Report of the Forty- First Meeting of the Regional Director with the WHO Representatives and summing up of Issues

1 WORLD HEALTHORGANIZATION Fom-first Meetina of the Redonal Director with the WHO Rewesentatives. New Delhi 12 to 25 November 1992 REGIONAL OFFICE FOR SOUTH-EAST ASIA SEdWVVR41IlO 9 D&ember 1992 1 . IMTRODUCTION The Forty-first annual meeting of the Regional Director with the WHO Representatives (WRs) was held in the,Regional Office, New' Delhi, from 12 to 25 November 1992. The agenda and programme for the meeting are attached (see Annex 1 and Annex 2). 1.1 OPPWING ADDRESS BY TBB RPGIONJLL DIRECTOR Inaugurating the meeting, the Regional Director referred to the address of the Director-General of WHO at the 45th session of ,: the WHO Regional Committee for South-East Asia, held in Kathmandu in September 1992. The Director-General had, over the past two :, years, alerted the governing bodies on how the changing socioeconomic and political realities had affected health development globally and in the countries. He had also attached the utmost importance to redefinition of international health action and coordination and he was determined to ensure the place of health at the centre of development, as well as WHO's leadership in international health work. The Director-General had been paying particular attention to improving collaboration and co-ordination with the agencies and organizations within the United Nations system and pointed out that WHO enjoyed good working relationships with United Nations Organization and agencies. Due to financial constraints, the proposed programme budget for 1994-1995 had been formulated on the basis of zero-level budget growth. The intercountry and the Regional Office programme, rather than the country programmes, had borne the brunt of budgetary constraints. More than 75 per cent of the regional Regular Budget had been allocated to countries for programme activities. The ' Regional Director, therefore, urged the WRs to ensure that the countries prepare realistic and sound annual plans of action for efficient and effective implementation of the 1994-1995 programme budget. Dr U Ko Ko then referred,to some of the important subjects included in the agenda of this annual meet-ing with the WRs. He particularly stressed that there was a need to strengthen national management capabilities in the health sector at all levels. The Regional Office and WHO Headquarters jointly provided technical inputs into different areas of health development in countries, with a view to strengthening the image of, WHO as the lead agency in the field of health development. In this regard, he singled out the. importance of fulfilling the managerial and technical role of the WRs. In conclusion, the Regional Director expressed his confidence that, using the technical and'other resources of the Organization at all levels, the WRs and the field staff would continue to provide optimum support to Member States in a concerted and coordinated manner. 1.2 deep and 2 STATEMENT BY TEE UNDP REPRESENTATIVE Mr Erling Dessau, Resident,Representative, UNDP, expressed his appreciation for the excellent relations existing between UNDP WHO throughout the world. He complimented WHO on the- -successful execution of many UNDP-assisted projects. UNDP's development initiative and programme strategies were in consonance with the tenets of Heal.th forAl b,y the Year:2.000. UNDP.'believed in social and economic development using a multisectoral approach and had included health management for human development,,community water supply and sanitation, etc.. in its technical cooperation programmes in the current programme cycle;-The ,UNDP pledged strong support to tackle the major challenge posed by HIV/AIDS and it appreciated WHO's all-out "efforts in this regard. 1.3 STATEMENT BY TIfB, UNICEF REPRESENTATIVE Dr (MS) Eimi Watanabe, UNICEF Representative, noted the high priority attached by WHO to the concept of safe motherhood.- She felt that efforts should also be made to improve Women's status in totality and said that UNICEF would like to collaborate with WHO and other sister agencies in such an endeavor. She felt that the UN agencies should act more pragmatically and- give more emphasisto sanitation, personal hygiene and nutrition, particularly for women. In health education and communication programmes, it was necessary to'exhort,men to be as equally responsible as women for the 'well- being and development of their families. 1.4 STATEiNtENT BY THE UNFPA REPRESENTATIVE Mr T. Abrams, Country Director, saidthatsignificant progress was noted in life expectancy and infant mo~rtality, but population increase remained a major problem in many countries of South-East Asia. He informed the WRs that the forthcoming Population Conference in Cairo in 1994 would take a ~ten-year .look at the. population problem worldwide. He mention&d that sustainable development of health and welfare could not be achieved unless growth of.population was significantly reducedin-the coming years, in spite of economic, political and. environmental constraints. UNFPA'was currently funding MCH, family,planning, safe motherhood, and child‘survival programmes. UNFPA also contributed'to "the AIDS prevention/and control programme. He stressed that the ,UN system needed to play a.'greater role-. in the ,promdtion of peace,~'and development around the world, and hoped for UNFPA's continued cooperation with WHO. 1..5 STATonsrm'BY THI+UNBScO REPRIPSENTATI-VE‘ ". 3 ,Dr John V..Kingston, Director; UNESCO,$said that UNESCO was 'adtively engaged in cooperation with WHO in the area. of: AIDS .3 education, and it was trying to develop responsible attitudes in young people, particularly through the teachers, unions. UNESCO had developed a programme related to pharmacology, chemistry and industrial utilization of medicinal plants, and was deeply involved in biotechnology. 2. wHOPRoGRAm4E REVIEW The Director, Programme Management said that in the context of 'zero, level growth of resources in the Organization's Regular Budget during the last four biennia, extra-budgetary resources played a crucial role in WHO's collaboration with the Member States in the light of their need for more funds to implement health development activities. It was rather regrettable to note, however, that the implementation of programmes~ financed by UNDP and UNFPA was slow. Referring to discussions at the last meeting of the CCPDM on low implementation of programmes financed by extra-budgetary sources, especially UNDP and UNFPA, he urged the WRs to review critically the management of programmes financedby extra-budgetary sources with a view to ensuring timely and proper use of these funds. With regard to the implementation of the 1992-1993 programme budget, he said that though the country programmes under the Regular Budget had achieved a comparatively high level of implementation as compared to the 1990-1991 biennium, some components such as S&E, fellowships, and LCS, still had sizeable amounts yet to be obligated. He urged the WRs to analyze the situation with Regional Office staff in totality and to initiate necessary action to carry out the remaining activities in an expeditious manner. action, Referring to the annual detailed plans of he stated that, based on the experience gained in 1992 and 1993, a proposal might be made to RD that the CCPDM be requested to review the format and contents of POA. In that case, the WRs might be requested to provide a critical review of the countries, experiences in the preparation of such POA. Concerning joint government-WHO evaluation of priority health programmes, Dr Bisht pointed out that those countries which had not yet completed this exercise should do so before 31 December 1993, as recommended by the CCPDM at its last meeting. Finally, he urged the WRs to liquidate obligations established during the 1990-1991 biennium as the reserves established during the 1990-1991 biennium could not be carried over to 1993. The following observations were made during the discussions: WHO should continue to play a significant guiding role in identifying appropriate programmes and projects for funding by other UN, bilateral and multilate-ral agencies. As new'donors 4 P are coming forward to ;fund programmes in the health sector, WHO should help in formulating, and documenting 'suitable project proposals. ., , I ; , WHO should seriously consider the need to exercise greater flexibility in charging programme support costs, as this might facilitate the mobilization of more resources. * ,: ,_ .:,.q, I r There is improvement in the presentation of information on programme delivery in the PDM, cards;" and the discrepancies between the information on programme implement-ation*maintained at country level and that in the PDM card ;have been considerably reduced. I The significant-,increase.in the-number of fellows undertaking study tours to some countries has resulted in problems-at the country level in managing such study tours., Though the introduction of annual POA has resulted in an overall reduction of programme changes,,--the quality of planning needs to be further improved. There is better monitoring at country level through the Government-WHO coordination mechanism. ,, One of the difficulties encountered in the-implementation of the fellowships component is the,delay in obtaining FAFs and securing placements. It may be useful to do,aduance planning in the fellowships programme, as this .would facilitate implementation. 2 There is a wide time gap in ,establishing .obligations for activities which are in the pipeline and~efforts should be made to cut down to the minimum tbe.pro:cessing time in the Regional Office and WHO Headquarters. In his summing up remarks, the Regional Director stated that though the resources from other sources at the.country level might increase, the number of,projects for WHO execution was likely to decrease. In this context, it was imperative to 'see .how WHO's technical expertise could be used to work with other UN and donor agencies, without WHO executing in t,he-tra~iti~onal~:way.'Ex,~a~ning the basic reasons for introduction .of annual. POAr he said the. ... activity was'intendedto provide countries with moreC~flexibility in the effective use of WHO's scarce resources, since POAs were formulated much closer to,the period,pf implementat&onthanbefore and would Simplify programme management at country level. There was, therefore, no -need to reverttback to the. former system of formulating a+ detailed ‘programme budget, but the Organization should see how to further improve the procesee~~~of,~preparation of POAs and implementation .of collaborative activities. He urged the WRs to closely study the historical background to the preparation of annual POA. &cx!Ioll POIWTS 1. WRs of all countries, except India, Indonesia, Mongolia and Nepal, should ensure that the joint evaluation of priority health programmes is completed well before 31 December 1993, as recommended by the 22nd CCPDM. WRs should also convey to SEAR0 a priority health programme for joint evaluation during the 1994-1995 biennium, as identified by the national authorities. 2. WRs should review the position of reserves (unliquidated obligations) established during the 1990-1991 budget and take the necessary steps to liquidate such reserves. 3. No programme changes will be necessary if additional funds needed for implementing activities planned under a particular component, eg. S&E, in the first year of the biennium, can be met from within the total biennial allocation of the project. A programme change will be necessary only if funds allocated under a component of the project are not sufficient to implement the planned activities, which, therefore require funds from another xomponent of the same project or some other project. 4. WRs and SEAR0 staff should ensure timely and speedy implementation of programmes funded by extrabudgetary resources. 5. SEAR0 should take the necessary action to reduce the time taken for processing of pipeline activities and speed up obligation. 6. A study should be undertaken by SEARO, 'considering the views of the- countries, on the usefulness of study tours:,as now practiced and the implications .of the large increase in study tours for the fellowships programme as a whole. .I 7. SEAR0 should prepare, and circulate to all WRs, a short note giving the historical background leading to the substitution of the detail.ed programme budget by the annual 6detailed POA, commencing with the discussions at the CCPDM and RC in 1986. 3. MANAGWIAL AND TECHNICAL ROLP OF TIUb WR8 -~~~1SEW~P&###kCTIvE In his presentation of this agenda item, PCI.'referred to WHA resolution WHA33,17 which called upon the Governing~Bij&es and the Member States to undertake a major reorientation“of the working of the Organization. On the basis o-f this resolution, a status report prepared by the Structure Study Working Group.:&i"'WHO's structures in the light of its functions in South-East Asia, was submitted to the 34th session of the Regional,Committee. TheGroup recommended, inter alia, that: the role and functions of' the WR should be strengthened; rank; the WR should be vested'with,an appropriately high and that the WR should be provided with adequate staff support while the WR's office should belocat*dwithin or close to the Ministry of Health wherever.fe?%sible. ' PCf then dwelt briefly on the functions of the WHO-Representative as laid down in the new managerial framework for optimal utilization of WHO regources, and touched upon new perspectives for the WR's Role. The WR should have a broad perspective of health'development ,and shou%& focus the attention of the Ministry of Health on changing disease patterns. The profile of a WR should be a-, balan'ced tiix of-'technocrat, bureaucrat and diplomat. -He/she *'should preferably be an international civil servant with adequate technical and'managerial competence, who.should try to change the ~attitude oft donors to WHO's role and who should participate in the formulation of regional and global health policy.- I;i . ,i 1 The WR's role in the 1970s was mosl!ly tezctinkc81,' while in the 1980s it was mostly managerial with.em@haBi-ti: oA pl'anning and mobilization of resources. But,in the 19'90s the empha5i.s shifted to health development work. A WR should be mo.re of a broad-based health developmentalis,t, -with a,.strong public health background..:_' ! ,, The subject evoked considerable discussion @r&many important observations were made, including : ,. WHO and the WR,,are considered by governments to ,hav& expertise in the field of health -and, as such, other agencies and government officials come to WHO for technical advice on health matters. Therefore, the WR sh6uLl.ld ha*ve quick access to valid technical information and‘be%conve~tisant with the latest technological and other advances'in health-and health-related fields in orderto fulfil*this.perceived role. - The WR should be kept informed of the +&forms and restructuring of the UN sistem taking place in the light of UNGA resolutions 44/211 and 461229.\ : i Pi 7 The increasing recognition given to, and awareness of, the . important role that the private sector, including.NGOs, has to play in health development activities will have implications on the future role of the WR. The new health paradigm, proposed by theDirector-General, has added the dimension of economic perspective to the implementation of national HFA strategies, and this will have an implication on the WR's future role'. The WR's office could be locatedclose to the Ministry of Health, but not absorbed by the Ministry. Based on the WR's technical competence, he/she should be able to influence decisions of the Ministry, particularly those relating to WHO's collaborative activities. At the same time, the WR should be more pro-active in other ministries, which would necessitate additional funds and staff support in the WR's office. The WR should have a balanced capability and capacity, both technical and managerial, in order to give visibility to WHO's inputs and work in a country. The WR could/ therefore, be a broad-based specialist and not necessarilya medical officer. The WR's office budget should be separate- from the country allocation, so that the WR can have more flexibility in the use of these funds. This should be kept in mind when the 1996- 1997 programme budget, in the context of the Ninth GPW, is being prepared. National programme officers have proved to be quite effective in many countries and their use as national professionals, instead of expatriate long-term staff, could be considered. A more detailed booklet on the Essence of WHO Cooperation should be prepared and distributed to government departments. Concluding the discussion, the Regional Director stated that a WR should necessarily have a medical background and qualification and, therefore, a non-medical person would not &suitable. It was necessary to strengthen the technical competence'at the WR level. SEAR0 should organize itself to effectively support WRs with relevant and updated technical information. With regard to providing additional staff support to WR'.s offices, he referred to the difficulty experienced in 'obtaining agreement from the countries concerned for establishing 'a 'second professional staff post in some WR's offices. He felt that more national expertise could be used for technical/administrative work a-t the country level. He advised the WRs to continue discussion on the subject among themselves and to be alert to the eme‘rging situation. 8ACTION POINTS 1. 2. 3 . 4 . 5. As the WR's role is evolving, discussion on this subject should be kept alive. ,WRs should send their- views to fhe Regional Office. for incorporation into future documentation and/or discussions on this subjectr- SEAR0 should expedite the WR's access to valid. technical information so that the WR can demonstrate technical competence in WHO's coilaborative and coordination activities at the country level. Action should be taken by SEAR0 and I-IQ to ensure WHO's technical excellence at the country level, especially through staff development and training for the WR and field staff. The WR should maintain close collaboration with sister UN agencies as well as bilateral and multilateral agencies with a view to mobilizing resources for health development in the countries. The WR should enhance WHO's involvement in identification of health programmes for funding by other Agencies. 4 . NINTH GRNERAL PROGRAlME OF WORK - IIilPLICATIONS FOR WRO ChNTRY PRoGRluamS In his introductory remarks, DPM referred to the steps in the preparation of the Ninth General Programme, of Work (GPW). He briefly outlined the major differences from the 8th GPW and recalled the contributions made by WRs and the Regional Office. There were still many issues regarding its operationalization, which the WRs and the Regional Office staff should look into more seriously. In his presentation, PLN informed the meeting.that the subject of the 9th GPW was discussed, along with the new health paradigm, at the 40th meeting of RD w,ith the WRs in November 1991. In particular, the draft table of contents and the proposed programme. classification structure were.discussed. The WRs had been kept informed of the progress at .a11 stages of preparation. The comments, observations and suggestions made by the Regional Office staff as well as by the WRs had been sent to HQ as the regional contribution. He then presented the progress made, the remaining activities, the proposed outline of the programme, the five main 9l policy directions and the proposed programme classification structure. It was emphasized that activities under the various programmes of the 9th GPW had to be identified within the framework of the five policy directions by using an appropriate matrix, The WRs were also informed that the preparation of the proposed programme budget for the 1996-1997 biennium would begin in August 1993, while the 9th GPW would be approved by the WHA only in May 1994. However, it was expected that the 91st session of the EB in January 1993 would at least finalize the programme classification for use as the basis in the preparation of the 1996-1997 biennial programme budget. PC1 supplemented the information by stating that, unlike the 7th and 8th GPWs, the 9th GPW was more simple and aimed at flexible use in programme budgeting. Though broad, it would be adequate to use as the basis for the formulation of biennial programme budgets. However, he cautioned that the effective implementation of the 9th GPW required some new ways of thinking, conceptualizing and application. It was also underlined that the process of the 9th GPW had been more geared towards development activities at the country level, particularly in countries of greatest need. The following main issues emerged during the discussions: The new health paradigm, espoused by the Director-General, proposes a new policy framework for public health action which will have implications and impact on WHO's collaborative activities at the country level. There may be a need for a country level government/WHO document for policy and procedural guidance in the use of the 9th GPW for the preparation of the biennial programme budget. The use of the 9th GPW as the framework for identifying and managing WHO collaborative activities should have significant implications for the selection of programmes and programme allocations for WHO's resources at the country level. Resource mobilization is missing from the proposed programme classification structure. Its absence from the programme classification may leave a vacuum. Does this mean that resource mobilization would remain the responsibility of individual programmes? The proposed programme classification suggests integrated programmes for WHO collaboration. Changes in the planning procedures are required for successful application of such an approach. This needs to be implemented at the country level. thoroughly examined and 5With the new programme classification structure, the number.of programmes'in the classified list may be reduced, but this may not be true forthe number of projects. . The 9th GPW will provide a broader focus through five policy directions and a broader environment in which WHO can work closely with other UN Organizations, bilateral agencies, Banks and NGOs, as well as sectors in the government. There is a need for an intensive reorientation of both WHO staff and concerned nationals in the use of the 9th GPW for development of WHO programme budgets. New expertise and involvement of social and economic experts is required for effective programme formulation in the framework of the 9th GPW. While formulation may be relatively uncomplicated, implementation of programmes under the 9th GPW may prove more complex. A "dummy" exercise could be conducted, if needed, with the support of the Regional Office staff in a few countries, to brief the WRs and nationals on how to operationalize the 9th GPW using the 1996-1997 PB as a candidate biennium. Winding up the discussions on the subject, the Regional Director stated that the year 1993 would be' important for WHO since, in the absence of approval from the WHA for the 9th GPW, the Director-General would issue procedural guidance for the elaboration of programme budget proposals for the biennium 1996- 1997, which was the first biennium of the 9th GPW. EB91 in January 1993 would review the policy and programme framework of the 9th GPW and approve its programme classification structure. A final‘ draft of the 9th GPW would be presented to the Regional Committees in September 1993, and the WHA in May 1994 would accord its approval to the 9th GPW. Thus, in 1993, the WRs would be required to formulate programme budget proposals for 1996-1997, ensuring that. the programmes conform to the 9th GPW. The Regional Director thought that the transition from the 8th GPW to the 9th GPW and formulation of programme proposals under the 9th GPW would not present particular problems. The implementation process might, however, be difficult since under the new policy directions, support to policy direction would have to be extended across different programme areas. He advised the WRs, therefore, that it would be prudent to retain long-term technical staff support at the country level as much as possible, so that their services could be best utilized. He also urged the WRs to explore the possibility of making more use of available national expertise in the development and management of WHO's collaborative programmes. 11 ACTION POINTS 1 . The Regional ‘Office should distribute to WRs the EB91 working paper on the 9th GPW as soon as it is received. The WRs will study this working paper along with the two other EB documents, circulated earlier, and provide suggestions/comments, if any, to the Regional Office by 31 December 1992. 2. At its 23rd meeting in April 1993, the CCPDM should be briefed on the 9th GPW and on how to use it in the preparation of WHO country programme budgets, especially in the light of the policy framework and the new programme classification structure. 3. The WRs will be informed of further progress in the preparation of the 9th GPW and its status at their 42nd meeting with the Regional Director in November 1993. 5. CCPDM WORKING GROUP STUDY ON WHO PROG- MANAGMNT UPDATE -AN theIn his presentation of the agenda item, PDO said that study concentrated on the process and contents of programme implementation, and that detailed protocols had been developed to undertake the study at the country and Regional Office levels. The study group's findings were also discussed.at the 22nd meeting of the CCPDM and the 45th Session of the Regional Committee in September 1992. Both the CCPDM and the Regional Committee had reviewed the report of the Group and endorsed its findings and recommendations. With regard to the periodic follow-up;of the implementation of the recommendations arising out of the Working Group Study, he requested all concerned to keep SEAR0 informed about the progress in implementation of these recommendations, which could then be placed before the CCPDM at a future meeting for its information. During the discussions, the following important points were brought up: Findings of the working group study have increased the a‘wareness of concerned health ministry officials about the needs- of efficient programme management. Management information'systems should be upgraded to link the Regional Office with-the WRs' offices, and WRs' offices should be strengthened with databases. SEAR0 should improve its technical management system. 12 . The actual progress in programme implementation should be reviewed. In areas where a programme is not being implemented well, justifiable programme changes should be issued. It would be useful if SEAR0 could compile country experiences in W WHO-Government coordinating mechanisms, (ii) intersectoral mechanisms, and (iii) inter-UN coordination mechanisms, agency and disseminate the information to WRs. There is a long delay in transferring the implementation figures from the country offices to the PDM card in the Regional Office. Reducing the delay will help in better follow up at the country level. Increase in study tours under the fellowships component, from 46 per cent in 1986 to 75 per cent in 1992, has serious implications and should be looked into as this consumes inordinate staff time. Eventually the subject can be presented to the CCPDM. Programme implementation has largely concerned financial accounting, and there is need to restore balance by introducing technical content into programme management monitoring and evaluation. Summing up the discussions, the Regional Director said that the deliberations were quite useful. The recommendations of the Working Group Study were meant for both the countries and the Regional Office. He advised the WRs to continue the flexible approach in use of WHO resources, and that it was not necessary to have a big programme management committee; even an ad-hoc committee could be formed to suit the country situation. Visits of fellows were not -being planned properly, and the Regional Director suggested that WRs should use,CCPDM members in the countries to sort out such issues. He thought that it was necessary to involve the nationals as much as possible and to see how other Regions were working, and then to ‘consolidate these findings into a report, which would 'greatly help in implementation of various activities., Many of the managerial problems could be solved by proper monitoring of S&E and fellowships, and by clearing pipeline activities. It was proposed to take the WR's budget out of the country budget, and this would be reflected in the 9th GPW. With regard to giving authority to WRs for more funds and signing of SSAs, he said that authority had been established at WR, Regional Office and HQ levels and it was not possible to go be,yond these limits. Within these constraints, every effort should be made to delegate more authority to WRs. The Regional Director'advised the senior staff ,and technical/administration. and finance units in SEAR0 also to be alert to the recommendations of the,Working Group and take action as appropriate. 13 ACTION POINTS 1. WRs should examine the findings and recommendations of the Working Group Study and brief their field staff on actions to be taken at the country level. 2. The senior staff in the Regional Office will brief their respective group of-RAs and' take follow-up actions required at the regional level. -1, L 3. A brief progress report on the actions taken following the recommendations of the' CCPDM Working Group Study will be prepared for presentation to the CCPDM at one of its future meetings. 4 . The information flow (MIS) between SEAR0 and the WR should be tailored to the needs of the WR for -optimizing collaborative and coordination work at the country level. 6. ACTION FOR WOMEN, HEALTH AND DEVELOPMENT In his introductory remarks PCI, Chairperson of 0 the WHD Advisory Group, emphasized that Wome.n, Health and Development was not a programme as such but rather an.initiative which should be an integral part of ongoing WHO collaborative programmes. He suggested potential areas for action 'and urged WRs to incorporate WHD components in relevant countfy programmes for the next biennium, perhaps using the Country Support Team (CST). He also sought their views and directions for future activities in order to make this initiative more action-oriented. The Chairperson, WHD Core Group, then elaborated on the history of the WHD initiative in WHO, stating that WHO's response to international developments for the advancement of women had been to integrate :WHD activities in all programme areas. The overall thrust was now to integrate women effectively and fully in the development process. As a result of the technical discussions and resolution WHA45.25 relating to WHD, great-er-~priority and support were,expected to .be given to meeting the objectives of this initiative. The overall and immediate objectives of WHD in SEAR were presented along with broad strategies and proposed activities for 1992-1993. During the discussion that followed a number of relevant issues were raised: 14 The situation of women in countries, particularly with respect to their health and socio-economic status, is quite low. While some limited. information is available on' traditional indicators.such as life expectancy, maternal mortality, etc., there is a lack of data regarding several other aspects of women's health, their.participation in development and other gender-specific issues. Examples mentioned included occupational health hazards of working women, especially those in the informal sector; violence against women; women and HIV infection/AIDS; andgender-differentials intheprevalence and consequences of diseases. Women should not just be seen as passive recipients of services, for example in health education activities, but they should be brought into the mainstream of development through processes aimed at empowering women and involving them in decision-making processes. A gender-sensitive focus is needed at each stage of health and development efforts, with gender being understood as the social, cultural and behavioural.characteristics that society ascribes to the two sexes. A conscious effort to change attitudes and to be more sensitive to gender-specific issues is necessary in order to achieve the WHD objectives. In many SEAR countries -the nationalfocal:points for women's affairs are outside the Ministry of Health, which may restrict WHO's involvement in country level women's development activities. WHO and Ministries of Health need to be proactive in collaborating with these focal points as well as other agencies and organizations, including NGOs. The WHD initiative .can thus .be seen as an opportunity for more effective intersectoral collaboration and for the incorporation of health aspects in development"programmes. WHD activities have been successfully integrated in various on-going WHO collaborative and national health programmes in Indonesia. These can be used .as illustrative examples for developing WHD activities in other countries. Other.UN agencies such as UNDP, UNICEF and UNFPA are often more directly and visibly involved in women's development activities. WHO should' continue to* strengthen .its collaboration with other ,agencies in order to intensify technical inputs on health aspects of women's development projects. There is a need to identify better ways of working with and supporting women's groups and NGOs who are actively involved in women's health and development programmes; especially at community level. . 15 More active collaboration between WRs and the WHD Core Group in conjunction with SEAR0 technical units would facilitate the exchange. and dissemination of information; advocacy for greater awareness of women's health issues and women's participation in development, and the incorporation of WHD components in country programmes. In conclusion, the Regional Director urgedthe WHD Core Group to prepare a more comprehensive report of the discussions for use in finalizing the proposed plan of, action. He requested that the Senior Staff carefully review reso3utiokWHA45.25 since.it provided a good framework -for developing- follow-up activities. He emphasized the nekd for WRs and the -WHD Core Group members to maintain close contact to ensure the incorporation of WHD components in relevant country programmes. ‘,.He stated that funding for WHD activities should be provided from the concerned programme area but that,. for particular focused activities, additional funding could be made available. * ACTION POINTS 1 . SEAR0 should- establish a systematic process to ensure the, incorporation of WHD components in WHO collaborative programmes, 'preferably throughlexisting mechanisms such as the CST. 2. WRs, LO/ESCAP and the WHD Core Group should regularly exchange information, on WHD activities and. resources,' which could be widely disseminated in order to strengthen the SEARO/WHD initiative and the WHD.components in country :programmes. 3 . WHO at all levels should become more active in advocating greater gender-sensitivity inthe design, implementation, monitoring and evaluation of health ',and 1 development programmes. 4 . WHO at all levels should intensify its collaboration and coordination with governments, other agencies and' NGOs in relation to WHD activities. 5. WRs in collaboration with the WHD Core Group and SEAR0 technical units should identify and incorporate specific activities related to WHD during the preparation of the detailed plans of action for the 1994-1995 biennium. 16 6 . The SEAR0 WHD Core Group should collaborate with the HS Unit to promote gender-specific data.collection in Member States, e.g. HST/HQ should be requested to incorporate gender- < disaggregated data during formulation of guidelines and format for CFM-3. 7 . AIDS - AN UPDATE In his presentation of the agenda item, TL-GPA stated that AIDS had, in a relatively short period of-time, established itself as an unprecedented health problem with enormous health, social and economic implications. In the South-East Asia Region, the introduction of AIDS and HIV infection occurred relatively late in the pandemic but the impact is already extremely severe. A number of countries had not only experienced explosive increases of HIV infection rates amonlg intravenous drug users, prostitutes and STD patients but there was evidence that HIV infection was now spreading from these groups into the general population. As of 1 November 1992, a total of 1,253 cases of AIDS had been reported in South-East Asia. Itwas estimated that as of November 1992, about 20,000 cases of .AIDS might have occurred in the Region. The relatively small number of AIDS cases reported.so far reflected factors such as late introduction of the virus into the Region, long average latency1 period of 10 years, and,, to:a lesser extent, under-recognition anld reporting. However, data on HIV infection showed that, although the pandemic in this Region was still at an early stage, there was serious concern that the virus might be spreading at a pace reminiscent of sub-Saharan Africa in the early 1980s. Based on the currently available data, it had been estimated that there were presently 450,000 HIVinfectedpersons in,Thailand, about 1 million in India and 15,0,000 in Myanmar. Given the prevailing sexual behaviour and high incidence of other STDs, there was a real possibility of a similar scenario being repeated in other countries of the South-East Asia Region, particularly Nepal, Bangladesh, Indonesia and Sri Lanka. TL-GPA also outlined the global strategy on-AIDS prevention and stated that sexual transmission was the mostpredominant mode of spread of HIV. In order to delay and prevent further spread of HIV, targeted intervention activities, ,includ-ing information and education, condom acces,s and STD management, needed to be expanded in all countries. These interventions had. 'bteen found to be effective in bringing about behavioural changes thereby contributing to a decline in the incidence of STDs and HIV. Examples were provided oS success.stories i.e., in Thailand with 100% condom use in the brothels resulting in a dramatic decline in STD among prostitutes, and of successful use of social marketing 17 . techniques leading to a substantial increase in condom distribution and usage. The points that emerged during the discussion were as follows: All countries should develop a comprehensive situation-based AIDS plan, which can be funded by different donors. A number of donors are interested in supporting AIDS programmes in different countries. WHO has an important role in coordinating donor support. While some countries in the Region have demonstrated political commitment to AIDS prevention, similar levels of commitment are required from all countries of the Region. Concern was expressed regarding the sustainability of AIDS prevention programmes. Studies carried out in Thailand could be used for this purpose. There is an urgent need to accelerate HIV prevention efforts in all countries. Since the level of HIV infection in the general population is still low, the window of opportunity is still open, which, however, may be fast closing. In this regard, experience gained and expertise available in countries in dealing with AIDS pandemic should be shared with programmes in other countries of the Region. In the absence of a vaccine or a cure, education and information programmes have a key role. However, the Central Health Education Bureaus in many countries are weak and need strengthening. Religious and cultural factors stillconstitute an important constraint in mounting effective AIDS education programme, particularly in relation to discussions about sex education and condom promotion. In certain countries, the existing laws do not permit national programmes to reach injecting drug users and prostitutes and educate them regarding HIV. The Regional Office and WHO headquarters should share the latest documents, guidelines and information with the WRs. The Regional Office should consider supplying the WHO country offices with the latest HIV situation and programme developments which will facilitate the advocacy role of WRs. Since STD management is more important as primary prevention against HIV, there is an urgent need to strengthen the STD programmes in all countries. The Regional Director, du,ring his concluding remarks, pointed out that AIDS programmes at:the country level were.likely to have enough funds available through multilateral or'bilateral donors. 18 It would be important for WHO to build good partnerships and work together with other agencies. He, however, cautionad that WHO should be alert and plan for long-term support and initiatives. 1 . 2. 3 0. 4 . WRs should continue to play the coordinating role ,in AIDS prevention efforts,at the country level as well as critical advocacy role to mobilize country- initiatives and"resources, including political commitment. WRs should play a catalytic role in promoting the involvement of; and support nongovernmental 'to,and community-based organizations in AIDS prevention activities. SEAR0 and HQ should support WRs by providing global and regional updates on AIDS situation and prevention initiatives and policies. SEAR0 should promote intervention programmes targeted at persons practicing high risk behaviour and assist ' countries in strengthening STD control activities. 8 . INTRORATION OF PROGRAWB MONITORING BRTWEEN COUNTRY AND RDOIOftAL OFFICE Introducing the agenda item, the .Regional Director said that the adoption of modern information technologies; including a computerized programme monitoring system in SEARO, was slow as compared to the other Regions. However, efforts were being made to develop and strengthen feasible and affordableci,nformation-systems in SEARO. He a-sked the WRs to give careful consideration to the points raised duringlthe session, as information was the basis on which effective monitoring and implementation rested;_ . _' In his introductory remarks, PC1 said,that any information system was a tool subordinate to cater to management needs., So, initially the progres,s might seem to be slow but it would steadily pick up. He briefly explained the background to the development of a‘ softwa.re programme to monitor WHO'programmes at the country level, which -wgs.now being used in seve'ra3 WRs' offices;', Based on the feedback from WRs, the software was later modified to take into account the introduction of the arinual Detailed-Plan of Action in programme budgeting. Referr.ing to the establ-ishment of the SEAR0 Local Area Network (LAN), in September 1992; he sald'that its'main thrust was to share data and improve communications among units in SEAR0 as well asbetween the RegidnaYL and the WRs' offices. PC1 said that the other key development in this field wassthe effort to , * 19. rewrite the Regional AFI system, which was expected to be completed by 1994 and implemented by 1995. This new system would enable SEAR0 units as well as >most WRs direct access to AFI*data for on-line queries on the SEAR0 LAN environment. He cautioned the WRs to be careful in selecting the information, and urged them to share their experiences and opinions with regard software, to the new monitoring identify the type of training they would like their staff to undergo and list their information priorities. Clarifying the definitions used in ,the working paper, OR0 said that there were several advantages in using a computerized monitoring system for managerial tasks, such as the preparation of the annual PoA. The main issue now concerned the convenience of integrating the regional monitoring system with the WR monitoring system, which would imply t-he need for the WRs' offices to progressively adopt the standard system developed by SEAR0 for this purpose, after eventual customization of the same. By achieving integration of programme monitoring, it would be possible to . exchange monitoring data between SEAR0 and the WRs. A demonstration of the SEAR0 monitoring system was then given in which it was briefly shown how regional advisers in SEAR0 could access basic data from Budget and,Finance, Fellowships, and Medical Supply Units, though not all these linkages were in place at present. The WRs were also shown how data regarding‘country detailed plan of action, which some WRs' offices kept sending to SEAR0 through diskettes, could be displayed on the SEAR0 monitoring system for Regional Advisers to look atand take necessary follow- up action. A second demonstration followed in which the WR India's Office accessed the SEAR0 Monitoring system,from a local computer via telephone lines for on-line queries into the SEAR0 monitoring system. Some WRs described their experience in implementing a computerized monitoring system and in stepping, up informatics support in their Offices, which- could be shared with, other WRs willing to strengthen automation in their office. The following observations were made during the ensuing discussions: The regional monitoring system should provide information of the date of receipt of a request for a implementation programme from the WR and where it is lying for processing at a given point of time, which can be used by Regional Advisers for early follow up. There should be eventual compatibility between the monitoring systems in the Regional Office and in the WR's office, in view of some WRs having their own monitoring systems. The rights ;and.~responsibilities of the: users of the,LAN and the present .and. future linkage between the SEAR0 monitoring 20 System and other sub-systems, such as FEL, MSU, PER should clearly be made known. There are no information major technical problems in 'making more 'available different needs. on the SEAR0 LAN to accommodate There is a need for a team-work discipline in each unit to update the information for project under its responsibility routinely, and to take action on delays flagged by the different monitoring systems used at each level. Each unit should adhere to standard monitoring procedures in orderto adjust to a work culture where sharing of information among units in SEAR0 and between SEAR0 and WR's office is the basis for WHO programme monitoring and follow up on a regional scale. Any regional monitoring system should provide feedback to WRs by prompt acknowledgment of requests forwarded to SEAR0 for processing. The standard monitoring system proposed for the WR's office, should be introduced in a phased manner-and should take into account already existing monitoring systems in each WR's office,. Linkage of the SEAR0 system to other Regional Office -systdms (MSU, Fellowships, BFU information systems) should be done in a phased manner,' by implementing simple linkages first and expanding them successively. The functioning of the regional monitoring and 'other sub- systems should not be disturbed in the process of linking them to the SEAR0 LAW; furthermore, priority should be given to linking the Fellowship, Budget and Finance,. Medical Supply systems to the SEAR0 Monitoring system at an early date. WRs should use cost-efficient informatics technologies, and strike a balance between the total budget for a programme and the budget allocated to informatics support' under the same programme. : Acce~ss to distant data bases and information systems-through E-Mail or other telematics services'may.not be free of charge. Somehow the value of the needed information must be matched with the cost of accessing it through-.f~&zt'technolog&es. Summing up, the Regional'Dlrector stated that the information technology should be put to best use by WHO/SEAR0 for its programme development and management. H e ,'had; therefore, supported computerization of work in the Regional Office and the WRS' offices * ‘ * 21. as well as the training of staff concerned. He would, however, like to caution the WRs that the expenditure incurred on the ,introduction of new information technology should be in proportion to the country programme budget and that there should not be too much dependence on this technology to solve problems encountered in programme implementation. ACTION POINTS: 1. WRs should send to PCI/SEARO their experience with the system of integrated programme monitoring between the country of'fice and the Regional Office. 2. Each unit in the Regional Office will be responsible for periodic and regular updating of information on programme monitoring for their respective country and projects. intercountry 9. s2wE MOTNEREOOD HSI, in his opening remarks, motherhood initiative (SMI) . stressed the importance of safe More than half a million women die every year from causes related to pregnancy and childbirth, and almost all of those deaths were in developing countries. Most of them were preventable with attainable resources and skills. RA-FH, in his presentation, provided basic information on SMI, which promotes action on four fronts, viz. (a) inequities confronting redressing women, planning, (c) devel (b) ensuring access to family oping community-based'maternity care, and (d) providing support at first level of referral for obstetric emergencies. Strategies for the reduction of maternal,mortality, based .on the risk approach, might include better, follow-up of pregnancytL improvement in the facilities of referral maternity hospitals, careful monitoring of progress of labour through the use of partagraph. and adaptation of family planning policy. After presentation of possible SMI activities at the country level, he emphasized the important role played by family planning in SMI and ‘. discussed unsafe abortion as one of the leading causes of maternal .- mortality, ,Conce,rning participation of TBAs ,in SMI, he explained that delive,ries .by conventionally-trained TBAs could prevent only 3 per cent 'of maternal deaths. TBA training and pre-natal care without adequate back-up referral system were most expensive and least effective in preventing maternal deaths. : The following main issues emerged during the discussions which f o l l o w e d : I 22 WHO should.take leadership in SMI and sensitize policy-makers in the countries,: in cooperation with other agencies. - Registration of maternal deaths and maternal death audit are very important matters. The status of women in SEAR is low and there is inadequate awareness of it among policy-makers. First referral level hospitals are not providing essential obstetric functions. Access to the family planning services is not universal. More attention should be given to the education of males in matters dealing with family planning. Development of comprehensive strategies and operational research should be initiated. The role of WHO in developing such strategies should be highlighted. The Regional Office should extend support to strengthen the system of data collection in order to provide continuous feedback on technological issues, and disseminate information about initiatives and policy matters in other countries. As maternal mortality is a multisectoral issue, WHO should provide strong and a well-integrated efforts to preserve leadership in SMI. From the level of headquarters to the Regional Office and to the countries, WHO should revive its commitment to MCH throughv the use of its Regular Budget. There is a need to perform a serious in-depth study on TBA training and on impact of TBAs on maternal mortality. TBAs in many countries are working outside the referral,system. RPD funds should be made available for innovative multicountry research and for support -of learning by doing and by exchanging experiences. SMI cannot be separated from child survival. Promotion of EPI may be done also in the framework of integrated approach to MCH. IKZTION POIHTS 1 . At the Regional. Office level, a multi- disciplinary task force be set up on matters dealing with safe motherhood. 23 2. There is an urgent need to improve the collection and registration of data on maternal deaths in SEAR countries, and undertaking some operational research on data collection. 3. Awareness of SMI importance and advocacy of S-MI at the country level shobld be continuous. 4. WHO should support 1 ‘Member Countries in developing a multisectoral' strategy for achieving safe motherhood goals and plans of action., 10. MEETINGS AND SPECIAL ADDRiQSS BY ADO, wSO/BQ In addition ,to the plenary sessions, the WRs also had an informal meeting among themselves before their confidential session with the Regional.Director. Support The WRs had separate meetings with the Programme on administrative matters, and with the representatives of the Staff Association on staff matters. ,There was also a special address by Dr R.H. Henderson, ADG/WHO Headquarters. 11. CONCLUSION WR, Mongolia, on behalf of the WRs, thanked the Regional Director for giving them an opportunity to discuss various issues concerning development in UN and WHO families, as well as for the warm hospitality extended to them in the past two weeks. He also thanked the Regional Director for giving an opportunity to the WRs to attend the Second AIDS Congress. .He said that such opportunities greatly helped in the promotionof WHO activities in the countries and suggested that such participation in important meetings ,should be continued. WR, Indonesia said that discussions on some issues Could be sharper. She suggested that the WRs could be used as resource persons, specifica.lly while formulhting'iSbue~ for di3cussion on the background papprs, and they could also be"requeSted to present agenda items with a view to focusing the discussion on the main issues and in finalizing the report. She also suggested a few items which could be considered for inclusion in the agenda for the WRs meeting next year: 1. Outcome of the International Congress on Malaria and Nutrition in terms of what they mean to country programmes. '* 2. Some,issu,es related.to health of indigenous people; 24 3 . Urban healkh; a' 4. Review of "study tours"; . I ._ ) I .' 5. Role of WRs on matters relating to ExpertAdvisory Panels and Collaborating Centres. * In his' concluding remarks, the .acting. Regional D%rector, Dr D.B. Bisht, conveyed bersonal greetings from the Regional Director, requesting the WRs to pursue smatters- discussed:& the meetihg and continue giving feed-backs.to the Regional Office* in order to further improve WHOfs collaboration with~:Member States. EB's Working Group was already working on Response of WHO in the changing global situation, and SEAR0 was closely progress about which the WRs would be kept informed. following the , '. ,. '. Dr Bisht said that 1993 would be a very critical one for the UN system. The ADG had mentioned about some ongoing.civil wars the outcome of which would be visible only in the,middle of next""iyear, and that discussions;in the next EB and WHA would be very crucial. He hoped that the staff would be able to respond quickly and effectively to the changing situation, and visualized that the entire Organization would emerge from these changes much stronger. He thanked WR Indonesia for suggesting some agenda items for the meeting next year, which had been noted, and request&& other WRs to suggest any items and issues that could be .discussed in the next WRs meeting. NC3 felt that if only 6-7 technical items were discussed, that would give more time for the discussions. He would consfder the items suggested by the WRs and draw up an appropriate agenda for next year's meeting for consideration and approval by' the Regional Director. Greater crystallization would okcur iI background documents were prepared focusing, on main issues, and then detailed discussion could take place. Thisiwould be kept in mind while preparing,background papers for the next meeting. Be would discuss in RPC and with the RegionaS Director regarding association of WRs as resource persons in the preparation for the background documents. Finally, the acting Regional Director thanked the WRs and wished them safe journey back to their respective,duty stations. Annex WORLD HEALTH REGIONAL OFFICE FOR ORGANIZATION SOUTH-EAST ASIA Forty-first Meetina of the Reqional Director wilh the WHO Rerxesehtatives, New Delhi 1 2 t o 2 5 November 1992 SEAtWR4lIl Revision 1 8 Sept. 1992 1 . 2. 3. 4. 5. 8. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. I'ROVlSlONALACENDA Opening address by the Regional Director and Statements by Agency Representatives WHO Programme Review by Director, Programme Management Managerial and Technical Role of the WRs - A New Perspective Ninth General Programme of Work - Implications on WHO Country Programmes CCPDM Working Group Study on WHO Programme Management - An Update Action for Women, Health and Development AIDS - An Update Integration of Programme Monitoring between Country and Regional Office Safe motherhood WHO Representatives’ Informal Meeting Adminisfratke Matters Meeting with Stalf Association Representalives Special RPC Meetings lo review (a) programme implementation during 1992 and (b) completed annual detailed plans of action for 1993 Confidential Session ol the Regional Director with the WHO Representatives Summing up of Issues Closing Session 1 . Annex 2 . SEA/WR41/1 Add.1 18 November 1992 Revision 3: :. _ .r -------------------_____________________----------------------------------------------------------------------------------------------------- Date -pi%! ,gl ‘^ Agenda Mein ---i---e-m --------‘-------‘-------------------------------------~~---~---~-~---------------------------------------------------------------- Thu. 12 Nov Sat, 14 Nov 0830 hrs to 1630 hrs Individual discussions with Programme Directors/Chief and their GI;IQ4ps to review (a) programme implementa& during !!?!J? $t$d (b) completed annual detailed plans of action far 1993 Mon, 16 Nov 0900 hrs to 0945 hrs Agenda Item 1: Opening address by the Regional Director and Statements by Agency Repte.sematives 0945 hrs to 1015 hrs Tea/Coffee Break 1015 hrs to 1045 hrs Agenda Item 2: WHO Programme Review by Director, Programme Managcmcnt ‘. ’ -1045 his to 1230 hjx _ -< ‘~Ase#&m 3: Managerial and Technical Role of the WRs _ A Miw Per$ective 1430 hrs tn 1630 hrs Axenda item 3 continucd Tut, 17 Nov 0900 hrs to 1045 hrs Agenda Item 5: CCPDM Working Group Study on WHO Programme Management - An Update 1 I00 hrs to 1230 hrs Agenda Item 4: Ninth Gcncral Programmc of Work - ImpIica,iions on WflO Country Programmes 1430 hrs.to 1600 hrs Agenda Item 7: AIDS - An CJpdate WetI, 18 Nov 0900 hrs to 1045 hrs Agenda Item 8: lntcgration of Programme Monitoring between Country and Regional Office 1100 hrs IO 1230 hrs ., : ; Agenda Item 9: Safe Motbhood 1430 hrs to 1600 hrs Agenda Ilem 10: WI IO Rcprcscntativ&’ informal Mccting -2- ------------------------------------------------------------------------------------------.--------------------------------- Date Tiring &em& Item “I Jq,mNfJv I_ub ihkw (a) pglamme nrplermncslior,dwing199u2Mldtb~colnplcloQarrwlsl~~ o!WohfstolO3ohls - Thailand 1045hrsto123Ohrs - Banglad& 1430 hrs to 1630 lirs daub Item 14: Confea$ab &siun of the Regianal Director witlt thi ‘WHO Repnzsentatives Mon. 23 Nov RR& Item 13 (Cod): Special RK Meetings to review (a) ‘-me implc~ion during I!392 and (b) completed ;rm+ detailed plans of act@ for 1993_ / 0830hrsto1000hrs - ‘Bhutan lOOOhrsto1200hrs - hdii 133Ohrsto 15OOhrs - Indonesia 15OOhrsto 163Ohrs - Maldives Tue. 24 Nov Aa- Itan 13 (Contd.): Special R4C Meetings to review (a) ’ ,$kgmdhe impbnemation during 1992 and (b) completed annual d&ailed pLs of action for 1993 0830hlsto1oalhrs - ’ Mongolia lOOOhrsto1200hrs - M yanmaf 1330 hrs to IWO hrs - Hepal 15Ohrsto 163Ohrs - Sri Lanka &xl, 25 Nov WOhrstolOOOhrs 1OOOhrs Aiemla Item 15: Summing up of Issues Ad&&s hy Dr R.H. Hen&r&, ADG/WHO HQ Amula Item 16: Closing Session _______________________c________________----------------------------------~~-----------------------------------------------------------~---- NOTE: 1. All pbary sessions during 16 - 18 November. and on 25 Nov.embcr will be hckl in the Conference Hall. 2 . The Informal Mecling of WHO Rcprescntalives (Item 10). Meeting on Administrative Maters #cm t I). Mccling with Slaff Association Represcntativcs (Item 12). and ~hc Confidrntial Session with the Regional Dircclor (Ilcm 14) will hc held in tic Committee Room. 3 . Tht Special RPC Meetings during 20-24 Novcmhcr will hc held in Room 220. 3 . Tca/Coffc.. Rrcak will bc at 1045 hrs. and IS15 hrs. and Lunch Drcak will bc during 1230.1430 hrs, unless shown othcrwisc. 5. DSP will hc lhc focal point liH nrpanbing stxinl cvcni*