legislation. The major challenge is to sustain efforts in developing appropriate legislation and implementing tobacco control measures, given the unique situation of the Region being a major producer and consumer of tobacco and tobacco products. Some countries are fully engaged in research and surveillance in the area of tobacco control in order to generate new evidence to help develop suitable tobacco control programmes, taking into account all related aspects. WHO is also engaged in fostering partnerships with civil society in support of implementation of FCTC in the Region.

Intergovernmental Working Group on FCTC, held in Geneva in January-February 2005, was supported.

Health Promotion Support was provided to Member States in developing health promotion programmes applying the strategies contained in the Ottawa Charter and the subsequent health promotion charters, through the healthy settings approach. However, progress in implementation has been slow. The overall goal is to create and maintain an environment that would support good health and well-being of all peoples throughout their lifespan. This can be achieved by reducing health risks, promoting healthy lifestyles, and responding to the underlying determinants of health. To better understand the situation of health promotion in the Region, an exercise in “Mapping of capacity to promote health” was undertaken. This revealed that most countries lacked the capacity to develop and implement comprehensive health promotion programmes, and in particular, were lacking in leadership and sustainable financial mechanisms for health promotion. In responding to these challenges, countries and WHO initiated the development of a regional strategy on comprehensive health promotion in December 2004. 36 THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION

As a result, efforts are being made to strengthen health advocacy for obtaining political commitment and creating a

supportive environment to develop sustainable partnerships revolving around priority health programmes and health development issues. Some countries have conducted operational research on behavioural pathways. Through training and resource mobilization, the existing health education and health promotion infrastructures in the Region have been strengthened. Existing alliances and networks for health promotion, both at national and international level, are also being mobilized. Community-based healthy settings projects are being initiated. Health promotion strategies are usually linked with healthy public policies. The challenges of formulating healthy public

Member States are developing health promotion programmes through community participation.

37 THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION

policies and partnerships for development that have an impact on health, are now being increasingly recognized not only in the context of health promotion but also for disease prevention and control.

Injuries, Violence and Disabilities Increased life expectancy in the Region is contributing to an increase in the population of the elderly. The elderly population in the Region is expected to increase to about 250 million by 2025. Similarly, the number of persons with disabilities is increasing due to chronic diseases and other degenerative processes. With growing urbanization and mechanization, injuries and traffic accidents are also increasing at an alarming rate in most countries of the Region. In fact, road traffic injuries are a major cause of death in the 5-44 years age group. Injuries and violence kill 5.1 million people worldwide, of which more than a quarter are in the SEA Region. Nearly one third of the global burden of disease, if disabilities and loss of premature lives are included, is borne by the Region. Injuries and violence typically affect the young and productive population, and thus are a major hurdle to development. It is estimated that currently there are approximately 15 million blind people in the Region or one third of the blind population of the world. This number is expected to double by 2020. In 1995, there were 120 million people in the world with impaired hearing. This number has almost doubled according to recent WHO estimates. A substantial proportion of these people live in countries of the Region. The Region also has an estimated one million leprosy cases, which represent 72% of the world’s total. The prevalence of severe mental disorders has been estimated to be 5-10 per 1000 population in various countries of the Region. Although the regional strategies for injury and violence prevention were developed in 2002, their implementation remains poor. During the reporting period, two main areas, namely, prehospital trauma care and injury surveillance were the focus of WHO support. Realizing the increasing public health importance and the need for long-term solutions, WHO

38 THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION

With increasing urbanization and mechanization, injuries and traffic accidents are also increasing in the Region.

worked with a few selected teaching institutions in developing a standard curriculum and teaching modules at the undergraduate level for the prevention and control of injuries and violence. Similarly, nursing education modules are also being developed. In addition to physical and mental disabilities, the two other important disabilities are blindness and deafness. WHO, in collaboration with other UN agencies and international partners, has drawn up global strategies for addressing them. There has been considerable progress in the prevention of blindness in India, Myanmar and Nepal through clearing of the backlog of cataract operations. Regional strategies for prevention of blindness and hearing loss focus on strengthening service delivery through primary health care; improving human resources for primary eye and ear health services, and advocacy for such initiatives by studies on blindness and deafness. WHO is working closely with the network of experts on deafness prevention and control from countries of the Region as part of the “Forum for Sound Hearing 2030” to enhance priority accorded to prevention of deafness. An advocacy module, “State of Hearing and Ear Care in the South-East Asia Region” was also published.

Mental Health and Substance Abuse Mental health activities in the countries of the Region have generally been concentrated on hospital-based psychiatry and 39 THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION

neurology. The challenge is to guard against the tendency to adopt a disease-based psychiatric model for mental health services in the community, rather than a broad-based view of mental well-being. Traditionally, people recognize mental illness, but not mental well-being. Mental health programmes should be community based and include mental health promotion and prevention of mental illness. Mental health services should be integrated into the overall primary health care system along with innovative community-based programmes. There is also an urgent need to recognize the importance of substance dependence, including the ill-effects of alcohol, and to clearly define the goals and objectives to control substance dependence. The mental health promotion strategy should include mental health promotion in schools using the life-skills approach, and the development of a model for the use of traditional methods, such as meditation as a public health strategy for mental health promotion among adults. Such programmes have been successfully implemented in India and Indonesia. WHO strategies for community-based rehabilitation (CBR) of intellectually challenged children include children in rural and remote areas. These strategies would not only help the affected individual but also reduce the burden among care givers. Trainees from India, Indonesia and Maldives were supported to attend a course for master trainers for CBR of the intellectually challenged. Despite rapid progress in medical sciences there is still a huge unmet need (as much as 90%) for appropriate treatment of persons with common neuropsychiatric conditions. The WHO strategy to reduce the treatment gap includes: (a) creating awareness in the community about the nature of neuropsychiatric illnesses; (b) stigma removal against neuropsychiatric illnesses; (c) training of village or community-level health workers in the identification of common neuropsychiatric conditions, and (d) enhancing the capacity of the primary health care system of Member States to deliver appropriate care and treatment. Programmes based on these strategies are being developed in DPR Korea, India, Indonesia, Maldives and Myanmar.

Traditionally, people recognize mental illness, but not mental well-being

40 THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION

Efforts are being made by Member States to reduce the treatment gap for common neuropsychiatric conditions.

Development of mental health legislation, policy, plans and services are necessary to enable Member States to create a legal and regulatory framework. This would help enhance national mental health programmes and provide legal recourse and protection to mentally-ill individuals. Women with mental illness face severe stigmatization within the community. In this regard, Member States have developed strategies to include provision of care, treatment and rehabilitation for these women with the ultimate objective of reuniting them with their families. The ill-effects of excessive consumption of alcohol have become a major public health problem in the Region. Substance abuse is also assuming multiple dimensions, such as the use of amphetamines in some countries and injecting drug use in others. The WHO strategy in this respect is to empower the community through information and knowledge to reduce the demand and harm from alcohol and other substances of abuse. Programmes being developed in this regard include: self-learning material for community volunteers on the prevention of harm from alcohol, and cost-effective interventions in the community for reducing harm from alcohol by empowering the consumer, in Sri Lanka; and prevention of harmful use of alcohol among schoolgoing adolescents using the life-skills approach, in India.

41 THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION

3

FAMILY AND COMMUNITY HEALTH Child and Adolescent Health Significant progress in reducing child mortality has been made by Member States of the Region in the last two decades. However, disparities in progress between countries still remain. The estimated under-five mortality rate in 2002 varied from 18.3 per 1000 live births in Sri Lanka to 125 per 1000 live births in Timor-Leste. Neonatal mortality contributes to about 40% of all child deaths. Of the over 3.1 million under-five deaths every year, 1.4 million are neonates. Underlying malnutrition is a contributory factor in over 50% of all child deaths. The proportion of underweight children below the age of five years ranges from 8.5% in Thailand to 48.3% in Nepal. Nine of the 11 Member States of the Region are at various stages of implementation of the Integrated Management of Childhood Illness (IMCI) programme. The Regional Office organized intercountry IMCI training courses and provided

43 THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION

technical support to DPR Korea for adaptation of IMCI and conducting a national-level IMCI training course. Findings of a study on IMCI were disseminated at the Mexico Ministerial Summit on Health Research in November 2004. Evidence from this study indicates that IMCI not only improves the quality of child care at first-level health facilities but also increases the health facility utilization rates. Significantly, in IMCI areas a higher proportion of very sick children likely to die are taken to health facilities. The Guidelines for Management of Common Diseases in Young Children in Emergencies were made available to all Member States and were posted on the Regional Office web site. The new, low osmolarity oral rehydration salt (ORS) for the treatment of dehydration due to diarrhoea is effective in reducing stool output and the incidence of vomiting, and in reducing the need for intravenous fluids. DPR Korea, Indonesia and Maldives plan to make future procurements as per the new formulation. A bi-regional (involving the South-East Asia and the Western Pacific regions) course on Emergency Assessment and Treatment of Children in hospitals was organized in collaboration with WHO headquarters. Participants from Bangladesh, Indonesia, Nepal and Timor-Leste attended the course. This effort is expected to introduce initiatives for improving the quality of care provided to children in health facilities. A regional strategy for promoting neonatal health was finalized. Countries were supported to strengthen newborn care initiatives. Bangladesh, India, Maldives and Nepal have taken steps to adopt the regional strategy in their programmes. Technical support was provided for: developing the child health component for the forthcoming World Bank-supported Reproductive and Child Health II programme in India; the formulation of the Health, Nutrition, Population Sector Programme in Bangladesh, and the Five-year Strategic Plan for Child Development in Myanmar. The World Health Day 2005, with the theme, “Make Every Mother and Child Count”, presented a unique opportunity for advocacy of maternal and child health issues. Wall and table calendars were printed, and photo and painting exhibitions as well as national debates organized. An advocacy document,

Make every mother and child count

44 THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION

World Health Day 2005 presented a unique opportunity to highlight maternal and child health issues.

“Improving Maternal, Newborn and Child Health in the SouthEast Asia Region” that profiles the efforts currently under way in Member States to improve maternal and child health was published. Adolescents (10-19 years) represent 18-25% of the population in the Region. Adolescence is a period of rapid transition from childhood to adulthood during which many of the behavioural patterns are acquired. Every year, 50% of new HIV infections occur among young people (10-24 years) due to their increased vulnerability. To gather epidemiological data and information, preparation of country profiles has been initiated in Bangladesh, Bhutan, Myanmar, Nepal, Sri Lanka and Thailand. Technical support was provided for the formulation and finalization of the strategic plan to be included in the RCH-II programme. Draft strategies are under preparation in Bangladesh, Bhutan, Sri Lanka and Thailand. A Regional Technical Advisory Group (RTAG) on adolescent health and development (AHD) has been established to provide technical advice and support for region-specific planning and programming on AHD. A regional profile on AHD is under finalization. A regional capacity-building workshop was organized in September 2004 in Bangkok. Experts in AHD from Member States were trained in the use of the Orientation Programme 45 THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION

on Adolescent-friendly Health Services (AFHS). Country plans for adaptation and implementation were prepared. Adaptation has been initiated in Bangladesh, India and Indonesia. Technical assistance was provided during a national review and dissemination meeting of AFHS centres in India, and to Bangladesh to develop national standards on AFHS. South-East Asia has been identified as one of the WHO regions to focus on HIV and young people. In collaboration with UNAIDS, documentation of ‘success stories’ on HIV and young people has been initiated. Technical assistance was provided to Bangladesh in developing an operational plan for implementation of GFATM-funded projects on HIV and young people. Increased attention is being paid to the health of adolescents in the Region.

Adolescent-specific issues were included in the Guidelines for Health Providers on Mental Health prepared by the Regional Office. A regional situational analysis and advocacy booklet on adolescent nutrition has been finalized. An annotated bibliography on different areas related to adolescent health and development is under preparation.

Reproductive Health The major challenge in the Region is to ensure the widest range of safe and effective reproductive health services across the health system. The problems of maternal and newborn health, quality of family planning services and unsafe abortion continue to remain major issues in most countries of the Region. The contraceptive prevalence rate varies from 7% in TimorLeste to 72.2% in Thailand. In most countries, contraceptive use has increased substantially during the last few decades; however, in some countries it has become stagnant, while in others there is a predominance of non-reversible contraception. The substantial unmet need for contraception has led to unintended pregnancies and subsequently to induced abortion.

46 THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION

In India alone, approximately 6.7 million induced abortions take place annually in unauthorized centres. Unsafe abortion accounts for approximately 13% of all pregnancy-related deaths. During the reporting period, the main objective of the reproductive health strategy has been to accelerate progress towards meeting internationally-agreed reproductive health targets. This will help in attaining the highest achievable standard of reproductive and sexual health for all. Evidence-based norms, standards and tools continued to be promoted. A regional training module for Reproductive Health Library (RHL) was published and used in countries as well as in international conferences of the Obstetric and Gynaecology Society held in the Region. A regional workshop on family planning and reproductive tract infections/sexually transmitted infections (RTIs/STIs) was conducted in mid-2004 in collaboration with UNFPA, under the Strategic Partnership Programme. The workshop facilitated countries to adapt and implement evidence-based guidelines on family planning and RTIs/STIs. In India, the Implementing Best Practices initiative – a collaborative effort among development partners in promoting the implementation of best practices – was followed up in four states by introducing an electronic communication system. Technical support was provided to countries affected by the tsunami in December 2004, especially Aceh Province, Indonesia, to restart and

The main objective of the reproductive health strategy is to accelerate progress towards attaining the highest achievable standard of reproductive and sexual health for all.

47 THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION

rehabilitate primary health care services including those related to reproductive health.

Making Pregnancy Safer Member States of the Region are committed to achieve the targets for skilled birth attendants. In 2002, the proportion of births attended to by skilled attendants ranged from around 20% in Bangladesh, Bhutan, Nepal, and Timor-Leste; less than 50% in India, to more than 90% in DPR Korea, Sri Lanka and Thailand.

Member States of the Region are committed to achieve the targets for skilled birth attendants

The total number of maternal deaths in the Region in 2000 was estimated at 174 000, which is one third of the global maternal deaths. The estimated maternal mortality ratio (MMR) in the Region varied from 13 for Thailand to 800 per 100 000 live births for Timor-Leste in 2002. More than 1.4 million, one third of the global neonatal deaths, occurred in the Region. The estimated neonatal mortality rate varied from 12 for Sri Lanka to 44 per 1000 live births for Nepal. Almost 98% maternal and newborn deaths occurred in Bangladesh, India, Indonesia, Myanmar and Nepal. The objectives of the WHO Strategy for Making Pregnancy Safer is to ensure safe pregnancy and childbirth through the availability, access and use of skilled care for all pregnant women. Improving access to skilled birth attendants and enhancing the quality of maternal and newborn care are priority issues in the Region. Technical support was continued to Indonesia, the Making Pregnancy Safer spotlight country, to finalize the evaluation of in-service competency-based training for skilled attendants. Support was also provided to Bangladesh in its efforts to achieve the proportion of deliveries assisted by skilled birth attendants from 13% to 50% by 2010, by training existing health providers at the community level, i.e. family welfare assistants (FWAs) and female health assistants (FHAs). Improvement of the curriculum of a competency-based sixmonth training course and development of supervisory tools and mechanisms for the new cadre of skilled birth attendants are under way. In Nepal, a plan for a rapid assessment of human resources for maternal and newborn health has been

48 THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION

The objective of the WHO Strategy for Making Pregnancy Safer is to ensure safe pregnancy and childbirth through the availability, access and use of skilled care for all pregnant women.

finalized, while a human resource strategy for safe motherhood is being developed. In order to ensure quality of care of maternal and newborn health services, evidence-based norms and standards for maternal and newborn care are being promoted. Most countries have adapted or translated at least one of the Integrated Management of Pregnancy and Childbirth (IMPAC) series, which include: (a) Managing complications in pregnancy and childbirth: A guide for midwives and doctors; (b) Pregnancy, childbirth, postpartum and newborn care: A guide for essential practice, and (c) Managing Newborn Problems: A guide for doctors, nurses and midwives. In

49 THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION

collaboration with CDC Atlanta, USA, four countries (Bangladesh, India, Indonesia and Myanmar) were supported in their assessment of the magnitude of the problem of malaria in pregnancy.

Women’s Health WHO ’s Gender and Women’s Health focal points in headquarters, regional and country offices are focused on addressing the impact of gender inequalities on women’s health. Several Member States have identified the lack of appropriate expertise (and attitudes) among health workers and policy-makers as a key constraint in promoting gender equity in public health policies and programmes in the Region. To address this constraint, health workers and policymakers need to be made more gender-sensitive. WHO supported capacity-building programmes focused on reshaping medical education to ensure that gender issues are properly integrated into the planning and delivery of services in the future. Support was also provided for the establishment of stand-alone courses for health workers and policy-makers in the Region on: gender and reproductive health; gender and HIV/AIDS; gender, sexuality and health; and gender and applied health research. The technical content of all these courses draws on WHO’s publication on Gender and Rights in Reproductive Health: Transforming Health Systems. In 2004, the second batch of medical educators participated in a two-week course on integrating gender into medical education. The course was developed by WHO and the Achutha Menon Centre for Health Science Studies, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala, India. Educators from medical colleges in Karnataka, Gujarat, and Maharastra, India; the Department of Community Medicine and Family Health, Institute of Medicine, Nepal; and the Faculty of Medicine, Chulalongkorn University, Thailand, have undertaken follow-on projects aimed at reshaping medical education curricula. The projects range from integrating gender into single disciplines, to the integration of gender across the curriculum. 50 THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION

WHO developed and tested a three-day training course manual on integrating gender into medical education in India

WHO is committed to addressing the impact of gender inequalities on women’s health.

and Thailand, and provided inputs to the development of a training manual on Orientation of Health Professionals on Gender and Health developed by the Institute of Medicine, Nepal. To reinforce these efforts, the Regional Office has been working with the South-East Asia Public Health Education Institutes Network to promote the development of genderbased competencies in public health.

Nursing and Midwifery The nursing and midwifery workforce in many countries of the Region faces several challenges. These include problems of continuing shortage and maldistribution of nurses and midwives, along with inappropriate professional skills mix and inadequate skills to respond to common health problems, emergencies and disasters. During the period under review, guidelines for strengthening nursing and midwifery workforce management were disseminated to Member States. They were, in turn, asked to take necessary steps to develop, implement, monitor and evaluate the relevant strategies and action plans. The close collaboration with WHO collaborating centres for nursing and midwifery development was continuously strengthened in order to build the capacity of nurses and midwives. The examples include: implementation of the first

51 THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION

regional training of trainers programme on nursing and midwifery management in HIV/AIDS prevention, care and support; development of educational modules on nursing management in malaria prevention and control in the community and hospitals; identification of core nursing and midwifery competencies and core curriculum, and development of educational modules on nursing management in injury prevention and control. Technical support was provided to strengthen country projects including the re-establishment of midwifery education and maternal and child health services in Aceh, Indonesia which were significantly damaged due to the tsunami of December 2004; implementation of clinical skills training in Nepal; development of a Master ’s programme in nursing in Bangladesh, and the development of a Bachelor of Nursing conversion programme in Bhutan. In addition, a web site on nursing and midwifery was developed by the Regional Office. It is now available on both WHO intranet and internet.

Nutrition It is a matter of great concern that while high rates of undernutrition in children (30-50%), adolescents and women are prevalent in the Region, over-nutrition resulting in obesity and chronic diseases is also increasing gradually. Micronutrient deficiencies such as iodine deficiency disorders (IDD), irondeficiency anaemia and vitamin A deficiency, although decreasing, are still public health problems. The Regional Office continued to work with Member States for implementation of the Global Strategy on Infant and Young Child Feeding. In Bangladesh, a workshop was conducted for developing a national strategy. Draft national policies for infant and young child feeding were developed by the ministries of health in Maldives, Myanmar and Nepal; India developed national guidelines. Bhutan has launched a nationwide iron supplementation programme for school children with Thursday being designated as Iron Day. India and Myanmar conducted training for increasing awareness about IDD. Training for laboratory technicians for IDD monitoring in India, and training of

52 THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION

midwives for monitoring the iodine content of salt at household and retail levels in Myanmar, were important activities undertaken to strengthen the IDD programme. A workshop for reviewing the maternal nutrition status and formulating action plans for decreasing maternal anaemia was conducted in Timor-Leste. With WHO’s support, Maldives and Myanmar demonstrated their commitment to improving the nutrition status of the population by observing Nutrition Promotion Week.

53 THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION

4

SUSTAINABLE DEVELOPMENT AND HEALTHY ENVIRONMENTS Sustainable Development WHO’s Health and Environment strategy for sustainable development focuses on incorporating health concerns into the work of development sectors of Member States. The rapid pace of urbanization and population pressure continue to expose large proportions of populations in the Member States to health risks associated with lack of clean water and basic sanitation. In the Region as elsewhere, it is the poor who suffer disproportionately from unsafe environmental conditions and food insecurity. Just as poverty is both a cause and a consequence of ill-health, it is also caused by growing environmental risks – both modern and traditional – and, in turn, it aggravates those risks. The need to develop action plans on health and environment has been highlighted in recent years. Nine countries have initiated/developed health

55 THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION

and environment programmes and adopted or drafted plans of action involving intersectoral partnerships. Member States have reacted very positively to the Report of the Commission on Macroeconomics and Health (CMH), published by WHO in 2002. During the year under review, the focus was on consolidating the work done since 2002, and developing national reports in the vision of CMH for scaling up essential health interventions. India, Sri Lanka and Thailand have completed their national reports while in Bangladesh, Indonesia and Nepal, this process is under way. General advocacy for health in sustainable development was carried forward through the meetings of health ministers and health secretaries as also in certain sessions of the Economic and Social Commission for Asia and the Pacific (ESCAP). These have served to enhance the advocacy for intersectoral policies, programmes and actions that are required for health development, particularly that of the poor and the vulnerable groups, in the perspective of sustainable development.

Health and Environment The Regional Offices for South-East Asia and the Western Pacific, supported by the Asian Development Bank, have initiated an Asia-wide consultative process on raising awareness on health and environment linkages at the highest decision-making levels. This process will culminate in a ministerial meeting on health and environment in 2006. According to the 2004 WHO/UNICEF Mid-term Report of Progress on Meeting the Millennium Development Goals (MDGs) for Drinking Water and Sanitation, the water supply coverage in the Region increased from 68% to 84% during the period 1990 to 2002. Services were extended to an additional 442 million people during this period, but despite this enormous effort, more than 262 million people, i.e. 16% of the population of the Region, currently lack access to this basic necessity of life (Table 4.1). As far as the MDGs are concerned, the Region appears on track to achieve the goals set for safe water supply. The challenge to provide really safe (bacteriologically and chemically) drinking water will however continue. With regard

56 THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION

to sanitation, major strides have been made in several countries following the South Asia Conference on Sanitation (SACOSAN) held in Dhaka in October 2003. If Bangladesh and India stand by their commitment to Total Sanitation by 2010 and 2012 respectively, the MDG for sanitation would be achieved. WHO supports Member States in strengthening their institutional capacities in water supply, sanitation and hygiene through national studies and surveillance for policy development and remedial action. This is through fellowships to enhance critical capacities in water quality surveillance and environmental health, and through support for regional awareness and policy-making efforts such as SACOSAN II, to be held in Islamabad in November 2005. In addition, through analysis and regular global reviews, such as through the WHO-UNICEF Joint Monitoring Programme (JMP) for Water and Sanitation, and through the Table 4.1: Water supply and sanitation coverage in the South-East Asia Region, by country, 1990-2002

Source: WHO/UNICEF Mid-term Report of Progress on Meeting the Millennium Development Goals for Drinking Water and Sanitation, Geneva, August 2004

57 THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION

revision of the Third Guidelines for Drinking Water Quality and associated documents, WHO continues to produce norms and guidance that can be introduced in country programming for water supply and sanitation. JMP also acts as the UN monitor for MDGs for water and sanitation. The publication of the 2004 WHO Guidelines for Drinking Water has boosted country-level interest in water quality and related health risk assessments. Bangladesh has taken the lead to develop Water Safety Plans and all countries are organizing promotional seminars to ensure application of the Guidelines. The Regional Office collaborated with AusAID in implementing pilot demonstration activities in water safety planning in Bangladesh, Bhutan and Maldives. Similar activities are being undertaken in India with the support of the US Environment Protection Agency. The collaboration between the Regional Offices for SouthEast Asia and the Western Pacific in matters of environmental health, particularly on water, sanitation and health, is proving very effective. It has also strengthened WHO’s position vis-à-vis regional water quality programming interests of donor agencies. The Regional Office has mobilized development partners for water quality through the Asia Water Quality Initiative. The UN International Decade for Action “Water for Life” was launched in March 2005 in most Member States with

58 THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION

Member States are strengthening their institutional capacities in water supply, sanitation and hygiene.

awareness-raising events highlighting the public health risks associated with inadequate water and sanitation. The messages focused on the returns that MDGs for safe drinking water and basic sanitation will bring as a payback worth many times the investments involved. In Thailand, WHO participated in the launch hosted by the Government of Thailand and facilitated by ESCAP on behalf of the UN family. In Bangladesh, the government, the NGO, Forum for Drinking Water Supply and Sanitation, WHO and UNICEF produced information material and a poster that were distributed during the launch of the Water for Life Decade. The Ministry of Health in Bhutan, through its Public Health Engineering Division, produced a colourful and informative insert on sector status in the national newspaper as well as technical materials. The Society of Public Health Engineers of Nepal organized a meeting on the issue in collaboration with the government and local partners. WHO will endeavour to support the goals of the Decade, and, in particular, to catalyse and scale up the participation of civil society towards increasing societal commitment for the Water for Life effort. WHO continued to support national authorities and NGOs in Bangladesh, India, Indonesia, Myanmar, Nepal and Sri Lanka to plan and implement low-cost water, sanitation and hygiene demonstration projects. The Third Meeting of the International Network to Promote Household Water Treatment and Safe Storage was held in June 2005 at the Asian Institute of Technology in collaboration with the Ministry of Public Health, Thailand. Over 40 papers and several posters presented scientific analysis and practical solutions to safe drinking water for households in remote or underserved areas, or during emergencies. In collaboration with WHO’s Emergency and Humanitarian Assistance programme, activities were initiated to implement the regional strategy for strengthening the capacity of the Regional Office to support water, sanitation and hygiene needs of Member States in emergencies. Information resources were developed and an in-house training course was conducted for concerned focal points. The practiceoriented ‘Fact Sheets’ on water and sanitation in emergencies that are available on the WHO as well as the Water, Engineering and Development Centre (WEDC) web sites have

59 THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION

Efforts are being made by Member States to provide safe water to its people.

proven very useful, and were appreciated during the tsunami crisis. Following the tsunami, support for water and sanitation capacity was mobilized throughout WHO and its partner network. Within a few days, sanitary engineers and environmental health specialists were on site to support governments with restoration of water supplies and provision of suitable water and sanitation facilities for displaced populations. It is expected that local health and water capabilities will be significantly strengthened as an outcome of this emergency.

Healthy settings/cities The rapidly growing cities in the Region need timely and community-based solutions to counter degrading environment and health situations. Urban primary health care approaches and the study of health and environment linkages could help many low-income and unplanned areas to redirect their efforts towards more healthy settings. Healthy settings approaches that promote health can be applied not only in mega cities and towns, but also in institutional settings such as childfriendly schools, and less formal environments like healthy villages and healthy islands. The healthy settings approach offers people and people’s representatives creative, health-

60 THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION

promoting opportunities to work together towards a sustainable and healthy living environment. WHO supports Member States in promoting health through: healthy settings; capacity building; awarenessraising, and information sharing. At national level, it encourages association of healthy cities with each other through regular exchange opportunities, as well as with similar efforts taking place in the urban sector. Healthy settings activities have been initiated in the Region over the past 10 years. This initiative is seen as an effective approach to supplement capacity building at the community level which has relevance in the context of decentralization being promoted by many governments in the Region. In Maldives, the Healthy Villingili island programme in Gaaf Alif Atoll, initiated in 2002, was evaluated after two years of operation. Drinking water availability has almost been doubled; privately-funded community sewers have been laid with community participation; nutrition has been enhanced through improved efforts at home gardening; mosquito and fly nuisance/breeding have been controlled; better solid waste disposal has been accomplished; antenatal care and ARI services have been improved, and better awareness has been created on the ill-effects of smoking. In Sri Lanka, the government is keen to establish a Healthy Colombo programme under the Colombo Municipal Council. Support was provided by the Regional Office in preparing a proposal for action and by the WHO Kobe Centre, Japan. The Kobe Centre has provided complementary support to Kathmandu, Bangkok and Colombo as part of its Cities and Health Programme.

An estimated 40-50 million people may be at risk for arsenicrelated diseases in Bangladesh, India, Myanmar and Nepal

Arsenic poisoning An estimated 40-50 million people may be at risk for arsenicrelated diseases by virtue of consuming arsenic-contaminated groundwater in Bangladesh, India, Myanmar and Nepal. Anthropogenic mining activities in one province in Thailand have also been responsible for arsenic contamination. To mitigate the health effects of arsenic poisoning in the Region, WHO launched an intercountry initiative focusing on 61 THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION

risk mitigation, capacity building and infrastructure strengthening. Activities in each of these areas have been initiated and are ongoing. The major achievement in risk mitigation was the finalization of a field guide for the detection, management and surveillance of arsenicosis in the Region. Risk assessment for potential arsenic contamination was also conducted in Bhutan to examine the health risk posed by hot spring water. An integral part of arsenic risk mitigation was conducting research on the extent of the disease through cluster sampling undertaken in Bangladesh and India. In order to improve management of the disease, research on treatment modality and in the pathogenesis of the disease was conducted in Bangladesh. Other research areas included a case control study on arsenicosis and nutritional factors; maintaining a regional arsenic GIS database; and developing a colour atlas on differential diagnosis of dermal arsenicosis. Regarding capacity building in arsenic mitigation, training of trainers in the use of the WHO field guide for the detection, management and surveillance of arsenicosis was conducted in Bangladesh, India and Thailand with the participation of national and intercountry staff. A cadre of some 150 trained personnel has been developed in the Region to date. To strengthen infrastructure for arsenic diagnosis, technical and material support was provided to laboratories for diagnosing arsenicosis accurately. The laboratory of the National Institute of Health in Thailand was identified as a potential reference laboratory. It has been entrusted with the task of designing, handling and analysing proficiency testing for arsenic to ensure the use of Standard Operating Procedures that have been developed by the Regional Office.

Occupational health The total workforce in countries of the Region is approximately 560 million. A variety of occupational hazards and unsafe work practices are prevalent in the workplace. In order to support Member States to adopt a systematic approach to occupational health, a three-point regional strategy has been formulated. This incudes establishment of

62 THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION

a regional occupational network, promotion of a health risk paradigm at the workplace and capacity building. Occupational health activities focused on translating the WHO regional strategy on occupational health and safety into specific plans of action. Bangladesh, India and Thailand formulated national plans modelled on the regional strategy and based on the actual occupational situation in the country. The Regional Office commissioned a study to review the available information on occupational health from Bangladesh, India, Nepal and Sri Lanka in areas of curriculum development and training. The goal is standardizing course contents and teaching methods in nationally relevant areas including industrial hygiene, basic medical surveillance, occupational health and safety management, and responding to specific occupational health hazards. This work is in progress.

Health impact assessment Previous health impact assessments in the Region have shown a variety of environmental hazards being associated with effluents from the growing number of industrial units. Furthermore, policy-makers lack specific data on the burden of disease associated with a development project in order to institute control measures. To overcome this gap, WHO is collaborating with the Health Effects Institute in Boston, USA which is conducting a study on public health and air pollution in Asia. The Institute is also collaborating with others in designing and conducting time series epidemiological studies to link health outcomes with hazardous levels of air pollution.

Most countries in the Region lag behind developed countries in terms of national capacities for a sound management of chemicals

Chemical safety Many chemicals pose significant health hazards due to their inherent toxicity. Despite the current international chemicals management regime that includes at least 50 legal agreements and about 40 specialized programmes and initiatives, most countries in the Region lag behind developed countries in terms of national capacities for sound management of chemicals. This situation is particularly alarming as the international chemical industry is increasing its production in developing countries.

63 THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION

Table 4.2: Year of joining international agreements on management of chemicals by countries of the South-East Asia Region

Source: 3w.basel.int/index.html ; 3w.pops.int ; 3w.pic.int ; 3w.unep.org/ozone/

The Regional Office supported the preparation/updating and implementation of national profiles for chemicals management and of national action plans in eight countries. The three priorities in this area are: sound management of health care waste; reducing reliance on pesticides for vector control, and protection of children’s environmental health. With WHO support, among others, countries of the Region have, or are in the process of becoming parties to the main four international agreements in pursuit of sound management of chemicals: the Stockholm Convention on Persistent Organic Pollutants, the Rotterdam Convention on the Prior Informed Consent Procedure for Certain Hazardous Chemicals and Pesticides in International Trade, the Basel Convention on the Transboundary Movement of Hazardous Wastes, and the Montreal Protocol on Substances that Deplete the Ozone Layer (Table 4.2).

Sound management of health care waste In 2004, WHO released a new policy for the management of health care wastes (HCW), in line with international agreements. The new policy promotes an integrated ‘cradle to grave’ approach to HCW management. In 2004-2005, the

64 THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION

Regional Office was closely involved in producing a policy paper, and also in the preparation and dissemination of a global WHO guidance document for selecting the most appropriate system for safely managing HCW generated at PHCs, in developing countries. To promote the new policy, the Regional Office provided proactive advocacy, publishing key background documents such as the first report on success stories of health care facilities that adopted sound HCW management systems in India. Guidelines for infection control developed by the Regional Offices for South-East Asia and the Western Pacific were also published and the final version of the distance learning course on HCW management was launched with the Indira Gandhi National Open University, New Delhi, India. This policy-cum-advocacy work, during the period under review, set the ground for countries to address HCW in a more dynamic and appropriate manner (Table 4.3). In close collaboration with NGOs, WHO supported India in the development of a new national system to deal with wastes, especially sharps, derived from immunization campaigns. The Indian “model” is based on the principles of patient safety and environmental viability, which is being implemented with multi-donor support and in collaboration with the Indian Reproductive Health and Child Health Programme. Table 4.3: National policy on health care waste management: Status in the South-East Asia Region

65 Source: WHO/SEARO THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION

In Maldives, WHO contributed significantly to the development of a national system to address HCW and trained over 20 health professionals. As of 2005, Bangladesh started implementing the new WHO health care waste management (HCWM) policy in 20 health facilities, and Nepal in five major hospitals. In September 2004, WHO sponsored a workshop on HCWM Policy in Bhutan. In 2004, WHO developed a holistic policy to address vector management. The Global Strategic Framework on Integrated Vector Management (IVM) sets out broad principles and approaches to vector control applicable to all vector-borne diseases. Integrated vector management seeks to improve the efficacy, cost-effectiveness, ecological soundness and sustainability of disease vector control. This Framework is intended to provide orientation to policy-makers within WHO and Member States on the development and implementation of IVM, and to strengthen collaboration with donors and other United Nations agencies, notably the Food and Agriculture Organization and the United Nations Environment Programme (UNEP). In 2005 a regional version of the IVM principles was developed, to be discussed at a regional workshop where first drafts for national IVM policies will be developed. Ten pilot projects are planned for implementation in 2006-2007 within a major WHO project funded by the Global Environment Facility (GEF) benefiting four countries in the South-East Asia and five countries in the Western Pacific regions.

Working with schools HRIDAY, an NGO in India, has been involved in providing environmental health-related awareness among youth since 1992. HRIDAY focuses on health awareness and informed health activism among students (ages 10-17 years) to positively influence the knowledge of students so as to bring about changes in the school environment in 230 schools in New Delhi. WHO support to “school-based interventions for youth mobilization” started in 2001. By 2005, this project had produced a series of educational material for teachers, students and their families. They include: several thousand posters, various fact sheets and calendars, manuals for trainers and specific school diaries for students. The school diary includes selected sheets with key facts on environmental health. Students carry this diary every day to the school, to write their daily notes, thereby coming across various pictures/caricatures/ jokes/quizzes. This helps in sensitizing the students and enables them to better correlate with the activities that their teachers will conduct in the classroom on Environment and Health. All the HRIDAY materials are 66 distributed to countries of the Region to consider possible replication of the initiative.

THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION

Poisoning by pesticides and household products, as well as overdoses with pharmaceuticals are frequent among children. Exposure to chemicals in the workplace is known to occur in countries with poorly supervised work regulations. A study in India revealed high lead levels in the blood of children working in petrol bunks and in the bangle industry. Likewise, UNIDO has reported on the ill-effects from exposure to mercury among children of gold washers in Indonesia; again, specialized NGOs have confirmed irreversible health damages to children from pesticides in the fruit-growing industry. The WHO-led Healthy Environments for Children Alliance or HECA is a worldwide alliance to reduce environmental risks to children’s health that arise from the settings where they live, learn, play, and sometimes work. The Regional Office has been promoting the need to urgently boost environmental protection to safeguard children’s health in the Region. For this purpose, three specific action research studies on children and environmental health and two pilot studies on indoor air quality were conducted in Bangladesh, India and Nepal. The WHO framework to prepare national profiles on the status of children’s environmental health was disseminated to all countries in the Region in order to obtain a first overview of issues to be addressed in 2006-2007. Over 2000 copies of the school-based environmental health model developed by the Regional Office, which promotes educational games, were also made available to all countries of the Region.

Food Safety There is an urgent need in many Member States to develop national policies on food safety. Consumers have to be informed about the health and economic consequences of foodborne diseases. There is also a need for a strong political commitment in countries to support food safety control systems and action. This would be part of a national strategy founded on the sharing of responsibilities among food safety authorities, farmers, food processors and manufacturers, food retailers, caterers and consumers with effective national and sub-national coordination. Since 1988, the Regional Office has been promoting an integrated approach to national food safety policies – a 67 THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION

farm-to-fork approach. A “10 Point Regional Strategy for Food Safety” has also been developed. A few countries have taken concrete action to reorganize their food safety systems towards a unified or integrated structure. As part of the general need of all countries to promote the exchange of food safety information and to improve collaboration among food safety authorities at national and international levels, WHO is supporting, together with all Member States, the establishment of a network for food safety authorities: the International Food Safety Authorities Network - INFOSAN. Launched in 2004, INFOSAN is an information network for the dissemination of important information about global food safety issues. Several regional focal points for INFOSAN have already been identified in all countries of the Region, where responsibilities are divided among several agencies. INFOSAN EMERGENCY will be used to alert food safety authorities to foodborne disease outbreaks or food contamination events of international significance. INFOSAN is closely linked to the other alert networks at both national and international levels. , WHO is in the process of reviewing In India and Thailand, the compatibility of existing national food safety policies, their relevance to society and appropriateness to protect the health of the population. The aim is to establish a multisectoral, single food safety agency.

68 THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION

There is a need to create greater awareness for the promotion of food safety in the Region.

Avian influenza and wet mark ets markets Poultry farms and “wet” markets have been recognized as a key source for transmission and spread of viruses. Wet markets are live animal markets, a common sight in many areas of the world, and a source of influenza viruses and other infectious disease agents for human beings. SARS outbreaks have been traced to wet markets in southern China. Wet markets sell live poultry, fish, reptiles and mammals of every kind. Animals may stay from days to weeks. Daily human contacts (including children) with the live animals make conditions optimal for the transfer and evolution of infectious disease agents. In the SEA Region, such wet markets remain extremely popular and largely unregulated. Birds and animals are slaughtered under poor hygienic conditions with faeces, feathers and aerosols contaminating the environment, humans and other food sold in the market. Though closure of these markets is unlikely as large numbers of the poor rely on them for food or employment, what is needed is appropriate controls. Better transportation of animals to the market; improved hygiene and sanitation; segregation of different species and also of wild animals and birds where required; and appropriate slaughter conditions could play a significant role in reducing the burden. To combat the risk of influenza and other emerging zoonoses, WHO is working with FAO and the World Organization for Animal Health (OIE) with a view to strengthening risk-based regulatory frameworks and to ensure they are enforced in relation to the marketing of live birds and animals for food. Photo: Angela Rey, 2005

In 2004-2005, with WHO support, Bhutan strengthened its food safety programme under the Ministry of Agriculture, initiating surveillance and prevention of foodborne health hazards. During the period under review, WHO also assisted Timor-Leste to develop its National Strategy on Food Safety which will be implemented in 2006-2007. The Regional Office supports the involvement and active participation of all countries of the Region in the work of the FAO/WHO Codex Alimentarius Commission. This is to help respond to the many challenges food regulators face, especially at the international level, with regard to compliance with global commitments. In-country laboratory-based surveillance of priority foodborne diseases and harmonized guidelines for data collection remain the prime objectives. The Regional Office’s immediate goal is to broaden epidemic surveillance capacity in Member States to include foodborne disease outbreaks. 69 THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION

Emergency Preparedness and Response Natural hazards, human-generated emergencies, and complex crises continued to affect countries and people in the Region during the period under review. These events and disasters in turn, posed challenges to WHO’s role and activities in the area of emergency preparedness and response. The status of emergency preparedness and the countries’ capacity to respond to crises vary from country to country and are closely related to the level of development of national health systems and services. Factors such as decentralization or political structure have either helped or hampered the establishment of an Emergency Preparedness and Response (EPR) programme in countries of the Region. These challenges became apparent in the aftermath of the tsunami of 26 December 2004. Nevertheless, regardless of the scenario and the national context, WHO supported the affected countries through respective ministries of health. The Organization’s strategy to strengthen its operational capacity to respond to crises was designed with the participation of over 300 key people, departments and agencies, and involved consensus building throughout the Organization. In line with WHO’s increased focus on building capacity within countries, the strategy takes into account the needs of authorities within Member States, and the UN system Country Teams (particularly WHO country offices), developing their capacity against benchmarks defined by the EPR programme within a global perspective. The Regional Office forms part of the programme’s Global Steering Group, which helps to develop, promote and refine this strategy as needed. The Regional Office, together with the WHO country offices, is working towards scaling up this in-house capacity for preparedness and response to better serve national and local authorities during crises. Member States reaffirmed their commitment to emergency preparedness and response during the Technical Discussions at the meeting of the Consultative Committee for Programme Development and Management in July 2004. These deliberations emphasized that emergency health preparedness was a cross-cutting issue that should be mainstreamed into health and development activities. As a follow-up of these

70 THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION

technical discussions, in September 2004, the Regional Committee for South-East Asia adopted a resolution urging Member States to further strengthen their national capacity in risk management; improve coordination among health actors in crises; develop and update legislation and policies, and map resources for preparedness and response. National legislation and policies, aimed at strengthening disaster preparedness and response in emergency situations have been considered and, in the case of India, Indonesia, Maldives and Sri Lanka, are in the process of being developed. During the reporting period, more than 30 health professionals were trained at an interregional management course on public health in emergencies, conducted in collaboration with the Asian Disaster Preparedness Centre (ADPC) and the WHO Regional Office for the Western Pacific. ADPC also worked with the Regional Office and UNDP’s Regional Bureau for Crises Management to implement the Pilot Course on Disasters and Development. At this high-level course, participants from the development and health sectors deliberated on integrating disaster preparedness, response, rehabilitation and recovery activities into the total development context. Technical cooperation was provided to countries in the Region to improve coordination and response; mobilize resources; manage logistics and supplies and human resources. Many technical tools are available and have been disseminated to support capacity building in emergency preparedness and response. However, many need to be adapted to the Region’s requirements or updated.

The unprecedented earthquakes and tsunamis of December 2004 severely affected six of the Region’s 11 Member States

The tsunamis and after The unprecedented earthquakes and tsunamis of December 2004 severely affected six of the Region’s 11 Member States (India, Indonesia, Maldives, Myanmar, Sri Lanka and Thailand). The tsunamis caused an estimated 280 000 deaths, with thousands still missing. Nearly half a million people were injured and at least five million rendered homeless and/or deprived of adequate access to safe drinking water, sanitation, food or health services. The health infrastructure was severely damaged. The aftermath of this crisis posed public health,

71 THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION

management and logistical challenges that shaped much of the Region’s emergency preparedness and response work during the first quarter of 2005. WHO mobilized available resources from all over the world, including emergency health experts, and deployed them to the worst-affected countries like Indonesia, Maldives, Sri Lanka and Thailand, to support the nationals in their relief and rehabilitation efforts. More than 200 international experts helped in relief work in Indonesia, Sri Lanka and Maldives. Support was provided in monitoring the quality of water and in disease surveillance. A Tsunami Technical Group (TTG) in the Regional Office coordinated mobilization of expertise, guidelines and tools and other required resources. Surveillance data were compiled and analysed weekly to signal any likely disease outbreak or unusual health event. Vaccines and lifesaving drugs were mobilized, logistical support provided to ensure fast shipment of these supplies to affected areas, and laboratory strengthening was supported through supply of reagents and technical support. Communicable disease experts, including those from the Global Outbreak Alert and Response Network, organized early warning and alert systems and set up a system of emergency disease surveillance to respond to outbreaks. As a result, no major outbreaks were reported. Mental health was recognized as a serious public health problem very early after the crisis, and psychosocial support and training was imparted to medical personnel and NGOs. Support was offered to Thailand in forensic identification of bodies, and in strengthening its forensic infrastructure. During the post-tsunami period, guidelines on a wide variety of technical topics - water and sanitation, vaccines, food safety and nutrition - were prepared and disseminated widely through various channels. As part of WHO’s response to the tsunami disaster, WHO country offices enlisted the support of WHO collaborating centres, and trained health workers to provide psychosocial support to disaster victims. Other partners, such as ADPC, also provided key support in capacity building by organizing training programmes and workshops to address specific gaps (e.g. humanitarian supplies management, and management of cadavers). Intercountry and interregional support from non-affected countries/regions to WHO country offices in

72 THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION

affected countries was another hallmark of the response to the tsunami. In February 2005, the Regional Office convened a coordination workshop for WHO and national staff from tsunami-affected countries. The aim was to clarify the process of implementation of the Flash Appeal projects and to review the implementation of workplans. In early May 2005, WHO convened an international conference on the health aspects of the tsunami crisis in Thailand, where international experts from within the Organization and outside, focused on lessons learnt from the immediate health sector response and during the early phase of recovery. Countries affirmed their willingness to be better prepared for major disasters and to invest in building stronger response capacity. WHO is working with NGOs, the Red Cross and UN agencies to develop standardized health assessment tools. The need to provide external assistance from a single integrated response support system was emphasized to ensure that national officials in disaster-affected countries were not overwhelmed with individual offers of help from external sources. The important contribution from NGOs was recognized and WHO was requested to find more efficient and effective means of coordination. The key role of the military and the private sector in responding to health aspects of disasters was recognized. The role of the media as an important partner was also acknowledged. The tsunamis killed more women than men, and as women play a vital nurturing role in most of the affected countries, their deaths left many families, particularly children, very vulnerable. There was a need to pay special attention to children who had lost their mothers, were living alone or with maleheaded households. The tsunamis also highlighted the fact that efforts must be redoubled by preparing Member States to lessen the impact of disasters on the health of the affected population as well as the health systems that serve them. Health action in relation to crises and disasters, with particular emphasis on the earthquakes and tsunamis of December 2004, was the subject of a resolution (WHA58.1) adopted by the Fifty-eighth World Health Assembly in May 2005. The Health Assembly called upon the international community to continue its strong and long-term support to areas affected by the tsunamis. It urged Member States to,

73 THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION

74 THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION

75 THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION

inter alia, pay particular attention to mental health needs and to formulate national emergency preparedness plans that give due attention to public health in order to improve the effectiveness of responses to crises and of contributions to the recovery of health systems. It requested the Director-General to, among other actions, take steps to intensify WHO support to affected countries in their efforts to establish effective disease surveillance systems etc.

76 THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION

5

HEALTH SYSTEMS DEVELOPMENT

Organization of Health Services Despite best efforts of Member States, significant challenges in the organization and delivery of health services persist. The major challenges are lack of reliable data; inadequate human resources in some countries and uneven distribution in others; affordability and cost of health care for the poor and the marginalized, and the lack of public health infrastructure. The broad strategies to counter the challenges include: building of management capacity; integration of health delivery system; increasing cost-effectiveness; promoting appropriate public-private mix ensuring equity and quality of services to the poor and the marginalized; alleviation of imbalances in the composition and distribution of human resources for public health, and implementation of quality assurance and accreditation.

77 THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION

Health systems In order to lay a strategic roadmap, a bold initiative in the form of “South-East Asia Public Health Initiative: 2004-2008” was launched to position public health high on regional and national health agendas. An in-house technical working group and a strategic advisory group were constituted to devise the framework and oversee the implementation of activities. Accordingly, resources were realigned to achieve these goals. Following the establishment of the South-East Asia Public Health Educational Institutes Network (SEAPHEIN) in April 2004, strategies and approaches for future country-specific action plans were formulated, and faculty exchanges within and between India, Indonesia, Nepal and Thailand facilitated. Preparation of a status paper on public health legislation and an assessment of public health functions in at least five countries of the Region were also undertaken. The draft Medical and Health Council Act, Rules and Regulations in Bhutan was finalized. In Sri Lanka, a draft document containing a synopsis of selected legislation has already been developed. The Management Effectiveness Programme and Clinical Performance Development Management Systems, with the objective of ascertaining the interest of Member States and impressing upon them the importance of including management development and clinical performance of health workers in their country workplans, is being finalized.

78 THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION

Member States are making concerted efforts to ensure the provision of quality health services.

Myanmar and Indonesia have shown good progress in this area while Sri Lanka and Timor-Leste are expected to initiate action soon. Expansion of the telemedicine programme to the district level in Bhutan is also being facilitated. The Policy and Planning Division in Bhutan has been strengthened with four staff supported to pursue the Master’s course in Health Policy, Health Information, Human Resource Management and Health Economics. Technical guidance to address the growing concern for patient safety and quality assurance was provided to Member States. Research proposals received in this area from Myanmar and Thailand are under review. Decentralized planning and financing at district level have contributed greatly in bringing appropriate services closer to the community. Selective support was provided to Sri Lanka in this initiative. In addition, district health planning was strengthened and the outcome was a five-year district health plan with strategies to address the issues related to marginalized populations. A new health service delivery model was also successfully implemented in a hospital with plans of replication in several health institutions. In Indonesia, printing of a periodical, “Health Decentralization Bulletin”, and the development of effective referral services in a highly decentralized system was supported.

Quantity and quality of human resources are issues that impact the health services in Member States of the Region

Human resources for health Quantity and quality of human resources are issues that impact the health services in Member States. Lack of planning, training capacity for human resources for health (HRH), mismatch and imbalance in the ratio of health personnel are other related factors. In the area of health manpower mix, while the ratio of nursing and midwifery personnel is higher compared to physicians in countries such as Bhutan, DPR Korea, India, Indonesia, Maldives, Sri Lanka, Thailand and Timor-Leste, the reverse is seen in Bangladesh, Myanmar and Nepal. Curriculum reform has been a continuous process in medical schools in Bangladesh, Sri Lanka and Thailand. The health promotion component in the health programme curricula in Thailand has been strengthened. Gender issues and women’s health have been addressed in India, Nepal and Thailand.

79 THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION

Development of human resources for health is an area of high priority in the Region.

Efforts are being intensified to focus on the development of a core curriculum in public health education through a workshop approach. Selective efforts in India, Indonesia and Nepal have been made to develop the Master’s in Public Health (MPH) curriculum. Allied health education and training have come into focus due to the lack of training and courses in laboratory technology. A regional core curriculum for laboratory technicians is being developed. Efforts are also being made to develop training modules for health financing, health economics and health management for public health programmes. Establishment of a Public Health Institute in Myanmar is under process. Similarly, public health programmes are being developed and strengthened in India, Indonesia, Nepal and Timor-Leste through training etc. WHO headquarters have launched health workforce studies and data collection and analysis focused on the World Health Report 2006, devoted to the theme of HRH, and the Human Resources Development decade. A survey to estimate the total public health workforce in the Region has also been initiated in conjunction with the above survey.

Education and training During the period under review, 688 letters of award were issued against 769 fellowship applications received. Countrywise data are presented in Table 5.1. There has been an appreciable increase in the receipt of Fellowships Termination

80 THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION

of Study Reports (FTSRs) which is presently 53.8%. Despite intensive efforts to obtain Utilization of Fellows’ Services Report, the progress has not been satisfactory. Technical and managerial support services were offered to the Western Pacific (WPR), Eastern Mediterranean (EMR) and Africa (AFR) regions in the implementation of a total of 105 fellowships and study tour programmes, with the active support of WHO country offices. Table 5.1: Implementation of fellowships in the South-East Asia Region, 1 July 2004 to 30 June 2005

Source: WHO/SEARO, ETS Unit - 2005

Applications for 110 study tours were processed for implementation by the technical units. Seventy-three meetings/group educational activities (GEAs) were held. Of these, 8 were policy meetings, 24 were advisory meetings and 41 were intercountry technical meetings. An electronic Documents Management System (eDMS) is firmly in place to serve as an electronic storage platform for all operational documents. Recently, a mission from WHO headquarters studied the system and commented favourably on the electronic storage and reporting systems as well as the extent of automation achieved. The web-based WHO Regional Directory of Training Institutions (RDTI), launched in April 2004, contains data of 81 THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION

49 institutions along with their related profiles. These include 29 clinical, 33 public health and 45 research institutional profiles. It is expected that the database will serve as a reference tool, among others, to facilitate placement in the Region and countries, support various network initiatives in the Region and identify a pool of expertise. A thematic evaluation of WHO’s Global Fellowships Programme took place last year and the report was endorsed by the Programme Budget and Administration Committee of the Executive Board in January 2005. It provided direction for improving the performance of the fellowships programme within the framework of results-based management. A web page with details of the respective programmes and activities in respect of health systems, human resources for health, education and training support units is available and is periodically updated.

Evidence for Health Policy The key challenges in this area are to improve the performance of the health information system (HIS) so that the data generated can be transformed into information for evidence-based decisionmaking; promote health policy and health systems analysis; and encourage evidence-based decision-making. Broadly, the main regional and national strategies addressing these challenges include: strengthening national health information systems for providing evidence-based information to policy-makers and for monitoring progress in achieving the Millennium Development Goals (MDGs); promoting and building capacity for health policy analysis, providing technical support to countries in using appropriate tools and methods for evidence-based decision-making (burden of diseases, enhancing health system performance, core health indicators), and increasing the capacity of countries for analytical thinking and use of reliable information emanating from the dynamic and responsive health information system. Work on updates of the health system profiles of countries of the Region was undertaken to address all components of the health system framework and prepare a base for the decision-making process for strengthening of the health

82 THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION

system. Final versions of the updates are being drafted and will be posted at the web sites of the Regional Office and the country offices. Use of “Health Mapper” a WHO software on health service availability and health situation monitoring, was promoted in the Region. Participants from Indonesia and Sri Lanka attended a training course, on use of the Health Mapper in districts. The capacity of countries to generate and use health information is not strong, and is often focused exclusively on disease-specific programme areas. They not only have the least information but also limited capacity (skills, systems) to generate, analyse, present and disseminate information. There is thus a need to develop a framework for strengthening health information through concerted efforts of all stakeholders and partners, and also to pave the way for collaboration between the Westen Pacific and South-East Asia regions in strengthening health information. A WHO Bi-regional Consultation on Strengthening Health Information Systems in Asia and the Pacific was held to discuss and formulate a framework for strengthening the health information system; to identify issues and challenges for collection, compilation, analysis and dissemination of basic core indicators including MDGs; and to review and finalize the publication on Core Indicators 2005 for Asia and the Pacific, and the progress made towards achievement of MDGs in Asia and the Pacific Region. As an outcome of the Consultation, a Framework for Strengthening Health Information in Asia and the Pacific has been drafted. This Framework will be finalized in consultation with countries of the SEA Region. Bi-regional collaboration related to health information system addresses the principles for creating a dataset for Core Health Indicators (CHI). It has been a WHO domain in all levels of the Organization, to recommend the CHI set for monitoring of health status and health system performance. Minimum essential categories have been identified, including equity, selected mortality and morbidity indicators and MDGs. A 2005 Core Health Indicators brochure has been published, for the first time for Asia and the Pacific. At the same time, another brochure focusing on progress in MDGs for Asia and the Pacific has also been produced. For improved data quality, data management and intercountry comparison, work on the implementation of International Classification of Diseases

The capacity of countries to generate and use health information is not strong, and is often focused exclusively on disease-specific programme areas

83 THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION

Pr ogress towar ds achieving MDGs Progress towards The Twenty-second Meeting of Ministers of Health of Countries of the South-East Asia Region, held in Maldives in September 2004, reviewed the progress towards achieving the MDGs in South-East Asia. The meeting recommended that Member States should identify specific challenges and develop appropriate intervention programmes with the support of all partners in health; it also recommended that WHO should continue to assist countries in their work on MDGs, particularly in technical support, monitoring and reporting and resource mobilization activities. At the country level, WHO continued its technical assistance in MDG monitoring and reporting, and in coordinating and collaborating with all stakeholders to support activities related to achieving the MDGs.

(ICD-10) in some countries (India, Maldives, Nepal, Sri Lanka) was supported and was focused mainly on training activities. A national-level Burden of Diseases methodology workshop was supported in Myanmar. Experts from India and Thailand participated at the global meeting on Family of International Classifications in Reykjavik, Iceland. During the Fortieth Meeting of CCPDM and the fifty-sixth session of the Regional Committee, Member States requested the Regional Office to share evidence-based information and country experiences on social health insurance and other riskpooling mechanisms. Member States also wanted to be supported in their efforts to introduce or expand alternative health care financing, including social health insurance schemes, in partnership with WHO collaborating centres, national centres of excellence and national expertise. As a follow-up, during the period under review, the Regional Office collaborated with the Regional Office for the Western Pacific to develop a draft bi-regional strategy on health care financing. In response to the above-mentioned Regional Committee resolution, selected case studies from countries in Asia and the Pacific were published as a SEA/WP Regional Offices’ collaborative effort. Work on National Health Accounts (NHA) continued in the countries of the SEA Region. As of now, NHA has been established in Bangladesh, Sri Lanka and Thailand. In India, Indonesia, Myanmar and Nepal, work on NHA is under process, while Maldives is considering to initiate work in this area. As one of the main products of bi-regional collaboration between the South-East Asia and Western Pacific Regions, production of a publication, Asia Health Report – Edition 2006, was agreed upon. This will be the first WHO publication of

84 THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION

its kind, focusing on areas such as health policies, policy options, and issues and challenges relevant to countries comprising the major portion of Asia and the Pacific regions. Prominent and dominant issues specific to these regions will be covered. Other areas, such as health care financing; emerging diseases; globalization and trade in relation to health; partnership, and stewardship/governance will also be addressed.

Research Policy and Cooperation The recent experience in effectively controlling SARS and avian influenza have highlighted the need for health research with stronger political support. Urgent and coordinated response by research institutions at global, regional and national levels in health and biomedical research has become important to generate evidence for prompt action. In this context, experts from countries in the Region discussed “Emerging Infectious Diseases” (EID) as the main subject at the Twenty-ninth session of the South-East Asia Advisory Committee on Health Research (SEA-ACHR) held in Yangon, Myanmar in June 2004. The EIDs were very relevant to Indonesia and Thailand which had been hit by an outbreak of the SARS virus. Nipah virus, kala-azar and dengue continued to place a high burden on Bangladesh. SEA-ACHR made recommendations on the following four areas of health research priorities on EIDs: (a) surveillance, (b) development of new diagnostics and tools: discovery of new vaccines and drugs; (c) studies to strengthen laboratories and the surveillance system, and (d) health systems and socioeconomic impact analysis. Accordingly, Indonesia, Maldives, Myanmar and Sri Lanka assessed their laboratory surveillance systems and reviewed the existing guidelines for strengthening laboratories, and developing integrated disease surveillance programmes. Member States were encouraged to develop national policies on EIDs, including the use of advocacy and mobilization of additional resources for supporting and enhancing epidemic preparedness plans. The SARS outbreak provided evidence of the close relationship between medical and health problems, as well as economic and social problems. Countries stressed the need for more attention to non-medical and non-health research,

The SARS outbreak provided evidence of the close relationship between medical and health problems, as well as economic and social problems

85 THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION

involving research on the cause-effect relationship between certain health problems and non-health factors such as the economy, education, and social and gender factors. Qualitative tools for assessing national health research system and analysis , which is globally developed, should be further (NHRSA), adapted to each country ’s context, especially if periodic assessment of performance is needed. As a continuing activity of the pilot study on health research system analysis involving Indonesia and Thailand, organized by WHO headquarters in 2002-2003, a “Capacity Strengthening Workshop on Health Research System Analysis” was held in October 2004. The workshop was attended by participants from selected countries of the South-East Asia, Western Pacific and European regions. Bangladesh, India and Myanmar, who are interested in assessing their national health research policy and programmes, will be adapting the framework and tools developed. Capacity building in the development of good research proposals that could meet the expectations of donors was a continuous effort of the Medical Research Council of Bangladesh, the Indian Council for Medical Research, the National Institute of Health Research and Development, Indonesia, the Department of Medical Research, Myanmar, medical schools in Sri Lanka and the Health Research System Institute of Thailand. Much of the work is being done in collaboration with international agencies and institutions, and these countries are progressing well in the area of building research capacity. Countries like Bhutan, DPR Korea, Maldives and TimorLeste received support from WHO’s Special Programme for Tropical Disease Research and Training through the project: “Small Grants Programme for Operational Research in Tropical Diseases”. The course pack was prepared and training workshops were conducted in Bhutan in August 2004, and in Maldives in December 2004. Given the training and funds for conducting research, young researchers in these countries are now capable of developing, carrying out and reporting health research. The project supports operational research on dengue, lymphatic filariasis, malaria and leishmaniasis. 86 THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION

To bring “knowledge into action”, WHO and its partners attended a high-level conference: “Ministerial Summit on Health Research” in November 2004 at Mexico. Fifty-eight ministers

of health, and ministers of science and technology, were among the 700 delegates from all over the world. From the Region, ministers or senior officials from Bhutan, India, Indonesia, Myanmar, Nepal, Sri Lanka and Thailand participated in the Summit. The ministers and high-level policy-makers signed ‘A Statement of Health Ministers’ which urged the WHO Director-General to request Member States to bridge the “know-do gap”. The statement stressed that governments should set aside 2% of their national budgets for research. The Report titled, “Knowledge for Better Health”, was also presented at the Ministerial Summit. The testing of teaching guidelines on medical ethics which was started in 2002 in seven medical schools in Bangladesh, Indonesia, Myanmar, Sri Lanka and Thailand, was completed. Some medical schools have used the guidelines to review and update their medical ethics curriculum. Additional cases, specific to the medical schools concerned, have been added to the guidelines. A workshop was held in August 2004 in Bangkok where the results of the field-testing of the Regional Health Ethics Teaching Guidelines were discussed. The final version of the guidelines will soon be printed and CD versions distributed in 2005 to all medical schools in the Region. In the area of ethical and legal issues of human genetics, ethical review committees need to be empowered with appropriate technical knowledge and skills to review proposals on human genetic research. Some countries have expressed the need for regional guidelines to help them develop their national guidelines on human genetic research. There is also a need for good research managers with requisite skills. To support countries to build knowledge and skills in research management, the final draft of 10 modules on health research management was developed by a group of experts. Indonesia took the lead to conduct orientation courses using the modules and assigned focal points, formed core groups of trainers, identified the target audience for the training and selected appropriate modules for developing the course pack. To identify national and regional experts, Thailand took the lead in creating a database and developing a web page on Thai national experts to enable them to share their experiences on international work. The Regional Office and Thailand

Ethical review committees need to be empowered with technical knowledge and skills to review proposals on human genetic research

87 THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION

assisted India and Indonesia in developing a suitable, simpleto-use electronic system for experts through a workshop held in December 2004. It is expected that Member States will further improve bilateral or horizontal collaboration, thereby helping each other through exchange of experts.

WHO collaborating centres and expert advisory panels WHO collaborating centres (WHO CCs) play a vital role in furthering WHO programmes in countries of the Region. To streamline the process of designation and re-designation of collaborating centres, WHO headquarters have finalized and circulated the revised forms for designation and evaluation. Henceforth, all proposals for designation will be approved electronically by the Global Screening Committee (GSC) Members as and when they are forwarded to WHO headquarters. This procedure would ensure speedy approval, though GSC would continue to meet bi-annually to discuss policy issues. As of June 2005, the total number of active WHO collaborating centres in the Region was 77: (Bangladesh – 2; DPR Korea – 1; India – 38; Indonesia – 4; Myanmar – 2; Nepal – 2; Sri Lanka – 2, and Thailand – 26). Four new proposals were ready to be reviewed by the Regional Development Committee (Table 5.2). Table 5.2: Status of WHO collaborating centres in the South-East Asia Region, June 2005

88 THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION

Source: WHO/SEARO, RPC Unit

National workshops on WHO collaborating centres held during the period under review recommended that the centres be used maximally at national, regional and international levels. WHO supported the establishment of a network of WHO collaborating centres and national centres of expertise in Thailand. A network secretariat was formed and a monthly newsletter distributed widely in Thailand, as well as to other Member States in the Region. The Regional Office is currently developing guidelines to promote national centres of expertise. The WHO Expert Advisory Panels (EAPs) and Expert Advisory Committees (EACs) support technical programmes with appropriate advice. These experts are selected and appointed by the WHO Director- General, on the recommendation of Member States and WHO technical programmes. As of June 2005, there were 80 experts from the Region on Expert Advisory Panels. The country-wise and gender-wise representation is as follows: Bangladesh (1 female); India (27 males, 8 females), Indonesia (7 males, 3 females); Myanmar (2 males, 1 female); Nepal (3 males, 1 female); Sri Lanka (5 males, 3 females), and Thailand (11 males, 8 females). The female:male ratio of EAP membership from the Region is the most favourable, as compared with other WHO regions.

Essential Medicines Countries are at the core of WHO’s Medicines Strategy (20042007). The vision is “People everywhere have access to essential medicines they need; that the medicines are safe, effective, and of good quality; and that medicines are prescribed and used rationally”. Achieving this vision in the Region is a complex and intricate task due to the enormous diversity in capacity for medicines in countries. On the one hand, India has the capability to discover potential new medicines and take the final product to patients; on the other, countries such as Bhutan and Maldives import virtually all their requirements of medicines. Each has its own strengths and problems: India is faced with an enormous number of trade names of drugs, some of which are unacceptably close and confusing with generic names; Maldives has to deal with the production and regulation of

89 THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION

medicinal oxygen as, unlike medicines, it is cost-effective to manufacture rather than import medicinal oxygen. Policy (based on the Essential Medicines Concept), is the first component of the WHO Medicines Strategy. Bangladesh updated its historic Medicines Policy of 1982. Acknowledging the vigorous pharmaceutical industry that has developed, there is a greater focus now in the policy on manufacturing. Sri Lanka, which undertook many ground-breaking activities in the 1970s, specifically addressed the needs of consumers/ patients in the draft policy, now on the internet for discussion. Bhutan updated its National Essential Medicines List further binding the procurement, supply and use of medicines in the country to the list. During the period under review, steps were initiated by some Member States to incorporate the public health provisions of Trade Related Intellectual Property Rights (TRIPS). India amended its National Patent Legislation to be in line, by 2005, with the international obligation of being a member of the World Trade Organization; the process was closely followed by other countries including those India exported to. Indonesia was the first country in the Region to issue a TRIPS-compliant “government use” decree for antiretroviral drugs (ARVs), thus ensuring potential access to adequate treatment for HIV/AIDS patients in the country. Bangladesh has until 2016 to enact the Patent Legislation; however, for its sophisticated pharmaceutical industry to reap the benefits the national drug policy will have to address these issues. Access is the second component of the WHO Medicines Strategy, with “fair financing mechanism and affordability of essential medicines” and “efficient and secure systems of medicines supply in both the public and private sector” as its core. The WHO Health Action International (HAI) project on Medicine Prices was taken up by India and Sri Lanka, results of which have contributed to the Global Medicines Prices Database. Surveys showed the persistence of expensive products and therefore the existing price regulation as not being a very efficient mechanism. India has become crucial to the WHO/UNAIDS “3 by 5” initiative by producing cheaper and high quality generic ARVs; five manufactures from India are now pre-qualified and further pre-qualifications are expected. Indonesia now has the

90 THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION

capability of producing the finished products of ARVs from imported raw materials. Thailand is focusing through its government manufacturing institutions to produce ARVs for its own patients. Quality and safety is the third component of the WHO Medicines Strategy; Nepal improved its inspection capacity for Good Manufacturing Practices (GMP) through workshops organized in collaboration with WHO. Some of its manufacturers have now achieved GMP certification from the national authority. However, the full impact of certification is yet to be felt as preferential procurement by the government from such manufacturers is planned, but not yet implemented. The simple monitoring for adverse drug reactions has now advanced to pharmacovigilance, which is the science dealing with the detection, assessment, understanding and prevention of adverse effects or any other drug-related problems. National activities in this regard have been initiated by Bhutan, India and Nepal. With regard to the fourth component of the WHO Medicines Strategy – rational use of drugs – many more activities need to be undertaken. A survey of advertising of drugs in India funded by the WHO country office, demonstrated the lack of standardized medicines information that should be included in such advertisements. This study, hopefully, would be the foundation for better regulation of drug promotion. Bangladesh, which published its National Formulary in 2001, brought out an enlarged and updated second edition in 2004. However, the small number of copies and therefore the limited distribution demonstrated the necessity for funding not only the development of a product but also its production, advocacy and distribution. Similarities in issues, problems and solutions in medicines activities transcend WHO regions. Fruitful collaboration between countries of different regions was witnessed in the areas of combating counterfeit medicines; medicines regulation, and HIV/AIDS. In combating counterfeit medicines, the continuing collaboration in the Mekong region which involves Thailand and Myanmar (and Indonesia, though not a Mekong country) and countries in the Western Pacific Region such as

Similarities in issues, problems and solutions in medicines activities transcend WHO regions

91 THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION

Laos, China and Cambodia, proved productive. The problem of counterfeit artesunate products is of prime concern. The response by countries in the area of medicines to the devastation of the tsunami demonstrated the varying capabilities. India and Thailand had sufficient capabilities in medicines and therefore did not request nor accept donations. Indonesia, Sri Lanka and Maldives, on the other hand, received substantial donations. The WHO Guidelines for Drug Donations were able, to some extent, funnel this generosity towards medicines that were needed. Regrettably, some of the donations comprised medicines that were unfamiliar or unwanted, and at times near expiry, and on some occasions were without any instructions for use.

Traditional medicine The publication, “Guidelines for Regulation of Herbal Medicines in the South-East Asia Region”, which was the result of a Regional Office workshop, held in June 2003, has brought the Region to the forefront of regulation in this area. This publication will be used in a workshop scheduled in the Western Pacific Region to develop regulations for herbal medicines. A Regional Working Group Meeting to review traditional medicine was held in August 2004, pursuant to a resolution of the fifty-sixth session of the Regional Committee. The group recommended a regional consultation on development of traditional medicine, which was held in June 2005 in Pyongyang, DPR Korea.

92 THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION

Regulation of herbal medicines in the Region is gathering increasing momentum.

Myanmar has provided a greater focus on traditional medicine and, through WHO cooperation, is updating its training from a diploma to a degree level.

Knowledge Management and Dissemination Concerted efforts were continued towards the proper management of health information materials, in terms of sources, collection, processing, storage, dissemination and retrieval. As a result, WHO Press (WHP) was established with the objective of ensuring Organization-wide commitment to quality assurance; disciplined and dedicated focus on customer service; services to developing countries and populations in greatest need, and promotion of multilingualism. Volume 8, No.2 (2004) of the Regional Health Forum covering topics like “Induced Abortion”, and “Medical Negligence and the Law” was issued. Volume 9, No. 1 (2005) of the Forum was mainly devoted to the World Health Day theme for 2005 – Healthy Mothers and Children, with contributions received from many countries in the Region. Articles covered by the Forum are now widely available electronically as they are being continuously posted on the Regional Office web site. The Forum continues to serve as a useful platform for debate and exchange of views and ideas on health-related issues of regional interest. Notable progress was achieved in increasing collaboration with WHO headquarters, as well as with the Regional Office for the Western Pacific, especially in the following areas: exploring possibilities of increased coverage by the Bulletin of the World Health Organization, of health development news from the SEA Region; joint SEARO/WPRO publications, and exchange visits among editorial and publications staff of WHO headquarters, and the South-East Asia and Western Pacific regional offices. A series of technical publications, newsletters and bulletins on HIV/AIDS, TB and other communicable diseases; comprehensive community and home-based health care; social health insurance; and newborn and adolescent health were brought out. The Regional Office continued to print documents for free distribution, including reports on various meetings and country missions, monographs, guidelines, training modules and advocacy materials covering different

93 THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION

technical areas. The report of the fifty-seventh session of the WHO Regional Committee for South-East Asia, as well as the report and recommendations of the Technical Discussions, were printed and distributed. Volume 3 of the Handbook of Resolutions and Decisions of the Regional Committee for South-East Asia was updated. Documents pertaining to the meetings of the WHO governing bodies such as the World Health Assembly and the Executive Board, held during 2004 and 2005, were also disseminated to the Regional Office staff as well as the concerned national health authorities. The Regional Office, in collaboration with country offices, participated in scientific congresses and Book Fairs held in Kolkata (India), and Colombo (Sri Lanka). In addition to sales of WHO publications, a large number of subscriptions as well as reprint and translation rights were also negotiated. In order to satisfy the identified needs of the Region, and with a view to reducing production costs and enabling wider distribution, reprint rights were granted to commercial publishers for low-cost local editions of 32 publications. Translation rights for 19 WHO titles were negotiated in various regional and local languages to promote access to WHO information products. The languages included: Bengali, Hindi, Korean, Bahasa Indonesia and Thai as well as a number of major Indian languages. The Regional Office web site carries comprehensive bibliographical descriptions and abstracts of recent WHO publications. The web site is updated regularly. The computerized sales operations of the Regional Office are helping to meet the increasing demand for WHO publications in the Region expeditiously and efficiently. As a result of these efforts, the sales turnover in the Region during the period under review was approximately US$ 210 000 (including US$ 12 342 received against royalties), which was among the highest globally. Provision of relevant and timely scientific information is among the important areas of WHO’s assistance to its Member States. Information management and dissemination (IMD) plays an important role in the management, sharing and dissemination of explicit knowledge. 94 THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION

Provision of relevant and timely scientific information is among the important areas of WHO’s assistance to its Member States

Member States are being supported in the retrieval and dissemination of information through orientations and workshops.

With the aim to enhance Organizational assets and facilitate knowledge sharing, the Regional Office has been digitizing health information materials as an ongoing activity. The information resources covering the period 1948 till date are now available on demand in digital format. During the year under review, the Regional Office also played an active role in Organization-wide knowledge management activities such as the WHO Global Health Library, eHealth and Health InterNetwork Access to Research Initiative (HINARI). HINARI provides free or nearly free access to over 2 200 biomedical journals to institutions in Bangladesh, Bhutan, Maldives, Myanmar, Nepal and Timor-Leste. Organizational digital photographic archives have been expanded to Women’s Health and tsunami, while work is in progress to store photo images of WHO activities covering the malaria and leprosy programmes as well. These digital image archives are among the high-demand information items that the Regional Office provides to the global audience. In the area of identification, management and dissemination of national knowledge assets in health to Member States of the Region, “product-oriented” technical support was provided through the HELLIS Network in the form of consultancies, orientations and workshops. Several information products were thus produced in Bhutan, Indonesia, Myanmar, Nepal, Sri Lanka and Thailand and can now be accessed through the

95 THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION

Regional Office Library and HELLIS web sites. Technical assistance provided through email communications are also archived as Technical Support Forum that can be accessed at the Library web site. Technical issues can be directly posted at the Forum and solutions received from the Regional Office Library. The Forum serves as an important knowledge base. To achieve optimal cost-effectiveness in access to international scientific literature in health, both at the Organizational level and for Member States, the Regional Office uses Networked Resource Sharing Model as the key strategy. Information Resource Stations have been established and strengthened in all WHO country offices. These resource stations, along with members of the HELLIS Network and HINARI serve as a useful reservoir for sharing resources. Provision of original scientific literature in full text has always been an important part of information services, especially for those Member States without HINARI eligibility such as India, Indonesia, Sri Lanka and Thailand. Being a member of several consortiums for acquisition of information materials, the Regional Office is able to provide the most costeffective document delivery services in the Region. In addition, several gifts and exchange agreements were initiated with partner institutions within the Region to facilitate free flow of scientific health literature, which is regarded as an indispensable resource for national health care development in Member States.

96 THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION

6

PROGRAMME PLANNING AND MANAGEMENT Governing Bodies World Health Assembly The Fifty-eighth World Health Assembly was held in Geneva from 16 to 25 May 2005. As an outcome of the Executive Board’s discussion on the working methods of the Health Assembly, the opening agenda items followed the pattern of those for the Fifty-seventh World Health Assembly. The Assembly elected Ms Elena Salgado (Spain) as President. From the South-East Asia Region, Professor Suchai Charoenratanakul (Thailand) was one of the five VicePresidents, while Dr Md Abdur Rahman (Bangladesh) served as one of the Vice-Presidents of Committee B.

97 THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION

His Excellency Mr Maumoon Abdul Gayoom, President of the Republic of Maldives and Mr Bill Gates, Co-founder of the Bill and Melinda Gates Foundation, addressed the Assembly. The Assembly adopted 34 resolutions and two decisions, of which 17 resolutions have implications for the Region. These included a resolution on establishment of an annual World Blood Donor Day. Other technical and health matters discussed included: Smallpox; Scaling up treatment and care within a coordinated and comprehensive response to HIV/AIDS; Traditional medicine; Strategic approach to international chemicals management; and Promotion of healthy lifestyles etc. During the Health Assembly, Bangladesh, India and Nepal signed a Memorandum of Understanding pledging to collaborate in eliminating kala-azar from their countries.

Executive Board The 115th session of the Executive Board was held in Geneva from 17 to 24 January 2005. The Board appointed Dr Luis Gomes Sambo as Regional Director for the African Region and reappointed Dr Marc Danzon as Regional Director for the European Region from 1 February 2005. The technical issues discussed included: Update on the Revision of the International Health Regulations; Status report on Achievement of health-related Millennium Development Goals; Social health insurance; Global smallpox vaccine reserve; Antiretrovirals and developing countries; Draft global immunization strategy; Rational use of medicines by prescribers and patients; and the Ministerial Summit on Health Research held in Mexico City in November 2004. Resolutions were adopted on Infant and young child nutrition; International Plan of Action on Ageing; Malaria; Public Health problems caused by alcohol; eHealth; Responding to health aspects of crises; Influenza pandemic preparedness and response; Establishment of World Blood Donor Day; and relations with nongovernmental organizations. 98 THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION

The Board also discussed the performance assessment report of the Programme Budget for the 2002-2003 biennium; the proposed Programme Budget 2006-2007; Review of the process

and draft outline of the General Programme of Work 20062015; Guiding principles for strategic resource allocations; the working methods of the Health Assembly; Staffing matters and the Real Estate Fund. The 116th session of the Executive Board was held in Geneva from 26 to 28 May 2005. Important technical matters discussed included: Control of genetic diseases; Nutrition; HIV/ AIDS and health; Gender and women’s health; and International trade and health. Guiding principles for strategic resource allocations and WHO country offices and country focus were some of the management and financial issues discussed. Bhutan was nominated as a member of the Programme, Budget and Administration Committee, while Thailand continued as member. Dr N. Acharya (Nepal) was nominated as one of the Vice-Chairmen of the Executive Board.

Regional Committee The fifty-seventh session of the Regional Committee for SouthEast Asia was held in Kurumba, Maldives, from 7 to 9 September 2004. Besides representatives of all Member States of the Region, the Director-General and representatives of other UN agencies, intergovernmental organizations and international and local nongovernmental organizations attended the session.

99 THE WORK2004. OF WHO IN THE The fifty-seventh session of the Regional Committee for South-East Asia was held in Maldives in September SOUTH-EAST ASIA REGION

The Committee discussed the Report of the Regional Director on the Work of WHO in the South-East Asia Region for the period 1 July 2003 to 30 June 2004. The Committee adopted four resolutions and four decisions. Noting the rising frequency of natural and man-made emergencies in recent years affecting human lives and causing socioeconomic burden, the Committee requested the Regional Director to intensify collaboration with Member States and assist in the mobilization of resources for ensuring emergency preparedness and response. It also expressed concern over iodine deficiency remaining a major challenge to the health and development of the population in the Region. The Regional Director was requested to strengthen cooperation and advocacy efforts with Member States, provide technical support and report on the results achieved at the sixtieth session of the Regional Committee in 2007. The Committee also noted with appreciation the Director-General’s proposal to increase the overall level of the budget as compared to the previous biennium.

Health Ministers’ Meeting The Twenty-second Meeting of Health Ministers of countries of the WHO South-East Asia Region was held in September 2004 in Maldives. At this meeting, the Health Ministers deliberated on the Global Fund to Fight AIDS, Tuberculosis and Malaria and recommended that WHO should continue to provide technical support in Global Fund proposal implementation and technical monitoring and evaluation, as well as in the preparation of new proposals for the forthcoming rounds. They also recommended that the Global Fund Board member from the Region should strongly articulate the concerns of the Region at the Global Fund Board meeting in consultation with other Member States, and keep the latter informed of new developments. The Health Ministers also reviewed the progress towards achieving the Millennium Development Goals (MDGs) and recommended that WHO should continue to support countries in their work on meeting the MDGs with particular emphasis on technical support, monitoring, reporting and resource mobilization.

100 THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION

The Health Ministers also deliberated on Intercountry Cooperation: Cross-border Control of Priority Communicable Diseases and recommended that WHO should assist Member States in mobilizing funds from appropriate sources, as successful and effective cross-border collaboration for disease control requires sustained financing.

Health Secretaries’ Meeting The Ninth Meeting of Health Secretaries of countries of the WHO South-East Asia Region was held in July 2004 in New Delhi. The health secretaries discussed the Revision of International Health Regulations. They recommended that Member States should continue the consultation process initiated at national and regional levels with other stakeholders in order to obtain maximum consensus on the IHR revision. The health secretaries reviewed the Status of HIV/AIDS in the Region, including the “3 by 5” initiative. They recommended that WHO should take measures to improve the access of developing countries to ARV drugs and diagnostics and support intercountry and inter-regional cooperation in the manufacture and supply of generic drugs. They also discussed Establishment of Regional Cooperation on Avian influenza – Prevention and Control. Development of an appropriate mechanism for regional cooperation on avian influenza prevention and control within the context of emerging and re-emerging diseases was recommended. The status of Iodine Deficiency Disorders was reviewed with a recommendation for harmonization of standards for iodized salt across countries in the Region. It was also recommended that WHO should provide technical assistance to countries for strengthening laboratory facilities for monitoring the iodine content in salt and for urinary iodine excretion. The health secretaries also discussed Globalization, Trade, Intellectual Property Rights (IPR) and Health. In this regard, they recommended that Member States should establish a national coordinating mechanism, wherever needed, for stronger coordination and collaboration among various ministries and civil society.

101 THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION

They also deliberated on the future collaboration of the Regional Office with Member States and recommended that the decentralization strategy should be implemented as planned. It was recommended that WHO country presence should be strengthened, and additional resources mobilized for this purpose.

Consultative Committee for Programme Development and Management (CCPDM) The Forty-first meeting of the Consultative Committee for Programme Development and Management (CCPDM) was held in the Regional Office in July 2004. The Committee was apprised of the salient issues with regard to Programme Development and Management in the context of WHO’s technical collaboration with the Member States, which were: • Future arrangements to replace ICP II; • Review of WHO collaborative programmes implemented during the 2002-2003 biennium; • Proposed Programme Budget 2006-2007, and • WHO’s Eleventh General Programme of Work for the period 2006-2015. The Committee recommended that the Regional Director should establish a Working Group for development of guiding principles, based on objective criteria, to be applied in the distribution of any additional funds to the Region. All countries of the Region should be represented in this Group. It recommended that mechanisms to support horizontal collaboration and intercountry activities should be explored to replace ICP II. The Regional Director’s Working Group for the distribution of additional Regular budget funding should suggest these new mechanisms. The CCPDM noted the indicators for financial implementation in the 2002-2003 biennium and reaffirmed the success achieved in meeting the targets. This was the result of close cooperation between WHO and the ministries of health of all Member States in the Region.

102 THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION

The Committee expressed its appreciation to the WHO Director-General for proposing an increase in the allocation of funds to regions and countries in the Proposed Programme Budget for 2006-2007. The Committee recommended that the Proposed Programme Budget 2006-2007, including the Draft Regional Areas of Work Statements outlining the regional situation and contributions towards achievement of Organization-wide Expected Results be submitted to the Regional Committee for endorsement. The CCPDM noted the progress relating to formulation of WHO’s Eleventh General Programme of Work and the preliminary draft outline of its broad contents. It also noted the reports by country representatives on their attendance at meetings of the coordinating bodies of WHO global programmes (TDR and HRP). It made recommendations to the Regional Committee on the regional implications of the decisions and resolutions of the World Health Assembly and the Executive Board.

Regional Working Group on Programme Budget Development A regional Working Group on Programme Budget Development and Management was established in August 2004, with representatives from all Member States in the Region. The terms of reference of the Working Group were confirmed by the fifty-seventh session of the Regional Committee as: • To review options and approaches which could be adopted globally in the allocation of funds from all sources to countries and regions, as a successor arrangement to resolution WHA51.31; • To propose guiding principles to be applied in the distribution of any additional funds to countries of the Region in 2006-2007 emanating from an increase in Assessed Contributions, and • To recommend ways and means of replacing the existing ICP II mechanism, while protecting the ability of the Regional Office to discharge its normative functions and technical cooperation vis-à-vis Member States in the Region.

103 THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION

The Working Group met three times in the year. It recommended that the guiding principles for budget allocations to the Region as well as countries should be based on the health needs, by using objective and internationally-accepted indicators, such as Burden of Diseases, MDG health indicators, poverty, education and access to essential health care services. A population adjustment mechanism also needs to be taken into account. As far as country allocations between areas of work are concerned, the Group recommended that specific regional priorities should continue to be identified within existing mechanisms. The allocation of assessed and voluntary contributions should continue to take such regional priorities into account. With regard to overall allocations, the allocations to individual countries in the Region should in no case be decreased as a result of trying to rectify existing imbalances. As such, the principles and criteria to be used in a more rational allocation process should only apply to increases coming from assessed contributions and unspecified voluntary contributions. It also recommended that the Secretariat should develop the formula for distributing unspecified funds which should be in accordance with a needs-based model on the same criteria used for strategic regional budget allocations. As for the replacement mechanism of ICP II, the Group concluded that the criteria currently guiding multi-country initiatives should continue. These initiatives should reflect high priority health problems of common concern to the Region: to develop partnerships, build institutional capacity and promote networking, facilitate technical cooperation, assist in the formulation of national policy and help mobilize additional resources. The Group recommended that the percentage reserved within each country budget for multi-country initiatives should at least be at the current level of 5.35%. It further recommended that guidelines and detailed mechanisms for multi-country initiatives, i.e. joint planning and approval mechanisms, implementation and follow-up should be referred to CCPDM for its consideration and endorsement. 104 THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION

Resource Mobilization, and External Cooperation and Partnerships Voluntary contributions play an increasingly critical role in WHO’s programmes and activities as they account for more than 70% of its integrated programme budget. External cooperation and partnerships are also one of WHO’s strategic focus areas for promoting an effective health dimension among various partners. In view of this, the Regional Office redefined in early 2004 the position of external relations as a core function of the Organization. The work on mobilizing voluntary contributions was significantly intensified during the period under review through a number of regional and country initiatives towards achieving the regional resource mobilization target of US$ 191.5 million. The Regional Office developed and implemented the Strategic Action Plan for Resource Mobilization, focusing on: enhancement of contacts and dialogue with current and potential donors to expand the donor base; strengthening the technical capacity for fund-raising in the Region and in country offices; and development and strengthening of planning, coordination and monitoring systems and tools for resource mobilization.

A number of regional and country initiatives were organized in order to intensify the mobilization of voluntary contributions for the Region.

105 THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION

A Memorandum of Understanding between the Regional Office for South-East Asia and the German Technical Cooperation agency (GTZ) was signed in Maldives in September 2004.

The Regional Office organized bilateral consultation meetings with the United States Agency for International Development (USAID), the Japanese Ministry of Health and Welfare, and German Technical Cooperation (GTZ). It also convened a partners’ meeting on the tsunami on 18 January 2005. Bilateral meetings were held with the Department for International Development (DFID, UK), USAID, the World Bank, Asian Development Bank (ADB), UN Foundation for International Partnership (UNFIP), and the European Union (EU) at their headquarters. These consultations and meetings provided a good forum to highlight WHO’s programmes identify funding opportunities and to develop collaborative activities with partners. The Regional Office and country offices worked closely with development agencies and UN system organizations at country level and concluded a number of project agreements and Memoranda of Understanding. The technical capacity for resource mobilization was improved through the Regional Office Workshop on Fundraising Principles held in November 2004, and the Joint Country Workshop on Skills Development for Project Proposal Writing and Communications for Indonesia and Timor-Leste, organized in December 2004, in Bali, Indonesia. Furthermore,

106 THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION

several management and monitoring systems and tools enabled improved information networking between the Regional Office and country offices. The Regional Office as well as country offices also maintained and strengthened close coordination with headquarters in mobilizing voluntary contributions through the donors’ core contributions to WHO. The Regional Office also helped to mobilize funds for emergency health operations under the Tsunami Flash Appeal. As a result of all these efforts, resource mobilization during the review period reached its highest level in recent years: as of 30 March 2005, the total allocation of voluntary contributions to the Region was US$ 193 million (including tsunami funding of US$ 31 million), which is well over the 2004-2005 biennium target of US$ 191.5 million (Figure 6.1). The relevant units in the Regional Office and country offices also provided technical support to Member States to prepare project proposals in the fifth round for funding from GFATM. This was in addition to facilitating national efforts for resource mobilization. Both the Regional Office and country offices strengthened coordination and collaboration with partners at regional and country levels to bring health into the multisectoral development agenda.

Figure 6.1: Trend of voluntary contributions, 1994-2007

Notes: 1. For 2004-05, the target for voluntary contributions was US$ 191.5 million; actual amount as of 31 May 2005 is US$ 212.3 million 2. The figure for 2006-07 is only a projection Source: WHO/SEARO

107 THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION

With WHO’s technical support, the United Nations Economic and Social Commission for Asia and the Pacific (UNESCAP) adopted a landmark resolution on the Regional Call for Action to Enhance Capacity Building in Public Health at its 61st Session held in Bangkok in May 2005. In order to strengthen collaboration with regional agencies, WHO and the Association of South East Asia Nations (ASEAN) developed a Strategic Framework for Collaboration which will guide the current and future collaboration between the two agencies. Collaboration with the South Asian Association of Regional Cooperation (SAARC) is also ongoing in the area of TB and HIV. With active coordination and collaboration of WHO country offices with respective governments and UN system agencies, new United Nations Development Assistance Frameworks (UNDAF) were developed and agreed upon in Bangladesh and Sri Lanka in 2005.

General Management Programme planning, monitoring and evaluation The WHO Secretariat has been following results-based management and the “One WHO ” approach since the programme budget for the 2000-2001 biennium, by integrating budgets of all levels of the Organization. During the year, these approaches were further supported by intensified efforts to involve regions and countries in developing the Organizationwide Expected Results and budgets covering all levels of WHO. This led to the development of Regional Expected Results (RER) for the first time. The RERs are meant to show what the Region is doing for each Organization-wide Expected Result, thereby facilitating technical and financial support for work in countries of the Region. Recent planning efforts have also emphasized the development of integrated workplans covering both assessed and voluntary contributions. Within the Region, voluntary contributions account for about two thirds of the WHO budget and this proportion is increasing. Previously, budgets for different sources were used to implement the same programme

108 THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION

but with different workplans, thereby resulting in parallel implementation even within the same WHO office. At the same time, the Region has been emphasizing support to country programmes through intensified joint planning exercises. The objective is to promote results-based management and to ensure improved support from the Regional Office for the implementation of country workplans. At the Regional Office level, this was achieved through joint planning where staff from the WHO country offices, and in some cases, representatives from ministries of health had detailed discussions with Regional Office staff on “expected results” for the 2006-2007 biennium workplans. They also discussed how the Regional Office would support their implementation. At country level, support for planning was intensified by holding two regional consultations of country office planning focal points, and by increasing the communication with and support for these focal points. The Regional Office planning experts were sent to several countries to assist with the preparations of the 2006-2007 workplans. The major emphasis for monitoring and evaluation concerned the mid-term 2004-2005 biennium assessment. A simplified methodology was developed by headquarters to identify major constraints in the implementation of workplans. In addition, there is now increased emphasis on developing workplans with measurable targets to assess the progress and achievement of “expected results” in countries.

WHO’s human resources are at the core of the coordinated support to Member States

Human resources The current Organizational Chart of the Regional Office is at Annex 1. WHO’s human resources are at the core of the coordinated support to Member States. This support is achieved and sustained through the recruitment and development of highly qualified staff and the provision of quality advice concerning human resources. The tsunami catastrophe affected six of the Region’s Member States – Indonesia, Sri Lanka, India, Thailand, Maldives, and Myanmar (in order of severity). An Operations Team 109 THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION

established in the Regional Office was able to rapidly deploy over 120 short-term professionals and consultants to these countries. Of the 168 established posts in the professional grade in the Region, 118 were occupied. Table 6.1 shows the distribution of professional staff in established offices and field offices as well as the proportion of serving professional female staff. Table 6.1: Distribution of professional staff and representation of women in the South-East Asia Region, 30 June 2005

*includes 4 interregional posts.

Constant efforts were made to improve gender equity in employment. Of the 17 new appointments made during the period under review, only nine (41%) were women, for want of adequately qualified female candidates. Also, in line with the targets set by governing bodies, conscientious efforts were made to recruit staff from unrepresented/under-represented countries. Two such new appointments (12%) were made during the reporting period. Initiatives were undertaken to emphasize the required functional competencies in the recruitment and selection process of professional staff; a new job description format and computerized system for classification of posts has been introduced and professional staff in the Regional Office have been trained to enhance their skills in designing competencybased job descriptions. A rotation policy aimed at expanding the career development potential and opportunities for General Service staff was introduced. Increased delegation of authority in certain areas of human resources services has facilitated deployment of staff at country level to better manage the work priorities.

110 THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION

On the basis of the new global policy guidelines for staff development and learning (SDL), the terms of reference for the Region’s SDL Committee were revised. The aim is to emphasize the strategic and policy-oriented nature of the Committee. A Global Staff Development Fund has been established to foster staff development and learning throughout the Organization. Emphasizing group activities, orientation workshops were held for staff members at regional and country levels. The focus was on strengthening their knowledge and understanding of their functions related to technical and nontechnical aspects of health development. The Regional Office offered French language training as part of the initiatives to develop language skills of staff members. Also, a series of distance learning courses on ‘Effective Writing Skills’ was organized. The Regional Office’s strong emphasis on streamlining procedures, and spearheading organizational and manpower changes in areas where impact can be greatest, have resulted in a more effective deployment of both Professional and General Service staff at regional and country levels. Efforts to bring about significant improvements in WHO’s activities with Member States have provided directions for staff to become more responsive, and services to become more relevant. Consolidation of teams comprising competent, efficient and effective staff will continue to be the essential thrust of the Regional and country offices’ human resources activities.

Budget and financial management The Regular budget funding of US$ 93.2 million for the SouthEast Asia Region for the 2004-2005 biennium is nearly the same as it was for the 2002-2003 biennium. This contrasts with the US$ 5 million decrease in the Region’s Regular budget over the previous two bienniums – 1998-1999 and 20002001 – as a consequence of resolution WHA51.31 which authorized a fund shift to the African and European regions from other WHO regions. Another US$ 1.5 million were transferred from the SEA Region prior to the start of the current biennium, but this was offset by the first-ever Regular budget allocation for Timor-Leste in 2004-2005.

111 THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION

Since the implementation of the action under resolution WHA51.31 will expire at the end of the current biennium, the Regular budget funding for the Region will no longer be subject to reductions. Rather, for the first time in several bienniums, the Fifty-eighth World Health Assembly in May 2005 approved a Regular Budget increase of 4%, which will bring an additional US$ 5.8 million to the SEA Region. In addition to supporting new or expanded programmes, the Regular budget increase will help to mitigate the substantial appreciation of some local currencies such as the Indian rupee against the US dollar in recent years, which has made local costs more expensive in dollar terms. As in previous bienniums, ambitious targets for accelerated implementation of Regular budget-funded activities in countries were established for the 2004-2005 biennium, in accordance with the recommendations of the Fortieth meeting of CCPDM and the fifty-sixth session of the Regional Committee. Acting upon these recommendations, the Regional Director set the implementation target of 75% for the first year of the biennium, and 100% by 31 August 2005. These targets were slightly lower than for the 2002-2003 biennium, partly in recognition of the progress the Region had made in utilizing its funding, and in limiting the reserves and surrenders. Figure 6.2 shows the substantial improvement achieved in the Region’s financial management over the last decade,

Figure 6.2: Regular budget reserves, South-East Asia Region: “established vs surrendered” 1994-1995 to 2002-2003

112 THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION

Source: WHO/SEARO

including a 39% reduction in surrenders from the 2002-2003 biennium, compared with 2000-2001. At the end of 2004, four of the 11 countries of the Region – India, Myanmar, Thailand and Timor-Leste – had reached the 75% target. The progress that countries have made towards fully utilizing the available Regular budget funds by the 31 August 2005 deadline is shown in Annexes 2-3. The implementation of EB funds is shown in Annexes 4-5.

Figure 6.3: Donor contributions to programmes (EB)

Source: WHO/SEARO

The growth in extrabudgetary (EB) funds for the Region has continued to the point that they are now twice the Regular budget allocation. At the start of the 2004-2005 biennium, the Programme Budget projection of US$ 191 million in EB resources for the SEA Region seemed optimistic, considering that it represented an increase of nearly 50% from 2002-2003. However, the December 2004 tsunami and the resulting UN consolidated Flash Appeal for disaster relief resulted in donations of more than US$ 40 million to the Region in the first four months of 2005, and pushed the overall EB funding beyond the projected budget figure. Besides Emergency Preparedness and Response, the programmes receiving the largest share of donor contributions in the Region are polio eradication; tuberculosis, and HIV/AIDS (Figure 6.3).

Informatics and infrastructure services WHO’s response to tsunami relief operations in affected countries of the Region was supported by the Regional Office 113 THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION

The Global Private Network served to improve communications particularly well during the tsunami crisis

by providing effective Information and Communication Technology (ICT), in close collaboration with WHO headquarters. The ICT staff and infrastructure were deployed for emergency operations including field visits to provide smooth support to the Organization’s needs immediately following the tsunami crisis (Phase 1), during the establishment of a field office (Phase 2) and beyond (Phase 3). Local Area Networks (LANs) were set up at field offices and staff in the field were equipped with portable satellite communication devices, such as radio phones, laptops, e-mail and internet services, thereby enabling information flow across all levels of the Organization. Throughout the various phases of the crisis and beyond, support was provided for effective information collection, analysis, presentation and dissemination by deploying information systems for tracking resources, setting up of operations rooms, geographical information systems (GIS) for health mapping, web publishing, and collaborative workspace. Policies, protocols and standard operating procedures were developed for effective use of ICT resources. The Regional Office has endeavoured to increase transparency and strengthen communication across the Organization. Within this context, connectivity was sought to be expanded to connect all country offices to the Global Private Network (GPN). The GPN has since been implemented in the Regional Office; country offices in DPR Korea, India, Indonesia, Nepal, Sri Lanka and Thailand and in field offices at Banda Aceh and Meulaboh in Indonesia. The GPN served to improve communications particularly well during the tsunami crisis. The establishment of GPN connectivity during tsunami relief operations at country offices in Indonesia and Sri Lanka, and in field offices at Banda Aceh and Meulaboh, Indonesia, played a vital role in dealing with the post-emergency health situation. Internet connectivity was provided to the District Health Office at Meulaboh and the Banda Aceh Provincial Health Office, Indonesia. In Sri Lanka, support was extended to the Regional Medical Supplies Division (RMSD) at Ampara, Galle and Jaffna to rebuild their ICT infrastructure destroyed by the tsunami.

114 THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION

Another ICT initiative taken in support of the Regional Director’s vision to strengthen communications was the

introduction of Mobile Enterprise solution for e-mail access anywhere in the world. Member States in the Region are faced with the challenge of extending equitable and quality basic health services to all people, especially those living in remote areas. Support was provided during the period of review to Member States towards achieving this goal through e-health services. In Bhutan, the pilot e-health project and its facilities, established between the National Hospital at Thimphu and the Regional Referral Hospital at Mongar in 2000, were extended to four more sites. Based on the evaluation of the pilot, the national plan for e-health will be developed. In Sri Lanka, the e-health systems in general hospitals at Ampara and Hambantota were used effectively to respond to patient care in the first few days of the tsunami crisis. In Maldives, implementation of a pilot e-health project was completed at four regional hospitals, including locations in the extreme north and south of the country. As a next step, protocols and guidelines on the usage of ICT and e-health services will be developed, and staff will be trained on these procedures. Additional services will also be implemented. A needs assessment study has been planned for tele-education services in Myanmar and Nepal. Electronic information dissemination has been further strengthened in the Region through continuous updating of the Regional Office web site for all areas of work, and through regular support to country office web sites. The Organization’s business processes were strengthened by developing and improving information systems as well as associated business practices in the Region. During the review period, 11 business applications were developed to help in automating processes, strengthening productivity, as well as in enhancing analytical and reporting capabilities. System development support was provided to interested Member States for various health-related information systems. The application of Geographical Information System (GIS) as a data analysis and presentation tool was further strengthened in the Regional Office. Consistent authoritative GIS data have been collected from five Member States – Bhutan, Myanmar, Sri Lanka, Thailand and Timor-Leste – in order to develop standardized GIS spatial database. The Regional Office Integrated Data Analysis System (SIDAS) was further enhanced.

115 THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION

A Health Mapper Training Workshop was facilitated in Colombo, Sri Lanka for district-level officers. GIS support was extended for tsunami operations.

Procurement services During the period under review, supplies were procured in support of technical programmes, amounting to US$ 27.57 million for Member States and the Regional Office. Of this, US$ 3.41 million were spent using Regular budget funds and US$ 22.51 million using other sources of funds. Procurement using other sources of funds included purchases made for individual countries on a reimbursable basis, amounting to US$ 1.65 million. A part of these purchases were made for GFATM-supported programmes, under the reimbursable procurement mechanism. The breakdown of various supplies (by type and cost) procured during the review period is shown in Figure 6.4. The Regional Office continued its efforts to procure various essential supplies, and also provide logistic support to the WHO Global Programme on Eradication of Poliomyelitis and the Directly Obser ved Treatment, Short-course (DOTS) programme. Procurements were also made as part of the emergency projects in Bangladesh (amounting to US$ 1.43 million), and

Figure 6.4: Procurement of supplies and equipment, South-East Asia Region, 2004-2005

116 THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION

Source: WHO/SEARO

for all countries affected by the tsunami (amounting to US$ 5.95 million). During the tsunami relief operations, emergency health kits and water purification materials were procured expeditiously; and many were shipped by special/ chartered flights to meet the emergency. Besides, supplies such as vehicles, bednets, communication equipment, waste management goods, etc. were also provided towards reconstruction of the tsunami-affected areas. With the implementation of the new web-based Supplies Management Information System (SMIS), and availability of the WHO Supplies catalogue on the intranet, the supplies data are now more easily accessible to country offices. These features enable reduction of lead time where countries are in a position to use catalogue products that are available on a global basis, as compared to ‘SPOT’ products that are procured individually.

General support services The importance of good record-keeping and archives management ensuring accountability and transparency has been recognized. In order to improve the utilization of space and the working environment, and to preserve WHO’s institutional memory, it was decided to introduce an electronic filing system – Integrated Records Information Management System (iRIMS); and implement the Records Evaluation and Preservation project (REAP) in the Regional Office. The new system aims to bring the Regional Office’s filing in line with the system (iRIMS), adopted by headquarters. Based on the recently-developed WHO Records Retention Schedules records that were not required for permanent retention were eliminated, thereby releasing valuable space for offices. A diesel generator of 1000 KVA capacity was set up and other modifications effected in order to provide uninterrupted supply of electricity. Electricity costs amounting to more than US$ 28 000 were saved in 2004 in spite of the continuous increase in electricity requirements. Planning and conceptual designing for renovating the Conference Hall is in progress.

Field security services During the period under review, security issues were discussed; office security surveys conducted; security surveillance

117 THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION

coordinated; and security awareness training courses for staff organized in Bangladesh, Bhutan, Indonesia, Maldives, Myanmar, Nepal, Sri Lanka and Thailand. In the aftermath of the tsunami disaster the Regional Office provided assistance to WHO staff and operations in the tsunami-affected areas and initiated appropriate relief measures. In order to ascertain the safety and security of WHO staff member(s) travelling to affected countries during this period, full assistance and cooperation were provided.

Medical services The most valuable resource of an organization is its staff, and it follows that the health and well-being of staff are essential conditions for the Organization to fulfil its mission. Increasing attention is now being given to value-added health strategies for disease prevention, and proactive health promotion/ education, with the ultimate objective of optimizing the health and well-being of staff in the Region. In an effort to scale up the UN system’s response and promote the WHO policy on HIV/AIDS in the workplace, a training module was developed. Using this module all regular UN staff underwent a half-day training programme in small groups beginning July 2004. The ergonomics environment in the Regional Office was evaluated. In addition to organizing a detailed workspace evaluation (which included assessment of workstations, noise exposure measurements, and indoor illumination and thermal environment evaluation), WHO staff were educated and sensitized on various aspects of ergonomics. Workshops were also organized for staff to provide practical advice and solutions.

WHO’s Presence in Countries During the period under review, policies for decentralization were promoted in line with the policies of the Director-General. This was reflected through increased delegation of authority to the WHO Representatives. Country offices now have increased authority to approve travel, contracts and procurement orders. This is meant to simplify and facilitate the administrative work to help country offices respond

118 THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION

quickly to the needs of the country. Along with increased delegation of authority, there is emphasis on the accountability of country offices as well. At the same time, decentralization is also being promoted through horizontal collaboration between country offices. The WHO Representatives are encouraged to contact other country offices and share staff as needed. With the end of the ICP II mechanism in 2005, the funds from this facility will be used to support multicountry projects, including horizontal collaboration, with the intention of strengthening country offices. The Country Cooperation Strategy (CCS) continues to play a major role in providing the basis for WHO’s work at country level. Better analysis of country needs, the work of other health development partners and the comparative advantages of WHO were used to determine the areas for WHO involvement over a five-year period. The CCS provides WHO a major opportunity to have a dialogue about its work of WHO at country level as the basis for biennium workplans and for reshaping the WHO country offices. The Fifty-fifth Meeting of the Regional Director with the WHO Representatives was held in the Regional Office in November 2004. This meeting was a departure from the previous meetings in terms of the increased consultative approach and the greater participation of Programme Directors, Coordinators and other Regional Office staff, and also by the participation of staff from WHO headquarters and other WHO offices. The Fifty-sixth Meeting of the Regional Director with the WHO Representatives was held in Phuket, Thailand, in May 2005. The key issue was the ICP II successor mechanism to be presented to the Forty-second meeting of CCPDM. Other sessions focused on the preparedness of country offices for emergency situations, especially using the lessons learnt from the tsunami, SARS and avian influenza experiences.

Public Relations and Media In order to ensure that the Region strengthens its public communication outreach, a draft communications strategy 119 THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION

for the Region was developed during the period under review. The strategy will be further updated to be in line with the headquarters Global Communications strategy which is being finalized. At the same time, the sudden and huge communications challenges posed by the tsunamis led to the formulation of a communications strategy for the posttsunamis communications work. The two-pronged communications challenge for the Regional Office and country offices has been the need to strengthen communications skills of their respective key professional staff, particularly to equip them to deal with the media. At the same time, it was important to build an ongoing relationship with national and international media reporting on countries in the Region. The tsunamis led to unprecedented international and national media attention on the work of WHO. There was an urgent need to ensure smooth and frequent transmission of information from the tsunami-affected areas, to country offices, the Regional Office and WHO headquarters. As a result, an information management system to ensure a steady flow of information was quickly developed and applied. This formed the basis of the “situation reports” posted almost daily on the regional web site. Both at the Regional Office and country offices, senior staff interacted regularly with the media. The Organization was able to articulate health concerns which were seen and heard through the media by people across the globe. To strengthen country offices to cope with the media, communication professionals were placed in affected areas, namely Colombo, Malé, Aceh and Jakarta, and at the Regional Office itself. Among the affected countries, Myanmar and Thailand already had communication professionals working in the respective country offices. The WHO global communications team worked in concert to bring health issues to the fore at all levels of the Organization. A system of “talking points” on a daily basis was developed to ensure that WHO headquarters, the Regional Office and countries were conveying the same message. At the same time, regional press releases that were contributed to by all countries were developed.

120 THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION

The global launch of the World Health Report 2005 was held in New Delhi on 7 April.

As with other parts of the world which have faced outbreaks, the Regional Office is becoming increasingly aware of the importance of Risk Communication, particularly as several countries in the Region have recently dealt with avian influenza (H5N1). Staff from the Regional Office and from Thailand attended the Global Meeting on Risk Communication in Singapore which was organized to fine-tune the principles to be adopted by the Organization in its Risk Communication Strategy. The staff of the Regional Office and the WHO country office in India were provided risk communication training by two eminent experts. Together with a communications specialist from WHO headquarters, media training was organized for WHO senior staff. The global launch of the World Health Report was held in New Delhi with the collaboration of the Regional Office, the WHO country office in India and WHO headquarters. A media orientation workshop was organized in Thailand for representative journalists from most of the Member States. This generated very good media coverage in countries. Furthermore, the Regional Office participated actively in the global “Great expectations” photo project which tracked six pregnant women from each WHO region, through pregnancy to childbirth.

121 THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION

Regional Director’s Development Fund The Regional Director’s Development Fund continued to cater to the special needs and initiatives of the Member States and the Regional Office, as well as to meet situations arising from health emergencies. These included, among others, the following: • supporting a situation analysis of public health development in Myanmar, Thailand and Timor-Leste, and in establishing the South-East Asia Public Health Education Institutes Network (SEAPHEIN). This included convening the first meeting of the Strategic Advisory Group for South-East Asia Public Health Initiative 20042008 in the Regional Office in November 2004; • finalization of the vision paper on emerging infectious diseases in the SEA Region; • encouraging promotion of water, sanitation and hygiene for health; • preparation of an overview of the existing human resource policies for maternal and newborn health in the Region and preparation of a position paper on health system requirements including human resources for the accelerated reduction of maternal and newborn morbidity and mortality; • preparation of concept papers on ethics and education in rational use of medicines; • assistance to kala-azar elimination activities; • revision of the draft Health Ethics Teaching guidelines for SEAR countries, and • support to a study on meliodosis in Myanmar.

122 THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION

Annexes

123 THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION

Annex 1

Organizational Structure Regional Director Regional Director ’s Office Administrative Internal Review and Support to RD Technical Assessment

WHO Countr y Offices WHO Representatives

Deputy Regional Director

Director, Programme Management

Director, Administration and Finance

Sustainable Development and Healthy Environment

Communicable Diseases

Informatics Systems Management Budget and Finance Management Administrative Services Regional Medical Services Human Resource Development

External Coordination Unit

Family and Community Health

Strategic Alliance and Partnerships

Health Systems Development

Public Information and Advocacy

Sustainable Health Policy Emergency Preparedness and Response

Noncommunicable Diseases and Mental Health

Medical Supplies

Immunization and Vaccine Development

Programme Planning and Coordination

Global Leprosy Programme

Field Security Services

123 THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION

Annex 2

Budgetary Implementation, 2004-2005 by country/intercountry Regular Budget ( as of 30 June 2005) Expressed in US $

124 THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION

Annex 3

Budgetary Implementation, 2004-2005 by area of work (in descending order) Regular Budget (as of 30 June 2005) Expressed in US$

125 THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION

Annex 4

Budgetary Implementation, 2004-2005 by country/intercountry Extrabudgetary Funds ( as of 30 June 2005) Expressed in US $

126 THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION

Annex 5

Budgetary Implementation, 2004-2005 by area of work (in descending order) Extrabudgetary Funds (as of 30 June 2005) Expressed in US$

127 THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION