(WPR/RC33/SR/5)
PROVISIONAL SUMMARY RECORD OF THE FIFTH MEETING WHO Conference Hall, Manila Wednesday, 22 September 1982 at 9.00 a.m CHAIRMAN: later: Dr S. Tapa (Tonga) Dr Abdul Khalid bin Sahan (Malaysia)
CONTENTS
1.
2.
3.
......... ............. . The role of nursing 1n primary health care ............... . Alcohol consumption as a major public health problem ...... Consideration of draft resolutions •·
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- 119 -
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COMMITTEE~
THIRTY-THIRD SESSION
1.
CONSIDERATION OF DRAFT RESOLUTIONS The Committee considered the following draft resolutions~
1.1
Sub-Committee Document WPR
Countries
Decision: The draft resolution was adopted without comment (see resolution WPR/RC33.R2). 1.2 Membershi of the Sub-Committee on Technical Coo eration Developing Countries (Document WPR RC33/Conf. Paper Decision: The draft resolution was adopted without comment (see resolution WPR/RC33.R3). 1.3 Sub-Committee on the General Pro ramme of Work (Document WPR/RC33/Conf. Paper No. 5 Decision: The draft resolution was adopted without comment (see resolution WPR/RC33.R4). 1.4
WHO's structures in the li ht of its functions (Document WPR/RC33/Conf. Paper No. 6 Decision: The draft resolution was adopted without comment (see resolution WPR/RC33.R5).
1.5
The role of ministries of health as directing and coordinating authorities on national health work (Document WPR/RC33/Conf. Paper No. 7) Decision: The draft resolution was adopted without comment (see resolution WPR/RC33.R6).
1.6
Regional Strategy for Health for All by the Year 2000: financial needs of the Strate : international flow of resources (Document WPR RC33 Con£. Paper No. 8
Replying to a question raised by Dr KHALID (Malaysia) as to the meaning of the word "prestige" in operative paragraph 2, Dr HAN (Director of Programme Management) said that that word had seemed to be the most appropriate with regard to both donors and recipients. Decision: The draft resolution was adopted (see resolution WPR/RC33. R7).
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1.7
Regional Strategy for Health for All by framework and format for monitorin ro Strategy (Document WPR/RC33/Conf. Paper
Common of the
Decision: The draft resolution was adopted without comment (see resolution WPR/RC33~R8). 1.8 Membership of the Sub-Committee on the General Programme of Work (Document WPR/RC33/Conf. Paper No. 10). Decision: The draft resolution was adopted without comment (see resolution WPR/RC33.R9). 1.9
by the Executive Board at its World Health Assembl Decision: The draft resolution was adopted without comment (see resolution WPR/RC33.Rl0).
1.10 Correlation of the work of the World Health Assembly, the Executive Board and the Regional Committee (Document WPR/RC33/Conf. Paper No. 12). Decision: The draft resolution was adopted without comment (see resolution WPR/RC33.Rll).
1.11 S ecial Pro ramme for Research and Joint Coordinating Board (Document
Diseases: No. 13 •
Decision: The draft resolution was adopted without comment (see resolution WPR/RC33.Rl2). 1.12 Development of health research (Document WPR/RC33/Conf. Paper No. 14). DR MINNERS (United States of America) referred to operative paragraph 3(1). The wording might be interpreted as implying that Member States were not making efforts to ensure that health research activities were related to the implementation of national strategies for health for all; he therefore proposed that the word "even" be inserted before "more closely". He further suggested that the paragraph begin "further to improve ••• " Decision: The draft resolution, as amended, was adopted (see resolution WPR/RC33.Rl3).
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Dr KHALID (Malaysia) took the Chair.
2.
THE ROLE OF NURSING IN PRIMARY HEALTH CARE; Supplementary Agenda Item 1 (Document WPR/RC33/18)
Dr CHRISTMAS (New Zealand), introducing the item, said that the plan of action approved by the Thirty-fifth World Health Assembly for implementing the strategy for "health for all" had been built on the foundation of primary health care. All countries must seek to develop or expand their national health systems on the basis of that fundamental principle. The scope of the plan was one of the most ambitious facing Member States and their health administrations and would require the harnessing of all health disciplines to achieve success within the limited time available. The task of achieving "health for all" could not be the sole responsibility of the medical profession: it must be attacked on a broad disciplines in a front; medicine must be linked with other multidisciplinary and multisectoral appproach and must enjoy the support of the people. Doctors, engineers, teachers, scientists and nurses must all contribute to the national health strategy. In the field of primary health care, one discipline; that of nursing, had a particularly valuable contribution to make. Emphasis on primary health care principles had to be incorporated within the nursing education curriculum at an early stage to ensure that such an important body of health professionals was adequately prepared to make a full contribution to the development of national primary health care systems. It was equally evident that health personnel trained in the nursing discipline had to be given greater opportunity to participate in the planning, management, supervisory and trainin g functions of the health service at all levels of the national health system. To ensure the effective implementation of such a policy, WHO should provide at the regional and global levels for greater participation and representation by health professionals with expertise in the nursing discipline to cooperate with countries in strengthening their own training and development programmes for primary health care. The Committee might wish to ask the Rapporteurs to rev1ew the draft resolution attached to document WPR/RC33/18 with a view to presenting it for consideration and adoption at a later meeting. Dr LAU BUONG YAN (Singapore), speaking in support of the proposal of the representative of New Zealand, said that in Singapore, due to the very large number of patients attending the Government's out-patient clinics, nurse practitioners had been introduced in such clinics. State trained registered nurses were selected and attended a short course of training attached to a senior doctor at a polyclinic for a period of four to six weeks. Such nurses attended to patients with simple ailments or to patients who came for follow-up treatment involving the administration of hypertensive or diabetic drugs.
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When the scheme had first been introduced, the doctors working at the clinics were not happy as they were responsible for the nurses. However, because of the type of patients selected to see the nurse practitioners, no problems had been encountered. Patients always had the right to ask to see the doctor. The nurse practitioners had cut down the waiting time of patients, especially those coming for their monthly supply of drugs. The number of patients requiring to see doctors had also been reduced. Mr DOO-HO RHEE (Republic of Korea) said that a special law had been enacted in his country on 31 December 1980 with a view to providing effective primary health care in remote rural areas within the context of the national health strategy. The Government's target was to train 2000 connnunity health practitioners (CHPs) within four years as from 1981; of that number, 396 had already been trained and assigned to designated areas while an additional 400 were currently undergoing training. Other steps planned included the education of administrators regarding the need to teach primary health care as part of the basic curriculum and the search for means of developing comprehensive primary health care and its support mechanisms. In that connexion, hospitals were being encouraged to play an enhanced role as a support system for primary health care; many hospitals were already operating community health departments. He would be interested to learn what types of personnel were used to implement primary health care in other countries of the Region, with a view to identifying means whereby technical cooperation among developing countries could be developed in that field. Mr POLSON (Australia), speaking in support of the views expressed by the representative of New Zealand, said that Australia had sent a representative to a WHO informal meeting on nursing in support of health for all by the year 2000 held in Geneva in November 1981. The meeting had been devoted to determining problems and formulating strategies for the implementation of primary health care nursing. The recommendations of the meeting were important and had been implemented in Australia. Dr MANAPSAL (Philippines) said that her country recognized that nursing had an important role to play in primary health care. In that connexion there was a need to reorient national health education from its current hospital-based and curative-oriented approach to a community-based and prevention-oriented approach. With WHO cooperation the Philippines was therefore implementing a reorientation programme on primary health care in nursing and midwifery schools throughout the country. There was a continuing need for the participation of the nursing discipline in the planning of primary health care programmes as well as in research. Dr LIU XIRONG (China) welcomed the Zealand and supported the proposed implementing the strategy of "health for all ministries and the entire community views of the representative of New draft resolution. The task of all" called for the involvement of on a multidisciplinary basis. The
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role of nursing in primary health care varied in different countries. In some countries there was a surplus and in others a lack of nurses. It was therefore important to encourage secondary workers and paramedics, including barefoot doctors, to play a significant role in primary health care. He suggested that the draft resolution would be more comprehensive if it included a reference to secondary medical workers. Dr SCHUSTER (Samoa), endorsing the proposal of the representative of New Zealand, said that Samoa recognized the importance of nursing in health care services and, in 1981, with WHO collaboration, had introduced post-basic nurse training courses which laid emphasis on primary health care. The nursing services provided a link with village commun1t1es, particularly in the rural areas. He agreed with the representative of New Zealand regarding the need for an interdisciplinary approach and the involvement of other sectors. In Samoa such an approach was developed through the women's committees. Mr NGUYEN DUY CUONG (Viet Nam) supported the proposal of the representative of New Zealand and considered that particular attention required to be paid to the role of nurses in primary health care. In earlier years, nurses had been used in hospitals in the rural areas but such an approach had not been successful; nurses had not liked to work in rural areas, due in large measure to the fact that normal daily nursing routine had not been adjusted to rural conditions. New cadres of village nurses were therefore being developed by means of short training courses. He suggested that the Regional Committee should consider introducing the concept of such cadre training into the draft resolution as it might be appropriate to a number of countries of the Region. Dr BIUMAIWAI (Fiji) said that his country was well aware of the responsibilities and importance of community-based nurses in primary health care throughout the Region. Problems remained in Fiji, including those relating to geographical factors and the distribution of nursing manpower. Nevertheless, nurses were not only performing excellent work through primary health care programmes but were also involved in matters, such as water supply construction and women's organizations at the village level, which were primarily the responsibility of others. Nurses made a considerable contribution towards helping the rural population to become self-sufficient in terms of primary health care. He was grateful to WHO for its provision of a consultant to rev1ew Fiji's programme; the consultant's report had been accepted by his Government. Post-basic training for nurses in the public health field had been going on for the past six years and he appreciated the contribution of the United States of America and other countries which had sent students to Fiji to participate in those programmes. Dr McCUDDIN (United States of America), supporting the New Zealand proposal, said that nurses played a particularly important role in small island territories such as American Samoa, where they assumed many of the roles of the medical profession.
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Dr NICHOLSON (United Kingdom of Great Britain and Northern Ireland) thought the New Zealand proposal a timely one since it represented formal recognition by WHO of the important role of the nursing profession in primary health care. Dr REILLY (Papua New Guinea) agreed with the representative of China that not only nurses but also allied health workers should be covered by the resolution. His country had long recognized the importance of nurses in primary health care. Nurses ran the smaller hospitals and the health centres. Community health nurses did the rounds of the villages and supervised the work of aid post orderlies, who were the equivalent of China's barefoot doctors. Dr country care. workers SOUVANNAVONG (Lao People 1 s Democratic Republic) said that in his nursing personnel played a very important role in primary health He supported the proposal to include a reference to allied health in the resolution.
Miss FILLMORE (Regional Adviser in Nursing) fully agreed that there should be greater involvement of nursing personnel in the broad sense in primary health care but it was important that they should be health-oriented and not regarded merely as a means of palliating the shortage of doctors. A great deal was being done to reorient nursing curricula in the Region towards primary health care, the main obstacle being that most training programmes were hospital-based, so that nurses were not properly prepared for work in the rural areas. The consultants engaged under various programmes were all actively concerned with bringing the nurses into the rural communities. Dr K.S. LEE (Scientist, Primary Health Care) said that much had been done in the Region in reorienting the training of nurses and allied health personnel towards primary health care and efforts would be intensified in the coming years. National and regional workshops and various types of course had been used to train or retrain the different categories of staff. Three countries had been collaborating with WHO in the training of nurses to train primary health care workers and ancillary staff. A meeting of directors of nursing schools and colleges in May 1982 had reviewed basic nursing programmes and the reorientation of nursing curricula towards primary health care. In the 13 countries represented, plans of action had been drawn up and their implementation would be monitored. The Seventh General Programme of Work would provide for further research on the role of nurses in the development of primary health care. Dr CHRISTMAS (New Zealand) thanked representatives for their support of his proposal, which was essentially designed to secure formal recognition of the role of nurses in primary health care. He fully agreed that allied and ancillary staff also made a substantial contribution and the resolution should recognize that contribution. Nursing experts must part1c1pate in planning and management as well as the training and supervision of the categories of staff involved.
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The REGIONAL DIRECTOR said he felt the discussion had highlighted three main aspects of nursing. First of all, there was the reorientation of the nursing profession towards primary health care, which required the revision of curricula. Secondly, the skills of nurses needed to be used more effectively in the planning, development, implementation and evaluation of primary health care at all levels. Thirdly, nursing was still mainly a female profession in the Region, and it was more difficult for women to visit remote rural areas or for married women to work in the evenings and at night. He drew attention to developments in Fiji, where nurses were receiving support from village women's associations in building up community health centres, where the local women performed some basic health measures under the nurses' supervision. There being no further comments, the CHAIRMAN asked the Rapporteurs to meet with the representative of New Zealand in order to draft an appropriate resolution. (For consideration of the draft resolution see the seventh meeting, section 1.1.). 3. ALCOHOL CONSUMPTION AS A MAJOR PUBLIC HEALTH PROBLEM: Agenda Item 2 (Document WPR/RC33/19) Supplementary
Dr CHRISTMAS (New Zealand) said he had been impressed, during the Technical Discussions on alcohol and alcohol-related problems at the Thirty-fifth World Health Assembly, by the seriousness with which the delegates, most of whom were themselves social drinkers, regarded alcohol consumption. In the past, the problem had been seen mainly in terms of acute alcohol abuse, but there was now growing concern at the large number of people who were steadily increasing their consumption. Even consumption generally regarded as normal was becoming a public health issue. Following the Technical Discussions, delegates of some 20 countries had drafted a resolution recommending programmes for the prevention and control of alcohol abuse. He invited the Committee to consider the draft resolution (A35/Technical Discussions/7, annexed to document WPR/RC33/19) and endorse its use as a basis for a draft resolution to be submitted to the Executive Board and subsequently to the World Health Assembly. Dr KVANS (Australia) said that, in many countries, alcoholism had now become the major public health problem. In Australia it was estimated that 50% of road accidents were associated with alcohol consumption. Many of those accidents led to death or severe and permanent disability, and a high proportion of them concerned young people. Alcohol was associated with many crimes of violence and there was increasing evidence of abnormalities in babies born to women who consumed alcohol in the early stages of pregnancy. Governments were traditionally reluctant to take action to reduce alcohol consumption because of the high revenues they received from the duty and tax on alcohol. Public health workers had pointed out that the drain on medical and financial resources caused by alcohol-related diseases and injuries more than offset the revenue from alcohol, but so far to little effect. Any resolution passed by the Committee should draw attention to the role of advertising practices and to the media's glorification of alcohol. Measures to limit the availability of alcohol would be helpful, and WHO could show leadership by banning or limiting alcohol at official functions. Parents should be encouraged to set an
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example for . their families. WHO should monitor national alcohol policies, and more resources should be allocated to alcohol programmes both 'by \4HO and by countries. R,eporting on consumption in individual countries would be a useful way of evaluating the problems. Dr DA PAZ (Portugal) expressed support for the recommendations made by the representatives of Australia and New Zealand. Until a fe~. )'~(irs ago there had been no alcohol problem in Macao, but consumption had ·ris-en rapidly and was now causing serious concern. Dr REILLY (Papua New Guinea) said that alcohol consumptioiJ. in his country had doubled from 1975 to 1980, and the associated problems were approaching the levels observed _ in developed countrJes. _ ._ .... Alco?ol advertising was frequently linked to sport, as a way of encouraging young people to drink. Dr MANAPSAL (Philippines) expressed concern at the practi~e of . yo\1I1g people in her country of consuming alcohol in conjunction with marijuana · or psychotropic drugs. No specific data were available on disease, accidents ' and crime associated with alcohol, but there was a definite need to develo~ programmes for the prevention and treatment of alcoholism, similar ..to those already set up for drug dependence. She fully s'u pported the recommendations made by the representative of New Zealand. Dr NICHOLSON (United Kingdom of Great Britain and Northern Ireland) commented that the resources available to brewers and distillers for advertising their products far exceeded those available to governments for health education on the dangers of alcohol. Dr SHINFUKU (Regional Adviser in Mental Health) welcomed the statement of the representative of New Zealand, which faithfully reflected the situation in the Region. He himself described the current and planned programmes and activities in the Region for prevention and control of alcoholism and alcohol-related problems adopted since 1976 in response to resolution WPR/RC27 .R5. Current activities included an investigation, by a thr~e-month consultant, of psychosocial factors related to the rapid deterioration in the situation in Papua New Guinea that was expected to reveal a close association between higher alcohol consumption and accidents, crime and violence. Further research also continued in the Philippines to determine the epidemiological picture. WHO and the South Pacific Commission planned a joint workshop in the South Pacific. Also projected were training courses on alcohol problems, but the necessary funds were not yet committed. Experts from various disciplines, including psychologists, neurologists and health education specialists, had attended the first meeting of the Regional Coordinating Group on the Mental Health Programme in 1979 to recommend activities to control and prevent alcoholism and related problems. In 1980, a working group had united 10 experts, including a representative of the United Nations Drug Information Centre. The 19 recommendations elaborated by the Working Group included training of health and related personnel in specific problems of alcohol and related diseases, as well as health education of the public; tra,t.nl.ng 1n individual countries according to their special situations appeared indispensable.
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Research had been undertaken in rural 1980-1981, and a consultant had studied violence in the Philippines.
areas in Papua alcohol-related
New Guinea in accidents and
There was a clear need for a consolidated plan to face the rapidly evolving situation in both developed and developing countries of the Region. In Australia and New Zealand, for example, family and employment involvement were becoming increasingly pronounced, while in Papua New Guinea traditional social behaviour was being affected by excessive drinking in an increasingly large proportion of the population. WHO gave priority to an assessment of the different problems and development of a system of monitoring; establishment of national bodies for prevention and control using multisectoral policies, includip.g taxation of alcoholic beverages, etc.; and to the primary health care approach in the training of personnel and education of the public, in which the collaboration of other agencies and nongovernmental bodies would be an important element. Dr MINNERS (United States of America), recalling the figure quoted earlier of US$50 000 million lost annually due to alcohol abuse, agreed with the comments of previous speakers on the association of alcohol abuse and accidents and crime, and referred to. the added complications introduced by the joint effects of alcohol and drug abuse. He further emphasized the role of alcohol as a cause of acute illness due to accident or behavioural changes, and the chronic effects of prolonged use in cancers and liver disease, including hepatitis. There was further the need to study the psychosocial significance not only of "social drinking" but also of drinking in isolation. The alcoholic deserved every assistance in combating his or her problem. In reply to a question by Dr DONG-MO RHIE (Republic of Korea) on the prevalence of chronic alcoholism in the Region, Dr SHINFUKU said that national mortality and morbidity figures varied widely and no regional picture had yet emerged. China and the Republic of Korea, for example, did not appear to consider alcoholism a problem. Australia and N'ew Zealand had developed sophisticated reporting procedures, for example associating alcoholism with 50% · of road accidents, higher hospital intake rates and psychiatric treatment. A study was required to determine more concrete data for the Region as a whole. · Dr ACOSTA (Philippines), supporting the representative of the Republic of Korea, stressed the need for welb-directed studies to determine the context of the problem and the possible situation in different contexts before activities could be planned. The REGIONAL DIRECTOR confirmed the need for further epidemiological studies and specific research activities on alcoholism as a major problem. The rapid increase in consumption was indeed alarming, especially in developing countries. Even in the absence of clear specific statistical data, the general trend was all too clear. Representatives had referred to the resulting changes in social behaviour, including the situation of women, as well as the work situation, in addition to direct effects in acute and chronic disease.
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Heavy promotional advertising could be held responsible for much of the deterioration, often directed from the main producing to non- or lesser producing countries. Health education was clearly a primary issue, and alc'o holism and drug abuse had been one of the main preoccupations of the International Conference on Health Education, held in Tasmania in August 1982. The discussion had also highlighted the differences in various countries of the Region in the patterns of alcohol use and abuse, including its association with other drugs. WHO recognized that association in combining alcohol and drug abuse in its progranune classification; the International Classification of Diseases made a more detailed breakdown according to similar principles, which were certainly borrie out by the experience of the Western Pacific Region. There was, of course, some difficulty in separating the medical and other aspects of the problem and the respective proportional responsibilities in each area affecting behavioural change and associated disease. (For continuation of discussions see the sixth m _ e eting, section 1).
The meeting rose at 12.10 noon