(WPRlRC4~/SRl~)
SUMMARY RECORD OF THE FIFfH MEETING Grand Ballroom I. Crown Princess Hotel. Kuala Lwnpur Wednesday. 21 September 1924 at 1.30 p.m. CHAIRMAN: Dr Abu Bakar (Malaysia) CONTENTS
ow 1.
Eradication of poliomyelitis in the Region: Progress report Sub-Committee of the Regional Committee on Programmes and Technical Cooperation .......................................................... .
168 176 176 179 180
2.
2.1 2.2
Country visits: Report of the Sub-Committee, Part I ............ .. Membership of the Sub-Committee .................................... .
3. 4.
Third monitoring of the Strategy for Health for All by the Year 2000: Report of the Sub-Committee, Part II Collaboration with nongovernmental organizations: Report of the Sub-Committee, Part III ............................................ .
186
- 167 -
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1.
ERADICATION OF POLIOMYELITIS IN THE REGION: Item 10 of the Agenda (Document WPRlRC4517)
PROGRESS REPORT:
The REGIONAL DIRECTOR introduced document WPRlRC4517, providing a progress report on poliomyelitis eradication. He was pleased to inform the Comminee of continued progress towards poliomyelitis eradication. The total number of poliolJlyelitis cases reported to the Regional Office continued to fall. It had reached an all-time low of 1214 in 1993, a further reduction of almost 40% from the 1992 level of 1912 cases. During the last four years the greatest concern had been the lack of oral poliovirus vaccine, which had been preventing countries from conducting national immunization days. That had been a major obstacle to one of the key strategies in the poliomyelitis eradication initiative. However, due to the strong commitment of governments and support from the international community, China, the Lao People's Democratic Republic, the Philippines and Viet Nam had been able to conduct national immunization days, with results that were a tribute to their leadership, organizational ability, commitment, and the generosity of donors. In China alone, over eighty million children had been immunized on 5 December 1993, and again on 5 January 1994. That was the largest number of people immunized in one single day ever recorded in the history of EPI and poliomyelitis eradication. days throughout the Region. The Lao People's Democratic Republic had reached 104 districts out of 129 and had achieved over 80% coverage of the target population. The Philippines had repeated its success of the previous year in organizing national immunization days and had again achieved more than 90% coverage. Viet Nam had conducted national immunization days that were among the most successful in the history of poliomyelitis eradication, achieving 98 % coverage. Cambodia had also launched a poliomyelitis eradication initiative, organizing Over one hundred million children under the age of five years had been immunized during those immunization
immunization days in two provinces. The Regional Director himself had had the opportunity to
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visit and observe the subnational immunization days in Cambodia, which involved 300 000 children, and had been most impressed by the dedication of the health staff at all levels. He congratulated the Ministers of Health of Cambodia, China, the Lao People's Democratic Republic, the Philippines and Viet Nam, and their staff, for their hard work. He also reiterated his appreciation to the international community for their supply of vaccine, particularly UNICEF, the Governments of Australia, Canada, France, Japan and the United States of America, the Centers for Disease Control and Prevention, (United States of America) and Rotary International. He thanked Malaysia again for the contribution to the campaign presented at the opening ceremony of the Committee. He would continue to do all he could to further strengthen collaboration and technology transfer among Member States, strengthening links with institutes in the Region to promote self-sufficiency in vaccine production. He was delighted to report that all the countries mentioned, including Cambodia, were already committed to conducting national immunization days for the fonhcoming low transmission season, in November 1994 and March 1995. The national immunization days already conducted, and to be conducted, would certainly have a marked impact on reducing the number of cases of poliomyelitis reported the following year. "Zero" status might be reached by the Philippines, and some provinces in China, by the end of 1994. The following year's goal would be WHO's slogan for World Health day, in 1995, reproduced on all calendars and publicity material, including those for countries with no poliomyelitis - "Zero Polio in 1995: Be wise, immunize". He was confident that together the Member States and WHO could build on the success of the poliomyelitis eradication initiative to strengthen the Expanded Programme on Immunization, including other disease control initiatives. However, he reminded the Committee that, as the number of cases of poliomyelitis was diminishing, it was becoming more and more important that not even one case was miSlled. All acute flaccid paralysis cases must be investigated thoroughly and without delay. investigation must include timely specimen analysis and follow-up for each case. Although there had been substantial progress in acute flaccid paralysis surveillance, there was still much to be done to improve the quality and timeliness of surveillance, especially in the use of the laboratory. Every case must be reported and investigated, with specimens tested in the laboratory, and followed up after 60 days. That
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Reporting zero cases was not sufficient for eradication.
Until a reliable acute flaccid
paralysis surveillance system was in place, the common goal of total eradication of poliomyelitis could not be achieved. The high level of political commitment must be continued if success was to be achieved. He invited everyone to take up the challenge for better surveillance, to continue together down the road towards eradication. Better surveillance was essential to prove to all that the common goal had really been achieved. . Dr ITO (Japan) congratulated the Regional Director and his staff on the marked progress made during the last 12 months, including the collaboration with the Governments of Cambodia, China, the Lao People's Democratic Republic, the Philippines and Viet Nam in organizing the successful national or subnational immunization days. Eradication of poliomyelitis was a global issue; Japan had sent project teams to
Shandong and neighbouring provinces in China, and to the Lao People's Democratic Republic, to work with both governments in order to improve the poliomyelitis surveillance system and conduct national immunization days. It was working closely with the Regional Office, through its participation in the Technical Advisory Group Meeting on the Expanded Progranune on Immunization and Poliomyelitis Eradication, and in the Interagency Coordinating Committee. Also, in response to the Regional Director's call in 1993 for support in the provision of oral poliovirus vaccine for national immunization days, it was cooperating or would cooperate in establishing management systems with Cambodia, China, the Lao People's Democratic Republic, the Philippines and Viet Nam. The Regional Office should continue to playa leading role in strengthening the regional capability for self-sufficiency in vaccine production. The national immunization days conducted during the winter of 1993 would have a positive impact on the number of poliomyelitis cases in 1994. It was hoped that the next year's report would be as encouraging as in 1994. Japan was ready to continue to work with the Regional Office, with countries still reporting poliomyelitis cases, and with other collaborating agencies, to achieve the goal of eradication. Dato' JEGATHESAN (Malaysia) said that his country was strongly committed to the eradication of poliomyelitis and would collaborate fully with WHO in establishing the epidemiological and laboratory systems for the eventual certification of eradication.
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Malaysia had reported three imported cases in 1992, and no case had occurred subsequently. In 1993, vaccination coverage had been 89.2%. Border coordination with neighbouring countries had been improved. Government staff had organized a fund-raising campaign for poliomyelitis eradication with associated bodies and industry, and a donation had been presented to WHO at the opening ceremony of the current session of the Regional Committee. Dato Awang CHUCHU (Brunei Darussalam) said that Brunei Darussalam had remained free of poliomyelitis since 1986. imported ones. The intensive efforts towards eradication made by WHO and its Member States where poliomyelitis was still endemic were commendable. The 40% reduction already achieved during 1993 and the progress towards the 1995 poliomyelitis eradication goal were very encouraging. It was hoped that continued efforts and further improvements in vaccine supply would ensure success. Dr DURHAM (New Zealand) commended the Regional Director for his report. She
It was maintaining very high immunization coverage and
further strengthening surveillance for acute flaccid paralysis to detect new cases, especially
asked whether there was any risk that the eradication programme would be compromised by a lack of vaccine, and what steps were envisaged to ensure that vaccine continued to be available for programmes in countries or areas at risk. Dr ZHOU (China) said that the report presented an objective analysis of the situation in the Region, confirming its achievements and difficulties and suggesting solutions, which strengthened confidence in the achievement of the goal. Untiring efforts had been made to coordinate the implementation of the Regional Committee's resolutions on the subject. The adoption of the right policy and strategies, with national immunization days in countries where the disease was still endemic, and strengthened surveillance, had enabled the Region to reduce incidence to the lowest level in 1993 and to enter the final stages of eradication. The achievements must be maintained by constant efforts, taking advantage of the opportunity to strengthen cooperation. On the basis of the experience gained, more effective national immunization days would be organized in the winter of 1994 so as to block the transmission of wild poliovirus and move nearer to the goal of eradication.
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China fully realized its position and responsibility in the Region;
in recent years the
priority given to the campaign by the Government and the hard work of all concerned, together with the great support of international organizations and donors had enabled much progress to be made. The incidence had continued to drop and the wild virus reserve was shrinking as a
result of the immunization days in 1993 and 1994. In order to strengthen surveillance, training courses had been held in epidemiology, and computer and laboratory technology, and there had been a national meeting with the participation of provincial health administrative workers in 1994. A field study of eradication was taking place in one-third of the provinces. Extended outbreak response immunization in two stages was being organized in six provinces. Shortage of resources affected the work to some extent. A survey had shown that the 1993 and 1994 national immunization days had cost US$ 100 million, most of the expense having been incurred in the health institutions at grass-roots level. More support was needed for publicity, surveillance and investigation, as well as operations in poor and remote areas. Cold-chain equipment was in urgent need of repair or replacement. He appealed to the international community to provide continued support. Dr MILAN (Philippines) said that the report gave grounds for optimism about the achievement of eradication. Countries had intensified their efforts, and surveillance capabilities had been reviewed and strengthened. example showed. In the Philippines there was high political and professional motivation and commitment. The third round of national immunization days was planned for February and March 1995. Booster vaccinations were scheduled in 1996, with a fourth dose to children of 15-18 months. Acute flaccid paralysis surveillance was continuing, with the appropriate follow-up, through 401 surveillance and reporting units; there was also community-based training for surveillance workers, immediate transfer of specimens, and standardization of case definition. Much remained to be done if eradication was to be assured. WHO's continued support was needed and she was confident of further collaboration. Dr HOP (Viet Nam) commended the Regional Director for the report which showed marked progress towards eradication. Viet Nam was firmly committed to that goal. Besides routine vaccination, two national immunization days had been organized in 1993; 9.3 million children under five years old had received two doses of oral poliovirus vaccine, giving the high Resource mobilization was continuing, as Malaysia's
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coverage (98 %) reported. Poliomyelitis incidence was at its lowest level in history. Further national immunization days would be organized in November and December 1994. The provision of vaccine was vital: 30 million doses would be needed. Viet Nam itself expected to be able to produce 16 million doses by the end of 1994 to add to the supplies of WHO, UNICEF, Rotary International, Australia, Canada, France, Japan and other countries, which it was hoped would complete the requirements. Dr WILLIAMS (Cook Islands) expressed appreciation of WHO's efforts in helping to achieve poliomyelitis eradication. He was impressed by the 40% reduction in cases since 1992 and the lowest incidence in history (1214 cases). The figures in the document showed a correlation between the immunization effort and progress towards the goal; if the curve was continued, the projection did not show that poliomyelitis would be eradicated from the Region in 1995, but gave good hopes for 1997 or at the latest 2000. If efforts were accelerated it might still be possible to achieve the 1995 goal. There was no poliomyelitis in Cook Islands and no cases had been introduced since 1959, thanks to the maintenance programme. He understood that free supplies of vaccine from UNICEF would soon end, and he appealed for continuation of the necessary cooperation even after eradication. Dr RHIE (Republic of Korea) expressed appreciation of the great success of WHO's continuous effort, which made poliomyelitis eradication achievable. In the Republic of Korea poliomyelitis had been completely eradicated by 1983. The Government would remain in close cooperation with WHO and its Member States for poliomyelitis eradication and the prevention of resurgence. Dr MONTAVILLE (France) expressed his country's support for the eradication programme and its view that both injectable and oral poliomyelitis vaccine could be used. Many countries had successfully used the former for their eradication campaigns. He observed that the law of diminishing returns and of economic efficiency applied also in the health field: just as in commerce, it might be said that 80% of the sales were made to 20% of customers, but that the remaining 20% had to be made to the rest of the consumer public at large. So too, in the health field, a relatively small number of diseases might account for most of the treatment, while for poliomyelitis eradication a major effort would be needed to complete the small but important remaining tasks.
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In such circumstances he urged that the use of injectable vaccine in WHO's progranune should be accepted to ensure that the achievements were not frustrated by last-moment difficulties with costs and failure of supplies. Mrs HONG TlY (Fiji) said that the progranune in her country had been a high priority since the 1950s and 1960s and that the importance of vaccination had increased further in the 19808 with the expanded progranune on immunization, which had raised coverage for vaccine-preventable diseases to over 90%. Difficulties had been encountered with the A major reduction had extension of measures to remoter parts of the main islands and to smaller islands. The cold chain was hard to provide and maintain under such conditions. nonetheless been achieved in vaccine preventable diseases in Fiji, which had had no case of poliomyelitis since 1962. A suspected case in 1993 had been found not to be poliomyelitis. Fiji was in a position to meet pre-eradication requirements according to the indicators. The government was pursuing the elimination of neonatal tetanus by 1995 and the reduction of measles cases by 90% by 1995. She appealed to WHO to continue to ensure the necessary trammg and supplies of vaccine to achieve eradication in the Region; UNICEF's withdrawal should not be allowed to interrupt supplies of essential vaccines. available. Dr NHONH (Cambodia) recognized WHO's part in the eradication campaign in his country which, like others where the disease was still endemic, had committed itself to the continuation of priority measures including national immunization days in the season of low transmission. Logistics and the quality of available vaccines created certain difficulties. Future support in removing the obstacles would be appreciated. Monitoring and surveillance were the key to continued success. Dr PY AKALYIA (Papua New Guinea) joined other speakers in commending the Regional Director for an excellent report. encouraging. The downward trend in reported cases was No case had been reported in his country in the last three years, but the She hoped adequate resources would be made
Bougainville crisis was a cause for concern, making reliable reporting difficult. He expressed appreciation of the cooperation of countries which had given support during the crisis.
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17S
Dr TAPA (Tonga) congratulated the countries in which poliomyelitis was endemic on the 40 % reduction in the total number of cases reponed in 1993 as compared to 1992. The Region was on target with respect to objectives, which was a remarkable achievement and an inspiration for other WHO regions which had not yet eradicated the disease. Tonga would continue to suppon both the eradication programme and surveillance even after the goal had been achieved. Donors had been very generous, and he hoped they would maintain their funding in order to free the last countries from the disease. Dr ABRAHAM (United States of America) agreed that progress towards poliomyelitis eradication in the Region had been truly remarkable and complimented the Regional Director on his vision and leadership in supponing that undenaking. China, in particular, was making an extraordinary effort to mobilize the entire country. A final drive must be made so as to certify eradication in the Region. He encouraged countries where the disease was not endemic to take the necessary steps to demonstrate interruption of transmission. He asked what constraints or obstacles remained on which the Committee should focus its attention. Dr PHILAYSAK (Lao People's Democratic Republic) said that during his country' S national immunization days in 1994, 80% of children under five years of age had received two doses of oral poliovirus vaccine. As a result of better intersectoral collaboration and good community participation, his country was approaching the goal fixed for 1995. He recognized the benefits of close collaboration with WHO, support from the Government of Japan, and other bilateral and multilateral cooperation. Mr WAENA (Solomon Islands) said that he looked forward to continued momentum in the six poliomyelitis-endemic countries to eradicate the disease by 1995, and hoped that every effort would be made to achieve the target set for the Region. He congratulated in particular the Government and people of Papua New Guinea for achieving zero cases for three consecutive years, and hoped that the country would soon be declared free from poliomyelitis. The REGIONAL DIRECTOR thanked the Government of Malaysia for its generous donation towards poliomyelitis eradication. He was sure that the remaining poliomyelitis-endemic Member States would make the utmost efforts to ensure that by the end of 1995 no new case would be reported. That did not mean complete eradication by the end of 1995. eradicated, which would take some years. Further mopping up operations would be necessary. Surveillance would have to demonstrate scientifically that poliomyelitis had been Surveillance mechanisms therefore had to be strengthened in all Member States. Vigilance was also necessary because at any time a case
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might be imported from neighbouring regions or countries or an occasional outbreak might occur. Naturally, immunization would have to continue in order to maintain the immunity level of the population until eradication could be declared throughout the world. In response to queries concerning vaccine requirements, he specified that for 1994, a total of 515 million doses of vaccine were required in order to be able to administer two doses of supplementary vaccine to children under five years of age (except in China where, because of the vast numbers involved, the age limit had been set at under four years). He was happy to report that with donations and support from the international community, together with local production of 16 million doses in Viet Nam, the required number of doses was available. The 1995 vaccine requirements, with a similar target population, were 525 million doses. There was, however, a shortfall of 186 million doses, at a cost of US$ 8.7 million. That calculation was based on a price of US$ 0.09 per dose for imported vaccine. In the case of locally produced vaccine, health authorities might have to purchase them from the producing institution, so external financial support would be used for procurement within the country. In China, for example, the unit cost had been calculated at US$ 0.02. The 186 million doses still needed did not include possible production in Viet Nam of 10 million doses. He urged the international community to increase support so that that shortfall could be bridged. He had learned that the Government of Japan was willing to increase its contribution, and that the Australian International Development Assistance Bureau had made a special provision of 110 million Australian dollars for health sector support in Indochina. Part of that amount would be allocated to poliomyelitis eradication. With those and other increased contributions he hoped that the required amount of vaccines could be obtained for next year. Together, the Member States, the international community and WHO would achieve the target of zero poliomyelitis cases by 1995.
2.
SUB-COMMITTEE OF THE REGIONAL COMMITTEE ON PROGRAMMES AND TECHNICAL COOPERAnON: Item 11 of the Agenda
2.1
Country visits:
Report of the Sub-Committee. Part I:
Item 11.1 of the Agenda
(Document WPRlRC45/8) Dr KOTEKA (Cook Islands), introducing the report of the Sub-Committee, said that item (5) of the Sub-Committee's terms of reference was "To undertake country visits to review and analyse the impact of WHO's cooperation with Member States". In June 1994, four of the Sub-Committee members had visited Solomon Islands, Singapore and the Philippines to review
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cooperation in the field of health and sustainable development - environmental health. implications.
The
Sub-Committee had then met as a whole in Manila to discuss their findings and their regional The individual recommendations made by the Sub-Committee to each country were included in the report. Key recommendations for the Region had included: (1) There must be involvement and support at the highest levels of government to effectively resolve issues of health and sustainable development; (2) WHO had an important role to play in building awareness, promoting intersectoral coordination, and finding creative approaches to problem-solving. Sometimes that would be a lead role; sometimes a supportive role would be more effective and appropriate; (3) There was considerable expertise and relevant experience on various environmental health issues in the Region. Member States, working with WHO, should take greater advantage of this indigenous talent; and, (4) The new focus provided by the Regional Strategy on Health and Environment, particularly as it related to the integration of health and environment concerns in sustainable development, was quite appropriate, and should continue to be vigorously implemented. It was hoped that the Regional Committee would endorse the recommendations of the Sub-Committee, and consider the subject of the country visits in 1995, as well as the Member States proposed to be visited. The proposed subject was WHO's collaboration in the field of healthy lifestyles with focus on tobacco-or-health activities. Australia, China and Singapore. Dr ADAMS (Australia) endorsed the report of the Sub-Committee and its The proposed countries were
recommendations. He supported both the suggested topic for review in 1995 and the proposed country visits. Australia would be pleased to facilitate the visit of the Sub-Committee in 1995. Dr NIETO (Philippines) said that the much-appreciated visit of the Sub-Committee to her country had resulted in measures that included the Philippine Council for Sustainable Development's efforts to ensure that environmental laws were enforced and the appropriate sectors involved in planning. A Presidential Executive Order required government agencies to contribute to an investment plan for water and sanitation including water resources management. A "Water Summit" was planned for all affected sectors and government offices in December 1994. The Department of Environment and Natural Resources had strict instructions to apply the necessary sanctions for illegal logging.
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The health sector had adopted for 1995-1996 the slogan "Think Health - Health Link" to emphasize the need for coordination and collaboration in and between all agencies and for the attainment of the health-for-all goal. The Philippines would continue to collaborate with WHO and other agencies and to seek their guidance in pursuing an integrated approach to health and the environment. Dr CHEN (Singapore) fully endorsed the recommendations of the Sub-Committee. She thanked the Regional Director for support provided to Singapore's environmental health programme in the form of training fellowships and expert advice. degradation. Noting the conclusion that there had been few ~ollaborative
Her
~ountry
had
progressively expanded environmental health activities in order to prevent environmental
activities in environmental ~ollaborate
health between Singapore and WHO she said that her country would be happy to
further and to share its experience on environmental health with Member States.
If the
Regional Office wished to establish a WHO collaborating centre for environmental health in the Western Pacific Region, Singapore would be most glad to offer its services, having recently set up an institute for environmental epidemiology. Singapore heartily welcomed the visit of the Sub-Committee in 1995 and undertook to share with it all its experien~e
in the field of healthy lifestyles.
Dr TAPA (Tonga) took note of the findings of the Sub-Committee during the country visits and the regional implications. He endorsed the recommendations of the report, the topic suggested for review in 1995 and the proposed country visits. Dato Awang CHUCHU (Brunei Darussalam) fully endorsed the conclusions and recommendations of the Sub-Committee. His country was committed at the highest political level to promoting health and sustainable development. A new high-level national committee on environment, in which the Minister of Health took full part, was responsible for coordinating the worle of concerned national agencies and for providing an overall framework for environmental management. His country had received technical support and advice on a number of environmental health matters, and he was grateful to Singapore for its support in the training of public health personnel in various fields of environmental health. Dr HAN (China) noted with pleasure that the Sub-Committee would visit his country next year, and endorsed the suggested topic. Sub-Committee any support it might require. China welcomed the visit and offered the
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Mr WAENA (Solomon Islands) expressed sincere appreciation for the visit of the Sub-Committee to the Solomon Islands. It had been extremely useful and very timely. The report of the Sub-Committee on its visit and its findings were concise and accurate. His country sincerely valued and took note of the recommendations which were being considered for appropriate action. He commended the hard work and dedication of the memben of the Sub-Committee, who had accomplished the programmed activities under difficult conditions. He fully supported and endorsed the general recommendations contained in the introduction to the report. Dr MONTA VILLE (France), praising the quality of the report, said that France was aware that environmental health problems were already significant in the Region and were likely to worsen. Their complexity and the cost of solutions called for better collaboration with institutions responsible for health, environment and development, such as, in the Region, the South Pacific Commission. Environmental health could also be an essential area of The Regional Office for Europe, for example, collaboration among WHO regional offices. already had solid expertise in that field. Dr ENOSA (Samoa) stressed the importance of environmental health issues, especially the problems of waste management and disposal in island nations. He expressed support for the report and its recommendations, and approval of the choice of countries to be visited in 1995. The CHAIRMAN requested the Rapporteurs to prepare an appropriate draft resolution.
2.2
Membership of the Sub-Committee: Item 11.2 of the Agenda The REGIONAL DIRECTOR said that the current members of the Sub-Committee were
Australia, China, Cook Islands, the Lao People's Democratic Republic, the Federated States of Micronesia, the Philippines, the Republic of Korea and Samoa. The members of the Sub-Committee whose periods of tenure were due to expire in 1994 were Cook Islands, the Lao People's Democratic Republic, the Republic of Korea and Samoa.
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In considering countries to replace the four outgoing members, it seemed desirable to maintain a representative variety of health and socioeconomic situations. He therefore suggested that the Committee consider appointing Japan, Malaysia, Tuvalu and the United States of America (Commonwealth of the Northern Mariana Islands), to replace the four outgoing members of the Sub-Committee. Dr ADAMS (Australia) proposed that the Regional Committee accept the Regional Director's suggestion. Dr TAPA (Tonga) seconded the proposal. Mr NIOWENMAL (Vanuatu), Mr MATSUNAGA (Japan) and Dr ENOSA (Samoa) also supported the proposal. The CHAIRMAN asked the Rapporteurs to prepare an appropriate draft resolution.
3.
THIRD MONITORING OF THE STRATEGY FOR HEALTH FOR ALL BY THE YEAR 2000: REPORT OF THE SUB-COMMITIEE, PART II: Item 12 of the Agenda (Documents WPRlRC45/9 Rev.1 and Corr.l) Mr KEO (Australia), introducing the report of the Sub-Committee, drew the Committee's
attention to document WPRlRC45/9 Rev.l. In 1981, the Committee had approved a Plan of Action for the implementation of the Regional Strategy for Health for All by the Year 2000. In that plan of action, explicit steps were to be taken to monitor and evaluate progress in the implementation of the strategy. The monitoring activities had been carried out by countries in 1983 and 1988, and evaluations in 1985 and 1991. The Committee was to examine the third report on monitoring. The document was a synthesis of the national monitoring reports, of which 18 had been received at the time of the Sub-Committee meeting. and an additional four received as at 5 September 1994. The revised document contained information from all the reports received. Although the response rate had been relatively low, the Sub-Committee believed that that did not indicate a loss of interest in the very useful and important activity. It would be useful if the Regional Committee would indicate how to improve the survey. The report emphasized that at the current stage of development, it was more important than ever for all countries to report and share their valuable experiences.
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All health systems in the Region were based on the assumption that they must contribute to making the population socially and economicaliy productive and be in harmony with overall socioeconomic development efforts. That assumption had been translated Into the health Indicators had in turn been
development goals formulated at the beginning of the 1980s. those indicators for all countries in the Region.
formulated to reflect the progress in achieving those goals. Tables I to 9 showed the status of
The economic advances in the Region had been followed by healthier lives for the people of those countries. However, they had also resulted in increased demands for a larger number of health services which cost more. Many countries were now re-examining the allocation of resources within their health systems. Health systems reform had become a major priority for those countries. In a number of countries and areas, despite gains such as the expected eradication of poliomyelitis, a number of the old problems such as malaria and tuberculosis remained. In the vast majority of countries, the emerging epidemiological disease pattern was influenced by the more chronic conditions resulting from aging or lifestyle-related degenerative diseases. addition, the possibility of an HIV/AIDS epidemic persisted. Community participation and intersectoral cooperation were receiving renewed emphasis. The promotion of healthy behaviour and the protection of a health-sustaining environment had become major concerns of the health sector and would continue to be principal areas of emphasis in the future. Prior to 1991, most reports on the health-for-all strategy had concluded that the main achievement of the health-for-all movement had been to enable countries to develop relevant frameworks for national health systems. That was in sharp contrast to previous simple descriptions of the health system before health for all started, as places where the ill received basic health services. The 1991 evaluation had shown that countries and areas were beginning to see how fundamental changes in the health system might be made in response to the rapid political, social and economic changes that countries were experiencing. The current In
monitoring report indicated that most countries and areas were embarking on significant health reform initiatives that would produce a long-lasting impact on the existing health system in the years to come.
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The Regional Director had shared his views on the new horizons in health. The repon before the Committee provided clear evidence of the progress that had taken place so far in the health status of the Region, and presented good grounds for expecting funher advances in the future. Dr HAN (China) welcomed the fact that the Region had made great strides towards health for all. However, many countries had experienced an increase in health needs and health expenditure.
It was essential not only to seek more resources for health, but also to use
resources more rationally and economically, through scientific management. Developing countries could learn better ways of running their health services from technically developed countries. Many countries still had to cope with so-called old diseases such as malaria and tuberculosis, but the Region was undergoing a change in the pattern of disease. As a result of unhealthy lifestyles, chronic diseases were on the increase, and there was a need to make correct choices concerning health care systems, policies and priorities. International cooperation had an imponant role to play in promoting health for all. WHO could help by summarizing the valuable experience of Member States resulting from health reforms and by strengthening exchanges between countries. There was a serious need to review and adjust the indicators for monitoring progress towards health for all in the light of the contrasting socioeconomic and health situations in different countries. indicators more scientific. China would be prepared to host such meetings. Mr KEO (Australia) said he welcomed the significant progress made towards improving the health situation in the Region. Member States should be encouraged to develop specific national strategies and contribute to the coordination and implementation of regional strategies for the prevention, treatment and control of malaria, tuberculosis and HIY/AiDS. imponant to maintain and improve upon the public health gains already achieved. His delegation disagreed with the statement in section 7.1 of the repon that population growth was not a major issue for most countries of the Region. The statement failed to Funhermore, recognize that population pressures were mounting, especially in urban areas. It seemed
appropriate to convene international meetings to pool knowledge and experience and make the
It was
the third paragraph of the conclusion, although factually accurate, offered little encouragement to Member States to develop national and regional strategies to limit and reverse the deterioration in the regional malaria situation, to integrate reproductive health into primary health care, to reduce the impact of the resurgence of tuberculosis, and to minimize the
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disastrous consequences of the anticipated HIV f AIDS epidemic by implementil18 comprehensive programmes for prevention and control. Dr ABRAHAM (United States of America) commended the Sub-Committee's comprehensive report for its thorough analysis of issues relating to health reform initiatives and their implementation. He asked if the representatives at the Regional Office had any explanation for the low response rate. Dr TAPA (Tonga) also expressed concern at the low number of countries that had submitted reports in time for the Sub-Committee's consideration, although it was gratifying that four more countries had submitted reports later. representative of Australia on section 7.1; He agreed with the comment of the population growth was certainly a problem in
Tonga, and he suggested that "most countries" be amended to "some countries". He urged the Regional Office to support countries, on request, in preparing their monitoring reports. He said he was heartened by the Sub-Committee's finding that there had been dramatic improvements in the health situation, and that it had been encouraged by the progress made. Tonga endorsed the report of the Sub-Committee. Dr PY AKALYIA (Papua New Guinea) said that many governments were not allocating a sufficient proportion of the national budget to the health services. insurance or health care. An adequate government allocation was particularly important in countries where few people could afford health He urged the Committee to recommend a desirable budgetary allocation for health, as that would help health ministries to obtain more funding. Dr HOP (Viet Nam) agreed that efforts were needed to secure a better response rate from Member States. He drew attention to an error in the first paragraph of section 4.1: Viet Nam allocated 4.5 % of its gross national product to health, not 1 %. The figure was given correctly in Table 2. Mr BENJAMIN (Federated States of Micronesia) pointed out that since his country's contribution had been received late some information had not been included in the report. He asked for the inclusion in section 4.2 of a reference to the Pacific Basin Medical Officers' Training Program based in Pohnpei. Subject to that amendment, his delegation fully endorsed the report. Dr ENOSA (Samoa) said he regretted that his country's monitoring report had not arrived in time. Director. He had brought the report with him and had handed it to the Regional He appreciated the importance of submitting monitoring reports, which were a
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source of valuable information and advice for other countries. He supported the amendment to section 7.1 proposed by the representative of Tonga. Dato' MEGAT (Malaysia) said that the evaluation of progress at national and regional levels was important for the purpose of reviewing and updating plans. His country found it useful to conduct mid-term and final reviews of five-year plans. Such reviews were helpful for improving plans, programmes, activities and targets. To keep pace with urbanization, for example, access to health services for lower-income groups had been given priority in the mid-term review of the 1991-1995 health plan and would again receive priority in the next five-year health plan. His delegation believed that the document was mosl useful and was worthy of consideration and use by various forums of WHO. Dr WILLIAMS (Cook Islands) congratulated the Sub-Committee on ils report, which he endorsed. He welcomed the progress made in the Region over the past three years. Changes in disease patterns and improving economies had given rise to new health problems, mainly related to changing lifestyles. Greater efforts and resources would be required to improve the situation in the future. Cook Islands recognized the value of the monitoring exercise. In view of the poor level of response, he requested the Regional Office to provide support to small island nations in preparing their country reports. Mr DICKINSON (Hong Kong) commended the report but drew attention to a minor discrepancy in section 7.1 of the Annex; the figure for the proportion of elderly in the population of Hong Kong should read 8.5 %, as correctly shown in Table 1. Dr DY (Cambodia) congratulated the Sub-Committee on its work. The low response
rate was partly due to the fact that, in some countries, information systems were inadequate. He hoped that support could be given to those countries to enable them to upgrade their systems. Nevertheless, the tables in the report permitted a useful comparison of the health status in the different countries in the Region, which should encourage countries to enhance their efforts towards health for all by the year 2000. Mr LUI (Tokelau), praised the report, expressed his regret that Tokelau had not participated in the monitoring and summarized the current situation in the country.
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For the first time a political leader headed the Department of Health in 1994. organizations.
That
ensured strong government support for policies, and the support of the various community
Reorganization of the health infrastructure had reaffirmed intersectoral links between government and nongovernmental organizations. Developed as part of the national strategic plan, the new organizational structure reflected a will to improve primary health care and all other forms of health care, also reflected in the programme for the biennium 1994-1995. The department was providing new services, and setting up a diagnostic unit. The restructuring of the department would be accelerated with the establishment of new managerial positions. The regional office was providing a resource person to help apply the managerial framework, also affecting the secondary level of care. The need for intersectoral collaboration and community involvement for health in social and economic community programmes was recognized. Communities had health committees which, in collaboration with the Health Department, carried out health-related activities. A health education officer had been appointed to help devise policies that enabled people to avoid health risks and ensure proper nutrition, reducing the risks of related diseases. The Health Education unit was developing a cookery book in Tokelauan, promoting local foods and giving guidance for their preparation. A 1991 survey showed that the water supply provided in the three atoll communities was 75 litres per person per day. Thanks to a programme initiated by the Government of New Zealand in collaboration with UNDP further improvements were under way. A UNFPA maternal health programme, with WHO as the executing agency, had been established. All pregnant mothers received care and their children were delivered in hospital by trained personnel. All infants were immunized against the six childhood diseases, with the exception of measles, before their first birthdays. Hepatitis B immunization had not been given under a regular programme until 1993. Mrs HONG TIY (Fiji) said that in Table 7 in the Annex to the report the number of cases of poliomyelitis reported by Fiji should read zero and not 33 as shown. Dr MONTAVILLE (France) said that in order to avoid so many blank entries in the tables and to support local administrations, which were sometimes overburdened with requests for data, it might be preferable to collect all the data available within the various units at the
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Regional Office and then to request Member States to validate or update that infonnation. France had made a similar suggestion some years earlier in the European Region. The REGIONAL DIRECTOR thanked representatives for their comments and assured them that the necessary corrections would be made to the report. Appropriate amendments would also be made to section 7.1 to take account of the comments made by the representatives of Australia, Tonga and others. He agreed with the representative of Australia that greater efforts were required in the areas of malaria and tuberculosis and would be happy to see the conclusions strengthened in that regard. The response rate from Member States, although somewhat slow, had improved to about 80%, compared with only around 65% in earlier exercises. The lack of response from the small Pacific countries and areas might be due to problems in preparing the data. If requested, the Regional Office could provide help in that regard, through the WHO Representatives in the first instance. However, the main purpose of the exercise was to help Member States to strengthen their health infonnation systems and to stimulate the development of their evaluation and monitoring mechanisms. It was an exercise for the benefit of Member States, not for the benefit of WHO. In reply to the representative of Papua New Guinea, he said that it was difficult to suggest an optimum level for the proportion of national resources to be spent on health but the indicator established in that regard in the formulation of the Global Health-for-All Strategy was that it should be at least 5 % of gross national product. idea of the appropriate level. The CHAIRMAN requested the Rapporteurs to prepare an appropriate draft resolution. Of course, that was open to interpretation, since the situation differed from country to country. Nevertheless it gave some
4.
COLLABORATION WITH NONGOVERNMENTAL ORGANIZATIONS: REPORT OF THE SUB-COMMITIEE, PART III: Item 13 of the Agenda (Document WPRfRC45/10) Dr HAN (China), introducing the report of the Sub-Committee, said that, at its fortieth
session in September 1989, the Regional Committee had established guiding principles for collaboration with nongovernmental organizations. Resolution WPRfRC40.Rll had requested the Regional Director, inter alia, to foster collaboration with selected nongovernmental organizations. The resolution had also requested the Sub-Committee to review WHO's
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collaboration with nongovernmental organizations from time to time as appropriate and to report to the Regional Committee on its findings. At its Ninth Meeting on 13-17 June 1994, the Sub-Committee had reviewed a report on the activities undertaken by the Regional Office in collaboration with nongovernmental organizations in the Region. It had noted that collaborative activities had been expanded and developed with 94 regional and national nongovernmental organizations according to the guiding principles adopted by the Regiotlal Committee at its fortieth session in 1989. All those nongovernmental organizations had shown keen interest in conducting joint activities. The Committee might wish to recommend that WHO should continue to foster working relations with nongovernmental organizations, that such relations might not need to be formalized if flexible working arrangements were adequate and effective, and that regional and national databases on nongovernmental organizations should be developed. He noted that the document WPRlRC45/1O had inadvertently omitted the entry for the World Organization of National Colleges, Academies and Academic Associations of General Practitioners/Family Physicians (WONCA). Dato' WAN MAHMUD (Malaysia) supported WHO collaboration with nongovernmental organizations. In Malaysia, the Ministry of Health held regular meetings with nongovernmental organizations in relation to food safety, cancer, AIDS and various other matters. The Ministry had encouraged the development of a nongovernmental organization council on AIDS and had provided financial support for AIDS activities through that body amounting to RM 100 000 in 1993 and RM 1 million in 1994. Mme SILVA (Macao) said her delegation supported the conclusions and
recommendations made by the Sub-Committee as her government had long recognized the importance of working with nongovernmental organizations. By reason of its small size and limited resources, Macao society had been structured to allow activities to be carried out through the combined efforts of the Government and nongovernmental organizations. For example, nurseries, kindergarten schools, old people's homes and residences for handicapped persons, were run by nongovernmental organizations with technical and financial support from the government. Church organizations had played an important role in the medical field with the first hospital being established in 1575 by a bishop. A Chinese charitable organization, "Tung Sin Tong" had contributed greatly to the practice of traditional medicine. Associations such as the Macau Social Science Association, the Association of Environment, the Green Power, the Association of Continuing Education, had worked closely with the Government on
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envirorunental issues. During the commemoration of the International Year of the Family, six out of seven executive committee members were representatives of nongovernmental organizations . In the health field, the Kiang Wu Charitable Association, the Macao Lions Club, World Vision, Caritas and various academic and professional associations had jointly organized activities in health education, maternal and child health and family planning, nutrition and food hygiene, anti-smoking and anti-drug campaigns and disease prevention and control including AIDS. The most important and fruitful collaboration was with the Macau "Kai Fong", the neighbourhood associations, which were well structured, basic community organizations covering the whole territory in 24 areas under the overall supervision of a head office. Those had contributed to health development, especially in mobilizing resources and community participation. Dr ADAMS (Australia) endorsed the conclusions and recommendations in the report. It would be particularly important to maintain close links with nongovernmental organizations concerned with HIV/AIDS during the transition to the new loint and Cosponsored United Nations Programme on HIV/AIDS. The CHAIRMAN requested the Rapporteurs to prepare an appropriate draft resolution.
The meeting rose at 4.45 p.m.