The work of WHO in the South-East Asia Region: biennial report of Regional Director: 1 July 1993 - 30 June 1995

The organ~zat~onal structure of the Regional Office, as of 30 June Organi~ational 1995, IS glven in Annex 1 Structure As of 30 June 1995 there were 149 establ~shed Profess~onal posts Personnel In the South-East Asla Reg~on as compared to 146 on 30 June 1994 and 141 on 30 June 1993 Table 13 shows the number of posts in the Profess~onal category In the Reg~on, funded from all sources, and the number actually filled as of 30 June 1995 'Includes 9 posts filled by short-term consultantslprokssionals. 'includes 4 posts filled by short-term consultantslprokssionals. Table 13. Number of pmfessional posts, by location, as of 30 June 1995 ..- Support ~ervlces 119 ~. ~ Established Frozen Filled by appo~ntment Still to be fllled Of which. - candidates selected - candidates yet to be selected Regional and Intercountry 78 6 65' 7 - 7 Country 71 2 54b 15 7 8 Total 149 8 119 22 7 15 i During the period under review, 228 consultants were employed in various projects for periods ranging from 1 week to ; 11 months. Twenty-nine Professional and 24 General Service (GS) staff members separated from WHO service; 46 Professional staff were recruited during the reporting period, of whom seven were women. Five staff members were reassigned to other WHO regions and eight were assigned to other UN Agencies on mission. As of 30 June 1995, 131 nationals were engaged on Special Services Agreements. Staff I In order to keep abreast with the Regional Office's and Member Devdopmmt Countries' evolving needs as well as with new technologies, while andTr* 1 at the same time developing skills needed to properly discharge i responsibilities at all levels, a number of staff development and T~ i training (SDT) activities were undertaken. In this framework, specific attention was given to enhancing the skills of WHO Representatives Ws). Two of them participated in a course on Managing Health Programme in Developing Countries at Harvard University, USA, in June-August 1994. One WR was : sponsored for an interregional seminar for WRs, held at WHO " 1 headquarters. Opportunities were also provided to three Professional staff from the Region to enhance their technical competence through attendance at short-term courses organized in different universities in the United Kingdom in 1994. Seven Professional staff attended introductory briefing programmes at WHO headquarters in 1994 and 1995. Staff development and training activities also focused on building team spirit and effectiveness. A weekend orientationltraining programme for new Professional and senior GS staff was organized in three sessions at a facility outside of New Delhi during MarchlApril 1995. A total of 56 staff members participated in this programme. A workshop on Experiential Learning for Professional and Organizational Effectiveness was also held on 5 January 1994 in SEARO, which was attended by 27 staff members from both the Professional and GS categories. Three 'retreats' were organized 120 The Work of WHO in SEA for wo staff in Indonesia - one in February 1994 for Professional staff and one each during the first half of 1995 for Professional i 1 and GS staff. A number of Professional and GS staff were provided - refresher courses on electronic data processing as well as on E-Mail, which has recently been installed in the Regional Office. '' :; Twenty GS staff from WRs' offices received training in SEAR0 in various fields of activity, using specific information system formats ; of the Regional Office. This included a library orientation programme, : imprest account system, LAN administration and other user-friendly I computer programmes. The proposal to replace the present air-conditioning system in the ' General Regional Office with a new and more powerful plant, as approved ; Administrative by the Forty-sixth World Health Assembly in May 1993, is being 1 Services implemented in a phased manner. New cooling towers and pumping ; systems have been installed, tested and put into operation along w~th the allied equipment. A new chiller is being installed and measures are being taken to replace the remaining parts of the air-conditioning system. The electrical wiring and distribution panels have been reviewed as a preliminary step towards replacing the 30-year old system of power supply. One of the two old lifts in the main building has been replaced, while work is under way to replace 2 the second lifl. A number of other major works were carried out in the area : of Building Maintenance, including renovation of the Reception area, the Conference Hall and the Committee Room. Other areas of World Health House and its compounds are under renovation1 redesigning. The Regular programme budget proposal for 1994-1995 had been Budget and developed within a total allocation of US$99 million. Due to the Finance budgetary and financial constraints of the Organization, only US$94.7 million was released by WHO headquarters as of 30 June 1995 as i the working allocation. The programme-wise distribution amounting I to US$82 million as of 31 December 1994 was as given in Figure 12. ' Support Services 121 Figure 12. Dlslrlbution of funds to high priority programmes (as of 31 December 1994) ou.u.*n*m.rolm S=W-~--~QN.~O wv 1 4.86 """A* *,,,urns m* W.L% ""<% m,". -- 0 2 1 1 10 12 14 IO (8 S- (US Dollam Mllliona) e.0 - In addition to the WHO'S Regular budget, the SEAR Member Countries receive a sizeable amount of funds from extrabudgetary sources, including the World Bank and the United Nations Development Programme (UNDP), for health programmes/projects ; entrusted to WHO as Executing Agency which cover national priorities in health. The funds received from extrabudgetary sources amounted to a total of US$ 58.5 million during the period 1 January 1994 to 30 June 1995. In the context of the revised WHO-w~de management ~nformatlon system development, the Reg~onal Office has been selected to test - the new Reg~onal OfficelAdm~n~strat~on and Flnance lnformatlon (ROIAFI) system whlch 1s expected to be ready for lmplementatlon by the end of 1995 SU plies and Med~cal suppl~es and equipment worth US38 2 mllllon were iUuipmenl procured dunng the perlod 1 July 1983 to 30 June I995 under the Regular budget and extrabudgetary resources Thls amount 1s h~gher than that for the preceding two-year penod, whlch was US$ 36 9 122 The Work of WHO in SEA million, indicating an upward trend. Supplies and equipment for : projects in Bangladesh, DPR Korea, India. Mongolia and Myanmar ! constituted the bulk of the procurement. . A large number of requests were processed during the reporting period under extrabudgetary resources in connection with projects executed by WHO on behalf of the UN and other agencies, viz. the Fourth Population and Health Project in Bangladesh (World Bank); AIDS Control Programme in lndia (World Bank); Malaria Control and Improvement of Primary Health Care Services in Myanmar : (uNDP); AIDS Control Programme in Sri Lanka (Asian Development Bank), and Tuberculosis Control Programme in lndia (Swedish International Development Agency). This resulted in a significant increase in the share of supplies and equipment procured under extrabudgetary resources, which accounted for about 60 per cent of the total procurement. Emergency kits, drugs, vaccines and other essential supplies were provided under the Regional Director's Development Fund to meet emergency situations arising as a result of epidemics and natural disasters in Bangladesh, Mongolia and Myanmar. Essential supplies on a reimbursable basis were procured for Bangladesh (vaccines and medical literature), lndia (drugs and teaching equipment), Maldives (vaccines). Myanmar (research supplies. teaching equipment and medical literature) and Nepal (vaccines and water purifying health chemicals). The ongoing market survey of local manufacturers has indicated the availability of several products of acceptable quality - at competitive prices. Purchases made from local sources have resulted in considerable savings to WHO. These have amounted to US$750 000 on account of purchases such as drugs, bicycles and office equipment. Benefits to programme delivery also accrued due to an increase in the limit of authority delegated to WHO Representatives. The Supplies Management Information System was fully implemented. This has resulted in improved operational efficiency and availability of more comprehensive information to the offices of the WHO Representatives. General Visitors and Visits Dr H. Nakajima, Director-General, WHO, visited lndia in September 1993. Apart from his other engagements, including meetings with senior government officials, the Director-General addressed the forty-sixth session of the WHO Regional Committee. In October, he visited Dhaka, Bangladesh, and addressed the eleventh meeting of the Ministers of Health of the South-East Asia Region. The Director-General visited Mongolia in September 1994 and addressed the forty-seventh session of the Regional Committee as well as the twelfth meeting of the Ministers of Health. Dr Nakajima paid official visits to lndia and Thailand in February 1994. In New Delhi, he attended the Meeting of the Task Force for Child Survival and Development, while in Bangkok he participated in the inauguration of the First International Conference of the International Medical Parliamentary Organization. In October 1994. the Director-General visited Surat (India) in connection with an outbreak of plague, and, in November, he paid an official visit to Indonesia. In March 1995, he participated h in the Interregional Meeting on Prevention and Control of Plague held in New Delhi. During his official visits to the countries, Dr Nakajima took the opportunity to discuss with top-ranking government officials WHO'S collaborative health activities in the Region. The Regional Director received visits of officials of Ministries of Health of various Member Countries, including Ministers and Deputy Ministers. He also received officials of national research councils, medical councils and associations and research institutions who visited SEARO. Other visitors included ambassadors of the Member Countries in New Delhi, a US Congressman, representatives of donor agencies and regional -. and international financial institutions such as the Asian .- i Development Bank and the World Bank. A member of the WHO Executive Board and heads of United Nations agencies in lndia and in other countries in the Region were among the other visitors who visited the Regional Office. The Regional Director gave several PressIradiofIV interviews and met with the media representatives on important occasions such as World Health Day and World No-Tobacco Day. 124 The Work of WHO in SEA Keynote and inaugural addresses were delivered by the Regional Director at various consultations, including those at ministers' level. conferences, symposia, inter-countly and national seminars and 'workshops on technical and scientific subjects. He also addressed sessions of various regional organizations and institutions working in the areas of environmental health, AIDS, cardiovascular diseases, women in development, human resources for health, leprosy elimination, medical research, gerontology, polio eradication. communicable diseases and vaccine production. - -- - -- . - - -- -- - - -- Support Services Meetings Attended/ Ina urated by 7 the egional Director

Section Ill Health Science and Technology I During the reporting period, action was taken to operationalize the research strategy endorsed by the South-East Asia Advisory Committee on Health Research (SENACHR) at its nineteenth session held in April 1993, which has now been published as a technical publication entitled "Health Research Strategies for the South-East Asia Region". The twentieth session of the SENACHR was held in Yogyakarta, Indonesia, from 11 to 15 April 1994. In view of the need to respond to the changing health scenario emphasized by the SENACHR in 1993, the following subjects were selected for technical discussion: health policy research; strategiesfor research on behavioural aspects of health in South-East Asian countries, and guidelines for the assessment, development and transfer of appropriate diagnostic technology. Several recommendations emerged from these discussions. Concerned with the serious health problem caused by the rapid spread of chloroquine- and multidrug-resistant Pfalciparum malaria, a long-term multicentre collaborative research programme has been initiated to develop and validate technical and operational guidelines aimed at stopping the spread of drug-resistant P.falciparum. Other activities undertaken in the field of malaria included a review of the current knowledge and status of research - - . ... Research Prornotlon and~eveloprnent 47 ; work on malariogenic stratification and establishment of a 1 / methodology for a geographical information system which would i enable the development of a monitoring database using "emote-sensing technology for the preparation of stratification maps. " AS well, a multicentre field study has commenced in lndia and Thailand to validate a newlydeveloped dip-stick method to detect ; P.falciparum malaria. In the field of nursing, a multicentre study on collaboration : between nursing services and nursing education was supported in ; three countries (India, Myanmar, Thailand) to improve the quality ! ; of nursing care and nursing education. In 1993, a review of the WHO-supported research promotion and development (RPD) programme was undertaken jointly with the National Institute of Health Research and Development, Indonesia. A similar review was also initiated in Myanmar. The purpose of these reviews was to assess how the RPD programme had contributed to the overall development of health research activities, the extent to which the programme had helped accomplish the * objectives of the national health research policies, the cost-effectiveness of various components of the programme, its strengths and weaknesses, and the degree to which the RPD programme had contributed to general health development in the : countries. Based on the results of the reviews, action has been I taken to further strengthen research promotion and development activities in these countries. Technical and financial support to the dengue vaccine development programme at Mahidol University, Thailand, was continued. At the last meeting of the Peer Review group, it was I decided to further refine the tetravalent vaccine formulations for w : children. A consultation on Research on PubliclPrivate Mix of Human Resources for Health was held in December 1993. It recommended that SEAR0 should support the Member States to establish information systems and conduct research to formulate policies towards equity, efficiency and quality of health care through a proper publiclprivate mix. At the Third Meeting of the SEA Nutrition Research-cum-Action Network, a strategic plan was developed for the years up to 2000, - 48 The Work of WHO in SEA emphasizing the problems of proteinenergy malnutrition and micronutrient deficiencies. Direct support was also provided to a wide range of research projects which included HIV infection; treatment of drug-resistant P,falciparurn malaria, influence of the reservoirs of malaria infection; tuberculosis; leptospirosis; self-care practices; care of the elderly; biochemical, electrophoretic and biological properties of Russell's viper venom; nutritton; traditional medicine; quality of antenatal care services; chronic lead exposure and weaning practices. Activities in the area of research capability strengthening tncluded the strengthening of national mechanisms for research coordination; support for the development of infrastructural facilities; and provision of visiting scientist grants and research training grants covering a wide spectrum of disciplines, viz. traditional medicine. ophthalmology, oral health, entomology, health statistics, vaccine trials and health care financing. At present there are 81 WHO collaborating centres in the Region covering various specialities. During the period under review, new collaborating centres were designated in the fields of health economics, health communication and cancer control. The ninth meeting of the Directors of Medical Research Councils or Analogous Bodies and Concerned Research Foci in the Relevant Ministries was held in Kandy, Sri Lanka, in October 1994. The meeting made a series of recommendations in the areas of HlVlAlDS. dengue vaccine, operational research on tuberculosis control and future trends assessment. The Twent~eth Ann~versary Commemorative Session of the SENACHR was held on 8 April 1995 at the Regional Office, where the past successes and failures of the RPD programme together with its future directions and partnership and management of research activities within the Region were discussed. The twenty-first SENACHR outlined the future research directions of the programme, which include: behavioural, socioeconomic and cultural aspects and determinants of health and diseases; development of human resources for health in all categories of health personnel at all levels of the health care system; assessment and rapid application of existing and emerging health, information and communication technologies in health programmes of the South-East Asian - - .- Research Promotton and~evelo~ment 49 countries; health policy and health promotion research, and identification of constraints to the implementation of health programmes as they affect recipients and providers of health care and policy and managerial apparatuses. N~ne of the 11 Member Countries have RPD projects supported by WHO Bhutan and Maldives do not yet have any project related d~rectly to research An analysis of the WHO country programme budgets and plans of action reveals that the main research-related activities supported by WHO were the following: (1) consultancy in health systems research, molecular biology, biotechnology, demography, nutrition. health statistics, rapid assessment procedures (RAP) in nutrition surveys, tobacco-related diseases, population genetics, laboratory techniques, pathogenesis of DHF, medical sociology, health behaviour, and health economics; (2) improvement of institutional facilities by the provision of supplies and equipment; (3) publication of research bibliographies and abstracts and periodicals related to research; (4) holding of meetings of policy-makers, administrators and researchers for the assessment of research needs and priorities and development of plans of action for national research programmes; (5) holding of workshops to impart training in research methodologies and for the development of research project proposals; (6) provision of research grants on identified national priority topics, and (7) award of fellowships in molecular biology including genetic engineering, cancer epidemiology, biomedical statistics, health management research, maintenance of biomedical equipment, advanced computer technology, library services, research administration and management, clinical research, HIV infection and AIDS, clinical genetics, organ transplantation, nutrition, environmental health and health behaviour. w -. 50 The work ofWH0 in SEA

Preface 7he political, social aizd ecottomic chattges iiz the past fau years hare had a profound impact on the public health situation mn'dw.de, includi~zg the Member Countries of the WHO South-East Asia Region (SEAR). In order to meel the chdenges brought about by these changes, and itt pursuance of the recommendations of the Erecutirk? Board Working Group on WHO Respotrre to Global Cbairge, WHO has undertakez atz organizatiott-wide r@orm of its stnrctrrre and functiotti. Reorgatriration of WHO programmes has been eflected and the mattagerial process for WHO programme da@lopme?rt and management reriised in the light ofthe Ninth General Programme of Work of WHOfor the period 1996-2001. Retaual of the health,for-all strategy has been initiated; a ttew WHO commr~rricatiot~ atid public relatiom policy is already utrder implementatiotz; a rzau WHO persotrtzel policy is otr the anvil, and strmzgthening of WHO coutrtry oflices is beitzg uizdertakett. A rtew Orga?rizatio~-u2de manaynetzt irijormatiort system is rrrtderdetelopme?rt to sene WIO attd its Member States more ejfectively. The Executiw Board, at its tritrety-fiph mion irr Jarruary 1995, nrdomed the concept of biennial strategic programme budgeting and ideeztified specific priority areasfor WHO programmes utrder the Regular budget. In thr, corItext of sr~ccessire "zero-growth" Regular budgets itz WI-IO, it i.s heartcttrr~g to ttote fhr slgt~iJkarif i?rrmlmment of multilateral fit~artcial itrrtitr~tiot~s, tzotab[y the IDA atrd thr AsDB, in the health sector br sereral cotrnlries .co/the Regiotr. The inmstmerrt by the Wodd Bank itz the health sector has beer1 tzotable, ie. IJS$197 miNiott itz Bangladesh (during 1992-196) and oter US$l billion in Itrdia during the period 1992.2000. 7be resrrlt~ of the third mot~itoritrg of the implemetttation ofHFA strategies itz SEAR hare corzjrmed a slow decline it^ crude death rates and itijatzt and rrt2derfile mortality rates. It ako rnealed the epidemiological trartiitiotz br cenaitr Member Courrtries where cbrorzic ~roncommut~icabLe dfieuses arc emergirrg ac importatrl curses of morbidity and mortality. The recnrdescence of cettain diseases, such as malaria and tr~berculosis, the resuvetrce oJplague, artd the loomrng danger of MDS and HIV itfectiotz are also causing graw concern and call for extreme Yigihnce and preemptive public health actionq. F With a view to tackling major public health problems of common concern in * a spirit of enhanced regional cooperation andsolidarity, theRegiona1 Comminee, at its Jorty-seventh session in 1994, endorsed the need to strengthen the WHO intercountry programmes in the Region. 'Ihis is a vay welcome dmlopment to combat health problems of a priori5 nature, such as mahria, polio and MV/AIDS, and to improw admacy and innovative approaches in other areas of priority. 7he Regional Office has, with the help of a cowltatiw group, dewloped spec& proposals and recommended modalities for augmenting the present allocation to the intercountyprogmmmes starting from the 1936-1997 biennium. WHO had heen playing the kad role in thepremtion and control of HN/AlDS under the Global Programme on AIDS. How, in view of the need for a multi-sectoral approach to address its wi'der socioeconomic impact, the Joint United Nations Programme on AIDS (WAIDS) is being established to rephce the Global Programme. WHO will continue its technical cooperation to support Member States, through the use of its oum Reguhr budgetary resources, in the irrtemz@Td pret~rrtion and control of sezuall) transmitted direuses and in stlstaining the esserrtial elements of national programmes on HN/AIDS. WHO contributed a position paper with a comprehensive definition of reproductive health to the International Conference on Population and Detelopment held in Cairo in 1994, which adopted a Global Plan of Action on Population andDefzlopment, 7he Ovanization at50 strongly andsuccessfull) adtacated the placement of health and human development at the centre of socioeconomic det~lopment at the World Summit on Social Development held itt Copenhagen in 1995, 7he Regional Oflce and the Member Countries ofthe Region were actiriely i~tcoloed in both of these global mts, which are likly to haw a sig~ziJicant bearing on international cooperation and actions in the coming decade. I haw great pka~rrre in submitting to the fo7fy-aghth session of the Rqional Committee my fitst bienttial report since assuming office as the Regional Director. Dr Uton Muchtar Rafei Regional Dtrector

It is being increasingly realized in Member Countries that behavioural and psychosocial issues, i.e. lifestyles, are of immense importance for the control of communicable and noncommunicable diseases. It has also become obvious that a prescriptivelclinical approach alone for advances in this field is as ineffective as are quantitative approaches, since they do not seem to have led to much progress in the difficult area of lifestyles and lifestylechangesforthe betterment of health. The Regional Office has, therefore, developed a technique. viz. 'stepwise ethnographic exploration' to bridge the gap between qualitative and quantitative methods of exploration and analysis. Using th~s technique to explore and quantify areas normally considered too 'subjective' for scientific inquiry, instruments have been developed in a Wocoordinated effort to measure the subjective well-being, the perceived burden on those who care for the incurably or chronically ill and the motivational patterns in adolescent behaviour. As adolescent behav~our and lifestyle are critical for a large number of potentially irreversible health-related problems such as STDMIV, early pregnancies, drug addiction and smoking, the subject is being pursued vigorously. In addition, WHO'S work in the field of psychosocial factors has focused on family and community life. The orientation towards community-based health care implies a shift of the burden of caring for the ill and the disabled from institutions to the family and the community. It is, therefore, considered timely to develop measures to quantify the perceived burden on care-givers as well as the quality of community life in Psychosocial and Behavioural Factors in the Promotion of Health and Human Development - - Protection and Promotion of Mental Health 63 order to assess community cohesion and the possibility of improving community participation in health and in the caring of the ill and the disabled. This work is being supported by the Indian Council of Medical Research (ICMR) based on a protocol developed during a WHO-sponsored intercountry workshop. Prevention over the years the open community approach to drug abuse control and Control of : has been developed in the Region, first for rural opium users in Alcohol and ~yanmar and Rajasthan, India, and later for rural alcohol abuse in Drug Abuse Tamil Nadu, India. It has now been successfully adapted to urban heroin users in lndia and Sri Lanka. This approach, based on the principle of rehabilitation beforelwithout detoxification, is gaining increasing international recognition as an effective way of demand reduction, harm minimization and HlV prevention in injecting d~g users. Furthermore, this appmach combines prevention, treatment and rehabilitation in one integrated and deprofessionalized manner. The European Commission is supporting pilot projects to adapt the open * community approach for Europe and is funding a network of NGOs which is implementing the programme in the Region and adjacent countries. This group met in Colombo in July 1994, with the active participation of WHO. A study by the All lndia Institute of Medical Sciences, New Delhi, aimed at developing indicators for the quality of drug services and process indicators for improvement in the social functioning of drug users, is being supported by WHO. WHO continued to execute a UNDCP-supported drug abuse control programme in Sri Lanka. In the process, new insights into the social processes leading to drug dependence have been gained, which are very useful in developing the open communrty approach further. .. Prevention As in the case of other noncommunicable diseases, reorientation control of of specialized services of psychiatry and neurology towards public Mental and mental health has continued to be a difficult task. However, Bhutan and lndonesia have now finally adopted this concept, and the latter country has, in its National Mental Health Programme, specified Disorders - the need to reorient the training of psychiatrists in the same way as that of public mental health specialists. lndonesia has also started to use some of the indicators of the quality of mental health care and the functioning of mental hospitals for monitoring aspects 1 of the public health orientation of mental health care. I . In addition to the National Institute of Mental Health and I Neurosciences, Bangalore, India, the Department of Psychiatly, a Madras Medical College, India, has been designated as the second WHO Collaborating Centre for Training and Research in Mental 1 Health in the Region. In one of the collaborative projects, the Madras centre has completed ethnographic work with families who care for a chronic psychotic patient. Based on this work, an .' instrument to quantify the perceived burden has been developed. ] This will permit the gearing of treatment of mental patients not only towards optimal symptom control but also towards minimization of suffering of the family members. ~p~ Protection and Prornotlon of Mental Health 65

The objective of WHO support to Maternal and Child Health, including Maternal and Family Planning (MCHIFP), is to collaborate with Member Countries Child Health, in the adaptation of technologies and the promotion of the health including of women of child-bearing age and children. Family The issues relating to child survival and development are I Planning receiving priority consideration in the countries of the Region. WHO, together with UNICEF, UNFPA, other international agencies, donor countries/institutions and nongovernmental organizations, is supporting governments in their endeavours in this area. An approach based on the concept of primary health care, with an in-built system of MCHIFP service, is now commonly accepted. Ten priority mid-decade goals targeted for achievement before the end of 1995 were once again brought to the attention of all heads of governmenWstate by the executive heads of UNICEF and WHO at a meeting organized by the Task Force for Child Survival in New Delhi in 1994. All countries have recorded a slgnlficant decrease In Infant mortality rates (IMR) over the last decade through successful ~mplementatlon of the expanded programme on lmmunlzat~on (EPI), and through the control of d~arrhoeal d~seases (CDD) and acute - . - - . . . . -. -- - Health of Specific Populattan Groups 55 ; respiratory infections (ARI) programmes. But the IMR still remains 1 high in some countries, for which neonatal mortality is mainly / responsible. While some countries in the Region have made 1 significant progress towards expanding access to maternal and " I reproductive health care, increasing educational levels and i ; bringing about improvements in other social and human indicators, 1 others are still lagging behind in these respects. The relative I success of some countries gives cause for optimism about what : can be accomplished in the area of MCH. Four countries in the ; Region have already achieved an IMR of less than 50 per 1000 i live births, and a maternal mortality rate (MMR) of less than 100 per 100 000 live births. However, the MMR still remains above 200 per 100 000 live births in the remaining seven countries (Figures 1 and 2). These facts indicate that much more needs to be done to improve women's reproductive health and to ensure safe motherhood. Reduction of matemal mortality and morbidity and m enhancement of the health of the newborns can be achieved through early and equitable access to primary health care, including family planning and prenatal and postnatal care. The existing extent of coverage of these services in the countries of the Region is given in Table 5. It shows that all components of matemal and infant care are not delivered with the same emphasis, and trained attendance at delivery time is still low in many countries. Accordingly. WHO has given high priority to the development of Safe Motherhood programmes in the Region and provided technical support to national workshops as well as to the development of national plans of action in Safe Motherhood. WHO has also produced strategic guidelines for the implementation of Safe Motherhood programmes in the form *L of a "Mother-Baby Package". The package defines a minimum set of interventions for each level of care. Four essential components of Safe Motherhood are: family planning, antenatal care, cleanlsafe delivery and essential obstetric care. These services should be delivered within primary health care and should be based on the principle of ensuring equity for women. This package has been introduced in Bangladesh. Bhutan, Mongolia and Nepal through an intercountry workshop on Safe Motherhood. Member Countries have been striving to strengthen the above four essential components, for which WHO has provided support in various ways. -- 56 The Work of WHO ~n SEA F;gore 1. Infant mortality rates in SEAR countries, 1 991-93 1 sourre: county on mid monit~nng o( pmgmaa in rmnmsnladon 01 HFA slrstsgt-, 1904 ..N#fbnal HesIth Suway, I004 Not* +Mjnfmum 0q.1 nlus lor plobal indroalor as bnnullsd in 7081, HFA rsries "0.3 Figure 2. Maternal mortality rates in SEAR countries, 1991-93 ~p~~~~ ~-~~ ~~ ~ ~ ~ ~~~ ~ ~ ~~ ~ -~.J -- ?alth of Specific Population Groups Table 5. Maternal care coverage in SEAR countries Country wo contributed a position paper on reproductive health and safe motherhood to the International Conference on Population and Development (ICPD) held in Cairo in 1994. The technical aspects of the recommendations of the ICPD are based on this position paper. In May 1995 the World Health Assembly passed a resolution on Reproductive Health: WHO'S Role in Global Strategy. The resolution recognizes reproductive health needs as a central component of women's health. It endorses WHO'S role in the global reproductive health strategy with respect to advocacy, normative i functions, research, and technical cooperation in the area of reproductive health. This resolution also urges Member States to further develop and strengthen their reproductive health strategies in keeping with the principles elaborated in the Programme oFAction of the ICPD and to strengthen reproductive health programmes through: needs assessment, development of medium- and long-term guiding principles, training of health workers in reproductive health and human sexuality, and monitoring and reporting to the Director-General of WHO as a part of the monitoring of progress of HFA strategies. Coverage by trained Pmgnant personnel women immunize with tetanua 42.0 8.0 ... 43.6 62.6 23.4 ... 21.6 24 0 62.0 58.2 cam Bangladesh 54.6 Bhutan 90.0 DPRKorea lW.O 79.4 Indonesia 76.5 Maldives 100.0 Mongolia 71.0 Myanmar 81 6 Nepal 18.0 Sri Lanka 97.0 Thailand 73.0 58 The Work of WHO in SEA e Source: WHOISEARO, Regional summary of progress, impediments, and further r actions needed in implementing national HFA Strategies, 1994 (SWRC47RO). Contraceptive prevalence (per cent) care ~.- 6.1 50.0 100.0 44.1 31.7 50-60 99.0 41 6 31.4 97.0 86.7 $r cam ... 50.0 100.0 90.0 65.5 100.0 94.01 ... ... 88.6 60.9 (per ent) 61.8 27.0 ... 79.4 63.9 95.2 ... 72.0 26.8 85.3 73.2 Nutrition Growth monitoring is an important mechanism to determine the nutritional status of children. Though much progress has been achieved, the Region continues to be the most affected area in the world with regard to malnutrition. - School Health Effective programmes for the healtR of the school-going child are being developed in the Region. It is now well accepted that in order to ensure a healthy adulthood, healthy habits need to be inculcated in the young. Maternal and Child Health The health of mothers and children is receiving priority attention in the Region. While emphasis is being placed on the integration of MCH and famify planning se~ices. efforts are also being made to improve the quality of sewices through appropriate training of health workers, including midwives. The resolution also requested the Director-General to continue : his efforts to: increase the resources for strengthening reproductive health in the context of PHC, including family health, develop programmatic approaches for research and action in reproductive health care, and report on progress to the ninety-seventh session of the Executive Board and the Forty-ninth World Health Assembly. Intensified efforts have been made at country and regional levels Women, Health to promote greater attention to women's health and to integrate "dDe~elo~ment women, health and development (WHD) components in relevant programme areas. National focal points for WHD have been designated in the ministries of health in several countries in order to facilitate coord~nation and collaboration within and among countries. A major concern has been the need to strengthen the resources for WHD in order to effectively meet the increasing demand for technical and information support at country and regional levels. Therefore, a WHD resource database has been established. compiling information on government departments, institutions. NGOs and UN and donor agencies active in issues related to women's health and development. A WHD resource centre has also been established in the Reg~onal Office. It contains over 300 reference materials, documents and reports and is being used as a source of information for identifying, documenting and analysing WHD concerns and for facilitating dissemination of valid information on WHD. In addition. a protocol has been developed which contains a list of indicators and discussion points for the preparation of WHD country profiles Th~s protocol will be used for compiling a regional perspective on women's health and development. The second major concern has been the need to promote dissemination in the Region of valid information on WHD issues for advocacy and publicity, aimed at increasing awareness of the major Issues and facilitating action. A resource kit on "Facilitating Health Action by Women" has been prepared for use by women's groups and others to promote health action by women for their own health as well as that of their families and communities. Two WHD issue papers - one on the health of poor women in urban areas and the other on the reproductive health of women - have been produced. -- - - - -- -- Health of Speclflc Populat~on Groups 59 These papers, among other things, suggest actions in the areas of policy, programme and research. Activities directed at improving women's health continued to be " carried out in the countries within the context of national programmes for Safe Motherhood and MCHIFP, prevention and control of HIVIAIDS and primary health care. For example, in Indonesia activities have been implemented in selected provinces, with support from NGOs, to enhance the empowerment of women and their participation in health development based on PHC. Research related to some of the emerging women's health issues has also been conducted; the studies in Thailand on factors related to the outcome of pregnancy among female factory workers and on osteoporosis in post-menopausal women in urban and ~ral communities are examples. A series of national meetings in Bangladesh. India, lndonesia and Thailand, followed by a regional consultation, have been held in order to mobilize country-level expertise and resources, to identify the major priorities for WHD activities and to initiate networking for c further collaboration on WHD within and among countries. The recommendations of the regional consultation on Action for Women's Health and Development, held in SEAR0 in February 1995, included the adoption of a life-cycle approach to women's health, integration of a gender perspective in health policies and programmes and education and training, support for research, collection of gender desegregated data and intensified inter-agency and NGO ' collaboration. These recommendations will form the basis of a regional WHD plan of action. The Region has contributed to theworkoftheGlobal Commission on Women's Health, established by WHO in 1993 as a high-level body for advocacy and advice to the Organization. The Commission has outlined an action plan for improving the health of women worldwide, which is to be implemented by June 1996. WHO and Member Countries actively participated in the preparatory activities for the Second Asia and Pacific Ministerial Conference on Women in Development, held in Jakarta in 1994, and are currently involved in preparatory activities for the Fourth World Conference on Women, to be held in Beijing in August-September 1995. As a result of these actlvlt~es, women's health Issues ach~eved a h~gher profile w~thln the context of overall development The Work of WHO In SEA Most countries in the Region have recognized the changing pattern 1 Adolescent of adolescent lifestyles and the importance of giving greater attention / Health , to adolescent health, for which focal points have been designated i in the ministries of health. The countries now face a situation where more than 50 per cent of the population is under 25 years of age. : Efforts are, therefore, being made to promote and protect the health of adolescents and youth by introducing healthy lifestyles, including i sports. Specific areas of concern include reproductive health, i increased use of tobacco and drug abuse. Adolescent health programmes have been operational in 1 Indonesia, Mongola. Myanmar and Sri Canka and WHO suppolt has been provided through seminars, conduct of relevant studies and production of physical fitness manuals. However, the fact remalns that programmes for adolescent health have not been developed to the extent they should have Governments need to formulate natlonal plans of actlon for adolescent health, and the efforts of NGOs, youth organlzatlons, the Red Cross and other agencles worklng In the prevention of substance abuse and other relevant areas need to be better coordinated and streamlined Collaboration with the Human Reproduction Research (HRP) Special Human Programme was continued during the period under review, with Reproduction strong inputs from the Regional Office in promoting and supporting Research research capability strengthening activities. Presently, India, Indonesia and Sri Lanka are on the WHO Policy and Coordination Committee (PCC). The Committee on Resources for Research (CRR) met in 1994 and reviewed and approved several long-term institutional development grants for various institutions in the Region. Training courses and workshops on different aspects of HRP were supported in Member Countries. Long-term institutional development and capital grants were approved for Bangladesh. India, Myanmar and Sri Lanka. In 1994, a WHO-cosponsored South Astan Soclal Sclence Research and Tralntng Workshop on Reproductive Health was held In New Delhl, whlch enabled researchers to develop research projects and proposals in the area of reproductive health ~ . . Health of Speclfic Populat~on Groups 61 Workers' The dimensions of the occupational health problems in the Region Health have changed and expanded due to the developmental processes in operation, such as rapid industrialization and modernization and privatization of manufacturing, construction and agricultural enterprises. WHO's efforts are aimed at assessing the existing and new emerging problems in order to develop and adapt technologies for early detection, prevention and control of health problems of working populations. Special emphasis is laid on assessing and dealing with the occupational health problems of those working in small-scale industries and unorganized sectors, including agriculture. through the development of occupational health infrastructures and promotion of community-based occupational health services within the framework of primary health care. Bangladesh, Indonesia, Myanmar. Sri Lanka and Thailand were supported by WHO through training programmes and development of occupational health service information systems. e Health of the The rapid demographic transition and increasing number of elderly Elderly people in the Region are causing concern to Member Countries. Creation of mass awareness about the special needs of the elderly and training of health personnel, families and the community to care for them received due attention in WHO's collaborative activities. In addition to the health-of-the-elderly programmes already existing in five countries of the Region, two more countries have established these programmes, in which they were supported by WHO. The Regional Office, in cullaburatiuo with EMRO, organized a bi-regional consultation on Health Care of the Elderly, with special emphasis on creating mass awareness, in New Delhi in December 1994. Nineteen countries from SEAR and EMR participated. As a " follow-up of this consultation, a workshop on campaigning for and with the elderly was organized by the Asian Training Centre on Aging in Chiang Mai, Thailand, to which WHO provided technical support. Support was also extended to a geriatric workshop in India which had creation of awareness as its main theme. Bangladesh. Indonesia, DPR Korea. Mongolia, Myanmar and Thailand received WHO support in the holding of country workshops, conduct of epidemiological studies on the elderly and fellowships for the study of gerontology and geriatrics. - - ...- -- 62 The Work of WHO bn SEA

The Member Countries have continued their information and education for health (IEH) activities in support of primary health care. Training in IEH through fellowships and study tours has .i strengthened their health education agencies to undertake activities related to training, production of information and educational materials and designing of IEH programmes. The three world days -World Health Day, World No-Tobacco Day and World AIDS Day - provide opportunities to disseminate health information to create mass awareness on various topics of health concern. There is now an increased awareness among the public about the prevention and control of HIV/AIDS, the hazards of tobacco use, the importance of immunizations during infancy and childhood and about various other issues concerning family health. L- Considerable IEH inputs went into the production of materials on HIVIAIDS in the Region. Inputs were also provided for the Women. Health and Development initiative with the publication of a resource kit on "Facilitating Health Action by Women" in a draft form. This publication has been distributed to selected relevant agencies in the Region for their comments and suggestions, which will be incorporated before its finalization. A video film on "Essential Drugs First" was produced, covering the important aspects of the essential drugs programmes in Bhutan and India. In view of the importance of school health. "Guidelines for Action on Comprehensive School The Work of WHO In SEA - Health Education", adapted for the Region, have been disseminated in the countries. s i At the regional level, IEH will receive a new impetus by the \ implementation of the WHO Communications and Public Relations : Policy. The main thrust of the policy is to create proper awareness of WHO, foster involvement in its work and advocate health for all and a coherent approach to health development. This reinforces efforts at health promotion to enable people to increase control over and improve the conditions that affect their health. Advocacy for health directed at decision-makers and implementors at different levels to stimulate action in support of health programmes is being initiated. As a beginning, health advocacy materials for the Region are being developed and efforts to strengthen links with the media through seminars have been undertaken. The first seminar was held in Dhaka, Bangladesh. in May 1995. A pictorial information booklet on "WHO in the South-East Asia Region - Fostering the Spirit of Partnership" was produced and distributed An intercountiy workshop on Development of Prototype Media Packages on Health Issues Related to HIVIAIDS and Tobacco Use was organized in March 1995 in collaboration with the Indian Institute of Mass Communications, New Delhi, which was designated as the WHO Collaborating Centre for Health Communication in 1994. The outbreak of plague in September 1994 in certain parts of India highlighted the need to intensify IEH linkages among SEAR countries through timely dissemination of information, using modern communication technology. This aspect was also highlighted at the interregional consultation on Prevention and Control of Plague held in SEAR0 In March 1995.

The third monitoring report on the implementation of strategies for health for all (HFA) confirmed that in almost all countries progress had been witnessed in the reorientation and restructuring of health systems based on primary health care. Countries had updated and r strengthened their HFA policies and strategies. Efforts were intensified for expanding the infrastructure for primary health care through strengthening district health systems and extending health care coverage to underserved and unsewed populations. Free health cards are being provided for the poor in some countries (e.g. Indonesia, Thailand) to ensure their access to essential health care. Health care targeting women and children was further improved as reflected in the increased coverages for immunization and maternal care. The role of the community as an active partner in action for health improved with the expansion of selection and training of s volunteers and health-for-all leadership. There is evidence that the slide in health status indicators in the early 1990s in some countries (e.g Mongolia) consequent on their economic restructuring and shift in economic policies is being reversed. Reorientation and Four countries (Mongolia, Myanmar, Nepal and Sri Lanka) formulated Restrutluring of new health policies and strategies for the reorganization of their HeallhSystems health services infrastructures. Decentralization and other administrative reforms were introduced in the management of the - - 26 The Work of WHO ~n SEA health systems. There is also a move to expand the role of the private sector and nongovernmental organizations in the provision of health care. A health management unit was established in the Advanced Training lnstitute in Mongolia, and the Centre for Management Administration in Maldives is establishing a module on health management for middle-level managers. WHO has been collaborating with Member Countries in the development of national health leadership, the conduct of local workshops and the documentation of case studies. The problem of maintenance of electro-medical equipment, particularly at district and lower levels, is receiving greater attention in the countries. Fellowships to develop human resources for health were supported, as were local-level workshops, and national institutions were provided with supplies and equipment. Countries are strengthening their district health systems based on ' Strengthening of primary health care as the main vehicle for achieving national goals District Health and targets. Administrative and organizational reforms have been ~~~t~~~ undertaken by the countries to encourage the decentralization process, thus creating an environment for effective planning as well as greater involvement and mobilization of communities in local health development activities. WHO headquarters and SEARO, in collaboration with other WHO regions, organized an interregional consultation on the Strengthening of Comprehensive Health Care Systems in Districts in Bandung, Indonesia. in August 1993. Mongolia is restructuring its health care delivery system at the somon level. In Bhutan, the field training area for the Royal lnstitute of Human Resource Development is being developed together with the ongoing model DHS activities in Mongar and Samchi districts. Myanmar and Bangladesh are receiving UNDP support for strengthening their district health systems. In DPR Korea, an integrated rural primary health care project in Hyangsan County could not be initiated due to a delay in the commitment of funds by other UN agencies. Many countries have shown an interest in integrating in-service training activities for health personnel at the district level and below. WHO is developing a package study tour on primary health care at district level to improve the capacity of middle-level managers in strengthening district health systems. -- Organlzatlon of Health Systems Based on PHC 27 Innovative approaches using outreach strategies are being applied to expand health care coverage from static facilities to the community. Outreach sites (e.g. posyandus in lndonesia, village : health posts in Bangladesh, sub-health posts in Nepal) have been 9 ; initiated for health care interventions for women and children, particularly immunization, growth monitoring, nutrition and maternal care. This provides for functional integration at the community level, and besides enlisting community support, it ensures efficient use of resources and sustainability and complementarity of various : programmes. Some countries (e.g. Indonesia. Thailand) have started to incorporate into this approach inte~entions for addressing emerging problems such as health care of the elderly and community-based long-term care for patients with chronic diseases. An interregional workshop on the Role of Health Centres in District Health Systems was organized at Surabaya. Indonesia, in 1994. Of the 17 participating countries. four were from this region. + Research studies on the role of health centres were reviewed and analysed, and suggestions to enhance this role were formulated. In Mongolia, training of family doctors in ten aimaks was supported. Management training of somon chief doctors and health managers of aimaks was conducted. A management consultant and a SEAR0 staff member visited Maldives and developed training modules to initiate management training for middle-level personnel. The atoll problem-solving initiative in Maldiveswas evaluated with encouraging results. A manual for health care stratification in Indonesia was revised. A workshop on the development of a proposal for strengthening the district health system in five states in lndia through the World Bank was technically supported. ul Expansion of WHO is collaborating with Member Countries in addressing the Health Care to issue of urban health development. Case studies on the performance Urban Areas of referral health centres in urban areas (e.g. in lndia, lndonesia, Mongolia and Thailand) were completed. WHO joined other agencies such as the World Bank and UNICEF in conducting national consultations on city health plan development. City health plans were formulated for Chittagong in Bangladesh and four metropolitan cities in lndia. 28 The Work of WHO ~n SEA * A short-term consultancy to formulate a proposal on an urban ; health care scheme for Bangladesh was supported by WHO in collaboration with the Overseas Development Administration (ODA). A study on the "Organizational effectiveness of the urban basic .!, services programme in selected slum areas of Delhi" was completed : and its findings were discussed in a one-day national seminar. Fellowships for the training of personnel in health care in urban areas were supported. The role of the community as an active partner in health development , cOmmuniit~ is receiving the attention of almost all Member Countries. Nearly for three million volunteers have been selected and trained in various Development countries. They play an important role in building health awareness in their communities and in promoting healthy lifestyles in their neighbourhoods. They work closely with health workers supporting outreach health care delivery sessions (e.g. posyandus, village health care posts) in the community. A large number of village health committees have been established to provide a mechanism for monitoring and guiding health action at the local level. "Community Action for Health" was the topic for the Technical Discussions held during the forty-sixth session of the Regional Committee. The Committee, in a resolution, urged Member States to reaffirm their commitment to community action for health as a fundamental and essential component of health development, and requested the Regional Director to support the countries in their efforts. As a follow-up of this resolution, an intercountry consultation on the "Role of Volunteers in Strengthening Community Action for Health" was held in Yangon, Myanmar, in February 1995. The meeting reviewed and analysed experiences in the countries and made recommendations on policies and strategies, selection and training, and sustainability of health volunteers. It also recommended enhanced resource allocation by WHO to support Member Countries. To promote community participation in health action, March 20 every year has been declared as the "National Health Volunteer Day" in Thailand, while health volunteers with exemplary achievements are honoured during the National Health Day celebrations in Indonesia. - Organization of Health Systems Based on PHC 29 Slrmgtkhning of Hospital Core OM! Refend Smites Pwliiy Assurance in Health Core In Bhutan, strengthening the diagnostic capability of district and national hospitals was supported through the provision of essential supplies and equipment and training of human resourcesfor essential surgery. In Indonesia, workshops for the formulation of guidelines * for the referral system, and for improving district-level supervisory activities and standards of nursing practices for class A. B and C hospitals, were supported. A manual on hospital sanitat~on was also prepared. A proposal for establishing a new regional hospital (community-based through the support of the Islamic Development Bank) was initiated in Maldives, while in Myanmar, fellowships in hospital management were supported. WHO, in cooperation with its Collaborating Centre for Quality Assurance in Health Care, Utrecht, the Netherlands, assisted Bangladesh in the formulation of the Health Care Quality Assurance project that is currently operational through the financial support of b the World Bank. Long-term experts are being recruited to support this project. In Nepal, a national workshop on quality assurance was supported. In Indonesia, a workshop on the formulation of draft quality assurance guidelines was conducted. In Myanmar, WHO is providing technical assistance in the implementation of the project "Improving Quality and Outreach of PHC Services" supported by UNDP. In Thailand, a research proposal for the assessment of quality of health care to develop a model for quality assurance in one province was supported. The need for strengthening WHO intercountry collaboration in the area of quality assurance was recently reflected in the report of the Regional Working Group on Resource Mobilization for the lntercountry and Regional WHO Collaborative Programmes, which met in New Delhi in February 1995. Quality assurance was listed among the priority areas requiring resources. Two candidates from Indonesia and Sri Lanka were nominated to attend the Meeting on Quality Assurance in Developing Countries held in Newfoundland, Canada. during May-June 1995. -. -- -- 30 The Work of WHO m SEA a

During the reporting period, the thrust of the environmental health * programme continued to be towards community water supply and sanitation. This programme has also been extensively used to support other activities such as the control of environmental health hazards and the promotion of chemical and food safety. Vibrant economic growth experienced in a number of SEAR countries has also created some adverse effects on the environment and human health, particularly in cities where most of the growth is taking place. This has led to an increased awareness of the problems caused by pollution and the need for programmes to address them. Following the United Nations Conference on Environment and Development, held in Rio de Janeiro in June 1992, WHO developed a Global Strategy for Health and Environment, thus creating a framework for collaboration with Member States in the area of health and environment. The strategy was further elaborated in a Regional Strategic Plan for Health and Environment prepared by SEARO. The plan includes comprehensive approaches to environmental health directed towards four broad priority areas: urban environmental health management; water supply, sanitation and hygiene (including food safety); health and environmental aspects of water resources, and promotion of chemical safety. A number of countries in the Region are in the process of incorporating health and environment considerations in their national sustainable --- .- 66 The Work of WHO in SEA development plans, lncludtng the elaborat~on of comprehensive env~ronmental health programmes Member Countries have set ambitious targets for water supply and / C0mtnUflity sanitation coverage as part of their health-for-all strategy. The : Water Supply coverage achieved at the end of 1990 and the targets set for the and ~~~it~ti~~ year 2000 are shown in Table 6 below: Table 6. Water Supply and sanitation coverage, 1990, and targets for 2000 ~ Countly Source: WHOISEAR0 IDWSS Assessment and Perspedlve for the 1990s. New Delhi. 1993 While the target of almost universal water supply coverage by the year 2000 appears feasible in most countries, universal sanitation coverage in some countries would require a seven-fold increase in the output achieved during the past decade. This has led to the realization that new approaches to sanitation are required. To this end, a regional consultation was organized which came up with recommendations for a new framework for action and directions for hygiene and sanitation promotion that would give priority to "hygiene promotion for all and latrine coverage for high-risk populations". -- . - - Promotion of Env~ronmental Health 67 Expanding drinking water supply coverage has not been matched by an equal emphasis on the safe quality of the water supplied to users. In order to stimulate the establishment of national programmes for safe water supply. SEARO has published a document = entitled "Overview and Framework of Action for Drinking Water Quality Surveillance". The growing health and environmental problems resulting from the use of wastewater and excreta for agricultural and aquacultural purposes were highlighted in a WHOIFAOIUNDP Regional Workshop on Health, Agricultural and Environmental Aspects of Wastewater and Excreta Use, held in SEARO in May 1994. In Nepal, a task force on drinking water quality surveillance prepared a plan of action for the introduction of a national surveillance programme. A national water supply and sanitation meeting was held in May 1994 which evaluated the impact of training courses and programmes organized for the sector. Strengthening of the sector monitoring capacity was supported * in Bangladesh, Myanmar and Nepal. The wafer supply and sanitation programmes in the countries were also provided with technical literature, computer hardware and software, and laboratory and office equipment. In Myanmar, WHO participated in a UN interagency mission on water supply and sanitation which visited the country in December 1994. WHO supported institutional development of key sector agencies of Member Countries through policy meetings, consultancies, special studies, training and study tours aswell as attendance at conferences and seminars at national and international levels. Environmental In order to increase awareness of the environmental problems in Health in cities, a review of the practices relating to municipal collection, ~~~~l and storage and transport of solid waste was completed in India with WHO support. A regional survey of hospital waste management Urban practices identified the magnitude of the problem and necessary intervention activities. A 'Healthy City' project was initiated in and Housing Chittagong. Bangladesh, where a series of community-based workshops was supported by WHO. As a result, the first 'City Health Plan' in this region was produced. Similar 'Healthy City' activities . ~~ - .. 68 The Work of WHO in SEA have started in Kathmandu, Bangkok and in Cox's Bazar and Bogra i in Bangladesh. Work is under way to expand the 'Healthy City' '/ activities into a regional network of healthy cities. . > $ W~th Increased use of chemlcals In agriculture and industr~es, there Health Risk is a growing concern about the result~ng hazards to pubkc health Assessment of WHO'S collaborat~on has been dlrected towards bu~ldtng natlonal POtentiallv capac tles for the appllcatlon of rlsk assessments strengthening ~~~i( Che;nicals lnformar~on on tox c cnemlca s lmprov~nq manaqement of chemlcals and preventing and treating chemical poisoning. In lndia and Indonesia. WHO supported activities for the establishment of poison control centre networks and the assessment of health risks from chemicals. In Indonesia, support was also provided for the development of a national system of registration of chemicals hazardous to public health and the training of provincial pesticide inspectors. In Mongolia, assistance was provided in the formulation of a national chemical safety programme, training of health personnel in toxicological surveillance methods and in the control of chemicals at the workplace. In India and Myanmar, intersectoral training courses on the safe use of pesticides were conducted. In DPR Korea, support was provided for developing the capability of the national reference laboratory to analyse pesticides and other toxic chemicals in air, water and food. As a follow-up of the International : Conference on Chemical Safety, SEAR0 completed a survey of chemical safety activities in Member Countries. The results indicate a need for: strengthening national capabilities to identify and evaluate chemical safety issues, developing chemical safety plans, increasing activities in chemical information and poison control, and improving capabilities to effectively respond to potential chemical emergencies. Collaboration with countries focused on the management of health C0ntl0l of hazards resulting from environmental pollution and degradation Environmental caused by domestic, agricultural and industrial activities. The main Health Hazards activities supported in Bangladesh, India. Indonesia, Maldives, Nepal. Sri Lanka and Thailand included reviews of legislations and : institutional frameworks for the control of environmental health hazards, strengthening of environmental monitoring and assessment - - Promotion of Environmental Health 69 Food Safety of pollution control and development of environmental epldemlology capabllltles through tralnlng Under the Global Environmental Monitoring System (GEMS), water quality monitoring was continued in lndia, lndonesia and Thailand. Assistance was provided under GEMSNVater to Bangladesh, lndia and Nepal to strengthen national water quality data management and regulatory aspects. A review of the status of the quality assurance programmes of GEMSIAir monitoring stations in lndia, lndonesia and Thailand was also conducted. WHO'S efforts in food safety were focused on the development of national programmes through institutional strengthening and human resource development. Technical assistance to countries included: reviews of the food safety situation in order to develop national plans of action and projects for external funding, development of laboratories for food analysis, use of 'hazard analysis critical control a point' (HACCP) methods and conduct of studies on food contamination. In Bangladesh. Maldives, Mongolia, Myanmar and Nepal, technical assistance was provided for situational reviews and preparation of plans for the development of national food safety programmes. Training was supported in Bangladesh. India, Indonesia. Maldives, Mongolia, Myanmar, Sri Lanka and Thailand to address such issues as sanitary inspections, safe food handling, consumer protection, analytical quality assurance of food testing laboratories and the use of HACCP methods. In India, WHO provided assistance for the training of food analystslchernists of state food control agencies in the analysis of food packaging materials and on aspects of chemical contaminants and food microbiology. In Bangladesh and Nepal, studies on street-vended and weaning foods " were completed, while similar studies are to be initiated in Myanmar and Sri Lanka. Food quality control and risk assessment of food contaminants and veterinary drug residues were studied in Thailand, while in lndia studies on plastic food packaging and commercial food products were completed. In Sri Lanka, technical support in food analysis and quality control was provided for preparing a UNDP-funded food safety project. In DPR Korea, the development of analytical techniques of microbial and chemical contamination of food was 70 The Work of WHO in SEA technically assisted. WHO provided assistance for Indian and Indonesian officials to participate in various Codex Alimentarius .: ,meetings as well as in the Second Asian Conference on Food . Safety. Study tours to observe the management of food safety programmes were organized for officials from India. Indonesia, Sri ' Lanka and Thailand. As a follow-up of the International Conference on Nutrition. SEAR0 reviewed the efforts of Member Countries to incorporate food safety activities in their national plans of action for nutrition. Promotion of Environmental Health 71

Section II Health System Infrastructure Epidemiological services and surveillance systems are in varying j Health stages of development in the countries of the Region. The outbreak / Situation of plague in certain parts of India in September 1994 highlighted ' and Trend the importance of having an effective epidemiological "early warning" A~~~~~~~~~ system. Thailand has a well-developed system of surveillance and is in the process of extending the computerization of surveillance : activities to the provinces. Nepal is developing a new health management information system which will incorporate epidemiological surveillance. Technical support to develop and strengthen epidemiological services was provided by the Regional Office. With WHO support, field epidemiology training was conducted at the National Institute of Communicable Diseases in Delhi, India, in December 1994. Six participants from Myanmar, Nepal and Sri Lanka attended this course. Training of epidemiologists was sustained by continued support to the field epidemiology training programmes conducted in the Region. Though some progress has been achieved, constraints such as rapid turnover of trained staff, inadequate laboratoly support and lack of an attractive career structure have hampered the development of epidemiological services to a satisfactory level in several countries of the Region. The Th~rd Monltor~ng of the lmplementat~on of strateg~es for health for all was completed by all Member Countries between September 1993 and April 1994 The country reports were prepared 19 Health System Development by multisectoral working groups and coordinating committees, with ministries of health playing a leading role. The Regional Summary 1 of Progress, Impediments and Further Action Needed in Implementing National HFA Strategies was prepared and endorsed a I i by the forty-seventh session of the Regional Committee. The results confirmed the existence of political will in Member Countries to achieve HFA goals and to develop primary health care further. Significant improvements have been observed in life expectancy at birth, infant mortality and in other mortality indicators, except for maternal mortality. Due to high immunization coverage, the incidence of EPI-target diseases has decreased. However, other infectious diseases now dominate the health situation in the Region. Some SEAR countries have entered the advanced stage of epidemiological transition with chronic non-infectious diseases emerging as important causes of morbidity and mortality. The population growth rates of some countries remain unchanged, and continue to affect economic growth and standards of living. There is a need to review and expand health education programmes and to address the weaknesses of health system management and health management information systems (HMIS) in some countries. There is also a need for better coordination of international support for health development in some of the countries. The eighth issue of the "Health Situation in the South-East Asia Region", previously titled the "Bulletin of Regional Health Information", has been brought out. This publication provides an ovewiew of the regional health situation and trends as well as a summary of the health programmes in the South-East Asia Region during 1991-1993. ST The countries continued their efforts to strengthen health information systems by improving the coverage and quality of data reported and recorded at the operational level. The generation and use of desegregated data and rational reduction of the information load in HMIS have been promoted. Technical support was provided to all countries except one with the general objective of assisting them in building up a decentralized, user-oriented and integrated HMIS. with emphasis on the collection and use of critical and valid information. A National Health Survey was successfully completed in Bhutan in 1994 with assistance from SEARO. - .- 20 The Work of WHO in SEA 't WHO collaborated in the development and implementation of health . policy in several countries. Nepal was assisted in prioritizing elements P~OC~SS for of its health policy for implementation within the overall context of , Nationd Hmhh the restructuring and reorganization of health services. Development WHO collaborated in the formulation, implementation and review of ~,,ti,,~,,l ~@,,llh national health plans. In lndonesia, a series of workshopslseminars ~~~~l~~~t was supported for the formulation of the health sector component plans of the Second Long-Term Development Plan (1994-2019) and development of the Sixth Five-Year Health Development Plan (1994-1999). Support was provided to Myanmar in the formulation of the national health plan (1993-96). In Sri Lanka, the formulation of a ten-year perspective plan (1994-2003) received support, while the preparation of a draft medium-term national health plan (1992-1996) in Thailand was also supported. National expertise in the formulation of country health plans requires further development. WHO supported health planning and management. decentralized planning and project formulation and budgeting in Bangladesh. Training of health personnel in the management of hospitals in India through distance learning was also assisted. In Indonesia, support was given to the review of existing organizationallmanagerial problems and to accounting and auditing procedures for integrated budget at local level. Training in health management for various categories of health worker at the central, airnak and sornon levels has been supported in Mongolia. In Sri Lanka, a serles of educational activities in the management of health education and an MSc, course in health administration were supported. Support was provided to DPR Korea in computer application in hospital management, and to Myanmar in system analysis and operational research. Besides train~ng activities, studies were supported in Bangladesh, India, Indonesia, Nepal, Sri Lanka and Thailand in such areas as organization and management of hospitals and district-level health care delivery, decentralized health planning and programme budgeting In Indonesia, a study for the restructuring - -- .- -- .. -- Health System Development 21 of the Ministry of Health and measures to rationalize and strengthen coordination and monitoring of foreign assistance were supported. Nepal was assisted in studying the coordination mechanism c with NGOs and also in developing procedures and methods for decentralized planning. A health status and health care delivery indicators survey, with special reference to district level, was also supported. Sri Lanka received support for the development and formulation of programmes and projects based on the national health policy. Health Economics Most Member Countries have shown an interest in health economics and health care financing against a backdrop of shrinking financial resources for health development activities. WHO helped Bangladesh, India, Indonesia and Nepal in training personnel in health economics and financial management. Besides. in-country training, seminars, workshops and the conduct of relevant I studies were financed by WHO in several countries. To assist in the development of a critical mass of health economists, the Centre for Health Economics. Chulalongkorn University, Thailand, which is the WHO Collaborating Centre on Health Economics, has been conducting M.Sc, and short-term courses in health economics with WHO support. Personnel from Bangladesh, India. Myanmar, Nepal, Sri Lanka and Thailand have been trained at this centre. Intensified WHO The number of participating countries in this initiative remains at Support six. These are: Bangladesh, Bhutan, Maldives. Mongolia, Myanmar and Nepal. Technical support has been provided to these countries in health policy development, health manpower development, health care financing, health management information systems, health infrastructure management and aid coordination and management. Support was continued to Bangladesh to improve coordination and implementation of 21 sub-projects under the Fourth Population and Health Project funded by the World Bank and its co-financiers. A study of the organization and administration of hospitals to improve management at different levels was completed. - - - 22 The Work of WHO in SEA - In Bhutan, Field training activities in the Punakha project and a study of the feasibility of setting up a radio communication network - linking basic health units (BHUs) with hospitals for referral purposes received support. Assistance was given to Maldives in the designing of management procedures for the lndira Gandhi Memorial Hospital. Preparation for a donors' meeting for mobilization of additional resources for health was also supported. Mongolia received support in three critical areas: training of medical and health personnel in health management at the central, aimak and somon levels in technical collaboration with the ASEAN Institute for Health Development, Mahidol University; health insurance to augment public sector financing, and health system reform. A national seminar on Aid Coordination and Management was also supported. In Nepal, the areas of health economics and health care financing, preparation of an HRH master plan, strengthening of the district health system and aid coordination and management received WHO support. In the revised research strategies for the Region, adopted in 1993, it was recommended that 'Research related to the promotive and preventive aspects of health and health care and to health systems research (HSR) should continue to receive the main thrust'. In view of this and in the light of the epidemiological transition taking place, a Task Force on HSR met in October 1993 to review the situation and recommend revisions/modifications in the current strategies and programmes pertaining to HSR that would strengthen regional and national activities in this field. The Task Force, while observing that the strategies currently pursued by the Reg~onal Office for the promotion of HSR were sound and the extent of their Implementation commendable, made severs\ recommendations which, inter alia, emphasized the need to focus regional HSR activities on research capability strengthening; training of trainers; development of innovat~ve research designs and appropriate methodologies, especially of the Social sciences type in the light of the demographic and epidemiological transition; Health Systems Research - .- Health System Development 23 mobilizing resources, including extrabudgetary funds, and promoting the dissemination and exchange of information at national and regional levels. s " As a follow-up of these recommendations, an interregional Training of Trainers Workshop on HSR was held in Bangkok in : 1993 in which officials from Member Countries were trained in the planning and conduct of HSR training programmes. The Regional Office, through its intercountry programme, suppotted a workshop for training of trainers in HSR, and one on HSR methodology in Mongolia in 1994. Plans of action for HSR have been worked out for the country, and are useful tools for improving health system performance. Additionally, Mongolia was provided with an institutional strengthening grant through which an HSR unit was established in the Directorate of Public Health, Ministry of Health. Technical and financial assistance was provided for a workshop on HSR in leprosy in lndia in 1994 in which participants from Myanmar and lndia were trained and research proposals pertaining to leprosy were developed. In Myanmar, training of trainers' courses in HSR were conducted at the central, state and divisional levels and an institutional strengthening grant was provided for health systems research infrastructure. Training courses on HSR methodology were conducted in Member Countries using country RPD funds During theseworkshops research proposals were developed Th~s approach proved very effective in promoting research in the countries Cv A publication entitled The Appraisal of Health Systems Research was brought out as a WHOISEAR0 Technical Publication. This publication will be useful for medical research councils and researchers. Hdth Legislalion The role of health legislation in providing support to health policy formulation is undisputed. Recent technological advances such as organ transplantation, in vftm fertilization and genetic manipulation have underlined the need for effective and vigilant regulatory 24 - The Work of WHO in SEA " mechanisms. Realizing this, many countries have been encouraged to formulate and strengthen health legislation. WHO provided support to Bangladesh to review and update its health legislation. Existing public health laws were also reviewed in India and technical support was provided during the passage of the Organ Transplantation Bill. Indonesian health officials were provided with an opportunity by WHO to examine comparative health legislation. In-country training activities to strengthen networking in health law documentation and workshops on disseminating health legislation information to medical practitioners and the public as well as on the rights and liabilities of patients, physicians and hospitals were also supported. Nepal undertook the development of appropriate legislation to improve the implementation of its health policy, while Thailand extensively reviewed its legislation on AIDS. WHO collaborated in both these undertakings. The health legislation activities in most countries remain piecemeal. Systematic re-examination and updating are necessary to meet the changing needs of public health. - .- - Health System Development 25

Section IV Programme Support The Regional Office Library continued to provide technical information and literature support to WHO staff members, Member Countries, United Nations agencies and biomedical researchers. Cooperation was extended to Member Countries in ensuring continuous availability of valid scientific, technical, managerial and other information related to health in printed and other forms, whether originating from within or outside the Organization. During the reporting period, the Regional Office Library received 708 books/monographs, proceedings, reports, pamphlets, WHO publications and issues of current periodicals. It has continued to process its collection using EMS (Books Management System) and PMS (Periodicals Management System) library management softwares. The Library facilities were used by 2640 visitors (2250 WHO staff and 390 others) and 870 books and periodicals were issued on loan. In response to requests from users, 102 inter-library loan requests were sent while 11 560 items were consulted in the Library itself. MEDLARSIMEDLINE searches for WHO staff members and photocopies of 2984 articles from in-house, local, regional and WHO headquarters and other international sources were arranged for the users. The compilation and distribution of SEAR0 Library Alerf (SLA). a monthly current awareness service covering selected periodicals, Library News and HELLlS Newsletter were continued. The Library continued to develop the "SEALIS" computerized database of Health Literature and Library Services (Including HELLIS) Regional Office Library Health Informatton Support 113 assignment reports and documents pertaining to various subject areas (Accidents - Malaria from 1948-todate, Maternal and Child Health -Women, Health and Development from 1975-to-date) and simultaneously issued these in hard copy as "SEADOC". To bring * the health literature published in Member Countries under bibliographical control, the Library issued Index Medicus for WHO South-East As~a (IMSEAR). Besides, the Library has acquired international databases, viz. Aidsline. Medline and Popline on CD-ROM and sub-sets of the WHO headquarters library database WHOLIS. All computerized systems of the Library have been linked to SEARO LAN (Local Area Network). To strengthen the WHO Representative (WR) offices' information retrieval and document delivery capabilities as well as to initiate their staff in the use of newer technology, a library orientation programme forthe concerned persons in the WR offices (Bangladesh, Bhutan, India, Indonesia, Mongolia and Sri Lanka) was conducted in the Regional Office in February 1994. As a result, library management sohares EMS and PMS and WHO databases, such .* as SEALIS and WHOLIS, have been installed in WR offices. The SEARO Library also provided orientation to WHO fellows in the use of various computer sohares and database input formats being used in the Library. Besides, it provided reference materials and services for group educational activities in SEAR. HELLIS The HELLIS (Health Literature, Library and lnformation Services) network now has designated national focal points (NFPs) in all SEAR countries, except Maldives, and in over 315 participating libraries. It has continued to provide such health literature information as is not available in the country of request, including MEDLARSIMEDLINE ? searches. For developing their minimal capabilities, health science libraries in Member Countries have been provided with photocopiers, computers, CD-ROM drives, MEDLINE, WHOLIS and SEALIS databases, biomedical literature, subscriptions to periodicals, and, on specific request, core lists of books, periodicals in the field of biomedical sciences and computer sohares for library automation. A Joint Asia-Pacific POPIN-HELLIS Workshop on "Database Development for Health Population lnformation Managers" was held in Bangkok, Thailand. in November 1994. In this workshop, the ~ ~ -- 114 The Work of WHO in SEA HELLIS Network participants and the Asia-POPIN Network exchanged 1 information about the developments in their respective institutions. i An overview of information regarding various health information : databases developed by the SEARO Library as well as a ; demonstration of EMS and PMS softwares was given to the : participants. These softwares of HELLIS Network were recommended for distribution among the Asia-Pacific POPlN members through : ESCAP. A one-day Regional HELLIS Network Meeting was organized : at the WHO Regional Oftice for the Americas (PAHO) in conjunction ' with the 7th International Congress on Medical Librarianship in Washington, DC, USA, 9-12 May 1995, to review the status, issues and problems related to the development of various types of [ databases in the field of health and allied sciences in Member Countries. These meetings were attended by the HELLIS Network participants from Bangladesh, India and Thailand as well as the : SEARO Librarian and Assistant Librarian. Six new titles were issued under the SEARO publications series Publications besides a revised edition of one publication. Non-priced documents, and Documents including reports of various kinds, were produced and distributed. The third meeting of the Interregional Committee on Policy and Coordination of Publications was held in the Regional Oftice in October 1994. Discussions covered a wide range of issues, including needs in publications, impact of WHO publications, funding, editing, translations, printing, promotion and distribution, electronic publishing and strengthening of national capacity in scientific communication. A number of countries In the Reg~on recelved support for translat~ng Translations and WHO publlcat~ons Into local languages Publications The Regional Office issued the following publications: a revised edition of Collaboration in Health Development in South-East Asia, 1948-1988 - Fortieth Anniversary Volume (Regional Publication No. 19); Nutrition Research in South-East Asia (Regional Publication No. 23); Health Laboratory Services in Support of Primaly Health Care in Developing Countries (Regional Publication No. 24); Health lnforrnatlon ~u~~oT 115 Multicentre Study on Low Birth Weight and Infant Mortality - in : India, Nepal and Sri Lanka (Regional Health PaperNo.25); Principles of Nutrition Management in Primary Health Care (Regional Health Paper No. 26); The Appraisal of Health Systems Research (~echnical' Publication No. 12), and Health Research Strategies of the South-East Asia Region (Technical Publication No. 13). Among non-serial publications, the nineteenth volume of Dengue Newsletter and the Health Situation in the South-East Asia Region covering the period 1991 -1 993 were issued. Documents The reports and documentation of the Technical Discussions on Community Action for Health, held during the forty-sixth session of the Regional Committee, and on Resurgence of Tuberculosis - The Challenge, held during the forty-seventh session, were brought out in book form. The second volume of the Handbook of Resolutions of the Regional Committee was revised and issued in November -* 1993 and further updated in November 1994. The loose-leaf list of technical documents issued since 1979 was updated in December 1993, July 1994 and January 1995. Lists of documents received from WHO headquarters and other regions and distributed by the Regional Office were issued periodically. Sales During the reporting period, a number of special distribution arrangements were made. For example, a pharmaceutical company reprinted and distributed, free of cost, 55 000 copies of Treatment of Tuberculosis: Guidelines for National Programmes. Low-priced editions of Essential Elements of Obstetric Care at First Referral Level and Acute Respiratory Infections in Children: Case - Management in Small Hospitals in Developing Countries -A Manual - for Doctors and Other Senior Health Workers were distributed by UNICEF at minimal cost. Apart from these, a total of 39 reprint agreements were signed. These will result in the dissemination of nearly 32 000 copies of WHO books through commercial publishers. The Regional Office has been assisting WHO headquarters in reprinting some of its publications such as The ICD-10 Classification of Mental and Behavioural Disorders on Clinical Descriptions and Diagnostic Guidelines and Diagnostic Criteria for Research. This The Wok of WHO in SEA 116 considerably reduces the production cost to the Organization and enables wider distribution. - When time and financial constraints do not permit WHO to 1 undertake a publication on its own, co-publication agreements are 1 made with leading publishers in the Region. For example, Oxford ! University Press, New Delhi, published the WHO publication f !, Contraceptive Research and Development 1984-1994 -the Road 1 from Mexico City to Cairo and Beyond. This book was extensively i distributed at the Cairo Conference on Population. 1 : t Efforts were continued to sell publications in bulk (1000 copies or more) to the book trade. Such transactions are intended to minimize the work in the Regional Office and maximize the profit to the bookseller. Books sold in bulk have included Manual of : Radiographic Interpretation for General Practitioners and Manual i of Radiographic Technique. A set of seven books, which constitutes a core library for doctors working in small hospitals and is available at a very special discount, has been very popular, as have been i books under the series lnternational Histological Classification of Tumours. In order to disseminate information, the Regional Office participated in 11 book fairs and medical congresses. In addition, SEARO assisted the lnternational Agency for Research on Cancer, Lyon. France, in their display at the XVI lnternational Cancer Congress in New Delhi in 1994. At the Book Fair in Patna, India, the WHO stall was awarded the first prize for display and decoration. Two sales agents have been appointed to cover areas of western and southern India, and each has organized special exhibitions of WHO publications. Visits by a SEARO staff member were undertaken - to explore similar arrangements in Bangladesh. Sri Lanka and Thailand. The entire sales operations of the Regional Office were computerized in April 1994. This has helped in meeting expeditiously and efficiently the increasing demand for WHO publications in the Region. As a result of these efforts, the sales turnover in the Region is next only to that of the USA and the UK. WHO publications are sold in the Region at half the regular price, and the Regional Office has made considerable strides in terms of dissemination of information, which is the primary objective. -- - Health lnforrnat~on Support 117 Details of the financ~al turnover are reflected in Table 12 Table 12. Sales of WHO publicatrons 1993 1994 July 1993 - June 1995 Subscriptions and sales of publications 1 182925 1 153947 1 350853 1 NOTE: The above figures represent actual receipts afler dedudion of all discounts and application of the concessional conversion rate of Geneva cover prices to Indian rupees. 118 The Work of WHO in SEA

Regional A review of the current knowledge and research work in SEAR Director's countries relating to the malariogenic stratification methodology, r; Development incorporating a remote sensing and geographical information system, ~~~d was undertaken with funding support from the Regional Director's Development Fund (RDDF). Assistance from the RDDF was given to a refresher course for health managers in Mongolia, which was organized in cooperation with the Moscow lnstitute of Advanced Training for Health Workers. With support from the RDDF, a meeting on dengueldengue haemorrhagic fever (DHF) was held at the National lnstitute of Virology, Pune, India, in 1994 where participants from SEAR and other regions deliberated on the prevention and controJ of denguelDHF. WHO cosponsored a joint SEARO/UNICEF/ICCIDD .- Regional Meeting on the elimination of iodine deficiency disorders ' (IDD) which was held in Dhaka, Bangladesh, in April 1995. Consultancy services were provided to different programmes and participation in international conferences was financially supported Assistance was provided under the RDDF to Bangladesh, India, Indonesia. Mongolia, Myanmar. Nepal and Sri Lanka to meet health situations resulting from earthquakes, volcanic eruptions and floods. -- -- 8 The Work of WHO in SEA Extensive technical collaboration was provided to Member States General for the planning, formulation, implementation and monitoring of WHO Pfogrclmme , collaborative programmes through the decentralized and Integrated ~~~~l~~~~~~ managerlal process Annual detailed plans of action were prepared by both countly and intercountry programmes for implementation of the programme budget for 1994.1995 The proposed regional programme budget for 1996-1997, the first of the three biennial programme budgets of the Ninth General Programme of Work, was completed in consultation with the Member States. It was endorsed by the Regional Committee at its forty-seventh session in August 1994. Member States and the Regional Office have commenced work on the preparation of annual detailed plans of action for 1996 to operationalize the 1996-1997 programme budget. In 1993, a Working Group constituted by the Executive Board had made 47 recommendations on WHO'S response to global change. The Director-General established six time-bound development teams for the implementation of these recommendations. The Development Teams on WHO Programme Development and Management and WHO Management Information System dealt with recommendations that had direct relevance to WHO programme development and management. In the regions. regional core groups provided useful inputs for these two development teams whose reports were submitted to the Executive Board in May 1995. The CCPDM rev~ewed the 18-month and 24-month implementation of WHO collaborative programmes in Member Countries for the 1992-1993 biennium at its meetings in September 1993 and April 1994, and the 6-month and 12-month implementation of the 1994-1995 programme budget at its meetings in August 1994 and April 1995. The CCPDM also reviewed the proposed intercountry programme budget for the 1996-1997 biennium at its meeting in April 1994. The annual detailed plans of action for the Implementation of the programme budget in 1994 and 1995 were also noted by the Committee. The working group set up by the Regional Director in response to a request from theforty-seventh session ofthe Regional Committee to recommend modalit~es for mobilizinglenhancing the allocations WHO'S General Programme Development and Management 9 External Coordination for Health and Social Development for intercountry programmes, met in February 1995 and identified .. three broadareas of focused priority. It requested thew0 secretariat ; to develop detailed proposals for enhanced intercountry programmes ' with estimated budgets. These proposals were subsequently w : endorsed by the twenty-seventh meeting of the CCPDM in April 1995. The 42nd and 43rd annual meetings of the Regional Director with the WHO Representatives were held in November 1993 and i November 1994 respectively, and issues relating to the development i and management of collaborative programmes in the Member : Countries were reviewed. The country support teams (CSTs) in the Regional Office continued to provide support to the WHO Representatives and concerned national officers at country level for the development of broad programme proposals and annual detailed plans of action. The Regional Office took steps to establish country programme formulation missions, as part of the CST mechanism, to support i+ the preparation of annual detailed plans of action for implementation of the 1996-1997 programme budget and for the formulation of programme budget proposals for the 1998-1999 biennium. Significant developments took place in inter-agency relationships within the United Nations system in the wake of the refom1 process of the UN. A trend is also emerging towards having multi-agency collaborative programmes to deal with major health problems. These lend a new perspective to, and place new demands on, WHO'S coordinating role in its collaborative relationship with other UN agencies in the field of health. In the context of these, WHO r participated in the Triennial Comprehensive Policy Review of the Operational Activities for Development of the United Nations System undertaken by the UN Secretaty-General. Member Countries and the Regional Office participated in the World Summit for Social Development held in Copenhagen in March 1995. It also took part in the preparatory meetings held before the Summit and contributed a position paper for advocacy of health. The Summit was preceded by a Regional Ministerial Conference on Social Development in Manila in October 1994. SEARO. with .- 10 The Work of WHO ~n SEA -P assistance from WPRO and EMRO, contributed a paper on the i Eradication of Preventable Diseases to this conference. i i SEAR0 also participated in the preparations for the Second ; Asia and Pacific Ministerial Conference on Women in Development 1 held in Jakarta in June 1994. The conclusions of this conference, issued as the Jakarta Declaration, emphasized health issues of women as a priority concern for women's development. WHO continued to collaborate with UNDP on important health-related issues. UNDP approved five new projects in the health sector in Myanmar, of which four - Integrated Primary Health Care, Malaria Control, Community Rehabilitation of Leprosy Patients, and Prevention and Control of AIDS - are being executed by WHO. In Nepal. WHO is executing a UNDP project on Human Resource Development for the Water Supply and Sanitation Sector. In Sri Lanka, WHO participated in the formulation of a UNDP project on strengthening health care facilities in the north and east of the country. In Mongolia, WHO supported UNDP in the formulation of the health components of the poverty alleviation strategy, and is also working with the agency on a joint project for health sector reforms. The Organization assisted in the preparation of documents for the Bhutan Round Table Meeting (RTM) and also attended the RTM for mobilization of resources in support of development programmes. In India. WHO cooperated with UNDP in organizing the Parliamentarians' Forum for Human Development which included health as one of the three key components of its agenda. Durlng the reporting penod, the Reg~onal ORce executed two lntercountry and 16 country projects funded by UNDP WHO and UNICEF worked closely towards the attainment of the common goals of ch~ld survival and development, maternal and child health and safe dr~nking water and sanitation. As a follow-up of thedeclaration of the World Summit for Children. WHO collaborated with UNICEF in the preparation of plans of action for child survival and development within the framework of HFA strategies. The two agencies also participated in the Rural Cohott Study on Child Collaboration with the United Nations System United Nations Development Programme IUNDPI Unifed Notions ChiMren 'r Fund lUNfC€F) WHOs General ~rogram~~evelopment and Management 11 : Suwival in lndia and in the development of a communication strategy i for AlDS prevention in Myanmar. In Thailand, WHO and UNICEF t .. 1 jointly provided assistance in the finalization of the code for the ! marketing of breast-milk substitutes and other related products. ' ? UnitedNotions Fund WHO continued to provide support to UNFPA programme reviews for Populolion and project formulation missions. SEAR0 executed one intercountry A&ities[u#fP~/ and five country projects and participated as an associate agency in the implementation of the UNFPA-funded MCH project in Bhutan. EconomicondSotiol , WHO is represented on the Regional Interagency Committee for bi?Im~~ for hi0 Asia and the Pacific (RICAP) set up by ESCAP to promote inter-agency andthePocific~t~(~~) coordination. In addition, WHO took part in health-related technical committees of ESCAP and carried out health advocacy at various high-level consultative meetings organized by it. Ofher Agencies WHO continued its collaboration with the United Nations International Drug Control Programme (UNDCP) in the drug abuse control activities in lndia and Sri Lanka. It also continued to promote health and nutrition in projects assisted by the World Food Programme (WFP). The Organization participated in the Asian Regional Planning Seminar on AlDS and Education within the School System, organized by UNESCO in January 1995. Colloborotion The Regional Office continued to execute 22 specific components with Development of the Fourth Population and Health Project in Bangladesh funded r Banks and Funds by the World Bank and several co-financiers. In India, it provided technical support for the implementation, monitoring and evaluatton of the IDA-funded programmes in AlDS prevention, leprosy eradication, prevention of blindness and tuberculosis control as well as the sixth population project. The first HQ-level WHOhVorld Bank Review Meeting, with the participation of representatives of a number of countries from WHO regions, took place at WHO headquarters in OctoberlNovember 1994. The purpose was to identify ways for more effective - - 12 The Work of WHO ln SEA governmen~ONvorld Bank collaboration. From this region, lndia i participated in the meeting. p The Second Joint Meeting of WHO and the Asian Development Bank (AsDB) was held in Manila in October 1993 to review the j collaborative activities. Steps were taken to intensify collaboration between WHO and the AsDB, and a meeting of the WHO ; Representatives in SEAR with the AsDB was organized in New Delhi i in November 1994. The priorities for collaboration as well as specific approaches and modalities of partnership in support of national ; health development were identified at this meeting. WHO agreed to provide technical support to the fact-finding, appraisal, project formulation and other review and monitoring missions of AsDB to the countries. One such AsDB fact-finding mission visited Mongolia in November 1994. The Arab Gulf Fund (AGFUND), which had suspended its operations following the Gulf War, has restored its funding to the : prevention of blindness and the prevention of deafness activities : in Bangladesh. Maldives, Myanmar, Nepal, Sri Lanka and Thailand. Bilateral agencies have played an important role in health Collaboration development in the Region. The Danish lnternational Development - with Bilateral Agency (DANIDA) continued to support the health learning materials i Agencies project in Mongolia and the strengthening of district health system ! project in Bangladesh. It also funded, through WHO, a project on Women and Development in Maldives. The Swedish International Development Agency (SIDA) funded tuberculosis and leprosy control programmes in lndia, which were executed by WHO. DANIDA and the Finnish lnternational Development Agency (FINNIDA) jointly funded the essential drugs programme in Bhutan. The Italian Government continued to provide financial assistance to the disaster preparedness and response programmes in Bangladesh and Sri Lanka. A mission of the German Agency of Technical Cooperation (GTZ) visited lndia and SEAR0 in Februaly 1995 to explore the possibility of expanding GTZ support to the health sector and to exchange views on possible collaboration with WHO. A team of experts from the Japan lnternat~onal Cooperat~on Centre (JICC) also v~slted lnd~a on a fact-findlng mlsslon wlth a vlew to expand~ng Japanese collaborat~on In the health sector The WHO'S General programme beve~opmen~ and Management 13 Canadian International Development Agency (CIDA), the Australia International Development Assistance Bureau (AIDAB), the German 1 ; Agency for Technical Cooperation (KRN), the Japan International i i Cooperation Agency (JCA), the Directorate General for International Cooperation (DGIS) of the Netherlands, the US Agency for i : International Development (USAID), the Overseas Development I Administration (ODA) of the United Kingdom, and the Nolwegian Agency for International Development (NORAD) are among the other major bilateral donors who supported a wide range of health projects in the Region. WHO maintained close collaboration with these agencies. Co~abomtion ' Intergovernmental organizations such as the Association of the with : South East Asian Nations (ASEAN) and the South Asian Association Intergovermmtd i for Regional Cooperation (SAARC) are, inter alia, promoting TCDC &gonixotionr ' in health also. SEAR0 has taken steps to reinforce collaboration with ASEAN. Technical support was provided to the ASEAN Academic and Research Experts Meeting on AIDS Prevention and Control in the preparation of a work plan for the ASEAN Regional Programme on AIDS. CoNabomtion , A new initiative was taken to enhance the participation of with , nongovernmental organizations (NGOs), palticularly those focusing Nongovernmental ' on women, in AlDS prevention and control programmes through Org~ni~ati~n~ partnership between governments, NGOs and WHO. WHO continued to promote and encourage the involvement of youths' and women's organizations in the health-for-all movement. Representatives of the Japanese Pharmaceutical Manufacturers' Association (JPMA) visited the Regional Office and developed collaborative programmes in specialized training in pharmaceuticals and also in the supply of essential drugs. Under this programme, JPMA offered six fellowships for training in pharmaceuticals and sets of pharmaceutical reference books to four countries. The Sasakawa Foundation supported leprosy control activities in the Region. The Regional Office also collaborated with the Dutch NGO, Medecins Sans Frontieres (MSF), in malaria control activities in Myanmar. -. 14 The Work of WHO in SEA An assessment of the current situation of WHOINGO collaboration in the Region was undertaken in order to identify measures for strengthening partnership with NGOs in health development. Based on this assessment, an action plan will be developed to improve the Organization's regional-level partnership with international NGOs having official relationship with WHO as well as to promote tripartite NGOIgovernmenVWHO collaboration in Member Countries where appropriate. As the evolving international trade and tariff norms are likely to World Trade have implications on essential drugs, breast-feeding, nutrition and Organization MCH. WHO is prepared to cultivate close association with WTO and [WO) work through the Codex Ailmentarits in order to be able to deal with the health-related aspects of WTO regulations. Significant activities took place in the Region to improve and Health strengthen national health infrastructures for emergency Emergency preparedness and management of humanitarian relief operations. preparedners Disaster-prone countries such as Bangladesh. India. Indonesia, Mongolia, Myanmar and Nepal initiated the development and and Response implementation of emergency preparedness and response (EPR) plans and programmes with support from WHO. A joint WHOlltalian Government mission reviewed the progress of EPR activities in Bangladesh in March 1994, and provided assistance for strengthening the operational and technical capacity of the EPR cell in the Ministry of Health. WHO assistance to Bangladesh also included development of a work plan for the establishment of a national centre for emergency preparedness and response; setting up of a computer software system, SUMA, for improved management of emergency supplies including training of personnel in the system through workshops; and supply of emergency health kits and other medical supplies to meet the emergency health needs resulting from a cyclone in Cox's Bazar. WHOparticipated in the activities ofthe UN Disaster Management Team in lndia. Assistance was given by way of technical expertise and supplies and equipment during the plague epidemic in certain parts of lndia. The WHO Collaborating Centre for Disaster Preparedness WHOs General Programme Development aid Management 15 at the All-India Institute of Hygiene and Public Health. Calcutta, conducted several training courses in disaster preparedness. Assistance was also provided to relief measures taken at the time of an earthquake in Maharashtra and during floods in different parts p. of India. In Indonesia, support was provided by way of equipment to the Ministry of Health in order to facilitate relief operations for the victims of the Mount Menapi volcanic eruption. WHO assigned an expert for assessing the situation arising out of the volcanic eruption i in Central Java. The Organization also supported Indonesia's participation in related world conferences. The Government was assisted by WHO in the preparation of a training manual and a master plan for disaster preparedness. WHO provided technical assistance to Mongolia, Myanmar, Nepal and Thailand in the review of disaster preparedness of health facilities and in the development of national plans of action for the management of emergency care. a Based on the recommendations of a Task Force set up by the Director-General to review WHO'S policy and functions in the context of its expanded role, the Organization's new role and strategies have been formulated. These strategies are aimed at reorienting WHO'S roles and functions towards meeting the needs of the progressively complex and expanding emergency and humanitarian action (EHA) activities. In the light of these new strategies, SEARO's programme for the 1996-1997 biennium will concentrate on: supporting the formulation of national plans and programmes for health emergency preparedness and relief operations; improvement of the infrastructural and disaster management capabilities of the countries, the Regional Office and the WHO Representatives' offices; development of human r; resources through large-scale training activities and promotion of inter-agency cooperation. Health During the reporting period, two meetings of Ministers of Health of Ministersf the countries of the WHO South-East Asia Region were held, one Meetings each in 1993 and 1994. The Eleventh Meeting was held in Dhaka, Bangladesh, from 1 to 3 November 1993. It was attended by Ministers of Health 16 The Work of WHO in SEA of all Member Countries except Bhutan, which was represented by an observer. The Director-General, Dr Hiroshi Nakajima, addressed the Ministers and participated in the discussions. The main subjects on the agenda were: (i) TCDC Programming in Health; (ii) Health Management, including Development of Human Resources for Health; (iii) AIDS and EPI-targeted Diseases, and (iv) Future Actions for Old Scourges - Malaria, Tuberculosis and Leprosy. The Ministers recognized the need to establish common principles and guidelines and equitable conditions for promoting TCDC. They suggested formulation of plans and programmes for strengthening health ; management and a balanced development of health manpower. The need to take urgent steps to prevent and control HIVIAIDS was acknowledged, and it was agreed that the control programmes in respect of malaria, tuberculosis and leprosy should be strengthened. The Twelfth Meeting of Ministers took place in Ulaanbaatar, Mongolia, from 30 August to 2 September 1994. It was attended I by the Ministers of Health of ten Member Countries, while Sri Lanka ' was represented by two observers. The Director-General addressed the Ministers and participated in the discussions. Subjects on the agenda included: (i) Health and Poverty; (ii) Better Education for Health, and (iii) Mental Health. The Ministers noted the very close relationship that exists between health and poverty. The Director-General informed the Ministers that one of the three agenda items of the World Summit for Social Development in 1995 would : relate to poverty. He highlighted that the real issue was how developing countries could help themselves in overcoming ill-health associated with poverty. The Min~sters recalled their discussions on the health of the underprivileged at their Ninth Meeting. They were of the opinion that it was necessary to lay emphasis on the promotive and preventive aspects of health care, ensuring nutrition, safe drinking water and adequate sanitation. The Ministers emphasized that a new and broader socio-scientific perspective of health education should replace the narrow one-way health communication system that had failed to adequately mobilize people for health action. The Ministers realized that mental health was becoming an important public health problem in the wake of rapid societal changes and transitions. They felt that mental health care should be expanded and made more accessible through the primary health care approach. - -. WHO'S General Programme Development and Management 17 ~nformotics Informatics support for effective programme management witnessed Management significant expansion and growth in SEARO as well as in Member Countries. The Local Area Network (LAN) in the Regional Office , was improved. About 200 computers in SEARO were connected to ' the LAN, and the average daily on-line usage is around 100 users. With the expansion of the LAN, there has been a concurrent increase in the use of e-mail within the Regional Office. More WHO Representatives' offices were linked to SEARO through e-mail during the reporting period. LAN-users in SEARO now have access to a CD-ROM-based Library Server that accesses health-related databases, including Medline, Popline and Aidsline. These facilities have improved the speed and efficiency of communication and contributed to the improvement of overall management of WHO'S technical cooperation programmes. Additional linkages between the LAN-based new test version of the Regional Office Administration and Financial Information (RO~AFI) and the SEAR0 LAN applications are being actively pursued in view of their future integration with the WHO Management Information System (MIS) that will support the Activity Management System (AMS). SEARO is represented in the global task force for the development of AMS. The Regional Office is in the process of upgrading the computing facilities in the WHO Representatives' offices to enable them to disseminate WHO information to ministries of health in a standardized format. In this connection, necessary advice and consultancy is being provided to the ministries to upgrade their informatics capabilities. - 1.9 The Work of WHO ln SEA

Human nutrition is a development priority in most SEAR countries. Nutrition WHO lays great emphasis on improving the quality of the existing nutrition programmes to combat the main nutritional deficiencies that people are prone to: protein-energy malnutrition, particularly of women and children, iodine-deficiency disorders, vitamin Adeficiency and anaemia in pregnant women. The SEAR Nutrition Research-cum-Action Network continued its activities, focusing on behavioural research and defining effective approaches to solve protein-energy malnutrition and micronutrient deficiencies. The Network Newsletter continued to be published and distributed widely. The feedback received from readers indicated that this newsletter is useful in disseminating nutrition information to national nutrition focal points and research centres. SEAR0 co-sponsored and participated in a regional meeting on Elimination of Iodine-deficiency Disorders organized by the lnternational Council for Control of Iodine-Deficiency Disorders in Bangladesh in April 1995. The main objective of the meeting was to renew international commitment to the goal of IDD elimination by the year 2000 set by the World Summit for Children. A SEARONPRO bi-regional meeting held in Manila in March 1994 discussed the progress in the two Regions in regard to the lnternational Code of Marketing Breast-Milk Substitutes. Most countries are now proceeding with legislation in this area. - .- -- - -- - - General Health Protection and Prornot~on 51 As a follow-up to the International Conference on Nutrition. information on the nutrition situation in SEAR countries was compiled. The data indicated that there was a need to strengthen the implementation of national plans of action for nutrition to addressP the priority nutrition problems in the countries. SEARO published a Regional Health Paper (No. 23) entitled "Nutrition Research in South-East Asia:The Emerging Agenda of the Future". WHO also published a booklet on "Principles of Nutrition Management in Primary Health Care" (Regional Health Paper SEARO. NO. 26), which is intended for persons responsible for integrating nutrition in primary health care at national, provincial or district levels. Bhutan, lndia and Mongolia received WHO assistance in the formulation of national plans of action for nutrition. Technical support was provided to Maldives in compiling and analysing data generated by the national nutrition survey. Nepal was assisted in anaemia control, promotion of breast-feeding and weaning foods and monitoring of the national nutrition programme. Myanmar was supported in the development of nutrition sentinel townships and strengthening of state and divisional nutrition teams. Supplies and equipment were provided to strengthen the national nutrition programmes in DPR Korea. India, Mongolia. Myanmar, Nepal and Sri Lanka. WHO supported the training of national personnel from lndia, Indonesia, Mongolia, Myanmar, Nepal and Sri Lanka by study tour and by their attendance at various meetings and training institutions throughout the world. In addition. workshops on nutrition-related subjects were supported in lndia, lndonesia and Mongolia. rn Oral Health The major thrusts of WHO'S collaboration and support to Member Countries in this area have been: assessing the overall oral health situation; promoting oral health care through strengthened health education; development of oral health care infrastructure, and appropriate training of various categories of health personnel. Specific components of the oral health programme are: provision of primary oral care for pre-school and school children; establishmentlstrengthening of national oral health centres, promotion and application of appropriate technology for reducing 52 The Work of WHO in SEA the incidence of dental diseases and maintenance of the DMFT (decayed missing filled tooth) level at 3.0. In Bangladesh. Indonesia, Nepal and Sri Lanka, promotional activities carried out since World Health Day, 1994, which had "Oral Health for A Healthy Life" as its theme, contributed in a big way to increasing public awareness about the importance of appropriate oral health care. Bangladesh has been assisted in the development of a community oral health care demonstration project which is now ready for implementation, and in educational activities for the prevention of oral and dental diseases. Essential medical equipment and books and literature were provided to Dhaka Dental College as well as to some thana health complex dental units. In India, support was provided for the formulation of a national oral health policy and for the reorientation of training for professional dentists. In Indonesia, workshops on dental rehabilitation for hospital staff were supported while technical assistance was given for training In dental auxiliary care for school teachers. The national fluoridation programme and a project on affordable toothpaste in West Kalimantan received WHO support. in Myanmar, technical support was provided for the planning and management of primary oral health care as well as group educational activities. In Sri Lanka, a workshop on bas~c oral health survey methods and production of audio-visual materials on oral health were supported. Epidemiological assessment of injuries, support for the formulation Accident and strengthening of comprehensive national programmes and Prevention education and training for creating community awareness were the major WHO collaborative efforts in the field of accident prevention. The subject of Accident Prevention, Trauma Care and Management : was discussed by the forty-seventh session of the Regional Committee, which urged the Member States to: consider setting up trauma care and management facilities; introduce legislation; enforce safety laws, and improve community awareness by popularizing safe practices. In Indonesia, collaborative efforts were directed towards improvement of safety through strengthening community awareness of, and participation in, the prevention of accident and rehabilitation .~ ~ ~ General Health Protection and Promotion 53 Tobacco or Health activities. In India, the WHO Collaborating Centre for Research and Training in Safety Technology organized an international training course on traKtc accidents and injuries. In Myanmar, support was provided fororganizing workshops on accident prevention for different * - types of personnel, from both the health and non-health sectors. In Mongolia, fellowships were provided on disaster management and emergency care. In Sri Lanka, monthly meetings of the national committee on accident prevention are held, and support was provided for the production of materials on the subject for use by the mass media. WHO continued its strong advocacy for increasing tobacco control in the Member Countries. Virtually all domestic flights in the Region are now smoke-free as are most hospitals, government offices and other workplaces. Surveys on tobacco use have been conducted in lndia, Mongolia and Thailand, which have produced baseline data for evaluating the impact of preventive education and other tobacco control activities. A major study on the health impact of smoking has been initiated in Bombay with WHO support. Technical support has been provided to Indonesia and Mongolia in order to strengthen their tobacco control programmes. Comprehensive legislation, as is already in force in Thailand, has been prepared by the Ministry of Health in lndia and has been placed before Parliament. The educational activities and campaigns against tobacco use are still mainly of the 'fear and danger' variety, which have been shown to have little impact, as is the case for other substances of abuse. Furthermore, such activities are still directed against tobacco alone, and do not address all psychoactive substances. It is necessary to stress the ~mportance of addressing all substances of abuse together in order to increase the effectiveness of such activities. The Alcohol and Drug Information Centre in Sri Lanka, an NGO, hasshown the effectiveness ofsuch an integrated approach. 54 The Work of WHO in SEA

ection I Direction, Coordination and Management The Forty-seventh World Health Assembly was held in Geneva World Health from 2 to 12 May 1994. The Minister of Health of Botswana. H.E. Assembly Mr B.K. Temane, was elected as its President. From SEAR, Dr A. Ourairat (Thailand) was elected as one of the Vice-Presidents, while Dr N.K Rai (Indonesia) was elected as Chairman of Committee 'A'. Thailand was elected as one of the Member States entitled to designate a person to serve on the Executive Board. Among the key Issues of the Assembly's 34-point agenda was the Global AlDS Strategy, which elicited much attention. The activities of the WHO Global Programme on AlDS at country, regional and global levels, including the technical support given by the Organization in a wide range of areas, the significant role played by nongovernmental organizations and the specific implications of HlVlAlDS for women were highhghted. A report was presented on the action taken to develop and establish a joint and cosponsored United Nations programme on HIVIAIDS The programme, to be administered by WHO, is expected to ensure combined effort in HIVIAIDS among six UN agencies: WHO. UNICEF, UNDP, UNFPA, UNESCO and the World Bank. The Assembly, as in the past, devoted particular attention to the implementation of its earlier resolutions, eg on the need to promote breast-feeding practices for infants and on young child nutrition. The Assembly noted the significant progress made in the improvement of maternal and infant health, but was concerned that the morbidity and mortality rates were still very high in many countries due to the poor quality of care and performance of health r care systems. It, therefore, felt that substantial improvement was 1 required. The situation with regard to tuberculosis was noted with a grave concern in view of the global spread of the disease, and i ; strong support was expressed by delegates for WHO'S tuberculosis - . programme policies and activities. "Community Action for Health" was the topic for the Technical Discussions. The need for solidarity between the health sector and : the community, particularly the role of women, and involvement of other sectors in health development were emphasized. The Forty-eighth World Health Assembly was held in Geneva : from 1 to 12 May 1995. The Minister of Health of Brunei Darussalam, Dato Dr Haji Johar Noordin, was elected as President. From the South-East Asia Region. Mr Than Nyunt (Myanmar), was elected as one of the Vice-Presidents of the Assembly. In April 1995, the Minister of Health of the Government of Mongolia wrote to the Director-General informing him of his Government's intention to join the Western Pacific Region. The Minister requested that this item be placed on the agenda of the Fortyeighth World Health Assembly. The Director-General submitted the request for consideration by the World Health Assembly under a provisional supplementary agenda item. The Assembly, by a resolution on the subject (WHA48.1) adopted on 4 May, resolved that Mongolia shall form part of the WHO Western Pacific Region. The Mongolian delegate to the Assembly expressed profound gratitude to the Regional Director and his team, as well as all Member Countries of the South-East Asia Region, for the close and fruitful cooperation that Mongolia had enjoyed during the past more than thirty years of collaboration. m In the framework of its 32-point agenda, the Assembly approved the programme budget for the financial period 1996-1997, which, in its content and presentation, took into account the various resolutions of the Executive Board and the World Health Assembly on budgetary reforms. As mentioned by the Director-General, the "budget lays the foundation for a new strategic approach to planning, budgeting and evaluation". In its relevant resolution, the Assembly appropriated an amount of US$ 842 654 000 under the Regular budget for the financial period 1996-1997. 2 The Work of WHO ~n SEA " Emergency and humanitarian action featured as an important item of concern. The Assembly recognized that disaster reduction was an integral part of sustainable development. In the relevant resolution, Member States were urged to include disaster reduction and emergency preparedness in their national development plans i and make special allocations for this purpose. Attention was also 1 focused on renewing the Health-for-All Strategy by developing a f new holistic global health policy, based on the concepts of equity 1 and solidarity. The growing inequity in health and lack of access 9 to basic health care was also highlighted in the World Health Report f 1995, the first annual survey of global health, published by WHO t at the time of the Assembly. This report will be issued every year i as a new, significant development of the WHO reform process. ! 8 Among other issues reviewed by the Assembly were: the global j strategy forthe prevention and control ofAIDS; the need to strengthen ! active surveillance of new, emerging, and re-emerging infectious ; diseases; strengthening of reproductive health in the context of ; primary health care, and recognizing reproductive health as a central component of women's health. Also, the Assembly endorsed the integrated management of the sick child as an essential tool for reaching the 1990 Summit goal of reduction of childhood mortality by 50 per cent by the year 2000. As regards WHO'S response to global change, the Assembly emphasized the need to carry the ; process forward at an accelerated pace, and to strengthen the i capacity of WHO headquartem to ensure that reforms permeate 1 through all levels of the Organization. i 1 The Assembly passed a total of 32 resolut~ons on the above ' and other subjects The South-East Asia Region is entitled to have three members on Executive the Executive Board. These are: Maldives (1991-94), Mongolia "oard (1992-95) and Nepal (1993-96). In May 1994, Thailand was i nominated to serve on the Executive Board in place of Maldives ' during the period 1994-1997. At the ninety-third session of the Board, Dr Uton Muchtar Rafei j was appointed as Regional Director for South-East Asia for five years from 1 March 1994. - Governing Bodies 3 The growlng problem of HIVIAIDS featured as an important subject on the agenda and in the debates. The Execulive Board passed a resolution rebmmending the development and eventual establishment of a joint and cosponsored United Nations programme on HIVIAIDS. -% Tuberculosis was another subject of concern. The Board approved the establishment of a Special Account for Tuberculosis within the Voluntary Fund for Health Promotion to attract increased external funding. Within the framework of review of its working, the Board decided to change its Programme Committee into a Programme Development Committee composed of six members of the Executive Board (one from each WHO region) and the Chairman or a Vice-Chairman of the Board. It also decided to establish an Administration, Budget and Finance Committee. t I The Board endorsed the Ninth General Programme of Work of ! WHO covering the period 1996-2001. w ! The ninety-fourth session of the Executive Board had a 15-point agenda. Among others, it took note of the Director-General's report on the meetings of various expert committees and study groups and on the implementation of the Global Malaria Control Shategy. It also i took note of the report of the UNICEFMMO Joint Committee on Health i Policy and endorsed its recommendatins pertaining to accelerated i action to achieve the middecade targets leading to the attainment of 1 the end-ofdecade goals set by the World Summit for Children. i ! The Board appointed Mongolia and Thailand from amongst its members to serve on the Programme Development Committee and on the Administration. Budget and Finance Committee respectively i for a period of two years. ~r The ninety-fifth session of the Executive Board held in January 1995 expressed satisfaction at the fact that over half of the 47 recommendations formulated in May 1993 by the Working Group on the WHO Response to Global Change had already been put into effect. The Board also reviewed the report of the Director-General on the progress made in the implementation of the strategy for health for all by the year 2000 and recognized that it must be continually adjusted to the evolving political, economic, sociocultural and health conditions in the world. The Board requested the - -- 4 The Work of WHO in SEA Director-General to shift additional five per cent of the budgetary resources to areas of priority indicated by it and submit the budget - ~ to the Forty-eighth World Health Assembly in May 1995. The ninety-sixth session of the Executive Board was held in Geneva on 15-16 May 1995, following the closure of the Fortyeighth World Health Assembly. Professor Li Shichuo, Director-General of the Department of International Cooperation, Ministry of Health, China, 1 4 was elected as Chairman of the Executive Board for one year. From 2 the South-East Asia Region, Bhutan was nominated as a Member i for the next three years and attended the Board meetings along with the two continuing members from the Region - Nepal and Thailand. The Executive Board heard the report of its representatives at the Forty-eighth World Health Assembly, discussed a number of reports of the scientific advisory bodies, dealt with a number of institutional and technical matters submitted for its attention and reviewed a number of documents prepared in the framework of WHO response to global change. Of the six development teams created to carry forward the process of WHO reforms, three submitted their reports to the Board: Programme Development and Management. Management Information System, and the Role of WHO Country Offices. The Board adopted two resolutions. One related to amendments to Articles 24 and 25 of the WO Constitution. It requested the Director-General to propose, for the consideration of the Forty-ninth World Health Assembly, drafl amendments to the Constitution increasing the membership of the Executive Board from 32 to 33, allowing for an additional member from the European Region. The second resolution confirmed the amendments to the Staff Rules made by the Director-General, with effect from 1 May 1995, concerning the appointment of close relatives, including spouses, as part of a United Nations system-wide plan for improving the status of women in various organizations. Two sessions of the Regional Committee for South-East Asia took : Regional place during the period covered by this report - the forty-sixth j Committee session was held in the Regional Oftice from 21 to 27 September j 1993 and the forty-seventh session in Ulaanbaatar. Mongolia, from ; 23 to 29 August 1994. Governing Bodies 5 At the forty-sixth session. Dr Uton Muchtar Rafei was nominated I r as the Regional Director for a five-year term effective 1 March 1994. The Committee also designated Dr U KO KO, the outgoing i Regional Director, as Regional Director Emeritus. The Committee reviewed the report of the Regional Director covering the period 1 July 1991 to 30 June 1993. It noted that, despite the global changes and upheavals, Member Countries of SEAR had moved forward with the formulation of national health policies and medium-term health plans to sustain the momentum for national health development and had achieved improvement in the health status of their people. "Community Action for Health" was the subject of the Technical Discussions. The Committee felt that community action for health, as an essential component of PHC, needed to be intensified and strengthened. There was a need to reorient HFA policies and strategies in view of the changing socioeconomic and epidemiological situation. The Committee expressed concern over the deteriorating .p HIVIAIDS situation. It also noted that the revised strategy for malaria, formulated at the International Conference on Malaria in Amsterdam, was being translated into national malaria control strategies in the affected countries of the Region. The Committee considered the recommendations of the Executive Board's Working Group on WHO Response to Global : Change and requested an ad hoc committee to study their implications at country and regional levels. The Sub-committee on Programme Budget reviewed the : implementation of WHO'S collaborative programme in the Region .* 1 during the first 18 months of the 1992-1993 biennium and noted : the guidelines for the preparation of the 1996-1997 programme : budget. It also urged that greater efforts be made to mobilize additional resources for health development. The forty-seventh session of the Regional Committee considered ) the report of the Regional Director for the period 1 July 1993 to ) 30 June 1994. The Committee called for the strengthening of epidemiological surveillance, for greater attention to the use of t epidemiological information and for improved laboratory support. 6 The Work of WHO in SEA "Resurgence of Tuberculosis -The Challenge" was the subject of the Technical Discussions. The Committee noted with concern the high incidence of tuberculosis in the Region and felt that the lack of diagnostic facilities and appropriately trained programme personnel were serious impediments to control. In view of the link between HIV and tuberculosis, it was necessary to strengthen sentinel su~eillance along with the training of field-level workers. With a view to evolving a stronger regional approach to address I problems common to countries of the SEA Region, the Committee E endorsed the recommendations by the Consultative Committee on j Programme Development and Management (CCPDM) to increase I resources for intercountry programmes. The Sub-committee on 1 Programme Budget also recommended that the allocation to the . intercountry programme be increased in order to provide additional f funds to tackle newly-emerging health problems that are common i to the countries of the Region and to foster regional solidarity and j cooperation. In this regard, the Regional Committee requested the 2 Regional Director to establish a working group to recommend ! modalities for mobilizinglenhancing the allocations for intercountry 1 programmes for its consideration in 1995. The Subcommittee on Programme Budget recommended that henceforth the review of the programme budget implementation by the CCPDM should cover 12-month and 24-month periods of the j biennium, while 6-month and 18-month implementation reviews ! should be carried out by the Sub-committee. The CCPDM would i thus be able to devote more attention than before to the qualitative ,! aspects of programme implementation and to advising the Regional Director on regional programme priorities.

Significant socioeconomic and political changes which had a varied Impact on public health in the countries of WOS South-East Asia Region were witnessed during the reporting period (1 July 1993 - 30 June 1995). It is now realized that the object of all development processes -social, economic, cultural and political - is the well-being of aN men and women who inhabit this world, and also of those who will do so in the future. Accordingly, the emphasis on sustainable development highlighting the place and role of health, which gained momentum with the Rio de Janeiro Summit on Environment and Development, has been carried to its logical conclusion at the World Summit for Social Development in Copenhagen in 1995. The central role of health in human development has been duly acknowledged in the Declaration and Programme of Action adopted at the Social Summit. Between Rio and Copenhagen, the disadvantaged position of women in respect of health was brought into sharp focus at the International Conference on Population and Development in Cairo in 1994, and it is hoped that the forthcoming World Conference on Women in Bepng wtll set the stage for women to occupy their rightful place in society. Happily, the worldwide focus on the health of children, highlighted by the World Summit for Children in 1990, has permeated through practically aN development activities in the Member Countries. In short, the health ofthe people has now come to occupy the centre-stage of global and national agendas for development. In 1990, the total population of the world was estimated to be 5.3 billion, of which 1.3 billion (24.5%) lived in the 11 (now 10) Member Countries of the South-East Asia Region (SEAR). The land area of the Region is approximately 8 466 600 sq km, which is six per cent of the global land mass. Between 1980 and 1990, the .~ - Executive Summary IX Region's population grew by almost 242 million and, by the year : 2000, it is expected to go up by a further 257 million, thus accounting : for 25.3 per cent of the wodd total. y The health situation in the Region is characterized by a slow decline in crude death rates and infant and under-five mortality rates as well as a gradual increase in life expectancy. The infant mortality rates have come down during the last decade in virtually all Member Countries, but they still remain high (70-100 per 1000 live births) in some countries. An analysis of under-five mortality rates shows a similar pattern. The maternal mortality rate, which has shown a slow overall decline during the last decade, continues to be high in some Member Countries. The main changes in mo~i~idity and mortality patterns during the last decade result from a decline in the incidence of polio, measles, neonatal tetanus and other EPI target diseases as well as from the declining prevalence of leprosy in the Region. The less * optimistic side of the regional health situation is characteriled by the high incidence ofacute respirato~infections, diarhoeal diseases, malnutrition and nutritional deficiency disorders, vector-bome diseases (especially malaria) and tuberculosis. The persistence of malaria and tuberculosis, the resurgence of plague, the emergence of chronic noncommunicable diseases such as cardiovascular diseases, cancer and diabetes, the emergence of other infectious diseases such as dengue haemormagic fever, Japanese encephalitis and the N tor strain of cholera, and the pandemic of AIDS and HIV infection, are the major challenges for the future. It is this scenario that has prompted the Regional Office to ~- urge governments to tackle major health problems of common concern through greater cooperation and willingness to pool and share resources in regional and intercounty programmes, the objective being to make a stronger impact on disease control and health problem reduction in a more cost-effective and cooperative manner. This initiative has given a new impetus to the spirit of solidarity that exists among Member Countries and has brought about an awareness of the benefits of cooperation in health even before cooperation in other fields of human endeavour - social, economic and ~olitical - is established. x The Work of WHO in SEA P The Consultative Committee for Programme Development and Management (CCPDM), which has been an effective and useful interface between the Regional Committee and the Regional Director and his secretariat, endorsed the need to increase the WHO Regular budget resources in regional/intercountry programmes. Following this, specific proposals were formulated under three broad strategic approaches, namely, advocacy for health, technical cooperation among countries, and international cooperation on standard setting and innovations. This augurs well for WHO'S overall technical cooperafion in the Region whjch, with endorsement by the Regional Committee, assumes importance in the context of building a regional platform for health development in a spirit of practical cooperation and partnership among Member Countries. Departing from past practice, the CCPDM also committed itself to assessing the health situation and trends and advisIng on priorities for the Region as a whole. While these initiatives give cause for satisfaction, there are continuing resource constraints within WHO. Therefore, it has now become even more important to make optimal use of the scarce resources available with the Organization. Another significant development has been the increasing involvement of multilateral financial institutions, mainly the lnternational Development Association (IDA), the lnternational Bank for Reconstruction and Development (IBRD) or the World Bank and the Asian Development Bank (AsDB). Some major bilateral agencies are also supporting ativities in the health sector. There have been changes in fnternatfonal relationships and also changes arising from reforms within the UN system itself The directing and coordinating role of WHO has not always been understood or accepted. Welcoming the interest and commitment of major financial institutions in the health sector, WHO is establishing new forms of partnership for health cooperation. The Regional Office has taken the initiative to define collaborative partnerships, for example, with the World Bank and the AsIan Development Bank. This report seeks to provide a summary of the major achievements of the WHO Regional Office for South-East Asia and its Member Countries and to draw attention to the unfinished public health agenda and the emerging challenges in the years to come. Executive Summary Governing The Forty-seventh and the Forty-eighth World Health Assemblies Bodies were held in Geneva in May 1994 and May 1995 respectively. The Foffy-seventh Health Assembly considered, inter alia, the worldwide w threat posed by the HIV/AIDS pandemic, reviewed WHO3 Global Programme to meet the challenge at all levels, and noted the action taken to develop and establish a joint and cosponsored UN pmgramme on HIV/AIDS. 'Community Action for Health' was the subject of the Technical Discussions during the Health Assembly. The role of intersectoral collaboration, with community involvement, particularly of women, was emphasized. Among other subjects discussed were infant and young child nutrition and maternal and child health, including family planning. The Forty-eight Health Assembly debated the subject of renewing the Health-for-AN Strategy and reviewed the World Health Report 1995, incorporating the Director-General's Report on The Work of WHO, which was produced for the first time and will henceforth be brought out annually Other subjects discussed % included: the third report of the monitoring of progress in the implementation of strategies for health for all by the year 2000, control of diarrhoea1 diseases and acute respiratory infections, as also emerging, re-emerging and new infectious diseases. The Health Assembly approved the programme budget for the 1996-1997 biennium. At the request of the Government of Mongolia, the Health Assembly adopted a resolution agreeing to the transfer of Mongolia from the South-East Asia to the Western Pacific Region. The Regional Committee provided guidance to Member Countries on regional health matters and on implications for the - Region of the policies enunciated at the World Health Assembly As a part of the ongoing reform process initiated by the Executive Boam: the Regional Committee undertook a review of its own method of work. The Committee decided to improve the linkages between its work and that of the Executive Board and the Health Assembly with a view to ensuring that the global policies and decisions were responsive to the regional health situation and priorities. The Forty-sixth session of the Regional Committee was held in the Regional Office in September 1993. The Committee nominated - - XII The Work of WHO~SEA Dr Uton Muchtar Rafei as the Regional Director for South-East Asia for a five-year term from 1 March 1994. It reviewed the report of the Regional Director for the period 1 July 1991 to 30 June 1993 and noted that, despite changes and upheavals, the Regional Office had continued to support the Member Countries in the formulation of national health policies and medium-term plans for sustaining health development. The Committee expressed concern over the deteriorating HIV/AlDS situation. It also reviewed the situation in respect of malaria and tuberculosis and resolved to take suitable action to tackle these problems. The forty-seventh session of the Regional Committee, held in Ulaanbaatar, Mongolia, in August 1994, considered the report of the Regional Director for the period 1 July 1993 to 30 June 1994. 'Resurgence of Tuberculosis - The Challenge', was the topic of the Technical Discussions. The Committee stressed the need for the training of field-level workers and the strengthening of technical capabilities at all levels, including sentinel surveillance. The Committee also discussed subjects such as control of preventable diseases, monitoring and evaluation of the strategies for health for all, WHO response to global change. AIDS and accident prevention and trauma care management. The Health Ministers of the countries of SEAR have established a fine tradition of developing good fraternal relationships. They have been addressing specific topics or important heatth issues in the Region. While there is a climate of understanding and cooperation, the full potential of mutual collaboration has not yet been achieved. The Ministers are agreed on the need to assess the outcome of theirpast meetings and to address the issue of technical cooperation in health among SEAR countries in a more determined manner. The Ministers met in Dhaka, Bangladesh, in November 1993 and in Ulaanbaatar, Mongolia, in August-September 1994. They discussed, inter alia, important topics such as TCDC in health, health management, new thrusts and concerns in health and health and poverty The MInIstersrecognized the need to develop common principles and guidelines for promoting TCDC and recommended formulation of plans and programmes for strengthening health management and ensuring a balanced development of health manpower While acknowledging the need to take urgent steps to arrest the spread of HlV/AIDS, they were agreed that the control - Executive Sumrnaly XIII programmes in respect of malaria, tuberculosis and leprosy needed further strengthening. The Ministers also emphasized that a new and broad socio-scientific perspective of education for health should .* *. replace the old one-way communication process that had failed to mobilize people for health action. WHO'S The Regional Director's Development Fund was effectively used Programme for the provision of specialized support to different programmes. ~~~~l~~~~~t These included: elimination of iodine-deficiency disorders, prevention and and control of dengue/DHF, review of malariogenic stratification and provision of material support, including emergency health kits, to Management meet the health situations arising from natural disasters. To reinforce support to Member Countries in the efficient delivery of the collaborative programme, the country support teams were activated through country programme formulation missions. The management infonation system has been further strengthened by improving the Local Area Network (LAN) and linking of several it offices of WHO Representatives with the Regional Office by E-mail. WHO, as the specialized UN agency for health, continued to coordinate with other UN agencies and bilateral and multilateral organizations to protect and promote the interests of the health sector. It provided support to Member Countries in the mobilization of external resources for health. Technical advice was given to the Wortd Bank and the Asian Development Bank on areas of investment in the health sector. Large funds from these two institutions are now available to health projects in Member Countries, notably India and Bangladesh. At the invitation of the Regional Director, senior officials from the Asian Development Bank met the WHO Representatives in New Delhi in November i994 and this meeting Z has led to reorientation and better understanding on the part of the Bank regarding the health sector needs in the Region. In view of the increasing importance of the role played by nongovernmental organizations, a new initiative has been taken to analyse and assess the current position of WHOiNGO colaboration in the Region. An action plan is being developed to promote NGO/GovernmenVWHO collaboration in the Member Countries. WHO assisted Member Countries in formulating emergency preparedness and response (EPR) plans and in strengthening the -- XI" The Work of WHO In SEA e health infrastructure of EPR operations. In view of the increasing demands made on WHO for technical advice and suppod relating .~ to health aspects of humanitarian emergency relief, the Organization has formulated global strategies. A Technical Officer for Emergency and Humanitarian Action has been appointed in the Regional Office in order to provide effective technical support to the Member Countries. The results of the third monitoring of the implementation of HFA Health strategies have confirmed that significant improvements have been Systems achieved in life expectancy at birth and infant mortality rates. But Development the maternal mortality rate fs still unacceptably hfgh in some countries. It has also been revealed that some countries have now entered the stage of epidemiological transition where chronic non-infectious diseases have become an important cause of morbidity and mortality. Unchanged rates of population growth in some countries is a matter of concern as the unchecked population growth largely offsets the gains of socioeconomic development thereby adversely affecting the health of the people as weN as the provision of health sewfces. The eighth issue of The Health Situation In SEA Region (1991-1993), previously entitled Bulletfn of Regional Heath Information, was published during the reporting period. it provides a comprehensive data-based analysis of the prevailing health conditions and health indicators and makes projections in the 11ght of the socioeconomic and other determinants of health. In view of the cr~t~cal importance of 'early warnfng su~eillance system' to detect communicable diseases before they assume epidemic proportions, WHO is assisting Member Countries through field epidemiological training programmes (FETPs). While such programmes are in place in Indonesia and Thailand, other countries are being provided short-term training in FETP at the National Institute of Communicable Diseases, Delhi. In the wake of the structural macroeconomic a@ustments under way in Member Countries, governmental allocations for the health sector have been reduced in real terms in several countries. The need for efficient use of the available resources for provision of quality health care with equitable access therefore becomes even more necessary. In the context of the reduced share of financial - - - Executive Summary xv Organization of Health Systems Based on Primary Health Care resources for health development activities in the national health budgets, most Member Countries are giving priority attention to health policy development and are exploring alternative methods .- of financing health care services, including privatization. WHO awarded fellowships for postgraduate training in health economics and financial management and provided financial support for organizing national workshops to sensitize senior officials to health economics and health care financing. WHO also supported studies on such subjects as health expenditure and health care utilization and management evaluation of free medical service. The Centre for Health Economics, Chulalongkorn University, Thailand, has been designated as the WHO Collaborating Centre on Health Economics. The Centre has been conducting M.Sc. and short-term courses on health economics, with support from WHO. The managerial process for national health development has been strengthened in the Member Countries with WHO'S support being provided in health policy analysis, rnedium-term planning and t development of a critical mass of health planners and managers. Technical support was also provided to countries with a view to attracting and propefiy utilizing the Wolld Bank's and other external assistance in the health sector. The role of health legislation in the implementation of HFA strategies has been acknowledged for long. WHO has extended support to Member Countries in formulating and strengthening their health legislat~ons. Almost a// Member Countries of the Region have recorded progress - in the reorientation and restructuring of their health systems based on primary health care. Access to primary health care is being expanded, through strengthening of the district health system, expansion of health infrastructure, improvement of health care for women and children and through a targeted approach to reach the underprivileged. Countries are now giving increased attention to urban health care through the application of WHO'S 'Healthy City' approach. The role of the community as an active partner in health development has been further developed through the training of health volunteers and HFA leadership. XVI The Work of WHO in SEA Efforts to improve hospital care, particularly at the first referral level, and strengthen linkage with primary health care have been - . pursued. A number of countries have initiated programmes for quality assurance of hospital care. However, differences in the general health status of people in the countries have persisted. Disaggregated data within countries also reflect inequities among different population groups. The coverage of the eight elements of primary health care has generally shown an improvement due largely to expanded health infrastructure, as reflected by the third monitoring of the implementation of HFA strategies. However, it has been obse~ed that health workers and their supervisors are not fully oriented to the PHC approach, which rests upon integrated delivery, ~ntersectoral collaboration and community pafticipation. Community involvement and mobilization through the selection and training of health volunteers have been established as strong components of national health policies and strategies in several - Member Countries. This approach has contributed to the development and promotion of self-care as pad of the daily life of the people. Various community-based innovative activities, such as village drug funds, village sanitation funds, village health ~nsurance schemes, community dental health schemes, maternity homes and traditional herbal gardens have also been evolved. Through the involvement of other social development sectors, a broader social development approach for achieving the basic minimum needs and improving the quality of life is the theme of health development in some of the countries. Community organization and mobilization, in partnership with health workers, is necessary in order to deliverheatth care package in the community, as the Posyandu and village health care post schemes are doing. There has been progress in the development of human resources Development for health (HRH) in most countries of the Region. Howeve!; lack of of Human relevance of training/educational programmes to the health needs Resources for of the people and imbalances in HRH, both in terms of numbers ~~,,l+h and categories and their deployment in rural and urban areas, continue to cause concern. The increasing role of the private sector tn providing medical and health care is partly responsible for the imbalance in HRH. Therefore, the role of governments in ensuring ~ Executive Summary xvli equity and quality of health care through proper regulation assumes greater importance. I The need to reorient medical education to be in line with the community's needs can scarcely be overemphasized in this context. Member Countries are linking up their medical schools with the health services in many ways. In some countries, research- and enquiry-driven approaches to reorient medical education are being developed, while others are implementing problem-based learning in their medical schools. WHO has continued to support the development of sustainable systems of medical education by aligning it with the health needs of the communities. Despite progress in the expansion and reorientation of basic and post-basic educational programmes for nursing and midwifery personnel, shortages and imbalances still persist in most Member Countries. In the context of programmes for safe motherhood and child survival, there is an urgent need to increase the production of nurses and trained midwives. P WHO'S programme for strengthening institutional capacity for the development of health learning materials (HLM) in Member Countries has started showing results in the range and quality of materials being developed or adapted to meet the needs of different categories of health workers. Since the completion of a regional HLM project in 1994, some of the countries have incorporated HLM in their regular human resources development plans and budgets. WHO'S Collaborating Centre for HLM in Kathmandu has continued to support Member Countries in key technical areas through training, consultancies and exchange of information. However, notwithstanding the progress made, much more needs to be done. The Organization will continue to support Member Countries' efforts = in this regard. WHO'S fellowship programme has enabled national health authorities to improve their human resources for health, both in terms of numbers and quality, and to keep abreast with the latest advances. As fellowsh$s play a significant role in the inprovement of HRH, 22 per cent of the total country allocations for the 1994-1995 biennium has been earmarked for this purpose. Further, in order to make study tours more cost-effective and relevant, a package study tour on PHC at the district level is being developed. xviii The Work of WHO in SEA C Information and education for heaMh (IEH) continues to be Public strengthened in support of primary health care. People now have information - a greater awareness of health matters like life-style-related diseases, and ~d~~~ti~~ the importance of immunization for children and prevention of communicable diseases, includfng HIV/AIDS. Designation of the for Health Indian Institute of Mass Communication in 1994 as a WHO Collaborating Centre for Health Communication is 11kely to accelerate progress in the dissemination of IEH through the electronic and prfnt media. Comprehensive guidelines for school health education would also help Member Countries in inculcating appropriate attitudes and behaviour towards better health among the youngergeneration. At the regional level, an added impetus to IEH is expected with the implemenfation of the new WHO Communications and Public Relations Policy, which aims at creatfng proper awareness of the objectives and programmes of WHO. fostering involvement in its work and advocating health for all, along with a coherent , approach to health development. To start with, health advocacy materials forthe Region are being developed and efforts to strengthen links with the media have been initfated. During the reporting period, the Regional Office initfated action to operationalize its research programme in accordance with the research strategy endorsed by the South-East Asia Advisory Committee on Health Research (ACHR) in 1993. Based on the strategy, a technical publication 'Health Research Strategies of the South-East Asia Reg~on' was produced. The strategy emphasizes that within HSR components such as health policy and health promotion, health economics, health behaviourand health manpower development should receive greater attention. The Regional Office has supported a series of inter-related activities for the promotion and development of research in these priority areas. A strategic plan for future activities was developed at the Th~rd Meetfng of the SEA Nutrition Research-cum-Action Network Direct support for research was provided, among others, for projects on HIV infection, treatment of drug-resistant Pfalciparum malarfa, influence of the reservoirs of malaria infection in transmission dynamics, tuberculosfs, the elderly, nutrition and traditional medicine, quality of antenatal care services, and weaning behaviour. Research Promotion and Development Including Research on Health- promoting Behaviour . . -. . . - Executive Summary National research capability has been strengthened through various forms of cooperation: e.g multicentre collaborative research programme fordevelqwnent and validation of technical and operational - guidelines for retarding the growth of drug-resistant P. falciparum; multbntre study of the process and outcome of collaboration between nu- services and nursing education, and technical and financial support to the dengue vaccine development programme at Mahidol Universify. Thailad. There are at present 81 WHO odlaborating centres in the Region in a variety of health-related Ws. During the period under review, new collaborating centres were designated in the fields of health economics, health communication and cancer control. The ACHR, at its twentieth meeting in 1994, recommended that research on health policy, assessment, development and transfer of appfupriate diagnostic technology and behavioural aspects of health should receive greater attention. At its twenty-first meeting in 1995, the Committee outlined specific research directions under the Regional Research Promotion and Development Programme for the next three biennia. s. The twentieth anniversaiy commemorative session of the ACHR was held in the Regional Office on 8 April 1995. In addition to the ACHR members and WHO secretariat, the past ACHR chairpersons and the Regional Director Emeritus pariicipated in the session. While commending its achievements since its inception, members recommended that the ACHR should take due cognizance of the epidemiologic, demographic, socioeconomic and cultural changes that had occurred in recent years and formulate appropriate health research strategies for the future. The ninth meeting of the Directors of Medical Research Councils or Analogous Bodies and Concerned Research Foci in the Relevant Ministries made recommendations relating to HIV/AIDS, dengue vaccine trial, operational research on tuberculosis control and future trends assessment It also discussed the mechanisms of implementing the regional strategy for health research in the Member Countries. Geneml Health Nutrition continues to remain a priority area in the Region. WHO Prote~tion 0~d : support has been given for improving the quality of national Promotion , prwrammes to address protein-energy malnutrition, iodine and vitamin A deficiency disorders and iron-deficiency anaemia, -- XX The Work of WHO In SEA particularly in pregnant women. The Nutrition Research-cum-Action Network, established in the Region, continued to address these - problems. The Network Newsletter was disseminated to national nutrition focal points and research centres. A regional meeting on Elimination of Iodine Defroency Disorders (IDD) reviewed international commitment to the goal of IDD elimination by the year 2000. The lnternational Code of Marketing Breast-milk Subsbtutes is being implemented in most countries of the Region. As a follow-up of the lnternational Conference on Nutrition (ICN), Member Countries have developed revised nutrition policies and programmes to implement the World Declaration and Plan of Action for Nutrition. WHO also supported training for micronutrient malnutrition control, breast-feeding and weaning foods, development of nutrition monitoring system and the production of radio and television programmes to address specific national nutritron problems. Though the importance of oral health and the health of working populations is well recognized, Member Countries need to match this commitment with financial outlays in their national health budgets. WHO's collaborative role has concentrated on sensitizing the decision-makers and health-providers in this regard as well as on the development and strengthening of national programmes with strong components to secure intersectoral action and inter-departmental collaboration. As activities towards reduction in tobacco consumption continue to face stiff resistance from certain quarters, WHO's role will have to consist mainly of supporling advocacy, research on demand reduction, health ~nformation and education and legislation for tobacco control in Member Countries. integration of MCHEP services in primary health care is now Protection and universally accepted Though significant achievements have been promotion of made in all Member Countries in bringing down the infant mortality ~~~l~h of rate ((IMR), similar success has not been achieved ;n the reduction of maternal and neonatal mortality. Therefore, while responding to Specific countw-specific needs in all aspects of MCH/FP, WHO has given a PO~ulati~n high priority to the safe motherhood programme in the Region. It Groups assisted national workshops and the development of national plans in safe motherhood. WHO's 'Mother-Baby Package' has been -- Execut~ve Summary XXI introduced in four countries having a high maternal mortality rate (MMR). WHO contributed globally-accepted conceptual and technical guidelines with regard to reproductive health at the International , Conference on Population and Development in Cairo in 1994. The plan of action adopted by the Conference included reduction of infant/child mortality and provision of universal access to reproductive health services, including family planning and sexual health, which are in line with WHO'S Ninth General Programme of Work (i996-2001). The Organization is fully committed to supporting the implementation of national plans of action while maintaining a broad and holistic approach to reproductive health care. Adolescent health was started as a separate WHO programme in 1991-92, and activities under this programme are gradually gaining momentum. Most Member Countries recognize the changing lifestyles of the young and accept the need for giving more attention to their health. At country level, WHO directed its efforts at the promotion and protection of health of adolescents and youth, particularly in the areas of reproductive health, use of tobacco, drug abuse and healthy lifestyles, including sports. Collaboration with the Special Programme on Human Reproduction Research was continued, with strong inputs from the Regional Office for strengthening research capabilities in Member Countries. Towards this end, regional and national workshops were supported, and long-term institutional development and capital grants were approved for four countries. Protection and The rapid demographic transition and the consequent Qreying of Promofion of populations', on an increasing scale, has particular health _ ~~~~d ~~~l~h implications. WHO'S catalytic role in sensitization and country support included assessment of the magnitude of the problem and strategies for coping with it. WHO'S collaborative programme in matters of lifestyle and behavioural-psychosocial health issues includes improvement of the quality of life and well-being of the mentally affected persons; lessening of the perceived burden on families caring for an incurably ill or disabled family member; psychosocial interventions to improve the capacity of disadvantaged families to cope with disaster survivors or refugees, and interventions to improve outcomes in disadvantaged - - xxlt The Woh of WHO ~n SEA - children. The bpen community approach' to drug abuse control, which combines elements ofprevention, treatment and rehabilitation, and minimization of harm to drug injectors, has gained further acceptance in the Region. Evaluation of some projects using this approach has shown excellent results. WHO continued to promote and demonstrate the concept of the public health approach in mental health in place of the traditional institution-orientedpsychiatry. Following the adoption of the WHO Global Strategy for Health and ' Promotion of Environment, a regional strategic plan was developed within the Environmental framework of the Organization's collaborative activities with Member ~~~l~h Countries. The promotion of environmental health is aimed at achieving universal safe drinking water supply and adequate sanitation by the year 2000, improved urban env~ronmental health conditions, safe management of chemicals, monitoring and control of environmental hazards from pollution, particularly in urban areas, and the strengthening of food safety programmes. In the area of community water supply, WHO has supported institutional development through review of policies, special studies, and human resource development in water quality surveillance, comrnunityinvolvement andsectorinformation management. A number of 'Healthy City' prujects have been initiated in the Region to improve municipal water supply, sanitation, solid waste management and other environmental health conditions. To cope with the growing problems posed by chemicals used in agriculture and Industries, WHO'S collaboration has been directed towards strengthening national capabilities to manage chemicals safely without adverse effects to human health and the environment. In the field of food safety, the focus was also on the development of institutional capabilities and human resources for national food control agencies. WHO continued its support to Member Countries in strengthening their health laboratory services through training programmes and sustenance of quality assurance. A regional publication, covering health laboratory network, appropriate technology and quality assurance, was published. Self-reliance in modern immunological and biological reagents, particularly for the development of rapid Diagnostic, Therapeutic and Rehabilitative Technology - ~- Execut~ve Summary xxiii diagnostic tests for communicable diseases, has been supported in the Region. WO continued to support proficiency testing and development of national capabilities in cost-effectivep -. sero-surveillance of AIDS. Support was also extended to safety measures in radiology and radiotherapy services. The WHO Collaborating Centre in Radiation Safety at Bombay will take over the thermoluminiscent dosimetry (TLD) services for some Member Countries in 1996. National drug programmes are developing in the context of the revised drug strategy of WHO. The drug situation has been reviewed, and plans of action have been developed, with emphasis on drug management and policy, quality assurance, rational use of drugs and the supply and logistics of essential drugs for primary health care. A WHO bi-regional meeting on technical cooperation among countries (TCACJ, involving the South-East Asia and the Western Pacific regions, discussed drug quality assurance and the use of the WHO certification scheme for ensuring the quality of pharmaceuticals moving in international trade. It was evident that development of human resources was the common need. WHO has given priority to strengthening drug quality control and assurance at regional and country levels. Three WHO collaborating centres are instrumental in promoting the quality of pharmaceutical products at the regional level. As traditional medicine (JRM) is ingrained in the cultural and social ethos of the peoples of the Region, WHO has been assisting Member Countr~es in strengthening national JRM programmes with emphasis on training TRM practitioners in the promotive and preventive aspects of health. Standardization, quality control and r; utilization of herbal medicines and other traditional remedies are also being supported. At the regional level, three WHO collaborating centres on TRM have been established, which are playing an important role in the training of human resources. The concept of community-based rehabilitation (CBR) was actively promoted. Besides strengthening referral systems for rehabilitation, activities such as the international initiative to prevent avoidable disabilities, production of low-cost prosthetic and orthotic appliances and training of health personnel in CBR were undertaken. XXIV The Work of WHO ~n SEA U During the reporting period, reduction in the incidence of vaccine-preventable diseases was quite impressive. Region-wide immunization coverage has been sustained at 80 per cent. The need now is to achieve a similar degree of coverage at sub-national levels which are poorly covered at present. Hence, WHO is giving priority for increasing immunization coverage in all areaddistricts within countries along with effective surveillance. As immunization coverage in Member Countries is now being reported on a district-wise basis, the emphasis is on targeting and reaching the undersewed. An analysis of the reported cases of poliomyelitis in India suggests that the occurrence of paralytic poliomyelitis is approaching a lower endemic pattern. WHO collaboration is, therefore, aimed at supporting the nation-wide intensification of immunization campaign strategies (e.g. National Immunization Day) for preventing outbreaks as occurred in the States of Gujarat and Kamataka in 1994. Technical support has been provided in the stratification of malarious areas to facilitate cost-effective and selective vector control in highly endemic foci. Integrated vector-bome disease control has been conducted in those Member Countries where kala-azar continues to be endemic. WHO has assisted in the formulation of guidelines for the control of kala-azar, training of staff in the control of dengue and Japanese encephalitis and ; integration of filariasis control programmes with other vector control activities. With the active collaboration and support of WHO, all malarious countries have completed reviews of their malaria situation and adopted the revised malaria control strategy. The regional collaborative programme on drug-resistant malaria was revived. j The overall malaria situation in the Region has remained static for ' the last ten years, with the case incidence ranging between 2.5 1 and 3.0 million cases. Mass treatment of children with intestinal parasitic diseases has been carried out by a majority of the Member Countries. A WHONNDP pilot project commenced in Bangladesh, while another in Maldives has been prepared for donor funding. Visceral ,, leishmaniasis continues to be a problem in some countries where '' WHO has supported training of medical officers. Lymphatic filariasis Disease Prevention and Control Executive Summary xxv continues to persist as a public health problem. UlHO supported the endemic countries to develop an integrated approach for the control of tllariasis with active community participation. India, the only country in the Region having guineaworn, expects to be rid B - I of rt by the end of 1995. i Collaboration with the UNDPMdd BankAwO Special Programme for Research and Training in Tropical Diseases was continued for research capability strengthening. A number of long- and short-term institutional grants and other grants were approved during the reporting period. A total of 47 projects went supported with grants for study in the fields of malaria, filariasis, leprosy and leishmaniasis. Major programmes supported during the period were filariasis, leprosy and malaria. 1 The regional diarrhoea1 disease control programme promoted 1 standard dianhoea case management at home and at health i facilities. With the production of oral rehydration solution (ORS) t reaching 121.5 million litres in 1994, access to ORS has increased. The proportion of trained supervisory and clinical management staff has also increased in all Member Countries. To help in combating the strain of V. Cholerae 0139, the Regional Offce has provided laboratory equipment and 0139 antiserum so that national : laboratories have the means to characterize the cultures. Acute respiratory infections (ARls) are the most common cause i of death among children under five years of age. ARls account for I more than four million deaths each year worldwide; more than 40 1 par cent of thase deaths occur in Bangladesh. India, lndonesia and i Nepal. AN the Member Countries with an IMR of more than 4W1000 i live births have initiated control of ARI with the objective of reducing deaths by using the standard case management method * recommended by WHO. The Regional Office is collaborating with j UNICEF, the World Bank, USAID and others to expand and strengthen : national control efforts. I WHO declared tuberculosis as a global emergency in 1993 as rt kills more adults than any other single infectious disease. I assemination of the wised strategy to provide standardized 1 short-course chemotherapy to at least aN sputum-positive I tuberculosis patients was promoted through training and advocacy. i Some Member Countries have revised their national tuberculosis XXVI The Work of WHO in SEA - programmes in line with the new strategy and have prepared five-year plans and started pilot projects. I P g .~ Implementation of multidrug therapy (MDV for a decade now [ has resulted in a dramatic decline in leprosy cases. Leprosy control i was intensified in the endemic countries, and WHO collaborated in : the review and updating of national plans of action. Based on the WHO regional strategy for the elimination of the disease, regional plans of action for the elimination of leprosy were developed. Member Countries have agreed to expand MOT to 100 per cent geographical coverage by December 1995 in order to achieve the goal of elimination by the year 2000. WHO also provided timely support for the control and containment of the plague outbreak in lndia in 1994, International experts were assigned to train local personnel in the laboratory diagnosis of plague. An independent team comprising international experts was formed by the WHO Director-General to investiage the outbreak. The Government of lndia appointed a speical advisory committee on plague to determine the factors responsible for this outbreak. An intenegional meeting on the prevention and control of plague epidemic was also convened in the Regional Office in March 1995. As sexually transmitted diseases (STDs) are a serious health problem, WHO is actively promoting ST0 case management as part of general health services. It also provides support to strengthen STD services as part of national AIDS prevention and control programmes. Concerted efforts are being made to overcome difficulties in condom promotion and its social marketing. In many countries, STD and AIDS programmes have now been integrated, but lack of drugs to treat ST0 is a major constraint. WHO continued to provide technical support to national AIDS control programmes, emphasizing the multisectoral approach and the involvement of NGOs Many Member Countries made progress in developing a broad-based multisectoral approach to HIV/AIDS. National efforts in areas such as health education and targeted interventions, treatment and prevention of sexually transmitted diseases, condom promotion and quality assurance, counselling, sentinel surveillance and laboratory diagnosis are being supported. ': Political commitment is well established. Care of HIV/AIDS patients, Executive Summary xxvii 1 as a part of primary health care, is now a priority. There are still constraints to mounting an effective response to the expanding pandemic. 'The need to step up national effort with intematmnal support to combat this threat to human civilization is urgent. "h i The Regional Office has brought out a monograph containing information on the prevention and control of denguaDHF. WHO supported national workshops and seminars on dengueDHF. A tetravalent live attenuated dengue vaccine has been developed : with WO support at Mahidol University, Thailand, and is ready to I undergo Phase 111 trials. i < Outbreaks of hepatitis A and hepatitis B infection have been I reported in a number of countries. WO provided technical information and diagnostic reagents to the countries. Neisseria meningitis is also a significant cause of mohidity and mortality in i some countries of the Region. WHO assisted in the organization of i surveillance, chemoprophylaxis and vaccination. P Many countries in the Region have had well-established programmes for the prevention of blindness formany years. Reducing the backlog of cataract-induced blindness, provision of outreach 1 services to the underserved and promotion of community eye care : are some of the significant objectives of blindness control i programmes. WHO'S collaborative role in canying out epidemiological ' surveys to assess the magnitude of the problems of deafness and hearing impairment, and to sensitize the decision-makers towards developing and/or strengthening national pmgmmmes for their : prevention was continued. { WHO continued to advocate the development and - i implementation of comprehensive national cancer control i : programmes, focusing on prevention, early detection and treatment $ i and on palliative care, and using inexpensive and effective ! interventions in preference to costly curative approaches requiring j sophisticated equipment. Inspection of the oral cavity of I tobacco-chewers and speculum inspection of the cervix with biopsy are typical examples of this approach. WHO is supporting studies $ i to establish the feasibility and effectiveness of various approaches i towards improving the public health relevance of cancer control i i programmes. XXVIII The Wok of WHO in SEA Since risk factors for cam'rovascular diseases tend to be the same as for cancer and diabetes, WHO is promoting an integrated . . approach to the reduction of such risks. Some baseline studies on risk factors like smoking, a sedentary lifestyle and a high animal-fat diet have been supported by WHO. Ways will be explored to promote an integrated and public health-oriented approach to the control of cardiovascular diseases. i 1 i The Regional Office Librarymntinuedto provide technicalinformation and literature support to WHO staff, health pmfessionals and informa~ion scientists, United Nations agencies, biomedical researchers and Support others interested. It continued to acquire health literature, ; international databases such as AIDSLINE, MEDLINE and POPLINE 1 i on CD-ROM and sub-sets of WHOLIS. It also developed and expanded its computerized databases V~Z. SEALIS, IMSEAR, EMS and PMS. Information retrieval and document delivery capabilities in the WHO 1 Representatives' offices were strengthened by providing library j orientation programme to their staff The HELLIS (Health Literature, Library and lnformation Services) network has now 10 designated ' national focal points and over 315 participating libraries. Health science libraries in the Member Countries were provided with ' photocopiers and computers and CD-ROM drives and EMS/PMS ! software for library automation. I Administration and Finance, formerly known as Support Services, continued to deploy its activities to provide the support required for the WHO Regional Office, the WHO country offices and all WHO collaborative programmes. Of the 149 established professional posts, 119 have been filled as of 30 June 1995. A total of 228 consultants were fielded during the two-yearperiod in addition, contracts with nationalprofessionals were concluded through Special Services Agreement to carry out activities of a technical or managerial nature. During June 1995, 131 such agreements were in operation in the Region. Staff development and training activities were continued as an essential component of human resources policy. Staff were enabled to take Support Services Execut~ve Summary xxix 1 part in seminars, workshops and courses in order to acquire or 1 improve technical and management skills. i ! Administrative services refurbished office premises. Renovation - e- I of the airconditioning plant was completed. One of the two old lies I in the main building was replaced while works wen, under way to i replace the second one. Renovation of the Reception area and the Committee Room is the main work done among other activities. The planned programme budget for the biennium 1994-1995 i from the Regular budget was US$99 million. In view of the budgetary : 1 constraints experienced by the Organization, only US94.7 million had been made available as of 30 June 1995. Of this, the total : obligation for the first 18 months of the biennium amounted to US$65 million. Medical supplies and equipment worth US$38.2 million were procured for various projects of technical cooperation under country and intercountry programmes from regular budget and extra-budgetary resources during the period. Extrabudgetary resources accounted for approximately 60 per cent of the total procurement. Procurement of drugs and office equipment through local supplies, wherever appropriate, resulted in considerable savings. The computerization of supply operations was completed with a view to making available a more comprehensive and timely information to the offices of the WHO Representatives. xxx The Wotk of WHO in SEA

Clinical, Laboratory and Radiological Technology for Health Systems Based on Primary Health Care The role of laboratories in health care is gaining increasing importance in view of the prevailing and reemerging infectious diseases, particularly in developing countries. WHO, therefore, has continued to support the strengthening of health laboratory services as an integral component of health care at intermediate and peripheral levels through the provision of supplies and equipment, national training programmes, introduction of appropriate laboratory technology and quality assurance programmes. An intercountry project to strengthen health laboratories for effective delivery of primary health care in Bhutan, India, Indonesia, Maldives, Mongolia and Myanmarwas completed in 1994. A Regional Publication (SEARO, No.24) entitled 'Health Laboratory Services in Support of Primary Health Care in Developing Countries' was brought out in 1994 to serve as a regional guide to countries. Assistance was continued to countries for achieving self-reliance " in imrnunodiagnostic reagents. Development and production of reagents for rapid diagnostic techniques for surveillance of priority communicable diseases such as dengue haemorrhagic fever. Japanese encephalitis, hepatitis, amoebiasis, enteric fever, shigellosis and acute respiratory infections was supported. The National Institute of Immunology, New Delhi. India, offered training facilities in the technology for rapid diagnostic reagents for amoebiasis, pregnancy testing, typhoid fever and hepatitis 8. Myanmar and Sri Lanka have adopted the rapid ELlSA technique - 72 The Work of WHO in SEA for the diagnosis of HBS antigen. The National lnstitute of Virology, ; Pune, India, and the National Institute of Health, Bangkok, Thailand, i I continued to supply test kits for the surveillance of Japanese 1 encephalitis and diagnostic antisera for Shigella dysenteriae to other institutions in the Region. WHO assisted Member Countries in the quality control of laboratory technology. India, Indonesia, Maldives. Nepal. Sri Lanka and Thailand received support for taking part in the global external quality assessment programmes in clinical chemistry, microbiology and haematology. National External Quality Assessment Schemes ' (NEQAS) have been introduced for clinical chemistcy, haematology, clinical microbiology and clinical immunology in India, Indonesia and Thailand. Nepal and Myanmar, which have been conducting NEQAS in clinical chemistry in selected laboratories, are poised for extending the network for clinical chemistry to cover clinical microbiology and haematology. Under the Global Programme on AIDS (GPA). WHO support was continued not only in improving HIV testing technology but also in disseminating knowledge about the cost-effectiveness of the HIV testing strategy developed by the Organization, which is being appropriately publicized. To improve HIV testing technology. the International Quality Assessment programme of HIV testing is being conducted globally by GPA where the participation of Bangladesh. Bhutan, India, Indonesia, Maldives, Myanmar, Nepal, Sri Lanka and Thailand is being supported by WHO. A network is being planned for HIV testing and evaluation of HIV test kits in the countries of the Region An intercountry workshop to promote distance learning materials in blood safety was held in Lucknow, India, in March 1995 for streamlining the training of laboratory technologists working in blood transfusion services. Progress in the development of national blood transfusion policies was made in all the countries of the Region. WHO continued to support safety measures in radiology and radiotherapy services. Support was given to Bangladesh. India. Maldives and Nepal for participation in a personal dosimetry monitoring programme conducted by the International Atomic Energy Agency (IAEA). [)lagnostic, Therapeutic and Rehabilitative Technology Essential WHO has been collaborating in the strengthening of national essential D~~~~ and drugs programmes with emphasis on national drug policies, drug quality control and assurance, rational use of drugs and Improvement of supplies and logistics An important element in the technical ' inputs to these programme areas was the development of human resources The 1994-1995 biennium witnessed some important achievements. The national drugs programmes developed in all SEAR countries in the context of the Revised Drug Strategy of WHO. Revision of national essential drugs lists, procurement and supply of essential drugs and their rational use, drug information, essential drugs production, drug legislation, regulatory control and quality assurance were some of the important components of these programmes. Bangladesh. Bhutan, India, Indonesia, Maldives, Mongolia, Myanmar, Nepal, Sri Lanka and Thailand were assisted by WHO in strengthening their essential drugs programmes. The success of the essential drugs programmes in the Region . sewed as a backdrop for a video film produced as an advocacy medium to promote the concept of essential drugs and to create awareness about the inter-dependence of all the components of a national drug policy The WHO Bi-regional Meeting on Technical Cooperation Among Countries VCAC) involving the South-East Asia and Western Pacific Regions was held in Kuala Lumpur in December 1994. The issues discussed related to the broad areas of drug quality assurance with a focus on current good manufacturing practices (GMP) in the production of pharmaceuticals, drug analysis, drug safety evaluation and the use of the WHO Certification Scheme. Human resources were given special consideration in the development and .- strengthening of the various programme areas. SEAR0 and WPRO are actively involved in providing assistance in the formulation and implementation of the ASEAN technical cooperation project in the field of pharmaceuticals. Starting from Phase IV of the project covering the period 1992 to 1996. DAPMQ has been supporting it technically and financially, as an interim arrangement, while assistance from the former supporter of the project, UNDP, and voluntarily donated funds are being sought. present activities of the programme include training of GMP -- The Work of WHO in SEA 74 inspectors/auditors, strengthening of quality assurance, drug I evaluation, production and utilization of regional standards and reference substances, clinical pharmacy and improvement of , communication skills of pharmacists and pharmacy staff. standardization, quality control and utilization of herbal medicine and exchange of information on drug regulatory matters. ASEAN Working Group Meetings were held in Jakarta in December 1993 and in Kuala Lumpur in December 1994 to review the progress of the programme, both in technical and financial terms, and to formulate work plans for the ensuing year. Rational use of drugs (RUD) has been receiving special attention in the Region. Regional and national strategies have been identified to promote RUD. Myanmar was specifically assisted in the application of RUD. Availability of essential drugs for primary health care is an important target of the health-for-all strategy. WHO has been strengthening the supply and logistics of essential drugs through support to the management systems of drugs at central and peripheral levels, including storage and distribution. One of the strategies for improving the management system is through computerization, which IS being assisted in several countries such as Bhutan, Maldives, Mongolia. Myanmar, Nepal and Thailand. This not only provides information on management of drugs but is also important in planning, procurement, recording and reporting of activities and budgetary control. The acute shortage of essential drugs in some countries necessitated mobilizatiion of resources for their procurement. The Mongo\emirnpex in Mongolia and nine townships of rural Myanmar were supplied with essential drugs purchased with extrabudgetary funds. WHO has been assisting in the development of regional and national Drugs and mechanisms for quality control and quality assurance of essential Vaccine drugs and vaccines. At the regional level, the three WHO Collaborating lit^, Centres for Qual~ty Assurance of Essential Drugs and the three centres for training and the testing of vaccines used in EPI are Safety and instrumental in promoting the quality of pharmaceutical products. Efficacy National centres for quality control of essential drugs are being strengthened in several countries. -- -- - Dlagnostlc ~herapeut~cand Rehabllltat~ve Technology 75 The Japan Pharmaceutical Manufacturers' Association (JPMA) has been collaborating with SEAR0 since November 1993 in the development, production and use of drug reference substances, ' donation of pharmaceutical books and acceptance of technical trainees from SEAR for training in JPMA-member companies in the area of quality control of pharmaceuticals. The WHO certification scheme on the quality of pharmaceutical products moving in international commerce is an effective mechanism for ensuring the quality of drugs and vaccines. The applicability of the scheme was assessed by DAPMQ in all regions of WHO, except the European Region. In SEAR, theassessment was carried out in Myanmar : and Sri Lanka as importing countries. The evaluation of the application of the scheme was canied out in India as an expohng wuntry. The use of the scheme provides information to importing countries about the licensing status of a pharmaceutical product in the exporting wuntry, the manufacturer's good manufacturing practices and the quality of individual batches of imported products. The exporting agency shares the responsibility for the quality of the products by providing * technical information, through its national authorities, to the importing wuntry. The scheme thus helps to ensure the quality of pharmaceutical products moving in international commerce. The scheme is being promoted for wider application in the Region. Traditional 1 Traditional medicine (TRM) is ingrained in the cultural and social fabric Medicine : of SEAR wuntries. WHO has been assisting Bangladesh, India. Indonesia. DPR Korea, Mongolia, Myanmar, Nepal and Thailand in strengthening the national TRM programmes with emphasis on the training of traditional practitioners in the promotive and preventive aspects of traditional medicine for primary health care, quality control -c : of traditional drugs and standardization of their raw materials, strengthening of pharmawgnosy, phytochemistry and pharmacology. It has also assisted in the preparation of herbaria in order to improve ! the preventive, promotional and curative properties of TRM. Rehabilitation Epidemiological assessment of various types of disabilities and i identification and adoption of appropriate approaches and technologies for their prevention and rehabilitation continued to The Work of WHO in SEA 76 receive attention during the reporting period. Promotion of community-based rehabilitation (CBR), training of various health personnel in CBR, production of lowcost prosthetic and orthotic - appliances and the development of referral service networks were the main focus of WHO collaborative activities in this field. Support was provided to Bangladesh, Indonesia, Sri Lanka and Thailand in the organization of training workshops, development of baseline data, strengthening of rehabilitation centres and development of rehabilitation networks. - - Diagnost~c, Therapeutic and Rehabilitative Technology 77

lmmunization During the 1993-1995 biennium, there has been a dramatic expansion of disease-reduction activities in the countries of the Region. Immunization coverage in the Region as a whole has been sustained at 80 per cent (Figures 3 and 4). However, concern has begun to be voiced regarding the maintenance of this percentage of coverage at country and sub-national levels, since, in some * countries, there has been a drop in coverage recently. WHO continued to give priority to increasing immunization coverage in all areasldistricts within the countries. I Figure 3. Immunization coverage in SEAR, 1988-1994 Flgure 4 Reported immunization coverage, 1993-1994 South-East Asia Region 100 I 60 40 ~ 20 I 0' lMN BilU liPHK IND IN0 MAY MOG MMR NFP SHl Tl(4 SEA EPI target diseases oontinue to show a declining trend in incidence in the Regron (Figure 4). In regard to poliomyelitis, this trend can very largely be attributed to the results of the programme in India. An analysis of the trend of reported cases of poliomyelitis suggests that perhaps India has now reached a national level of control where the occurrence of paralytic poliomyelitis is predominantly endemic rather than epidemic (Figure 5). This finding strongly supports the Government's decision to conduct an All-India National Immunization Day for polio eradication in December 1995. While Thailand and Sri Lanka have been consistently monitoring and evaluating poliomyelitis surveillance indicators, the other countries are currently taking steps that will significantly enhance the sensitivity of acute flaccid paralysis (AFP) reporting. In 1993. the SEAR Poliomyelitis Laboratory Network, consisting of 11 laboratories, processed approximately 2000 stool specimens. There is a critical need to expand and improve public health laboratory services for the eradication of poliomyelitis in the Region. It rs estimated that half a mill~on deaths from newborn tetanus are prevented annually in the Reg~on, through tetanus toxo~d Disease Prevention and Control 79 I @po,#o NNT Meaiies ! Figure 5 Reported cases of paralytic poliomyelitis, neonatal tetanus and measles, SEAR, 1987-1994 Figure 6. Reported poliomyelitis cases by month, India, January 1992 -December 1994 .. 0 Jan feb Ma, @r May Jun Jul Aug Sep OQ Nov Dnc Saws Gmmmm1 a1 InW - The Work of WHO In immunization of pregnant women and women of childbearing age, as well as clean delivery practices. The reported and estimated : data suggest that Bhutan, Maldives, Mongolia, DPR Korea, Sri Lanka 2 and Thailand may already have achieved the neonatal tetanus elimination goal of less than 1 case per 1000 live births in all , districts (Figure 7). Other countries, such as lndia, lndonesia, Bangladesh and Nepal, have accelerated their activities for neonatal tetanus elimination by the identification of high-risk areas, tetanus toxoid immunization of women of childbearing age and pregnant women in those areas, and the promotion of clean delivery practices. The high-risk area approach has been promoted in all the countries and is considered to be critical for the elimination of neonatal tetanus in the Reg~on Immunization with an overall coverage of about 80 per cent of infants has significantly contributed to the control of measles. There is a declining trend in the number of measles cases. It is estimated that 22 million cases of measles are prevented and 700 000 measles-associated deaths are averted annually in the Region. The countries are controlling measles by increasing routine immunization coverage and by adopting the high-risk approach to identify and immunize children not previously reached (eg. large urban agglomerates with pockets containing unimmunized children). This approach has been implemented in lndia (such as in the State of Delhi). In order to reduce mortality, countries have implemented clinical case management of measles as a part of outbreak response. Hepatitis-B vaccination has been implemented in phases as part of the EPI services in Indonesia, Mongolia. Maldives and Thailand. In view of the relatively high cost of HE vaccine, other countries are not yet in a position to use the vaccine because of lack of financial sustainability in the long run. Given the progress made so far, efforts to eliminateleradicate neonatal tetanus and poliomyelitis and to bring about a significant reduction in measles, diphtheria, pertussis and child tuberculosis cases must continue. Routine immunization services must be improved and achievements sustained. Further resources will, of : course, be required and the international community must come forward to assist in the spirit of human solidarity. Disease Prevention and Control 81 Figure 7. Neonatal tetanus in SEAR, 1993 I < Estimated Rate 1 1000 Live Births 1 Is $0 6.5 6.6 ond 0-r. Reported Rate 1 1000 Live Births I 82 The Work of WHO in SEA During 1993-1995, the Regional Oftice organized a number of meetings and workshops and provided technical support to the countries. It also mobilized financial and moral support from the ' international community at large and voluntary organizations in particular. Many of these organizations contributed generously to the eradication of poliomyelitis and other preventable diseases. With technical support from WHO, stratification of malarious areas has been carried out by all the malarious countries in the Region to facilitate cost-effective and selective vector control in highly endemic areas. Training of staff in the control of dengue and Japanese encephalitis and the integration of filariasis control programmes into other vector control activities, with community participation. also received support. Since 1993, integrated vector-borne disease control has been conducted in those areas of India. Bangladesh and Nepal where kala-azar continues to be a health problem. In 1993, there were about 3 million reported malaria cases in the Region. Overall, the malaria situation has remained somewhat static for the last ten years, with the reported case incidence ranging between 2.5 and 3.0 million cases. The proportion of Plasmod~um falciparum malaria went up to 41.4 per cent of total malaria cases in 1992 but came down to 39.7 per cent in 1993. During 1993, the slide positivity rates in the Region ranged behveen 2 and 4 per cent except in Myanmar (I6 per cent). Sri Lanka (24.4 per cent) and Bhutan (35.9 per cent). The proportion of Pfalciparum was highest in Myanmar (84.9 per cent) followed by Thailand (59.2 per cent) and Sri Lanka (22.5 per cent). In the remaining countries (except Nepal), it varied from 13 to 15 per cent. The malaria profile in the countries of the Region is shown in Figure 6 and Table 7. The malaria s~tuation in forest and forest-fringe areas has remained serious owing to highly efficient vectors, multiple-vector transmission, prolonged transmission seasons and drug-resistant P.falciparum malaria combined with large-scale and uncontrolled population movements. P. falcfparum resistance to various antimalarials still constitutes one of the main technical problems in Disease Vector Control Malaria . - .. Esease Prevention and Control 83 Figure 8. Malaria profile of South-East Asia Region Thousand 4000 1 (11 . The Work of WHO in SEA Table 7. Malana pmhle of South-East Asia Region -- -- D~sease Preventon and Control -~ - - - - 115 660 6.03 51 775 44.76 125 361 768 54 954 43.84 165 102 10.40 81 027 49.08 ~~ ~~ ~ ~ ~ ~ 355 28 900 39.06 14 092 48.76 363' 28 116 35.93 12 943 46.03 370' 38 901 39.93 15 998 41 12 .. - 2 125 826 2.69 879 383 41.37 2 207 431 2.84 852 763 38.63 2 222 869 2.99 836 432 37.63 . ~ ~- ~~ 13 715 0.18 6 935 50.57 21 559 0.37 11 433 53.03 ... ... ... ... - 231 25' 0.07 7' 28.00 238 29' 011 5' 17.24 246 16' 0.07 2' 12.50 . ..... Myanmar 1992 38 633 125 710 1400 106 695 84.87 39 653 117 068 1595 99 404 84.91 94 527 17 75 78 951 83 52 ~~ ~ . - ~~.~ ~~ 1992 12 120 23 234 321 2 954 12.71 Sn Lanka ~ Thailand - SEAR -. .~ ~~ NOTES: Figures for 1994 are provisional F~gures m shaded area relate to Java and Bali only. = Data not available. 'Mid-year estimates of people living in rnalarious region. b~rojected from last year. Clrnported cases dlncomplete data for 1994 1993 12 355 1994 ' 12 622' -~~.~~ 16 380 9 442 2.75 2.20 1992 1993 1994 1992 1993 1994 . . 1992 25.62 24.44 19.96 1 540 1 087 - 13 900 14 081b 14 ~64~ 43 536 43 942 44601b 1 147 749 9.40 11.51 82 675 73 532 46 986 ~ ~ ~ ~.. 399 349 327 020 273 434 168 370 115 220 102119 .. 3 000 789 20.70 22.49 17.18 .~ 57.84 59.25 55.89 41.39 3.02 2.38 2.15 3.18 97 389 68 270 57073 1 241 905 malaria control in the countries of the Region. The foci of P.falciparum malaria resistant to various antimalarials have been gradually spreading in all the malarious countries and the degree of resistance i has been increasing from SlRl to RII and RIII. ++ There are some 25 Anopheline species known to be primary or secondary vectors of malaria in endemic areas. Of these, six species have major operational implications for disease control. However, only Anopheles culicifacies is resistant to DDT and malathion and Anaconitus is resistant to DOT. Other administrative and operational constraints to the control of malaria include inadequate national budgets, fluctuations in budget allocation, acute shortages of trained personnel, uncontrolled large-scale population movements, lack of intersectoral collaboration and community participation, and excessive delays in reporting from the periphery to the centre as well as irregular feedback from the centre to the periphery. Since the endorsement of the Global Malaria Control Strategy - (consisting of early diagnosis and prompt treatment, selective and sustainable preventive measures, prevention and control of epidemics and regular assessment of the programme management) by the Ministerial Conference on Malaria held in Amsterdam in November 1992, collaboration between the Regional Office and the eight Member Countries where malaria is a problem has been accelerated. Greater support and technical guidelines, i.e. training at regional level, country programme assessment and country working groups, have been provided for the implementation of the Revised Malaria Control Strategy. As recommended by the Regional Working Group Meeting on Malaria held in March 1993, WHO also extended technical support for carrying out critical reviews of the * malaria situation and malaria control activities in Bangladesh, Indonesia, Maldives, Myanmar and Nepal. It actively collaborated in country working group meetings to implement the Revised Strategy in Bangladesh, Bhutan, Indonesia, Maldives, Myanmar, Nepal, Sri Lanka and Thailand. With the active collaboration and support of the Regional Office, all the malarious countries have completed their country reviews of the malaria situation and have adopted the recommendations of the Country Working Group on Revised Malaria Control Strategy. Most of them have started implementing the revised strategy. -- .. - -- 86 The Work of WHO In An lntercountry Consultative Meeting to review the progress of implementation of the Revised Malaria Control Strategy was held in the Regional Office from 20 to 24 March 1995. The central theme 'of the meeting was the operationalization of the recommendation of the Country Working Group on the control of multidrug-resistant malaria, through coordinated control programmes among the countries and with the support of the Regional Office. WHO continued to provide support to the nine malarious countries for: external assessments of their national malaria control programmes; organization of national workshopslseminars; planning, implementation and evaluation of control activities; and carrying out drug-sensitivity tests and other operational field studies. Increased emphasis is now being placed on the development of capabilities in applied research methodology with particular reference to stratification, epidemiology of severe and drug-resistant Pfalcipawm malaria and its control, clinical trials of new drugs, insecticide-impregnated bednets, evaluationloutput parameters and indicators for measuring the dynamics of the disease in the populations, and early warning systems for impending epidemicsloutbreaks. The Region has also initiated the revival of the Regional Collaborative Programmeon Drug-resistant P. falciparum. Situational analyses of the status of Pfalcparum drug resistance have been completed in all the malarious countries. Detailed plans have also been made for carrying out operational field research, as well as a programme management and reporting system for the prevention and control of drug-resistant malaria. Preparations have begun for launching a BI-regional Collaborative Programme on Drug-resistant Malaria jointly with the Western Pacific Region. Many international agencies continued to support the malaria control programmes in the Region. The World Bank has granted a credit of US$.6.4 million to Bangladesh for Integrated Control of Vector-Borne Diseases (ICOVED). The Bank is also providing US$100 million for five years (1989190-1993194) for the improvement of the health infrastructure, including malaria control, in Kalimantan and Nusatenggara Barat (NTB) in Indonesia, while OECF Japan is providing a grant for malaria control. UNDP is providing Myanmar with US$ 1.6 million for reducing malaria morbidity and mortality through upgrading infrastructure and increased community - Dlsease Preventlon and Control participation. DANIDA and Japanese Debt Relief Fund supported : Nepal with US$0.8 million and US00.4 million, respectively, for malaria control activities. 7 Parasitic India, Nepal, Sri Lanka and Thailand have carried out programmes Diseases for the mass treatment of children in highly infected areas. Significant progress has been made in Indonesia, which has taken steps for the mass stool examination and treatment of school children for Intestinal Parasitic intestinal parasitic infections (IPI). Infections A WHOMlorld Bank pilot project for the control of intestinal parasitic infections has started in Bangladesh. Technical support has been provided for the training of project staff, development of methodology, and the monitoring and evaluation of activities. WHO supported national workshops, seminars and training courses on intestinal parasitic infections in various countries and provided necessary supplies and equipment. A project proposal for the control of IPI in Maldives has been prepared for donor support. * ViSceral Since 1987, kala-azar has been a major health problem in the rural Lei~hmaniasis areas of the States of Bihar and West Bengal in lndia as well as (Ka'a-Azar) in Bangladesh and Nepal. Approximately 75 million, 30 million and 5.3 million people respectively live in kala-azar-affected areas in these countries. Table 8 shows the number of kala-azar cases and deaths in Bangladesh, lndia and Nepal during the period 1981-1994. WHO organized a consultative meeting on visceral leishmaniasis (vL) in July 1993 to formulate guidelines for the prevention and control of the disease. As a result of the implementation of the control strategy on VL in lndia in 1993, a decline in the incidence of VL cases and deaths was seen during 1993-1994. In Bangladesh and Nepal, some progress has been made in the control of VL through its integration with the vector-borne disease control programmes. WHO supported national training courses for medical officers on clinical and laboratory diagnosis, treatment and reporting of VL cases. Support was also provided for seminars on VL with specific reference to vector control. The Organization's assistance also included the procurement of drugs for treatment. aa The Work of WHO m SEA Lymphaticfilariasis persists as a public health problem in Bangladesh, Filoriaris India, Indonesia, Maldives, Myanmar, Nepal, Sri Lanka and Thailand. A recent assessment of available information shows that in lndia alone there are an estimated 36 million microfilaria carriers. Table 8. Visceral leishmaniasis in Bangladesh, lndia and Nepal, 1981-1994 WHO'S operational research projects in lndia, Indonesia and Thailand facilitated development of new control strategies for lymphatic filariasis infection and diseases, which were formulated at a WHO Consultative Meeting held in Penang, Malaysia, from 22 to 24 August 1994. WHO continued to provide technical support to endemic countries for the development of integrated control of the disease with community participation. Schistosomiasis is endemically present in Nepal, the Besoa Valley Sthistosomiosis of Central Sulawesi. Indonesia, and in very limited areas of Thailand. It has shown a downward trend in prevalence due to multipronged interventions, including chemotherapy. ' WHO has been supporting annual meetings of the Task Force on Guineaworm Guineaworm Eradication in lndia. The meetings held in 1994 and Disease 1995 recommended a strategy to bring down the incidence of the (Dr"unmQliasis) =In,amatlOnnola"alala 'JanUaySaplsmbLi ~ Disease Prevention and Control 89 Nepal Cases Deaths ~~--lT 442 291 446 34 870 56 1 395 1 500 .., 1 200 ... .. India p~ ~- ~ . Bangladesh . Case* 22 34 489 739 57 742 61 670 77 101 44 844 22831 ~ - year - Case6 -~ Deaths --pF 497 606 838 1 419 709 349 ~. - Deaths 1987 1988 1g81-8f~~~ 1989 2 548 526 ' 1990 3 334 1991 3 039 1992 6 818 1993 6 030 1994 5 800' ~ .. ~~- Tropical Diseases Research disease to zero by 1995. WHO supports epidemiological surveillance in the guineaworm-endemic states of lndia under the National Guineaworm Eradication Programme. During the period under review, collaboration with the Tropical Diseases Research (TDR) Special Programme continued and the Regional Office extended support in promoting research capability strengthening in six Member Countries of the Region. There was a total of eleven projects (including long-term institutional grants, short-term institutional grants, programme-based grants and the TDRlRockefeller grants), and two new grants were approved for funding in 1993 - one for linkage between Myanmar. Sri Lanka and Thailand, and one partnership grant. The linkage grant involves collaboration between institutions within the Region, and the partnership grant helps promote collaborative arrangements between institutions in both developing and developed countries. Another new initiative is a small grants scheme for improvement of the use of antimalarials in the South-East Asia Region. In this regard, a total of four grants were approved for this region. Further, thirteen research training grants were approved. Site visits were undertaken to six countries, mainly for monitoring and follow up of on-going projects, and for initiating the promotion of research capability strengthening in one country. Two new collaborative research projects were initiated in the Region. A three-centre study was carried out for the field evaluation of an antigen dip-stick test for falciparum malaria. This joint activity was funded by TDR and SEARO. Another ioint research proiect on leishmaniasis involving three countries was started; this is also a joint TDRICTD HQISEARO activity. A total of eighteen research projects were funded in 1993 by the TDR Special Programme. = In the area of research capability strengthening, a total of thirteen projects in Thailand, Nepal, Myanmar, lndonesia and Sri Lanka were approved for funding in 1994. In regard to research and development, 29 projects were approved in 1994, out of which 21 projects were awarded to lndia, four to Thailand, two to Sri Lanka, and one each to lndonesia and Myanmar. Major programmes supported through this effort were in the fields of filariasis, leprosy. leishmaniasis and malaria in countries such as lndia and lndonesia. -- 90 The Work of WHO in SEA * The objective of the Regional Control of Diarrhoea1 Diseases (CDD) C0ntr0l of Programme is to reduce mortality, morbidity and malnutrition caused ! Diarrhoeal by diarrhoea1 diseases. Towards this end, the Programme assists Diseases national CDD activities in promoting standard case management at " home and at health facilities so as to prevent diarrhoea-associated deaths in the most efficient manner. The current status of selected indicators together with the targets for 1995 and 2000 are presented in Figure 9. Access to ORS has been increasing steadily; by the end of 1995 it should reach the mid-decade goal of 85 per cent. In addition, training rates for supervisory and clinical management staff should have reached the target of 40 per cent by the end of 1995. CDD programme activities may be divided into operations. planning, training, communication and evaluation. The operations are carrted out by a reglonal staff of four - a team leader and a techn~cal officer supported by two general servlce staff In addlt~on, the CDD and ARI programmes share the cost of two med~cal officers, one posted in Bangladesh and the other In Figure 9. CDD programme status of selected indicators and targets for the years 1995 and 2000 I 90 Case management ralc" Manqlld nf home !illpBcVSO!y iklls" 0 70 40 60 MI1 100 ~ . Disease Prevention and Control Indonesia, and an associate professional officer in Nepal. It is planned to assign two more associate professional officers, one each in Bangladesh and Myanmar. The production or import of ORS reached 121.5 million litres in 1994, and nine out of the eleven 9 countries in the Region now produce the major part of their requirements locally. Regarding planning, by July 1995 all the countries had well established CDD programmes and had implemented plans of action, most of which have been revised. As for training, WHO has continued to develop and distribute useful training materials to assist the Member Countries' national CDD programmes in providing health workers high quality "hands on" training in the clinical management of diarrhoea. It has supported the establishment of 133 diarrhoea training units (DTU) located at major hospitals and medical colleges in nine countries of the Region. In 1994, at least 320 five-day clinical management courses were held in theseDTUs. In addition, one intercountly Clinical Management Course was held in New Delhi to train prospective DTU directors in establishing new units in their respective countries. The other training courses organized in the Region are shown in Table 9. Table 9. Courses in diani~oeal disease control Country -- Bangladesh Bhutan OPR Korea India Indonesia MaldNes Mongolia Myanmar Nepal Sri Lanka Thailand 92 The Work of WHO in SEA Management Cllnlcal ---- of tralnem - - X X X X X Cllnlcal management .-. .. -- - - X X X X X X X X WHO has developed the package "Strengthening the Teaching " i of Diarrhoea1 Diseases in Medical Schools" (MedEd) to help medical schools upgrade their curricula and improve the theoretical and practical knowledge of medical students in respect of the management and prevention of diarrhoea1 diseases. By July 1993, Indonesia, the first country to hold a medical education workshop, : had completed an evaluation of the participating schools. During 1993-1994, similar MedEd workshops were held in Bangladesh and Myanmar, where heads of departments and key medical educators from these countries and Nepal revised their curricula. Regarding evaluation. WHO has developed three major tools for the evaluation of CDD programmes: the Focused Programme Review, the Household Case Management Survey, and the Health Facility Survey. In 1993-1994, a focused programme review was conducted in lndonesia and similar reviews are planned for Mongolia and Myanmar. Household surveys were completed in lndonesia and Myanmar, and a survey is planned for Bangladesh. Health I facility surveys were conducted in lndonesia, Myanmar and Nepal, and a diarrhoea mortality survey was completed in Bangladesh. Since the end of 1992, when a new strain of V~brbrro cholerae 0139 (Bengal) was discovered in outbreaks of diarrhoea in India and Bangladesh, additional cases have been identified in Bangladesh, India, Myanmar, Nepal, Sri Lanka and Thailand. WHO has assisted governments in carrying out further laboratory ' characterization, and is also supporting the production and supply of 0139 antisera (used for isolating the new strain) available in the Region. In the meantime, the Regions\ Office has advised Member Countries to report all cases of both V. cholerae 0139 and V. cholerae 01 as cases of cholera. According to WHO'S estimates, ARI and diarrhoea together account for 60-70 per cent of the visits of sick children to health facilities in most developing countries. Each episode of infection contributes to malnutrition and when episodes of infection are prolonged, their negative impact on growth is increased. Bangladesh, India, lndonesia and Nepal together account for about 40 per cent of the global mortality caused by ARI. At least seven countries in the Region continue to have infant mortality rates (IMR) exceeding 4011000 live Acute Respiratory Infections (ARU Disease Prevention and Control 93 i births. The case-fatality rates among children who are hospitalized 1 continue to be high in the countries of the Region. For these 3 reasons, all the countries with high IMR, as well as Sri Lanka and 1 Thailand, have established national ARI control programmes. ~* The main objective of the Regional ARI control programme is to assist the Member Countries in reducing the mortality and morbidity resulting from ARI in children under the age of five years. Standard case management is the central strategy to achieve the objective of reducing the mortality. For prevention, immunization by the vaccines included in the EPI programme is emphasized. The ARI programme maintains a regional staff of hvo -a medical officer and a secretaly. In addition, it shares with CDD the cost of medical officers in Bangladesh and lndonesia and an associate pmfessional officer (APO) in Nepal. Additional APOs' positions with job descriptions covering both CDD and ARI are pmposed in Bangladesh and Myanmar. All the 10 countries with an ARI programme have allocated funds for the control of ARI separately or as a part of * communicable-disease control efforts or child survival activities. In all the countries, the programme continues to receive technical and other assistance from WHO, which collaborates with UNICEF and other international organizations, including the World Bank. Collaboration with national and international NGOs was initiated in Bangladesh, lndia and Nepal during 1994-1995. Bangladesh, Bhutan, lndia and Nepal have revised the technical guidelines for ARI. The control efforts are being progressively integrated with the child survival programme or communicable disease control in lndia, lndonesia, Myanmar and Nepal. In other countries, action has been initiated to combine the ARI and CDD programmes in accordance with the national policy. After the completion of the training of national programme managers, the emphasis is now on the training of programme managers at the district and provincial levels. Training courses were organized with WHO support in Bangladesh, Bhutan, lndonesia and Nepal. It is now proposed to undertake combined CDDIARI training of programme managers. In Bangladesh, since the CDD programme coordinators at the district level are also responsible for the monitoring and supelvision of the ARI programme, they have been given training 3 I in this task. The national policy in Mongolia and Thailand is to ; support the introduction of standard case management in the 94 The Work of WHO in SEA pre-service training of undergraduates. Similar efforts are being made in Bhutan and Nepal. Training of the doctors and health workers responsible for the treatment of children with ARI visiting first-level health facilities and small hospitals has been given priority. All the countries have adapted and translated the required range of training materials and are using them in the programme. They have also expanded the coverage of training in standard case management of ARI (Table 10). In addition to the achievement of training targets, the programme lays stress on the quality of training. For this purpose, the training of trainers was undertaken, with WHO assistance, in Bangladesh, India, Indonesia, Maldives, Mongolia. Nepal, Sri Lanka and Thailand. Training units have been established in Bangladesh, Mongolia and Thailand. The monitoring of training courses has been initiated and the follow-up supervision is being increasingly incorporated in the programmes. Table 10. Summary of training in the control of ARI in Member Countries ~ ~~-~~~~ ~. ~ Programme ~ -- ~p~ .... Bangladesh lndla 1 875 4 673 lndones~a 4 470 5 637 19 404 Maldives Mongolia - 425 500 - Myanmar - 1 400 977 Nepal 40 1 359 734 Sri Lanka 12 899 1 119 - Thailand 53 2 000 16 000 30 000 ~ ~- ~~ -. Total 543 10 100 31 123 53 362 Source: Estimates based on Countty Programme Profiles received from SEAR countries -- -- Dlsease Preventton and Control 95 Tuberculosis To extend the impact of the programme to difficult and unreached areas, meetings were organized with NGOs in Bangladesh and Nepal. The programme is beginning to combine the training in CDD and ARI. In India, Indonesia, Myanmar and Nepal, it is proposed 7 to integrate the management of the sick child through the sick child initiative or child survival projects. For long-lasting results, training in standard case management has been introduced in pre-service settings. The ARI standard case management has been introduced in the training of auxiliaries in Bhutan, and in a medical school in Nepal. The curriculum for the training of nurses was revised in Thailand. Changes in the curriculum of undergraduate medical students are being made in Mongolia and Thailand. In order to secure endorsement of the programme and to seek the advice of paediatricians and professionals, support was provided for organizing national and international meetings. Seminars/symposia on ARI were supported in Bangladesh, India. - Mongolia. Myanmar and Thailand. The WHO ARI control programme has finalized the survey instruments on household survey, health facility survey and focused ethnographic studies. Two health facility surveys were carried out in Thailand, and similar surveys are proposed in Bangladesh. lndonesia and Mongolia during 1995. A mortality survey is in progress in Myanmar. Focused ethnographic studies were carried out in Mongolia. Focused groups were organized in Myanmar and Thailand to strengthen the communication messages. Studies on bacterial drug resistance were completed in Thailand. Similar studies are proposed to be initiated in Bangladesh in collaboration with the Shishu Hospital and the International Centre - for Diarrhoea1 Disease Research. Studies on indoor air pollution are in progress in Nepal. The burden of tuberculosis in the Region is immense. The estimated incidence of new tuberculosis cases for 1995 is 3.5 million, which represents about 50 per cent of the global burden of the disease. It includes 2.3 million new cases in India, 0.5 million in Indonesia, and 0.4 million in Bangladesh. An estimated 1.2 million people will p~ 96 The Work of WHO in SEA ,. die of tuberculosis in the Region in 1995 - nearly 50 per cent of all deaths from tuberculosis world-wide. The co-epidemic of TBIHIV will cause substantial numbers of deaths during the next ten years. : Inappropriate control measures in the past have resulted in a high j number of treatment failures and chronic cases with multid~g resistance. Available information suggests that cure rates range from 20 per cent to 40 per cent in most countries of the Region. In response to the above challenges, WHO continued to provide technical assistance and support to Member Countries, mainly in the areas of internal evaluations; review and revision of plans of action; training activities, and providing financial support for control efforts. Regional and national training workshops, based on the WHO modules for "Management of Tuberculosis at the District Level", were held so as to prepare skilled trainers at the national level. Since then, many countries have initiated such training. With the assistance of WHO, Indonesia, Nepal and Thailand have carried out reviews of their national tuberculosis programmes. India, Indonesia, Nepal, Bangladesh and Sri Lanka now have national plans for tuberculosis control and have developed operational manuals based on the revlsed strategy. Bangladesh, India, Indonesia and Nepal have established pilot projects based on the WHO strategy. Technical discussions on the resurgence of tuberculosis were organized during the 47th session of the WHOISEA Regional Committee in August 1994, and were followed up at the 43rd Meeting of the Regional Director with the WHO Representatives in November 1994. A workshop was held in April 1995 to develop a drafl "Strategic Plan for Tuberculosis Control in the South-East Asia Region, 1995-2000". An Intercountry Meeting of National Tuberculosis Programme Managers in the South-East Asia Region was held in Thailand in June 1995 to review the WHO global policy and strategy for tuberculosis control, review the development and management of NTP in Member Countries, finalize the above-mentioned draft document on the Strategic Plan, and develop a plan of work for its implementation. Several constra~nts limit the rapid expansion of the revised strategy for tuberculosis control. Solutions to address such problems ~nclude government commitment, intensification of passive case detection based on sputum smear examination, establishment of a laboratoly network, standardized short-course chemotherapy. - . . . - - - -- -- -- D~sease Preventton and Control 97 Leprosy continuous and uninterrupted drug supply, training, supervision. monitoring and evaluation. Other issues that need attention are advocacy, a coordinated policy for TBMIV, tuberculosis control in urbanlperi-urban areas, cooperation with NGOS and the private * sector, and operational research. Since the introduction of multidrug treatment (MDT) more than ten years ago, the leprosy situation in South-East Asia has improved. although the Region still accounts for about 65 per cent of the global caseload. The percentage of registered cases covered with MOT in the countries in 1994 was 54, while the prevalence rate was 8.5110 000 population - higher than in any other WHO region. An Intercountry Consultative Meeting of Leprosy Programme Managers was held in February 1993 in the Regional Office to develop guidelines for updating national strategies and plans of action. Another consultative meeting was held in November 1994, with the objective of finalizing practical and acceptable national - plans of action for the period 1995-2000 towards attainment of the goal of leprosy elimination by the year 2000, or earlier. In response to a recommendation of the Intercounty Consultative Meeting of Leprosy Programme Managers, held in Bali in November 1994, that "It is highly important that accessibility to MDT further improves particularly in the high leprosy-endemic countries of Bangladesh, India. Indonesia. Myanmar and Nepal through extension of MDT coverage to 100 per cent of the geographic area", a series of donors' meetings have been held in the countries to obtain NGOs' commitment in respect of assistance and cooperation in accelerating leprosy elimination by covering 100 per cent of the geographical area with MDT by the end of 1995, and to reach the global target by the year 2000. The International Conference held in Hanoi, Vietnam, in July 1993, ~nter aha, recommended creation of a Steering Committee on Special Action Projects for the Elimination of Leprosy (SAPEL). The Steering Committee held its first meeting in January 1995 to discuss the purpose and the working mechanism of SAPEL. The objective of SAPEL, which is a part of the global plan of action for the elimination of leprosy as a public health problem, is to identify special situations and areas requiring rapid action towards leprosy -- 98 The Work of WHO in SEA Environmental Health The main aim of community water supply and sanitation programmes is to ensure that safe water and adequate sanitation facilities are made available to the people. Health Laboratory Services Health laboratory servlces play a crucial role in epidemiological surveillance and in supporting PHC programmes in the Region, WHO collaboration in this area is focussed on strengthening these services. Essential Drugs A major thrust of the essential drugs programme in the Rcg~on is on assurlng the provlslon of safe and effective drugs of good quality and ensurlnq their rational use. Sfrengthenlng of quality assurance systems ?*.I manpower development are the other priority areas ofw~o,s collaboration. Leprosy Leprosy is an important public health problem in the Region, accounting for more than half of the estimated cases in the world. Through efforts at early detection and rapid implementation of the standard multi-drug treatment regimen, however, significant improvements have been noted and the Region is confident of achieving the target of elimination of leprosy by the year 2000. Malaria Tne malar a stt..at on n tntx Regton is be~nq c osrly mon tored w lh tne h gt. ncloence of falctparum ma ar a causing nor nus concern Tlv rev.sPrl maoarma-confro slratrqles nr .!d? sfralrfcnt on of ma artot.s areas. 1,r;ll ng pos I ve cases dlagno-ec! cl ncal y and by laboralow trstlng. -s ng new trcnn q.m -4- -.-. . . s-cn as permethr n.treal~rl oel nets ana slronqrhrntnq corllro act v I ps . ellmlnat~on, and to develop and Implement lnnovatlve and feas~ble strategles ! Leprosy elimination programmes are beginning to have an i impact on the problem in Bangladesh. India, Indonesia, Maldives. Myanmar and Nepal, thanks to MDT, international support and funding. WHO'S technical cooperation, and the coordinated efforts of governments. NGOs and others. While lndonesia expects to eliminate leprosy by 1996, lndia, Myanmar and Bangladesh expect to attain this goal only by the turn of the century. Maldives. Bhutan and Nepal are also advancing towards the goal. Sri Lanka and Thailand are now in a position to implement postelimination strategies and concentrate on pockets of prevalence. During the period under review, countries in the Region received Zoonoses WHO assistance in their efforts to launch measures for the prevention ': and control of rabies, anthrax, toxoplasmosis, brucellosis. : cysticercosis, food-borne diseases and plague. WHO provided support through consultants, supplies and equipment, training health personnel and organizing national workshops on rabies control programmes and on zoonotic diseases in lndia, lndonesia. Nepal. Sri Lanka and Thailand. Large-scale dog vaccination programmes are being carried out in lndonesia, Sri Lanka and Thailand. WHO provided fellowships to two Mongolian officials to study brucellosis control in Kazakhistan and to one from lndonesia to study rabies control in Canada. Some steps for the effective preventlon and control of anthrax, toxoplasmosis, brucellos~s, cystlcercos~s and food-borne dlseases have been taken Seven countries of the Reglon produce more than 50 m~lllon ml and 100 million ml of nervous tlssue vacclne (NTV) for human and anlmal use respect~vely Durlng the last 3-4 years, WHO has prov~ded support to Indla, lndones~a and Thalland in the development and product~on of cell-culture vacclne Disease Prevention and doitrol 99 Plague During the period under review, lndia. Myanmar and Mongolia reported cases of plague. During 1994, Mongolia reported 19 cases of bubonic plague and Myanmar reported six. No death was reported by either country. i Between 1967 and 1993, lndia did not report any case of human plague. The 1994 outbreak of plague in lndia started in Mamla village in Beed district of Maharashtra State. In this village, rat-fall was reported on 5 August 1994 followed by reports of flea nuisance. On 26 August, thirty-three patients with lymphadenitis were reported. During September and October 1994, suspected bubonic cases were reported from other villages of Beed district and some other districts of the State. A total of 3701 clinically suspected cases (including 596 presumptive cases, i.e with positive serology) of bubonic plague (without any death) were reported. The last case of bubonic plague occurred in Beed district on 2 October 1994. The patient was isolated, cured and discharged on 7 October. The outbreak of acute respiratory illness characterized by fever, -. cough, haemoptysis and pneumonic infiltration seen in radiographs, occurred in Surat, Gujarat State. in September-October 1994. This infection occurred with greatest frequency in young adults. It did not respond to treatment with penicillin, but responded well to tetracycline. The case fatality was high during the early stage of the outbreak. Based on the above clinical picture and the plague outbreak in the neighbouring State of Maharashtra, a diagnosis of suspected pneumonic plague was made. A total of 1088 clinically suspected and 146 presumptive (seropositive) cases and 54 deaths due to plague took place during the period 19 September to 22 October 1994. Seroactivity to the F1 antigen of Yersinia pestis was found among the affected patients. Vigorous control measures undertaken by the Government of lndia and the State Government in subsequent days resulted in no transmission of pulmonary plague outside of Surat. The last case of presumptive pneumonic plague in Surat city occurred on 11 October 1994. The patient was isolated, cured and discharged on 15 October 1994. The surveillance capabilities were adequate to detect suspected cases of human plague. Case containment, case treatment, contact tracing, and the administration of prophylactic antibiotics to populations at risk were timely and comprehensive. 100 The Work of WHO in SEA WHO provided support for control and containment measures in lndia. In collaboration with the National Institute of Communicable Diseases (NICD), a daily bulletin on the plague situation in lndia 1 *was communicated to WHO Headquarters, other Regional Offices and to WHO Representatives in the countries of the Region. The Director-General of WHO, accompanied by the Regional Director. visited Surat on 7 and 8 October. WHO provided the services of international experts (three from USA and two from Russia) who trained national personnel in the laboratory diagnosis of plague. WHO supported a study tour for four Indian researchers to WHO reference laboratories for plague in the USA, France and Russia. In addition, two \aboratory workers have been trained in the USA in the production of diagnostic reagents for plague. On 7 October 1994, the Director-General of WHO announced the formation of an independent international team to investigate the plague situation in lndia. The Regional Director was designated as the Team Leader. Following investigations, the team concluded, jnter alia, that: A limited outbreak of bubonic plague occurred in Beed District of Maharashtra State in August-September 1994 which was preceded by an epizootic of plague in commensal rodents in Mamla village. The clinical, epidemiological and serological findings suggest that Ypestis was the probable cause of the outbreak of respiratory illness in Surat, Gujarat State, in September-October. Sulveillance capabilities were adequate to detect suspect cases of human plague. Case containment, case treatment, contact tracing and the administration of prophylactic antibiotics to populations at risk were timely and comprehens~ve. The Government of lndia established a Technical Advisory Committee on Plague to elucidate factors responsible for the outbreak of plague and to make recommendations for the future control and prevention of outbreaks. This committee, in its interim report, concluded that it was possible to establish conclusively by culture and other tests that Ypestis was the causative organism of the outbreak. WHO convened, in March 1995, an Interregional Meeting on Prevention and Control of the Plague Epidemic. The main objective of this meeting, which was held in the Regional Office, was to learn lessons from the 1994 outbreak of plague in some parts of lndia and to make recommendations on the development of new strategies for -- -- - - Dtsease Prevention and Control 101 strengthening the exlsting system of surveillance of plague and other emerging, reemerging and new infectious diseases around the globe The main conclusion of this meeting was that there is increasing .t concern about the global prevalence of infectious diseases as a leading cause ofdeath. The recent plague epidemic in India highlights the threat posed by the new, emerging and reemerging infectious diseases, most of which have an epidemic potential. Sexually Although reliable data on the prevalence and incidence of sexually Transmitted transmitted diseases (STD) are not available in many countries, Diseases studies indicate that STDs remain a serious health problem. An attempt is being made by the Regional Office to collate available information on STDs in the Region. WHO is actively promoting STD case management as a part of general health services based on the syndromic approach. During the programme managers meeting in November 1993, the issue of STD prevention and control as a part of primary health care was discussed. All countries in the * Region are now actively promoting condom use to reduce the risk of HIV infection and STDs. During 1993-1994, WHO collaboration with the countries included the: provision of technical and financial support in strengthening STD services as a part of national AlDS prevention and control programmes, development of STD treatment guidelines, and the conduct of national AlDS programme reviews, including the evaluation of STD activities. Consultancy services were provided in Bangladesh. India, Indonesia and Myanmar. In October 1993, the Regional OKie supported an intercountry meeting of national STD programme managers in Chiang Mai, Thailand. In June 1995. participants at an intercountry meeting on Integrated Approach to STD Prevention and Control in Sri Lanka discussed the integration of the STD programme as a part of primary health care. Since sexual transmission accounts for 80-90 per cent of HIV infections in the Region, WHO is urging countries to focus most of their efforts and resources on: prevention; promotion of safer sexual behaviour by educating population groups through the use of mass media and interpersonal methods; targeted interventions among people with high-risk behaviour, including promotion of condom use; and the provision of early diagnosis and treatment of sexually --- 102 The Work of WHO in SEA transmitted diseases, particularly those which facilitate HIV transmission. Although difficulty in the promotion of condom use from the religious and cultural points of view has been one of the ' major handicaps in some countries, efforts have been made to make condoms available in as many outlets as possible. Condom social marketing is at present in operation in Bangladesh, India. Indonesia, Nepal, Sri Lanka and Thailand. An lntercountry Workshop on Condom Social Marketing for AIDSISTD Prevention was convened in Nepal in November 1994. , In view of the association between HIV and STD and the role played by STD, particularly genital ulcer disease, in the acquisition and transmission of HIV, the Regional Office is focusing its support on strengthening STD services in the countries. Early diagnosis and treatment of STDs is being given high priority as primary preventive measures against HIV infection, and STD control is a standing agenda item at annual meetings of programme managers. As a result, the programmes are now trying to focus on the diagnosis of STD using the syndromic approach and providing the most effective drugs at the first contact with health services. In many countries, STD and AIDS programmes have now been integrated. However, the lack of drugs to treat STD is a major constraint in many countries. The Regional Office has supported headquarters in encouraging Member Countries to promote research in: disease-specific vaccinology concerning bacterial and viral diarrhoea; meningococcal meningitis and pneumococcal pneumonia; tuberculosis and leprosy; new measles vaccines for early infancy; and dengue and Japanese encephalitis. The general objective is to improve vaccine immunogenicity and simplify vaccine delivery. Research and Development h the Reld of Vaccines Most researchers in the countries of the Region have focused on subjects related to operational services rather than on basic studies of EPI vaccines. Strengthening of the research capability of national personnel is being continued in collaboration with research training-related unitdagenciedinstitutes within and outside their countries. WHO prov~des support to natlonal AIDS control programmes on the AIDS prevention of HIV transmlsslon and on HIVIAIDS care in varlous -- Disease Prevention and Control 103 areas such as health education and targeted interventions, treatment i and prevention of sexually transmitted diseases, condom promotion 1 and quality assurance, counselling, sentinel surveillance and i laboratory diagnosis, and the provision of supplies and equipment. * I Technical support was given to Bhutan. India, Thailand, Bangladesh, i Indonesia, Mongolia. Myanmar and Sri Lanka for carrying out external programme reviews. Second medium-term plans emphasizing the multisectoral approach and the involvement of NGOs were formulated during 1993-1994 in Thailand, Maldives. Myanmar, Nepal, India, Mongolia and Indonesia. 1 To enhance the technical capacity at the national level, the Regional Office organized the first Programme Management Course in June 1994. Based on the modular approach, the course provided skills in planning, implementing and evaluating national AlDS control programmes. A facilitators training programme for this course was organized in May 1994. In Thailand, major business houses, both multinational and , national, have come together to form a "business coalition against AIDS" and to mount an appropriate business response to AIDS. In India, the Confederation of Indian Industries has developed plans of work for AlDS prevention activities to be carried out by industry NGO activities have increased tremendously over the last 1-2 years in all countries, particulariy in peripheral areas. Collaboration between NGOs and national programmes and among NGOs themselves is being increased. In Myanmar, community involvement in AlDS prevention, including contributions made by NGOs and the private sector, is particularly noteworthy. In Nepal, various ministries have committed themselves to participating in HIVIAIDS prevention; so have ministries in Mongolia, Sri Lanka, Indonesia, India and Thailand. A workshop on enhancing private sector involvement was held in * January 1995 in the Regional Office. Political commitment is well established. Besides focusing on HIVIAIDS prevention, provision of comprehensive HIVIAIDS care as a part of primary health care is now a major priority for the Region. To respond to this need, an intercounty workshop was held in the Regional Office from 29 March to 2 April 1993 to discuss i the HIVIAIDS continuum of care at various levels, i.e. institution, community and home. 104 The Work of WHO in SEA In spite of the progress achieved in the implementation of : national AlDS control activities, there still remain constraints in mounting an effective response to the expanding pandemic in some - countries of this region. Table 11 gives the situation in respect of : AlDS and HIV infections in SEAR countries. Table 11. AlDS and HIV infections in SEAR countries (as of 15 May 1995) Reported I Estimated Countly AIDS cases HIV infections Bangladesh Bhutan DPR Korea lndta lndonesla Maidlves Mongolla Myanmar Nepal Sn Lanka Thalland - -- -- Total Major priorities for national programmes include the following: Translating high-level political commitment to the ground level, in terms of both finances and trained manpower, so that national programme activities can be planned, implemented and evaluated in an efficient and coordinated manner. Mounting a multisectoral response with the involvement of all relevant government ministries, nongovernmental organizations including community-based organizations, and the private sector, both in prevention and care activities. Expanding programmes to the most peripheral level, with the full participation of communities, groups and individuals. . Focus~ng llmlted resources on the prevention of sexual transmlsslon of HIV, slnce up to 90 per cent of all HIV -- Disease Prevention and Control 105 Other Communicable Disease Prevention and Control Act~ties infections in the Region are caused by sexual intercourse. predominantly heterosexual. Avoiding measures such as mandatoty HIV testing and short-term travel restrictions based on HIV status because ' these are not only ineffective and wasteful of resources but are also counter-productive. The main objective of this programme is to improve surveillance, prevention and control capabilities in SEAR countries to cope effectively with problems of dengueldengue haemorrhagic fever, viral hepatitis. Japanese encephalitis and meningococcal meningitis. Dengue/Dangw Dengueldengue haemorrhagic fever (DHF) is the most important Haernorrfiagic and rapidly increasing arbovirus infection in the world. It is the ,, Fever leading cause of hospitalization and death among children in many countries of this region. DenguelDHF continues to persist in Indonesia, Myanmar and Thailand in endemic form. Sporadic outbreaks of DHF have also been reported from Bangladesh, India, Maldives and Sri Lanka. DenguelDHF is a notifiable disease in Indonesia, Myanmar and Thailand, where national denguelDHF control programmes have been developed with technical support from WHO. The Regional Office brought out a monograph on denguelDHF w~th full and updated information on its prevention and control - WHO and the Rockefeller Foundation jointly organized an International Conference on DHF in February 1994. The Conference ; recommended the inclusion of DHF in the list of notifiable diseases. WHO has provided consultancy services for reviewing the control programmes in Myanmar and Thailand and for assisting in the preparation of a national strategy for control of dengue1DHF in India. A national workshop on denguelDHF in New Delhi in Februaty 1995 was also supported. 106 The Work of WHO ln SEA % The Organization continued its collaboration with endemic j countries in operational research, technology development, training " of health staff, and health education on dengue1DHF. i 2 i The Regional Office participated in the review and revision of i VvHOguidelineson "Dengue Haemorrhagic Fever: Diagnosis, Treatment i and Control". The revised version will be available in late 1995. The Vaccine Development Centre of Mahidol University, Thailand, with technical and financial support from WHO, successfully developed a tetravalent vaccine. This was a major and significant achievement in the Region in vaccine development. The results of ' the clinical trials of this vaccine in adult volunteers have shown that it is safe and that the immunological response to it isencouraging. The Phase I and II trials of this vaccine in children were carried out during 1993-1995. WHO supported two important Peer Review Meetings on Dengue Vaccine Development in 1993 and 1994. The impact of viral hepatitis, as indeed of almost all other infectious Viral Hepatitis diseases, poses a serious health problem in SEAR countries. Hepatitis A Virus (HAV) infection is very common in all countries of the Region. Some outbreaks of HAV infection in children have been reported from India, Indonesia and Nepal. Increase in morbidity of HAV infection has been observed in children and young adults in Mongolia and Thailand. WHO has provided technical information and diagnostic reagents to these countries. The prevalence of hepatitis B virus (HBV) infection and related diseases, such as chronic hepatitis, cirrhosis and hepatocellular carcinoma, remains a public health problem in the Region. Every year, approximately 12-14 million people are infected with HBV. It is estimated that there are 78 million HBV carriers in the Region. ' During the period under review, a WHO-supported sero-epidemiological study on hepatitis B virus was initiated in Bangladesh, Bhutan and Sri Lanka. The results obtained so far show a high prevalence of HBsAg (more than 20 per cent) in pregnant women and in the general population in Bhutan, indicating that vertical transmission of HBV infection is very common. Very j low prevalence of HEisAg (0.1-0.2 per cent) was found in these : groups of population in Sri Lanka. Disease Prevention and Control 107 About a decade ago, only some of the SEAR countries had : developed mandatory screening of blood and blood products for ; HBsAg. Now, in a majority of the countries, this screening has been ? established. As a result of WHO support, DPR Korea, India, Indonesia, * : Myanmar and Thailand are producing diagnostic tests for detection of HBsAg. WHO has also supported the development of hepatitis B vaccine (plasma derived) in DPR Korea, Mongolia and Myanmar. During 1994-95, these countries produced some quantities of hepatitis B vaccine for conducting field trials. The testing of the hepatitis B vaccine produced in Myanmar in chimpanzees shows that it is safe and gives protective immunity against HBV infection. Sufficient progress has been made in hepatitis B control in some countries of the Region. Hepatitis B vaccination, integrated with EPI, has started in lndonesia, Maldives, Mongolia and Thailand. Sri Lanka has introduced this vaccination in medical personnel. The prevalence of Hepatitis C virus (HCV) infection in the Region is still not known. A WHO multicentre collaborative epidemiological study of HCV infection is under way in Indonesia, Myanmar. Mongolia and Thailand. Delta virus (DV) is common only in Mongolia, India. Indonesia, Maldives and Myanmar. Thailand reported only a few cases of mixed HBV and DV infection. Hepatitis E vi~s (HEV) infection is an emerging health problem in the Region. Water-borne outbreaks of HEV infection have been reported from Bangladesh, India, Indonesia, Myanmar and Nepal. Sporadic cases of this infection have also been detected in other countries of the Region. WHO supported various national workshops, meetings and seminars on viral hepatitis. Technical information and diagnostic reagents have also been provided to Member Countries. " 'rie Japanese encephalitis (JE) has been a major public health problem Entop lit'' in some areas of the South-East Asia Region, especially in Northern Thailand, the Indian states of Bihar, Uttar Pradesh and West Bengal, the terai areas of Nepal, and in Sri Lanka. Cases have also been reported in Bangladesh and Myanmar. WHO provided technical support to the endemic countries in its control, and helped India. Nepal and Sri Lanka in the procurement of JE vaccine. -- -. 108 The Work of WHO in SEA The majority of the meningococcal meningitis cases and outbreaks . Meningococcal are associated with serogroups A and C in children as well as in Meningitis adults. Only a small number of cases of this disease are connected r ' with serogroup 0. During the first six months of 1994, Mongolia reported 2661 cases with 273 deaths among children under 5 years of age. WHO provided the sewices of two short-term consultants from the Centre for Disease Control, Atlanta. USA, to investigate the outbreak. Laboratory findings and investigations revealed that the epidemic was associated with Neissena meningitides serogroup A. To prevent recurrence of the epidemic, the country decided to vaccinate high-risk groups. WHO provided 450 000 doses of bivalent (A+C) meningococcal vaccine and 30 000 doses of ciprofloxacin for chemoprophylaxis to persons having close contact with the disease. Some 213 000 children between the ages of 2 and 18 years were vaccinated. During 1994-1995, outbreaks of meningitis occurred in different parts of Bangladesh, India, Nepal and Myanmar. A small number of cases have also been reported from Indonesia and Thailand. WHO's assistance is mainly through the provision of technical cooperation to Member Countries to help organize surveillance, chemoprophylaxis, treatment and vaccination against meningococcal meningitis. The main thrust of WHO's collaborative efforts in the prevention of Blindness blindness in the Region is directed at further strengthening andlor and developing eye health care infrastructure, including referral and ~~~f~~~~ outreach services; expanding the coverage and quality of eye care to the unreached and underserved; training of personnel at all levels; and promotion of the local production of eye care supplies. As far as the prevention of deafness and hearing impairment programme is concerned, the main emphasis is on epidemiological assessment; identification of the principal causes of deafness; and support for the development and strengthening of national programmes for ear care, including training of personnel. In Bangladesh. Ind~a, Myanmar, Nepal and Srl Lanka, workshopsltra~n~ng courses on prlmary eye care for all levels of health workers have been organ~zed wlth WHO support Fellowships Disease Prevention and Control 109 have been awarded to ophthalmic personnel for advanced study. j Necessary equipment has also been provided. Technical support has been extended to community-based eye care programmes in 1 most countries as well as to the World Bank-funded blindness ' ; control programme in lndia. Indonesia is carrying out a major survey r on ophthalmic diseases and hearing impairment in three of its provinces with technical back-up from WHO. Cancer : Substantial funding has been made available by the World Bank for WHO execution of a project to establish an epidemiological surveillance system for cancer, and for public preventive education, in Bangladesh. In India, a cancer control project has been prepared with WHO assistance, for World Bank funding. Based on the National Cancer Control Programme (NCCP) in lndia, model district cancer control activities are being implemented, with WHO support, and a these district programmes are continuously being expanded with : the Government's own resources. An evaluation of some of those programmes has clearly shown that the rate of cancers that appear incurable at the time of diagnosis can be lowered substantially. A small follow-up study of patients with incurable cancer has shown the high prevalence of severe uncontrolled pain, and pointed : towards the urgency to improve palliative care in lndia. Unfortunately, the production of oral morphine is still not sufficient for effective use for severe cancer pain in the majority of patients in lndia and ,' in other countries of the Region. CO~OVOSQ~I~ i Data from the SEA Region as well as from elsewhere show that. ... Diseclses ! with life expectancy having risen to above 60 years, cardiovascular ' diseases tend to become the leading cause of death. WHO'S response to this situation so far has mainly been to support studies estimating the prevalence of risk factors in different populations and exploring the feasibility and effectiveness of lowering the prevalence of risk factors for cardiovascular diseases, hypertension, and diabetes mellitus. Smoking, sedentary lifestyle, and a diet kgh in animal fat contribute towards cardiovascular diseases. However, the impact of lowering the prevalence of risk factom on mortality has been disappointing, indicating the need for further research, 110 The Work of WHO in SEA WHO has continued to execute an AGFUND-supported programme to establish the feasibility and cost-effectiveness of the control of rheumatic feverlrheumatic heart disease through an ' integrated approach. This project is ongoing in India, Sri Lanka and Thailand. Bangladesh was assisted in the establishment of angio-surgery through the provision of equipment and consultancy services. Consultants also assisted DPR Korea in upgrading their angio-surgery and cardio-surgery facilities. WHO supports its Collaborating Centre, viz. the Bangladesh Institute ' Other Non- of Research and Rehabilitation in Diabetes. Endocrine and Metabolic communicable Disorders (BIRDEM) for research and training in the prevention and Diseases control of diabetes mellitus. An impressive model of integrated diabetes control has been developed. This public health approach to diabetes control can serve as a model for other countries where the prevalence of diabetes is rapidly increasing. In India, for example. the prevalence of diabetes is estimated at 2 per cent in rural areas whereas in a survey in Madras. 8 per cent of the population were found to be affected. WHO has assisted Maldives in developing a thalassaemia control programme. A consultant reviewed the possible etiological factors in the unusually high rates of kidney failure in the country. D~sease Preventuon and Control 111

The main thrust of the human resources for health (HRH) programme, j Managerial as defined in the WHO Eighth General Programme of Work, is to PM~SS for the . cooperate with Member States in planning for, and properly training, Development the types and numbers of health personnel that they require, and H~~~~ to help ensure that such personnel are deployed and utilized optimally to meet the requirements of national strategies to achieve Resources for health for all. Health Over the past decade, SEAR countries have recognized the Balanceand importance of human resources for health and have made efforts Relevance of for training and re-training a growing number of health personnel ' Human Resources of different categories through continuing education programmes for Haallh and making their educational programmes more community-based and community-oriented. In spite of these efforts, the question of the relevance of training and educational programmes to the needs ' of comprehensive health services based on primary health care still remains unresolved. Moreover, new problems of imbalance in the mix of health personnel are emerging, as exemplified by the proportion of physicians to nurses. Geographical imbalance of availability of health personnel, especially doctors, in rural versus urban areas is worsening. WHO endeavoured to promote a balance between training w~thin countries in the Region and outside the Region. While extra-regional training contributed to the development of specialist skills in selected areas, regional fellowships were supported for all SEAR countries in an effort to increase the technical competence of health personnel. Development of Human Resources for Health 31 In-country fellowsh~ps were supported in Bangladesh, Indonesia and Nepal, w~th the spec~fic purpose of develop~ng adequate numbers of health personnel to man areas that are currently ~nadequately covered by trained health personnel. P Policy and Health personnel policies and plans in some countries are not Plannbof entirely based on economic realities and are not aimed at a Human Resources cost-effective mix of health personnel. Since up to 70 per cent of for Health health budgets are taken up by personnel costs, even minor weaknesses in HRH policies and plans can lead to costly imbalances. Recognizing the need of the Member Countries for technical support in HRH policies and plans, WHO has supported the development of methodologies for HRH policy analysis and strengthening of national capabilities in the implementation of the policies. The Organization has prepared a "Guide to Policy Analysis and Formulation for Human Resources for Health", which has been used in Bhutan, Mongolia. Sri Lanka and Thailand to review HRH " policies. WHO has also continued to support HRH planning in the context of health planning in all Member States. Privatization of A significant factor contributing to the imbalance of human resources Health Care for health in the Region is the competition between the public and private sectors. This has, of late, become rather acute in many countries; in some countries, up to 60 per cent of the professional HRH are in the private sector. A rapidly expanding private sector can drain the public sector of its highly skilled health personnel. Further, in a rapidly expanding -, private sector, there is a need to ensure quality and standard of health care services through better regulation. Nevertheless, the potential positive contribution of the private sector is also recognized in relation to the provision of health care. It is necessary to take account of the private sector in the planning, production and management of HRH. Bearing in mind these problems, a consultation on "Public/Private Mix of HRH" was held in Bangkok in July 1994. In examining how governments will need to act in order to alleviate problems due to the increase of privatization, participants at the consultation recommended that governments have the following - -- -- - 32 The Work of WHO ~n SEA Health Information Syskm Most countries in the Region are strengthening their information systems with essential health information being generated by the appropriate recording and reporting of data at the primary health care level. Human Resource Development Medical education and training programmes in the Region are in keeping with national health priorities. WHO collaboration continues to be focused on making the Member Countries self-sufficient with regard to their human resource needs. Information and Education for Health The mass media, ~ncluding folk theatre, is being effectively used in the Region to create the necessary awareness on priority health issues including MCH environmental health, HIVIAIDS, etc The role of the media IS also recognized as being crucial in the area of population control and to ensure that the gains achieved on various fronts are not negated by the population explosion. three critical roles to play in ensuring equity and quality of care in the context of the publiclprivate mix of HRH: (1) role as policy-maker 'f and regulator; (2) role as a source of information, and (3) advocacy role for implementation. WHO will continue to play the lead role in assisting governments to manage problems that result from the increased privatization that is taking place in the Region. Paradoxically, at the same time as governments are being forced Management Of to reduce health expenditures due to financial constraints, they are Human Resources under pressure to expand health services and make them both f0rHealth accessible and affordable. These conflicting pressures can be reconciled only by improving the productivity of health services. and attention has naturally turned to the most costly component, viz. personnel. Low productivity of health personnel is often not recognized, partly because it is rarely measured. Low productivity may result from ineffective use of personnel, bottlenecks in the supportservices, inadequate skills, failure to delegate authority and low morale and motivation. WHO has continued to provide support to Member States to improve the management and productivity of their health personnel as exemplified by the in-service training workshops organized in Bhutan, Bangladesh, India, Indonesia, Mongolia. Nepal. Sri Lanka and Thailand. Decision-linked health systems research for the development of Research in HRH continues to be supported. HRH policy analysis was carried the out in Bhutan. Mongolia. Sri Lanka and Thailand. However, much ~~~~l~~~~~~ more remains to be done. Further research is needed to clarify how best the productivity of health personnel can be improved. of Human Studies aimed at developing and refining the indicators, standards and norms used to denote numerical balance of health personnel Health as well as developing criteria and methodology to determine the optimal mix of health teams in relation to defined tasks at different levels of health care are needed. Development of Human ~Gources for Health 33 Progress in the development of research in nursing has been continued. Mechanisms to intensify the coordination of research activities and the dissemination and utilization of research findings continue to be promoted. lnquirydriven strategies for changing medical education continue to be supported. Nevertheless, there is still a need for research to improve the linkage between the training and service sectors of health systems. Medical The ma~n thrust of WHO collaborat~on w~th the Member States was Education on lmprovlng the relevance and quallty of medical educat~on to meet commun~ty health needs The areas of focus lncluded reinforcement of the advocacy role in the countries, development of nat~onal-level coordlnatinq mechanisms for health personnel education, introduction of a population perspective in the educational programmes, acceleration of the entire range of educational reforms, establishment of functional linkages beGeen medical education, medical practice and the community, and a wider use of . research-based strategies to intensify the reorientation of medical education efforts. The regional-level activities were designed to address common priorities and issues of the countries and to complement national agendas in medical education development. In Bangladesh, Indonesia, Mongolia, Myanmar and Sri Lanka. WHO supported the orientation of leadership groups in the Ministries of Health and Education for aligning medical education to meet priority community needs. Policy redirection, coordination and introduction of innovative educational reforms are beimg pursued by relevant national groups. Policy reviews were also undertaken in lndonesia, Nepal and Thailand. Indonesia has developed a number of specific projects which will explore alternative models " of linking the medical and public health education institutions with the respective regional health services and the communities they serve. A majority of the activities during the reporting period related to the improvement of undergraduate medical education. These further built upon the recommendations of the Regional Consultation on Reorientation of Medical Education, held in the Regional Office in 1993. Similar follow-up consultations were held at the national level in India. Indonesia, Mongolia, Myanmar, Sri Lanka and Thailand. Mongolia is now finalizing a new national medical education policy - -- 34 The Work of WHO ln SEA in the context of the ongoing national socioeconomic transition and the new practice patterns. In Thailand, the Coordinating Centre for Medical and Health Affairs has laid down guidelines for continued development of medical education and medical practice in the country. In Indonesia. WHO continued its technical collaboration to extend the problem-based and theme-based concepts in medical education as the basis for the main teaching and learning strategies of the second core curriculum. The response of the medical schools is positive, and, in the next few years, the Indonesian model of problem-based learning (PEL) could serve as a possible option to introduce its essential elements into a conventional curriculum. Indonesia is also developing a comprehensive accreditation system to promote and ensure the quality of health personnel education programmes in the country. The Regional Office and WHO headquarters are planning to assist a few other countries to review and/or institute appropriate accreditation systems and "national board8'-type examinations as a means of quality assurance of the education programmes and of the graduates. Bangladesh is making major improvements in its medical education system through support from the WHO regular budget as well as from extrabudgetary resources. The Centre for Medical Education and the medical education units in all medical schools are being strengthened. A large number of teachers have been trained in educational methods. The reproductive health component IS being streamlined whilea numberof innovativecommunity-oriented educational activities have been started. Similar developments have taken place in the two Institutes of Medical Sciences in Nepal. Participants from the Region attended the first-ever Global Conference on International Collaboration on Medical Education and Practice. held at Rockford. Illinois. USA, in June 1994. The conference recognized the increasing pressure for social accountability and identified new quality standards. It designed tools for implementing and assessing strategies for making medical education more relevant to society's needs. Above all, it explored the basis for the formation of new and productive partnerships among institutions involved in adapting medical education, medical practice and health care to better meet people's needs. .- - .- Development of Human Resources for Health 35 WHO, along with the Network of Community-Oriented Health ,. Personnel Education Institutions, cosponsored an International Conference on the Role of Universities in Research for Health Systems Development, which was held in lndia in February 1995. * - This meeting undertook a detailed review of the current WHO-supported country strategies to utilize HSR for educational reforms for community orientation of medical education. In postgraduate medical education, WHO'S efforts have been directed towards bringing about overall systems development. i providing technical services to improve the assessment and evaluation methodologies, and improving teacher quality and capacity. Such collaborative programmes have been undertaken in Bangladesh, Indonesia, Nepal and Sri Lanka. Bhutan hasstreamlined its linkages with the health sector, which continues to be the main employer of specialist doctors, and has improved the selection process, field-based training and the assessment and certification methodologies. In Nepal, the postgraduate programme, conducted jointly by the Institute of Medicine and the Valley Group of Hospitals, is now fully functional and WHO has been supporting the authorities to improve the teaching and learning methods, the educational expertise of the teachers, the quality of the student research projects and the library and literature services. In Bangladesh and Sri Lanka, the main area of WHO collaboration continued to be the provision of external examiners with the twin objectives of quality assurance and improving the expertise of national examiners. WHO is continuing support to Bhutan to train its essential postgraduate medical personnel, mainly in India, Myanmar and Sri Lanka. This is illustrative of the technical cooperation that is being fostered among the countries of the Region and is expected to increase even further over the years. ws The redeeming feature of WHO collaboration in medical education has been the narrowing down of the unacceptably wide gap that existed earlier between the plans and the actual programme implementation. At the same time, the changing economic, epidemiological and technological transitions have imposed newer responsibilities on medical educators. New paitems of privatelpublii sector relabnship call for greater social responsibility and value for money in ed~cation and practice will inevitably demand some fundamental changes in the mission, goak and pms of medical education. 36 The Work of WHO tn SEA Support was continued to national efforts to strengthen the planning, production and utilization of nursing and midwifely personnel. A significant achievement in the Region has been the initiation of strategic planning for nursing and midwifely development within the context of national health and HRH plans. In Bangladesh and Thailand, the planning exercises have focused on the development of national action plans for nursing and midwifery in general. In Indonesia, Mongolia and Nepal, planning activities have concentrated on specific aspects of nursing and midwifely education. In addition, mechanisms have been established in the Ministries of Health in Mongolia and Nepal to ensure nursing input in national policy-making and planning processes. At the regional level, a position paper on nursing and midwifery has been developed to facilitate strategic planning for nursinglmidwifely development in the Region and to serve as a reference guide for technical assistance to countries. Nursing/ , Midwifery Education and Services WHO collaborated with countries in their continuing efforts to expand and strengthen educational programmes in order to alleviate the persistent shortages of nursing personnel and to increase the relevance of the programmes. Specific activities have included revision or evaluation of curricula in Bhutan, Mongolia, Nepal and Thailand; establishment of a Master's programme in nursing in Nepal; development of B.Sc nursing programmes in Myanmar and Sri Lanka; and a pilot project in lndonesia to introduce problem-based learning. Recent efforts by the Regional Oftice focused on promoting stronger links between nursing education and services and improving the quality of nursing care. These include a multi-centre research study, under way in three countries, on collaboration between nursing education and services; a review paper on strategies for optimizing utilization of nursing personnel in hospital nursing services; and the development of guidelines and resource materials on quality assurance in nursing education and services. In addition. Bangladesh and lndonesia have been carrying out activities directed at quality care improvements, while community health nursing has been further strengthened in lndonesia and Myanmar. Midwifery services and training are receiving greater attention in view of the national Safe Motherhood programmes initiated in several countries. An inter-country consultation on the Training and Utilization of Health Personnel with Midwifery Skills held in the Regional Office in December 1993 recommended that Member ~ -. Development of Human Resources for Health 37 - Health Learning Materials Countries should formulate a comprehensive plan for human resources development in midwifery, including training of these personnel in life-saving interventions relevant to the level of care, they provide. Follow-up actions have been taken at country and regional levels on the recommendations of the Global Advisory Group on Nursing and Midwifery, set up by WHO in 1992. Emphasis has been given to promoting mechanisms for coordination and integration of nursing and midwifery activities and to implementing guidelines for national action plans. Closely linked to the Global Advisory Group was a WHO Study Group on Nursing Beyond the year 2000. convened in Geneva in July 1993, in which the South-East Asia Region was represented. Recommendations, inter alia, called for a multisectoral collaborative approach to health and nursing care delivery and a shift in the focus of workforce development in nursing and midwifery to reflect country health needs. .m Despite the achievements in nursinglmidwifery education and practice development, a number of issues remain to be addressed. These include the continuing shortages and imbalances in the number and type of personnel and their maldistribution, inadequate mechanisms and leadership development to enable effective nursing participation in national-level policy and decision-making processes. and constraints of financial and human resources that are essential to bring about the needed improvements. Continued attention is also needed to strengthen training facilities and teaching resources as well as to develop and implement mechanisms for quality assurancelimprovement in nursing practice. fa A regional project, funded by UNDP, to develop a network of institutions for Health Learning Materials (HLM) in Indonesia, Myanmar, Nepal, Sri Lanka and Thailand was completed in the first quarter of 1994. The project has enhanced the technical capacity of the concerned institutions to produce relevant and usable health learning materials for different categories of health personnel. Improvements have been noted in the quality of the education and training programmes conducted by these institutions. These countries, therefore, now possess a nucleus of expertise in health learning materials development and are expanding their activities to meet the increasing needs. -. - - -- 38 The Work of WHO ~n SEA + The HLM project at the Institute of Medicine, Kathmandu. Nepal, which is a WHO Collaborating Centre for Health Learning Materials, continued its regular activities such as producing the bibliography of health literature in Nepal, conducting training programmes on different subjects for educators from the Region and providing a variety of consultancy services in HLM. The Centre also functions as the focal point for the "health net" information base for Nepal. A book on medical education, containing contributions from eminent authors from the Region, is being completed by the Centre. This will provide the conceptual base and illustrative practical and situational experiences in the development and implementation of relevant policies, plans and strategies for the development of medical education in the countries. The Centre is also collaborating technicalb to produce a television serial for health education of the public in Nepal. The SEAR0 HLM network now includes a total of nine countries - Bangladesh, Bhutan and Maldives having joined during the past two years. Each of these countries is also producing and adapting materials necessary for their education and training programmes. However, the conclusion of the UNDP project and the limitation of intercountry funds have tended to slow down the initial pace of network development activities. An urgent need, therefore, exists to mobilize further resources so that these countries can achieve a measure of self-reliance in HLM development. An intercountry workshop on Management of HLM Projects was held in the Regional Office in March 1994 to strengthen the managerial expertise of the responsible national HLM staff. In particular, the workshop focused its attention on issues such as priority setting and scheduling, leadership and responsibility. problem-solving and innovation, communication, promotion and marketing of HLM and resource mobilization. In the light of the perceived usefulness of the workshop, it was recommended that similar training activities should be held for other national staff who have managerial responsibilities. Health learning mater~als for different types of health worker continue to be produced by many of the main technical programmes. often in collaboration with their counterparts at WHO headquarters. These include production of materials on diarrhoea1 diseases for the training of medical students, nurses and other health workers; modular materials on acute respiratory diseases and on - - Development of Human Resources for Health immunization; a report of a low-birth-weight study conducted in SEAR countries, and a variety of pre-service and in-service learning materials in disease control programmes. * Fellowships The regional fellowship programme continued to make a substantial contribution in complementing the HRH plans developed by the countries. It has also enabled health personnel in Member Countries to acquire updated knowledge and skills to keep abreast of the latest technical knowhow in specific health-related fields. Public health and communicable diseases accounted for 63 per cent whjle dinical scjences accounted for 17 per cent of the fellowships awarded during the period under review (Table 1). Table 1. D~stnbution of fellowships under the regular budget, by subject of study and country of origin of fellows 1 (1 July 1993 - 30 June 1995) - 40 The Work of WHO in SEA .* During the 1994-1995 biennium, 22 per cent of the WHO Regular budget has been allocated for the fellowships component of the HRH training programme. With the introduction of yearly plans of action, the majority of the applications for fellowships were received in the first year of the biennium, which facilitated better implementation of the programme. To make short-term study tours, which constitute a major portion of the fellowship component, more effective, a package study tour on PHC at district level is being developed. Arrangements are being finalized for the first seven-week package study tour in October-November 1995 with visits to Thailand, lndonesia and Sri Lanka. The main objective is to develop health personnel, especially at the middle level, in PHCIdistrict health systems. For the 1994-1995 blennlum, the approved Regular budget for the ~lnplernent~tion fellowshlp component IS US$ 17 113 80 and its utlllzatlon up to 30 June 1995 was US$ 11 399 581 ( 65%) During the period under review, 1918 fellowship application forms (FAFs) were received in SEAR0 and 1277 fellowships were awarded. One hundred and seventy-seven fellowships, utilizing funds from other sources, were awarded. In addition. 604 in-country fellowships were provided. Table 2 shows the number of fellowships awarded by duration and country during the reporting period. Table 2. Distribution of fellowshlp application forms (FAFsJ, by duration (1 July 1993 - 30 June 1995) ~ ~ ~ - . -- ~ ~ ~~. .. 1 < 3 I Per 1 3-6 I Per 1 6-12 1 Per / > 12 I Per / Total 1 1 months cent months cent months cent months cent -- Bhutan India Indonesia Maldives Nepal Total 1 1586 / 82-7 - -~ Development of Human Resources for Health 41 By and large, the implementation of the fellowship programme proceeded satisfactorily, though a continuing trend with regard to increase in the number of short-term study tours under the fellowship te component was observed (Table 3). = Table 3. Distribution of awards in SEAR0 by duration (Regular budget only) 1 / < 3 months 1 36 months 1 642 months 1 W 12 months / 1 Out of a total of 1277 fellowships awarded, 828 ( 64.8%) were regional and 449 (35.2%) were extra-regional fellowships. The extra-regional fellowships were placed mostly in AMR (23%), EUR (25%) and WPR (49%). From other regions, especially WPR and EMR, SEAR0 catered for 267 fellowships in different institutions in the countries of the Region. Year It is observed that the cost of fellowships in some developed as well as developing countries has increased. This is due to a rise in tuition fees and training charges. The increase in the number of study tours involving visits to more than two or three countries has also accentuated the overall budgetary constraints. Group During the reporting period. 16 policy and advisory meetings and Educational 47 technical meetings were held. Subjects covered included ~~ti~iti~~ tuberculosis at district level, visceral leishmaniasis control, health care systems in districts, the dengue vaccine development programme, health systems research, nutrition, prevention and control of HIV infection, environmental health, health of the elderly. diarrhoea1 diseases, medical education, leprosy, essential drugs, -- . 1 TOW / . - -- -- 42 The Work of WHO In SEA 'f - NO. Per cent NO. Per cent "' cent NO. -- cent EPI diseases, women, health and development, safe motherhood. 1 noncommunicable diseases, malaria, community action for health. !, safe blood and blood products, STD management, prevention of d blindness and control of plague. Table 4 shows the distribution of participants in intercountry 1 activities, by type of activity. Table 4. Distribution of partic~pants in intercountry activities. by type of activity (1 July 1993 - 30 June 1995) / Typa of activity 1 Number ~-p-~-~~ -~ ... ~ Regjonai meetlngs 5 Workshops 11 Consultative meetlngs 27 4 Total 47 Number of participants - ~ . . - 90 175 401 80 . .~ .. 746 - Development of Human Resources for Health

in the South-East Asia Re@@ Biennial Report of the Regional Director I duly 1993 - 30 June 1995 World Health Organization Regional Office for South-East &ia New Delhi, 1995 Biennial Report of the Regional Director 1 July 1993 - 30 June 1995 ISBN 92 9022 2050 @ World Health Organization 1995 Publications of the World Health Organization enjoy copyright protection in accordance with the provisbns of Protocol 2 of the Universal Copyright Convention. For rights of reproduction *, or translation, in part or in toto, of publications issued by the WHO Regional ORw for South-East Asia, appliiin should be made to the Regional Olhce for South-East Asia. World Health House. lndraprastha Estate, New Delhi 110002. India. - The designations employed and the presentation of the material in this publi&tion do not imply the expression of any opinion whatsoever on the part of the Secretariat of the World Health Organization concerning the legal status of any country, territory, dty or area or of its authorities, or concerning the delimitation of its frontiers or bundaries. Printed in India The Work of WHO in the South-East Asia Region Biennial Report of the Regional Director I July 1993 - 30 June 1995 World Health Organization Regional Office for South-East Asia New Delhi. 1995 A World Without Polio World Health Day, 1995, with its theme of polio eradication, helped to further strengthen Member Countries' resolve to achieve the target of a world without polio by the year 20W. Contents Page Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vii Executive Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ix Saction I Direction, Coordination and Management . Governing Bodies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . f World Health Assembly . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 Executive Board . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 Regional Committee . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 2. WHO'S General Programme Development and Management . . . . . . 8 Regional Director's Development Fund . . . . . . . . . . . . . General Programme Development , . . . . . . . . . . . . . . . External Coordination for Health and Social Development Health Emergency Preparedness and Response . . . . . Health Ministers' Meetings . . . . . . . . . . . . . . . . . Informatics Management . . . . . . . . . . . . . . . . . . . Section II Health System Infrastructure 3. Health System Development . . . . . . . . . . . . . . . Health Situation and Trend Assessment . . . . . . . . . Managerial Process for National Health Development Health Systems Research . . . . . . . . . . . . . . . . . . . Health Legislation . . . . . . . . . . . . . . . . . . . . . . . . . Page 4 . OrganlzaUon of . Health Systems Based on ................. Primary Health Care 5 . Development of Human Resources for Health Managerial Process for the Development of Human Resources for Health ................. Research in the Development of Human Resources for Health ......................... .................... Medical Education NursingIMidwife~y Education and Services ...... Health Learning Materiels .............. ........................ Fellowships Group Educational Activities .............. 6 . Public Information and Educatlon for Health . . Section Ill Health Sdena and Techdogy 7 . Research Promotion and Development. lncludlng Research on Health-Pmmotlng Behavlour ...... 8 . General Health Protection and Pmmot\on .................... 51 .......... Nutrition ................. . 51 Oral Heanh ............. .......... . . 52 .* .................................. Accident Prevention 53 Tobacco or Health .................................. 51 9 . Pmtectlon and Pmmotlon of the Health of Specific .................................... PopulaUonGroups 55 ............. Maternal and Child Heahh. induding Family Planning 55 Adolescent Health ..................................... 61 Human Reproduction Research ............................ 61 Workers' Heanh ....................................... 62 Health of the Elderly ................................. 62 10 . Protection and Prornotlon of Mental Health .................. 63 Psychosocial and Behavioural Factors in the Promotion of Health and Human Development ....................... 63 Prevention and Control of Alcohol and Drug Abuse ............... 64 Prevention and Control of Mental and Neurological Disorders . 64 I1 . Promotion of Environmental Health ........................ 66 Community Water Supply and Sanitation .................... 67 Environmental Health in Rural and Urban Development and Housing ........................... . 68 Health Risk Assessment of Potentially Toxic Chemicals . 69 Control of Environmental Health Hazards .................. 69 Food Safety . . .............................. 70 12 . Diagnostic. Therapeutlc and Rehabilitative Technology ......... 72 Clinical. Laboratory and Radiological Technology for Health Systems Based on Primary Health Care .......... 72 Essential Drugs and Vaccines ....... .... 74 Drugs and Vaccine Quality. Safety and Efficacy . . ... . 75 Traditional Medicine ..................... 76 Rehabilitation ......................... . 76 13 . Disease Prevention and Control ................... Immunization ... ... ......... Disease Vector Control . . Malaria ..... . . ... ... Parasitic Diseases ...... ........... Tropical Diseases Research .............. Control of Diarrhoea1 Diseases .................. Acute Respiratory Infections (ARI) .......... .. Tuberculosis ............ ...... Leprosy . . .... ....... Zoonoses ......... . . ...... Sexually Transmitted Diseases .............. Research and Development in the Field of Vaccines .... AIDS ..................................... 103 ...... Other Communicable Disease Prevention and Control Activities 106 Blindness and Deafness ......................... 109 Cancer ..... ......................... 110 Cardiovascular Diseases ............... Other Noncommlmicable Diseases ....... kabn IV Rorrolm support 14 . Health Information Support .................. HeaRh Lnerature and Library Services (Including HELLIS) Publications and Documents .................... 16 . Support Sewlces .............. ................... Personnel General Administrative Services ..... .............. Budget and Finance Supplies and Equipment ........... .................... General Annexes Organizational Structure ..................................... 127 Projects in Operation in Member Countries ..................... 129 Preface 7he political, social aizd ecottomic chattges iiz the past fau years hare had a profound impact on the public health situation mn'dw.de, includi~zg the Member Countries of the WHO South-East Asia Region (SEAR). In order to meel the chdenges brought about by these changes, and itt pursuance of the recommendations of the Erecutirk? Board Working Group on WHO Respotrre to Global Cbairge, WHO has undertakez atz organizatiott-wide r@orm of its stnrctrrre and functiotti. Reorgatriration of WHO programmes has been eflected and the mattagerial process for WHO programme da@lopme?rt and management reriised in the light ofthe Ninth General Programme of Work of WHOfor the period 1996-2001. Retaual of the health,for-all strategy has been initiated; a ttew WHO commr~rricatiot~ atid public relatiom policy is already utrder implementatiotz; a rzau WHO persotrtzel policy is otr the anvil, and strmzgthening of WHO coutrtry oflices is beitzg uizdertakett. A rtew Orga?rizatio~-u2de manaynetzt irijormatiort system is rrrtderdetelopme?rt to sene WIO attd its Member States more ejfectively. The Executiw Board, at its tritrety-fiph mion irr Jarruary 1995, nrdomed the concept of biennial strategic programme budgeting and ideeztified specific priority areasfor WHO programmes utrder the Regular budget. In thr, corItext of sr~ccessire "zero-growth" Regular budgets itz WI-IO, it i.s heartcttrr~g to ttote fhr slgt~iJkarif i?rrmlmment of multilateral fit~artcial itrrtitr~tiot~s, tzotab[y the IDA atrd thr AsDB, in the health sector br sereral cotrnlries .co/the Regiotr. The inmstmerrt by the Wodd Bank itz the health sector has beer1 tzotable, ie. IJS$197 miNiott itz Bangladesh (during 1992-196) and oter US$l billion in Itrdia during the period 1992.2000. 7be resrrlt~ of the third mot~itoritrg of the implemetttation ofHFA strategies itz SEAR hare corzjrmed a slow decline it^ crude death rates and itijatzt and rrt2derfile mortality rates. It ako rnealed the epidemiological trartiitiotz br cenaitr Member Courrtries where cbrorzic ~roncommut~icabLe dfieuses arc emergirrg ac importatrl curses of morbidity and mortality. The recnrdescence of cettain diseases, such as malaria and tr~berculosis, the resuvetrce oJplague, artd the loomrng danger of MDS and HIV itfectiotz are also causing graw concern and call for extreme Yigihnce and preemptive public health actionq. F With a view to tackling major public health problems of common concern in * a spirit of enhanced regional cooperation andsolidarity, theRegiona1 Comminee, at its Jorty-seventh session in 1994, endorsed the need to strengthen the WHO intercountry programmes in the Region. 'Ihis is a vay welcome dmlopment to combat health problems of a priori5 nature, such as mahria, polio and MV/AIDS, and to improw admacy and innovative approaches in other areas of priority. 7he Regional Office has, with the help of a cowltatiw group, dewloped spec& proposals and recommended modalities for augmenting the present allocation to the intercountyprogmmmes starting from the 1936-1997 biennium. WHO had heen playing the kad role in thepremtion and control of HN/AlDS under the Global Programme on AIDS. How, in view of the need for a multi-sectoral approach to address its wi'der socioeconomic impact, the Joint United Nations Programme on AIDS (WAIDS) is being established to rephce the Global Programme. WHO will continue its technical cooperation to support Member States, through the use of its oum Reguhr budgetary resources, in the irrtemz@Td pret~rrtion and control of sezuall) transmitted direuses and in stlstaining the esserrtial elements of national programmes on HN/AIDS. WHO contributed a position paper with a comprehensive definition of reproductive health to the International Conference on Population and Detelopment held in Cairo in 1994, which adopted a Global Plan of Action on Population andDefzlopment, 7he Ovanization at50 strongly andsuccessfull) adtacated the placement of health and human development at the centre of socioeconomic det~lopment at the World Summit on Social Development held itt Copenhagen in 1995, 7he Regional Oflce and the Member Countries ofthe Region were actiriely i~tcoloed in both of these global mts, which are likly to haw a sig~ziJicant bearing on international cooperation and actions in the coming decade. I haw great pka~rrre in submitting to the fo7fy-aghth session of the Rqional Committee my fitst bienttial report since assuming office as the Regional Director. Dr Uton Muchtar Rafei Regional Dtrector Significant socioeconomic and political changes which had a varied Impact on public health in the countries of WOS South-East Asia Region were witnessed during the reporting period (1 July 1993 - 30 June 1995). It is now realized that the object of all development processes -social, economic, cultural and political - is the well-being of aN men and women who inhabit this world, and also of those who will do so in the future. Accordingly, the emphasis on sustainable development highlighting the place and role of health, which gained momentum with the Rio de Janeiro Summit on Environment and Development, has been carried to its logical conclusion at the World Summit for Social Development in Copenhagen in 1995. The central role of health in human development has been duly acknowledged in the Declaration and Programme of Action adopted at the Social Summit. Between Rio and Copenhagen, the disadvantaged position of women in respect of health was brought into sharp focus at the International Conference on Population and Development in Cairo in 1994, and it is hoped that the forthcoming World Conference on Women in Bepng wtll set the stage for women to occupy their rightful place in society. Happily, the worldwide focus on the health of children, highlighted by the World Summit for Children in 1990, has permeated through practically aN development activities in the Member Countries. In short, the health ofthe people has now come to occupy the centre-stage of global and national agendas for development. In 1990, the total population of the world was estimated to be 5.3 billion, of which 1.3 billion (24.5%) lived in the 11 (now 10) Member Countries of the South-East Asia Region (SEAR). The land area of the Region is approximately 8 466 600 sq km, which is six per cent of the global land mass. Between 1980 and 1990, the .~ - Executive Summary IX Region's population grew by almost 242 million and, by the year : 2000, it is expected to go up by a further 257 million, thus accounting : for 25.3 per cent of the wodd total. y The health situation in the Region is characterized by a slow decline in crude death rates and infant and under-five mortality rates as well as a gradual increase in life expectancy. The infant mortality rates have come down during the last decade in virtually all Member Countries, but they still remain high (70-100 per 1000 live births) in some countries. An analysis of under-five mortality rates shows a similar pattern. The maternal mortality rate, which has shown a slow overall decline during the last decade, continues to be high in some Member Countries. The main changes in mo~i~idity and mortality patterns during the last decade result from a decline in the incidence of polio, measles, neonatal tetanus and other EPI target diseases as well as from the declining prevalence of leprosy in the Region. The less * optimistic side of the regional health situation is characteriled by the high incidence ofacute respirato~infections, diarhoeal diseases, malnutrition and nutritional deficiency disorders, vector-bome diseases (especially malaria) and tuberculosis. The persistence of malaria and tuberculosis, the resurgence of plague, the emergence of chronic noncommunicable diseases such as cardiovascular diseases, cancer and diabetes, the emergence of other infectious diseases such as dengue haemormagic fever, Japanese encephalitis and the N tor strain of cholera, and the pandemic of AIDS and HIV infection, are the major challenges for the future. It is this scenario that has prompted the Regional Office to ~- urge governments to tackle major health problems of common concern through greater cooperation and willingness to pool and share resources in regional and intercounty programmes, the objective being to make a stronger impact on disease control and health problem reduction in a more cost-effective and cooperative manner. This initiative has given a new impetus to the spirit of solidarity that exists among Member Countries and has brought about an awareness of the benefits of cooperation in health even before cooperation in other fields of human endeavour - social, economic and ~olitical - is established. x The Work of WHO in SEA P The Consultative Committee for Programme Development and Management (CCPDM), which has been an effective and useful interface between the Regional Committee and the Regional Director and his secretariat, endorsed the need to increase the WHO Regular budget resources in regional/intercountry programmes. Following this, specific proposals were formulated under three broad strategic approaches, namely, advocacy for health, technical cooperation among countries, and international cooperation on standard setting and innovations. This augurs well for WHO'S overall technical cooperafion in the Region whjch, with endorsement by the Regional Committee, assumes importance in the context of building a regional platform for health development in a spirit of practical cooperation and partnership among Member Countries. Departing from past practice, the CCPDM also committed itself to assessing the health situation and trends and advisIng on priorities for the Region as a whole. While these initiatives give cause for satisfaction, there are continuing resource constraints within WHO. Therefore, it has now become even more important to make optimal use of the scarce resources available with the Organization. Another significant development has been the increasing involvement of multilateral financial institutions, mainly the lnternational Development Association (IDA), the lnternational Bank for Reconstruction and Development (IBRD) or the World Bank and the Asian Development Bank (AsDB). Some major bilateral agencies are also supporting ativities in the health sector. There have been changes in fnternatfonal relationships and also changes arising from reforms within the UN system itself The directing and coordinating role of WHO has not always been understood or accepted. Welcoming the interest and commitment of major financial institutions in the health sector, WHO is establishing new forms of partnership for health cooperation. The Regional Office has taken the initiative to define collaborative partnerships, for example, with the World Bank and the AsIan Development Bank. This report seeks to provide a summary of the major achievements of the WHO Regional Office for South-East Asia and its Member Countries and to draw attention to the unfinished public health agenda and the emerging challenges in the years to come. Executive Summary Governing The Forty-seventh and the Forty-eighth World Health Assemblies Bodies were held in Geneva in May 1994 and May 1995 respectively. The Foffy-seventh Health Assembly considered, inter alia, the worldwide w threat posed by the HIV/AIDS pandemic, reviewed WHO3 Global Programme to meet the challenge at all levels, and noted the action taken to develop and establish a joint and cosponsored UN pmgramme on HIV/AIDS. 'Community Action for Health' was the subject of the Technical Discussions during the Health Assembly. The role of intersectoral collaboration, with community involvement, particularly of women, was emphasized. Among other subjects discussed were infant and young child nutrition and maternal and child health, including family planning. The Forty-eight Health Assembly debated the subject of renewing the Health-for-AN Strategy and reviewed the World Health Report 1995, incorporating the Director-General's Report on The Work of WHO, which was produced for the first time and will henceforth be brought out annually Other subjects discussed % included: the third report of the monitoring of progress in the implementation of strategies for health for all by the year 2000, control of diarrhoea1 diseases and acute respiratory infections, as also emerging, re-emerging and new infectious diseases. The Health Assembly approved the programme budget for the 1996-1997 biennium. At the request of the Government of Mongolia, the Health Assembly adopted a resolution agreeing to the transfer of Mongolia from the South-East Asia to the Western Pacific Region. The Regional Committee provided guidance to Member Countries on regional health matters and on implications for the - Region of the policies enunciated at the World Health Assembly As a part of the ongoing reform process initiated by the Executive Boam: the Regional Committee undertook a review of its own method of work. The Committee decided to improve the linkages between its work and that of the Executive Board and the Health Assembly with a view to ensuring that the global policies and decisions were responsive to the regional health situation and priorities. The Forty-sixth session of the Regional Committee was held in the Regional Office in September 1993. The Committee nominated - - XII The Work of WHO~SEA Dr Uton Muchtar Rafei as the Regional Director for South-East Asia for a five-year term from 1 March 1994. It reviewed the report of the Regional Director for the period 1 July 1991 to 30 June 1993 and noted that, despite changes and upheavals, the Regional Office had continued to support the Member Countries in the formulation of national health policies and medium-term plans for sustaining health development. The Committee expressed concern over the deteriorating HIV/AlDS situation. It also reviewed the situation in respect of malaria and tuberculosis and resolved to take suitable action to tackle these problems. The forty-seventh session of the Regional Committee, held in Ulaanbaatar, Mongolia, in August 1994, considered the report of the Regional Director for the period 1 July 1993 to 30 June 1994. 'Resurgence of Tuberculosis - The Challenge', was the topic of the Technical Discussions. The Committee stressed the need for the training of field-level workers and the strengthening of technical capabilities at all levels, including sentinel surveillance. The Committee also discussed subjects such as control of preventable diseases, monitoring and evaluation of the strategies for health for all, WHO response to global change. AIDS and accident prevention and trauma care management. The Health Ministers of the countries of SEAR have established a fine tradition of developing good fraternal relationships. They have been addressing specific topics or important heatth issues in the Region. While there is a climate of understanding and cooperation, the full potential of mutual collaboration has not yet been achieved. The Ministers are agreed on the need to assess the outcome of theirpast meetings and to address the issue of technical cooperation in health among SEAR countries in a more determined manner. The Ministers met in Dhaka, Bangladesh, in November 1993 and in Ulaanbaatar, Mongolia, in August-September 1994. They discussed, inter alia, important topics such as TCDC in health, health management, new thrusts and concerns in health and health and poverty The MInIstersrecognized the need to develop common principles and guidelines for promoting TCDC and recommended formulation of plans and programmes for strengthening health management and ensuring a balanced development of health manpower While acknowledging the need to take urgent steps to arrest the spread of HlV/AIDS, they were agreed that the control - Executive Sumrnaly XIII programmes in respect of malaria, tuberculosis and leprosy needed further strengthening. The Ministers also emphasized that a new and broad socio-scientific perspective of education for health should .* *. replace the old one-way communication process that had failed to mobilize people for health action. WHO'S The Regional Director's Development Fund was effectively used Programme for the provision of specialized support to different programmes. ~~~~l~~~~~t These included: elimination of iodine-deficiency disorders, prevention and and control of dengue/DHF, review of malariogenic stratification and provision of material support, including emergency health kits, to Management meet the health situations arising from natural disasters. To reinforce support to Member Countries in the efficient delivery of the collaborative programme, the country support teams were activated through country programme formulation missions. The management infonation system has been further strengthened by improving the Local Area Network (LAN) and linking of several it offices of WHO Representatives with the Regional Office by E-mail. WHO, as the specialized UN agency for health, continued to coordinate with other UN agencies and bilateral and multilateral organizations to protect and promote the interests of the health sector. It provided support to Member Countries in the mobilization of external resources for health. Technical advice was given to the Wortd Bank and the Asian Development Bank on areas of investment in the health sector. Large funds from these two institutions are now available to health projects in Member Countries, notably India and Bangladesh. At the invitation of the Regional Director, senior officials from the Asian Development Bank met the WHO Representatives in New Delhi in November i994 and this meeting Z has led to reorientation and better understanding on the part of the Bank regarding the health sector needs in the Region. In view of the increasing importance of the role played by nongovernmental organizations, a new initiative has been taken to analyse and assess the current position of WHOiNGO colaboration in the Region. An action plan is being developed to promote NGO/GovernmenVWHO collaboration in the Member Countries. WHO assisted Member Countries in formulating emergency preparedness and response (EPR) plans and in strengthening the -- XI" The Work of WHO In SEA e health infrastructure of EPR operations. In view of the increasing demands made on WHO for technical advice and suppod relating .~ to health aspects of humanitarian emergency relief, the Organization has formulated global strategies. A Technical Officer for Emergency and Humanitarian Action has been appointed in the Regional Office in order to provide effective technical support to the Member Countries. The results of the third monitoring of the implementation of HFA Health strategies have confirmed that significant improvements have been Systems achieved in life expectancy at birth and infant mortality rates. But Development the maternal mortality rate fs still unacceptably hfgh in some countries. It has also been revealed that some countries have now entered the stage of epidemiological transition where chronic non-infectious diseases have become an important cause of morbidity and mortality. Unchanged rates of population growth in some countries is a matter of concern as the unchecked population growth largely offsets the gains of socioeconomic development thereby adversely affecting the health of the people as weN as the provision of health sewfces. The eighth issue of The Health Situation In SEA Region (1991-1993), previously entitled Bulletfn of Regional Heath Information, was published during the reporting period. it provides a comprehensive data-based analysis of the prevailing health conditions and health indicators and makes projections in the 11ght of the socioeconomic and other determinants of health. In view of the cr~t~cal importance of 'early warnfng su~eillance system' to detect communicable diseases before they assume epidemic proportions, WHO is assisting Member Countries through field epidemiological training programmes (FETPs). While such programmes are in place in Indonesia and Thailand, other countries are being provided short-term training in FETP at the National Institute of Communicable Diseases, Delhi. In the wake of the structural macroeconomic a@ustments under way in Member Countries, governmental allocations for the health sector have been reduced in real terms in several countries. The need for efficient use of the available resources for provision of quality health care with equitable access therefore becomes even more necessary. In the context of the reduced share of financial - - - Executive Summary xv Organization of Health Systems Based on Primary Health Care resources for health development activities in the national health budgets, most Member Countries are giving priority attention to health policy development and are exploring alternative methods .- of financing health care services, including privatization. WHO awarded fellowships for postgraduate training in health economics and financial management and provided financial support for organizing national workshops to sensitize senior officials to health economics and health care financing. WHO also supported studies on such subjects as health expenditure and health care utilization and management evaluation of free medical service. The Centre for Health Economics, Chulalongkorn University, Thailand, has been designated as the WHO Collaborating Centre on Health Economics. The Centre has been conducting M.Sc. and short-term courses on health economics, with support from WHO. The managerial process for national health development has been strengthened in the Member Countries with WHO'S support being provided in health policy analysis, rnedium-term planning and t development of a critical mass of health planners and managers. Technical support was also provided to countries with a view to attracting and propefiy utilizing the Wolld Bank's and other external assistance in the health sector. The role of health legislation in the implementation of HFA strategies has been acknowledged for long. WHO has extended support to Member Countries in formulating and strengthening their health legislat~ons. Almost a// Member Countries of the Region have recorded progress - in the reorientation and restructuring of their health systems based on primary health care. Access to primary health care is being expanded, through strengthening of the district health system, expansion of health infrastructure, improvement of health care for women and children and through a targeted approach to reach the underprivileged. Countries are now giving increased attention to urban health care through the application of WHO'S 'Healthy City' approach. The role of the community as an active partner in health development has been further developed through the training of health volunteers and HFA leadership. XVI The Work of WHO in SEA Efforts to improve hospital care, particularly at the first referral level, and strengthen linkage with primary health care have been - . pursued. A number of countries have initiated programmes for quality assurance of hospital care. However, differences in the general health status of people in the countries have persisted. Disaggregated data within countries also reflect inequities among different population groups. The coverage of the eight elements of primary health care has generally shown an improvement due largely to expanded health infrastructure, as reflected by the third monitoring of the implementation of HFA strategies. However, it has been obse~ed that health workers and their supervisors are not fully oriented to the PHC approach, which rests upon integrated delivery, ~ntersectoral collaboration and community pafticipation. Community involvement and mobilization through the selection and training of health volunteers have been established as strong components of national health policies and strategies in several - Member Countries. This approach has contributed to the development and promotion of self-care as pad of the daily life of the people. Various community-based innovative activities, such as village drug funds, village sanitation funds, village health ~nsurance schemes, community dental health schemes, maternity homes and traditional herbal gardens have also been evolved. Through the involvement of other social development sectors, a broader social development approach for achieving the basic minimum needs and improving the quality of life is the theme of health development in some of the countries. Community organization and mobilization, in partnership with health workers, is necessary in order to deliverheatth care package in the community, as the Posyandu and village health care post schemes are doing. There has been progress in the development of human resources Development for health (HRH) in most countries of the Region. Howeve!; lack of of Human relevance of training/educational programmes to the health needs Resources for of the people and imbalances in HRH, both in terms of numbers ~~,,l+h and categories and their deployment in rural and urban areas, continue to cause concern. The increasing role of the private sector tn providing medical and health care is partly responsible for the imbalance in HRH. Therefore, the role of governments in ensuring ~ Executive Summary xvli equity and quality of health care through proper regulation assumes greater importance. I The need to reorient medical education to be in line with the community's needs can scarcely be overemphasized in this context. Member Countries are linking up their medical schools with the health services in many ways. In some countries, research- and enquiry-driven approaches to reorient medical education are being developed, while others are implementing problem-based learning in their medical schools. WHO has continued to support the development of sustainable systems of medical education by aligning it with the health needs of the communities. Despite progress in the expansion and reorientation of basic and post-basic educational programmes for nursing and midwifery personnel, shortages and imbalances still persist in most Member Countries. In the context of programmes for safe motherhood and child survival, there is an urgent need to increase the production of nurses and trained midwives. P WHO'S programme for strengthening institutional capacity for the development of health learning materials (HLM) in Member Countries has started showing results in the range and quality of materials being developed or adapted to meet the needs of different categories of health workers. Since the completion of a regional HLM project in 1994, some of the countries have incorporated HLM in their regular human resources development plans and budgets. WHO'S Collaborating Centre for HLM in Kathmandu has continued to support Member Countries in key technical areas through training, consultancies and exchange of information. However, notwithstanding the progress made, much more needs to be done. The Organization will continue to support Member Countries' efforts = in this regard. WHO'S fellowship programme has enabled national health authorities to improve their human resources for health, both in terms of numbers and quality, and to keep abreast with the latest advances. As fellowsh$s play a significant role in the inprovement of HRH, 22 per cent of the total country allocations for the 1994-1995 biennium has been earmarked for this purpose. Further, in order to make study tours more cost-effective and relevant, a package study tour on PHC at the district level is being developed. xviii The Work of WHO in SEA C Information and education for heaMh (IEH) continues to be Public strengthened in support of primary health care. People now have information - a greater awareness of health matters like life-style-related diseases, and ~d~~~ti~~ the importance of immunization for children and prevention of communicable diseases, includfng HIV/AIDS. Designation of the for Health Indian Institute of Mass Communication in 1994 as a WHO Collaborating Centre for Health Communication is 11kely to accelerate progress in the dissemination of IEH through the electronic and prfnt media. Comprehensive guidelines for school health education would also help Member Countries in inculcating appropriate attitudes and behaviour towards better health among the youngergeneration. At the regional level, an added impetus to IEH is expected with the implemenfation of the new WHO Communications and Public Relations Policy, which aims at creatfng proper awareness of the objectives and programmes of WHO. fostering involvement in its work and advocating health for all, along with a coherent , approach to health development. To start with, health advocacy materials forthe Region are being developed and efforts to strengthen links with the media have been initfated. During the reporting period, the Regional Office initfated action to operationalize its research programme in accordance with the research strategy endorsed by the South-East Asia Advisory Committee on Health Research (ACHR) in 1993. Based on the strategy, a technical publication 'Health Research Strategies of the South-East Asia Reg~on' was produced. The strategy emphasizes that within HSR components such as health policy and health promotion, health economics, health behaviourand health manpower development should receive greater attention. The Regional Office has supported a series of inter-related activities for the promotion and development of research in these priority areas. A strategic plan for future activities was developed at the Th~rd Meetfng of the SEA Nutrition Research-cum-Action Network Direct support for research was provided, among others, for projects on HIV infection, treatment of drug-resistant Pfalciparum malarfa, influence of the reservoirs of malaria infection in transmission dynamics, tuberculosfs, the elderly, nutrition and traditional medicine, quality of antenatal care services, and weaning behaviour. Research Promotion and Development Including Research on Health- promoting Behaviour . . -. . . - Executive Summary National research capability has been strengthened through various forms of cooperation: e.g multicentre collaborative research programme fordevelqwnent and validation of technical and operational - guidelines for retarding the growth of drug-resistant P. falciparum; multbntre study of the process and outcome of collaboration between nu- services and nursing education, and technical and financial support to the dengue vaccine development programme at Mahidol Universify. Thailad. There are at present 81 WHO odlaborating centres in the Region in a variety of health-related Ws. During the period under review, new collaborating centres were designated in the fields of health economics, health communication and cancer control. The ACHR, at its twentieth meeting in 1994, recommended that research on health policy, assessment, development and transfer of appfupriate diagnostic technology and behavioural aspects of health should receive greater attention. At its twenty-first meeting in 1995, the Committee outlined specific research directions under the Regional Research Promotion and Development Programme for the next three biennia. s. The twentieth anniversaiy commemorative session of the ACHR was held in the Regional Office on 8 April 1995. In addition to the ACHR members and WHO secretariat, the past ACHR chairpersons and the Regional Director Emeritus pariicipated in the session. While commending its achievements since its inception, members recommended that the ACHR should take due cognizance of the epidemiologic, demographic, socioeconomic and cultural changes that had occurred in recent years and formulate appropriate health research strategies for the future. The ninth meeting of the Directors of Medical Research Councils or Analogous Bodies and Concerned Research Foci in the Relevant Ministries made recommendations relating to HIV/AIDS, dengue vaccine trial, operational research on tuberculosis control and future trends assessment It also discussed the mechanisms of implementing the regional strategy for health research in the Member Countries. Geneml Health Nutrition continues to remain a priority area in the Region. WHO Prote~tion 0~d : support has been given for improving the quality of national Promotion , prwrammes to address protein-energy malnutrition, iodine and vitamin A deficiency disorders and iron-deficiency anaemia, -- XX The Work of WHO In SEA particularly in pregnant women. The Nutrition Research-cum-Action Network, established in the Region, continued to address these - problems. The Network Newsletter was disseminated to national nutrition focal points and research centres. A regional meeting on Elimination of Iodine Defroency Disorders (IDD) reviewed international commitment to the goal of IDD elimination by the year 2000. The lnternational Code of Marketing Breast-milk Subsbtutes is being implemented in most countries of the Region. As a follow-up of the lnternational Conference on Nutrition (ICN), Member Countries have developed revised nutrition policies and programmes to implement the World Declaration and Plan of Action for Nutrition. WHO also supported training for micronutrient malnutrition control, breast-feeding and weaning foods, development of nutrition monitoring system and the production of radio and television programmes to address specific national nutritron problems. Though the importance of oral health and the health of working populations is well recognized, Member Countries need to match this commitment with financial outlays in their national health budgets. WHO's collaborative role has concentrated on sensitizing the decision-makers and health-providers in this regard as well as on the development and strengthening of national programmes with strong components to secure intersectoral action and inter-departmental collaboration. As activities towards reduction in tobacco consumption continue to face stiff resistance from certain quarters, WHO's role will have to consist mainly of supporling advocacy, research on demand reduction, health ~nformation and education and legislation for tobacco control in Member Countries. integration of MCHEP services in primary health care is now Protection and universally accepted Though significant achievements have been promotion of made in all Member Countries in bringing down the infant mortality ~~~l~h of rate ((IMR), similar success has not been achieved ;n the reduction of maternal and neonatal mortality. Therefore, while responding to Specific countw-specific needs in all aspects of MCH/FP, WHO has given a PO~ulati~n high priority to the safe motherhood programme in the Region. It Groups assisted national workshops and the development of national plans in safe motherhood. WHO's 'Mother-Baby Package' has been -- Execut~ve Summary XXI introduced in four countries having a high maternal mortality rate (MMR). WHO contributed globally-accepted conceptual and technical guidelines with regard to reproductive health at the International , Conference on Population and Development in Cairo in 1994. The plan of action adopted by the Conference included reduction of infant/child mortality and provision of universal access to reproductive health services, including family planning and sexual health, which are in line with WHO'S Ninth General Programme of Work (i996-2001). The Organization is fully committed to supporting the implementation of national plans of action while maintaining a broad and holistic approach to reproductive health care. Adolescent health was started as a separate WHO programme in 1991-92, and activities under this programme are gradually gaining momentum. Most Member Countries recognize the changing lifestyles of the young and accept the need for giving more attention to their health. At country level, WHO directed its efforts at the promotion and protection of health of adolescents and youth, particularly in the areas of reproductive health, use of tobacco, drug abuse and healthy lifestyles, including sports. Collaboration with the Special Programme on Human Reproduction Research was continued, with strong inputs from the Regional Office for strengthening research capabilities in Member Countries. Towards this end, regional and national workshops were supported, and long-term institutional development and capital grants were approved for four countries. Protection and The rapid demographic transition and the consequent Qreying of Promofion of populations', on an increasing scale, has particular health _ ~~~~d ~~~l~h implications. WHO'S catalytic role in sensitization and country support included assessment of the magnitude of the problem and strategies for coping with it. WHO'S collaborative programme in matters of lifestyle and behavioural-psychosocial health issues includes improvement of the quality of life and well-being of the mentally affected persons; lessening of the perceived burden on families caring for an incurably ill or disabled family member; psychosocial interventions to improve the capacity of disadvantaged families to cope with disaster survivors or refugees, and interventions to improve outcomes in disadvantaged - - xxlt The Woh of WHO ~n SEA - children. The bpen community approach' to drug abuse control, which combines elements ofprevention, treatment and rehabilitation, and minimization of harm to drug injectors, has gained further acceptance in the Region. Evaluation of some projects using this approach has shown excellent results. WHO continued to promote and demonstrate the concept of the public health approach in mental health in place of the traditional institution-orientedpsychiatry. Following the adoption of the WHO Global Strategy for Health and ' Promotion of Environment, a regional strategic plan was developed within the Environmental framework of the Organization's collaborative activities with Member ~~~l~h Countries. The promotion of environmental health is aimed at achieving universal safe drinking water supply and adequate sanitation by the year 2000, improved urban env~ronmental health conditions, safe management of chemicals, monitoring and control of environmental hazards from pollution, particularly in urban areas, and the strengthening of food safety programmes. In the area of community water supply, WHO has supported institutional development through review of policies, special studies, and human resource development in water quality surveillance, comrnunityinvolvement andsectorinformation management. A number of 'Healthy City' prujects have been initiated in the Region to improve municipal water supply, sanitation, solid waste management and other environmental health conditions. To cope with the growing problems posed by chemicals used in agriculture and Industries, WHO'S collaboration has been directed towards strengthening national capabilities to manage chemicals safely without adverse effects to human health and the environment. In the field of food safety, the focus was also on the development of institutional capabilities and human resources for national food control agencies. WHO continued its support to Member Countries in strengthening their health laboratory services through training programmes and sustenance of quality assurance. A regional publication, covering health laboratory network, appropriate technology and quality assurance, was published. Self-reliance in modern immunological and biological reagents, particularly for the development of rapid Diagnostic, Therapeutic and Rehabilitative Technology - ~- Execut~ve Summary xxiii diagnostic tests for communicable diseases, has been supported in the Region. WO continued to support proficiency testing and development of national capabilities in cost-effectivep -. sero-surveillance of AIDS. Support was also extended to safety measures in radiology and radiotherapy services. The WHO Collaborating Centre in Radiation Safety at Bombay will take over the thermoluminiscent dosimetry (TLD) services for some Member Countries in 1996. National drug programmes are developing in the context of the revised drug strategy of WHO. The drug situation has been reviewed, and plans of action have been developed, with emphasis on drug management and policy, quality assurance, rational use of drugs and the supply and logistics of essential drugs for primary health care. A WHO bi-regional meeting on technical cooperation among countries (TCACJ, involving the South-East Asia and the Western Pacific regions, discussed drug quality assurance and the use of the WHO certification scheme for ensuring the quality of pharmaceuticals moving in international trade. It was evident that development of human resources was the common need. WHO has given priority to strengthening drug quality control and assurance at regional and country levels. Three WHO collaborating centres are instrumental in promoting the quality of pharmaceutical products at the regional level. As traditional medicine (JRM) is ingrained in the cultural and social ethos of the peoples of the Region, WHO has been assisting Member Countr~es in strengthening national JRM programmes with emphasis on training TRM practitioners in the promotive and preventive aspects of health. Standardization, quality control and r; utilization of herbal medicines and other traditional remedies are also being supported. At the regional level, three WHO collaborating centres on TRM have been established, which are playing an important role in the training of human resources. The concept of community-based rehabilitation (CBR) was actively promoted. Besides strengthening referral systems for rehabilitation, activities such as the international initiative to prevent avoidable disabilities, production of low-cost prosthetic and orthotic appliances and training of health personnel in CBR were undertaken. XXIV The Work of WHO ~n SEA U During the reporting period, reduction in the incidence of vaccine-preventable diseases was quite impressive. Region-wide immunization coverage has been sustained at 80 per cent. The need now is to achieve a similar degree of coverage at sub-national levels which are poorly covered at present. Hence, WHO is giving priority for increasing immunization coverage in all areaddistricts within countries along with effective surveillance. As immunization coverage in Member Countries is now being reported on a district-wise basis, the emphasis is on targeting and reaching the undersewed. An analysis of the reported cases of poliomyelitis in India suggests that the occurrence of paralytic poliomyelitis is approaching a lower endemic pattern. WHO collaboration is, therefore, aimed at supporting the nation-wide intensification of immunization campaign strategies (e.g. National Immunization Day) for preventing outbreaks as occurred in the States of Gujarat and Kamataka in 1994. Technical support has been provided in the stratification of malarious areas to facilitate cost-effective and selective vector control in highly endemic foci. Integrated vector-bome disease control has been conducted in those Member Countries where kala-azar continues to be endemic. WHO has assisted in the formulation of guidelines for the control of kala-azar, training of staff in the control of dengue and Japanese encephalitis and ; integration of filariasis control programmes with other vector control activities. With the active collaboration and support of WHO, all malarious countries have completed reviews of their malaria situation and adopted the revised malaria control strategy. The regional collaborative programme on drug-resistant malaria was revived. j The overall malaria situation in the Region has remained static for ' the last ten years, with the case incidence ranging between 2.5 1 and 3.0 million cases. Mass treatment of children with intestinal parasitic diseases has been carried out by a majority of the Member Countries. A WHONNDP pilot project commenced in Bangladesh, while another in Maldives has been prepared for donor funding. Visceral ,, leishmaniasis continues to be a problem in some countries where '' WHO has supported training of medical officers. Lymphatic filariasis Disease Prevention and Control Executive Summary xxv continues to persist as a public health problem. UlHO supported the endemic countries to develop an integrated approach for the control of tllariasis with active community participation. India, the only country in the Region having guineaworn, expects to be rid B - I of rt by the end of 1995. i Collaboration with the UNDPMdd BankAwO Special Programme for Research and Training in Tropical Diseases was continued for research capability strengthening. A number of long- and short-term institutional grants and other grants were approved during the reporting period. A total of 47 projects went supported with grants for study in the fields of malaria, filariasis, leprosy and leishmaniasis. Major programmes supported during the period were filariasis, leprosy and malaria. 1 The regional diarrhoea1 disease control programme promoted 1 standard dianhoea case management at home and at health i facilities. With the production of oral rehydration solution (ORS) t reaching 121.5 million litres in 1994, access to ORS has increased. The proportion of trained supervisory and clinical management staff has also increased in all Member Countries. To help in combating the strain of V. Cholerae 0139, the Regional Offce has provided laboratory equipment and 0139 antiserum so that national : laboratories have the means to characterize the cultures. Acute respiratory infections (ARls) are the most common cause i of death among children under five years of age. ARls account for I more than four million deaths each year worldwide; more than 40 1 par cent of thase deaths occur in Bangladesh. India, lndonesia and i Nepal. AN the Member Countries with an IMR of more than 4W1000 i live births have initiated control of ARI with the objective of reducing deaths by using the standard case management method * recommended by WHO. The Regional Office is collaborating with j UNICEF, the World Bank, USAID and others to expand and strengthen : national control efforts. I WHO declared tuberculosis as a global emergency in 1993 as rt kills more adults than any other single infectious disease. I assemination of the wised strategy to provide standardized 1 short-course chemotherapy to at least aN sputum-positive I tuberculosis patients was promoted through training and advocacy. i Some Member Countries have revised their national tuberculosis XXVI The Work of WHO in SEA - programmes in line with the new strategy and have prepared five-year plans and started pilot projects. I P g .~ Implementation of multidrug therapy (MDV for a decade now [ has resulted in a dramatic decline in leprosy cases. Leprosy control i was intensified in the endemic countries, and WHO collaborated in : the review and updating of national plans of action. Based on the WHO regional strategy for the elimination of the disease, regional plans of action for the elimination of leprosy were developed. Member Countries have agreed to expand MOT to 100 per cent geographical coverage by December 1995 in order to achieve the goal of elimination by the year 2000. WHO also provided timely support for the control and containment of the plague outbreak in lndia in 1994, International experts were assigned to train local personnel in the laboratory diagnosis of plague. An independent team comprising international experts was formed by the WHO Director-General to investiage the outbreak. The Government of lndia appointed a speical advisory committee on plague to determine the factors responsible for this outbreak. An intenegional meeting on the prevention and control of plague epidemic was also convened in the Regional Office in March 1995. As sexually transmitted diseases (STDs) are a serious health problem, WHO is actively promoting ST0 case management as part of general health services. It also provides support to strengthen STD services as part of national AIDS prevention and control programmes. Concerted efforts are being made to overcome difficulties in condom promotion and its social marketing. In many countries, STD and AIDS programmes have now been integrated, but lack of drugs to treat ST0 is a major constraint. WHO continued to provide technical support to national AIDS control programmes, emphasizing the multisectoral approach and the involvement of NGOs Many Member Countries made progress in developing a broad-based multisectoral approach to HIV/AIDS. National efforts in areas such as health education and targeted interventions, treatment and prevention of sexually transmitted diseases, condom promotion and quality assurance, counselling, sentinel surveillance and laboratory diagnosis are being supported. ': Political commitment is well established. Care of HIV/AIDS patients, Executive Summary xxvii 1 as a part of primary health care, is now a priority. There are still constraints to mounting an effective response to the expanding pandemic. 'The need to step up national effort with intematmnal support to combat this threat to human civilization is urgent. "h i The Regional Office has brought out a monograph containing information on the prevention and control of denguaDHF. WHO supported national workshops and seminars on dengueDHF. A tetravalent live attenuated dengue vaccine has been developed : with WO support at Mahidol University, Thailand, and is ready to I undergo Phase 111 trials. i < Outbreaks of hepatitis A and hepatitis B infection have been I reported in a number of countries. WO provided technical information and diagnostic reagents to the countries. Neisseria meningitis is also a significant cause of mohidity and mortality in i some countries of the Region. WHO assisted in the organization of i surveillance, chemoprophylaxis and vaccination. P Many countries in the Region have had well-established programmes for the prevention of blindness formany years. Reducing the backlog of cataract-induced blindness, provision of outreach 1 services to the underserved and promotion of community eye care : are some of the significant objectives of blindness control i programmes. WHO'S collaborative role in canying out epidemiological ' surveys to assess the magnitude of the problems of deafness and hearing impairment, and to sensitize the decision-makers towards developing and/or strengthening national pmgmmmes for their : prevention was continued. { WHO continued to advocate the development and - i implementation of comprehensive national cancer control i : programmes, focusing on prevention, early detection and treatment $ i and on palliative care, and using inexpensive and effective ! interventions in preference to costly curative approaches requiring j sophisticated equipment. Inspection of the oral cavity of I tobacco-chewers and speculum inspection of the cervix with biopsy are typical examples of this approach. WHO is supporting studies $ i to establish the feasibility and effectiveness of various approaches i towards improving the public health relevance of cancer control i i programmes. XXVIII The Wok of WHO in SEA Since risk factors for cam'rovascular diseases tend to be the same as for cancer and diabetes, WHO is promoting an integrated . . approach to the reduction of such risks. Some baseline studies on risk factors like smoking, a sedentary lifestyle and a high animal-fat diet have been supported by WHO. Ways will be explored to promote an integrated and public health-oriented approach to the control of cardiovascular diseases. i 1 i The Regional Office Librarymntinuedto provide technicalinformation and literature support to WHO staff, health pmfessionals and informa~ion scientists, United Nations agencies, biomedical researchers and Support others interested. It continued to acquire health literature, ; international databases such as AIDSLINE, MEDLINE and POPLINE 1 i on CD-ROM and sub-sets of WHOLIS. It also developed and expanded its computerized databases V~Z. SEALIS, IMSEAR, EMS and PMS. Information retrieval and document delivery capabilities in the WHO 1 Representatives' offices were strengthened by providing library j orientation programme to their staff The HELLIS (Health Literature, Library and lnformation Services) network has now 10 designated ' national focal points and over 315 participating libraries. Health science libraries in the Member Countries were provided with ' photocopiers and computers and CD-ROM drives and EMS/PMS ! software for library automation. I Administration and Finance, formerly known as Support Services, continued to deploy its activities to provide the support required for the WHO Regional Office, the WHO country offices and all WHO collaborative programmes. Of the 149 established professional posts, 119 have been filled as of 30 June 1995. A total of 228 consultants were fielded during the two-yearperiod in addition, contracts with nationalprofessionals were concluded through Special Services Agreement to carry out activities of a technical or managerial nature. During June 1995, 131 such agreements were in operation in the Region. Staff development and training activities were continued as an essential component of human resources policy. Staff were enabled to take Support Services Execut~ve Summary xxix 1 part in seminars, workshops and courses in order to acquire or 1 improve technical and management skills. i ! Administrative services refurbished office premises. Renovation - e- I of the airconditioning plant was completed. One of the two old lies I in the main building was replaced while works wen, under way to i replace the second one. Renovation of the Reception area and the Committee Room is the main work done among other activities. The planned programme budget for the biennium 1994-1995 i from the Regular budget was US$99 million. In view of the budgetary : 1 constraints experienced by the Organization, only US94.7 million had been made available as of 30 June 1995. Of this, the total : obligation for the first 18 months of the biennium amounted to US$65 million. Medical supplies and equipment worth US$38.2 million were procured for various projects of technical cooperation under country and intercountry programmes from regular budget and extra-budgetary resources during the period. Extrabudgetary resources accounted for approximately 60 per cent of the total procurement. Procurement of drugs and office equipment through local supplies, wherever appropriate, resulted in considerable savings. The computerization of supply operations was completed with a view to making available a more comprehensive and timely information to the offices of the WHO Representatives. xxx The Wotk of WHO in SEA ection I Direction, Coordination and Management The Forty-seventh World Health Assembly was held in Geneva World Health from 2 to 12 May 1994. The Minister of Health of Botswana. H.E. Assembly Mr B.K. Temane, was elected as its President. From SEAR, Dr A. Ourairat (Thailand) was elected as one of the Vice-Presidents, while Dr N.K Rai (Indonesia) was elected as Chairman of Committee 'A'. Thailand was elected as one of the Member States entitled to designate a person to serve on the Executive Board. Among the key Issues of the Assembly's 34-point agenda was the Global AlDS Strategy, which elicited much attention. The activities of the WHO Global Programme on AlDS at country, regional and global levels, including the technical support given by the Organization in a wide range of areas, the significant role played by nongovernmental organizations and the specific implications of HlVlAlDS for women were highhghted. A report was presented on the action taken to develop and establish a joint and cosponsored United Nations programme on HIVIAIDS The programme, to be administered by WHO, is expected to ensure combined effort in HIVIAIDS among six UN agencies: WHO. UNICEF, UNDP, UNFPA, UNESCO and the World Bank. The Assembly, as in the past, devoted particular attention to the implementation of its earlier resolutions, eg on the need to promote breast-feeding practices for infants and on young child nutrition. The Assembly noted the significant progress made in the improvement of maternal and infant health, but was concerned that the morbidity and mortality rates were still very high in many countries due to the poor quality of care and performance of health r care systems. It, therefore, felt that substantial improvement was 1 required. The situation with regard to tuberculosis was noted with a grave concern in view of the global spread of the disease, and i ; strong support was expressed by delegates for WHO'S tuberculosis - . programme policies and activities. "Community Action for Health" was the topic for the Technical Discussions. The need for solidarity between the health sector and : the community, particularly the role of women, and involvement of other sectors in health development were emphasized. The Forty-eighth World Health Assembly was held in Geneva : from 1 to 12 May 1995. The Minister of Health of Brunei Darussalam, Dato Dr Haji Johar Noordin, was elected as President. From the South-East Asia Region. Mr Than Nyunt (Myanmar), was elected as one of the Vice-Presidents of the Assembly. In April 1995, the Minister of Health of the Government of Mongolia wrote to the Director-General informing him of his Government's intention to join the Western Pacific Region. The Minister requested that this item be placed on the agenda of the Fortyeighth World Health Assembly. The Director-General submitted the request for consideration by the World Health Assembly under a provisional supplementary agenda item. The Assembly, by a resolution on the subject (WHA48.1) adopted on 4 May, resolved that Mongolia shall form part of the WHO Western Pacific Region. The Mongolian delegate to the Assembly expressed profound gratitude to the Regional Director and his team, as well as all Member Countries of the South-East Asia Region, for the close and fruitful cooperation that Mongolia had enjoyed during the past more than thirty years of collaboration. m In the framework of its 32-point agenda, the Assembly approved the programme budget for the financial period 1996-1997, which, in its content and presentation, took into account the various resolutions of the Executive Board and the World Health Assembly on budgetary reforms. As mentioned by the Director-General, the "budget lays the foundation for a new strategic approach to planning, budgeting and evaluation". In its relevant resolution, the Assembly appropriated an amount of US$ 842 654 000 under the Regular budget for the financial period 1996-1997. 2 The Work of WHO ~n SEA " Emergency and humanitarian action featured as an important item of concern. The Assembly recognized that disaster reduction was an integral part of sustainable development. In the relevant resolution, Member States were urged to include disaster reduction and emergency preparedness in their national development plans i and make special allocations for this purpose. Attention was also 1 focused on renewing the Health-for-All Strategy by developing a f new holistic global health policy, based on the concepts of equity 1 and solidarity. The growing inequity in health and lack of access 9 to basic health care was also highlighted in the World Health Report f 1995, the first annual survey of global health, published by WHO t at the time of the Assembly. This report will be issued every year i as a new, significant development of the WHO reform process. ! 8 Among other issues reviewed by the Assembly were: the global j strategy forthe prevention and control ofAIDS; the need to strengthen ! active surveillance of new, emerging, and re-emerging infectious ; diseases; strengthening of reproductive health in the context of ; primary health care, and recognizing reproductive health as a central component of women's health. Also, the Assembly endorsed the integrated management of the sick child as an essential tool for reaching the 1990 Summit goal of reduction of childhood mortality by 50 per cent by the year 2000. As regards WHO'S response to global change, the Assembly emphasized the need to carry the ; process forward at an accelerated pace, and to strengthen the i capacity of WHO headquartem to ensure that reforms permeate 1 through all levels of the Organization. i 1 The Assembly passed a total of 32 resolut~ons on the above ' and other subjects The South-East Asia Region is entitled to have three members on Executive the Executive Board. These are: Maldives (1991-94), Mongolia "oard (1992-95) and Nepal (1993-96). In May 1994, Thailand was i nominated to serve on the Executive Board in place of Maldives ' during the period 1994-1997. At the ninety-third session of the Board, Dr Uton Muchtar Rafei j was appointed as Regional Director for South-East Asia for five years from 1 March 1994. - Governing Bodies 3 The growlng problem of HIVIAIDS featured as an important subject on the agenda and in the debates. The Execulive Board passed a resolution rebmmending the development and eventual establishment of a joint and cosponsored United Nations programme on HIVIAIDS. -% Tuberculosis was another subject of concern. The Board approved the establishment of a Special Account for Tuberculosis within the Voluntary Fund for Health Promotion to attract increased external funding. Within the framework of review of its working, the Board decided to change its Programme Committee into a Programme Development Committee composed of six members of the Executive Board (one from each WHO region) and the Chairman or a Vice-Chairman of the Board. It also decided to establish an Administration, Budget and Finance Committee. t I The Board endorsed the Ninth General Programme of Work of ! WHO covering the period 1996-2001. w ! The ninety-fourth session of the Executive Board had a 15-point agenda. Among others, it took note of the Director-General's report on the meetings of various expert committees and study groups and on the implementation of the Global Malaria Control Shategy. It also i took note of the report of the UNICEFMMO Joint Committee on Health i Policy and endorsed its recommendatins pertaining to accelerated i action to achieve the middecade targets leading to the attainment of 1 the end-ofdecade goals set by the World Summit for Children. i ! The Board appointed Mongolia and Thailand from amongst its members to serve on the Programme Development Committee and on the Administration. Budget and Finance Committee respectively i for a period of two years. ~r The ninety-fifth session of the Executive Board held in January 1995 expressed satisfaction at the fact that over half of the 47 recommendations formulated in May 1993 by the Working Group on the WHO Response to Global Change had already been put into effect. The Board also reviewed the report of the Director-General on the progress made in the implementation of the strategy for health for all by the year 2000 and recognized that it must be continually adjusted to the evolving political, economic, sociocultural and health conditions in the world. The Board requested the - -- 4 The Work of WHO in SEA Director-General to shift additional five per cent of the budgetary resources to areas of priority indicated by it and submit the budget - ~ to the Forty-eighth World Health Assembly in May 1995. The ninety-sixth session of the Executive Board was held in Geneva on 15-16 May 1995, following the closure of the Fortyeighth World Health Assembly. Professor Li Shichuo, Director-General of the Department of International Cooperation, Ministry of Health, China, 1 4 was elected as Chairman of the Executive Board for one year. From 2 the South-East Asia Region, Bhutan was nominated as a Member i for the next three years and attended the Board meetings along with the two continuing members from the Region - Nepal and Thailand. The Executive Board heard the report of its representatives at the Forty-eighth World Health Assembly, discussed a number of reports of the scientific advisory bodies, dealt with a number of institutional and technical matters submitted for its attention and reviewed a number of documents prepared in the framework of WHO response to global change. Of the six development teams created to carry forward the process of WHO reforms, three submitted their reports to the Board: Programme Development and Management. Management Information System, and the Role of WHO Country Offices. The Board adopted two resolutions. One related to amendments to Articles 24 and 25 of the WO Constitution. It requested the Director-General to propose, for the consideration of the Forty-ninth World Health Assembly, drafl amendments to the Constitution increasing the membership of the Executive Board from 32 to 33, allowing for an additional member from the European Region. The second resolution confirmed the amendments to the Staff Rules made by the Director-General, with effect from 1 May 1995, concerning the appointment of close relatives, including spouses, as part of a United Nations system-wide plan for improving the status of women in various organizations. Two sessions of the Regional Committee for South-East Asia took : Regional place during the period covered by this report - the forty-sixth j Committee session was held in the Regional Oftice from 21 to 27 September j 1993 and the forty-seventh session in Ulaanbaatar. Mongolia, from ; 23 to 29 August 1994. Governing Bodies 5 At the forty-sixth session. Dr Uton Muchtar Rafei was nominated I r as the Regional Director for a five-year term effective 1 March 1994. The Committee also designated Dr U KO KO, the outgoing i Regional Director, as Regional Director Emeritus. The Committee reviewed the report of the Regional Director covering the period 1 July 1991 to 30 June 1993. It noted that, despite the global changes and upheavals, Member Countries of SEAR had moved forward with the formulation of national health policies and medium-term health plans to sustain the momentum for national health development and had achieved improvement in the health status of their people. "Community Action for Health" was the subject of the Technical Discussions. The Committee felt that community action for health, as an essential component of PHC, needed to be intensified and strengthened. There was a need to reorient HFA policies and strategies in view of the changing socioeconomic and epidemiological situation. The Committee expressed concern over the deteriorating .p HIVIAIDS situation. It also noted that the revised strategy for malaria, formulated at the International Conference on Malaria in Amsterdam, was being translated into national malaria control strategies in the affected countries of the Region. The Committee considered the recommendations of the Executive Board's Working Group on WHO Response to Global : Change and requested an ad hoc committee to study their implications at country and regional levels. The Sub-committee on Programme Budget reviewed the : implementation of WHO'S collaborative programme in the Region .* 1 during the first 18 months of the 1992-1993 biennium and noted : the guidelines for the preparation of the 1996-1997 programme : budget. It also urged that greater efforts be made to mobilize additional resources for health development. The forty-seventh session of the Regional Committee considered ) the report of the Regional Director for the period 1 July 1993 to ) 30 June 1994. The Committee called for the strengthening of epidemiological surveillance, for greater attention to the use of t epidemiological information and for improved laboratory support. 6 The Work of WHO in SEA "Resurgence of Tuberculosis -The Challenge" was the subject of the Technical Discussions. The Committee noted with concern the high incidence of tuberculosis in the Region and felt that the lack of diagnostic facilities and appropriately trained programme personnel were serious impediments to control. In view of the link between HIV and tuberculosis, it was necessary to strengthen sentinel su~eillance along with the training of field-level workers. With a view to evolving a stronger regional approach to address I problems common to countries of the SEA Region, the Committee E endorsed the recommendations by the Consultative Committee on j Programme Development and Management (CCPDM) to increase I resources for intercountry programmes. The Sub-committee on 1 Programme Budget also recommended that the allocation to the . intercountry programme be increased in order to provide additional f funds to tackle newly-emerging health problems that are common i to the countries of the Region and to foster regional solidarity and j cooperation. In this regard, the Regional Committee requested the 2 Regional Director to establish a working group to recommend ! modalities for mobilizinglenhancing the allocations for intercountry 1 programmes for its consideration in 1995. The Subcommittee on Programme Budget recommended that henceforth the review of the programme budget implementation by the CCPDM should cover 12-month and 24-month periods of the j biennium, while 6-month and 18-month implementation reviews ! should be carried out by the Sub-committee. The CCPDM would i thus be able to devote more attention than before to the qualitative ,! aspects of programme implementation and to advising the Regional Director on regional programme priorities. Regional A review of the current knowledge and research work in SEAR Director's countries relating to the malariogenic stratification methodology, r; Development incorporating a remote sensing and geographical information system, ~~~d was undertaken with funding support from the Regional Director's Development Fund (RDDF). Assistance from the RDDF was given to a refresher course for health managers in Mongolia, which was organized in cooperation with the Moscow lnstitute of Advanced Training for Health Workers. With support from the RDDF, a meeting on dengueldengue haemorrhagic fever (DHF) was held at the National lnstitute of Virology, Pune, India, in 1994 where participants from SEAR and other regions deliberated on the prevention and controJ of denguelDHF. WHO cosponsored a joint SEARO/UNICEF/ICCIDD .- Regional Meeting on the elimination of iodine deficiency disorders ' (IDD) which was held in Dhaka, Bangladesh, in April 1995. Consultancy services were provided to different programmes and participation in international conferences was financially supported Assistance was provided under the RDDF to Bangladesh, India, Indonesia. Mongolia, Myanmar. Nepal and Sri Lanka to meet health situations resulting from earthquakes, volcanic eruptions and floods. -- -- 8 The Work of WHO in SEA Extensive technical collaboration was provided to Member States General for the planning, formulation, implementation and monitoring of WHO Pfogrclmme , collaborative programmes through the decentralized and Integrated ~~~~l~~~~~~ managerlal process Annual detailed plans of action were prepared by both countly and intercountry programmes for implementation of the programme budget for 1994.1995 The proposed regional programme budget for 1996-1997, the first of the three biennial programme budgets of the Ninth General Programme of Work, was completed in consultation with the Member States. It was endorsed by the Regional Committee at its forty-seventh session in August 1994. Member States and the Regional Office have commenced work on the preparation of annual detailed plans of action for 1996 to operationalize the 1996-1997 programme budget. In 1993, a Working Group constituted by the Executive Board had made 47 recommendations on WHO'S response to global change. The Director-General established six time-bound development teams for the implementation of these recommendations. The Development Teams on WHO Programme Development and Management and WHO Management Information System dealt with recommendations that had direct relevance to WHO programme development and management. In the regions. regional core groups provided useful inputs for these two development teams whose reports were submitted to the Executive Board in May 1995. The CCPDM rev~ewed the 18-month and 24-month implementation of WHO collaborative programmes in Member Countries for the 1992-1993 biennium at its meetings in September 1993 and April 1994, and the 6-month and 12-month implementation of the 1994-1995 programme budget at its meetings in August 1994 and April 1995. The CCPDM also reviewed the proposed intercountry programme budget for the 1996-1997 biennium at its meeting in April 1994. The annual detailed plans of action for the Implementation of the programme budget in 1994 and 1995 were also noted by the Committee. The working group set up by the Regional Director in response to a request from theforty-seventh session ofthe Regional Committee to recommend modalit~es for mobilizinglenhancing the allocations WHO'S General Programme Development and Management 9 External Coordination for Health and Social Development for intercountry programmes, met in February 1995 and identified .. three broadareas of focused priority. It requested thew0 secretariat ; to develop detailed proposals for enhanced intercountry programmes ' with estimated budgets. These proposals were subsequently w : endorsed by the twenty-seventh meeting of the CCPDM in April 1995. The 42nd and 43rd annual meetings of the Regional Director with the WHO Representatives were held in November 1993 and i November 1994 respectively, and issues relating to the development i and management of collaborative programmes in the Member : Countries were reviewed. The country support teams (CSTs) in the Regional Office continued to provide support to the WHO Representatives and concerned national officers at country level for the development of broad programme proposals and annual detailed plans of action. The Regional Office took steps to establish country programme formulation missions, as part of the CST mechanism, to support i+ the preparation of annual detailed plans of action for implementation of the 1996-1997 programme budget and for the formulation of programme budget proposals for the 1998-1999 biennium. Significant developments took place in inter-agency relationships within the United Nations system in the wake of the refom1 process of the UN. A trend is also emerging towards having multi-agency collaborative programmes to deal with major health problems. These lend a new perspective to, and place new demands on, WHO'S coordinating role in its collaborative relationship with other UN agencies in the field of health. In the context of these, WHO r participated in the Triennial Comprehensive Policy Review of the Operational Activities for Development of the United Nations System undertaken by the UN Secretaty-General. Member Countries and the Regional Office participated in the World Summit for Social Development held in Copenhagen in March 1995. It also took part in the preparatory meetings held before the Summit and contributed a position paper for advocacy of health. The Summit was preceded by a Regional Ministerial Conference on Social Development in Manila in October 1994. SEARO. with .- 10 The Work of WHO ~n SEA -P assistance from WPRO and EMRO, contributed a paper on the i Eradication of Preventable Diseases to this conference. i i SEAR0 also participated in the preparations for the Second ; Asia and Pacific Ministerial Conference on Women in Development 1 held in Jakarta in June 1994. The conclusions of this conference, issued as the Jakarta Declaration, emphasized health issues of women as a priority concern for women's development. WHO continued to collaborate with UNDP on important health-related issues. UNDP approved five new projects in the health sector in Myanmar, of which four - Integrated Primary Health Care, Malaria Control, Community Rehabilitation of Leprosy Patients, and Prevention and Control of AIDS - are being executed by WHO. In Nepal. WHO is executing a UNDP project on Human Resource Development for the Water Supply and Sanitation Sector. In Sri Lanka, WHO participated in the formulation of a UNDP project on strengthening health care facilities in the north and east of the country. In Mongolia, WHO supported UNDP in the formulation of the health components of the poverty alleviation strategy, and is also working with the agency on a joint project for health sector reforms. The Organization assisted in the preparation of documents for the Bhutan Round Table Meeting (RTM) and also attended the RTM for mobilization of resources in support of development programmes. In India. WHO cooperated with UNDP in organizing the Parliamentarians' Forum for Human Development which included health as one of the three key components of its agenda. Durlng the reporting penod, the Reg~onal ORce executed two lntercountry and 16 country projects funded by UNDP WHO and UNICEF worked closely towards the attainment of the common goals of ch~ld survival and development, maternal and child health and safe dr~nking water and sanitation. As a follow-up of thedeclaration of the World Summit for Children. WHO collaborated with UNICEF in the preparation of plans of action for child survival and development within the framework of HFA strategies. The two agencies also participated in the Rural Cohott Study on Child Collaboration with the United Nations System United Nations Development Programme IUNDPI Unifed Notions ChiMren 'r Fund lUNfC€F) WHOs General ~rogram~~evelopment and Management 11 : Suwival in lndia and in the development of a communication strategy i for AlDS prevention in Myanmar. In Thailand, WHO and UNICEF t .. 1 jointly provided assistance in the finalization of the code for the ! marketing of breast-milk substitutes and other related products. ' ? UnitedNotions Fund WHO continued to provide support to UNFPA programme reviews for Populolion and project formulation missions. SEAR0 executed one intercountry A&ities[u#fP~/ and five country projects and participated as an associate agency in the implementation of the UNFPA-funded MCH project in Bhutan. EconomicondSotiol , WHO is represented on the Regional Interagency Committee for bi?Im~~ for hi0 Asia and the Pacific (RICAP) set up by ESCAP to promote inter-agency andthePocific~t~(~~) coordination. In addition, WHO took part in health-related technical committees of ESCAP and carried out health advocacy at various high-level consultative meetings organized by it. Ofher Agencies WHO continued its collaboration with the United Nations International Drug Control Programme (UNDCP) in the drug abuse control activities in lndia and Sri Lanka. It also continued to promote health and nutrition in projects assisted by the World Food Programme (WFP). The Organization participated in the Asian Regional Planning Seminar on AlDS and Education within the School System, organized by UNESCO in January 1995. Colloborotion The Regional Office continued to execute 22 specific components with Development of the Fourth Population and Health Project in Bangladesh funded r Banks and Funds by the World Bank and several co-financiers. In India, it provided technical support for the implementation, monitoring and evaluatton of the IDA-funded programmes in AlDS prevention, leprosy eradication, prevention of blindness and tuberculosis control as well as the sixth population project. The first HQ-level WHOhVorld Bank Review Meeting, with the participation of representatives of a number of countries from WHO regions, took place at WHO headquarters in OctoberlNovember 1994. The purpose was to identify ways for more effective - - 12 The Work of WHO ln SEA governmen~ONvorld Bank collaboration. From this region, lndia i participated in the meeting. p The Second Joint Meeting of WHO and the Asian Development Bank (AsDB) was held in Manila in October 1993 to review the j collaborative activities. Steps were taken to intensify collaboration between WHO and the AsDB, and a meeting of the WHO ; Representatives in SEAR with the AsDB was organized in New Delhi i in November 1994. The priorities for collaboration as well as specific approaches and modalities of partnership in support of national ; health development were identified at this meeting. WHO agreed to provide technical support to the fact-finding, appraisal, project formulation and other review and monitoring missions of AsDB to the countries. One such AsDB fact-finding mission visited Mongolia in November 1994. The Arab Gulf Fund (AGFUND), which had suspended its operations following the Gulf War, has restored its funding to the : prevention of blindness and the prevention of deafness activities : in Bangladesh. Maldives, Myanmar, Nepal, Sri Lanka and Thailand. Bilateral agencies have played an important role in health Collaboration development in the Region. The Danish lnternational Development - with Bilateral Agency (DANIDA) continued to support the health learning materials i Agencies project in Mongolia and the strengthening of district health system ! project in Bangladesh. It also funded, through WHO, a project on Women and Development in Maldives. The Swedish International Development Agency (SIDA) funded tuberculosis and leprosy control programmes in lndia, which were executed by WHO. DANIDA and the Finnish lnternational Development Agency (FINNIDA) jointly funded the essential drugs programme in Bhutan. The Italian Government continued to provide financial assistance to the disaster preparedness and response programmes in Bangladesh and Sri Lanka. A mission of the German Agency of Technical Cooperation (GTZ) visited lndia and SEAR0 in Februaly 1995 to explore the possibility of expanding GTZ support to the health sector and to exchange views on possible collaboration with WHO. A team of experts from the Japan lnternat~onal Cooperat~on Centre (JICC) also v~slted lnd~a on a fact-findlng mlsslon wlth a vlew to expand~ng Japanese collaborat~on In the health sector The WHO'S General programme beve~opmen~ and Management 13 Canadian International Development Agency (CIDA), the Australia International Development Assistance Bureau (AIDAB), the German 1 ; Agency for Technical Cooperation (KRN), the Japan International i i Cooperation Agency (JCA), the Directorate General for International Cooperation (DGIS) of the Netherlands, the US Agency for i : International Development (USAID), the Overseas Development I Administration (ODA) of the United Kingdom, and the Nolwegian Agency for International Development (NORAD) are among the other major bilateral donors who supported a wide range of health projects in the Region. WHO maintained close collaboration with these agencies. Co~abomtion ' Intergovernmental organizations such as the Association of the with : South East Asian Nations (ASEAN) and the South Asian Association Intergovermmtd i for Regional Cooperation (SAARC) are, inter alia, promoting TCDC &gonixotionr ' in health also. SEAR0 has taken steps to reinforce collaboration with ASEAN. Technical support was provided to the ASEAN Academic and Research Experts Meeting on AIDS Prevention and Control in the preparation of a work plan for the ASEAN Regional Programme on AIDS. CoNabomtion , A new initiative was taken to enhance the participation of with , nongovernmental organizations (NGOs), palticularly those focusing Nongovernmental ' on women, in AlDS prevention and control programmes through Org~ni~ati~n~ partnership between governments, NGOs and WHO. WHO continued to promote and encourage the involvement of youths' and women's organizations in the health-for-all movement. Representatives of the Japanese Pharmaceutical Manufacturers' Association (JPMA) visited the Regional Office and developed collaborative programmes in specialized training in pharmaceuticals and also in the supply of essential drugs. Under this programme, JPMA offered six fellowships for training in pharmaceuticals and sets of pharmaceutical reference books to four countries. The Sasakawa Foundation supported leprosy control activities in the Region. The Regional Office also collaborated with the Dutch NGO, Medecins Sans Frontieres (MSF), in malaria control activities in Myanmar. -. 14 The Work of WHO in SEA An assessment of the current situation of WHOINGO collaboration in the Region was undertaken in order to identify measures for strengthening partnership with NGOs in health development. Based on this assessment, an action plan will be developed to improve the Organization's regional-level partnership with international NGOs having official relationship with WHO as well as to promote tripartite NGOIgovernmenVWHO collaboration in Member Countries where appropriate. As the evolving international trade and tariff norms are likely to World Trade have implications on essential drugs, breast-feeding, nutrition and Organization MCH. WHO is prepared to cultivate close association with WTO and [WO) work through the Codex Ailmentarits in order to be able to deal with the health-related aspects of WTO regulations. Significant activities took place in the Region to improve and Health strengthen national health infrastructures for emergency Emergency preparedness and management of humanitarian relief operations. preparedners Disaster-prone countries such as Bangladesh. India. Indonesia, Mongolia, Myanmar and Nepal initiated the development and and Response implementation of emergency preparedness and response (EPR) plans and programmes with support from WHO. A joint WHOlltalian Government mission reviewed the progress of EPR activities in Bangladesh in March 1994, and provided assistance for strengthening the operational and technical capacity of the EPR cell in the Ministry of Health. WHO assistance to Bangladesh also included development of a work plan for the establishment of a national centre for emergency preparedness and response; setting up of a computer software system, SUMA, for improved management of emergency supplies including training of personnel in the system through workshops; and supply of emergency health kits and other medical supplies to meet the emergency health needs resulting from a cyclone in Cox's Bazar. WHOparticipated in the activities ofthe UN Disaster Management Team in lndia. Assistance was given by way of technical expertise and supplies and equipment during the plague epidemic in certain parts of lndia. The WHO Collaborating Centre for Disaster Preparedness WHOs General Programme Development aid Management 15 at the All-India Institute of Hygiene and Public Health. Calcutta, conducted several training courses in disaster preparedness. Assistance was also provided to relief measures taken at the time of an earthquake in Maharashtra and during floods in different parts p. of India. In Indonesia, support was provided by way of equipment to the Ministry of Health in order to facilitate relief operations for the victims of the Mount Menapi volcanic eruption. WHO assigned an expert for assessing the situation arising out of the volcanic eruption i in Central Java. The Organization also supported Indonesia's participation in related world conferences. The Government was assisted by WHO in the preparation of a training manual and a master plan for disaster preparedness. WHO provided technical assistance to Mongolia, Myanmar, Nepal and Thailand in the review of disaster preparedness of health facilities and in the development of national plans of action for the management of emergency care. a Based on the recommendations of a Task Force set up by the Director-General to review WHO'S policy and functions in the context of its expanded role, the Organization's new role and strategies have been formulated. These strategies are aimed at reorienting WHO'S roles and functions towards meeting the needs of the progressively complex and expanding emergency and humanitarian action (EHA) activities. In the light of these new strategies, SEARO's programme for the 1996-1997 biennium will concentrate on: supporting the formulation of national plans and programmes for health emergency preparedness and relief operations; improvement of the infrastructural and disaster management capabilities of the countries, the Regional Office and the WHO Representatives' offices; development of human r; resources through large-scale training activities and promotion of inter-agency cooperation. Health During the reporting period, two meetings of Ministers of Health of Ministersf the countries of the WHO South-East Asia Region were held, one Meetings each in 1993 and 1994. The Eleventh Meeting was held in Dhaka, Bangladesh, from 1 to 3 November 1993. It was attended by Ministers of Health 16 The Work of WHO in SEA of all Member Countries except Bhutan, which was represented by an observer. The Director-General, Dr Hiroshi Nakajima, addressed the Ministers and participated in the discussions. The main subjects on the agenda were: (i) TCDC Programming in Health; (ii) Health Management, including Development of Human Resources for Health; (iii) AIDS and EPI-targeted Diseases, and (iv) Future Actions for Old Scourges - Malaria, Tuberculosis and Leprosy. The Ministers recognized the need to establish common principles and guidelines and equitable conditions for promoting TCDC. They suggested formulation of plans and programmes for strengthening health ; management and a balanced development of health manpower. The need to take urgent steps to prevent and control HIVIAIDS was acknowledged, and it was agreed that the control programmes in respect of malaria, tuberculosis and leprosy should be strengthened. The Twelfth Meeting of Ministers took place in Ulaanbaatar, Mongolia, from 30 August to 2 September 1994. It was attended I by the Ministers of Health of ten Member Countries, while Sri Lanka ' was represented by two observers. The Director-General addressed the Ministers and participated in the discussions. Subjects on the agenda included: (i) Health and Poverty; (ii) Better Education for Health, and (iii) Mental Health. The Ministers noted the very close relationship that exists between health and poverty. The Director-General informed the Ministers that one of the three agenda items of the World Summit for Social Development in 1995 would : relate to poverty. He highlighted that the real issue was how developing countries could help themselves in overcoming ill-health associated with poverty. The Min~sters recalled their discussions on the health of the underprivileged at their Ninth Meeting. They were of the opinion that it was necessary to lay emphasis on the promotive and preventive aspects of health care, ensuring nutrition, safe drinking water and adequate sanitation. The Ministers emphasized that a new and broader socio-scientific perspective of health education should replace the narrow one-way health communication system that had failed to adequately mobilize people for health action. The Ministers realized that mental health was becoming an important public health problem in the wake of rapid societal changes and transitions. They felt that mental health care should be expanded and made more accessible through the primary health care approach. - -. WHO'S General Programme Development and Management 17 ~nformotics Informatics support for effective programme management witnessed Management significant expansion and growth in SEARO as well as in Member Countries. The Local Area Network (LAN) in the Regional Office , was improved. About 200 computers in SEARO were connected to ' the LAN, and the average daily on-line usage is around 100 users. With the expansion of the LAN, there has been a concurrent increase in the use of e-mail within the Regional Office. More WHO Representatives' offices were linked to SEARO through e-mail during the reporting period. LAN-users in SEARO now have access to a CD-ROM-based Library Server that accesses health-related databases, including Medline, Popline and Aidsline. These facilities have improved the speed and efficiency of communication and contributed to the improvement of overall management of WHO'S technical cooperation programmes. Additional linkages between the LAN-based new test version of the Regional Office Administration and Financial Information (RO~AFI) and the SEAR0 LAN applications are being actively pursued in view of their future integration with the WHO Management Information System (MIS) that will support the Activity Management System (AMS). SEARO is represented in the global task force for the development of AMS. The Regional Office is in the process of upgrading the computing facilities in the WHO Representatives' offices to enable them to disseminate WHO information to ministries of health in a standardized format. In this connection, necessary advice and consultancy is being provided to the ministries to upgrade their informatics capabilities. - 1.9 The Work of WHO ln SEA Section II Health System Infrastructure Epidemiological services and surveillance systems are in varying j Health stages of development in the countries of the Region. The outbreak / Situation of plague in certain parts of India in September 1994 highlighted ' and Trend the importance of having an effective epidemiological "early warning" A~~~~~~~~~ system. Thailand has a well-developed system of surveillance and is in the process of extending the computerization of surveillance : activities to the provinces. Nepal is developing a new health management information system which will incorporate epidemiological surveillance. Technical support to develop and strengthen epidemiological services was provided by the Regional Office. With WHO support, field epidemiology training was conducted at the National Institute of Communicable Diseases in Delhi, India, in December 1994. Six participants from Myanmar, Nepal and Sri Lanka attended this course. Training of epidemiologists was sustained by continued support to the field epidemiology training programmes conducted in the Region. Though some progress has been achieved, constraints such as rapid turnover of trained staff, inadequate laboratoly support and lack of an attractive career structure have hampered the development of epidemiological services to a satisfactory level in several countries of the Region. The Th~rd Monltor~ng of the lmplementat~on of strateg~es for health for all was completed by all Member Countries between September 1993 and April 1994 The country reports were prepared 19 Health System Development by multisectoral working groups and coordinating committees, with ministries of health playing a leading role. The Regional Summary 1 of Progress, Impediments and Further Action Needed in Implementing National HFA Strategies was prepared and endorsed a I i by the forty-seventh session of the Regional Committee. The results confirmed the existence of political will in Member Countries to achieve HFA goals and to develop primary health care further. Significant improvements have been observed in life expectancy at birth, infant mortality and in other mortality indicators, except for maternal mortality. Due to high immunization coverage, the incidence of EPI-target diseases has decreased. However, other infectious diseases now dominate the health situation in the Region. Some SEAR countries have entered the advanced stage of epidemiological transition with chronic non-infectious diseases emerging as important causes of morbidity and mortality. The population growth rates of some countries remain unchanged, and continue to affect economic growth and standards of living. There is a need to review and expand health education programmes and to address the weaknesses of health system management and health management information systems (HMIS) in some countries. There is also a need for better coordination of international support for health development in some of the countries. The eighth issue of the "Health Situation in the South-East Asia Region", previously titled the "Bulletin of Regional Health Information", has been brought out. This publication provides an ovewiew of the regional health situation and trends as well as a summary of the health programmes in the South-East Asia Region during 1991-1993. ST The countries continued their efforts to strengthen health information systems by improving the coverage and quality of data reported and recorded at the operational level. The generation and use of desegregated data and rational reduction of the information load in HMIS have been promoted. Technical support was provided to all countries except one with the general objective of assisting them in building up a decentralized, user-oriented and integrated HMIS. with emphasis on the collection and use of critical and valid information. A National Health Survey was successfully completed in Bhutan in 1994 with assistance from SEARO. - .- 20 The Work of WHO in SEA 't WHO collaborated in the development and implementation of health . policy in several countries. Nepal was assisted in prioritizing elements P~OC~SS for of its health policy for implementation within the overall context of , Nationd Hmhh the restructuring and reorganization of health services. Development WHO collaborated in the formulation, implementation and review of ~,,ti,,~,,l ~@,,llh national health plans. In lndonesia, a series of workshopslseminars ~~~~l~~~t was supported for the formulation of the health sector component plans of the Second Long-Term Development Plan (1994-2019) and development of the Sixth Five-Year Health Development Plan (1994-1999). Support was provided to Myanmar in the formulation of the national health plan (1993-96). In Sri Lanka, the formulation of a ten-year perspective plan (1994-2003) received support, while the preparation of a draft medium-term national health plan (1992-1996) in Thailand was also supported. National expertise in the formulation of country health plans requires further development. WHO supported health planning and management. decentralized planning and project formulation and budgeting in Bangladesh. Training of health personnel in the management of hospitals in India through distance learning was also assisted. In Indonesia, support was given to the review of existing organizationallmanagerial problems and to accounting and auditing procedures for integrated budget at local level. Training in health management for various categories of health worker at the central, airnak and sornon levels has been supported in Mongolia. In Sri Lanka, a serles of educational activities in the management of health education and an MSc, course in health administration were supported. Support was provided to DPR Korea in computer application in hospital management, and to Myanmar in system analysis and operational research. Besides train~ng activities, studies were supported in Bangladesh, India, Indonesia, Nepal, Sri Lanka and Thailand in such areas as organization and management of hospitals and district-level health care delivery, decentralized health planning and programme budgeting In Indonesia, a study for the restructuring - -- .- -- .. -- Health System Development 21 of the Ministry of Health and measures to rationalize and strengthen coordination and monitoring of foreign assistance were supported. Nepal was assisted in studying the coordination mechanism c with NGOs and also in developing procedures and methods for decentralized planning. A health status and health care delivery indicators survey, with special reference to district level, was also supported. Sri Lanka received support for the development and formulation of programmes and projects based on the national health policy. Health Economics Most Member Countries have shown an interest in health economics and health care financing against a backdrop of shrinking financial resources for health development activities. WHO helped Bangladesh, India, Indonesia and Nepal in training personnel in health economics and financial management. Besides. in-country training, seminars, workshops and the conduct of relevant I studies were financed by WHO in several countries. To assist in the development of a critical mass of health economists, the Centre for Health Economics. Chulalongkorn University, Thailand, which is the WHO Collaborating Centre on Health Economics, has been conducting M.Sc, and short-term courses in health economics with WHO support. Personnel from Bangladesh, India. Myanmar, Nepal, Sri Lanka and Thailand have been trained at this centre. Intensified WHO The number of participating countries in this initiative remains at Support six. These are: Bangladesh, Bhutan, Maldives. Mongolia, Myanmar and Nepal. Technical support has been provided to these countries in health policy development, health manpower development, health care financing, health management information systems, health infrastructure management and aid coordination and management. Support was continued to Bangladesh to improve coordination and implementation of 21 sub-projects under the Fourth Population and Health Project funded by the World Bank and its co-financiers. A study of the organization and administration of hospitals to improve management at different levels was completed. - - - 22 The Work of WHO in SEA - In Bhutan, Field training activities in the Punakha project and a study of the feasibility of setting up a radio communication network - linking basic health units (BHUs) with hospitals for referral purposes received support. Assistance was given to Maldives in the designing of management procedures for the lndira Gandhi Memorial Hospital. Preparation for a donors' meeting for mobilization of additional resources for health was also supported. Mongolia received support in three critical areas: training of medical and health personnel in health management at the central, aimak and somon levels in technical collaboration with the ASEAN Institute for Health Development, Mahidol University; health insurance to augment public sector financing, and health system reform. A national seminar on Aid Coordination and Management was also supported. In Nepal, the areas of health economics and health care financing, preparation of an HRH master plan, strengthening of the district health system and aid coordination and management received WHO support. In the revised research strategies for the Region, adopted in 1993, it was recommended that 'Research related to the promotive and preventive aspects of health and health care and to health systems research (HSR) should continue to receive the main thrust'. In view of this and in the light of the epidemiological transition taking place, a Task Force on HSR met in October 1993 to review the situation and recommend revisions/modifications in the current strategies and programmes pertaining to HSR that would strengthen regional and national activities in this field. The Task Force, while observing that the strategies currently pursued by the Reg~onal Office for the promotion of HSR were sound and the extent of their Implementation commendable, made severs\ recommendations which, inter alia, emphasized the need to focus regional HSR activities on research capability strengthening; training of trainers; development of innovat~ve research designs and appropriate methodologies, especially of the Social sciences type in the light of the demographic and epidemiological transition; Health Systems Research - .- Health System Development 23 mobilizing resources, including extrabudgetary funds, and promoting the dissemination and exchange of information at national and regional levels. s " As a follow-up of these recommendations, an interregional Training of Trainers Workshop on HSR was held in Bangkok in : 1993 in which officials from Member Countries were trained in the planning and conduct of HSR training programmes. The Regional Office, through its intercountry programme, suppotted a workshop for training of trainers in HSR, and one on HSR methodology in Mongolia in 1994. Plans of action for HSR have been worked out for the country, and are useful tools for improving health system performance. Additionally, Mongolia was provided with an institutional strengthening grant through which an HSR unit was established in the Directorate of Public Health, Ministry of Health. Technical and financial assistance was provided for a workshop on HSR in leprosy in lndia in 1994 in which participants from Myanmar and lndia were trained and research proposals pertaining to leprosy were developed. In Myanmar, training of trainers' courses in HSR were conducted at the central, state and divisional levels and an institutional strengthening grant was provided for health systems research infrastructure. Training courses on HSR methodology were conducted in Member Countries using country RPD funds During theseworkshops research proposals were developed Th~s approach proved very effective in promoting research in the countries Cv A publication entitled The Appraisal of Health Systems Research was brought out as a WHOISEAR0 Technical Publication. This publication will be useful for medical research councils and researchers. Hdth Legislalion The role of health legislation in providing support to health policy formulation is undisputed. Recent technological advances such as organ transplantation, in vftm fertilization and genetic manipulation have underlined the need for effective and vigilant regulatory 24 - The Work of WHO in SEA " mechanisms. Realizing this, many countries have been encouraged to formulate and strengthen health legislation. WHO provided support to Bangladesh to review and update its health legislation. Existing public health laws were also reviewed in India and technical support was provided during the passage of the Organ Transplantation Bill. Indonesian health officials were provided with an opportunity by WHO to examine comparative health legislation. In-country training activities to strengthen networking in health law documentation and workshops on disseminating health legislation information to medical practitioners and the public as well as on the rights and liabilities of patients, physicians and hospitals were also supported. Nepal undertook the development of appropriate legislation to improve the implementation of its health policy, while Thailand extensively reviewed its legislation on AIDS. WHO collaborated in both these undertakings. The health legislation activities in most countries remain piecemeal. Systematic re-examination and updating are necessary to meet the changing needs of public health. - .- - Health System Development 25 The third monitoring report on the implementation of strategies for health for all (HFA) confirmed that in almost all countries progress had been witnessed in the reorientation and restructuring of health systems based on primary health care. Countries had updated and r strengthened their HFA policies and strategies. Efforts were intensified for expanding the infrastructure for primary health care through strengthening district health systems and extending health care coverage to underserved and unsewed populations. Free health cards are being provided for the poor in some countries (e.g. Indonesia, Thailand) to ensure their access to essential health care. Health care targeting women and children was further improved as reflected in the increased coverages for immunization and maternal care. The role of the community as an active partner in action for health improved with the expansion of selection and training of s volunteers and health-for-all leadership. There is evidence that the slide in health status indicators in the early 1990s in some countries (e.g Mongolia) consequent on their economic restructuring and shift in economic policies is being reversed. Reorientation and Four countries (Mongolia, Myanmar, Nepal and Sri Lanka) formulated Restrutluring of new health policies and strategies for the reorganization of their HeallhSystems health services infrastructures. Decentralization and other administrative reforms were introduced in the management of the - - 26 The Work of WHO ~n SEA health systems. There is also a move to expand the role of the private sector and nongovernmental organizations in the provision of health care. A health management unit was established in the Advanced Training lnstitute in Mongolia, and the Centre for Management Administration in Maldives is establishing a module on health management for middle-level managers. WHO has been collaborating with Member Countries in the development of national health leadership, the conduct of local workshops and the documentation of case studies. The problem of maintenance of electro-medical equipment, particularly at district and lower levels, is receiving greater attention in the countries. Fellowships to develop human resources for health were supported, as were local-level workshops, and national institutions were provided with supplies and equipment. Countries are strengthening their district health systems based on ' Strengthening of primary health care as the main vehicle for achieving national goals District Health and targets. Administrative and organizational reforms have been ~~~t~~~ undertaken by the countries to encourage the decentralization process, thus creating an environment for effective planning as well as greater involvement and mobilization of communities in local health development activities. WHO headquarters and SEARO, in collaboration with other WHO regions, organized an interregional consultation on the Strengthening of Comprehensive Health Care Systems in Districts in Bandung, Indonesia. in August 1993. Mongolia is restructuring its health care delivery system at the somon level. In Bhutan, the field training area for the Royal lnstitute of Human Resource Development is being developed together with the ongoing model DHS activities in Mongar and Samchi districts. Myanmar and Bangladesh are receiving UNDP support for strengthening their district health systems. In DPR Korea, an integrated rural primary health care project in Hyangsan County could not be initiated due to a delay in the commitment of funds by other UN agencies. Many countries have shown an interest in integrating in-service training activities for health personnel at the district level and below. WHO is developing a package study tour on primary health care at district level to improve the capacity of middle-level managers in strengthening district health systems. -- Organlzatlon of Health Systems Based on PHC 27 Innovative approaches using outreach strategies are being applied to expand health care coverage from static facilities to the community. Outreach sites (e.g. posyandus in lndonesia, village : health posts in Bangladesh, sub-health posts in Nepal) have been 9 ; initiated for health care interventions for women and children, particularly immunization, growth monitoring, nutrition and maternal care. This provides for functional integration at the community level, and besides enlisting community support, it ensures efficient use of resources and sustainability and complementarity of various : programmes. Some countries (e.g. Indonesia. Thailand) have started to incorporate into this approach inte~entions for addressing emerging problems such as health care of the elderly and community-based long-term care for patients with chronic diseases. An interregional workshop on the Role of Health Centres in District Health Systems was organized at Surabaya. Indonesia, in 1994. Of the 17 participating countries. four were from this region. + Research studies on the role of health centres were reviewed and analysed, and suggestions to enhance this role were formulated. In Mongolia, training of family doctors in ten aimaks was supported. Management training of somon chief doctors and health managers of aimaks was conducted. A management consultant and a SEAR0 staff member visited Maldives and developed training modules to initiate management training for middle-level personnel. The atoll problem-solving initiative in Maldiveswas evaluated with encouraging results. A manual for health care stratification in Indonesia was revised. A workshop on the development of a proposal for strengthening the district health system in five states in lndia through the World Bank was technically supported. ul Expansion of WHO is collaborating with Member Countries in addressing the Health Care to issue of urban health development. Case studies on the performance Urban Areas of referral health centres in urban areas (e.g. in lndia, lndonesia, Mongolia and Thailand) were completed. WHO joined other agencies such as the World Bank and UNICEF in conducting national consultations on city health plan development. City health plans were formulated for Chittagong in Bangladesh and four metropolitan cities in lndia. 28 The Work of WHO ~n SEA * A short-term consultancy to formulate a proposal on an urban ; health care scheme for Bangladesh was supported by WHO in collaboration with the Overseas Development Administration (ODA). A study on the "Organizational effectiveness of the urban basic .!, services programme in selected slum areas of Delhi" was completed : and its findings were discussed in a one-day national seminar. Fellowships for the training of personnel in health care in urban areas were supported. The role of the community as an active partner in health development , cOmmuniit~ is receiving the attention of almost all Member Countries. Nearly for three million volunteers have been selected and trained in various Development countries. They play an important role in building health awareness in their communities and in promoting healthy lifestyles in their neighbourhoods. They work closely with health workers supporting outreach health care delivery sessions (e.g. posyandus, village health care posts) in the community. A large number of village health committees have been established to provide a mechanism for monitoring and guiding health action at the local level. "Community Action for Health" was the topic for the Technical Discussions held during the forty-sixth session of the Regional Committee. The Committee, in a resolution, urged Member States to reaffirm their commitment to community action for health as a fundamental and essential component of health development, and requested the Regional Director to support the countries in their efforts. As a follow-up of this resolution, an intercountry consultation on the "Role of Volunteers in Strengthening Community Action for Health" was held in Yangon, Myanmar, in February 1995. The meeting reviewed and analysed experiences in the countries and made recommendations on policies and strategies, selection and training, and sustainability of health volunteers. It also recommended enhanced resource allocation by WHO to support Member Countries. To promote community participation in health action, March 20 every year has been declared as the "National Health Volunteer Day" in Thailand, while health volunteers with exemplary achievements are honoured during the National Health Day celebrations in Indonesia. - Organization of Health Systems Based on PHC 29 Slrmgtkhning of Hospital Core OM! Refend Smites Pwliiy Assurance in Health Core In Bhutan, strengthening the diagnostic capability of district and national hospitals was supported through the provision of essential supplies and equipment and training of human resourcesfor essential surgery. In Indonesia, workshops for the formulation of guidelines * for the referral system, and for improving district-level supervisory activities and standards of nursing practices for class A. B and C hospitals, were supported. A manual on hospital sanitat~on was also prepared. A proposal for establishing a new regional hospital (community-based through the support of the Islamic Development Bank) was initiated in Maldives, while in Myanmar, fellowships in hospital management were supported. WHO, in cooperation with its Collaborating Centre for Quality Assurance in Health Care, Utrecht, the Netherlands, assisted Bangladesh in the formulation of the Health Care Quality Assurance project that is currently operational through the financial support of b the World Bank. Long-term experts are being recruited to support this project. In Nepal, a national workshop on quality assurance was supported. In Indonesia, a workshop on the formulation of draft quality assurance guidelines was conducted. In Myanmar, WHO is providing technical assistance in the implementation of the project "Improving Quality and Outreach of PHC Services" supported by UNDP. In Thailand, a research proposal for the assessment of quality of health care to develop a model for quality assurance in one province was supported. The need for strengthening WHO intercountry collaboration in the area of quality assurance was recently reflected in the report of the Regional Working Group on Resource Mobilization for the lntercountry and Regional WHO Collaborative Programmes, which met in New Delhi in February 1995. Quality assurance was listed among the priority areas requiring resources. Two candidates from Indonesia and Sri Lanka were nominated to attend the Meeting on Quality Assurance in Developing Countries held in Newfoundland, Canada. during May-June 1995. -. -- -- 30 The Work of WHO m SEA a The main thrust of the human resources for health (HRH) programme, j Managerial as defined in the WHO Eighth General Programme of Work, is to PM~SS for the . cooperate with Member States in planning for, and properly training, Development the types and numbers of health personnel that they require, and H~~~~ to help ensure that such personnel are deployed and utilized optimally to meet the requirements of national strategies to achieve Resources for health for all. Health Over the past decade, SEAR countries have recognized the Balanceand importance of human resources for health and have made efforts Relevance of for training and re-training a growing number of health personnel ' Human Resources of different categories through continuing education programmes for Haallh and making their educational programmes more community-based and community-oriented. In spite of these efforts, the question of the relevance of training and educational programmes to the needs ' of comprehensive health services based on primary health care still remains unresolved. Moreover, new problems of imbalance in the mix of health personnel are emerging, as exemplified by the proportion of physicians to nurses. Geographical imbalance of availability of health personnel, especially doctors, in rural versus urban areas is worsening. WHO endeavoured to promote a balance between training w~thin countries in the Region and outside the Region. While extra-regional training contributed to the development of specialist skills in selected areas, regional fellowships were supported for all SEAR countries in an effort to increase the technical competence of health personnel. Development of Human Resources for Health 31 In-country fellowsh~ps were supported in Bangladesh, Indonesia and Nepal, w~th the spec~fic purpose of develop~ng adequate numbers of health personnel to man areas that are currently ~nadequately covered by trained health personnel. P Policy and Health personnel policies and plans in some countries are not Plannbof entirely based on economic realities and are not aimed at a Human Resources cost-effective mix of health personnel. Since up to 70 per cent of for Health health budgets are taken up by personnel costs, even minor weaknesses in HRH policies and plans can lead to costly imbalances. Recognizing the need of the Member Countries for technical support in HRH policies and plans, WHO has supported the development of methodologies for HRH policy analysis and strengthening of national capabilities in the implementation of the policies. The Organization has prepared a "Guide to Policy Analysis and Formulation for Human Resources for Health", which has been used in Bhutan, Mongolia. Sri Lanka and Thailand to review HRH " policies. WHO has also continued to support HRH planning in the context of health planning in all Member States. Privatization of A significant factor contributing to the imbalance of human resources Health Care for health in the Region is the competition between the public and private sectors. This has, of late, become rather acute in many countries; in some countries, up to 60 per cent of the professional HRH are in the private sector. A rapidly expanding private sector can drain the public sector of its highly skilled health personnel. Further, in a rapidly expanding -, private sector, there is a need to ensure quality and standard of health care services through better regulation. Nevertheless, the potential positive contribution of the private sector is also recognized in relation to the provision of health care. It is necessary to take account of the private sector in the planning, production and management of HRH. Bearing in mind these problems, a consultation on "Public/Private Mix of HRH" was held in Bangkok in July 1994. In examining how governments will need to act in order to alleviate problems due to the increase of privatization, participants at the consultation recommended that governments have the following - -- -- - 32 The Work of WHO ~n SEA Health Information Syskm Most countries in the Region are strengthening their information systems with essential health information being generated by the appropriate recording and reporting of data at the primary health care level. Human Resource Development Medical education and training programmes in the Region are in keeping with national health priorities. WHO collaboration continues to be focused on making the Member Countries self-sufficient with regard to their human resource needs. Information and Education for Health The mass media, ~ncluding folk theatre, is being effectively used in the Region to create the necessary awareness on priority health issues including MCH environmental health, HIVIAIDS, etc The role of the media IS also recognized as being crucial in the area of population control and to ensure that the gains achieved on various fronts are not negated by the population explosion. three critical roles to play in ensuring equity and quality of care in the context of the publiclprivate mix of HRH: (1) role as policy-maker 'f and regulator; (2) role as a source of information, and (3) advocacy role for implementation. WHO will continue to play the lead role in assisting governments to manage problems that result from the increased privatization that is taking place in the Region. Paradoxically, at the same time as governments are being forced Management Of to reduce health expenditures due to financial constraints, they are Human Resources under pressure to expand health services and make them both f0rHealth accessible and affordable. These conflicting pressures can be reconciled only by improving the productivity of health services. and attention has naturally turned to the most costly component, viz. personnel. Low productivity of health personnel is often not recognized, partly because it is rarely measured. Low productivity may result from ineffective use of personnel, bottlenecks in the supportservices, inadequate skills, failure to delegate authority and low morale and motivation. WHO has continued to provide support to Member States to improve the management and productivity of their health personnel as exemplified by the in-service training workshops organized in Bhutan, Bangladesh, India, Indonesia, Mongolia. Nepal. Sri Lanka and Thailand. Decision-linked health systems research for the development of Research in HRH continues to be supported. HRH policy analysis was carried the out in Bhutan. Mongolia. Sri Lanka and Thailand. However, much ~~~~l~~~~~~ more remains to be done. Further research is needed to clarify how best the productivity of health personnel can be improved. of Human Studies aimed at developing and refining the indicators, standards and norms used to denote numerical balance of health personnel Health as well as developing criteria and methodology to determine the optimal mix of health teams in relation to defined tasks at different levels of health care are needed. Development of Human ~Gources for Health 33 Progress in the development of research in nursing has been continued. Mechanisms to intensify the coordination of research activities and the dissemination and utilization of research findings continue to be promoted. lnquirydriven strategies for changing medical education continue to be supported. Nevertheless, there is still a need for research to improve the linkage between the training and service sectors of health systems. Medical The ma~n thrust of WHO collaborat~on w~th the Member States was Education on lmprovlng the relevance and quallty of medical educat~on to meet commun~ty health needs The areas of focus lncluded reinforcement of the advocacy role in the countries, development of nat~onal-level coordlnatinq mechanisms for health personnel education, introduction of a population perspective in the educational programmes, acceleration of the entire range of educational reforms, establishment of functional linkages beGeen medical education, medical practice and the community, and a wider use of . research-based strategies to intensify the reorientation of medical education efforts. The regional-level activities were designed to address common priorities and issues of the countries and to complement national agendas in medical education development. In Bangladesh, Indonesia, Mongolia, Myanmar and Sri Lanka. WHO supported the orientation of leadership groups in the Ministries of Health and Education for aligning medical education to meet priority community needs. Policy redirection, coordination and introduction of innovative educational reforms are beimg pursued by relevant national groups. Policy reviews were also undertaken in lndonesia, Nepal and Thailand. Indonesia has developed a number of specific projects which will explore alternative models " of linking the medical and public health education institutions with the respective regional health services and the communities they serve. A majority of the activities during the reporting period related to the improvement of undergraduate medical education. These further built upon the recommendations of the Regional Consultation on Reorientation of Medical Education, held in the Regional Office in 1993. Similar follow-up consultations were held at the national level in India. Indonesia, Mongolia, Myanmar, Sri Lanka and Thailand. Mongolia is now finalizing a new national medical education policy - -- 34 The Work of WHO ln SEA in the context of the ongoing national socioeconomic transition and the new practice patterns. In Thailand, the Coordinating Centre for Medical and Health Affairs has laid down guidelines for continued development of medical education and medical practice in the country. In Indonesia. WHO continued its technical collaboration to extend the problem-based and theme-based concepts in medical education as the basis for the main teaching and learning strategies of the second core curriculum. The response of the medical schools is positive, and, in the next few years, the Indonesian model of problem-based learning (PEL) could serve as a possible option to introduce its essential elements into a conventional curriculum. Indonesia is also developing a comprehensive accreditation system to promote and ensure the quality of health personnel education programmes in the country. The Regional Office and WHO headquarters are planning to assist a few other countries to review and/or institute appropriate accreditation systems and "national board8'-type examinations as a means of quality assurance of the education programmes and of the graduates. Bangladesh is making major improvements in its medical education system through support from the WHO regular budget as well as from extrabudgetary resources. The Centre for Medical Education and the medical education units in all medical schools are being strengthened. A large number of teachers have been trained in educational methods. The reproductive health component IS being streamlined whilea numberof innovativecommunity-oriented educational activities have been started. Similar developments have taken place in the two Institutes of Medical Sciences in Nepal. Participants from the Region attended the first-ever Global Conference on International Collaboration on Medical Education and Practice. held at Rockford. Illinois. USA, in June 1994. The conference recognized the increasing pressure for social accountability and identified new quality standards. It designed tools for implementing and assessing strategies for making medical education more relevant to society's needs. Above all, it explored the basis for the formation of new and productive partnerships among institutions involved in adapting medical education, medical practice and health care to better meet people's needs. .- - .- Development of Human Resources for Health 35 WHO, along with the Network of Community-Oriented Health ,. Personnel Education Institutions, cosponsored an International Conference on the Role of Universities in Research for Health Systems Development, which was held in lndia in February 1995. * - This meeting undertook a detailed review of the current WHO-supported country strategies to utilize HSR for educational reforms for community orientation of medical education. In postgraduate medical education, WHO'S efforts have been directed towards bringing about overall systems development. i providing technical services to improve the assessment and evaluation methodologies, and improving teacher quality and capacity. Such collaborative programmes have been undertaken in Bangladesh, Indonesia, Nepal and Sri Lanka. Bhutan hasstreamlined its linkages with the health sector, which continues to be the main employer of specialist doctors, and has improved the selection process, field-based training and the assessment and certification methodologies. In Nepal, the postgraduate programme, conducted jointly by the Institute of Medicine and the Valley Group of Hospitals, is now fully functional and WHO has been supporting the authorities to improve the teaching and learning methods, the educational expertise of the teachers, the quality of the student research projects and the library and literature services. In Bangladesh and Sri Lanka, the main area of WHO collaboration continued to be the provision of external examiners with the twin objectives of quality assurance and improving the expertise of national examiners. WHO is continuing support to Bhutan to train its essential postgraduate medical personnel, mainly in India, Myanmar and Sri Lanka. This is illustrative of the technical cooperation that is being fostered among the countries of the Region and is expected to increase even further over the years. ws The redeeming feature of WHO collaboration in medical education has been the narrowing down of the unacceptably wide gap that existed earlier between the plans and the actual programme implementation. At the same time, the changing economic, epidemiological and technological transitions have imposed newer responsibilities on medical educators. New paitems of privatelpublii sector relabnship call for greater social responsibility and value for money in ed~cation and practice will inevitably demand some fundamental changes in the mission, goak and pms of medical education. 36 The Work of WHO tn SEA Support was continued to national efforts to strengthen the planning, production and utilization of nursing and midwifely personnel. A significant achievement in the Region has been the initiation of strategic planning for nursing and midwifely development within the context of national health and HRH plans. In Bangladesh and Thailand, the planning exercises have focused on the development of national action plans for nursing and midwifery in general. In Indonesia, Mongolia and Nepal, planning activities have concentrated on specific aspects of nursing and midwifely education. In addition, mechanisms have been established in the Ministries of Health in Mongolia and Nepal to ensure nursing input in national policy-making and planning processes. At the regional level, a position paper on nursing and midwifery has been developed to facilitate strategic planning for nursinglmidwifely development in the Region and to serve as a reference guide for technical assistance to countries. Nursing/ , Midwifery Education and Services WHO collaborated with countries in their continuing efforts to expand and strengthen educational programmes in order to alleviate the persistent shortages of nursing personnel and to increase the relevance of the programmes. Specific activities have included revision or evaluation of curricula in Bhutan, Mongolia, Nepal and Thailand; establishment of a Master's programme in nursing in Nepal; development of B.Sc nursing programmes in Myanmar and Sri Lanka; and a pilot project in lndonesia to introduce problem-based learning. Recent efforts by the Regional Oftice focused on promoting stronger links between nursing education and services and improving the quality of nursing care. These include a multi-centre research study, under way in three countries, on collaboration between nursing education and services; a review paper on strategies for optimizing utilization of nursing personnel in hospital nursing services; and the development of guidelines and resource materials on quality assurance in nursing education and services. In addition. Bangladesh and lndonesia have been carrying out activities directed at quality care improvements, while community health nursing has been further strengthened in lndonesia and Myanmar. Midwifery services and training are receiving greater attention in view of the national Safe Motherhood programmes initiated in several countries. An inter-country consultation on the Training and Utilization of Health Personnel with Midwifery Skills held in the Regional Office in December 1993 recommended that Member ~ -. Development of Human Resources for Health 37 - Health Learning Materials Countries should formulate a comprehensive plan for human resources development in midwifery, including training of these personnel in life-saving interventions relevant to the level of care, they provide. Follow-up actions have been taken at country and regional levels on the recommendations of the Global Advisory Group on Nursing and Midwifery, set up by WHO in 1992. Emphasis has been given to promoting mechanisms for coordination and integration of nursing and midwifery activities and to implementing guidelines for national action plans. Closely linked to the Global Advisory Group was a WHO Study Group on Nursing Beyond the year 2000. convened in Geneva in July 1993, in which the South-East Asia Region was represented. Recommendations, inter alia, called for a multisectoral collaborative approach to health and nursing care delivery and a shift in the focus of workforce development in nursing and midwifery to reflect country health needs. .m Despite the achievements in nursinglmidwifery education and practice development, a number of issues remain to be addressed. These include the continuing shortages and imbalances in the number and type of personnel and their maldistribution, inadequate mechanisms and leadership development to enable effective nursing participation in national-level policy and decision-making processes. and constraints of financial and human resources that are essential to bring about the needed improvements. Continued attention is also needed to strengthen training facilities and teaching resources as well as to develop and implement mechanisms for quality assurancelimprovement in nursing practice. fa A regional project, funded by UNDP, to develop a network of institutions for Health Learning Materials (HLM) in Indonesia, Myanmar, Nepal, Sri Lanka and Thailand was completed in the first quarter of 1994. The project has enhanced the technical capacity of the concerned institutions to produce relevant and usable health learning materials for different categories of health personnel. Improvements have been noted in the quality of the education and training programmes conducted by these institutions. These countries, therefore, now possess a nucleus of expertise in health learning materials development and are expanding their activities to meet the increasing needs. -. - - -- 38 The Work of WHO ~n SEA + The HLM project at the Institute of Medicine, Kathmandu. Nepal, which is a WHO Collaborating Centre for Health Learning Materials, continued its regular activities such as producing the bibliography of health literature in Nepal, conducting training programmes on different subjects for educators from the Region and providing a variety of consultancy services in HLM. The Centre also functions as the focal point for the "health net" information base for Nepal. A book on medical education, containing contributions from eminent authors from the Region, is being completed by the Centre. This will provide the conceptual base and illustrative practical and situational experiences in the development and implementation of relevant policies, plans and strategies for the development of medical education in the countries. The Centre is also collaborating technicalb to produce a television serial for health education of the public in Nepal. The SEAR0 HLM network now includes a total of nine countries - Bangladesh, Bhutan and Maldives having joined during the past two years. Each of these countries is also producing and adapting materials necessary for their education and training programmes. However, the conclusion of the UNDP project and the limitation of intercountry funds have tended to slow down the initial pace of network development activities. An urgent need, therefore, exists to mobilize further resources so that these countries can achieve a measure of self-reliance in HLM development. An intercountry workshop on Management of HLM Projects was held in the Regional Office in March 1994 to strengthen the managerial expertise of the responsible national HLM staff. In particular, the workshop focused its attention on issues such as priority setting and scheduling, leadership and responsibility. problem-solving and innovation, communication, promotion and marketing of HLM and resource mobilization. In the light of the perceived usefulness of the workshop, it was recommended that similar training activities should be held for other national staff who have managerial responsibilities. Health learning mater~als for different types of health worker continue to be produced by many of the main technical programmes. often in collaboration with their counterparts at WHO headquarters. These include production of materials on diarrhoea1 diseases for the training of medical students, nurses and other health workers; modular materials on acute respiratory diseases and on - - Development of Human Resources for Health immunization; a report of a low-birth-weight study conducted in SEAR countries, and a variety of pre-service and in-service learning materials in disease control programmes. * Fellowships The regional fellowship programme continued to make a substantial contribution in complementing the HRH plans developed by the countries. It has also enabled health personnel in Member Countries to acquire updated knowledge and skills to keep abreast of the latest technical knowhow in specific health-related fields. Public health and communicable diseases accounted for 63 per cent whjle dinical scjences accounted for 17 per cent of the fellowships awarded during the period under review (Table 1). Table 1. D~stnbution of fellowships under the regular budget, by subject of study and country of origin of fellows 1 (1 July 1993 - 30 June 1995) - 40 The Work of WHO in SEA .* During the 1994-1995 biennium, 22 per cent of the WHO Regular budget has been allocated for the fellowships component of the HRH training programme. With the introduction of yearly plans of action, the majority of the applications for fellowships were received in the first year of the biennium, which facilitated better implementation of the programme. To make short-term study tours, which constitute a major portion of the fellowship component, more effective, a package study tour on PHC at district level is being developed. Arrangements are being finalized for the first seven-week package study tour in October-November 1995 with visits to Thailand, lndonesia and Sri Lanka. The main objective is to develop health personnel, especially at the middle level, in PHCIdistrict health systems. For the 1994-1995 blennlum, the approved Regular budget for the ~lnplernent~tion fellowshlp component IS US$ 17 113 80 and its utlllzatlon up to 30 June 1995 was US$ 11 399 581 ( 65%) During the period under review, 1918 fellowship application forms (FAFs) were received in SEAR0 and 1277 fellowships were awarded. One hundred and seventy-seven fellowships, utilizing funds from other sources, were awarded. In addition. 604 in-country fellowships were provided. Table 2 shows the number of fellowships awarded by duration and country during the reporting period. Table 2. Distribution of fellowshlp application forms (FAFsJ, by duration (1 July 1993 - 30 June 1995) ~ ~ ~ - . -- ~ ~ ~~. .. 1 < 3 I Per 1 3-6 I Per 1 6-12 1 Per / > 12 I Per / Total 1 1 months cent months cent months cent months cent -- Bhutan India Indonesia Maldives Nepal Total 1 1586 / 82-7 - -~ Development of Human Resources for Health 41 By and large, the implementation of the fellowship programme proceeded satisfactorily, though a continuing trend with regard to increase in the number of short-term study tours under the fellowship te component was observed (Table 3). = Table 3. Distribution of awards in SEAR0 by duration (Regular budget only) 1 / < 3 months 1 36 months 1 642 months 1 W 12 months / 1 Out of a total of 1277 fellowships awarded, 828 ( 64.8%) were regional and 449 (35.2%) were extra-regional fellowships. The extra-regional fellowships were placed mostly in AMR (23%), EUR (25%) and WPR (49%). From other regions, especially WPR and EMR, SEAR0 catered for 267 fellowships in different institutions in the countries of the Region. Year It is observed that the cost of fellowships in some developed as well as developing countries has increased. This is due to a rise in tuition fees and training charges. The increase in the number of study tours involving visits to more than two or three countries has also accentuated the overall budgetary constraints. Group During the reporting period. 16 policy and advisory meetings and Educational 47 technical meetings were held. Subjects covered included ~~ti~iti~~ tuberculosis at district level, visceral leishmaniasis control, health care systems in districts, the dengue vaccine development programme, health systems research, nutrition, prevention and control of HIV infection, environmental health, health of the elderly. diarrhoea1 diseases, medical education, leprosy, essential drugs, -- . 1 TOW / . - -- -- 42 The Work of WHO In SEA 'f - NO. Per cent NO. Per cent "' cent NO. -- cent EPI diseases, women, health and development, safe motherhood. 1 noncommunicable diseases, malaria, community action for health. !, safe blood and blood products, STD management, prevention of d blindness and control of plague. Table 4 shows the distribution of participants in intercountry 1 activities, by type of activity. Table 4. Distribution of partic~pants in intercountry activities. by type of activity (1 July 1993 - 30 June 1995) / Typa of activity 1 Number ~-p-~-~~ -~ ... ~ Regjonai meetlngs 5 Workshops 11 Consultative meetlngs 27 4 Total 47 Number of participants - ~ . . - 90 175 401 80 . .~ .. 746 - Development of Human Resources for Health The Member Countries have continued their information and education for health (IEH) activities in support of primary health care. Training in IEH through fellowships and study tours has .i strengthened their health education agencies to undertake activities related to training, production of information and educational materials and designing of IEH programmes. The three world days -World Health Day, World No-Tobacco Day and World AIDS Day - provide opportunities to disseminate health information to create mass awareness on various topics of health concern. There is now an increased awareness among the public about the prevention and control of HIV/AIDS, the hazards of tobacco use, the importance of immunizations during infancy and childhood and about various other issues concerning family health. L- Considerable IEH inputs went into the production of materials on HIVIAIDS in the Region. Inputs were also provided for the Women. Health and Development initiative with the publication of a resource kit on "Facilitating Health Action by Women" in a draft form. This publication has been distributed to selected relevant agencies in the Region for their comments and suggestions, which will be incorporated before its finalization. A video film on "Essential Drugs First" was produced, covering the important aspects of the essential drugs programmes in Bhutan and India. In view of the importance of school health. "Guidelines for Action on Comprehensive School The Work of WHO In SEA - Health Education", adapted for the Region, have been disseminated in the countries. s i At the regional level, IEH will receive a new impetus by the \ implementation of the WHO Communications and Public Relations : Policy. The main thrust of the policy is to create proper awareness of WHO, foster involvement in its work and advocate health for all and a coherent approach to health development. This reinforces efforts at health promotion to enable people to increase control over and improve the conditions that affect their health. Advocacy for health directed at decision-makers and implementors at different levels to stimulate action in support of health programmes is being initiated. As a beginning, health advocacy materials for the Region are being developed and efforts to strengthen links with the media through seminars have been undertaken. The first seminar was held in Dhaka, Bangladesh. in May 1995. A pictorial information booklet on "WHO in the South-East Asia Region - Fostering the Spirit of Partnership" was produced and distributed An intercountiy workshop on Development of Prototype Media Packages on Health Issues Related to HIVIAIDS and Tobacco Use was organized in March 1995 in collaboration with the Indian Institute of Mass Communications, New Delhi, which was designated as the WHO Collaborating Centre for Health Communication in 1994. The outbreak of plague in September 1994 in certain parts of India highlighted the need to intensify IEH linkages among SEAR countries through timely dissemination of information, using modern communication technology. This aspect was also highlighted at the interregional consultation on Prevention and Control of Plague held in SEAR0 In March 1995. Section Ill Health Science and Technology I During the reporting period, action was taken to operationalize the research strategy endorsed by the South-East Asia Advisory Committee on Health Research (SENACHR) at its nineteenth session held in April 1993, which has now been published as a technical publication entitled "Health Research Strategies for the South-East Asia Region". The twentieth session of the SENACHR was held in Yogyakarta, Indonesia, from 11 to 15 April 1994. In view of the need to respond to the changing health scenario emphasized by the SENACHR in 1993, the following subjects were selected for technical discussion: health policy research; strategiesfor research on behavioural aspects of health in South-East Asian countries, and guidelines for the assessment, development and transfer of appropriate diagnostic technology. Several recommendations emerged from these discussions. Concerned with the serious health problem caused by the rapid spread of chloroquine- and multidrug-resistant Pfalciparum malaria, a long-term multicentre collaborative research programme has been initiated to develop and validate technical and operational guidelines aimed at stopping the spread of drug-resistant P.falciparum. Other activities undertaken in the field of malaria included a review of the current knowledge and status of research - - . ... Research Prornotlon and~eveloprnent 47 ; work on malariogenic stratification and establishment of a 1 / methodology for a geographical information system which would i enable the development of a monitoring database using "emote-sensing technology for the preparation of stratification maps. " AS well, a multicentre field study has commenced in lndia and Thailand to validate a newlydeveloped dip-stick method to detect ; P.falciparum malaria. In the field of nursing, a multicentre study on collaboration : between nursing services and nursing education was supported in ; three countries (India, Myanmar, Thailand) to improve the quality ! ; of nursing care and nursing education. In 1993, a review of the WHO-supported research promotion and development (RPD) programme was undertaken jointly with the National Institute of Health Research and Development, Indonesia. A similar review was also initiated in Myanmar. The purpose of these reviews was to assess how the RPD programme had contributed to the overall development of health research activities, the extent to which the programme had helped accomplish the * objectives of the national health research policies, the cost-effectiveness of various components of the programme, its strengths and weaknesses, and the degree to which the RPD programme had contributed to general health development in the : countries. Based on the results of the reviews, action has been I taken to further strengthen research promotion and development activities in these countries. Technical and financial support to the dengue vaccine development programme at Mahidol University, Thailand, was continued. At the last meeting of the Peer Review group, it was I decided to further refine the tetravalent vaccine formulations for w : children. A consultation on Research on PubliclPrivate Mix of Human Resources for Health was held in December 1993. It recommended that SEAR0 should support the Member States to establish information systems and conduct research to formulate policies towards equity, efficiency and quality of health care through a proper publiclprivate mix. At the Third Meeting of the SEA Nutrition Research-cum-Action Network, a strategic plan was developed for the years up to 2000, - 48 The Work of WHO in SEA emphasizing the problems of proteinenergy malnutrition and micronutrient deficiencies. Direct support was also provided to a wide range of research projects which included HIV infection; treatment of drug-resistant P,falciparurn malaria, influence of the reservoirs of malaria infection; tuberculosis; leptospirosis; self-care practices; care of the elderly; biochemical, electrophoretic and biological properties of Russell's viper venom; nutritton; traditional medicine; quality of antenatal care services; chronic lead exposure and weaning practices. Activities in the area of research capability strengthening tncluded the strengthening of national mechanisms for research coordination; support for the development of infrastructural facilities; and provision of visiting scientist grants and research training grants covering a wide spectrum of disciplines, viz. traditional medicine. ophthalmology, oral health, entomology, health statistics, vaccine trials and health care financing. At present there are 81 WHO collaborating centres in the Region covering various specialities. During the period under review, new collaborating centres were designated in the fields of health economics, health communication and cancer control. The ninth meeting of the Directors of Medical Research Councils or Analogous Bodies and Concerned Research Foci in the Relevant Ministries was held in Kandy, Sri Lanka, in October 1994. The meeting made a series of recommendations in the areas of HlVlAlDS. dengue vaccine, operational research on tuberculosis control and future trends assessment. The Twent~eth Ann~versary Commemorative Session of the SENACHR was held on 8 April 1995 at the Regional Office, where the past successes and failures of the RPD programme together with its future directions and partnership and management of research activities within the Region were discussed. The twenty-first SENACHR outlined the future research directions of the programme, which include: behavioural, socioeconomic and cultural aspects and determinants of health and diseases; development of human resources for health in all categories of health personnel at all levels of the health care system; assessment and rapid application of existing and emerging health, information and communication technologies in health programmes of the South-East Asian - - .- Research Promotton and~evelo~ment 49 countries; health policy and health promotion research, and identification of constraints to the implementation of health programmes as they affect recipients and providers of health care and policy and managerial apparatuses. N~ne of the 11 Member Countries have RPD projects supported by WHO Bhutan and Maldives do not yet have any project related d~rectly to research An analysis of the WHO country programme budgets and plans of action reveals that the main research-related activities supported by WHO were the following: (1) consultancy in health systems research, molecular biology, biotechnology, demography, nutrition. health statistics, rapid assessment procedures (RAP) in nutrition surveys, tobacco-related diseases, population genetics, laboratory techniques, pathogenesis of DHF, medical sociology, health behaviour, and health economics; (2) improvement of institutional facilities by the provision of supplies and equipment; (3) publication of research bibliographies and abstracts and periodicals related to research; (4) holding of meetings of policy-makers, administrators and researchers for the assessment of research needs and priorities and development of plans of action for national research programmes; (5) holding of workshops to impart training in research methodologies and for the development of research project proposals; (6) provision of research grants on identified national priority topics, and (7) award of fellowships in molecular biology including genetic engineering, cancer epidemiology, biomedical statistics, health management research, maintenance of biomedical equipment, advanced computer technology, library services, research administration and management, clinical research, HIV infection and AIDS, clinical genetics, organ transplantation, nutrition, environmental health and health behaviour. w -. 50 The work ofWH0 in SEA Human nutrition is a development priority in most SEAR countries. Nutrition WHO lays great emphasis on improving the quality of the existing nutrition programmes to combat the main nutritional deficiencies that people are prone to: protein-energy malnutrition, particularly of women and children, iodine-deficiency disorders, vitamin Adeficiency and anaemia in pregnant women. The SEAR Nutrition Research-cum-Action Network continued its activities, focusing on behavioural research and defining effective approaches to solve protein-energy malnutrition and micronutrient deficiencies. The Network Newsletter continued to be published and distributed widely. The feedback received from readers indicated that this newsletter is useful in disseminating nutrition information to national nutrition focal points and research centres. SEAR0 co-sponsored and participated in a regional meeting on Elimination of Iodine-deficiency Disorders organized by the lnternational Council for Control of Iodine-Deficiency Disorders in Bangladesh in April 1995. The main objective of the meeting was to renew international commitment to the goal of IDD elimination by the year 2000 set by the World Summit for Children. A SEARONPRO bi-regional meeting held in Manila in March 1994 discussed the progress in the two Regions in regard to the lnternational Code of Marketing Breast-Milk Substitutes. Most countries are now proceeding with legislation in this area. - .- -- - -- - - General Health Protection and Prornot~on 51 As a follow-up to the International Conference on Nutrition. information on the nutrition situation in SEAR countries was compiled. The data indicated that there was a need to strengthen the implementation of national plans of action for nutrition to addressP the priority nutrition problems in the countries. SEARO published a Regional Health Paper (No. 23) entitled "Nutrition Research in South-East Asia:The Emerging Agenda of the Future". WHO also published a booklet on "Principles of Nutrition Management in Primary Health Care" (Regional Health Paper SEARO. NO. 26), which is intended for persons responsible for integrating nutrition in primary health care at national, provincial or district levels. Bhutan, lndia and Mongolia received WHO assistance in the formulation of national plans of action for nutrition. Technical support was provided to Maldives in compiling and analysing data generated by the national nutrition survey. Nepal was assisted in anaemia control, promotion of breast-feeding and weaning foods and monitoring of the national nutrition programme. Myanmar was supported in the development of nutrition sentinel townships and strengthening of state and divisional nutrition teams. Supplies and equipment were provided to strengthen the national nutrition programmes in DPR Korea. India, Mongolia. Myanmar, Nepal and Sri Lanka. WHO supported the training of national personnel from lndia, Indonesia, Mongolia, Myanmar, Nepal and Sri Lanka by study tour and by their attendance at various meetings and training institutions throughout the world. In addition. workshops on nutrition-related subjects were supported in lndia, lndonesia and Mongolia. rn Oral Health The major thrusts of WHO'S collaboration and support to Member Countries in this area have been: assessing the overall oral health situation; promoting oral health care through strengthened health education; development of oral health care infrastructure, and appropriate training of various categories of health personnel. Specific components of the oral health programme are: provision of primary oral care for pre-school and school children; establishmentlstrengthening of national oral health centres, promotion and application of appropriate technology for reducing 52 The Work of WHO in SEA the incidence of dental diseases and maintenance of the DMFT (decayed missing filled tooth) level at 3.0. In Bangladesh. Indonesia, Nepal and Sri Lanka, promotional activities carried out since World Health Day, 1994, which had "Oral Health for A Healthy Life" as its theme, contributed in a big way to increasing public awareness about the importance of appropriate oral health care. Bangladesh has been assisted in the development of a community oral health care demonstration project which is now ready for implementation, and in educational activities for the prevention of oral and dental diseases. Essential medical equipment and books and literature were provided to Dhaka Dental College as well as to some thana health complex dental units. In India, support was provided for the formulation of a national oral health policy and for the reorientation of training for professional dentists. In Indonesia, workshops on dental rehabilitation for hospital staff were supported while technical assistance was given for training In dental auxiliary care for school teachers. The national fluoridation programme and a project on affordable toothpaste in West Kalimantan received WHO support. in Myanmar, technical support was provided for the planning and management of primary oral health care as well as group educational activities. In Sri Lanka, a workshop on bas~c oral health survey methods and production of audio-visual materials on oral health were supported. Epidemiological assessment of injuries, support for the formulation Accident and strengthening of comprehensive national programmes and Prevention education and training for creating community awareness were the major WHO collaborative efforts in the field of accident prevention. The subject of Accident Prevention, Trauma Care and Management : was discussed by the forty-seventh session of the Regional Committee, which urged the Member States to: consider setting up trauma care and management facilities; introduce legislation; enforce safety laws, and improve community awareness by popularizing safe practices. In Indonesia, collaborative efforts were directed towards improvement of safety through strengthening community awareness of, and participation in, the prevention of accident and rehabilitation .~ ~ ~ General Health Protection and Promotion 53 Tobacco or Health activities. In India, the WHO Collaborating Centre for Research and Training in Safety Technology organized an international training course on traKtc accidents and injuries. In Myanmar, support was provided fororganizing workshops on accident prevention for different * - types of personnel, from both the health and non-health sectors. In Mongolia, fellowships were provided on disaster management and emergency care. In Sri Lanka, monthly meetings of the national committee on accident prevention are held, and support was provided for the production of materials on the subject for use by the mass media. WHO continued its strong advocacy for increasing tobacco control in the Member Countries. Virtually all domestic flights in the Region are now smoke-free as are most hospitals, government offices and other workplaces. Surveys on tobacco use have been conducted in lndia, Mongolia and Thailand, which have produced baseline data for evaluating the impact of preventive education and other tobacco control activities. A major study on the health impact of smoking has been initiated in Bombay with WHO support. Technical support has been provided to Indonesia and Mongolia in order to strengthen their tobacco control programmes. Comprehensive legislation, as is already in force in Thailand, has been prepared by the Ministry of Health in lndia and has been placed before Parliament. The educational activities and campaigns against tobacco use are still mainly of the 'fear and danger' variety, which have been shown to have little impact, as is the case for other substances of abuse. Furthermore, such activities are still directed against tobacco alone, and do not address all psychoactive substances. It is necessary to stress the ~mportance of addressing all substances of abuse together in order to increase the effectiveness of such activities. The Alcohol and Drug Information Centre in Sri Lanka, an NGO, hasshown the effectiveness ofsuch an integrated approach. 54 The Work of WHO in SEA The objective of WHO support to Maternal and Child Health, including Maternal and Family Planning (MCHIFP), is to collaborate with Member Countries Child Health, in the adaptation of technologies and the promotion of the health including of women of child-bearing age and children. Family The issues relating to child survival and development are I Planning receiving priority consideration in the countries of the Region. WHO, together with UNICEF, UNFPA, other international agencies, donor countries/institutions and nongovernmental organizations, is supporting governments in their endeavours in this area. An approach based on the concept of primary health care, with an in-built system of MCHIFP service, is now commonly accepted. Ten priority mid-decade goals targeted for achievement before the end of 1995 were once again brought to the attention of all heads of governmenWstate by the executive heads of UNICEF and WHO at a meeting organized by the Task Force for Child Survival in New Delhi in 1994. All countries have recorded a slgnlficant decrease In Infant mortality rates (IMR) over the last decade through successful ~mplementatlon of the expanded programme on lmmunlzat~on (EPI), and through the control of d~arrhoeal d~seases (CDD) and acute - . - - . . . . -. -- - Health of Specific Populattan Groups 55 ; respiratory infections (ARI) programmes. But the IMR still remains 1 high in some countries, for which neonatal mortality is mainly / responsible. While some countries in the Region have made 1 significant progress towards expanding access to maternal and " I reproductive health care, increasing educational levels and i ; bringing about improvements in other social and human indicators, 1 others are still lagging behind in these respects. The relative I success of some countries gives cause for optimism about what : can be accomplished in the area of MCH. Four countries in the ; Region have already achieved an IMR of less than 50 per 1000 i live births, and a maternal mortality rate (MMR) of less than 100 per 100 000 live births. However, the MMR still remains above 200 per 100 000 live births in the remaining seven countries (Figures 1 and 2). These facts indicate that much more needs to be done to improve women's reproductive health and to ensure safe motherhood. Reduction of matemal mortality and morbidity and m enhancement of the health of the newborns can be achieved through early and equitable access to primary health care, including family planning and prenatal and postnatal care. The existing extent of coverage of these services in the countries of the Region is given in Table 5. It shows that all components of matemal and infant care are not delivered with the same emphasis, and trained attendance at delivery time is still low in many countries. Accordingly. WHO has given high priority to the development of Safe Motherhood programmes in the Region and provided technical support to national workshops as well as to the development of national plans of action in Safe Motherhood. WHO has also produced strategic guidelines for the implementation of Safe Motherhood programmes in the form *L of a "Mother-Baby Package". The package defines a minimum set of interventions for each level of care. Four essential components of Safe Motherhood are: family planning, antenatal care, cleanlsafe delivery and essential obstetric care. These services should be delivered within primary health care and should be based on the principle of ensuring equity for women. This package has been introduced in Bangladesh. Bhutan, Mongolia and Nepal through an intercountry workshop on Safe Motherhood. Member Countries have been striving to strengthen the above four essential components, for which WHO has provided support in various ways. -- 56 The Work of WHO ~n SEA F;gore 1. Infant mortality rates in SEAR countries, 1 991-93 1 sourre: county on mid monit~nng o( pmgmaa in rmnmsnladon 01 HFA slrstsgt-, 1904 ..N#fbnal HesIth Suway, I004 Not* +Mjnfmum 0q.1 nlus lor plobal indroalor as bnnullsd in 7081, HFA rsries "0.3 Figure 2. Maternal mortality rates in SEAR countries, 1991-93 ~p~~~~ ~-~~ ~~ ~ ~ ~ ~~~ ~ ~ ~~ ~ -~.J -- ?alth of Specific Population Groups Table 5. Maternal care coverage in SEAR countries Country wo contributed a position paper on reproductive health and safe motherhood to the International Conference on Population and Development (ICPD) held in Cairo in 1994. The technical aspects of the recommendations of the ICPD are based on this position paper. In May 1995 the World Health Assembly passed a resolution on Reproductive Health: WHO'S Role in Global Strategy. The resolution recognizes reproductive health needs as a central component of women's health. It endorses WHO'S role in the global reproductive health strategy with respect to advocacy, normative i functions, research, and technical cooperation in the area of reproductive health. This resolution also urges Member States to further develop and strengthen their reproductive health strategies in keeping with the principles elaborated in the Programme oFAction of the ICPD and to strengthen reproductive health programmes through: needs assessment, development of medium- and long-term guiding principles, training of health workers in reproductive health and human sexuality, and monitoring and reporting to the Director-General of WHO as a part of the monitoring of progress of HFA strategies. Coverage by trained Pmgnant personnel women immunize with tetanua 42.0 8.0 ... 43.6 62.6 23.4 ... 21.6 24 0 62.0 58.2 cam Bangladesh 54.6 Bhutan 90.0 DPRKorea lW.O 79.4 Indonesia 76.5 Maldives 100.0 Mongolia 71.0 Myanmar 81 6 Nepal 18.0 Sri Lanka 97.0 Thailand 73.0 58 The Work of WHO in SEA e Source: WHOISEARO, Regional summary of progress, impediments, and further r actions needed in implementing national HFA Strategies, 1994 (SWRC47RO). Contraceptive prevalence (per cent) care ~.- 6.1 50.0 100.0 44.1 31.7 50-60 99.0 41 6 31.4 97.0 86.7 $r cam ... 50.0 100.0 90.0 65.5 100.0 94.01 ... ... 88.6 60.9 (per ent) 61.8 27.0 ... 79.4 63.9 95.2 ... 72.0 26.8 85.3 73.2 Nutrition Growth monitoring is an important mechanism to determine the nutritional status of children. Though much progress has been achieved, the Region continues to be the most affected area in the world with regard to malnutrition. - School Health Effective programmes for the healtR of the school-going child are being developed in the Region. It is now well accepted that in order to ensure a healthy adulthood, healthy habits need to be inculcated in the young. Maternal and Child Health The health of mothers and children is receiving priority attention in the Region. While emphasis is being placed on the integration of MCH and famify planning se~ices. efforts are also being made to improve the quality of sewices through appropriate training of health workers, including midwives. The resolution also requested the Director-General to continue : his efforts to: increase the resources for strengthening reproductive health in the context of PHC, including family health, develop programmatic approaches for research and action in reproductive health care, and report on progress to the ninety-seventh session of the Executive Board and the Forty-ninth World Health Assembly. Intensified efforts have been made at country and regional levels Women, Health to promote greater attention to women's health and to integrate "dDe~elo~ment women, health and development (WHD) components in relevant programme areas. National focal points for WHD have been designated in the ministries of health in several countries in order to facilitate coord~nation and collaboration within and among countries. A major concern has been the need to strengthen the resources for WHD in order to effectively meet the increasing demand for technical and information support at country and regional levels. Therefore, a WHD resource database has been established. compiling information on government departments, institutions. NGOs and UN and donor agencies active in issues related to women's health and development. A WHD resource centre has also been established in the Reg~onal Office. It contains over 300 reference materials, documents and reports and is being used as a source of information for identifying, documenting and analysing WHD concerns and for facilitating dissemination of valid information on WHD. In addition. a protocol has been developed which contains a list of indicators and discussion points for the preparation of WHD country profiles Th~s protocol will be used for compiling a regional perspective on women's health and development. The second major concern has been the need to promote dissemination in the Region of valid information on WHD issues for advocacy and publicity, aimed at increasing awareness of the major Issues and facilitating action. A resource kit on "Facilitating Health Action by Women" has been prepared for use by women's groups and others to promote health action by women for their own health as well as that of their families and communities. Two WHD issue papers - one on the health of poor women in urban areas and the other on the reproductive health of women - have been produced. -- - - - -- -- Health of Speclflc Populat~on Groups 59 These papers, among other things, suggest actions in the areas of policy, programme and research. Activities directed at improving women's health continued to be " carried out in the countries within the context of national programmes for Safe Motherhood and MCHIFP, prevention and control of HIVIAIDS and primary health care. For example, in Indonesia activities have been implemented in selected provinces, with support from NGOs, to enhance the empowerment of women and their participation in health development based on PHC. Research related to some of the emerging women's health issues has also been conducted; the studies in Thailand on factors related to the outcome of pregnancy among female factory workers and on osteoporosis in post-menopausal women in urban and ~ral communities are examples. A series of national meetings in Bangladesh. India, lndonesia and Thailand, followed by a regional consultation, have been held in order to mobilize country-level expertise and resources, to identify the major priorities for WHD activities and to initiate networking for c further collaboration on WHD within and among countries. The recommendations of the regional consultation on Action for Women's Health and Development, held in SEAR0 in February 1995, included the adoption of a life-cycle approach to women's health, integration of a gender perspective in health policies and programmes and education and training, support for research, collection of gender desegregated data and intensified inter-agency and NGO ' collaboration. These recommendations will form the basis of a regional WHD plan of action. The Region has contributed to theworkoftheGlobal Commission on Women's Health, established by WHO in 1993 as a high-level body for advocacy and advice to the Organization. The Commission has outlined an action plan for improving the health of women worldwide, which is to be implemented by June 1996. WHO and Member Countries actively participated in the preparatory activities for the Second Asia and Pacific Ministerial Conference on Women in Development, held in Jakarta in 1994, and are currently involved in preparatory activities for the Fourth World Conference on Women, to be held in Beijing in August-September 1995. As a result of these actlvlt~es, women's health Issues ach~eved a h~gher profile w~thln the context of overall development The Work of WHO In SEA Most countries in the Region have recognized the changing pattern 1 Adolescent of adolescent lifestyles and the importance of giving greater attention / Health , to adolescent health, for which focal points have been designated i in the ministries of health. The countries now face a situation where more than 50 per cent of the population is under 25 years of age. : Efforts are, therefore, being made to promote and protect the health of adolescents and youth by introducing healthy lifestyles, including i sports. Specific areas of concern include reproductive health, i increased use of tobacco and drug abuse. Adolescent health programmes have been operational in 1 Indonesia, Mongola. Myanmar and Sri Canka and WHO suppolt has been provided through seminars, conduct of relevant studies and production of physical fitness manuals. However, the fact remalns that programmes for adolescent health have not been developed to the extent they should have Governments need to formulate natlonal plans of actlon for adolescent health, and the efforts of NGOs, youth organlzatlons, the Red Cross and other agencles worklng In the prevention of substance abuse and other relevant areas need to be better coordinated and streamlined Collaboration with the Human Reproduction Research (HRP) Special Human Programme was continued during the period under review, with Reproduction strong inputs from the Regional Office in promoting and supporting Research research capability strengthening activities. Presently, India, Indonesia and Sri Lanka are on the WHO Policy and Coordination Committee (PCC). The Committee on Resources for Research (CRR) met in 1994 and reviewed and approved several long-term institutional development grants for various institutions in the Region. Training courses and workshops on different aspects of HRP were supported in Member Countries. Long-term institutional development and capital grants were approved for Bangladesh. India, Myanmar and Sri Lanka. In 1994, a WHO-cosponsored South Astan Soclal Sclence Research and Tralntng Workshop on Reproductive Health was held In New Delhl, whlch enabled researchers to develop research projects and proposals in the area of reproductive health ~ . . Health of Speclfic Populat~on Groups 61 Workers' The dimensions of the occupational health problems in the Region Health have changed and expanded due to the developmental processes in operation, such as rapid industrialization and modernization and privatization of manufacturing, construction and agricultural enterprises. WHO's efforts are aimed at assessing the existing and new emerging problems in order to develop and adapt technologies for early detection, prevention and control of health problems of working populations. Special emphasis is laid on assessing and dealing with the occupational health problems of those working in small-scale industries and unorganized sectors, including agriculture. through the development of occupational health infrastructures and promotion of community-based occupational health services within the framework of primary health care. Bangladesh, Indonesia, Myanmar. Sri Lanka and Thailand were supported by WHO through training programmes and development of occupational health service information systems. e Health of the The rapid demographic transition and increasing number of elderly Elderly people in the Region are causing concern to Member Countries. Creation of mass awareness about the special needs of the elderly and training of health personnel, families and the community to care for them received due attention in WHO's collaborative activities. In addition to the health-of-the-elderly programmes already existing in five countries of the Region, two more countries have established these programmes, in which they were supported by WHO. The Regional Office, in cullaburatiuo with EMRO, organized a bi-regional consultation on Health Care of the Elderly, with special emphasis on creating mass awareness, in New Delhi in December 1994. Nineteen countries from SEAR and EMR participated. As a " follow-up of this consultation, a workshop on campaigning for and with the elderly was organized by the Asian Training Centre on Aging in Chiang Mai, Thailand, to which WHO provided technical support. Support was also extended to a geriatric workshop in India which had creation of awareness as its main theme. Bangladesh. Indonesia, DPR Korea. Mongolia, Myanmar and Thailand received WHO support in the holding of country workshops, conduct of epidemiological studies on the elderly and fellowships for the study of gerontology and geriatrics. - - ...- -- 62 The Work of WHO bn SEA It is being increasingly realized in Member Countries that behavioural and psychosocial issues, i.e. lifestyles, are of immense importance for the control of communicable and noncommunicable diseases. It has also become obvious that a prescriptivelclinical approach alone for advances in this field is as ineffective as are quantitative approaches, since they do not seem to have led to much progress in the difficult area of lifestyles and lifestylechangesforthe betterment of health. The Regional Office has, therefore, developed a technique. viz. 'stepwise ethnographic exploration' to bridge the gap between qualitative and quantitative methods of exploration and analysis. Using th~s technique to explore and quantify areas normally considered too 'subjective' for scientific inquiry, instruments have been developed in a Wocoordinated effort to measure the subjective well-being, the perceived burden on those who care for the incurably or chronically ill and the motivational patterns in adolescent behaviour. As adolescent behav~our and lifestyle are critical for a large number of potentially irreversible health-related problems such as STDMIV, early pregnancies, drug addiction and smoking, the subject is being pursued vigorously. In addition, WHO'S work in the field of psychosocial factors has focused on family and community life. The orientation towards community-based health care implies a shift of the burden of caring for the ill and the disabled from institutions to the family and the community. It is, therefore, considered timely to develop measures to quantify the perceived burden on care-givers as well as the quality of community life in Psychosocial and Behavioural Factors in the Promotion of Health and Human Development - - Protection and Promotion of Mental Health 63 order to assess community cohesion and the possibility of improving community participation in health and in the caring of the ill and the disabled. This work is being supported by the Indian Council of Medical Research (ICMR) based on a protocol developed during a WHO-sponsored intercountry workshop. Prevention over the years the open community approach to drug abuse control and Control of : has been developed in the Region, first for rural opium users in Alcohol and ~yanmar and Rajasthan, India, and later for rural alcohol abuse in Drug Abuse Tamil Nadu, India. It has now been successfully adapted to urban heroin users in lndia and Sri Lanka. This approach, based on the principle of rehabilitation beforelwithout detoxification, is gaining increasing international recognition as an effective way of demand reduction, harm minimization and HlV prevention in injecting d~g users. Furthermore, this appmach combines prevention, treatment and rehabilitation in one integrated and deprofessionalized manner. The European Commission is supporting pilot projects to adapt the open * community approach for Europe and is funding a network of NGOs which is implementing the programme in the Region and adjacent countries. This group met in Colombo in July 1994, with the active participation of WHO. A study by the All lndia Institute of Medical Sciences, New Delhi, aimed at developing indicators for the quality of drug services and process indicators for improvement in the social functioning of drug users, is being supported by WHO. WHO continued to execute a UNDCP-supported drug abuse control programme in Sri Lanka. In the process, new insights into the social processes leading to drug dependence have been gained, which are very useful in developing the open communrty approach further. .. Prevention As in the case of other noncommunicable diseases, reorientation control of of specialized services of psychiatry and neurology towards public Mental and mental health has continued to be a difficult task. However, Bhutan and lndonesia have now finally adopted this concept, and the latter country has, in its National Mental Health Programme, specified Disorders - the need to reorient the training of psychiatrists in the same way as that of public mental health specialists. lndonesia has also started to use some of the indicators of the quality of mental health care and the functioning of mental hospitals for monitoring aspects 1 of the public health orientation of mental health care. I . In addition to the National Institute of Mental Health and I Neurosciences, Bangalore, India, the Department of Psychiatly, a Madras Medical College, India, has been designated as the second WHO Collaborating Centre for Training and Research in Mental 1 Health in the Region. In one of the collaborative projects, the Madras centre has completed ethnographic work with families who care for a chronic psychotic patient. Based on this work, an .' instrument to quantify the perceived burden has been developed. ] This will permit the gearing of treatment of mental patients not only towards optimal symptom control but also towards minimization of suffering of the family members. ~p~ Protection and Prornotlon of Mental Health 65 During the reporting period, the thrust of the environmental health * programme continued to be towards community water supply and sanitation. This programme has also been extensively used to support other activities such as the control of environmental health hazards and the promotion of chemical and food safety. Vibrant economic growth experienced in a number of SEAR countries has also created some adverse effects on the environment and human health, particularly in cities where most of the growth is taking place. This has led to an increased awareness of the problems caused by pollution and the need for programmes to address them. Following the United Nations Conference on Environment and Development, held in Rio de Janeiro in June 1992, WHO developed a Global Strategy for Health and Environment, thus creating a framework for collaboration with Member States in the area of health and environment. The strategy was further elaborated in a Regional Strategic Plan for Health and Environment prepared by SEARO. The plan includes comprehensive approaches to environmental health directed towards four broad priority areas: urban environmental health management; water supply, sanitation and hygiene (including food safety); health and environmental aspects of water resources, and promotion of chemical safety. A number of countries in the Region are in the process of incorporating health and environment considerations in their national sustainable --- .- 66 The Work of WHO in SEA development plans, lncludtng the elaborat~on of comprehensive env~ronmental health programmes Member Countries have set ambitious targets for water supply and / C0mtnUflity sanitation coverage as part of their health-for-all strategy. The : Water Supply coverage achieved at the end of 1990 and the targets set for the and ~~~it~ti~~ year 2000 are shown in Table 6 below: Table 6. Water Supply and sanitation coverage, 1990, and targets for 2000 ~ Countly Source: WHOISEAR0 IDWSS Assessment and Perspedlve for the 1990s. New Delhi. 1993 While the target of almost universal water supply coverage by the year 2000 appears feasible in most countries, universal sanitation coverage in some countries would require a seven-fold increase in the output achieved during the past decade. This has led to the realization that new approaches to sanitation are required. To this end, a regional consultation was organized which came up with recommendations for a new framework for action and directions for hygiene and sanitation promotion that would give priority to "hygiene promotion for all and latrine coverage for high-risk populations". -- . - - Promotion of Env~ronmental Health 67 Expanding drinking water supply coverage has not been matched by an equal emphasis on the safe quality of the water supplied to users. In order to stimulate the establishment of national programmes for safe water supply. SEARO has published a document = entitled "Overview and Framework of Action for Drinking Water Quality Surveillance". The growing health and environmental problems resulting from the use of wastewater and excreta for agricultural and aquacultural purposes were highlighted in a WHOIFAOIUNDP Regional Workshop on Health, Agricultural and Environmental Aspects of Wastewater and Excreta Use, held in SEARO in May 1994. In Nepal, a task force on drinking water quality surveillance prepared a plan of action for the introduction of a national surveillance programme. A national water supply and sanitation meeting was held in May 1994 which evaluated the impact of training courses and programmes organized for the sector. Strengthening of the sector monitoring capacity was supported * in Bangladesh, Myanmar and Nepal. The wafer supply and sanitation programmes in the countries were also provided with technical literature, computer hardware and software, and laboratory and office equipment. In Myanmar, WHO participated in a UN interagency mission on water supply and sanitation which visited the country in December 1994. WHO supported institutional development of key sector agencies of Member Countries through policy meetings, consultancies, special studies, training and study tours aswell as attendance at conferences and seminars at national and international levels. Environmental In order to increase awareness of the environmental problems in Health in cities, a review of the practices relating to municipal collection, ~~~~l and storage and transport of solid waste was completed in India with WHO support. A regional survey of hospital waste management Urban practices identified the magnitude of the problem and necessary intervention activities. A 'Healthy City' project was initiated in and Housing Chittagong. Bangladesh, where a series of community-based workshops was supported by WHO. As a result, the first 'City Health Plan' in this region was produced. Similar 'Healthy City' activities . ~~ - .. 68 The Work of WHO in SEA have started in Kathmandu, Bangkok and in Cox's Bazar and Bogra i in Bangladesh. Work is under way to expand the 'Healthy City' '/ activities into a regional network of healthy cities. . > $ W~th Increased use of chemlcals In agriculture and industr~es, there Health Risk is a growing concern about the result~ng hazards to pubkc health Assessment of WHO'S collaborat~on has been dlrected towards bu~ldtng natlonal POtentiallv capac tles for the appllcatlon of rlsk assessments strengthening ~~~i( Che;nicals lnformar~on on tox c cnemlca s lmprov~nq manaqement of chemlcals and preventing and treating chemical poisoning. In lndia and Indonesia. WHO supported activities for the establishment of poison control centre networks and the assessment of health risks from chemicals. In Indonesia, support was also provided for the development of a national system of registration of chemicals hazardous to public health and the training of provincial pesticide inspectors. In Mongolia, assistance was provided in the formulation of a national chemical safety programme, training of health personnel in toxicological surveillance methods and in the control of chemicals at the workplace. In India and Myanmar, intersectoral training courses on the safe use of pesticides were conducted. In DPR Korea, support was provided for developing the capability of the national reference laboratory to analyse pesticides and other toxic chemicals in air, water and food. As a follow-up of the International : Conference on Chemical Safety, SEAR0 completed a survey of chemical safety activities in Member Countries. The results indicate a need for: strengthening national capabilities to identify and evaluate chemical safety issues, developing chemical safety plans, increasing activities in chemical information and poison control, and improving capabilities to effectively respond to potential chemical emergencies. Collaboration with countries focused on the management of health C0ntl0l of hazards resulting from environmental pollution and degradation Environmental caused by domestic, agricultural and industrial activities. The main Health Hazards activities supported in Bangladesh, India. Indonesia, Maldives, Nepal. Sri Lanka and Thailand included reviews of legislations and : institutional frameworks for the control of environmental health hazards, strengthening of environmental monitoring and assessment - - Promotion of Environmental Health 69 Food Safety of pollution control and development of environmental epldemlology capabllltles through tralnlng Under the Global Environmental Monitoring System (GEMS), water quality monitoring was continued in lndia, lndonesia and Thailand. Assistance was provided under GEMSNVater to Bangladesh, lndia and Nepal to strengthen national water quality data management and regulatory aspects. A review of the status of the quality assurance programmes of GEMSIAir monitoring stations in lndia, lndonesia and Thailand was also conducted. WHO'S efforts in food safety were focused on the development of national programmes through institutional strengthening and human resource development. Technical assistance to countries included: reviews of the food safety situation in order to develop national plans of action and projects for external funding, development of laboratories for food analysis, use of 'hazard analysis critical control a point' (HACCP) methods and conduct of studies on food contamination. In Bangladesh. Maldives, Mongolia, Myanmar and Nepal, technical assistance was provided for situational reviews and preparation of plans for the development of national food safety programmes. Training was supported in Bangladesh. India, Indonesia. Maldives, Mongolia, Myanmar, Sri Lanka and Thailand to address such issues as sanitary inspections, safe food handling, consumer protection, analytical quality assurance of food testing laboratories and the use of HACCP methods. In India, WHO provided assistance for the training of food analystslchernists of state food control agencies in the analysis of food packaging materials and on aspects of chemical contaminants and food microbiology. In Bangladesh and Nepal, studies on street-vended and weaning foods " were completed, while similar studies are to be initiated in Myanmar and Sri Lanka. Food quality control and risk assessment of food contaminants and veterinary drug residues were studied in Thailand, while in lndia studies on plastic food packaging and commercial food products were completed. In Sri Lanka, technical support in food analysis and quality control was provided for preparing a UNDP-funded food safety project. In DPR Korea, the development of analytical techniques of microbial and chemical contamination of food was 70 The Work of WHO in SEA technically assisted. WHO provided assistance for Indian and Indonesian officials to participate in various Codex Alimentarius .: ,meetings as well as in the Second Asian Conference on Food . Safety. Study tours to observe the management of food safety programmes were organized for officials from India. Indonesia, Sri ' Lanka and Thailand. As a follow-up of the International Conference on Nutrition. SEAR0 reviewed the efforts of Member Countries to incorporate food safety activities in their national plans of action for nutrition. Promotion of Environmental Health 71 Clinical, Laboratory and Radiological Technology for Health Systems Based on Primary Health Care The role of laboratories in health care is gaining increasing importance in view of the prevailing and reemerging infectious diseases, particularly in developing countries. WHO, therefore, has continued to support the strengthening of health laboratory services as an integral component of health care at intermediate and peripheral levels through the provision of supplies and equipment, national training programmes, introduction of appropriate laboratory technology and quality assurance programmes. An intercountry project to strengthen health laboratories for effective delivery of primary health care in Bhutan, India, Indonesia, Maldives, Mongolia and Myanmarwas completed in 1994. A Regional Publication (SEARO, No.24) entitled 'Health Laboratory Services in Support of Primary Health Care in Developing Countries' was brought out in 1994 to serve as a regional guide to countries. Assistance was continued to countries for achieving self-reliance " in imrnunodiagnostic reagents. Development and production of reagents for rapid diagnostic techniques for surveillance of priority communicable diseases such as dengue haemorrhagic fever. Japanese encephalitis, hepatitis, amoebiasis, enteric fever, shigellosis and acute respiratory infections was supported. The National Institute of Immunology, New Delhi. India, offered training facilities in the technology for rapid diagnostic reagents for amoebiasis, pregnancy testing, typhoid fever and hepatitis 8. Myanmar and Sri Lanka have adopted the rapid ELlSA technique - 72 The Work of WHO in SEA for the diagnosis of HBS antigen. The National lnstitute of Virology, ; Pune, India, and the National Institute of Health, Bangkok, Thailand, i I continued to supply test kits for the surveillance of Japanese 1 encephalitis and diagnostic antisera for Shigella dysenteriae to other institutions in the Region. WHO assisted Member Countries in the quality control of laboratory technology. India, Indonesia, Maldives. Nepal. Sri Lanka and Thailand received support for taking part in the global external quality assessment programmes in clinical chemistry, microbiology and haematology. National External Quality Assessment Schemes ' (NEQAS) have been introduced for clinical chemistcy, haematology, clinical microbiology and clinical immunology in India, Indonesia and Thailand. Nepal and Myanmar, which have been conducting NEQAS in clinical chemistry in selected laboratories, are poised for extending the network for clinical chemistry to cover clinical microbiology and haematology. Under the Global Programme on AIDS (GPA). WHO support was continued not only in improving HIV testing technology but also in disseminating knowledge about the cost-effectiveness of the HIV testing strategy developed by the Organization, which is being appropriately publicized. To improve HIV testing technology. the International Quality Assessment programme of HIV testing is being conducted globally by GPA where the participation of Bangladesh. Bhutan, India, Indonesia, Maldives, Myanmar, Nepal, Sri Lanka and Thailand is being supported by WHO. A network is being planned for HIV testing and evaluation of HIV test kits in the countries of the Region An intercountry workshop to promote distance learning materials in blood safety was held in Lucknow, India, in March 1995 for streamlining the training of laboratory technologists working in blood transfusion services. Progress in the development of national blood transfusion policies was made in all the countries of the Region. WHO continued to support safety measures in radiology and radiotherapy services. Support was given to Bangladesh. India. Maldives and Nepal for participation in a personal dosimetry monitoring programme conducted by the International Atomic Energy Agency (IAEA). [)lagnostic, Therapeutic and Rehabilitative Technology Essential WHO has been collaborating in the strengthening of national essential D~~~~ and drugs programmes with emphasis on national drug policies, drug quality control and assurance, rational use of drugs and Improvement of supplies and logistics An important element in the technical ' inputs to these programme areas was the development of human resources The 1994-1995 biennium witnessed some important achievements. The national drugs programmes developed in all SEAR countries in the context of the Revised Drug Strategy of WHO. Revision of national essential drugs lists, procurement and supply of essential drugs and their rational use, drug information, essential drugs production, drug legislation, regulatory control and quality assurance were some of the important components of these programmes. Bangladesh. Bhutan, India, Indonesia, Maldives, Mongolia, Myanmar, Nepal, Sri Lanka and Thailand were assisted by WHO in strengthening their essential drugs programmes. The success of the essential drugs programmes in the Region . sewed as a backdrop for a video film produced as an advocacy medium to promote the concept of essential drugs and to create awareness about the inter-dependence of all the components of a national drug policy The WHO Bi-regional Meeting on Technical Cooperation Among Countries VCAC) involving the South-East Asia and Western Pacific Regions was held in Kuala Lumpur in December 1994. The issues discussed related to the broad areas of drug quality assurance with a focus on current good manufacturing practices (GMP) in the production of pharmaceuticals, drug analysis, drug safety evaluation and the use of the WHO Certification Scheme. Human resources were given special consideration in the development and .- strengthening of the various programme areas. SEAR0 and WPRO are actively involved in providing assistance in the formulation and implementation of the ASEAN technical cooperation project in the field of pharmaceuticals. Starting from Phase IV of the project covering the period 1992 to 1996. DAPMQ has been supporting it technically and financially, as an interim arrangement, while assistance from the former supporter of the project, UNDP, and voluntarily donated funds are being sought. present activities of the programme include training of GMP -- The Work of WHO in SEA 74 inspectors/auditors, strengthening of quality assurance, drug I evaluation, production and utilization of regional standards and reference substances, clinical pharmacy and improvement of , communication skills of pharmacists and pharmacy staff. standardization, quality control and utilization of herbal medicine and exchange of information on drug regulatory matters. ASEAN Working Group Meetings were held in Jakarta in December 1993 and in Kuala Lumpur in December 1994 to review the progress of the programme, both in technical and financial terms, and to formulate work plans for the ensuing year. Rational use of drugs (RUD) has been receiving special attention in the Region. Regional and national strategies have been identified to promote RUD. Myanmar was specifically assisted in the application of RUD. Availability of essential drugs for primary health care is an important target of the health-for-all strategy. WHO has been strengthening the supply and logistics of essential drugs through support to the management systems of drugs at central and peripheral levels, including storage and distribution. One of the strategies for improving the management system is through computerization, which IS being assisted in several countries such as Bhutan, Maldives, Mongolia. Myanmar, Nepal and Thailand. This not only provides information on management of drugs but is also important in planning, procurement, recording and reporting of activities and budgetary control. The acute shortage of essential drugs in some countries necessitated mobilizatiion of resources for their procurement. The Mongo\emirnpex in Mongolia and nine townships of rural Myanmar were supplied with essential drugs purchased with extrabudgetary funds. WHO has been assisting in the development of regional and national Drugs and mechanisms for quality control and quality assurance of essential Vaccine drugs and vaccines. At the regional level, the three WHO Collaborating lit^, Centres for Qual~ty Assurance of Essential Drugs and the three centres for training and the testing of vaccines used in EPI are Safety and instrumental in promoting the quality of pharmaceutical products. Efficacy National centres for quality control of essential drugs are being strengthened in several countries. -- -- - Dlagnostlc ~herapeut~cand Rehabllltat~ve Technology 75 The Japan Pharmaceutical Manufacturers' Association (JPMA) has been collaborating with SEAR0 since November 1993 in the development, production and use of drug reference substances, ' donation of pharmaceutical books and acceptance of technical trainees from SEAR for training in JPMA-member companies in the area of quality control of pharmaceuticals. The WHO certification scheme on the quality of pharmaceutical products moving in international commerce is an effective mechanism for ensuring the quality of drugs and vaccines. The applicability of the scheme was assessed by DAPMQ in all regions of WHO, except the European Region. In SEAR, theassessment was carried out in Myanmar : and Sri Lanka as importing countries. The evaluation of the application of the scheme was canied out in India as an expohng wuntry. The use of the scheme provides information to importing countries about the licensing status of a pharmaceutical product in the exporting wuntry, the manufacturer's good manufacturing practices and the quality of individual batches of imported products. The exporting agency shares the responsibility for the quality of the products by providing * technical information, through its national authorities, to the importing wuntry. The scheme thus helps to ensure the quality of pharmaceutical products moving in international commerce. The scheme is being promoted for wider application in the Region. Traditional 1 Traditional medicine (TRM) is ingrained in the cultural and social fabric Medicine : of SEAR wuntries. WHO has been assisting Bangladesh, India. Indonesia. DPR Korea, Mongolia, Myanmar, Nepal and Thailand in strengthening the national TRM programmes with emphasis on the training of traditional practitioners in the promotive and preventive aspects of traditional medicine for primary health care, quality control -c : of traditional drugs and standardization of their raw materials, strengthening of pharmawgnosy, phytochemistry and pharmacology. It has also assisted in the preparation of herbaria in order to improve ! the preventive, promotional and curative properties of TRM. Rehabilitation Epidemiological assessment of various types of disabilities and i identification and adoption of appropriate approaches and technologies for their prevention and rehabilitation continued to The Work of WHO in SEA 76 receive attention during the reporting period. Promotion of community-based rehabilitation (CBR), training of various health personnel in CBR, production of lowcost prosthetic and orthotic - appliances and the development of referral service networks were the main focus of WHO collaborative activities in this field. Support was provided to Bangladesh, Indonesia, Sri Lanka and Thailand in the organization of training workshops, development of baseline data, strengthening of rehabilitation centres and development of rehabilitation networks. - - Diagnost~c, Therapeutic and Rehabilitative Technology 77 lmmunization During the 1993-1995 biennium, there has been a dramatic expansion of disease-reduction activities in the countries of the Region. Immunization coverage in the Region as a whole has been sustained at 80 per cent (Figures 3 and 4). However, concern has begun to be voiced regarding the maintenance of this percentage of coverage at country and sub-national levels, since, in some * countries, there has been a drop in coverage recently. WHO continued to give priority to increasing immunization coverage in all areasldistricts within the countries. I Figure 3. Immunization coverage in SEAR, 1988-1994 Flgure 4 Reported immunization coverage, 1993-1994 South-East Asia Region 100 I 60 40 ~ 20 I 0' lMN BilU liPHK IND IN0 MAY MOG MMR NFP SHl Tl(4 SEA EPI target diseases oontinue to show a declining trend in incidence in the Regron (Figure 4). In regard to poliomyelitis, this trend can very largely be attributed to the results of the programme in India. An analysis of the trend of reported cases of poliomyelitis suggests that perhaps India has now reached a national level of control where the occurrence of paralytic poliomyelitis is predominantly endemic rather than epidemic (Figure 5). This finding strongly supports the Government's decision to conduct an All-India National Immunization Day for polio eradication in December 1995. While Thailand and Sri Lanka have been consistently monitoring and evaluating poliomyelitis surveillance indicators, the other countries are currently taking steps that will significantly enhance the sensitivity of acute flaccid paralysis (AFP) reporting. In 1993. the SEAR Poliomyelitis Laboratory Network, consisting of 11 laboratories, processed approximately 2000 stool specimens. There is a critical need to expand and improve public health laboratory services for the eradication of poliomyelitis in the Region. It rs estimated that half a mill~on deaths from newborn tetanus are prevented annually in the Reg~on, through tetanus toxo~d Disease Prevention and Control 79 I @po,#o NNT Meaiies ! Figure 5 Reported cases of paralytic poliomyelitis, neonatal tetanus and measles, SEAR, 1987-1994 Figure 6. Reported poliomyelitis cases by month, India, January 1992 -December 1994 .. 0 Jan feb Ma, @r May Jun Jul Aug Sep OQ Nov Dnc Saws Gmmmm1 a1 InW - The Work of WHO In immunization of pregnant women and women of childbearing age, as well as clean delivery practices. The reported and estimated : data suggest that Bhutan, Maldives, Mongolia, DPR Korea, Sri Lanka 2 and Thailand may already have achieved the neonatal tetanus elimination goal of less than 1 case per 1000 live births in all , districts (Figure 7). Other countries, such as lndia, lndonesia, Bangladesh and Nepal, have accelerated their activities for neonatal tetanus elimination by the identification of high-risk areas, tetanus toxoid immunization of women of childbearing age and pregnant women in those areas, and the promotion of clean delivery practices. The high-risk area approach has been promoted in all the countries and is considered to be critical for the elimination of neonatal tetanus in the Reg~on Immunization with an overall coverage of about 80 per cent of infants has significantly contributed to the control of measles. There is a declining trend in the number of measles cases. It is estimated that 22 million cases of measles are prevented and 700 000 measles-associated deaths are averted annually in the Region. The countries are controlling measles by increasing routine immunization coverage and by adopting the high-risk approach to identify and immunize children not previously reached (eg. large urban agglomerates with pockets containing unimmunized children). This approach has been implemented in lndia (such as in the State of Delhi). In order to reduce mortality, countries have implemented clinical case management of measles as a part of outbreak response. Hepatitis-B vaccination has been implemented in phases as part of the EPI services in Indonesia, Mongolia. Maldives and Thailand. In view of the relatively high cost of HE vaccine, other countries are not yet in a position to use the vaccine because of lack of financial sustainability in the long run. Given the progress made so far, efforts to eliminateleradicate neonatal tetanus and poliomyelitis and to bring about a significant reduction in measles, diphtheria, pertussis and child tuberculosis cases must continue. Routine immunization services must be improved and achievements sustained. Further resources will, of : course, be required and the international community must come forward to assist in the spirit of human solidarity. Disease Prevention and Control 81 Figure 7. Neonatal tetanus in SEAR, 1993 I < Estimated Rate 1 1000 Live Births 1 Is $0 6.5 6.6 ond 0-r. Reported Rate 1 1000 Live Births I 82 The Work of WHO in SEA During 1993-1995, the Regional Oftice organized a number of meetings and workshops and provided technical support to the countries. It also mobilized financial and moral support from the ' international community at large and voluntary organizations in particular. Many of these organizations contributed generously to the eradication of poliomyelitis and other preventable diseases. With technical support from WHO, stratification of malarious areas has been carried out by all the malarious countries in the Region to facilitate cost-effective and selective vector control in highly endemic areas. Training of staff in the control of dengue and Japanese encephalitis and the integration of filariasis control programmes into other vector control activities, with community participation. also received support. Since 1993, integrated vector-borne disease control has been conducted in those areas of India. Bangladesh and Nepal where kala-azar continues to be a health problem. In 1993, there were about 3 million reported malaria cases in the Region. Overall, the malaria situation has remained somewhat static for the last ten years, with the reported case incidence ranging between 2.5 and 3.0 million cases. The proportion of Plasmod~um falciparum malaria went up to 41.4 per cent of total malaria cases in 1992 but came down to 39.7 per cent in 1993. During 1993, the slide positivity rates in the Region ranged behveen 2 and 4 per cent except in Myanmar (I6 per cent). Sri Lanka (24.4 per cent) and Bhutan (35.9 per cent). The proportion of Pfalciparum was highest in Myanmar (84.9 per cent) followed by Thailand (59.2 per cent) and Sri Lanka (22.5 per cent). In the remaining countries (except Nepal), it varied from 13 to 15 per cent. The malaria profile in the countries of the Region is shown in Figure 6 and Table 7. The malaria s~tuation in forest and forest-fringe areas has remained serious owing to highly efficient vectors, multiple-vector transmission, prolonged transmission seasons and drug-resistant P.falciparum malaria combined with large-scale and uncontrolled population movements. P. falcfparum resistance to various antimalarials still constitutes one of the main technical problems in Disease Vector Control Malaria . - .. Esease Prevention and Control 83 Figure 8. Malaria profile of South-East Asia Region Thousand 4000 1 (11 . The Work of WHO in SEA Table 7. Malana pmhle of South-East Asia Region -- -- D~sease Preventon and Control -~ - - - - 115 660 6.03 51 775 44.76 125 361 768 54 954 43.84 165 102 10.40 81 027 49.08 ~~ ~~ ~ ~ ~ ~ 355 28 900 39.06 14 092 48.76 363' 28 116 35.93 12 943 46.03 370' 38 901 39.93 15 998 41 12 .. - 2 125 826 2.69 879 383 41.37 2 207 431 2.84 852 763 38.63 2 222 869 2.99 836 432 37.63 . ~ ~- ~~ 13 715 0.18 6 935 50.57 21 559 0.37 11 433 53.03 ... ... ... ... - 231 25' 0.07 7' 28.00 238 29' 011 5' 17.24 246 16' 0.07 2' 12.50 . ..... Myanmar 1992 38 633 125 710 1400 106 695 84.87 39 653 117 068 1595 99 404 84.91 94 527 17 75 78 951 83 52 ~~ ~ . - ~~.~ ~~ 1992 12 120 23 234 321 2 954 12.71 Sn Lanka ~ Thailand - SEAR -. .~ ~~ NOTES: Figures for 1994 are provisional F~gures m shaded area relate to Java and Bali only. = Data not available. 'Mid-year estimates of people living in rnalarious region. b~rojected from last year. Clrnported cases dlncomplete data for 1994 1993 12 355 1994 ' 12 622' -~~.~~ 16 380 9 442 2.75 2.20 1992 1993 1994 1992 1993 1994 . . 1992 25.62 24.44 19.96 1 540 1 087 - 13 900 14 081b 14 ~64~ 43 536 43 942 44601b 1 147 749 9.40 11.51 82 675 73 532 46 986 ~ ~ ~ ~.. 399 349 327 020 273 434 168 370 115 220 102119 .. 3 000 789 20.70 22.49 17.18 .~ 57.84 59.25 55.89 41.39 3.02 2.38 2.15 3.18 97 389 68 270 57073 1 241 905 malaria control in the countries of the Region. The foci of P.falciparum malaria resistant to various antimalarials have been gradually spreading in all the malarious countries and the degree of resistance i has been increasing from SlRl to RII and RIII. ++ There are some 25 Anopheline species known to be primary or secondary vectors of malaria in endemic areas. Of these, six species have major operational implications for disease control. However, only Anopheles culicifacies is resistant to DDT and malathion and Anaconitus is resistant to DOT. Other administrative and operational constraints to the control of malaria include inadequate national budgets, fluctuations in budget allocation, acute shortages of trained personnel, uncontrolled large-scale population movements, lack of intersectoral collaboration and community participation, and excessive delays in reporting from the periphery to the centre as well as irregular feedback from the centre to the periphery. Since the endorsement of the Global Malaria Control Strategy - (consisting of early diagnosis and prompt treatment, selective and sustainable preventive measures, prevention and control of epidemics and regular assessment of the programme management) by the Ministerial Conference on Malaria held in Amsterdam in November 1992, collaboration between the Regional Office and the eight Member Countries where malaria is a problem has been accelerated. Greater support and technical guidelines, i.e. training at regional level, country programme assessment and country working groups, have been provided for the implementation of the Revised Malaria Control Strategy. As recommended by the Regional Working Group Meeting on Malaria held in March 1993, WHO also extended technical support for carrying out critical reviews of the * malaria situation and malaria control activities in Bangladesh, Indonesia, Maldives, Myanmar and Nepal. It actively collaborated in country working group meetings to implement the Revised Strategy in Bangladesh, Bhutan, Indonesia, Maldives, Myanmar, Nepal, Sri Lanka and Thailand. With the active collaboration and support of the Regional Office, all the malarious countries have completed their country reviews of the malaria situation and have adopted the recommendations of the Country Working Group on Revised Malaria Control Strategy. Most of them have started implementing the revised strategy. -- .. - -- 86 The Work of WHO In An lntercountry Consultative Meeting to review the progress of implementation of the Revised Malaria Control Strategy was held in the Regional Office from 20 to 24 March 1995. The central theme 'of the meeting was the operationalization of the recommendation of the Country Working Group on the control of multidrug-resistant malaria, through coordinated control programmes among the countries and with the support of the Regional Office. WHO continued to provide support to the nine malarious countries for: external assessments of their national malaria control programmes; organization of national workshopslseminars; planning, implementation and evaluation of control activities; and carrying out drug-sensitivity tests and other operational field studies. Increased emphasis is now being placed on the development of capabilities in applied research methodology with particular reference to stratification, epidemiology of severe and drug-resistant Pfalcipawm malaria and its control, clinical trials of new drugs, insecticide-impregnated bednets, evaluationloutput parameters and indicators for measuring the dynamics of the disease in the populations, and early warning systems for impending epidemicsloutbreaks. The Region has also initiated the revival of the Regional Collaborative Programmeon Drug-resistant P. falciparum. Situational analyses of the status of Pfalcparum drug resistance have been completed in all the malarious countries. Detailed plans have also been made for carrying out operational field research, as well as a programme management and reporting system for the prevention and control of drug-resistant malaria. Preparations have begun for launching a BI-regional Collaborative Programme on Drug-resistant Malaria jointly with the Western Pacific Region. Many international agencies continued to support the malaria control programmes in the Region. The World Bank has granted a credit of US$.6.4 million to Bangladesh for Integrated Control of Vector-Borne Diseases (ICOVED). The Bank is also providing US$100 million for five years (1989190-1993194) for the improvement of the health infrastructure, including malaria control, in Kalimantan and Nusatenggara Barat (NTB) in Indonesia, while OECF Japan is providing a grant for malaria control. UNDP is providing Myanmar with US$ 1.6 million for reducing malaria morbidity and mortality through upgrading infrastructure and increased community - Dlsease Preventlon and Control participation. DANIDA and Japanese Debt Relief Fund supported : Nepal with US$0.8 million and US00.4 million, respectively, for malaria control activities. 7 Parasitic India, Nepal, Sri Lanka and Thailand have carried out programmes Diseases for the mass treatment of children in highly infected areas. Significant progress has been made in Indonesia, which has taken steps for the mass stool examination and treatment of school children for Intestinal Parasitic intestinal parasitic infections (IPI). Infections A WHOMlorld Bank pilot project for the control of intestinal parasitic infections has started in Bangladesh. Technical support has been provided for the training of project staff, development of methodology, and the monitoring and evaluation of activities. WHO supported national workshops, seminars and training courses on intestinal parasitic infections in various countries and provided necessary supplies and equipment. A project proposal for the control of IPI in Maldives has been prepared for donor support. * ViSceral Since 1987, kala-azar has been a major health problem in the rural Lei~hmaniasis areas of the States of Bihar and West Bengal in lndia as well as (Ka'a-Azar) in Bangladesh and Nepal. Approximately 75 million, 30 million and 5.3 million people respectively live in kala-azar-affected areas in these countries. Table 8 shows the number of kala-azar cases and deaths in Bangladesh, lndia and Nepal during the period 1981-1994. WHO organized a consultative meeting on visceral leishmaniasis (vL) in July 1993 to formulate guidelines for the prevention and control of the disease. As a result of the implementation of the control strategy on VL in lndia in 1993, a decline in the incidence of VL cases and deaths was seen during 1993-1994. In Bangladesh and Nepal, some progress has been made in the control of VL through its integration with the vector-borne disease control programmes. WHO supported national training courses for medical officers on clinical and laboratory diagnosis, treatment and reporting of VL cases. Support was also provided for seminars on VL with specific reference to vector control. The Organization's assistance also included the procurement of drugs for treatment. aa The Work of WHO m SEA Lymphaticfilariasis persists as a public health problem in Bangladesh, Filoriaris India, Indonesia, Maldives, Myanmar, Nepal, Sri Lanka and Thailand. A recent assessment of available information shows that in lndia alone there are an estimated 36 million microfilaria carriers. Table 8. Visceral leishmaniasis in Bangladesh, lndia and Nepal, 1981-1994 WHO'S operational research projects in lndia, Indonesia and Thailand facilitated development of new control strategies for lymphatic filariasis infection and diseases, which were formulated at a WHO Consultative Meeting held in Penang, Malaysia, from 22 to 24 August 1994. WHO continued to provide technical support to endemic countries for the development of integrated control of the disease with community participation. Schistosomiasis is endemically present in Nepal, the Besoa Valley Sthistosomiosis of Central Sulawesi. Indonesia, and in very limited areas of Thailand. It has shown a downward trend in prevalence due to multipronged interventions, including chemotherapy. ' WHO has been supporting annual meetings of the Task Force on Guineaworm Guineaworm Eradication in lndia. The meetings held in 1994 and Disease 1995 recommended a strategy to bring down the incidence of the (Dr"unmQliasis) =In,amatlOnnola"alala 'JanUaySaplsmbLi ~ Disease Prevention and Control 89 Nepal Cases Deaths ~~--lT 442 291 446 34 870 56 1 395 1 500 .., 1 200 ... .. India p~ ~- ~ . Bangladesh . Case* 22 34 489 739 57 742 61 670 77 101 44 844 22831 ~ - year - Case6 -~ Deaths --pF 497 606 838 1 419 709 349 ~. - Deaths 1987 1988 1g81-8f~~~ 1989 2 548 526 ' 1990 3 334 1991 3 039 1992 6 818 1993 6 030 1994 5 800' ~ .. ~~- Tropical Diseases Research disease to zero by 1995. WHO supports epidemiological surveillance in the guineaworm-endemic states of lndia under the National Guineaworm Eradication Programme. During the period under review, collaboration with the Tropical Diseases Research (TDR) Special Programme continued and the Regional Office extended support in promoting research capability strengthening in six Member Countries of the Region. There was a total of eleven projects (including long-term institutional grants, short-term institutional grants, programme-based grants and the TDRlRockefeller grants), and two new grants were approved for funding in 1993 - one for linkage between Myanmar. Sri Lanka and Thailand, and one partnership grant. The linkage grant involves collaboration between institutions within the Region, and the partnership grant helps promote collaborative arrangements between institutions in both developing and developed countries. Another new initiative is a small grants scheme for improvement of the use of antimalarials in the South-East Asia Region. In this regard, a total of four grants were approved for this region. Further, thirteen research training grants were approved. Site visits were undertaken to six countries, mainly for monitoring and follow up of on-going projects, and for initiating the promotion of research capability strengthening in one country. Two new collaborative research projects were initiated in the Region. A three-centre study was carried out for the field evaluation of an antigen dip-stick test for falciparum malaria. This joint activity was funded by TDR and SEARO. Another ioint research proiect on leishmaniasis involving three countries was started; this is also a joint TDRICTD HQISEARO activity. A total of eighteen research projects were funded in 1993 by the TDR Special Programme. = In the area of research capability strengthening, a total of thirteen projects in Thailand, Nepal, Myanmar, lndonesia and Sri Lanka were approved for funding in 1994. In regard to research and development, 29 projects were approved in 1994, out of which 21 projects were awarded to lndia, four to Thailand, two to Sri Lanka, and one each to lndonesia and Myanmar. Major programmes supported through this effort were in the fields of filariasis, leprosy. leishmaniasis and malaria in countries such as lndia and lndonesia. -- 90 The Work of WHO in SEA * The objective of the Regional Control of Diarrhoea1 Diseases (CDD) C0ntr0l of Programme is to reduce mortality, morbidity and malnutrition caused ! Diarrhoeal by diarrhoea1 diseases. Towards this end, the Programme assists Diseases national CDD activities in promoting standard case management at " home and at health facilities so as to prevent diarrhoea-associated deaths in the most efficient manner. The current status of selected indicators together with the targets for 1995 and 2000 are presented in Figure 9. Access to ORS has been increasing steadily; by the end of 1995 it should reach the mid-decade goal of 85 per cent. In addition, training rates for supervisory and clinical management staff should have reached the target of 40 per cent by the end of 1995. CDD programme activities may be divided into operations. planning, training, communication and evaluation. The operations are carrted out by a reglonal staff of four - a team leader and a techn~cal officer supported by two general servlce staff In addlt~on, the CDD and ARI programmes share the cost of two med~cal officers, one posted in Bangladesh and the other In Figure 9. CDD programme status of selected indicators and targets for the years 1995 and 2000 I 90 Case management ralc" Manqlld nf home !illpBcVSO!y iklls" 0 70 40 60 MI1 100 ~ . Disease Prevention and Control Indonesia, and an associate professional officer in Nepal. It is planned to assign two more associate professional officers, one each in Bangladesh and Myanmar. The production or import of ORS reached 121.5 million litres in 1994, and nine out of the eleven 9 countries in the Region now produce the major part of their requirements locally. Regarding planning, by July 1995 all the countries had well established CDD programmes and had implemented plans of action, most of which have been revised. As for training, WHO has continued to develop and distribute useful training materials to assist the Member Countries' national CDD programmes in providing health workers high quality "hands on" training in the clinical management of diarrhoea. It has supported the establishment of 133 diarrhoea training units (DTU) located at major hospitals and medical colleges in nine countries of the Region. In 1994, at least 320 five-day clinical management courses were held in theseDTUs. In addition, one intercountly Clinical Management Course was held in New Delhi to train prospective DTU directors in establishing new units in their respective countries. The other training courses organized in the Region are shown in Table 9. Table 9. Courses in diani~oeal disease control Country -- Bangladesh Bhutan OPR Korea India Indonesia MaldNes Mongolia Myanmar Nepal Sri Lanka Thailand 92 The Work of WHO in SEA Management Cllnlcal ---- of tralnem - - X X X X X Cllnlcal management .-. .. -- - - X X X X X X X X WHO has developed the package "Strengthening the Teaching " i of Diarrhoea1 Diseases in Medical Schools" (MedEd) to help medical schools upgrade their curricula and improve the theoretical and practical knowledge of medical students in respect of the management and prevention of diarrhoea1 diseases. By July 1993, Indonesia, the first country to hold a medical education workshop, : had completed an evaluation of the participating schools. During 1993-1994, similar MedEd workshops were held in Bangladesh and Myanmar, where heads of departments and key medical educators from these countries and Nepal revised their curricula. Regarding evaluation. WHO has developed three major tools for the evaluation of CDD programmes: the Focused Programme Review, the Household Case Management Survey, and the Health Facility Survey. In 1993-1994, a focused programme review was conducted in lndonesia and similar reviews are planned for Mongolia and Myanmar. Household surveys were completed in lndonesia and Myanmar, and a survey is planned for Bangladesh. Health I facility surveys were conducted in lndonesia, Myanmar and Nepal, and a diarrhoea mortality survey was completed in Bangladesh. Since the end of 1992, when a new strain of V~brbrro cholerae 0139 (Bengal) was discovered in outbreaks of diarrhoea in India and Bangladesh, additional cases have been identified in Bangladesh, India, Myanmar, Nepal, Sri Lanka and Thailand. WHO has assisted governments in carrying out further laboratory ' characterization, and is also supporting the production and supply of 0139 antisera (used for isolating the new strain) available in the Region. In the meantime, the Regions\ Office has advised Member Countries to report all cases of both V. cholerae 0139 and V. cholerae 01 as cases of cholera. According to WHO'S estimates, ARI and diarrhoea together account for 60-70 per cent of the visits of sick children to health facilities in most developing countries. Each episode of infection contributes to malnutrition and when episodes of infection are prolonged, their negative impact on growth is increased. Bangladesh, India, lndonesia and Nepal together account for about 40 per cent of the global mortality caused by ARI. At least seven countries in the Region continue to have infant mortality rates (IMR) exceeding 4011000 live Acute Respiratory Infections (ARU Disease Prevention and Control 93 i births. The case-fatality rates among children who are hospitalized 1 continue to be high in the countries of the Region. For these 3 reasons, all the countries with high IMR, as well as Sri Lanka and 1 Thailand, have established national ARI control programmes. ~* The main objective of the Regional ARI control programme is to assist the Member Countries in reducing the mortality and morbidity resulting from ARI in children under the age of five years. Standard case management is the central strategy to achieve the objective of reducing the mortality. For prevention, immunization by the vaccines included in the EPI programme is emphasized. The ARI programme maintains a regional staff of hvo -a medical officer and a secretaly. In addition, it shares with CDD the cost of medical officers in Bangladesh and lndonesia and an associate pmfessional officer (APO) in Nepal. Additional APOs' positions with job descriptions covering both CDD and ARI are pmposed in Bangladesh and Myanmar. All the 10 countries with an ARI programme have allocated funds for the control of ARI separately or as a part of * communicable-disease control efforts or child survival activities. In all the countries, the programme continues to receive technical and other assistance from WHO, which collaborates with UNICEF and other international organizations, including the World Bank. Collaboration with national and international NGOs was initiated in Bangladesh, lndia and Nepal during 1994-1995. Bangladesh, Bhutan, lndia and Nepal have revised the technical guidelines for ARI. The control efforts are being progressively integrated with the child survival programme or communicable disease control in lndia, lndonesia, Myanmar and Nepal. In other countries, action has been initiated to combine the ARI and CDD programmes in accordance with the national policy. After the completion of the training of national programme managers, the emphasis is now on the training of programme managers at the district and provincial levels. Training courses were organized with WHO support in Bangladesh, Bhutan, lndonesia and Nepal. It is now proposed to undertake combined CDDIARI training of programme managers. In Bangladesh, since the CDD programme coordinators at the district level are also responsible for the monitoring and supelvision of the ARI programme, they have been given training 3 I in this task. The national policy in Mongolia and Thailand is to ; support the introduction of standard case management in the 94 The Work of WHO in SEA pre-service training of undergraduates. Similar efforts are being made in Bhutan and Nepal. Training of the doctors and health workers responsible for the treatment of children with ARI visiting first-level health facilities and small hospitals has been given priority. All the countries have adapted and translated the required range of training materials and are using them in the programme. They have also expanded the coverage of training in standard case management of ARI (Table 10). In addition to the achievement of training targets, the programme lays stress on the quality of training. For this purpose, the training of trainers was undertaken, with WHO assistance, in Bangladesh, India, Indonesia, Maldives, Mongolia. Nepal, Sri Lanka and Thailand. Training units have been established in Bangladesh, Mongolia and Thailand. The monitoring of training courses has been initiated and the follow-up supervision is being increasingly incorporated in the programmes. Table 10. Summary of training in the control of ARI in Member Countries ~ ~~-~~~~ ~. ~ Programme ~ -- ~p~ .... Bangladesh lndla 1 875 4 673 lndones~a 4 470 5 637 19 404 Maldives Mongolia - 425 500 - Myanmar - 1 400 977 Nepal 40 1 359 734 Sri Lanka 12 899 1 119 - Thailand 53 2 000 16 000 30 000 ~ ~- ~~ -. Total 543 10 100 31 123 53 362 Source: Estimates based on Countty Programme Profiles received from SEAR countries -- -- Dlsease Preventton and Control 95 Tuberculosis To extend the impact of the programme to difficult and unreached areas, meetings were organized with NGOs in Bangladesh and Nepal. The programme is beginning to combine the training in CDD and ARI. In India, Indonesia, Myanmar and Nepal, it is proposed 7 to integrate the management of the sick child through the sick child initiative or child survival projects. For long-lasting results, training in standard case management has been introduced in pre-service settings. The ARI standard case management has been introduced in the training of auxiliaries in Bhutan, and in a medical school in Nepal. The curriculum for the training of nurses was revised in Thailand. Changes in the curriculum of undergraduate medical students are being made in Mongolia and Thailand. In order to secure endorsement of the programme and to seek the advice of paediatricians and professionals, support was provided for organizing national and international meetings. Seminars/symposia on ARI were supported in Bangladesh, India. - Mongolia. Myanmar and Thailand. The WHO ARI control programme has finalized the survey instruments on household survey, health facility survey and focused ethnographic studies. Two health facility surveys were carried out in Thailand, and similar surveys are proposed in Bangladesh. lndonesia and Mongolia during 1995. A mortality survey is in progress in Myanmar. Focused ethnographic studies were carried out in Mongolia. Focused groups were organized in Myanmar and Thailand to strengthen the communication messages. Studies on bacterial drug resistance were completed in Thailand. Similar studies are proposed to be initiated in Bangladesh in collaboration with the Shishu Hospital and the International Centre - for Diarrhoea1 Disease Research. Studies on indoor air pollution are in progress in Nepal. The burden of tuberculosis in the Region is immense. The estimated incidence of new tuberculosis cases for 1995 is 3.5 million, which represents about 50 per cent of the global burden of the disease. It includes 2.3 million new cases in India, 0.5 million in Indonesia, and 0.4 million in Bangladesh. An estimated 1.2 million people will p~ 96 The Work of WHO in SEA ,. die of tuberculosis in the Region in 1995 - nearly 50 per cent of all deaths from tuberculosis world-wide. The co-epidemic of TBIHIV will cause substantial numbers of deaths during the next ten years. : Inappropriate control measures in the past have resulted in a high j number of treatment failures and chronic cases with multid~g resistance. Available information suggests that cure rates range from 20 per cent to 40 per cent in most countries of the Region. In response to the above challenges, WHO continued to provide technical assistance and support to Member Countries, mainly in the areas of internal evaluations; review and revision of plans of action; training activities, and providing financial support for control efforts. Regional and national training workshops, based on the WHO modules for "Management of Tuberculosis at the District Level", were held so as to prepare skilled trainers at the national level. Since then, many countries have initiated such training. With the assistance of WHO, Indonesia, Nepal and Thailand have carried out reviews of their national tuberculosis programmes. India, Indonesia, Nepal, Bangladesh and Sri Lanka now have national plans for tuberculosis control and have developed operational manuals based on the revlsed strategy. Bangladesh, India, Indonesia and Nepal have established pilot projects based on the WHO strategy. Technical discussions on the resurgence of tuberculosis were organized during the 47th session of the WHOISEA Regional Committee in August 1994, and were followed up at the 43rd Meeting of the Regional Director with the WHO Representatives in November 1994. A workshop was held in April 1995 to develop a drafl "Strategic Plan for Tuberculosis Control in the South-East Asia Region, 1995-2000". An Intercountry Meeting of National Tuberculosis Programme Managers in the South-East Asia Region was held in Thailand in June 1995 to review the WHO global policy and strategy for tuberculosis control, review the development and management of NTP in Member Countries, finalize the above-mentioned draft document on the Strategic Plan, and develop a plan of work for its implementation. Several constra~nts limit the rapid expansion of the revised strategy for tuberculosis control. Solutions to address such problems ~nclude government commitment, intensification of passive case detection based on sputum smear examination, establishment of a laboratoly network, standardized short-course chemotherapy. - . . . - - - -- -- -- D~sease Preventton and Control 97 Leprosy continuous and uninterrupted drug supply, training, supervision. monitoring and evaluation. Other issues that need attention are advocacy, a coordinated policy for TBMIV, tuberculosis control in urbanlperi-urban areas, cooperation with NGOS and the private * sector, and operational research. Since the introduction of multidrug treatment (MDT) more than ten years ago, the leprosy situation in South-East Asia has improved. although the Region still accounts for about 65 per cent of the global caseload. The percentage of registered cases covered with MOT in the countries in 1994 was 54, while the prevalence rate was 8.5110 000 population - higher than in any other WHO region. An Intercountry Consultative Meeting of Leprosy Programme Managers was held in February 1993 in the Regional Office to develop guidelines for updating national strategies and plans of action. Another consultative meeting was held in November 1994, with the objective of finalizing practical and acceptable national - plans of action for the period 1995-2000 towards attainment of the goal of leprosy elimination by the year 2000, or earlier. In response to a recommendation of the Intercounty Consultative Meeting of Leprosy Programme Managers, held in Bali in November 1994, that "It is highly important that accessibility to MDT further improves particularly in the high leprosy-endemic countries of Bangladesh, India. Indonesia. Myanmar and Nepal through extension of MDT coverage to 100 per cent of the geographic area", a series of donors' meetings have been held in the countries to obtain NGOs' commitment in respect of assistance and cooperation in accelerating leprosy elimination by covering 100 per cent of the geographical area with MDT by the end of 1995, and to reach the global target by the year 2000. The International Conference held in Hanoi, Vietnam, in July 1993, ~nter aha, recommended creation of a Steering Committee on Special Action Projects for the Elimination of Leprosy (SAPEL). The Steering Committee held its first meeting in January 1995 to discuss the purpose and the working mechanism of SAPEL. The objective of SAPEL, which is a part of the global plan of action for the elimination of leprosy as a public health problem, is to identify special situations and areas requiring rapid action towards leprosy -- 98 The Work of WHO in SEA Environmental Health The main aim of community water supply and sanitation programmes is to ensure that safe water and adequate sanitation facilities are made available to the people. Health Laboratory Services Health laboratory servlces play a crucial role in epidemiological surveillance and in supporting PHC programmes in the Region, WHO collaboration in this area is focussed on strengthening these services. Essential Drugs A major thrust of the essential drugs programme in the Rcg~on is on assurlng the provlslon of safe and effective drugs of good quality and ensurlnq their rational use. Sfrengthenlng of quality assurance systems ?*.I manpower development are the other priority areas ofw~o,s collaboration. Leprosy Leprosy is an important public health problem in the Region, accounting for more than half of the estimated cases in the world. Through efforts at early detection and rapid implementation of the standard multi-drug treatment regimen, however, significant improvements have been noted and the Region is confident of achieving the target of elimination of leprosy by the year 2000. Malaria Tne malar a stt..at on n tntx Regton is be~nq c osrly mon tored w lh tne h gt. ncloence of falctparum ma ar a causing nor nus concern Tlv rev.sPrl maoarma-confro slratrqles nr .!d? sfralrfcnt on of ma artot.s areas. 1,r;ll ng pos I ve cases dlagno-ec! cl ncal y and by laboralow trstlng. -s ng new trcnn q.m -4- -.-. . . s-cn as permethr n.treal~rl oel nets ana slronqrhrntnq corllro act v I ps . ellmlnat~on, and to develop and Implement lnnovatlve and feas~ble strategles ! Leprosy elimination programmes are beginning to have an i impact on the problem in Bangladesh. India, Indonesia, Maldives. Myanmar and Nepal, thanks to MDT, international support and funding. WHO'S technical cooperation, and the coordinated efforts of governments. NGOs and others. While lndonesia expects to eliminate leprosy by 1996, lndia, Myanmar and Bangladesh expect to attain this goal only by the turn of the century. Maldives. Bhutan and Nepal are also advancing towards the goal. Sri Lanka and Thailand are now in a position to implement postelimination strategies and concentrate on pockets of prevalence. During the period under review, countries in the Region received Zoonoses WHO assistance in their efforts to launch measures for the prevention ': and control of rabies, anthrax, toxoplasmosis, brucellosis. : cysticercosis, food-borne diseases and plague. WHO provided support through consultants, supplies and equipment, training health personnel and organizing national workshops on rabies control programmes and on zoonotic diseases in lndia, lndonesia. Nepal. Sri Lanka and Thailand. Large-scale dog vaccination programmes are being carried out in lndonesia, Sri Lanka and Thailand. WHO provided fellowships to two Mongolian officials to study brucellosis control in Kazakhistan and to one from lndonesia to study rabies control in Canada. Some steps for the effective preventlon and control of anthrax, toxoplasmosis, brucellos~s, cystlcercos~s and food-borne dlseases have been taken Seven countries of the Reglon produce more than 50 m~lllon ml and 100 million ml of nervous tlssue vacclne (NTV) for human and anlmal use respect~vely Durlng the last 3-4 years, WHO has prov~ded support to Indla, lndones~a and Thalland in the development and product~on of cell-culture vacclne Disease Prevention and doitrol 99 Plague During the period under review, lndia. Myanmar and Mongolia reported cases of plague. During 1994, Mongolia reported 19 cases of bubonic plague and Myanmar reported six. No death was reported by either country. i Between 1967 and 1993, lndia did not report any case of human plague. The 1994 outbreak of plague in lndia started in Mamla village in Beed district of Maharashtra State. In this village, rat-fall was reported on 5 August 1994 followed by reports of flea nuisance. On 26 August, thirty-three patients with lymphadenitis were reported. During September and October 1994, suspected bubonic cases were reported from other villages of Beed district and some other districts of the State. A total of 3701 clinically suspected cases (including 596 presumptive cases, i.e with positive serology) of bubonic plague (without any death) were reported. The last case of bubonic plague occurred in Beed district on 2 October 1994. The patient was isolated, cured and discharged on 7 October. The outbreak of acute respiratory illness characterized by fever, -. cough, haemoptysis and pneumonic infiltration seen in radiographs, occurred in Surat, Gujarat State. in September-October 1994. This infection occurred with greatest frequency in young adults. It did not respond to treatment with penicillin, but responded well to tetracycline. The case fatality was high during the early stage of the outbreak. Based on the above clinical picture and the plague outbreak in the neighbouring State of Maharashtra, a diagnosis of suspected pneumonic plague was made. A total of 1088 clinically suspected and 146 presumptive (seropositive) cases and 54 deaths due to plague took place during the period 19 September to 22 October 1994. Seroactivity to the F1 antigen of Yersinia pestis was found among the affected patients. Vigorous control measures undertaken by the Government of lndia and the State Government in subsequent days resulted in no transmission of pulmonary plague outside of Surat. The last case of presumptive pneumonic plague in Surat city occurred on 11 October 1994. The patient was isolated, cured and discharged on 15 October 1994. The surveillance capabilities were adequate to detect suspected cases of human plague. Case containment, case treatment, contact tracing, and the administration of prophylactic antibiotics to populations at risk were timely and comprehensive. 100 The Work of WHO in SEA WHO provided support for control and containment measures in lndia. In collaboration with the National Institute of Communicable Diseases (NICD), a daily bulletin on the plague situation in lndia 1 *was communicated to WHO Headquarters, other Regional Offices and to WHO Representatives in the countries of the Region. The Director-General of WHO, accompanied by the Regional Director. visited Surat on 7 and 8 October. WHO provided the services of international experts (three from USA and two from Russia) who trained national personnel in the laboratory diagnosis of plague. WHO supported a study tour for four Indian researchers to WHO reference laboratories for plague in the USA, France and Russia. In addition, two \aboratory workers have been trained in the USA in the production of diagnostic reagents for plague. On 7 October 1994, the Director-General of WHO announced the formation of an independent international team to investigate the plague situation in lndia. The Regional Director was designated as the Team Leader. Following investigations, the team concluded, jnter alia, that: A limited outbreak of bubonic plague occurred in Beed District of Maharashtra State in August-September 1994 which was preceded by an epizootic of plague in commensal rodents in Mamla village. The clinical, epidemiological and serological findings suggest that Ypestis was the probable cause of the outbreak of respiratory illness in Surat, Gujarat State, in September-October. Sulveillance capabilities were adequate to detect suspect cases of human plague. Case containment, case treatment, contact tracing and the administration of prophylactic antibiotics to populations at risk were timely and comprehens~ve. The Government of lndia established a Technical Advisory Committee on Plague to elucidate factors responsible for the outbreak of plague and to make recommendations for the future control and prevention of outbreaks. This committee, in its interim report, concluded that it was possible to establish conclusively by culture and other tests that Ypestis was the causative organism of the outbreak. WHO convened, in March 1995, an Interregional Meeting on Prevention and Control of the Plague Epidemic. The main objective of this meeting, which was held in the Regional Office, was to learn lessons from the 1994 outbreak of plague in some parts of lndia and to make recommendations on the development of new strategies for -- -- - - Dtsease Prevention and Control 101 strengthening the exlsting system of surveillance of plague and other emerging, reemerging and new infectious diseases around the globe The main conclusion of this meeting was that there is increasing .t concern about the global prevalence of infectious diseases as a leading cause ofdeath. The recent plague epidemic in India highlights the threat posed by the new, emerging and reemerging infectious diseases, most of which have an epidemic potential. Sexually Although reliable data on the prevalence and incidence of sexually Transmitted transmitted diseases (STD) are not available in many countries, Diseases studies indicate that STDs remain a serious health problem. An attempt is being made by the Regional Office to collate available information on STDs in the Region. WHO is actively promoting STD case management as a part of general health services based on the syndromic approach. During the programme managers meeting in November 1993, the issue of STD prevention and control as a part of primary health care was discussed. All countries in the * Region are now actively promoting condom use to reduce the risk of HIV infection and STDs. During 1993-1994, WHO collaboration with the countries included the: provision of technical and financial support in strengthening STD services as a part of national AlDS prevention and control programmes, development of STD treatment guidelines, and the conduct of national AlDS programme reviews, including the evaluation of STD activities. Consultancy services were provided in Bangladesh. India, Indonesia and Myanmar. In October 1993, the Regional OKie supported an intercountry meeting of national STD programme managers in Chiang Mai, Thailand. In June 1995. participants at an intercountry meeting on Integrated Approach to STD Prevention and Control in Sri Lanka discussed the integration of the STD programme as a part of primary health care. Since sexual transmission accounts for 80-90 per cent of HIV infections in the Region, WHO is urging countries to focus most of their efforts and resources on: prevention; promotion of safer sexual behaviour by educating population groups through the use of mass media and interpersonal methods; targeted interventions among people with high-risk behaviour, including promotion of condom use; and the provision of early diagnosis and treatment of sexually --- 102 The Work of WHO in SEA transmitted diseases, particularly those which facilitate HIV transmission. Although difficulty in the promotion of condom use from the religious and cultural points of view has been one of the ' major handicaps in some countries, efforts have been made to make condoms available in as many outlets as possible. Condom social marketing is at present in operation in Bangladesh, India. Indonesia, Nepal, Sri Lanka and Thailand. An lntercountry Workshop on Condom Social Marketing for AIDSISTD Prevention was convened in Nepal in November 1994. , In view of the association between HIV and STD and the role played by STD, particularly genital ulcer disease, in the acquisition and transmission of HIV, the Regional Office is focusing its support on strengthening STD services in the countries. Early diagnosis and treatment of STDs is being given high priority as primary preventive measures against HIV infection, and STD control is a standing agenda item at annual meetings of programme managers. As a result, the programmes are now trying to focus on the diagnosis of STD using the syndromic approach and providing the most effective drugs at the first contact with health services. In many countries, STD and AIDS programmes have now been integrated. However, the lack of drugs to treat STD is a major constraint in many countries. The Regional Office has supported headquarters in encouraging Member Countries to promote research in: disease-specific vaccinology concerning bacterial and viral diarrhoea; meningococcal meningitis and pneumococcal pneumonia; tuberculosis and leprosy; new measles vaccines for early infancy; and dengue and Japanese encephalitis. The general objective is to improve vaccine immunogenicity and simplify vaccine delivery. Research and Development h the Reld of Vaccines Most researchers in the countries of the Region have focused on subjects related to operational services rather than on basic studies of EPI vaccines. Strengthening of the research capability of national personnel is being continued in collaboration with research training-related unitdagenciedinstitutes within and outside their countries. WHO prov~des support to natlonal AIDS control programmes on the AIDS prevention of HIV transmlsslon and on HIVIAIDS care in varlous -- Disease Prevention and Control 103 areas such as health education and targeted interventions, treatment i and prevention of sexually transmitted diseases, condom promotion 1 and quality assurance, counselling, sentinel surveillance and i laboratory diagnosis, and the provision of supplies and equipment. * I Technical support was given to Bhutan. India, Thailand, Bangladesh, i Indonesia, Mongolia. Myanmar and Sri Lanka for carrying out external programme reviews. Second medium-term plans emphasizing the multisectoral approach and the involvement of NGOs were formulated during 1993-1994 in Thailand, Maldives. Myanmar, Nepal, India, Mongolia and Indonesia. 1 To enhance the technical capacity at the national level, the Regional Office organized the first Programme Management Course in June 1994. Based on the modular approach, the course provided skills in planning, implementing and evaluating national AlDS control programmes. A facilitators training programme for this course was organized in May 1994. In Thailand, major business houses, both multinational and , national, have come together to form a "business coalition against AIDS" and to mount an appropriate business response to AIDS. In India, the Confederation of Indian Industries has developed plans of work for AlDS prevention activities to be carried out by industry NGO activities have increased tremendously over the last 1-2 years in all countries, particulariy in peripheral areas. Collaboration between NGOs and national programmes and among NGOs themselves is being increased. In Myanmar, community involvement in AlDS prevention, including contributions made by NGOs and the private sector, is particularly noteworthy. In Nepal, various ministries have committed themselves to participating in HIVIAIDS prevention; so have ministries in Mongolia, Sri Lanka, Indonesia, India and Thailand. A workshop on enhancing private sector involvement was held in * January 1995 in the Regional Office. Political commitment is well established. Besides focusing on HIVIAIDS prevention, provision of comprehensive HIVIAIDS care as a part of primary health care is now a major priority for the Region. To respond to this need, an intercounty workshop was held in the Regional Office from 29 March to 2 April 1993 to discuss i the HIVIAIDS continuum of care at various levels, i.e. institution, community and home. 104 The Work of WHO in SEA In spite of the progress achieved in the implementation of : national AlDS control activities, there still remain constraints in mounting an effective response to the expanding pandemic in some - countries of this region. Table 11 gives the situation in respect of : AlDS and HIV infections in SEAR countries. Table 11. AlDS and HIV infections in SEAR countries (as of 15 May 1995) Reported I Estimated Countly AIDS cases HIV infections Bangladesh Bhutan DPR Korea lndta lndonesla Maidlves Mongolla Myanmar Nepal Sn Lanka Thalland - -- -- Total Major priorities for national programmes include the following: Translating high-level political commitment to the ground level, in terms of both finances and trained manpower, so that national programme activities can be planned, implemented and evaluated in an efficient and coordinated manner. Mounting a multisectoral response with the involvement of all relevant government ministries, nongovernmental organizations including community-based organizations, and the private sector, both in prevention and care activities. Expanding programmes to the most peripheral level, with the full participation of communities, groups and individuals. . Focus~ng llmlted resources on the prevention of sexual transmlsslon of HIV, slnce up to 90 per cent of all HIV -- Disease Prevention and Control 105 Other Communicable Disease Prevention and Control Act~ties infections in the Region are caused by sexual intercourse. predominantly heterosexual. Avoiding measures such as mandatoty HIV testing and short-term travel restrictions based on HIV status because ' these are not only ineffective and wasteful of resources but are also counter-productive. The main objective of this programme is to improve surveillance, prevention and control capabilities in SEAR countries to cope effectively with problems of dengueldengue haemorrhagic fever, viral hepatitis. Japanese encephalitis and meningococcal meningitis. Dengue/Dangw Dengueldengue haemorrhagic fever (DHF) is the most important Haernorrfiagic and rapidly increasing arbovirus infection in the world. It is the ,, Fever leading cause of hospitalization and death among children in many countries of this region. DenguelDHF continues to persist in Indonesia, Myanmar and Thailand in endemic form. Sporadic outbreaks of DHF have also been reported from Bangladesh, India, Maldives and Sri Lanka. DenguelDHF is a notifiable disease in Indonesia, Myanmar and Thailand, where national denguelDHF control programmes have been developed with technical support from WHO. The Regional Office brought out a monograph on denguelDHF w~th full and updated information on its prevention and control - WHO and the Rockefeller Foundation jointly organized an International Conference on DHF in February 1994. The Conference ; recommended the inclusion of DHF in the list of notifiable diseases. WHO has provided consultancy services for reviewing the control programmes in Myanmar and Thailand and for assisting in the preparation of a national strategy for control of dengue1DHF in India. A national workshop on denguelDHF in New Delhi in Februaty 1995 was also supported. 106 The Work of WHO ln SEA % The Organization continued its collaboration with endemic j countries in operational research, technology development, training " of health staff, and health education on dengue1DHF. i 2 i The Regional Office participated in the review and revision of i VvHOguidelineson "Dengue Haemorrhagic Fever: Diagnosis, Treatment i and Control". The revised version will be available in late 1995. The Vaccine Development Centre of Mahidol University, Thailand, with technical and financial support from WHO, successfully developed a tetravalent vaccine. This was a major and significant achievement in the Region in vaccine development. The results of ' the clinical trials of this vaccine in adult volunteers have shown that it is safe and that the immunological response to it isencouraging. The Phase I and II trials of this vaccine in children were carried out during 1993-1995. WHO supported two important Peer Review Meetings on Dengue Vaccine Development in 1993 and 1994. The impact of viral hepatitis, as indeed of almost all other infectious Viral Hepatitis diseases, poses a serious health problem in SEAR countries. Hepatitis A Virus (HAV) infection is very common in all countries of the Region. Some outbreaks of HAV infection in children have been reported from India, Indonesia and Nepal. Increase in morbidity of HAV infection has been observed in children and young adults in Mongolia and Thailand. WHO has provided technical information and diagnostic reagents to these countries. The prevalence of hepatitis B virus (HBV) infection and related diseases, such as chronic hepatitis, cirrhosis and hepatocellular carcinoma, remains a public health problem in the Region. Every year, approximately 12-14 million people are infected with HBV. It is estimated that there are 78 million HBV carriers in the Region. ' During the period under review, a WHO-supported sero-epidemiological study on hepatitis B virus was initiated in Bangladesh, Bhutan and Sri Lanka. The results obtained so far show a high prevalence of HBsAg (more than 20 per cent) in pregnant women and in the general population in Bhutan, indicating that vertical transmission of HBV infection is very common. Very j low prevalence of HEisAg (0.1-0.2 per cent) was found in these : groups of population in Sri Lanka. Disease Prevention and Control 107 About a decade ago, only some of the SEAR countries had : developed mandatory screening of blood and blood products for ; HBsAg. Now, in a majority of the countries, this screening has been ? established. As a result of WHO support, DPR Korea, India, Indonesia, * : Myanmar and Thailand are producing diagnostic tests for detection of HBsAg. WHO has also supported the development of hepatitis B vaccine (plasma derived) in DPR Korea, Mongolia and Myanmar. During 1994-95, these countries produced some quantities of hepatitis B vaccine for conducting field trials. The testing of the hepatitis B vaccine produced in Myanmar in chimpanzees shows that it is safe and gives protective immunity against HBV infection. Sufficient progress has been made in hepatitis B control in some countries of the Region. Hepatitis B vaccination, integrated with EPI, has started in lndonesia, Maldives, Mongolia and Thailand. Sri Lanka has introduced this vaccination in medical personnel. The prevalence of Hepatitis C virus (HCV) infection in the Region is still not known. A WHO multicentre collaborative epidemiological study of HCV infection is under way in Indonesia, Myanmar. Mongolia and Thailand. Delta virus (DV) is common only in Mongolia, India. Indonesia, Maldives and Myanmar. Thailand reported only a few cases of mixed HBV and DV infection. Hepatitis E vi~s (HEV) infection is an emerging health problem in the Region. Water-borne outbreaks of HEV infection have been reported from Bangladesh, India, Indonesia, Myanmar and Nepal. Sporadic cases of this infection have also been detected in other countries of the Region. WHO supported various national workshops, meetings and seminars on viral hepatitis. Technical information and diagnostic reagents have also been provided to Member Countries. " 'rie Japanese encephalitis (JE) has been a major public health problem Entop lit'' in some areas of the South-East Asia Region, especially in Northern Thailand, the Indian states of Bihar, Uttar Pradesh and West Bengal, the terai areas of Nepal, and in Sri Lanka. Cases have also been reported in Bangladesh and Myanmar. WHO provided technical support to the endemic countries in its control, and helped India. Nepal and Sri Lanka in the procurement of JE vaccine. -- -. 108 The Work of WHO in SEA The majority of the meningococcal meningitis cases and outbreaks . Meningococcal are associated with serogroups A and C in children as well as in Meningitis adults. Only a small number of cases of this disease are connected r ' with serogroup 0. During the first six months of 1994, Mongolia reported 2661 cases with 273 deaths among children under 5 years of age. WHO provided the sewices of two short-term consultants from the Centre for Disease Control, Atlanta. USA, to investigate the outbreak. Laboratory findings and investigations revealed that the epidemic was associated with Neissena meningitides serogroup A. To prevent recurrence of the epidemic, the country decided to vaccinate high-risk groups. WHO provided 450 000 doses of bivalent (A+C) meningococcal vaccine and 30 000 doses of ciprofloxacin for chemoprophylaxis to persons having close contact with the disease. Some 213 000 children between the ages of 2 and 18 years were vaccinated. During 1994-1995, outbreaks of meningitis occurred in different parts of Bangladesh, India, Nepal and Myanmar. A small number of cases have also been reported from Indonesia and Thailand. WHO's assistance is mainly through the provision of technical cooperation to Member Countries to help organize surveillance, chemoprophylaxis, treatment and vaccination against meningococcal meningitis. The main thrust of WHO's collaborative efforts in the prevention of Blindness blindness in the Region is directed at further strengthening andlor and developing eye health care infrastructure, including referral and ~~~f~~~~ outreach services; expanding the coverage and quality of eye care to the unreached and underserved; training of personnel at all levels; and promotion of the local production of eye care supplies. As far as the prevention of deafness and hearing impairment programme is concerned, the main emphasis is on epidemiological assessment; identification of the principal causes of deafness; and support for the development and strengthening of national programmes for ear care, including training of personnel. In Bangladesh. Ind~a, Myanmar, Nepal and Srl Lanka, workshopsltra~n~ng courses on prlmary eye care for all levels of health workers have been organ~zed wlth WHO support Fellowships Disease Prevention and Control 109 have been awarded to ophthalmic personnel for advanced study. j Necessary equipment has also been provided. Technical support has been extended to community-based eye care programmes in 1 most countries as well as to the World Bank-funded blindness ' ; control programme in lndia. Indonesia is carrying out a major survey r on ophthalmic diseases and hearing impairment in three of its provinces with technical back-up from WHO. Cancer : Substantial funding has been made available by the World Bank for WHO execution of a project to establish an epidemiological surveillance system for cancer, and for public preventive education, in Bangladesh. In India, a cancer control project has been prepared with WHO assistance, for World Bank funding. Based on the National Cancer Control Programme (NCCP) in lndia, model district cancer control activities are being implemented, with WHO support, and a these district programmes are continuously being expanded with : the Government's own resources. An evaluation of some of those programmes has clearly shown that the rate of cancers that appear incurable at the time of diagnosis can be lowered substantially. A small follow-up study of patients with incurable cancer has shown the high prevalence of severe uncontrolled pain, and pointed : towards the urgency to improve palliative care in lndia. Unfortunately, the production of oral morphine is still not sufficient for effective use for severe cancer pain in the majority of patients in lndia and ,' in other countries of the Region. CO~OVOSQ~I~ i Data from the SEA Region as well as from elsewhere show that. ... Diseclses ! with life expectancy having risen to above 60 years, cardiovascular ' diseases tend to become the leading cause of death. WHO'S response to this situation so far has mainly been to support studies estimating the prevalence of risk factors in different populations and exploring the feasibility and effectiveness of lowering the prevalence of risk factors for cardiovascular diseases, hypertension, and diabetes mellitus. Smoking, sedentary lifestyle, and a diet kgh in animal fat contribute towards cardiovascular diseases. However, the impact of lowering the prevalence of risk factom on mortality has been disappointing, indicating the need for further research, 110 The Work of WHO in SEA WHO has continued to execute an AGFUND-supported programme to establish the feasibility and cost-effectiveness of the control of rheumatic feverlrheumatic heart disease through an ' integrated approach. This project is ongoing in India, Sri Lanka and Thailand. Bangladesh was assisted in the establishment of angio-surgery through the provision of equipment and consultancy services. Consultants also assisted DPR Korea in upgrading their angio-surgery and cardio-surgery facilities. WHO supports its Collaborating Centre, viz. the Bangladesh Institute ' Other Non- of Research and Rehabilitation in Diabetes. Endocrine and Metabolic communicable Disorders (BIRDEM) for research and training in the prevention and Diseases control of diabetes mellitus. An impressive model of integrated diabetes control has been developed. This public health approach to diabetes control can serve as a model for other countries where the prevalence of diabetes is rapidly increasing. In India, for example. the prevalence of diabetes is estimated at 2 per cent in rural areas whereas in a survey in Madras. 8 per cent of the population were found to be affected. WHO has assisted Maldives in developing a thalassaemia control programme. A consultant reviewed the possible etiological factors in the unusually high rates of kidney failure in the country. D~sease Preventuon and Control 111 Section IV Programme Support The Regional Office Library continued to provide technical information and literature support to WHO staff members, Member Countries, United Nations agencies and biomedical researchers. Cooperation was extended to Member Countries in ensuring continuous availability of valid scientific, technical, managerial and other information related to health in printed and other forms, whether originating from within or outside the Organization. During the reporting period, the Regional Office Library received 708 books/monographs, proceedings, reports, pamphlets, WHO publications and issues of current periodicals. It has continued to process its collection using EMS (Books Management System) and PMS (Periodicals Management System) library management softwares. The Library facilities were used by 2640 visitors (2250 WHO staff and 390 others) and 870 books and periodicals were issued on loan. In response to requests from users, 102 inter-library loan requests were sent while 11 560 items were consulted in the Library itself. MEDLARSIMEDLINE searches for WHO staff members and photocopies of 2984 articles from in-house, local, regional and WHO headquarters and other international sources were arranged for the users. The compilation and distribution of SEAR0 Library Alerf (SLA). a monthly current awareness service covering selected periodicals, Library News and HELLlS Newsletter were continued. The Library continued to develop the "SEALIS" computerized database of Health Literature and Library Services (Including HELLIS) Regional Office Library Health Informatton Support 113 assignment reports and documents pertaining to various subject areas (Accidents - Malaria from 1948-todate, Maternal and Child Health -Women, Health and Development from 1975-to-date) and simultaneously issued these in hard copy as "SEADOC". To bring * the health literature published in Member Countries under bibliographical control, the Library issued Index Medicus for WHO South-East As~a (IMSEAR). Besides, the Library has acquired international databases, viz. Aidsline. Medline and Popline on CD-ROM and sub-sets of the WHO headquarters library database WHOLIS. All computerized systems of the Library have been linked to SEARO LAN (Local Area Network). To strengthen the WHO Representative (WR) offices' information retrieval and document delivery capabilities as well as to initiate their staff in the use of newer technology, a library orientation programme forthe concerned persons in the WR offices (Bangladesh, Bhutan, India, Indonesia, Mongolia and Sri Lanka) was conducted in the Regional Office in February 1994. As a result, library management sohares EMS and PMS and WHO databases, such .* as SEALIS and WHOLIS, have been installed in WR offices. The SEARO Library also provided orientation to WHO fellows in the use of various computer sohares and database input formats being used in the Library. Besides, it provided reference materials and services for group educational activities in SEAR. HELLIS The HELLIS (Health Literature, Library and lnformation Services) network now has designated national focal points (NFPs) in all SEAR countries, except Maldives, and in over 315 participating libraries. It has continued to provide such health literature information as is not available in the country of request, including MEDLARSIMEDLINE ? searches. For developing their minimal capabilities, health science libraries in Member Countries have been provided with photocopiers, computers, CD-ROM drives, MEDLINE, WHOLIS and SEALIS databases, biomedical literature, subscriptions to periodicals, and, on specific request, core lists of books, periodicals in the field of biomedical sciences and computer sohares for library automation. A Joint Asia-Pacific POPIN-HELLIS Workshop on "Database Development for Health Population lnformation Managers" was held in Bangkok, Thailand. in November 1994. In this workshop, the ~ ~ -- 114 The Work of WHO in SEA HELLIS Network participants and the Asia-POPIN Network exchanged 1 information about the developments in their respective institutions. i An overview of information regarding various health information : databases developed by the SEARO Library as well as a ; demonstration of EMS and PMS softwares was given to the : participants. These softwares of HELLIS Network were recommended for distribution among the Asia-Pacific POPlN members through : ESCAP. A one-day Regional HELLIS Network Meeting was organized : at the WHO Regional Oftice for the Americas (PAHO) in conjunction ' with the 7th International Congress on Medical Librarianship in Washington, DC, USA, 9-12 May 1995, to review the status, issues and problems related to the development of various types of [ databases in the field of health and allied sciences in Member Countries. These meetings were attended by the HELLIS Network participants from Bangladesh, India and Thailand as well as the : SEARO Librarian and Assistant Librarian. Six new titles were issued under the SEARO publications series Publications besides a revised edition of one publication. Non-priced documents, and Documents including reports of various kinds, were produced and distributed. The third meeting of the Interregional Committee on Policy and Coordination of Publications was held in the Regional Oftice in October 1994. Discussions covered a wide range of issues, including needs in publications, impact of WHO publications, funding, editing, translations, printing, promotion and distribution, electronic publishing and strengthening of national capacity in scientific communication. A number of countries In the Reg~on recelved support for translat~ng Translations and WHO publlcat~ons Into local languages Publications The Regional Office issued the following publications: a revised edition of Collaboration in Health Development in South-East Asia, 1948-1988 - Fortieth Anniversary Volume (Regional Publication No. 19); Nutrition Research in South-East Asia (Regional Publication No. 23); Health Laboratory Services in Support of Primaly Health Care in Developing Countries (Regional Publication No. 24); Health lnforrnatlon ~u~~oT 115 Multicentre Study on Low Birth Weight and Infant Mortality - in : India, Nepal and Sri Lanka (Regional Health PaperNo.25); Principles of Nutrition Management in Primary Health Care (Regional Health Paper No. 26); The Appraisal of Health Systems Research (~echnical' Publication No. 12), and Health Research Strategies of the South-East Asia Region (Technical Publication No. 13). Among non-serial publications, the nineteenth volume of Dengue Newsletter and the Health Situation in the South-East Asia Region covering the period 1991 -1 993 were issued. Documents The reports and documentation of the Technical Discussions on Community Action for Health, held during the forty-sixth session of the Regional Committee, and on Resurgence of Tuberculosis - The Challenge, held during the forty-seventh session, were brought out in book form. The second volume of the Handbook of Resolutions of the Regional Committee was revised and issued in November -* 1993 and further updated in November 1994. The loose-leaf list of technical documents issued since 1979 was updated in December 1993, July 1994 and January 1995. Lists of documents received from WHO headquarters and other regions and distributed by the Regional Office were issued periodically. Sales During the reporting period, a number of special distribution arrangements were made. For example, a pharmaceutical company reprinted and distributed, free of cost, 55 000 copies of Treatment of Tuberculosis: Guidelines for National Programmes. Low-priced editions of Essential Elements of Obstetric Care at First Referral Level and Acute Respiratory Infections in Children: Case - Management in Small Hospitals in Developing Countries -A Manual - for Doctors and Other Senior Health Workers were distributed by UNICEF at minimal cost. Apart from these, a total of 39 reprint agreements were signed. These will result in the dissemination of nearly 32 000 copies of WHO books through commercial publishers. The Regional Office has been assisting WHO headquarters in reprinting some of its publications such as The ICD-10 Classification of Mental and Behavioural Disorders on Clinical Descriptions and Diagnostic Guidelines and Diagnostic Criteria for Research. This The Wok of WHO in SEA 116 considerably reduces the production cost to the Organization and enables wider distribution. - When time and financial constraints do not permit WHO to 1 undertake a publication on its own, co-publication agreements are 1 made with leading publishers in the Region. For example, Oxford ! University Press, New Delhi, published the WHO publication f !, Contraceptive Research and Development 1984-1994 -the Road 1 from Mexico City to Cairo and Beyond. This book was extensively i distributed at the Cairo Conference on Population. 1 : t Efforts were continued to sell publications in bulk (1000 copies or more) to the book trade. Such transactions are intended to minimize the work in the Regional Office and maximize the profit to the bookseller. Books sold in bulk have included Manual of : Radiographic Interpretation for General Practitioners and Manual i of Radiographic Technique. A set of seven books, which constitutes a core library for doctors working in small hospitals and is available at a very special discount, has been very popular, as have been i books under the series lnternational Histological Classification of Tumours. In order to disseminate information, the Regional Office participated in 11 book fairs and medical congresses. In addition, SEARO assisted the lnternational Agency for Research on Cancer, Lyon. France, in their display at the XVI lnternational Cancer Congress in New Delhi in 1994. At the Book Fair in Patna, India, the WHO stall was awarded the first prize for display and decoration. Two sales agents have been appointed to cover areas of western and southern India, and each has organized special exhibitions of WHO publications. Visits by a SEARO staff member were undertaken - to explore similar arrangements in Bangladesh. Sri Lanka and Thailand. The entire sales operations of the Regional Office were computerized in April 1994. This has helped in meeting expeditiously and efficiently the increasing demand for WHO publications in the Region. As a result of these efforts, the sales turnover in the Region is next only to that of the USA and the UK. WHO publications are sold in the Region at half the regular price, and the Regional Office has made considerable strides in terms of dissemination of information, which is the primary objective. -- - Health lnforrnat~on Support 117 Details of the financ~al turnover are reflected in Table 12 Table 12. Sales of WHO publicatrons 1993 1994 July 1993 - June 1995 Subscriptions and sales of publications 1 182925 1 153947 1 350853 1 NOTE: The above figures represent actual receipts afler dedudion of all discounts and application of the concessional conversion rate of Geneva cover prices to Indian rupees. 118 The Work of WHO in SEA The organ~zat~onal structure of the Regional Office, as of 30 June Organi~ational 1995, IS glven in Annex 1 Structure As of 30 June 1995 there were 149 establ~shed Profess~onal posts Personnel In the South-East Asla Reg~on as compared to 146 on 30 June 1994 and 141 on 30 June 1993 Table 13 shows the number of posts in the Profess~onal category In the Reg~on, funded from all sources, and the number actually filled as of 30 June 1995 'Includes 9 posts filled by short-term consultantslprokssionals. 'includes 4 posts filled by short-term consultantslprokssionals. Table 13. Number of pmfessional posts, by location, as of 30 June 1995 ..- Support ~ervlces 119 ~. ~ Established Frozen Filled by appo~ntment Still to be fllled Of which. - candidates selected - candidates yet to be selected Regional and Intercountry 78 6 65' 7 - 7 Country 71 2 54b 15 7 8 Total 149 8 119 22 7 15 i During the period under review, 228 consultants were employed in various projects for periods ranging from 1 week to ; 11 months. Twenty-nine Professional and 24 General Service (GS) staff members separated from WHO service; 46 Professional staff were recruited during the reporting period, of whom seven were women. Five staff members were reassigned to other WHO regions and eight were assigned to other UN Agencies on mission. As of 30 June 1995, 131 nationals were engaged on Special Services Agreements. Staff I In order to keep abreast with the Regional Office's and Member Devdopmmt Countries' evolving needs as well as with new technologies, while andTr* 1 at the same time developing skills needed to properly discharge i responsibilities at all levels, a number of staff development and T~ i training (SDT) activities were undertaken. In this framework, specific attention was given to enhancing the skills of WHO Representatives Ws). Two of them participated in a course on Managing Health Programme in Developing Countries at Harvard University, USA, in June-August 1994. One WR was : sponsored for an interregional seminar for WRs, held at WHO " 1 headquarters. Opportunities were also provided to three Professional staff from the Region to enhance their technical competence through attendance at short-term courses organized in different universities in the United Kingdom in 1994. Seven Professional staff attended introductory briefing programmes at WHO headquarters in 1994 and 1995. Staff development and training activities also focused on building team spirit and effectiveness. A weekend orientationltraining programme for new Professional and senior GS staff was organized in three sessions at a facility outside of New Delhi during MarchlApril 1995. A total of 56 staff members participated in this programme. A workshop on Experiential Learning for Professional and Organizational Effectiveness was also held on 5 January 1994 in SEARO, which was attended by 27 staff members from both the Professional and GS categories. Three 'retreats' were organized 120 The Work of WHO in SEA for wo staff in Indonesia - one in February 1994 for Professional staff and one each during the first half of 1995 for Professional i 1 and GS staff. A number of Professional and GS staff were provided - refresher courses on electronic data processing as well as on E-Mail, which has recently been installed in the Regional Office. '' :; Twenty GS staff from WRs' offices received training in SEAR0 in various fields of activity, using specific information system formats ; of the Regional Office. This included a library orientation programme, : imprest account system, LAN administration and other user-friendly I computer programmes. The proposal to replace the present air-conditioning system in the ' General Regional Office with a new and more powerful plant, as approved ; Administrative by the Forty-sixth World Health Assembly in May 1993, is being 1 Services implemented in a phased manner. New cooling towers and pumping ; systems have been installed, tested and put into operation along w~th the allied equipment. A new chiller is being installed and measures are being taken to replace the remaining parts of the air-conditioning system. The electrical wiring and distribution panels have been reviewed as a preliminary step towards replacing the 30-year old system of power supply. One of the two old lifts in the main building has been replaced, while work is under way to replace 2 the second lifl. A number of other major works were carried out in the area : of Building Maintenance, including renovation of the Reception area, the Conference Hall and the Committee Room. Other areas of World Health House and its compounds are under renovation1 redesigning. The Regular programme budget proposal for 1994-1995 had been Budget and developed within a total allocation of US$99 million. Due to the Finance budgetary and financial constraints of the Organization, only US$94.7 million was released by WHO headquarters as of 30 June 1995 as i the working allocation. The programme-wise distribution amounting I to US$82 million as of 31 December 1994 was as given in Figure 12. ' Support Services 121 Figure 12. Dlslrlbution of funds to high priority programmes (as of 31 December 1994) ou.u.*n*m.rolm S=W-~--~QN.~O wv 1 4.86 """A* *,,,urns m* W.L% ""<% m,". -- 0 2 1 1 10 12 14 IO (8 S- (US Dollam Mllliona) e.0 - In addition to the WHO'S Regular budget, the SEAR Member Countries receive a sizeable amount of funds from extrabudgetary sources, including the World Bank and the United Nations Development Programme (UNDP), for health programmes/projects ; entrusted to WHO as Executing Agency which cover national priorities in health. The funds received from extrabudgetary sources amounted to a total of US$ 58.5 million during the period 1 January 1994 to 30 June 1995. In the context of the revised WHO-w~de management ~nformatlon system development, the Reg~onal Office has been selected to test - the new Reg~onal OfficelAdm~n~strat~on and Flnance lnformatlon (ROIAFI) system whlch 1s expected to be ready for lmplementatlon by the end of 1995 SU plies and Med~cal suppl~es and equipment worth US38 2 mllllon were iUuipmenl procured dunng the perlod 1 July 1983 to 30 June I995 under the Regular budget and extrabudgetary resources Thls amount 1s h~gher than that for the preceding two-year penod, whlch was US$ 36 9 122 The Work of WHO in SEA million, indicating an upward trend. Supplies and equipment for : projects in Bangladesh, DPR Korea, India. Mongolia and Myanmar ! constituted the bulk of the procurement. . A large number of requests were processed during the reporting period under extrabudgetary resources in connection with projects executed by WHO on behalf of the UN and other agencies, viz. the Fourth Population and Health Project in Bangladesh (World Bank); AIDS Control Programme in lndia (World Bank); Malaria Control and Improvement of Primary Health Care Services in Myanmar : (uNDP); AIDS Control Programme in Sri Lanka (Asian Development Bank), and Tuberculosis Control Programme in lndia (Swedish International Development Agency). This resulted in a significant increase in the share of supplies and equipment procured under extrabudgetary resources, which accounted for about 60 per cent of the total procurement. Emergency kits, drugs, vaccines and other essential supplies were provided under the Regional Director's Development Fund to meet emergency situations arising as a result of epidemics and natural disasters in Bangladesh, Mongolia and Myanmar. Essential supplies on a reimbursable basis were procured for Bangladesh (vaccines and medical literature), lndia (drugs and teaching equipment), Maldives (vaccines). Myanmar (research supplies. teaching equipment and medical literature) and Nepal (vaccines and water purifying health chemicals). The ongoing market survey of local manufacturers has indicated the availability of several products of acceptable quality - at competitive prices. Purchases made from local sources have resulted in considerable savings to WHO. These have amounted to US$750 000 on account of purchases such as drugs, bicycles and office equipment. Benefits to programme delivery also accrued due to an increase in the limit of authority delegated to WHO Representatives. The Supplies Management Information System was fully implemented. This has resulted in improved operational efficiency and availability of more comprehensive information to the offices of the WHO Representatives. General Visitors and Visits Dr H. Nakajima, Director-General, WHO, visited lndia in September 1993. Apart from his other engagements, including meetings with senior government officials, the Director-General addressed the forty-sixth session of the WHO Regional Committee. In October, he visited Dhaka, Bangladesh, and addressed the eleventh meeting of the Ministers of Health of the South-East Asia Region. The Director-General visited Mongolia in September 1994 and addressed the forty-seventh session of the Regional Committee as well as the twelfth meeting of the Ministers of Health. Dr Nakajima paid official visits to lndia and Thailand in February 1994. In New Delhi, he attended the Meeting of the Task Force for Child Survival and Development, while in Bangkok he participated in the inauguration of the First International Conference of the International Medical Parliamentary Organization. In October 1994. the Director-General visited Surat (India) in connection with an outbreak of plague, and, in November, he paid an official visit to Indonesia. In March 1995, he participated h in the Interregional Meeting on Prevention and Control of Plague held in New Delhi. During his official visits to the countries, Dr Nakajima took the opportunity to discuss with top-ranking government officials WHO'S collaborative health activities in the Region. The Regional Director received visits of officials of Ministries of Health of various Member Countries, including Ministers and Deputy Ministers. He also received officials of national research councils, medical councils and associations and research institutions who visited SEARO. Other visitors included ambassadors of the Member Countries in New Delhi, a US Congressman, representatives of donor agencies and regional -. and international financial institutions such as the Asian .- i Development Bank and the World Bank. A member of the WHO Executive Board and heads of United Nations agencies in lndia and in other countries in the Region were among the other visitors who visited the Regional Office. The Regional Director gave several PressIradiofIV interviews and met with the media representatives on important occasions such as World Health Day and World No-Tobacco Day. 124 The Work of WHO in SEA Keynote and inaugural addresses were delivered by the Regional Director at various consultations, including those at ministers' level. conferences, symposia, inter-countly and national seminars and 'workshops on technical and scientific subjects. He also addressed sessions of various regional organizations and institutions working in the areas of environmental health, AIDS, cardiovascular diseases, women in development, human resources for health, leprosy elimination, medical research, gerontology, polio eradication. communicable diseases and vaccine production. - -- - -- . - - -- -- - - -- Support Services Meetings Attended/ Ina urated by 7 the egional Director ANNEXES Annex 1 Organizational Structure Regional Director u I I Director Administration and Finsnrr FIELD PROGRAMMES s Annex 2 Projects in Operation in Member Countries In the list of projects, the followibg abreviations are used under "Funds": Speual Account for Servicing Costs United Nations Development Programme United Nations Environment Programme Associate Professional Oficers United Nations International Drug Control Programme United Nations Fund for Population Activities Trust Funds Trust Fund for Global Programme on AIDS Regular Budget Sasakawa Health Trust Fund United Nations Children's Fund Voluntary Fund for Prevention of Blindness Voluntary Fund for Diarrhoea1 Diseases including Cholera Voluntary Fund for Others Voluntary Fund for Maternal Health and Safe Motherhood Voluntary Fund for Medical Research (Specified) - other than Human Reproduction Voluntary Fund for Expanded Programme on Immunization Voluntary Fund for Miscellaneous Designated Contributions (DANIDA) Voluntary Fund for Leprosy Programme Voluntary Fund for Malaria Voluntaty Fund for Disasters and Natural Catastrophes Voluntary Fund for Tuberculosis Voluntary Fund for Community Water Supply Prolects in Operation in Member Countries 129 Project No. Funds Project Title BANGLADESH BAN EHA 600 VN BAN COR 003 AS BAN HST 004 VD BAN HST 005 VD BAN HST 006 VD BAN HST 007 VD BAN MPN 002 RB BAN MPN 200 RE BAN MPN 215 VD BAN PHC 003 REND BAN PHC OM RB BAN PHC 006 DP BAN PHC 008 VD BAN HRH 007 RB BAN HRH 014 RE BAN HRH 015 RB BAN HRH 016 RB BAN HRH 018 VD BAN HRH 019 VD BAN HRH 020 VD BAN HRH 021 VD BAN IEH 001 RB BAN RPD 001 RB BAN RPD 002 VD BAN NUT 004 VD BAN ORH 001 RB BAN MCH 005 VD BAN MCH 006 RB BAN MCH 007 VD BAN MCH 008 VD BAN OCH 001 RB BAN HEE 001 RB BAN MND 001 RB BAN CWS 001 RB BAN CWS 003 VW BAN CEH 001 RB Emergency Response Coordination for Health Promotion Further Development of Tuberculosis and Leprosy Control Services Management Information for Health Strengthening of Management lnformation SystemJFamily Planning Unit Strengthening of Institute of Epidemiology, Disease Control and Research (IEDCR) Planning and Management of Health Services Managerial Process for National Health Development Intensified WHO Cooperation, Bangladesh Organization of Healih System Based on Primary Health Care Repair and Maintenance of Eledm-Medical Equipment Intensification of Primary Health Care Health Care Quality Assurance Nursing Advisory Services and Training Health Manpower Development - Training of Paramedical Workers Strengthening of Postgraduate Medical Education Undergraduate Medical Education Expansion and Development of National lnstnute of Preventive and Social Medicine (NIPSOM) Master Plan for Human Resources for Health Development (TAPP) Training of all Categories of Health Personnel in Operational Management of Different Clinical Specialities Further Development of Medical Colleges Development of Health Education Services Research Promotion and Development Strengthening of Bangladesh Medical Research Council (BMRC) Coordinated Nutrition Programme of Bangladesh National Nutrition Council -~*. Oral Health Family Planning Clinical Supervision Team Maternal and Child Health, including Family Planning Pilot Project for Development of Maternal and Neonatal Health Care MCH Programme Coordination Cell Workers' Health Health of the Elderly Prevention and Treatment of Mental and Neurological Disorders Community Water Supply and Sannation MonitoringIEvaluation of GOBIUNICEF Rural Water Supply and Sanitation Programme Environmental Health The Work of WHO in SEA BAN FOS 001 RB BAN CLR 002 RB BAN EDV 001 REND .'BAN DSE 001 RB BAN DSE 002 VD BAN TRM 003 RB BAN RHB 001 RB BAN EPI 001 RB BAN CTD 001 VD BAN CTD 002 VD BAN CTD 003 RB BAN CTD 004 RB BAN LEP 002 ST BAN CDD 001 RBNC BAN CDD 002 VD BAN ARI 001 REND BAN ARI 002 VD BAN VDT 002 VD BAN GPA 001 FX BAN PBD 001 RB BAN PBD 002 VD BAN PBD 003 RB BAN CAN 003 RB BAN CAN 004 VD BAN CVD 001 RB BAN NCD 001 RB BAN HBI 001 RB BHUTAN BHU HST 001 RB BHU MPN 001 RBIFB BHU MPN 215 VD BHU PHC 001 RB BHU HRH 003 RB BHU IEH 001 RB BHU MCH 003 FP BHU EDV 001 VD BHU GPA 001 FX BHU CTD 001 RB BHU CDD 001 RB BHU ARI 001 RB BHU TUB 001 RB BHU OCD 001 RB BHU NCD 001 RB Food Safety Clinical, Laboratory and Radiological Technology for Health Systems based on Primary Health Care Essential Drugs and Vaccines Drug and Vaune Quality. Safety and Efficacy Modernization and Reorganization of Existing Drug Testing Laboratory at Dhaka Development of Manpower in Traditional Medicine Rehabilitation of the Disabled Expanded Programme on Immunization Integrated Control of Vector-borne Diseases (ICOVED) Intestinal Parasite Control (Pilot Project) Malaria Control Programme Parasitic Disease Programme Leprosy Control Prevention and Control of Diarrhoeal Diseases Control of Diarrhoeal Diseases Control of Acute Respiratory Infections Acute Respiratory Infection Control Programme Prevention and Control of Sexually Transmitted Diseases (STD) Prevention and Control of AIDS Prevention of Blindness Primary Eye Care Prevention of Hearing Impairment Prevention and Control of Cancer Development of Epidemiological Surveillance System and Control and Prevention of Cancer (TAPP) Cardiovascular Diseases Other Non-Communicable Disease Prevention and Control Activities Development of Health Literature, Library and Information Selvices Health Situation and Trend Assessment Managerlal Process for National Health Development Human Resources Development Organization of Health Systems Based on Primary Health Care Development of Human Resources for Health Public Information and Education for Health Strengthening of MCHIFP Services in Bhutan Essential Drugs Programme Prevention and Control of AlDS National Malaria Control Programme National Diarrhoeal Diseases Control Programme National ARI Control Programme National Tuberculosis Control Other Communicable Disease Prevention and Control Activities Prevention and Control of Non-Communicable Diseases Projects in Operation in Member Countries 131 DPR KOREA KRD MPN 001 KRD PHC 001 KRD PHC 002 KRD HRH 002 KRD RPD 001 KRD NUT 001 KRD ORH 001 KRD MCH 003 KRD HEE 001 KRD CEH 003 KRD CLR 001 KRD DSE 001 KRD TRM 001 KRD GPA 001 KRD CAN 001 KRD CVD 001 KRD NCD 001 INDIA IND HSC 001 IND HST 003 IND HST 005 IND MPN 001 IND MPN 002 IND MPN 003 IND MPN 200 IND HSR 001 IND PHC 001 IND PHC 002 IND EHA 600 IND HRH 001 IND IEH 001 IND IEH 002 IND RPD 001 IND RPD 002 IND NUT 006 IND ORH 001 IND MCH 003 IND MCH 004 IND MCH 005 IND HE€ W1 IND CWS 001 IND CWS 002 Managerial Process for National Health Development Organization of Heanh Systems Based on PHC + Integrated PHC in Hyangsan County Human Resources Development Research Promotion and Development including Research on Health Promoting Behav~our Nutrition Oral Health Strengthening MCHIFP Services Health of the Elderly Control of Environmental Health Hazards (Phase II) Clinical, Laboratory and Radiological Technology for Health Systems Based on PHC Drug and Vaccine Qualay. Safety and Efficacy Traditional Medicine Prevention and Control of AIDS Cancer Cardiovascular Diseases Other Non-communicable Diseases Prevention and Control Activit'ms HFA Strategy Coordination Epidemiology Training and Services Development and Training of Health Information Services Country Health Planning Strengthening of Health Programming and Management Health Economics B Financing Managerial Process for National Health Development Health System Research and Development Organization of Heaiih Systems based on Primary Heaith Care Disaster Preparedness Programme Emergency Preparedness Development of Human Resources for Health Public lnformation and Education for Health Information, Education and Communication for Family Welfare Research Promotion and Development, including Health Behaviour Studies on Tribal Heaith Nutrition including Goitre Oral Health Maternal and Child Heaith Promotion of Family Welfare Services and Research Family Welfare Services and Research Health of the EWerkj Urban Community Water Supply and Sanitation Rural Community Water Supply and Sanltation The Work of WHO in SEA IND CEH 001 IND CEH 002 IND FOS 001 , IND CLR 001 IND EDV 001 IND EDV 101 IND TRM 001 IND RHB 001 IND EPI 001 iND CTD 001 IND CTD 003 IND CDD 001 IND ARI 001 IND TUB 001 IND TUB 002 IND LEP 001 IND VDT 001 IND GPA 001 IND GPA 002 IND OCD 001 IND OCD 002 IND PBD 001 IND PBD 002 IND CAN 006 IND CVD 003 IND NCD 001 INDONESIA RB VD RB RB RB VD RB RE RB RB RB RB RB RBM VI RB RB RBlFX FT RB RE RBNB RB RB REND RE IN0 HST 101 RB IN0 HST 108 RB IN0 MPN 101 RB IN0 MPN 200 RB IN0 HSR 002 RE IN0 HSR 003 RB IN0 HLE 001 RB IN0 EHA 105 RB IN0 PHC 101 RB IN0 PHC 102 RB IN0 PHC 104 RE IN0 HRH 015 DP IN0 HRH 101 RE IN0 HRH 102 RB Control of Environmental Health Hazards Support for Environmental Epidemiology Workshops Food Safety Clinical. Laboratory and Radiological Technology for Health Essential Drugs and Vaccines Promotion of Essential Drugs Concept (EDC) in India Tradbional Medicine, including Homoeopathy and Yoga Development of Rehabilitation Services and Training Expanded Programme on Immunization Malaria Control Parasitic Diseases Control Diarrhoea1 Diseases Control Prevention and Control of Acute Respiratory Infections Tuberculosis Control TB Control (Pilot Project) Leprosy Control Prevention and Control of Sexually Transmitted Diseases AlDS Prevention and Control WHOlGOlllDA Procurement Agreement for National AlDS Control Programme - India Other Communicable Diseases Prevention and Control Activities Guineaworm Eradication Programme Prevention of Blindness Prevention of Deafness Cancer Control Cardiovascular Diseases Other Non-communicable Dlsease Prevention and Control Activities Health Situation and Trend Assessment Strengthening of Disease Surveillance Strengthening of the Management Process for National Health Development Managerial Process for National Health Development Health Systems Research and Development Health Systems Research and Development (NIHRD) Strengthening of Health Legislation Disaster Preparedness Organization of Health System Based on Primary Health Care Organization of Health System Based on PHC. Strengthening of Hospital Referral System, Quallty Assurance, Financial Self-Suficiency, Nursing and Sanitation Organization of Health System Based on PHC, Strengthening of Community Participation Development of Nursing HQher Education System, including a Faculty of Nursing at the University of Indonesia Overall Development and Coordination of Health Manpower and Training Development Development of Nursing Manpower Projects in Operation ~n Member Countries 133 IN0 HRH 105 IN0 HRH 106 IN0 HRH 107 IN0 HRH 108 IN0 iEH 101 IN0 RPD 001 IN0 NUT 005 IN0 ORH 002 IN0 APR 001 IN0 MCH 003 IN0 ADH 001 IN0 OCH 001 IN0 HEE 101 IN0 ADA 001 IN0 MND 001 \NO CWS 007 IN0 CWS 007 IN0 PCS 001 IN0 CEH 001 IN0 FOS 102 IN0 CLR 001 IN0 EDV 001 IN0 DSE 001 IN0 DSE 002 IN0 TRM 102 IN0 RHB 001 \NO EPI 001 IN0 CTD 001 IN0 CTD 002 IN0 CTD 003 IN0 CDD 001 IN0 ARi 001 IN0 TUB 001 IN0 LEP 001 IN0 VPH 001 IN0 VDT 001 IN0 GPA 001 IN0 PBD 001 IN0 CAN 001 IN0 CVD 001 IN0 HBI 001 RB RB RB RB RB RB RB RB RB RB DP RB RB RB RB RBND RB RB RB RB RB RB RB RB RBNC REND RB RB RB RB RBIFX RB RB RB RB Development of Higher Education in Health Development of Public Health Education System Strengthenjng of FETP Training in Epidemiology lnzountry Fellowship for S-I and S-2 Levels for those from Developing Regions, Programme Priorities, and Remote Areas Information and Education for Health - Centres for Community Health Education Research Promotion and Development, including Research on Health Promoting Behaviour General Heanh Protection and Promotion Nutihion Improved Programme General Health Promotion and Prevention - Oral Health General Health Protedion and Promotiin - Accident Prevention Protedion and Promotion of Health of Specific Population Groups - Maternal and ChiM Health, including Family Planning Adolescent Health Protection and Promotion of Health of Spemc Population Groups - Workers' Health Health of the Elderly Prevention and Control of Alcohol and Drug Abuse Prevention and Treahnent of Mental and Neurological Disorders Strengthening oi Environments\ Health Rural Water Supply and Sanitation - Bengkulu and Lampung Provinces Health Risk Assessment of Potentially Toxic Chemicals Control of Environmental Health Hazards Food Safety and Food Sanitation Clinical Laboratory and Radiological Technology for Health Systems based on Primary Health Care Management and Control of Essential Generic Drugs Drugs and Vaccine QualRy, Safety and Efficacy Management of Medical Devices Control Development of Traditional Health System and Utiluation of Traditional Medicine Rehabilitation Expanded Programme on ImmunUafMn Diseases Vector Control Malaria Control Programme Parasitic Diseases Prevention and Control of Diarrhoea1 Diseases Control of Acute Respiratory Infedions Tuberculosis Control Leprosy Veterinary Public Heanh (Zoonoses) Sexually Transmitted Diseases and Yaws Control Prevention and Control of HIVIAIDS Prevention of Blindness and Deafnes Cancer Preventiin Programme Cardiovascular Prevention and Control Scientific lnformation Network and Health Infonation Support The Work of WHO in SEA MALDIVES MAV MPN 200 RB MAV PHC 001 RB MAV HRH 004 RB MAV MCH 001 RB MAV CWS 001 RB MAV EDV 001 VD MAV CTD 001 RB MAV GPA 001 FX MAV NCD 001 RB MAV HBI 001 RB MONGOLIA MOG HST 001 MOG MPN 200 MOG MPN 001 MOG MPN 221 MOG PHC 002 -. MOG PHC 004 MOG HRH 005 MOG HRH 006 MOG RPD 001 MOG NUT 002 MOG ORH 001 MOG APR 001 MOG MCH 002 MOG ADH 001 MOG OCH 002 MOG HEE 001 MOG MND 001 MOG CWS 001 MOG CEH 001 MOG FOS 001 MOG CLR 002 MOG EDV 001 MOG EDV 003 MOG DSE 001 MOG TRM 001 MOG RHB 001 Mffi EPI 001 Mffi CDD 001 MOG ARI 001 MOG TUB 001 Managerial Process for National Healih Development organization of Heakh System based on Primary Heakh Care Development of Human Resources for Health Maternal and Child Healih, including Family Planning Community Water Supply and Sanitation Essential Drugs Programme Malaria and Other Vector-borne Disease Control Prevention and Control of AIDS Non-Communicable Disease Prevention and Control Health Information Support Health Situation and Trend Assessment Managerial Process for National Health Development Health Planning and Management Health System Management Organization of HeaRh System Based on Primary Health Care Repair 8 Maintenance of Medical Equipment Development of Human Resources for Health National Health Learning Medical Network Research Promotion and Development, including Research on Health Promoting Eehaviour Nutrition Oral Health Accident Prevention Maternal and Child Healih, including Family Planning and Human Reproductive Research Adolescent Health Workers Health neanh of the Elderly Prevention and Treatment of Mental and Neurological Disorders Community Water Supply and Sanitation Control of Environmental Health Hazards Food Safety Clinical, Laboratory and Radiological Technology for Health Systems based on PHC National Essential Drugs Programme Mongolia National Essential Drugs Programme Drug and Vaccine Quality, Safety and Efficacy Tradnional Medicine Rehabilitation Immunization Diarrhoea1 Diseases Acute Respiratory Infection Tuberculosis Projects in Operation ~n Member Countries 135 MOG VPH 001 RB MOG RDVWI RB MOG GPA 001 FX MOG GPA 002 RB MOG CAN 001 RB MOG CVD 001 RB MYANMAR MMR HST 001 RB MMR HST 002 RB MMR MPN 002 RB MMR MPN 200 RB MMR HSR 001 RB MMR PHC 001 RB MMR PHC 003 RB MMR PHC OM RB MMR PHC 007 OP MMR HRH 008 RB MMR HRH 009 RB MMR HRH 010 RB MMR HRH 020 RB MMR IEH 001 RB MMR RPD 001 RBNG MMR RPD 002 RB MMR RPD 003 RB MMR NUT 002 RB MMR ORH 001 RB MMR APR 001 RB MMR MCH 002 FP MMR MCH 004 RB MMR ADH 001 RB MMR OCH 002 RB MMR HEE 001 RE MMR MND 001 RB MMR ADA 001 RB MMR CWS 001 RB MMR CEH 001 RB MMR CLR 001 RE MMR EDV 001 VD MMR EDV 002 DP MMR EDV 003 RBND MMR DSE 001 RB MMR TRM 003 RB Zoonoses Research and Development in the FieM of Vaccines Prevention and Control of AlDS AlDS and other STD Cancer Cardiovascular Diseases Health Situation and Trend Assessment Epidemiological Surveillance of Communicable Diseases Health Services Planning and Management Managerial Process for National Health Development Health Systems Research Primary Health Care and Basic Health Sewices Hospital Services Management and upgrading of Medical Social Services in Myanmar Supply System and Maintenance and Repair of Medical Equipment Improving Quality and Outreach of Primary Health Care Services Development of Mi-level Heah Personnel Development of Medical Education System Health Manpower Development HFA Leadership Development Public Information and Education for Health Health Research In Support of National Health Plan Research Training Programme Development of Research lnfrastrudure Nutrition Primary Oral Health Care Accident Prevention Strengthening of MCH Services Family Health Care Development of Physical Health Workers' Health Health Care for the Elderly Community Mental Heanh Drug Abuse Control Environmental Health Planning and Management Control of Environmental Health Hazards Laboratory Support Programme Essential Drugs Programme Development of Hepat'kis B Vaccine Essential Drugs Programme Development of Produdion and Quality Control of Biologicals and Pharmaceutical Produds Promotion of Research and Development Activities in resped of Myanmar Tradlional Mediune The Work of WHO in SEA MMR EPI 001 RB MMR CTD 001 REND MMR CTD 002 DP MMR CDD 001 RB MMR ARI 001 RB MMR TUB 001 RB MMR LEP 001 RBNL MMR LEP 002 DP MMR GPA 001 FX MMR GPA 002 RB MMR GPA 004 DP MMR PBD 001 REND MMR PBD 002 RB MMR PBD 004 VB MMR CAN 001 RB MMR CVD 001 RB NEPAL NEP HST 001 RB NEP MPN 002 RBlST NEP MPN 200 RB NEP EHA 003 RB NEP PHC 001 RB NEP HRH 005 RBIFB NEP HRH 006 RB NEP HRH 009 RB NEP IEH 001 RB NEP RPD 001 RB NEP NUT 003 RBIFB NEP MCH 003 RB NEP MND 001 RB NEP CWS 001 RB NEP CWS 004 DP NEP CLR 001 REND NEP EDV 001 VD NEP TRM 001 RB NEP EPI 001 RB NEP CDD 002 FB NEP CTD 001 RE NEP CDD 001 RB NEP TUB 001 RE NEP LEP 001 REND NEP VDT 001 R8 Expanded Programme on Immunization Vector-Borne Disease Control Reducing Malaria Morbidity and Mortality through Upgrading Health Sewices and Increased Community Participation Control of Diarrhoeal Diseases Acute Respiratory Infections Control Programme Tuberculosis Control Leprosy Control Programme Community-based Rehabilitation of Leprosy Patients Prevention and Control of AlDS Control of AlDS and other Sexually Transmitled Diseases Support to National AlDS Programme II Trachoma Control and Prevention of Blindness Programme Prevention of Deafness Prevention of Blindness - Model Primary Eye Care Project at Sintgaing, Myanmar Cancer Control Programme Cardiovascular Disease Ep~dem~ologlcal Suwelllance and Dlsease Control Country Health Planning, Programming and Health lnformatlon System Managerla1 Process for Natlonal Heakh Development Emergency and Dlsaster Preparedness Community Health Development and Development of Referral System through Prlmary Health Care and Community-based Rehab~l~tat~on Development of Human Resources for Health (IOM) Develo~ment of Human Resources for Health lBPKlHSl Development of Human Resources for Health (MOH) Publiclnformation and Education for Health, and Development of Health Literature and Library Services Research Promotion and Development Strenglhening ot Nutiion Component in Primary Heahh Care Maternal and Child Heakh, including Family Planning Protection and Promotion of Mental Health, including Alcoholism and Drug Abuse Community Water Supply and Sanitation Human Resources Development for Water Supply and Sanitation Development of Health Laboratory Technology Services Drug Pol~cy. Legislation and Information Promotion of Traditional Medicine Expanded Programme on Immunization Control of Diarrhoeal Diseases - Assouate Professional Officer Vector-borne Disease Control Programme Control of Dlarrhoeal Diseases and ARI Tuberculosis Control Control of Leprosy Prevention and Control of Sexually Transmitted Diseases, Including AlDS Projects in Operation in Member Countries 137 NEP GPA 001 FX NEP PBD 001 RBNB NEP PBD 002 RB SRI LANKA SRL HST 001 RB SRL HST 002 RB SRL MPN 001 RB SRL MPN 002 RB SRL MPN 200 RB SRL EHA 6001 VN SRL PHC 101 RB SRL PHC 102 RB SRL PHC 103 RB SRL PHC 104 RB SRL PHC 105 RB SRL PHC 106 RB SRL HRH 011 RB SRL HRH 012 RB SRL HRH 014 RB SRL HRH 019 RB SRL HRH 101 RB SRL HRH 102 RB SRL HRH 103 RB SRL HRH 104 RB SRL HRH 105 RB SRL HRH 106 RB SRL iEH 001 RB SRL RPD 001 RB SRL NUT 002 RB SRL ORH 001 RB SRL APR 001 RB SRL MCH 009 RB SRL ADH 001 RB SRL OCH 001 RB SRL ADA 001 RB SRL ADA 003 FD SRL MND 001 RB SRL CWS 001 RB SRL FOS 001 RB SRL CLR 001 RB SRL EDV 001 REND SRL TRM 002 DP SRL RHB 001 RB SRL EPI 001 RB Prevention and Control of AIDS Prevenlion and Control of Blindness Prevention and Control of Deafness Strengthening of Health Information system Strengthening of Epidemiological Surveillance Country Heanh Programme Strengthening of Planning and Management Managerial Process for National Health Development Mental HeaHh of Displaced Population Development of Primary Health Care - PHC Management and Inter-Sedoral Coordination Development of Primary Health Care - Trad'itwnal Mediane Development of Primary Health Care - Tertiary Referral Hospitals Development of Primary Health Care - Referral Hospilals (Secondary) Development of Primary Health Care - Biomedical Engineering Services Development of Primary Heanh Care - Health of the Underprivileged Nursing Education Postgraduate Medical Education Development of National Institute of Heaith Sckncer Development of Manpower for Forensic Medicine Undergraduate Medical Education - University of Colombo Undergraduate Medical Education - University of Ruhuna Undergraduate Medical Education - University of Peradeniya Undergraduate Medical Education - University of Jaffna Undergraduate Medical Education - University of Kalaniya Undergraduate Medical Education - University of Sri Jayawardanapura Heaith Education Research Promotion and Development Nutrition Community Oral Health Development of a National Programme on Accident Prevenlion Development of Family Health Programme School Heanh Adolescent Heaith Programme Workers' Health Prevention and Control of Alcohol and Drug Abuse Prevention and Treatment of Problems Related to Abuse of Drugs, Phase II Mental Heanh Community Water Supply and Santation Proiect Report Food Safety Strengthening of Laboratory Sewicas Essential Drugs and Vaccines Development of Tradtional Mediane - Phase II Communlty-Oriented Rehabiliation Services Expanded Programme on Immunization The Work of WHO in SEA SRL CTD 001 SRL CDD 001 SRL ARI 001 ' SRL TUB 001 SRL VPH 002 SRL LEP 001 SRL VDT 001 SRL GPA 001 SRL GPA 002 SRL PBD 001 SRL PBD 002 SRL CAN 002 SRL CVD 003 SRL HBI 001 THAILAND THA HST 001 THA MPN 001 THA MPN 200 THA PHC 002 THA PHC 003 THA HRH 015 THA IEH 001 THA RPD 001 THA NUT 001 THA APR 001 THA TOH 001 THA MCH 007 THA OCH 001 THA HEE 001 THA PSF 001 THA CEH 001 THA CLR 001 THA EDV 001 THA DSE 001 THA TRM 001 THA RHB 001 THA GPA 001 THA CVD 002 THA RDV 001 THA OCD 001 THA HBI 001 Disease Vector Control Diarrhoea1 Diseases Control of Acute Respiratory Diseases Tuberculosis Control Accelerated Rabies Control Campaign Leprosy Control Control of Sexually Transmated Diseases Prevention and Control of AIDS Development of National AlDSlSTD Prevention and Control Programme Prevention of Blindness Primary Eye Care Prevention and Control of Cancer Prevention of Rheumatic FeverlRheumatic Heart Disease Development of Health Literature and Library Network Health Situation and Trend Assessment Managerial Process for National Health Development Managerial Process for National Health Development Support for Self-Managed Primary Health Care Development Health Systems Reorientation and Development in support of PHC Development of Human Resources for Health Public lnformation and Education for Health Research Promotion and Development Nutrition and Lifestyle Accident Prevention Tobacco or Heanh Mate~nal and Child Health. including Family Planning Workers' Health Health of the Elderly Protection and Promotion of Mental Health Control of Environmental Heanh Hazards Clinical, Laboratory and Radiological Technology for Health Systems Based on Primary Health Care Essential Drugs and Vaccines Drugs and Vaccine Quality, Safety and Efficacy Traditional Med~cine Rehabilitatlon AIDS Prevention and Control Programme Prevention of Rheumatic FeverRheumatic Heart Disease Research and Development in the Field of Vaccines Other Communicable Diseases Health lnformation Support Projects in Operation in Member Countries 139 INTERCOUNTR) ICP DGP 001 ICP COR 100 ICP COR 001 ICP COR 002 ICP HSC 001 ICP HST 001 ICP HST 002 ICP HST 100 ICP MPN 001 ICP MPN 004 ICP EHA 600 ICP MPN 005 ICP PHC 002 ICP PHC 100 ICP HRH 014 ICP HRH 019 ICP HRH 100 ICP HRH 100 ICP IEH 002 ICP IEH 100 ICP RPD 001 ICP RPD 002 ICP RPD 003 ICP RPD 100 ICP NUT 005 ICP NUT 007 ICP NUT 100 ICP MCH 012 ICP MCH 014 ICP MCH 015 ICP APR 001 ICP MCH 100 ICP HEE 001 ICP PSF 100 ICP CWS 001 ICP CWS 004 ICP cws 100 ICP RUD 001 ICP PCS 001 ICP CEH 001 ICP FOS 001 1 PROJECTS RB Director-General's and Regional Directoh Development Programme AS Coordination with other Organizations AS Liaison wfih ESCAP AS Coordination for Health Promotion RB Health-for-All Strategy Coordination RE Strengthening of Epidemiological Surveillance System RBlAS Heallh Situation and Trend Assessment RB Health Situation and Trend Assessment RBIFB Managerial Process for Health Development ST Strengthening Capaaly of WRs' Ofhs and JointGovernmenW#liO Coordination Mechanism VN Promotion of EHA Activities in SEAR Countries VD Intensified WHO Cooperation in SEAR RBND Promotion of Health for All with Primary Heailh Care as Key Approach, including Appropriate Technology for Health RE Organization of Health Systems Based on Primary Heakh Care RBND Development of Human Resources for Health VD Support for Management of Health Learning Materials Programmes RE Development of Human Resources for Health AS Planning and Information System for Development of Human Resources for , Health RWAS Promotion of Health Education RE Public Information and Education for Health RB Research Promotion and Development RE Collaboration in Research Programme RE Institutional Strengthening for Research RB Research Promotion and Development, including Research on Health-promoting Behaviour RB Nutrition Monitoring and Evaluation RE Strengthening Nutrition Programmes in Health Sector for Population in Greatest Need RE Nuuition FP WHO TSS Coordinator - SEAR0 VD Women. Health and Development VE Safe Motherhood Initiative RB Accident Prevention RB Maternal 8 Child Health, including Family Planning RB Health Care of the Elderly RB Psychosocial and Behavioural Factors in the Promotion of Health and Human Development RB Community Water Supply and Sanitation VD Building up of an Information Service in Environmental Health in Soulh-East %la RB Communily Water Supply and Sanitation RB Environmental Health in Rural and Urban Development 8 Housing RE Health Risk Assessment of Potentially Toxic Chemicals RBND Control of Environmental Pollutants and Hazards RBND Food Safety 140 The Work of WHO in SEA ICP CLR 001 ICP CLR 100 ICP EDV 001 ICP EDV 004 ICP EDV 005 ICP EDV 006 ICP EDV 100 ICP RHB 001 ICP RHB 100 ICP EPI 001 ICP CTD 001 RBNDI AS VD VD VD RB REND RB RBNl REND Clinical, Laboratory and Radiological Technology for Health Systems based on Primary Health Care Clinical. Laboratory and Radiological Technology for Health Systems based on Primary Health Care Development of Essential Drugs: Legislation and Quality Control Technlcal Cooperation in Pharmaceuticals in ASEAN Countries Development of Essential Drugs - Audiovisual Material Bi-Regtonal TCDC Meeting on Essential Drugs Action Programme on Essential Drugs and Vaccines Rehabilltatlon Rehabilitation Expanded Programme on Immunization Malaria and other Vector-borne Diseases Control Programme ICP CTD 002 RB Parasitic Diseases Control (ICP PDP 001) ICP CTD 100 ICP LEP 001 ICP CDD 001 ICP ARI 001 ICP TUB 001 ICP OCD 001 ICP VPH 001 ICP PBD 001 ICP NCD 001 ICP NCD 002 ICP GPA 100 ICP TDR 100 RB ST RBNC REND RBND RB VD RB RB VD FX AS Malaria and other Vector-borne Diseases Control Programme Leprosy Control Diarrhoea1 Diseases, including Cholera Prevention and Control of Acute Respiratory Infections Tuberculosis Control Other Communicable Diseases including Zoonoses Control of Zoonoses and Food-borne Diseases Prevention of Blindness and Deafness A Community-oriented Approach to the Prevention 8 Control of Non-communicable Diseases Prevention 8 Control of Deafness AIDS Prevention and Control Programme Strengthening of Biomedical Research Capacities REGIONAL OFFICE PROJECTS 000 RCO 103 000 EXM 001 000 GPD 001 000 GPD 002 000 ISS 001 000 IEH 001 000 HBI 001 000 HBI 002 000 PER 001 000 GAD 001 000 SUP 001 RB RB RB RB RB RB AS AS RBlAS RBIASI FB RBIASI FT RBlAS Regional Comminees Executive Management General Programme Development Staff Development and Training Informatics Management Public Information and Education for Health Health Information System Health Literature, Library and Information Services Support Services Personnel General Admlnistration and Services Support Services - Budget and Finance Equipment and Supplies for Member States Projects in Operation ~n Member Countries 141

Annex 2 Projects in Operation in Member Countries In the list of projects, the followibg abreviations are used under "Funds": Speual Account for Servicing Costs United Nations Development Programme United Nations Environment Programme Associate Professional Oficers United Nations International Drug Control Programme United Nations Fund for Population Activities Trust Funds Trust Fund for Global Programme on AIDS Regular Budget Sasakawa Health Trust Fund United Nations Children's Fund Voluntary Fund for Prevention of Blindness Voluntary Fund for Diarrhoea1 Diseases including Cholera Voluntary Fund for Others Voluntary Fund for Maternal Health and Safe Motherhood Voluntary Fund for Medical Research (Specified) - other than Human Reproduction Voluntary Fund for Expanded Programme on Immunization Voluntary Fund for Miscellaneous Designated Contributions (DANIDA) Voluntary Fund for Leprosy Programme Voluntary Fund for Malaria Voluntaty Fund for Disasters and Natural Catastrophes Voluntary Fund for Tuberculosis Voluntary Fund for Community Water Supply Prolects in Operation in Member Countries 129 Project No. Funds Project Title BANGLADESH BAN EHA 600 VN BAN COR 003 AS BAN HST 004 VD BAN HST 005 VD BAN HST 006 VD BAN HST 007 VD BAN MPN 002 RB BAN MPN 200 RE BAN MPN 215 VD BAN PHC 003 REND BAN PHC OM RB BAN PHC 006 DP BAN PHC 008 VD BAN HRH 007 RB BAN HRH 014 RE BAN HRH 015 RB BAN HRH 016 RB BAN HRH 018 VD BAN HRH 019 VD BAN HRH 020 VD BAN HRH 021 VD BAN IEH 001 RB BAN RPD 001 RB BAN RPD 002 VD BAN NUT 004 VD BAN ORH 001 RB BAN MCH 005 VD BAN MCH 006 RB BAN MCH 007 VD BAN MCH 008 VD BAN OCH 001 RB BAN HEE 001 RB BAN MND 001 RB BAN CWS 001 RB BAN CWS 003 VW BAN CEH 001 RB Emergency Response Coordination for Health Promotion Further Development of Tuberculosis and Leprosy Control Services Management Information for Health Strengthening of Management lnformation SystemJFamily Planning Unit Strengthening of Institute of Epidemiology, Disease Control and Research (IEDCR) Planning and Management of Health Services Managerial Process for National Health Development Intensified WHO Cooperation, Bangladesh Organization of Healih System Based on Primary Health Care Repair and Maintenance of Eledm-Medical Equipment Intensification of Primary Health Care Health Care Quality Assurance Nursing Advisory Services and Training Health Manpower Development - Training of Paramedical Workers Strengthening of Postgraduate Medical Education Undergraduate Medical Education Expansion and Development of National lnstnute of Preventive and Social Medicine (NIPSOM) Master Plan for Human Resources for Health Development (TAPP) Training of all Categories of Health Personnel in Operational Management of Different Clinical Specialities Further Development of Medical Colleges Development of Health Education Services Research Promotion and Development Strengthening of Bangladesh Medical Research Council (BMRC) Coordinated Nutrition Programme of Bangladesh National Nutrition Council -~*. Oral Health Family Planning Clinical Supervision Team Maternal and Child Health, including Family Planning Pilot Project for Development of Maternal and Neonatal Health Care MCH Programme Coordination Cell Workers' Health Health of the Elderly Prevention and Treatment of Mental and Neurological Disorders Community Water Supply and Sannation MonitoringIEvaluation of GOBIUNICEF Rural Water Supply and Sanitation Programme Environmental Health The Work of WHO in SEA BAN FOS 001 RB BAN CLR 002 RB BAN EDV 001 REND .'BAN DSE 001 RB BAN DSE 002 VD BAN TRM 003 RB BAN RHB 001 RB BAN EPI 001 RB BAN CTD 001 VD BAN CTD 002 VD BAN CTD 003 RB BAN CTD 004 RB BAN LEP 002 ST BAN CDD 001 RBNC BAN CDD 002 VD BAN ARI 001 REND BAN ARI 002 VD BAN VDT 002 VD BAN GPA 001 FX BAN PBD 001 RB BAN PBD 002 VD BAN PBD 003 RB BAN CAN 003 RB BAN CAN 004 VD BAN CVD 001 RB BAN NCD 001 RB BAN HBI 001 RB BHUTAN BHU HST 001 RB BHU MPN 001 RBIFB BHU MPN 215 VD BHU PHC 001 RB BHU HRH 003 RB BHU IEH 001 RB BHU MCH 003 FP BHU EDV 001 VD BHU GPA 001 FX BHU CTD 001 RB BHU CDD 001 RB BHU ARI 001 RB BHU TUB 001 RB BHU OCD 001 RB BHU NCD 001 RB Food Safety Clinical, Laboratory and Radiological Technology for Health Systems based on Primary Health Care Essential Drugs and Vaccines Drug and Vaune Quality. Safety and Efficacy Modernization and Reorganization of Existing Drug Testing Laboratory at Dhaka Development of Manpower in Traditional Medicine Rehabilitation of the Disabled Expanded Programme on Immunization Integrated Control of Vector-borne Diseases (ICOVED) Intestinal Parasite Control (Pilot Project) Malaria Control Programme Parasitic Disease Programme Leprosy Control Prevention and Control of Diarrhoeal Diseases Control of Diarrhoeal Diseases Control of Acute Respiratory Infections Acute Respiratory Infection Control Programme Prevention and Control of Sexually Transmitted Diseases (STD) Prevention and Control of AIDS Prevention of Blindness Primary Eye Care Prevention of Hearing Impairment Prevention and Control of Cancer Development of Epidemiological Surveillance System and Control and Prevention of Cancer (TAPP) Cardiovascular Diseases Other Non-Communicable Disease Prevention and Control Activities Development of Health Literature, Library and Information Selvices Health Situation and Trend Assessment Managerlal Process for National Health Development Human Resources Development Organization of Health Systems Based on Primary Health Care Development of Human Resources for Health Public Information and Education for Health Strengthening of MCHIFP Services in Bhutan Essential Drugs Programme Prevention and Control of AlDS National Malaria Control Programme National Diarrhoeal Diseases Control Programme National ARI Control Programme National Tuberculosis Control Other Communicable Disease Prevention and Control Activities Prevention and Control of Non-Communicable Diseases Projects in Operation in Member Countries 131 DPR KOREA KRD MPN 001 KRD PHC 001 KRD PHC 002 KRD HRH 002 KRD RPD 001 KRD NUT 001 KRD ORH 001 KRD MCH 003 KRD HEE 001 KRD CEH 003 KRD CLR 001 KRD DSE 001 KRD TRM 001 KRD GPA 001 KRD CAN 001 KRD CVD 001 KRD NCD 001 INDIA IND HSC 001 IND HST 003 IND HST 005 IND MPN 001 IND MPN 002 IND MPN 003 IND MPN 200 IND HSR 001 IND PHC 001 IND PHC 002 IND EHA 600 IND HRH 001 IND IEH 001 IND IEH 002 IND RPD 001 IND RPD 002 IND NUT 006 IND ORH 001 IND MCH 003 IND MCH 004 IND MCH 005 IND HE€ W1 IND CWS 001 IND CWS 002 Managerial Process for National Health Development Organization of Heanh Systems Based on PHC + Integrated PHC in Hyangsan County Human Resources Development Research Promotion and Development including Research on Health Promoting Behav~our Nutrition Oral Health Strengthening MCHIFP Services Health of the Elderly Control of Environmental Health Hazards (Phase II) Clinical, Laboratory and Radiological Technology for Health Systems Based on PHC Drug and Vaccine Qualay. Safety and Efficacy Traditional Medicine Prevention and Control of AIDS Cancer Cardiovascular Diseases Other Non-communicable Diseases Prevention and Control Activit'ms HFA Strategy Coordination Epidemiology Training and Services Development and Training of Health Information Services Country Health Planning Strengthening of Health Programming and Management Health Economics B Financing Managerial Process for National Health Development Health System Research and Development Organization of Heaiih Systems based on Primary Heaith Care Disaster Preparedness Programme Emergency Preparedness Development of Human Resources for Health Public lnformation and Education for Health Information, Education and Communication for Family Welfare Research Promotion and Development, including Health Behaviour Studies on Tribal Heaith Nutrition including Goitre Oral Health Maternal and Child Heaith Promotion of Family Welfare Services and Research Family Welfare Services and Research Health of the EWerkj Urban Community Water Supply and Sanitation Rural Community Water Supply and Sanltation The Work of WHO in SEA IND CEH 001 IND CEH 002 IND FOS 001 , IND CLR 001 IND EDV 001 IND EDV 101 IND TRM 001 IND RHB 001 IND EPI 001 iND CTD 001 IND CTD 003 IND CDD 001 IND ARI 001 IND TUB 001 IND TUB 002 IND LEP 001 IND VDT 001 IND GPA 001 IND GPA 002 IND OCD 001 IND OCD 002 IND PBD 001 IND PBD 002 IND CAN 006 IND CVD 003 IND NCD 001 INDONESIA RB VD RB RB RB VD RB RE RB RB RB RB RB RBM VI RB RB RBlFX FT RB RE RBNB RB RB REND RE IN0 HST 101 RB IN0 HST 108 RB IN0 MPN 101 RB IN0 MPN 200 RB IN0 HSR 002 RE IN0 HSR 003 RB IN0 HLE 001 RB IN0 EHA 105 RB IN0 PHC 101 RB IN0 PHC 102 RB IN0 PHC 104 RE IN0 HRH 015 DP IN0 HRH 101 RE IN0 HRH 102 RB Control of Environmental Health Hazards Support for Environmental Epidemiology Workshops Food Safety Clinical. Laboratory and Radiological Technology for Health Essential Drugs and Vaccines Promotion of Essential Drugs Concept (EDC) in India Tradbional Medicine, including Homoeopathy and Yoga Development of Rehabilitation Services and Training Expanded Programme on Immunization Malaria Control Parasitic Diseases Control Diarrhoea1 Diseases Control Prevention and Control of Acute Respiratory Infections Tuberculosis Control TB Control (Pilot Project) Leprosy Control Prevention and Control of Sexually Transmitted Diseases AlDS Prevention and Control WHOlGOlllDA Procurement Agreement for National AlDS Control Programme - India Other Communicable Diseases Prevention and Control Activities Guineaworm Eradication Programme Prevention of Blindness Prevention of Deafness Cancer Control Cardiovascular Diseases Other Non-communicable Dlsease Prevention and Control Activities Health Situation and Trend Assessment Strengthening of Disease Surveillance Strengthening of the Management Process for National Health Development Managerial Process for National Health Development Health Systems Research and Development Health Systems Research and Development (NIHRD) Strengthening of Health Legislation Disaster Preparedness Organization of Health System Based on Primary Health Care Organization of Health System Based on PHC. Strengthening of Hospital Referral System, Quallty Assurance, Financial Self-Suficiency, Nursing and Sanitation Organization of Health System Based on PHC, Strengthening of Community Participation Development of Nursing HQher Education System, including a Faculty of Nursing at the University of Indonesia Overall Development and Coordination of Health Manpower and Training Development Development of Nursing Manpower Projects in Operation ~n Member Countries 133 IN0 HRH 105 IN0 HRH 106 IN0 HRH 107 IN0 HRH 108 IN0 iEH 101 IN0 RPD 001 IN0 NUT 005 IN0 ORH 002 IN0 APR 001 IN0 MCH 003 IN0 ADH 001 IN0 OCH 001 IN0 HEE 101 IN0 ADA 001 IN0 MND 001 \NO CWS 007 IN0 CWS 007 IN0 PCS 001 IN0 CEH 001 IN0 FOS 102 IN0 CLR 001 IN0 EDV 001 IN0 DSE 001 IN0 DSE 002 IN0 TRM 102 IN0 RHB 001 \NO EPI 001 IN0 CTD 001 IN0 CTD 002 IN0 CTD 003 IN0 CDD 001 IN0 ARi 001 IN0 TUB 001 IN0 LEP 001 IN0 VPH 001 IN0 VDT 001 IN0 GPA 001 IN0 PBD 001 IN0 CAN 001 IN0 CVD 001 IN0 HBI 001 RB RB RB RB RB RB RB RB RB RB DP RB RB RB RB RBND RB RB RB RB RB RB RB RB RBNC REND RB RB RB RB RBIFX RB RB RB RB Development of Higher Education in Health Development of Public Health Education System Strengthenjng of FETP Training in Epidemiology lnzountry Fellowship for S-I and S-2 Levels for those from Developing Regions, Programme Priorities, and Remote Areas Information and Education for Health - Centres for Community Health Education Research Promotion and Development, including Research on Health Promoting Behaviour General Heanh Protection and Promotion Nutihion Improved Programme General Health Promotion and Prevention - Oral Health General Health Protedion and Promotiin - Accident Prevention Protedion and Promotion of Health of Specific Population Groups - Maternal and ChiM Health, including Family Planning Adolescent Health Protection and Promotion of Health of Spemc Population Groups - Workers' Health Health of the Elderly Prevention and Control of Alcohol and Drug Abuse Prevention and Treahnent of Mental and Neurological Disorders Strengthening oi Environments\ Health Rural Water Supply and Sanitation - Bengkulu and Lampung Provinces Health Risk Assessment of Potentially Toxic Chemicals Control of Environmental Health Hazards Food Safety and Food Sanitation Clinical Laboratory and Radiological Technology for Health Systems based on Primary Health Care Management and Control of Essential Generic Drugs Drugs and Vaccine QualRy, Safety and Efficacy Management of Medical Devices Control Development of Traditional Health System and Utiluation of Traditional Medicine Rehabilitation Expanded Programme on ImmunUafMn Diseases Vector Control Malaria Control Programme Parasitic Diseases Prevention and Control of Diarrhoea1 Diseases Control of Acute Respiratory Infedions Tuberculosis Control Leprosy Veterinary Public Heanh (Zoonoses) Sexually Transmitted Diseases and Yaws Control Prevention and Control of HIVIAIDS Prevention of Blindness and Deafnes Cancer Preventiin Programme Cardiovascular Prevention and Control Scientific lnformation Network and Health Infonation Support The Work of WHO in SEA MALDIVES MAV MPN 200 RB MAV PHC 001 RB MAV HRH 004 RB MAV MCH 001 RB MAV CWS 001 RB MAV EDV 001 VD MAV CTD 001 RB MAV GPA 001 FX MAV NCD 001 RB MAV HBI 001 RB MONGOLIA MOG HST 001 MOG MPN 200 MOG MPN 001 MOG MPN 221 MOG PHC 002 -. MOG PHC 004 MOG HRH 005 MOG HRH 006 MOG RPD 001 MOG NUT 002 MOG ORH 001 MOG APR 001 MOG MCH 002 MOG ADH 001 MOG OCH 002 MOG HEE 001 MOG MND 001 MOG CWS 001 MOG CEH 001 MOG FOS 001 MOG CLR 002 MOG EDV 001 MOG EDV 003 MOG DSE 001 MOG TRM 001 MOG RHB 001 Mffi EPI 001 Mffi CDD 001 MOG ARI 001 MOG TUB 001 Managerial Process for National Healih Development organization of Heakh System based on Primary Heakh Care Development of Human Resources for Health Maternal and Child Healih, including Family Planning Community Water Supply and Sanitation Essential Drugs Programme Malaria and Other Vector-borne Disease Control Prevention and Control of AIDS Non-Communicable Disease Prevention and Control Health Information Support Health Situation and Trend Assessment Managerial Process for National Health Development Health Planning and Management Health System Management Organization of HeaRh System Based on Primary Health Care Repair 8 Maintenance of Medical Equipment Development of Human Resources for Health National Health Learning Medical Network Research Promotion and Development, including Research on Health Promoting Eehaviour Nutrition Oral Health Accident Prevention Maternal and Child Healih, including Family Planning and Human Reproductive Research Adolescent Health Workers Health neanh of the Elderly Prevention and Treatment of Mental and Neurological Disorders Community Water Supply and Sanitation Control of Environmental Health Hazards Food Safety Clinical, Laboratory and Radiological Technology for Health Systems based on PHC National Essential Drugs Programme Mongolia National Essential Drugs Programme Drug and Vaccine Quality, Safety and Efficacy Tradnional Medicine Rehabilitation Immunization Diarrhoea1 Diseases Acute Respiratory Infection Tuberculosis Projects in Operation ~n Member Countries 135 MOG VPH 001 RB MOG RDVWI RB MOG GPA 001 FX MOG GPA 002 RB MOG CAN 001 RB MOG CVD 001 RB MYANMAR MMR HST 001 RB MMR HST 002 RB MMR MPN 002 RB MMR MPN 200 RB MMR HSR 001 RB MMR PHC 001 RB MMR PHC 003 RB MMR PHC OM RB MMR PHC 007 OP MMR HRH 008 RB MMR HRH 009 RB MMR HRH 010 RB MMR HRH 020 RB MMR IEH 001 RB MMR RPD 001 RBNG MMR RPD 002 RB MMR RPD 003 RB MMR NUT 002 RB MMR ORH 001 RB MMR APR 001 RB MMR MCH 002 FP MMR MCH 004 RB MMR ADH 001 RB MMR OCH 002 RB MMR HEE 001 RE MMR MND 001 RB MMR ADA 001 RB MMR CWS 001 RB MMR CEH 001 RB MMR CLR 001 RE MMR EDV 001 VD MMR EDV 002 DP MMR EDV 003 RBND MMR DSE 001 RB MMR TRM 003 RB Zoonoses Research and Development in the FieM of Vaccines Prevention and Control of AlDS AlDS and other STD Cancer Cardiovascular Diseases Health Situation and Trend Assessment Epidemiological Surveillance of Communicable Diseases Health Services Planning and Management Managerial Process for National Health Development Health Systems Research Primary Health Care and Basic Health Sewices Hospital Services Management and upgrading of Medical Social Services in Myanmar Supply System and Maintenance and Repair of Medical Equipment Improving Quality and Outreach of Primary Health Care Services Development of Mi-level Heah Personnel Development of Medical Education System Health Manpower Development HFA Leadership Development Public Information and Education for Health Health Research In Support of National Health Plan Research Training Programme Development of Research lnfrastrudure Nutrition Primary Oral Health Care Accident Prevention Strengthening of MCH Services Family Health Care Development of Physical Health Workers' Health Health Care for the Elderly Community Mental Heanh Drug Abuse Control Environmental Health Planning and Management Control of Environmental Health Hazards Laboratory Support Programme Essential Drugs Programme Development of Hepat'kis B Vaccine Essential Drugs Programme Development of Produdion and Quality Control of Biologicals and Pharmaceutical Produds Promotion of Research and Development Activities in resped of Myanmar Tradlional Mediune The Work of WHO in SEA MMR EPI 001 RB MMR CTD 001 REND MMR CTD 002 DP MMR CDD 001 RB MMR ARI 001 RB MMR TUB 001 RB MMR LEP 001 RBNL MMR LEP 002 DP MMR GPA 001 FX MMR GPA 002 RB MMR GPA 004 DP MMR PBD 001 REND MMR PBD 002 RB MMR PBD 004 VB MMR CAN 001 RB MMR CVD 001 RB NEPAL NEP HST 001 RB NEP MPN 002 RBlST NEP MPN 200 RB NEP EHA 003 RB NEP PHC 001 RB NEP HRH 005 RBIFB NEP HRH 006 RB NEP HRH 009 RB NEP IEH 001 RB NEP RPD 001 RB NEP NUT 003 RBIFB NEP MCH 003 RB NEP MND 001 RB NEP CWS 001 RB NEP CWS 004 DP NEP CLR 001 REND NEP EDV 001 VD NEP TRM 001 RB NEP EPI 001 RB NEP CDD 002 FB NEP CTD 001 RE NEP CDD 001 RB NEP TUB 001 RE NEP LEP 001 REND NEP VDT 001 R8 Expanded Programme on Immunization Vector-Borne Disease Control Reducing Malaria Morbidity and Mortality through Upgrading Health Sewices and Increased Community Participation Control of Diarrhoeal Diseases Acute Respiratory Infections Control Programme Tuberculosis Control Leprosy Control Programme Community-based Rehabilitation of Leprosy Patients Prevention and Control of AlDS Control of AlDS and other Sexually Transmitled Diseases Support to National AlDS Programme II Trachoma Control and Prevention of Blindness Programme Prevention of Deafness Prevention of Blindness - Model Primary Eye Care Project at Sintgaing, Myanmar Cancer Control Programme Cardiovascular Disease Ep~dem~ologlcal Suwelllance and Dlsease Control Country Health Planning, Programming and Health lnformatlon System Managerla1 Process for Natlonal Heakh Development Emergency and Dlsaster Preparedness Community Health Development and Development of Referral System through Prlmary Health Care and Community-based Rehab~l~tat~on Development of Human Resources for Health (IOM) Develo~ment of Human Resources for Health lBPKlHSl Development of Human Resources for Health (MOH) Publiclnformation and Education for Health, and Development of Health Literature and Library Services Research Promotion and Development Strenglhening ot Nutiion Component in Primary Heahh Care Maternal and Child Heakh, including Family Planning Protection and Promotion of Mental Health, including Alcoholism and Drug Abuse Community Water Supply and Sanitation Human Resources Development for Water Supply and Sanitation Development of Health Laboratory Technology Services Drug Pol~cy. Legislation and Information Promotion of Traditional Medicine Expanded Programme on Immunization Control of Diarrhoeal Diseases - Assouate Professional Officer Vector-borne Disease Control Programme Control of Dlarrhoeal Diseases and ARI Tuberculosis Control Control of Leprosy Prevention and Control of Sexually Transmitted Diseases, Including AlDS Projects in Operation in Member Countries 137 NEP GPA 001 FX NEP PBD 001 RBNB NEP PBD 002 RB SRI LANKA SRL HST 001 RB SRL HST 002 RB SRL MPN 001 RB SRL MPN 002 RB SRL MPN 200 RB SRL EHA 6001 VN SRL PHC 101 RB SRL PHC 102 RB SRL PHC 103 RB SRL PHC 104 RB SRL PHC 105 RB SRL PHC 106 RB SRL HRH 011 RB SRL HRH 012 RB SRL HRH 014 RB SRL HRH 019 RB SRL HRH 101 RB SRL HRH 102 RB SRL HRH 103 RB SRL HRH 104 RB SRL HRH 105 RB SRL HRH 106 RB SRL iEH 001 RB SRL RPD 001 RB SRL NUT 002 RB SRL ORH 001 RB SRL APR 001 RB SRL MCH 009 RB SRL ADH 001 RB SRL OCH 001 RB SRL ADA 001 RB SRL ADA 003 FD SRL MND 001 RB SRL CWS 001 RB SRL FOS 001 RB SRL CLR 001 RB SRL EDV 001 REND SRL TRM 002 DP SRL RHB 001 RB SRL EPI 001 RB Prevention and Control of AIDS Prevenlion and Control of Blindness Prevention and Control of Deafness Strengthening of Health Information system Strengthening of Epidemiological Surveillance Country Heanh Programme Strengthening of Planning and Management Managerial Process for National Health Development Mental HeaHh of Displaced Population Development of Primary Health Care - PHC Management and Inter-Sedoral Coordination Development of Primary Health Care - Trad'itwnal Mediane Development of Primary Health Care - Tertiary Referral Hospitals Development of Primary Health Care - Referral Hospilals (Secondary) Development of Primary Health Care - Biomedical Engineering Services Development of Primary Heanh Care - Health of the Underprivileged Nursing Education Postgraduate Medical Education Development of National Institute of Heaith Sckncer Development of Manpower for Forensic Medicine Undergraduate Medical Education - University of Colombo Undergraduate Medical Education - University of Ruhuna Undergraduate Medical Education - University of Peradeniya Undergraduate Medical Education - University of Jaffna Undergraduate Medical Education - University of Kalaniya Undergraduate Medical Education - University of Sri Jayawardanapura Heaith Education Research Promotion and Development Nutrition Community Oral Health Development of a National Programme on Accident Prevenlion Development of Family Health Programme School Heanh Adolescent Heaith Programme Workers' Health Prevention and Control of Alcohol and Drug Abuse Prevention and Treatment of Problems Related to Abuse of Drugs, Phase II Mental Heanh Community Water Supply and Santation Proiect Report Food Safety Strengthening of Laboratory Sewicas Essential Drugs and Vaccines Development of Tradtional Mediane - Phase II Communlty-Oriented Rehabiliation Services Expanded Programme on Immunization The Work of WHO in SEA SRL CTD 001 SRL CDD 001 SRL ARI 001 ' SRL TUB 001 SRL VPH 002 SRL LEP 001 SRL VDT 001 SRL GPA 001 SRL GPA 002 SRL PBD 001 SRL PBD 002 SRL CAN 002 SRL CVD 003 SRL HBI 001 THAILAND THA HST 001 THA MPN 001 THA MPN 200 THA PHC 002 THA PHC 003 THA HRH 015 THA IEH 001 THA RPD 001 THA NUT 001 THA APR 001 THA TOH 001 THA MCH 007 THA OCH 001 THA HEE 001 THA PSF 001 THA CEH 001 THA CLR 001 THA EDV 001 THA DSE 001 THA TRM 001 THA RHB 001 THA GPA 001 THA CVD 002 THA RDV 001 THA OCD 001 THA HBI 001 Disease Vector Control Diarrhoea1 Diseases Control of Acute Respiratory Diseases Tuberculosis Control Accelerated Rabies Control Campaign Leprosy Control Control of Sexually Transmated Diseases Prevention and Control of AIDS Development of National AlDSlSTD Prevention and Control Programme Prevention of Blindness Primary Eye Care Prevention and Control of Cancer Prevention of Rheumatic FeverlRheumatic Heart Disease Development of Health Literature and Library Network Health Situation and Trend Assessment Managerial Process for National Health Development Managerial Process for National Health Development Support for Self-Managed Primary Health Care Development Health Systems Reorientation and Development in support of PHC Development of Human Resources for Health Public lnformation and Education for Health Research Promotion and Development Nutrition and Lifestyle Accident Prevention Tobacco or Heanh Mate~nal and Child Health. including Family Planning Workers' Health Health of the Elderly Protection and Promotion of Mental Health Control of Environmental Heanh Hazards Clinical, Laboratory and Radiological Technology for Health Systems Based on Primary Health Care Essential Drugs and Vaccines Drugs and Vaccine Quality, Safety and Efficacy Traditional Med~cine Rehabilitatlon AIDS Prevention and Control Programme Prevention of Rheumatic FeverRheumatic Heart Disease Research and Development in the Field of Vaccines Other Communicable Diseases Health lnformation Support Projects in Operation in Member Countries 139 INTERCOUNTR) ICP DGP 001 ICP COR 100 ICP COR 001 ICP COR 002 ICP HSC 001 ICP HST 001 ICP HST 002 ICP HST 100 ICP MPN 001 ICP MPN 004 ICP EHA 600 ICP MPN 005 ICP PHC 002 ICP PHC 100 ICP HRH 014 ICP HRH 019 ICP HRH 100 ICP HRH 100 ICP IEH 002 ICP IEH 100 ICP RPD 001 ICP RPD 002 ICP RPD 003 ICP RPD 100 ICP NUT 005 ICP NUT 007 ICP NUT 100 ICP MCH 012 ICP MCH 014 ICP MCH 015 ICP APR 001 ICP MCH 100 ICP HEE 001 ICP PSF 100 ICP CWS 001 ICP CWS 004 ICP cws 100 ICP RUD 001 ICP PCS 001 ICP CEH 001 ICP FOS 001 1 PROJECTS RB Director-General's and Regional Directoh Development Programme AS Coordination with other Organizations AS Liaison wfih ESCAP AS Coordination for Health Promotion RB Health-for-All Strategy Coordination RE Strengthening of Epidemiological Surveillance System RBlAS Heallh Situation and Trend Assessment RB Health Situation and Trend Assessment RBIFB Managerial Process for Health Development ST Strengthening Capaaly of WRs' Ofhs and JointGovernmenW#liO Coordination Mechanism VN Promotion of EHA Activities in SEAR Countries VD Intensified WHO Cooperation in SEAR RBND Promotion of Health for All with Primary Heailh Care as Key Approach, including Appropriate Technology for Health RE Organization of Health Systems Based on Primary Heakh Care RBND Development of Human Resources for Health VD Support for Management of Health Learning Materials Programmes RE Development of Human Resources for Health AS Planning and Information System for Development of Human Resources for , Health RWAS Promotion of Health Education RE Public Information and Education for Health RB Research Promotion and Development RE Collaboration in Research Programme RE Institutional Strengthening for Research RB Research Promotion and Development, including Research on Health-promoting Behaviour RB Nutrition Monitoring and Evaluation RE Strengthening Nutrition Programmes in Health Sector for Population in Greatest Need RE Nuuition FP WHO TSS Coordinator - SEAR0 VD Women. Health and Development VE Safe Motherhood Initiative RB Accident Prevention RB Maternal 8 Child Health, including Family Planning RB Health Care of the Elderly RB Psychosocial and Behavioural Factors in the Promotion of Health and Human Development RB Community Water Supply and Sanitation VD Building up of an Information Service in Environmental Health in Soulh-East %la RB Communily Water Supply and Sanitation RB Environmental Health in Rural and Urban Development 8 Housing RE Health Risk Assessment of Potentially Toxic Chemicals RBND Control of Environmental Pollutants and Hazards RBND Food Safety 140 The Work of WHO in SEA ICP CLR 001 ICP CLR 100 ICP EDV 001 ICP EDV 004 ICP EDV 005 ICP EDV 006 ICP EDV 100 ICP RHB 001 ICP RHB 100 ICP EPI 001 ICP CTD 001 RBNDI AS VD VD VD RB REND RB RBNl REND Clinical, Laboratory and Radiological Technology for Health Systems based on Primary Health Care Clinical. Laboratory and Radiological Technology for Health Systems based on Primary Health Care Development of Essential Drugs: Legislation and Quality Control Technlcal Cooperation in Pharmaceuticals in ASEAN Countries Development of Essential Drugs - Audiovisual Material Bi-Regtonal TCDC Meeting on Essential Drugs Action Programme on Essential Drugs and Vaccines Rehabilltatlon Rehabilitation Expanded Programme on Immunization Malaria and other Vector-borne Diseases Control Programme ICP CTD 002 RB Parasitic Diseases Control (ICP PDP 001) ICP CTD 100 ICP LEP 001 ICP CDD 001 ICP ARI 001 ICP TUB 001 ICP OCD 001 ICP VPH 001 ICP PBD 001 ICP NCD 001 ICP NCD 002 ICP GPA 100 ICP TDR 100 RB ST RBNC REND RBND RB VD RB RB VD FX AS Malaria and other Vector-borne Diseases Control Programme Leprosy Control Diarrhoea1 Diseases, including Cholera Prevention and Control of Acute Respiratory Infections Tuberculosis Control Other Communicable Diseases including Zoonoses Control of Zoonoses and Food-borne Diseases Prevention of Blindness and Deafness A Community-oriented Approach to the Prevention 8 Control of Non-communicable Diseases Prevention 8 Control of Deafness AIDS Prevention and Control Programme Strengthening of Biomedical Research Capacities REGIONAL OFFICE PROJECTS 000 RCO 103 000 EXM 001 000 GPD 001 000 GPD 002 000 ISS 001 000 IEH 001 000 HBI 001 000 HBI 002 000 PER 001 000 GAD 001 000 SUP 001 RB RB RB RB RB RB AS AS RBlAS RBIASI FB RBIASI FT RBlAS Regional Comminees Executive Management General Programme Development Staff Development and Training Informatics Management Public Information and Education for Health Health Information System Health Literature, Library and Information Services Support Services Personnel General Admlnistration and Services Support Services - Budget and Finance Equipment and Supplies for Member States Projects in Operation ~n Member Countries 141

ANNEXES Annex 1 Organizational Structure Regional Director u I I Director Administration and Finsnrr FIELD PROGRAMMES s