(WPR/RC35/SR/4)
SUMMARY RECORD OF THE FOURTH MEETING New Town Hall, Civic Centre, Suva Thursday, 6 September 1984 at 2.30 p.m. CHAIRMAN: Dr T.M. Biumaiwai (Fiji) CONTENTS
1.
Consideration of proposed programme budget estimates (continued) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . • • . . . • • • . • • . • . • . . . 98
l.l Proposed programme budget estimates, 1986-1987 (continued) ··••••••••••••••••••••••••••••••••••••••••••
98
- 97 -
98
REGIONAL COMMITTEE:
THIRTY-FIFTH SESSION
1.
CONSIDERATION OF PROPOSED PROGRAMME BUDGET ESTIMATES: Agenda (continued from the third meeting, section 3)
Item 8 of the
1.1
Proposed programme budget estimates, 1986-1987: Item 8.2 of the Agenda (Documents WPR/RC35/3 and WPR/RC35/INF DOC/3) (continued from the third meeting, sectiou 3.2)
Mr UHDE (Director, Support Programme) presented supplementary visual information concerning the proposed regular budget estimates for 1986-1987, providing, in particular, an analysis of real, cost and currency increases and decreases by budget level, and illustrating real and cost increases in regional regular biennial budgets during the period 1980-1987, &:ff well as increases in country and intercountry budgets from 1980 to 19·8 7. The Committee noted a significant increase in country allocations from US$17 485 100 to US$28 362 000 during the period 1980-1987, with a lesser increase in intercountry allocations from US$11 243 300 to US$16 067 600. Dr KITAGAWA (Japan) congratulated the Regional Director and his staff on the preparation of the programme and budget estimates for 1986-1987. He believed that, within budgetary limitations, resources should be allocated to high priority programmes. He drew the Committee's attention to the fact that an increase in the budget would imply an increase in .the contributions of Member States. His country was attempting to reduce the national budget in the face of a severe financial crisis; accordingly, he believed that the proposals for 1986-1987 should be kept low. Dr SUNG WOO LEE (Republic of Korea) commended the Regional Director and his staff on the excellent preparation of the proposed programme budget estimates for 1986-1987. Mr BOYER (United States of America) expressed satisfaction at the inclusion of information on the budgetary implications of proposed new programme activities. In his view the regional presentation of such information was more effective than in the global programme budget document. However, he suggested that, in future, similar information should be included on regional and intercountry programme activities. He noted with pleasure the emphasi~ given ~oth 1n the Regional Director's introduction and throughout the document to community selfreliance; self-help by individuals and communities to complement government action was increasingly important. Similarly, the emphasis given to the need for effective national monitoring and evaluation procedures to ensure the effective use of resources in countries was gratifying and possibly resulted from discussions at the thirty-fourth session of the Regional Committee concerning inadequacies in the WHO monitoring framework. The increased attention paid to alcohol and drug abuse was commended. He hoped that similar attention paid to essential drugs would result 1n implementation by Member States of programmes ensuring access to a limited number of products. Noting the decrease in the allocation for administrative support from 10.52% to 7.41%, and recalling the allocation of 16.5% by WHO at global level for overheads and similar support, be wondered whether a lesson might be drawn from the Western Pacific Region in that respect.
SUMMARY RECORD OF THE FOURTH MEETING
99
Appreciation was expressed of the useful information document visual display concerning the progratmne budget. His Government shared concern of Japan regarding budgetary increases and wished to retain a growth in the budgets of WHO and other international organizations. United States could accept tbP. 4% increase in country allocations i f was offset in the total budget of the Organization.
and the zero The this
He expressed concern at the absence of an analysis of what constituted the real increase proposed. Similarly, he regretted the lack of an analysis of cost increases in relation to the figures of 13.5% and 20% proposed for the country and regional levels, respectively. Information to clarify the basis from which these percentages were drawn would be helpful. Inflation was decreasing generally, and had declined to 4% in the United States. While a somewhat higher rate would be acceptable for WHO, the current figure of 16.6% seemed too high, particularly in the absence of any guiding analysis. A combination of the real increase and the cost increase resulted in an increase of 18. 7% in the proposed budget estimates. His Government would be unlikely to support an increase of 18.7% in the WHO global proposals, even with a zero progratmne growth. On the other band, it was gratifying to note the adjustment made to take account of the favourable exchange rate in the Philippines. His Government believed that the equation of the exchange rate adjustment should be automatic. The fact that it implied a net budgetary increase of 11.2% should not obscure the actual increase of 18.7%. Mr UHDE (Director, Support Progratmne) agreed with the representative of the United States of America that there was a possibility that the overall figures would be changed once the global progratmne budget had been finalized. However, he reassured the Committee that the cost increases given were low, the total annual increase being only about 8%. Extensive surveys had been made in formulating the budget, and the increases were, in fact, inadequate when factors such as inflation were considered. In 1983, a World Bank report showed that inflation in developing countries was over 50%, compared with less than 10% in industrialized countries. In view of such wide deviation between developing and developed countries, it was felt that the cost increases in the budget were not excessive. There were as yet no details from individual countries, and certain assumptions based on past trends had had to be made in reaching the figure of 4% real increase for country activities. Since the 18.7% total increase included a statutory cost increase of 2.5%, the effective increase due to real growth and inflation was only 16.2%. The REGIONAL DIRECTOR added that the general policy bad been to maximize the country allocations at the expense of regional and intercountry activities. Referring to inflation, he pointed out that, in addition to the "natural" inflation that was occurring in many parts of the Region, there was also the added inflation stimulated by the high exchange rate of the US dollar. It was not possible to allow for all such inflation in the budget, since it would have necessitated minus real growth in the programme budget and it was intended to try to absorb extra costs in the intercountry programme and in the Regional Office.
100
REGIONAL COMMITTEE :
TiliR.Tf..,FIFTlt SESSION
Mr BOYER {United States of America), supporting the cOUPDenta of the Regional Director, stated that lack of money should not necessitate a reduction in prograt~~t~~e activities. Staff should be stiuaulated to be more efficient in their use of available funds, and it was pleasing to b~ar that the Regional Office was trying to absorb same of the coat increases. Dr LIU XIRONG (China) thought that · the proposed prograllliDe budaet estimates were souncUy based on proposah by the various countries, and took account of the need for development within the Region. The progratmDe budget was in line. with the pl:i.nciplee laid Seventh General Progr4tll1De of Work, aOd took into con&i<ler.a tion areae requiring strengthening in order to achieve health for all 2000. The estimate was therefore perfectly acceptable, and he Regional Director and his st.aff for th•ir eff.o rts. dot.,7n in the the . various by the year thanked the
Considering the important developa1ents that had oecurred in dt areas of activity in the Region, the increase in the naber of Member States, and the effect of inflation, the increase cf 11.2% in the regular budget between 1984-1985 and 1986-1987 was necessary. '!be increase in real terms was only 2.1%, which he did not consider to be very high. The proposed programme laid stress on particular activit i.e•; for exaaple, there was an increase of 17 •.5% in tbe allocation to countries and territories, an increase of 10. 9%' for intercountry prograDDes, and a reduction of 8.6% for the Regional ().f fice. The efforts 111ade t ;o reduce Regional Office ex.penditure and :i:ncreaae the allocations to health activities deserved appreciation. The large increase in the regular budget funds alloca~ed to Health situation and trend assessment (3.1) ~·· necessary, as w~r,e . t"e increaees in the fields of Workers' health (9.3), Health of the elderly (9.4), Malaria (13.3), Diarrhoeal diseases (13.6), atUl Euential drugs a~d vaccines (12.2). The important field of Oral health (8.2) deaerve<i to be strengthened, but unfortunately, the budget alloc4tion had. been red\lced by 13.4%. '!:beRegional Committee should also take accou.n,t of the nee4 expressed by ~he majcri ty of Member States for traditi;ona 1 medicine, and inc~e1ase th• bufl••t allocation accordingly. The present allocatioo wafil quite insufficient ( 12 .4). Prevention and contro 1 of cardiovascular diseases was another important area. Reports indicated that morbidity and mortality due to hypertension, coronary disease, etc. were increasing, and it was thus important to strengthen that progratlllJle (13.16). 4ppropriate increases in funds sh. o uld be dlo.ca:ted to these thl'ee areas by transferring resources from other programme areas. Dr KHALID (Malaysia) asked for · clarifica.tion regardiQg extrabudgetary fun~~, which were much lower than ~bose availa,ble 1984-1985, and be wished to know to what extent the figures were fixed. the for
SUMMARY RECOJU) OF THE l'Olli;Tli JfJETING
101
Dr HAN (Director, Progra~e Manag~ent) replied that only firm commitments bad been incluqed ill the pr()glj'.-e budget. . D,ata on input that had not yet been fi'nilly COUliDitted by other organizati()QS, perhaps because their programming cycle did not cov.er the period i986-1987, would be supplied to Member States as they beca~ available. Dr KEAN (Australia) cotmDen.ded t:be Regi:Onal Director on the foraat of the budget presentation, particularly the information documents and expl,anations provideQ.. The budget cont;ained a number of very co.aendable trends - especially the emphasi's on tbe development of expertise in Health situation and trend aaaesstne\lt (.3.1) - an aspect that was particularly important for the health-for-all strategy. He welcomed the Regional Director's references to cost absorption; any attempt to absorb costs was commendable. Dr TAPA (Tonga) congratulated the Jl.e~Jional Director and his staff on the programme buqget presented. As tb~ r4preaeotative of a small State, which had a population of only 100 0~ and , w.as ae&e88~d at the mini-.um rate in the scale of aaeess111ents for the WHO budget (0.01%), he spoke in all hu111ility to States contributing a hi&b perC:enta8e of the budget ( iQcluding Australia, China, Japan, and the thiited States of America) arui . urged sympathetic consideration of the bu4get p.r oposed by ttie R~gional Dir.~ctor. I t was based in the main on the needs •nd requests o·f individual countries. Every government had the righ·t to accept or oppo$e the proposed increases. However, be refer.r ed to tbe st_ a ;temeot on page 1/2 of d:ocuaaent WPR/RC35/INF DOC/3 that the estimates for ·c ountry activ1ties included a real increase of 4% as compat'ed with the ap:proved level for 1984-198'5 . He would stress that the noble goal of he.a lth for all could only be achieve:d at the country level. lbe statement cited went oq to note t~_at the inc~,eaee w!&.s conditional and eub.j'ect to review and decision by the Director-Geoeral at the time 0 f finaH~a.tion of WHO's proposed prograt~~~~~e budget for 1986-1987. None of tbos~ . pre$Mt at the Regional Co~ittee was a p.ropbet, and _ $ble to foresee wlJat the itiflation ra.t es would actu.~ly b' in tt'~~-1987, or what was goigg to happen beween the cun·ent seteion and. ' &y 196,5, wb.en the Health Asseutbly WQuld be ct,)Dsidering the 198~-1987 budget. He ""'ould urge the more wealthy countrie~ to consider the real needs of the small countries of the Region. Mr HARPER (SolotJaon Islands) said that his Government highly appreciated the new approach ai;lopted by the Jl•giooal Director in selecting proj·e cts and assigning priorities in the 1986-1987 budgetary alloc,ations. In Solomon bl.!lnds, the priwary health care concept had been applied to the health services only since 198(), which aeant that reorientation, reorganization and retraining were of para~DQUnt importAmce. Outs:i.de cooperation woulQ. be eseential if his cOtJ:ntry was to achieve the objective of he.alth for all by th~ . year 2000s pert:ieularly in the trainin,g of physicians, nurses, nursing aide~ at\({ vilhg~- -h,alth workers. I~ . would be desir~i,l.e to .set up a WHO offi~e il:l IJQl\iara 't() enabie pio•pt 4echians to be tek'en on matb~rs of importance in cons.ultation with the Regiqaal D.i rector. 'He suggested that the post of malariologist be re-established and extrabudgetary assistance sought in support of the organization in Solomon Is lancl& of a health system baaed on pritnary health cal"e.
102
REGIONAL COMMITTEE:
THIRTY-FIFTH SESSION
Dr KHALID (.Malaysia) said that the 11.2% increa$e in the regul~r budget included substantial. and well-justified increases in the sums allocat~d for Health system dev~<l,opuaent (3), .. Research promotion and development ( 7), Prote~tion and pr. 0111oti,on of tbe health of specific population groups (9), Protection and pr011otion of mental h.a!l,th 00), and Diainostic, therapeutic and rehabilitative technology (1.2 ). The 20.9% increase in allocations for Promotion of Environmental health ( 11) and the increase of US$1 250 000 in the amount set aside for Health syste• development (3) were fully justified. He assumed that efforts t<> iaprove monitori:pg o.f health-for-all programme's would coatinue to be in~eQa;i;fied. The planned training in the use of computers sbould be accotllpanied by training in the application of information in support of decision""Ulatcing. When drawi~g up estimates fQ. r Pl'oaaotioo of Enviro•e.G.t:al beatth (ll), account should be taken of the re~ent ~onaultation to review progreu in the International Drinking Water Supply an<l SaQitation Decade. Satlitation was lagging bebind dl;'tnk~q-wat.er e,_upply. UtiDP ebould review its decision to terminate its c:ontrib1;ation to certain Deeadie projects and reduce its contribution to other$ sinc: e international cooperation was required more than ever before at a time when certain countries were striving to accelerate their Deead~ activities. More support should be given. to PEPAS, .·. although some o·f its activities required review. E1npbaeis · sbQUl~ be laid ol'l t:rdrli~g in system rehabilitation, operation and maint~t\aace, and Ort tbe pt'eparat.ion of. 111anuals for training ll$nagere and field et:aff as a wey o·f o~ercot~ing ·t he eboetege of such staff in many countrie.s . The Cent.r e should . give more att$.ntion to Decade needs. The increase of USSl 205 800 proposed for Die~ase prevention and control (13), with con.tinued etnpha'-h on malaria and diurboeal dheaaee, was justified. Malaria control through primary health care bad been proposed and docum. e nts should be p.r;epared on that subject in order to provide information for countries concerned. In regard to Acute respiratory inf~ctions (13. 7), be welcO'ined the proposed collaboration in the trainina of peripheral he,a ltb workers and the production of manuaLs. In the era of antibiotics, it should be posaible to prevent d,e aths fro& such diseases if front-1 ine workers were given proper training. He hoped that tbe Action Prograt,llllle for Es•ential Drugs and Vaccines could be developed furtbe.r in ttle R._l.on, particularly at country level. Small cou.n tries were at a particular disadvantage in reg: a rd to drug prices and quality control. He propos~d a regional consultation to map out a strategy for the action prograURDe. ·
He
fully
suppo.rted
the
pr<)poaed
progr...-e
btidget · estim4tes
for
1986 ...1987•
SUMMARY RECORD OF THE FOtJR.TH MEETING
103
Dr TIRA (Kir~bAlti) ~ndorsed the plea made by the representative of Tonga. He woul~ welcome the gteatest possible flexib.i lity in allocating funds, partici.1larly as many countries were just entering upon the most decisive phase in developing their· primary health care progra11101es. He could assure representatives that Kiribati would exercise strict budgetary control over funds allocated to it. The CHAUHAN pr_ o posed that the progratQIIe bud;get document be considered by programme area. 1. Governing bodiee (pages 21-23} There were no counnent$. 2. WHO's gene,ral I,rro&r!f!!e develoen.t: and .,anai•"'•nt (pages 24-33) There were no c01D1Xlents. 3. Health system develoewent (pages 34-47) Ther:e wer:e no cQPI!entJ.
4.
Orsanizat~
of ' b:ealth sy&te!!f! ba.-ed
()g
tri.mary bealtb care
(pages 48-52) 'fbere were. n,o c-ent•· 5. aealth ·•!'f'e'e~ (page.;, 53-57)
Mr BOYER. (United States of Alaerica) said the* Health m&upower, including fellowships, accounted for 19~ l% . of the rea~l&T budget if that progratmDe alone was taken into account and probably for as much as 30% i f fellowships under ot.t,er headings were inc~uded. He feLt that such a high perc~ntage probably was n. o t justified in vi•• of the fac·t · that ;OU'le netional governments appeared to be using fellowsh.i.ps as a catcb,..all category not specifically related to particular WHO priorities or to the general programme of work. Six countries or areas used the whole of their allocations from WH() for health manpower development and others used almost as high a proportion. Fellowships should only be allocated if they were to serve a specific purpoae in the attainment of WHO's object,ives. Dr KEAN (Australia) expreued t..greeaent with the comments of the representative of tbe United States of America. In 1982 Australia had provided training for 22 WHO fellows and ig 1984 it had already placed 104 fellows. There was a tendency for col.lntries to make repeated requests for tbe same type of training, which suggested that, on returning to their cot,~,ntriea, fellows were being employed as field work.e rs rather than as treiners. Mo~eo.ve ~, such repeat. requests had led some Australian institutions to set q. u otas for fellowship students. .' ' . -. . ::.,_ .. ' _: :. ·. . . ' '' .. . . .. .' ~ ' !" .•.
Funds allocated for health manpo'"Jr programmes could be used in other ways. A more practical approach would be to set up training programmes in the countries tb~selves, for staf'f at all levels.
104
REGIONAL COMMITTEE:
THIRTY-FIFTH SESSION
Dr BARKER (New Zealand) said his country's experience was similar to that of Australia. People were sometimes selected for fellowships without any consideration of the country 1 s needs, and on returning home they found no vacancies in the field in which they bad been trained. Dr TAPA (Tonga) said that, although he understood the reservations of some other delegations, his Government was happy that the bulk of the WHO funds allocated to Tonga was spent on health manpower development. Human resources were the most important of all resources, and the biggest single need in the health field was for properly trained personnel. Tonga appreciated WHO's support for its efforts to improve the quantity and quality of its health manpower, and would continue to give top priority to the development of health personnel. Dr KHALID (Malaysia) shared the views expressed by the representatives of the United States of America and Australia regarding the importance of making the most effective use of resources. His own country consistently endeavoured to produce a programme-based budget, in wb ich all requests for fellowships or consultant services were related to specific programmes. His delegation agreed that in general it was preferable to select for fellowships people who would be able to pass on their training to others when they returned to their own country. Malaysia followed that approach in most instances, but it was not feasible in the case of highly specific programmes that required very few staff, and for which a local training programme would not be justified. Dr LIU XIRONG (China) outlined the efforts made in China to make the most effective use of the WHO fellowship programme. Since 1949, the number of health personnel in China had increased from 500 000 to almost 3 million, but the available manpower was still insufficient, in both quantity and quality, to meet the demand. Accordingly, the Government attached great importance to health manpower development, and greatly appreciated the support of WHO, which since 1978 had provided training abroad for almost 300 Chinese health workers through its fellowship programme. The 100 who had already returned bad learnt a great deal and had become valuable workers and trainers. Fellowships were one of the most important of all WHO's activities and, on the basis of an analysis of the realities of the country's situation, the Chinese Government and health authorities had decided to use 50% of allocated WHO funds for that purpose. China fully endorsed the importance attached by WHO to health manpower development. Dr HAN (Director, Programme Management) pointed out that the budget allocations reflected the high priority given to health manpower development by Member States. In the 1984-1985 programme budget, US$8. 84 million was allocated to health manpower development, including US$4.2 million for fellowships. Other components of health manpower development included long-term staff, consultants, supplies and equipment. In addition, US$4. 9 million was allocated to fellowships within other programme areas, so that the total amount allocated to health manpower development was US$13.7 million, about 30% of the total regular budget for the Region. Some programmes funded with extrabudgetary resources also contained a substantial fellowship component.
SUMMARY RECORD OF THE FOURTH MEETING
105/106
Fellowships available under the Health manpower programme were not normally allocated to specific progratmnes until detailed progratDtDing was undertaken. Of the 798 fellowships provided under the regular budget for 1984-1985, 95% had been allocated to specific programme areas at the time of detailed programming, in other words one year before the fellowships were due to be taken up. That seemed a satisfactory performance, particularly in view of the policy of flexibility in programming. Countries were not always able to determine their training needs and to find suitable candidates two or three years in advance. The REGIONAL DIRECTOR said he paid close attention to the way in which the WHO fellowship programme was used. Two years previously, the Regional Committee had taken the initiative of evaluating that programme, and had endorsed it. The programme was particularly useful to the small newly independent States which in the past bad relied heavily on expatriate staff. It was not feasible for them to set up schools for health personnel, and WHO fellowships were invaluable to them. Fellowships were essential for a developing country. When China resumed its active membership of WHO in 1978, cooperation had at first been confined to fellowships, and was gradually expanding to other areas. When Japan was a developing country, it had made full use of the WHO fellowship programme. Most of the country's senior medical officers had benefited from it, and were now prepared to pass on their knowledge to other nations. (For continuation of the discussion, see the fifth meeting, section 1.1).
The meeting rose at 5 p.m.