(WPR/RC37/SR/l)
SUMMARY RECORD OF THE FIRST MEETING WHO Conference Hall, Manila Monday, 15 September 1986 at 9 a.m. CHAIRMAN: later: Dr Terapai Maoate (Cook Islands) Dr B.W. Christmas (New Zealand)
CONTENTS
1. 2.
Formal opening of the session •••••••••••••••••••••••••••••••••• Address by the retiring Chairman •••••••••••••••••·············· Election of new officers: Technical Discussions: Chairman, Vice-Ghairman and Rapporteurs • • . . • • . • • • • . . • • • • • • • • . . • . . • • • . . . . . . • • • . • • . • . . • • •
60 60
3. 4.
60
Appointment of a Moderator •••••••••••••
60 60
5. 6.
Address by the Director-General •••••••••••••••••••••••········· Adoption of the agenda ..
....................................... .
61 61
7.
Report of the Regional Director ....................•.......••••
- 59 -
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1.
FORMAL OPENING OF THE SESSION:
Item 1 of the Provisional Agenda
Dr TEREPAI MAOATE, retiring Chairman, declared the thirty-seventh session of the WHO Regional Committee for the Western Pacific open. 2. ADDRESS BY THE RETIRING CHAIRMAN: Item 2 of the Provisional Agenda Committee as retiring
Dr TEREPAI MAOATE made a statement to the Chairman (see Annex 1 for a copy of his statement). 3. 3.1
ELECTION OF NEW OFFICERS! CHAIRMAN, VICE-CHAIRMAN AND RAPPORTEURS Item 4 of the Provisional Agenda Election of Chairman this
Dr TAPA (Tonga) nominated Dr CHRISTMAS (New Zealand) as Chairman; was seconded by Dr VILLAROSA (Philippines). Decision: Dr CHRISTMAS (New Zealand) was elected unanimously.
Dr CHRISTMAS took the chair. 3.2 Election of Vice-Chairman
Mr KUNIYASU (Japan) nominated Dr SUNG WOO LEE (Republic of Korea) as Vice-Chairman; this was seconded by Dr YU (Singapore). Decision: 3.3 Dr SUNG WOO LEE was elected unanimously.
Election of Rapporteurs
Dr CHEN MINZHANG (China) nominated Dr NAKATANI (Japan) as Rapporteur for the English language; this was seconded by Dr LEE (United Kingdom of Great Britain and Northern Ireland). Mr LECLERC (France) nominated Dr SOUVANNAVONG (Lao People's Democratic Republic) as Rapporteur for the French language; this was seconded by Mr LEODORO (Vanuatu). Decision: 4. Dr NAKATANI and Dr SOUVANNAVONG were elected unanimously. APPOINTMENT OF A MODERATOR
TECHNICAL DISCUSSIONS:
The CHAIRMAN moved the appointment of a moderator for the Technical Discussions and proposed Dr KHALID (Malaysia). Decision: 5. The proposal was adopted unanimously. Item 3 of the Provisional Agenda
ADDRESS BY THE DIRECTOR-GENERAL!
The CHAIRMAN invited Dr H. Mahler to address the meeting (see Annex 2 for a copy of his statement).
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6.
ADOPTION OF THE AGENDA: (Document WPR/RC37/l)
Item 6 of the Provisional Agenda
The CHAIRMAN moved the adoption of the agenda. Decision: 7. In the absence of comments the agenda was adopted.
REPORT OF THE REGIONAL DIRECTOR: Item 7 of the Agenda (Documents WPR/RC37/2 and WPR/RC37/INF.DOC./l)
The REGIONAL DIRECTOR, introducing the report on activities of the Organization during the previous twelve months, said that, in the introduction to the report, he had referred to some of the benefits produced by the evaluation conducted by Member States of their national health-for-all strategies, including the increase 1n cost consciousness among health authorities. The present preoccupation with cost containment was inevitable, given the number of adverse factors facing Member States, including the unfavourable economic climate, the decision forced upon WHO to cut back on its budgetary expenditure, and the rapidly escalating costs of medical care and drugs. All those factors were placing a heavy burden on the budgets of Member States, and the spectre of implacably growing health costs made it imperative for governments to find a solution to the problem. A number of options were available to governments faced with severe resource limitations. More attention could be given to improving the organization and management of health care facilitiesJ including information support, and to achieving greater efficiency in their use. In some cases a shift in emphasis might be indicated, away from the provision of costly, sophisticated health care at tertiary level and towards the use of more appropriate and less costly technologies at community level or even district level. Other economies could be generated by promoting, where feasible, the local production of drugs and vaccines, the development of alternative therapies and the use of traditional medicine under appropriate circumstances. First and foremost, greater emphasis needed to be placed on the preventive and promotional aspects of health care based on the primary health care philosophy, the impact of which was, admittedly, not always readily apparent. Within the framework of their health-for-all strategies, governments had the possibility of promoting greater individual and community self-reliance 1n health care. A timely investment by health authorities in a vigorous and sustained health education campaign, fully supported by the mass media, to promote a healthy life-style based on sound nutritional principles, a clean environment and behavioural change could provide handsome dividends in the medium and long term by improving the health of the community in general and reducing expenditures on non-essential drugs and unnecessary diagnostic procedures and therapeutic activities~
At the same time he felt it necessary to point out that - in one or two countries in the Region - the health component of the budget was seriously underfunded with the result that the health services provided were very inadequate.
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At Regional Office level, efforts had continued to further streamline the mechanisms for monitoring and evaluating programme and budget implementation. This would in turn promote accountability in the use of resources and also facilitate the process of auditing, which would be conducted in future in policy and programme terms. In the same context, a programme budget policy document had now been prepared and finalized, as decided by the Regional Committee at its last session, with a view to facilitating the preparation of country programme budgets and promoting the rational and optimal use of resources. Recalling that there were only fourteen years to go to the target date - the year 2000, the Regional Director said that, by and large, significant progress had been achieved by Member States in the context of primary health care organization and development. A number of activities had been vigorously pursued during the past year to facilitate the delivery of the essential elements of primary health care, particularly in the areas of organizational restructuring, promotion of community participation and intersec tor a 1 cooperation, research and development, strengthening of the support system, and orientation of health manpower development activities to primary health care. Training courses and workshops had been conducted in the areas of primary health care management, urban primary health care, data analysis and curriculum development. The health manpower programme had as always continued to play a very large role in activities in the Region. Increasing importance was attached to the reorientation of health workers to the changes going on in the corttext of primary health care, never forgetting that health was for the people's actual needs. In that connection, efforts had continued to promote the adoption of more appropriate approaches to the training and management of health workers, consistent with the primary health care philosophy, including the introduction of changes in the training institutions themselves and the reorientation or restructuring of training programmes and curricula to a more student-centred and community-oriented approach. Follow-up meetings to the Tokyo Conference had been held during the year. The Conference on Changing Community Needs and Future Medical Education, held in Kyoto and Kurasiki, Japan, in June 1986, had reviewed the present status of medical education in that country and recommended a number of fundamental reforms in undergraduate and post-graduate education, including the development of cooperation with community medical and service organizations. Similar meetings would continue to be held in countries faced with critical problems in medical education, stemming from the inability of existing health manpower to satisfy the requirements of the future health system in the light of changing community needs. Training activities had been conducted in a large number of programme areas, with a view to strengthening and developing managerial capabilities and technical skills at various levels of the health system. Within the Regional Office, language training was now being offered to both WHO and national staff as well as orientation on WHO's policies and procedures, with a view to developing communication skills and overcoming
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the language barrier. Training had also been provided for WHO and national staff in computer operation following the introduction of microcomputers into the Regional Office to streamline administrative and technical functions and facilitate data exchange. The Regional Director informed the Committee that the regional publications programme established in January 1986 was now in successful operation. The focus of publications was on priority programme areas where information was most needed. Apart from the Seventh Report on the World Health Situation, with the printers, and the newsletter on Japanese encephalitis and haemorrhagic fever with renal syndrome (known as the JE and HFRS Bulletin), five publications had already appeared or were under printing on assorted topics. Others were under preparation. He hoped that the programme would be fully utilized by governments, not only in order to gain access to health and related information produced elsewhere but also to share information produced by their own experts with other Members States in the true spirit of technical cooperation. Dr TAPA (Tonga) thanked the Regional Director accompanying information document and commended him continued devoted hard work during the period under maintained excellent relations with WHO, thanks also the Office in Suva. for his report and the and his staff for their review. His Government to good liaison through
He had been moved by the Director-General 1 s insp1r1ng address. His Government wished to place on record its gratitude also to other intergovernmental and nongovernmental organizations, especially those working in the field of health, for their cooperative efforts in Tonga. He was among those who believed that the goals of health for all would be reached, not only in the Western Pacific Region, but in all regions. Dr FURUICHI (Japan) welcomed the achievements that had resulted from the collaborative work of Member States and the Secretariat, and commended the leadership of the Regional Director, without whose efforts much less would have been achieved. His country had contributed to international health development through WHO channels in a number of ways: ( 1) organizing programmes for more than eighty WHO fellows; (2) hosting a number of important WHO meetings, including the Tokyo and Kyoto meetings on the future of medical education and the meeting of the Western Pacific Advisory Committee on Health Research; (3) providing Japanese experts as WHO consultants and temporary advisers in every field of WHO programmes; and (4) having leading Japanese institutes designated as WHO collaborating centres. The efforts from the Japanese side had been made in the context of WHO programmes, providing a demonstrable contribution to health development in the Region. The work of WHO had also contributed to national health development in Japan. Two manpower meetings had had a considerable influence on health manpower development policy. The first, held in Tokyo in April 1985, had directed the attention of medical educators, health administrators and
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planners to the need for change in health manpower policy. The health manpower who would be responsible for health care in the twenty-first century were now being trained, so that their expected role and function should be reflected in today's medical education. Such a far-sighted activity had been welcomed during discussions at the Thirty-eighth World Health Assembly. On the basis of the first preparatory meeting, a second had been held in Kyoto and Kurasiki in June 1986. The meeting had been supported by all the medical school deans in Japan, who had shared experiences with innovative medical educators coming from countries in the Region as well as from other regions. It was the biggest forum ever held to debate the future direction of medical education. In addition to providing a useful report, the meeting had served to promoted awareness and a common base for discussion among all parties concerned, medical educators, health care providers, health administrators, and education administrators. The organ1z1ng of such meetings would in itself contribute to identifying weaknesses in health manpower policy and practice. WHO should support governments who wished to organize similar meetings. Japan would be happy to offer exper~ise, if requested. The meeting of the Western Pacific Advisory Committee Research, held in March 1986, had also been very useful. on Health
Japan was facing a rapid growth in the elderly population, so that priority was being given to research and development in health protection and promotion and health systems research for that population group. Special attention was being given to: (1) strengthening the infrastructure of basic research, (2) emphasizing creative technology; (3) mobilizing · governmental and nongovernmental resources; and (4) coordinating the public and private sectors. The discussions of the Western Pacific Advisory Committee on Health Research would be duly reflected in Japan's science and technology policies. He connnended the collaboration of the Secretariat in his country's bilateral international health activities. Japan had been one of the most loyal supporters of the United Nations system and its bilateral international cooperation, which differed from multilateral cooperation through WHO channels, was now growing rapidly. WHO had provided long and extensive expertise and the information collected by the Organization was very valuable. By strengthening both the collaborative activities of WHO and bilateral cooperation, all parties would benefit, provided that each party respected the position of the others. As indicated by his delegation at the Thirty-ninth World Health Assembly, Japan wished to strengthen its international cooperation in the field of connnunicable diseases control. Four missions were examining the situation in the developing countries with the aid of information supplied by WHO. Another type of collaboration was the provision of expertise by WHO. More than twenty group training courses for health workers were being held in Japan with the technical support of WHO. Further, the number of WHO fellows going to Japan had increased. He concluded by reiterating his country's sincere wish cooperation with WHO and the Member States in the Region. to strengthen
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recognized the The CHAIRMAN said that the Regional Committee significant and generous contribution made by Japan to both the regular and extrabudgetary funding of WHO's operations in the Region. Dr SUNG WOO LEE (Republic of Korea) commended the Regional Director and his staff on the preparation of an excellent report, which covered all the important issues, even though it was the short report usual for even years. The progress achieved over the past year had been largely due to the sound leadership of the Regional Director. His delegation was pleased to note the active support given to Member States, particularly in their evaluation of primary health care activities. Since the Alma-Ata Declaration of 1978, which had set the goal of health for all by the year 2000, one-third of the time available had already passed, and only fourteen years were left for the attainment of the goal. Evaluation activities should therefore be maintained and strengthened in order to determine the existing situation and to re-establish the direction of future activities. He was pleased to note that work was conti~uing on the Region's current problems diarrhoeal diseases, nutrition, acquired immunodeficiency syndrome (AIDS) and hepatitis B - as well as on potential problems such as health of the elderly, workers' health, mental health, etc. He appreciated the support given by WHO to his own country's health programmes over the past year, particularly in the areas of strengthening of research capabilities, health education planning, health manpower development, and protection and promotion of mental health. Dr LEE (United Kingdom of Great Britain and Northern Ireland) joined previous speakers in commending the Regional Director and his staff on a clear and comprehensive report which reflected the considerable progress achieved in the period under review. Particular praise was due for their work in promoting technical cooperation among the Member States of the Region and for their efforts to improve the health of the people. He welcomed the continued support of WHO in providing technical advice 1n manpower development and in collaborating in the establishment of a surveillance mechanism for viral hemorrhaegic fever with renal syndrome, and of rehabilitative services. Dr CHEN MINZHANG (China) welcomed the Regional Director's report, which reflected the various activities undertaken by WHO in support of Member States in the implementation of strategies for health for all by the year 2000 and the progress achieved. The Regional Director and his staff were to be congratulated on the achievements of the past year and on their efforts to promote technical cooper at ion among Member States and to raise health levels. The Secretariat had given active support to the strengthening of certain areas of importance to the attainment of the goal of health for all, including orientation towards preventive medicine, development of systems based . on primary health care, information support to national health systems, health manpower development, management and delivery of disease control programmes, and research promotion and development.
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He was pleased to note the priority given by WHO to the strengthening of national health management processes, which had helped to organize seven national management workshops. In the field of health manpower, the conference on future health and medical manpower, held in Tokyo in April 1985, had been widely publicized, and WHO had helped other countries to organize similar national meetings. Such activities would facilitate the attainment of health for all by the year 2000 by Member States. WHO had also strengthened hepatitis B control programmes and made great efforts in helping Member States with research on and production of hepatitis B vaccines and diagnostic reagents. His Government greatly appreciated its support to China in that regard. Under the sound leadership of the Regional Director and with the collaboration of Member States great progress had been made, but the remaining tasks were considerable, and he hoped that WHO would continue to strengthen technical cooperation among Member States and to work out and implement practical programmes appropriate to the conditions prevailing in countries, thus ensuring early attainment of the health-for-all goal in the Region. Dr NGUYEN TANG AM (Viet Nam) welcomed the Regional Director's clear and comprehensive report. During the past year health services in Viet Nam had done their best to implement the resolutions adopted at the previous session of the Regional Committee, particularly in the field of primary health services and the training of managers, and had given priority to those programmes emphasized by WHO. Acute respiratory infections, diarrhoeal disease and malaria were the prevalent diseases in Viet Nam. The Government was currently assessing the overall health situation and had collated health data collected over the past ten years. He would be happy to make that information available to the Secretariat. Dr PONMEK DARALOY (Lao People's Democratic Republic) commended the Regional Director and his staff on their t.Jork and on their report, which correctly reflected the activities undertaken at both regional and national levels. His country had made headway in its own national health programmes and was starting on the second five-year programme. The strategies implemented, particularly those for health for all by the year 2000, were being evaluated. The evaluation exercise was proving fruitful and positive, indicating the adverse effects of past wars and of colonial times, increasing awareness of the obstacles still to be overcome, and helping to define future objectives and approaches. His was still a developing country which needed to improve the birth and death rates and to combat the communicable diseases that were still prevalent. Together with WHO, it had therefore defined priority areas, including programmes on immunization, water management, malaria control, health services infrastructure, maternal and child health serv1ces, provision of drugs and the improvement of control and surveillance capabilities at all levels. The vicious circle was still there and had to be broken - the Director-General had spoken of envelopes, and it was true
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67
that there were many constraints still to be overcome. WHO's continued support would be needed in that regard. His Government had the will, but better internal and external coordination would be needed if a viable programme was to be established for the next two years. Dr NOBLE (United States of America) welcomed the Regional Director's report. His delegation supported the objectives of the report and was anxious to work with WHO and the Secretariat in finding ways of making opt ~mum use of the limited resources now available, in identifying the most important problems, in establishing commonly agreed priorities and implementation plans, and in evaluating the results achieved so that goals could be reassessed. He was pleased to note the collaboration in many impbrtant areas, particularly maternal and child health, communicable diseases such as Japanese encephalitis, haemorrhagic fever with renal synprome and malaria, development of malaria vaccines, and emerging problems such as smoking and environmental and occupational hazards. Dr TAPA (Tonga) said that the Introduction in the Regional Director's report referred to two outstanding matters:. the first evaluation of progress achieved in implementing the health-for-all strategies, and the preparation of the Seventh Report on the World Health Situation. As stated 1n the report, the former was undoubtedly one of the most significant happenings in the course of the year. He would go further and suggest that it was one of the most significant happenings in the history of WHO. Dr KHALID (Malaysia) congratulated the Regional Director on his very comprehensive and lucid report. The Director-General, in his address, had referred to evaluation as being a springboard for action and not merely an exercise in history; his own references to the Regional Director's report would be made in that spirit. There was a need to review what had been done during the past year, to see what positive developments had taken place, and what lessons could be learnt. Despite the fact that the annual report and the financial report (covering the period 1984-1985) were, inevitably, being considered separately, it was very important to link both programme and financial evaluation, shortfalls in programmes often being the result of shortfalls in financial performance. Malaysia had benefited tremendously from WHO collaboration. Such good understanding at the country level between Member States and WHO was essential for the effective implementation of programmes. In addition, Malaysia had been cooperating with WHO in the establishment of collaborating centres for drugs, malaria, tropical disease research and environmental sanitation, in the organization of various seminars and forums, and by receiving an increasing number of fellows under the WHO fellowship programme. It had also provided a number of consultants, temporary advisers and members of WHO panels of experts, and would continue to collaborate with WHO at global and regional levels. Malaysia believed that health systems research was a very useful tool 1n management development, and had accordingly given it the necessary emphasis. It was currently undertaking an extensive morbidity survey and a
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survey to find out how patients responded - a means of ascertaining the extent and nature of health problems, and whether the system being designed was compatible with real needs. He noted that the expenditure for 1984-1985 had fallen short of the budgeted amount. There were probably various reasons for that, but he believed that health systems research was such an important tool that it should be an integral part of the health-for-all strategy, and that capability in that area should be developed. Regarding the organization of health systems, he had had the opportunity of attending a most useful conference on rural health services, organized by the Asian Development Bank at the beginning of 1986. One of the issues highlighted had been the organization of health services and the relative under-utilization of certain services and particular levels in some countries. WHO should review some of the recommendations it had made to countries in that respect, particularly with relation to the various levels of the medical hierarchy. A national conference on the reorientation of medical education for primary health care had recently been held in Malaysia. It was necessary for the Region to prepare for a similar cemference to be held at the regional level in 1987. Regarding the prevention and control of alcohol and drug abuse, he referred to the Conference of Ministers of Health on Narcotic and Psychotropic Drug Misuse, held in London in March 1986 as a prelude to the forthcoming United Nations International Conference on Drug Abuse and Illicit Trafficking, to be held in June 1987; the concern with that problem should be reflected in the regional programme. Regarding drug and vaccine quality, safety and efficacy, would be considering the resolutions of the Thirty-ninth Assembly on the subject. the Committee World Health
It was necessary to keep a watch on malaria. The situation in many countries either remained static or was deteriorating, and it was important to keep on the alert for possible epidemic outbreaks. The main problem in that respect was the shortage of adequately trained malariologists; hence the need to develop training in that field. Even now, many doctors and medical students did not know how to diagnose or treat malaria. It had not been possible to staff the training secretariat 1n Kuala Lumpur with full-time malariologists. It was important that WHO provide adequate support and financial allocation for the control of sexually transmitted diseases a serious problem in many countries. No cases of AIDS - a subject of public concern, even if there were other more serious problems - had been diagnosed in Malaysia, although some carriers had been detected. There was a need to develop both the capacity to diagnose the disease and the epidemiological capability to control it. In that respect, he thanked the Government of Australia, which had provided assistance to Malaysia by testing the samples sent for diagnosis. The CHAIRMAN said that an update could be anticipated by representatives on the important topic of AIDS which might appropriately be considered in conjunction with item 16 on blood and blood products.
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Mr HAJI MAIDIN HAJI AHMAD (Brunei Darussalam) commended the Director-General for his inspiring address and the Regional Director for his comprehensive report. Brunei Darussalam was particularly concerned with the promotion of environmental health, the control of hepatitis B, the development of health inf6rmation systems, and the improvement of surveillance mechanisms. Dr MAOATE (Cook Islands) likewise congratulated both the Dir;e ctor-General and Regional Director, and expressed thanks to WHO for all its cooperation. Regarding the development of water supply and sanitation, it had been possible to extend the services of a sanitary engineer; the den;tal consultant had provided support for a programme on the training of dental auxiliaries, to be started early in 1987. Mr FUNIFAKA (Solomon Islands) welcomed the Regional Director's comprehensive report and expressed thanks both to WHO staff working at country and regional levels and to the staff of health ministries who had cooperated in the provision of information. He expressed appreciation of the Director-General adddress, which had set the tone for the Committee's session - in particular, the strict warning concerning financial guidelines. While accepting the advocated principles of financial control, he stressed the need for flexibility and the importance of decisions being taken at the country leve 1, between country liaison officers and ministries of health. Given the present financial constraints, more attention should be given to the smaller Member States of the Region. WHO experts should be assigned to the areas where there were particular problems; for example, malariologists were needed for Papua New Guinea, Solomon Islands and Vanuatu, where malaria was a major problem. It was important that the experts should not work in isolation; they should meet to discuss how problems should be tackled. Similarly, in view of the financial constraints, it was important that countries give due attention to the optimal use of their manpower. Solomon Islands accepted the principle of health for all but it had to be realistic and face the fact that it would be far from reaching the goal in the year 2000, because of all the constraints. Dr TAPA (Tonga), referring to general programme development, noted with pleasure the strengthening of country liaison offices. He was pleased that the Organization was making efforts to replace the officer in Tonga, who had left. Regarding the restructuring of coverage in the South Pacific, he welcomed the forthcoming establishment of a WHO representative's office in Samoa. With regard to the managerial process for national health development, Tonga was grateful to WHO for cooperation in drawing up its next national health development plan.
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The WHO/UNDP-supported programme in Tonga for the strengthening middle-level management was regarded as particularly successful, important aspect being the participation of locals from the islands facilitators.
of an as
Regarding health manpower development, Tonga was particularly grateful for WHO's collaboration in studies on the modification of training curricula for health officers and inspectors, radiographers, laboratory workers and nurse midwives. Tonga was laying particular emphasis on the training of nurses , and in that respect he asked whether the post of Regional Adviser 1n Nursing had been filled. Tonga was receiving advice and support from WHO, both under an intercountry project based in Suva concerning the formulation of a national food and nutrition policy, and for a national oral health survey. It was encouraging to note that WHO had given support to eighteen countries or areas in the field of maternal and child health, including family planning. WHO was to be commended on the holding of the South Pacific Commission/WHO Joint Conference on Alcohol-related Problems in Pacific Island Countries, in Noumea in September 1985. Tonga was studying the long list of recommendations ar1s1ng from that conference. Regarding environmental health, it was gratifying to note that good progress was being made in the provision of safe water and that attention was being given to the improvement of sanitation, even if progress was slow. He was particularly pleased to note the inclusion of housing sanitation; there was no doubt that there was a link between acute respiratory infections and bad housing. The joint Tonga/Japan/WHO health laboratory project was particularly successful, and it was hoped that WHO collaboration would continue when the Japanese element ended at the end of 1986. He was pleased to note that the WHO pharmacist based in Apia would contine to work for the improvement of drug supply in the South Pacific. Tonga had received excellent collaboration from WHO and UNICEF in connection with the expanded programme on immunization, which was a priority and extremely successful programme. It was also particularly interested in the programme on acute respiratory infections, which were an important cause of morbidity, especially in the under-5 age group. Tonga had received technical support leptospirosis and marine food poisoning, and collaboration in those fields. from WHO for surveys on looked forward to continued
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Th€ representative of Malaysia had already referred to the generous collaboration of the Government of Australia with regard to AIDS. No cases had been diagnosed in Tonga so far, but he congratulated the Organization as a whole on the prompt action taken against the disease. A successful joint Tonga/ Japan/WHO programme had been started for the preparation of hepatitis B vaccine for infants.
The meeting rose at 12.15 p.m.
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ANNEX 1
ADDRESS BY THE RETIRING CHAIRMAN
Distinguished Representatives, the Director-General of the World Health Organization, the Regiona 1 Director of the Regional Office for the Western Pacific, Representatives of Nongovernmental Organizations and Specialized Agencies of the United Nations, the World Health Organization Secretariat, Ladies and Gentlemen, As my term as Chairman draws to a close, it is my pleasure and honour to address the Committee. First of all, I would like to say how privileged I have felt to have been elected Chairman of the thirty-sixth session. For me it has been a most rewarding experience and I would like to thank the members of the Committee and everyone concerned for making it such an interesting year for me. I thank you all for your help and understanding. I would also like to make a special mention of the WHO Secretariat, which provides such unobtrusive but effective support for the work of this Committee. To Dr Hiroshi Nakajima, our most amiable Regional Director, I would like to say, thank you for your help and for all the efforts of your staff. Once again we are meeting here in Manila, and once again we shall enjoy the friendship and courtesy of our Filipino friends. I would like now to mention some of the important act1v1t1es and events of this past year that have influenced the development of health in this region and in which WHO has been significantly involved. Our esteemed Director-General, Dr Mahler, both in his speech to our thirty-sixth session last September and to the World Health Assembly in May of this year, spoke with justifiable pride of the recent global evaluation of the progress made towards health for all, which was completed in 1985. At our last session we considered the evaluation of our own national as well as regional strategies for health for all, and I feel that this may turn out to have been a landmark for all of us. In discussing the evaluation last year, our Committee noted that many countries 1n the Region had made gratifying progress in providing coverage for the ir peoples with the essential elements of primary health care, coverages of 80 to 90 per cent being reported. This has been made possible by the considerable progress in community involvement, intersectoral coordination and improved management. Nevertheless, we arrived at two important conclusions that I would like to mention now. First, the changes in the health services require d for health f o r a ll have only just begun to take place, and must be continued without any slackening of efforts; and second, although coverage with primary health care may be approaching the level of our targets, the quality and impact of this coverage on health are still far from adequate.
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Annex 1
I think that. in the last year, we have taken positive steps in this region to address these two issues. I refer specifically to the managerial process for national health development, to the strengthening of leadership and advocacy for health for all, and to the follow-up activities of the Tokyo Declaration on future health manpower needs. We are all agreed, I am sure. that improved management of our services and of our health resources is needed. and I think we welcome the initiatives that WHO has taken. In my part of the world in the Pacific. I think the activities directed to the training of middle-level managers have been particularly appropriate. I think that we also agree that top-level policy makers and managers involved in health need to be able to promote and advocate the needs of the health sector much more vigorously. In government, at cabinet level, there also seems to be a need for better communication between ministers, especially between health, education and finance. With regard to the content of primary health care - the quality and impact that I referred to earlier, I think here again that our region is taking positive steps to improve this. There is no doubt that we have a better idea of the priority problems to be addressed. The rapid development of the immunization, diarrhoeal diseases and acute respiratory infections programmes, and the extensive interest and investment in the development of new vaccines for hepatitis and other viral infections as well as for leprosy, are all indicators of the way things may develop in the future. We should not forget also the present concern with the impact of changing life-styles on health patterns and the need to respond to this. In that part of the Pacific which I come from, this is an issue that is already recognized as presenting a challenge to the health services and, in the future, we will be investing much more in the promotion of healthy life-styles and education of the public something that many health services are not very good at at present. Another important initiative taken by WHO that has been of particular relevance in the last year has been the follow up to the Declaration of Tokyo. We are all very much aware that the provision of appropriate health manpower is one of the keystones of health for a 11. and that training institutions have up to now been painfully slow to realize their role in this respect. The Tokyo Declaration was a call to action and I am glad to note that in the last year there have been national workshops to follow up on this in China, Japan and Malaysia. In addition, this topic will be the subject of this year's Technical Discussions after this session of our Committee. To come back to our deliberations of the thirty-sixth session, I would like to remind Distinguished Representatives that there were 24 resolutions ar1s1ng from our discussions, four of which were sent to the Director-General for consideration by the global programmes concerned. It is interesting to note that the four resolutions transmitted concerned AIDS,
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Annex 1
alcohol abuse, cardiovascular diseases and the health manpower. I am sure that these, among concern us again at this thirty-seventh session.
Declaration of Tokyo on other issues, will also
I would like, Ladies and Gentlemen, to cone lude by once again thanking you all for according me the privilege of being your Chairman an experience that I will always cherish. I feel that I have gained many insights into our region and how WHO works, and I can only say that this experience has given me great confidence in the future for health in the Region. May I wish my successor and yours e lves a fruitful and stimulating thirty-seventh session. Thank you.
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ANNEX 2
ADDRESS BY DR H. MAHLER DIRECTOR-GENERAL OF THE WORLD HEALTH ORGANIZATION
ACCOUNTABILITY FOR HEALTH FOR ALL
Mr Chairman, Distinguished Representatives and Friends, I had a friend who died a few days ago, who had the honour to serve this country twenty years ago as UNDP Resident Representative. He wrote to me a week ago and said: "You do remember what development means in its or1g1n. Development means getting out of envelopes, and you do remember that WHO should not give to its Member States new envelopes unless it is what they want themselves collectively as new envelopes in the field of health." So when you sometimes may feel that I express concern about your Organization, I hope you will believe me when I say that, if I express your good conscience, I do it with great joy and, whenever I feel there is a need to be your bad conscience, I do it with great pain, and not in any way in a superficial kind of self-inflicted masochism. I hope you will take my words today in that spirit. Thirty-ninth World Health Assembly
1. Four months ago the Thirty-ninth World Health Assembly took place in Geneva. To judge from the press coverage, it was a political jamboree with little health content. The reality was very different. It was full of health content in spite of the ever-present danger of political explosions. That that danger was averted is a tribute to the good sense that prevailed when matters came to the brink of disaster. Honourable Representatives, you, we, all of us need to keep up that very good sense all the time if your Organization is to survive as the socially relevant international health Organization. Evaluation of the strategy for health for all 2. The most important single item at the Thirty-ninth World Health Assembly was the worldwide evaluation of the strategy for health for all to which your region made a valuable contribution. Ninety percent of Member States reported on their strategies. I would say that that 1s a rather unique social phenomenon, a sure sign that you are taking the goal of health for all by the year 2000 seriously, as pointed out by the outgoing Chairman, and a slap in the face to those many cynics who claim that our goal is nothing but a WHO artefact. The most important single lesson we learnt is that evaluation must be undertaken by you in your countries as a normal part of the management of your health systems, and certainly not because you have to write a report to your WHO in two years' time. And we learnt also that evaluation has to be used as a springboard for action and not as a mere exercise in history. So good sense dictates that whatever you learn from your evaluation has to be ploughed back into the improvement of your health
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system. What is more, recent memories are more vivid than distant ones, except perhaps for very old arteriosclerotics; but none of us have reached that stage as yet! So it is good sense to use the findings of your evaluation right away to improve your health system rcither than referring back at some later date to some outdated evaluation report. District health systems 3. In my presentation to you last year, I talked about the significance of targeting on health for all and advocated establishing action programmes for primary health care. I mentioned briefly district health systems in that context. Well, that theme was taken up and widely reviewed at the recent Health Assembly. As a result, further ideas on the matter crystallized out, and I should like to share some of them with you so that you can put them to good use. That is as it should be in a d~::mocratic organization like WHO; ideas floated at the regional committees are then considered by the Organization's supreme policy organ and returned to the regional committees for further action. 4. It has become clear that district health systems can provide a good opportunity for people to become genuinely involved in shaping their own health care. Because the size of the system places it within their grasp, they can see for themselves what is going well and what is not, and they are close enough to those who manage the system to be able to influence their decisions. But obviously we must not over-romantlclse the situation. Decentralization to districts has to take place within a sound national policy framework and in a politically and fiscally responsible manner. District authorities have to be given power to act, but also responsibility to act with good sense. They have to be accountable not only to the people in the district, but also to the central authorities. These central authorities, as part of their political and fiscal responsibility, have to define clearly and sharply the country's health policy as a basis for decentralized action, as well as certain technical and financial norms. At the same time they have to allow for initiative within that policy and those norms; otherwise decentralization of authority becomes a mere pretence, a mere facade. I should add that the health system is only one part of the country's social and econom1.c system, so its pattern has to be able to relate harmoniously to the administrative pattern of the country as a whole. Of course, the health system can pioneer administrative innovation, but the political authorities have to be persuaded to accept that. I mention these few points because if we neglect them we will find ourselves facing a wall of political opposition to our good intentions. 5. But the opposite situation can also arise - where the transfer of authority from centre to district is understood to mean unconstrained and uncontrolled freedom of action. I recently came across a country in which the President had decreed absolute decentralization to districts. So the district hospitals proceeded to buy drugs locally without respect for the country's drug policy and for the list of essential drugs that had been drawn up for the country as a whole. These hospitals soon exhausted their budget for drugs, whereas central purchasing could have reduced costs by a
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half and enabled them to have sufficient drugs for the whole year. A similar situation could arise regarding other supplies, as well as equipment, logistics and communication systems. So we must remember that a district is part of a whole. Decentralization does not imply anarchy; it demands responsible management. 6. But the main message I want to get across 1s that we should not consider the establishment of district health systems as a new academic exercise surrounded by a new mystique. All the ingredients for setting them up are there and have been amply described - in the Alma-Ata Repoit and the global strategy for health for all and the regional strategies - and they have formed the baseline for the evaluation of national strategies. These ingredients have to be mixed in the right amounts according to every country's special situation. Here is a glorious challenge for down-to-earth health systems research. Your WHO is ready to ~ork with each and every one of you - anxious to work with you - in facing up to that challenge. But in the final analysis the challenge is yours; in WHO the era of paternalism has come to an end; at least I hope so. Political and fiscal responsibility 7. Honourable Representatives, just as the transfer of responsibility from the central level of government to the districts has to take place within a national policy framework and in a politically and fiscally responsible manner, so the transfer of responsibility in WHO to the governments of its Member States has to take place within an internationally collective po l icy framework and in a politically and fiscally responsible manner. I need not elaborate on the collective policy framework. We have built it up together, we are living in it and we are not afraid to evaluate its consequences. So I shall start with fiscal responsibility. To make the most of what your WHO has to offer, you have to squeeze all its resources to the maximum. These resources are far greater than financial resources alone. They include human resources, moral, emotional and intellectual resources, they include information, and the fruits of experience. They are vast because they represent the sum total of human endeavour for health in all 166 Member States. The financial resources are not so vast; they are severely limited and the belt is tightening. 8. It is precisely in order to help you to use these resources optimally it is precisely for that reason that we have been devoting so much energy to establishing regional programme budget policies. I have personally provided you with guidelines that sum up years of experience of working together to heighten the relevance of our investments in health and improve the efficiency with which they are used. These guidelines show how your collective resources can be used sensibly to support you in building up your health systems so tha~hey really do reflect your strategies for health for all. They show how you can consistently reinforce your own capacities to do that and to manage the system by yourselves, by using the information - the knowledge, the know-how, the experience - that has been accumulating in WHO over the years, thanks in no small measure to your own personal efforts. And they show how you can use your WHO to rationalize and mobilize your own resources and reach that longed-for status of national self-reliance 1n
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health matters. To crown it all, they show how all that can be done in a highly democratic manner as, I believe, befits the WHO of the 1980s and the 1990s. 9. Why then, I ask, why then, Honourable Representatives, are so many of you reluctant to seize the opportunity you have been offered? Why do so many of you continue to use your Organization as only one of many funding agencies feeding you with crumbs? Why do so many of you still consider your Organization as a small donor rather than as a big partner? As long as you do that, you will surely misuse your collective resources. But if you accept that partnership, you wi 11 realize what I have been repeating year after year, day after day, over and over again: WHO is your Organization. You can be your own executioners; you can be your own saviours. 10. Now why am 1 using such words - executioners and saviours? Why such apocalyptic pronouncements? I am using them because we are facing attacks from without and managerial weakness from within, and the two are not unrelated. We are doing splendid work in generating health information, in planning, in monitoring, in evaluating. Unfortunately, our performance in supporting national programmes inside countries is not so spl e ndid. We are still not spending nearly as wisely as we could and should in countries. In spite of the highly flexible process of programme budg eting of our resources in countries, in spite of emerging regional programme budget pol icy, i n spite of the managerial arrangements we have introduced to make it easier to use our resources optimally in support of your health programmes managed by your health personnel, in spite of all that, too many of you are still spending far too much on ad hoc supplies and equipment and too much of that is taking place in the last quarter of th e budgetary biennium; sometimes you are spending more on these ad hoc items in that last quarter than in the three previous ones. That unfortunately is a sure signal to our critics that we are not spending our resources in a planned manner. Too many of you are still sending people on fellowships in an unplanne d wa y, not using the fellows properly on their return and not even letting your Organization know what happens to them and to our partnership investment. 11. There is nothing new in what I am saying. I have been t ell ing you that for years. It 1s almost masochistic to repeat it. But, Honourable Representatives, I am r e peating it more forcefully than ever this year because the external climate has changed. Past indulgence towards well-meaning if somewhat romantic health administrators has g iven way to disillusionment, suspicion and even outright hostility. I will not pretend that this is entirely due to our managerial weaknesses, but these add too much fat to the fire. I have seen the writing on the wall for too long. Two years ago I warned you that, if the mana g eme nt of our cooperative activities in countries did not improve, the technical cooperation component in our regular budget could risk being criticized out o f existe nce, logically leading to the end of our constitutional reg ional arrangements. That is why I was in such a hurry to introduce reg i onal programme b udget policy, and to initiate a new kind of financial audit that reveals how your collective resources are being used by Member States, or are not being used by them, to set up th e kind of policies and programme s you voted for unanimously in the governing bodies.
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12. It may be too late. The financial squeeze 1s starting in one part of the globe could easily lead to other parts and all of it leading up to an eventual . The early signs are there, and the less said about them Confidence crisis
on, and the squeeze similar squeezes from financial landslide • in public the better.
13. Honourable Representatives, we call this euphemistically a liquidity cr1s1s, but in reality it 1s far more than that; it is a confidence crisis. How can we restore that confidence? Not by verbal acrobatics, but by demonstrating in practice that we ~ capable of practising what we preach; that we can use our resources efficiently and effectively; and that we will reach our goal of health for all by the year 2000. I know that a number of countries are demonstrating just that. But there are far too few of them. We need a critical mass of countries like these to give living evidence beyond doubt that our strategy is not only viable, but that it is the only reasonable response in a situation of growing problems and diminishing resources. Yes, it is a miraculous strategy, but not a supernatural miracle - it is a very down-to-earth one that can be produced by hard work and good sense, as .we know from a number of countries. I could be genuinely optimistic, I could infect others with that optimism, if only I were sure that you are indeed doing your utmost to make the most of what your Organization has to offer. When I say you, I mean all of us. I am not exonerating the Secretariat and least of all myself from the defect of unnecessary bureaucracy. There is still far too much of that, impeding the speed of our action and casting dark shadows on the sincerity of our efforts. We must loosen up that bureaucracy to make way for initiative - the kind of initiative I mentioned a few moments ago that thrives in a climate of collective policy and fiscal responsibility.
14.
15. Honourable Representatives, we are on trial, like it or n ot. I think we could emerge with flying colours if only we used the tools we have. We have a unique policy ahd strategy. We have a reasonably sound general programme of work; it can help you to build up health infrastructures that conform to the collective policy and use technology that is really appropriate to your country. We have a programme budget that. is not a mere bag atelle, but a powerful i nstrument - i f we want to use it as a powerful instrument. But I shall not beg of you to i:iS'e my guidanc e f or regional programme budget policy. I shall not beg of you to start auditing the way you use your own collective resources - or the way you do not use them - to set up sound policies and soundly manage your programmes to g i ve effect to them. It is not for me to beg any more. Your Organization has set up these tools on your behalf.--It is up to you to d e c1de if you want to use them and how best to use them. That is your pol i tic al responsibility , and I am sure, Friends, you will display good sense in discharging it. If we use our collective resources wisely, come what may, your Organization will not only survive, it will flourish under the momentum of its powerful collective decisions and wise knowledge and experience that it has accumulated. But if you continue to use resources in an ad hoc short-term expe dient manner, t he se resources will vanish, leaving little behind but th e s ke l eton of a once-thriving Organization.
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Accountability 16. Well, of course you may ask, if WHO faded into oblivion, would the difference be the same? I think it would make a vast difference. Organizations may not be important, but to me people are. The people of this region need your continued support and guidance until they attain that long-cherished goal of self-reliance in health matters. You are their regional health guardians. As for you, within your WHO, each and every one of you is responsible to your collective selves. That is by no means a relinquishment of your individual responsibility; quite apart from your moral responsibility to all the people in the Region, it is you who bear the consequences of your action within your own country. 17. Now, I said that within your Organization you are accountable to your collective selves. And outside the Organization? Outside you are being judged daily by the world surrounding you, which still does not consider action for health as an investment in development, but rather as a troublesome consumption of resources that could be better used elsewhere to boost the economy. There is only one way to combat that hostile environment. That is to demonstrate in practice that, by the proper use of your own resources and of those you share collectively in WHO, by the proper use of these and of the resources of other enlightened external supporters, you ~ and will forge ahead towards the attainment of the goal of health for all by the year 2000, and through that to the attainment of the other social and economic goals of your people. 18. Yes, Mr Chairman, Honourable Representatives, the moral value system that inspired the goal of health for all could also inspire other social and economic goals; unfortunately it has not done so as yet. If, thanks in no small measure to your WHO, there has been a relatively high degree of national interdependence and international solidarity regarding health, there has been little or no international solidarity regarding other sectors of development. On the contrary, North/South and South/North relationships have degenerated into a dialogue of the deaf, and the deafness I am sorry to say affects both sides and all ears. There is a terrible danger that that North/South deafness will infiltrate international health endeavours too. You, Honourable Representatives, can help to restore that mutually lost confidence by exemplary action in the field of health. 19. To succeed, you will have to display outstanding leadership, if only to overcome the all-too-prevalent cynicism and no less pernicious apathy. What is more, if you succeed with regard to health, you may even influence the restoration of confidence in other international social and economic spheres. And if strong leadership is needed to attain a goal that has been so clearly defined and universally accepted as health for all, you can imagine the intensity of leadership required to make sure that our common health goal does indeed contribute to the broader socioeconomic development goals and genuine international dialogue to attain those goals. You can exert that leadership if you try hard enough, fortified by your Organization's common but most uncommon value system and resulting health policy. By exerting that, you will fill an all-too-evident vacuum, not for
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personal glorification, but for the benefit of your people. For 1n the final analysis, you are accountable to them, to your people. And in the final analysis, your WHO is accountable to all people throughout the world. Thank you.