(WPRlRC44/SRl5)
SUMMARY RECORD OF THE FIFTH MEETING WHO Conference Hall. Manila Wednesday. 15 September 1993 at 9 a.m. CHAIRMAN: Mr S. Naivalu (Fiji)
CONTENTS
1.
Consideration of draft resolutions ............................................................ 1.1 1.2 AIDS and sexually transmitted diseases ............................................. Global Programme on AIDS: Membership of the Management Committee ................................................................
170 170 172 173 179
2. 3.
Eradication of poliomyelitis in the Region: Progress report (continued) ............. Sub-Committee of the Regional Committee on Programmes and Technical Cooperation: Report on country visits .........................................
- 169-
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1.
CONSIDERATION OF DRAFT RESOLUTIONS The Conunittee considered the following draft resolutions:
1.1
AIDS and sexually transmitted diseases (Document WPRlRC44/Conf. Paper No.1) Mr SAITO (Japan) said that, although drug abuse was a problem worldwide, its
significance in HIV transmission varied from country to country. He therefore proposed that operative paragraph 1 (7) be amended to read as follows: "to focus socially and culturally relevant initiatives ... " Mr LOVELACE (New Zealand), noting the absence of any specific reference to the security of the blood supply, which his Government believed was a vital consideration in HIV transmission, proposed the following amendments: (I) to add as a last preambular paragraph, "Noting the importance of the safety of the entire blood supply; and (2) to add as operative paragraph 1 (8) "to progressively move towards 100% screening of the entire blood supply in the Region" . Referring to operative paragraph 2 (2), he wondered whether it was appropriate to request the Regional Director to seek an increase in resources without the Conunittee having first clearly defined what those resources would be directed to. Dr MONT AVILLE (France) proposed that the phrase "strengthening of confidentiality and surveillance" be included in operative paragraph I (4). He also proposed that operative paragraph 1 (7) should refer to the emphasis being given at country level to activities on prevention and information. Dr TAPA (Tonga), noting the adding of the words "until deemed unnecessary" on operative paragraph 2 (4), said that it was the prerogative of the Regional Conunittee to determine the periodicity of the reporting or to discontinue it and therefore those words should be deleted. The REGIONAL DIRECTOR read out the proposed amendments to ensure that the Secretariat had understood the meaning and spirit of the proposals. (1)
At the end of the preambular paragraph, "noting the importance of safety of
blood and blood products;" should be added.
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(2)
On operative paragraph 1 (4), the word "and confidentiality" would be added
after the word "surveillance", if the Committee so agreed, as the Secretariat would like to stress the surveillance aspect, but include confidentiality. (3) On operative paragraph 1 (7), the phrase "for infonnation and prevention"
would be included. (4) On the last operative paragraph, under 1 (8), "to move progressively towards
100% screening of blood and blood products in the Region;" would be added. (5) To delete the last three words on the draft resolution, "until deemed
unnecessary" . (6) The words "socially and culturally relevant" would be inserted after "focus"
under operative paragraph 1 (7), as proposed by the representative from Japan. Professor NGUYEN TRONG NHAN (Viet Nam) said thaI since AIDS was linked to the drug problems in several regions, he proposed that in operative paragraphs 2 (1) and (2), the words "and drug abuse" should be added after "sexually transmitted diseases" . The REGIONAL DIRECTOR remarked that drug abuse was a very important aspect of AIDS and HIV infection, as important as sexually transmitted diseases. the Committee so wished. Mr AGUIGUI (United States of America), while supporting the proposed amendments of the representative from Japan on operative paragraph I (7), sought clarification on the insertion of the words "for information and prevention" as previously proposed by the representative from France. Pending clarification, he proposed the following amendment, "to focus socially and culturally relevant initiatives and use of resources to reduce the prevalence of risk activities responsible for ... " Dr MONTA VILLE (France), explaining the amendment proposed earlier by France, said that it was desirable to emphasize the need for additional information, besides what was routinely provided, on the infection itself. Dr ADAMS (Australia) proposed that the United States amendment to operative paragraph 2 (1) and 2 (2) should be made more specific by referring to "injecting drug use". Therefore, the amendment would read" ... control of AIDS, sexually transmitted diseases and drug abuse", if
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Mr SAITO (Japan) supported the United States amendment to paragraph 1 (7), substituting "to reduce the prevalence of" for the word "on" before "risk activities". The REGIONAL DIRECTOR again read out the proposed amendments, suggesting that the United States amendment concerning additional information would be best accommodated in operative paragraph 1 (6), which would then read: (6) to encourage increased exchange of information and experience, and to provide
also additional information needed in the prevention and control of AIDS and sexually transmitted diseases; Paragraph 1 (7) would read: "to focus socially and culturally relevant initiatives and
use of resources to reduce the prevalence of risk activities responsible for HIV transmission, such as commercial sex activity, injecting drug use, and the spread of sexually transmitted diseases" . Paragraphs 2 (1) and 2 (2) WOUld, by virtue of the United States amendment, completed by the Australian proposal, refer to AIDS, sexually transmitted diseases and injecting drug use. Paragraph 2 (2) would need a slight editorial adjustment so that it was clear it referred to ... "optimum implementation of AIDS and sexually transmitted diseases programmes, and for control of injecting drug use in the Region;" . It was so agreed. Decision: The resolution, as amended, was adopted (see resolution WPRlRC44.R2).
1.2
Global Programme on AIDS: Membership of the Management Committee (Document WPRlRC44/Conf. Paper No.2) Decision: The resolution was adopted (see resolution WPRlRC44.R3).
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2.
ERADICATION OF POLIOMYELITIS IN THE REGION: PROGRESS REPORT: Item 11 of the Agenda (Document WPRlRC44I7) (continued from the fourth meeting, section 2) Dr ABU BAKAR (Malaysia) said that his country had been free of the disease from
1986 until 1991, when three cases had been reported which had all been traced to sources of infection outside the country. A comprehensive national eradication programme had been drawn up incorporating surveillance for acute flaccid paralysis, which was among the diseases regularly monitored. Immunization coverage for all doses of poliovirus vaccine was about 90%, and the current strategy was to concentrate on non-immunized and high-risk groups. He requested information on the magnitude of the shortfall in vaccine supplies indicated in the report. Mr SAKAI (Japan) congratulated the Secretariat on the strong leadership permitting marked progress in the initiative to eradicate poliomyelitis by 1995. Eradication programmes had received continuous support since 1988; since 1990 there had been technical cooperation between Japan and some countries, where considerable reduction in incidence had been found. It had participated in the Technical Advisory Group since its first meeting in Tokyo in 1991, where the focus was on preparation of guidelines and strategy for eradication. In the previous two meetings more specific issues had been discussed and solutions proposed, including the financial aspects of meeting the vaccine shortage. Through the collaboration of various agencies and donors it would be possible to have immunization days during the coming winter. Now that the regional programme was entering the crucial stage requiring accelerated action, Japan wished to work closely with WHO and other Member States to ensure its success. Dr MONTAVILLE (France), fully supporting the programme, and referring also to the vaccine supply shortage, said that resolution WHA46.33 of the Health Assembly, which France endorsed, did not specify which method of immunization should be preferred. Immunization with live poliovirus vaccine should only be resorted to in the absence of safer options where the particular conditions were carefully considered, and expert advice should be available in such cases. Dr MILAN (Philippines) expressed concern over the vaccine shortfall in conditions where the technology and political will were present to carry out the programme. She endorsed
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the policy that included immunization days, and the policy guidelines drawn up by the Secretariat. The programme in the Philippines owed its initial success to clear directives; mass activities for mobilization and advocacy; level; an appropriate communications strategy; active involvement of the community and community leaders; strong political support at the highest and financial support from donors and cooperating agencies, particularly WHO, UNICEF, AIDAB, CIDA, US AID and Rotary International. Japan had indicated that it might be able to provide poliovirus vaccine for the second round of national immunization days in February and March 1994. The remaining challenges included: maintenance of the high coverage with oral
poliovirus vaccine (OPV) and local support for the programme with the recent decentralization of services; reaching remote areas with OPV; ensuring the supply not only of vaccine but of needles, syringes and cold-chain equipment. She endorsed the Regional Director's appeals for support to win the fight against poliomyelitis. Professor NGUYEN TRONG NHAN (Viet Nam) said that since 1985, with the cooperation of WHO, UNICEF, Rotary International and other international and nongovernmental organizations, his country had successfully carried out its expanded programme on immunization, exceeding 80% coverage of infants under one year in the last four years. Poliomyelitis had been reduced by 70%, but there were still 553 cases in 1992. Its eradication would require 36 million more doses for children under five years each year. Only part of this could be supplied by national production. Production of 16 million doses had been planned in 1993. A first round of national immunization days were planned in November, and second round in December 1993, for all children under five, involving 250000 staff and volunteers in 60000 health centres - the largest mass immunization campaign ever organized. In order to attain the hoped-for goal by 1995, Viet Nam would need the cooperation of international organizations and countries for vaccine supplies and cold-chain equipment, with WHO as the main agency. Dr DURHAM (New Zealand) noted the importance attached in the report to the maintenance of surveillance and plans of action in countries free from poliomyelitis. The last
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endemic case in New Zealand had occurred in 1977; there had been one imported case in 1990. Her country's experience was that as first-hand knowledge of the effects of the disease became more remote, reports of adverse reactions to immunization acquired greater importance in the community and might affect coverage. She requested WHO to comment regularly on the safety and efficacy of poliomyelitis and other vaccines in its reports. Dr PRETRICK (Federated States of Micronesia) said that 50 % of the widely dispersed rural population of his country's more than 65 inhabited islands (1.2 million square miles) were under twenty years old, while 17% were under five years. Since the poliomyelitis outbreak in the early 1960s no cases of paralytic poliomyelitis had been reported, but vaccine coverage was not as high as could be wished. Only about 70% of children had received three doses of oral poliovirus vaccine by the age of two years; by the age of five coverage rose to 80%-90%. After the lesson of the 1960s and outbreaks of other diseases like tuberculosis, mumps and measles, Micronesia remained dedicated to integrated preventive measures and the eradication of poliomyelitis. Dr RASMY (Lao People's Democratic Republic) said that his country's eradication programme, which was part of the Expanded Programme on Immunization had achieved remarkable progress since its inception in 1989, although immunization coverage remained quite low at barely 27 %. Nine cases of acute flaccid paralysis had been reported in 1992, five of . them being confirmed as poliomyelitis. Since the creation of the National Committee for the Mother and Child in 1992 and the adoption in June 1993 of a resolution on the subject, the Expanded Programme on Immunization and poliomyelitis eradication programme had been given high priority in the socioeconomic development plan running until 1996, and efforts were being redoubled. coverage was to reach 80%. Immunization The President of the Republic had himself taken charge of a
campaign in eight provinces, and the Minister of Health was the focal point for equipment, staff and programme management. National days had been organized in 48 out of 129 districts in 17 provinces in November and December 1992, and 77% of the target population of children under five years had been immunized. The cold-chain had been imprOVed in over 20 districts using gas refrigeration. Training according to the WHO module had been completed throughout the country for 1200 vaccinators for mobile teams and centres.
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Coverage with three doses of OPV had reached 26 % in 1990, 22 % in 1991 and 27 % in 1992. The campaign was still dependent on increased cooperation, like that of UNICEF, and vaccine supplies. Other weaknesses included poor public health infrastructure, inadequate coldchain equipment and health education, and problems of access to remote mountain villages, especially in the six-month-long rainy season. Two more national days were planned in 100 districts in 1994, with WHO and Japanese support. The surveillance system was to be extended to all provinces and districts, dispensaries were to be rehabilitated and community involvement, emphasizing women's groups, increased. The Lao People's Democratic Republic looked forward to greater collaboration with international governmental and nongovernmental organizations. Dr LIN (United States of America) commended the Regional Director on the informative and timely document, and complimented him on the continued efforts to accelerate poliomyelitis eradication. example in organizing He also congratulated Member States on their efforts to reduce national immunization days in accordance with resolution incidence of the disease to its lowest point thus far, and urged them to follow the Philippines' WPRJRC43.R3. He believed the Region could be the next to achieve eradication. Noting with concern the low EPI coverage in some countries, he asked for information on particular activities to be targeted, and urged that Member States be encouraged to ensure that they remained free of poliomyelitis by such means as national immunization days. no avail; 50% measures. to
If
sufficient supplies of vaccines were not forthcoming, commitment and know-how would be of 100% more vaccines were required to supplement the routine immunization The Quality assurance was also vital to ensure potency, safety and efficacy.
Regional Director was requested to study the means of maintaining the highest standards in that regard, and to be firm in ensuring cooperation with Member States with a view to the goal of eradication. Mr WAENA (Solomon Islands) said that, while there had been no cases of acute flaccid paralysis in his country, he recognized the need to maintain high levels of immunization and efficient cold-chain services. His country would need support for the necessary measures and in ensuring the supply of vaccine. eradication. He reiterated his country's commitment to the goal of
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Dr SCHUSTER (Samoa) commended the report. Significant headway had been made and progress would no doubt continue under the intensified effort of national programmes with immunization days. WHO's cooperation was essential, particularly to ensure supplies of vaccine so that all eligible children were reached. Samoa had been free of poliomyelitis for ten years, and would continue surveillance to ensure that it remained so. Dr Haji JOHAR (Brunei Darussalam) said that his country had been free of poliomyelitis since 1986. It supported the goal of eradication, but was concerned about the risk represented by guest workers and their dependants from areas where compulsory immunization in infancy was no longer considered necessary or was not possible. Surveillance was thus the primary preoccupation, although full immunization coverage was provided throughout the country. The technical and advisory support of WHO was much appreciated. Dr TAPA (Tonga) said that countries of the Region should not waver in their determination to achieve eradication, in which Tonga assured them of its moral support; and he urged others that could afford to do so to give more than moral support; in particular vaccines and equipment, in an effort of solidarity to att.ain the goal. Mrs HOMASI (Tuvalu) said that there were currently no cases of poliomyelitis in Tuvalu but that that situation might change in the future unless the cold-chain and transport of vaccines to the widely dispersed islands were improved. She urged WHO to help in that regard. Dr OMI (Regional Adviser, Expanded Programme on Immunization), replying to the representative of Malaysia on vaccine requirements, said that, despite encouraging support from the international community, there was still a shortfall of oral poliovirus vaccine (OPV) for the conduct of immunization days in countries reporting poliomyelitis. Total vaccine requirements for both routine and supplementary immunization activities had been calculated on the assumption that: (1) routine immunization included three or four doses for 100% of infants (45% in the case of the Lao People's Democratic Republic); (2) supplementary immunization included both immediate outbreak response immunization around cases and national immunization days; (3) two doses would be given to all children under five years of age (under four years in China) on immunization days; (4) two doses would be given to all children under five years in communities around cases in outbreak response immunization; and (5) the cost of improved imported OPV was nine cents per dose and that of locally produced vaccine in China was two cents per dose. Based on those assumptions the requirement for 1993 totalled 491 million doses of which 412 million had already been committed by national governments or external support agencies. That left a shortfall of 79 million doses, costing US$ 3.6 million.
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The costs of regional shortfalls for 1994 and 1995 totalled US$ 7.1 million and US$ 7.6 million respectively. In reply to the representative of France the report of the Thirteenth Global Advisory Group on the Expanded Programme of Immunization (document WHO/EPI/GM/9.3) stated that OPV was the vaccine of choice for poliomyelitis eradication. There had been no change in policy since then. The rationale for that policy was as follows. Firstly, OPV was the only Secondly. vaccine shown to displace circulating wild poliovirus and was therefore the vaccine of choice to assure community protection in countries where poliomyelitis was still endemic. OPV was easy to administer in oral drop form and could be safely given by volunteer health workers; syringes and needles were not needed. which reduced logistical requirements. Thirdly. at nine cents per dose OPV was much less expensive than injectable inactivated poliovirus vaccine (IPV) at 75 cents per dose. The Global Advisory Group would be considering making a recommendation for the use of IPV in industrialized countries with high standards of sanitation and no known circulation of wild poliovirus. and where vaccine cost was not an issue. However, the vaccine of choice during poliomyelitis outbreaks would still be the oral vaccine. The REGIONAL DIRECTOR added that through 1995 the total vaccine requirement was 1484 million doses while the total amount available was 795 million doses, leaving a shortfall costing around US$ 18.3 million. As he had mentioned at the previous meeting. a number of governments and agencies were making contributions in that area and their generous support was greatly appreciated. Rotary International had been supporting China and would be discussing further collaboration at a meeting to be held in the Regional Office immediately following the current Regional Committee session. Japan had agreed to provide US$ 6 million over the next three years for vaccine procurement in China. He hoped that Japan would be able to offer further help as its economy improved. In addition Australia and other Member States were providing vaccines. As Dr Omi had said, OPV was the vaccine of choice as recommended by the Global Advisory Group. That Group represented the best technical expertise available in the world and its advice should guide regional policy. He was not discarding the use of IPV but suggested that it might be considered for use jointly with OPV or during the vigilance and maintenance phase that would be necessary following poliomyelitis eradication. He agreed that safeguarding the efficacy and safety of vaccines was essential and assured the Committee that WHO would continue to give due attention to those aspects.
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However, excessive emphasis on improving quality might force up the price of vaccines. It was important to find an appropriate balance between efficacy and safety on the one hand and affordability on the other. November 1993. The CHAIRMAN requested the Rapporteurs to prepare an appropriate draft resolution. He hoped that the issue would be addressed at the Vaccine Development Initiative meeting, which he hoped to attend with the Director-General at Kyoto in
3.
SUB-COMMITTEE OF THE REGIONAL COMMITTEE ON PROGRAMMES AND TECHNICAL COOPERATION: REPORT ON COUNTRY VISITS: [tern 12 of the Agenda (Document WPRlRC44/8) Dr MILAN (Philippines), introducing the report of the Sub-Committee, said that item
(5) of the Sub-Committee's terms of reference was "To undertake country visits to review and analyse the impact of WHO's cooperation with Member States". In June 1993. four of the SubCommittee members had visited Fiji and the Republic of Korea to review cooperation in the field of district health systems. discuss their findings. The purpose of the country visits in 1993 had been to observe whether the district health system approach was really a part of overall health development in those countries. The members had noted that in Fiji and the Republic of Korea, there was a very strong link between the development of district health systems and overall health development.
The Sub-Committee had then met as a whole in Manila to
A
number of features of that development would be of interest to most Member States. There was a marked awareness of the importance of integrating and coordinating the functions of the hospital and public health at the district level. valuable lessons which could be shared. In both countries, it had been very clear how much the dynamic management and leadership of the district health system had contributed to its success. The countries had been aware of that fact and had been addressing the question of how strengthening management within the district could be institutionalized throughout the health system. Closely aligned to strong leadership at the district had been the awareness that more authority must be provided to those managers to make operational decisions. Though it was progressing differently in each country, that most essential feature of a viable district health system provided
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High priority had been placed on continuous education and training at the district level. That reflected the perceived value of their human resources and the need to be able to respond quickly and effectively to the changing needs of a district health system. Details of the Sub-Committee's findings and recommendations were set out in the report. The country visits had taken place from 14 to 25 June. Excellent progranunes had been prepared. On behalf of the Sub-Committee, Dr Milan expressed her sincere gratitude to the Member States concerned for their hospitality and full cooperation in the assignment. With regard to the future work of the Sub-Committee, it was proposed that the subject for review in 1994 should be "health and sustainable development - environmental health", and that, subject to the agreement of their governments, the countries to be visited should be the Philippines and Singapore. Dr LIN (United States of America) commended the Sub-Committee on its work. He also commended Fiji and the Republic of Korea on their progress in improving the organization and management of the health systems reviewed. He had particularly noted the comments in the report about involvement of local government in the administration of district health activities, greater integration of the private sector into health services delivery, and the importance of the efforts to strengthen the capabilities and authority of district managers for assuring the quality of both management and delivery of health services. Placing responsibility for managing and monitoring health care services close to the people being served and involving community leaders in decisions affecting those services were two principles of "community-oriented primary care" that motivated efforts for improving access to and containing the costs of health care. He noted that those principles were already being incorporated into the systems of both countries visited. He commended the efforts being made by the two countries to conduct effective research projects to further the development of health systems. The conduct of such research was becoming more widely understood and utilized in the United States of America. It was becoming paramount to evaluate the quality as well as the outcome of health services in order to contain costs while maintaining the highest possible standards of patient care.
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He endorsed the Sub-Committee's recommendations to the two Member States and suggested that all Member States should examine them for applicability to their own district health systems. His delegation acknowledged the common features of district health systems in countries in the Region and also respected those features that were unique to each. The presentation and discussion of the Sub-Committee's report provided an excellent opportunity to exchange relevant technology and other information, enabling Member States to learn and grow through each other's efforts. He requested further information as to how the significant reduction in infant mortality in Fiji, from 40 to 20 per 1000 live births over a period of 15 years, had been achieved, in particular in relation to the fact that 95 % of primary health care was provided in government health facilities. The report stated that projected health expenditure in the Republic of Korea had risen from 5.6 % in 1988 to 6.4 % in 1990. However, the proportions of those percentages devoted to
primary health care were not indicated. The report also noted that through government efforts since 1987, the proportion of primary health care physicians had risen by 30%-40%. Assuming that primary health care had been accepted as the entry point for health care promotion and disease prevention, it would be helpful to know whether an increase in the number of primary health care physicians had a significant effect on national health care costs after a period of several years. Although the relative costs for primary health care training and services could be expected to increase, aggregate health costs (primarily expended on treatment and rehabilitation rather than prevention) could be expected to decline over the same period. It might therefore be helpful for the Regional Director to compare total national health expenditures with those specifically for primary health care where there had been a significant increase in the numbers of primary health care specialists, in order to examine the validity of primary health care as a model for reducing treatment and rehabilitation expenditures. He suggested that, where possible, Sub-Committee recommendations should be made in the context of the national plans of action developed in accordance with the WHO health-for-all strategy. Such an approach would provide a consistent framework against which a Member State could evaluate its progress in implementing both the recommendations and the strategy. In conclusion he endorsed the Sub-Committee's support for decentralized decisionmaking and empowerment of health systems at the operational level and encouraged the Regional Director to continue to support Member States in the area under discussion.
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Dr TAPA (Tonga) thanked the Chairman of the Sub-Committee for her introduction to the Sub-Committeee's excellent report. The findings, particularly those on Fiji, were of some relevance to the development of district health systems in Tonga. He endorsed the conclusions and recommendations contained in sections 2.2 and 2.3 of the. report which might also be of relevance to other Member States in the Region. He supported the subject proposed for the 1994 country visits, "Health and sustainable development - environmental health" and the two countries suggested, Singapore, subject to the agreement of their Governments. Mr BUNE (Fiji) expressed appreciation for the Sub-Committee's visit to Fiji. continue. The Sub-Committee's conclusions and recommendations in respect of Fiji reflected the views and concerns and some of the possible solutions expressed by Ministry of Health officials during the visit. The decentralization called for in recommendation (1) had been proposed by his Ministry in 1987-1988, following an exercise undertaken with WHO support, but owing to budgetary constraints at that time it had not been approved. It was hoped that the policy could be introduced within the next 12 months. Recommendation (2) concerning district health planning and the training of district health staff in planning and management also involved the decentralization policy. A health planning unit had been established with support from the United Kingdom and two advisers from that country were helping the unit in drawing up a national health plan which it was hoped to complete in the next 12 months. Reorientation of staff and role clarification called for in recommendation (3) were also being tackled within the decentralization policy and through a job evaluation exercise. Training would be considered further under item 15.2 of the agenda, Fiji School of Medicine. In the School's new two-tier curriculum the first tier would cover epidemiology, public health, occupational health, health education and health management, and the second would deal with health planning and economics, with the aim of enhancing the managerial capabilities of future medical personnel. The issue of health financing, covered in recommendation (4), was being considered by the health planning unit, and cost-recovery had been addressed at a recent workshop sponsored He the Philippines and
commended the Regional Committee's initiative in that regard and hoped that such visits would
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by USAID. The World Bank study of health policy priorities in South Pacific countries referred to at an earlier meeting had also addressed the issue. Fiji was still providing free medical services, which was a great strain on the budget. Cost-recovery would be a priority over the next five years and it was hoped that government approval for implementation would be given within 12 months. Fiji had already taken steps to implement recommendation (5) on intersectoral collaboration and there was now a regular forum for discussion and planning between the health and finance sectors and the Public Service Commission. Fiji accepted recommendation (6) on continuing and in-service training and was taking steps to implement it with the support of the health planning unit. Fiji also accepted recommendation (7), which called for a comprehensive human resources policy, and had discussed it with the visiting team. Fiji had noted recommendation (8) on standards of care which were the subject of continuous review. He thanked the Regional Director for the opportunity to visit the Republic of Korea immediately prior to the Regional Committee session to share their experiences in that regard. It was hoped that WHO could collaborate so as to improve standards. With regard to recommendation (9) on community involvement, he quoted from the report of a recent World Bank study: Fiji had been most successful in grafting primary health care facilities on to existing hospital-based systems, with spending on rural health services averaging over 10% of recurrent health outlays in the 1980s. Fiji's achievements could be seen in the utilization figures: 3.1 outpatients visits per person per year to government facilities. Village committees were supporting 12 nursing stations, and some 3000 village health workers had been given a six-week training course by the Government to enable them to provide primary health care services. Such workers were supported by the village leadership, either by contributions in kind or by small cash payments. Fiji accepted recommendation (10) on WHO collaboration, and looked to WHO for budgetary support in implementing it. He assured the Committee that Fiji expected to be able to report good progress in implementing the Sub-Committee's recommendations by the end of the biennium. countries to be visited in 1994. Fiji also supported the proposals of the Sub-Committee concerning the subject for review in 1994 and the
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Dr MA Po-Ling (Hong Kong) described a test project for the introduction of a district health system in an urban setting, the Kwun Tong District of Hong Kong, in December 1991. The aim was to develop a primary health care system that would permit the delivery of the services most relevant to the community's needs, through a team approach involving all health care providers within the district and the participation of the community. All six government health institutions in the district level had been grouped together to form a network, managed by a multidisciplinary district management committee. That committee had already coordinated improvements in services provided by the general outpatient clinic and family health centres. To facilitate community participation, a multisectoral district health committee had been set up in March 1992. By enhancing the role of the community in identifying health needs and During its brief period of implementing health programmes, that committee could channel community resources towards health promotion and disease prevention services in the district. existence the district health service had already proved its value in enlisting community participation in health and in improving cooperation between clinics and hospitals and between the public and private sectors. He congratulated the Sub-Committee on its work and looked forward to further opportunities for exchanging information and sharing experience. Dr NOGUEIRA DA CANHOTA (Portugal) told the Committee that Macao had adopted an integrated health policy based on primary health care in 1985. The entire population had access to primary health care free of charge, while hospital care was free for certain risk groups. Under the integrated system, all medical staff at health centres were on hospital duty once a week and were thus able to benefit from contact with specialists. information system linked hospitals and health centres. for the population. Mr Jeong-In SUH (Republic of Korea) expressed his Government's gratitude for the Sub-Committee's visit and for its excellent report. The findings and recommendations of the Sub-Committee would be of great help in planning the nationwide implementation of district health services. Thanks were also due to the Secretariat for their support and cooperation in developing district health services in the Republic of Korea. Mr KOIMANREA (Papua New Guinea) said that the concept of district health systems had long been neglected in his country. but the new Government was endeavouring to rectify that. He himself came from a rural area, and as Minister of Health had decided to introduce a new policy on district hospitals. He endorsed the views of the representative of Fiji and hoped A central computerized Through such coordination of
resources, Macao's health system was able to provide a comprehensive range of health services
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he would be able to visit that country to learn from its eXPllrience. His GoverJlffient agreed with the recommendations of the Sub-Committee, 1.00ked forward to increased collaboration within the Region, and hoped that WHO would prov!de support in the implementation of policies. Dr HONG SUN HUOT (Cambodia) said his Government supported the growing emphasis on district health systems in the Region. He drew attention to the contributions of
WHO and other international agencies to the development of national policies and plans and the strengthening of health systems management in Cambodia. WHO had been working with the Cambodian health administration for nearly two years, helping to restructure the entire health system. Under the new health system provincial departments of health would concentrate most resources at the district level, with a clear mandate to promote, implement and support primary health care in the villages. Basic medical care would be available from district and subdistrict hospitals, dispensaries and mobile teams, and serious cases could be referred to provincial hospitals. Public health centres would be set up in each district, supported by a network of
public health posts at commune and village level. Mobile teams would visit rural communities to perform immunizations and provide antenatal care and health education. National
programmes, such as those for the control of malaria and tuberculosis, would gradually be integrated with district-level activities. A choice between public and private health services would be encouraged, but quality must be maintained in both sectors. services, not replacing them. services was to be introduced. He congratulated the Sub-Committee on its work and proposed that it should visit Cambodia in the near future. A suitable subject for review, where collaboration had been under way for a considerable period of time, would be tile planning and management of malaria control. Mr WAENA (Solomon Islands) thanked the Sub-Committee for its findings and recommendations, expressing particular interest in those concerning Fiji. He would support a draft resolution adopting the recommendations of the Sub-Committee. The subject proposed for review in 1994, "WHO's collaboration in the field of health and sustainable development environmental health", was of great importance to his country. There was an urgent need to protect the environment and make it safer and cleaner. Private services must be seen as complementing public
A programme of supervision and inspection of both types of
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He stressed that the Sub-Committee should visit a South Pacific country each year as well as an Asian country. For the small island nations of the Pacific, global warming represented a serious threat, and it was important that the Regional Committee should address their unique situation. Furthermore, such countries were at risk from unplanned development, for which multinational companies were often to blame. For example, the activities of logging companies had produced disastrous effects in his own country. Unlike Fiji, Solomon Islands had a decentralized health system, whereby the provincial authorities were empowered to take policy decisions, but his country was willing to learn from the experience of Fiji and was grateful for its support. Mr HENRY (Cook Islands), thanking the Secretariat for its support to Cook Islands, said the experience gained by his country's Secretary of Health as a member of the SubCommittee had proved invaluable to the Health Board and the national health services. The Sub-Committee had produced an excellent report, and its recommendations regarding Fiji were of particular relevance to Cook Islands. His country had had district health services since 1901, for each of the 12 inhabited islands duplicated the services available on the main island. becoming easier with the use of satellites. Communications were now The Health Board had Many of the Sub-Committee's recommendations
concerning Fiji had already been put into effect in Cook Islands.
complete control over its financial resources and had been delegated decision-making powers previously held by the Cabinet. The main task assigned to the Health Board, to make the health services self-sufficient, was wellnigh impossible, but some progress towards it had been made by involving the commercial sector, the community, traditional leaders, nongovernmental organizations and youth movements in producing a district health scheme understood by all. Mrs HOMASI (Tuvalu) commended the Sub-Committee's report. of the Region's newest Member State. She felt the
Committee would appreciate some general information on the health situation and health system During the past decade, health and education had accounted for 27 % of recurrent expenditure and 20 % of externally funded development expenditure. However, it was no easy matter to ensure adequate health services in a country consisting of nine scattered islands. The Government's health policy was based on primary health care, with a significant level of community involvement. In 1984 a national primary health care committee had been established. The greatest constraints on the provision of better health services were the shortage of doctors and dentists and the excessive centralization of medical resources on the main island
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of Funafuti, aggravated by the difficulties of referring patients to the 3D-bed hospital there from the outlying islands. The overall health situation was relatively good for a least developed country. The
universal child immunization standards had been achieved, but there was still a high incidence of respiratory infections, diarrhoeal diseases, conjunctivitis, influenza and food poisoning, and a significant number of cases of dengue, tuberculosis, hepatitis, measles and meningitis. In 1990 there had been a severe outbreak of cholera, with a 20% attack rate, which had been attributed to contaminated water sources and poor personal hygiene. Average life expectancy had been estimated in 1986 at 57 years for males and 60 years for females, over 10 years below the average for the Pacific region. The pattern of morbidity indicated that life expectancy could be extended through improved community health care, better access to safe water and sanitation facilities, and health education. Tuvalu had always been self-sufficient in food, with ample supplies of coconuts, fish and vegetables. However, increasing consumption of imported foods low in fibre and high in carbohydrates was leading to increased incidence of diabetes and cardiovascular diseases. Lack of fresh fruit and vegetables in the diet was resulting in vitamin and mineral deficiencies. The country's health administration had recently been reorganized and a Department of Health created in the Ministry of Health and Human Resource Development. The Department of Health was subdivided into three functional units: public health services, curative services, and nursing services. The second national development plan called for wider health responsibilities for each island council and for greater community involvement in the promotion of primary health care and environmental health. Given the constraints of a small and scattered island population with limited resources, the results achieved so far in the health sector were reasonably encouraging. The major problems facing the country in its efforts to improve the people's health concerned the health workforce population growth (population density already exceeded 300 persons per km 2), environmental health, communicable diseases, and management of health services. Health expenditure accounted for 7.7% of gross national product, of which 30% was devoted to primary health care. One of the greatest obstacles to achieving the goal of health for all by the year 2000 was the shortage of functional management systems and the inadequacy of Iilanagement skills.
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Tuvalu had been collaborating with WHO since 1982 and she believed that full membership would strengthen that partnership. Her Government was pleased with the outcome of the recent WHO mission to Tuvalu, whose findings and recommendations offered a mutual opportunity for greater collaboration in the great cause of health for all. Dr TINIELU (Tokelau) thanked the Sub-Committee for its report. Fiji was a useful model for other Pacific island states, and most of the recommendations concerning that country applied also to Tokelau. Dr DURHAM (New Zealand) supported the proposal by the representative of Solomon Islands that the Sub-Committee should visit a South Pacific country each year. Dr ROMUALDEZ (Director, Health Services Development and Planning), replying to the representative of the United States of America, suggested that the remarkable improvement in the infant mortality rate and other health indicators in Fiji was probably due largely to the general improvement in socioeconomic standards and equitable access to health services. The health system of the Republic of Korea was at a transitional stage, having adopted universal health insurance as recently as 1989. It was difficult to analyse in detail the resources devoted to primary health care on the one hand and hospital facilities on the other. The country had established a very strong health services research capability in various institutions, and the Secretariat was working closely with those institutions, in the conviction that developments in the Republic of Korea would be helpful to other countries of the Region undergoing similar changes. The REGIONAL DIRECTOR invited the Committee to accept the Sub-Committee's proposal concerning the subject for review in 1994: WHO's collaboration in the field of health and sustainable development. He suggested that, as several representatives had urged, a South Pacific country be added to the list of countries to be visited. Solomon Islands would be an appropriate choice. The CHAIRMAN requested the Rapporteurs to prepare an appropriate draft resolution.
The meeting rose at 12: 15 p.m.