WORLD 1-IEALTH ORGANIZ.ATION
ORGANISATION MONDIALE DE LA SANTE
REGIONAL OFFICE FOR
THE WESTERN PACIFIC
BUREAU R~GIONAL DU PACIFIQUE OCCIDENTAL
REGIONAL COMMITTEE Thirty-fourth sess1on Manila
WPR/RC34/SR/l 5 September 1983 ORIGINAL; ENGLISH
PROVISIONAL SUMMARY RECORD OF THE FIRST MEETING WHO Conference Hall, Manila Monday, 5 September 1983 at 9.00 a.m. CHAIRMAN; later: Dr S. Tapa (Tonga) Dr Khalid (Malaysia)
CONTENTS
1. 2. 3. 3.1 3.2 3.3
Formal opening of the session
.............................. .
3 3 .3
Address by the retiring Chairman •••••••••••••••••••.••••••• Election of. new officers: and Rapporteurs Election of Chairman Chairman, Vice-Chairman, ••••••••
.......................................
3 3 3 3 3
Election of Vice-Chairman ................................. .
Election of Rapporteurs ..•....•••.••.•....••.•••.•.••••••••
4.
Address by the Director-General ••.••••••••••••••••••••••••• Technical Discussions: Adoption of the agenda Appointment of a Moderator •.••.••••
s. 6.
.................................... .
4 4
7.
Acknowledgement by the Chairman of brief reports •••••.••••• received from governments on the progress of their health activities Report of the Regional Director ••••••••••••••..•••.•..••••.
8.
4
Note: Corrections to this summary record should be given to the Programme and Reports Officer, Room 326, or handed to the Enquiry Desk in the lobby of the Conference Hall, within 24 hours of its distribution.
WPR/RC34/SR/l page 2
For the List of Representatives at separately issued document WPR/RC34/DIV/l.
the thirty-fourth session,
see
WPR/RC34/SR/l page 3
1.
FORMAL OPENING OF THE SESSION:
Item 1 of the Provisional Agenda
Dr TAPA, retiring Chairman, declared the thirty-fourth session of the WHO Regional Connnittee for the Western Pacific open. 2. ADDRESS BY THE RETIRING CHAIRMAN: Item 2 of the Provisional Agenda
Dr TAPA made a statement to the Connnittee as retiring Chairman (see Annex 1 for a copy of his statement). 3. 3.1 ELECTION OF NEW OFFICERS: CHAIRMAN, VICE-CHAIRMAN AND RAPPORTEURS Item 4 of the Provisional Agenda Election of Chairman
Dr XU SHOUREN (China) nominated Dr KHALID (Malaysia) as Chairman; this was seconded by Dr GALVEZ (Philippines). Decision: Dr KHALID was elected unanimously.
Dr KHALID took the Chair. 3.2 Election of Vice-Chairman
Dr SUNG WOO LEE (Republic of Korea) nominated Dr OGATUTI (Solomon Islands) as Vice-Chairman; this was seconded by Dr MONTEIRO (Singapore). Decision: 3.3 Dr OGATUTI was elected unanimously.
Election of Rapporteurs
Mr LAVEA LIO (Samoa) nominated Dr MONTEIRO (Singapore) as Rapporteur for the English language; this was seconded by Dr SIALIS (Papua New Guinea). Dr REYNES (France) nominated Dr DA PAZ (Portugal) as Rapporteur for the French language; this was seconded by Dr SOUVANNAVONG (Lao People's Democratic Republic). Decision: 4. Dr MONTEIRO and Dr DA PAZ were elected unanimously. Item 3 of the Provisional Agenda
ADDRESS BY THE DIRECTOR-:-GENERAL:
The CHAIRMAN invited Dr Mahler to address the meeting (see Annex 2 for a copy of his statement). 5. TECHNICAL DISCUSSIONS: APPOINTMENT OF A MODERATOR
The CHAIRMAN moved the appointment of a moderator for the Technical Discussions and proposed Dr CHRISTMAS (New Zealand). Decision: The proposal was adopted unanimously.
WPR/RC34/SR/l page 4
6.
ADOPTION OF THE AGENDA; (Document WPR/RC34/l)
Item 6 of the Provisional Agenda
The CHAIRMAN moved the adoption of the agenda. Decision: 7. In the absence of comments the agenda was adopted.
ACKNOWLEDGEMENT BY THE CHAIRMAN OF BRIEF REPORTS RECEIVED FROM GOVERNMENTS ON THE PROGRESS OF THEIR HEALTH ACTIVITIES: Item 7 of the Agenda
The CHAIRMAN acknowledged reports on the progress of health activities received from the following countries or areas: Australia, China, Guam, Japan, Lao People's Democratic Republic, New Caledonia, New Zealand, Republic of Korea, Samoa and Viet Nam, which were being distributed to the Committee. 8. REPORT OF THE REGIONAL DIRECTOR: Item 9 of the Agenda (Document WPR/RC34/3, Corr.l and Corr.2)
The REGIONAL DIRECTOR presented the report on the work of WHO in the Western Pacific Region for the period 1 July 1981 to 30 June 1983. He said that, if they were to compare the report, · which covered the last half of the last biennium of the Sixth General Programme of Work, with that prepared in 1979, the year after Alma-Ata, they would be more than gratified with the evidence of changed concepts and approaches towards the goal of health for all by the year 2000. That had been achieved through the determined efforts of Member States, both individually and collectively in the governing bodies of WHO, with the support of the WHO Secretariat. The Regional Committee for the Western Pacific had played a leading role in those efforts. Its role in encouraging technical cooperation among developing countries was also clear, and could be further enhanced, in such areas as the sharing of information, pharmaceutical production and management activities. Through his own v1s1ts to countries, the visits of WHO technical staff, meetings of WHO Programme Coordinators, and reviews of national programmes in the countries themselves with all the agencies involved, the current Sixth General Programme of Work had been evaluated. One such review of a national programme had taken place in Lao People's Democratic Republic in June 1983, with the participation of the government authorities, and representatives of UNICEF and WHO. The primary health care, malaria, water and sanitation, health manpower development, prevention of blindness, maternal and chilq health and nursing education progratinnes had been extensively discussed; the extent of government and international resources reviewed; and plans made for future action. Another was being planned for the South Pacific in November 1983, to take place in Manila. The report provided information on activities being carried out in areas of priority for the achievemertt of health for all and also illustrated how institutes in the Region were playing a leading role in research on diseases of high prevalence, the results of which would be of global benefit.
WPR/RC34/SR/l page 5
The Regional Director drew attention to section 10.2 (Basic sanitary measures), which formed part of the chapter on Promotion of Environmental Health. The Western Pacific Regional Centre for the Promotion of Environmental Planning and Applied Studies (PEPAS) was continuing to provide much of the cooperation under that programme. At the second meeting of its Advisory Committee, held in June 1983, it had become evident that its activities should be concentrated mainly on water supply and sanitation. Operative paragraph 3(1) of resolution WHA36.13 invited the Regional Committee to review the progress of International Drinking-Water Supply and Sanitation Decade activities, if possible in 1983. He had hoped to include such a review on the agenda of the current session but there had been time constraints. Instead an attempt had been made to summarize the progress of activities in section 10.2. Dr CHRISTMAS (New Zealand) commended the Regional Director and his staff on the clear presentation of the report, particularly its introduction highlighting main features of the activities covered. Work under the Expanded Programme on Immunization in the Region during the period deserved special mention and warranted increased support in the future. Commenting on the postponement of the review of the activities for the International Drinking-Water Supply and Sanitation Decade (IDWSSD), he said New Zealand would like to see some report on progress of PEPAS, and in particular on its recommendations. Dr SUNG WOO LEE (Republic of Korea) noted the new aspects in the community-based orientation of noncommunicable disease prevention and control, and welcomed the emphasis on health services research and the activities for IDWSSD. He Region. expressed concern about the worsening malaria situation in the
Dr LIU GUO-BIN (Director of Drug Policy, Environmental Health and Health Technology), replying to the representative of New Zealand, said that PEPAS was devoting much effort to the International Drinking-Water Supply and Sanitation Decade, particularly the quality assurance of water safety. In the past year, the financing of water supplies had been studied, and workshops and training courses had been held, both at the Centre and in countries; further cooperation with countries on drinking-water supplies was anticipated. He outlined the Region's present situation with regard to the Decade. In Malaysia, the Philippines and the Republic of Korea, urban water supply services had reached high levels, but rural programmes had had varied success. A number of countries in the South Pacific had made good progress, reflecting two decades of WHO cooperation. However, Papua New Guinea, the Solomon Islands and Vanuatu had advanced more slowly, and their attainment
WPR/RC34/SR/l page 6
of high levels of water supply and sanitation would depend on active national programmes over the Decade. Lao People's Democratic Republic had had considerable success, and in 1982 a UNDP/WHO Decade project had been approved, with the focus on the training of a cadre of trainers and the formulation of a national Decade programme. Brunei, Hong Kong, Macao and Singapore had a high level of water and sewerage services, although all had limited water resources; water pollution was one of the main concerns. In China, a UNDP/WHO project to initiate Decade activities had been approved in 1982. Although nightsoil collection was practiced in most urban and rural areas, the hygienic handling of human wastes remained a problem. To sum up, the Region had made substantial progress towards achieving the Decade goals for 1990, but there was still a long way to go, and further efforts and resources were needed. Mr LAVEA LIO (Samoa) said that WHO and UNDP had assisted in forming R Samoan national Decade committee which met every two months. A national water supply plan had been agreed in principle. The Decade committee had suggested the creation of a national board with statutory powers. Chapter 1; General Programme Development and Management (pages 3-6) the report and expressed
Mr NGUYEN DUY CUONG (Viet Nam) cornmended gratitude for WHO's cooperation with his country.
Commenting on specific points, he noted that the Region had approved a strategy that was fully applicable to the countries; however, much remained to be done to meet countries' needs in staff training for primary health care. Secondly, he would like to see activities in the exchange of information and health statistics intensified. Lastly, more should be done in the field of prophylactic, diagnostic and therapeutic substances. Chapter 2: Coordination (pages 7-11)
There were no comments. Chapter 3; Research Promotion and Development (pages 12-14)
Dr SUNG WOO LEE (Republic of Korea) recalled that, in the past, the Committee had adopted several resolutions referring to the establishment of a focal point to coordinate health research at the national level. What was the rationale for the establishment of national research councils or similar bodies?
WPR/RC34/SR/l page 7
Dr ROMUALDEZ (Philippines) said that, in 1982, in recognition of the need for such a focal point, his country had set up the Philippine Council for Health Research and Development under the National Science and Technology Authority. The Council helped to focus research resources on national health problems, coordinating the research efforts of the Ministry of Health, the scientific and technological community, and academic institutions. The Council had initiated research into acute respiratory infections. WHO had cooperated in the establishment of an urban study unit for those infections in Manila, and subsequently the National Science and Technology Authority had taken over support of the unit, and with Australia's help was extending research to a rural community in the South. The newly formed National Council for Acute Respiratory Infections intended to draw on the results of the research to formulate a national plan for control. It was hoped that that model could be used for other health research activities. Dr PAIK (Chief, Research Promotion and Development), replying to the representative of the Republic of Korea, said that, in resolution WPR/RC3l.R22, adopted in 1980, the Regional Committee had asked countries to establish national health research mechanisms to enable research activities to be related to well-defined national health development goals. WHO was now promoting programme-oriented or need-based research to study problems impeding progress towards health for all. Research should be directed to problems with a bearing on national strategies and plans of action. The richer countries could afford fundamental research. The developing countries, however, were short of funds and trained manpower, so that it was essential for them to select research topics carefully. A health research council could coordinate research, ensure that it was related to national health programmes, and avoid duplication. Australia, New Zealand, and the Philippines now had fully pledged health research councils, while a number of other countries had set up coordinating bodies; the Republic of Korea was contemplating similar action. Chapter 4; Health Services Development (pages 15-25)
Dr KITAGAWA (Japan) welcomed the clear and comprehensive report, which described the considerable progress made during the biennium towards health for all. His Government was particularly interested in the programme on care of the elderly, in view of the general ageing of the population, the need to provide health and social services for the elderly, and the importance of avoiding a loss of vitality in society. New programmes had been introduced in Japan in 1983. WHO should carefully monitor the progress of the care of the elderly programme, and further efforts should be made to develop related research. Dr SUNG WOO LEE (Republic of Korea) referred to primary health care and the financing of health services. This country fully recognized the basic right of all its people to good health. It was in constant contact with all agencies and groups to implement its health policies through a delivery
WPR/RC34/SR/l page 8
system based on primary health care, with the emphasis on promoting access to basic health services. The national health insurance scheme, started in 1977, now embraced half the population; it was hoped to achieve full coverage in the near future. Dr GALVEZ (Philippines) said that his country had undertaken health services research for some time, the information generated serving as an input to health programming, though more effort was still needed. Operational research had been used to improve the delivery of hospital services. It was hoped to undertake further studies on health financing. Chapter 5: Family Health (pages 26-35)
There were no comments. Chapter 6: Mental Health (pages 36-38)
Dr CHRISTMAS (New Zealand) commended the Regional Director and his sercretariat on the excellent progress that had been made in the field of alcohol control. A workshop had recently been held on the subject in the Philippines and the reports presented on that occasion had been most encouraging. Dr SUNG WOO LEE (Republic of Korea) observed that his Government was currently working on the promulgation of a new Mental Health Act and welcomed any cooperation WHO might be able to afford it. Chapter 7: Prophylactic, Diagnostic and Therapeutic Substances (pages 39-41)
There were no comments. Chapter 8: Communicable Disease Prevention and Control (pages 42-58)
Dr KITAGAWA (Japan) stressed the long-term importance of the training of personnel in tuberculosis control programmes. Joint WHO/ Japan courses had been held every year since 1967 at the Tuberculosis Research Institute in Tokyo. They had been attended by some 560 participants from about 45 countries or areas and had been most successful. A major effort needed to be made to strengthen training programmes in the developing countries. Hepatitis, and particularly hepatitis B, was another major health problem in the Asian region. Persistent hepatitis B infection was thought to be a significant factor in the incidence of primary liver cancer. He wished to know what were the priority areas in hepatitis research, what was the present production of hepatitis B vaccine in the Region, and what prospect there was of using the vaccine on a vast scale. Dr CHRISTMAS (New Zealand) recalled resolution WHA36.30 adopted by the Thirty-sixth World Health Assembly which called on countries to intensify their efforts to extend tuberculosis services to the entire population and the resolution adopted at the thirty-first session of the Regional Committee for the Western Pacific which further called on the Regional Director to promote collaboration in the field of tuberculosis control. Countries where tuberculosis control had been effective should make their skills and
WPR/RC34/SR/l page 9
capabilities available to their neighbours. Since tuberculosis had been shown to be a preventable disease, it was essential that such expertise be shared. Similar collaboration was required in malaria control programmes and in the fight against hepatitis. Priority, however, must go to tuberculosis control and he suggested that WHO might organize a workshop on the subject for the South Pacific area. Dr REYNES (France) mentioned that an international training course for French-speaking countries had been initiated in 1983 in Paris, where it had been attended by two Western Pacific countries. Mr LAVEA LIO (Samoa) observed that, though most endemic cOtiiDUnicable diseases were under control, cardiovascular diseases, hypertension, cancer and diabetes were increasingly prevalent in his country. The suicide rate, especially among young adults between the ages of 14 and 25, was particularly alarming. Mr NGUYEN DUY CUONG (Viet Nam) felt that the Report might have placed more emphasis on diarrhoeal diseases and on the resistance of malaria and sexually transmitted diseases to present forms of treatment. Dr EVANS (Regional Adviser in Chronic Diseases) praised the joint WHO/Japan training courses on tuberculosis control in Tokyo and welcomed the decision to organize courses in Paris for French-speaking countries. He agreed with the representative of New Zealand that countries with expertise in tuberculosis control should share their know-how with others. Joint tuberculosis control courses were organized by WHO and the South Pacific Commission (SPC) roughly every five years; the next course would be held in 1985 or 1986. In addition, WHO had a very active regional tuberculosis advisory team which had visited numerous countries in the area in order to advise on tuberculosis control. In 1983 the team had concentrated on the South Pacific area. Dr PAIK (Chief, Research Promotion and Development), referring to the questions raised by the representative of Japan, said that WHO studies in Japan had revealed that there were approximately 215 million hepatitis B virus carriers in the world, 168 million of whom were in Asia and Oceania (excluding Australia and New Zealand). There was therefore an urgent need to develop collaborative research activities in the Region. The first priority of a research programme should be to standardize and distribute low-cost but sensitive reagents and to share available expertise. The Regional Office had organized a scientific group on hepatitis in Nagasaki, Japan, in 1982, with the support of the Japanese Government. It had been most successful in collecting first-hand epidemiological information from va.r ious countries in the Region. Another important area of research was the prevention of mother-to-infant transmission of the hepatitis B virus. Finally, if countries were to engage in mass vaccination, the transfer of technology from developed to developing countries for the production of the vaccine wae also a priority. It was clear, then, that the crucial factor in hepatitis control was effective cooperation among countries.
WPR/RC34/SR/l page 10
Dr UMENAI (Regional Adviser in Communicable Diseases) stated that the currently available hepatitis B vaccine was the 22 nanometer particle vaccine which was prepared from the blood plasma of hepatitis B carriers. The vaccine 1 s effectiveness had been proved in Japan. Production of the vaccine was progressing in China and the Republic of Korea; Singapore, too, was planning to start production. Unfortunately, the process was complex and the cost involved extremely high. Some countries of the Region had recently initiated steps to produce other hepatitis B vaccines, and certain laboratories in Japan were already preparing vaccines by means of DNA recombinant techniques, as well as syntpet ic vaccines. Severa 1 more years were needed, however, before such vaccines could become generally available. Although, for the time being, the high cost of the 22 nanometer vaccine rendered mass vaccination impc;>ssible for most countries of the Region, the prospects for the near future were promising. The Regional Office was organizing a hepatitis task force meeting and other consultative meetings in Manila in November 1983 in order to develop a regional policy on hepatitis B control, including the production and distribution of vaccine. Dr LEE (Republic of Korea) pointed out that hepatitis vaccine was now available in the Republic of Korea. Dr SHINFUKU (Regional Adviser in Mental Health), responding to the point raised by the representative of Samoa, observed that the high suicide rate in the country appeared to be linked to social and cultural factors. A study should be ma~e of the magnitude and nature of the problem, of the possible causes of suicide and of the situation in other islands with a similar social structure. Once the causes had been ascertained, it would be possible to investigate possible forms of intervention by WHO in collaboration with ·the governments concerned. It was the first time that the issue had been broached officially. It could provide an interesting field for research. Dr TAPA (Tonga) inquired whether there were any recorded cases of the acquired immunity deficiency syndrome (AIDS) and of genital herpes in the Region.
The meeting rose at 12:00 noon.
WPR/RC34/SR/l page 11
ANNEX 1
ADDRESS BY THE RETIRING CHAIRMAN
Honourable Representatives of the Member States of the Western Pacific Region, the Director-General of the World Health Organization, Dr Halfdan Mahler, the Regional Director for the Western Pacific, Dr Hiroshi Nakajima, Distinguished Representatives of the United Nations, the Specialized Agencies, and Intergovernmental and Nongovernmental Organizations, the World Health Organization Secretariat, Ladies and Gentlemen, I feel deeply grateful and greatly honoured to have this opportunity in which it is customary for the retiring Ch~irman to give an address. First of all, I am thankful and happy that a 11 of us present here today are well, each person according to his or her accepted level of health. Secondly, I should like to express once again my sincere gratitude to the Regional Committee for the great honour of electing me your Chairman for the thirty-third session and for your kind cooperation and understanding. I would now wish to take a glance over the past twelve months and to review some of the main and important events that occurred during that period, and also to give ~:~orne thoughts about the future in the Western Pacific Region. The Regio11al Committee at its thirty-third session carried out its work in a cordial atmosphere and in a spirit of friendly cooperation which enabled it to deal with diverse difficult problems and needs in the Region. within the allotted time. In reviewing the Report of the Regional Director covering the period 1 July 1981 to 30 June 1982 at the thirty-third session, representatives referred to such issues as: (1) the need for different approaches to the delivery of primary health care, depending on the circumstances prevailing in each country; (2) the extension of primary health care in the urban areas; (3) the programme for health care of the elderly; (4) once again, the deteriorating malaria situation in the Region; (5) the need for exchanges of experience between Member States, especially with regard to the managerial processes for health development; (6) the recently recommended multi-drug short course regimerts for the treatment of leprosy; and (7) the need to concentrate on communicable disease control efforts as a whole, particularly the strengthening of research. Allow me to recapitulate some of the important matters discussed by the Regional Committee at its thirty-third session. The Committee examined and adopted a resolution on the regional programme budget estimates for 1984-1985 amounting to some us$46 million for the regular budget. This 1S the programme budget for the first biennium (1984-1985) of the Seventh
WPR/RC34/SR/l page 12 Annex 1
General Programme of Work (1984-1989). It reviewed the report of the Sub-Committee on the General Programme of Work and accepted its recommendations and adopted resolutions on them. The Committee also reviewed the report of the Sub-Committee on Technical Cooperation among Developing Countries and accepted its recommendations and adopted resolutions on them. Other items discussed and resolutions adopted by the Committee were the role of nursing in primary health care, alcohol as a major public health problem, the International Code of Marketing of Breast-milk Substitutes, the regional biomedical information system, epidemiological surveillance and health services in international ports, and health research. The number of Member States in the Region increased by two when Vanuatu became a Member of the World Health Organization on 7 March 1983 and the Solomon Islands on 4 April 1983. It is wi~h particular pleasure that I welcome the honourable representatives of these two South Pacific island nations to their first participation in a session of the Regional Committee. An event of great significance and importance to the Western Pacific Region was the holding of the First International Symposium on Public Health in Asia and the Pacific Basin, from 7 to 11 March 1983 at the School of Public Health, University of Hawaii at Manoa, Honolulu. The sponsoring agencies of the symposium were the World Health Organization, the South Pacific Commission, the United States Public Health Service and the Centers for Disease Control, the East-West Centre, the Association of Schools of Public Health, and the University of Hawaii. The scientific programme had four themes: (a) health promotion, (b) health of resettling populations, (c) primary health care, and (d) disease prevention and control. This international symposium and its published proceedings should contribute to and encourage the achievement of the goal of health for all by the year 2000. I want to place on record my thanks to the World Health Organization for enabling me to attend and to benefit from the symposium. One of the highlights of the period under review was the first visit by the Director-General of the World Health Organization, Dr Halfdan Mahler, to four of the Member States of the Region in the South Pacific - Samoa, Tonga, Vanuatu, Solomon Islands - and also to Fiji in July 1983. I am sure that I speak for all these Member States when I say how happy and delighted we were that the Director-General, as well as the Regional Director, could find the time from his many heavy global responsibilities to visit our small island nations for familiarization and discussions of mutual benefit to both sides. A happy occasion which gave rise to much relief to the small island health administrations from concern on the potential spread of cholera from the North Pacific to South Pacific islands was the official notification by the World Health Organization in July 1983 that Truk, Trust Territory of the Pacific Islands, had been declared free of cholera. Before I give some thoughts to the future, I should like to express my grateful thanks to the Regional Director, Dr Hiroshi Nakajima, and his Secretariat for the great help, guidance and hospitality given to me rluring the period of my chairmanship. I would also like to commend the Director-General, Dr Halfdan Mahler, the Regional Director and their staff
WPR/RC34/SR/l page 13 Annex 1
for all the continued support and the friendly cooperation they have rendered loyally and effectively in the performance of their duties to ongoing activities, projects and programmes and to new activities, projects and progranunes in the Member States and in other countries of the Western Pacific Region, despite their own problems and difficulties. Similarly, the friendly cooperative efforts between individual Member States and other countries in the Region and the World Health Organization, and between Member States and countries themselves, are to be commended. I am sure that all of us can draw courage from the examples of · these efforts despite all sorts of problems and difficulties, so as to lead us on to greater efforts still in order to achieve ultimately our goal of health for all by the year 2000. I should like now to give some thoughts to the future in the Region with particular emphasis on primary pealth care and health for all by the year 2000. Much has been said in sp.eeches and written in publications and in the popular press on this key approach and on this noble goal respectively. I believe that in the "Health for All" series of publications, the World Health Organization has clearly and fully stated the case for both primary health care and health for all by the year 2000. There is in existence a publication entitled "Regional Strategy for Health for All by the Year 2000", which was produced by the WHO Regional Office for th,e Western Pacific in 1982. In his message to the thirty-third session of the Regional Committee in 1982, the Director-General of the World Health Organization, Dr Halfdan Mahler, ended as follows: "Honourable representatives, the showdown for health for all li~s begun, no less than the countdown. And I repeat, there are less than eighteen years to go." In this year, 1983, there are less than seventeen years to go. And so with every session of the Regional Committee in the future, the target date of the year 2000 will get closer by one year but there will be more people to cater for. It seems to me, therefore, that this Region, with an estimate of over 1.3 billion people of diverse cultures and varying levels of development and the most populous amongst the six regions of WHO, is racing against time, against the one factor over which no mortal has any control or influence. There are, of course, other factors in our struggle to reach our goal of health for all by the year 2000. One such powerful factor is the economic situation which has prevailed in the world in the past few years, the economic slowdown that turned into the economic recession from which the world is now slowly recovering. At about the same time that the primary health care approach and the goal of health for all by the year 2000 were adopted by the World Health Assembly, there were great expectations and fervent hopes in the international conununity of a New International Economic Order that would contribute in some way towards providing the basic human needs and, ultimately, the achievement of health for all by the year 2000. The World Health Assembly in its collective lV'isdom in 1977 set the target date of the year 2000 to strive for b~cause its goal was first and foremost for human beings, and the sooner it was achieved the better. But I am sure that we also believe and hope that humanity will continue on after the year 2000. Honourable Representatives, let not the mixed picture I have painted discourage us or cause us to deviate from the firm resolve of our total
WPR/RC34/SR/l page 14 Annex 1 commitment to our noble and dignified goal. The goal is noble and dignified because it is a goal for humanity at all times and at all places in our spaceship Earth. The goal was based on the acceptance of the grandeur and dignity of each and every human being, in both a healthful life and a peaceful death, without distinction of race, religion, political belief, economic or social condition. The countdown for health for all by the year 2000 has begun. And I repeat, there are less than seventeen years to go. But, who actually does the countdown? Let me try to give an answer. I think, for a start it is done by each one of us, by each individual person, then by each family, by each community, by each Member State of WHO, by each non-Member State working with WHO, by each Region of WHO, by each Regional Committee, by the WHO Executive Board, by the World Health Assembly, and so on by other Organizations. I believe that only a person with consciousness, who has knowledge and experience of health, can be aware of his or her own health. Every such person adds up to make the all of health for all. I ~urther believe that only such a person who knows, feels and appreciates his or her health is able to know, to feel and to appreciate the health he or she is advocating for other persons to get and enjoy because he or she possesses that health which he or she can afford to offer others to share or to share it with others. It is in difficult and problematic times like the present, and no doubt also in the future, that there are temptations to relax and to deviate from the firm resolve of our total commitment to our noble and dignified goal of health for all by the year 2000. But we must make every effort to guard against these weaknesses. If we do not, then we are inviting only disappointment and failure later on. It is also in such times that there is a great need for each and everyone of us as individual persons, as representatives of Member States of WHO, as officers of the World Health Organization, as representatives of the United Nations, the Specialized Agencies, Intergovernmental and Nongovernmental Organizations, and whatever other capacity in which we serve, to reaffirm our determination, our confidence and our faith in ourselves and in the moral rightness and the economic and social justice of the goal of health for all by the year 2000, so that we shall continue to work hard together, to try to resolve all problems, to make certain necessary personal sacrifices, and to implement the Regional Strategy through the Regional Plan of Action, and also do the same with the National Strategy and the National Plan of Action, in order to achieve our goal of health for all by the year 2000. These are some of the thoughts I should like to leave with us all as we travel along on the difficult, tortuous, and uneven road to the goal - less than seventeen years away - of health for all by the year 2000. In conclusion, allow me to take this opportunity to wish all of you every success in your deliberations, and also to wish in the spirit of sharing: Health for you, health for me, Health for them, health for us, Health for all by the year 2000. Thank you.
WPR/RC34/SR/l page 15
ANNEX2
ADDRESS BY DR H. MAHLER DIRECTOR-GENERAL OF THE WORLD HEALTH ORGANIZATION to the THIRTY-FOURTH SESSION OF THE REGIONAL COMMITTEE FOR THE WESTERN PACIFIC Manila, S-9 September 1983 THE MARATHON FOR HEALTH FOR ALL Mr Chairman, Excellencies, honourable gentlemen, colleagues and friends, representatives, ladies and
Monitoring the strategies for health for all of the countries of the Western Pacific 1. Who would have thought when we started our dialogue in this Regional Cormnittee ten years ago that so much would happen in such a short decade? For the changes that have taken place in the health scene in the countries of the Western Pacific in recent years are truly remarkable. And that makes it all the more sobering to realize how much remains to be achieved. A short while ago the news media were exultant about the success of an athlete who had knocked two hundredths of a second off the world record for the hundred metre sprint. And I could not help wondering - what next? What will come after the sprint? 2. I had the same feeling on reflecting on health developments in the countries of the Western Pacific in recent years. You will be reviewing at this session progress in implementing your strategies for health for all. My impression on reading the report you have before you, my purely subjective impression, is that the countries of the Western Pacific have made a tremendous sprint towards health for all and that the time has now come to take a second breath and brace ourselves for the marathon for the year 2000. For that is what lies ahead - a marathon. And we have to remind ourselves - there are less than 17 years to go. 3. What have you achieved, as I can gather, since you embarked on your new health policies? The policy for health for all has been endorsed by the majority of the countries in the Region. In about half of these countries people ar~ involved in one way or another in their country's health system. These are encouraging signs but now comes the sobering reality. In only about one tenth of countries have explicit resource allocations been made to implement a national strategy for health for all. Less than a third of the countries in the Region appear to know how much is being spent on health in general and on primary health care at the community level in particular. As the report euphemistically puts it: "action to expand coverage of health care and retrain health manpower has taken precedence over preparing planning
WPR/RC34/SR/l page 16 Annex 2 documents". Nevertheless, some analytical informl;ltion on the health situation is needed if action is to be focussed on essentials. And yet only about one tenth of those countries eligible for sustained support for their health strategies from more affluent countries appear to be receiving it. Perhaps the lack of analytical information and the lack of national and international support are in some way linked? So in spite of the sporadic sprints here and there you can see the extent of the long race we still have to run together. The long race 4. We are well prepared for that race. We have sufficient technology for most of our needs, even if we have to keep on trying and trying to improve it and make it easier to deliver. But I am afraid that this is an obstacle race. I see three main types of obstacles. One is political tension, the other economic regression and the third the health infrastructure. 5. I cannot recall any period in human history without political tension. Had we been deterred by it we would never have embarked on our ambitious strategies for health for all. But I still maintain that we can do much more to influence the heads of state insistently and persistently th~t the improvement of their people's health is a good political investment, quite apart from the social and economic benefits it will ultimately bring about. I know that heads of states are being consistently bombarded by hard-nosed technocrats shouting loudly in their ears that health is a mere consumption commodity that drains the country's scarce resources. Perhaps there was some truth in that when all we had to offer were individual medical care transactions - and even that in my humble opinion is highly debatable - but it is certainly not true now that we have a collective strategy for health. 6. The economic regression is undoubtedly a great source of worry. The President of the World Bank recently stated that the average per capita income of the developing countries had actually declined in 1981 and 1982, and that as a result promising initiatives have been held back because of budget pressures, including initiatives tq improve health. But surely it is precisely because of such cut-backs that we have to entrench ourselves more firmly than ever in our strategy for health for all - a low cost solution by any standards. And that too is a message that has to be drummed home day after day into the ears of the supreme decision-makers. For as little as five dollars a head per year in investment costs, and ten dollars a head per year in recurrent costs, most developing countries would be able to go a long way in carrying out their health for all strategies. Good management for health for all 7. When it comes to political persuasion of the powers that be you can rely to some extent on the moral and political standing of your WHO to support you the international declarations, the resolutions of this regional committee and of the Health Assembly and the very existence of strategies and plans of action for health for all. But when it comes to the third obstacle - building up the health infrastructure - you have to rely on very much more than that. This is where the marathon nature of the race is most in evidence. I see no alternative but to keep on stubbornly,
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tenaciously, building up the people health power step by step until it reaches the critical mass of self-sustaining expansion. And by people health power I mean the whole human potential of your population and not only health personnel. But all this has to be done systematically and that is the most difficult part of it all. There is no alternative to what is called "good management" for want of a better name. 8. I will not weary you by repeating once more what a managerial process for national health development is all about. You are no doubt saturated with exhortations, such as to introduce central planning of community programming. But I often have an uneasy feeling that even if the process has got off ground in many countries and has been instrumental in developing your health strategies, even then it is rarely pursued with dogged determination. For that is what is required if the managerial process is to lead to the building up and operation of sound infrastructures that are capable of delivering the programmes, applying the technology and inculcating the social and behavioural measures in such a way as to have lasting and incremental effects. There is nothing new in all this. Building up the mainstream of health systems through sound management is a leitmotiv of all planned endeavours for health for all. I well remember stressing it when I presented you with a blue print for health for all some six years ago. Admittedly, at that time we did not have a consensus on what such a process should consist of; we do now. You may have to adapt it to your circumstances, but the principles are there to help you. 9. Incidentally, I am a little bit afraid that when it comes to setting up mechanisms for applying the managerial process we may be going off the track - a disaster for marathon runners. These mechanisms have to be bui 1 t up step by step by encouraging and challenging individuals and institutions to tackle specific problems whose solutions are essential for working out and carrying out our health strategy. When attempts are made to establish managerial mechanisms without clear definition of the specific problems they are being set up to solve, when that happens they become mere paper tigers. So it is not surprising that they mostly remain only at the preparatory stage because paper tigers have no place in the race for health for all. 10. Another important aspect of management is to make the most of whatever resources are available. I am greatly disturbed by our inability even to put together the information required to do that - another fact I have learned from your report on the monitoring of your strategies. It is only when you know how much is being spent on what and by whom that you are in a position to start controlling your own resources let alone mobilizing additional national and external resources. And even when you have that information you still have to contend with competition for external resources from other interests. So I return to the need to impress on heads of states the urgency and comparatively low cost of the health for all strategy. Even if having the information required to control and mobilize resources is only part of the resource story, not having it makes the story a fictitious fantasy.
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11. Need I say more about good management for shaping the mainstreams of your health system and mobilizing the resources to set it up and keep it up. Well, just one last word. Beware of bureaucracy; management is often equated with that. In reality it is when imaginative management is in short supply that bureaucracy takes over. So bureaucracy means mediocracy and both are enemies of · any strategy for health for all. Together with the Regional Director I am doing my best to rid WHO of these enemies. New managerial framework 12. Honourable representatives, last year I was unfortunately not able to participate in your deliberations. But I did send you a message in which I told you that we were about to introduce a new managerial framework precisely to ensure that you can make optimal use of your Organization 1 s resources with a minimum of bureaucracy. That framework has two dimensions. One relates to the style of management and the other to practical managerial arrangements. New managerial style 13. I shall start with the style because that is the key to understanding the arrangements. The first essential ingredient is trust in one another. It is only because of that trust that we are in the unique position of having a collectively agreed world-wide policy, a strategy for giving effect to it, and a plan of action for carrying out that strategy. But that trust will now have to be deepened if we are to become intimate partners in carrying out these agreements together. We will have to be ready to talk very frankly to one another - country to country, country to secretariat, and secretariat to country - without getting upset if the truth is sometimes unpleasant to our ears. I firmly maintain that we can to a large extent sustain the objectivity of our dialogue by basing it on our collective agreements. These were forged out of our trust; they have now become the keystones to susta1m.ng our trust and demonstrating continuously that we deserve it. For we are all guardians of our collective agreements. Those who are more familiar with them have the duty to draw them to the attention of those who are less familiar with them. They must do so politely if they are to retain the trust of their interlocutors, but firmly if they are to retain the trust of the collective interlocutors of all of us - that is the totality of the Organization 1 s Member States. This is democratic mutual control at its best. 14. The other ingredients in the new style of management follow on logically from the principles of mutual trust and mutual control. I shall spell them out concisely one by one. You, the governments of WHO 1 s Member States, are responsible for the use of WHO 1 s resources whether these are used 1n your country or for intercountry activities. 16. You are responsible for using these resources to give effect to the collective policy, stra~egy and plan of action of WHO.
15.
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17. WHO's fundamental policy and strategy is the attainment of health for all by the year \2000 through health systems based on primary health care. You are therefore responsible for using WHO's resources to develop, implement and support your national policy and strategy for health for all as reflexion of the collective policy and strategy in the light of your national reality. 18. Your individual responsibility implies your to the collectivity of WHO's Member States. individual accountability
19. Your collective responsibility implies your accountability to another as guardians of the collective agreements for health for all.
one
20. The Secretariat, under the direction and leadership of the Director-General and Regional Directors as his alter ego in their respective regions, the Secretariat has the responsibility of supporting you in fulfilling your individual and collective responsibilities. It therefore has the duty to draw the attention of individual governments to collective agreements, to bring to the attention of the collectivity of Member States the status of compliance with these agreements and to account to that collectivity for its own performance. New managerial arrangements 21. And now I come to the practical arrangements for managing our affairs in this new style. I shall start where it means most and where it hurts most - inside countries. I am referring in particular, but not exclusively, to those countries in which substantial amounts of WHO's resources are being used. 22. Joint government/WHO mechanisms will review your health policies and strategies and will help to assess to what extent they are consistent with the collective policy and strategy for health for all. 23. These joint reviews will thus make it possible to identify activities for the use of WHO's resources that are consistent with collective policy. 24. The joint reviews will therefore make it possible to use WHO's resources for the mainstream of activities required by you to strengthen your managerial capacities to develop and carry out your strategies, and to build up your health infrastructure to deliver your programmes using technology that is appropriate to your social economic realities - all in conformity with collective agreements in WHO. This of course means that there can be no separate WHO projects in the country, only WHO participation in national activities. 25. These joint reviews will incidentally identify the main activities for which additional national resources need to be mobilized both inside and outside the government sector and for which external resources need to be attracted from bilateral, multilateral, nongovernmental and voluntary partners. They will at the same time identify activities that would seem to lend themselves to fruitful cooperation with other countries.
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26. The joint government/WHO reviews will include the monitoring and evaluation of the use of WHO's resources in the country. This process will reveal whether WHO's resources in the country are being used in support of the mainstream of national health activities required to implement the national strategy for health for all, and will facilitate rational planning of the future use of these resources to this end. 27. In all these r~views the WHO Programme Coordinator, or Country Liaison Officer as the case may be, will act on behalf of WHO as a whole, as the jealous guardian of the Organization 1 s policy and strategy for health for all. 28. The Regional Director will support the joint government/WHO mechanisms in carrying out all their functions. This will include guidance concerning collective policy, as well as technical, managerial, administrative and financial support. Where there is no WHO Programme Coordinator or Country Liaison Officer, the Regional Director will designate a senior Regional Office staff member to participate in joint government/WHO reviews. 29. The Regional Director, as guardian in the region of WHO 1 s collective policy, will review with governments WHO's regional response to their needs. To this end he will ensure that Regional Office staff devote th~ir energies to supporting the joint government/WHO mechanisms in countries and to bringing to bear from their own and other parts of the Organization a coherent and coordinated response to the country's needs as identified by these country level mechanisms. This will include seizing opportunities that emerge from reviews with governments to facilitate cooperation among thet}lselves in the spirit of TCDC. Implementation of new arrangements 30. Honourable representatives, as you can see, this managerial framework is a far cry from the donor relationship of a technical assistance agency to its dependent rec1p1ents. It implies democratic cooperation, but cooperation within a defined set of rules and not in the context of anarchy. It will be your responsibility as a Regional Committee including all countries in the Region to make sure that the new style of management and the new managerial arrangements are in fact introduced and adhered to in your Region. I can assure you that they are in full conformity with the Health Assembly's unanimous decisions when it concluded its review of the study of WHO's structures in the light of its functions some three years ago and when it adopted the Global Strategy for Health for All some two years ago. Yet these arrangements have not gone without criticism. I have been told repeatedly that we are going too far too fast, that some staff members will not be capable of carrying out the duties devolving on them, and that some governments might abuse their responsibility for the use of WHO's resources in this new spirit of management.
31. Well, your Regional Director and I will do our best to ensure that all staff members are able to fulfil their new responsibilities. As for the speed of implementation, I am convinced, from personal experience, that your Regional Director is already vigorously introducing this new style of management. I realize that the practical arrangements may have to be
WPR/RC34/SR/1 page 21 Annex 2 introduced in stages, but I would beg of you to remember that the year 2000 is drawing closer daily. I should like all of you to benefit from these arrangements in very good time to help you reach the goal of health for all by that date. And now I have to make it clear - I am plagued by my conscience. It worries me most in relation to the all in health for all the suffering majority of humankind. The best protection for them is their and their governments' adfierence to the Organization's collective agreements. So in any phasing in of the new arrangements I shall have to insist on giving preferential support to countries that are trying hard to use WHO's resources to build up their health systems in accordance with collectively decided policies and strategies and that provide relevant and adequate information to give ~vidence of that in keeping with their accountability to their Organization. 32. It is that accountability to one another in the Regional Committee and It is the World Health Assembly that will also help to prevent abuses. accountability of your Regional Director to the Organization that will oblige him to report fearlessly to you and to me of progress and of problems. And it is in keeping with my ultimate accountability to all Member States that I shall have to keep the Board and the Assembly fully and frankly informed in order to ensure that optimal use is being made of WHO's limited resources - throughout the Organization, everywhere, at all levels. That is the only way to keep up the pressure required to use your WHO properly and thus help health for all by the year 2000 become a living reality. 33. Mr Chairman, Excellencies, honourable representatives, you have clearly shown that you are champion health sprinters and that you have been preparing yourselves carefully for the long race. But it is not enough to be properly trained for the marathon that lies ahead; we must have the supreme courage and the strong determination to use our training to the full. If we do, I remain utterly convinced that we will complete the race in time, breathlessly perhaps, but triumphant. Thank you.