Chapter 15 SUPPORT SERVICES Organizational Structure The organizational structure of the Regional Office as of 30 June 1990 is shown in Annex 1. 15.1 PERSONNEL As of 30 June 1990, the Regional Office had 133 established professional posts as compared to 135 on 30 June 1989. Table 13 shows the number of posts in the professional category in the Region, funded from all sources, and the number actually filled, as of 30 June 1990. During the period under review, 196 consultants were employed in various programmes for periods ranging from one week to eleven months. This represents an increase of 17 per cent in the number of consultants employed, compared with the previous year. Eight professional and three general service staff members separated from WHO service. One general service staff member died during the year. Three professional and eight general service staff members retired during the year. Five professional and two general service staff members left the Region on reassignment to other regions of WHO or other UN Agencies. TABLE 13. Number of professional posts, by location (As of 30 June 1990) Posts Regional and Country Total intercountry Established 72 61 133 Filled by appointment* 61 46 107 Posts frozen 3 1 4 Still to be filled 8 14 22 Of which: (a) candidates selected 5 3 8 (b) candidates yet to be selected 3 11 14 *Includes 8 posts filled by consultants. As of 30 June 1990, 33 national staff were employed on Special Service Agreements. A list of projects in operation during the year is given in Annex 2. Staff Developent and Training A seminar for country-based administrative staff was held in the Regional Office from 18 to 21 July 1989 with a view to improving communication between the country offices and the Regional Office and expediting implementation of WHO programmes in the Member Countries. It enabled the participants to have a better understanding of WHO'S procedures and processes as well as programme management. Some General Service staff in the Regional Office were trained in computer operations, including word processing. Consideration is being given to the introduction of self-learning programmes on a trial basis. Between July and October 1989, selected General Service staff from the WHO Representatives' Offices in Bangladesh, Bhutan, Indonesia, Maldives, Mongolia, Myanmar, Nepal, Sri Lanka and Thailand were imparted two-week's training in computer operations in the Regional Office. A training seminar for professional staff was held on 18 September 1989 to improve the efficiency of the staff and the functioning of the Organization. It covered such areas as completed staff work, report writing, and financial and personnel management. The WHO Representatives to Bangladesh and Mongolia participated in the Sixth Interregional Seminar for WHO Representatives, held in Geneva from 31 October to 10 November 1989. Support was provided to enable a staff member to participate in an international health programme. 15.2 GENERAL ADMINISTRATIVE SWVICES 1. Regional Office Building The installation of a second standby generator is in progress and is expected to be completed in 1990 providing full back-up for all Regional Office electrical requirements. The upgrading of fire prevention and safety installations is in progress and is expected to be completed before the end of 1990. Both projects are expected to be completed within the financial provision allotted for the purpose under the Real Estate Fund. An additional project to renovate and upgrade the existing telephone system in the Regional Office was approved by the Forty-third World Health Assembly in May 1990 and will be implemented during 1990-1991. 2. Office Autoriation The Regional Administration and Finance Information System has been implemented on an IBM 36 mini computer. This will provide expanded capability for financial and implementation information for operational and managerial purposes. Additional information systems in support of personnel, supply services and administra- tive processes are in operation and are being further developed with a view to interlinking them to provide a comprehensive administrative data base in support of managerial decision- making. 15.3 BUDGET AND FINANCE The total obligations for the biennium 1988-1989, as of 31 December 1989, under all sources of funds, amounted to US$ 99 774 588 - an increase of 9.0 per cent over the previous biennium - as against the total obligations of US$ 91 521 299 during 1986-1987 (Table 14). TABLE 14. Total obligations 1984-1985 1986-1987 1988-1989 US $ Amount Percentage Amount Percentage US $ Increase1 US $ Increase1 (Decrease) (Decrease) Regular Budget 61 203 672 60 970 500 (.4) 69 704 600 14.3 UNDP 7 420 104 10 095 289 36.1 7 972 569 (21.0) UNFPA 2 026 202 1 119 458 (44.8) 1277 466 14.1 Other Sources 15 628 267 19 336 052 23.7 20 819 953 7.7 Total 86 278 245 91 521 299 6.1 99 774 588 9.0 The total obligations from 1 January to 31 May 1990 under the Regular Budget amounted to US$ 23 976 293 representing 29.7 per cent of the regional allocation for the 1990-1991 biennium. WHO internal auditors visited the Regional Office in November- December 1989 to conduct routine financial audit. In addition, the Organization's external auditors visited the Regional Office in January 1990 and conducted a financial audit in respect of the closure of 1988-1989 accounts of the Regional Office. 15.4 SUPPLIES AND EQUIPMENT Medical supplies and equipment worth ~S$16 737 078 were procured during the period July 1989 - June 1990. Apart from conventional items such as drugs, laboratory equipment, hospital equipment, surgical instruments and office equipment, an increased number of requests for diagnostic kits and supplies were processed in this period. In the area of health literature, the period also witnessed an increasing number of requests for CD-ROMs, particularly for projects related to medical research and environmental health. CD-ROMs, medical literature and publications worth US$ 345 541 were procured of which WHO publications accounted for US$ 18 536. While processing requests for health care equipment, emphasis was laid on factors such as training and installation services offered by suppliers, proximity of suppliers, availability of spare parts, etc., in accordance with WHO'S Global Action Plan on Management, Maintenance and Repair of Health Care Equipment. Local purchase is being encouraged to the extent possible where improved support and maintenance facilities may be available, while at the same time ensuring quality of the products and competitive prices. Figure 5 provides the procurement trends in recent years. 1. hergency Supplies To meet requests from Member States arising out of emergency situations, such as epidemics and calamities, supplies were arranged against requests, particularly from India, Bangladesh and Nepal. Such requests amounted to a total of US$ 235 466. Figure 5. PROCUREMENT TRENDS US$ (millions) ~ .~.. ~ Jul 87-Jun 88 Jul 88-Jun 89 Jul 89-Jun 90 TOTAL PROCUREMENT LOCAL PURCHASE - 2. Purchases Under Revolving Fund and on Reimbursable Basis Some of the Member States of the Region e.g. Myanmar, India, Bangladesh and Nepal availed of the Organization's procurement services under its Revolving Fund scheme or on a reimbursable basis. The total value of such supplies was US$ 1 970 956. 15.5 GENERAL 1. Visits and Visitors The Director-General, Dr H. Nakajima visited the Regional Office in March 1990. The Regional Director attended the Symposium of the Indian Academy of Paediatrics on Survival of the Underprivileged child, held in Agra in October 1989. In December 1989, he attended the Symposium on Management of Medicine and Health Care, organized by the Indian Pharmaceutical Association, and had discussions with the national authorities on health matters. In February 1990, he attended the Task Force for Child Su~ival (Bellegio IV) in Thailand and accompanied the Director-General on his country visit. The Regional Director visited Pakistan in March 1990 to attend the Safe Motherhood Conference in Lahore and to visit the Aga Khan University in Karachi. During the year, the Regional Director visited Geneva to attend the fourteenth session of the Programme Committee of the WHO Executive Board, the Technical Advisory Group meeting on Tobacco or Health and World AIDS Day. He also attended the eighty-fourth and eighty-sixth sessions of the WHO Executive Board, the Director-General's Meeting with Regional Directors, and the Forty-third World Health Assembly. Within the Region, the Regional Director attended the forty- second session of the WHO Regional Committee for South-East Asia, held in Bandung, Indonesia and the Eighth Meeting of Ministers of Health from the Region, held in Jakarta, Indonesia. The Regional Director also visited Bangladesh, Maldives and Thailand for discussions on WHO collaborative programmes in the respective countries as well as to attend the sixteenth session of ACHR, held in Chiang Mai, Thailand. The Regional Director inaugurated and participated in a number of important meetings, symposia and workshops - national as well as regional and intercountry and also those organized by UN and other agencies. The Regional Director also gave the Father James Tong Memorial Oration on "Taking Health to the People" at the Lady Hardinge Medical College and Hospital, New Delhi on 9 September 1989. During the year, the Regional Office received a number of promi- nent visitors including: H.E. Dr Li Jong Ryul, Minister of Health, DPR Korea; H.E.Dr D. Monkhoo, Deputy Minister of Health, Mongolian People's Republic; H.E. Mr Homi J.H. Taleyarkhan, Member, Minorities Commission, Government of India; H.E. Dr Mario Paz Zamorra, Minister of Health, Bolivia; H.E. Mr Nilamani Routray, Minister of Health and Family Welfare, Government of India; H.E. Mr I.K. Gujral, Minister of External Affairs; Government of India; Dr R.J. Singh, President, Indian Medical Association; Professor Charas Suwanwela, President, Chulalongkorn University, Thailand; Sir John Wilson, Vice- President, Royal Commonwealth Society for the Blind, UK; Dr S.D.M. Fernando, Secretary, Ministry of Health and Women's Affairs, Sri Lanka; Professor Thet Htar Wai, President, Myanmar Hedical Association and other senior officials; Mr R. Srinivasan, Secretary, Ministry of Health and Family Welfare, Government of India; Dr A.S. Paintal, Director-General, Indian Council of Medical Research; Dr U Aung Tun Thet, Director- General of Health Services, Ministry of Health, Myanmar, and Dr P.C. Bhatla, Director-General, National Institute of Primary Health Care, New Delhi.
SECTION I11 HEALTH SCIENCE AND TECHNOLOGY Chapter 7 RESEARCH PROMOTION AND DEVELOPMENT INCLUDING RESEARCH ON HEALTH- PROMOTING BEHAVIOUR The regional research programme aims at strengthening national research capabilities, promoting and coordinating research on regional priority problems related to social and economic development, and at promoting research designed to facilitate the rapid application of existing and emerging scientific knowledge. Towards this end, the Regional Office obtains expert advice on policy and direction of research from the South-East Asia Advisory Committee on Health Research (SEA/ACHR), and technical advice from its sub-committees and scientific working groups. Biennial meetings of the Directors of Medical Research Councils or Analogous Bodies and Concerned Research Foci in the Relevant Ministries (MRCs) are important for obtaining the views of the countries on the implementation of the regional research programme and for mobilizing support. The fifteenth session of SEA/ACHR, held in Jakarta from 6 to 12 June 1989, recommended that a sub-committee of SEA/ACHR be set up to make preparations for the technical discussions on the "Role of Health Research in Strategies for HFA/2000" at the Forty-third World Health Assembly in 1990, and to produce a document containing relevant information from the South-East Asia Region as a contribution to the documentation being prepared by WHO headquarters. The Sub-committee met on 30 and 31 October 1989 and outlined its regional concerns and priorities in a report which formed the contribution to the Technical Discussions at the Forty-third World Health Assembly. There was active participation by countries of the Region in these technical discussions. The General chairman and the keynote speakers were eminent scientists from the Region while senior researchers and research administrators included in the national delegations to the Health Assembly as well as the chairman and several members of SEA/ACHR and former members of the Global ACHR from the Region also took part. The fifteenth session of SEAIACHR, while taking note of the progress made in the implementation of the regional research programme and the follow-up actions taken by the Regional Office on its recommendations, further recommended that the Regional Office continue its activities to prepare for a comprehensive review by SEA/ACHR of its role, functions and working, and that the subject of "the role, functions and working of ACHR and related matters" be taken up as an item for discussion at the sixteenth session of ACHR. A consultative meeting, held in the Regional office from 26 to 28 February 1990, reviewed the role, functions and working of SEAIACHR in health research, and included a discussion of the report by the short-term consultant as well as other relevant material prepared for the meeting. The report of the meeting was presented to the sixteenth session of sEAIACHR. The sixteenth session met from 2 to 6 April 1990 in Chiang Mai, Thailand. It reviewed the Regional Research Programme and recommended to WHO to increase its efforts to help countries to develop a policy to transfer health related technologies and to help countries develop mechanisms for the monitoring and recog- nition of health technology that is appropriate and assimilable, especially at the PHC level. It reviewed the role, function and working of SEAIACHR, and in endorsing the conclusion of the consultative meeting which preceded it, reaffirmed that the terms of reference as enunciated in 1976 continued to be rele- vant and valid. The technical topics taken up for discussion were Xesearch on Oral Health, Research on Tuberculosis and Research on Performance Assessment and Quality Assurance in Health Care Delivery. Among the important recommendations pertaining to these topics is the establishment of a Task Force on Research on Tuberculosis and for commissioned health research to be promoted and supported by the Regional Office. As recommended by the Regional Committee, ACHR and MRCs, more emphasis is now given to direct institutional strengthening for research. The Regional Office started an institutional streng- thening scheme in 1988. Following the task force meeting to advise on the ways and means of institutional strengthening for research, and the meeting of the Panel of Scientists, discus- sions were started with four countries. Two countries complied in 1989 by identifying institutions for the strengthening of HSR, completing the project outline, and identifying the different components and modus operandi. Institutional streng- thening grants were awarded to two countries. The take-off in regard to activities identified in the original grant applica- tions sent to the Regional Office is still slow. Mechanisms to further stimulate activities need to be identified and discussed with the countries. The Regional Office continued to provide technical and financial support to research projects of regional priority and interest, which included investigator-originated projects, as well as commissioned collaborative projects in priority areas where little or no research is being done. In addition to research grants, these multicentre collaborative projects require considerable nurturing, in the form of technical support, organization and coordination by the Regional Office, as well as visits by consultants. Nevertheless, they are an important means of strengthening the research capability of institutions and of providing direct technical support to the pertinent health programmes of the countries. The distribution of research topics supported by WHO includes a majority of field-based studies in health systems research, a few concerned with epidemiological and intervention studies in communicable diseases, a few hospitsl-based clinical studies, and even fewer studies concerned with experimental laboratory investigations. Studies on the epidemiology of dengue haemorrhagic fever are in progress in two countries. Vector control for DHF, with community participation (Phase I), has been completed in two countries. The progress reports received have been reviewed by a core group at the Regional Office. Further extension of the studies, with enhanced community participation, is being planned. Research on the developnent of dengue vaccine is progressing well. The Seventh Peer Review Meeting, held in August 1989, recommended the trial of three candidate dengue vaccines, 1,2 and 4, as a single inoculation, and also recommended clinical trials in children. This in itself is a noteworthy achievement. It also accords valuable opportunities for the transfer of technology in vaccine development to the institution involved in the project, which is the WHO Collaborating Centre for Research on the Immunopathology of Dengue Haemorrhagic Fever and for the Production of Immunological Reagents as well as the Centre for Research in the Development of Dengue Vaccine. The multicentre collaborative epidemiology study on non-A non-B hepatitis is progressing well in Myanmar. India, Mongolia and Thailand, and will lead to a better understanding of the epidemiology of the disease, which is prevalent in epidemic and endemic forms in the Region. Entericallrtransmitted-non-A non-B hepatitis (ET-NANB) seems to carry a high mortality among pregnant women during epidemic outbreaks. There is reaaon to believe that the virulence of the organism(s) may be altered during epidemics. The magnitude of exposure of children to ET-NANB virus is not well documented. Many aspects of the etiological agents remain unknown and need further study. Research in maternal and child health is being supported through an important collaborative study of low birth-weight babies and their determinants, which is going on in several countries. Status reports of individual study centres were presented at the meeting of the Principal Investigators held in September 1989. Good progress had been made in all study centres and registration of pregnant women had been completed (Pune 4 388; Nepal Rural approximately 3 000; Nepal Urban 3 670; and Sri Lanka approximately 1800). Regarding data entry, both study centres in Nepal had completed initial entry and editing of data up to the time of delivery, while India and Sri Lanka are expected to complete data entry soon. Collaborative studies on the epidemiological and socio-cultural aspects of ageing are being implemented. A short-term consultant is being recruited to complete follow-up actions after the first meeting of principal investigators. In addition to the ongoing research projects supported by intercountry funds, 52 research projects have been funded through WHO country budget allocations for RPD and HSR. As of March 1990, there were 63 active collaborating centres, with a wide scope of function ranging from health programme development to cardiovascular diseases. Some 20 centres are related to the programme areas of disease prevention and control, as compared to 16 centres concerned with diagnostic and therapeutic technology. Of the 63 centres, over 33 are actively involved in health service development and 25 are concerned with research and training in various subjects. Strengthening of research capability in the countries is a major aim of the regional research programme. To this end, a number of visiting scientist grants and research training grants have been awarded in priority topics identified by the countries. The award of research grants to individuals, as well as to several commissioned collaborative research projects, also contributed significantly towards improving the research capabilities of the participating institutions in the countries. The limited resources made available from the Regional Office are coordinated with, and supplemented through, inputs from WHO headquarters in the form of special programmes, such as the Programme for Research Development and Research Training in Human Reproduction (HRP), the Programme for Research and Training in Tropical Diseases (TDR), and the Global Programme on AIDS.
Chapter 10 PROTECTION AND PROMOTION OF MENTAL HEALTH 10.1 PSYCHOSOCIAL. AND BEHAVIOURAL FACTORS IN THE PROMOTION OF HEALTH AND HUWAH DEVELOPMKNT The importance of psychosocial and behavioural factors in healthy child development has been further corroborated by the findings of a WHO-supported multicentre study in India which confirmed the high correlation between social aspects of family functioning, subjective well-being in mothers, and parameters of healthy development in children, especially their cognitive development and nutritional status. This and related work, carried out in Sri Lanka and Indonesia and coordinated by WHO, has now resulted in well-focused and realistic intervention trials in the functioning of dysfunctional families, focusing on the well-being and coping skills in mothers as vehicles for healthy child development. This work was planned by the Regional Coordinating Group for the Mental Health Programme (RCG), which met in Dhaka in September 1989. It will be supported in India by the Indian Council of Medical Research (ICMR) and in Sri Lanka by UNICEF. The RCG has also developed a protocol outline for a multicentre study aimed at clarifying some basic concepts in good medical out-patients care, or the psychosocial sensitivity of physicians of primary care, as preparatory work for intervention trials to improve, through brief in-service interventions, the functioning of services of primary health care. This was in continuation of the previous WHO-supported work on the same issue, carried out in Indonesia. A series of decision-linked behavioural studies for the develop- ment of paychosocial interventions for the containment of AIDS was launched in the Region following the intercountry Workshop on Social and Behavioural Research for the Containment of AIDS, held in Bangkok in January 1990. Some of these studies, of a descriptive type of 'street corner epidemiology', have already shown first results in terms of a reduction in risk behaviour in selected high-risk groups. The substantial WHO-supported project on health behaviour research in Thailand has expanded to include decision-linked studies on behaviours related to the spread of HIV, alcohol and tobacco use. 10.2 PREVENTION AND CONTROL OF ALCOHOL AND DRUG MUSE WHO has continued to execute the UNFDAC-supported drug abuse control programmes in Myanmar and Sri Lanka. In both countries, the epidemic of heroin dependence seems to have been contained and the rate of recruitment of new dependents is lower than the rate of withdrawal among those already dependent. In addition, WHO continued to execute a UNDP-supported project to establish a drug abuse monitoring system in Sri Lanka. In both countries, the WHO-executed projects have helped to improve the effective- ness of drug abuse control activities and to increase national expertise in the field of addiction behaviour. The 'camp' or 'drug-free zone' approach, used to maximize community involvement in localized activities to eliminate rural opium use as well as urban heroin use, has now been shown to reduce rural alcohol problems too. WHO is supporting studies to identify socio-cultural elements necessary for the success of this approach when dealing with problems of illicit as well as licit substance abuse. The Regional Offices for South-East Asia and the Western Pacific have jointly supported an ESCAP-executed study on rehabilitation programmes for drug dependent persons in both the regions. This report has been published and further collaboration in more in-depth studies on the rehabilitation process is planned. The involvement of ministries of health in programmes to reduce problems related to alcohol and drug abuse are still limited in most countries of the Region. Especially, health systems appear reluctant to involve themselves in the prevention of substance abuse although studies in many countries have shown that health personnel can play a very effective role in preventing and reducing, for example, cigarette smoking. WHO has, therefore, continued to promote the involvement of health perso~el in substance abuse programmes through the dissemination of training material. In line with this goal WHO has organized a training course on alcohol and drug abuse control for health personnel from India and Sri Lanka, with DANIDA support. With the high risk of HIV infection in injection drug users, the problem of drug dependence has gained a new and threatening dimension. During an intercountry Workshop on HIV Infection in Injection Drug Users in Goa, India, in December 1989, plans were drawn up to establish a monitoring system regarding the route of drug administration where injection is thought to be rare or absent, and to develop technologies, through coordinated intervention trials, to reduce the risk of HIV infection in drug injectors and their sex partners. 10.3 PREVENTION AND TREATMENT OF MENTAL AND NEUROLOGICAL DISORDEXS WHO'S activities in this sub-programme area continue to have two main thrusts: of development of technologies and of support to countries for the improvement of national capabilities for national mental health planning. Integration programmes aimed at improving basic mental health skills at all levels of health care have continued on an increasing scale in most countries of the Region. The Regional Coordinating Group for the Mental Health Programme (RCG) has reviewed the list of apportioned skills which should be present at the PHC level (the 'mental health kit'), established in 1982, and has updated the agenda prioritizing the research necessary to fill the gaps in the existing knowledge for such integration. At the same time, a list of indicators for the quality of mental health care and the functioning of mental hospitals has been developed as a collaborative effort in the Region. These indicators form the basis for the National Mental Health Programme (NMHP) in Indonesia. The targets in this programme are in fact indicators from this list of indicators. As a remarkable innovation, NMHP sets out to restructure postgraduate training in psychiatry into training in public mental health. The National Mental Health Programme in India, adopted by the Government in 1982, was evaluated, reviewed and updated during a WHO-supported national workshop. An update of the national programme in Sri Lanka has also been prepared with WHO support. Mechanisms to facilitate implementation of the updated plan were reviewed jointly during a country visit by WHO staff.
Chapter 9 PROTECTION AND PROMOTION OF THE HEALTH OF SPECIFIC POPULATION GROUPS 9.1 MAl!JBhN AND CHILD HEALTH, INCLUDING FAMILY PLANNING A positive trend that favours a holistic approach to the delivery of maternal and child health services is gradually emerging in the countries of the Region. This is exemplified by the acceptance of an integrated system of service delivery, in respect of maternal and child health and family planning, by all the countries. Some countries have further broadened this approach through close coordination between MCH/FP services and other programmes directly related to MCH, such as EPI, CDD, ARI and nutrition. These initiatives will, in the long term, help to develop a comprehensive health infrastructure in which continuity of services needed for MCH care can be fostered and sustained. An outstanding feature of the reporting period has been the firm acceptance by the countries of the Region of the need to address the problem of maternal mortality, with greater emphasis on maternal care and safe motherhood. While selected interven- tions aimed at child survival continued to be vigorously pur- sued, improvement in the accessibility and quality of maternal care would not only contribute directly to child survival but also encourage a holistic approach to child development. There is also a gradual trend in most countries towards an integrated system of service delivery, vis-a-vis maternal and child health, family planning and programmes directed at prevention and control of the common childhood diseases. With regard to population policy and family planning, the emphasis placed on fertility and population growth is varied among the countries. All countries have, however, accepted . family planning and child-spacing as a vital component of programmes aimed at achieving better health for mothers and children. It is worthy of mention that in Bhutan a population policy was approved in early 1990 while Myanmar decided to include child-spacing in routine health and welfare activities. WHO collaboration in FHlMCH was directed mainly at achieving wider service coverage and improving the quality of services. Exchange of ideas and sharing of country experiences through visits to countries were also supported. In order to improve the quality of services as well as programme management, most countries utilized in-service training programmes, meetings and consultations. In Myanmar, in-service training of MCH officers, divisional health officers, lady health visitors, midwives and auxiliary midwives figured prominently. In Nepal, in-service training of public health nurses in IUD insertion and the use of injectable8 was an innovative activity to achieve wider service coverage, while at a more peripheral level, the involvement of Panchayat-based health workers in promoting oral rehydration therapy, nutrition, immunization, basic health care and child- spacing is being attempted. In Sri Lanka, midwives in hospitals and maternity homes were given refresher training aimed at improving the quality of institutional care. In Maldives, selected family health workers will receive three months of intensive training. In Bhutan, UN volunteers were used to support training at the Institute of Family Health. In Bangladesh, the use of family planning clinical supervision teams for quality assurance of services related to family plan- ning continued. This initiative was subjected to a recent four- partite review, with possible modification of the existing strategy. Meetings and consultations were also supported during the period under review. In Indonesia, a series of meetings was held to develop strategies for improving perinatal care and maternal health. Review meetings to monitor and evaluate MCH programme performance were also held in eleven provinces. An innovative scheme was introduced to train health workers at Puskesmas and Posyandu levels to train cadres who, in turn, would implement a group-learning scheme for pregnant and lactating mothers. In Sri Lanka, a national consultative meeting was held to review the performance of the MCHlPP programme. In Thailand, a Seminar on MCH and Noncommunicable Diseases was held for paediatricians, obstetricians and provincial medical officers, as a means of promoting prevention and control of noncommunicable diseases in mothers and children. Maternal and Child Health The health of mothers and children continues to be the cornerstone on which the health of the nation rests. Efforts in the Member countries are therefore aimed at strengthening MCH services, integrating them w~th other appropriate areas like EPI. d~arrhoeal diseases control. etC. Health of the Elderly With the proportion of the elderly in the populat~on steadily increas~ng in the Region. Member countries are Initiating action plans for the health care of the elderly. k I B , . Environmental Health World Health Day 1990 focussed attention on the close l~nks between health and the env~ronment The Day evoked w~despread response with actlve community partlclpatlon in lnitlatlng measures to curb pollut~on and to generally make the environment healthier Water and Sanitation As the lnternat~onal Dr~nk~ng Water Supply and Sanitat~on Decade comes to an end (1990) efforts are being accelerated to hasten the provlslon of regular supply of safe water and to provide sanitation fac~l~ties part~cularly to unserved populations Study tours and fellowships were also supported. Two batches of four medical officers each from India visited some countries of the Region to observe and share experiences regarding imple- mentation of basic MCH services; two medical officers (MCH) from Sri Lanka were awarded fellowships for in-depth study in MCH with emphasis on maternal mortality, morbidity and family planning; eleven fellowships were availed of by medical officers in Mongolia for specializing in selected fields of MCH, while in Thailand six fellowships were awarded for postgraduate study. Indonesia utilized a scheme of in-country fellowships for language training and report writing, documentation, financial management and computer training. Support was also provided for studies aimed at obtaining information needed to strengthen programme development and improve strategies in the delivery of MCH/FP services. In India, as in the previous years, a number of such studies were initiated. These include: evaluation of the functioning of post-partum centres at the sub-divisional level, models for integrated delivery of MCH/FP and PHC, reorganization of integrated family welfare/PHC service delivery in urban areas with special emphasis on slums, a study on people's health seeking behaviour, and measuring acceptability of family planning in rural areas with possibilities of using doctors of indigenous systems of medicine and village practitioners. The utilization of the findings of these studies and those conducted in the previous years will need to be followed up and assessed. In Thailand, studies involving model development and field-testing included: strengthening MCH service delivery at the health centre level to improve birth-weight, use of "model mothers" (mothers with an ideal set of maternal health criteria) as indicators of health in the community, improvement in child-rearing practices to support normal child development utilizing simplified child development booklets at the family level, and a study on child-rearing practices among working mothers, both urban and rural. Since the International Safe Motherhood Initiative in February 1987, most countries of the Region have initiated safe motherhood activities. Operational research projects directed at improving maternal health have been undertaken recently in many countries. These include: the maternal mortality and morbidity surveillance system in Bhutan; maternal morbidity and mortality in South Indian women in India; a multicentre control trial on the use of the Partograph in the management of labour and a maternal/perinatal mortality study in rural Central Java, Indonesia; and two studies in Nepal, namely, a study on the prevention of maternal mortality in selected hospitals, and a KAP of mothers-in-law regarding maternity care of their daughters-in-law before and after group-learning sessions. Technical support was provided by both WHO headquarters and Regional Office staff in research project formulation, data validation, processing and analysis, and strengthening research capabilities at both field and institutional levels. A study on maternal mortality in Central Java, Indonesia, has been completed and its results were reviewed in February 1990. The report of the study was discussed at a national seminar held in May 1990. A national workshop on Maternal and Perinatal Mortality was held in Sri Lanka in collaboration with the Ministry of Health, College of Obstetricians and Gynaecologists and the Asia Oceania Federation of Obstetrics and Gynaecology, with the objective of reducing maternal and perinatal mortality. An intercountry workshop titled 'Safe Motherhood Initiative - Recent Developments and Key Issues' was held in the Regional Office in November 1989, with participants from eight SEAR countries. Follow-up national workshops on the subject have been planned for Bhutan, India, Indonesia and Maldives. Regional Office staff and nationals from nine SEAR countries also participated in the Safe Motherhood South Asia Conference, held in Lahore, Pakistan, in March 1990. The Government of India, after close scrutiny of the family welfare programme, has decfded to promote, on a voluntary basis, responsible and planned parenthood, emphasizing a "two-child norm" through independent choice of family planning methods suited to acceptors. The UNFPA-funded Regional Advisory Team on MCH~FP, with one Senior Medical Officer and one Technical Officer (Management, and Evaluation), supported by a Consultant (Statistician) and MCH staff from the Regional Office, assisted in project formu- lation, project monitoring and evaluation of MCHIFP programmes, including technical support for research activities related to MCH/ PP . Women, Health and Development Activities under the "Women, Health and Development" (WHD) programme continued to be directed at strengthening the involvement of women's organizations in health promotion, and enhancing the exchange and dissemination of information to encourage the participation of women in health and development. Efforts were directed at the promotion of operational research in maternal health under the Safe Motherhood Initiative and mobilization of women's organizations in the prevention and control of HIV infection/AIDS in collaboration with national AIDS programmes. In conjunction with other international and bilateral agencies concerned with Women and Development programmes, major issues related to women's roles at various levels, such as professional and personal, were identified. Emphasis has been laid on the need to work on women's issues, with small groups, on technical matters, such as drinking water and irrigation projects. In this regard, interagency meetings, sponsored by the participat- ing agencies on a rotational basis, are being held every month. 9.2 ADOLESCBNT HEALTH With the commencement of the Eighth General Programme of Work the subject of Adolescent Health, included earlier under Maternal and Child Health, has been designated as a separate sub-programme. This has been reflected accordingly in the Medium-Term Programme for 1990-1995. With the exception of Indonesia and Myanmar, other countries of the Region have not made provision for Adolescent Health activities as a separate sub-programme for the 1990-1991 biennium. Some countries, such as Sri Lanka, have made modest budgetary provisions under the sub-programme of Maternal and Child Health. Though preliminary activities in support of adolescent health have been initiated in many countries of the Region, with collaboration from WHO headquarters, further progress during the reporting period does not appear to have been made. The multidisciplinary nature of this sub-programme calls for dynamic leadership at the national level if the desired objectives are to be achieved. 9.3 HUK4N REPRODUCTION RESEARCH The South-East Asia Regional Office continued to collaborate very closely with the WHO Special Programme of Research, Development and Research Training in Human Reproduction. Currently, there are five members from the Region on the Programme's Policy and Coordination Committee (PCC), which meets every year. The most recent meeting of PCC was held in June 1990. In addition, the Committee on Resources for Research (CRR), which deals with research strengthening activities, met in April-May 1990 and approved, among other things, long-term institutional development (LID) grants for institutions in the Region for 1991. With regard to research, the Programme concentrates on two major activities, namely, support for research aimed at finding and developing new, safe and effective methods of fertility regulation, and support for research aimed at improving the performance of existing methods of fertility regulation. In order to undertake research on these aspects, a number of research grants were awarded to various institutions in the Region. In this context, projects in the former category included (a) clinical trials on long-acting injectable contraceptives; and (b) experimental studies in monkeys on post-ovulatory methods of contraception. Projects in the latter category included several on evaluating and monitoring contraceptive safety, e.g., surveillance of norplant use, and contraceptive effects on blood factors, cardiovascular system and ectopic pregnancy. In addition, there were projects on contraceptive use dynamics, which relate to the acceptability of the contraceptive, and on lactation, which relate to the efficacy of the contraceptive. A few projects involved more than one country in the Region. Such multicentre studies are usually double-blind clinical trials. The total number of these projects was 45, of which 22 were ongoing and 23 were initiated during the period under review. Another important activity was concerned with infertility. Several multicentre research projects are continuing, with especial regard to the role of sexually-transmitted diseases and other infections as a cause of infertility. There are currently five WHO collaborating centres in human reproduction in the Region - three in India and two in Thailand. Ten institutions - one in Sri Lanka, one in India, four in Indonesia, one in Nepal, and three in Thailand - continued to receive LID grants while some supplies were provided to one institution in Indonesia. Fifteen research training grants were provided during the period under report. A national Workshop on the Assessment of Research Needs for Reproductive Health was held in Sri Lanka in November 1989. The final report, printed in April 1990, forms the basis of the request to funding agencies for institutional strengthening grants support. A site-visit was made to Myanmar to plan a similar workshop, which is proposed to be held in August 1990. The programme is being monitored to study its effect on developing countries. An external impact evaluation report was finalized and submitted to PCC 3 st its meeting in June 1990. Occupational health is of significance in the Region, with the rapid development of industries resulting in an increase in the incidence and variety of occupational diseases and accidents. However, there is strong evidence of a failure to recognize the growing importance of occupational health and safety, with a lack of adequate policies and legislation for the protection of health and safety of workers being evident in most of the countries. There is, therefore, an urgent need to promote an in-depth study of occupational health problems, strengthen research capability in this field, develop appropriate technolo- gies for prevention and control and to promote multidisciplinary and multisectoral collaboration. Special attention should be paid to problems related to child labour in many countries of the Region. Support was provided for in-service training of nurses in occu- pational health in Myanmar. Training modules on occupational health for doctors and a basic occupational health service package for non-formal workers were prepared by national consultants in Indonesia. Training courses and workshops were conducted in Bangladesh and India under the LCS component. Support was also provided for fellowships and logistics in all the countries with WHO collaborative projects on occupational health. 9.5 HEALTH OF THE ELDERLY Emerging issues related to socioeconomic health and humanitarian aspects of ageing populations in developing countries, which are expected to accommodate 61 per cent of the world's elderly population by the year 2000, have not yet received appropriate attention in many of the countries of the Region. The aged, as a vulnerable section of the population and espe- cially susceptible to physical and mental health deterioration and rapid social and environmental changes, require careful scientific assessment of their living conditions, social status and needs, including the availability of affordable health and services. In this regard, a multicountry study is being carried out in Bangladesh, DPR Korea, Indonesia, Myanmar, Sri Lanka and Thailand, using a common protocol approved at a meeting of principal investigators held in March 1989. A Consultant has been recruited to assist the principal investigators. Countries were supported in conducting various training activities and in publishing educational material, through LCS and fellowships and logistic support. A manual on the care of the elderly is under preparation in Indonesia. Emphasis was laid on strengthening institutional capacities and on promoting the concept of self-care and self-help among the elderly as well as among families of the aged.
Chapter 6 PUBLIC INFORMATION AND EDUCATION FOR HEALTH Information and Education for Health, which is aimed at helping people to lead a healthy life, gathered momentum in the Member Countries. More intensive methods in health education were applied to reach the community, and the media were also utilized as allies in the war against disease and ill-health. Health education, recognized as an integral component of the health care system in Member Countries, is aimed at strengthening programmes of information and education for health. Lhring the period under review, significant developments took place, both at regional and country levels, to strengthen information and education for health (IEH) activities, with an increasing focus on school health education. "Youth in Health Development" activities were further encouraged through CSAs, in Bangladesh, Indonesia and Myanmar, for strengthening youth involvement in health development programmes. The theme of World No-Tobacco Day 1990, focusing on youth, provided further impetus to the mobilization of youth for promoting healthy lifestyles. In the area of AIDS, intercountry group educational activities were held to address those aspects of AIDS prevention and control that were still largely underdeveloped in the Member Countries. An intercountry Workshop on psychosocial counselling was held in Bombay in November 1989, and another intercountry Workshop on Monitoring and Evaluation of Health Promotion Activities was held in Dhaka in January 1990. An intercountry consultation on AIDS was also held in New Delhi in December 1989. At the country level, follow-up national workshops on the development of health education materials for AIDS control took place in Myanmar. Whereas these workshops focused on AIDS, the training provided was equally applicable to other health promotion and IEH programmes for achieving HFA12000. Three countries of the Region, viz., India, Indonesia and Thailand, participated in the Working Group Meeting on Health Promotion in Developing Countries, convened by WHO headquarters in October 1989. The Working Group considered ways whereby health promotion approaches and concepts which have been deemed effective in a number of developed countries could be made relevant and applied to the developing world. At the country level, WHO'S collaborative activities were aimed at strengthening health education at the district level, through consultative review meetings (such as those held in Bangladesh and India, which involved health education personnel from states, provinces and districts), through training for district personnel (such as that in Bhutan), and through fellowships for district-level health educators (as in Sri Lanka). Bhutan will comence, for the first time during this biennium, a separate WHO collaborative programme to strengthen the information and education component of the district health system as an integral part of primary health care. Fellowships in health education, to provide masters, diploma and certificate training, and short study tours were availed of by health educators in Bangladesh, India, Indonesia, Myanmar, Nepal and Sri Lanka. Starting from March 1990, a series of discussions on "tobacco or health" for different population groups were held in Indonesia. Seminars and courses in public relations and media were held in Indonesia and Thailand. Collaboration was strengthened in the area of development of educational materials. In Thailand, materials were developed to disseminate health messages concerned with creating healthy behaviour among the public, and a no-smoking campaign in the community was carried out. In Bangladesh, flip charts were prepared to educate communities on colmnon health problems. A health communications workshop was held in India in December 1989 to provide communication skills to staff of central and state bureaus and other agencies involved in health education; a national conference of voluntary organizations was convened in December 1989, and a national workshop on production of scriptslmessages on oral health was held in May 1990. Short-term consultants were provided to Bangladesh, for their review meetings, and to India for the health communications workshop. Collaborative activities in IEH research continued with the initiation of studies which included the utilization of health education personnel at the district level in Bangladesh, and of health education materials in India. Efforts to strengthen the links between health personnel and the media continued. An intercountry media consultation on AIDS, held in New Delhi in December 1989, brought together media practitioners and health officials for a better under- standing of a health problem of major significance to the Region, and provided a forum for the media to understand health personnel better and vice versa. The UNICEF/WHO/UNESCO publi- cation "Facts For Life" was widely distributed to health personnel as well as to the media and nongovernmental organizations. The publication is being adapted to suit respective country needs, while Thai and Bahasa Indonesia versions have already been published. World Health Day, which focused on the environment, evoked widespread interest in the Region with information kits being widely distributed and adapted in the Member Countries. The Regional Director's World Health Day broadcast was beamed to many countries in the Region by All India Radio, and tapes were sent to Member Countries for their use. Seminars, talks, exhibitions, health fairs, etc. were organized by government and nongovernmental organizations, as well as by educational institutions, for the comunity. World Health Day, No-Tobacco Day and World AIDS Day generated extensive media interest, helping to focus attention on issues that have a direct bearing on health. As a means of providing valid information on important subjects, information kits were produced on "Prevention and Control of Accidents", "Self-care and Healthy Lifestyles" and "Promotion of Women's Health in South-East Asia" in addition to the kits distributed widely in the Region on World Health Day, No-Tobacco Day and World AIDS Day. Several countries have reported good use of the kits and their adaptation by nongovernmental organizations. It is therefore proposed to continue this activity. A folio containing a sample of health education materials developed in the Region for the prevention and control of AIDS was published and distributed to concerned agencies. The photo library in the Regional Office was streamlined with better cataloguing, and a small photo display on WHO'S collaborative activities in the Region was prepared for use in the WHO Representatives' offices. School health education was also the focus of a joint conaul- tative seminar on "School Education for the Prevention and Control of AIDS in Asia and the Pacific", jointly organized by WHO and UNESCOIPROAP in Bangkok in February 1990. Seven countries from the South-East Asia Region and ten countries from the Western Pacific Region participated in the meeting and made specific recommendations pertaining to regional and national action strategies to introduce AIDSISTD education in schools. This event was a significant landmark in inter-agency collaboration. Collaboration was further strengthened with the establishment of a regional AIDS education and health promotion materials Exchange Centre at uNESCO~PROAP Bangkok, and with the representation by a delegate from Thailand at the World Consultation of Teachers' Organizations in Education For AIDS, held in Paris in April 1990. In March 1990, the Region was represented at the Round-table discussion on "Education For All: Enabling School Age Children and Adults for Healthy Living," at the UNDP/UNESCOIUNICEF/WO~~~ Bank, World Conference on "Education For All" (WCEFA) held in Jomtien, Thailand. Pour country situation reports on school health education were prepared by nationals from India, Indonesia, Sri Lanka and Thailand for distribution at the Conference. The World Declaration on "Education For All" contains specific reference to the need for educating children, youth and adults in health and nutrition.
Chapter 4 ORGANIZATION OF HEALTH SYSTEMS BASED ON PRIMARY HEALTH CARE Reorientation of the health system infrastructure forms the bed-rock of national strategies for attaining the goal of Health for All by the Year 2000. Since the concept of primary health care was defined and given international recognition at the Alma-Ata Conference in 1978, primary health care has become the main thrust for total health care. Countries in the South-East Asia Region have made great efforts to organize effective health systems so as to provide efficient and universal primary health care. Considerable resources have been allocated to the building of health facilities, to the strengthening of health infrastructure and to increasing coverage, especially of the underserved and unserved areas. All countries of the Region have shown growing concern for equity and social justice - the two basic principles of primary health care - so that health has become a basic right of every individual. In reducing gaps between those who have access to primary health care and those who do not, priority is given to the underserved and unreached populations. Greater emphasis is laid on community participation, enabling women and the community to be involved in their own economic and health developnent . In recognizing the importance of intersectoral action for health as a key factor for overall socioeconomic development, in many countries, formal mechanisms have been introduced, with WHO support, for dialogue between health and other allied sectors. WHO'S efforts are aimed at ensuring that the use of intersectoral action steadily improves not only health but also the quality of life of the people. Steady progress has been achieved in the distribution, organization, management and orientation of a comprehensive health system based on primary health care. A Regional Conference on Health Development, held in New Delhi in March 1989, reviewed the progress in the light of the Riga framework. It noted that Member Countries were already reviewing their targets and policies with a view to accelerating implementation. The Conference emphasized the need to develop new ways of understanding and facing problems, as well as of identifying newer approaches to solve them. Coverage through the health infrastructure has increased in almost all countries as a result of improvement of the management process. Due attention has been paid to the development of human resources through training and retraining of health workers. It is increasingly apparent that the more pressing problems of organization of national health systems based on primary health care occur close to where people live. Intensification of health development in the district has been pursued with commendable results. This district health system approach, comprising critical areas of primary health care, among others, provides for decentralized management responsibilities. Attempts have been made to develop adequate supervisory planning and management skills among district-level health managers and planners in order to strengthen district health systems. 1. Strengthening of Ministries of Health and Expanding Coverage of Health Infrastructure Countries in the Region are being supported in improving the existing health infrastructure and expanding coverage through an epidemiological approach aimed at reaching the underserved and unreached population. Activities carried out in the first year of the biennium contributed to health development at the community and health centre levels and aimed st improving the local capacity and quality of health services provided. Overall, there has been progress in the implementation of primary health care as well as in improving the performance of the health infrastructure, particularly at the primary level. With the strengthening of the health infrastructure and expansion of the PHC activities in the form of various models, such as the Mongar project in Bhutan, the Huvsgul Aimak project in Mongolia, Posyandu in Indonesia, the Upazila Health Complex in Bangladesh, etc., a coverage of 65-70 per cent has been achieved. Some of the well-known constraints, such as the lack of equipment, drugs, transport and other support facilities, poor supervision, unequal distribution, inadequate management, and inefficient use of resources, still remain. WHO has been collaborating with national authorities in enhanc- ing their capabilities to plan and manage health programmes status at the district level, particularly through training in planning and management, so as to help managers at the central and district levels play a leadership role. The support also involves the development of intersectoral action and community participation, as well as of information systems, monitoring and evaluation, computerization and systems analysis. An interregional meeting on Strengthening Information Support for Management of District Health System based on Primary Health Care was held in Surabaya, Indonesia, in October 1989. The meeting identified the information needs for effective management of the district health system, methods and technologies for collaboration, and processing and utilization of information needed by district managers. WHO also supported the referral system at various levels, primarily at the first referral level. Workshops for strengthening PHC were held in Indonesia and Sri Lanka to re-examine the health care delivery systems. Fellowships were awarded in hospital administration, nursing and medical care, including specialized health care. A short-term consultant was assigned to identify hospital sanitation problems in hospitals in Indonesia. Realizing the need for efficient maintenance, WHO is also providing support for nationals to acquire skills in the maintenance and repair of equipment. Bangladesh, Myanmar and Sri Lanka have set up their own training workshops. An intercountry meeting on Strengthening Ministries of Health was held in Geneva in March 1990. Bangladesh and Sri Lanka participated in this meeting. It was decided to continue with the previous activities in Sri Lanka while in Bangladesh a new project is planned. A Consultative Committee Meeting on PHC Development, held in Geneva in Aprll 1990, reviewed country experiences in PHC implementation, options for financing PHC implementation, and increasing the sustainability of PHC in the 1990s. It emerged in the meeting that the main problems in the 1990s will be the emerging mega cities with alarming increases of population, environmental deterioration, and socioeconomic and political problems. National governmenta will have to anticipate these problems and take appropriate measures well in time before they begin to adversely affect the health of the people. 2. District Health System Intensification of Action Programe for Primary Health Care As part of the process for intensifying health development in defined geographical areas, such as districts, efforts are being made by countries, with technical support from WHO, for the development of an effective district health system. Based on the experience of projects in this area and the recommendation of the Regional Committee for South-East Asia for recommending intensification of primary health care in these manageable geographical units, a UNDP-funded project "Intensification of Action Programme for Primary Health Care" was launched in January 1987 in 21 districts of the countries of the Region. The main objective of this project is to develop a system of decentralized health care management at the district level through coordination among national ministries/ institutes, primary health care programmes, NGOs and district authorities, concentrating on four major elements of PHC, viz. immunization, diarrhoea1 diseases control, respiratory diseases and essential drugs, within the framework of plans of action. Following the guidelines prepared by the Regional Office, baseline surveys have been completed and national and district work plans developed in sli the countries. A regional, integrated learning module, prepared by the Regional Office, has been sent to the countries for use in training health managers, supervisors and workers in the project districts. Workshops for health managers were held in Bangladesh, Bhutan, India, Indonesia, Mongolia, Myanmar, Nepal, Sri Lanka and Thailand. In-service training of health workers and health supervisors have also been conducted using the integrated learning module. Training in laboratory diagnosis in the control of diarrhoea1 diseases and acute respiratory infections have been completed in Bangladesh, Bhutan, India, Indonesia, Mongolia, Sri Lanks and Thailand. NGOs, especially women's organizations, are closely involved in project implementation in Bangladesh, Bhutan, India, Indonesia, Mongolia, Myanmar, Sri Lanka and Thailand. Fellowships and study tours were provided for training in epidemiological surveillance, drug analysis and diagnostic techniques. To overcome bottlenecks that impede the delivery of health services, assistance was provided in the form of equipment and supplies. With a view to developing a system of decentralized management district-level health managers and planners have been trained in supervisory management and planning skills. A new UNDP project "Strengthening Medical Care Facilities in Districts", especially designed for the least developed countries, is awaiting UNDP approval. The objective of this project is to improve the delivery of medical care at district and peripheral health centres. The duration of the project is three years. The expected outcome at the end of the project is an optimal level of health care delivery through improved functioning of medical care facilities. 3. Intersectoral Action for Health In many countries, mortality and morbidity have been reduced through both improved health infrastructure and appropriate sectoral policies, with consequent improvement in overall socio- economic conditions. Intersectoral coordination and formulation of policiea is a prerequisite for achieving Health For All. WHO has continued to facilitate the dialogue between health and other relevant sectors by supporting and strengthening mecha- nisms for intersectoral coordination for health development. As a follow-up of the Inter-agency Regional Conference on Health Development, held in New Delhi, March 1989, a Regional Symposium on the Implications of Public Policy on Health Status and Quality of Life was organized jointly by WHO headquarters, the Regional Office and the Indian Institute of Management, Bangalore, in Bangalore, India. Three important areas were dealt with, namely: urbanization, covering housing and slums; indust- rialization, covering occupational health and child labour; and agricultural development, covering irrigation and pesticides. The emerging health problems resulting from urbanization, industrialization and agricultural development, including agro-industries, are assuming increasing importance and should be the subject of future workshops of WHO and countries. A mechanism for intersectoral collaboration has been developed in Mongolia through which it is now possible to provide primary health care to various groups of population. The Great People's Khural, the Council of Ministers, and the State Planning Committee play coordinating roles in intersectoral actions. The Aimak Council of People's Deputies and its Executive Committee collaborate at the highest level in providing primary health care to the population of the aimak. Multisectoral National Health Committees, headed by the Minister for Health or Minister of Interior or analogous policy makers, have been formed in Sri Lanka, Myanmar, Indonesia and Thailand with the Director-General or Deputy Ministers from Ministries of Agriculture and Forest, Planning and Finance, Education, Industry, Trade, Cooperative and Social Welfare, etc. as members. This high-level body, amongst other bodies, acts in an advisory and coordinating capacity and takes policy decisions relating to health and socioeconomic development. One of the major achievements of the Mongar project in Bhutan was the interlinking of all levels involved through the formation of intralintersectoral committees at district, block and village levels. It succeeded in achieving almost total coverage by the PHC elements in spite of the difficult terrain. In Chagalnaya Upazila, Feni district, Bangladesh, an analytical study funded by WHO was conducted to identify options to be pursued for improving health and the quality of life of the people as an integral part of the efforts to develop inter- sectoral action to meet the basic minimum needs. Support was also provided for conducting workshops to evolve plans for PHC intensification, with multisectoral participation, in Sreepur and Kalihati Upazilas in Dhaka Division. Indonesia and Thailand have been implementing primary health care with the support of community participation and inter- sectoral action. They are now embarking on policy formulation in other sectors with a view to reducing the negative impact on health. Progress in the development of primary health care was slower than what it would have been had the mechanism for plan- ning, as suggested by the National Rural Development Committee, been implemented. Thailand is now stressing environmental issues, drug abuse addicts and AIDS, while Indonesia is dealing more with urban issues and how to reach the unreached. 4. Cmity Participation Decentralization of management and administration, including development programmes, has been further taken from the district level down to the block level. Block Development Committees are being formed to facilitate community participation. Farmers and village volunteer health workers are trained to work in close collaboration with communities under the supervision of Block Committees. Trained voluntary village health workers are now available to provide health care in their respective communities situated in difficult and inaccessible, remote areas in Bhutan and India. Training of community health volunteers, selected on a neighbourhood basis, was initiated in Bangladesh. Nearly two-thirds of the selected volunteers were women, reflecting a social change at the village level. These selected volunteers, besides making home visits and promoting healthy lifestyles, also organize village health posts for monthly delivery of integrated packages with community participation. WHO supports the training of ten-households health workers and their trainers in Myanmar, who are key persona for constant motivation of families, while in Indonesia the emphasis is on strengthening Posyandu and development of ten-household units. WHO is supporting the expansion of the Revolving Community Drug Cooperative Scheme in Nepal. During 1989-1990 it was expanded to two districts each in the Central and Western Regions. WHO also supported two national workshops in Indonesia on Development of Community Health Fund programmes, which dealt with the mobilization of community resources on health care financing, formulation of community resources, operational ,guidance on Dana Sehat (community health fund) implementation, and improving the coordination mechanism and management aspects of Dana Sehat. Similar workshops were also conducted at the district level in four provinces. A workshop on community participation in the transmigration area was also conducted with the participation of health and related sectors from the central level. Five fellowships for studying community participation, with emphasis on health insurance schemes and community health funding programmes, were arranged. In Sri Lanka, the Jana Saviya movement, with its multisectoral development programme for the "poorest of the poor" is carried out through a mechanism of reaching a consensus within the community. The health sector component, known as Suva Saviya, deals with primary health care as a practical approach to making essential health care available to identified families in an acceptable and affordable way, with full participation of the community in hamlets. A meeting of the WHO Study Group on Community Involvement in Health Management was held in Geneva in 1989. Participants from the South-East Asia Region were India and Thailand. 5. Urban Primary Health Care In November 1989, an Interregional Meeting on City Health : The Challenge of Social Justice, was held in Karachi, Pakistan. Health administrators and Mayors of Bangkok, Bombay, Colombo, and Jakarta participated from the South-East Asia Region. The Symposium on the Implications of Public Policy on Health Status and Quality of Life in Bangalore, 1989, laid stress on housing and urban slums, and suggested policy options. Urban health cannot be undertaken by the health sector alone and an intersectoral strategy is called for. WHO is supporting countries in developing strategies and appropriate technology among the Member Countries. It is providing support to Thailand in various projects such as the application of a PHC development model in low income urban communities. A film, entitled "Quality of Life at Hua Rod Chak Tuk Dang", using Basic Minimum Needs as material, was developed. WHO also provided support for the community financing scheme through urban health cards. The health cards input was implemented in Thippanent and Rahang. It is encouraging that NGOs and associations in various fields are taking a positive interest in urban areas of India. Community Health Workers Community health workers are playlng a lead~ng role in providing health care to the masses in the Member countries Nutrition Nutrition monitoring and surveillance activities are being continuously promoted in the Region. Oral Health Education and promotion of oral health are vital tools in the programmeon prevention of dental caries.
Chapter 11 PROMOTION OF ENVIRONMENTAL HEALTH The Community Water Supply and Sanitation Programme continued to be accorded high priority in most countries. The emphasis of the WHO programme is, however, shifting to broader issues of the environment due to the growing awareness of the adverse effects on health by environmental pollution. This is due mainly to rapid urbanization and industrialization, and to continuous migration of people from rural to urban core areas and urban fringe areas. Many countries have initiated activities related to environmental health in rural and urban development and housing, prevention and control of environmental pollution and health hazards, environmental health impact assessment, control of poisoning, hazardous waste management, health risk assessment, epidemiology and chemical safety. The new global environmental health strategy, of which global community water supply and sanitation strategy is a component, received a favourable response from most countries. 11.1 COWITY WATER SUPPLY AND SANITATION In order to accelerate the implementation of the Community Water Supply and Sanitation (CWSS) Programme, the "Action Agenda", as recommended by the International Drinking Water Supply and Sanitation Decade (IDWSSD) Consultation, held in the Regional Office in July 1988, was pursued with the countries. According to the recommendations, the countries would establish new sector targets after review and development of new sector action plans for institutional development, and carry out realignment and decentralization to secure better community ~articiwtion. oarticularlv of women. A workshop to develop a . . strategy for co~mnunity water supply and sanitation in the Five-Year Plan was also organized in Indonesia. The development of a management information system (MIS) for promoting a realistic data base for better planning and management received special attention. Efforts are now concentrated on the develop- ment of a new global community water supply and sanitation strategy for better comprehensive planning and on the implemen- tation of sustainable sectoral activities in the 1990s. For this purpose, a global CWSS strategy meeting was held in March 1990 in Rabat, Morocco, in which the Regional Office participated. A regional consultation on CWSS was held from 4 to 8 June 1990 in Manila, in which five countries of the Region participated. A global Consultation on Safe Water Supply and Sanitation for the 1990s has been planned for September 1990 in New Delhi, for which support is being mobilized and the necessary background documents have been made available to the secretariat. Technical support was provided through consultation in the area of operation and maintenance in Bangladesn, Indonesia and Nepal, in the area of water quality surveillance and monitoring in India, Indonesia, Myanmar, Nepal, and Sri Lanka, and in the area of low-cost sanitation in Bhutan, India, Indonesia, Myanmar and Nepal. Efforts to mobilize the support of external agencies also continued. In this context, the Regional Office participated in review meetings of certain UNDP-funded projects, namely, those in Indonesia and Nepal. Joint activities were initiated in collaboration with the Regional Water Supply and Sanitation project of the World Bank in Bangladesh, India, Nepal and Sri Lanka. 1. Manpower Training WHO support to manpower development through fellowships, special courses, observation tours within and outside the countries and through other group educational activities relevant to the countries' needs was continued in most countries. In-country training of sanitation workers, sub-professionals and engineers was arranged in Bangladesh, India, Indonesia, Myanmar and Nepal. Training curricula for various levels of public health engineers and sub-professionals were reviewed, and a proposal for the eeteblishment of a trainiw institute was finalized in Bangladesh. In-country training courses were conducted for the training of trainers of various levels of PHE staff as well as for the training of Upazila water supply committees and other community-level water supply and sanitation workers in Bangladesh. In Bangladesh and Nepal, training courses on the computer-aided design of water supply and sewerage networks were conducted in collaboration with the World Bank. Training in data collection, planning and management of water supply and sanitation was also provided to village cadres in Bangladesh, Indonesia and Nepal. Special short courses were conducted for sector officials in operation and maintenance aspects of CWSS installation in Bangladesh, Myanmar and Nepal. Training, through special courses, on trenchleas technology of micro-tunnelling, on low-cost water and sanitation technology for senior sector officials from India, and on the planning and management of rural water supply for officials from Maldives. was arranged. In-country training courses were arranged for Indonesian sector officials in intersectoral planning and in health education for village volunteers. The Desa "Demo" concept was field-tested. 2. Institutional Development Progress continued to be made in the developsent of a management information system for planning, manpower and financial manage- ment in Bangladesh, India, Nepal and Sri Lanka. A consultation for the exchange of knowledge and information, including a review of micro computer programmes and the development of new softwares, including their testing, was organized in India and was attended by participants from India, Indonesia, Nepal and Sri Lanka. Support for the purchase of computer hardware was also provided. The responeibllities of the Department of Public Health Engineering (DPHE) and the Local Government Engineering Bureau in Bangladesh were reviewed. In India, assistance was provided for the preparation of a Rural Water Supply and Sanitation Manual. In Myanmar, guides, books and manuals on the sanitation programme were prepared in the local language. In Nepal, the sanitation strategy was reviewed and the preparation of a sector study and a master plan is being supported. 3. Water Quality Surveillance A training workshop on water quality monitoring was organized by ESCAP in which senior sector officials from India, Indonesia, Nepal and Sri Lanka participated. Senior officials from India attended a course in water quality management for decisionlnakers. In Mongolia, a fellowship was provided for studies on water quality surveillance and control. Workshops on drinking water quality surveillance were held in India, Myanmar and Mongolia. A workshop on flouride removal was also organized in India. In Indonesia, wastewater quality aspects and environmental health impact aspects received special attention. The Regional Drinking Water Quality Surveillance and Monitoring Guide was finalized. 4. Groundwater Development Activities connected with groundwater development continued to be of high priority in Bangladesh, Myanmar, India, Indonesia and Sri Lanka. Hydrogeological surveys, test drilling and exploitation of ground water continued in Bengkulu, Lampung and Tim Tim provinces of Indonesia, Myanmar and Sri Lanka. A workshop on the construction of radial wells was also organized in Myanmar. 5. Research Research studies into the factors that Lead to the persistence of diarrhoea1 diseases in Sri Lanka, with emphasis on water quality and pollution aspects, and into appropriate types of latrines for rural communities in Thailand, were completed. In addition, research on different topics was continuing in India, Indonesia, Sri Lanka and Thailand. 11.2 ENVIRONPIBNTAL HEALTH IN RURAL AND URBAN DBVELOPMKNT AND HOUSING With the rapid increases in populations, developing countries are faced with problems associated with urbanization, resulting in squatter settlements and overcrowding in existing housing areas, and concomitant deteriorating environmental conditions and services such as water supply, excreta disposal, waste water and refuse collection and disposal facilities etc. In order to cope with these environmental health problems, activi- ties in this sub-programme area concentrated on promoting intersectoral cooperation and community self-reliance using appropriate technology. In this connection, studies in selected areas were supported in Bangladesh, Myanmar, Sri Lanka and Thailand for developing plans for corrective action. The report on action study on environmental health problems and strategies for the improvement of conditions in six settlement areas in Sri Lanka was presented at a Conference on Community Environmental Health, held in Colombo in December 1989 to discuss concepts and methodologies, including their dissemination and wider application. The emphasis of this action study was to identify environmental health deficiencies and solicit solutions through active intersectoral cooperation and community participation. In view of the increasing problems of solid waste management in most countries, an intercountry consultation on solid waste management is planned for late 1990 in collaboration with Gesellschaft fur Technische Zusammenarbeit (GTZ). A regional overview of solid waste management, based on country reports from Bangladesh, India, Indonesia, Myanmar. Nepal, Sri Lanka and Thailand, has been prepared for presentation at this consultation. In Calcutta, India, a research project on the socioeconomic aspects of recycling urban solid waste is nearing completion. 11.3 HWTH RISK ASSESSMENT OF POTENTIALLY TOXIC CHEMICALS This sub-programme started in January 1990 and is primarily research-oriented, focusing on the development of research and evaluation methodologies as well as on the production and dis- semination of public information on potentially toxic chemicals for use by countries in such programme areas as control of environmental health hazards, food safety and workers' health. In Indonesia, a consultant assisted the national authorities in finalizing draft legislation on labelling, handling, storage and transportation of hazardous substances, which would help in the adoption of appropriate chemical safety measures in the country. U.4 CONTBOL OF F2WIRONMENlAL HEALTH HAWBDS WHO'S collaborative efforts with Member Countries involved the strengthening of national institutional and manpower capabilities in the areas of air, water and land pollution prevention, as well as the promotion of chemical safety and control of other environmental health hazards. A tripartite review meeting of the UNDP-assisted intercountry project "Safety and Control of Pollutants and Toxic Chemicals" was held in the Regional Office in September 1989. Officials from India, Indonesia, Myanmar, Sri Lanka and Thailand participated. Immediately prior to the review meeting an intercountry conference, held in the Regional Office, identified several activities for the project, including hazardous waste management, emergency preparedness/response , poison control networks, information systems, essential equipment and manpower development. Subsequently, a draft project document for UNDP assistance under the UNDP Fourth Country Programme was prepared for Sri Lanka. The UNDP-funded project in DPR Korea on "Control of Environ- mental Health Hazards" was completed in December 1989, and the terminal tripartite review recommended an in-depth evaluation of the project. The tripartite evaluation team completed ita mission in mid-March, and two project documents - one to strengthen the central laboratory of the Central Hygienic and Anti-Epidemic Station and the other to develop the capabilities of related provincial and municipal surveillance laboratories - were drafted. In April 1990, a UNDP/WHO health sector mission in Indonesia identified two potential new projects - one on environmental health impact assessment and the other on the establishment of a national poison centre network - for UNDP assistance in the UNDP's Fourth Country Programme. In addition, the mission recommended the preparation of guidelines for health aspects in tourism as part of an existing UNDP pipeline project in the Comprehensive Tourism Development Plan. 1. Menpower Training Nationals from Indonesia, Sri Lanka and Thailand attended a Poison Control Workshop in Malaysia in NovemberIDecember 1989. Three health officials from Indonesia also attended a meeting of the International Programme on Chemical Safety (IPCS) in Malaysia in November 1989, to improve their capabilities in the monitoring and control of chemical safety, particularly with respect to pesticides. In December 1989, an IPCS course on "Risk Assessment and Management of Toxic Chemicals: Principles and Applications" was conducted in Thailand. National workshops on "Safety and Control of Toxic Chemicals and Pollutants" were held in Sri Lanka in February 1990 and in Myanmar in April 1990. A national training course on "Soil and Groundwater Pollution" was held in India in September 1989 for officials of the central and state Boards for the Prevention and Control of Pollution. A national training workshop on Environmental Impact Asseasment was also conducted in India. A national workshop on Packaging, Labelling, Storage and Transportation of, and Information on, Hazardous Substances was held in Indonesia. Two officials of the Central Hygienic and Anti-epidemic Station (CHAES) laboratory in DPR Korea underwent special training in toxicology. An In-country study tour was arranged for central and state officials in India, to acquaint themselves with the latest industrial pollution problems and their control. For Indian officials, training in hazardous waste disposal and soil pollution control methods and in conducting environmental epidemiology was also arranged. 2. Institutional Development WHO assistance in water pollution monitoring and control was provided to the Central Hygienic and Anti-epidemic Station laboratory in DPR Korea. In India, assistance was given to the central and state Boards for the Prevention and Control of Pollution in tannery waste management practices in West Bengal and Tamil Nadu. In proposing improvements to tannery waste treatment plants, the consultant recommended ways for the cost-effective recovery of chromium metal from waste water. Stemming from the tragic deaths (in 1989) caused by accidental chemical poisoning of food, support for drafting national legislation on hazardous substances was provided in Indonesia. Two WHO consultants assisted the Indian National Institute of Occupational Health in December 1989 and January 1990 in the training of staff in quality assurance of analytical pesticide residues and heavy metals. A pilot-cum-demonstration project on "Waste Management in the Electroplating Industry" in Delhi was completed, and information concerning the demonstrated approaches to promoting the methodology developed for reducing pollution is being disseminated. Computer hardware and software was procured for the establishment of poison information network centres in India, Indonesia and Thailand. In Sri Lanka, a computer to process information on chemicals in use was installed in the Central Environmental Authority. In Thailand, a national expert was engaged to review laws and regulations concerned with the control of chemical hazards and to study appropriate technologies related to the prevention of chemical poisoning, particularly that due to agro-chemicals. 3. Global Environmental Monitoring Under the Global Environmental Monitoring System (GEMS), water quality monitoring activities continued in Bangladesh, India, Indonesia and Thailand, ambient air quality monitoring continued in India, Indonesia and Thailand, and food contamination moni- toring continued in Thailand; while health effects monitoring continued in Central Bombay, India, under the Human Exposure Assessment Location (HEAL) project. 4. Research Research studies in safe chemical exposure, vehicular emissions, agro-chemicals, air pollution, pesticides residues and chemical contamination in food are being supported in Thailand. 11.5 FOOD SAFETY WHO efforts in food safety were primarily aimed at strengthening national infrastructures, at developing standards and legisla- tion, and at monitoring and inspection. In India, WHO supported a national Workshop on Food Safety in Public Catering, in Hyderabad, in November 1989. The workshop identified shortcomings in food safety practices and recommended actions for improving the hygienic quality of foods served by public catering establishments and for the development of national food safety policies and strategies for public catering. In Indonesia, support was provided for the formulation of health regulations for restaurant hygiene and sanitation and for the preparation of guidelines for hygiene and sanitation inspectors in tourist areas. A visit by national staff to various countries to acquaint themaelves with food aafety legislation and administration and with current practices in food safety management was also organized. In April 1990, a UNDP/WHO health sector mission identified a new project for the promotion of food safety and food sanitation under the Fourth Country UNDP Programme. A research project on food contamination monitoring systems is also being supported. In India and DPR Korea, support was given for monitoring food contamination due to pesticides by providing equipment and consultants to strengthen laboratories in food analysis and monitoring. Surveys on pesticide residues in food commodities and on the use of food additives were initiated in India. Several countries participated in the seventh session of the Codex Alimentarius Coordinating Committee for Asia, held in Chiang Mai, Thailand, in February 1990. A project document on infrastructure development for food and drug control administration in Myanmar was prepared for UNDP support.
SECTION I1 HEALTH SYSTEM INFRASTRUCTURE Chapter 3 HEALTH SYSTEM DEVELOPMENT 3.1 HWTH SITUATION AND TREND ASSBSSKENT Most countries of the Region continued their efforts to further strengthen their health information systems by system redesign, staff training and support in the use of information, especially at intermediate and lower levels. Test-runs of health management information systems have been completed in four districts in India and two districts in Nepal. Collaborative efforts in improving the quality of mortality statistics are continuing in India, Sri Lanka and Thailand. Steps are being taken to familia- rize national authorities with the Tenth Revision of the International Classification of Diseases, which will come into effect on 1 January 1993. Their comments on the draft proposal of a three-character version of ICD-10, and its suitability for both mortality and morbidity purposes, are being sought. Activities related to the second evaluation of the health-for- all strategies began in the second half of 1989. A document entitled "Evaluating the Strategies for Health for All by the Year 2000, Common Framework: Second Evaluation" (CFE/2), together with the list of global indicators, was prepared by WHO headquarters. The revised version of CFE/2 and the revised list of global indicators were finalized following extensive discua- sions with regional offices and Member Countries. The revised CFE/2 was pretested in India and Mongolia. National authorities were briefed by the Regional Office on methodology procedures and the time-table of the second evaluation, and advised to undertake this task as an integral part of the national health management process. The second evaluation vill be carried out by Member Countries between September 1990 and January 1991. The plan of action includes intersectoral aspects of health development and the presentation of information on indicators and other relevant data for all identifiable sub-groups of the population. Epidemiological Surveillance Considering the role of epidemiology in the attainment of health for all and its contribution to primary health care, efforts have been made to secure competent epidemiologists through the development of Field Epidemiology Training Programmes (FETP). Sentinel surveillance and follow-up proce- dures for polio and neonatal tetanus cases have been developed using WHO~PAHO training material, to support EPI efforts to eliminate the transmission of these diseases in Indonesia. FETP has been strengthened in three countries, namely, India, Indonesia and Thailand. In India, modules concerning the epi- demiological characteristics of various diseases were drafted, and research activities utilizing the computer analysis of data concerning communicable diseases were started. Epidemiological surveillance without adequate laboratory support will not be helpful in containing communicable diseases. India is the only country that has a combined laboratory epidemiology centre and can demonstrate the value of laboratory-based surveillance. The project will undergo major modifications which are under dis- cussion between the collaborating agencies and the Government. In Indonesia, the FETP is effectively being run by the national authorities. WHO actively collaborated in the designing, conduct, and analysis of public health surveillance systems and assisted in the development and management of FETP. The trainees and staff under FETP conducted various case-control studies and carried out investigations of epidemic outbreaks of measles and malaria. FETP, which was initiated by the Ministry of Public Health, with the assistance of WHO, has been part of the post- graduate curriculum of the School of Public Health at the University of Indonesia since 1987. The University-based regular FETP is scheduled for external evaluation in July-August 1990. Thailand has concentrated on developing trained manpower in epidemiological surveillance. Training in basic epidemiology and biostatistics, as well as field experience in surveillance activities for certain diseases, were covered under FETP. Special attention was paid to the preparation of sentinel surveillance for AIDS, EPI and CDD. In order to effectively control and prevent major communicable diseases, an epidemiological surveillance programme has been developed ensuring the availability of essential epidemiological information. Most of the Member Countries were assisted, through training of health personnel at intermediate and peripheral levels, in the collection of epidemiological data and the use of epidemio- logical information at all levels. WHO assisted by providing computers and training facilities so that Member Countries could effectively introduce computerization for analysing epidemiological data. Despite the progress made towards the promotion of epidemiological surveillance, common problems and constraints, such as the lack of personnel trained in the use of epidemiological information and the lack of laboratory support, still exist. 3.2 WERIAL PROCESS FOR NATIONAL WTH DEVELOPMENT 1. National Health Policies There is a continuous effort by the Member Countries to update national health policies. WHO actively supports these endeavours. A high-powered committee of the Government of Bangladesh prepared a draft national health and population policy. The draft national health policy, formulated in Bhutan in 1986, is still undergoing a comprehensive review in the Ministry of Social Services prior to its adoption by the Government. Also under review are national health-for-all strategies for establishing comprehensive guidelines to facilitate smooth implementation of the health policy. There has been an ongoing, intensive effort in Myanmar to evaluate the health policy with a view to drafting a new one, taking into account recent political and socioeconomic developments. 2. National Health Development Plans National health development plans were formulated to implement national health-for-all strategies and to develop primary health care. The Organization collaborated with several countries in the preparation and implementation of health plans or health components of national development plans. In India, the Eighth Five-Year Plan, including the health sector plan, was formulated. A background document in the context of the national health policy, prepared with WHO collaboration, outlines such essential elements as the recent status of the health sector, existing gaps, national leadership strategies for health care, future prospects and a plan of action. In Indonesia, WHO support was provided for developing the health component of the Fifth Five-Year Development Plan (Repelita V). An extensive, collaborative effort is being made to strengthen national capabilities in health planning and management in Myanmar, particularly in the preparation of the forthcoming two-year health plan. The task is even more demanding in the light of the changing health policies and priorities. As a preparatory measure, the impact of the previous People's Health Plans was assessed. 3. Strengthening of Health Economics Health economics, including the financing of health services and the mobilization of resources for health development, constitutes a priority area for WHO collaboration with Member Countries. The support extended by the Organization takes various forms, such as insti tutional strengthening, research and development, group training, fellomhips, and consultative services. The subject of health financing and mobilization of resources for health development received significant attention during the forty-second session of the Regional Committee. In its resolution the Committee urged Member Countries to review their current patterns of resource allocation in the health sector and to reorient their spending priorities. It was empha- sized that additional resources should be sought and preferen- tial attention given to the most needy segments of the population. In several countries of the Region, activities are being undertaken to estimate realistic costs of implementing national health policies. Support was provided to Mongolia and Myanmar for developing/strengthening the information basis for better financial planning. A series of simple health systems research projects has been initiated in India, Mongolia and Thailand to estimate unit costs and expenditure on health, including household expenditure. At the regional level, efforts are being made to establish and maintain an information base on health planning and management, including health economics and the financing and mobilization of resources for health. This computerized information base contains data on training institutions, resource persons and relevant materials and documents in this field. The forthcoming major consultation on health economics, scheduled for later this year, will review the current status of health care financing and resource allocation in the Region. The consultation will also help to establish a regional programme of activities in Member Countries. Several options for health care financing are being established or strengthened in the countries of the Region. In Myanmar, a review of the national health policy was undertaken while proposals for alternative means of health care financing were developed. In other countries, various other methods of paying for health services, such as community financing, health insurance and user charges, are being implemented. 4. Strengthening of Operational Hanagentent Strengthening of operational management of health services remained a high priority in many countries of the Region. The Organization extended technical support through consultancies and training. In Bangladesh, two workshops on the strengthening of operational management were conducted for multisectoral supervisory staff. These workshops resulted in the development of work targets, action plans, monitoring systems, etc., and in the identification of training needs of health officials in operational management. In Indonesia, support was provided for clarifying the structural and functional relationships between health centres and integrated service posts (Posyandu). As a parallel activity, a series of job analysis activities, including the development of job descriptions for central- and provincial-level health offices, was supported. A "Job Analysis Programme" was initiated, with the objective of developing job descriptions for central, provincial, district and municipal- level health offices, hospitals and health centres. 5. Decentralization of Health Services It has been acknowledged that decentralization of health services plays an important role in increasing their effectiveness. The policy of decentralization is being followed in a number of countries of the Region. In Bhutan, the process of decentralization through delegation of authority has been strengthened with the establishment of four zones which will have limited authority to take limited decisions. It is believed that the establishment of zones will help in a better planning and implementation process and will increase the participation of community leaders. Further, the decentralization process has been carried down to the block level, which facilitates effective community development and strengthening of primary health care. Various approaches to decentralization have been adopted in many countries - Bangladesh, Nepal, Sri Lanka, Thailand, to quote just a few examples - and are gradually being further strengthened. 6. Support to Countries Facing Serious Bconomic Constraints As in many developing countries, the health situation in the Region remains unsatisfactory due to serious obstacles to effective implementation of primary health care caused by the unfavourable economic situation. The country-centered strategy, initiated recently by WHO for overcoming these obstacles, is being implemented in three countries of the Region. New mechanisms and approaches are being used in this collaboration, and include a holistic view of the planning and implementation of country activities, improved coordination, and advocacy for larger resource allocation for health. The more important problems identified in the countries so far have been weak management, lack of rationalization of the financing of health care, inadequate human resources for health and inability to ensure appropriate economic support for the health sector. Other problems include poor health system coordination and design, inadequate integration of delivery of primary health care and lack of technical capability for preventing and treating priority health problems. WHO undertook a number of activities in order to meet such constraints. In Nepal, short-term, immediate support was given for studies on the financing of health services, health manpower development and utilization, and accelerated development of the health information system. In Bangladesh and Bhutan, this initiative is in an early stage of development. 7. Training in Health Planning and Managerent WHO supported a wide variety of training activities in the field of health planning and management as well as that of health care financing. This training was directed at various levels of health managers, including central-level health planners and district health officers. Some training efforts, such as the series of seminars and workshops in health plan development for provincial and district-level personnel, were aimed at strengthening institutional capacity in health pla~ing and monitoring. As an integral part of staff development in health planning and management, the Organization organized GUS, workshops, and training courses and provided fellowships to countries. 3.3 HEALTH SYSTEMS RESEARCH AM) DEVEU)PWT The Regional Office continued to promote and support health systems research (HSR) in the Region. A major effort of the Regional office was directed towards the strengthening of institutions to undertake health systems research. This was in pursuance of the recommendations made by the meeting of the Task Force on Health Systems Research in 1987. As decided by the Regional Committee and the Regional Advisory Committee on Health Research, four Member Countries are being supported under the programme of institutional strengthening, which includes training of research and support personnel, infrastructure development such as library and data processing facilities, and provision of consultants. The SUIACHR Sub-committee on the Role of Health Research in the Strategy for Health for All by the Year 2000, which was convened to prepare the regional contribution for the technical discussions at the Forty-third World Health Assembly, met in New Delhi on 30-31 October 1989. Recent and important developments and issues in health systems research in the Region, identified by the Sub-committee, constituted an important part of the report, which was submitted to WHO headquarters. An assessment of the volume of health systems research being conducted in the Region is rather difficult. This is due to the fact that a considerable number of research projects in various fields have an HSR component integrated into them. This HSR component is not always evident on a cursory examination of the title of a project. However, this obscurity is to be expected since health behaviour research, health economics research and research on the development of human resources for health and health services are also integral parts of health systems research. Health systems research is also integrated into ongoing opera- tional projects, such as the Expanded Programme on Immunization and the Maternal and Child Health programme. HSR has also been used in the Region in the development of training manuals for health workers and IEH materials. One of the objectives of the Second International Conference of the Consortium of Indian Health Institutions for the Reform of Medical Education, held in New Delhi from 23 to 25 April 1990, was to illustrate the role of HSR in eliciting the need for innovation in medical education, in determining the planning process for innovation, and in monitoring the implementation of the innovations. Collaboration with other programmes of WHO, such as Maternal and Child Health (MCH), Acute Respiratory Infections (ARI), and the Special Progrannnes on Tropical Disease Research (TDR) and Human Reproduction (HRP), has resulted in the involvement of Member Countries in health systems research projects, including field studies in the various programme areas. 3.4 HEALTH LBGISUTION Important activities in the field of health legislation were carried out throughout the Region with technical and financial support from the Organization. The main objective of these collaborative activities was to develop or strengthen existing legislation in support of health development policies and to monitor and evaluate the impact of legislative measures on health situations and trends. The Organization played a support- ing role in facilitating information exchange between Member Countries of the Region at both regional and interregional levels. India and Indonesia are the two countries where colla- borative activities in health legislation were most intensive. Close collaboration was maintained with WHO headquarters from where relevant documents and working materials were received, and distributed to Member Countries. Legal documentation on the control of AIDS epidemics in various countriea of the world was of particular interest and usefulness, and was shared through appropriate channels.
SECTION IV PROGRAMME SUPPORT Chapter 14 HEALTH INFORMATION SUPPORT 14.1 HEALTH LITERATUBE AND LIBRARY SERVICES (INCLUDING HELLIS) Health Literature, Library and Information Services (HELLIS) The HELLIS (Health Literature, Library and Information Services) network, now functional in eight Member Countries, continued to be an effective mechanism for information support to varied health clientele in the Region. Besides, with the provision of free MEDLARSIMEDLINE search(es) and photocopies of references that are not available in countries from where requests originate, it has been possible to help meet the information needs of health researchers, administrators, planners, managers, postgraduate students and others in the Member Countries. To introduce newer technologies in health science libraries in Member Countries, HELLIS National Focal Points (NFPs) participated in the Workshop on Application of Micro-ISIS Software, in Bangkok, from 23 October to 3 November 1989 and CD-ROM (Compact Disk Read-only Memory) MEDLINE Data Base Training, in Mahidol University, Thailand, from 4 to 6 November 1989. With a view to making them self-sufficient in their information retrieval capabilities as well as to have quick access to the relevant health literature/information, a one-time subscription to CD-ROM MEDLINE data base along with the CD-ROM drive was provided to HELLIS NFPs in Bangladesh, India, Indonesia, Myanmar and Sri lanka. For easier interaction among the network libraries, the Regional Office is compiling a directory of HELLIS NFPs and participating libraries. In order to bring under bibliographical control health literature published in the Member Countries, the Index Medicus for WHO South-East Asia Region (IMSEAR) continued to be compiled with the active participation of HELLIS NPPs in the collection and indexing of the material. Regional Office Library During the reporting period the Regional Office Library received 628 bookslmonographs, proceedings, reports, pamphlets, WHO publications and issues of current periodicals. Library facilities were used by 2 654 visitors (2 311 WHO staff and 343 others); 1 244 books and periodicala were issued on loan. In response to requests from Regional Office staff, field staff and headquarters, 88 inter-library loan requests were sent; 9 922 items were consulted in the library itself. 131 MEDLARSIMEDLINE searches and photocopies of 2 875 articles from in-house, local, regional, and headquarters and other international sources were arranged for WHO staff and Member Countries. The compilation and distribution of SEARO Library Alert (SIA) - a monthly current awareness service covering - selected periodicals and HELLIS Newsletter - was continued. The Library provided reference material and services for group educational activities and actively assisted in the development and monitoring of HELLIS network activitiea at national and international levels. The compilation and publication of Index Medicus for WHO South-East Asia Region (IMSEAR) was continued. IMSEAR volume 5 covering the period January-December 1985 is in press. Volume 6 covering the period January-December 1986 was being processed for publication in two parts. The library has acquired a computer and is in the process of automating its services. Action was also initiated for the installation of a CD-ROM MEDLINE data base. 14.2 PUBLICATIONS AND DOCUMENTS During the period under reporting, one new title was published under the SEARO publications series, while the first revision of another title was issued. Non-priced documents, including reports of various kinds, were produced (Table 11) and distributed. The sale of WHO publications increased over that of the previous year. 143 TABLE 11. Production of docments, 1989-90 Item Number Pages Pages edited printed Assignment reports 139 1 847 1 303 Reports of group educational activities 22 902 580 Terminal reports of UNDP projects 1 42 47 Other documents 10 923 168 Total 172 3 714 2 098 Translation and Publications Significant progress was made in continuing the WHO policy of disseminating information to the grassroots level by making available WHO publications in regional languages. Support was given to India for the translation of Cancer Pain Relief into Gujarati and The Community Health Worker into Hindi; to Indonesia for the translation into Bahasa Indonesia of the WHO Laboratory Manual for Examination of Human Semen and Semen- cervical Mucus Interaction; Education for Health; Health by the People; The Role of Food Safety in Health and Development: Joint WHOIFAO Expert Committee; Vitamin A Supplements: A Guide to their Use in the Treatment and Prevention of Vitamin A Deficiency and Xerophthalmia; Conjunctivitis of the Newborn; The Provision of Spectacles at Low Cost; A Guide to Nutritional Assessment; Oral Health Surveys: Basic Methods, 3rd Ed.; Respiratory Infections in Children: Management in Small Hospitals; Protecting, Promoting and Supporting Breast-feeding: The Special Role of Maternity Services - A Joint WHO/UNICEF Statement, WHO "Health for All" Series; Food Irradiation: A Technique for Preserving and Improving the Safety of Food; Rapid Assessment of Sources of Air, Water and Land Pollution; The Management of Diarrhoea and Use of Oral Rehydration Therapy; Manual of Radiographic Interpretation for General Practitioners, WHO 'Health for All' Series; to Nepal for the translation into Nepali of Educational Handbook for Health Personnel, 6th Ed.; Weaning - From Breast Milk to Family Food: A Guide for Health and Community Workers; Protecting, Promoting and Supporting Breast-feeding: The Special Role of Maternity Services - A Joint WHO/lJNICEF Statement; Treatment and Prevention of Acute Diarrhoea: Practical Guidelines, 2nd Ed.; and to Thailand for the translation into Thai of The Community Health Worker; Education for Health; Health Principles of Housing; Protecting, Promoting and Supporting Breast-feeding; Treatment and Prevention of Acute Diarrhoea: Practical Guidelines, 2nd Ed.; and Manual of Basic Techniques for a Health Laboratory. The Regional Office issued one title, 'The Use of Traditional Medicine in Primary Health Care in South-East Asia' (Regional Health Papers No. 19). Another publication, Health Care in South-East Asia (Regional Publication No. 14), first issued in 1985, was revised and updated. Documents The Regional Office brought out the Forty-second Report of the Regional Director, the Proposed Programme Budget for 1992-1993, and 'Dengue Newsletter' No. 15. The loose-leaf 'List of Technical Documents Issued Since 1979' was updated and the ninth edition of the 'Handbook of Resolutions and Decisions of the WHO Regional Committee for South-East Asia' was issued. Sales Apart from the routine display of publications at group educational activities held in the Regional Office and those organized in New Delhi by the scientific community, the Regional Office participated in selected book and trade fairs. The Regional Office and ILO, New Delhi, participated jointly, with success, in the India International Trade Fair, 14-29 November 1989, which had 'environment' as its theme. Over 820 books were sold during this fair. Participation at the Madras Book Fair, 22 December 1989 to 1 January 1990, generated interest among medical and paramedical personnel as well as the trade circle, and opened new vistas with Tamil book publishers for possible translation of WHO publications into Tamil in order to make them available at affordable prices. Negotiations with a distributor, for catering to the needs of the entire region of southern India, also commenced. At the New Delhi World Book Fair, 13-18 February 1990, requests for reprint rights for over 30 titles were received. The collection from sales over the counter and registration of new subscriptions for WHO periodicals surpassed all earlier figures. The response at the Health and Medicare exhibition, 25-31 March 1990, was very encouraging in that the visitors belonged exclusively to the medical community. The average sales reached nearly Rs. 10 000 per day. Reprint rights were granted for 12 WHO books which included two SEAR0 titles. A total of 26 306 books were sold in the calendar year 1989. Details of the financial turnover are reflected in Table 12. TABLE 12. Sales of WHO publications, 1988-1989 Item 1988 1989 July 88-June 89 us $ us $ us $ Subscriptions 77 138 85 124 77 879 Other publications 103 394 71 095 113 444 Total 180 532 156 219 191 323 NOTE: The above figures represent actual receipts after deduc- tion of all discounts and application of concessional conversion rate of Geneva cover prices to Indian rupees.
Chapter 2 WHO'S GENERAL PROGRAMME DEVELOPMENT AND MANAGEMENT 2.1 REGIONAL DIRECTOR'S DEVElOPI4ENT PROGEWME The Director-General's and Regional Director's Development Programme, established in 1978, aims at providing assistance to Member Countries to meet emergent situations created by natural calamities such as floods, cyclones or epidemics of diseases. The activities under the Programme are directed mainly at supporting national efforts in providing emergency relief, such as medical supplies, to several countries of the Region. The Programme also provides seed money to countries as initial investment for implementing innovative programmes. Many countries in the Region were again victims of natural disasters and calamities. Assistance was provided to Bangladesh for rapid assessment of health needs during national disasters and in the organization of disaster preparedness as a research and development activity. Emergency assistance was provided to Nepal, Myanmar and Thailand (please also see Section 2.4). 2.2 GENERAL PROCRAMNE DEVELOP= Support was provided for overall management of collaborative programmes with Member Countries. As part of a continuing dialogue with governments, joint government/WHO policy and programme reviews supported the development of WHO'S collaborative activities. In order to ensure the optimal use of WHO'S resources in support of national health programmes, the WHO programme budget was linked closely to national medium-term health plans, programmes and budgets. The working of the joint government/WHO coordination mechanism was reviewed with a view to identifying practical ways and means of improving its functioning. With funding from the Japan Ship-building Industry Foundation, an intercountry project was established with the objective of strengthening the capacity of WHO Representatives' offices and the joint government/WH0 coordination mechanism in the planning, management and coordination of external cooperation in health in the least developed countries. The forty-second session of the Regional Committee requested the Regional Director, inter alia, to take necessary action to submit a single progrsaudget document for 1992-1993. The seventeenth session of CCPDM reviewed the steps to be taken for a single Programme Budget document to be submitted for endorse- ment by the Regional Committee at its forty-third session to be held in 1990. The CCPOM also reviewed the procedures and the plan of action for evaluating the HFA strategies using the Second Common Framework, and the intercountry programme for the 1992-1993 biennium. The eighty-third session of the Executive Board had requested the Director-General, inter alia, to undertake studies on the criteria used at different levels of the Organization with a view to identifying those which could be used for the determi- nation of priorities, including the possible utilization of cost-benefit criteria. Case studies on two countries viz., Indonesia and Sri Lanka, were prepared. In this connection, one member of the Executive Board visited Indonesia and the Regional Off ice. The Regional Committee noted the Detailed Programme Budget for 1990-1991 and urged the Member Countries, inter alia, to initiate preliminary steps for its timely Wm-tion. Detailed plans of action were prepared for all country and intercountry programmes/projects. Country Support Teams, led by programme directors and programme chief, supported such preparation in several countries during their visits in the first quarter of 1990. To further enhance programme implementation, more authority was delegated to the WHO Representatives. Besides, programme implementation has been constantly monitored with a view to removing delaying factors. Continued efforts had also been made to further improve WHO'S information system and training of staff for supporting effective implementation and monitoring of the Organization's collaborative activities. These resulted in better implementation of the 1988-1989 programme as compared to the previous biennium. 2.3 WTWNAL COORD~ION FOR HEALTH AM) SOCJAL DEVELOPMENT The nature and magnitude of major development issues, such as environment, population, education and health, call for extensive and efficient inter-agency coordination and cooperation. By virtue of its Constitution, WHO is to act as the directing and coordinating authority on international health work. The Regional Office has continued to carry out this function. The Regional Director's thirty-eighth meeting with the WHO Representatives in November 1989 dealt specifically with this topic. Interagency coordination has improved further. A meeting of the Task Force for Child Survival was held in Bangkok in March 1990, and was attended by the heads of WHO, UNICEF, World Bank, WDP and the Rockefeller Foundation in a common and wide-ranging endeavour to protect the children of the world. Another international event was the Conference on Safe Motherhood in South Asia, held in Lahore, Pakistan, in March 1990, which was sponsored by the International Planned Parenthood Federation, UNDP, UNFPA, UNICEF, WHO, the World Bank and the Population Council. In a distinct but equally significant vein, WHO headquarters and the Regional Office were associated with the International Conference on "Education For All", held in Jomtien, Thailand, in March 1990, under the aegis of UNDP, UNESCO, UNICEF and the World Bank. Furthermore, inter-agency collaboration and cooperation has been promoted through resource mobilization meetings, held in Bangkok, in November 1989, and in Kathmandu, in February 1990, as well as other international and inter-agency meetings in support of HIV and AIDS prevention and control. 1. Colleboration with the United Nations system United Nations Develo&ment Programme (UNDP) WHO continued to collaborate with UNDP in mobilizing resources for health sector priorities of the countries. WDP's technical assistance provided catalytic support to a wide range of health promotion activities, including, inter alia, control of environmental hazards, health infrastructure development, epidemiological surveillance, health laboratories and drug quality control, food safety, rehabilitation, primary health care, improvement of nursing services and strengthening of institutional facilities. During the year, the Regional Office executed eleven intercountry and thirty-four country projects funded by UNDP. The total input through these projects amounted to US$ 6.0 million. Under UNDP's new strategy of programme approach, comprehensive reviews were conducted by WHO teams in Myanmar and Indonesia to identify potential projects for UNDP support under country programmes. Based on the mission's report, UNDP Myanmar approved six projects with a budget of US$ 4.3 million for immediate implementation. Five other projects were retained in the pipeline for future consideration. In the Indonesia review, the areas of concentration were environmental health, water supply and sanitation, communicable diseases and maternal and child health. The Regional Office also collaborated closely in Nepal's Fifth UNDP country programming exercise (1991-1995). Health planning and management, including rational use of resources, emerged as the immediate priority for tripartite collaboration between UNDP, WHO and the World Bank. Two new intercountry projects for the Region were approved by UNDP for execution by WHO. These are: Regional Programme for the Development of Health Learning Materials, and Introduction of Quality Standards and Appropriate Technology for Laboratory Services in Support of Primary Health Care. UNDP approved four new country projects during this period while eleven more country projects with an estimated input of about US$ 10.0 million are in the pipeline. Within the framework of the WHOIUNDP alliance to combat AIDS, UNDP made available US$ 1,5 million for Sri Lanka and US$ 1.0 million for Thailand from its country programme resources. These inputs were in addition to US$ 1.4 million provided for the countries of Asia and the Pacific Region through its intercountry project on Prevention and Control of AIDS, being implemented under WHO'S Global Programme on AIDS. UNDP collaborated in the IMPACT field study initiative of the Regional Office to test the feasibility of an integrated approach for the prevention of avoidable disabilities. The declining trend of UNDP resources in the overall health sector continued. Concerted efforts at the country level to project the importance of health in the development process, active participation of ministries of health, with technically sound priority project proposals, in the UNDP country programme formulation exercise, and adequate resource mobilization efforts of ministries of health are essential to reverse this trend. United Nations Population Fund (UNFPA) Collaboration between WHO and UNFPA continued in maternal and child health and family planning, the main fields of common interest between the two organizations. The Regional Office participated in two UNFPA Country Needs Assessment missions and Programme Formulation exercises in DPR Korea and Nepal. The Regional office executed nine UNFPA-funded projects with a total budget of about US$ 1.5 million. Two new projects, viz., Strengthening of Family Health/Birth-Spacing Services, in Maldives, and Centre for Family Health, in Nepal, were approved for joint government/WHO execution. Regular exchange of information and the consultative process were further streamlined for improved coordination and collaboration between the two organizations. United Nations Children's Fund (UNICEF) WHO and UNICEF continued to pursue close collaboration at the country level in areas of common interest. The Regional Office participated in the UNICEP-WHO Inter- secretariat Meeting, held in Geneva in September 1989. The Meeting reviewed, among other matters, WHOfUNICEF Common Goals for the Health of Women and Children by the Year 2000; WHO/UNICEP Strategy for Improved Nutrition of Mothers and Children in the Developing World; and Public Education to Reduce the Use of Tobacco. WHO and UNICEF worked together with the Government of Myanmar in the evaluation of the Joint Nutrition Support Programme in that country. Economic and Social Commission for Asia and the Pacific (BSCAP) Cooperation and collaboration with ESCAP continued in the fields of human resources development, integrated rural development, population and drug abuse rehabilitation. Country studies, carried out in India, Myanmar and Thailand under the WHOIESCAP project on Drug Abuse Rehabilitation in Asia and the Pacific, were reviewed at a joint meeting in Bangkok in January 1990. The meeting produced several project profiles for follow-up activities. Technical and financial support was extended to the ESCAP Seminar on Water Quality Monitoring, held at Beijing, China, in September 1989. WHOlESCAP Collaboration - The Present Situation and Future Prospects, was reviewed at the Regional Director's thirty- eighth meeting with the WHO Representatives in November 1989. United Nations Educational. Scientific and Cultural Organization (UNESCO) WHO entered into an agreement with UNESCO to establish in Bangkok a Regional AIDS Education and Health Promotion Materials Exchange Centre, to facilitate the exchange of health promotion materials relating to AIDS prevention and control. United Nations Fund for Drug Abuse Control (WAC) WHO continued to execute, amongst other things, the health components of UNFDAC-funded drug abuse control projects in Sri Lanka and Myanmar. International Fund for Agricultural Development ( IFAD) IFAD is supporting agricultural development projects in SEAR countries. In April 1990, an IFAD project preparation mission to Andhra Pradesh, India, was joined by a WHO consultant to explore and assess the prospect of incorporating a compre- hensive health services component in the future IFAD-supported project in that state. Other Agencies WHO continued to promote health and nutrition in projects assisted by the World Food Programme and to liaise with other agencies of the UN system, including the International Labour Organisation and the UN Food and Agriculture Organization, which have a supportive role in health development. 2. The Development Banks and Funds The twenty-third annual meeting of the Board of Governors of the Asian Development Bank was held in New Delhi in May 1990. A representative of the Regional Office attended on behalf of WHO. In 1989-1990, the World Bank considered new initiatives and projects for health sector development in Indonesia, Nepal and Sri Lanka, among other countries. In the case of Nepal, a World Bank mission visiting the country in September 1989 to prepare a comprehensive population and health project, was offered technical advice by WHO, inter alia, through WHO'S contribution to a health resources and priorities study for the country. Also, in Nepal, WHO, in collaboration with the World Bank and UNDP, has been formulating a project on "Strengthening Resource Allocation, Planning Formulation and Implementation in the Health Sector". Plans have been made for the World Bank to execute the project in association with WHO. The Regional Office continued to receive financial support from the Arab Gulf Programme for the United Nations Development Organizations (AGFUND). Promotion of oral health, and prevention of blindness and deafness were among the projects which benefited from these funds. The OPEC Fund for International Development extended support through WHO for the purchase of emergency medical supplies to Bangladesh. 3. Bilateral Agencies A wide range of health development projects in the Region is being supported through bilateral collaboration schemes. Most of the countries providing bilateral support for socioeconomic development in the Region are members of the Developmeat Assistance Committee (DAC) of the Organization of Economic Cooperation and Development. WHO has been executing the Field Epidemiology/Laboratory Services Programme in India, supported by the United States Agency for International Development (USAID). During the reporting period, a decision was taken by the collaborating parties to redesign the project. The implementation of malaria, tuberculosis and leprosy control programmes in India continued with support from the Swedish International Development Authority (SIDA), with WHO as the executing agency, following the extension of previous agreements which expired in 1989. In Bangladesh, the project "Family Planning Clinical Supervision Team", executed by WHO with support from the Norwegian Agency for International Development (NORAD), was reviewed in February 1990 by a four-partite mission comprising the Government of Bangladesh, NORAD, the world Bank and WHO. Extension of the current agreement, which expires on 30 June 1990, is being considered. The Canadian International Development Agency (CIDA) supported the AIDS control and prevention programme in Thailand and continued to fund the WHO-executed vector-borne disease control project in Myanmar. The Finnish International Development Agency (FINNIDA) funded the essential drugs programme in Bhutan and Myanmar and supported the district health system development in Nepal. FINNIDA also donated vaccine to Maldives. In Nepal, the Swiss Government, through its Development Cooperation and Humanitarian Aid (DM), continued to fund a health laboratory services project being executed by WHO. The Danish International Development Agency (DANIDA) continued to fund drug action programmes in Bangladesh and Bhutan. It was also involved in an external evaluation of the WHO Action Programme on Essential Drugs, which included visits to Indonesia in August-September 1989, and to Bangladesh in October 1989. The Government of Japan is contributing, through WHO, to the funding of the AIDS prevention and control programme in Thailand. A fact-finding mission from the Japan International Cooperation Agency (JIM) visited Thailand in December 1989 to study the Thai programme management and health facilities in respect of AIDS prevention and control. A mission from Japan International Corporation of Welfare Services (JICWELS) visited the Regional Office in March 1990 to discuss, amongst other things, potential support for the prevention and control of diseases as well aa human reaources development for health in South-Fast Asia. 4. Collaboration with Nongovernmental Organizations (NGOa) An area of collaboration with NGOs, where intensified efforts have been deployed, ia that of prevention and control of HIV infection and AIDS. In May 1990, the Regional Office convened a meeting on Mobilization of Women's Organizations and NGOs in the Prevention and Control of AIDS in New Delhi. Collaboration with Rotary International has been enhanced, particularly in the field of poliomyelitis control and EPI. Prevention of blindness, leprosy control, rehabilitation of the handicapped and other traditional areas of collaboration with NGOs continued to attract support from Helen Keller Inter- national Inc., the Christoffel Blinden mission and the Sasakawa Health Trust Fund, among other agencies. 2.4 HEALTH EMERGENCY PREPAREDNESS AHD RESPONSE The countries of South-East Asia are particularly vulnerable to natural disasters. The interplay of natural factors acting upon areas with some of the highest population concentrations in the world causes recurrent disasters of magnitudes incomparable to those elsewhere. During the period under review, many Member Countries in the Region were affected by natural disasters which included floods in Bangladesh and India during the summer of 1989; a cyclone devastating the eastern coast of India in November 1989; a typhoon in November 1989, which wought extensive damage to the coast off the Gulf of Thailand; floods and landslides following torrential rains in Indonesia and Sri Lanka, in January 1990; the volcanic eruption of Mount Kelud, in Indonesia in March 1990; and the cyclone on the east coast of India in May 1990. In response to such aituationa, WHO provided emergency medical supplies and supported efforts to strengthen the health sector's emergency preparedness and response activities. In Thailand. water ourification and chlorination eouimnent was provided.to the &phoon-sffected provinces. In Bangladesh, WHO supplied water-purifying tablets, bleaching powder, anti-snake venom serum and other emergency supplies. The Regional Office also supported the Government of Bangladesh in initiating implementation of disaster planning and training components of the Bangladesh Health Sector Disaster Preparedness and Response Programme, developed earlier in collaboration with WHO. In India, WHO supported training in disaster management and a study on the impact of floods on health and health services management. In Indonesia, Consultations on the inclusion of health sector requirements were held with a UN mission preparing a new proposal on disaster preparedness, mitigation and response. The Regional Committee, at its forty-second session, addressed the issue of disaster preparedness and response, based on a report prepared by the Regional Office, and including, amongst other things, the findings of the assessment of the capabilities of national health infrastructures in handling emergencies1 disaster situations, carried out by nationalIWH0 teams in Bangladesh, India, Indonesia and Nepal in early 1989. The deliberations and decision of the Regional Committee helped enhance awareness of the need to develop national health disaster preparedness and response programmes and led to renewed political commitment to developing and integrating such programmes within the national programme for disaster preparedness. Efforts to develop and implement disaster preparedness programmes, which Member Countries and WHO have undertaken or will undertake in the coming years, will also contribute to the success of the International Decade for Natural Disaster Reduction (IDNDR) decided upon by the United Nations General Assembly in December 1989, and launched by the UN Secretary- General the following month. Within the International Framework of Action for IDNDR, all governments are called upon, inter alia, to "pay due attention to the impact of natural disasters on health care, particularly to activities to mitigate the vulnerability of hospitals and health centres, as well as the impact on food storage facilities, human shelter and other social and economic infrastructure". The objective of the Decade is to reduce, through concerted international action, especially in developing countries, loss of life, damage to property and social and economic disruption. To this end WHO is joining forces with other international organizations and Member Countries. 2.5 HEALR1-POR--W S!LWlSY COORDINATION The primary objective of the strategy for Health for All is equity in the availability of health care. Member Countries in the Region have striven to develop and reorient their health systems so as to make health care available, especially to the vulnerable and disadvantaged groups of the population. The coverage by the health sector and access to health care have increased substantially, and it is expected that the evaluation in 1991 will provide quantitative data to substantiate this. As a follow-up of the Inter-agency Regional Conference on Health Development, held in Riga in March 1989, and to give a deeper thrust to the objective of achieving Health For All by the Year 2000, a Symposium on Public Policy on Health Status and Quality of Life was held in Bangalore, India, in September 1989. It is being followed by national workshops in India, Indonesia, Sri Lenka and Thailand. A number of activities and initiatives have taken place in Member Countries in relation to health policy formulations and implementation of health-for-all strategies. Bangladesh has drawn up a new health policy in keeping with its principle of decentralization of financial and administrative authority. India, Indonesia and Thailand have identified areas needing attention and incorporated the same in their medium-cerm plans. A joint mission to Nepal highlighted the impediments to effec- tive primary health care. In the light of the new initiative of the Director-General to support people and countries most in need, India Mongolia and Nepal have been chosen for special attention while Bangladesh and Bhutan have been approached for inclusion in this initiative. In Bangladesh, the Health Care System Improvement Committee has made a series of recommendations regarding medical education, hospital administration, the health care delivery system, and cost-sharing, which are now under the consideration of the Government. In India, based on the moaitoring of the HFA strategy, progress in health development has been reviewed to form an important input for the Eighth Five-Year Plan. In Sri Lanks, a policy background document for the health component (Suva Ssviya) of the poverty alleviation programme has been prepared. This seeks to provide health and health-related benefits as an integral component of the national programme for poverty alleviation. In Thailand, activities of the National Health Assembly were followed up with a view to assessing the existing health situation and seeking ways of solving current and emerging health problems. This included health policy analysis and systems research. WA Leadership Development Activities to further strengthen health-for-all leadership development at intermediate and lower levels have been pursued vigorously in almost all Member Countries. The Mahidol University in Thailand has been nominated as a WHO Collaborating Centre in HFA Leadership Development. In India, besides organizing a meeting on HFA leadership development for senior officials of the health sector, state- level workshops, inter-state dialogues, as well as a National Conference on HFA Leadership Initiative were organized. In Indonesia, a national core group for HFA leadership develop- ment, established under the Director-General, Community Health, developed a plan for HFA leadership development consisting of a number of training activities, and set up a HFA leadership laboratory. Modules have been developed for HFA leadership training for middle-level officials and trainers. Several workshops have been held at national and provincial levels. The Informatics Management Programme supported the Organiza- tion's programme development and management through the provision of appropriate and relevant informatics technologies, and training on their use. A new Administrative and Financial Information System (AFI) was installed in the Regional Office with support from WHO headquarters, to bring it in line with other regional offices. Informatics support activities focused on the training of staff of the Regional Office as well as of the WHO Representatives' offices. Details of the implementation of the Regional Office Local Area Network (LAN) were worked out. Coordination of policies on informatics development was achieved through the Regional Informatics Support Committee. An incre- mental approach to informatics support development was adopted by screening emerging technologies with a view to selecting those which are cost-efficient, affordable and relevant to the overall objectives of management. Full use of the available technologies was maintained before introducing new systems.
Chapter 8 GENERAL HEALTH PROTECTION AND PROMOTION 8.1 NUTRITION The Joint wHO/UNICEF Nutrition Support Programmes (JNSP) in Myanmar and Nepal continue to work towards targeted nutritional objectives. The Myanmar programme was evaluated in late 1989 and appears to have resulted in a small but real reduction in malnutrition in the one-third of the population of the country that it covers. This has been achieved by a heavy emphasis on careful training, utilizing a 'cascading' model in which training of trainers precedes that of community workers. The first step was a situation analysis that determined the training needs. Then curricula were modified, lesson plans drawn up and learning aids prepared. Trainers were given refresher courses so as to be able to adopt new approaches. The upgraded training focused on community-level workers. It has been accompanied by an emphasis on supportive supervision and monitoring. The Nepal JNSP was redesigned during the year to concentrate on health sector support to community-level nutrition activities with a corresponding emphasis on training. Low birth-weight is largely a reflection of foetal malnutrition. Eight South-East Asian countries have adopted this indicator in their health-for-all strategies. In four of them, more than 20 per cent of newborns weigh less than 2 500 g. This is the highest proportion in any region. This indicates that protein- energy malnutrition is still a severe problem in this region. Although repeat surveys in Bangladesh, India, Myanmar, Sri Lanka and Thailand indicate that prevalences of protein-energy malnutrition are decreasing at between two and five per cent a year, nearly half of the preschool-age children in the Region are found to be moderately to seriously malnourished. The wHO/UNICEF/ICCIDD Consultation and Workshop on Iodine Deficiency Disorders in South-East Asia, held in New Delhi in March 1989, indicated that considerable advances had occurred in programmes against IDD since the Regional Committee had, in 1981, set a target of control of IDD by the year 2000, and the regional strategy was endorsed in 1985. The need for regular technical consultations amongst country managers of IDD programmes was identified. The first meeting of the South-East Asia Regional IDD Working Group is scheduled to be held in the Regional Office in October 1990 to exchange information and programme experiences, facilitate the search for external resources, support government programmes and contribute to programme planning. Responsible technical officers and researchers from the countries of the Region participated in the interregional Symposium on Vitamin A Deficiency, held in Kathmandu in November 1989, under the auspices of the International Vitamin A Consultative Group. They reviewed strategies and new developments, including in particular the balance between programmes to distribute high-potency vitamin A capsules (perhaps through the EPI system) and the promotion of food sources of vitamin A. Efforts were made during the period to improve the distribution of technical materials and information on nutrition to key individuals and imtitutions in the countries of the Region. Po this end a selected and annotated bibliography of WHO publi- cations in nutrition was prepared and widely distributed along with selected available publications. WHO supported fellows from regional countries and others have, for many years, participated in the M.Sc. and certificate courses in Nutrition at the National Institute of Nutrition in Hyderabad, India. An assessment of the relevance, effectiveness and impact of the courses was carried out through a mailed questionnaire, interviews with ex-participants and their supervisors in Indonesia and Thailand, and through a review at the Institute itself. Several ex-participants are now in crucial positions in governments and other organizations. Many are involved in the planning and implementation of national health and nutrition programmes. The review concluded that the courses have been successful in providing a sound basis for the future roles and responsibilities of the participants. Successive courses have increased their relevance to operational nutritional issues. Without sacrificing the excellent scientific content of the courses greater attention needs to be given to issues of practical management of the nutrition components of health programmes and of intersectoral strategies for nutrition. The South-East Asia WHO Advisory Committee on Health Research approved a nutrition research policy for the Region in 1988 as part of the global nutrition programme. Discussions have been held at key institutions in the Region and a Nutrition Research- cum-Action Network is being set up to define operational research priorities, to carry out and support collaborative research projects and to develop training programmes to enable operational managers to use research to solve problems they encounter. The first meeting of the Network is scheduled to take place in Thailand in August 1990. 8.2 ORAL HEALTH Low levels of oral hygiene, lack of adequate nutrition, environmental factors, and the non-availability of oral health care and services in most of the countries are the major causes of dental caries and periodontal diseases, which are increasing sharply. For example, the dentistlpopulation ratio in India is 1 : 47 000. However, as most of the dentists are clustered in urban areas, the dentistlpopulation ratio in rural areas is 1 : 350 000. This disproportionately large difference between the ratios in urban and rural areas is a common feature of all Member Countries. Surveys were conducted in February/March 1990 in Indonesia, India, Sri Lanka and Thailand in oral health research, so as to assess the magnitude of oral health problems, identify problem- orientation and appropriateness of oral health resources, determine measures for improving both research and service quality, and to decide upon ways and means of accelerating implementation of research findings. The consolidated outcome of the survey was submitted to the sixteenth session of sFA/ACHR, held from 2 to 6 April 1990. The Committee deemed that levels of oral hygiene were unacceptably low. Harmful local habits, such as chewing tobacco, betelnut and pan, and beedi-smoking, etc., combined with the lack of oral health services, were considered to be some of the important factors contributing to oral diseases, including oral malignancies. WHO collaborated with Member Countries in the training of national oral health personnel through local cost subsidies and fellowships for assessing oral health situations, strengthening institutional capabilities and providing essential equipment, instruments and literature. 8.3 ACCIDENT PREVENTION A quarter of the 3 million deaths occurring in the world as a result of injury took place in the countries of the South-East Asia Region of WHO. Traffic accidents have been found to be one of the most important causes of injuries in the Region. In Sri Lanka, the number of fatalities due to traffic accidents, per million population, increased from 56 in 1974 to 89 in 1983. The number of fatalities per 10 000 vehicles rose from 6 to 8 and from 32 to 34 in Nepal and Sri Lanka respectively, during the period 1975-1984. In Thailand, accidents have been the leading cause of death since 1968. In India, about 10 per cent of the vehicles are involved in road accidents, killing 25 000 persons and injuring more than 100 000 persons per year. However, the information available in all the countries is far from sufficient to assess the magnitude of the problem and does not provide a scientific basis for interdisciplinary and intersectoral approaches to the prevention of injury. Therefore, emphasis has bee; laid on the prbmotion of surve;s,~data collec- tion and eoidemiolo~ical and o~erational studies with a view to - creating national awareness of the problem, including its socioeconomic and health implications. WHO provided technical and financial support for conducting national workshops and seminars in Thailand and Indonesia, and facilitated countries' participation in the First World Conference on Accident and Injury Prevention, held in Sweden from 17 to 20 September 1989. WHO'S collaborative activities were also directed to the training of national personnel in accident and injury prevention through study tours and fellowships, and to the strengthening of institutional capacity through the provision of logistic support. There is a need for further strengthening of collaborative activities, particularly in epidemiological research and in the coordination of injury prevention activities, which are carried out in different sectors of the countries. Continuous efforts should be made for strengthening and streamlining legislation, including rules, regulations, instructions etc., and for the enforcement of law in all the countries. 8.4 TOBACCO OR WTH This new sub-programme area is only slowly beginning to be reflected in specific activities in most countries of the Region. However, in some countries, activities with a remarkable scope have been initiated within a short time. These activities are strongly linked with more general health promotion and disease control programmes, as testified by the absence of specific Tobacco or Health projects in any of the countries. Bhutan has started to declare entire districts as tobacco-free areas. In Thailand, a high-level, multisectoral National Committee for the Control of Tobacco Use has been formed, resulting in high public visibility of the importance of a reduction in tobacco use for improving the health status of the population. This visibility was further increased by the international repercussions of one of the measures spearheaded by this Committee, viz., the prohibition of cigarette imports into the country. Also, all types of sales promotion of tobacco products are now prohibited, as is smoking in public transport. In India, preparatory work has been initiated for the establishment of a national plan of work for the control of tobacco-related cancers. Indian Airlines has also instituted a ban on smoking on all domestic flights. In Thailand, too, smoking is banned on national flights. In Bangladesh, the involvement of the highest govenunent levels in anti-tobacco activities has continued, and preparatory work for a countrywide representative survey on tobacco use has been completed. 'No-tobacco Day', 31 May 1990, with the focus on 'Childhood end Youth without Tobacco', was observed with much participation by, and public visibility in, the countries of the Region. In several countries, these activities for increased public awareness were observed even at provincial and district levels. The Director-General presented the 'Tobacco or Health' medal to prominent leaders in the "No-Tobacco Movement" in the Region.
SECTION I DIRECTION, COORDINATION AND MANAGEMENT I Chapter 1 GOVERNING BODIES 1.1 WORLD HEALTH ASSEMBLY The Forty-third World Health Assembly was held in Geneva from 7 to 18 May 1990. Dr Plutarco Naranjo, Minister of Health of Ecuador, was elected President, and Dr Pagvajavyn Nymadawa, Minister of Public Health and Social Services of Mongolia, was elected one of the five Vice-Presidents. The Assembly was historic in the sense that the Member Countries showed a high degree of diplomacy and understanding which resulted in harmonious and purposeful cohesiveness. The Assembly considered a broad range of health issues and adopted 26 resolutions, including a few on politically-sensitive topics, with general consensus and without resort to voting. The Assembly expressed deep concern at the scale of the international problem of illicit drugs production, trafficking and abuse and noted that a United Nations Special Session on Drugs, held in February 1990, had proclaimed 1991-2000 to be the United Nations Decade against Drug Abuse. While urging Member Countries to devote appropriate resources to the development of national programmes of action, the Assembly has, inter alia, urged the Director-General of WHO to ensure a -- coherent approach between WHO'S action to reduce drug abuse and its action in related areas such as alcohol abuse and prevention of the spread of AIDS. Stressing the importance of the Paris Declaration on Women, Children and AIDS, the Assembly urged Member Countries to ensure that programmes for the control of HIV infection/AI~S are coordinated or integrated with other programmes for women, children and families, and that, if infected, these groups receive appropriate information and counselling. Member Countries were urged to implement multisectoral, comprehensive tobacco control strategies as also plans for legislation and other effective measures providing for effective protection from involuntary exposure to tobacco smoke in indoor work places, enclosed public places and public transport. While requesting Member Countries to support the WHO Action Programme on Essential Drugs, the Assembly invited bilateral agencies and ultilateral agencies inside and outside the UN system, and voluntary agencies to support developing countries in setting up and carrying out programmes aimed at ensuring rational use of drugs, in particular the essential drugs programme. As regards iodine deficiency disorders, the Assembly decided that considering the progress already made and keeping in view the potential of current and planned national prevention and control programmes, WHO should aim at eliminating iodine deficiency disorders as a major public health problem in all the countries by the year 2000. With a view to improving technical cooperation among developing countries, the Assembly called upon the developed countries to intensify their support to the developing countries, parti- cularly the least developed ones, for accelerated implementation of Health for All through primary health care for effective implementation of health development programmes. The Assembly commended WHO for establishing the Commission on Health and Environment to examine, inter alia, the subject of hazardous wastes and their potential effects on human health. Member Countries were urged to establish and strengthen programmes for environmentally sound management of hazardous wastes in accordance with health-based hazards and to extend the health surveillance system, including epidemiological studies. Technical Discussions were held on the "Role of Health Research in the Strategy for Health for All by the Year 2000". While the Assembly noted the various recommendations dealing with health systems research, nutrition research, research capability strengthening and recent advances in biological and physical sciences and their implications for health care, it called on all Member Countries to undertake essential health research appropriate to national needs. 1.2 EXECUTIVE BOARD The three countries from the South-East Asia Region entitled to designate a person each to serve on the Executive Board are Bangladesh (1988-1990), India (1989-1991) and DPR Korea (1990-1992). The Programme Committee of the Executive Board met in Geneva from 3 to 6 July 1989 and reviewed the presentations of programme orientation by the Director-General and the Regional Directors, the proposed allocation of resources and draft procedural guidance to be issued by the Director-General in co~ection with the preparation of the Proposed Programme Budget for 1992-1993, changes in the programme budget for 1990-1991, and method of work of the World Health Assembly. The manner and schedule of reporting by the Director-General to the Executive Board and the World Health Assembly on the work of WHO and the progress in implementing the Global Strategy for Health For All were also examined. Certain suggestions were made for the consideration of the regional committees, the Executive Board and the World Health Assembly on the above issues, which were taken up at the forty-second session of the Regional Committee as well as at the eighty-fifth session of the Executive Board. The eighty-fifth session of the Executive Board was held from 15 to 24 January 1990. The Board considered the report of the Director-General on strengthening technical and economic support to countries facing serious economic constraints and proposed a resolution for adoption by the Forty-third World Health Assembly recommending actions by Member Countries, the international community and the Organization. The Board endorsed the reformulated global indicators for the monitoring and evaluation of national strategies for Health for All, particularly for the second evaluation to be undertaken in 1990-1991. WHO'S continuing efforts to provide a strong, effective and coordinated leadership in global activities for the prevention and control of AIDS were noted. The Board agreed that WHO shall aim at the elimination of iodine-deficiency disorders as a major public health problem in all countries by the year 2000. The Board expressed concern over the decreasing prevalence and duration of breast-feeding in many countries. It reaffirmed the unique biological properties of breast milk, providing protection against -infection and stimulating the development of the immune system in infants, besides having a positive impact on the physical and emotional health of the mother and contributing to child-spacing. The Board recommended for the consideration of the Forty-third World Health Assembly enhanced travel standards for members of the Executive Board, delegates to the World Health Assembly, representatives at regional committees and members of expert committees, study groups and scientific groups. In addition, substantive discussions were held on relations with NGOa, international classification of diseases, and certain financial matters. Every year, WHO awards a number of prizes and medals in recognition of outstanding work done by individuals andlor institutions in the field of health, such as the Leon Bernard Foundation Prize, Sasakawa Health Prize, Darling Foundation Prize, and so on. It is heartening to note that this year Dr B.N. Tandon (India) has been awarded the Sasakawa Health Prize, and Dr S. Pattanayak (India) the Darling Foundation Prize. These prizes were presented during a plenary meeting of the Forty-third World Health Assembly. The eighty-sixth session of the Executive Board was held in Geneva on 21 May 1990 where Mr R. Srinivasan, Secretary, Ministry of Health and Family Welfare, Government of India, was elected its chairman. Amongst the items dealt with were the report on the meetings of expert committees and study groups as well as reports of the Joint Inspection Unit. The Board selected "Women, Health and Lkvelopment" as the topic for the Technical Discussions during the Forty-fifth World Health Assembly. It decided to hold its eighty-seventh session in Geneva from 14 to 25 January 1991. The Board also decided that the Forty-fourth World Health Assembly would open in Geneva on Monday 6 May 1991. 1.3 REGIONAL COMMITTEE The forty-second session of the Regional Committee for South- East Asia was held in Bandung, Indonesia, from 26 September to 2 October 1989. It was attended by representatives from all the KeglOnal Lommlttee Meeting the forty-second session of the Reg~onal Comm~ttee for South-East Asla was held in Bandung. lndonesia. from 26September-2 October 1989. T jesslon was Inaugurated by H.E. Dr Adhyatma. M~n~ster of Health. Republic of Indonesia. The Regional Committee elected Dr S.L. Leimena (second - - -1 - h A n. m k! 0- If h 4 I .. h f h f+ cocclnn Healt 1 :h Ministers' Meeting eleven Member Countries of the Region, two United Nations agencies, one intergovernmental and twenty nongovernmental organizations having official relations with WHO. The session was opened by Dr Joe Fernando, Chairman of the forty-first session, and inaugurated by His Excellency, Dr M. Adhyatma, Minister of Health, Republic of Indonesia. Dr S.L. Leimena (Indonesia) was elected Chairman and Dr D.N. Regmi (Nepal) as Vice-Chairman. Dr Hatai Chitanondh (Thailand) was elected Chairman of the Technical Discussions, and Dr G. Vishwakarma (India) as Chairman of the Sub-committee on Programme Budget. The Committee reviewed the Regional Director's Annual Report, concentrating on issues highlighted by the Consultative Committee on Programme Development and Management which had discussed the report in depth. Technical discussions were held on the subject of 'Role of Epidemiology in Health for All'. The importance and the need to strengthen and expand the use of epidemiology in HFA/2000 were emphasized. While describing the progress made in their countries, the participants highlighted the prevailing condi- tions as well as the problems encountered and made various recommendations, which were endorsed by the Regional Committee. On the recommendation of the Sub-committee on Programme Budget, the Regional Committee adopted a resolution requesting the Regional Director to take necessary action to submit a single programme budget document that would allow increased flexibility in the planning and implementation of WHO'S collaborative programmes and better use of the resources. The Committee was concerned at the potential for further spread of AIDS in the countries of the Region and cautioned that systematic monitoring and a balanced approach were essential to avoid a negative effect on other health programmes. Discussions were also held on subjects such as goitre, disaster preparedness, health care financing and mobilization of resources for health development, and such routine adminis- trative subjects as nomination of countries from the Region to the Policy and Coordinacion Committee of the Special Programme of Research, Development and Research Training in Human Reproduction, the Joint Coordinating Board of the Special Programme for Research and Training in Tropical Diseases, and the Management Committee of the Global Programme on AIDS. The Committee decided to hold its forty-third session in September 1990 at the Regional Office in New Delhi and its forty-fourth session in Maldives, the timing of which will be decided at its forty-third session. The Committee decided to hold technical discussions on the subject of 'Health of the Underprivileged' during its forty-third session. The Eighth Meeting of Ministers of Health of the countries of the WHO South-East Asia Region was held in Jakarta, Indonesia, from 3 to 5 October 1989. At this meeting, the Ministers reviewed the progress in the implementation of the decisions taken st the Seventh Meeting, held in 1987, in relation to technical cooperation among developing countries, national HFA strategies, health manpower development, essential drugs, traditional medicine, health care financing, etc. The meeting also discussed in depth the reorientation of health system infrastructure for primary health care, particularly in the context of scarcity of resources and the need to provide equitable distribution. The Ministers emphasized the need to bring about necessary political and social changes in keeping with the commitment of Health for All by the Year 2000, and felt that, in addition to the emphasis on public health, greater reliance at macro-level planning would help in the successful implementation of their national HFA strategies. The Ministers took note of the progress made in introducing reforms in medical education and the discussions st the World Conference on Medical Education, held at Edingburgh in 1988. Stressing the need to inculcate appropriate social orientation to medical students by exposing them to humanities, such as sociology, anthropology and behavioural sciences, the Ministers agreed on the need to include the subject of health economics at the undergraduate level. They discussed at length the methodology to strengthen intercountry and interregional mechanisms and recognized that countries had not yet developed effective mechanisms to collaborate with one another in the identification of elements of common interest. They felt that it was necessary to encourage a larger number of intercountry programmes if common problems were to be solved by a cooperative approach. Discussing the subject of health economics and financing of health services, the Ministers were of the opinion that the health sector ought to speedily acquire expertise in health economics so as to be able to investigate and analyse various options and alternatives for the financing of health care. During the field visit arranged by the Republic of Indonesia, the Ministers saw primary health care in action, especially the work of Posyandu, and highly appreciated community partici- pation, including the financing of health care activities. They agreed that concerted efforts were needed to identify and mobilize alternative sources of health care financing.
FOREWORD A6 we entet the fabt decade 06 the twentieth centuty, the datlr, icy doudb 06 cold war, which had enveloped the wotld 601 ovet two bcore yearb, appeal to be teceding and yielding to the gentle .ray5 06 peace bhining ovet the globe. With the dawn 06 a new era 06 peace and mutual ttubt, we bhould heel emboldened and envigoured to accomp!ibh out cheubhed aim 06 health 60% all babed on the twin noble ptincipleb 06 equity and docid justice. We can ttead our choben path with gzeatez con6idence - con6idence that pobtezity would not 6ind ub wanting. Pfogtebb can be attained only id the 6oundationb ate 6itm. Late? in the yeat we will be tebting the btfengthb 06 out 6oundationb and ptobing 60.1 weaknebbeb ubing the common 6tamewotn 60% evaluation. It will fwovide ub all an opportunity not only to meaau?e succebbeb and dailuteb in quantitative and qualitative terms but dbo to ponder on the apptoptiatenebb 06 out apptoacheb and btxategieb and to introduce necebbaty coutbe CotteCIionb. Human development hnb to ocut within 6<agile natutal boundatieb 06 ait boil and wate?. ule cannot exceed the bleak point 06 the tegenerating capacity 06 the ecobybtem. Thub the Uitectot-General 06 WHO hub advocated and pleaded 601 emphubib in dive impoxtant attab, viz., envi%onmental health and bubtainable development, nutrition, an integtated approach to dibeabe control, a cleat underbtanding 06 the relationbhip between the btafe 06 the world economy and health development and, 6inafly. genetation and ube 06 valid in6ormation. The need to dobely redlect and recabt our bttategy hot he&h development to 6it into thebe ptiotity bettingb ib patently obvioub, and will tequile our utgent attention. The South-Eabt Asia Region ib home to a quarter 06 the worfd popu(ation. 06 the eleven Member Countueb, a6 m a6 dive belong to the category 06 'lea6t developed countriebl?fgnomce, povettq and mdnutution btill pfague our region. To add to the misetq, the Region ih pfone to varioub kndb 06 nnturaf and man-induced dhterb. Our people, however, have mebbdu((y combated al( buch problem6 with coutage and determination. rhere id a growing awarenebb among all our people6 to look a6tet theit debtinieb and match with the febt 06 the world. Thi6 mlufb,weU 60f their betterment and wiU entail addition& te4ponbi &te6 06 a di66erent genre in the national decibion-making ptOCebbeb. The era 06 opportunity hub begun. It behove6 ub to implement, in letter and bpifit, individuaUq and co(cectivelg, the bolemn and correct decision6 that we have jointfg taken and to tread boldly on the path that we have carved 6or ourbelveb. With the hope 06 a bright and developmentaffy meaning6ul decade, I have great pleasure in presenting thib report on the work od WHO in the South-Eat Asia Region bar the period 1989-1990. 1 am convinced thai we will witnebb a ~eburgence 06 the bpi& 06 compaAdon and goodwiU coupled with bo(dnebb and adventure in OUT path 06 ptogttbb. I& - Dr U Ko Ko Regional Director
EXECUTIVE SUMMARY WHO'S GENeRAL PROGRAElME DEVFLOPMENT AND MANAGEMENT WHO has continued to provide strong and effective leadership in the improvement of health in all countries of the world. The Director-General has initiated a new programme to strengthen technical and economic support to countries facing serious economic constraints. In line with this concern for continued existence of inequities within and among nations, the Eighth Meeting of Ministers of Health of the countries of the WHO South-East Asia Region, held in Jakarta in October 1989, stressed the need to strengthen intercountry and interregional mechanisms. The Ministers also opined that the health sector had to speedily acquire expertise in health economics so as to be able to investigate and analyse various options and alternatives for financing health care, particularly since resources for health were not expected to increase sub- stantially. The Regional Office has continued to support Member Countries in the overall management of their health programmes. The working of the joint government-WHO coordination mechanism, which guides the formulation and implementation of WHO'S collaborative activities at the country level, was reviewed in 1989 with a view to improving its functioning. The forty-second sesston of the Regional Committee desired that the Regional Director submit a single programme budget document for the 1992- 1993 biennium for endorsement at the forty-third session of the Regional Committee in September 1990. The South-East Asia Regional Office participated closely in the study by the Execu- tive Board on the setting of priorities for WHO collaborative programmes. The implementation of the programme during 1988-1989 was highly satisfactory, much better than that of the previous biennium. This was made possible by the improved WHO information system for supporting programme monitoring. Major development issues, such as environmental pollution, education and health, are of such an inter-connected nature that they call for extensive and efficient interagency and intersectoral coordination and cooperation. During the period under review, cooperative efforts were pursued and new initia- tives taken to further strengthen interagency collaboration. A number of new projects to be executed by WHO with financial support from UNDP and UNFPA, among others, were approved. Member Countries have taken a number of new initiatives to reorient their health policies and strategies in keeping with the principle of decentralization of financial and sdminis- trative authority. Efforts to inculcate leadership qualities at intermediate and lower levels have been pursued vigorously in almost all Member Countries. In South-East Asia, the interplay of natural forces acting upon areas with high population concentrations causes recurrent disasters of great magnitude. WHO is contributing effectively to developing and implementing disaster preparedness programmes. This will contribute to the success of the International Decade for Natural Disaster Reduction launched by the United Nations in January 1990. Informatics support activities focused mainly on the provision of appropriate and relevant technologies and training to staff at regional and country office levels. An information system for administrative and financial services of the Regional Office (AFI) was installed in 1990. HEALTH SYSTEM DEVRLOPMENT The main thrust of the managerial processes in national health development programmes continued to be reviewed with reformula- tion of national policies, and development and ioaplementation of health plans. Strengthening of operational management of health services at various levels in the context of decentralization of health services and training in health planning management and health care financing were also undertaken. Realth ewnogics, including financing of health services and mobilization of resources for health development, constitute a priority area for support to Member countries by WHO. In several countries of the Region, activities are being undertaken to estimate realistic costs of implementing national health policies. Due to serious obstacles in the implementation of primary health care, resulting from unfavourable economic situations, the health situation in many countries of the Region continues to be unsatisfactory. WHO has recently initiated a country-centred strategy for overcoming the obstacles using new mechanisms and approaches and obtaining a holistic view of planning and implementing country activities. This includes, -- inter alia, advocacy for larger resource allocations for health. The second evaluation of the implementation of strategies for Health for All by the Year 2000 is to be undertaken by all Member Countries in 1990. Preliminary activities connected with the second evaluation have alreaJy been carried out. The revised version of the Common Framework for Evaluation (CFE-2) was finalized by WHO headquarters. India and Mongolia from this region participated in the pre-testing. National authorities have been briefed on the methodology, procedures and time-table for the second evaluation and assisted in working out necessary plans of action. Field Epidemiology Training Programmes (FETP) have been conti- nued and strengthened so as to secure competent epidemiologists. India, Indonesia and Thailand have participated in FETP. In order to effectively control and prevent major communicable diseases, an epidemiological surveillance programme has been developed to ensure the availability of essential epidemio- logical information. Health systems research (HSR) continued to be promoted with greater attention being given to the strengthening of institu- tions, as recommended by the Task Force on HSR. The role of health research in Health for All by the Year 2000 was reviewed by a sub-committee of SFA/ACHR in October 1989. Health systems research is an integral part of ongoing operational projects in programmes such as EPI and MCH. HSR has also been used in the development of training manuals for health workers and for IEH materials. Legislative support for national health strategies is an important requisite for successful implementation of HFA/2000. WHO support to Member Countries in this area included review and/or revision of existing health legislation, organization of group educational activities, dissemination of new developments on the subject, and contributions to the strengthening of national capabilities. ORGANIWTION OF HEALTH SYSTEMS BASED ON PRIMARY HEALTH CILBg Ever since the concept of primary health care was defined and given international recognition at Alma-Ata, Member Countries have undertaken a number of activities so as to improve their health syatems and to provide efficient and universal primary health care. Consequently, considerable resources have also been allocated to increase coverage and reorient the health system infrastructure. Concern continues to be expressed for attaining equity and social justice, the twin bedrock of the movement towards HF~/2000. Priority has been given to underserved and unreached populations. In many countries, in recognition of the effect of development of other sectors on the improvement of health of the population, formal mechanisms for intersectoral dialogue, cooperation and action have been introduced, based on the common perspective of the need to improve the quality of life of the people. The progress achieved in the distribution, organization, manage- ment and orientation of comprehensive health systems based on primary health care was reviewed at a regional conference on health development, held in New Delhi in March 1989. This was the first year of follow-up in the world to the Riga meeting of 1988. The conference emphasized the need to develop an under- standing in facing problems as well as to identify clear approaches to solving problems. The district health systems approach comprising four critical areas of primary health care and providing for decentralized management responsibilities has been pursued vigorously in all Member Countries. Overall, there has been perceptible progress in the implementation of primary health care as well as improvement in the performance of health infrastructure, even while some of the well-known constraints, such as the lack of equipment, drugs, transport and other support facilities, poor supervision, unequal distribution, inefficient provision of resources etc., remained. Information support for the management of district health syatems was the subject of a meeting held in Surabaya in Indonesia in October 1989. It identified information needs for effective management as well a8 the process of utilization of information. Referral systems have continued to develop. A meeting on Primary Health Care Development, held in Geneva in April 1990, reviewed country experiences in primary health care implementation, options for financing primary health care and the sustainability of primary health care in the last decade of the century. Concern was expressed about environmental deterioration, the emergence of mega cities with alarming increases in population and socioeconomic and political problems besetting countries. It is necessary to anticipate such problems and to take appropriate measures in advance if the health of the people is to be protected. As a follow-up of the UNDP-funded project "Intensification of Action Programme for Primary Health Care", a new project on strengthening medical care facilities in districts, especially designed for the least developed countries, has been submitted to UNDP for approval. It aims to improve the delivery of medical care to district and peripheral health sectors. A regional symposium on the implications of public policy on health status and quality of liie was organized in Bangalore, India. It dealt with urbanization, industrialization and agricultural development as well as the health problems emerging therefrom. A wide variety of experience in terms of inter- sectoral action has been collated by Member Countries in the last two years and it will be possible to build on this in the future. WHO has continued to support efforts to improve and increase community participation in health development. Consequently, in addition to programmes for training health volunteers, other programmes, such as community health fund programmes and mobilization of community resources, have been actively supported. Decentralization of management and administration from the district level down has also been actively pursued. Participants from India and Thailand attended a WHO Study Group on Community Involvement in Health Management, held in Geneva in 1989. In Sri Lanka, an ambitious programme for the alleviation of poverty commenced in October 1989. The supplementary health programme, called Suvasaviya, aims at strengthening primary health care activities and making essential health care available to identified families. This is being supported by WHO. In addition, WHO, in collaboration with the Ministry of Health, has developed suitable research programmes to study the health and nutrition of recipients as well as processes/factors influencing their health. Urban primary health care is receiving closer attention although this is still not adequate. Nongovernmental organizations are taking active interest in urban primary health care. Health administrators and mayors, from Bangkok, Bombay, Colombo and Jakarta in the South-East Asia Region, participated in an interregional meeting on City Health - The Challenge of Social Justice, held in Karachi, Pakistan in November 1989. The inevitability of close intersectoral action to attain better urban health was stressed by the symposium held in Bangalore, India in 1989. DmPMENT OF HUMAN RBSOUBCES FOR HEALTH WHO has continued to support and facilitate the development of human resources for health in pursuance of the goal of Health for All through the primary health care approach. Support has been provided for strengthening technical, planning and manage- ment capabilities in the development of human resources for health as well as for upgrading training facilities and educa- tional technology. This support has not only been through the fellowships programme but also through consultants, supplies and equipment as well as through neetings and workshops. Despite these efforts, there are still imbalances in human resources for health and many projections are over-optimistic and need to be readjusted to take into account the economic slow-down. One effort to redress this has been through the promotion of policy and programme analysis of the development of human resources for health. Following the interregional Seminar on the Financing of Human Resources for Health, held in Bangkok in March 1989, a follow-up workshop was held in Yangon, Myanmar, in February 1990, to formulate the methodology for developing the optimal mix of human resources for health. This innovative approach will be field-tested before adaptation in other countries. Another effort to redress the problems facing the development of human resources for health has been the promotion of research in this area. National workshops to promote research in the development of human resources for health were held in Bangkok, Thailand, in June 1989, in Jakarta, Indonesia, in January 1990 and in Kathmandu, Nepal, in May 1990. Similar workshops will be held in other countries in 1990 and 1991. Since 60 to 80 per cent of health budgets are devoted to human resources for health, a small improvement in productivity or efficiency brought about by appropriate training and deployment of human resources can provide a substantial increase in coat-effectiveness. It is therefore hoped that, through the mechanism of research in the development of human resources for health, it will be possible to redress the problem of imbalance, increase cost-effective planning, production and utilization of human resources. The efforts of Member Countries to strengthen their medical education systems and attain a greater balance of relevance in education and training programnes, particularly at the under- graduate level, have made modest progress towards achieving community orientation of curricula and development of appropriate skills and attitudes. WHO has collaborated with institutions in India, Indonesia, Myanmar and Thailand in experimenting with the introduction of problem-based community- oriented curricula and has also assisted in the planning of a new problem-based Medical School at Thammasat University in Bangkok. In Bangladesh, a high-powered steering committee has been constituted to improve the quality of medical education. A national workshop on the development of methodology to determine the optimal mix of human resources for health was held at Yangon from 13 to 17 February 1990. The three monographs published by the Regional Office in the series on "Reorientation of Medical Education" are being used by Member Countries in their programmes to reorient their medical education systems. WHO has also worked closely with Member Countries to solve their recurrent quantitative and qualitative problems of teacher shortages, lack of essential equipment and supplies and coordination of education systems with the health care systems. It has also provided technical support for overall system development and quality control in respect of postgraduate medical education in Member Countries. WHO has continued to support the development of a core of nurse leaders in the Region. Support has cootinued for the reorienta- tion of basic and post-basic nursing education. Support has also been provided for research in the development of nursing resources. WHO has continued to collaborate with Member Countries in the training of health personnel, particularly in the areas of teacher training, strengthening of training institutions, improvement of educational technology and curriculum develop- ment. The activities include support to countries to develop, field-test, produce and effectively utilize different types of teaching and Learning materials for paramedical, medical and nursing personnel. With the support of UNDP, WHO will provide technical and financial support in the development of health learning materials, including those for distance learning. As a follow-up action to the resolution of the Executive Board in 1983 on WHO fellowships policy (EB71.R6), indicators and guidelines for the self-assessment of the fellowships programme were developed in the Region and field-tested in Indonesia. A preliminary report of the fellowships programme was prepared and submitted to WHO headquarters in November 1989. Supplemented by updated information received from countries on self-sssess- ment of the fellowships programme, these reports are being processed in WHO headquarters for inclusion in the report of the Director-General to the Executive Board in 1991. PUBLIC INFORMATION AND EDUCATION FOR HEALTH During the period under review, information and education for health activities were further strengthened in the Region through programmes of training, development of health education material, research and greater involvement of the media. There was increasing focus on school health education. In view of the increasing importance of health education in AIDS prevention and control, interagency and interregional collaboration was consolidated. Intercountry group educational activities were undertaken to address such aspects of AIDS prevention and control as psychosocial counselling, monitoring and evaluation of health promotion activities, development of health education material for AIDS control, etc. A consultation on AIDS and Media Involvement was held in New Delhi in December 1989. Development, production and dissemination of information and education material were augmented both at regional and country levels. World Health Day, World No-Tobacco Day, World AIDS Day, and other similar occasions were effectively used to draw attention to priority health issues. In particular, this year the focus on environment, which formed the centrepiece for World Health Day, evoked widespread interest. A variety of information kits on subjects such as prevention and control of accidents, self-care and healthy lifestyles, and promotion of women's health in South-East Asia were produced to provide valid information on important subjects. RESEARCH PROMOTION AND DEVELOPPIENT The focus of the regional research programme continues to be on objectives of the programme including the strengthening of national research capabilities, promoting and coordinating research on regional priority problems linked to social and economic conditions of the countries and promoting research designed to enable the application of advanced technologies and modern scientific knowledge to conditions prevalent in the countries. The South-East Asia Advisory Committee on Health Research is a valuable forum which provides expert advice on the nature and type of research to be undertaken in the Region. The role, function and working of the South-East Asia ACHR was considered in detail by a consultative meeting. The sixteenth session of SEAIACHR, held from 2 to 6 April 1990 in Chiang Mai, Thailand, undertook an overall review of the regional research programme and in particular discussed research issues related to oral health, tuberculosis and quality assessment of health care delivery systems. A number of collaborative research projects, including investigator-originated projects, focusing on issues of regional priority and interest, have been supported. The multicentre collaborative projects require considerable nurturing in the form of technical support, organization and coordination by the Regional Office. However, considering the potential for long-term benefits from auch projects, these continued to be supported. In addition, consequent on the advice of the Regional Advisory Committee on Health Research and the Regional Committee, institutional strengthening is receiving greater attention in the Region through supplemen- tation of research projects. To achieve progress in this area, discussions commenced with four countries and resulted in two of the countries being given grants for institutional strengthening. Progress in the development of dengue vaccine has been steady. The Seventh Peer Review Meeting, held in August 1989, recom- mended the trial of three candidate dengue vaccines (1, 2 and 4) as a single inoculation and also recommended clinical trials in general. It is a matter of satisfaction that this project is also providing valuable opportunities for the transfer of tech- nology to the institutions. A collaborative epidemiological study on non-A non-B hepatitis is progressing in Myanmar, Indonesia, Mongolia and Thailand, and is expected to lead to better understanding of the epidemiology of the disease. A number of other collaborative research studies on auch subjects as research in maternal and child health, epidemiological and socio-cultural aspects of ageing, etc., have been supported. In addition to intercountry research funds, 52 research projects have been funded through country RPD and HSR allocations. The award of visiting scientist and research training grants has helped in significantly improving the research capabilities of the Region. Gm HEALTH PROTECTION AND PROMOTION The training aspects of the nutrition programme were modified by taking into account the needs of the programme. Low birth-weight arising out of foetal malnutrition is a common phenomenon in many of the Member States. Protein-energy malnutrition, which, inter alia, is also responsible for low birth-weight, has shown -- a slow but steady decline. Considerable advances have taken place in the programme on Iodine Deficiency Disorders (IDD) since its initiation in 1989. The progress will be reviewed in October 1990. Ao interregional Symposium on Vitamin A Deficiency was held in Kathmandu in November 1989. The symposium reviewed strategies and new developments, and stressed the need for a balance between the production of high potency vitamin A capsules and the promotion of food sources of vitamin A. Discussions have been initiated to set up a nutrition research- cum-action network and the first meeting in this regard will be held in Thailand in August 1990. The global Joint WHO/ UNICEF Nutrition Support Programme (JNSP) is coming to an end. The activities will be absorbed into the regular programme. The JNSP in Myanmar is due to be incorporated into that country's national budget by the end of 1990. An evaluation in Myanmar shows a small reduction in malnutrition deapite a stagnant economy. The increased emphasis on training in the programme has already been incorporated into regular practice. In Nepal, the JNSP has been considerably revised. There is now a strong emphasis on job-related nutrition training of health workers. Dental caries and periodontal diseases are increasing sharply in most countries due to lack of adequate nutrition, non- availability of oral health care and low levels of oral hygiene. Surveys were conducted in February 1990 in Indonesia, Sri Lanka and Thailand to assess the magnitude of oral health problems. The results of the surveys were reviewed by the sixteenth session of SEA~ACHR in April 1990 and the levels of oral hygiene were deemed as unacceptably low. WHO has continued to collaborate with Member Countries in training national oral health personnel, strengthening institutional capabilities and providing equipment and literature. The South-East Asia Region accounts for 25 per cent of the three million deaths which occur in the world as a result of injuries, with traffic accidents being the prime cause. Fatality rates due to traffic accidents have been on the increase in almost all countries. WHO lays great emphasis on the promotion of surveys, data collection, and epidemiological and operational studies, so as to increase national awareness on the health aspects of injuries and accidents as well as the socio-economic effects. There is also a need to improve, streamline and strengthen legislation and associated rules, regulations etc. as well as a need for fair and equitable enforcement of the law. The ill-effects of tobacco are being increasingly realized in most countries. World No-Tobacco Day on 31 May was observed with much public participation and much visibility. 'Tobacco or Health' Medals were awarded to prominent health leaders of the Region who have been outstanding in the 'No Tobacco' movement. In Bhutan, entire districts have been declared tobacco-free. In India, work has been initiated for developing a national plan of action for the control of tobacco-related cancers. Smoking has also been banned on national carriers in many countries. A Multicentre National Committee for Control of Tobacco Use has been formed in Thailand, which is spearheading the movement for the prohibition of cigarette imports into Thailand. In Bangladesh, a countrywide survey on tobacco use has been completed, and support to anti-tobacco activities is available from the highest levels of the Government. PROTECTION AND PROMOTION OF THE HEALTH OF SPECIFIC POPULATION GROUPS It is encouraging to note the current trend in the countries of the Region where the holistic, integrated approach to the delivery of maternal and child health is being accepted as a standard. This has resulted in an integrated system of service delivery in the context of PHC. The gravity, as exemplified by high maternal mortality, has been recognized with countries determining the need to address this problem with greater emphasis on maternal care and safe motherhood. Most countries have initiated safe motherhood activities. Family planning and child-spacing are vital components of the programme in achieving better health for mothers and children. In most countries, priority programmes like FP, EPI, CDD, ARI and nutrition are implemented within the framework of the MCH infrastructure, or at least in close coordination with MCH. The need for wider service coverage and improvement of the quality of services is being recognized. Collaborative programmes are included in service training, meetings and consultations. Support has also been provided for studies aimed at strengthening programme development and improved strategies for the delivery of MCHtFP services. National research projects directed towards improving maternal health have been undertaken in many countries and, inter alia, include maternal mortality and morbidity surveys, multidisciplinary control trials on the use of the partograph in the management of labour, and a KAP study for mothers-in-law regarding maternity care of daughters- in-law. An intercountry Workshop on Safe Motherhood Initiative was held in the Regional Office in November 1989. Representa- tives from SEAR countries also participated in the Safe Motherhood Confcrence, held in Lahore, Pakistan in March 1990. Activities under the Women, Health and Development (WHD) programmes were aimed at strengthening the involvement of women's organizations in health promotion and at enhancing the exchange and dissemination of information. Major issues relating to women's roles at various levels were identified in conjunction with other international and bilateral agencies. Interagency meetings, sponsored by the participating agencies on a rotational basis, are being held every month. Programmes for adolescent health, which, in the earlier years, formed a part of maternal and child health, are now being stressed separately, with countries making modest budgetary provisions for the same. It is evident that this programme calls for dynamic leadership and multidisciplinary approaches. The South-East Asia Region has continued to collaborate actively in the WHO Special Programme for Research, Development and Research Training in Human Reproduction (HRP) within its two major areas, namely, support for research into finding and developing new, safe and effective methods of fertility regulation and support for research aimed at improving the performance of existing methods of fertility regulation. Research grants have been awarded to various institutions in the Region to pursue clinical trials on long-acting injectable contraceptives, experimental studies on post-ovulatory methods of contraception, evaluation and monitoring of contraceptive safety, contraceptive effects on blood factors, the cardio- vascular system, and ectopic pregnancy, etc. The rapid industrialization in many countries of the Region has resulted in increases in the extent and variety of occupational diseases and accidents. Occupational health is therefore of great significance to the Region, but there is a general failure to recognize the growing importance of occupational health and safety. This is exemplified, among other things, by the lack of adequate policies and legislation for the protection of health and the safety of workers. Problems of long-term socio-economic and health implications, such as rapidly greying populations, increasing occupational health hazards, and ever-increasing rates of injuries and disabilities of different causations, have always been over- whelmed by more urgent problems leaving the long-term problems behind as far as health allocations are concerned. Now it is time to take these problems more seriously, as the quality of life and the very philosophy of HFA/2000 will be greatly affected by such problems, which call strongly for timely inter- vention and interdisciplinary and intersectoral cooperation based on sound scientific knowledge. PRO~ION AND PROTECTION OF KENTAL IIBALTH A WHO-supported multicentre study in India has confirmed the high correlation between social aspects of family functioning, subjective well-being of mothers, and parameters of healthy development in children, particularly their cognitive development and nutritional status. This and related studies in Sri Lanka and Indonesia, have resulted in the development of realistic interventions focusing particularly on the well-being and coping skills of mothers for healthy child development in dysfunctional families. The Regional Coordinating Group for Mental Health Programme has also developed a protocol for a study to clarify the psychosocial sensitivity of physicians. Studies are also being undertaken on the development of psychosocial interventions for the containment of AIDS, and preliminary findings show a reduction in risk behaviour in selected risk groups. The involvement of ministries of health in programmes to reduce problems relating to alcohol and drug abuse is still limited in most countries of the Region. Although studies in many countries have shown that health personnel can play a very effective role in preventing and reducing substance abuse, the health systems do not appear to involve themselves closely. WHO has organized training courses for health personnel in India and Sri Lanka. It has also supported a study, conjointly with ESCAP, on a rehabilitation programme for drug dependent persons. A drug abuse monitoring system is being established in Sri Lanka and WHO has continued to execute UNFMC-supported drug abuse control programmes in Myanmar and Sri Lank. In both these countries the epidemic of heroin dependence seems to have been contained. Efforts are also on to maximize community involvement in localized activities for eliminating rural opium use as well as urban heroin use. The high risk of HIV infection in injection drug users has added a new dimension to drug dependence. Plans have been drawn up to establish a monitoring system concerning the route of drug administration and to reduce the risk of HIV infection in drug injectors and their partners . WHO'S activities in regard to prevention and treatment of mental and neurological disorders have two major thrusts, namely, development of technologies and support for the improvement of national capabilities for national mental health planning. The Regional Coordinating Group for Mental Health Programme has reviewed the list of skills needed at the primary health care level in relation to mental health, and has prioritized research needed to fill the gaps in existing knowledge. A list of indicators for the quality of mental health care in mental health hospitals has also been developed. These form the basis for the national mental health programme in Indonesia and have resulted in the restructuring of postgraduate training in psychiatry. PROHOTION OF ENVIRONMENTAL HEALTH The emphasis of the WHO programme has shifted to the broader issues of environment in keeping with rapid urbanization and industrialization, continued migration from rural areas to urban core and urban fringe areas, and with the growing awareness of the adverse effects on health by environmental pollution. The new global environmental health strategy, including as it does environmental health in rural and urban development and housing, prevention and control of environmental pollution and health hazards, environmental health impact assessment, control of poisoning, hazardous waste management, health risk assessment, and epidemiological and chemical safety has been received favourably by most countries. The action agenda recommended by the Consultation on International Drinking Water Supply and Sanitation Decade (IDWSSD), 1988 has been pursued vigourously. Efforts are now concentrated on the development of a new global community water supply and sanitation strategy for better comprehensive planning and on the implementation of sustainable sectoral activities in the last decade of the century. Efforts for the mobilization by communities of support of external agencies, with emphasis being given to manpower training, institutional development, and water quality surveillance, have continued. Groundwater development continued to be given high priority in Bangladesh, Myanmar, India, Indonesia and Sri Lanka, with emphasis on hydrogeological services, test drilling and exploitation of groundwater resources. All developing countries of the Region are faced with problems associated with unbridled urbanization. This has resulted in squatter settlements and overcrowding with consequent over- loading of the water supply, and of excreta disposal, waste water, collection and disposal facilities, etc. WHO has continued to support the promotion of intersectoral cooperation and co~mnunity self-reliance along with the use of appropriate technology. Solid waste management is also emerging as an important problem. An intercountry Consultation on Solid Waste Management, using the available information from the Member Countries, will be held in late 1990. Recycling of urban solid waste has been studied through a research project in Calcutta, India. The programme of health risk assessment of potential toxic chemicals began in 1990. This is largely research-oriented and aims to produce and disseminate public information on poten- tially toxic chemicals for use by the countries. WHO has assisted Indonesia in drafting legislation for labelling, storage and transportation of hazardous substances. In regard to the control of environmental health hazards, WHO'S collaborative efforts have been in the strengthening of national institutions and manpower capabilities. An intercountry conference, held in 1989 in the Regional office, resulted in the identification of several activities including hazardous waste management, emergency preparedness/response, poison control, etc. This has helped not only in the tripartite review of the UNDP assisted intercountry project on safety and control of pollutants and toxic chemicals, but also in the development of a new project document for UNDP assistance. WHO has supported the training of nationals from Indonesia, Sri Lanka and Thailand in a poison control workshop, held in Malaysia in November 1989. A course on risk assessment and management of toxic chemicals was conducted in December 1989 in Thailand. National workshops have been held in Sri Lanka, India and Indonesia. In addition to supporting institutional developoent, infotoation use in management has also been supported by the supply of computer hardware and software. Water quality monitoring activities under the Global Environmental Modtoring System (GEMS) have continued in Bangladesh, India, Indoneeia and Thailand. Likewise, ambient air quality monitoring and food contamination monitoring were undertaken in India, Indonesia and Thailand. WIO has supported the strengthening of national infrastructures and development of standards and legislation for ensuring greater food safety. A national Workshop on Food Safety in Public Catering, held in Hyderabad, India in November 1989, identified shortcomings in food safety practices. WHO supported the formulation of health regulations for restaurant hygiene and sanitation in Indonesia and the preparation of guidelines for hygiene and sanitation inspectors. Support for monitoring fwd contamination by pesticides was provided to India and DPR Korea. Surveys on pesticide residues in food commodities and on the use of food additives were initiated in India. The Codex Alimentarius Coordinating Committee for Asia held its seventh session in Chiang Mai, Thailand, in February 1990, and was attended by several countries of the Region. DIAGNOSTIC, THERAPEUTIC AND RElUBILITAl'IVB TECENOLLYX Since health laboratory services play a vital role in health care programmes, WHO has continued to support Member Countries in strengthening laboratory services, particularly at the district level, through training programmes. Supplies and equipment, reagents and kits have also been provided to a number of institutions in almost all countries of the Region. The production of modern immunological and biological reagents in Bangladesh, India and Sri Lanka is being supported with a view to achieving regional self-reliance through a UNDP-funded project. Efforts were made to strengthen health laboratories and hold workshops to improve methods for the diagnosis and control of Shigella-Dysenteriae-I. The National Institute of Health in Thailand has been able to provide diagnostic antisera to other countries of the Region. Similarly, the WHO Colla- borating Centre for Reference and Training in Streptococcal Diseases at the Lady Hardinge Medical College, New Delhi, in addition to carrying out reorientation courses, has also supplied reagents for the diagnosis of streptococcal infection to several institutions in the Region. Support was given for improving capabilities of producing reagents in rapid diagnostic techniques for the surveillance of priority diseases. WHO has supported the development of national capabilities in the sers-surveillance of AIDS. An intercountry Workshop on Advanced Techniques of HIV Antibody and Antigen Detection was held in Bangkok in December 1989. This will be pursued in the coming year. A workshop, held in December 1989, reviewed the progress in the streamlining of blood transfusion services and formulated guidelines for improving the safety of blood and blood products utilizing modern technology. Hospital-acquired infections have a high average incidence of 10 per cent in the countries of the Region. WHO, in taking note of this, is trying to develop regional and national strategies for HA1 control and surveillance, and has held workshops in Bangladesh, Nepal, Sri Lsnks, India and Myanmar. Though plague is no longer a problem, it is still necessary to keep track of the continued existence of natural foci of sylvatic plague. An interregional Consultation on Plague, held in New Delhi in September 1989, laid down guidelines for epidemiological surveillance, preventive technologies, strengthening of laboratories and supply of reagents. WHO has also stressed the need to promote regional self-sufficiency in monitoring radiation effects. Through collaboration with the countries in the Region the Essential Drugs Programme has been strengthened, especially in quality assurance, manpower development and rational use of drugs. Also, collaboration to improve drug procurement, storage and distribution has been initiated in Bhutan. Essential Drugs Programmes have been initiated in Myanmar and Thailand. The UNDP-funded ASEAN~WHO pharmaceutical project is an example of successful technical cooperation in the field of pharmaceu- ticals, and is progressing satisfactorily. Standard treatment regimens have been established and imple- mented in the countries of the Region. Rational use of drugs has been further promoted through national and interregional training courses. Computer technology in regard to drug management, drug information and adverse reactions has been adopted in several programmes. The production of plasma-derived hepatitis B and oral polio vaccines has been strengthened, and emphasis has been placed on assuring quality. To ensure drug quality, safety and efficacy, much emphasis has been placed on training in good manufacturing practices and on different aspects of drug quality control, such as equipment, manpower training and management. The WHO Certification Scheme has been promoted and several recommendations were made for its optimal utilization. To facilitate dmg evaluation and regis- tration and to promote rational use of druga, the establishment of drug information systems is being supported by WHO in several countries. Cultivation, production and quality assurance aspects of traditional medicines have been promoted through WHO colla- boration. Guidelines to support the countries in setting up or strengthening, as necessary, legislative and administrative systems for the registration of traditional medicine products have been provided to all countries in the Region. Research projects and educational activities have been supported in order to promote the utilization and integration of traditional medicine in the health care system. DISEASE PREVENTION AND CONTROL Substantial progress has been made towards achieving the main objectives of EPI and also the goal of Universal Child Immunization by the end of 1990. The surveillance system has been improved in all the countries in respect of the six target diseases, and the immunization coverage percentage has increased to 69 per cent for DPT-3, 66 per cent for OPV-3, 78 per cent for BCG, 54 per cent for measles and 51 per cent for TT2B. The health infrastructure is playing a more positive role wlth immunization being provided through an integrated approach. This integrated strategy was also discussed st a workshop held in New Delhi in March 1990. Initiatives have also been taken with regard to the manufacture of EPI vaccines. India is proceeding with plans for the manufacture of measles and polio vaccines in 1993. Indonesia is also taking similar steps. Practical training in laboratory diagnosis, cell culture and potency-testing of polio as well as measles vaccines was imparted in an intercountry workshop held in Harch-April 1990. The results of potency testing have not been encouraging, due mainly to cold chain failure. The cold chain and logistics system is under constant review. Solar refrigerators are now being used in problem areas and attempts are being made to improve and introduce sustainable technology for the cold chain. The financial resources for achieving the goal of Universal Child Immunization are short of requirements. This may have some effect on the intensive activities needed in the next ten years for polio eradication, neonatal tetanus elimination and measles reduction. Vector-borne diseases are the cause of a great deal of morbidity and considerable mortality in the countries of the Region. The control of vector-borne diseases is complex. It is becoming increasingly apparent that the effective use of control methods requires a sound knowledge of the epidemiology of the specific disease and of the biology and ecology of the vectors. WHO has continued its technical support to Member Countries in their programmes to reduce morbidity and mortality caused by vector-borne diseases. Greater emphasis is being laid on technological development, applied field research including social and behavioural aspects of communities, and on technical manpower development for the control of vector-borne diseases. Though the malaria situation continued to show a declining trend in most of the malarious countries, the malariogenic potential was still very high in the Region, with the disease ever ready to assume epidemic proportions or to re-establish a high degree of endemicity when control operations slacken or are discontinued. The incidence of P falci arum malaria, parti- cularly of its resistant strains, te any signi- ficant change, and is thus continuing to pose a major technical problem. This has been compounded by the further spread of vector resistance to a wide range of insecticides, by large- scale population movements, by vector exophily and by human behaviour factors. Administrative and financial constraints as well as civil unrest are also contributing factors to the present, somewhat slow progress of malaria control programmes. However, stratification of malarious areas, development of appropriate manpower at district and peripheral levels, and adaptation, based on an epidemiological approach, of the revised malaria control strategies through primary health care aystems has brought the malaria control programmes closer towards their general objectivea of preventing mortality and decreasing disease morbidity. Considerable efforts have been made by WHO, in collaboration with the countries, in conducting training, planning, and implementation and evaluation of malaria control activities in a rational manner, keeping in mind the limited resources available for the control of the disease. The promotion of programme-oriented field studies and research to solve both technical and operational problems in the malaria control programmes was one of the main concerns of WHO. These studies have helped the countries to further strengthen national research cadres, develop appropriate national policies and review disease control methodologies. Countries of the Region continue to be affected by a variety of parasitic diseases of public health importance. Intestinal parasitic infections associated with undernutrition, poor personal hygiene and environmental sanitation continue to be public health problems. Sumeillance has been undertaken in India and Nepal and new approaches for mass treatment of children and women of child-bearing age by training of health personnel and community involvement are under contemplation. India is the only country in the Region affected by guineaworm infection, with seven states reporting guineaworm cases before, although now the number of endemic states has been reduced to six. In all these states, the number of cases is declining. Ten epidemiological team were deployed in 1989 and it is hoped, with increased community participation, to eradicate this disease by the end of 1991. Visceral leishmaniasis is a health problem particularly affecting the underprivileged and lower socioeconomic groups in the rural areas of the states of Bihar, West Bengal and Uttar Pradesh in India as well as in Bangladesh and Nepal. WHO collaborated with UNDP from 1986 to 1989 in an intercountry project for the control of leishaaniasis. This has resulted in improving research capabilities and strengthening training facilities. Bangladesh has worked out a national control programme. With regard to filariasis, in addition to intensive research, particularly on chemotherapy, an integrated control strategy in the context of PHC is gaining ground. The UNDPlWorld BanklWHO Special Programme for Research and Training in Tropical Diseases (TDR) has supported the Region and helped in achieving good progress in the ongoing field trials of new drugs against malaria, filariasis and leprosy. Progress has also been achieved in the development of nwer immunological test kits and DNA probes for diagnosis and in field trials of biological control agents in malaria. The constant follow-up on studies of transmission-blocking antigens of P.vivax has continued. New institutional strengthening grants have been awarded to institutions in the Member Countries of the Region, in order to ensure that institutions eupported by TDR are able to use their increased capabilities and participate in the Programme's research and development activities, as well as in the control programmes of their countries. The Regional CDD Programme was established in 1979 and all the eleven Member Countries have national programmes which are being implemented as part of the primary health care services. The objectives are to reduce mortality due to diarrhoea in the short-term through increased use of ORT, and ultimately to reduce morbidity through the promtion of improved maternal and child health care, improved environmental sanitation, and epidemic control. The major strategy continues to focus on improved case management, primarily through increased use of ORT. To implement this strategy, training activities in programme management, supervisory skills and clinical management continued to receive high priority during the year. In addition, the establishment of diarrhoea training units was encouraged in all the countries of the Region. The ORS access rate reached 67 per cent for the Region as a whole while the ORT use rate reached about 30 per cent. The total of locally-produced and imported ORS surpassed 100 million litres for the first time. Eight Member Countries have completed household clinical management surveys or plan to conduct such surveys to evaluate their CDD programme indicators. ARI, together with diarrhoea1 diseases and malnutrition, are the leading causes of death each year among children in the countries of the Region, with the death rate due to ARI in children under 5 years of age varying from 20 to 30 per cent. Most countries have developed national plans for the control of ARI. Of the four intervention studies on ARI, those in Nepal and India have been completed. Training modules using a multi-media approach have been prepared and field-tested and these are now being used in India and Indonesia. There has been no perceptible let-up in the effect of tuber- culosis. Sustained efforts have continued for the detection of new cases and appropriate treatment. The appearance of HIV infection is now causing concern since dual infection with M.tuberculosis and the HIV virus is likely to result in increasing incidence of tubercuolsis. WHO has been supporting Member Countries in epidemiological surveillance on the prevalance and incidence of the disease. In particular. WHO collaborated in various facets of the programme with Bangladesh, India, Indonesia, Nepal, Sri Lanka and Thailand, including, inter alia, improvement of diagnosis and treatment facilities, -- strengthening clinical research activities, providing training facilities, providing supplies and equipment and in intervention studies. The sixteenth session of the SEA~ACHR, held in Chiang Mai, Thailand, in April 1990 discussed research in tuberculosis and recommended further intensification of research in tuberculosis, including a review, of the effectiveness of BCG as a tool in EPI. The external donor support for tuberculosis has been on the decline and concerted efforts are needed to mobilize additional resources for the programme. While leprosy still continues to be among the major public health problems in 9 out of 11 Member Countries of the Region, notable progress has been made in leprosy control activities during the past year. A rapid expansion of MDT coverage, early detection of infection and a marked reduction in deformity in newly-diagnosed cases have been witnessed. Increased awareness and confidence in IfDT regimens has been instrumental in further promoting political commitments at all levels and in promoting an appreciable increase in early detection of cases. WHO on its part continued to provide technical and financial support from regular and extrabudgetary resources. As a steady decline in the patient load is being witnessed, the need for the rehabili- tation of deformed cases is emerging as an important challenge to Member Countries as well as to WHO. This further reiterates the need for the integration of leprosy control activities with primary health care, in order to rationalize and optimize available human and material resources. WHO supported Member Countries in their endeavours to reduce the incidence and prevalence of zoonotic diseases, with the ultimate aim of preventing them in man. WHO supported three workshops in India on laboratory techniques in rabies, on vaccines and treatment of rabies and on control of lepto- spirosis. Nepal has beea supported in its programme for the control and elimination of rabies with funds from a French organization, Veterinarians sans Frontieres. In Sri Lanka too, the implementation of a new Rabies Control Act is being pursued vigorouely with the objective of eliminating human and canine rabies . WHO continued to assist Hember Countries in reviewing their programmes for the production of vaccines, strengthening the monitoring process, introducing newer technologies and strengthening quality control capabilities. A regional strategy for self-sufficiency in EPI vaccines has beea formulated. Myanmar and Mongolia are being assisted in producing hepatitis B vaccine. Sexually transmitted diseases (STD) have assumed a higher priority with the advent of AIDS in some countries of the Region. WHO has supported Member Countries in strengthening national capabilities for the collection and analysis of epidemiological data in respect of STD and AIDS and in developing suitable control strategies. A meeting held in Geneva in January 1989 identified STD as a risk factor for HIV transmission and agreed that the programmes on STD and AIDS should work together. AIDS is not yet considered to be a priority health problem in many countries of the Region, though the situation is getting worse and causing concern in some countries. In the absence of a cure, the focus of WHO attention has been on prevention through health education. WHO has supported Member Countries in the formulation of short-term and medium-term plans of action to effectively prevent the spread of HIV infection. There is a need for coordinated action at all levels. This has been recognized in the Regional Plan of Action under which an epidemiology-based strategy has been developed. The emphasis in Member Countries has been on epidemiological surveillance to learn the extent of the disease and its prevalence in high-risk groups, detection of HIV infections, improvement in public health information through mass media, and on safe use of blood and blood products, etc. From an overall epidemiological viewpoint, the problem of AIDS is of great concern in Thailand and India. Bangladesh, Bhutan, DPR Korea, Maldives and Mongolia have reported '0' HIV positives as of 30 April 1990. In India, while HIV infection has so far been recorded only among female prostitutes, evidence has come to light that heterosexual transmission is taking place. In Thailand, the number of HIV-infected persons has increased very rapidly. In Myanmar too, the transmission of HIV among intravenous drug users is viewed as a major problem. WHO has collaborated with Member Countries in enhancing their capabilities in the prevention and control of other communicable diseases, including Japanese encephalitis (JE), meningococcal meningitis, viral hepatitis and dengue haemorrhagic fever. Japanese encephalitis is a public health problem in India, Indonesia, Nepal, Sri Lanka and Thailand. In Nepal, a detailed work plan for mass vaccination against Japanese encephalitis has been prepared. Meningococcal meningitis is a health problem in India and Nepal. WHO has collaborated in developing an early warning system for early detection and reporting of cases in the states of Gujarat, Orissa, Bihar, Rajasthan, Mahsrashtra and Delhi in India. In Nepal, after the last epidemic of 1983-1984, mass vaccination campaign was successful in containing further outbreaks. Haj pilgrims leaving India are being provided with imported bivalent (A+C) vaccines. An intercountry Consultative Meeting on Surveillance and Control of Meningitis was held in Kathmandu in October 1989 to review the situation and improve the guidelines. Hepatitis A virus infection is a common problem in South-East Asia. Hepatitis B virus infection is also a serious problem in the Region with an estimated 70 million carriers. Non-A and non-B hepatitis is also emerging as a problem in the Region. WHO has sponsored epidemiological studies in Indonesia, Mongolia, Myanmar and Thailand and has already provided laboratory facilities, kits and reagents for diagnosis. An intercountry Meeting on Entericslly Transmitted Non-A and Non-B Hepatitis was organized in New Delhi in July 1989. WHO has also collaborated in the production of local HEV diagnostic reagents in India, Indonesia, Mongolia, Myanmar and Thailand. In the area of blindness and deafness prevention, greater emphasis has been placed on the strengthening of managerial skills and capabilities of national-level personnel. While disease trends have shorn a reduction in communicable and nutrition-related diseases causing blindness, ageing-related conditions, such as cataract and glaucoma, pose an increasingly formidable challenge. Intensified interventions for such conditions are being planned and implemented in several Member Countries. Cancer is slowly emerging as an important cause of death in the countries of the Region with the problem being aggravated by late detection. This is true particularly of oral cancer and cervical cancer. India has a comprehensive national cancer control programme. WHO has supported the improvement and extension of the existing cancer registries and has stressed the importance of prevention and early detection of most cormon cancers through public education campaigns and development of educational materials. Such activities are being supported in Myanmar, Sri Lanka and Thailand. Cardiovascular diseases seem to be on the rise in the Region as seen from the available lnformation based on hospital statistics. WHO is supporting studies on risk factors in India, Myanmar and Sri Lanka. Hypertension and the related risk of stroke are recognized as being prevalent in the countries of the Region though the countries do not have resources for large-scale hypertension control programmes. WHO has supported Bhutan and Myanmar in planning control measures for cardio- vascular diseases. DPR Korea has been supported in the improve- ment of vascular surgery. The control of rheumatic fever and rheumatic heart disease in some countries, with AGFUND support, has entered the second phase. The incidence rates of these diseases are high enough to warrant the inclusion of rheumatic fever and rheumatic heart disease control measures in school health programmes. HEALTH MOORMATION SYSTEM Information support to various health clientele in the Region is being effectively supplied by the HeLLIS network which continues to be fully operational in eight Member Countries. The HeLLJS national focal points met at a workshop in Bangkok from 23 October to 6 November 1989 to acquaint themselves in newer technologies in health science libraries such as Micro-ISIS Software, CD-ROM and MEDLINE Database training. CE-ROM is now available in Bangladesh, India, Indonesia, Myanmar and Sri Lanka. The compilation and publication of Index Medicua for the WHO South-East Asia Region has been continued. While only one new title was published under the SeARO Publication Series, the sale of WHO publications has increased over that of the previous year. In line with its avowed policy of making available valid information, support has been provided for the translation of WHO publications into regional and local languages. WHO also participated at the World Book Fair held from 13 to 18 February 1990 and the Health and Medicare Exhibition held from 25 to 31 March 1990 in New Delhi. SUPPORT SERVICES A number of visitors, including ministers of health from South-East Asia and other regions, visited the Regional office. The two-way exchange of views that occurred during their visits helped in strengthening the mutually-interactive process of decision-making. The Director-General visited the Regianal Office in March 1990 and also met dignitaries in India. The Regional Director espoused the cause of the Member Countries of the Region at the Executive Board and the World Health Assembly. He also participated in a number of workshops, seminars etc., both within and outside the Region, and utilized these occasions to focus on the valuable efforts being made by Member Countries in their efforts to achieve the goal of Health for All by the Year 2000, and also to seek financial, physical and moral support. A total number of 107* established professional posts have been filled, and four posts have remained frozen. Twenty-two posts have remained vacant as of 30 June 1990. A total number of 196 consultants were utilized in various projects to provide the much-needed technical support to the countries. The Administration and Finance information system has been implemented on an IBM-36 minicomputer. This will provide expanded capabilities for financial and implementation information for operational and managerial purposes. *Includes 8 posts filled by consultants. The total obligation during the biennium 1988-1989 as of 31 December 1989, under all sources of funds, was uS$99 774 588. This was 9 per cent higher than the corresponding figure of 1986-1987. The obligation from 1 January to 31 May 1990 under the Regular budget was uS$23 976 293 amounting to 29.7 per cent of the regional allocation for the 1990-1991 biennium. During the period July 1989 to March 1990, medical supplies and equipment worth U~$14 741 482 were procured. Apart from the usual items, there has been an increase in the number of requests for diagnostic kits and supplies. Local purchases were increased to the extent possible where improved support and maintenance facilities were available. Requests for a total of US$235 466 from India, Nepal and Bangladesh to meet emergency situationa such as natural calamities were responded to. Myanmar, India, Bangladesh and Nepal have availed of the revolving funds scheme under which a total of US$1.97 million were spent. The above summary gives a vivid picture of the activities of WHO in the South-East Asia Region. Complete details of the above are available in the following pages.
Chapter 12 DIAGNOSTIC THERAPEUTIC AND REHABILITA~VE TECHNOLOGY 12.1 CLINICAL, LABORATORY AND RADIOLOGICAL TECHNOLOGY FOR HEALTH SYSTEMS BASED ON PRIHARY HEALTH CARE Health laboratory services play an important role in supporting health care programmes. WHO continued its collaboration with Member Countries in strengthening health laboratories through activities directed towards strengthening of the existing infrastructures, introduction of appropriate laboratory technology, provision of supplies and equipment and towards the strengthening of quality control programmes. Laboratory Services and Technology WHO continued to collaborate in the strengthening of laboratory services, particularly at the district level, through national training programmes and through the provision of supplies and equipment to almost all the countries of the Region. Reagents and kits were provided to the Institute of Public Health, Dhaka, the Thimphu Hospital in Bhutan, the National Health Laboratory, Yangon, the Male Hospital Laboratory in Maldives, the Central Health Laboratory, Kathmandu, the Medical Research Institute, Colombo, and the Department of Medical Sciences, Bangkok. Laboratory animals were provided to the National Institute of Nutrition, Hyderabad, while reagents and kits were provided to the National Institute of Virology, Pune, and the Central Research Institute, Kasauli, India. A UNDP-funded intercountry project has been initiated for strengthening health laboratories in primary health care covering six countries of the Region. Assistance will be in the form of support for national consultations and workshops on health laboratory service policies, quality standards, appropriate technology and the introduction of quality control in peripheral-level laboratories. In view of the continued prevalence of shigellosis in the countries, particularly periodic epidemics due to Shi ella dysenteriae I, health laboratories are being strength* several countries in collaboration with the diarrhoea1 disease control programme. During the year, national workshops were held in Bangladesh, Myanmar, Nepal, Sri Lanka and Thailand. Through the technical cooperation scheme, the National Institute of Health, Thailand, provided diagnostic sntisera for Shigella dysenteriae to other countries of the Region. The WHO Collaborating Centre for Reference and Training in Streptococcal Diseases at the Lady Hardinge Medical College, New Delhi, carried out a national reorientation course on streptococcal bacteriology and serology, and organized a meeting of the zonal centres for the monitoring and strengthening of activities for the control of rheumatic feverlrheumatic heart diseases in March 1990. This Centre continued to supply reagents for the diagnosis of streptococcal infection to other institutions in the Region. Efforts to achieve regional self-reliance in the production of immunodiagnostic reagents continued. The production of modern immunological and biological reagents in Bangladesh, Myanmar, India and Sri Lanka is being supported through a UNDP-funded project. WHO supported facilities at Mahidol University in Bangkok and continued to support other countries by providing reagents as well as the methodology for their production. The National Institute of Virology, Pune, India, supplied test kits for the surveillance of Japanese encephalitis to the countries of the Region. There is a need to increase the capabilities of the countries for producing reagents for rapid diagnostic techniques and surveillance of priority diseases in the Region, such as dengue haemorrhagic fever, Japanese encephalitis, hepatitis, shigellosis and acute respiratory infections. In the field of quality control of health care technology, WHO is supporting an "External Quality Assessment Scheme" (EQAS) in India, Indonesia, Nepal, Sri Lanka and Thailand. Several laboratories are taking part in the global programme on external quality monitoring in clinical chemistry, microbiology and haematology. WHO provided technical support through consultants for conducting national workshops on external quality assessment in haematology in Indonesia. WHO continued to support the development of national capabili- ties in sero-surveillance of AIDS. An intercountry Workshop on Advanced Techniques in HIV Antibody and Antigen Detection was held in Bangkok in December 1989. It is hoped that national expertise thus developed would lead to a network of HIV testing centres in the countries. It will be followed by a bench-level intercountry workshop on quality control methodology for HIV testing in Pune in October 1990. These activities are likely to improve the performance of HIV testing laboratories in the Region. Under the Global Programme on AIDS and the global blood safety initiative, WHO organized an intercountry Workshop on Safety of Blood and Blood Products in Kathmandu, Nepal, in December 1989. The workshop reviewed the progress in the streamlining of blood transfusion services in the countries of the Region and formulated guidelines to improve the safety of blood and blood products utilizing modem methodology. Hospital-acquired infections still exact a high toll in the developing countries. An average incidence of 10 per cent has been noted in the countries of this Region. WHO is trying to develop regional and national strategies for HAI control and surveillance through national workshops. Such workshops were held in Bangladesh, Nepal, Sri Lanka, India and Myanmar during December 1989-January 1990. It is hoped that national networks for HAI control will be developed in the countries of the Region. The Forty-first World Health Assembly committed WHO to global eradication of poliomyelitis by the year 2000. One cardinal requirement to support and smtain the programme is the strengthening of national laboratories in polio diagnosis and vaccine potency testing. WHO conducted an intercountry Workshop on Viral Vaccine Potency Testing in March-April 1990 in Coonoor, India, to improve the expertise of nationals in vaccine potency testing, serology and tissue-culture techniques of polio and measles. The incidence and prevalence of rickettsioses are perhaps being greatly underestimated as causes of human disease worldwide, since the information available is meagre. One of the major obstacles in acquiring epidemiological information has been the non-availability of simple ricketssia-specific laboratory tests. WHO has initiated a global programe for rickettsial disease epidemiology and developed @ programme for distributing rickettsial antigens for indirect imunofluorescence tests. In October 1989, one consultant from CDC visited national laboratories in India, Bangladesh, Nepal and Thailand, and conducted courses for nationals in developing rickettsia1 antibody testing programmes. It is expected that in the near future a realistic epidemiological picture will emerge. Though plague is no longer a problem in most countries of the world, the existence of continued natural foci of sylvatic plague in various parts of the world continues to pose a threat of resurgence. WHO held an interregional Consultation on Plague in New Delhi in September 1989, which laid down guidelines for epidemiological surveillance, preventive technologies, strengthening of laboratories, and supply of reagents, and reiterated the need for international cooperation to control this ancient disease which is still lurking on this planet. WHO continued to monitor exposure to X-rays in the departments of radiology, to monitor the safety of cobalt irradiation units in several countries, and to promote the provision of basic radiological services. WHO is endeavouring to promote regional self-sufficiency in monitoring radiation effects. Most countries still need to be supported in the, development of sufficient facilities to establish appropriate imaging technology. 12.2 ESSENTIAL DRUGS AND VACCINES WHO collaborated with countries of the Region in the strengthening of different aspects of their essential drugs programmes. The major thrusts were towards strengthening quality assurance in all its aspects, manpower development and rational use of drugs. Technical and financial inputs, including funds from extra- budgetary sources, were provided to Bangladesh, Bhutan, India, Indonesia and Myanmar. Technical collaboration between the ASEAN countries, of which Indonesia and Thailand are from the South- East Asia Region of WHO, continued with the support of UNDP. 1. Drug Policies and Programes Several countries of the Region have based their drug policies on the new perspectives in the field of health policies and developments which followed the Alma-Ata Conference. Based on the recommendations of an intercountry meeting, held in the Regional Office in August 1987, countries reviewed their drug policies and management in order to ensure the provision of safe, essential and effective drugs of appropriate quality, particularly in the context of primary health care. Following a mission to Thailand in 1986, a project is being implemented for providing financial and technical support to strengthen the essential drugs programme. The project deals wlth drug information, evaluation, registration and re-evaluation of drugs, pricing policy, quality control and good manufacturing practices (GMP), drug management and rational use of drugs, etc. A WHO consultant visited Thailand to assist in the preparation of a detailed work plan. An essential drugs programme was developed in Myanmar with support from FINNIDA and, as a first step in the process of implementation, a drug policy meeting was held in July 1989. The Myanmar project lays emphasis on strengthening drug policies, quality assurance, and on the procurement system, including the provision of essential drugs in nine townships in a phased manner over the next four years. 2. TCDC in Pharmaceuticals In the last ten years, India, Indonesia and Thailand have developed capabilities for the production and quality assurance of essential drugs and biologicals. This has provided scope for technical cooperation among the countries of the Region. Also, the geopolitical grouping of the countries provides a favourable climate for cooperative efforts in health development. The UNDP-funded, ASEAN-WHO pharmaceutical project is a successful example of technical cooperation in the field of pharma- ceuticals. In the first phase of the project, the ASEAN countries developed five centres of excellence in the fields of quality control, drug management, reference substances, GMP and drug evaluation. In the second phase, these centres are being used for manpower training, not only by the ASEAN countries, but also by countries in the Region. New areas have been identified for developing technical cooperation. These are herbal medicine, hospital pharmacy, drug information and drug management at the primary health care level. National consul- tants have prepared monographs on the commonly-used traditional medicines in ASEAN countries. With the assistance of a consultant guidelines on hospital pharmacy management have been prepared. 3. Rational Use of Drugs WHO collaborated with countries in promoting rational use of drugs in all its aspects, and actively promoted rational drug therapy and drug management in Bhutan, India, Indonesia and Myanmar. In Bhutan, support was given for improving the procurement, storage and distribution of drugs, and for the development of management capabilities. India constituted a technical committee to evaluate irrational drug combinations and took steps to remove from the market several such combinations. Similar action was taken by Nepal. Standard treatment regimens, particularly at the primary health care level, were promoted. Bhutan, Myanmar, Nepal and Sri Lanka initiated steps to establish standard treatment regimens which are now being implemented at the primary health care level. A pilot project on the quantification of drugs, based on standard treatment regimens, was successfully implemented in Sri Lanka. It is expected that, based on the experience gained, this approach will be adopted by other countries of the Region. With advances in the adoption of computer technology, computers have now been introduced to facilitate drug management, drug information and adverse reaction monitoring in some countries of the Region. WHO continued to assist countries in reviewing their programmes of production of vaccines, strengthening monitoring processes, introducing newer technologies and strengthening quality control capabilities. Transfer of technology has been effected for the production of plasma-derived hepatitis B vaccine in Mongolia. A regional strategy for self-sufficiency in EPI vaccines has been formulated. 12.3 DBUG AND VACCINE QUALITY, SAFETY AND EFFICACY WHO'S main thrust of activities in several countries of this region has been towards strengthening different facets of quality assurance programmes. Manpower development was under- taken in several countries. Country and intercountry courses on GMP were organized in India, Bangladesh and Sri Lanka. WHO consultants provided technical inputs to countries for improving drug information and registration. WHO actively promoted the implementation of the WHO Certifica- tion Scheme in the countries of the Region. This scheme is of great importance in ensuring quality assurance for countries that have not yet developed comprehensive quality control systems. Problems and constraints in the implementation and utilization of the scheme, both by the importing and the exporting countries, as well as in the principal goals and objectives have been identified. The scheme provided an opportunity for dialogue among regulatory authorities in the countries of the Region. 1. Quality Control and Assurance WHO continued to assist the countries in improving quality control and quality assurance of drugs. In several countries, the major thrust was towards the development of appropriate technical manpower, strengthening of drug testing laboratories through the provision of supplies and equipment, and towards drug evaluation. The SIDAIDANIDAIWHO-funded project on "Essential Drugs and Vaccines" in Bangladesh served to strengthen quality control laboratories through the provision of supplies and equipent, as well as consultants to establish methodologies for drug analysis and to train national staff at the bench level, to establish systems for repairs and preventive maintenance of equipment and to establish a methodology for the production of biologicals. WHO collaborating centres in India, Indonesia and Thailand have been utilized for quality control by those countries which are still to develop their own facilities. 2. Drug Information and Adverse Drug Reactions Information on different aspects of drugs is an important step in achieving their rational use. WHO collaborated with India and Indonesia in establishing a dtug information system. In Indonesia, steps were taken to adapt and implement the Swedish mug Information System (SUEDIS). WHO provided substantid training and consultancies in this area. A network of national information officers to act as focal points for the wide dissemination of drug information was established. They are expected to play an important role in the transfer of authentic drug information required by various groups, such as regulatory agencies, clinicians, quality assurance personnel and the community. WHO collaborated with India and Mongolia in developing and strengthening adverse reaction monitoring systems. 12.4 TRADITIONAL MEDICINE The activities of the WHO programme on traditional medicine focused on the identification of popular traditional medicines used for common ailments, on training practitioners in the use of traditional medicines and in general public health concepts enabling them to participate in PHC programmes, on strengthening quality assurance aapecta in a broad sense, and on the production of, and research in, traditional medicines. Several countries in the Region developed and strengthened training programmes with assistance from experts from within the Region. Fellowships and study tours were arranged for nationals of DPR Korea, Indonesia, Myanmar, Nepal and Sri Lanka. Technical collaboration among the ASEtW countries on the standardization, quality control and utilization of herbal medicines is continuing into the third phase of a project. In order to strengthen manpower development, the ASW project was also involved in preparing training programmes and manuals on the cultivation, production and utilization of traditional medicines. Activities to assure the quality of herbal medicines, including training courses, were undertaken. Standards and quality control procedures for selected medicinal plants, and drafting of monographs, were initiated in some of the countries. WHO assisted countries in establishing quality assurance systems for traditional remedies and provided technical assistance to Indonesia, Mongolia, Myanmar and Nepal. The Regional Office distributed copies of "Guidelines for the Registration of Herbal Products" to all the countries, with a view to assisting them to develop the necessary legislative and regulatory background and to establish an adequate registration system. As part of the activities of the second phase of the UNDPIWHO project on traditional medicine, a manual on "Standardization, Quality Control and Utilization of Herbal Medicines in ASEAN countries" was completed. Training programmes for practitioners of traditional medicine, with emphasis on primary health care, were developed, and several workshops were held. In order to enable countries to achieve self-sufficiency in the cultivation and production of herbs, WHO supported national programmes through training activities and by providing supplies to Bangladesh, India, Mongolia and Nepal. In order to promote the utilization and integration of traditional medicines, WHO continued its support to research activities in India, Indonesia and Mongolia. The increasing rate of injuries and continued high prevalence of certain disabling diseases and malnutritions suggest that measures for the prevention of disabilities cannot achieve the desired result unless the efforts of different groups dealing with these problems are integrated and unless community awareness of the problem and of its cause is created. The concept of community-based rehabilitation (CBR) is gaining further ground and many countries of the Region have adopted it as the most feasible approach, which is estimated to meet the essential needs of 70-80 per cent of the disabled in a community. However, progress in this regard needs to be accelerated. The Regional Office, therefore, continues to support and collaborate with Member Countries in developing adequate policies of rehabilitation, in undertaking development programmes in CBR, and in training national cadres. Training of community and family members of the disabled in the early detection of disability, in simple rehabilitation methods, and in the mobilization and utilization of community resources in the most effective and supportive way have remained the centre of attention. A pilot research atudy project in "Integrated Prevention of Avoidable Disabilities" (IMPACT) has been put into operation in India, to teat the operational feasibility of delivering a package of selected interventions through MCH and school health programmes using the existing health care infrastructure. A number of training activities such as workshops and seminars on different aspects of rehabilitation were conducted in Nepal, India and Indonesia. Support was provided for training nationals through WHO fellowships. Some equipment, books and other educational materials were also provided.
Chapter 13 DISEASE PREVENTION AND CONTROL During the period under review, Member Countries made progress in achieving the main objectives of EPI towards the goal of Universal Child Immunization by the end of 1990. The first objective, viz., reducing morbidity, disability and mortality from the six EPI-target diseases, has been achieved by improving the surveillance system in the countries. Member Countries are committed to obtaining valid information on EPI diseases incidence (see Table 7 and Figure 1) and, together with the increasing coverage, to confirming, even at district and sub-district levels, the impact of immunization coverage on disease reduction. Sri Lanka, Indonesia, Thailand, Myanmar and India have achieved this objective in some areas. Maldives and Sri Lanka have declared that they achieved Universal Child Immunization in May 1989 and December 1989 respectively. Immunization coverage all over the Region has been increasing. The coverage so far achieved is 69 per cent for the third dose of diphtheria-pertussis-tetanus vaccine (DPT3), 66 per cent for the third dose of oral polio-vaccine (OPV3), 78 per cent for the vaccine against tuberculosis (BCG), 54 per cent for measles vaccine (MSL) and 51 per cent for the second dose/booster of tetanus toxoid in mothers or women in child-bearing age (TTZB) (see Figures 2 and 3). TABLE 7. Cases of EPI target diseases reported by SEAR countries, 1989 Diseases BAN BW DPRK IND IN0 HAV MOG MPlR NJlP SRL THA SEAR Diphtheria 1229 l* .. . 10626 8 0 7 171 3 0 81 12126 Measles 27327 554 ... 144470 4456 0 2176 1930 171 409 11270 192763 Pertussis 83057 219* 126501 256 0 0 2678 18 17 1065 214174 Polio 449 0 8* 10376 107 0 0 50 21 4 17 11032 Neonatal tetanus 1105 2 4* 9613 531 . . . 0 58 3 8 270 11594 All tetanus 4137 9. 24* 24794 .. . . . . 0 1005 ... ... .. . 29969 All tuber culosis 23856 174* ... 940664 ... 216 2237 10558 ... 6429 16993 1001127 *Data for 1988 ... = Data not available I Figure 1. CASES OF EPI TARGET DISEASES REPORTED* BY SEAR COUNTRIES, 1974-1989 I .Undcrr.portlng was oseurned in sonle coustriea. Source: Country Rcports, Junc 1890 Figure 2. PERCENTAGE OF IMMUNIZATION COVERAGE* AMONG CHILDREN OF LESS THAN 1 YEAR OF AGE AND PREGNANT WOMEN IN SEAR COUNTRIES, 1977-1989 .B.S.~ on UN dananlnatars only. . 6onfes: country nepona. Figure 3. PERCENTAGE OF IMMUNIZATION COVERAGE* AMONG CHILDREN OF LESS THAN 1 YEAR OF AGE AND PREGNANT WOMEN IN SEAR COUNTRIES, 1989 I.!.. The need for more active involvement of curative health facilities in the actual implementation of EPI was stressed during the period under review. It is encouraging that the countries of the Region specifically mention the provision of immunization at some fixed curative centres as an integrated approach through the health infrastructure. In the context of PHC, the countries have integrated EPI along with CDD, ARI and MCH. This is important at this stage of the programme, taking into account the second objective, promoting self-reliance among the countries in the delivery of immunization services within the framework of comprehensive health services. Details of this strategy were widely discussed at the meeting of EPI Managers, held In Balt, Indonesia, in June 1989, and at the Integrated Poliomyelitts/Neonatal Tetanus/~easles/MCH Workshop, held in New Delhi in March 1990, in which plans of action for the countries were reviewed and updated. As regards the promotion of quality control and vaccine production, which is the third main objective, some countries sre already producing EPI bacterial vaccines. Most of them are importing measles and polio vaccines. India has taken the initiative to manufacture measles (5-dose vials) and polio vaccines by 1993 in collaboration with USSR and France; Indonesia, through her domestic Bio Farma Company, has taken similar steps in collaboration with Japan. An intercountry practical training in recent technology on laboratory diagnosis, cell culture and potency-testing of polio vaccine was held in Coonoor, India, in March-April 1990. The results of the OPV vaccine potency testing were not encouraging in some countries in the Region. A national EPI review, undertaken in India, in MarchIApril 1989, showed that about 40 per cent of the testing was unsatisfactory in one state, while in another State the results were even more discouraging with 60 per cent unsatisfactory testing. In Indonesia, about 50 per cent of health facilities at district and sub-district levels, in eight randomly-selected provinces, were considered to have "cold chain failure" in their storage systems. However, tests conducted during the reporting period have revealed that the situation has improved significantly, and more satisfactory results (about 90 per cent) have been reported in India while further relevant training and supervision have been provided in Indonesia. Following the training in Coonoor in March-April 1990, Regional Office and headquarters staff have planned to visit some countries to assist in the strengthening of laboratory capacity to support polio eradication activities. Computerized BPI Information System (CEIS) All countries of the Region are expected to establish their basic CEIS by the end of 1990. During the period under review, Phase I (1987-1990) of the system was finalized. This was made possible through the assistance of the concerned government, WHO, UNICEF, and other agencies, such as USAID and REACH. Bangladesh started CEIS in 198611989, Bhutan in 1990, India in 198611989, Indonesia in 1987, Maldives in 1990, Mongolia in 198911990, Myanmar in 198811989, Nepal in 1988189, Sri Lanlca in 198911990 and Thailand in 198811969. DPR Korea plans to start CEIS in 1990. Bangladesh, Bhutan, Indonesia, Myanmar, Nepal, and Thailand plan to expand, or have already expanded, their systems to sub-national levels. In Phase I1 (1991-19941, based on country needs, the development of CEIS software with more sophisticated programmes will be encouraged by inputs from governments and national prograornes and from other inter- national agencies. Cold Chain and Logistics Cold chain reviews, using cold chain monitor cards, were conducted in DPR Korea, Bhutan, Myanmar and Sri Lanka. Similar reviews have been planned for Indonesia, India and Thailand leading to routine use of monitor cards in order to ensure a reliable cold chain. A newly-developed 'refrigerator watch' has been introduced in Rajaethan state in India to monitor the operation of refrigerators, and will be gradually introduced in the other countries of the Region if the trial is successful. Assisted by the World Bank, solar refrigerators are now in use in problem areas in Irian Jaya, and 100 more are being procured for Indonesia. Some new makes of solar refrigerators are under field trial in India, Maldives, Myanmar and Thailand. The Asian Institute of Technology has established facilities, with assistance from WHO, for conducting routine training courses for solar refrigerator repair and maintenance technicians. The Institute has also been recognized by WHO as a test centre for cold chain equipment. Pressurized steam sterilization of injection equipment is being widely promoted in all the countries. A solar ateam sterilizer, developed in France, is under field trial in India. In view of the sustainability of the cold chain, efforts are being made to develop and test indigenous cold chain equipment, including ILKS, refrigerators, deep freezers, vaccine carriers and cold boxes in some countries. Training and Research Training in the management and technical aspects of EPI has been a high priority for the programme. The emphasis now is on national, rather than intercountry, training workshops. This allows adaptation of course material to local situations. EPI is encouraging an integrated approach to training, utilizing materials from CDD, ARI and other relevant programmes in the same workshop. During the period under review, two regional workshops were organized: one for UNICEF-EPI State Managers from India and some other countries (with the technical leadership of WHO headquarters and the Regional Office) and the aecond, the Integrated Polio/Neonatal Tetanus/~easles/~CH Workshop, for national EPI managers. Following these, a similar workshop was held in India in May 1990 and will be followed by another in Thailand in November 1990. Preparations are in progress for an interregional training course in solar refrigerator maintenance, to be organized jointly by WHO and the Asian Institute of Technology, in Bangkok in July 1990. EPI promotes other studies, such as the development of pertussis and live rubella vaccines in Thailand, and cold chain monitoring in India and Sri Lanka. Immunization coverage surveys in Mongolia (7), Nepal (4), Indonesia (71, Bangladesh (111, Myanmar (26) and Sri Lanka (1) were conducted in order to justify the findings of routine reporting of immunization coverage and to boost immunization activities. These were in addition to national EPI reviews conducted in Sri Lanka (December 19891, Mongolia (~pril/May 19901, Nepal (May 1990), Thailand (May/~une 1990, and possibly in December 1990 as well) and Bangladesh (June 1990). In Indonesia, a study of the surveillance model to monitor adverse reactions is being developed in Yogyakarta in collaboration with Bio Farma. India produced a paper on adverse reactions of immunization (1989) and will participate in a seminar on this subject in Geneva in July 1990. Assessment of Progress Regionwise, the immunization coverage of children below one year of age for BCG was 78 per cent , for DPT3 69 per cent, for OPV3 66 per cent, for measles 54 per cent and for TT2 51 per cent. Achievements and problems in EPI activities in the Member Countries were discussed and analyzed in the Integrated Poliomyelitis/Neonatal Tetanus/Measles/MCH Workshop, mentioned earlier, in which plans of action for the countries were discussed and updated. India, Sri Lanka, Bangladesh, Nepal, Thailand and Mongolia conducted international EPI reviews in 1989-1990 in which the remarkable progress of EPI on immuniza- tion coverage among under one-year children was confirmed. In spite of the increase in immunization coverage in each country, no dramatic decrease in EPI target diseases has been observed. Thus, in order to achieve the EPI targets, efforts have been concentrated on intensifying and improving national surveillance systems (at national and sub-nationalldistrict levels), implementing country EPI and MCH plans in the context of PHC, and on enhancing disease control at the sub-national level. Poliomyelitis ~radication/~eonatal Tetanus Hlimination/Measles Reduction Initiatives All Member Countries are committed to the implementation of the World Health Assembly resolution on this subject. This implies polio eradication by the year 2000, neonatal tetanus elimination by 1995, 90 per cent reduction of measles by 1995, and reductions of diphtheria, pertussis and child tuberculosis. However, the targets differ from one country to another, based on the local health infrastructure and available resources. In regard to polio eradication initiatives, national plans of action were prepared at the meeting of national EPI managers in Bali, Indonesia in 1989 and were subsequently revised during the Integrated Polio/Neonatal TetanusIMeasleslMCH Workshop in New Delhi, in March 1990. The coverage with oral polio vaccine 3 increased from 11 per cent in 1982 to 66 per cent in 1989. With marked reductions in reported cases of poliomyelitis in DPR Korea, Maldives, Mongolia, Sri Lanka and Thailand, the stage has been set for possible eradication of the disease even before the year 2000, at least in some sub-national areas of these countries. Further strengthening of the surveillance system at state, district, sub-district, and other sub-national levels, which is an essential tool for these initiatives, is envisaged for the coming years. Neonatal tetanus elimination initiatives have been undertaken in collaboration with MCH and PHC programmes. Immunization coverage by TT2 has slowly increased in the Region in the last six years; in 1989 it crossed 50 per cent. The regional coverage does not include DPR Korea and Mongolia, which do not have national policies on the use of TT in pregnant women. Most Member Countries have implemented two or more doses of TT to eliminate NNT before 1995. A few countries have introduced TT among all women of child-bearing age. UNICEF, India, in collaboration with the Regional Office and WHO headquarters, conducted a Neonatal Tetanus workshop for UNICEF statelcountry EPI Managers in September 1989. The issue of adequate dosage of TT was also discussed during the Integrated Polio/Neonatal ~etanus/~easles/MCH Workshop of EPI Managers in March 1990. In some countries, initiatives for the reduction of measles through vaccination were introduced only in 1984/1985. The immunization coverage has been lower compared to other antigens (54 per cent in 1989). Because of the limitation of the surveillance system for measles in Member Countriea and the lower immunization coverage achieved in some countries, no impact of immunization coverage on the incidence of the disease has been observed. Immunization coverage, together with strengthening of the surveillance system and development of a new E-Z measles vaccine for children of six months of age, is a good starting point for the reduction of the disease in the future. Expanded Programme on Immunization Accelerated efforts by all countries in the Region have led to a substantial increase in immunizaton coverage. Tuberculosis Tuberculosis control programmes as components of primary health care are being strengthened with WHO collaboration. Early casefindtng and short-course chemotherapy are important elements of the programme. Malar~a cont~nues to ~e a major ~UDIIC nealtn promem or tne neglon. Collecting blood smears. promoting effective vector control measures and strengthening national vector surveillance systems are part of the control measures being adopted to tackle the nrnhlem Resources All Member Countries are trying their best to achieve the goal of Universal Child Immunization by the end 1990. However, government inputs (about 63 per cent of total EPI costs in the Region during 1985-1988) may not yet be adequate for more intensive activities in the areas of polio eradication, neonatal tetanus elimination and measles reduction planned for the next ten years. It is necessary to develop a basic framework for country-level training in financial management for EPI Managers in order to achieve EPI targets in the next 5-10 years with the limited funds available. This issue will be discussed during the meetings on Financial Managernet~t and Sustainability of EPI in January and June 1991. The principles of resource mobilization, recommended by the meeting of the Task Force for Child Sursival, held in Bangkok from 1 to 3 March 1990, have been further promoted in the countries. 13.2 DISEASE VECTOR CONTROL Several countries of the Region have a long history of seriou8 vector-borne disease problems. At present, these infections, as a group, constitute the leading public health problem; the most crucial is malaria. ~enguefdengue hemorrhagic fever (DHF), Japanese encephalitis (JE), filariasis and visceral leish- maniasis (VL) are also of considerable importance. So far, the principal method of control of these diseases has been, and probably will remain, the use of chemical insecti- cides. However, their more efficient, economic and selective use presents a real challenge. A gradual shift is taking place towards reshaping the strategy of vector-borne disease control with greater emphasis being placed on environmental management and design of integrated methods of control with varying degrees of community participation. Emphasis is also being laid on technological development, applied field research and training towards the control of vector-borne diseases. The control of malaria vectors continues to pose problems. Due to technical obstacles, such as the problem of insecticide resistance in vector species, the exophilic and exophagic nature of vectors, lack of interest by the community in accept- ing residual insecticide spraying and the increasing cost of insecticides, the achievement of the desired goals is being impeded. WHO has continued to collaborate wlth national programmes in developing effective control measures for carrying out field trials of new methods as well as assisting in research and training of personnel engaged in vector control programmes. With technical collaboration from WHO and financial assistance from UNDP, investigation is in progress to determine whether indoor residual spraying with 75 per cent wdp DDT has any impact on Anopheles dirus, the malaria vector in south-eastern parts of Bangladesh, while in the Terai region of Nepal a study is being carried out on the effectiveness of environmental measures against Anopheles fluvistilis and Anopheles maculatus. The effi- ciency of biological control agents, auch as larvivorous fish, Bacillus thuringiensis H-14 and Bacillus sphaericus is being aetermined, especially for use as a tool in intearated disease vector control-strategies in India, Indonesia and Thailand. Steps for the cytogenetic study of sibling species, Anopheles culicifacies and Anopheles subpictus, funded by the Regional Office, have already been initiated in Sri Lanka. Dengue Haemorrhagic Fever In Indonesia, Myanmar and Thailand, dengue haemorrhagic fever (DHF) continues to occur as an endemic disease. Sporadic cases of dengue fever with haemorrhagic manifestations have also been reported from India and Sri Lanks. During 1989, Myanmar reported 899 cases and 52 deaths due to DHF; Indonesia 8 216 cases and 333 deaths; and Thailand reported 53 625 DHF cases with 1 053 cases of DSS. The number of cases reported is approximately double that reported in 1988, but is still close to the median number of cases reported during the period 1984-1988 (median DHF cases reported 49 829, DSS 981). A multi-centre project to control DHF vectors with community participation, sponsored by the Regional Office, has been in progress in Indonesia and Thailand since 1988. The project was initiated with the objective of identifying the type of control activities that are best suited to community participation and which are focused on source reduction of the vector in the context of the local situation. The results of entomological surveys were generally satisfactory but those of KAP and socio-anthropological studies indicated the need for a new direction in the IEH strategy, from the general to the target-specific approach, which should include fewer, specific messages for target groups, mothers, grandmothers (older people) and health workers. This should remove particular misconceptions which prevent people from undertaking DHF control measures. The WHO Dengue Newsletter (volume 15), containing the latest valuable information on the DHF situation and control activi- ties, especially community-based control of Aedes aegypti, was issued in February 1990. Japanese Encephalitis Japanese encephalitis (JE) is predominantly a rural disease associated with rice cultivation. Outbreaks occurred recently in India, Nepal, Sri Lanka and Thailand. The average case- fatality rate ranges between 10 per cent and 50 per cent in these countries. The virus is maintained in nature by mosquitoes and non-human vertebrates. Culex tritaeniorhynchus, a paddy field breeding mosquito, is the principal vector, and feeds mainly on larne animals and birds. Elsewhere in the area of - -~~ -- distribution, Culex gelidus, Culex fuscocephala id Culex vishnui group mosquitoes are also involved. The virus has been isolated from other Culex spp as well as Aedes and Anopheles mosquitoes. Control measures in affected areas were primarily devoted to vector control by focal spraying and fogging of outdoor tracts with insecticides. However, the areas involved are generally very large and the bionomics of all vectors involved in JE do not lend themselves to any simple and straightforward method of vector control. Mass vaccination is advisable in highly endemic areas. Filariasis Bancroftian filariasis is essentially a problem of environmental sanitation in many urban areas in the Region. Wuchereria bancrofti is prevalent in Bangladesh, India, Indonesia, Maldives, Myanmar, Nepal, Sri Lanka and Thailand. Lack of general sanitation, maintenance and repair of drains, septic tanks and the sewerage system result in conditions suitable for the breeding of the ubiquitous mosquito Culex quinquefasciatus. Brugian filariasis is mostly confined to rural areas and occurs on the West coast of India in Kerala, on several islands in Indonesia and in some parts of Thailand. Strains of B+ugia nalayi are transmitted by M~nsonia apE and Anopheles spp, while Brugia timori is restricted to the Indonesian islands of Plores and Timor. The only known vector of 8. timori is Anopheles barbirostris. Filaria control, using antilarval measures has. been practised over the years in the countries of the Region, but has not so far yielded satisfactory results. Since vector control has a slow effect on the prevalence of filariasis infection in a population, WliO has continued to extend technical support for the development of integrated approaches to the control of this disease, including chemotherapy with DEC and Ivemectin. Visceral leishmaniasis (VL) or Kala-azar, caused by Leishmania donovani, is a problem of public health importance in some parts of Bangladesh, India and Nepal. The most lmportant vector in the Indian sub-continent is Phlebotomus argentipes. In India, Bihar and West Bengal were the most affected, with 34 174 cases and 486 deaths reported in 1989, of which 30 601 cases with 466 deaths were from Bihar and 3 753 cases and 20 deaths from West Bengal. In Bangladesh, 2 303 cases and five deaths were recorded. The control of Kala-azar has been undertaken by insecticidal spraying and treatment of cases. However, owing to administrative and financial reasons, spraying operations were very limited and the supply of drug was inadequate. Manpower in Entomology In order to deal with the complexities of vector-borne disease problems and to make effective use of the limited, available resources, there is a great need for contributions by medical entomologists and vector control specialists to operations and research in the control of disease vectors. WliO support has been focused in particular on the strengthening of national entomological services through training. These institutions in the Region, i.e. the Vector Control Research Centre, Pondicherry, India; Mahidol University, Bangkok, 'Thailand; and Bogor University, Bogor, Indonesia, continue to provide academic training in medical entomology (M.Sc. courses). The National Institute of Communicable Diseases, Delhi, India, conducted advanced courses in medical entomology for medical officers and entomologists. Regular and refresher training courses for different categories of entomological staff have also been carried out in several countries, while certain countries of the Region also have their own education and training facilities to varying degrees. Bhutan and Maldives still depend entirely on other countries of the Region for routine and job-specific training of staff. With financial support from WHO headquarters, an intercountry Training Course on Detection of Sporozoites in Anopheline Mosquitoes by the ELISA technique was held in Bangkok, in December 1989, to enable entomologists to gain up-to-date information on modern techniques and their application in the field. Malaria continued to be one of the main public health problem in the majority of the countries of the Region, since more than 85 per cent of the total population reside either in areas with active malaria transmission or in areas with great potential for malaria outbreaks or epidemics. The revised malaria control strategy through the primary health care system has been adopted by all malarious countries of the Region. The malariogenic stratification concept, based on recognition of the diversity of malaria epidemiological situations, was considered to be the main approach to malaria control in the Region. The malaria control programmes in all the countries of the Region have already completed broad stratification of malaria endemic/epidemic-prone areas and identified high-risk groups of the population. Further progress was observed in the process of detailed stratification employing various innovative methods, in order to formulate cost-effective operational plans of action. The latter have been fully integrated into the basic health services in Bangladesh, India, Indonesia, Maldives, Myanmar and Nepal at the intermediate and peripheral levels in order to meet the principal objectives of the programmes in Figure 4. PROFILE OF MALARIA IN SELECTED COUNTRIES OF WHO SOUTH-EAST ASIA REGION, 1984-89 +--+ I) O SEA REGION I a0 SPRX 8v-_js Iln nlllional 5, P.I.I case. ~ot.1 rasaa I .....D...D. 0.. OD lea? BANGLADESII MALDIVES* I. - P.f.1 case. TOt.1 cases LOO, MYANMAR Year NEPAL Il" m0us.nd.l 700 :560 " z420 d 280 z 140 84 85 86 81 88 89 THAILAND "mar *AU ealss detected slnce 1981 are imported. NOTE: SPR = 8Ude Posltlvity R.1. (per hundred slldes) 8fR = Suds Illelparum Rate (per hundred alldeal 1989 data: pmvlslonll terms of prevention of mortality, reduction of morbidity and control of malaria epidemics. In Bhutan, Sri Lanka and Thailand, malaria control continued to be implemented as a special programme, although the links with the basic health services were further strengthened, particularly in relation to the diagnosis and treatment of malaria cases. Community involvement in case-finding, simple drug treatment and referring severe cases to nearby health centreslhealth institutions, as well as intersectoral collaboration. es~eciallv of deoartments of ~. ~ - agriculture, fishing, forestry, irrigation, public works, etc., have been progressing in many countries. Further attempts have been made by some of the programmes to reduce the dependence on residual insecticides to the extent possible under prevailing epidemiological conditions, while savings on the purchase of insecticides have been earmarked for development and operational use of bioenvironmental and personal protection measures. Malaria control activities continued in nine countries of the Region. During the period under review, the situation in the malarious countries did not show any remarkable change over the previous year. A provisional report indicates that 2.46 million cases were reported in 1989 as against 2.7 million in 1988. In Maldives, no indigenous case has been detected during the past several years. However, the number of imported cases from neighbouring countries almost doubled as compared to last year. Though the country at present is free from local malaria trans- mission, the Government continues to pay high priority to vigilance activities. The overall malaria situation in Indonesia, Nepal, Sri Lanka and Thailand showed slight improve- ment, while it remained unchanged in India and showed an upward trend in Bangladesh and Bhutan. The Plasmodium falciparum rate showed an upward trend in Bangladesh and Bhutan among indigenous cases, and in Maldives, among imported cases. The malaria profile in the countries of the Region is shown in Figure 4. Though the principal elements of malaria control programmes in the Region continued to be case detection, drug treatment and various vector control activities, there has been an increasing emphasis on prompt diagnosis and treatment of cases and increasing trends in reducing the use of chemical insecticides for indoor house spraying, in introducing bioenvironmental methods and in fostering integrated vector control approaches through active community participation and intersectoral collaboration. In areas where malaria vectors have developed resistance to DDT and HCH, more effective and potent insecticides replaced their use, i.e. fenitrothion was being used in Indonesia, and malathion and a few other insecticides were used in Sri Lanka, India and Nepal. However, countries experienced some difficulties in procuring insecticides from abroad due to high costs and shifts in emphasis of some donor agencies. WHO assisted the countries to overcome the problem, particularly through the involvement of bilateral agencies. The foci of P.falciparum resistance were promptly dealt with through the intensification of vector control, providing radical treatment of P.falciparum with the second or even the third line of drug treatment, and through monitoring the movement of malaria high-risk population groups. Technical problems of P.falciparum resistance to various antimalarials and vector resistance to a range of insecticides aided by large-scale population movements, resulting in changing epidemiological patterns of the disease, continue to exist in the Region. Inadequate field supervision due to the shortage of trained manpower, especially at the district level, was felt by most of the programmes. In this regard, WHO collaboration to solve both the technical as well as operational problems in the Member Countries was continued. Support was ~rovided to the programmes to carry out staff training, study tours and workshops and for the procurement of needed supplies and equipment. Efforts were made to improve trained manpower at all levels of the country programmes using for these purposes either WHO country budgets, or the assistance of bilateral agencies such as CIDA, SIDA, etc. and international agencies such as UNDP. A number of health services staff at the peripheral level in most of the countries were given training in malaria and malaria control activities. Technical manuals and guidelines on malaria control were updated. Basic courses on malaria and planning antimalaria activities were held in Thailand and Italy and were attended by middle-level staff engaged in the implementation of control programmes. A series of seminars on the management of acute and complicated malaria is being conducted for both health service staff and private practitioners in Bangladesh, India and Sri Lanka. To facilitate these seminars, WHO reprinted, in 1989, the second edition of the publication "The Clinical Management of Acute Malaria" and organized and financially supported the meeting of a task force to review the second edition of the said book. The members of the task force, who were eminent clinicians from the countries of the Region, came up with an updated version of the third edition, which is currently in press. Programme-oriented field studies continued, especially on malaria control through the primary health care approach. To develop cost-effective intervention measures through research and developent approaches, the countries of the Region have taken up several research projects aimed at promoting biological, environmental and personal protection measures. Studies on community participation in case-finding and treatment were continued in India, Indonesia and Thailand, with encouraging results. In vitro and in vivo drug sensitivity tests continued in eight of the nine malarious countries of the Region. These studies proved to be helpful not only in providing a basis for early warnings of reduced sensitivity of P.falciparum to anti- mslarlals , but also facilitated the fornulation of national drug policies. The present status of drug resistance in malarious countries of the Region shows a very mosaic picture. Resistance to chloroquine is most pronounced in all countries except Maldives. Long-acting sulfa- yrimethamine drug combina- i tions (SP) - FansidarR. Metakelfin , etc. - were introduced in countries with a high degree of resistance to the 4-amino- quinolinea. Experience has shown that eventually resistance develops to the SP combination, a situation that has been reported throughout Thailand, parts of Myanmar, Bangladesh, Bhutan and Indonesia. The Thailand experience detected mostly falciparum cases giving an RII-RIII response, a major setback that required the introduction of the triple combination mefloquine-sulfadoxine-pyrimethamine (FansimefR) into the country programme in early 1985. Though a cure rate of about 96 per cent following treatment with MSP continued to be achieved by the Thai malaria programe, after four years of operational usage there have recently been reports from the Thai-Combodia border of a decreasing trend in the cure rate of the triple drug. Baseline data collections in various countries continue to report susceptibility to quinine, although some reduced sensitivity has been recorded on the Thai-Combodia border. In addition to the WHO financial inputs, UNDP provided funds for conducting training courses in in vitro microtechniques and for providing test kits. A study was carried out to determine an appropriate dosage regimen of primaquine for radical cure of P.vivax malaria in Thailand. Two field research projects are in progress in Bangladesh - on the efficacy of combination mefloquine-sulfadoxine-pyrimethamine (MSP) against chloroquine and Fansidar-resistant P falci arum strains and on the impact of residual spraying -0therapy in high malaria transmission areas. Studies for the determination of sporozoites in Anopheles vectors and identification of the human plasmodia involved, by using the ELISA technique, were conducted in Sri Lanka. International evaluation of the malaria control programme in Bangladesh was carried out jointly by WHO and the Government of Bangladesh with the participation of JICA (Japan) and ODA (UK) in October 1989. The main findings of the review were that in spite of all the efforts of the health services, malaria remains a major health problem in certain parts of the country, and has the potential to worsen due to various technical, operational and administrative causes. To improve the situa- tion, the assessment team suggested a package of corrective actions, which the Government of Bangladesh accepted. The most important development was the prompt preparation of a suitable plan of action by the malaria control programe to implement the recommendations of the assessment team, which was endorsed by the Director-General of Health Services in December 1989. The ~HOlGovernment of India independent appraisal of the malaria programme took place in November/December 1989. The independent appraisal team agreed, in principle, with the outlines of the Eighth Five-Year Plan of NMEP aimed at considerable reduction of spraying operations in areas under its purview and expansion of integrated vector control methodologies, particularly those related to bioenvironmental and personal protection measures. Particular attention of NMEP was drawn to the protection from malaria of labour in various sectors of the economy - in intensive agricultural areas, with special reference to irrigated areas, in urban areas and in areas with high malaria transmission. External assessment of the malaria control programme in Nepal and Sri Lanka took place in June 1990. Some bilateral and multilateral agencies, such as SIDA in India, CIDA in Myanmar, USAID in Sri Lanka, ODA (UK) in Nepal and Bangladesh, and the world Bank and JICA in Indonesia, are actively collaborating with the countries concerned in their malaria control activities. 13.4 PARASITIC DISEASES he main activity during the period under review was facili- tating effective control of parasitic diseases of public health importance, mainly leishmaniasis and guineaworm disease, and, to a limited extent, filariasis, intestinal parasitoses and schistosomiasis. Intestinal Parasitic Infections Intestinal parasitic infections, such as roundworm, hookworm, amoebiasis, giardiasis, etc., which are closely associated with undernutrition, poor personal hygiene and environmental sanitation, continue to be public health problems in the Region. Many countries are engaged in research and control of these parasitic diseases through ongoing projects such as those in family planning, school health, nutrition, etc. Surveys of intestinal parasitic infections, undertaken by the National Institute of Communicable Diseases (NICD), Delhi, in rural areas of Maharashtra and Rajasthan in 1989 and 1990, revealed high infestations with Giardia intestinalis (11.8 per cent and 24.4 per cent respectively). The Central Health Laboratory in Kathmandu conducted an intestinal helminthic survey in five regions of Nepal. The survey demonstrated a prevalence of 23.7 per cent of Ascaris lumbricoides; 24.8 per cent of hookworm and 8.7 per cent of Trichuris trichiura out of a total of 16 515 stool samples. Antiparasitic actions are linked with MCH, EPI, CDD, ARI and environmental sanitation, since the main target groups are children and women of child-bearing age, and approaches towarda training and community involvement are addressing the same categories of health personnel and population groups. Masa treatment of target groups in highly-infected areas is envisaged. Visceral leishmaniasis is a health problem of importance in rural areas of the three states of Bihar, West Bengal and Uttar Pradesh in India, as well as in Bangladesh and Nepal. The disease affects people in the underprivileged and lower socioeconomic groups mostly in the age-group under 20 years. During 1989, a considerable increase in morbidity and mortality was reported from India, particularly from Bihar. Since the morbidity data derive mainly from passive case detection, a three to four times higher actual prevalence is expected. A WHOIUNDP intercountry project on the control of visceral leishmaniasis was in operation from 1986 to 1989 in these three countries. The terminal Tripartite Review elucidated the achievements and constraints of the project. Research capabilities and training facilities have been adequately developed. By multi-centre chemotherapy research, different schedules for first and second line treatment were elaborated. Sero-epidemiological studies were carried out in some endemic districts of Nepal, Bangladesh and India. Monthly training courses for medical officers of primary health care centres continue to be held at the Kala-azar Unit of NICD in Bihar. Similar courses were organized by the Institute of Epidemiology, Disease Control and Research, Dhaka, for 40 district medical officers in 1989/1990. WHO recommended the development of national programmes for the control of visceral leisbmaniasis in the context of primary health care, making the disease reportable and earmarking budgets in order to better coordinate and integrate existing activities. So far only Bangladesh has worked out a national control programme. India has yet to decide on the reportability of the disease. Lymphatic filariasis remains a public health problem in eight countries of the Region. No major changes in prevalence rates or control strategies have been reported. WHO cantinued to encourage integrated control strategies and facilitated TDR- sponsored operational projects in India, Thailand and Indonesia, especially chemotherapy trials with diethylcarbamazine, Ivermectin, CGP 20376 and other new drugs in microfilaria carriers. The encouraging results now need implementation in well-planned action models in highly infested areas. Schistosomiasis Schistosomiasis is endemic in limited areas of Indonesia (Schistosoma japonicum), and Thailand (Schistosoma mekongi). Control activities were continued in the endemic vallevs in Indonesia to interrupt the transmission cycle and to prevent further spread in these development areas. TDR-sponsored research, which continued in Thailand, is envisaged for India and Indonesia. Guineaworm Msease (Dracunculiasis) India, the only country in the Region affected by guineaworm, entered the pre-final phase of its guineaworm eradication programme, initiated in 1984 with WHO assistance. Tamil Nadu is free from guineaworm. Of the remaining six states, Gujarat, with only 6 reported cases in 1989, is closer to the goal of zero incidence. Major problems are faced by Rajasthan, which contributed 62 per cent of the total cases in 1989, followed by Madhys Pradesh, with 18 per cent. Based on the latest evaluation report, the number of reported cases is declining in all the six states where guineaworm infection is still prevalent, the total cases reported in 1989 being 7 881 as against 12 023 cases reported in 1988. The twelfth Task Force Meeting on Guineaworm Eradication, held in New Delhi in January 1990, stressed the importance of active search and proper surveillance as well as the need for increased community participation to achieve the goal of zero incidence by the end of 1991. With the assistance of WHO, ten epidemio- logical surveillance teams were deployed in December 1989 under Technical Service Agreements. 13.5 TROPICAL DISEASES RESEARCH The UND~lWorld Bank/WHO Special Programme for Research and Training in Tropical Diseases (TDR) is a gosl-oriented global programme with two main objectives: (1) research and development to obtain new and improved tools for the control of major tropical diseases, and (2) strengthening of research capabilities of endemic countries. The Special Programme has identified four priorities or major thrust areas for the 1990s, viz., (1) field research; (2) product developnent, including rational drug development; (3) social and economic research; and (4) research capability strengthening. Research capability strengthening has been allocated 25.9 per cent of the total budget of the Special Programme for the 1990-1991 biennium. Serious efforts have been made by the Special Programme to see that plans in research capability strengthening are made operational during the biennium. For this purpose, site visits have been made by TDR executives to a number of institutions in Indonesia and India. The response has been very positive. Two programme-based grants were awarded to two institutions in Thailand; four long-term grants have been extended to four institutions, in India, Indonesia, Sri Lanka and Thailand. In addition, three institutions, in India, Sri Lanka and Thailand, were found worthy of extended support by the TDR-Rockefeller Foundation joint venture, based on their - initial performance in research efforts in malaria. The number of training activities supported by the Special Programme has been substantial - 157 up to the end of 1989 - with the result that the institutions have benefited immensely from trained personnel. Nearly 5000 researchers, worldwide, in rich and poor countries, are cooperating with TDR in developing new drugs, vaccines, diagnostic tests and control methods for carrier insects and snails, and in investigating the social and economic circumstances that can either help or impede treatment and control. As a result, several new tools for disease control and treatment - drugs, vaccines, traps, insecticides, and diagnostic tests - are now in different stages of development and trial. Malaria Among the TDR target diseases, malaria received the highest share of the budget - almost one-third of the total research and development budget during 1990-1991. TDR has provided support to several projects in the area of field and clinical trials of antimalarial drugs (such as mefloquine, artemisinin, halofantrine) to the development of immuno test kits and DNA probe kits, and to the development and field-testing of biological control agents against some vectors. The Social and Economic Research component of the Special Programme has been supporting, by way of social research, the "Pattern of Utilization of Antimalarial Drugs", and studies of vectoral bionomics of the various anopheles species (such as Anopheles dirus and Anopheles minimus) identified as potentially important - vectors of malaria. Bednets impregnated with insecticides are currently undergoing field-testing, but it is too early to assess their usefulness. These antimalarial studies have been largely focused in India, Indonesia and Thailand. In Sri Lanka, good progress has been made in the study of transmission-blocking antigens of P.vivax. Leprosy Amongst the TDR-funded activities in leprosy research were several studies related to clinical trials of newer drugs plus the formulations of multidrug therapy and their field trials. In addition, sero-epidemiological studies using new specific antigens have been initiated in the Region. The multi-centre field trial of leprosy vaccine is an important ongoing activity. Most leprosy research activities are focused in India, which is the largest reservoir of the disease. Filariasis TDR continues to provide strong support to the development of new drugs for this disease. The evaluation of clinical trials using Ivermectin for the treatment of lymphatic filariasis is in progress. This has moved into the second phase, in which Ivermectin is being compared to DEC in its efficacy. In Indonesia, a monkey model has been developed and is being used for screening new antifilarial drugs. Field trials of Ivermectin have largely been focused in India, Indonesia and Sri Lanka. Leishmaniasis and Schistosomiasis Field trials of commonly-used antimonial drugs and the introduction of new compounds have been continuing. Five small projects have been funded by TDR in these two target diseases, including studies on the vectors of leishmaniasis in Nepal, drug susceptibility of schistosome parasites in Thailand, and the treatment of Kala-azar in Bangladesh. 13.6 DIARRHOEAL DISEASES The Control of Diarrhoea1 Diseases Programme (CDD) has been recognized as one of the priority programmes of WHO in the countries of South-East Asia. This programme came into existence in 1979. The short-term objective of the Programme is to reduce diarrhoea-associated mortality among children 0-4 years of age through proper case management and extensive use of oral rehydration therapy (ORT). The long-term objectives are to reduce morbidity due to diarrhoea among children 0-4 years of age through the promotion of improved maternal and child health care practices, to encourage improvement in environmental sanitation, and to control epidemics. A11 countries of the Region are implementing their programmes as part of their primary health care systems. Training continued to receive high priority during the year. The main training activities included clinical management, supervisory skills, programme management, and, to a lesser extent, laboratory techniques. Courses in programme management were held at the intercountry level in India and Nepal. Eighteen supervisory skills courses were conducted in Bangladesh, India, Indonesia, Myanmar, Nepal and Sri Lanka. An intercountry Course on Clinical Management was conducted in India while over 50 national courses were held in Bangladesh, Bhutan, India, Maldives, Myanmar, Nepal and Thailand. In order to improve qualitative services in diarrhoea case management and provide clinical management training for medical officers, about 48 new diarrhoea training units (DTUs) were established in Bangladesh, India, Maldives, Myanmar, Nepal, Mongolia and Thailand. Two courses on laboratory aspects of diarrhoea1 diseases were conducted in Bangladesh. In eight countries, viz., Bangladesh, DPR Korea, India, Indonesia, Maldives, Mongolia, Myanmar and Nepal, priority was given to the translation and adaptation of CDD training modules and other relevant training materials into the national languages. To achieve the training targets, as outlined in national programmes, the Regional Office staff assisted in developing training plans. Nine countries revised their national plans for training and operation. These were discussed at the meeting of programme managers, held in Bangkok, in May 1990. Two common indicators used by the Member Countries to measure programe performance are ORS access rates and ORT use rates. The estimated ORS access rates and ORT use rates for 1988 were 62 per cent and 28 per cent respectively. The regional targets for ORS access and ORT use rates for 1991 have been set at 85 per cent and 60 per cent respectively. Local production and importation of ORS in 1988 increased to over 107 million litres, compared to 83 million litres in 1986 and 99 million in 1987. Visits were made to India, DPR Korea, Indonesia and Sri Lanka by the WHO ORS Production Engineer to assess the quality of ORS production. CDD health education and communication activities in the Region were further strengthened by the provision of technical information and printed materials on ORT and on preventive strategies for reducing the incidence of diarrhoea. CDD communication guidelines were of significant interest to the meeting of programme managers, held in May 1990. National CDD programmes collaborated with other programmes in both training and preventive strategies, as an integrated approach. Some training courses are combined with EPI or ARI. Coordination of programmes was carried out in the areas of breast-feeding, improved weaning practices, use of clean water, handwashing, proper disposal of human excreta and measles immunization. Breast-feeding intervention strategies were discussed at the meeting of programme managers. Comprehensive programme reviews on CDD are being planned for Bangladesh, DPR Korea, Myanmar, Nepal and Sri Lanlca during 1991. In India, a review of the ongoing ORT programme was completed in six randomly-selected states. Household case management surveys were conducted in Maldives and Sri Lanka with a view to obtaining data on correct household treatment practices and other programme indicators. Plans to conduct similar surveys in Bangladesh, Bhutan, Indonesia, DPR Korea, Myanmar and Nepal are under way. Most diarrhoea1 diseases research in the Region is coordinated through three CDD global scientific working groups while regional activities focused on research related to solving operational problems of national programmes. The WHO Collaborating Centres at the National Institute of Cholera and other Enteric Diseases, Calcutta, International Centre for Diarrhoea1 Diseases Research, Bangladesh, Dhaka, and the Regional Training Centre in Jakarta continued to work closely with the regional CDD programme in the areas of training and research. Other major agencies such as UNICEF, UNDP, and USAID continued their support in the implementation of CDD activities at the national level. 13.7 ACUTE RESPIRATORY INFECIIONS Acute respiratory infections (ARI), together with diarrhoea1 diseases and malnutrition, are still the leading causes of death among children in all the countries of the Region. The central objective of the WHO programme is to reduce, in the countries mortality from ARI especially from pneumonia, among children 0-4 years of age. The death rate due to ARI in children varied from 20 to 30 per cent during the period under review, while the infant mortality rate, inter alia, due to ARI was higher than 40 per 1000 in many countries. Because of the magnitude of the problem, the ARI Programme must be seen as an important part of efforts directed towards child survival and as an essential component of primary health care. Over the years, various types of national committees or advisory groups on ARI have been constituted in almost all the countries, for promoting prevention and control activities. By early 1990, national plans had been developed in many countries. Bangladesh, India, Indonesia, Myanmar and Sri Lanka have already developed long-term plans of operations. Technical guidelines on case detection and management have been formulated and programme managers appointed to implement the activities. Nepal and Thailand have prepared technical guidelines and drafted long-term plans of action. Thailand has been selected by UNICEF for an intensified ARI programme, to which the Regional Office has given technical support. National seminars and workshops on ARI were organized in Bangladesh, India, Indonesia, Mongolia, Myanmar, Nepal, Sri Lanka and Thailand. Paediatricians and paediatric associations were very much involved in meetings and courses in Bangladesh, India, Indonesia, Mongolia and Thailand. A new supervisory skills module "Management of a Child with ARI", and a training video were field-tested in Thailand. Similarly, the new "Programme Managers' Course Modules" were field-tested at a WHO interregional course in Bangkok in 1989 with the participation of programme managers, senior health officers and paediatricians from 30 countries, and representa- tives of UNICEF, the International Children's Centre, Paris, and the US Center for Disease Control, Atlanta, USA. Courses utilizing new material have already started in India, Indonesia and Thailand. These countries have already translated or adapted the new training material. Of the four intenrention studies on ARI, one each in Nepal (Kathmandu) and India (Haryana) have been completed while one in Indonesia (Kediri) and one in Nepal (Jumea) are continuing. The results of these studies indicate that the interventions are feasible and effective in reducing morbidity and mortality from pneumonia. Information on biomedical and epidemiological research priorities in ARI was disseminated to all countries. There is an encouraging trend towards the intervention of operational Ail1 control programmes with programmes for diarrhoea1 disease control, imnunization, nutrition and essential drugs, in the HCH and PKC systems since many of the activities concerned are similar and implemented by the same health personnel. 13.8 TUBERCULOSIS Tuberculosis is a major public health problem in the countries of the Region. WHO'S efforts have been concentrated on the strengthening of the tuberculosis programme as an integral component of primary health care. The strategy for tuberculosie control depends mainly on the detection of new cases of tuberculosis and the provision of appropriate treatment. The main strategies of the countries were: intensification of case-finding and highly effective case-holding and training activities to upgrade the knowledge and skills of tuberculosis workers for better implementation of national tuberculosis programmes. Despite the existence of national tuberculosis programmes in the Member Countries, the problem of tuberculosis has-been further confounded by the appearance of HIV infection. Dual infection with M. tuberculosis and the human immuno- deficiency virus is likely to result in increasing incidence of tuberculosis. WHO has been assisting Member Countries in epidemiological surveillance of the prevalence and incidence of infection and disease, which is useful in assessing the magnitude of the problem and impressing on the countries the importance of allocating substantial resources for tuberculosis control programmes at the country level. WHO provided to the countries, through regular and extra- budgetary resources, technical inputs, supplies including drugs, and X-ray equipment. Support was also provided for training personnel and in arranging study tours to upgrade the knowledge and skills required for effective implementation of programmes. In Bangladesh, diagnosis of TB patients through sputum examination and their treatment at Upazila health complexes were accelerated. Diagnosis and treatment facilities for TB patients were introduced in district hospitals which did not have TB clinics. In India, WHO assisted in strengthening clinical research activities and providing training facilities for district-level officers as well as training in micro- biological techniques, and in the planning, conducting and evaluation of multi-centre controlled clinical trials. Apart from supplies and equipment, Indonesia was provided with support for a workshop on diagnosis of TB and on treatment regimens of anti-TB drugs. A WO consultant was provided to assist the Government in assessing and reviewing the National TB Control Programme to suit the Fifth Five-Year Development Plan of Indonesia commencing in 1990. WHO also provided a subsidy for conducting a national workshop on TB in March 1990. In Nepal, the number of new sputum-positive TB patients detected has increased and the total number of TB patients under treatment was reported as 10 305. A WHO consultant assisted Sri Lanka in assessing the disease situation. The Tuberculosis Division in Thailand is continuing its intervention studies, including field studies on chemotherapy and chemo- prophylaxis, under a tripartite agreement between Thailand, Japan and WHO. The sixteenth session of the South-East Asia Advisory Committee on Health Research, held in Chisng Mai, in April 1990, discussed research on tuberculosis as one of the agenda items and recommended further intensification of research in tuberculosis, including a review of effectiveness of BCG as a tool in EPI. WHO has been making efforts to assist Member Countries in expanding case-finding and case-holding and in promoting short-course chemotherapy for improving management of the treatment system. The lack of adequate support by donor countries inhibits the mobilization of extrabudgetary resources. A concerted effort therefore needs to be made to mobilize resources in order for the programme to have a real effect on control of the disease. 13.9 LEPROSY The implementation and further expansion of the multidrug treatment (MDT) regimen within the framework of primary health care is the key strategy for leprosy control in the Region. While in most countries the integration of leprosy control into primary health care is in progress, in a few countries, especially in the hyperendemic areas, leprosy control is implemented as a vertical programe. During the period under review, noteworthy success has been achieved in early case detection and MDT coverage in nine endemic countries indicating steady progress in the implementation of individual five-year plans. Increasing awareness of patients and the general public and their confidence in MDT as well as the political commitment at various levels have contributed significantly to tNs. In the area of chemotherapy, the search for a new and more effective drug against M. Leprae is being continued with the support of the TDR Programme of WHO headquarters, while clinical trials of ofloxacin and long-acting sulphone drugs in the treatment of lepromatous leprosy are also being pursued. Field trials with a number of candidate vaccines are being carried out in India. These vaccines include heat-killed M. Leprae combined with BCG, and cultivable mycobacteria related to M le rae used in a live form (e.g., BCG) or in a killed form e.g., ICRC bacillus, Mycobacterium W, or Mycobacterium Habana). i-e Of these, Phase I1 vaccine trials of M. leprae, combined with BCG are progressing satisfactorily in a study being carried out by ICMR with support from the TDR Programme. Thanks to early detection of cases resulting from extension of facilities as well as increased self-reporting, followed by effective treatment, a steady, declining trend in deformity rates has been witnessed. In October 1989, an intercountry Consultation on Implementation and Evaluation of Multidrug Therapy, Prevention of Disabilities and Rehabilitation of the Disabled in leprosy control programmes was held in Madras, India, with the participation of senior- level programme managers from eight countries. The meeting noted with satisfaction the progress made by the Member Countries in implementing their respective programmes while urging them to continue to give high priority to the extension of MDT coverage and integration of leprosy control programmes with primary health care. As the significance of leprosy as a public health problem diminishes, it is envisaged that rehabilitation of former leprosy patients with deformities will emerge as a problem of increasing importance. WHO will continue to collaborate with Member Countries in the area, especially in promoting community-based rehabilitation. The third independent evaluation of the National Leprosy Eradi- cation Programe in India, jointly organized by the Government of India and WHO, was carried out in October 1989. Several international expert. were associated with the exercise. With the MDT coverage extending to nearly 65 per cent of the leprosy cases residing in 112 districts and involving 2.1 million population, the task of the evaluation team was a formidable one. The results of the evaluation have shown that the performance in regard to case-detection and treatment are satisfactory, with the majority of states exceeding the targets set. It was also observed that the completion of treatment following the detection of disease is also very high. With these encouraging results, it is targeted that all the 196 endemic districts should be brought under MDT by 1992. Some of the areas recommended by the evaluation teams to receive greater attention were: training of medical officers in leprosy, optimum utilization of existing training capacity, improvement of laboratory services including mechanisms for quality control, strengthening of administrative and technical supervision, exploration for alternative approaches to the integration of leprosy services with primary health care, strengthening of rehabilitation services, increasing health awareness within the community in relation to leprosy and promotion of operational research in leprosy. In Myanmar, a three-year plan of action for increased coverage of MDT has been prepared and is expected to be implemented with support from extrabudgetary resources. In Maldives, a plan of action to achieve zero transmission is being implemented with support from a voluntary organization and technical assistance from WHO. WHO also continued to collaborate with six other endemic countries in their leprosy control programmes and provided support through regular and extrabudgetary resources, technical inplts, supplies including antileprosy drugs as well as equipment. Support was provided for training leprosy workers and for other group educational activities. 13.10 ZOONOSES The aim of the regional programme on zoonoses is to support Member Countries in their endeavours to reduce the incidence and prevalence of these diseases, with the ultimate aim of preventing them in man. WHO provided financial support to India for conducting three workshops - on laboratory techniques in rabies, on vaccines and treatment of rabies, and on surveillance and control of leptospirosis and treatment of snakebite. In addition, fellowships were awarded to two health personnel to study rabies control activities in the countries of the Region. The National Institute of Communicable Diseases, Delhi, received equipment for strengthening its laboratory services in the surveillance of rabies control. The zoonoses project in Indonesia carried out various activities on surveillance and control of rabies, plague, anthrax and tapeworms in collaboration with the veterinary services. Surveillance of rodent and human plague in Boyolali and other plague foci was continued. WHO assisted the country in organiz- ing regional and extra-regional study tours to train nationals in the epidemiology and operational aspects of toxoplasmosis, in the epidemiology of plague and in rabies control. A WHO-assisted project for the control and elimination of rabies is being implemented in Nepal in collaboration with the French organization, Veterinarians sans Frontleres (VSF). Assistance was also provided for the strengthening of manpower in Nepal by arranging training of health personnel in the study of zoonotic diseases through courses in Master of Public Health (MPH) abroad. A National Zoonoses and Food Hygiene Consulting Centre was established in the country in December 1989 with a view to conducting epidemiological surveillance on zoonotic diseases, such as rabies, brucellosis, Japanese encephalitis, visceral leishmaniasis, snakebite, etc. among its main objectives. In Sri Lanka, the objectives of the programme, inter alia, are: to coordinate the activities of the rabies control programme in achieving its objective of eliminating human and canine rabies; to study dog ecology in rural areas in relation to rabies epidemiology; to strengthen rabies surveillance; and to implement mass vaccination of the dog population. The programme includes consultantships for the redesigning of programes, fellowships for training in veterinary public health and the utilization of national expertise. Identification of dogs after vaccination, implementation of the new Rabies Control Act and establishment of two diagnostic laboratories - one in Gslle and the other in Kandy - to strengthen rabies surveillance, are some of the activities planned for 1990 with WHOIAGFUND support. 13.11 SEXUALLY-TRANSMITTED DISEASES With the advent of acquired immunodeficiency syndrome (AIDS) in some countries of the Region, control of sexually-transmitted diseases (STD) received a high priority in these countries. WHO supported Member Countries in strengthening national capabilities in the collection and analysis of epidemiological data for assessing the magnitude and impact of STD and AIDS and for developing suitable control strategies. A meeting, held in Geneva under the auspices of the Global Programme on AIDS and Programme of STD, from 4 to 6 January 1989, identified STD as a risk factor for HIV transmission and reached a consensus that both these programmes should work together and identify future research priorities and methodologies for better understanding of the biological interactions between HIV and STD. WHO supported Bangladesh with supplies and equipment needed by the STD control programme during the year under review. In Indonesia, health personnel were trained abroad in the control of sexually-transmitted diseases. Support was provided to Sri Lanka by way of supplies and equipment, development of manpower through training abroad in sexually transmitted diseases, and by providing subsidies for organizing national training programmes in sexually- transmitted diseases for its medical officers, as well as a Consultative Conference on National Policy on Safe Blood in Relation to HIV Infection and AIDS, held during the last quarter of 1989. 13.12. RESEARCH AND DEVELOPMENT IN THE FIELD OF VACCINES Health laboratory services play an important role in supporting programmes of research and development of vaccines. WHO continued to assist countries in promoting self-reliance in the ~roduction of vaccines, and strengthening the monitoring process and quality control capabilities, besides introducing newer technologies for research and development of new vaccines. A regional strategy for self-sufficiency in EPI vaccines has been formulated with the premise that several countries in the Region have no vaccine production facility and that starting such a facility in each country will not be cost-effective. Myanmar and Mongolia are being assisted through a UNDP programme in the development of expertise in the production of hepatitis B vaccine, while Thailand and Indonesia are developing expertise through international collaboration. Support was also given to countries for improving their vaccine distribution and storage systems. In the efforts for global eradication of poliomyelitis by the year 2000, national laboratories for the diagnosis of poliomyelitis as well as vaccine-potency testing are being strengthened. Towards thls effort, and to improve the expertise of nationals in vaccine potency-testing and serological and tissue culture techniques for polio as well as measles, WHO conducted an intercountry Workshop on Viral Vaccine Potency- testing in March-April 1990, in Coonoor, India. 13.13 AIDS Acquired immunodeficiency syndrome (AIDS) is not yet considered a priority health problem in many countries of the Region. It is nevertheless a matter of concern for the countries given the pandemic nature of the disease. WHO has so far endeavoured to give proper direction to Member Countries in the effective prevention of the spread of HIV infection through the formu- lation of short- and medium-term plans of action. In view of the fact that no cure for the disease is in sight, the focus of WHO attention has been on its prevention through health education. Epidemiological Situation Three epidemiological patterns of AIDS can be identifled worldwide, viz. I, I1 or 111. But this classification is not static and changes occur according to the epidemiological situation. Thailand, which was earlier in pattern 111, can now be considered as being in patterns I and III, whereas other countries continue to be in the pattern 111 classification. The overall epidemiological situation indicates that the problem is most serious in Thailand and India (see Table 8). In India, where HIV infection has so far been identified, mostly amongst female prostitutes, more and more seropositive cases are being identified in other categories of high-risk population groups indicating that heterosexual transmission of HIV is becoming predominant. Most of the HIV seropositives in India are in the age group of 20-40 years, wtth promiscuous men and women forming the single largest group. As of 31 May 1990, altogether 486 804 persons, the majority of them belonging to high-risk groups, were screened in 42 surveillance centres. TABLE 8. Situation of AIDS and HIV infection in SEAR countries, as of 30 April 1990 Country Number of Number Number Month persons of HIV of last examined positives eases reported Bangladesh Bhutan DPR Korea India Indonesia Maldives Mongolia Myanmar Nepal Sri Lanka Thailand 42 266 2 172 7 580 461 118 96 963 2 606 9 665 18 274 15 897 98 834 1 700 000* -- *Information as of September 1989. Of these, a total of 2 575 were found to be HIV seropositives (5.311 OOO), including 48 AIDS cases and 2 527 HIV asymptomatic carriers. Table 9 shows the break-up of seropositives in India. In Thailand, the direction and the magnitude of the epidemic has changed over the past few years. The number of HIV-infected persons increased sharply between 1987 and 1989 (Table 10) and was attributed mainly to the problem of intravenous drug users in the country. In Indonesia, of the 96 963 persons examined, 16 were found to be HIV positive while seven were AIDS cases. Sri Lanka also had four AIDS cases and 21 HIV positives among the 98 834 persons examined for HIV infection. In Myanmar, recent serological studies indicated that transmission of HIV among intravenous drug users was a major problem. Regional Plan of Action Member Countries are endeavouring to implement the regional plan of action for prevention and control of AIDS in the best possible manner through short- and medium-term plans. With WHO TABLE 9. Break-up of seropositives, by group, in India Group Males Females Total Indians Heterosexually promiscuous 590 825 1 415 Homosexuals 6 - 6 Blood donors 527 5 532 Patients on dialysis 3 0 3 Antenatal mothers 0 7 7 Recipient of bloodlblood products 48 5 53 Relatlves of HIV patients 11 18 29 Suspected ARCIAIDS cases 29 8 37 Drug Users I/V 2 13 1 2 14 Others 130 30 160 Sub-total 1 557 899 2 456 Non-Indians Students Others Sub-total 96 23 119 Total TABLE 10. Situation of AIDS and HIV infection in Thailand, 1984-1989 Year AIDS AIDS-related HIV Total cases Total 34 103 13 349 13 486 collaboration, short-term plans have been implemented in ten countries of the Region while medium-term plans have either been implemented or are in the process of being implemented. AIDS knows no geographical boundaries and may represent a threat to Health for All if it is not contained through appro- priate measures. An increase in the number of cases in the countries of the Region may be expected in the near future. The need for coordinated action at all levels is evident. Under the regional plan of action, an epidemiologically-based strategy for the control of HIV/AIDS has been developed. In the absence of a cure for the disease and the lack of a vaccine for its effective prevention and control, the emphasis in the Member Countries has been on epidemiological surveil- lance to learn the extent of the disease and its prevalence among the high-risk groups, detection of HIV-infected persons, improved public health information through the mass media, counselling of seropoaitives and education of the target groups and the community, promotion of condoms and sex education, safe use of blood and blood products and on the use of sterilized syringes and needles. 13.14 OTHER CONMUNICABLE DISEASES PRBVENTION AND CONTROL ACTIVITIES The main objective of this programme is to improve national capabilities in communicable diseases surveillance, prevention and control, with international coordination where necessary, and with special reference to vector-borne diseases. The important diseases which come under this programme include Japanese encephalitis, meningococcal meningitis, viral hepa- titis and dengue haemorrhagic fever. The type of assistance that WHO provides to Member Countries for the containment of the diseases mainly includes the provision of consultancy services, fellowships, and supplies and equipment, as well as organization of consultative meetings. Japanese Encephalitis Japanese encephalitis is a public health problem in India, Indonesia, Nepal, Sri Lanka and Thailand. WHO has been providing technical assistance, and insecticides and sprayers to the countries. During the reporting period, eight health personnel from India were sent on study tour to Thailand, Japan and China for acquainting themselves with the latest knowledge on the control of JE. In Nepal, a detailed work plan on mass vaccination for JE has been prepared. Nepal was also supported by way of supply of malathion and JE diagnostic kits. A WHO consultant from Japan assisted the Government of Sri Lanka in evaluating the efficacy of vaccination programmes and advised on a long-term plan for the control of JE. The incidence of the disease in 1989 was only one-third of that reported in 1988. Meningococcal Meningitis Meningococcal meningitis poses a health problem mainly in India and Nepal. The reported occurrence of the disease is small scale, with the greatest variation seen during the last four years in Bhutan, where a minimum number of cases was seen in 1988 (3 cases with no deaths) and a maximum number in 1986 (188 cases with 25 deaths). In India, the disease is reportable only in some states and union territories. According to a report of the National Institute of Communicable Diseases, the number of cases in Delhi was 2 630 and the number of deaths was 501 during 1988, while the corresponding figures for 1989 were 2 018 and 307 respectively. Laboratory diagnostic facilities are available in most of the medical colleges, Imported bivalent (A<) vaccine is used for Haj pilgrims, close contacts of index cases, and for medical and paramedical personnel. Attempts are being made to develop an early warning system for early detection and reporting of cases, starting with the states of Gujarat, Madhya Pradesh, Orissa, Bihar, Rajasthan, Maharashtra and the union territory of Delhi. In Nepal, since the epidemic of 1983-84 in the Kathmandu Valley, meningococcal meningitis has emerged as a disease of public health importance. A mass vaccination campaign, using the bivalent meningococcal polysaccharide A, C vaccine was success- ful in containing the outbreak of 1983-84. Vaccination is now provided, on request, at the Epidemiology Division, Teku. WHO has been assisting Member Countries through the provision of meningitis vaccine, especially for Haj pilgrims. An intercountry Consultative Meeting on Surveillance and Control of Meningitis was held in Kathmandu, from 18 to 20 October 1989. The meeting reviewed the situation of the disease in the countries of the Region and formulated improved guidelines for epidemiological surveillance to suit the changed trend in disease prevalence. Viral Hepatitis Hepatitis A Virus (HAV) infection is a common problem in South-East Asia where more than 70 per cent of sporadic acute hepatitis cases in children are due to HAV. Sero-epidemiologi- cal studies, conducted in Bangladesh, India, Myanmar, Mongolia and Nepal, showed that 85-95 per cent of children in the age-group 6-10 years are immune to HAV, and that HAV cases in adults in these countries are very few. It has been observed that the morbidity of HAV infection in adults has increased in Indonesia and Thailand. This might be linked to a higher proportion of infection occurring later in life when it is more likely to cause overt symptoms. Hepatitis B virua (HBV) infec-ion is a serious problem in the Region. It is estimated that about 70 million (6 per cent) of the total population in South-East Asia are HB carriers. Only Nepal and Sri Lanka have shown low HB carrier rates (0.9-1 per cent). Other countries of the Region have shown higher HB carrier rates (6-15 per cent). The overall prevalence of hepatocellular carcinoma and cirrhosis is high in countries with high HB carrier rates. Significant progress has been made in the implementation of demonstration programmes for the control of HBV infection in Indonesia, Mongolia and Thailand. WHO collaborated in the production of local HBV diagnostic reagents in India, Indonesia, Mongolia, Myanmar and Thailand. The prevalence of hepatitis C Virus (HCV) infection (post- transfusion non-A non-B hepatitis) in the Region is not known. Some cases of this infection have been reported in India, Mongolia and Thailand. Meagre information is available on the prevalence of Delta virus in the Region. Mongolia has reported a high positivity for the presence of antibodies to Delta virus in healthy populations and in HBV cases. India, Myanmar and Thailand also reported some cases of mixed infections (Delta and HBV). Enterically-transmitted non-A non-B hepatitis (HEV) is an emerging problem in the Region. Outbreaks of HEV occurred in India and Indonesia, with a large number of cases in adults and children and a high mortality rate, especially in pregnant women. WHO sponsored epidemiological studies of HEV in Indonesia, Mongolia, Myanmar, Nepal and 'Thailand and provided laboratory facilities, kits and reagents for diagnosis. An intercountry Meeting on HEV was organized in New Delhi, from 10 to 13 July 1989. Based on the recommendations of this meeting, guidelines for future epidemiological studies of HEV and research were revised and circulated to the countries of the Region. WHO'S collaborative efforts to combat HEV infection continue through the promotion of research activities. In India and Myanmar, virological and laboratory studies of HEV in non-human primates are in progress. 13.15 BLINDNESS AND DEAFNESS During the course of evaluation of the national programmes for the control of blindness in India, Nepal and Thailand, it was revealed that weakness in managerial skills amongst middle- level workers was the most significant constraint. As an initial effort to meet this shortcoming, a bi-regional Workshop on Prevention of Blindness and Eye Care Management was held in Korat, Thailand, in February 1990. This workshop, which was a cooperative effort of the Western Pacific and the South-East Asia Regions, brought together experts from WHO collaborating centres and national centres in the two Regions. Eleven participants from seven countries of the South-East Asia Region attended. A terminal evaluation of the workshop revealed that the participants gained insight into the concepts of management and acquired some basic managerial skills. Trends in blinding eye disease prevalence and incidence, as revealed in epidemiological studies carried out in India in the late 19808, show an increase in age-related blinding conditions such as cataract and glaucoma. However, there was a downward trend in the prevalence of communicable diseases such as trachoma- and malnutrition-related blindness. These trends have important implications for priority action. Several programmes in the Region have intensified activities to deal with the increasing backlog of blindness related to cataract. These activities include enhancement of the capabilities of programmes to reach out to underserved communities, such as in Myanmar, through the provision of mobile units and equipment. Human resource development, through both indigenous training and the fellowships programme, continued to receive high priority. Nongovernmental organizations have traditionally reflected the programme for the prevention of blindness, and there was a renewed commitment by several international nongovernmental organizations to assist Member Countries in the areas of strengthening of human resource development infrastructure, health systems research, and programe evaluation. There are indications that these complementary efforts would also be intensified in regard to sight restoration. Activities related to deafness control were initiated in some countries through the provision of consultancy services. Rapid assessment techniques are being introduced to ascertain the magnitude of the problem. Integrated approaches to deafness and control of visual impairment through various health services are being explored. 13.16 CANCER With increasing life expectancy cancer is emerging as one of the leading causes of death in the countries of the Region. This situation is further aggravated by the fact that in several countries cancers which can be cured with early diagnosis and treatment are detected only at an incurable stage. This is particularly true of two leading cancers in most countries of the Region, viz., cancer of the oral cavity and cancer of the cervix uteri. Besides, palliative care and pain relief services are still lacking in most of the countries. A comprehensive National Cancer Control Programme exists in India, the implementation of which is coordinated by the National Cancer Control Board. This national mechanism is complemented by state programmes and boards. In Gujarat and Maharashtra, state-level activities have been initiated in line with the national programme. WHO has continued to assist the improvement and extension of existing cancer registries. WHO assistance in in-service training activities for non- specialized health staff has continued. In view of the great importance of prevention and early detection of the most common cancers, public education campaigns and development of educational material have been supported in Bangladesh, Bhutan, Sri Lanka and Thailand. 13.17 CARDIOVASCULAR DISEASES Whereas the incidence and the prevalence of cardiovascular diseases are being controlled in some developed countries, hospital-based statistics from the countries of the Region, particularly from Sri Lanka and Thailand, seem to indicate a substantial increase in these diseases. The increase in ischaemic heart disease in Sri Lanka reportedly greatly outnumbers the decrease in rheumatic heart disease in the country. Knowledge on specific risk factors in the countries is still lacking. WHO is therefore supporting studies on such risk factors in India, Myanmar and Sri Lanka. Hypertension and the related risk, especially of stroke, is recognized to be highly prevalent in the countries of the Region. However, the initiation of large-scale hypertension control programmes is hampered by the relatively high cost of maintenance medication that may be required. Only Mongolia is reported to have achieved a high treatment coverage of hypertensive subjects, surpassing even most developed countries. WHO assisted Bhutan and Myanmar, through consultants, in the planning of control measures for cardiovascular diseases. A consultant also assisted DPR Korea in the improvement of services for vascular surgery. An AGFUND-supported programme for the control of rheumatic feverlrheumatic heart disease (RF/RHD) in some countries has entered the second phase. The incidence rates in school children found in these countries justify the specific inclu- sion of RF/RHD control measures into school health programmes. In Myanmar, extensive training programmes for the prevention, recognition and management of cardiovascular diseases were supported by WHO and a regular CVD Newsletter aims at helping to retain the gains in knowledge and expertise following this training. 13.18 OTHER NONCOMMUNICABLE DISEASE PREVEWTION AND CONTROL ACTIVITIES WHO assistance in this sub-programme area has continued to vary according to the specific needs of the countries. Assistance was provided for further strengthening of diabetology and endocrinology in Bangladesh. Bangladesh has also continued to upgrade the expertise in renal trans- plantation in the context of total cases in diabetology and nephrology. India and Thailand have strengthened their activities for the control of thalassemia, which is a major cause for concern. Maldives has also initiated activities to study and control thalassemia. An expert committee on rheumatology in Thailand prepared an action plan in this field with WHO assistance. = "Getting Set" for health for all.
Chapter 5 DEVELOPMENT OF HUMAN RESOURCES FOR HEALTH 5.1 N4NAGEEIAL PROCESS FOR THE DETIBLOPPIENT OF HUMAN BESOURCES FOR HJiALTH Achievement of the targets for the development of human resources for health with the aim of achieving health for all through the primary health care approach is of paramount importance. Towards this end, support has been provided to improve capabilities and training facilities and to upgrade educational technology as well as capabilities in planning and management. Fellowships have been provided in support of national needs to strengthen the development of human resources for health. Support was provided to strengthen the planning of human resources for health in all the countries of the Region. Fellowships in health planning were supported in Indonesia and Thailand, and workshops on health planning were supported in India, Indonesia and Thailand. In Thailand, a data base for planning was started with WHO support and training provided for health planners and managers. Support was also provided to strengthen training institutions in all the countries of the Region through fellowships, consultants and supplies and equipment. WHO continued to collaborate actively with Member Countries in improving health systems manpower development (HSMD) mechanisms. and activities were undertaken in Indonesia, Mongolia and Thailand. Continuing efforts to strengthen nursing service management, to effectively utilize nursing personnel in the delivery of health care, especially at the district level, and to strengthen referral facilities in support of PHC are evident in the various activities carried out in several countries of the Region in collaboration with, and support of, WHO. A comprehensive situation analysis of nursing services in Bangladesh has been published for widespread dissemination and use as the basis for long-term planning in nursing development. Training courses at the district level were expanded to improve nurses' management, supervision, research capabilities and skills in carrying out PHC-oriented activities. The strengthening of nursing services, especially for the development of referral systems for PHC, is being promoted through improved training of nursing personnel in Bhutan, through the development of hospital nursing guidelines and a research study on hospital nursing services for improving the quality of nursing care in Indonesia, and through re-examination of nursing regulatory mechanisms in India. Increasing emphasis was given in other countries to strengthening nursing skills in priority speciality areas, through in-country and regional training courses. In Myanmar, efforts were made to strengthen nursing services at central and state/division levels through the formulation of long-term development plans for nursing education and services, including a nursing procedures manual, nursing care standards, staffing patter- and job descriptions for nursing personnel. Modules in nursing administration and management were developed and used extensively in training courses for nurses in key administrative and managerial positions. Progress has been made in improving hospital and district-level nursing services in Nepal, in the areas of nursing skills and infection control measures, through in-service education of nursing personnel in five regions, using manuals developed with WHO assistance. Support was also provided to the Division of Nursing for the development of the national programme for training of MCH workers and for systematic training of TBAs throughout the country. In spite of efforts to further strengthen the managerial process for the development of human resources for health in the Region, much remains to be done. For example, a number of human resource development plans have yet to be effectively linked operational- ly to national health plans in the pursuit of the goal of Health for All. Further, many countries still face gross imbalances in human resources for health besides inadequately trained personnel. In many instances, specific human resources for health targets have not been adjusted to take into account the economic slordown. Human resources are also based on over- optimistic economic projections. Consequently, WHO has actively pursued the introduction of economic aspects to the development of human resources for health. Following the interregional Seminar on Financing of Human Resources for Health, held in Bangkok in 1989, a workshop to develop a methodology for determining the optimal mix of human resources for health was held in Myanmar in February 1990. Field trials will now be carried out to teat this methodology. Continued efforts are also required for improving the quality of programmes of continuing education, for planning career structures and job descriptions, and for the development of good information systems for decision-making. 5.2 RESEARCH IN THE DEVELOPMENT OF HUMAN RESOURCES FOR HEALTH WHO has renewed its efforts to increase the capabilities of the countries for carrying out research into the development of human resources for health. In this regard, the intercountry Consultative Meeting on Reoearch into the Development of Human Resources for Health, held in the Regional Office io January 1989, developed guidelines and a regional plan. It recommended that decision-linked research be carried out in support of decision-making in the development of human resources for health. Three commissioned research projects in the development of human resources for health were supported in 1989-1990. In addition, national workshops on research into the development of human resources for health were held in Bangkok, in June 1989; in Jakarta, in January 1990; and in Kathmandu in May 1990. These will be followed by further research workshops in other countries during 1990-1991. A national workshop on the development of a methodology to determine the optimal mix of human resources for health was held at Yangon from 13 to 17 February 1990. Resulting from this, there is a pilot proposal to carry out studies to determine the optimal mix of human resources for health. The importance of promoting research in nursing and its role in the improvement of health care in general and nursing in particular, was underscored during the fifteenth session of SEA~ACHR in Indonesia in June 1989. One of the recommendations of this meeting related to the use of WHO Collaborating Centres in Nursing and the formation of national task forces/study groups as mechanisms in the development of research in nursing within the framework of health-related research in the countries. The formation of these national groups was supported in India, Indonesia and Thailand. Despite the increase in research activities into the development of human resources for health, much remains to be done. Since 60 to 80 per cent of health budgets are devoted to human resources for health, a small increase in the productivity or efficiency of human resources would result in substantial increases in cost-effectiveness. It is therefore important that decision-linked research into the development of human resources for health be actively pursued. 5.3 MEDICAL EDUCATION WHO continued to support the efforts of Member Countries in further strengthening their medical education systems through the introduction of greater balance and relevance in education and training programmes, particularly at the undergraduate level. Further progress was noted in the trends set over the past few years towards achieving community orientation of curricula, and in the development of appropriate skills and attitudes of students enabling them to serve the needs of communities within comprehensive health systems based on primary health care. WHO collaborated with institutions in India, Indonesia, Myanmar and Thailand in experimenting with the introduction of problem-based curricula, either in totality as parallel tracks or in a phased manner through organ-system and other unit approaches. Similar interests expressed by certain other schools in India and Sri Lanka are being pursued. Through the Collaborating Centre for Medical Education in Thailand, WHO is also assisting in the planning of a new problem-based medical school at Thammasat University in Bangkok. Bangladesh continues to lay great emphasis on the improvement of medical education. In consonance with this approach, a high-powered steering committee, including medical educationists and general educationists, has been constituted to improve the quality of medical education. WHO supported the visit of a four-member team from the Royal Postgraduate Medical School, London, to Myanmar from 19 to 24 February 1990. It is felt that, with the rapid advances in medicine and medical practice, continued and urgent reorientation of medical education would be needed to help medical students and young doctors face future challenges in health care. The Regional Office published the first three monographs in the series on "Reorientation of Medical Education", which are being used by the Member Countries as a key technical response in their attempts to reorient their medical education systems. Towards achieving appropriate education a number of activities have taken place. Thailand has already completed a baseline study of the current situation, based on an adapted version of the regional targets and indicators, while Indonesia and Nepal are in the process of similar exercises. WHO also continued to support a consortium of four medical schools in India viz., All India Institute of Medical Sciences, New Delhi; Jawaharlal Institute for Postgraduate Medical Education and Research, Pondicherry; Banaras Hindu University, Varanasi; and Christian Medical College, Vellore, in developing a comprehensive data base for reorienting medical education, the results of which will be used in formulating strategies and plans for the reorientation of medical education. With wide dissemination of the findings, it is anticipated that more institutions in India will undertake similar exercises, and will initiate innovative approaches in the orientation of medical education. In the sphere of postgraduate medical education, WHO provided technical support and subsidies for overall system development and quality control in Bangladesh and Indonesia, for the organization of lecture tours and resources development in Myanmar, and for the conduct of examinations by the Postgraduate Institute of Medicine in Sri Lanks. Countries are earnestly attempting to develop postgraduate medical education systems consistent with their needs and socioeconomic realities. The recurrent quantitative and qualitative problems of teacher shortages, lack of essential equipment and supplies, and coordination of education systems with health care systems, continue to pose difficulties and limit the pace of development, and further support will be needed in overcoming these. The trends in medical education development provide a basis for cautious optimism that greater balance and relevance will be achieved in the Region in the coming decade, and that physicians of the twenty-first century will be appropriately prepared to meet the challenges of Health for All. 5.4 NURSING EDUWION In several countries, cumulative efforts to strengthen basic nursing education are now yielding tangible results. Significant improvements are manifest in the increasing numbers and quality of national nurse teachers. In Bhutan, the preparation of a qualified core of national teaching staff has enabled the nursing programme to progress towards self- sufficiency. Assistance in the upgrading of teachers and managers of nurses was continued through fellowships for advanced studies or speciality training in educational mthods, management, or clinical nursing specialities, both within and outside the countries, in Bangladesh, Sri Lanka, Nepal, and India. The baccalaureate (S-1) programme in Indonesia has been steadily increasing the strength of its full-time nursing faculty, and ensures ongoing opportunities for faculty and staff development. Community-oriented nursing curricula are being implemented in five countries of the Region. These nursing educational programmes are now initiating periodic evaluations to provide feedback on the progress of implementation and to enable ongoing modifications and improvements to be made. WHO assistance has also been provided for the strengthening of institutional fraoeworks. educational policies and teachinn- - learning resources as essential support for the reorientation process. The effective implementation of the reoriented nursing curricula and the increasing demand for better qualified nursing personnel relative to community health needs also calla for innovations in teaching-learning strategies. Support is being given to initiatives, such as community-based team training in Nepal, and the model field practice areas in Indonesia, as well as to further development of self-learning modules as part of a distance learning initiative for upgrading the knowledge and skill of auxiliary nursing personnel in remote areas of Indonesia. A critical appraisal of the use of distance education for nursing and other health personnel is also being taken up at the regional level. Despite the increasing demand in the Region for higher education for nurse teachers, managers and specialists, institutional resources for post-basic and graduate nursing programmes are limited. Efforts to address this need, such as long-term planning and feasibility studies for programme development, revision and expansion of existing programmes, and promotion of innovative approaches to graduate education, are already under way in Nepal, India and Thailand. Greater support in this area will contribute to the development of the overall nursing education system. 5.5 TEACHER TRAINING Technical support was provided to all the countries for improving educational capabilities of teachers of health sciences. In Indonesia, the Consortium of Health Sciences has continued with its programmes of staff development and the development of problem-based approaches to teaching. A review of the programme for the development of human resources for health, particularly that developed through the Consortium of Health Sciences and the Faculty of Public Health, University of Indonesia, was undertaken in April 1990, with a view to redirecting the programme towards peripheral medical schools and schools of public health. The development of a system of continuing education and the strengthening of research capability among the academic staff of the State Medical Institute and the Medical Technicum in Mongolia were supported. In addition, an integrated clinical curriculum and improved training methods were developed in Mongolia with WHO support. In Myanmar, support was provided for the development of continuing education and a PHC-oriented curriculum. Support was also provided for training in medical school management. The strengthening of the Institute of Medicine, Kathmandu, was undertaken in support of the development of human resources for health. In Sri Lanka, teacher training was further strengthened to increase educational capability. In Thailand, support was provided for the development of innovative medical education oriented to problem-based and community-oriented educational programmes for human resources for health. WHO continued to maintain a coordinated staff development programme for national staff, to upgrade and reorient teachers in the Region, with the result that the Region has a fair pool of expertise in the basics of educational science and technology. However, the slow progress in educational institutions is due mainly to the universal resistance to changing traditional values and practices. Nonetheless, it will seem that, given the conducive internal and external support, the goals that the countries have set for themselves will be realized in time. The UNDP-funded, WHO-executed project to develop an intercountry network of institutions for health learning materials develop- ment organized its first workshop in Kathmandu in January 1990, to plan the details of implementation and coordination of the project. The first five participating countries formulated national work plans, and these activities are expected to draw technical support from the successful Health Learning Materials project of the Institute of Medicine, Kathmandu, which is the WHO Collaborating Centre in this field. It is estimated that, by the end of the first phase of the project, each of the countries will be able to lay the foundation for a sustainable, national health learning materials programme. On the basis of experience with this project, it is planned to invite the remaining countries of the Region who wish to join this network to do so. The first set of English Language Self-Instructional Packages (ELSIP) were assembled in the Regional Office and distributed to 33 institutions of the Member Countries and to nine WHO Representatives' offices of the Region. Initial reports of their usefulness are encouraging, and further requests for additional sets are being received. The situation with respect to health learning materials for the education and training of middle- and basic-level health workers is still far from satisfactory, but the concerted efforts of the Member Countries, with support from WHO as well as other donors, are finally beginning to show tangible results. With further perseverance and application of the knowledge and experience gained thus far, there is every hope that this perennial problem will be overcome during the current decade. All the countries of the Region have reflected human resources for health needs in the overall objectives and targets of their health policies and health development plans, while some countries have made specific mention of such needs for meeting the health strategy. All countries include fellowships in the WHO country budget. The seventy-first session of the Executive Board, in 1983, requested the Director-General and the Regional Directors to respond fsvourably to government requests for fellowships only if these are in conformity with the Organization's policy on fellowships. Such fellowships should be relevant to health manpower needs for achieving the goal of HFA/2000, and they should be the most appropriate means of attaining clearly- defined objectives. The resolution further recommended that the Director-General and the Regional Directors, in cooperation with Member Countries, continue improving the reporting procedures on fellowships and carry out systematic evaluations of the implementation of WHO'S health manpower development programme, including fellowships, and its contribution to the national health systems. Earlier, in 1979 and 1982, at the first and second Regional Conferences on WHO Fellowships, it was recommended that such evaluations could he more effectively conducted st the country level rather than at the regional level. The importance of developing a mechanism for evaluation became an urgent issue after the Executive Board adopted, at its seventy-first session, a resolution on fellowships. In pursuance of this resolution a time-frame for action was drawn up and follow-up activities were undertaken. The Third South-East Asia Regional Conference on WHO Fellowshi~s. held in November/December -1988, concentrated on the modality of implementation and evaluation of WHO'S fellowships policy. In order to enable countries to undertake systematic evaluation of the extent to which the programe has benefited health development, certain indicators and guidelines were identified and adopted. Indonesia carried out field-testing of these guidelines and indicators. The outcome of this trial was circulated to all countries to help them evaluate their own programmes. So far six countries, namely Bangladesh, Indonesia, Mongolia, Myanmar, Nepal and Thailand have made a self-assessment based on the following policy guidelines: (1) Development of a health manpower policy as part of the national strategies for HFA. (2) Effective use of the wide variety of training mechanimus available, including fellowships. (3) Fellowships to be requested only if it is considered to be the most appropriate means of achieving clearly-defined objectives. (4) Establisbent of an adequate selection mechanism to ensure that the most suitable candidates are selected. (5) Periodic evaluation of the progress made in health manpower development efforts, especially fellowships: (a) evaluation of administrative processes; and (b) evaluation of its impact. Almost all countries of the Region utilize in-country training in the form of in-country fellowships for academic courses or continuing education. It is the explicit policy of most countries to use national training institutions as far as possible. Other mechanisms which may be used include visiting scientist grants and research training grants. During the period 1984-1989, 45.3 per cent of the fellowships were taken up within the South-East Asia Region, while 8.2 per cent were in the Western Pacific Region and 25.5 per cent in the Americas or Europe; 21 per cent were multiregional. In the South-East Asia Region, fellowships are awarded in the context of joint WHO/collaborative programmes and projects of countries, which, by definition, relate to national priorities and to the attainment of HFA. Fellowships are awarded by a well-defined selection mechanism which is revised and improved periodically. As part of the evaluation of the fellowships programme in the context of the resolution adopted by the seventy-first session of the Executive Board, countries in the South-East Asia Region are evaluating the implementation of the fellowships programmes and responding to the Regional Office. A detailed report on the analysis of these replies has been compiled by the Regional Office and submitted to WHO headquarters from where a global report will be presented to the Executive Board in 1991 and subsequently to the Forty-fourth World Health Assembly. In response to the request of the Regional Office for utilization reports in respect of 320 fellowships, mainly related to the 1984-85 biennium, only 100 reports have been received. Similarly, a request for reports on 369 fellowships, mainly covering the 1986-87 biennium, has so far produced only 44 reports. The feedback provided by these reports will enable a review of the capacity and capabilities of training institutions for future placements. As an instrument for evaluation, fellowship utilization reports will supplement national efforts in evaluating the fellowships programme. Though Member Countries and WHO have already made some progress towards achieving the recommendations of the fourteenth meeting of CCPDM, considerable efforts are still necessary for develop- ing appropriate terms of reference for individual fellowships with well-defined objectives, for timely nominations, and for strengthening review mechanisms and selection procedures for fellowships at the national level. Within the context of national health manpower development policies and strategies it is observed that Member Countries of the Region are using the fellowships programme, among the other varieties of training mechanisms available to them, as an essential and effective component in the development of health manpower. Though the fellowships budget for the 1988-1989 biennium has been fully utilized through the combined efforts of Member Countries and the Regional Office, much more concerted action is necessary on the parts of all concerned to overcome problems and constraints and to achieve overall improvement in the management of the fellowships programme. The policy of Member Countries to promote their in-country training capabilities through the development and strengthening of training institutions has continued to be supported by WHO through technical inputs, training of tutors, supplies and equipment, etc., with a view to helping the countries attain self-reliance in trained manpower within as short a time as possible. WHO also provides assistance for the development of resource personnel, which not only strengthens in-country training of nationals, but also contributes to promoting the quality of regional training institutions. The Fellowships programne of 1988-89 (Regular budget) has been fully implemented in terms of the budget provision (101.74 per cent), the extent of implementation exceeding the previous biennium by about 45 per cent. During the period under review, 612 fellowships were awarded under the Regular budget at an estimated cost of $5 960 925 involving a period of 3 348 man months (Table 1). TABLE 1. Mstribution of fellowships under WHO regular budget, by region of study (1 July 1988 to 30 June 1989) Country No. of Man month Expenditure Regions of study f ellor American European South- Western More ships East Pacific than one Asia region Bangladesh 110 994.75 1 911 450 Bhutan 11 80 .OO 117 110 1 4 6 0 0 DPR Korea 19 128 .OO 159 100 0 13 2 4 0 India 162 328.00 1 137 405 40 23 12 8 79 - Indonesia 47 225.00 438 100 6 9 5 13 14 Maldives 32 445.00 264 700 0 1 31 0 0 Mongolia 8 35.00 59 470 0 8 0 0 0 Myanmar 77 407.75 882 910 14 20 20 7 16 Nepal 79 455.75 518 100 3 8 60 4 4 Sri Lanka 55 185 -00 336 550 3 5 25 3 19 Thailand 12 64.00 136 030 6 3 1 0 2 Total 612 3 348.25 5 960 925 79 134 185 71 143 Petcentage 12.91 21.90 30.23 ll.60 23.36 The distribution of fellowships, by profession, is given in Table 2. TABLE 2. Distribution of fellowships, under the regular budget, by profession (1 July 1989 - 30 June 1990) Profession Number Percentage Doctors Engineers Nurses Others Total 612 100.00 The subjects of training of the fellowships are given in Table 3. The duration of the training programmes is given in Table 4. The representation of women, in the awarding of fellowships, is still low. The mechanism of contractual service agreements was utilized to cover 112 fellowships. Another 66 fellowships covering 422 man months were awarded during the same period under projects funded from extrabudgetary resources but executed by WHO. The Regional Office also arranged the training of 197 fellows from other WHO regions during this period. It is gratifying to see that fellowships are being utilized with increasing orientation towards the goal of HFA/2000 and development of PHC. There is a tendency to use more short training programmes and study tours, particularly by the more developed countries of the Region. Besides direct management of the fellowships programme, other related activities have been carried out during this period. A new methodology regarding the payment of stipends to fellows, related to the per diem rate, has been implemented globally, and was made effective in SEAR countries from 1 November 1989. The stipend will be revised from time to time, as appropriate. 'Instructions to Fellows', a supplement to the 'Fellowship Information Booklet', has been revised and finalized for use by fellows during the course of their fellowships programmes. The Region is also actively involved in the revision of the fellowship application form, which requires streamlining to meet the requirements of changing situations. TABLE 3. Distribution of fellowships under the regular budget, by subject of study and country of origin of the fellow (1 July 1988 - 30 July 1989) Subject BAN BAU DFRK IND IN0 HAV HOG MMR NEP SRL THA Total Per centage Public health administration 18 4 0 3 9 2 2161410 2 80 13.07 Environmental health 16 0 0387008591 84 13.73 Nursing 0 2 000901640 22 3.59 ~- ~ ~ Maternal and child health 4 0 2150002131 28 4.58 Communicable diseases and laboratory services 18 3 0 45 14 1 0 17 17 12 4 131 21.41 Clinical sciences 27 2 8 1113 111 6 11 72 11.76 Basic medical sciences and education 13 0 210417060 34 5.56 Research methodology 0 0 091003010 14 2.28 Others 14 0 7 50 15 3 4 12 30 9 3 147 24.02 Total 110 11 19 162 47 32 8 77 79 55 10 610 100.00 TABLE 4. Distribution of fellorehips, by duration (1 July 1989 - 30 June 1990) Duration Number Percentage (months) 4-6 7-12 Over 12 Total 612 100 .00 1. Directory of Regional Training Institutions The Directory of Regional Training Institutions has been revised with the support of a consultant in collaboration with Member Countries. After the incorporation of specific comments by the various technical units, the second edition of the Directory is now in press, and will soon be distributed to Member Countries and relevant international agencies. The Directory will enable all those interested to scan the currently available educational resources in the Region, in various fields of medical and health sciences. 2. Group Educational Activities During the period under review, 33 meetingslgroup educational activities were held, of which 25 were regional and the remainder policy or advisory meetings. A review shows that justifications for the meetings were clearly spelt out, that the objectives in respect of most of the meetings were achieved, and that the methods adopted appeared appropriate for achieving these objectives. In most cases, follow-up activities have been initiated. These group educational activities, excluding policy and advisory meetings, consisted mainly of regional meetings, workshops, consultative meetings and short training courses covering different subjects, such as safe motherhood, nursing and midwifery, management for prevention and control of HIV infectionIAIDS, safety of blood and blood products, drinking water quality surveillance, etc. The representation of countries and the number of participants are shown in Table 5. TABLE 5. Representation of countries and number of participants in intercountry and inter- regional group educational activities (1 July 1989 - 30 June 1990) Country Number of Number of activities participants Bangladesh 11 16 Bhutan 13 19 DPR Korea 2 4 India 24 66 Indonesia 21 49 Maldives 14 20 Mongolia 12 20 Myanmar 16 29 Nepal 21 48 Sri Lanka 24 41 Thailand 24 69 Total 381 Table 6 shows the distribution of participants in intercountry activities, by type of activity. TABLE 6. Distribution of participants in intercountry activities, by type (1 July 1989 - 30 June 1990) Type of activity Nmber Number of participants Regional meetings 7 85 Workshops 10 192 Consultative meetings 5 73 Short training courses 3 31 Total 25 381
The Work of WHO in the South-East Asia Region 1 July 1989 to 30 June 1990 Forty-second Annual Report 7f the Regional Director THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION 1989-90 ISBN 82 9022 202 G 0 World Health Organization 1990 Publications of the World Health Organization enjoy copyright protection in accordance with the provisionsof Protocol 2 of the Universal Copyright Convention. For rights of reproduction or translation, in pan orintolo, ofpublicationsissued by the WHO Regional OficeforSouth-East Asia, application should be made to the Regional Ofice for South- East Asia. World Health Houx, Nerv Delhi I10 002, lndia The designations employed and the presentation of the material in this publication do not imply the expression ofany opinion whatsoever on the pan of the Secretariat of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or coricerning the delimitation of its frontiers or boundaries. Printed in lndia SEAlRC4312 The Work of WHO in the South-East Asia Region 1 July 1989 to 30 June 1990 Forty-second Annual Report of the Regional Director The manch .toudh HFA/2000 .i~ gdhehing momentum an peopLe in .the SouXh-EaX Ania Region n.t&ive .to heach the chehinhed god. CONTENTS FOREWORD EXECUTIVE SUhNARY SECTION I DIRECTION, COORDINATION AND MANAGEMENT Chapter 1: GOVERNING BODIES 1.1 World Health Assembly 1.2 Executive Board 1.3 Regional Committee 1.4 Ministers' Meeting Chapter 2: WHO'S GENERAL PROGRAMME DEVELOPMENT AND MANAGEMENT 2.1 Regional Director's Development Programme 2.2 General Programme Development 2.3 External Coordination for Health and Social Development 2.4 Health Emergency Preparedness and Response 2.5 Health-for-All Strategy Coordination 2.6 Informatics Management SECTION 11 HEALTH SYSTEM INFRASTRUCTURE Chapter 3: HEALTH SYSTEM DEVELOPMWT 3.1 Health Situation and Trend Assessment 3.2 Managerial Process for National Health Development 3.3 Health Systems Research and Development 3.4 Health Legislation Page vi i ix Chapter 4: ORGANIZATION OF HEALTH SYSTEMS BASED ON PRIMARY HEALTH CARE Chapter 5: DEVELOPMWT OF HUMAN RESOURCES FOR HEALTH 5.1 Managerial Process for the Development of Human Resources for Health 5.2 Research in the Development of Human Resources for Health 5.3 Medical Education 5.4 Nursing Education 5.5 Teacher Training 5.6 Health Learning Materials 5.7 Fellowships Chapter 6: PUBLIC INFORMATION AND EDUCATION FOR HFALTH SECTION 111 HEALTH SCIENCE AND TECHNOLOGY Chapter 7: RESEARCH PROMOTION AND DEVELOPMENT INCLUDING RESEARCH ON HEALTH-PROMOTING BEHAVIOUR Chapter 8: GENF.UL HEALTH PROTECTION AND PROMOTION 8.1 Nutrition 8.2 Oral Health 8.3 Accident Prevention 8.4 Tobacco or Health Chapter 9: PROTECTION AND PROMOTION OF THE HEALTH OF SPECIFIC POPULATION GROUPS Page 29 9.1 Maternal and Child Health, Including Family Planning 67 9.2 Adolescent Health 71 9.3 Human Reproduction Research 71 9.4 Workers' Health 73 9.5 Health of the Elderly 73 Page Chapter 10: PROTECTION AND PROMOTION OF MENTAL HEALTH 10.1 Psychosocial and Behavioural Factors in the Promotion of Health and Human Development 75 10.2 Prevention and Control of Alcohol and Drug Abuse 76 10.3 Prevention and Treatment of Mental and Neurological Disorders 77 Chapter 11: PROMOTION OF ENVIRONMENTAL HEALTH 11.1 Community Water Supply and Sanitation 11.2 Environmental Health in Rural and Urban Development and Housing 11.3 Health Risk Assessment of Potentially Toxic Chemicals 11.4 Control of Environmental Health Hazards 11.5 Food Safety Chapter 12: DIAGNOSTIC, THERAPEUTIC AND RBHABILITATIVE TECHNOLOGY 12.1 Clinical, Laboratory and Radiological Technology for Health Systems Based on Primary Health Care 87 12.2 Essential Drugs and Vaccines 90 12.3 Drug and Vaccine Quality, Safety and Efficacy 93 12.4 Traditional Medicine 94 12.5 Rehabilitation 95 Chapter 13: DISEASE PREVENTION AND CONTROL 13.1 Immunization 97 13.2 Disease Vector Control 105 13.3 Malaria 109 13.4 Parasitic Diseases 115 13.5 Tropical Diseases Research 118 13.6 Diarrhoea1 Diseases 120 13.7 Acute Respiratory Infections 122 13.8 Tuberculosis 124 13.9 Leprosy 125 13.10 Zoonoses 127 13.11 Sexually Transmitted Diseases 128 13.12 Research and Development in the Field of Vaccines 129 Page 13.13 AIDS 13.14 Other Communicable Disease Prevention and Control Activities 13.15 Blindness and Deafness 13.16 Cancer 13.17 Cardiovascular Diseases 13.18 Other Noncomunicable Disease Prevention and Control Activities SECTION IV PROGRAMME SUPPGilT Chapter 14 HEALTH INFORMATION SUPPORT 14.1 Health Literature and Library Services (Including HELLIS) 14.2 Publications and Documents Chapter 15: SUPPORT SERVICES 15.1 Personnel 15.2 General Administrative Services 15.3 Budget and Finance 15.4 Supplies and Equipment 15.5 General ANNEXES 1. Organizational Structure 2. Projects in Operation in Member Countries FOREWORD A6 we entet the fabt decade 06 the twentieth centuty, the datlr, icy doudb 06 cold war, which had enveloped the wotld 601 ovet two bcore yearb, appeal to be teceding and yielding to the gentle .ray5 06 peace bhining ovet the globe. With the dawn 06 a new era 06 peace and mutual ttubt, we bhould heel emboldened and envigoured to accomp!ibh out cheubhed aim 06 health 60% all babed on the twin noble ptincipleb 06 equity and docid justice. We can ttead our choben path with gzeatez con6idence - con6idence that pobtezity would not 6ind ub wanting. Pfogtebb can be attained only id the 6oundationb ate 6itm. Late? in the yeat we will be tebting the btfengthb 06 out 6oundationb and ptobing 60.1 weaknebbeb ubing the common 6tamewotn 60% evaluation. It will fwovide ub all an opportunity not only to meaau?e succebbeb and dailuteb in quantitative and qualitative terms but dbo to ponder on the apptoptiatenebb 06 out apptoacheb and btxategieb and to introduce necebbaty coutbe CotteCIionb. Human development hnb to ocut within 6<agile natutal boundatieb 06 ait boil and wate?. ule cannot exceed the bleak point 06 the tegenerating capacity 06 the ecobybtem. Thub the Uitectot-General 06 WHO hub advocated and pleaded 601 emphubib in dive impoxtant attab, viz., envi%onmental health and bubtainable development, nutrition, an integtated approach to dibeabe control, a cleat underbtanding 06 the relationbhip between the btafe 06 the world economy and health development and, 6inafly. genetation and ube 06 valid in6ormation. The need to dobely redlect and recabt our bttategy hot he&h development to 6it into thebe ptiotity bettingb ib patently obvioub, and will tequile our utgent attention. The South-Eabt Asia Region ib home to a quarter 06 the worfd popu(ation. 06 the eleven Member Countueb, a6 m a6 dive belong to the category 06 'lea6t developed countriebl?fgnomce, povettq and mdnutution btill pfague our region. To add to the misetq, the Region ih pfone to varioub kndb 06 nnturaf and man-induced dhterb. Our people, however, have mebbdu((y combated al( buch problem6 with coutage and determination. rhere id a growing awarenebb among all our people6 to look a6tet theit debtinieb and match with the febt 06 the world. Thi6 mlufb,weU 60f their betterment and wiU entail addition& te4ponbi &te6 06 a di66erent genre in the national decibion-making ptOCebbeb. The era 06 opportunity hub begun. It behove6 ub to implement, in letter and bpifit, individuaUq and co(cectivelg, the bolemn and correct decision6 that we have jointfg taken and to tread boldly on the path that we have carved 6or ourbelveb. With the hope 06 a bright and developmentaffy meaning6ul decade, I have great pleasure in presenting thib report on the work od WHO in the South-Eat Asia Region bar the period 1989-1990. 1 am convinced thai we will witnebb a ~eburgence 06 the bpi& 06 compaAdon and goodwiU coupled with bo(dnebb and adventure in OUT path 06 ptogttbb. I& - Dr U Ko Ko Regional Director EXECUTIVE SUMMARY WHO'S GENeRAL PROGRAElME DEVFLOPMENT AND MANAGEMENT WHO has continued to provide strong and effective leadership in the improvement of health in all countries of the world. The Director-General has initiated a new programme to strengthen technical and economic support to countries facing serious economic constraints. In line with this concern for continued existence of inequities within and among nations, the Eighth Meeting of Ministers of Health of the countries of the WHO South-East Asia Region, held in Jakarta in October 1989, stressed the need to strengthen intercountry and interregional mechanisms. The Ministers also opined that the health sector had to speedily acquire expertise in health economics so as to be able to investigate and analyse various options and alternatives for financing health care, particularly since resources for health were not expected to increase sub- stantially. The Regional Office has continued to support Member Countries in the overall management of their health programmes. The working of the joint government-WHO coordination mechanism, which guides the formulation and implementation of WHO'S collaborative activities at the country level, was reviewed in 1989 with a view to improving its functioning. The forty-second sesston of the Regional Committee desired that the Regional Director submit a single programme budget document for the 1992- 1993 biennium for endorsement at the forty-third session of the Regional Committee in September 1990. The South-East Asia Regional Office participated closely in the study by the Execu- tive Board on the setting of priorities for WHO collaborative programmes. The implementation of the programme during 1988-1989 was highly satisfactory, much better than that of the previous biennium. This was made possible by the improved WHO information system for supporting programme monitoring. Major development issues, such as environmental pollution, education and health, are of such an inter-connected nature that they call for extensive and efficient interagency and intersectoral coordination and cooperation. During the period under review, cooperative efforts were pursued and new initia- tives taken to further strengthen interagency collaboration. A number of new projects to be executed by WHO with financial support from UNDP and UNFPA, among others, were approved. Member Countries have taken a number of new initiatives to reorient their health policies and strategies in keeping with the principle of decentralization of financial and sdminis- trative authority. Efforts to inculcate leadership qualities at intermediate and lower levels have been pursued vigorously in almost all Member Countries. In South-East Asia, the interplay of natural forces acting upon areas with high population concentrations causes recurrent disasters of great magnitude. WHO is contributing effectively to developing and implementing disaster preparedness programmes. This will contribute to the success of the International Decade for Natural Disaster Reduction launched by the United Nations in January 1990. Informatics support activities focused mainly on the provision of appropriate and relevant technologies and training to staff at regional and country office levels. An information system for administrative and financial services of the Regional Office (AFI) was installed in 1990. HEALTH SYSTEM DEVRLOPMENT The main thrust of the managerial processes in national health development programmes continued to be reviewed with reformula- tion of national policies, and development and ioaplementation of health plans. Strengthening of operational management of health services at various levels in the context of decentralization of health services and training in health planning management and health care financing were also undertaken. Realth ewnogics, including financing of health services and mobilization of resources for health development, constitute a priority area for support to Member countries by WHO. In several countries of the Region, activities are being undertaken to estimate realistic costs of implementing national health policies. Due to serious obstacles in the implementation of primary health care, resulting from unfavourable economic situations, the health situation in many countries of the Region continues to be unsatisfactory. WHO has recently initiated a country-centred strategy for overcoming the obstacles using new mechanisms and approaches and obtaining a holistic view of planning and implementing country activities. This includes, -- inter alia, advocacy for larger resource allocations for health. The second evaluation of the implementation of strategies for Health for All by the Year 2000 is to be undertaken by all Member Countries in 1990. Preliminary activities connected with the second evaluation have alreaJy been carried out. The revised version of the Common Framework for Evaluation (CFE-2) was finalized by WHO headquarters. India and Mongolia from this region participated in the pre-testing. National authorities have been briefed on the methodology, procedures and time-table for the second evaluation and assisted in working out necessary plans of action. Field Epidemiology Training Programmes (FETP) have been conti- nued and strengthened so as to secure competent epidemiologists. India, Indonesia and Thailand have participated in FETP. In order to effectively control and prevent major communicable diseases, an epidemiological surveillance programme has been developed to ensure the availability of essential epidemio- logical information. Health systems research (HSR) continued to be promoted with greater attention being given to the strengthening of institu- tions, as recommended by the Task Force on HSR. The role of health research in Health for All by the Year 2000 was reviewed by a sub-committee of SFA/ACHR in October 1989. Health systems research is an integral part of ongoing operational projects in programmes such as EPI and MCH. HSR has also been used in the development of training manuals for health workers and for IEH materials. Legislative support for national health strategies is an important requisite for successful implementation of HFA/2000. WHO support to Member Countries in this area included review and/or revision of existing health legislation, organization of group educational activities, dissemination of new developments on the subject, and contributions to the strengthening of national capabilities. ORGANIWTION OF HEALTH SYSTEMS BASED ON PRIMARY HEALTH CILBg Ever since the concept of primary health care was defined and given international recognition at Alma-Ata, Member Countries have undertaken a number of activities so as to improve their health syatems and to provide efficient and universal primary health care. Consequently, considerable resources have also been allocated to increase coverage and reorient the health system infrastructure. Concern continues to be expressed for attaining equity and social justice, the twin bedrock of the movement towards HF~/2000. Priority has been given to underserved and unreached populations. In many countries, in recognition of the effect of development of other sectors on the improvement of health of the population, formal mechanisms for intersectoral dialogue, cooperation and action have been introduced, based on the common perspective of the need to improve the quality of life of the people. The progress achieved in the distribution, organization, manage- ment and orientation of comprehensive health systems based on primary health care was reviewed at a regional conference on health development, held in New Delhi in March 1989. This was the first year of follow-up in the world to the Riga meeting of 1988. The conference emphasized the need to develop an under- standing in facing problems as well as to identify clear approaches to solving problems. The district health systems approach comprising four critical areas of primary health care and providing for decentralized management responsibilities has been pursued vigorously in all Member Countries. Overall, there has been perceptible progress in the implementation of primary health care as well as improvement in the performance of health infrastructure, even while some of the well-known constraints, such as the lack of equipment, drugs, transport and other support facilities, poor supervision, unequal distribution, inefficient provision of resources etc., remained. Information support for the management of district health syatems was the subject of a meeting held in Surabaya in Indonesia in October 1989. It identified information needs for effective management as well a8 the process of utilization of information. Referral systems have continued to develop. A meeting on Primary Health Care Development, held in Geneva in April 1990, reviewed country experiences in primary health care implementation, options for financing primary health care and the sustainability of primary health care in the last decade of the century. Concern was expressed about environmental deterioration, the emergence of mega cities with alarming increases in population and socioeconomic and political problems besetting countries. It is necessary to anticipate such problems and to take appropriate measures in advance if the health of the people is to be protected. As a follow-up of the UNDP-funded project "Intensification of Action Programme for Primary Health Care", a new project on strengthening medical care facilities in districts, especially designed for the least developed countries, has been submitted to UNDP for approval. It aims to improve the delivery of medical care to district and peripheral health sectors. A regional symposium on the implications of public policy on health status and quality of liie was organized in Bangalore, India. It dealt with urbanization, industrialization and agricultural development as well as the health problems emerging therefrom. A wide variety of experience in terms of inter- sectoral action has been collated by Member Countries in the last two years and it will be possible to build on this in the future. WHO has continued to support efforts to improve and increase community participation in health development. Consequently, in addition to programmes for training health volunteers, other programmes, such as community health fund programmes and mobilization of community resources, have been actively supported. Decentralization of management and administration from the district level down has also been actively pursued. Participants from India and Thailand attended a WHO Study Group on Community Involvement in Health Management, held in Geneva in 1989. In Sri Lanka, an ambitious programme for the alleviation of poverty commenced in October 1989. The supplementary health programme, called Suvasaviya, aims at strengthening primary health care activities and making essential health care available to identified families. This is being supported by WHO. In addition, WHO, in collaboration with the Ministry of Health, has developed suitable research programmes to study the health and nutrition of recipients as well as processes/factors influencing their health. Urban primary health care is receiving closer attention although this is still not adequate. Nongovernmental organizations are taking active interest in urban primary health care. Health administrators and mayors, from Bangkok, Bombay, Colombo and Jakarta in the South-East Asia Region, participated in an interregional meeting on City Health - The Challenge of Social Justice, held in Karachi, Pakistan in November 1989. The inevitability of close intersectoral action to attain better urban health was stressed by the symposium held in Bangalore, India in 1989. DmPMENT OF HUMAN RBSOUBCES FOR HEALTH WHO has continued to support and facilitate the development of human resources for health in pursuance of the goal of Health for All through the primary health care approach. Support has been provided for strengthening technical, planning and manage- ment capabilities in the development of human resources for health as well as for upgrading training facilities and educa- tional technology. This support has not only been through the fellowships programme but also through consultants, supplies and equipment as well as through neetings and workshops. Despite these efforts, there are still imbalances in human resources for health and many projections are over-optimistic and need to be readjusted to take into account the economic slow-down. One effort to redress this has been through the promotion of policy and programme analysis of the development of human resources for health. Following the interregional Seminar on the Financing of Human Resources for Health, held in Bangkok in March 1989, a follow-up workshop was held in Yangon, Myanmar, in February 1990, to formulate the methodology for developing the optimal mix of human resources for health. This innovative approach will be field-tested before adaptation in other countries. Another effort to redress the problems facing the development of human resources for health has been the promotion of research in this area. National workshops to promote research in the development of human resources for health were held in Bangkok, Thailand, in June 1989, in Jakarta, Indonesia, in January 1990 and in Kathmandu, Nepal, in May 1990. Similar workshops will be held in other countries in 1990 and 1991. Since 60 to 80 per cent of health budgets are devoted to human resources for health, a small improvement in productivity or efficiency brought about by appropriate training and deployment of human resources can provide a substantial increase in coat-effectiveness. It is therefore hoped that, through the mechanism of research in the development of human resources for health, it will be possible to redress the problem of imbalance, increase cost-effective planning, production and utilization of human resources. The efforts of Member Countries to strengthen their medical education systems and attain a greater balance of relevance in education and training programnes, particularly at the under- graduate level, have made modest progress towards achieving community orientation of curricula and development of appropriate skills and attitudes. WHO has collaborated with institutions in India, Indonesia, Myanmar and Thailand in experimenting with the introduction of problem-based community- oriented curricula and has also assisted in the planning of a new problem-based Medical School at Thammasat University in Bangkok. In Bangladesh, a high-powered steering committee has been constituted to improve the quality of medical education. A national workshop on the development of methodology to determine the optimal mix of human resources for health was held at Yangon from 13 to 17 February 1990. The three monographs published by the Regional Office in the series on "Reorientation of Medical Education" are being used by Member Countries in their programmes to reorient their medical education systems. WHO has also worked closely with Member Countries to solve their recurrent quantitative and qualitative problems of teacher shortages, lack of essential equipment and supplies and coordination of education systems with the health care systems. It has also provided technical support for overall system development and quality control in respect of postgraduate medical education in Member Countries. WHO has continued to support the development of a core of nurse leaders in the Region. Support has cootinued for the reorienta- tion of basic and post-basic nursing education. Support has also been provided for research in the development of nursing resources. WHO has continued to collaborate with Member Countries in the training of health personnel, particularly in the areas of teacher training, strengthening of training institutions, improvement of educational technology and curriculum develop- ment. The activities include support to countries to develop, field-test, produce and effectively utilize different types of teaching and Learning materials for paramedical, medical and nursing personnel. With the support of UNDP, WHO will provide technical and financial support in the development of health learning materials, including those for distance learning. As a follow-up action to the resolution of the Executive Board in 1983 on WHO fellowships policy (EB71.R6), indicators and guidelines for the self-assessment of the fellowships programme were developed in the Region and field-tested in Indonesia. A preliminary report of the fellowships programme was prepared and submitted to WHO headquarters in November 1989. Supplemented by updated information received from countries on self-sssess- ment of the fellowships programme, these reports are being processed in WHO headquarters for inclusion in the report of the Director-General to the Executive Board in 1991. PUBLIC INFORMATION AND EDUCATION FOR HEALTH During the period under review, information and education for health activities were further strengthened in the Region through programmes of training, development of health education material, research and greater involvement of the media. There was increasing focus on school health education. In view of the increasing importance of health education in AIDS prevention and control, interagency and interregional collaboration was consolidated. Intercountry group educational activities were undertaken to address such aspects of AIDS prevention and control as psychosocial counselling, monitoring and evaluation of health promotion activities, development of health education material for AIDS control, etc. A consultation on AIDS and Media Involvement was held in New Delhi in December 1989. Development, production and dissemination of information and education material were augmented both at regional and country levels. World Health Day, World No-Tobacco Day, World AIDS Day, and other similar occasions were effectively used to draw attention to priority health issues. In particular, this year the focus on environment, which formed the centrepiece for World Health Day, evoked widespread interest. A variety of information kits on subjects such as prevention and control of accidents, self-care and healthy lifestyles, and promotion of women's health in South-East Asia were produced to provide valid information on important subjects. RESEARCH PROMOTION AND DEVELOPPIENT The focus of the regional research programme continues to be on objectives of the programme including the strengthening of national research capabilities, promoting and coordinating research on regional priority problems linked to social and economic conditions of the countries and promoting research designed to enable the application of advanced technologies and modern scientific knowledge to conditions prevalent in the countries. The South-East Asia Advisory Committee on Health Research is a valuable forum which provides expert advice on the nature and type of research to be undertaken in the Region. The role, function and working of the South-East Asia ACHR was considered in detail by a consultative meeting. The sixteenth session of SEAIACHR, held from 2 to 6 April 1990 in Chiang Mai, Thailand, undertook an overall review of the regional research programme and in particular discussed research issues related to oral health, tuberculosis and quality assessment of health care delivery systems. A number of collaborative research projects, including investigator-originated projects, focusing on issues of regional priority and interest, have been supported. The multicentre collaborative projects require considerable nurturing in the form of technical support, organization and coordination by the Regional Office. However, considering the potential for long-term benefits from auch projects, these continued to be supported. In addition, consequent on the advice of the Regional Advisory Committee on Health Research and the Regional Committee, institutional strengthening is receiving greater attention in the Region through supplemen- tation of research projects. To achieve progress in this area, discussions commenced with four countries and resulted in two of the countries being given grants for institutional strengthening. Progress in the development of dengue vaccine has been steady. The Seventh Peer Review Meeting, held in August 1989, recom- mended the trial of three candidate dengue vaccines (1, 2 and 4) as a single inoculation and also recommended clinical trials in general. It is a matter of satisfaction that this project is also providing valuable opportunities for the transfer of tech- nology to the institutions. A collaborative epidemiological study on non-A non-B hepatitis is progressing in Myanmar, Indonesia, Mongolia and Thailand, and is expected to lead to better understanding of the epidemiology of the disease. A number of other collaborative research studies on auch subjects as research in maternal and child health, epidemiological and socio-cultural aspects of ageing, etc., have been supported. In addition to intercountry research funds, 52 research projects have been funded through country RPD and HSR allocations. The award of visiting scientist and research training grants has helped in significantly improving the research capabilities of the Region. Gm HEALTH PROTECTION AND PROMOTION The training aspects of the nutrition programme were modified by taking into account the needs of the programme. Low birth-weight arising out of foetal malnutrition is a common phenomenon in many of the Member States. Protein-energy malnutrition, which, inter alia, is also responsible for low birth-weight, has shown -- a slow but steady decline. Considerable advances have taken place in the programme on Iodine Deficiency Disorders (IDD) since its initiation in 1989. The progress will be reviewed in October 1990. Ao interregional Symposium on Vitamin A Deficiency was held in Kathmandu in November 1989. The symposium reviewed strategies and new developments, and stressed the need for a balance between the production of high potency vitamin A capsules and the promotion of food sources of vitamin A. Discussions have been initiated to set up a nutrition research- cum-action network and the first meeting in this regard will be held in Thailand in August 1990. The global Joint WHO/ UNICEF Nutrition Support Programme (JNSP) is coming to an end. The activities will be absorbed into the regular programme. The JNSP in Myanmar is due to be incorporated into that country's national budget by the end of 1990. An evaluation in Myanmar shows a small reduction in malnutrition deapite a stagnant economy. The increased emphasis on training in the programme has already been incorporated into regular practice. In Nepal, the JNSP has been considerably revised. There is now a strong emphasis on job-related nutrition training of health workers. Dental caries and periodontal diseases are increasing sharply in most countries due to lack of adequate nutrition, non- availability of oral health care and low levels of oral hygiene. Surveys were conducted in February 1990 in Indonesia, Sri Lanka and Thailand to assess the magnitude of oral health problems. The results of the surveys were reviewed by the sixteenth session of SEA~ACHR in April 1990 and the levels of oral hygiene were deemed as unacceptably low. WHO has continued to collaborate with Member Countries in training national oral health personnel, strengthening institutional capabilities and providing equipment and literature. The South-East Asia Region accounts for 25 per cent of the three million deaths which occur in the world as a result of injuries, with traffic accidents being the prime cause. Fatality rates due to traffic accidents have been on the increase in almost all countries. WHO lays great emphasis on the promotion of surveys, data collection, and epidemiological and operational studies, so as to increase national awareness on the health aspects of injuries and accidents as well as the socio-economic effects. There is also a need to improve, streamline and strengthen legislation and associated rules, regulations etc. as well as a need for fair and equitable enforcement of the law. The ill-effects of tobacco are being increasingly realized in most countries. World No-Tobacco Day on 31 May was observed with much public participation and much visibility. 'Tobacco or Health' Medals were awarded to prominent health leaders of the Region who have been outstanding in the 'No Tobacco' movement. In Bhutan, entire districts have been declared tobacco-free. In India, work has been initiated for developing a national plan of action for the control of tobacco-related cancers. Smoking has also been banned on national carriers in many countries. A Multicentre National Committee for Control of Tobacco Use has been formed in Thailand, which is spearheading the movement for the prohibition of cigarette imports into Thailand. In Bangladesh, a countrywide survey on tobacco use has been completed, and support to anti-tobacco activities is available from the highest levels of the Government. PROTECTION AND PROMOTION OF THE HEALTH OF SPECIFIC POPULATION GROUPS It is encouraging to note the current trend in the countries of the Region where the holistic, integrated approach to the delivery of maternal and child health is being accepted as a standard. This has resulted in an integrated system of service delivery in the context of PHC. The gravity, as exemplified by high maternal mortality, has been recognized with countries determining the need to address this problem with greater emphasis on maternal care and safe motherhood. Most countries have initiated safe motherhood activities. Family planning and child-spacing are vital components of the programme in achieving better health for mothers and children. In most countries, priority programmes like FP, EPI, CDD, ARI and nutrition are implemented within the framework of the MCH infrastructure, or at least in close coordination with MCH. The need for wider service coverage and improvement of the quality of services is being recognized. Collaborative programmes are included in service training, meetings and consultations. Support has also been provided for studies aimed at strengthening programme development and improved strategies for the delivery of MCHtFP services. National research projects directed towards improving maternal health have been undertaken in many countries and, inter alia, include maternal mortality and morbidity surveys, multidisciplinary control trials on the use of the partograph in the management of labour, and a KAP study for mothers-in-law regarding maternity care of daughters- in-law. An intercountry Workshop on Safe Motherhood Initiative was held in the Regional Office in November 1989. Representa- tives from SEAR countries also participated in the Safe Motherhood Confcrence, held in Lahore, Pakistan in March 1990. Activities under the Women, Health and Development (WHD) programmes were aimed at strengthening the involvement of women's organizations in health promotion and at enhancing the exchange and dissemination of information. Major issues relating to women's roles at various levels were identified in conjunction with other international and bilateral agencies. Interagency meetings, sponsored by the participating agencies on a rotational basis, are being held every month. Programmes for adolescent health, which, in the earlier years, formed a part of maternal and child health, are now being stressed separately, with countries making modest budgetary provisions for the same. It is evident that this programme calls for dynamic leadership and multidisciplinary approaches. The South-East Asia Region has continued to collaborate actively in the WHO Special Programme for Research, Development and Research Training in Human Reproduction (HRP) within its two major areas, namely, support for research into finding and developing new, safe and effective methods of fertility regulation and support for research aimed at improving the performance of existing methods of fertility regulation. Research grants have been awarded to various institutions in the Region to pursue clinical trials on long-acting injectable contraceptives, experimental studies on post-ovulatory methods of contraception, evaluation and monitoring of contraceptive safety, contraceptive effects on blood factors, the cardio- vascular system, and ectopic pregnancy, etc. The rapid industrialization in many countries of the Region has resulted in increases in the extent and variety of occupational diseases and accidents. Occupational health is therefore of great significance to the Region, but there is a general failure to recognize the growing importance of occupational health and safety. This is exemplified, among other things, by the lack of adequate policies and legislation for the protection of health and the safety of workers. Problems of long-term socio-economic and health implications, such as rapidly greying populations, increasing occupational health hazards, and ever-increasing rates of injuries and disabilities of different causations, have always been over- whelmed by more urgent problems leaving the long-term problems behind as far as health allocations are concerned. Now it is time to take these problems more seriously, as the quality of life and the very philosophy of HFA/2000 will be greatly affected by such problems, which call strongly for timely inter- vention and interdisciplinary and intersectoral cooperation based on sound scientific knowledge. PRO~ION AND PROTECTION OF KENTAL IIBALTH A WHO-supported multicentre study in India has confirmed the high correlation between social aspects of family functioning, subjective well-being of mothers, and parameters of healthy development in children, particularly their cognitive development and nutritional status. This and related studies in Sri Lanka and Indonesia, have resulted in the development of realistic interventions focusing particularly on the well-being and coping skills of mothers for healthy child development in dysfunctional families. The Regional Coordinating Group for Mental Health Programme has also developed a protocol for a study to clarify the psychosocial sensitivity of physicians. Studies are also being undertaken on the development of psychosocial interventions for the containment of AIDS, and preliminary findings show a reduction in risk behaviour in selected risk groups. The involvement of ministries of health in programmes to reduce problems relating to alcohol and drug abuse is still limited in most countries of the Region. Although studies in many countries have shown that health personnel can play a very effective role in preventing and reducing substance abuse, the health systems do not appear to involve themselves closely. WHO has organized training courses for health personnel in India and Sri Lanka. It has also supported a study, conjointly with ESCAP, on a rehabilitation programme for drug dependent persons. A drug abuse monitoring system is being established in Sri Lanka and WHO has continued to execute UNFMC-supported drug abuse control programmes in Myanmar and Sri Lank. In both these countries the epidemic of heroin dependence seems to have been contained. Efforts are also on to maximize community involvement in localized activities for eliminating rural opium use as well as urban heroin use. The high risk of HIV infection in injection drug users has added a new dimension to drug dependence. Plans have been drawn up to establish a monitoring system concerning the route of drug administration and to reduce the risk of HIV infection in drug injectors and their partners . WHO'S activities in regard to prevention and treatment of mental and neurological disorders have two major thrusts, namely, development of technologies and support for the improvement of national capabilities for national mental health planning. The Regional Coordinating Group for Mental Health Programme has reviewed the list of skills needed at the primary health care level in relation to mental health, and has prioritized research needed to fill the gaps in existing knowledge. A list of indicators for the quality of mental health care in mental health hospitals has also been developed. These form the basis for the national mental health programme in Indonesia and have resulted in the restructuring of postgraduate training in psychiatry. PROHOTION OF ENVIRONMENTAL HEALTH The emphasis of the WHO programme has shifted to the broader issues of environment in keeping with rapid urbanization and industrialization, continued migration from rural areas to urban core and urban fringe areas, and with the growing awareness of the adverse effects on health by environmental pollution. The new global environmental health strategy, including as it does environmental health in rural and urban development and housing, prevention and control of environmental pollution and health hazards, environmental health impact assessment, control of poisoning, hazardous waste management, health risk assessment, and epidemiological and chemical safety has been received favourably by most countries. The action agenda recommended by the Consultation on International Drinking Water Supply and Sanitation Decade (IDWSSD), 1988 has been pursued vigourously. Efforts are now concentrated on the development of a new global community water supply and sanitation strategy for better comprehensive planning and on the implementation of sustainable sectoral activities in the last decade of the century. Efforts for the mobilization by communities of support of external agencies, with emphasis being given to manpower training, institutional development, and water quality surveillance, have continued. Groundwater development continued to be given high priority in Bangladesh, Myanmar, India, Indonesia and Sri Lanka, with emphasis on hydrogeological services, test drilling and exploitation of groundwater resources. All developing countries of the Region are faced with problems associated with unbridled urbanization. This has resulted in squatter settlements and overcrowding with consequent over- loading of the water supply, and of excreta disposal, waste water, collection and disposal facilities, etc. WHO has continued to support the promotion of intersectoral cooperation and co~mnunity self-reliance along with the use of appropriate technology. Solid waste management is also emerging as an important problem. An intercountry Consultation on Solid Waste Management, using the available information from the Member Countries, will be held in late 1990. Recycling of urban solid waste has been studied through a research project in Calcutta, India. The programme of health risk assessment of potential toxic chemicals began in 1990. This is largely research-oriented and aims to produce and disseminate public information on poten- tially toxic chemicals for use by the countries. WHO has assisted Indonesia in drafting legislation for labelling, storage and transportation of hazardous substances. In regard to the control of environmental health hazards, WHO'S collaborative efforts have been in the strengthening of national institutions and manpower capabilities. An intercountry conference, held in 1989 in the Regional office, resulted in the identification of several activities including hazardous waste management, emergency preparedness/response, poison control, etc. This has helped not only in the tripartite review of the UNDP assisted intercountry project on safety and control of pollutants and toxic chemicals, but also in the development of a new project document for UNDP assistance. WHO has supported the training of nationals from Indonesia, Sri Lanka and Thailand in a poison control workshop, held in Malaysia in November 1989. A course on risk assessment and management of toxic chemicals was conducted in December 1989 in Thailand. National workshops have been held in Sri Lanka, India and Indonesia. In addition to supporting institutional developoent, infotoation use in management has also been supported by the supply of computer hardware and software. Water quality monitoring activities under the Global Environmental Modtoring System (GEMS) have continued in Bangladesh, India, Indoneeia and Thailand. Likewise, ambient air quality monitoring and food contamination monitoring were undertaken in India, Indonesia and Thailand. WIO has supported the strengthening of national infrastructures and development of standards and legislation for ensuring greater food safety. A national Workshop on Food Safety in Public Catering, held in Hyderabad, India in November 1989, identified shortcomings in food safety practices. WHO supported the formulation of health regulations for restaurant hygiene and sanitation in Indonesia and the preparation of guidelines for hygiene and sanitation inspectors. Support for monitoring fwd contamination by pesticides was provided to India and DPR Korea. Surveys on pesticide residues in food commodities and on the use of food additives were initiated in India. The Codex Alimentarius Coordinating Committee for Asia held its seventh session in Chiang Mai, Thailand, in February 1990, and was attended by several countries of the Region. DIAGNOSTIC, THERAPEUTIC AND RElUBILITAl'IVB TECENOLLYX Since health laboratory services play a vital role in health care programmes, WHO has continued to support Member Countries in strengthening laboratory services, particularly at the district level, through training programmes. Supplies and equipment, reagents and kits have also been provided to a number of institutions in almost all countries of the Region. The production of modern immunological and biological reagents in Bangladesh, India and Sri Lanka is being supported with a view to achieving regional self-reliance through a UNDP-funded project. Efforts were made to strengthen health laboratories and hold workshops to improve methods for the diagnosis and control of Shigella-Dysenteriae-I. The National Institute of Health in Thailand has been able to provide diagnostic antisera to other countries of the Region. Similarly, the WHO Colla- borating Centre for Reference and Training in Streptococcal Diseases at the Lady Hardinge Medical College, New Delhi, in addition to carrying out reorientation courses, has also supplied reagents for the diagnosis of streptococcal infection to several institutions in the Region. Support was given for improving capabilities of producing reagents in rapid diagnostic techniques for the surveillance of priority diseases. WHO has supported the development of national capabilities in the sers-surveillance of AIDS. An intercountry Workshop on Advanced Techniques of HIV Antibody and Antigen Detection was held in Bangkok in December 1989. This will be pursued in the coming year. A workshop, held in December 1989, reviewed the progress in the streamlining of blood transfusion services and formulated guidelines for improving the safety of blood and blood products utilizing modern technology. Hospital-acquired infections have a high average incidence of 10 per cent in the countries of the Region. WHO, in taking note of this, is trying to develop regional and national strategies for HA1 control and surveillance, and has held workshops in Bangladesh, Nepal, Sri Lsnks, India and Myanmar. Though plague is no longer a problem, it is still necessary to keep track of the continued existence of natural foci of sylvatic plague. An interregional Consultation on Plague, held in New Delhi in September 1989, laid down guidelines for epidemiological surveillance, preventive technologies, strengthening of laboratories and supply of reagents. WHO has also stressed the need to promote regional self-sufficiency in monitoring radiation effects. Through collaboration with the countries in the Region the Essential Drugs Programme has been strengthened, especially in quality assurance, manpower development and rational use of drugs. Also, collaboration to improve drug procurement, storage and distribution has been initiated in Bhutan. Essential Drugs Programmes have been initiated in Myanmar and Thailand. The UNDP-funded ASEAN~WHO pharmaceutical project is an example of successful technical cooperation in the field of pharmaceu- ticals, and is progressing satisfactorily. Standard treatment regimens have been established and imple- mented in the countries of the Region. Rational use of drugs has been further promoted through national and interregional training courses. Computer technology in regard to drug management, drug information and adverse reactions has been adopted in several programmes. The production of plasma-derived hepatitis B and oral polio vaccines has been strengthened, and emphasis has been placed on assuring quality. To ensure drug quality, safety and efficacy, much emphasis has been placed on training in good manufacturing practices and on different aspects of drug quality control, such as equipment, manpower training and management. The WHO Certification Scheme has been promoted and several recommendations were made for its optimal utilization. To facilitate dmg evaluation and regis- tration and to promote rational use of druga, the establishment of drug information systems is being supported by WHO in several countries. Cultivation, production and quality assurance aspects of traditional medicines have been promoted through WHO colla- boration. Guidelines to support the countries in setting up or strengthening, as necessary, legislative and administrative systems for the registration of traditional medicine products have been provided to all countries in the Region. Research projects and educational activities have been supported in order to promote the utilization and integration of traditional medicine in the health care system. DISEASE PREVENTION AND CONTROL Substantial progress has been made towards achieving the main objectives of EPI and also the goal of Universal Child Immunization by the end of 1990. The surveillance system has been improved in all the countries in respect of the six target diseases, and the immunization coverage percentage has increased to 69 per cent for DPT-3, 66 per cent for OPV-3, 78 per cent for BCG, 54 per cent for measles and 51 per cent for TT2B. The health infrastructure is playing a more positive role wlth immunization being provided through an integrated approach. This integrated strategy was also discussed st a workshop held in New Delhi in March 1990. Initiatives have also been taken with regard to the manufacture of EPI vaccines. India is proceeding with plans for the manufacture of measles and polio vaccines in 1993. Indonesia is also taking similar steps. Practical training in laboratory diagnosis, cell culture and potency-testing of polio as well as measles vaccines was imparted in an intercountry workshop held in Harch-April 1990. The results of potency testing have not been encouraging, due mainly to cold chain failure. The cold chain and logistics system is under constant review. Solar refrigerators are now being used in problem areas and attempts are being made to improve and introduce sustainable technology for the cold chain. The financial resources for achieving the goal of Universal Child Immunization are short of requirements. This may have some effect on the intensive activities needed in the next ten years for polio eradication, neonatal tetanus elimination and measles reduction. Vector-borne diseases are the cause of a great deal of morbidity and considerable mortality in the countries of the Region. The control of vector-borne diseases is complex. It is becoming increasingly apparent that the effective use of control methods requires a sound knowledge of the epidemiology of the specific disease and of the biology and ecology of the vectors. WHO has continued its technical support to Member Countries in their programmes to reduce morbidity and mortality caused by vector-borne diseases. Greater emphasis is being laid on technological development, applied field research including social and behavioural aspects of communities, and on technical manpower development for the control of vector-borne diseases. Though the malaria situation continued to show a declining trend in most of the malarious countries, the malariogenic potential was still very high in the Region, with the disease ever ready to assume epidemic proportions or to re-establish a high degree of endemicity when control operations slacken or are discontinued. The incidence of P falci arum malaria, parti- cularly of its resistant strains, te any signi- ficant change, and is thus continuing to pose a major technical problem. This has been compounded by the further spread of vector resistance to a wide range of insecticides, by large- scale population movements, by vector exophily and by human behaviour factors. Administrative and financial constraints as well as civil unrest are also contributing factors to the present, somewhat slow progress of malaria control programmes. However, stratification of malarious areas, development of appropriate manpower at district and peripheral levels, and adaptation, based on an epidemiological approach, of the revised malaria control strategies through primary health care aystems has brought the malaria control programmes closer towards their general objectivea of preventing mortality and decreasing disease morbidity. Considerable efforts have been made by WHO, in collaboration with the countries, in conducting training, planning, and implementation and evaluation of malaria control activities in a rational manner, keeping in mind the limited resources available for the control of the disease. The promotion of programme-oriented field studies and research to solve both technical and operational problems in the malaria control programmes was one of the main concerns of WHO. These studies have helped the countries to further strengthen national research cadres, develop appropriate national policies and review disease control methodologies. Countries of the Region continue to be affected by a variety of parasitic diseases of public health importance. Intestinal parasitic infections associated with undernutrition, poor personal hygiene and environmental sanitation continue to be public health problems. Sumeillance has been undertaken in India and Nepal and new approaches for mass treatment of children and women of child-bearing age by training of health personnel and community involvement are under contemplation. India is the only country in the Region affected by guineaworm infection, with seven states reporting guineaworm cases before, although now the number of endemic states has been reduced to six. In all these states, the number of cases is declining. Ten epidemiological team were deployed in 1989 and it is hoped, with increased community participation, to eradicate this disease by the end of 1991. Visceral leishmaniasis is a health problem particularly affecting the underprivileged and lower socioeconomic groups in the rural areas of the states of Bihar, West Bengal and Uttar Pradesh in India as well as in Bangladesh and Nepal. WHO collaborated with UNDP from 1986 to 1989 in an intercountry project for the control of leishaaniasis. This has resulted in improving research capabilities and strengthening training facilities. Bangladesh has worked out a national control programme. With regard to filariasis, in addition to intensive research, particularly on chemotherapy, an integrated control strategy in the context of PHC is gaining ground. The UNDPlWorld BanklWHO Special Programme for Research and Training in Tropical Diseases (TDR) has supported the Region and helped in achieving good progress in the ongoing field trials of new drugs against malaria, filariasis and leprosy. Progress has also been achieved in the development of nwer immunological test kits and DNA probes for diagnosis and in field trials of biological control agents in malaria. The constant follow-up on studies of transmission-blocking antigens of P.vivax has continued. New institutional strengthening grants have been awarded to institutions in the Member Countries of the Region, in order to ensure that institutions eupported by TDR are able to use their increased capabilities and participate in the Programme's research and development activities, as well as in the control programmes of their countries. The Regional CDD Programme was established in 1979 and all the eleven Member Countries have national programmes which are being implemented as part of the primary health care services. The objectives are to reduce mortality due to diarrhoea in the short-term through increased use of ORT, and ultimately to reduce morbidity through the promtion of improved maternal and child health care, improved environmental sanitation, and epidemic control. The major strategy continues to focus on improved case management, primarily through increased use of ORT. To implement this strategy, training activities in programme management, supervisory skills and clinical management continued to receive high priority during the year. In addition, the establishment of diarrhoea training units was encouraged in all the countries of the Region. The ORS access rate reached 67 per cent for the Region as a whole while the ORT use rate reached about 30 per cent. The total of locally-produced and imported ORS surpassed 100 million litres for the first time. Eight Member Countries have completed household clinical management surveys or plan to conduct such surveys to evaluate their CDD programme indicators. ARI, together with diarrhoea1 diseases and malnutrition, are the leading causes of death each year among children in the countries of the Region, with the death rate due to ARI in children under 5 years of age varying from 20 to 30 per cent. Most countries have developed national plans for the control of ARI. Of the four intervention studies on ARI, those in Nepal and India have been completed. Training modules using a multi-media approach have been prepared and field-tested and these are now being used in India and Indonesia. There has been no perceptible let-up in the effect of tuber- culosis. Sustained efforts have continued for the detection of new cases and appropriate treatment. The appearance of HIV infection is now causing concern since dual infection with M.tuberculosis and the HIV virus is likely to result in increasing incidence of tubercuolsis. WHO has been supporting Member Countries in epidemiological surveillance on the prevalance and incidence of the disease. In particular. WHO collaborated in various facets of the programme with Bangladesh, India, Indonesia, Nepal, Sri Lanka and Thailand, including, inter alia, improvement of diagnosis and treatment facilities, -- strengthening clinical research activities, providing training facilities, providing supplies and equipment and in intervention studies. The sixteenth session of the SEA~ACHR, held in Chiang Mai, Thailand, in April 1990 discussed research in tuberculosis and recommended further intensification of research in tuberculosis, including a review, of the effectiveness of BCG as a tool in EPI. The external donor support for tuberculosis has been on the decline and concerted efforts are needed to mobilize additional resources for the programme. While leprosy still continues to be among the major public health problems in 9 out of 11 Member Countries of the Region, notable progress has been made in leprosy control activities during the past year. A rapid expansion of MDT coverage, early detection of infection and a marked reduction in deformity in newly-diagnosed cases have been witnessed. Increased awareness and confidence in IfDT regimens has been instrumental in further promoting political commitments at all levels and in promoting an appreciable increase in early detection of cases. WHO on its part continued to provide technical and financial support from regular and extrabudgetary resources. As a steady decline in the patient load is being witnessed, the need for the rehabili- tation of deformed cases is emerging as an important challenge to Member Countries as well as to WHO. This further reiterates the need for the integration of leprosy control activities with primary health care, in order to rationalize and optimize available human and material resources. WHO supported Member Countries in their endeavours to reduce the incidence and prevalence of zoonotic diseases, with the ultimate aim of preventing them in man. WHO supported three workshops in India on laboratory techniques in rabies, on vaccines and treatment of rabies and on control of lepto- spirosis. Nepal has beea supported in its programme for the control and elimination of rabies with funds from a French organization, Veterinarians sans Frontieres. In Sri Lanka too, the implementation of a new Rabies Control Act is being pursued vigorouely with the objective of eliminating human and canine rabies . WHO continued to assist Hember Countries in reviewing their programmes for the production of vaccines, strengthening the monitoring process, introducing newer technologies and strengthening quality control capabilities. A regional strategy for self-sufficiency in EPI vaccines has beea formulated. Myanmar and Mongolia are being assisted in producing hepatitis B vaccine. Sexually transmitted diseases (STD) have assumed a higher priority with the advent of AIDS in some countries of the Region. WHO has supported Member Countries in strengthening national capabilities for the collection and analysis of epidemiological data in respect of STD and AIDS and in developing suitable control strategies. A meeting held in Geneva in January 1989 identified STD as a risk factor for HIV transmission and agreed that the programmes on STD and AIDS should work together. AIDS is not yet considered to be a priority health problem in many countries of the Region, though the situation is getting worse and causing concern in some countries. In the absence of a cure, the focus of WHO attention has been on prevention through health education. WHO has supported Member Countries in the formulation of short-term and medium-term plans of action to effectively prevent the spread of HIV infection. There is a need for coordinated action at all levels. This has been recognized in the Regional Plan of Action under which an epidemiology-based strategy has been developed. The emphasis in Member Countries has been on epidemiological surveillance to learn the extent of the disease and its prevalence in high-risk groups, detection of HIV infections, improvement in public health information through mass media, and on safe use of blood and blood products, etc. From an overall epidemiological viewpoint, the problem of AIDS is of great concern in Thailand and India. Bangladesh, Bhutan, DPR Korea, Maldives and Mongolia have reported '0' HIV positives as of 30 April 1990. In India, while HIV infection has so far been recorded only among female prostitutes, evidence has come to light that heterosexual transmission is taking place. In Thailand, the number of HIV-infected persons has increased very rapidly. In Myanmar too, the transmission of HIV among intravenous drug users is viewed as a major problem. WHO has collaborated with Member Countries in enhancing their capabilities in the prevention and control of other communicable diseases, including Japanese encephalitis (JE), meningococcal meningitis, viral hepatitis and dengue haemorrhagic fever. Japanese encephalitis is a public health problem in India, Indonesia, Nepal, Sri Lanka and Thailand. In Nepal, a detailed work plan for mass vaccination against Japanese encephalitis has been prepared. Meningococcal meningitis is a health problem in India and Nepal. WHO has collaborated in developing an early warning system for early detection and reporting of cases in the states of Gujarat, Orissa, Bihar, Rajasthan, Mahsrashtra and Delhi in India. In Nepal, after the last epidemic of 1983-1984, mass vaccination campaign was successful in containing further outbreaks. Haj pilgrims leaving India are being provided with imported bivalent (A+C) vaccines. An intercountry Consultative Meeting on Surveillance and Control of Meningitis was held in Kathmandu in October 1989 to review the situation and improve the guidelines. Hepatitis A virus infection is a common problem in South-East Asia. Hepatitis B virus infection is also a serious problem in the Region with an estimated 70 million carriers. Non-A and non-B hepatitis is also emerging as a problem in the Region. WHO has sponsored epidemiological studies in Indonesia, Mongolia, Myanmar and Thailand and has already provided laboratory facilities, kits and reagents for diagnosis. An intercountry Meeting on Entericslly Transmitted Non-A and Non-B Hepatitis was organized in New Delhi in July 1989. WHO has also collaborated in the production of local HEV diagnostic reagents in India, Indonesia, Mongolia, Myanmar and Thailand. In the area of blindness and deafness prevention, greater emphasis has been placed on the strengthening of managerial skills and capabilities of national-level personnel. While disease trends have shorn a reduction in communicable and nutrition-related diseases causing blindness, ageing-related conditions, such as cataract and glaucoma, pose an increasingly formidable challenge. Intensified interventions for such conditions are being planned and implemented in several Member Countries. Cancer is slowly emerging as an important cause of death in the countries of the Region with the problem being aggravated by late detection. This is true particularly of oral cancer and cervical cancer. India has a comprehensive national cancer control programme. WHO has supported the improvement and extension of the existing cancer registries and has stressed the importance of prevention and early detection of most cormon cancers through public education campaigns and development of educational materials. Such activities are being supported in Myanmar, Sri Lanka and Thailand. Cardiovascular diseases seem to be on the rise in the Region as seen from the available lnformation based on hospital statistics. WHO is supporting studies on risk factors in India, Myanmar and Sri Lanka. Hypertension and the related risk of stroke are recognized as being prevalent in the countries of the Region though the countries do not have resources for large-scale hypertension control programmes. WHO has supported Bhutan and Myanmar in planning control measures for cardio- vascular diseases. DPR Korea has been supported in the improve- ment of vascular surgery. The control of rheumatic fever and rheumatic heart disease in some countries, with AGFUND support, has entered the second phase. The incidence rates of these diseases are high enough to warrant the inclusion of rheumatic fever and rheumatic heart disease control measures in school health programmes. HEALTH MOORMATION SYSTEM Information support to various health clientele in the Region is being effectively supplied by the HeLLIS network which continues to be fully operational in eight Member Countries. The HeLLJS national focal points met at a workshop in Bangkok from 23 October to 6 November 1989 to acquaint themselves in newer technologies in health science libraries such as Micro-ISIS Software, CD-ROM and MEDLINE Database training. CE-ROM is now available in Bangladesh, India, Indonesia, Myanmar and Sri Lanka. The compilation and publication of Index Medicua for the WHO South-East Asia Region has been continued. While only one new title was published under the SeARO Publication Series, the sale of WHO publications has increased over that of the previous year. In line with its avowed policy of making available valid information, support has been provided for the translation of WHO publications into regional and local languages. WHO also participated at the World Book Fair held from 13 to 18 February 1990 and the Health and Medicare Exhibition held from 25 to 31 March 1990 in New Delhi. SUPPORT SERVICES A number of visitors, including ministers of health from South-East Asia and other regions, visited the Regional office. The two-way exchange of views that occurred during their visits helped in strengthening the mutually-interactive process of decision-making. The Director-General visited the Regianal Office in March 1990 and also met dignitaries in India. The Regional Director espoused the cause of the Member Countries of the Region at the Executive Board and the World Health Assembly. He also participated in a number of workshops, seminars etc., both within and outside the Region, and utilized these occasions to focus on the valuable efforts being made by Member Countries in their efforts to achieve the goal of Health for All by the Year 2000, and also to seek financial, physical and moral support. A total number of 107* established professional posts have been filled, and four posts have remained frozen. Twenty-two posts have remained vacant as of 30 June 1990. A total number of 196 consultants were utilized in various projects to provide the much-needed technical support to the countries. The Administration and Finance information system has been implemented on an IBM-36 minicomputer. This will provide expanded capabilities for financial and implementation information for operational and managerial purposes. *Includes 8 posts filled by consultants. The total obligation during the biennium 1988-1989 as of 31 December 1989, under all sources of funds, was uS$99 774 588. This was 9 per cent higher than the corresponding figure of 1986-1987. The obligation from 1 January to 31 May 1990 under the Regular budget was uS$23 976 293 amounting to 29.7 per cent of the regional allocation for the 1990-1991 biennium. During the period July 1989 to March 1990, medical supplies and equipment worth U~$14 741 482 were procured. Apart from the usual items, there has been an increase in the number of requests for diagnostic kits and supplies. Local purchases were increased to the extent possible where improved support and maintenance facilities were available. Requests for a total of US$235 466 from India, Nepal and Bangladesh to meet emergency situationa such as natural calamities were responded to. Myanmar, India, Bangladesh and Nepal have availed of the revolving funds scheme under which a total of US$1.97 million were spent. The above summary gives a vivid picture of the activities of WHO in the South-East Asia Region. Complete details of the above are available in the following pages. SECTION I DIRECTION, COORDINATION AND MANAGEMENT I Chapter 1 GOVERNING BODIES 1.1 WORLD HEALTH ASSEMBLY The Forty-third World Health Assembly was held in Geneva from 7 to 18 May 1990. Dr Plutarco Naranjo, Minister of Health of Ecuador, was elected President, and Dr Pagvajavyn Nymadawa, Minister of Public Health and Social Services of Mongolia, was elected one of the five Vice-Presidents. The Assembly was historic in the sense that the Member Countries showed a high degree of diplomacy and understanding which resulted in harmonious and purposeful cohesiveness. The Assembly considered a broad range of health issues and adopted 26 resolutions, including a few on politically-sensitive topics, with general consensus and without resort to voting. The Assembly expressed deep concern at the scale of the international problem of illicit drugs production, trafficking and abuse and noted that a United Nations Special Session on Drugs, held in February 1990, had proclaimed 1991-2000 to be the United Nations Decade against Drug Abuse. While urging Member Countries to devote appropriate resources to the development of national programmes of action, the Assembly has, inter alia, urged the Director-General of WHO to ensure a -- coherent approach between WHO'S action to reduce drug abuse and its action in related areas such as alcohol abuse and prevention of the spread of AIDS. Stressing the importance of the Paris Declaration on Women, Children and AIDS, the Assembly urged Member Countries to ensure that programmes for the control of HIV infection/AI~S are coordinated or integrated with other programmes for women, children and families, and that, if infected, these groups receive appropriate information and counselling. Member Countries were urged to implement multisectoral, comprehensive tobacco control strategies as also plans for legislation and other effective measures providing for effective protection from involuntary exposure to tobacco smoke in indoor work places, enclosed public places and public transport. While requesting Member Countries to support the WHO Action Programme on Essential Drugs, the Assembly invited bilateral agencies and ultilateral agencies inside and outside the UN system, and voluntary agencies to support developing countries in setting up and carrying out programmes aimed at ensuring rational use of drugs, in particular the essential drugs programme. As regards iodine deficiency disorders, the Assembly decided that considering the progress already made and keeping in view the potential of current and planned national prevention and control programmes, WHO should aim at eliminating iodine deficiency disorders as a major public health problem in all the countries by the year 2000. With a view to improving technical cooperation among developing countries, the Assembly called upon the developed countries to intensify their support to the developing countries, parti- cularly the least developed ones, for accelerated implementation of Health for All through primary health care for effective implementation of health development programmes. The Assembly commended WHO for establishing the Commission on Health and Environment to examine, inter alia, the subject of hazardous wastes and their potential effects on human health. Member Countries were urged to establish and strengthen programmes for environmentally sound management of hazardous wastes in accordance with health-based hazards and to extend the health surveillance system, including epidemiological studies. Technical Discussions were held on the "Role of Health Research in the Strategy for Health for All by the Year 2000". While the Assembly noted the various recommendations dealing with health systems research, nutrition research, research capability strengthening and recent advances in biological and physical sciences and their implications for health care, it called on all Member Countries to undertake essential health research appropriate to national needs. 1.2 EXECUTIVE BOARD The three countries from the South-East Asia Region entitled to designate a person each to serve on the Executive Board are Bangladesh (1988-1990), India (1989-1991) and DPR Korea (1990-1992). The Programme Committee of the Executive Board met in Geneva from 3 to 6 July 1989 and reviewed the presentations of programme orientation by the Director-General and the Regional Directors, the proposed allocation of resources and draft procedural guidance to be issued by the Director-General in co~ection with the preparation of the Proposed Programme Budget for 1992-1993, changes in the programme budget for 1990-1991, and method of work of the World Health Assembly. The manner and schedule of reporting by the Director-General to the Executive Board and the World Health Assembly on the work of WHO and the progress in implementing the Global Strategy for Health For All were also examined. Certain suggestions were made for the consideration of the regional committees, the Executive Board and the World Health Assembly on the above issues, which were taken up at the forty-second session of the Regional Committee as well as at the eighty-fifth session of the Executive Board. The eighty-fifth session of the Executive Board was held from 15 to 24 January 1990. The Board considered the report of the Director-General on strengthening technical and economic support to countries facing serious economic constraints and proposed a resolution for adoption by the Forty-third World Health Assembly recommending actions by Member Countries, the international community and the Organization. The Board endorsed the reformulated global indicators for the monitoring and evaluation of national strategies for Health for All, particularly for the second evaluation to be undertaken in 1990-1991. WHO'S continuing efforts to provide a strong, effective and coordinated leadership in global activities for the prevention and control of AIDS were noted. The Board agreed that WHO shall aim at the elimination of iodine-deficiency disorders as a major public health problem in all countries by the year 2000. The Board expressed concern over the decreasing prevalence and duration of breast-feeding in many countries. It reaffirmed the unique biological properties of breast milk, providing protection against -infection and stimulating the development of the immune system in infants, besides having a positive impact on the physical and emotional health of the mother and contributing to child-spacing. The Board recommended for the consideration of the Forty-third World Health Assembly enhanced travel standards for members of the Executive Board, delegates to the World Health Assembly, representatives at regional committees and members of expert committees, study groups and scientific groups. In addition, substantive discussions were held on relations with NGOa, international classification of diseases, and certain financial matters. Every year, WHO awards a number of prizes and medals in recognition of outstanding work done by individuals andlor institutions in the field of health, such as the Leon Bernard Foundation Prize, Sasakawa Health Prize, Darling Foundation Prize, and so on. It is heartening to note that this year Dr B.N. Tandon (India) has been awarded the Sasakawa Health Prize, and Dr S. Pattanayak (India) the Darling Foundation Prize. These prizes were presented during a plenary meeting of the Forty-third World Health Assembly. The eighty-sixth session of the Executive Board was held in Geneva on 21 May 1990 where Mr R. Srinivasan, Secretary, Ministry of Health and Family Welfare, Government of India, was elected its chairman. Amongst the items dealt with were the report on the meetings of expert committees and study groups as well as reports of the Joint Inspection Unit. The Board selected "Women, Health and Lkvelopment" as the topic for the Technical Discussions during the Forty-fifth World Health Assembly. It decided to hold its eighty-seventh session in Geneva from 14 to 25 January 1991. The Board also decided that the Forty-fourth World Health Assembly would open in Geneva on Monday 6 May 1991. 1.3 REGIONAL COMMITTEE The forty-second session of the Regional Committee for South- East Asia was held in Bandung, Indonesia, from 26 September to 2 October 1989. It was attended by representatives from all the KeglOnal Lommlttee Meeting the forty-second session of the Reg~onal Comm~ttee for South-East Asla was held in Bandung. lndonesia. from 26September-2 October 1989. T jesslon was Inaugurated by H.E. Dr Adhyatma. M~n~ster of Health. Republic of Indonesia. The Regional Committee elected Dr S.L. Leimena (second - - -1 - h A n. m k! 0- If h 4 I .. h f h f+ cocclnn Healt 1 :h Ministers' Meeting eleven Member Countries of the Region, two United Nations agencies, one intergovernmental and twenty nongovernmental organizations having official relations with WHO. The session was opened by Dr Joe Fernando, Chairman of the forty-first session, and inaugurated by His Excellency, Dr M. Adhyatma, Minister of Health, Republic of Indonesia. Dr S.L. Leimena (Indonesia) was elected Chairman and Dr D.N. Regmi (Nepal) as Vice-Chairman. Dr Hatai Chitanondh (Thailand) was elected Chairman of the Technical Discussions, and Dr G. Vishwakarma (India) as Chairman of the Sub-committee on Programme Budget. The Committee reviewed the Regional Director's Annual Report, concentrating on issues highlighted by the Consultative Committee on Programme Development and Management which had discussed the report in depth. Technical discussions were held on the subject of 'Role of Epidemiology in Health for All'. The importance and the need to strengthen and expand the use of epidemiology in HFA/2000 were emphasized. While describing the progress made in their countries, the participants highlighted the prevailing condi- tions as well as the problems encountered and made various recommendations, which were endorsed by the Regional Committee. On the recommendation of the Sub-committee on Programme Budget, the Regional Committee adopted a resolution requesting the Regional Director to take necessary action to submit a single programme budget document that would allow increased flexibility in the planning and implementation of WHO'S collaborative programmes and better use of the resources. The Committee was concerned at the potential for further spread of AIDS in the countries of the Region and cautioned that systematic monitoring and a balanced approach were essential to avoid a negative effect on other health programmes. Discussions were also held on subjects such as goitre, disaster preparedness, health care financing and mobilization of resources for health development, and such routine adminis- trative subjects as nomination of countries from the Region to the Policy and Coordinacion Committee of the Special Programme of Research, Development and Research Training in Human Reproduction, the Joint Coordinating Board of the Special Programme for Research and Training in Tropical Diseases, and the Management Committee of the Global Programme on AIDS. The Committee decided to hold its forty-third session in September 1990 at the Regional Office in New Delhi and its forty-fourth session in Maldives, the timing of which will be decided at its forty-third session. The Committee decided to hold technical discussions on the subject of 'Health of the Underprivileged' during its forty-third session. The Eighth Meeting of Ministers of Health of the countries of the WHO South-East Asia Region was held in Jakarta, Indonesia, from 3 to 5 October 1989. At this meeting, the Ministers reviewed the progress in the implementation of the decisions taken st the Seventh Meeting, held in 1987, in relation to technical cooperation among developing countries, national HFA strategies, health manpower development, essential drugs, traditional medicine, health care financing, etc. The meeting also discussed in depth the reorientation of health system infrastructure for primary health care, particularly in the context of scarcity of resources and the need to provide equitable distribution. The Ministers emphasized the need to bring about necessary political and social changes in keeping with the commitment of Health for All by the Year 2000, and felt that, in addition to the emphasis on public health, greater reliance at macro-level planning would help in the successful implementation of their national HFA strategies. The Ministers took note of the progress made in introducing reforms in medical education and the discussions st the World Conference on Medical Education, held at Edingburgh in 1988. Stressing the need to inculcate appropriate social orientation to medical students by exposing them to humanities, such as sociology, anthropology and behavioural sciences, the Ministers agreed on the need to include the subject of health economics at the undergraduate level. They discussed at length the methodology to strengthen intercountry and interregional mechanisms and recognized that countries had not yet developed effective mechanisms to collaborate with one another in the identification of elements of common interest. They felt that it was necessary to encourage a larger number of intercountry programmes if common problems were to be solved by a cooperative approach. Discussing the subject of health economics and financing of health services, the Ministers were of the opinion that the health sector ought to speedily acquire expertise in health economics so as to be able to investigate and analyse various options and alternatives for the financing of health care. During the field visit arranged by the Republic of Indonesia, the Ministers saw primary health care in action, especially the work of Posyandu, and highly appreciated community partici- pation, including the financing of health care activities. They agreed that concerted efforts were needed to identify and mobilize alternative sources of health care financing. Chapter 2 WHO'S GENERAL PROGRAMME DEVELOPMENT AND MANAGEMENT 2.1 REGIONAL DIRECTOR'S DEVElOPI4ENT PROGEWME The Director-General's and Regional Director's Development Programme, established in 1978, aims at providing assistance to Member Countries to meet emergent situations created by natural calamities such as floods, cyclones or epidemics of diseases. The activities under the Programme are directed mainly at supporting national efforts in providing emergency relief, such as medical supplies, to several countries of the Region. The Programme also provides seed money to countries as initial investment for implementing innovative programmes. Many countries in the Region were again victims of natural disasters and calamities. Assistance was provided to Bangladesh for rapid assessment of health needs during national disasters and in the organization of disaster preparedness as a research and development activity. Emergency assistance was provided to Nepal, Myanmar and Thailand (please also see Section 2.4). 2.2 GENERAL PROCRAMNE DEVELOP= Support was provided for overall management of collaborative programmes with Member Countries. As part of a continuing dialogue with governments, joint government/WHO policy and programme reviews supported the development of WHO'S collaborative activities. In order to ensure the optimal use of WHO'S resources in support of national health programmes, the WHO programme budget was linked closely to national medium-term health plans, programmes and budgets. The working of the joint government/WHO coordination mechanism was reviewed with a view to identifying practical ways and means of improving its functioning. With funding from the Japan Ship-building Industry Foundation, an intercountry project was established with the objective of strengthening the capacity of WHO Representatives' offices and the joint government/WH0 coordination mechanism in the planning, management and coordination of external cooperation in health in the least developed countries. The forty-second session of the Regional Committee requested the Regional Director, inter alia, to take necessary action to submit a single progrsaudget document for 1992-1993. The seventeenth session of CCPDM reviewed the steps to be taken for a single Programme Budget document to be submitted for endorse- ment by the Regional Committee at its forty-third session to be held in 1990. The CCPOM also reviewed the procedures and the plan of action for evaluating the HFA strategies using the Second Common Framework, and the intercountry programme for the 1992-1993 biennium. The eighty-third session of the Executive Board had requested the Director-General, inter alia, to undertake studies on the criteria used at different levels of the Organization with a view to identifying those which could be used for the determi- nation of priorities, including the possible utilization of cost-benefit criteria. Case studies on two countries viz., Indonesia and Sri Lanka, were prepared. In this connection, one member of the Executive Board visited Indonesia and the Regional Off ice. The Regional Committee noted the Detailed Programme Budget for 1990-1991 and urged the Member Countries, inter alia, to initiate preliminary steps for its timely Wm-tion. Detailed plans of action were prepared for all country and intercountry programmes/projects. Country Support Teams, led by programme directors and programme chief, supported such preparation in several countries during their visits in the first quarter of 1990. To further enhance programme implementation, more authority was delegated to the WHO Representatives. Besides, programme implementation has been constantly monitored with a view to removing delaying factors. Continued efforts had also been made to further improve WHO'S information system and training of staff for supporting effective implementation and monitoring of the Organization's collaborative activities. These resulted in better implementation of the 1988-1989 programme as compared to the previous biennium. 2.3 WTWNAL COORD~ION FOR HEALTH AM) SOCJAL DEVELOPMENT The nature and magnitude of major development issues, such as environment, population, education and health, call for extensive and efficient inter-agency coordination and cooperation. By virtue of its Constitution, WHO is to act as the directing and coordinating authority on international health work. The Regional Office has continued to carry out this function. The Regional Director's thirty-eighth meeting with the WHO Representatives in November 1989 dealt specifically with this topic. Interagency coordination has improved further. A meeting of the Task Force for Child Survival was held in Bangkok in March 1990, and was attended by the heads of WHO, UNICEF, World Bank, WDP and the Rockefeller Foundation in a common and wide-ranging endeavour to protect the children of the world. Another international event was the Conference on Safe Motherhood in South Asia, held in Lahore, Pakistan, in March 1990, which was sponsored by the International Planned Parenthood Federation, UNDP, UNFPA, UNICEF, WHO, the World Bank and the Population Council. In a distinct but equally significant vein, WHO headquarters and the Regional Office were associated with the International Conference on "Education For All", held in Jomtien, Thailand, in March 1990, under the aegis of UNDP, UNESCO, UNICEF and the World Bank. Furthermore, inter-agency collaboration and cooperation has been promoted through resource mobilization meetings, held in Bangkok, in November 1989, and in Kathmandu, in February 1990, as well as other international and inter-agency meetings in support of HIV and AIDS prevention and control. 1. Colleboration with the United Nations system United Nations Develo&ment Programme (UNDP) WHO continued to collaborate with UNDP in mobilizing resources for health sector priorities of the countries. WDP's technical assistance provided catalytic support to a wide range of health promotion activities, including, inter alia, control of environmental hazards, health infrastructure development, epidemiological surveillance, health laboratories and drug quality control, food safety, rehabilitation, primary health care, improvement of nursing services and strengthening of institutional facilities. During the year, the Regional Office executed eleven intercountry and thirty-four country projects funded by UNDP. The total input through these projects amounted to US$ 6.0 million. Under UNDP's new strategy of programme approach, comprehensive reviews were conducted by WHO teams in Myanmar and Indonesia to identify potential projects for UNDP support under country programmes. Based on the mission's report, UNDP Myanmar approved six projects with a budget of US$ 4.3 million for immediate implementation. Five other projects were retained in the pipeline for future consideration. In the Indonesia review, the areas of concentration were environmental health, water supply and sanitation, communicable diseases and maternal and child health. The Regional Office also collaborated closely in Nepal's Fifth UNDP country programming exercise (1991-1995). Health planning and management, including rational use of resources, emerged as the immediate priority for tripartite collaboration between UNDP, WHO and the World Bank. Two new intercountry projects for the Region were approved by UNDP for execution by WHO. These are: Regional Programme for the Development of Health Learning Materials, and Introduction of Quality Standards and Appropriate Technology for Laboratory Services in Support of Primary Health Care. UNDP approved four new country projects during this period while eleven more country projects with an estimated input of about US$ 10.0 million are in the pipeline. Within the framework of the WHOIUNDP alliance to combat AIDS, UNDP made available US$ 1,5 million for Sri Lanka and US$ 1.0 million for Thailand from its country programme resources. These inputs were in addition to US$ 1.4 million provided for the countries of Asia and the Pacific Region through its intercountry project on Prevention and Control of AIDS, being implemented under WHO'S Global Programme on AIDS. UNDP collaborated in the IMPACT field study initiative of the Regional Office to test the feasibility of an integrated approach for the prevention of avoidable disabilities. The declining trend of UNDP resources in the overall health sector continued. Concerted efforts at the country level to project the importance of health in the development process, active participation of ministries of health, with technically sound priority project proposals, in the UNDP country programme formulation exercise, and adequate resource mobilization efforts of ministries of health are essential to reverse this trend. United Nations Population Fund (UNFPA) Collaboration between WHO and UNFPA continued in maternal and child health and family planning, the main fields of common interest between the two organizations. The Regional Office participated in two UNFPA Country Needs Assessment missions and Programme Formulation exercises in DPR Korea and Nepal. The Regional office executed nine UNFPA-funded projects with a total budget of about US$ 1.5 million. Two new projects, viz., Strengthening of Family Health/Birth-Spacing Services, in Maldives, and Centre for Family Health, in Nepal, were approved for joint government/WHO execution. Regular exchange of information and the consultative process were further streamlined for improved coordination and collaboration between the two organizations. United Nations Children's Fund (UNICEF) WHO and UNICEF continued to pursue close collaboration at the country level in areas of common interest. The Regional Office participated in the UNICEP-WHO Inter- secretariat Meeting, held in Geneva in September 1989. The Meeting reviewed, among other matters, WHOfUNICEF Common Goals for the Health of Women and Children by the Year 2000; WHO/UNICEP Strategy for Improved Nutrition of Mothers and Children in the Developing World; and Public Education to Reduce the Use of Tobacco. WHO and UNICEF worked together with the Government of Myanmar in the evaluation of the Joint Nutrition Support Programme in that country. Economic and Social Commission for Asia and the Pacific (BSCAP) Cooperation and collaboration with ESCAP continued in the fields of human resources development, integrated rural development, population and drug abuse rehabilitation. Country studies, carried out in India, Myanmar and Thailand under the WHOIESCAP project on Drug Abuse Rehabilitation in Asia and the Pacific, were reviewed at a joint meeting in Bangkok in January 1990. The meeting produced several project profiles for follow-up activities. Technical and financial support was extended to the ESCAP Seminar on Water Quality Monitoring, held at Beijing, China, in September 1989. WHOlESCAP Collaboration - The Present Situation and Future Prospects, was reviewed at the Regional Director's thirty- eighth meeting with the WHO Representatives in November 1989. United Nations Educational. Scientific and Cultural Organization (UNESCO) WHO entered into an agreement with UNESCO to establish in Bangkok a Regional AIDS Education and Health Promotion Materials Exchange Centre, to facilitate the exchange of health promotion materials relating to AIDS prevention and control. United Nations Fund for Drug Abuse Control (WAC) WHO continued to execute, amongst other things, the health components of UNFDAC-funded drug abuse control projects in Sri Lanka and Myanmar. International Fund for Agricultural Development ( IFAD) IFAD is supporting agricultural development projects in SEAR countries. In April 1990, an IFAD project preparation mission to Andhra Pradesh, India, was joined by a WHO consultant to explore and assess the prospect of incorporating a compre- hensive health services component in the future IFAD-supported project in that state. Other Agencies WHO continued to promote health and nutrition in projects assisted by the World Food Programme and to liaise with other agencies of the UN system, including the International Labour Organisation and the UN Food and Agriculture Organization, which have a supportive role in health development. 2. The Development Banks and Funds The twenty-third annual meeting of the Board of Governors of the Asian Development Bank was held in New Delhi in May 1990. A representative of the Regional Office attended on behalf of WHO. In 1989-1990, the World Bank considered new initiatives and projects for health sector development in Indonesia, Nepal and Sri Lanka, among other countries. In the case of Nepal, a World Bank mission visiting the country in September 1989 to prepare a comprehensive population and health project, was offered technical advice by WHO, inter alia, through WHO'S contribution to a health resources and priorities study for the country. Also, in Nepal, WHO, in collaboration with the World Bank and UNDP, has been formulating a project on "Strengthening Resource Allocation, Planning Formulation and Implementation in the Health Sector". Plans have been made for the World Bank to execute the project in association with WHO. The Regional Office continued to receive financial support from the Arab Gulf Programme for the United Nations Development Organizations (AGFUND). Promotion of oral health, and prevention of blindness and deafness were among the projects which benefited from these funds. The OPEC Fund for International Development extended support through WHO for the purchase of emergency medical supplies to Bangladesh. 3. Bilateral Agencies A wide range of health development projects in the Region is being supported through bilateral collaboration schemes. Most of the countries providing bilateral support for socioeconomic development in the Region are members of the Developmeat Assistance Committee (DAC) of the Organization of Economic Cooperation and Development. WHO has been executing the Field Epidemiology/Laboratory Services Programme in India, supported by the United States Agency for International Development (USAID). During the reporting period, a decision was taken by the collaborating parties to redesign the project. The implementation of malaria, tuberculosis and leprosy control programmes in India continued with support from the Swedish International Development Authority (SIDA), with WHO as the executing agency, following the extension of previous agreements which expired in 1989. In Bangladesh, the project "Family Planning Clinical Supervision Team", executed by WHO with support from the Norwegian Agency for International Development (NORAD), was reviewed in February 1990 by a four-partite mission comprising the Government of Bangladesh, NORAD, the world Bank and WHO. Extension of the current agreement, which expires on 30 June 1990, is being considered. The Canadian International Development Agency (CIDA) supported the AIDS control and prevention programme in Thailand and continued to fund the WHO-executed vector-borne disease control project in Myanmar. The Finnish International Development Agency (FINNIDA) funded the essential drugs programme in Bhutan and Myanmar and supported the district health system development in Nepal. FINNIDA also donated vaccine to Maldives. In Nepal, the Swiss Government, through its Development Cooperation and Humanitarian Aid (DM), continued to fund a health laboratory services project being executed by WHO. The Danish International Development Agency (DANIDA) continued to fund drug action programmes in Bangladesh and Bhutan. It was also involved in an external evaluation of the WHO Action Programme on Essential Drugs, which included visits to Indonesia in August-September 1989, and to Bangladesh in October 1989. The Government of Japan is contributing, through WHO, to the funding of the AIDS prevention and control programme in Thailand. A fact-finding mission from the Japan International Cooperation Agency (JIM) visited Thailand in December 1989 to study the Thai programme management and health facilities in respect of AIDS prevention and control. A mission from Japan International Corporation of Welfare Services (JICWELS) visited the Regional Office in March 1990 to discuss, amongst other things, potential support for the prevention and control of diseases as well aa human reaources development for health in South-Fast Asia. 4. Collaboration with Nongovernmental Organizations (NGOa) An area of collaboration with NGOs, where intensified efforts have been deployed, ia that of prevention and control of HIV infection and AIDS. In May 1990, the Regional Office convened a meeting on Mobilization of Women's Organizations and NGOs in the Prevention and Control of AIDS in New Delhi. Collaboration with Rotary International has been enhanced, particularly in the field of poliomyelitis control and EPI. Prevention of blindness, leprosy control, rehabilitation of the handicapped and other traditional areas of collaboration with NGOs continued to attract support from Helen Keller Inter- national Inc., the Christoffel Blinden mission and the Sasakawa Health Trust Fund, among other agencies. 2.4 HEALTH EMERGENCY PREPAREDNESS AHD RESPONSE The countries of South-East Asia are particularly vulnerable to natural disasters. The interplay of natural factors acting upon areas with some of the highest population concentrations in the world causes recurrent disasters of magnitudes incomparable to those elsewhere. During the period under review, many Member Countries in the Region were affected by natural disasters which included floods in Bangladesh and India during the summer of 1989; a cyclone devastating the eastern coast of India in November 1989; a typhoon in November 1989, which wought extensive damage to the coast off the Gulf of Thailand; floods and landslides following torrential rains in Indonesia and Sri Lanka, in January 1990; the volcanic eruption of Mount Kelud, in Indonesia in March 1990; and the cyclone on the east coast of India in May 1990. In response to such aituationa, WHO provided emergency medical supplies and supported efforts to strengthen the health sector's emergency preparedness and response activities. In Thailand. water ourification and chlorination eouimnent was provided.to the &phoon-sffected provinces. In Bangladesh, WHO supplied water-purifying tablets, bleaching powder, anti-snake venom serum and other emergency supplies. The Regional Office also supported the Government of Bangladesh in initiating implementation of disaster planning and training components of the Bangladesh Health Sector Disaster Preparedness and Response Programme, developed earlier in collaboration with WHO. In India, WHO supported training in disaster management and a study on the impact of floods on health and health services management. In Indonesia, Consultations on the inclusion of health sector requirements were held with a UN mission preparing a new proposal on disaster preparedness, mitigation and response. The Regional Committee, at its forty-second session, addressed the issue of disaster preparedness and response, based on a report prepared by the Regional Office, and including, amongst other things, the findings of the assessment of the capabilities of national health infrastructures in handling emergencies1 disaster situations, carried out by nationalIWH0 teams in Bangladesh, India, Indonesia and Nepal in early 1989. The deliberations and decision of the Regional Committee helped enhance awareness of the need to develop national health disaster preparedness and response programmes and led to renewed political commitment to developing and integrating such programmes within the national programme for disaster preparedness. Efforts to develop and implement disaster preparedness programmes, which Member Countries and WHO have undertaken or will undertake in the coming years, will also contribute to the success of the International Decade for Natural Disaster Reduction (IDNDR) decided upon by the United Nations General Assembly in December 1989, and launched by the UN Secretary- General the following month. Within the International Framework of Action for IDNDR, all governments are called upon, inter alia, to "pay due attention to the impact of natural disasters on health care, particularly to activities to mitigate the vulnerability of hospitals and health centres, as well as the impact on food storage facilities, human shelter and other social and economic infrastructure". The objective of the Decade is to reduce, through concerted international action, especially in developing countries, loss of life, damage to property and social and economic disruption. To this end WHO is joining forces with other international organizations and Member Countries. 2.5 HEALR1-POR--W S!LWlSY COORDINATION The primary objective of the strategy for Health for All is equity in the availability of health care. Member Countries in the Region have striven to develop and reorient their health systems so as to make health care available, especially to the vulnerable and disadvantaged groups of the population. The coverage by the health sector and access to health care have increased substantially, and it is expected that the evaluation in 1991 will provide quantitative data to substantiate this. As a follow-up of the Inter-agency Regional Conference on Health Development, held in Riga in March 1989, and to give a deeper thrust to the objective of achieving Health For All by the Year 2000, a Symposium on Public Policy on Health Status and Quality of Life was held in Bangalore, India, in September 1989. It is being followed by national workshops in India, Indonesia, Sri Lenka and Thailand. A number of activities and initiatives have taken place in Member Countries in relation to health policy formulations and implementation of health-for-all strategies. Bangladesh has drawn up a new health policy in keeping with its principle of decentralization of financial and administrative authority. India, Indonesia and Thailand have identified areas needing attention and incorporated the same in their medium-cerm plans. A joint mission to Nepal highlighted the impediments to effec- tive primary health care. In the light of the new initiative of the Director-General to support people and countries most in need, India Mongolia and Nepal have been chosen for special attention while Bangladesh and Bhutan have been approached for inclusion in this initiative. In Bangladesh, the Health Care System Improvement Committee has made a series of recommendations regarding medical education, hospital administration, the health care delivery system, and cost-sharing, which are now under the consideration of the Government. In India, based on the moaitoring of the HFA strategy, progress in health development has been reviewed to form an important input for the Eighth Five-Year Plan. In Sri Lanks, a policy background document for the health component (Suva Ssviya) of the poverty alleviation programme has been prepared. This seeks to provide health and health-related benefits as an integral component of the national programme for poverty alleviation. In Thailand, activities of the National Health Assembly were followed up with a view to assessing the existing health situation and seeking ways of solving current and emerging health problems. This included health policy analysis and systems research. WA Leadership Development Activities to further strengthen health-for-all leadership development at intermediate and lower levels have been pursued vigorously in almost all Member Countries. The Mahidol University in Thailand has been nominated as a WHO Collaborating Centre in HFA Leadership Development. In India, besides organizing a meeting on HFA leadership development for senior officials of the health sector, state- level workshops, inter-state dialogues, as well as a National Conference on HFA Leadership Initiative were organized. In Indonesia, a national core group for HFA leadership develop- ment, established under the Director-General, Community Health, developed a plan for HFA leadership development consisting of a number of training activities, and set up a HFA leadership laboratory. Modules have been developed for HFA leadership training for middle-level officials and trainers. Several workshops have been held at national and provincial levels. The Informatics Management Programme supported the Organiza- tion's programme development and management through the provision of appropriate and relevant informatics technologies, and training on their use. A new Administrative and Financial Information System (AFI) was installed in the Regional Office with support from WHO headquarters, to bring it in line with other regional offices. Informatics support activities focused on the training of staff of the Regional Office as well as of the WHO Representatives' offices. Details of the implementation of the Regional Office Local Area Network (LAN) were worked out. Coordination of policies on informatics development was achieved through the Regional Informatics Support Committee. An incre- mental approach to informatics support development was adopted by screening emerging technologies with a view to selecting those which are cost-efficient, affordable and relevant to the overall objectives of management. Full use of the available technologies was maintained before introducing new systems. SECTION I1 HEALTH SYSTEM INFRASTRUCTURE Chapter 3 HEALTH SYSTEM DEVELOPMENT 3.1 HWTH SITUATION AND TREND ASSBSSKENT Most countries of the Region continued their efforts to further strengthen their health information systems by system redesign, staff training and support in the use of information, especially at intermediate and lower levels. Test-runs of health management information systems have been completed in four districts in India and two districts in Nepal. Collaborative efforts in improving the quality of mortality statistics are continuing in India, Sri Lanka and Thailand. Steps are being taken to familia- rize national authorities with the Tenth Revision of the International Classification of Diseases, which will come into effect on 1 January 1993. Their comments on the draft proposal of a three-character version of ICD-10, and its suitability for both mortality and morbidity purposes, are being sought. Activities related to the second evaluation of the health-for- all strategies began in the second half of 1989. A document entitled "Evaluating the Strategies for Health for All by the Year 2000, Common Framework: Second Evaluation" (CFE/2), together with the list of global indicators, was prepared by WHO headquarters. The revised version of CFE/2 and the revised list of global indicators were finalized following extensive discua- sions with regional offices and Member Countries. The revised CFE/2 was pretested in India and Mongolia. National authorities were briefed by the Regional Office on methodology procedures and the time-table of the second evaluation, and advised to undertake this task as an integral part of the national health management process. The second evaluation vill be carried out by Member Countries between September 1990 and January 1991. The plan of action includes intersectoral aspects of health development and the presentation of information on indicators and other relevant data for all identifiable sub-groups of the population. Epidemiological Surveillance Considering the role of epidemiology in the attainment of health for all and its contribution to primary health care, efforts have been made to secure competent epidemiologists through the development of Field Epidemiology Training Programmes (FETP). Sentinel surveillance and follow-up proce- dures for polio and neonatal tetanus cases have been developed using WHO~PAHO training material, to support EPI efforts to eliminate the transmission of these diseases in Indonesia. FETP has been strengthened in three countries, namely, India, Indonesia and Thailand. In India, modules concerning the epi- demiological characteristics of various diseases were drafted, and research activities utilizing the computer analysis of data concerning communicable diseases were started. Epidemiological surveillance without adequate laboratory support will not be helpful in containing communicable diseases. India is the only country that has a combined laboratory epidemiology centre and can demonstrate the value of laboratory-based surveillance. The project will undergo major modifications which are under dis- cussion between the collaborating agencies and the Government. In Indonesia, the FETP is effectively being run by the national authorities. WHO actively collaborated in the designing, conduct, and analysis of public health surveillance systems and assisted in the development and management of FETP. The trainees and staff under FETP conducted various case-control studies and carried out investigations of epidemic outbreaks of measles and malaria. FETP, which was initiated by the Ministry of Public Health, with the assistance of WHO, has been part of the post- graduate curriculum of the School of Public Health at the University of Indonesia since 1987. The University-based regular FETP is scheduled for external evaluation in July-August 1990. Thailand has concentrated on developing trained manpower in epidemiological surveillance. Training in basic epidemiology and biostatistics, as well as field experience in surveillance activities for certain diseases, were covered under FETP. Special attention was paid to the preparation of sentinel surveillance for AIDS, EPI and CDD. In order to effectively control and prevent major communicable diseases, an epidemiological surveillance programme has been developed ensuring the availability of essential epidemiological information. Most of the Member Countries were assisted, through training of health personnel at intermediate and peripheral levels, in the collection of epidemiological data and the use of epidemio- logical information at all levels. WHO assisted by providing computers and training facilities so that Member Countries could effectively introduce computerization for analysing epidemiological data. Despite the progress made towards the promotion of epidemiological surveillance, common problems and constraints, such as the lack of personnel trained in the use of epidemiological information and the lack of laboratory support, still exist. 3.2 WERIAL PROCESS FOR NATIONAL WTH DEVELOPMENT 1. National Health Policies There is a continuous effort by the Member Countries to update national health policies. WHO actively supports these endeavours. A high-powered committee of the Government of Bangladesh prepared a draft national health and population policy. The draft national health policy, formulated in Bhutan in 1986, is still undergoing a comprehensive review in the Ministry of Social Services prior to its adoption by the Government. Also under review are national health-for-all strategies for establishing comprehensive guidelines to facilitate smooth implementation of the health policy. There has been an ongoing, intensive effort in Myanmar to evaluate the health policy with a view to drafting a new one, taking into account recent political and socioeconomic developments. 2. National Health Development Plans National health development plans were formulated to implement national health-for-all strategies and to develop primary health care. The Organization collaborated with several countries in the preparation and implementation of health plans or health components of national development plans. In India, the Eighth Five-Year Plan, including the health sector plan, was formulated. A background document in the context of the national health policy, prepared with WHO collaboration, outlines such essential elements as the recent status of the health sector, existing gaps, national leadership strategies for health care, future prospects and a plan of action. In Indonesia, WHO support was provided for developing the health component of the Fifth Five-Year Development Plan (Repelita V). An extensive, collaborative effort is being made to strengthen national capabilities in health planning and management in Myanmar, particularly in the preparation of the forthcoming two-year health plan. The task is even more demanding in the light of the changing health policies and priorities. As a preparatory measure, the impact of the previous People's Health Plans was assessed. 3. Strengthening of Health Economics Health economics, including the financing of health services and the mobilization of resources for health development, constitutes a priority area for WHO collaboration with Member Countries. The support extended by the Organization takes various forms, such as insti tutional strengthening, research and development, group training, fellomhips, and consultative services. The subject of health financing and mobilization of resources for health development received significant attention during the forty-second session of the Regional Committee. In its resolution the Committee urged Member Countries to review their current patterns of resource allocation in the health sector and to reorient their spending priorities. It was empha- sized that additional resources should be sought and preferen- tial attention given to the most needy segments of the population. In several countries of the Region, activities are being undertaken to estimate realistic costs of implementing national health policies. Support was provided to Mongolia and Myanmar for developing/strengthening the information basis for better financial planning. A series of simple health systems research projects has been initiated in India, Mongolia and Thailand to estimate unit costs and expenditure on health, including household expenditure. At the regional level, efforts are being made to establish and maintain an information base on health planning and management, including health economics and the financing and mobilization of resources for health. This computerized information base contains data on training institutions, resource persons and relevant materials and documents in this field. The forthcoming major consultation on health economics, scheduled for later this year, will review the current status of health care financing and resource allocation in the Region. The consultation will also help to establish a regional programme of activities in Member Countries. Several options for health care financing are being established or strengthened in the countries of the Region. In Myanmar, a review of the national health policy was undertaken while proposals for alternative means of health care financing were developed. In other countries, various other methods of paying for health services, such as community financing, health insurance and user charges, are being implemented. 4. Strengthening of Operational Hanagentent Strengthening of operational management of health services remained a high priority in many countries of the Region. The Organization extended technical support through consultancies and training. In Bangladesh, two workshops on the strengthening of operational management were conducted for multisectoral supervisory staff. These workshops resulted in the development of work targets, action plans, monitoring systems, etc., and in the identification of training needs of health officials in operational management. In Indonesia, support was provided for clarifying the structural and functional relationships between health centres and integrated service posts (Posyandu). As a parallel activity, a series of job analysis activities, including the development of job descriptions for central- and provincial-level health offices, was supported. A "Job Analysis Programme" was initiated, with the objective of developing job descriptions for central, provincial, district and municipal- level health offices, hospitals and health centres. 5. Decentralization of Health Services It has been acknowledged that decentralization of health services plays an important role in increasing their effectiveness. The policy of decentralization is being followed in a number of countries of the Region. In Bhutan, the process of decentralization through delegation of authority has been strengthened with the establishment of four zones which will have limited authority to take limited decisions. It is believed that the establishment of zones will help in a better planning and implementation process and will increase the participation of community leaders. Further, the decentralization process has been carried down to the block level, which facilitates effective community development and strengthening of primary health care. Various approaches to decentralization have been adopted in many countries - Bangladesh, Nepal, Sri Lanka, Thailand, to quote just a few examples - and are gradually being further strengthened. 6. Support to Countries Facing Serious Bconomic Constraints As in many developing countries, the health situation in the Region remains unsatisfactory due to serious obstacles to effective implementation of primary health care caused by the unfavourable economic situation. The country-centered strategy, initiated recently by WHO for overcoming these obstacles, is being implemented in three countries of the Region. New mechanisms and approaches are being used in this collaboration, and include a holistic view of the planning and implementation of country activities, improved coordination, and advocacy for larger resource allocation for health. The more important problems identified in the countries so far have been weak management, lack of rationalization of the financing of health care, inadequate human resources for health and inability to ensure appropriate economic support for the health sector. Other problems include poor health system coordination and design, inadequate integration of delivery of primary health care and lack of technical capability for preventing and treating priority health problems. WHO undertook a number of activities in order to meet such constraints. In Nepal, short-term, immediate support was given for studies on the financing of health services, health manpower development and utilization, and accelerated development of the health information system. In Bangladesh and Bhutan, this initiative is in an early stage of development. 7. Training in Health Planning and Managerent WHO supported a wide variety of training activities in the field of health planning and management as well as that of health care financing. This training was directed at various levels of health managers, including central-level health planners and district health officers. Some training efforts, such as the series of seminars and workshops in health plan development for provincial and district-level personnel, were aimed at strengthening institutional capacity in health pla~ing and monitoring. As an integral part of staff development in health planning and management, the Organization organized GUS, workshops, and training courses and provided fellowships to countries. 3.3 HEALTH SYSTEMS RESEARCH AM) DEVEU)PWT The Regional Office continued to promote and support health systems research (HSR) in the Region. A major effort of the Regional office was directed towards the strengthening of institutions to undertake health systems research. This was in pursuance of the recommendations made by the meeting of the Task Force on Health Systems Research in 1987. As decided by the Regional Committee and the Regional Advisory Committee on Health Research, four Member Countries are being supported under the programme of institutional strengthening, which includes training of research and support personnel, infrastructure development such as library and data processing facilities, and provision of consultants. The SUIACHR Sub-committee on the Role of Health Research in the Strategy for Health for All by the Year 2000, which was convened to prepare the regional contribution for the technical discussions at the Forty-third World Health Assembly, met in New Delhi on 30-31 October 1989. Recent and important developments and issues in health systems research in the Region, identified by the Sub-committee, constituted an important part of the report, which was submitted to WHO headquarters. An assessment of the volume of health systems research being conducted in the Region is rather difficult. This is due to the fact that a considerable number of research projects in various fields have an HSR component integrated into them. This HSR component is not always evident on a cursory examination of the title of a project. However, this obscurity is to be expected since health behaviour research, health economics research and research on the development of human resources for health and health services are also integral parts of health systems research. Health systems research is also integrated into ongoing opera- tional projects, such as the Expanded Programme on Immunization and the Maternal and Child Health programme. HSR has also been used in the Region in the development of training manuals for health workers and IEH materials. One of the objectives of the Second International Conference of the Consortium of Indian Health Institutions for the Reform of Medical Education, held in New Delhi from 23 to 25 April 1990, was to illustrate the role of HSR in eliciting the need for innovation in medical education, in determining the planning process for innovation, and in monitoring the implementation of the innovations. Collaboration with other programmes of WHO, such as Maternal and Child Health (MCH), Acute Respiratory Infections (ARI), and the Special Progrannnes on Tropical Disease Research (TDR) and Human Reproduction (HRP), has resulted in the involvement of Member Countries in health systems research projects, including field studies in the various programme areas. 3.4 HEALTH LBGISUTION Important activities in the field of health legislation were carried out throughout the Region with technical and financial support from the Organization. The main objective of these collaborative activities was to develop or strengthen existing legislation in support of health development policies and to monitor and evaluate the impact of legislative measures on health situations and trends. The Organization played a support- ing role in facilitating information exchange between Member Countries of the Region at both regional and interregional levels. India and Indonesia are the two countries where colla- borative activities in health legislation were most intensive. Close collaboration was maintained with WHO headquarters from where relevant documents and working materials were received, and distributed to Member Countries. Legal documentation on the control of AIDS epidemics in various countriea of the world was of particular interest and usefulness, and was shared through appropriate channels. Chapter 4 ORGANIZATION OF HEALTH SYSTEMS BASED ON PRIMARY HEALTH CARE Reorientation of the health system infrastructure forms the bed-rock of national strategies for attaining the goal of Health for All by the Year 2000. Since the concept of primary health care was defined and given international recognition at the Alma-Ata Conference in 1978, primary health care has become the main thrust for total health care. Countries in the South-East Asia Region have made great efforts to organize effective health systems so as to provide efficient and universal primary health care. Considerable resources have been allocated to the building of health facilities, to the strengthening of health infrastructure and to increasing coverage, especially of the underserved and unserved areas. All countries of the Region have shown growing concern for equity and social justice - the two basic principles of primary health care - so that health has become a basic right of every individual. In reducing gaps between those who have access to primary health care and those who do not, priority is given to the underserved and unreached populations. Greater emphasis is laid on community participation, enabling women and the community to be involved in their own economic and health developnent . In recognizing the importance of intersectoral action for health as a key factor for overall socioeconomic development, in many countries, formal mechanisms have been introduced, with WHO support, for dialogue between health and other allied sectors. WHO'S efforts are aimed at ensuring that the use of intersectoral action steadily improves not only health but also the quality of life of the people. Steady progress has been achieved in the distribution, organization, management and orientation of a comprehensive health system based on primary health care. A Regional Conference on Health Development, held in New Delhi in March 1989, reviewed the progress in the light of the Riga framework. It noted that Member Countries were already reviewing their targets and policies with a view to accelerating implementation. The Conference emphasized the need to develop new ways of understanding and facing problems, as well as of identifying newer approaches to solve them. Coverage through the health infrastructure has increased in almost all countries as a result of improvement of the management process. Due attention has been paid to the development of human resources through training and retraining of health workers. It is increasingly apparent that the more pressing problems of organization of national health systems based on primary health care occur close to where people live. Intensification of health development in the district has been pursued with commendable results. This district health system approach, comprising critical areas of primary health care, among others, provides for decentralized management responsibilities. Attempts have been made to develop adequate supervisory planning and management skills among district-level health managers and planners in order to strengthen district health systems. 1. Strengthening of Ministries of Health and Expanding Coverage of Health Infrastructure Countries in the Region are being supported in improving the existing health infrastructure and expanding coverage through an epidemiological approach aimed at reaching the underserved and unreached population. Activities carried out in the first year of the biennium contributed to health development at the community and health centre levels and aimed st improving the local capacity and quality of health services provided. Overall, there has been progress in the implementation of primary health care as well as in improving the performance of the health infrastructure, particularly at the primary level. With the strengthening of the health infrastructure and expansion of the PHC activities in the form of various models, such as the Mongar project in Bhutan, the Huvsgul Aimak project in Mongolia, Posyandu in Indonesia, the Upazila Health Complex in Bangladesh, etc., a coverage of 65-70 per cent has been achieved. Some of the well-known constraints, such as the lack of equipment, drugs, transport and other support facilities, poor supervision, unequal distribution, inadequate management, and inefficient use of resources, still remain. WHO has been collaborating with national authorities in enhanc- ing their capabilities to plan and manage health programmes status at the district level, particularly through training in planning and management, so as to help managers at the central and district levels play a leadership role. The support also involves the development of intersectoral action and community participation, as well as of information systems, monitoring and evaluation, computerization and systems analysis. An interregional meeting on Strengthening Information Support for Management of District Health System based on Primary Health Care was held in Surabaya, Indonesia, in October 1989. The meeting identified the information needs for effective management of the district health system, methods and technologies for collaboration, and processing and utilization of information needed by district managers. WHO also supported the referral system at various levels, primarily at the first referral level. Workshops for strengthening PHC were held in Indonesia and Sri Lanka to re-examine the health care delivery systems. Fellowships were awarded in hospital administration, nursing and medical care, including specialized health care. A short-term consultant was assigned to identify hospital sanitation problems in hospitals in Indonesia. Realizing the need for efficient maintenance, WHO is also providing support for nationals to acquire skills in the maintenance and repair of equipment. Bangladesh, Myanmar and Sri Lanka have set up their own training workshops. An intercountry meeting on Strengthening Ministries of Health was held in Geneva in March 1990. Bangladesh and Sri Lanka participated in this meeting. It was decided to continue with the previous activities in Sri Lanka while in Bangladesh a new project is planned. A Consultative Committee Meeting on PHC Development, held in Geneva in Aprll 1990, reviewed country experiences in PHC implementation, options for financing PHC implementation, and increasing the sustainability of PHC in the 1990s. It emerged in the meeting that the main problems in the 1990s will be the emerging mega cities with alarming increases of population, environmental deterioration, and socioeconomic and political problems. National governmenta will have to anticipate these problems and take appropriate measures well in time before they begin to adversely affect the health of the people. 2. District Health System Intensification of Action Programe for Primary Health Care As part of the process for intensifying health development in defined geographical areas, such as districts, efforts are being made by countries, with technical support from WHO, for the development of an effective district health system. Based on the experience of projects in this area and the recommendation of the Regional Committee for South-East Asia for recommending intensification of primary health care in these manageable geographical units, a UNDP-funded project "Intensification of Action Programme for Primary Health Care" was launched in January 1987 in 21 districts of the countries of the Region. The main objective of this project is to develop a system of decentralized health care management at the district level through coordination among national ministries/ institutes, primary health care programmes, NGOs and district authorities, concentrating on four major elements of PHC, viz. immunization, diarrhoea1 diseases control, respiratory diseases and essential drugs, within the framework of plans of action. Following the guidelines prepared by the Regional Office, baseline surveys have been completed and national and district work plans developed in sli the countries. A regional, integrated learning module, prepared by the Regional Office, has been sent to the countries for use in training health managers, supervisors and workers in the project districts. Workshops for health managers were held in Bangladesh, Bhutan, India, Indonesia, Mongolia, Myanmar, Nepal, Sri Lanka and Thailand. In-service training of health workers and health supervisors have also been conducted using the integrated learning module. Training in laboratory diagnosis in the control of diarrhoea1 diseases and acute respiratory infections have been completed in Bangladesh, Bhutan, India, Indonesia, Mongolia, Sri Lanks and Thailand. NGOs, especially women's organizations, are closely involved in project implementation in Bangladesh, Bhutan, India, Indonesia, Mongolia, Myanmar, Sri Lanka and Thailand. Fellowships and study tours were provided for training in epidemiological surveillance, drug analysis and diagnostic techniques. To overcome bottlenecks that impede the delivery of health services, assistance was provided in the form of equipment and supplies. With a view to developing a system of decentralized management district-level health managers and planners have been trained in supervisory management and planning skills. A new UNDP project "Strengthening Medical Care Facilities in Districts", especially designed for the least developed countries, is awaiting UNDP approval. The objective of this project is to improve the delivery of medical care at district and peripheral health centres. The duration of the project is three years. The expected outcome at the end of the project is an optimal level of health care delivery through improved functioning of medical care facilities. 3. Intersectoral Action for Health In many countries, mortality and morbidity have been reduced through both improved health infrastructure and appropriate sectoral policies, with consequent improvement in overall socio- economic conditions. Intersectoral coordination and formulation of policiea is a prerequisite for achieving Health For All. WHO has continued to facilitate the dialogue between health and other relevant sectors by supporting and strengthening mecha- nisms for intersectoral coordination for health development. As a follow-up of the Inter-agency Regional Conference on Health Development, held in New Delhi, March 1989, a Regional Symposium on the Implications of Public Policy on Health Status and Quality of Life was organized jointly by WHO headquarters, the Regional Office and the Indian Institute of Management, Bangalore, in Bangalore, India. Three important areas were dealt with, namely: urbanization, covering housing and slums; indust- rialization, covering occupational health and child labour; and agricultural development, covering irrigation and pesticides. The emerging health problems resulting from urbanization, industrialization and agricultural development, including agro-industries, are assuming increasing importance and should be the subject of future workshops of WHO and countries. A mechanism for intersectoral collaboration has been developed in Mongolia through which it is now possible to provide primary health care to various groups of population. The Great People's Khural, the Council of Ministers, and the State Planning Committee play coordinating roles in intersectoral actions. The Aimak Council of People's Deputies and its Executive Committee collaborate at the highest level in providing primary health care to the population of the aimak. Multisectoral National Health Committees, headed by the Minister for Health or Minister of Interior or analogous policy makers, have been formed in Sri Lanka, Myanmar, Indonesia and Thailand with the Director-General or Deputy Ministers from Ministries of Agriculture and Forest, Planning and Finance, Education, Industry, Trade, Cooperative and Social Welfare, etc. as members. This high-level body, amongst other bodies, acts in an advisory and coordinating capacity and takes policy decisions relating to health and socioeconomic development. One of the major achievements of the Mongar project in Bhutan was the interlinking of all levels involved through the formation of intralintersectoral committees at district, block and village levels. It succeeded in achieving almost total coverage by the PHC elements in spite of the difficult terrain. In Chagalnaya Upazila, Feni district, Bangladesh, an analytical study funded by WHO was conducted to identify options to be pursued for improving health and the quality of life of the people as an integral part of the efforts to develop inter- sectoral action to meet the basic minimum needs. Support was also provided for conducting workshops to evolve plans for PHC intensification, with multisectoral participation, in Sreepur and Kalihati Upazilas in Dhaka Division. Indonesia and Thailand have been implementing primary health care with the support of community participation and inter- sectoral action. They are now embarking on policy formulation in other sectors with a view to reducing the negative impact on health. Progress in the development of primary health care was slower than what it would have been had the mechanism for plan- ning, as suggested by the National Rural Development Committee, been implemented. Thailand is now stressing environmental issues, drug abuse addicts and AIDS, while Indonesia is dealing more with urban issues and how to reach the unreached. 4. Cmity Participation Decentralization of management and administration, including development programmes, has been further taken from the district level down to the block level. Block Development Committees are being formed to facilitate community participation. Farmers and village volunteer health workers are trained to work in close collaboration with communities under the supervision of Block Committees. Trained voluntary village health workers are now available to provide health care in their respective communities situated in difficult and inaccessible, remote areas in Bhutan and India. Training of community health volunteers, selected on a neighbourhood basis, was initiated in Bangladesh. Nearly two-thirds of the selected volunteers were women, reflecting a social change at the village level. These selected volunteers, besides making home visits and promoting healthy lifestyles, also organize village health posts for monthly delivery of integrated packages with community participation. WHO supports the training of ten-households health workers and their trainers in Myanmar, who are key persona for constant motivation of families, while in Indonesia the emphasis is on strengthening Posyandu and development of ten-household units. WHO is supporting the expansion of the Revolving Community Drug Cooperative Scheme in Nepal. During 1989-1990 it was expanded to two districts each in the Central and Western Regions. WHO also supported two national workshops in Indonesia on Development of Community Health Fund programmes, which dealt with the mobilization of community resources on health care financing, formulation of community resources, operational ,guidance on Dana Sehat (community health fund) implementation, and improving the coordination mechanism and management aspects of Dana Sehat. Similar workshops were also conducted at the district level in four provinces. A workshop on community participation in the transmigration area was also conducted with the participation of health and related sectors from the central level. Five fellowships for studying community participation, with emphasis on health insurance schemes and community health funding programmes, were arranged. In Sri Lanka, the Jana Saviya movement, with its multisectoral development programme for the "poorest of the poor" is carried out through a mechanism of reaching a consensus within the community. The health sector component, known as Suva Saviya, deals with primary health care as a practical approach to making essential health care available to identified families in an acceptable and affordable way, with full participation of the community in hamlets. A meeting of the WHO Study Group on Community Involvement in Health Management was held in Geneva in 1989. Participants from the South-East Asia Region were India and Thailand. 5. Urban Primary Health Care In November 1989, an Interregional Meeting on City Health : The Challenge of Social Justice, was held in Karachi, Pakistan. Health administrators and Mayors of Bangkok, Bombay, Colombo, and Jakarta participated from the South-East Asia Region. The Symposium on the Implications of Public Policy on Health Status and Quality of Life in Bangalore, 1989, laid stress on housing and urban slums, and suggested policy options. Urban health cannot be undertaken by the health sector alone and an intersectoral strategy is called for. WHO is supporting countries in developing strategies and appropriate technology among the Member Countries. It is providing support to Thailand in various projects such as the application of a PHC development model in low income urban communities. A film, entitled "Quality of Life at Hua Rod Chak Tuk Dang", using Basic Minimum Needs as material, was developed. WHO also provided support for the community financing scheme through urban health cards. The health cards input was implemented in Thippanent and Rahang. It is encouraging that NGOs and associations in various fields are taking a positive interest in urban areas of India. Community Health Workers Community health workers are playlng a lead~ng role in providing health care to the masses in the Member countries Nutrition Nutrition monitoring and surveillance activities are being continuously promoted in the Region. Oral Health Education and promotion of oral health are vital tools in the programmeon prevention of dental caries. Chapter 5 DEVELOPMENT OF HUMAN RESOURCES FOR HEALTH 5.1 N4NAGEEIAL PROCESS FOR THE DETIBLOPPIENT OF HUMAN BESOURCES FOR HJiALTH Achievement of the targets for the development of human resources for health with the aim of achieving health for all through the primary health care approach is of paramount importance. Towards this end, support has been provided to improve capabilities and training facilities and to upgrade educational technology as well as capabilities in planning and management. Fellowships have been provided in support of national needs to strengthen the development of human resources for health. Support was provided to strengthen the planning of human resources for health in all the countries of the Region. Fellowships in health planning were supported in Indonesia and Thailand, and workshops on health planning were supported in India, Indonesia and Thailand. In Thailand, a data base for planning was started with WHO support and training provided for health planners and managers. Support was also provided to strengthen training institutions in all the countries of the Region through fellowships, consultants and supplies and equipment. WHO continued to collaborate actively with Member Countries in improving health systems manpower development (HSMD) mechanisms. and activities were undertaken in Indonesia, Mongolia and Thailand. Continuing efforts to strengthen nursing service management, to effectively utilize nursing personnel in the delivery of health care, especially at the district level, and to strengthen referral facilities in support of PHC are evident in the various activities carried out in several countries of the Region in collaboration with, and support of, WHO. A comprehensive situation analysis of nursing services in Bangladesh has been published for widespread dissemination and use as the basis for long-term planning in nursing development. Training courses at the district level were expanded to improve nurses' management, supervision, research capabilities and skills in carrying out PHC-oriented activities. The strengthening of nursing services, especially for the development of referral systems for PHC, is being promoted through improved training of nursing personnel in Bhutan, through the development of hospital nursing guidelines and a research study on hospital nursing services for improving the quality of nursing care in Indonesia, and through re-examination of nursing regulatory mechanisms in India. Increasing emphasis was given in other countries to strengthening nursing skills in priority speciality areas, through in-country and regional training courses. In Myanmar, efforts were made to strengthen nursing services at central and state/division levels through the formulation of long-term development plans for nursing education and services, including a nursing procedures manual, nursing care standards, staffing patter- and job descriptions for nursing personnel. Modules in nursing administration and management were developed and used extensively in training courses for nurses in key administrative and managerial positions. Progress has been made in improving hospital and district-level nursing services in Nepal, in the areas of nursing skills and infection control measures, through in-service education of nursing personnel in five regions, using manuals developed with WHO assistance. Support was also provided to the Division of Nursing for the development of the national programme for training of MCH workers and for systematic training of TBAs throughout the country. In spite of efforts to further strengthen the managerial process for the development of human resources for health in the Region, much remains to be done. For example, a number of human resource development plans have yet to be effectively linked operational- ly to national health plans in the pursuit of the goal of Health for All. Further, many countries still face gross imbalances in human resources for health besides inadequately trained personnel. In many instances, specific human resources for health targets have not been adjusted to take into account the economic slordown. Human resources are also based on over- optimistic economic projections. Consequently, WHO has actively pursued the introduction of economic aspects to the development of human resources for health. Following the interregional Seminar on Financing of Human Resources for Health, held in Bangkok in 1989, a workshop to develop a methodology for determining the optimal mix of human resources for health was held in Myanmar in February 1990. Field trials will now be carried out to teat this methodology. Continued efforts are also required for improving the quality of programmes of continuing education, for planning career structures and job descriptions, and for the development of good information systems for decision-making. 5.2 RESEARCH IN THE DEVELOPMENT OF HUMAN RESOURCES FOR HEALTH WHO has renewed its efforts to increase the capabilities of the countries for carrying out research into the development of human resources for health. In this regard, the intercountry Consultative Meeting on Reoearch into the Development of Human Resources for Health, held in the Regional Office io January 1989, developed guidelines and a regional plan. It recommended that decision-linked research be carried out in support of decision-making in the development of human resources for health. Three commissioned research projects in the development of human resources for health were supported in 1989-1990. In addition, national workshops on research into the development of human resources for health were held in Bangkok, in June 1989; in Jakarta, in January 1990; and in Kathmandu in May 1990. These will be followed by further research workshops in other countries during 1990-1991. A national workshop on the development of a methodology to determine the optimal mix of human resources for health was held at Yangon from 13 to 17 February 1990. Resulting from this, there is a pilot proposal to carry out studies to determine the optimal mix of human resources for health. The importance of promoting research in nursing and its role in the improvement of health care in general and nursing in particular, was underscored during the fifteenth session of SEA~ACHR in Indonesia in June 1989. One of the recommendations of this meeting related to the use of WHO Collaborating Centres in Nursing and the formation of national task forces/study groups as mechanisms in the development of research in nursing within the framework of health-related research in the countries. The formation of these national groups was supported in India, Indonesia and Thailand. Despite the increase in research activities into the development of human resources for health, much remains to be done. Since 60 to 80 per cent of health budgets are devoted to human resources for health, a small increase in the productivity or efficiency of human resources would result in substantial increases in cost-effectiveness. It is therefore important that decision-linked research into the development of human resources for health be actively pursued. 5.3 MEDICAL EDUCATION WHO continued to support the efforts of Member Countries in further strengthening their medical education systems through the introduction of greater balance and relevance in education and training programmes, particularly at the undergraduate level. Further progress was noted in the trends set over the past few years towards achieving community orientation of curricula, and in the development of appropriate skills and attitudes of students enabling them to serve the needs of communities within comprehensive health systems based on primary health care. WHO collaborated with institutions in India, Indonesia, Myanmar and Thailand in experimenting with the introduction of problem-based curricula, either in totality as parallel tracks or in a phased manner through organ-system and other unit approaches. Similar interests expressed by certain other schools in India and Sri Lanka are being pursued. Through the Collaborating Centre for Medical Education in Thailand, WHO is also assisting in the planning of a new problem-based medical school at Thammasat University in Bangkok. Bangladesh continues to lay great emphasis on the improvement of medical education. In consonance with this approach, a high-powered steering committee, including medical educationists and general educationists, has been constituted to improve the quality of medical education. WHO supported the visit of a four-member team from the Royal Postgraduate Medical School, London, to Myanmar from 19 to 24 February 1990. It is felt that, with the rapid advances in medicine and medical practice, continued and urgent reorientation of medical education would be needed to help medical students and young doctors face future challenges in health care. The Regional Office published the first three monographs in the series on "Reorientation of Medical Education", which are being used by the Member Countries as a key technical response in their attempts to reorient their medical education systems. Towards achieving appropriate education a number of activities have taken place. Thailand has already completed a baseline study of the current situation, based on an adapted version of the regional targets and indicators, while Indonesia and Nepal are in the process of similar exercises. WHO also continued to support a consortium of four medical schools in India viz., All India Institute of Medical Sciences, New Delhi; Jawaharlal Institute for Postgraduate Medical Education and Research, Pondicherry; Banaras Hindu University, Varanasi; and Christian Medical College, Vellore, in developing a comprehensive data base for reorienting medical education, the results of which will be used in formulating strategies and plans for the reorientation of medical education. With wide dissemination of the findings, it is anticipated that more institutions in India will undertake similar exercises, and will initiate innovative approaches in the orientation of medical education. In the sphere of postgraduate medical education, WHO provided technical support and subsidies for overall system development and quality control in Bangladesh and Indonesia, for the organization of lecture tours and resources development in Myanmar, and for the conduct of examinations by the Postgraduate Institute of Medicine in Sri Lanks. Countries are earnestly attempting to develop postgraduate medical education systems consistent with their needs and socioeconomic realities. The recurrent quantitative and qualitative problems of teacher shortages, lack of essential equipment and supplies, and coordination of education systems with health care systems, continue to pose difficulties and limit the pace of development, and further support will be needed in overcoming these. The trends in medical education development provide a basis for cautious optimism that greater balance and relevance will be achieved in the Region in the coming decade, and that physicians of the twenty-first century will be appropriately prepared to meet the challenges of Health for All. 5.4 NURSING EDUWION In several countries, cumulative efforts to strengthen basic nursing education are now yielding tangible results. Significant improvements are manifest in the increasing numbers and quality of national nurse teachers. In Bhutan, the preparation of a qualified core of national teaching staff has enabled the nursing programme to progress towards self- sufficiency. Assistance in the upgrading of teachers and managers of nurses was continued through fellowships for advanced studies or speciality training in educational mthods, management, or clinical nursing specialities, both within and outside the countries, in Bangladesh, Sri Lanka, Nepal, and India. The baccalaureate (S-1) programme in Indonesia has been steadily increasing the strength of its full-time nursing faculty, and ensures ongoing opportunities for faculty and staff development. Community-oriented nursing curricula are being implemented in five countries of the Region. These nursing educational programmes are now initiating periodic evaluations to provide feedback on the progress of implementation and to enable ongoing modifications and improvements to be made. WHO assistance has also been provided for the strengthening of institutional fraoeworks. educational policies and teachinn- - learning resources as essential support for the reorientation process. The effective implementation of the reoriented nursing curricula and the increasing demand for better qualified nursing personnel relative to community health needs also calla for innovations in teaching-learning strategies. Support is being given to initiatives, such as community-based team training in Nepal, and the model field practice areas in Indonesia, as well as to further development of self-learning modules as part of a distance learning initiative for upgrading the knowledge and skill of auxiliary nursing personnel in remote areas of Indonesia. A critical appraisal of the use of distance education for nursing and other health personnel is also being taken up at the regional level. Despite the increasing demand in the Region for higher education for nurse teachers, managers and specialists, institutional resources for post-basic and graduate nursing programmes are limited. Efforts to address this need, such as long-term planning and feasibility studies for programme development, revision and expansion of existing programmes, and promotion of innovative approaches to graduate education, are already under way in Nepal, India and Thailand. Greater support in this area will contribute to the development of the overall nursing education system. 5.5 TEACHER TRAINING Technical support was provided to all the countries for improving educational capabilities of teachers of health sciences. In Indonesia, the Consortium of Health Sciences has continued with its programmes of staff development and the development of problem-based approaches to teaching. A review of the programme for the development of human resources for health, particularly that developed through the Consortium of Health Sciences and the Faculty of Public Health, University of Indonesia, was undertaken in April 1990, with a view to redirecting the programme towards peripheral medical schools and schools of public health. The development of a system of continuing education and the strengthening of research capability among the academic staff of the State Medical Institute and the Medical Technicum in Mongolia were supported. In addition, an integrated clinical curriculum and improved training methods were developed in Mongolia with WHO support. In Myanmar, support was provided for the development of continuing education and a PHC-oriented curriculum. Support was also provided for training in medical school management. The strengthening of the Institute of Medicine, Kathmandu, was undertaken in support of the development of human resources for health. In Sri Lanka, teacher training was further strengthened to increase educational capability. In Thailand, support was provided for the development of innovative medical education oriented to problem-based and community-oriented educational programmes for human resources for health. WHO continued to maintain a coordinated staff development programme for national staff, to upgrade and reorient teachers in the Region, with the result that the Region has a fair pool of expertise in the basics of educational science and technology. However, the slow progress in educational institutions is due mainly to the universal resistance to changing traditional values and practices. Nonetheless, it will seem that, given the conducive internal and external support, the goals that the countries have set for themselves will be realized in time. The UNDP-funded, WHO-executed project to develop an intercountry network of institutions for health learning materials develop- ment organized its first workshop in Kathmandu in January 1990, to plan the details of implementation and coordination of the project. The first five participating countries formulated national work plans, and these activities are expected to draw technical support from the successful Health Learning Materials project of the Institute of Medicine, Kathmandu, which is the WHO Collaborating Centre in this field. It is estimated that, by the end of the first phase of the project, each of the countries will be able to lay the foundation for a sustainable, national health learning materials programme. On the basis of experience with this project, it is planned to invite the remaining countries of the Region who wish to join this network to do so. The first set of English Language Self-Instructional Packages (ELSIP) were assembled in the Regional Office and distributed to 33 institutions of the Member Countries and to nine WHO Representatives' offices of the Region. Initial reports of their usefulness are encouraging, and further requests for additional sets are being received. The situation with respect to health learning materials for the education and training of middle- and basic-level health workers is still far from satisfactory, but the concerted efforts of the Member Countries, with support from WHO as well as other donors, are finally beginning to show tangible results. With further perseverance and application of the knowledge and experience gained thus far, there is every hope that this perennial problem will be overcome during the current decade. All the countries of the Region have reflected human resources for health needs in the overall objectives and targets of their health policies and health development plans, while some countries have made specific mention of such needs for meeting the health strategy. All countries include fellowships in the WHO country budget. The seventy-first session of the Executive Board, in 1983, requested the Director-General and the Regional Directors to respond fsvourably to government requests for fellowships only if these are in conformity with the Organization's policy on fellowships. Such fellowships should be relevant to health manpower needs for achieving the goal of HFA/2000, and they should be the most appropriate means of attaining clearly- defined objectives. The resolution further recommended that the Director-General and the Regional Directors, in cooperation with Member Countries, continue improving the reporting procedures on fellowships and carry out systematic evaluations of the implementation of WHO'S health manpower development programme, including fellowships, and its contribution to the national health systems. Earlier, in 1979 and 1982, at the first and second Regional Conferences on WHO Fellowships, it was recommended that such evaluations could he more effectively conducted st the country level rather than at the regional level. The importance of developing a mechanism for evaluation became an urgent issue after the Executive Board adopted, at its seventy-first session, a resolution on fellowships. In pursuance of this resolution a time-frame for action was drawn up and follow-up activities were undertaken. The Third South-East Asia Regional Conference on WHO Fellowshi~s. held in November/December -1988, concentrated on the modality of implementation and evaluation of WHO'S fellowships policy. In order to enable countries to undertake systematic evaluation of the extent to which the programe has benefited health development, certain indicators and guidelines were identified and adopted. Indonesia carried out field-testing of these guidelines and indicators. The outcome of this trial was circulated to all countries to help them evaluate their own programmes. So far six countries, namely Bangladesh, Indonesia, Mongolia, Myanmar, Nepal and Thailand have made a self-assessment based on the following policy guidelines: (1) Development of a health manpower policy as part of the national strategies for HFA. (2) Effective use of the wide variety of training mechanimus available, including fellowships. (3) Fellowships to be requested only if it is considered to be the most appropriate means of achieving clearly-defined objectives. (4) Establisbent of an adequate selection mechanism to ensure that the most suitable candidates are selected. (5) Periodic evaluation of the progress made in health manpower development efforts, especially fellowships: (a) evaluation of administrative processes; and (b) evaluation of its impact. Almost all countries of the Region utilize in-country training in the form of in-country fellowships for academic courses or continuing education. It is the explicit policy of most countries to use national training institutions as far as possible. Other mechanisms which may be used include visiting scientist grants and research training grants. During the period 1984-1989, 45.3 per cent of the fellowships were taken up within the South-East Asia Region, while 8.2 per cent were in the Western Pacific Region and 25.5 per cent in the Americas or Europe; 21 per cent were multiregional. In the South-East Asia Region, fellowships are awarded in the context of joint WHO/collaborative programmes and projects of countries, which, by definition, relate to national priorities and to the attainment of HFA. Fellowships are awarded by a well-defined selection mechanism which is revised and improved periodically. As part of the evaluation of the fellowships programme in the context of the resolution adopted by the seventy-first session of the Executive Board, countries in the South-East Asia Region are evaluating the implementation of the fellowships programmes and responding to the Regional Office. A detailed report on the analysis of these replies has been compiled by the Regional Office and submitted to WHO headquarters from where a global report will be presented to the Executive Board in 1991 and subsequently to the Forty-fourth World Health Assembly. In response to the request of the Regional Office for utilization reports in respect of 320 fellowships, mainly related to the 1984-85 biennium, only 100 reports have been received. Similarly, a request for reports on 369 fellowships, mainly covering the 1986-87 biennium, has so far produced only 44 reports. The feedback provided by these reports will enable a review of the capacity and capabilities of training institutions for future placements. As an instrument for evaluation, fellowship utilization reports will supplement national efforts in evaluating the fellowships programme. Though Member Countries and WHO have already made some progress towards achieving the recommendations of the fourteenth meeting of CCPDM, considerable efforts are still necessary for develop- ing appropriate terms of reference for individual fellowships with well-defined objectives, for timely nominations, and for strengthening review mechanisms and selection procedures for fellowships at the national level. Within the context of national health manpower development policies and strategies it is observed that Member Countries of the Region are using the fellowships programme, among the other varieties of training mechanisms available to them, as an essential and effective component in the development of health manpower. Though the fellowships budget for the 1988-1989 biennium has been fully utilized through the combined efforts of Member Countries and the Regional Office, much more concerted action is necessary on the parts of all concerned to overcome problems and constraints and to achieve overall improvement in the management of the fellowships programme. The policy of Member Countries to promote their in-country training capabilities through the development and strengthening of training institutions has continued to be supported by WHO through technical inputs, training of tutors, supplies and equipment, etc., with a view to helping the countries attain self-reliance in trained manpower within as short a time as possible. WHO also provides assistance for the development of resource personnel, which not only strengthens in-country training of nationals, but also contributes to promoting the quality of regional training institutions. The Fellowships programne of 1988-89 (Regular budget) has been fully implemented in terms of the budget provision (101.74 per cent), the extent of implementation exceeding the previous biennium by about 45 per cent. During the period under review, 612 fellowships were awarded under the Regular budget at an estimated cost of $5 960 925 involving a period of 3 348 man months (Table 1). TABLE 1. Mstribution of fellowships under WHO regular budget, by region of study (1 July 1988 to 30 June 1989) Country No. of Man month Expenditure Regions of study f ellor American European South- Western More ships East Pacific than one Asia region Bangladesh 110 994.75 1 911 450 Bhutan 11 80 .OO 117 110 1 4 6 0 0 DPR Korea 19 128 .OO 159 100 0 13 2 4 0 India 162 328.00 1 137 405 40 23 12 8 79 - Indonesia 47 225.00 438 100 6 9 5 13 14 Maldives 32 445.00 264 700 0 1 31 0 0 Mongolia 8 35.00 59 470 0 8 0 0 0 Myanmar 77 407.75 882 910 14 20 20 7 16 Nepal 79 455.75 518 100 3 8 60 4 4 Sri Lanka 55 185 -00 336 550 3 5 25 3 19 Thailand 12 64.00 136 030 6 3 1 0 2 Total 612 3 348.25 5 960 925 79 134 185 71 143 Petcentage 12.91 21.90 30.23 ll.60 23.36 The distribution of fellowships, by profession, is given in Table 2. TABLE 2. Distribution of fellowships, under the regular budget, by profession (1 July 1989 - 30 June 1990) Profession Number Percentage Doctors Engineers Nurses Others Total 612 100.00 The subjects of training of the fellowships are given in Table 3. The duration of the training programmes is given in Table 4. The representation of women, in the awarding of fellowships, is still low. The mechanism of contractual service agreements was utilized to cover 112 fellowships. Another 66 fellowships covering 422 man months were awarded during the same period under projects funded from extrabudgetary resources but executed by WHO. The Regional Office also arranged the training of 197 fellows from other WHO regions during this period. It is gratifying to see that fellowships are being utilized with increasing orientation towards the goal of HFA/2000 and development of PHC. There is a tendency to use more short training programmes and study tours, particularly by the more developed countries of the Region. Besides direct management of the fellowships programme, other related activities have been carried out during this period. A new methodology regarding the payment of stipends to fellows, related to the per diem rate, has been implemented globally, and was made effective in SEAR countries from 1 November 1989. The stipend will be revised from time to time, as appropriate. 'Instructions to Fellows', a supplement to the 'Fellowship Information Booklet', has been revised and finalized for use by fellows during the course of their fellowships programmes. The Region is also actively involved in the revision of the fellowship application form, which requires streamlining to meet the requirements of changing situations. TABLE 3. Distribution of fellowships under the regular budget, by subject of study and country of origin of the fellow (1 July 1988 - 30 July 1989) Subject BAN BAU DFRK IND IN0 HAV HOG MMR NEP SRL THA Total Per centage Public health administration 18 4 0 3 9 2 2161410 2 80 13.07 Environmental health 16 0 0387008591 84 13.73 Nursing 0 2 000901640 22 3.59 ~- ~ ~ Maternal and child health 4 0 2150002131 28 4.58 Communicable diseases and laboratory services 18 3 0 45 14 1 0 17 17 12 4 131 21.41 Clinical sciences 27 2 8 1113 111 6 11 72 11.76 Basic medical sciences and education 13 0 210417060 34 5.56 Research methodology 0 0 091003010 14 2.28 Others 14 0 7 50 15 3 4 12 30 9 3 147 24.02 Total 110 11 19 162 47 32 8 77 79 55 10 610 100.00 TABLE 4. Distribution of fellorehips, by duration (1 July 1989 - 30 June 1990) Duration Number Percentage (months) 4-6 7-12 Over 12 Total 612 100 .00 1. Directory of Regional Training Institutions The Directory of Regional Training Institutions has been revised with the support of a consultant in collaboration with Member Countries. After the incorporation of specific comments by the various technical units, the second edition of the Directory is now in press, and will soon be distributed to Member Countries and relevant international agencies. The Directory will enable all those interested to scan the currently available educational resources in the Region, in various fields of medical and health sciences. 2. Group Educational Activities During the period under review, 33 meetingslgroup educational activities were held, of which 25 were regional and the remainder policy or advisory meetings. A review shows that justifications for the meetings were clearly spelt out, that the objectives in respect of most of the meetings were achieved, and that the methods adopted appeared appropriate for achieving these objectives. In most cases, follow-up activities have been initiated. These group educational activities, excluding policy and advisory meetings, consisted mainly of regional meetings, workshops, consultative meetings and short training courses covering different subjects, such as safe motherhood, nursing and midwifery, management for prevention and control of HIV infectionIAIDS, safety of blood and blood products, drinking water quality surveillance, etc. The representation of countries and the number of participants are shown in Table 5. TABLE 5. Representation of countries and number of participants in intercountry and inter- regional group educational activities (1 July 1989 - 30 June 1990) Country Number of Number of activities participants Bangladesh 11 16 Bhutan 13 19 DPR Korea 2 4 India 24 66 Indonesia 21 49 Maldives 14 20 Mongolia 12 20 Myanmar 16 29 Nepal 21 48 Sri Lanka 24 41 Thailand 24 69 Total 381 Table 6 shows the distribution of participants in intercountry activities, by type of activity. TABLE 6. Distribution of participants in intercountry activities, by type (1 July 1989 - 30 June 1990) Type of activity Nmber Number of participants Regional meetings 7 85 Workshops 10 192 Consultative meetings 5 73 Short training courses 3 31 Total 25 381 Chapter 6 PUBLIC INFORMATION AND EDUCATION FOR HEALTH Information and Education for Health, which is aimed at helping people to lead a healthy life, gathered momentum in the Member Countries. More intensive methods in health education were applied to reach the community, and the media were also utilized as allies in the war against disease and ill-health. Health education, recognized as an integral component of the health care system in Member Countries, is aimed at strengthening programmes of information and education for health. Lhring the period under review, significant developments took place, both at regional and country levels, to strengthen information and education for health (IEH) activities, with an increasing focus on school health education. "Youth in Health Development" activities were further encouraged through CSAs, in Bangladesh, Indonesia and Myanmar, for strengthening youth involvement in health development programmes. The theme of World No-Tobacco Day 1990, focusing on youth, provided further impetus to the mobilization of youth for promoting healthy lifestyles. In the area of AIDS, intercountry group educational activities were held to address those aspects of AIDS prevention and control that were still largely underdeveloped in the Member Countries. An intercountry Workshop on psychosocial counselling was held in Bombay in November 1989, and another intercountry Workshop on Monitoring and Evaluation of Health Promotion Activities was held in Dhaka in January 1990. An intercountry consultation on AIDS was also held in New Delhi in December 1989. At the country level, follow-up national workshops on the development of health education materials for AIDS control took place in Myanmar. Whereas these workshops focused on AIDS, the training provided was equally applicable to other health promotion and IEH programmes for achieving HFA12000. Three countries of the Region, viz., India, Indonesia and Thailand, participated in the Working Group Meeting on Health Promotion in Developing Countries, convened by WHO headquarters in October 1989. The Working Group considered ways whereby health promotion approaches and concepts which have been deemed effective in a number of developed countries could be made relevant and applied to the developing world. At the country level, WHO'S collaborative activities were aimed at strengthening health education at the district level, through consultative review meetings (such as those held in Bangladesh and India, which involved health education personnel from states, provinces and districts), through training for district personnel (such as that in Bhutan), and through fellowships for district-level health educators (as in Sri Lanka). Bhutan will comence, for the first time during this biennium, a separate WHO collaborative programme to strengthen the information and education component of the district health system as an integral part of primary health care. Fellowships in health education, to provide masters, diploma and certificate training, and short study tours were availed of by health educators in Bangladesh, India, Indonesia, Myanmar, Nepal and Sri Lanka. Starting from March 1990, a series of discussions on "tobacco or health" for different population groups were held in Indonesia. Seminars and courses in public relations and media were held in Indonesia and Thailand. Collaboration was strengthened in the area of development of educational materials. In Thailand, materials were developed to disseminate health messages concerned with creating healthy behaviour among the public, and a no-smoking campaign in the community was carried out. In Bangladesh, flip charts were prepared to educate communities on colmnon health problems. A health communications workshop was held in India in December 1989 to provide communication skills to staff of central and state bureaus and other agencies involved in health education; a national conference of voluntary organizations was convened in December 1989, and a national workshop on production of scriptslmessages on oral health was held in May 1990. Short-term consultants were provided to Bangladesh, for their review meetings, and to India for the health communications workshop. Collaborative activities in IEH research continued with the initiation of studies which included the utilization of health education personnel at the district level in Bangladesh, and of health education materials in India. Efforts to strengthen the links between health personnel and the media continued. An intercountry media consultation on AIDS, held in New Delhi in December 1989, brought together media practitioners and health officials for a better under- standing of a health problem of major significance to the Region, and provided a forum for the media to understand health personnel better and vice versa. The UNICEF/WHO/UNESCO publi- cation "Facts For Life" was widely distributed to health personnel as well as to the media and nongovernmental organizations. The publication is being adapted to suit respective country needs, while Thai and Bahasa Indonesia versions have already been published. World Health Day, which focused on the environment, evoked widespread interest in the Region with information kits being widely distributed and adapted in the Member Countries. The Regional Director's World Health Day broadcast was beamed to many countries in the Region by All India Radio, and tapes were sent to Member Countries for their use. Seminars, talks, exhibitions, health fairs, etc. were organized by government and nongovernmental organizations, as well as by educational institutions, for the comunity. World Health Day, No-Tobacco Day and World AIDS Day generated extensive media interest, helping to focus attention on issues that have a direct bearing on health. As a means of providing valid information on important subjects, information kits were produced on "Prevention and Control of Accidents", "Self-care and Healthy Lifestyles" and "Promotion of Women's Health in South-East Asia" in addition to the kits distributed widely in the Region on World Health Day, No-Tobacco Day and World AIDS Day. Several countries have reported good use of the kits and their adaptation by nongovernmental organizations. It is therefore proposed to continue this activity. A folio containing a sample of health education materials developed in the Region for the prevention and control of AIDS was published and distributed to concerned agencies. The photo library in the Regional Office was streamlined with better cataloguing, and a small photo display on WHO'S collaborative activities in the Region was prepared for use in the WHO Representatives' offices. School health education was also the focus of a joint conaul- tative seminar on "School Education for the Prevention and Control of AIDS in Asia and the Pacific", jointly organized by WHO and UNESCOIPROAP in Bangkok in February 1990. Seven countries from the South-East Asia Region and ten countries from the Western Pacific Region participated in the meeting and made specific recommendations pertaining to regional and national action strategies to introduce AIDSISTD education in schools. This event was a significant landmark in inter-agency collaboration. Collaboration was further strengthened with the establishment of a regional AIDS education and health promotion materials Exchange Centre at uNESCO~PROAP Bangkok, and with the representation by a delegate from Thailand at the World Consultation of Teachers' Organizations in Education For AIDS, held in Paris in April 1990. In March 1990, the Region was represented at the Round-table discussion on "Education For All: Enabling School Age Children and Adults for Healthy Living," at the UNDP/UNESCOIUNICEF/WO~~~ Bank, World Conference on "Education For All" (WCEFA) held in Jomtien, Thailand. Pour country situation reports on school health education were prepared by nationals from India, Indonesia, Sri Lanka and Thailand for distribution at the Conference. The World Declaration on "Education For All" contains specific reference to the need for educating children, youth and adults in health and nutrition. SECTION I11 HEALTH SCIENCE AND TECHNOLOGY Chapter 7 RESEARCH PROMOTION AND DEVELOPMENT INCLUDING RESEARCH ON HEALTH- PROMOTING BEHAVIOUR The regional research programme aims at strengthening national research capabilities, promoting and coordinating research on regional priority problems related to social and economic development, and at promoting research designed to facilitate the rapid application of existing and emerging scientific knowledge. Towards this end, the Regional Office obtains expert advice on policy and direction of research from the South-East Asia Advisory Committee on Health Research (SEA/ACHR), and technical advice from its sub-committees and scientific working groups. Biennial meetings of the Directors of Medical Research Councils or Analogous Bodies and Concerned Research Foci in the Relevant Ministries (MRCs) are important for obtaining the views of the countries on the implementation of the regional research programme and for mobilizing support. The fifteenth session of SEA/ACHR, held in Jakarta from 6 to 12 June 1989, recommended that a sub-committee of SEA/ACHR be set up to make preparations for the technical discussions on the "Role of Health Research in Strategies for HFA/2000" at the Forty-third World Health Assembly in 1990, and to produce a document containing relevant information from the South-East Asia Region as a contribution to the documentation being prepared by WHO headquarters. The Sub-committee met on 30 and 31 October 1989 and outlined its regional concerns and priorities in a report which formed the contribution to the Technical Discussions at the Forty-third World Health Assembly. There was active participation by countries of the Region in these technical discussions. The General chairman and the keynote speakers were eminent scientists from the Region while senior researchers and research administrators included in the national delegations to the Health Assembly as well as the chairman and several members of SEA/ACHR and former members of the Global ACHR from the Region also took part. The fifteenth session of SEAIACHR, while taking note of the progress made in the implementation of the regional research programme and the follow-up actions taken by the Regional Office on its recommendations, further recommended that the Regional Office continue its activities to prepare for a comprehensive review by SEA/ACHR of its role, functions and working, and that the subject of "the role, functions and working of ACHR and related matters" be taken up as an item for discussion at the sixteenth session of ACHR. A consultative meeting, held in the Regional office from 26 to 28 February 1990, reviewed the role, functions and working of SEAIACHR in health research, and included a discussion of the report by the short-term consultant as well as other relevant material prepared for the meeting. The report of the meeting was presented to the sixteenth session of sEAIACHR. The sixteenth session met from 2 to 6 April 1990 in Chiang Mai, Thailand. It reviewed the Regional Research Programme and recommended to WHO to increase its efforts to help countries to develop a policy to transfer health related technologies and to help countries develop mechanisms for the monitoring and recog- nition of health technology that is appropriate and assimilable, especially at the PHC level. It reviewed the role, function and working of SEAIACHR, and in endorsing the conclusion of the consultative meeting which preceded it, reaffirmed that the terms of reference as enunciated in 1976 continued to be rele- vant and valid. The technical topics taken up for discussion were Xesearch on Oral Health, Research on Tuberculosis and Research on Performance Assessment and Quality Assurance in Health Care Delivery. Among the important recommendations pertaining to these topics is the establishment of a Task Force on Research on Tuberculosis and for commissioned health research to be promoted and supported by the Regional Office. As recommended by the Regional Committee, ACHR and MRCs, more emphasis is now given to direct institutional strengthening for research. The Regional Office started an institutional streng- thening scheme in 1988. Following the task force meeting to advise on the ways and means of institutional strengthening for research, and the meeting of the Panel of Scientists, discus- sions were started with four countries. Two countries complied in 1989 by identifying institutions for the strengthening of HSR, completing the project outline, and identifying the different components and modus operandi. Institutional streng- thening grants were awarded to two countries. The take-off in regard to activities identified in the original grant applica- tions sent to the Regional Office is still slow. Mechanisms to further stimulate activities need to be identified and discussed with the countries. The Regional Office continued to provide technical and financial support to research projects of regional priority and interest, which included investigator-originated projects, as well as commissioned collaborative projects in priority areas where little or no research is being done. In addition to research grants, these multicentre collaborative projects require considerable nurturing, in the form of technical support, organization and coordination by the Regional Office, as well as visits by consultants. Nevertheless, they are an important means of strengthening the research capability of institutions and of providing direct technical support to the pertinent health programmes of the countries. The distribution of research topics supported by WHO includes a majority of field-based studies in health systems research, a few concerned with epidemiological and intervention studies in communicable diseases, a few hospitsl-based clinical studies, and even fewer studies concerned with experimental laboratory investigations. Studies on the epidemiology of dengue haemorrhagic fever are in progress in two countries. Vector control for DHF, with community participation (Phase I), has been completed in two countries. The progress reports received have been reviewed by a core group at the Regional Office. Further extension of the studies, with enhanced community participation, is being planned. Research on the developnent of dengue vaccine is progressing well. The Seventh Peer Review Meeting, held in August 1989, recommended the trial of three candidate dengue vaccines, 1,2 and 4, as a single inoculation, and also recommended clinical trials in children. This in itself is a noteworthy achievement. It also accords valuable opportunities for the transfer of technology in vaccine development to the institution involved in the project, which is the WHO Collaborating Centre for Research on the Immunopathology of Dengue Haemorrhagic Fever and for the Production of Immunological Reagents as well as the Centre for Research in the Development of Dengue Vaccine. The multicentre collaborative epidemiology study on non-A non-B hepatitis is progressing well in Myanmar. India, Mongolia and Thailand, and will lead to a better understanding of the epidemiology of the disease, which is prevalent in epidemic and endemic forms in the Region. Entericallrtransmitted-non-A non-B hepatitis (ET-NANB) seems to carry a high mortality among pregnant women during epidemic outbreaks. There is reaaon to believe that the virulence of the organism(s) may be altered during epidemics. The magnitude of exposure of children to ET-NANB virus is not well documented. Many aspects of the etiological agents remain unknown and need further study. Research in maternal and child health is being supported through an important collaborative study of low birth-weight babies and their determinants, which is going on in several countries. Status reports of individual study centres were presented at the meeting of the Principal Investigators held in September 1989. Good progress had been made in all study centres and registration of pregnant women had been completed (Pune 4 388; Nepal Rural approximately 3 000; Nepal Urban 3 670; and Sri Lanka approximately 1800). Regarding data entry, both study centres in Nepal had completed initial entry and editing of data up to the time of delivery, while India and Sri Lanka are expected to complete data entry soon. Collaborative studies on the epidemiological and socio-cultural aspects of ageing are being implemented. A short-term consultant is being recruited to complete follow-up actions after the first meeting of principal investigators. In addition to the ongoing research projects supported by intercountry funds, 52 research projects have been funded through WHO country budget allocations for RPD and HSR. As of March 1990, there were 63 active collaborating centres, with a wide scope of function ranging from health programme development to cardiovascular diseases. Some 20 centres are related to the programme areas of disease prevention and control, as compared to 16 centres concerned with diagnostic and therapeutic technology. Of the 63 centres, over 33 are actively involved in health service development and 25 are concerned with research and training in various subjects. Strengthening of research capability in the countries is a major aim of the regional research programme. To this end, a number of visiting scientist grants and research training grants have been awarded in priority topics identified by the countries. The award of research grants to individuals, as well as to several commissioned collaborative research projects, also contributed significantly towards improving the research capabilities of the participating institutions in the countries. The limited resources made available from the Regional Office are coordinated with, and supplemented through, inputs from WHO headquarters in the form of special programmes, such as the Programme for Research Development and Research Training in Human Reproduction (HRP), the Programme for Research and Training in Tropical Diseases (TDR), and the Global Programme on AIDS. Chapter 8 GENERAL HEALTH PROTECTION AND PROMOTION 8.1 NUTRITION The Joint wHO/UNICEF Nutrition Support Programmes (JNSP) in Myanmar and Nepal continue to work towards targeted nutritional objectives. The Myanmar programme was evaluated in late 1989 and appears to have resulted in a small but real reduction in malnutrition in the one-third of the population of the country that it covers. This has been achieved by a heavy emphasis on careful training, utilizing a 'cascading' model in which training of trainers precedes that of community workers. The first step was a situation analysis that determined the training needs. Then curricula were modified, lesson plans drawn up and learning aids prepared. Trainers were given refresher courses so as to be able to adopt new approaches. The upgraded training focused on community-level workers. It has been accompanied by an emphasis on supportive supervision and monitoring. The Nepal JNSP was redesigned during the year to concentrate on health sector support to community-level nutrition activities with a corresponding emphasis on training. Low birth-weight is largely a reflection of foetal malnutrition. Eight South-East Asian countries have adopted this indicator in their health-for-all strategies. In four of them, more than 20 per cent of newborns weigh less than 2 500 g. This is the highest proportion in any region. This indicates that protein- energy malnutrition is still a severe problem in this region. Although repeat surveys in Bangladesh, India, Myanmar, Sri Lanka and Thailand indicate that prevalences of protein-energy malnutrition are decreasing at between two and five per cent a year, nearly half of the preschool-age children in the Region are found to be moderately to seriously malnourished. The wHO/UNICEF/ICCIDD Consultation and Workshop on Iodine Deficiency Disorders in South-East Asia, held in New Delhi in March 1989, indicated that considerable advances had occurred in programmes against IDD since the Regional Committee had, in 1981, set a target of control of IDD by the year 2000, and the regional strategy was endorsed in 1985. The need for regular technical consultations amongst country managers of IDD programmes was identified. The first meeting of the South-East Asia Regional IDD Working Group is scheduled to be held in the Regional Office in October 1990 to exchange information and programme experiences, facilitate the search for external resources, support government programmes and contribute to programme planning. Responsible technical officers and researchers from the countries of the Region participated in the interregional Symposium on Vitamin A Deficiency, held in Kathmandu in November 1989, under the auspices of the International Vitamin A Consultative Group. They reviewed strategies and new developments, including in particular the balance between programmes to distribute high-potency vitamin A capsules (perhaps through the EPI system) and the promotion of food sources of vitamin A. Efforts were made during the period to improve the distribution of technical materials and information on nutrition to key individuals and imtitutions in the countries of the Region. Po this end a selected and annotated bibliography of WHO publi- cations in nutrition was prepared and widely distributed along with selected available publications. WHO supported fellows from regional countries and others have, for many years, participated in the M.Sc. and certificate courses in Nutrition at the National Institute of Nutrition in Hyderabad, India. An assessment of the relevance, effectiveness and impact of the courses was carried out through a mailed questionnaire, interviews with ex-participants and their supervisors in Indonesia and Thailand, and through a review at the Institute itself. Several ex-participants are now in crucial positions in governments and other organizations. Many are involved in the planning and implementation of national health and nutrition programmes. The review concluded that the courses have been successful in providing a sound basis for the future roles and responsibilities of the participants. Successive courses have increased their relevance to operational nutritional issues. Without sacrificing the excellent scientific content of the courses greater attention needs to be given to issues of practical management of the nutrition components of health programmes and of intersectoral strategies for nutrition. The South-East Asia WHO Advisory Committee on Health Research approved a nutrition research policy for the Region in 1988 as part of the global nutrition programme. Discussions have been held at key institutions in the Region and a Nutrition Research- cum-Action Network is being set up to define operational research priorities, to carry out and support collaborative research projects and to develop training programmes to enable operational managers to use research to solve problems they encounter. The first meeting of the Network is scheduled to take place in Thailand in August 1990. 8.2 ORAL HEALTH Low levels of oral hygiene, lack of adequate nutrition, environmental factors, and the non-availability of oral health care and services in most of the countries are the major causes of dental caries and periodontal diseases, which are increasing sharply. For example, the dentistlpopulation ratio in India is 1 : 47 000. However, as most of the dentists are clustered in urban areas, the dentistlpopulation ratio in rural areas is 1 : 350 000. This disproportionately large difference between the ratios in urban and rural areas is a common feature of all Member Countries. Surveys were conducted in February/March 1990 in Indonesia, India, Sri Lanka and Thailand in oral health research, so as to assess the magnitude of oral health problems, identify problem- orientation and appropriateness of oral health resources, determine measures for improving both research and service quality, and to decide upon ways and means of accelerating implementation of research findings. The consolidated outcome of the survey was submitted to the sixteenth session of sFA/ACHR, held from 2 to 6 April 1990. The Committee deemed that levels of oral hygiene were unacceptably low. Harmful local habits, such as chewing tobacco, betelnut and pan, and beedi-smoking, etc., combined with the lack of oral health services, were considered to be some of the important factors contributing to oral diseases, including oral malignancies. WHO collaborated with Member Countries in the training of national oral health personnel through local cost subsidies and fellowships for assessing oral health situations, strengthening institutional capabilities and providing essential equipment, instruments and literature. 8.3 ACCIDENT PREVENTION A quarter of the 3 million deaths occurring in the world as a result of injury took place in the countries of the South-East Asia Region of WHO. Traffic accidents have been found to be one of the most important causes of injuries in the Region. In Sri Lanka, the number of fatalities due to traffic accidents, per million population, increased from 56 in 1974 to 89 in 1983. The number of fatalities per 10 000 vehicles rose from 6 to 8 and from 32 to 34 in Nepal and Sri Lanka respectively, during the period 1975-1984. In Thailand, accidents have been the leading cause of death since 1968. In India, about 10 per cent of the vehicles are involved in road accidents, killing 25 000 persons and injuring more than 100 000 persons per year. However, the information available in all the countries is far from sufficient to assess the magnitude of the problem and does not provide a scientific basis for interdisciplinary and intersectoral approaches to the prevention of injury. Therefore, emphasis has bee; laid on the prbmotion of surve;s,~data collec- tion and eoidemiolo~ical and o~erational studies with a view to - creating national awareness of the problem, including its socioeconomic and health implications. WHO provided technical and financial support for conducting national workshops and seminars in Thailand and Indonesia, and facilitated countries' participation in the First World Conference on Accident and Injury Prevention, held in Sweden from 17 to 20 September 1989. WHO'S collaborative activities were also directed to the training of national personnel in accident and injury prevention through study tours and fellowships, and to the strengthening of institutional capacity through the provision of logistic support. There is a need for further strengthening of collaborative activities, particularly in epidemiological research and in the coordination of injury prevention activities, which are carried out in different sectors of the countries. Continuous efforts should be made for strengthening and streamlining legislation, including rules, regulations, instructions etc., and for the enforcement of law in all the countries. 8.4 TOBACCO OR WTH This new sub-programme area is only slowly beginning to be reflected in specific activities in most countries of the Region. However, in some countries, activities with a remarkable scope have been initiated within a short time. These activities are strongly linked with more general health promotion and disease control programmes, as testified by the absence of specific Tobacco or Health projects in any of the countries. Bhutan has started to declare entire districts as tobacco-free areas. In Thailand, a high-level, multisectoral National Committee for the Control of Tobacco Use has been formed, resulting in high public visibility of the importance of a reduction in tobacco use for improving the health status of the population. This visibility was further increased by the international repercussions of one of the measures spearheaded by this Committee, viz., the prohibition of cigarette imports into the country. Also, all types of sales promotion of tobacco products are now prohibited, as is smoking in public transport. In India, preparatory work has been initiated for the establishment of a national plan of work for the control of tobacco-related cancers. Indian Airlines has also instituted a ban on smoking on all domestic flights. In Thailand, too, smoking is banned on national flights. In Bangladesh, the involvement of the highest govenunent levels in anti-tobacco activities has continued, and preparatory work for a countrywide representative survey on tobacco use has been completed. 'No-tobacco Day', 31 May 1990, with the focus on 'Childhood end Youth without Tobacco', was observed with much participation by, and public visibility in, the countries of the Region. In several countries, these activities for increased public awareness were observed even at provincial and district levels. The Director-General presented the 'Tobacco or Health' medal to prominent leaders in the "No-Tobacco Movement" in the Region. Chapter 9 PROTECTION AND PROMOTION OF THE HEALTH OF SPECIFIC POPULATION GROUPS 9.1 MAl!JBhN AND CHILD HEALTH, INCLUDING FAMILY PLANNING A positive trend that favours a holistic approach to the delivery of maternal and child health services is gradually emerging in the countries of the Region. This is exemplified by the acceptance of an integrated system of service delivery, in respect of maternal and child health and family planning, by all the countries. Some countries have further broadened this approach through close coordination between MCH/FP services and other programmes directly related to MCH, such as EPI, CDD, ARI and nutrition. These initiatives will, in the long term, help to develop a comprehensive health infrastructure in which continuity of services needed for MCH care can be fostered and sustained. An outstanding feature of the reporting period has been the firm acceptance by the countries of the Region of the need to address the problem of maternal mortality, with greater emphasis on maternal care and safe motherhood. While selected interven- tions aimed at child survival continued to be vigorously pur- sued, improvement in the accessibility and quality of maternal care would not only contribute directly to child survival but also encourage a holistic approach to child development. There is also a gradual trend in most countries towards an integrated system of service delivery, vis-a-vis maternal and child health, family planning and programmes directed at prevention and control of the common childhood diseases. With regard to population policy and family planning, the emphasis placed on fertility and population growth is varied among the countries. All countries have, however, accepted . family planning and child-spacing as a vital component of programmes aimed at achieving better health for mothers and children. It is worthy of mention that in Bhutan a population policy was approved in early 1990 while Myanmar decided to include child-spacing in routine health and welfare activities. WHO collaboration in FHlMCH was directed mainly at achieving wider service coverage and improving the quality of services. Exchange of ideas and sharing of country experiences through visits to countries were also supported. In order to improve the quality of services as well as programme management, most countries utilized in-service training programmes, meetings and consultations. In Myanmar, in-service training of MCH officers, divisional health officers, lady health visitors, midwives and auxiliary midwives figured prominently. In Nepal, in-service training of public health nurses in IUD insertion and the use of injectable8 was an innovative activity to achieve wider service coverage, while at a more peripheral level, the involvement of Panchayat-based health workers in promoting oral rehydration therapy, nutrition, immunization, basic health care and child- spacing is being attempted. In Sri Lanka, midwives in hospitals and maternity homes were given refresher training aimed at improving the quality of institutional care. In Maldives, selected family health workers will receive three months of intensive training. In Bhutan, UN volunteers were used to support training at the Institute of Family Health. In Bangladesh, the use of family planning clinical supervision teams for quality assurance of services related to family plan- ning continued. This initiative was subjected to a recent four- partite review, with possible modification of the existing strategy. Meetings and consultations were also supported during the period under review. In Indonesia, a series of meetings was held to develop strategies for improving perinatal care and maternal health. Review meetings to monitor and evaluate MCH programme performance were also held in eleven provinces. An innovative scheme was introduced to train health workers at Puskesmas and Posyandu levels to train cadres who, in turn, would implement a group-learning scheme for pregnant and lactating mothers. In Sri Lanka, a national consultative meeting was held to review the performance of the MCHlPP programme. In Thailand, a Seminar on MCH and Noncommunicable Diseases was held for paediatricians, obstetricians and provincial medical officers, as a means of promoting prevention and control of noncommunicable diseases in mothers and children. Maternal and Child Health The health of mothers and children continues to be the cornerstone on which the health of the nation rests. Efforts in the Member countries are therefore aimed at strengthening MCH services, integrating them w~th other appropriate areas like EPI. d~arrhoeal diseases control. etC. Health of the Elderly With the proportion of the elderly in the populat~on steadily increas~ng in the Region. Member countries are Initiating action plans for the health care of the elderly. k I B , . Environmental Health World Health Day 1990 focussed attention on the close l~nks between health and the env~ronment The Day evoked w~despread response with actlve community partlclpatlon in lnitlatlng measures to curb pollut~on and to generally make the environment healthier Water and Sanitation As the lnternat~onal Dr~nk~ng Water Supply and Sanitat~on Decade comes to an end (1990) efforts are being accelerated to hasten the provlslon of regular supply of safe water and to provide sanitation fac~l~ties part~cularly to unserved populations Study tours and fellowships were also supported. Two batches of four medical officers each from India visited some countries of the Region to observe and share experiences regarding imple- mentation of basic MCH services; two medical officers (MCH) from Sri Lanka were awarded fellowships for in-depth study in MCH with emphasis on maternal mortality, morbidity and family planning; eleven fellowships were availed of by medical officers in Mongolia for specializing in selected fields of MCH, while in Thailand six fellowships were awarded for postgraduate study. Indonesia utilized a scheme of in-country fellowships for language training and report writing, documentation, financial management and computer training. Support was also provided for studies aimed at obtaining information needed to strengthen programme development and improve strategies in the delivery of MCH/FP services. In India, as in the previous years, a number of such studies were initiated. These include: evaluation of the functioning of post-partum centres at the sub-divisional level, models for integrated delivery of MCH/FP and PHC, reorganization of integrated family welfare/PHC service delivery in urban areas with special emphasis on slums, a study on people's health seeking behaviour, and measuring acceptability of family planning in rural areas with possibilities of using doctors of indigenous systems of medicine and village practitioners. The utilization of the findings of these studies and those conducted in the previous years will need to be followed up and assessed. In Thailand, studies involving model development and field-testing included: strengthening MCH service delivery at the health centre level to improve birth-weight, use of "model mothers" (mothers with an ideal set of maternal health criteria) as indicators of health in the community, improvement in child-rearing practices to support normal child development utilizing simplified child development booklets at the family level, and a study on child-rearing practices among working mothers, both urban and rural. Since the International Safe Motherhood Initiative in February 1987, most countries of the Region have initiated safe motherhood activities. Operational research projects directed at improving maternal health have been undertaken recently in many countries. These include: the maternal mortality and morbidity surveillance system in Bhutan; maternal morbidity and mortality in South Indian women in India; a multicentre control trial on the use of the Partograph in the management of labour and a maternal/perinatal mortality study in rural Central Java, Indonesia; and two studies in Nepal, namely, a study on the prevention of maternal mortality in selected hospitals, and a KAP of mothers-in-law regarding maternity care of their daughters-in-law before and after group-learning sessions. Technical support was provided by both WHO headquarters and Regional Office staff in research project formulation, data validation, processing and analysis, and strengthening research capabilities at both field and institutional levels. A study on maternal mortality in Central Java, Indonesia, has been completed and its results were reviewed in February 1990. The report of the study was discussed at a national seminar held in May 1990. A national workshop on Maternal and Perinatal Mortality was held in Sri Lanka in collaboration with the Ministry of Health, College of Obstetricians and Gynaecologists and the Asia Oceania Federation of Obstetrics and Gynaecology, with the objective of reducing maternal and perinatal mortality. An intercountry workshop titled 'Safe Motherhood Initiative - Recent Developments and Key Issues' was held in the Regional Office in November 1989, with participants from eight SEAR countries. Follow-up national workshops on the subject have been planned for Bhutan, India, Indonesia and Maldives. Regional Office staff and nationals from nine SEAR countries also participated in the Safe Motherhood South Asia Conference, held in Lahore, Pakistan, in March 1990. The Government of India, after close scrutiny of the family welfare programme, has decfded to promote, on a voluntary basis, responsible and planned parenthood, emphasizing a "two-child norm" through independent choice of family planning methods suited to acceptors. The UNFPA-funded Regional Advisory Team on MCH~FP, with one Senior Medical Officer and one Technical Officer (Management, and Evaluation), supported by a Consultant (Statistician) and MCH staff from the Regional Office, assisted in project formu- lation, project monitoring and evaluation of MCHIFP programmes, including technical support for research activities related to MCH/ PP . Women, Health and Development Activities under the "Women, Health and Development" (WHD) programme continued to be directed at strengthening the involvement of women's organizations in health promotion, and enhancing the exchange and dissemination of information to encourage the participation of women in health and development. Efforts were directed at the promotion of operational research in maternal health under the Safe Motherhood Initiative and mobilization of women's organizations in the prevention and control of HIV infection/AIDS in collaboration with national AIDS programmes. In conjunction with other international and bilateral agencies concerned with Women and Development programmes, major issues related to women's roles at various levels, such as professional and personal, were identified. Emphasis has been laid on the need to work on women's issues, with small groups, on technical matters, such as drinking water and irrigation projects. In this regard, interagency meetings, sponsored by the participat- ing agencies on a rotational basis, are being held every month. 9.2 ADOLESCBNT HEALTH With the commencement of the Eighth General Programme of Work the subject of Adolescent Health, included earlier under Maternal and Child Health, has been designated as a separate sub-programme. This has been reflected accordingly in the Medium-Term Programme for 1990-1995. With the exception of Indonesia and Myanmar, other countries of the Region have not made provision for Adolescent Health activities as a separate sub-programme for the 1990-1991 biennium. Some countries, such as Sri Lanka, have made modest budgetary provisions under the sub-programme of Maternal and Child Health. Though preliminary activities in support of adolescent health have been initiated in many countries of the Region, with collaboration from WHO headquarters, further progress during the reporting period does not appear to have been made. The multidisciplinary nature of this sub-programme calls for dynamic leadership at the national level if the desired objectives are to be achieved. 9.3 HUK4N REPRODUCTION RESEARCH The South-East Asia Regional Office continued to collaborate very closely with the WHO Special Programme of Research, Development and Research Training in Human Reproduction. Currently, there are five members from the Region on the Programme's Policy and Coordination Committee (PCC), which meets every year. The most recent meeting of PCC was held in June 1990. In addition, the Committee on Resources for Research (CRR), which deals with research strengthening activities, met in April-May 1990 and approved, among other things, long-term institutional development (LID) grants for institutions in the Region for 1991. With regard to research, the Programme concentrates on two major activities, namely, support for research aimed at finding and developing new, safe and effective methods of fertility regulation, and support for research aimed at improving the performance of existing methods of fertility regulation. In order to undertake research on these aspects, a number of research grants were awarded to various institutions in the Region. In this context, projects in the former category included (a) clinical trials on long-acting injectable contraceptives; and (b) experimental studies in monkeys on post-ovulatory methods of contraception. Projects in the latter category included several on evaluating and monitoring contraceptive safety, e.g., surveillance of norplant use, and contraceptive effects on blood factors, cardiovascular system and ectopic pregnancy. In addition, there were projects on contraceptive use dynamics, which relate to the acceptability of the contraceptive, and on lactation, which relate to the efficacy of the contraceptive. A few projects involved more than one country in the Region. Such multicentre studies are usually double-blind clinical trials. The total number of these projects was 45, of which 22 were ongoing and 23 were initiated during the period under review. Another important activity was concerned with infertility. Several multicentre research projects are continuing, with especial regard to the role of sexually-transmitted diseases and other infections as a cause of infertility. There are currently five WHO collaborating centres in human reproduction in the Region - three in India and two in Thailand. Ten institutions - one in Sri Lanka, one in India, four in Indonesia, one in Nepal, and three in Thailand - continued to receive LID grants while some supplies were provided to one institution in Indonesia. Fifteen research training grants were provided during the period under report. A national Workshop on the Assessment of Research Needs for Reproductive Health was held in Sri Lanka in November 1989. The final report, printed in April 1990, forms the basis of the request to funding agencies for institutional strengthening grants support. A site-visit was made to Myanmar to plan a similar workshop, which is proposed to be held in August 1990. The programme is being monitored to study its effect on developing countries. An external impact evaluation report was finalized and submitted to PCC 3 st its meeting in June 1990. Occupational health is of significance in the Region, with the rapid development of industries resulting in an increase in the incidence and variety of occupational diseases and accidents. However, there is strong evidence of a failure to recognize the growing importance of occupational health and safety, with a lack of adequate policies and legislation for the protection of health and safety of workers being evident in most of the countries. There is, therefore, an urgent need to promote an in-depth study of occupational health problems, strengthen research capability in this field, develop appropriate technolo- gies for prevention and control and to promote multidisciplinary and multisectoral collaboration. Special attention should be paid to problems related to child labour in many countries of the Region. Support was provided for in-service training of nurses in occu- pational health in Myanmar. Training modules on occupational health for doctors and a basic occupational health service package for non-formal workers were prepared by national consultants in Indonesia. Training courses and workshops were conducted in Bangladesh and India under the LCS component. Support was also provided for fellowships and logistics in all the countries with WHO collaborative projects on occupational health. 9.5 HEALTH OF THE ELDERLY Emerging issues related to socioeconomic health and humanitarian aspects of ageing populations in developing countries, which are expected to accommodate 61 per cent of the world's elderly population by the year 2000, have not yet received appropriate attention in many of the countries of the Region. The aged, as a vulnerable section of the population and espe- cially susceptible to physical and mental health deterioration and rapid social and environmental changes, require careful scientific assessment of their living conditions, social status and needs, including the availability of affordable health and services. In this regard, a multicountry study is being carried out in Bangladesh, DPR Korea, Indonesia, Myanmar, Sri Lanka and Thailand, using a common protocol approved at a meeting of principal investigators held in March 1989. A Consultant has been recruited to assist the principal investigators. Countries were supported in conducting various training activities and in publishing educational material, through LCS and fellowships and logistic support. A manual on the care of the elderly is under preparation in Indonesia. Emphasis was laid on strengthening institutional capacities and on promoting the concept of self-care and self-help among the elderly as well as among families of the aged. Chapter 10 PROTECTION AND PROMOTION OF MENTAL HEALTH 10.1 PSYCHOSOCIAL. AND BEHAVIOURAL FACTORS IN THE PROMOTION OF HEALTH AND HUWAH DEVELOPMKNT The importance of psychosocial and behavioural factors in healthy child development has been further corroborated by the findings of a WHO-supported multicentre study in India which confirmed the high correlation between social aspects of family functioning, subjective well-being in mothers, and parameters of healthy development in children, especially their cognitive development and nutritional status. This and related work, carried out in Sri Lanka and Indonesia and coordinated by WHO, has now resulted in well-focused and realistic intervention trials in the functioning of dysfunctional families, focusing on the well-being and coping skills in mothers as vehicles for healthy child development. This work was planned by the Regional Coordinating Group for the Mental Health Programme (RCG), which met in Dhaka in September 1989. It will be supported in India by the Indian Council of Medical Research (ICMR) and in Sri Lanka by UNICEF. The RCG has also developed a protocol outline for a multicentre study aimed at clarifying some basic concepts in good medical out-patients care, or the psychosocial sensitivity of physicians of primary care, as preparatory work for intervention trials to improve, through brief in-service interventions, the functioning of services of primary health care. This was in continuation of the previous WHO-supported work on the same issue, carried out in Indonesia. A series of decision-linked behavioural studies for the develop- ment of paychosocial interventions for the containment of AIDS was launched in the Region following the intercountry Workshop on Social and Behavioural Research for the Containment of AIDS, held in Bangkok in January 1990. Some of these studies, of a descriptive type of 'street corner epidemiology', have already shown first results in terms of a reduction in risk behaviour in selected high-risk groups. The substantial WHO-supported project on health behaviour research in Thailand has expanded to include decision-linked studies on behaviours related to the spread of HIV, alcohol and tobacco use. 10.2 PREVENTION AND CONTROL OF ALCOHOL AND DRUG MUSE WHO has continued to execute the UNFDAC-supported drug abuse control programmes in Myanmar and Sri Lanka. In both countries, the epidemic of heroin dependence seems to have been contained and the rate of recruitment of new dependents is lower than the rate of withdrawal among those already dependent. In addition, WHO continued to execute a UNDP-supported project to establish a drug abuse monitoring system in Sri Lanka. In both countries, the WHO-executed projects have helped to improve the effective- ness of drug abuse control activities and to increase national expertise in the field of addiction behaviour. The 'camp' or 'drug-free zone' approach, used to maximize community involvement in localized activities to eliminate rural opium use as well as urban heroin use, has now been shown to reduce rural alcohol problems too. WHO is supporting studies to identify socio-cultural elements necessary for the success of this approach when dealing with problems of illicit as well as licit substance abuse. The Regional Offices for South-East Asia and the Western Pacific have jointly supported an ESCAP-executed study on rehabilitation programmes for drug dependent persons in both the regions. This report has been published and further collaboration in more in-depth studies on the rehabilitation process is planned. The involvement of ministries of health in programmes to reduce problems related to alcohol and drug abuse are still limited in most countries of the Region. Especially, health systems appear reluctant to involve themselves in the prevention of substance abuse although studies in many countries have shown that health personnel can play a very effective role in preventing and reducing, for example, cigarette smoking. WHO has, therefore, continued to promote the involvement of health perso~el in substance abuse programmes through the dissemination of training material. In line with this goal WHO has organized a training course on alcohol and drug abuse control for health personnel from India and Sri Lanka, with DANIDA support. With the high risk of HIV infection in injection drug users, the problem of drug dependence has gained a new and threatening dimension. During an intercountry Workshop on HIV Infection in Injection Drug Users in Goa, India, in December 1989, plans were drawn up to establish a monitoring system regarding the route of drug administration where injection is thought to be rare or absent, and to develop technologies, through coordinated intervention trials, to reduce the risk of HIV infection in drug injectors and their sex partners. 10.3 PREVENTION AND TREATMENT OF MENTAL AND NEUROLOGICAL DISORDEXS WHO'S activities in this sub-programme area continue to have two main thrusts: of development of technologies and of support to countries for the improvement of national capabilities for national mental health planning. Integration programmes aimed at improving basic mental health skills at all levels of health care have continued on an increasing scale in most countries of the Region. The Regional Coordinating Group for the Mental Health Programme (RCG) has reviewed the list of apportioned skills which should be present at the PHC level (the 'mental health kit'), established in 1982, and has updated the agenda prioritizing the research necessary to fill the gaps in the existing knowledge for such integration. At the same time, a list of indicators for the quality of mental health care and the functioning of mental hospitals has been developed as a collaborative effort in the Region. These indicators form the basis for the National Mental Health Programme (NMHP) in Indonesia. The targets in this programme are in fact indicators from this list of indicators. As a remarkable innovation, NMHP sets out to restructure postgraduate training in psychiatry into training in public mental health. The National Mental Health Programme in India, adopted by the Government in 1982, was evaluated, reviewed and updated during a WHO-supported national workshop. An update of the national programme in Sri Lanka has also been prepared with WHO support. Mechanisms to facilitate implementation of the updated plan were reviewed jointly during a country visit by WHO staff. Chapter 11 PROMOTION OF ENVIRONMENTAL HEALTH The Community Water Supply and Sanitation Programme continued to be accorded high priority in most countries. The emphasis of the WHO programme is, however, shifting to broader issues of the environment due to the growing awareness of the adverse effects on health by environmental pollution. This is due mainly to rapid urbanization and industrialization, and to continuous migration of people from rural to urban core areas and urban fringe areas. Many countries have initiated activities related to environmental health in rural and urban development and housing, prevention and control of environmental pollution and health hazards, environmental health impact assessment, control of poisoning, hazardous waste management, health risk assessment, epidemiology and chemical safety. The new global environmental health strategy, of which global community water supply and sanitation strategy is a component, received a favourable response from most countries. 11.1 COWITY WATER SUPPLY AND SANITATION In order to accelerate the implementation of the Community Water Supply and Sanitation (CWSS) Programme, the "Action Agenda", as recommended by the International Drinking Water Supply and Sanitation Decade (IDWSSD) Consultation, held in the Regional Office in July 1988, was pursued with the countries. According to the recommendations, the countries would establish new sector targets after review and development of new sector action plans for institutional development, and carry out realignment and decentralization to secure better community ~articiwtion. oarticularlv of women. A workshop to develop a . . strategy for co~mnunity water supply and sanitation in the Five-Year Plan was also organized in Indonesia. The development of a management information system (MIS) for promoting a realistic data base for better planning and management received special attention. Efforts are now concentrated on the develop- ment of a new global community water supply and sanitation strategy for better comprehensive planning and on the implemen- tation of sustainable sectoral activities in the 1990s. For this purpose, a global CWSS strategy meeting was held in March 1990 in Rabat, Morocco, in which the Regional Office participated. A regional consultation on CWSS was held from 4 to 8 June 1990 in Manila, in which five countries of the Region participated. A global Consultation on Safe Water Supply and Sanitation for the 1990s has been planned for September 1990 in New Delhi, for which support is being mobilized and the necessary background documents have been made available to the secretariat. Technical support was provided through consultation in the area of operation and maintenance in Bangladesn, Indonesia and Nepal, in the area of water quality surveillance and monitoring in India, Indonesia, Myanmar, Nepal, and Sri Lanka, and in the area of low-cost sanitation in Bhutan, India, Indonesia, Myanmar and Nepal. Efforts to mobilize the support of external agencies also continued. In this context, the Regional Office participated in review meetings of certain UNDP-funded projects, namely, those in Indonesia and Nepal. Joint activities were initiated in collaboration with the Regional Water Supply and Sanitation project of the World Bank in Bangladesh, India, Nepal and Sri Lanka. 1. Manpower Training WHO support to manpower development through fellowships, special courses, observation tours within and outside the countries and through other group educational activities relevant to the countries' needs was continued in most countries. In-country training of sanitation workers, sub-professionals and engineers was arranged in Bangladesh, India, Indonesia, Myanmar and Nepal. Training curricula for various levels of public health engineers and sub-professionals were reviewed, and a proposal for the eeteblishment of a trainiw institute was finalized in Bangladesh. In-country training courses were conducted for the training of trainers of various levels of PHE staff as well as for the training of Upazila water supply committees and other community-level water supply and sanitation workers in Bangladesh. In Bangladesh and Nepal, training courses on the computer-aided design of water supply and sewerage networks were conducted in collaboration with the World Bank. Training in data collection, planning and management of water supply and sanitation was also provided to village cadres in Bangladesh, Indonesia and Nepal. Special short courses were conducted for sector officials in operation and maintenance aspects of CWSS installation in Bangladesh, Myanmar and Nepal. Training, through special courses, on trenchleas technology of micro-tunnelling, on low-cost water and sanitation technology for senior sector officials from India, and on the planning and management of rural water supply for officials from Maldives. was arranged. In-country training courses were arranged for Indonesian sector officials in intersectoral planning and in health education for village volunteers. The Desa "Demo" concept was field-tested. 2. Institutional Development Progress continued to be made in the developsent of a management information system for planning, manpower and financial manage- ment in Bangladesh, India, Nepal and Sri Lanka. A consultation for the exchange of knowledge and information, including a review of micro computer programmes and the development of new softwares, including their testing, was organized in India and was attended by participants from India, Indonesia, Nepal and Sri Lanka. Support for the purchase of computer hardware was also provided. The responeibllities of the Department of Public Health Engineering (DPHE) and the Local Government Engineering Bureau in Bangladesh were reviewed. In India, assistance was provided for the preparation of a Rural Water Supply and Sanitation Manual. In Myanmar, guides, books and manuals on the sanitation programme were prepared in the local language. In Nepal, the sanitation strategy was reviewed and the preparation of a sector study and a master plan is being supported. 3. Water Quality Surveillance A training workshop on water quality monitoring was organized by ESCAP in which senior sector officials from India, Indonesia, Nepal and Sri Lanka participated. Senior officials from India attended a course in water quality management for decisionlnakers. In Mongolia, a fellowship was provided for studies on water quality surveillance and control. Workshops on drinking water quality surveillance were held in India, Myanmar and Mongolia. A workshop on flouride removal was also organized in India. In Indonesia, wastewater quality aspects and environmental health impact aspects received special attention. The Regional Drinking Water Quality Surveillance and Monitoring Guide was finalized. 4. Groundwater Development Activities connected with groundwater development continued to be of high priority in Bangladesh, Myanmar, India, Indonesia and Sri Lanka. Hydrogeological surveys, test drilling and exploitation of ground water continued in Bengkulu, Lampung and Tim Tim provinces of Indonesia, Myanmar and Sri Lanka. A workshop on the construction of radial wells was also organized in Myanmar. 5. Research Research studies into the factors that Lead to the persistence of diarrhoea1 diseases in Sri Lanka, with emphasis on water quality and pollution aspects, and into appropriate types of latrines for rural communities in Thailand, were completed. In addition, research on different topics was continuing in India, Indonesia, Sri Lanka and Thailand. 11.2 ENVIRONPIBNTAL HEALTH IN RURAL AND URBAN DBVELOPMKNT AND HOUSING With the rapid increases in populations, developing countries are faced with problems associated with urbanization, resulting in squatter settlements and overcrowding in existing housing areas, and concomitant deteriorating environmental conditions and services such as water supply, excreta disposal, waste water and refuse collection and disposal facilities etc. In order to cope with these environmental health problems, activi- ties in this sub-programme area concentrated on promoting intersectoral cooperation and community self-reliance using appropriate technology. In this connection, studies in selected areas were supported in Bangladesh, Myanmar, Sri Lanka and Thailand for developing plans for corrective action. The report on action study on environmental health problems and strategies for the improvement of conditions in six settlement areas in Sri Lanka was presented at a Conference on Community Environmental Health, held in Colombo in December 1989 to discuss concepts and methodologies, including their dissemination and wider application. The emphasis of this action study was to identify environmental health deficiencies and solicit solutions through active intersectoral cooperation and community participation. In view of the increasing problems of solid waste management in most countries, an intercountry consultation on solid waste management is planned for late 1990 in collaboration with Gesellschaft fur Technische Zusammenarbeit (GTZ). A regional overview of solid waste management, based on country reports from Bangladesh, India, Indonesia, Myanmar. Nepal, Sri Lanka and Thailand, has been prepared for presentation at this consultation. In Calcutta, India, a research project on the socioeconomic aspects of recycling urban solid waste is nearing completion. 11.3 HWTH RISK ASSESSMENT OF POTENTIALLY TOXIC CHEMICALS This sub-programme started in January 1990 and is primarily research-oriented, focusing on the development of research and evaluation methodologies as well as on the production and dis- semination of public information on potentially toxic chemicals for use by countries in such programme areas as control of environmental health hazards, food safety and workers' health. In Indonesia, a consultant assisted the national authorities in finalizing draft legislation on labelling, handling, storage and transportation of hazardous substances, which would help in the adoption of appropriate chemical safety measures in the country. U.4 CONTBOL OF F2WIRONMENlAL HEALTH HAWBDS WHO'S collaborative efforts with Member Countries involved the strengthening of national institutional and manpower capabilities in the areas of air, water and land pollution prevention, as well as the promotion of chemical safety and control of other environmental health hazards. A tripartite review meeting of the UNDP-assisted intercountry project "Safety and Control of Pollutants and Toxic Chemicals" was held in the Regional Office in September 1989. Officials from India, Indonesia, Myanmar, Sri Lanka and Thailand participated. Immediately prior to the review meeting an intercountry conference, held in the Regional Office, identified several activities for the project, including hazardous waste management, emergency preparedness/response , poison control networks, information systems, essential equipment and manpower development. Subsequently, a draft project document for UNDP assistance under the UNDP Fourth Country Programme was prepared for Sri Lanka. The UNDP-funded project in DPR Korea on "Control of Environ- mental Health Hazards" was completed in December 1989, and the terminal tripartite review recommended an in-depth evaluation of the project. The tripartite evaluation team completed ita mission in mid-March, and two project documents - one to strengthen the central laboratory of the Central Hygienic and Anti-Epidemic Station and the other to develop the capabilities of related provincial and municipal surveillance laboratories - were drafted. In April 1990, a UNDP/WHO health sector mission in Indonesia identified two potential new projects - one on environmental health impact assessment and the other on the establishment of a national poison centre network - for UNDP assistance in the UNDP's Fourth Country Programme. In addition, the mission recommended the preparation of guidelines for health aspects in tourism as part of an existing UNDP pipeline project in the Comprehensive Tourism Development Plan. 1. Menpower Training Nationals from Indonesia, Sri Lanka and Thailand attended a Poison Control Workshop in Malaysia in NovemberIDecember 1989. Three health officials from Indonesia also attended a meeting of the International Programme on Chemical Safety (IPCS) in Malaysia in November 1989, to improve their capabilities in the monitoring and control of chemical safety, particularly with respect to pesticides. In December 1989, an IPCS course on "Risk Assessment and Management of Toxic Chemicals: Principles and Applications" was conducted in Thailand. National workshops on "Safety and Control of Toxic Chemicals and Pollutants" were held in Sri Lanka in February 1990 and in Myanmar in April 1990. A national training course on "Soil and Groundwater Pollution" was held in India in September 1989 for officials of the central and state Boards for the Prevention and Control of Pollution. A national training workshop on Environmental Impact Asseasment was also conducted in India. A national workshop on Packaging, Labelling, Storage and Transportation of, and Information on, Hazardous Substances was held in Indonesia. Two officials of the Central Hygienic and Anti-epidemic Station (CHAES) laboratory in DPR Korea underwent special training in toxicology. An In-country study tour was arranged for central and state officials in India, to acquaint themselves with the latest industrial pollution problems and their control. For Indian officials, training in hazardous waste disposal and soil pollution control methods and in conducting environmental epidemiology was also arranged. 2. Institutional Development WHO assistance in water pollution monitoring and control was provided to the Central Hygienic and Anti-epidemic Station laboratory in DPR Korea. In India, assistance was given to the central and state Boards for the Prevention and Control of Pollution in tannery waste management practices in West Bengal and Tamil Nadu. In proposing improvements to tannery waste treatment plants, the consultant recommended ways for the cost-effective recovery of chromium metal from waste water. Stemming from the tragic deaths (in 1989) caused by accidental chemical poisoning of food, support for drafting national legislation on hazardous substances was provided in Indonesia. Two WHO consultants assisted the Indian National Institute of Occupational Health in December 1989 and January 1990 in the training of staff in quality assurance of analytical pesticide residues and heavy metals. A pilot-cum-demonstration project on "Waste Management in the Electroplating Industry" in Delhi was completed, and information concerning the demonstrated approaches to promoting the methodology developed for reducing pollution is being disseminated. Computer hardware and software was procured for the establishment of poison information network centres in India, Indonesia and Thailand. In Sri Lanka, a computer to process information on chemicals in use was installed in the Central Environmental Authority. In Thailand, a national expert was engaged to review laws and regulations concerned with the control of chemical hazards and to study appropriate technologies related to the prevention of chemical poisoning, particularly that due to agro-chemicals. 3. Global Environmental Monitoring Under the Global Environmental Monitoring System (GEMS), water quality monitoring activities continued in Bangladesh, India, Indonesia and Thailand, ambient air quality monitoring continued in India, Indonesia and Thailand, and food contamination moni- toring continued in Thailand; while health effects monitoring continued in Central Bombay, India, under the Human Exposure Assessment Location (HEAL) project. 4. Research Research studies in safe chemical exposure, vehicular emissions, agro-chemicals, air pollution, pesticides residues and chemical contamination in food are being supported in Thailand. 11.5 FOOD SAFETY WHO efforts in food safety were primarily aimed at strengthening national infrastructures, at developing standards and legisla- tion, and at monitoring and inspection. In India, WHO supported a national Workshop on Food Safety in Public Catering, in Hyderabad, in November 1989. The workshop identified shortcomings in food safety practices and recommended actions for improving the hygienic quality of foods served by public catering establishments and for the development of national food safety policies and strategies for public catering. In Indonesia, support was provided for the formulation of health regulations for restaurant hygiene and sanitation and for the preparation of guidelines for hygiene and sanitation inspectors in tourist areas. A visit by national staff to various countries to acquaint themaelves with food aafety legislation and administration and with current practices in food safety management was also organized. In April 1990, a UNDP/WHO health sector mission identified a new project for the promotion of food safety and food sanitation under the Fourth Country UNDP Programme. A research project on food contamination monitoring systems is also being supported. In India and DPR Korea, support was given for monitoring food contamination due to pesticides by providing equipment and consultants to strengthen laboratories in food analysis and monitoring. Surveys on pesticide residues in food commodities and on the use of food additives were initiated in India. Several countries participated in the seventh session of the Codex Alimentarius Coordinating Committee for Asia, held in Chiang Mai, Thailand, in February 1990. A project document on infrastructure development for food and drug control administration in Myanmar was prepared for UNDP support. Chapter 12 DIAGNOSTIC THERAPEUTIC AND REHABILITA~VE TECHNOLOGY 12.1 CLINICAL, LABORATORY AND RADIOLOGICAL TECHNOLOGY FOR HEALTH SYSTEMS BASED ON PRIHARY HEALTH CARE Health laboratory services play an important role in supporting health care programmes. WHO continued its collaboration with Member Countries in strengthening health laboratories through activities directed towards strengthening of the existing infrastructures, introduction of appropriate laboratory technology, provision of supplies and equipment and towards the strengthening of quality control programmes. Laboratory Services and Technology WHO continued to collaborate in the strengthening of laboratory services, particularly at the district level, through national training programmes and through the provision of supplies and equipment to almost all the countries of the Region. Reagents and kits were provided to the Institute of Public Health, Dhaka, the Thimphu Hospital in Bhutan, the National Health Laboratory, Yangon, the Male Hospital Laboratory in Maldives, the Central Health Laboratory, Kathmandu, the Medical Research Institute, Colombo, and the Department of Medical Sciences, Bangkok. Laboratory animals were provided to the National Institute of Nutrition, Hyderabad, while reagents and kits were provided to the National Institute of Virology, Pune, and the Central Research Institute, Kasauli, India. A UNDP-funded intercountry project has been initiated for strengthening health laboratories in primary health care covering six countries of the Region. Assistance will be in the form of support for national consultations and workshops on health laboratory service policies, quality standards, appropriate technology and the introduction of quality control in peripheral-level laboratories. In view of the continued prevalence of shigellosis in the countries, particularly periodic epidemics due to Shi ella dysenteriae I, health laboratories are being strength* several countries in collaboration with the diarrhoea1 disease control programme. During the year, national workshops were held in Bangladesh, Myanmar, Nepal, Sri Lanka and Thailand. Through the technical cooperation scheme, the National Institute of Health, Thailand, provided diagnostic sntisera for Shigella dysenteriae to other countries of the Region. The WHO Collaborating Centre for Reference and Training in Streptococcal Diseases at the Lady Hardinge Medical College, New Delhi, carried out a national reorientation course on streptococcal bacteriology and serology, and organized a meeting of the zonal centres for the monitoring and strengthening of activities for the control of rheumatic feverlrheumatic heart diseases in March 1990. This Centre continued to supply reagents for the diagnosis of streptococcal infection to other institutions in the Region. Efforts to achieve regional self-reliance in the production of immunodiagnostic reagents continued. The production of modern immunological and biological reagents in Bangladesh, Myanmar, India and Sri Lanka is being supported through a UNDP-funded project. WHO supported facilities at Mahidol University in Bangkok and continued to support other countries by providing reagents as well as the methodology for their production. The National Institute of Virology, Pune, India, supplied test kits for the surveillance of Japanese encephalitis to the countries of the Region. There is a need to increase the capabilities of the countries for producing reagents for rapid diagnostic techniques and surveillance of priority diseases in the Region, such as dengue haemorrhagic fever, Japanese encephalitis, hepatitis, shigellosis and acute respiratory infections. In the field of quality control of health care technology, WHO is supporting an "External Quality Assessment Scheme" (EQAS) in India, Indonesia, Nepal, Sri Lanka and Thailand. Several laboratories are taking part in the global programme on external quality monitoring in clinical chemistry, microbiology and haematology. WHO provided technical support through consultants for conducting national workshops on external quality assessment in haematology in Indonesia. WHO continued to support the development of national capabili- ties in sero-surveillance of AIDS. An intercountry Workshop on Advanced Techniques in HIV Antibody and Antigen Detection was held in Bangkok in December 1989. It is hoped that national expertise thus developed would lead to a network of HIV testing centres in the countries. It will be followed by a bench-level intercountry workshop on quality control methodology for HIV testing in Pune in October 1990. These activities are likely to improve the performance of HIV testing laboratories in the Region. Under the Global Programme on AIDS and the global blood safety initiative, WHO organized an intercountry Workshop on Safety of Blood and Blood Products in Kathmandu, Nepal, in December 1989. The workshop reviewed the progress in the streamlining of blood transfusion services in the countries of the Region and formulated guidelines to improve the safety of blood and blood products utilizing modem methodology. Hospital-acquired infections still exact a high toll in the developing countries. An average incidence of 10 per cent has been noted in the countries of this Region. WHO is trying to develop regional and national strategies for HAI control and surveillance through national workshops. Such workshops were held in Bangladesh, Nepal, Sri Lanka, India and Myanmar during December 1989-January 1990. It is hoped that national networks for HAI control will be developed in the countries of the Region. The Forty-first World Health Assembly committed WHO to global eradication of poliomyelitis by the year 2000. One cardinal requirement to support and smtain the programme is the strengthening of national laboratories in polio diagnosis and vaccine potency testing. WHO conducted an intercountry Workshop on Viral Vaccine Potency Testing in March-April 1990 in Coonoor, India, to improve the expertise of nationals in vaccine potency testing, serology and tissue-culture techniques of polio and measles. The incidence and prevalence of rickettsioses are perhaps being greatly underestimated as causes of human disease worldwide, since the information available is meagre. One of the major obstacles in acquiring epidemiological information has been the non-availability of simple ricketssia-specific laboratory tests. WHO has initiated a global programe for rickettsial disease epidemiology and developed @ programme for distributing rickettsial antigens for indirect imunofluorescence tests. In October 1989, one consultant from CDC visited national laboratories in India, Bangladesh, Nepal and Thailand, and conducted courses for nationals in developing rickettsia1 antibody testing programmes. It is expected that in the near future a realistic epidemiological picture will emerge. Though plague is no longer a problem in most countries of the world, the existence of continued natural foci of sylvatic plague in various parts of the world continues to pose a threat of resurgence. WHO held an interregional Consultation on Plague in New Delhi in September 1989, which laid down guidelines for epidemiological surveillance, preventive technologies, strengthening of laboratories, and supply of reagents, and reiterated the need for international cooperation to control this ancient disease which is still lurking on this planet. WHO continued to monitor exposure to X-rays in the departments of radiology, to monitor the safety of cobalt irradiation units in several countries, and to promote the provision of basic radiological services. WHO is endeavouring to promote regional self-sufficiency in monitoring radiation effects. Most countries still need to be supported in the, development of sufficient facilities to establish appropriate imaging technology. 12.2 ESSENTIAL DRUGS AND VACCINES WHO collaborated with countries of the Region in the strengthening of different aspects of their essential drugs programmes. The major thrusts were towards strengthening quality assurance in all its aspects, manpower development and rational use of drugs. Technical and financial inputs, including funds from extra- budgetary sources, were provided to Bangladesh, Bhutan, India, Indonesia and Myanmar. Technical collaboration between the ASEAN countries, of which Indonesia and Thailand are from the South- East Asia Region of WHO, continued with the support of UNDP. 1. Drug Policies and Programes Several countries of the Region have based their drug policies on the new perspectives in the field of health policies and developments which followed the Alma-Ata Conference. Based on the recommendations of an intercountry meeting, held in the Regional Office in August 1987, countries reviewed their drug policies and management in order to ensure the provision of safe, essential and effective drugs of appropriate quality, particularly in the context of primary health care. Following a mission to Thailand in 1986, a project is being implemented for providing financial and technical support to strengthen the essential drugs programme. The project deals wlth drug information, evaluation, registration and re-evaluation of drugs, pricing policy, quality control and good manufacturing practices (GMP), drug management and rational use of drugs, etc. A WHO consultant visited Thailand to assist in the preparation of a detailed work plan. An essential drugs programme was developed in Myanmar with support from FINNIDA and, as a first step in the process of implementation, a drug policy meeting was held in July 1989. The Myanmar project lays emphasis on strengthening drug policies, quality assurance, and on the procurement system, including the provision of essential drugs in nine townships in a phased manner over the next four years. 2. TCDC in Pharmaceuticals In the last ten years, India, Indonesia and Thailand have developed capabilities for the production and quality assurance of essential drugs and biologicals. This has provided scope for technical cooperation among the countries of the Region. Also, the geopolitical grouping of the countries provides a favourable climate for cooperative efforts in health development. The UNDP-funded, ASEAN-WHO pharmaceutical project is a successful example of technical cooperation in the field of pharma- ceuticals. In the first phase of the project, the ASEAN countries developed five centres of excellence in the fields of quality control, drug management, reference substances, GMP and drug evaluation. In the second phase, these centres are being used for manpower training, not only by the ASEAN countries, but also by countries in the Region. New areas have been identified for developing technical cooperation. These are herbal medicine, hospital pharmacy, drug information and drug management at the primary health care level. National consul- tants have prepared monographs on the commonly-used traditional medicines in ASEAN countries. With the assistance of a consultant guidelines on hospital pharmacy management have been prepared. 3. Rational Use of Drugs WHO collaborated with countries in promoting rational use of drugs in all its aspects, and actively promoted rational drug therapy and drug management in Bhutan, India, Indonesia and Myanmar. In Bhutan, support was given for improving the procurement, storage and distribution of drugs, and for the development of management capabilities. India constituted a technical committee to evaluate irrational drug combinations and took steps to remove from the market several such combinations. Similar action was taken by Nepal. Standard treatment regimens, particularly at the primary health care level, were promoted. Bhutan, Myanmar, Nepal and Sri Lanka initiated steps to establish standard treatment regimens which are now being implemented at the primary health care level. A pilot project on the quantification of drugs, based on standard treatment regimens, was successfully implemented in Sri Lanka. It is expected that, based on the experience gained, this approach will be adopted by other countries of the Region. With advances in the adoption of computer technology, computers have now been introduced to facilitate drug management, drug information and adverse reaction monitoring in some countries of the Region. WHO continued to assist countries in reviewing their programmes of production of vaccines, strengthening monitoring processes, introducing newer technologies and strengthening quality control capabilities. Transfer of technology has been effected for the production of plasma-derived hepatitis B vaccine in Mongolia. A regional strategy for self-sufficiency in EPI vaccines has been formulated. 12.3 DBUG AND VACCINE QUALITY, SAFETY AND EFFICACY WHO'S main thrust of activities in several countries of this region has been towards strengthening different facets of quality assurance programmes. Manpower development was under- taken in several countries. Country and intercountry courses on GMP were organized in India, Bangladesh and Sri Lanka. WHO consultants provided technical inputs to countries for improving drug information and registration. WHO actively promoted the implementation of the WHO Certifica- tion Scheme in the countries of the Region. This scheme is of great importance in ensuring quality assurance for countries that have not yet developed comprehensive quality control systems. Problems and constraints in the implementation and utilization of the scheme, both by the importing and the exporting countries, as well as in the principal goals and objectives have been identified. The scheme provided an opportunity for dialogue among regulatory authorities in the countries of the Region. 1. Quality Control and Assurance WHO continued to assist the countries in improving quality control and quality assurance of drugs. In several countries, the major thrust was towards the development of appropriate technical manpower, strengthening of drug testing laboratories through the provision of supplies and equipment, and towards drug evaluation. The SIDAIDANIDAIWHO-funded project on "Essential Drugs and Vaccines" in Bangladesh served to strengthen quality control laboratories through the provision of supplies and equipent, as well as consultants to establish methodologies for drug analysis and to train national staff at the bench level, to establish systems for repairs and preventive maintenance of equipment and to establish a methodology for the production of biologicals. WHO collaborating centres in India, Indonesia and Thailand have been utilized for quality control by those countries which are still to develop their own facilities. 2. Drug Information and Adverse Drug Reactions Information on different aspects of drugs is an important step in achieving their rational use. WHO collaborated with India and Indonesia in establishing a dtug information system. In Indonesia, steps were taken to adapt and implement the Swedish mug Information System (SUEDIS). WHO provided substantid training and consultancies in this area. A network of national information officers to act as focal points for the wide dissemination of drug information was established. They are expected to play an important role in the transfer of authentic drug information required by various groups, such as regulatory agencies, clinicians, quality assurance personnel and the community. WHO collaborated with India and Mongolia in developing and strengthening adverse reaction monitoring systems. 12.4 TRADITIONAL MEDICINE The activities of the WHO programme on traditional medicine focused on the identification of popular traditional medicines used for common ailments, on training practitioners in the use of traditional medicines and in general public health concepts enabling them to participate in PHC programmes, on strengthening quality assurance aapecta in a broad sense, and on the production of, and research in, traditional medicines. Several countries in the Region developed and strengthened training programmes with assistance from experts from within the Region. Fellowships and study tours were arranged for nationals of DPR Korea, Indonesia, Myanmar, Nepal and Sri Lanka. Technical collaboration among the ASEtW countries on the standardization, quality control and utilization of herbal medicines is continuing into the third phase of a project. In order to strengthen manpower development, the ASW project was also involved in preparing training programmes and manuals on the cultivation, production and utilization of traditional medicines. Activities to assure the quality of herbal medicines, including training courses, were undertaken. Standards and quality control procedures for selected medicinal plants, and drafting of monographs, were initiated in some of the countries. WHO assisted countries in establishing quality assurance systems for traditional remedies and provided technical assistance to Indonesia, Mongolia, Myanmar and Nepal. The Regional Office distributed copies of "Guidelines for the Registration of Herbal Products" to all the countries, with a view to assisting them to develop the necessary legislative and regulatory background and to establish an adequate registration system. As part of the activities of the second phase of the UNDPIWHO project on traditional medicine, a manual on "Standardization, Quality Control and Utilization of Herbal Medicines in ASEAN countries" was completed. Training programmes for practitioners of traditional medicine, with emphasis on primary health care, were developed, and several workshops were held. In order to enable countries to achieve self-sufficiency in the cultivation and production of herbs, WHO supported national programmes through training activities and by providing supplies to Bangladesh, India, Mongolia and Nepal. In order to promote the utilization and integration of traditional medicines, WHO continued its support to research activities in India, Indonesia and Mongolia. The increasing rate of injuries and continued high prevalence of certain disabling diseases and malnutritions suggest that measures for the prevention of disabilities cannot achieve the desired result unless the efforts of different groups dealing with these problems are integrated and unless community awareness of the problem and of its cause is created. The concept of community-based rehabilitation (CBR) is gaining further ground and many countries of the Region have adopted it as the most feasible approach, which is estimated to meet the essential needs of 70-80 per cent of the disabled in a community. However, progress in this regard needs to be accelerated. The Regional Office, therefore, continues to support and collaborate with Member Countries in developing adequate policies of rehabilitation, in undertaking development programmes in CBR, and in training national cadres. Training of community and family members of the disabled in the early detection of disability, in simple rehabilitation methods, and in the mobilization and utilization of community resources in the most effective and supportive way have remained the centre of attention. A pilot research atudy project in "Integrated Prevention of Avoidable Disabilities" (IMPACT) has been put into operation in India, to teat the operational feasibility of delivering a package of selected interventions through MCH and school health programmes using the existing health care infrastructure. A number of training activities such as workshops and seminars on different aspects of rehabilitation were conducted in Nepal, India and Indonesia. Support was provided for training nationals through WHO fellowships. Some equipment, books and other educational materials were also provided. Chapter 13 DISEASE PREVENTION AND CONTROL During the period under review, Member Countries made progress in achieving the main objectives of EPI towards the goal of Universal Child Immunization by the end of 1990. The first objective, viz., reducing morbidity, disability and mortality from the six EPI-target diseases, has been achieved by improving the surveillance system in the countries. Member Countries are committed to obtaining valid information on EPI diseases incidence (see Table 7 and Figure 1) and, together with the increasing coverage, to confirming, even at district and sub-district levels, the impact of immunization coverage on disease reduction. Sri Lanka, Indonesia, Thailand, Myanmar and India have achieved this objective in some areas. Maldives and Sri Lanka have declared that they achieved Universal Child Immunization in May 1989 and December 1989 respectively. Immunization coverage all over the Region has been increasing. The coverage so far achieved is 69 per cent for the third dose of diphtheria-pertussis-tetanus vaccine (DPT3), 66 per cent for the third dose of oral polio-vaccine (OPV3), 78 per cent for the vaccine against tuberculosis (BCG), 54 per cent for measles vaccine (MSL) and 51 per cent for the second dose/booster of tetanus toxoid in mothers or women in child-bearing age (TTZB) (see Figures 2 and 3). TABLE 7. Cases of EPI target diseases reported by SEAR countries, 1989 Diseases BAN BW DPRK IND IN0 HAV MOG MPlR NJlP SRL THA SEAR Diphtheria 1229 l* .. . 10626 8 0 7 171 3 0 81 12126 Measles 27327 554 ... 144470 4456 0 2176 1930 171 409 11270 192763 Pertussis 83057 219* 126501 256 0 0 2678 18 17 1065 214174 Polio 449 0 8* 10376 107 0 0 50 21 4 17 11032 Neonatal tetanus 1105 2 4* 9613 531 . . . 0 58 3 8 270 11594 All tetanus 4137 9. 24* 24794 .. . . . . 0 1005 ... ... .. . 29969 All tuber culosis 23856 174* ... 940664 ... 216 2237 10558 ... 6429 16993 1001127 *Data for 1988 ... = Data not available I Figure 1. CASES OF EPI TARGET DISEASES REPORTED* BY SEAR COUNTRIES, 1974-1989 I .Undcrr.portlng was oseurned in sonle coustriea. Source: Country Rcports, Junc 1890 Figure 2. PERCENTAGE OF IMMUNIZATION COVERAGE* AMONG CHILDREN OF LESS THAN 1 YEAR OF AGE AND PREGNANT WOMEN IN SEAR COUNTRIES, 1977-1989 .B.S.~ on UN dananlnatars only. . 6onfes: country nepona. Figure 3. PERCENTAGE OF IMMUNIZATION COVERAGE* AMONG CHILDREN OF LESS THAN 1 YEAR OF AGE AND PREGNANT WOMEN IN SEAR COUNTRIES, 1989 I.!.. The need for more active involvement of curative health facilities in the actual implementation of EPI was stressed during the period under review. It is encouraging that the countries of the Region specifically mention the provision of immunization at some fixed curative centres as an integrated approach through the health infrastructure. In the context of PHC, the countries have integrated EPI along with CDD, ARI and MCH. This is important at this stage of the programme, taking into account the second objective, promoting self-reliance among the countries in the delivery of immunization services within the framework of comprehensive health services. Details of this strategy were widely discussed at the meeting of EPI Managers, held In Balt, Indonesia, in June 1989, and at the Integrated Poliomyelitts/Neonatal Tetanus/~easles/MCH Workshop, held in New Delhi in March 1990, in which plans of action for the countries were reviewed and updated. As regards the promotion of quality control and vaccine production, which is the third main objective, some countries sre already producing EPI bacterial vaccines. Most of them are importing measles and polio vaccines. India has taken the initiative to manufacture measles (5-dose vials) and polio vaccines by 1993 in collaboration with USSR and France; Indonesia, through her domestic Bio Farma Company, has taken similar steps in collaboration with Japan. An intercountry practical training in recent technology on laboratory diagnosis, cell culture and potency-testing of polio vaccine was held in Coonoor, India, in March-April 1990. The results of the OPV vaccine potency testing were not encouraging in some countries in the Region. A national EPI review, undertaken in India, in MarchIApril 1989, showed that about 40 per cent of the testing was unsatisfactory in one state, while in another State the results were even more discouraging with 60 per cent unsatisfactory testing. In Indonesia, about 50 per cent of health facilities at district and sub-district levels, in eight randomly-selected provinces, were considered to have "cold chain failure" in their storage systems. However, tests conducted during the reporting period have revealed that the situation has improved significantly, and more satisfactory results (about 90 per cent) have been reported in India while further relevant training and supervision have been provided in Indonesia. Following the training in Coonoor in March-April 1990, Regional Office and headquarters staff have planned to visit some countries to assist in the strengthening of laboratory capacity to support polio eradication activities. Computerized BPI Information System (CEIS) All countries of the Region are expected to establish their basic CEIS by the end of 1990. During the period under review, Phase I (1987-1990) of the system was finalized. This was made possible through the assistance of the concerned government, WHO, UNICEF, and other agencies, such as USAID and REACH. Bangladesh started CEIS in 198611989, Bhutan in 1990, India in 198611989, Indonesia in 1987, Maldives in 1990, Mongolia in 198911990, Myanmar in 198811989, Nepal in 1988189, Sri Lanlca in 198911990 and Thailand in 198811969. DPR Korea plans to start CEIS in 1990. Bangladesh, Bhutan, Indonesia, Myanmar, Nepal, and Thailand plan to expand, or have already expanded, their systems to sub-national levels. In Phase I1 (1991-19941, based on country needs, the development of CEIS software with more sophisticated programmes will be encouraged by inputs from governments and national prograornes and from other inter- national agencies. Cold Chain and Logistics Cold chain reviews, using cold chain monitor cards, were conducted in DPR Korea, Bhutan, Myanmar and Sri Lanka. Similar reviews have been planned for Indonesia, India and Thailand leading to routine use of monitor cards in order to ensure a reliable cold chain. A newly-developed 'refrigerator watch' has been introduced in Rajaethan state in India to monitor the operation of refrigerators, and will be gradually introduced in the other countries of the Region if the trial is successful. Assisted by the World Bank, solar refrigerators are now in use in problem areas in Irian Jaya, and 100 more are being procured for Indonesia. Some new makes of solar refrigerators are under field trial in India, Maldives, Myanmar and Thailand. The Asian Institute of Technology has established facilities, with assistance from WHO, for conducting routine training courses for solar refrigerator repair and maintenance technicians. The Institute has also been recognized by WHO as a test centre for cold chain equipment. Pressurized steam sterilization of injection equipment is being widely promoted in all the countries. A solar ateam sterilizer, developed in France, is under field trial in India. In view of the sustainability of the cold chain, efforts are being made to develop and test indigenous cold chain equipment, including ILKS, refrigerators, deep freezers, vaccine carriers and cold boxes in some countries. Training and Research Training in the management and technical aspects of EPI has been a high priority for the programme. The emphasis now is on national, rather than intercountry, training workshops. This allows adaptation of course material to local situations. EPI is encouraging an integrated approach to training, utilizing materials from CDD, ARI and other relevant programmes in the same workshop. During the period under review, two regional workshops were organized: one for UNICEF-EPI State Managers from India and some other countries (with the technical leadership of WHO headquarters and the Regional Office) and the aecond, the Integrated Polio/Neonatal Tetanus/~easles/~CH Workshop, for national EPI managers. Following these, a similar workshop was held in India in May 1990 and will be followed by another in Thailand in November 1990. Preparations are in progress for an interregional training course in solar refrigerator maintenance, to be organized jointly by WHO and the Asian Institute of Technology, in Bangkok in July 1990. EPI promotes other studies, such as the development of pertussis and live rubella vaccines in Thailand, and cold chain monitoring in India and Sri Lanka. Immunization coverage surveys in Mongolia (7), Nepal (4), Indonesia (71, Bangladesh (111, Myanmar (26) and Sri Lanka (1) were conducted in order to justify the findings of routine reporting of immunization coverage and to boost immunization activities. These were in addition to national EPI reviews conducted in Sri Lanka (December 19891, Mongolia (~pril/May 19901, Nepal (May 1990), Thailand (May/~une 1990, and possibly in December 1990 as well) and Bangladesh (June 1990). In Indonesia, a study of the surveillance model to monitor adverse reactions is being developed in Yogyakarta in collaboration with Bio Farma. India produced a paper on adverse reactions of immunization (1989) and will participate in a seminar on this subject in Geneva in July 1990. Assessment of Progress Regionwise, the immunization coverage of children below one year of age for BCG was 78 per cent , for DPT3 69 per cent, for OPV3 66 per cent, for measles 54 per cent and for TT2 51 per cent. Achievements and problems in EPI activities in the Member Countries were discussed and analyzed in the Integrated Poliomyelitis/Neonatal Tetanus/Measles/MCH Workshop, mentioned earlier, in which plans of action for the countries were discussed and updated. India, Sri Lanka, Bangladesh, Nepal, Thailand and Mongolia conducted international EPI reviews in 1989-1990 in which the remarkable progress of EPI on immuniza- tion coverage among under one-year children was confirmed. In spite of the increase in immunization coverage in each country, no dramatic decrease in EPI target diseases has been observed. Thus, in order to achieve the EPI targets, efforts have been concentrated on intensifying and improving national surveillance systems (at national and sub-nationalldistrict levels), implementing country EPI and MCH plans in the context of PHC, and on enhancing disease control at the sub-national level. Poliomyelitis ~radication/~eonatal Tetanus Hlimination/Measles Reduction Initiatives All Member Countries are committed to the implementation of the World Health Assembly resolution on this subject. This implies polio eradication by the year 2000, neonatal tetanus elimination by 1995, 90 per cent reduction of measles by 1995, and reductions of diphtheria, pertussis and child tuberculosis. However, the targets differ from one country to another, based on the local health infrastructure and available resources. In regard to polio eradication initiatives, national plans of action were prepared at the meeting of national EPI managers in Bali, Indonesia in 1989 and were subsequently revised during the Integrated Polio/Neonatal TetanusIMeasleslMCH Workshop in New Delhi, in March 1990. The coverage with oral polio vaccine 3 increased from 11 per cent in 1982 to 66 per cent in 1989. With marked reductions in reported cases of poliomyelitis in DPR Korea, Maldives, Mongolia, Sri Lanka and Thailand, the stage has been set for possible eradication of the disease even before the year 2000, at least in some sub-national areas of these countries. Further strengthening of the surveillance system at state, district, sub-district, and other sub-national levels, which is an essential tool for these initiatives, is envisaged for the coming years. Neonatal tetanus elimination initiatives have been undertaken in collaboration with MCH and PHC programmes. Immunization coverage by TT2 has slowly increased in the Region in the last six years; in 1989 it crossed 50 per cent. The regional coverage does not include DPR Korea and Mongolia, which do not have national policies on the use of TT in pregnant women. Most Member Countries have implemented two or more doses of TT to eliminate NNT before 1995. A few countries have introduced TT among all women of child-bearing age. UNICEF, India, in collaboration with the Regional Office and WHO headquarters, conducted a Neonatal Tetanus workshop for UNICEF statelcountry EPI Managers in September 1989. The issue of adequate dosage of TT was also discussed during the Integrated Polio/Neonatal ~etanus/~easles/MCH Workshop of EPI Managers in March 1990. In some countries, initiatives for the reduction of measles through vaccination were introduced only in 1984/1985. The immunization coverage has been lower compared to other antigens (54 per cent in 1989). Because of the limitation of the surveillance system for measles in Member Countriea and the lower immunization coverage achieved in some countries, no impact of immunization coverage on the incidence of the disease has been observed. Immunization coverage, together with strengthening of the surveillance system and development of a new E-Z measles vaccine for children of six months of age, is a good starting point for the reduction of the disease in the future. Expanded Programme on Immunization Accelerated efforts by all countries in the Region have led to a substantial increase in immunizaton coverage. Tuberculosis Tuberculosis control programmes as components of primary health care are being strengthened with WHO collaboration. Early casefindtng and short-course chemotherapy are important elements of the programme. Malar~a cont~nues to ~e a major ~UDIIC nealtn promem or tne neglon. Collecting blood smears. promoting effective vector control measures and strengthening national vector surveillance systems are part of the control measures being adopted to tackle the nrnhlem Resources All Member Countries are trying their best to achieve the goal of Universal Child Immunization by the end 1990. However, government inputs (about 63 per cent of total EPI costs in the Region during 1985-1988) may not yet be adequate for more intensive activities in the areas of polio eradication, neonatal tetanus elimination and measles reduction planned for the next ten years. It is necessary to develop a basic framework for country-level training in financial management for EPI Managers in order to achieve EPI targets in the next 5-10 years with the limited funds available. This issue will be discussed during the meetings on Financial Managernet~t and Sustainability of EPI in January and June 1991. The principles of resource mobilization, recommended by the meeting of the Task Force for Child Sursival, held in Bangkok from 1 to 3 March 1990, have been further promoted in the countries. 13.2 DISEASE VECTOR CONTROL Several countries of the Region have a long history of seriou8 vector-borne disease problems. At present, these infections, as a group, constitute the leading public health problem; the most crucial is malaria. ~enguefdengue hemorrhagic fever (DHF), Japanese encephalitis (JE), filariasis and visceral leish- maniasis (VL) are also of considerable importance. So far, the principal method of control of these diseases has been, and probably will remain, the use of chemical insecti- cides. However, their more efficient, economic and selective use presents a real challenge. A gradual shift is taking place towards reshaping the strategy of vector-borne disease control with greater emphasis being placed on environmental management and design of integrated methods of control with varying degrees of community participation. Emphasis is also being laid on technological development, applied field research and training towards the control of vector-borne diseases. The control of malaria vectors continues to pose problems. Due to technical obstacles, such as the problem of insecticide resistance in vector species, the exophilic and exophagic nature of vectors, lack of interest by the community in accept- ing residual insecticide spraying and the increasing cost of insecticides, the achievement of the desired goals is being impeded. WHO has continued to collaborate wlth national programmes in developing effective control measures for carrying out field trials of new methods as well as assisting in research and training of personnel engaged in vector control programmes. With technical collaboration from WHO and financial assistance from UNDP, investigation is in progress to determine whether indoor residual spraying with 75 per cent wdp DDT has any impact on Anopheles dirus, the malaria vector in south-eastern parts of Bangladesh, while in the Terai region of Nepal a study is being carried out on the effectiveness of environmental measures against Anopheles fluvistilis and Anopheles maculatus. The effi- ciency of biological control agents, auch as larvivorous fish, Bacillus thuringiensis H-14 and Bacillus sphaericus is being aetermined, especially for use as a tool in intearated disease vector control-strategies in India, Indonesia and Thailand. Steps for the cytogenetic study of sibling species, Anopheles culicifacies and Anopheles subpictus, funded by the Regional Office, have already been initiated in Sri Lanka. Dengue Haemorrhagic Fever In Indonesia, Myanmar and Thailand, dengue haemorrhagic fever (DHF) continues to occur as an endemic disease. Sporadic cases of dengue fever with haemorrhagic manifestations have also been reported from India and Sri Lanks. During 1989, Myanmar reported 899 cases and 52 deaths due to DHF; Indonesia 8 216 cases and 333 deaths; and Thailand reported 53 625 DHF cases with 1 053 cases of DSS. The number of cases reported is approximately double that reported in 1988, but is still close to the median number of cases reported during the period 1984-1988 (median DHF cases reported 49 829, DSS 981). A multi-centre project to control DHF vectors with community participation, sponsored by the Regional Office, has been in progress in Indonesia and Thailand since 1988. The project was initiated with the objective of identifying the type of control activities that are best suited to community participation and which are focused on source reduction of the vector in the context of the local situation. The results of entomological surveys were generally satisfactory but those of KAP and socio-anthropological studies indicated the need for a new direction in the IEH strategy, from the general to the target-specific approach, which should include fewer, specific messages for target groups, mothers, grandmothers (older people) and health workers. This should remove particular misconceptions which prevent people from undertaking DHF control measures. The WHO Dengue Newsletter (volume 15), containing the latest valuable information on the DHF situation and control activi- ties, especially community-based control of Aedes aegypti, was issued in February 1990. Japanese Encephalitis Japanese encephalitis (JE) is predominantly a rural disease associated with rice cultivation. Outbreaks occurred recently in India, Nepal, Sri Lanka and Thailand. The average case- fatality rate ranges between 10 per cent and 50 per cent in these countries. The virus is maintained in nature by mosquitoes and non-human vertebrates. Culex tritaeniorhynchus, a paddy field breeding mosquito, is the principal vector, and feeds mainly on larne animals and birds. Elsewhere in the area of - -~~ -- distribution, Culex gelidus, Culex fuscocephala id Culex vishnui group mosquitoes are also involved. The virus has been isolated from other Culex spp as well as Aedes and Anopheles mosquitoes. Control measures in affected areas were primarily devoted to vector control by focal spraying and fogging of outdoor tracts with insecticides. However, the areas involved are generally very large and the bionomics of all vectors involved in JE do not lend themselves to any simple and straightforward method of vector control. Mass vaccination is advisable in highly endemic areas. Filariasis Bancroftian filariasis is essentially a problem of environmental sanitation in many urban areas in the Region. Wuchereria bancrofti is prevalent in Bangladesh, India, Indonesia, Maldives, Myanmar, Nepal, Sri Lanka and Thailand. Lack of general sanitation, maintenance and repair of drains, septic tanks and the sewerage system result in conditions suitable for the breeding of the ubiquitous mosquito Culex quinquefasciatus. Brugian filariasis is mostly confined to rural areas and occurs on the West coast of India in Kerala, on several islands in Indonesia and in some parts of Thailand. Strains of B+ugia nalayi are transmitted by M~nsonia apE and Anopheles spp, while Brugia timori is restricted to the Indonesian islands of Plores and Timor. The only known vector of 8. timori is Anopheles barbirostris. Filaria control, using antilarval measures has. been practised over the years in the countries of the Region, but has not so far yielded satisfactory results. Since vector control has a slow effect on the prevalence of filariasis infection in a population, WliO has continued to extend technical support for the development of integrated approaches to the control of this disease, including chemotherapy with DEC and Ivemectin. Visceral leishmaniasis (VL) or Kala-azar, caused by Leishmania donovani, is a problem of public health importance in some parts of Bangladesh, India and Nepal. The most lmportant vector in the Indian sub-continent is Phlebotomus argentipes. In India, Bihar and West Bengal were the most affected, with 34 174 cases and 486 deaths reported in 1989, of which 30 601 cases with 466 deaths were from Bihar and 3 753 cases and 20 deaths from West Bengal. In Bangladesh, 2 303 cases and five deaths were recorded. The control of Kala-azar has been undertaken by insecticidal spraying and treatment of cases. However, owing to administrative and financial reasons, spraying operations were very limited and the supply of drug was inadequate. Manpower in Entomology In order to deal with the complexities of vector-borne disease problems and to make effective use of the limited, available resources, there is a great need for contributions by medical entomologists and vector control specialists to operations and research in the control of disease vectors. WliO support has been focused in particular on the strengthening of national entomological services through training. These institutions in the Region, i.e. the Vector Control Research Centre, Pondicherry, India; Mahidol University, Bangkok, 'Thailand; and Bogor University, Bogor, Indonesia, continue to provide academic training in medical entomology (M.Sc. courses). The National Institute of Communicable Diseases, Delhi, India, conducted advanced courses in medical entomology for medical officers and entomologists. Regular and refresher training courses for different categories of entomological staff have also been carried out in several countries, while certain countries of the Region also have their own education and training facilities to varying degrees. Bhutan and Maldives still depend entirely on other countries of the Region for routine and job-specific training of staff. With financial support from WHO headquarters, an intercountry Training Course on Detection of Sporozoites in Anopheline Mosquitoes by the ELISA technique was held in Bangkok, in December 1989, to enable entomologists to gain up-to-date information on modern techniques and their application in the field. Malaria continued to be one of the main public health problem in the majority of the countries of the Region, since more than 85 per cent of the total population reside either in areas with active malaria transmission or in areas with great potential for malaria outbreaks or epidemics. The revised malaria control strategy through the primary health care system has been adopted by all malarious countries of the Region. The malariogenic stratification concept, based on recognition of the diversity of malaria epidemiological situations, was considered to be the main approach to malaria control in the Region. The malaria control programmes in all the countries of the Region have already completed broad stratification of malaria endemic/epidemic-prone areas and identified high-risk groups of the population. Further progress was observed in the process of detailed stratification employing various innovative methods, in order to formulate cost-effective operational plans of action. The latter have been fully integrated into the basic health services in Bangladesh, India, Indonesia, Maldives, Myanmar and Nepal at the intermediate and peripheral levels in order to meet the principal objectives of the programmes in Figure 4. PROFILE OF MALARIA IN SELECTED COUNTRIES OF WHO SOUTH-EAST ASIA REGION, 1984-89 +--+ I) O SEA REGION I a0 SPRX 8v-_js Iln nlllional 5, P.I.I case. ~ot.1 rasaa I .....D...D. 0.. OD lea? BANGLADESII MALDIVES* I. - P.f.1 case. TOt.1 cases LOO, MYANMAR Year NEPAL Il" m0us.nd.l 700 :560 " z420 d 280 z 140 84 85 86 81 88 89 THAILAND "mar *AU ealss detected slnce 1981 are imported. NOTE: SPR = 8Ude Posltlvity R.1. (per hundred slldes) 8fR = Suds Illelparum Rate (per hundred alldeal 1989 data: pmvlslonll terms of prevention of mortality, reduction of morbidity and control of malaria epidemics. In Bhutan, Sri Lanka and Thailand, malaria control continued to be implemented as a special programme, although the links with the basic health services were further strengthened, particularly in relation to the diagnosis and treatment of malaria cases. Community involvement in case-finding, simple drug treatment and referring severe cases to nearby health centreslhealth institutions, as well as intersectoral collaboration. es~eciallv of deoartments of ~. ~ - agriculture, fishing, forestry, irrigation, public works, etc., have been progressing in many countries. Further attempts have been made by some of the programmes to reduce the dependence on residual insecticides to the extent possible under prevailing epidemiological conditions, while savings on the purchase of insecticides have been earmarked for development and operational use of bioenvironmental and personal protection measures. Malaria control activities continued in nine countries of the Region. During the period under review, the situation in the malarious countries did not show any remarkable change over the previous year. A provisional report indicates that 2.46 million cases were reported in 1989 as against 2.7 million in 1988. In Maldives, no indigenous case has been detected during the past several years. However, the number of imported cases from neighbouring countries almost doubled as compared to last year. Though the country at present is free from local malaria trans- mission, the Government continues to pay high priority to vigilance activities. The overall malaria situation in Indonesia, Nepal, Sri Lanka and Thailand showed slight improve- ment, while it remained unchanged in India and showed an upward trend in Bangladesh and Bhutan. The Plasmodium falciparum rate showed an upward trend in Bangladesh and Bhutan among indigenous cases, and in Maldives, among imported cases. The malaria profile in the countries of the Region is shown in Figure 4. Though the principal elements of malaria control programmes in the Region continued to be case detection, drug treatment and various vector control activities, there has been an increasing emphasis on prompt diagnosis and treatment of cases and increasing trends in reducing the use of chemical insecticides for indoor house spraying, in introducing bioenvironmental methods and in fostering integrated vector control approaches through active community participation and intersectoral collaboration. In areas where malaria vectors have developed resistance to DDT and HCH, more effective and potent insecticides replaced their use, i.e. fenitrothion was being used in Indonesia, and malathion and a few other insecticides were used in Sri Lanka, India and Nepal. However, countries experienced some difficulties in procuring insecticides from abroad due to high costs and shifts in emphasis of some donor agencies. WHO assisted the countries to overcome the problem, particularly through the involvement of bilateral agencies. The foci of P.falciparum resistance were promptly dealt with through the intensification of vector control, providing radical treatment of P.falciparum with the second or even the third line of drug treatment, and through monitoring the movement of malaria high-risk population groups. Technical problems of P.falciparum resistance to various antimalarials and vector resistance to a range of insecticides aided by large-scale population movements, resulting in changing epidemiological patterns of the disease, continue to exist in the Region. Inadequate field supervision due to the shortage of trained manpower, especially at the district level, was felt by most of the programmes. In this regard, WHO collaboration to solve both the technical as well as operational problems in the Member Countries was continued. Support was ~rovided to the programmes to carry out staff training, study tours and workshops and for the procurement of needed supplies and equipment. Efforts were made to improve trained manpower at all levels of the country programmes using for these purposes either WHO country budgets, or the assistance of bilateral agencies such as CIDA, SIDA, etc. and international agencies such as UNDP. A number of health services staff at the peripheral level in most of the countries were given training in malaria and malaria control activities. Technical manuals and guidelines on malaria control were updated. Basic courses on malaria and planning antimalaria activities were held in Thailand and Italy and were attended by middle-level staff engaged in the implementation of control programmes. A series of seminars on the management of acute and complicated malaria is being conducted for both health service staff and private practitioners in Bangladesh, India and Sri Lanka. To facilitate these seminars, WHO reprinted, in 1989, the second edition of the publication "The Clinical Management of Acute Malaria" and organized and financially supported the meeting of a task force to review the second edition of the said book. The members of the task force, who were eminent clinicians from the countries of the Region, came up with an updated version of the third edition, which is currently in press. Programme-oriented field studies continued, especially on malaria control through the primary health care approach. To develop cost-effective intervention measures through research and developent approaches, the countries of the Region have taken up several research projects aimed at promoting biological, environmental and personal protection measures. Studies on community participation in case-finding and treatment were continued in India, Indonesia and Thailand, with encouraging results. In vitro and in vivo drug sensitivity tests continued in eight of the nine malarious countries of the Region. These studies proved to be helpful not only in providing a basis for early warnings of reduced sensitivity of P.falciparum to anti- mslarlals , but also facilitated the fornulation of national drug policies. The present status of drug resistance in malarious countries of the Region shows a very mosaic picture. Resistance to chloroquine is most pronounced in all countries except Maldives. Long-acting sulfa- yrimethamine drug combina- i tions (SP) - FansidarR. Metakelfin , etc. - were introduced in countries with a high degree of resistance to the 4-amino- quinolinea. Experience has shown that eventually resistance develops to the SP combination, a situation that has been reported throughout Thailand, parts of Myanmar, Bangladesh, Bhutan and Indonesia. The Thailand experience detected mostly falciparum cases giving an RII-RIII response, a major setback that required the introduction of the triple combination mefloquine-sulfadoxine-pyrimethamine (FansimefR) into the country programme in early 1985. Though a cure rate of about 96 per cent following treatment with MSP continued to be achieved by the Thai malaria programe, after four years of operational usage there have recently been reports from the Thai-Combodia border of a decreasing trend in the cure rate of the triple drug. Baseline data collections in various countries continue to report susceptibility to quinine, although some reduced sensitivity has been recorded on the Thai-Combodia border. In addition to the WHO financial inputs, UNDP provided funds for conducting training courses in in vitro microtechniques and for providing test kits. A study was carried out to determine an appropriate dosage regimen of primaquine for radical cure of P.vivax malaria in Thailand. Two field research projects are in progress in Bangladesh - on the efficacy of combination mefloquine-sulfadoxine-pyrimethamine (MSP) against chloroquine and Fansidar-resistant P falci arum strains and on the impact of residual spraying -0therapy in high malaria transmission areas. Studies for the determination of sporozoites in Anopheles vectors and identification of the human plasmodia involved, by using the ELISA technique, were conducted in Sri Lanka. International evaluation of the malaria control programme in Bangladesh was carried out jointly by WHO and the Government of Bangladesh with the participation of JICA (Japan) and ODA (UK) in October 1989. The main findings of the review were that in spite of all the efforts of the health services, malaria remains a major health problem in certain parts of the country, and has the potential to worsen due to various technical, operational and administrative causes. To improve the situa- tion, the assessment team suggested a package of corrective actions, which the Government of Bangladesh accepted. The most important development was the prompt preparation of a suitable plan of action by the malaria control programe to implement the recommendations of the assessment team, which was endorsed by the Director-General of Health Services in December 1989. The ~HOlGovernment of India independent appraisal of the malaria programme took place in November/December 1989. The independent appraisal team agreed, in principle, with the outlines of the Eighth Five-Year Plan of NMEP aimed at considerable reduction of spraying operations in areas under its purview and expansion of integrated vector control methodologies, particularly those related to bioenvironmental and personal protection measures. Particular attention of NMEP was drawn to the protection from malaria of labour in various sectors of the economy - in intensive agricultural areas, with special reference to irrigated areas, in urban areas and in areas with high malaria transmission. External assessment of the malaria control programme in Nepal and Sri Lanka took place in June 1990. Some bilateral and multilateral agencies, such as SIDA in India, CIDA in Myanmar, USAID in Sri Lanka, ODA (UK) in Nepal and Bangladesh, and the world Bank and JICA in Indonesia, are actively collaborating with the countries concerned in their malaria control activities. 13.4 PARASITIC DISEASES he main activity during the period under review was facili- tating effective control of parasitic diseases of public health importance, mainly leishmaniasis and guineaworm disease, and, to a limited extent, filariasis, intestinal parasitoses and schistosomiasis. Intestinal Parasitic Infections Intestinal parasitic infections, such as roundworm, hookworm, amoebiasis, giardiasis, etc., which are closely associated with undernutrition, poor personal hygiene and environmental sanitation, continue to be public health problems in the Region. Many countries are engaged in research and control of these parasitic diseases through ongoing projects such as those in family planning, school health, nutrition, etc. Surveys of intestinal parasitic infections, undertaken by the National Institute of Communicable Diseases (NICD), Delhi, in rural areas of Maharashtra and Rajasthan in 1989 and 1990, revealed high infestations with Giardia intestinalis (11.8 per cent and 24.4 per cent respectively). The Central Health Laboratory in Kathmandu conducted an intestinal helminthic survey in five regions of Nepal. The survey demonstrated a prevalence of 23.7 per cent of Ascaris lumbricoides; 24.8 per cent of hookworm and 8.7 per cent of Trichuris trichiura out of a total of 16 515 stool samples. Antiparasitic actions are linked with MCH, EPI, CDD, ARI and environmental sanitation, since the main target groups are children and women of child-bearing age, and approaches towarda training and community involvement are addressing the same categories of health personnel and population groups. Masa treatment of target groups in highly-infected areas is envisaged. Visceral leishmaniasis is a health problem of importance in rural areas of the three states of Bihar, West Bengal and Uttar Pradesh in India, as well as in Bangladesh and Nepal. The disease affects people in the underprivileged and lower socioeconomic groups mostly in the age-group under 20 years. During 1989, a considerable increase in morbidity and mortality was reported from India, particularly from Bihar. Since the morbidity data derive mainly from passive case detection, a three to four times higher actual prevalence is expected. A WHOIUNDP intercountry project on the control of visceral leishmaniasis was in operation from 1986 to 1989 in these three countries. The terminal Tripartite Review elucidated the achievements and constraints of the project. Research capabilities and training facilities have been adequately developed. By multi-centre chemotherapy research, different schedules for first and second line treatment were elaborated. Sero-epidemiological studies were carried out in some endemic districts of Nepal, Bangladesh and India. Monthly training courses for medical officers of primary health care centres continue to be held at the Kala-azar Unit of NICD in Bihar. Similar courses were organized by the Institute of Epidemiology, Disease Control and Research, Dhaka, for 40 district medical officers in 1989/1990. WHO recommended the development of national programmes for the control of visceral leisbmaniasis in the context of primary health care, making the disease reportable and earmarking budgets in order to better coordinate and integrate existing activities. So far only Bangladesh has worked out a national control programme. India has yet to decide on the reportability of the disease. Lymphatic filariasis remains a public health problem in eight countries of the Region. No major changes in prevalence rates or control strategies have been reported. WHO cantinued to encourage integrated control strategies and facilitated TDR- sponsored operational projects in India, Thailand and Indonesia, especially chemotherapy trials with diethylcarbamazine, Ivermectin, CGP 20376 and other new drugs in microfilaria carriers. The encouraging results now need implementation in well-planned action models in highly infested areas. Schistosomiasis Schistosomiasis is endemic in limited areas of Indonesia (Schistosoma japonicum), and Thailand (Schistosoma mekongi). Control activities were continued in the endemic vallevs in Indonesia to interrupt the transmission cycle and to prevent further spread in these development areas. TDR-sponsored research, which continued in Thailand, is envisaged for India and Indonesia. Guineaworm Msease (Dracunculiasis) India, the only country in the Region affected by guineaworm, entered the pre-final phase of its guineaworm eradication programme, initiated in 1984 with WHO assistance. Tamil Nadu is free from guineaworm. Of the remaining six states, Gujarat, with only 6 reported cases in 1989, is closer to the goal of zero incidence. Major problems are faced by Rajasthan, which contributed 62 per cent of the total cases in 1989, followed by Madhys Pradesh, with 18 per cent. Based on the latest evaluation report, the number of reported cases is declining in all the six states where guineaworm infection is still prevalent, the total cases reported in 1989 being 7 881 as against 12 023 cases reported in 1988. The twelfth Task Force Meeting on Guineaworm Eradication, held in New Delhi in January 1990, stressed the importance of active search and proper surveillance as well as the need for increased community participation to achieve the goal of zero incidence by the end of 1991. With the assistance of WHO, ten epidemio- logical surveillance teams were deployed in December 1989 under Technical Service Agreements. 13.5 TROPICAL DISEASES RESEARCH The UND~lWorld Bank/WHO Special Programme for Research and Training in Tropical Diseases (TDR) is a gosl-oriented global programme with two main objectives: (1) research and development to obtain new and improved tools for the control of major tropical diseases, and (2) strengthening of research capabilities of endemic countries. The Special Programme has identified four priorities or major thrust areas for the 1990s, viz., (1) field research; (2) product developnent, including rational drug development; (3) social and economic research; and (4) research capability strengthening. Research capability strengthening has been allocated 25.9 per cent of the total budget of the Special Programme for the 1990-1991 biennium. Serious efforts have been made by the Special Programme to see that plans in research capability strengthening are made operational during the biennium. For this purpose, site visits have been made by TDR executives to a number of institutions in Indonesia and India. The response has been very positive. Two programme-based grants were awarded to two institutions in Thailand; four long-term grants have been extended to four institutions, in India, Indonesia, Sri Lanka and Thailand. In addition, three institutions, in India, Sri Lanka and Thailand, were found worthy of extended support by the TDR-Rockefeller Foundation joint venture, based on their - initial performance in research efforts in malaria. The number of training activities supported by the Special Programme has been substantial - 157 up to the end of 1989 - with the result that the institutions have benefited immensely from trained personnel. Nearly 5000 researchers, worldwide, in rich and poor countries, are cooperating with TDR in developing new drugs, vaccines, diagnostic tests and control methods for carrier insects and snails, and in investigating the social and economic circumstances that can either help or impede treatment and control. As a result, several new tools for disease control and treatment - drugs, vaccines, traps, insecticides, and diagnostic tests - are now in different stages of development and trial. Malaria Among the TDR target diseases, malaria received the highest share of the budget - almost one-third of the total research and development budget during 1990-1991. TDR has provided support to several projects in the area of field and clinical trials of antimalarial drugs (such as mefloquine, artemisinin, halofantrine) to the development of immuno test kits and DNA probe kits, and to the development and field-testing of biological control agents against some vectors. The Social and Economic Research component of the Special Programme has been supporting, by way of social research, the "Pattern of Utilization of Antimalarial Drugs", and studies of vectoral bionomics of the various anopheles species (such as Anopheles dirus and Anopheles minimus) identified as potentially important - vectors of malaria. Bednets impregnated with insecticides are currently undergoing field-testing, but it is too early to assess their usefulness. These antimalarial studies have been largely focused in India, Indonesia and Thailand. In Sri Lanka, good progress has been made in the study of transmission-blocking antigens of P.vivax. Leprosy Amongst the TDR-funded activities in leprosy research were several studies related to clinical trials of newer drugs plus the formulations of multidrug therapy and their field trials. In addition, sero-epidemiological studies using new specific antigens have been initiated in the Region. The multi-centre field trial of leprosy vaccine is an important ongoing activity. Most leprosy research activities are focused in India, which is the largest reservoir of the disease. Filariasis TDR continues to provide strong support to the development of new drugs for this disease. The evaluation of clinical trials using Ivermectin for the treatment of lymphatic filariasis is in progress. This has moved into the second phase, in which Ivermectin is being compared to DEC in its efficacy. In Indonesia, a monkey model has been developed and is being used for screening new antifilarial drugs. Field trials of Ivermectin have largely been focused in India, Indonesia and Sri Lanka. Leishmaniasis and Schistosomiasis Field trials of commonly-used antimonial drugs and the introduction of new compounds have been continuing. Five small projects have been funded by TDR in these two target diseases, including studies on the vectors of leishmaniasis in Nepal, drug susceptibility of schistosome parasites in Thailand, and the treatment of Kala-azar in Bangladesh. 13.6 DIARRHOEAL DISEASES The Control of Diarrhoea1 Diseases Programme (CDD) has been recognized as one of the priority programmes of WHO in the countries of South-East Asia. This programme came into existence in 1979. The short-term objective of the Programme is to reduce diarrhoea-associated mortality among children 0-4 years of age through proper case management and extensive use of oral rehydration therapy (ORT). The long-term objectives are to reduce morbidity due to diarrhoea among children 0-4 years of age through the promotion of improved maternal and child health care practices, to encourage improvement in environmental sanitation, and to control epidemics. A11 countries of the Region are implementing their programmes as part of their primary health care systems. Training continued to receive high priority during the year. The main training activities included clinical management, supervisory skills, programme management, and, to a lesser extent, laboratory techniques. Courses in programme management were held at the intercountry level in India and Nepal. Eighteen supervisory skills courses were conducted in Bangladesh, India, Indonesia, Myanmar, Nepal and Sri Lanka. An intercountry Course on Clinical Management was conducted in India while over 50 national courses were held in Bangladesh, Bhutan, India, Maldives, Myanmar, Nepal and Thailand. In order to improve qualitative services in diarrhoea case management and provide clinical management training for medical officers, about 48 new diarrhoea training units (DTUs) were established in Bangladesh, India, Maldives, Myanmar, Nepal, Mongolia and Thailand. Two courses on laboratory aspects of diarrhoea1 diseases were conducted in Bangladesh. In eight countries, viz., Bangladesh, DPR Korea, India, Indonesia, Maldives, Mongolia, Myanmar and Nepal, priority was given to the translation and adaptation of CDD training modules and other relevant training materials into the national languages. To achieve the training targets, as outlined in national programmes, the Regional Office staff assisted in developing training plans. Nine countries revised their national plans for training and operation. These were discussed at the meeting of programme managers, held in Bangkok, in May 1990. Two common indicators used by the Member Countries to measure programe performance are ORS access rates and ORT use rates. The estimated ORS access rates and ORT use rates for 1988 were 62 per cent and 28 per cent respectively. The regional targets for ORS access and ORT use rates for 1991 have been set at 85 per cent and 60 per cent respectively. Local production and importation of ORS in 1988 increased to over 107 million litres, compared to 83 million litres in 1986 and 99 million in 1987. Visits were made to India, DPR Korea, Indonesia and Sri Lanka by the WHO ORS Production Engineer to assess the quality of ORS production. CDD health education and communication activities in the Region were further strengthened by the provision of technical information and printed materials on ORT and on preventive strategies for reducing the incidence of diarrhoea. CDD communication guidelines were of significant interest to the meeting of programme managers, held in May 1990. National CDD programmes collaborated with other programmes in both training and preventive strategies, as an integrated approach. Some training courses are combined with EPI or ARI. Coordination of programmes was carried out in the areas of breast-feeding, improved weaning practices, use of clean water, handwashing, proper disposal of human excreta and measles immunization. Breast-feeding intervention strategies were discussed at the meeting of programme managers. Comprehensive programme reviews on CDD are being planned for Bangladesh, DPR Korea, Myanmar, Nepal and Sri Lanlca during 1991. In India, a review of the ongoing ORT programme was completed in six randomly-selected states. Household case management surveys were conducted in Maldives and Sri Lanka with a view to obtaining data on correct household treatment practices and other programme indicators. Plans to conduct similar surveys in Bangladesh, Bhutan, Indonesia, DPR Korea, Myanmar and Nepal are under way. Most diarrhoea1 diseases research in the Region is coordinated through three CDD global scientific working groups while regional activities focused on research related to solving operational problems of national programmes. The WHO Collaborating Centres at the National Institute of Cholera and other Enteric Diseases, Calcutta, International Centre for Diarrhoea1 Diseases Research, Bangladesh, Dhaka, and the Regional Training Centre in Jakarta continued to work closely with the regional CDD programme in the areas of training and research. Other major agencies such as UNICEF, UNDP, and USAID continued their support in the implementation of CDD activities at the national level. 13.7 ACUTE RESPIRATORY INFECIIONS Acute respiratory infections (ARI), together with diarrhoea1 diseases and malnutrition, are still the leading causes of death among children in all the countries of the Region. The central objective of the WHO programme is to reduce, in the countries mortality from ARI especially from pneumonia, among children 0-4 years of age. The death rate due to ARI in children varied from 20 to 30 per cent during the period under review, while the infant mortality rate, inter alia, due to ARI was higher than 40 per 1000 in many countries. Because of the magnitude of the problem, the ARI Programme must be seen as an important part of efforts directed towards child survival and as an essential component of primary health care. Over the years, various types of national committees or advisory groups on ARI have been constituted in almost all the countries, for promoting prevention and control activities. By early 1990, national plans had been developed in many countries. Bangladesh, India, Indonesia, Myanmar and Sri Lanka have already developed long-term plans of operations. Technical guidelines on case detection and management have been formulated and programme managers appointed to implement the activities. Nepal and Thailand have prepared technical guidelines and drafted long-term plans of action. Thailand has been selected by UNICEF for an intensified ARI programme, to which the Regional Office has given technical support. National seminars and workshops on ARI were organized in Bangladesh, India, Indonesia, Mongolia, Myanmar, Nepal, Sri Lanka and Thailand. Paediatricians and paediatric associations were very much involved in meetings and courses in Bangladesh, India, Indonesia, Mongolia and Thailand. A new supervisory skills module "Management of a Child with ARI", and a training video were field-tested in Thailand. Similarly, the new "Programme Managers' Course Modules" were field-tested at a WHO interregional course in Bangkok in 1989 with the participation of programme managers, senior health officers and paediatricians from 30 countries, and representa- tives of UNICEF, the International Children's Centre, Paris, and the US Center for Disease Control, Atlanta, USA. Courses utilizing new material have already started in India, Indonesia and Thailand. These countries have already translated or adapted the new training material. Of the four intenrention studies on ARI, one each in Nepal (Kathmandu) and India (Haryana) have been completed while one in Indonesia (Kediri) and one in Nepal (Jumea) are continuing. The results of these studies indicate that the interventions are feasible and effective in reducing morbidity and mortality from pneumonia. Information on biomedical and epidemiological research priorities in ARI was disseminated to all countries. There is an encouraging trend towards the intervention of operational Ail1 control programmes with programmes for diarrhoea1 disease control, imnunization, nutrition and essential drugs, in the HCH and PKC systems since many of the activities concerned are similar and implemented by the same health personnel. 13.8 TUBERCULOSIS Tuberculosis is a major public health problem in the countries of the Region. WHO'S efforts have been concentrated on the strengthening of the tuberculosis programme as an integral component of primary health care. The strategy for tuberculosie control depends mainly on the detection of new cases of tuberculosis and the provision of appropriate treatment. The main strategies of the countries were: intensification of case-finding and highly effective case-holding and training activities to upgrade the knowledge and skills of tuberculosis workers for better implementation of national tuberculosis programmes. Despite the existence of national tuberculosis programmes in the Member Countries, the problem of tuberculosis has-been further confounded by the appearance of HIV infection. Dual infection with M. tuberculosis and the human immuno- deficiency virus is likely to result in increasing incidence of tuberculosis. WHO has been assisting Member Countries in epidemiological surveillance of the prevalence and incidence of infection and disease, which is useful in assessing the magnitude of the problem and impressing on the countries the importance of allocating substantial resources for tuberculosis control programmes at the country level. WHO provided to the countries, through regular and extra- budgetary resources, technical inputs, supplies including drugs, and X-ray equipment. Support was also provided for training personnel and in arranging study tours to upgrade the knowledge and skills required for effective implementation of programmes. In Bangladesh, diagnosis of TB patients through sputum examination and their treatment at Upazila health complexes were accelerated. Diagnosis and treatment facilities for TB patients were introduced in district hospitals which did not have TB clinics. In India, WHO assisted in strengthening clinical research activities and providing training facilities for district-level officers as well as training in micro- biological techniques, and in the planning, conducting and evaluation of multi-centre controlled clinical trials. Apart from supplies and equipment, Indonesia was provided with support for a workshop on diagnosis of TB and on treatment regimens of anti-TB drugs. A WO consultant was provided to assist the Government in assessing and reviewing the National TB Control Programme to suit the Fifth Five-Year Development Plan of Indonesia commencing in 1990. WHO also provided a subsidy for conducting a national workshop on TB in March 1990. In Nepal, the number of new sputum-positive TB patients detected has increased and the total number of TB patients under treatment was reported as 10 305. A WHO consultant assisted Sri Lanka in assessing the disease situation. The Tuberculosis Division in Thailand is continuing its intervention studies, including field studies on chemotherapy and chemo- prophylaxis, under a tripartite agreement between Thailand, Japan and WHO. The sixteenth session of the South-East Asia Advisory Committee on Health Research, held in Chisng Mai, in April 1990, discussed research on tuberculosis as one of the agenda items and recommended further intensification of research in tuberculosis, including a review of effectiveness of BCG as a tool in EPI. WHO has been making efforts to assist Member Countries in expanding case-finding and case-holding and in promoting short-course chemotherapy for improving management of the treatment system. The lack of adequate support by donor countries inhibits the mobilization of extrabudgetary resources. A concerted effort therefore needs to be made to mobilize resources in order for the programme to have a real effect on control of the disease. 13.9 LEPROSY The implementation and further expansion of the multidrug treatment (MDT) regimen within the framework of primary health care is the key strategy for leprosy control in the Region. While in most countries the integration of leprosy control into primary health care is in progress, in a few countries, especially in the hyperendemic areas, leprosy control is implemented as a vertical programe. During the period under review, noteworthy success has been achieved in early case detection and MDT coverage in nine endemic countries indicating steady progress in the implementation of individual five-year plans. Increasing awareness of patients and the general public and their confidence in MDT as well as the political commitment at various levels have contributed significantly to tNs. In the area of chemotherapy, the search for a new and more effective drug against M. Leprae is being continued with the support of the TDR Programme of WHO headquarters, while clinical trials of ofloxacin and long-acting sulphone drugs in the treatment of lepromatous leprosy are also being pursued. Field trials with a number of candidate vaccines are being carried out in India. These vaccines include heat-killed M. Leprae combined with BCG, and cultivable mycobacteria related to M le rae used in a live form (e.g., BCG) or in a killed form e.g., ICRC bacillus, Mycobacterium W, or Mycobacterium Habana). i-e Of these, Phase I1 vaccine trials of M. leprae, combined with BCG are progressing satisfactorily in a study being carried out by ICMR with support from the TDR Programme. Thanks to early detection of cases resulting from extension of facilities as well as increased self-reporting, followed by effective treatment, a steady, declining trend in deformity rates has been witnessed. In October 1989, an intercountry Consultation on Implementation and Evaluation of Multidrug Therapy, Prevention of Disabilities and Rehabilitation of the Disabled in leprosy control programmes was held in Madras, India, with the participation of senior- level programme managers from eight countries. The meeting noted with satisfaction the progress made by the Member Countries in implementing their respective programmes while urging them to continue to give high priority to the extension of MDT coverage and integration of leprosy control programmes with primary health care. As the significance of leprosy as a public health problem diminishes, it is envisaged that rehabilitation of former leprosy patients with deformities will emerge as a problem of increasing importance. WHO will continue to collaborate with Member Countries in the area, especially in promoting community-based rehabilitation. The third independent evaluation of the National Leprosy Eradi- cation Programe in India, jointly organized by the Government of India and WHO, was carried out in October 1989. Several international expert. were associated with the exercise. With the MDT coverage extending to nearly 65 per cent of the leprosy cases residing in 112 districts and involving 2.1 million population, the task of the evaluation team was a formidable one. The results of the evaluation have shown that the performance in regard to case-detection and treatment are satisfactory, with the majority of states exceeding the targets set. It was also observed that the completion of treatment following the detection of disease is also very high. With these encouraging results, it is targeted that all the 196 endemic districts should be brought under MDT by 1992. Some of the areas recommended by the evaluation teams to receive greater attention were: training of medical officers in leprosy, optimum utilization of existing training capacity, improvement of laboratory services including mechanisms for quality control, strengthening of administrative and technical supervision, exploration for alternative approaches to the integration of leprosy services with primary health care, strengthening of rehabilitation services, increasing health awareness within the community in relation to leprosy and promotion of operational research in leprosy. In Myanmar, a three-year plan of action for increased coverage of MDT has been prepared and is expected to be implemented with support from extrabudgetary resources. In Maldives, a plan of action to achieve zero transmission is being implemented with support from a voluntary organization and technical assistance from WHO. WHO also continued to collaborate with six other endemic countries in their leprosy control programmes and provided support through regular and extrabudgetary resources, technical inplts, supplies including antileprosy drugs as well as equipment. Support was provided for training leprosy workers and for other group educational activities. 13.10 ZOONOSES The aim of the regional programme on zoonoses is to support Member Countries in their endeavours to reduce the incidence and prevalence of these diseases, with the ultimate aim of preventing them in man. WHO provided financial support to India for conducting three workshops - on laboratory techniques in rabies, on vaccines and treatment of rabies, and on surveillance and control of leptospirosis and treatment of snakebite. In addition, fellowships were awarded to two health personnel to study rabies control activities in the countries of the Region. The National Institute of Communicable Diseases, Delhi, received equipment for strengthening its laboratory services in the surveillance of rabies control. The zoonoses project in Indonesia carried out various activities on surveillance and control of rabies, plague, anthrax and tapeworms in collaboration with the veterinary services. Surveillance of rodent and human plague in Boyolali and other plague foci was continued. WHO assisted the country in organiz- ing regional and extra-regional study tours to train nationals in the epidemiology and operational aspects of toxoplasmosis, in the epidemiology of plague and in rabies control. A WHO-assisted project for the control and elimination of rabies is being implemented in Nepal in collaboration with the French organization, Veterinarians sans Frontleres (VSF). Assistance was also provided for the strengthening of manpower in Nepal by arranging training of health personnel in the study of zoonotic diseases through courses in Master of Public Health (MPH) abroad. A National Zoonoses and Food Hygiene Consulting Centre was established in the country in December 1989 with a view to conducting epidemiological surveillance on zoonotic diseases, such as rabies, brucellosis, Japanese encephalitis, visceral leishmaniasis, snakebite, etc. among its main objectives. In Sri Lanka, the objectives of the programme, inter alia, are: to coordinate the activities of the rabies control programme in achieving its objective of eliminating human and canine rabies; to study dog ecology in rural areas in relation to rabies epidemiology; to strengthen rabies surveillance; and to implement mass vaccination of the dog population. The programme includes consultantships for the redesigning of programes, fellowships for training in veterinary public health and the utilization of national expertise. Identification of dogs after vaccination, implementation of the new Rabies Control Act and establishment of two diagnostic laboratories - one in Gslle and the other in Kandy - to strengthen rabies surveillance, are some of the activities planned for 1990 with WHOIAGFUND support. 13.11 SEXUALLY-TRANSMITTED DISEASES With the advent of acquired immunodeficiency syndrome (AIDS) in some countries of the Region, control of sexually-transmitted diseases (STD) received a high priority in these countries. WHO supported Member Countries in strengthening national capabilities in the collection and analysis of epidemiological data for assessing the magnitude and impact of STD and AIDS and for developing suitable control strategies. A meeting, held in Geneva under the auspices of the Global Programme on AIDS and Programme of STD, from 4 to 6 January 1989, identified STD as a risk factor for HIV transmission and reached a consensus that both these programmes should work together and identify future research priorities and methodologies for better understanding of the biological interactions between HIV and STD. WHO supported Bangladesh with supplies and equipment needed by the STD control programme during the year under review. In Indonesia, health personnel were trained abroad in the control of sexually-transmitted diseases. Support was provided to Sri Lanka by way of supplies and equipment, development of manpower through training abroad in sexually transmitted diseases, and by providing subsidies for organizing national training programmes in sexually- transmitted diseases for its medical officers, as well as a Consultative Conference on National Policy on Safe Blood in Relation to HIV Infection and AIDS, held during the last quarter of 1989. 13.12. RESEARCH AND DEVELOPMENT IN THE FIELD OF VACCINES Health laboratory services play an important role in supporting programmes of research and development of vaccines. WHO continued to assist countries in promoting self-reliance in the ~roduction of vaccines, and strengthening the monitoring process and quality control capabilities, besides introducing newer technologies for research and development of new vaccines. A regional strategy for self-sufficiency in EPI vaccines has been formulated with the premise that several countries in the Region have no vaccine production facility and that starting such a facility in each country will not be cost-effective. Myanmar and Mongolia are being assisted through a UNDP programme in the development of expertise in the production of hepatitis B vaccine, while Thailand and Indonesia are developing expertise through international collaboration. Support was also given to countries for improving their vaccine distribution and storage systems. In the efforts for global eradication of poliomyelitis by the year 2000, national laboratories for the diagnosis of poliomyelitis as well as vaccine-potency testing are being strengthened. Towards thls effort, and to improve the expertise of nationals in vaccine potency-testing and serological and tissue culture techniques for polio as well as measles, WHO conducted an intercountry Workshop on Viral Vaccine Potency- testing in March-April 1990, in Coonoor, India. 13.13 AIDS Acquired immunodeficiency syndrome (AIDS) is not yet considered a priority health problem in many countries of the Region. It is nevertheless a matter of concern for the countries given the pandemic nature of the disease. WHO has so far endeavoured to give proper direction to Member Countries in the effective prevention of the spread of HIV infection through the formu- lation of short- and medium-term plans of action. In view of the fact that no cure for the disease is in sight, the focus of WHO attention has been on its prevention through health education. Epidemiological Situation Three epidemiological patterns of AIDS can be identifled worldwide, viz. I, I1 or 111. But this classification is not static and changes occur according to the epidemiological situation. Thailand, which was earlier in pattern 111, can now be considered as being in patterns I and III, whereas other countries continue to be in the pattern 111 classification. The overall epidemiological situation indicates that the problem is most serious in Thailand and India (see Table 8). In India, where HIV infection has so far been identified, mostly amongst female prostitutes, more and more seropositive cases are being identified in other categories of high-risk population groups indicating that heterosexual transmission of HIV is becoming predominant. Most of the HIV seropositives in India are in the age group of 20-40 years, wtth promiscuous men and women forming the single largest group. As of 31 May 1990, altogether 486 804 persons, the majority of them belonging to high-risk groups, were screened in 42 surveillance centres. TABLE 8. Situation of AIDS and HIV infection in SEAR countries, as of 30 April 1990 Country Number of Number Number Month persons of HIV of last examined positives eases reported Bangladesh Bhutan DPR Korea India Indonesia Maldives Mongolia Myanmar Nepal Sri Lanka Thailand 42 266 2 172 7 580 461 118 96 963 2 606 9 665 18 274 15 897 98 834 1 700 000* -- *Information as of September 1989. Of these, a total of 2 575 were found to be HIV seropositives (5.311 OOO), including 48 AIDS cases and 2 527 HIV asymptomatic carriers. Table 9 shows the break-up of seropositives in India. In Thailand, the direction and the magnitude of the epidemic has changed over the past few years. The number of HIV-infected persons increased sharply between 1987 and 1989 (Table 10) and was attributed mainly to the problem of intravenous drug users in the country. In Indonesia, of the 96 963 persons examined, 16 were found to be HIV positive while seven were AIDS cases. Sri Lanka also had four AIDS cases and 21 HIV positives among the 98 834 persons examined for HIV infection. In Myanmar, recent serological studies indicated that transmission of HIV among intravenous drug users was a major problem. Regional Plan of Action Member Countries are endeavouring to implement the regional plan of action for prevention and control of AIDS in the best possible manner through short- and medium-term plans. With WHO TABLE 9. Break-up of seropositives, by group, in India Group Males Females Total Indians Heterosexually promiscuous 590 825 1 415 Homosexuals 6 - 6 Blood donors 527 5 532 Patients on dialysis 3 0 3 Antenatal mothers 0 7 7 Recipient of bloodlblood products 48 5 53 Relatlves of HIV patients 11 18 29 Suspected ARCIAIDS cases 29 8 37 Drug Users I/V 2 13 1 2 14 Others 130 30 160 Sub-total 1 557 899 2 456 Non-Indians Students Others Sub-total 96 23 119 Total TABLE 10. Situation of AIDS and HIV infection in Thailand, 1984-1989 Year AIDS AIDS-related HIV Total cases Total 34 103 13 349 13 486 collaboration, short-term plans have been implemented in ten countries of the Region while medium-term plans have either been implemented or are in the process of being implemented. AIDS knows no geographical boundaries and may represent a threat to Health for All if it is not contained through appro- priate measures. An increase in the number of cases in the countries of the Region may be expected in the near future. The need for coordinated action at all levels is evident. Under the regional plan of action, an epidemiologically-based strategy for the control of HIV/AIDS has been developed. In the absence of a cure for the disease and the lack of a vaccine for its effective prevention and control, the emphasis in the Member Countries has been on epidemiological surveil- lance to learn the extent of the disease and its prevalence among the high-risk groups, detection of HIV-infected persons, improved public health information through the mass media, counselling of seropoaitives and education of the target groups and the community, promotion of condoms and sex education, safe use of blood and blood products and on the use of sterilized syringes and needles. 13.14 OTHER CONMUNICABLE DISEASES PRBVENTION AND CONTROL ACTIVITIES The main objective of this programme is to improve national capabilities in communicable diseases surveillance, prevention and control, with international coordination where necessary, and with special reference to vector-borne diseases. The important diseases which come under this programme include Japanese encephalitis, meningococcal meningitis, viral hepa- titis and dengue haemorrhagic fever. The type of assistance that WHO provides to Member Countries for the containment of the diseases mainly includes the provision of consultancy services, fellowships, and supplies and equipment, as well as organization of consultative meetings. Japanese Encephalitis Japanese encephalitis is a public health problem in India, Indonesia, Nepal, Sri Lanka and Thailand. WHO has been providing technical assistance, and insecticides and sprayers to the countries. During the reporting period, eight health personnel from India were sent on study tour to Thailand, Japan and China for acquainting themselves with the latest knowledge on the control of JE. In Nepal, a detailed work plan on mass vaccination for JE has been prepared. Nepal was also supported by way of supply of malathion and JE diagnostic kits. A WHO consultant from Japan assisted the Government of Sri Lanka in evaluating the efficacy of vaccination programmes and advised on a long-term plan for the control of JE. The incidence of the disease in 1989 was only one-third of that reported in 1988. Meningococcal Meningitis Meningococcal meningitis poses a health problem mainly in India and Nepal. The reported occurrence of the disease is small scale, with the greatest variation seen during the last four years in Bhutan, where a minimum number of cases was seen in 1988 (3 cases with no deaths) and a maximum number in 1986 (188 cases with 25 deaths). In India, the disease is reportable only in some states and union territories. According to a report of the National Institute of Communicable Diseases, the number of cases in Delhi was 2 630 and the number of deaths was 501 during 1988, while the corresponding figures for 1989 were 2 018 and 307 respectively. Laboratory diagnostic facilities are available in most of the medical colleges, Imported bivalent (A<) vaccine is used for Haj pilgrims, close contacts of index cases, and for medical and paramedical personnel. Attempts are being made to develop an early warning system for early detection and reporting of cases, starting with the states of Gujarat, Madhya Pradesh, Orissa, Bihar, Rajasthan, Maharashtra and the union territory of Delhi. In Nepal, since the epidemic of 1983-84 in the Kathmandu Valley, meningococcal meningitis has emerged as a disease of public health importance. A mass vaccination campaign, using the bivalent meningococcal polysaccharide A, C vaccine was success- ful in containing the outbreak of 1983-84. Vaccination is now provided, on request, at the Epidemiology Division, Teku. WHO has been assisting Member Countries through the provision of meningitis vaccine, especially for Haj pilgrims. An intercountry Consultative Meeting on Surveillance and Control of Meningitis was held in Kathmandu, from 18 to 20 October 1989. The meeting reviewed the situation of the disease in the countries of the Region and formulated improved guidelines for epidemiological surveillance to suit the changed trend in disease prevalence. Viral Hepatitis Hepatitis A Virus (HAV) infection is a common problem in South-East Asia where more than 70 per cent of sporadic acute hepatitis cases in children are due to HAV. Sero-epidemiologi- cal studies, conducted in Bangladesh, India, Myanmar, Mongolia and Nepal, showed that 85-95 per cent of children in the age-group 6-10 years are immune to HAV, and that HAV cases in adults in these countries are very few. It has been observed that the morbidity of HAV infection in adults has increased in Indonesia and Thailand. This might be linked to a higher proportion of infection occurring later in life when it is more likely to cause overt symptoms. Hepatitis B virua (HBV) infec-ion is a serious problem in the Region. It is estimated that about 70 million (6 per cent) of the total population in South-East Asia are HB carriers. Only Nepal and Sri Lanka have shown low HB carrier rates (0.9-1 per cent). Other countries of the Region have shown higher HB carrier rates (6-15 per cent). The overall prevalence of hepatocellular carcinoma and cirrhosis is high in countries with high HB carrier rates. Significant progress has been made in the implementation of demonstration programmes for the control of HBV infection in Indonesia, Mongolia and Thailand. WHO collaborated in the production of local HBV diagnostic reagents in India, Indonesia, Mongolia, Myanmar and Thailand. The prevalence of hepatitis C Virus (HCV) infection (post- transfusion non-A non-B hepatitis) in the Region is not known. Some cases of this infection have been reported in India, Mongolia and Thailand. Meagre information is available on the prevalence of Delta virus in the Region. Mongolia has reported a high positivity for the presence of antibodies to Delta virus in healthy populations and in HBV cases. India, Myanmar and Thailand also reported some cases of mixed infections (Delta and HBV). Enterically-transmitted non-A non-B hepatitis (HEV) is an emerging problem in the Region. Outbreaks of HEV occurred in India and Indonesia, with a large number of cases in adults and children and a high mortality rate, especially in pregnant women. WHO sponsored epidemiological studies of HEV in Indonesia, Mongolia, Myanmar, Nepal and 'Thailand and provided laboratory facilities, kits and reagents for diagnosis. An intercountry Meeting on HEV was organized in New Delhi, from 10 to 13 July 1989. Based on the recommendations of this meeting, guidelines for future epidemiological studies of HEV and research were revised and circulated to the countries of the Region. WHO'S collaborative efforts to combat HEV infection continue through the promotion of research activities. In India and Myanmar, virological and laboratory studies of HEV in non-human primates are in progress. 13.15 BLINDNESS AND DEAFNESS During the course of evaluation of the national programmes for the control of blindness in India, Nepal and Thailand, it was revealed that weakness in managerial skills amongst middle- level workers was the most significant constraint. As an initial effort to meet this shortcoming, a bi-regional Workshop on Prevention of Blindness and Eye Care Management was held in Korat, Thailand, in February 1990. This workshop, which was a cooperative effort of the Western Pacific and the South-East Asia Regions, brought together experts from WHO collaborating centres and national centres in the two Regions. Eleven participants from seven countries of the South-East Asia Region attended. A terminal evaluation of the workshop revealed that the participants gained insight into the concepts of management and acquired some basic managerial skills. Trends in blinding eye disease prevalence and incidence, as revealed in epidemiological studies carried out in India in the late 19808, show an increase in age-related blinding conditions such as cataract and glaucoma. However, there was a downward trend in the prevalence of communicable diseases such as trachoma- and malnutrition-related blindness. These trends have important implications for priority action. Several programmes in the Region have intensified activities to deal with the increasing backlog of blindness related to cataract. These activities include enhancement of the capabilities of programmes to reach out to underserved communities, such as in Myanmar, through the provision of mobile units and equipment. Human resource development, through both indigenous training and the fellowships programme, continued to receive high priority. Nongovernmental organizations have traditionally reflected the programme for the prevention of blindness, and there was a renewed commitment by several international nongovernmental organizations to assist Member Countries in the areas of strengthening of human resource development infrastructure, health systems research, and programe evaluation. There are indications that these complementary efforts would also be intensified in regard to sight restoration. Activities related to deafness control were initiated in some countries through the provision of consultancy services. Rapid assessment techniques are being introduced to ascertain the magnitude of the problem. Integrated approaches to deafness and control of visual impairment through various health services are being explored. 13.16 CANCER With increasing life expectancy cancer is emerging as one of the leading causes of death in the countries of the Region. This situation is further aggravated by the fact that in several countries cancers which can be cured with early diagnosis and treatment are detected only at an incurable stage. This is particularly true of two leading cancers in most countries of the Region, viz., cancer of the oral cavity and cancer of the cervix uteri. Besides, palliative care and pain relief services are still lacking in most of the countries. A comprehensive National Cancer Control Programme exists in India, the implementation of which is coordinated by the National Cancer Control Board. This national mechanism is complemented by state programmes and boards. In Gujarat and Maharashtra, state-level activities have been initiated in line with the national programme. WHO has continued to assist the improvement and extension of existing cancer registries. WHO assistance in in-service training activities for non- specialized health staff has continued. In view of the great importance of prevention and early detection of the most common cancers, public education campaigns and development of educational material have been supported in Bangladesh, Bhutan, Sri Lanka and Thailand. 13.17 CARDIOVASCULAR DISEASES Whereas the incidence and the prevalence of cardiovascular diseases are being controlled in some developed countries, hospital-based statistics from the countries of the Region, particularly from Sri Lanka and Thailand, seem to indicate a substantial increase in these diseases. The increase in ischaemic heart disease in Sri Lanka reportedly greatly outnumbers the decrease in rheumatic heart disease in the country. Knowledge on specific risk factors in the countries is still lacking. WHO is therefore supporting studies on such risk factors in India, Myanmar and Sri Lanka. Hypertension and the related risk, especially of stroke, is recognized to be highly prevalent in the countries of the Region. However, the initiation of large-scale hypertension control programmes is hampered by the relatively high cost of maintenance medication that may be required. Only Mongolia is reported to have achieved a high treatment coverage of hypertensive subjects, surpassing even most developed countries. WHO assisted Bhutan and Myanmar, through consultants, in the planning of control measures for cardiovascular diseases. A consultant also assisted DPR Korea in the improvement of services for vascular surgery. An AGFUND-supported programme for the control of rheumatic feverlrheumatic heart disease (RF/RHD) in some countries has entered the second phase. The incidence rates in school children found in these countries justify the specific inclu- sion of RF/RHD control measures into school health programmes. In Myanmar, extensive training programmes for the prevention, recognition and management of cardiovascular diseases were supported by WHO and a regular CVD Newsletter aims at helping to retain the gains in knowledge and expertise following this training. 13.18 OTHER NONCOMMUNICABLE DISEASE PREVEWTION AND CONTROL ACTIVITIES WHO assistance in this sub-programme area has continued to vary according to the specific needs of the countries. Assistance was provided for further strengthening of diabetology and endocrinology in Bangladesh. Bangladesh has also continued to upgrade the expertise in renal trans- plantation in the context of total cases in diabetology and nephrology. India and Thailand have strengthened their activities for the control of thalassemia, which is a major cause for concern. Maldives has also initiated activities to study and control thalassemia. An expert committee on rheumatology in Thailand prepared an action plan in this field with WHO assistance. = "Getting Set" for health for all. SECTION IV PROGRAMME SUPPORT Chapter 14 HEALTH INFORMATION SUPPORT 14.1 HEALTH LITERATUBE AND LIBRARY SERVICES (INCLUDING HELLIS) Health Literature, Library and Information Services (HELLIS) The HELLIS (Health Literature, Library and Information Services) network, now functional in eight Member Countries, continued to be an effective mechanism for information support to varied health clientele in the Region. Besides, with the provision of free MEDLARSIMEDLINE search(es) and photocopies of references that are not available in countries from where requests originate, it has been possible to help meet the information needs of health researchers, administrators, planners, managers, postgraduate students and others in the Member Countries. To introduce newer technologies in health science libraries in Member Countries, HELLIS National Focal Points (NFPs) participated in the Workshop on Application of Micro-ISIS Software, in Bangkok, from 23 October to 3 November 1989 and CD-ROM (Compact Disk Read-only Memory) MEDLINE Data Base Training, in Mahidol University, Thailand, from 4 to 6 November 1989. With a view to making them self-sufficient in their information retrieval capabilities as well as to have quick access to the relevant health literature/information, a one-time subscription to CD-ROM MEDLINE data base along with the CD-ROM drive was provided to HELLIS NFPs in Bangladesh, India, Indonesia, Myanmar and Sri lanka. For easier interaction among the network libraries, the Regional Office is compiling a directory of HELLIS NFPs and participating libraries. In order to bring under bibliographical control health literature published in the Member Countries, the Index Medicus for WHO South-East Asia Region (IMSEAR) continued to be compiled with the active participation of HELLIS NPPs in the collection and indexing of the material. Regional Office Library During the reporting period the Regional Office Library received 628 bookslmonographs, proceedings, reports, pamphlets, WHO publications and issues of current periodicals. Library facilities were used by 2 654 visitors (2 311 WHO staff and 343 others); 1 244 books and periodicala were issued on loan. In response to requests from Regional Office staff, field staff and headquarters, 88 inter-library loan requests were sent; 9 922 items were consulted in the library itself. 131 MEDLARSIMEDLINE searches and photocopies of 2 875 articles from in-house, local, regional, and headquarters and other international sources were arranged for WHO staff and Member Countries. The compilation and distribution of SEARO Library Alert (SIA) - a monthly current awareness service covering - selected periodicals and HELLIS Newsletter - was continued. The Library provided reference material and services for group educational activities and actively assisted in the development and monitoring of HELLIS network activitiea at national and international levels. The compilation and publication of Index Medicus for WHO South-East Asia Region (IMSEAR) was continued. IMSEAR volume 5 covering the period January-December 1985 is in press. Volume 6 covering the period January-December 1986 was being processed for publication in two parts. The library has acquired a computer and is in the process of automating its services. Action was also initiated for the installation of a CD-ROM MEDLINE data base. 14.2 PUBLICATIONS AND DOCUMENTS During the period under reporting, one new title was published under the SEARO publications series, while the first revision of another title was issued. Non-priced documents, including reports of various kinds, were produced (Table 11) and distributed. The sale of WHO publications increased over that of the previous year. 143 TABLE 11. Production of docments, 1989-90 Item Number Pages Pages edited printed Assignment reports 139 1 847 1 303 Reports of group educational activities 22 902 580 Terminal reports of UNDP projects 1 42 47 Other documents 10 923 168 Total 172 3 714 2 098 Translation and Publications Significant progress was made in continuing the WHO policy of disseminating information to the grassroots level by making available WHO publications in regional languages. Support was given to India for the translation of Cancer Pain Relief into Gujarati and The Community Health Worker into Hindi; to Indonesia for the translation into Bahasa Indonesia of the WHO Laboratory Manual for Examination of Human Semen and Semen- cervical Mucus Interaction; Education for Health; Health by the People; The Role of Food Safety in Health and Development: Joint WHOIFAO Expert Committee; Vitamin A Supplements: A Guide to their Use in the Treatment and Prevention of Vitamin A Deficiency and Xerophthalmia; Conjunctivitis of the Newborn; The Provision of Spectacles at Low Cost; A Guide to Nutritional Assessment; Oral Health Surveys: Basic Methods, 3rd Ed.; Respiratory Infections in Children: Management in Small Hospitals; Protecting, Promoting and Supporting Breast-feeding: The Special Role of Maternity Services - A Joint WHO/UNICEF Statement, WHO "Health for All" Series; Food Irradiation: A Technique for Preserving and Improving the Safety of Food; Rapid Assessment of Sources of Air, Water and Land Pollution; The Management of Diarrhoea and Use of Oral Rehydration Therapy; Manual of Radiographic Interpretation for General Practitioners, WHO 'Health for All' Series; to Nepal for the translation into Nepali of Educational Handbook for Health Personnel, 6th Ed.; Weaning - From Breast Milk to Family Food: A Guide for Health and Community Workers; Protecting, Promoting and Supporting Breast-feeding: The Special Role of Maternity Services - A Joint WHO/lJNICEF Statement; Treatment and Prevention of Acute Diarrhoea: Practical Guidelines, 2nd Ed.; and to Thailand for the translation into Thai of The Community Health Worker; Education for Health; Health Principles of Housing; Protecting, Promoting and Supporting Breast-feeding; Treatment and Prevention of Acute Diarrhoea: Practical Guidelines, 2nd Ed.; and Manual of Basic Techniques for a Health Laboratory. The Regional Office issued one title, 'The Use of Traditional Medicine in Primary Health Care in South-East Asia' (Regional Health Papers No. 19). Another publication, Health Care in South-East Asia (Regional Publication No. 14), first issued in 1985, was revised and updated. Documents The Regional Office brought out the Forty-second Report of the Regional Director, the Proposed Programme Budget for 1992-1993, and 'Dengue Newsletter' No. 15. The loose-leaf 'List of Technical Documents Issued Since 1979' was updated and the ninth edition of the 'Handbook of Resolutions and Decisions of the WHO Regional Committee for South-East Asia' was issued. Sales Apart from the routine display of publications at group educational activities held in the Regional Office and those organized in New Delhi by the scientific community, the Regional Office participated in selected book and trade fairs. The Regional Office and ILO, New Delhi, participated jointly, with success, in the India International Trade Fair, 14-29 November 1989, which had 'environment' as its theme. Over 820 books were sold during this fair. Participation at the Madras Book Fair, 22 December 1989 to 1 January 1990, generated interest among medical and paramedical personnel as well as the trade circle, and opened new vistas with Tamil book publishers for possible translation of WHO publications into Tamil in order to make them available at affordable prices. Negotiations with a distributor, for catering to the needs of the entire region of southern India, also commenced. At the New Delhi World Book Fair, 13-18 February 1990, requests for reprint rights for over 30 titles were received. The collection from sales over the counter and registration of new subscriptions for WHO periodicals surpassed all earlier figures. The response at the Health and Medicare exhibition, 25-31 March 1990, was very encouraging in that the visitors belonged exclusively to the medical community. The average sales reached nearly Rs. 10 000 per day. Reprint rights were granted for 12 WHO books which included two SEAR0 titles. A total of 26 306 books were sold in the calendar year 1989. Details of the financial turnover are reflected in Table 12. TABLE 12. Sales of WHO publications, 1988-1989 Item 1988 1989 July 88-June 89 us $ us $ us $ Subscriptions 77 138 85 124 77 879 Other publications 103 394 71 095 113 444 Total 180 532 156 219 191 323 NOTE: The above figures represent actual receipts after deduc- tion of all discounts and application of concessional conversion rate of Geneva cover prices to Indian rupees. Chapter 15 SUPPORT SERVICES Organizational Structure The organizational structure of the Regional Office as of 30 June 1990 is shown in Annex 1. 15.1 PERSONNEL As of 30 June 1990, the Regional Office had 133 established professional posts as compared to 135 on 30 June 1989. Table 13 shows the number of posts in the professional category in the Region, funded from all sources, and the number actually filled, as of 30 June 1990. During the period under review, 196 consultants were employed in various programmes for periods ranging from one week to eleven months. This represents an increase of 17 per cent in the number of consultants employed, compared with the previous year. Eight professional and three general service staff members separated from WHO service. One general service staff member died during the year. Three professional and eight general service staff members retired during the year. Five professional and two general service staff members left the Region on reassignment to other regions of WHO or other UN Agencies. TABLE 13. Number of professional posts, by location (As of 30 June 1990) Posts Regional and Country Total intercountry Established 72 61 133 Filled by appointment* 61 46 107 Posts frozen 3 1 4 Still to be filled 8 14 22 Of which: (a) candidates selected 5 3 8 (b) candidates yet to be selected 3 11 14 *Includes 8 posts filled by consultants. As of 30 June 1990, 33 national staff were employed on Special Service Agreements. A list of projects in operation during the year is given in Annex 2. Staff Developent and Training A seminar for country-based administrative staff was held in the Regional Office from 18 to 21 July 1989 with a view to improving communication between the country offices and the Regional Office and expediting implementation of WHO programmes in the Member Countries. It enabled the participants to have a better understanding of WHO'S procedures and processes as well as programme management. Some General Service staff in the Regional Office were trained in computer operations, including word processing. Consideration is being given to the introduction of self-learning programmes on a trial basis. Between July and October 1989, selected General Service staff from the WHO Representatives' Offices in Bangladesh, Bhutan, Indonesia, Maldives, Mongolia, Myanmar, Nepal, Sri Lanka and Thailand were imparted two-week's training in computer operations in the Regional Office. A training seminar for professional staff was held on 18 September 1989 to improve the efficiency of the staff and the functioning of the Organization. It covered such areas as completed staff work, report writing, and financial and personnel management. The WHO Representatives to Bangladesh and Mongolia participated in the Sixth Interregional Seminar for WHO Representatives, held in Geneva from 31 October to 10 November 1989. Support was provided to enable a staff member to participate in an international health programme. 15.2 GENERAL ADMINISTRATIVE SWVICES 1. Regional Office Building The installation of a second standby generator is in progress and is expected to be completed in 1990 providing full back-up for all Regional Office electrical requirements. The upgrading of fire prevention and safety installations is in progress and is expected to be completed before the end of 1990. Both projects are expected to be completed within the financial provision allotted for the purpose under the Real Estate Fund. An additional project to renovate and upgrade the existing telephone system in the Regional Office was approved by the Forty-third World Health Assembly in May 1990 and will be implemented during 1990-1991. 2. Office Autoriation The Regional Administration and Finance Information System has been implemented on an IBM 36 mini computer. This will provide expanded capability for financial and implementation information for operational and managerial purposes. Additional information systems in support of personnel, supply services and administra- tive processes are in operation and are being further developed with a view to interlinking them to provide a comprehensive administrative data base in support of managerial decision- making. 15.3 BUDGET AND FINANCE The total obligations for the biennium 1988-1989, as of 31 December 1989, under all sources of funds, amounted to US$ 99 774 588 - an increase of 9.0 per cent over the previous biennium - as against the total obligations of US$ 91 521 299 during 1986-1987 (Table 14). TABLE 14. Total obligations 1984-1985 1986-1987 1988-1989 US $ Amount Percentage Amount Percentage US $ Increase1 US $ Increase1 (Decrease) (Decrease) Regular Budget 61 203 672 60 970 500 (.4) 69 704 600 14.3 UNDP 7 420 104 10 095 289 36.1 7 972 569 (21.0) UNFPA 2 026 202 1 119 458 (44.8) 1277 466 14.1 Other Sources 15 628 267 19 336 052 23.7 20 819 953 7.7 Total 86 278 245 91 521 299 6.1 99 774 588 9.0 The total obligations from 1 January to 31 May 1990 under the Regular Budget amounted to US$ 23 976 293 representing 29.7 per cent of the regional allocation for the 1990-1991 biennium. WHO internal auditors visited the Regional Office in November- December 1989 to conduct routine financial audit. In addition, the Organization's external auditors visited the Regional Office in January 1990 and conducted a financial audit in respect of the closure of 1988-1989 accounts of the Regional Office. 15.4 SUPPLIES AND EQUIPMENT Medical supplies and equipment worth ~S$16 737 078 were procured during the period July 1989 - June 1990. Apart from conventional items such as drugs, laboratory equipment, hospital equipment, surgical instruments and office equipment, an increased number of requests for diagnostic kits and supplies were processed in this period. In the area of health literature, the period also witnessed an increasing number of requests for CD-ROMs, particularly for projects related to medical research and environmental health. CD-ROMs, medical literature and publications worth US$ 345 541 were procured of which WHO publications accounted for US$ 18 536. While processing requests for health care equipment, emphasis was laid on factors such as training and installation services offered by suppliers, proximity of suppliers, availability of spare parts, etc., in accordance with WHO'S Global Action Plan on Management, Maintenance and Repair of Health Care Equipment. Local purchase is being encouraged to the extent possible where improved support and maintenance facilities may be available, while at the same time ensuring quality of the products and competitive prices. Figure 5 provides the procurement trends in recent years. 1. hergency Supplies To meet requests from Member States arising out of emergency situations, such as epidemics and calamities, supplies were arranged against requests, particularly from India, Bangladesh and Nepal. Such requests amounted to a total of US$ 235 466. Figure 5. PROCUREMENT TRENDS US$ (millions) ~ .~.. ~ Jul 87-Jun 88 Jul 88-Jun 89 Jul 89-Jun 90 TOTAL PROCUREMENT LOCAL PURCHASE - 2. Purchases Under Revolving Fund and on Reimbursable Basis Some of the Member States of the Region e.g. Myanmar, India, Bangladesh and Nepal availed of the Organization's procurement services under its Revolving Fund scheme or on a reimbursable basis. The total value of such supplies was US$ 1 970 956. 15.5 GENERAL 1. Visits and Visitors The Director-General, Dr H. Nakajima visited the Regional Office in March 1990. The Regional Director attended the Symposium of the Indian Academy of Paediatrics on Survival of the Underprivileged child, held in Agra in October 1989. In December 1989, he attended the Symposium on Management of Medicine and Health Care, organized by the Indian Pharmaceutical Association, and had discussions with the national authorities on health matters. In February 1990, he attended the Task Force for Child Su~ival (Bellegio IV) in Thailand and accompanied the Director-General on his country visit. The Regional Director visited Pakistan in March 1990 to attend the Safe Motherhood Conference in Lahore and to visit the Aga Khan University in Karachi. During the year, the Regional Director visited Geneva to attend the fourteenth session of the Programme Committee of the WHO Executive Board, the Technical Advisory Group meeting on Tobacco or Health and World AIDS Day. He also attended the eighty-fourth and eighty-sixth sessions of the WHO Executive Board, the Director-General's Meeting with Regional Directors, and the Forty-third World Health Assembly. Within the Region, the Regional Director attended the forty- second session of the WHO Regional Committee for South-East Asia, held in Bandung, Indonesia and the Eighth Meeting of Ministers of Health from the Region, held in Jakarta, Indonesia. The Regional Director also visited Bangladesh, Maldives and Thailand for discussions on WHO collaborative programmes in the respective countries as well as to attend the sixteenth session of ACHR, held in Chiang Mai, Thailand. The Regional Director inaugurated and participated in a number of important meetings, symposia and workshops - national as well as regional and intercountry and also those organized by UN and other agencies. The Regional Director also gave the Father James Tong Memorial Oration on "Taking Health to the People" at the Lady Hardinge Medical College and Hospital, New Delhi on 9 September 1989. During the year, the Regional Office received a number of promi- nent visitors including: H.E. Dr Li Jong Ryul, Minister of Health, DPR Korea; H.E.Dr D. Monkhoo, Deputy Minister of Health, Mongolian People's Republic; H.E. Mr Homi J.H. Taleyarkhan, Member, Minorities Commission, Government of India; H.E. Dr Mario Paz Zamorra, Minister of Health, Bolivia; H.E. Mr Nilamani Routray, Minister of Health and Family Welfare, Government of India; H.E. Mr I.K. Gujral, Minister of External Affairs; Government of India; Dr R.J. Singh, President, Indian Medical Association; Professor Charas Suwanwela, President, Chulalongkorn University, Thailand; Sir John Wilson, Vice- President, Royal Commonwealth Society for the Blind, UK; Dr S.D.M. Fernando, Secretary, Ministry of Health and Women's Affairs, Sri Lanka; Professor Thet Htar Wai, President, Myanmar Hedical Association and other senior officials; Mr R. Srinivasan, Secretary, Ministry of Health and Family Welfare, Government of India; Dr A.S. Paintal, Director-General, Indian Council of Medical Research; Dr U Aung Tun Thet, Director- General of Health Services, Ministry of Health, Myanmar, and Dr P.C. Bhatla, Director-General, National Institute of Primary Health Care, New Delhi. ANNEXES Annex 1 ORGANIZATIONAL STRUCTURE 1 FIELD PROORAMME Annex 2 PROJECTS IN OPERATION IN MEMBER COUNTRIES In the list of projects, the following abbreviations are used under "Source of Funds": AGFUND Arab Gulf Programme for the United Nations Development Organizations AS Special Account for Servicing Costs DL Standard Letter of Agreement Between Executing Agencies DM United Nations Development Programme/Special Measures DP United Nations Development Programme FA Trust Fund for the Special Programme for Research and Training in Tropical Diseases FB Associate Experts Other Than UNDP FD United Nations Fund for Drug Abuse Control FP United Nations Population Fund FX Voluntary Fund for AIDS RB Regular Budget ST Sasakawa Health Trust Fund VB Voluntary Fund for Prevention of Blindness VC Voluntary Fund for Diarrhoea1 Diseases Including Cholera VD Voluntary Fund - Other VG Voluntary Fund for Medical Research - Other (General) VI Voluntary Fund for Expanded Programme on Immunization VK Voluntary Fund for Training Courses (DANIDA) VL Voluntary Fund for Leprosy Programme VM Voluntary Fund for Malaria VN Voluntary Fund for Disasters and Natural Catastrophes Project Source number of funds Title BAN COR 001 BAN COR 002 BAN ISS 001 BAN HST 001 BAN HST 003 BAN MPN 002 BAN MPN 200 BAN HSR 001 BAN PHC 003 BAN PHC 004 BAN PHC 005 BAN HMD 007 BAN HMD 008 BAN HMD 010 BAN HMD 011 BAN HMD 014 BAN HMD 015 BAN HMD 016 BAN HMD 017 BAN IEH 001 BAN RPD 001 BAN RPD 002 BAN NUT 003 BAN ORH 001 BAN APR 001 BAN MCH 005 BAN MCH 006 BAN OCH 001 BAN HEE 001 BAN MND 001 BAN CWS 001 BAN FOS 001 Emergency Relief Operations Emergency Preparedness and Response Informatics Development Health Situation and Trend Assessment Field Epidemiological Surveillance and Disease Control Planning and Management of Health Services Managerial Process for National Health Development Health Systems Research Organization of Health Systems Based on Primary Health Care Repair and Maintenance of Electro-medical Equipment Community Participation and Health For All Leaderahip Development Nursing Advisory Services and Training Health Manpower Development Training of Senior Nurses Development of the Centre for Medical Education Human Resources Development - Training of Paramedical Workers Strengthening of Postgraduate Medical Education Undergraduate Medical Education Strengthening of National Institute of Preventive and Social Medicine Development of Health Education Services Research Promotion and Development Strengthening of Selected Institutions Community-baaed Nutrition Improvement Programme Oral Health Accident Prevention Family Planning Clinical Supervision Team Maternal and Child Health, including Family Planning Workers' Health Health of the Elderly Prevention and Treatment of Mental and Neuro- logical Disorders Community Water Supply and Sanitation Food Safety BAN CLR 002 BAN EDV 001 BAN EDV 003 BAN DSE 001 BAN TRM 003 BAN RHB 001 BAN EPI 001 BAN MAL 001 BAN MAL 002 BAN PDP 001 BAN CDD 001 BAN ARI 001 BAN TUB 001 BAN LEP 001 BAN VDT 001 BAN GPA 001 BAN PBD 001 BAN PBL 002 BAN CAN 003 BAN CVD 001 BAN NCD 001 BAN HBI 001 BHUTAN BHU HST 001 RB BHU MPN 001 RB BHU PHC 001 RB BHU HMD 001 DP BHU HMD 002 DP BHU HMD 003 RB BHU IEH 001 RB BHU MCH 002 FP BHU EDV 001 VD BHU OCD 001 RB BHU NCD 001 RB Clinical, Laboratory and Radiological Technology for Health Systems based on Primary Health Care Essential Drugs and Vaccines Essential Dmgs Production Drug and Vaccine Quality, Safety and Efficacy Development of Manpower in Traditional Medicine Rehabilitation of the Disabled Immunization Malaria Control Malaria Control Programme Parasitic Diseases Diarrhoea1 Diseases Control of Acute Respiratory Infections Tuberculosis Leprosy Sexually Transmitted Diseases Prevention and Control of AIDS Prevention of Blindness Primary Eye Care Prevention and Control of Cancer Cardiovascular Diseases Other Noncommunicable Disease Prevention and Control Activities Development of Health Literature and Library and Information Services Health Situation and Trend Assessment Country Health Programing Primary Health Care - Promotion and Health Infra- structure Development Development of Human Resources for Health strengthening and Development of Nursing Services Development of Human Resources for Health Strengthening of Health Education Programme Development and Strengthening of MCH and Family Health Services Essential Drugs Programme Prevention and Control of Specific Communicable Diseases Prevention and Control of Noncommunicable Diseases DEMOCRATIC PEOPLE'S REPUBLIC OP KOREA KRD MPN 001 RB Managerial Process for National Health Develop- ment KRD HMD 002 RB Development of Human Resources for Health KRD RPD 001 RB Promotion of Research KRD NUT 001 RB Nutritional Hygiene KRD ORH 001 RB Oral Health KRD MCH 001 RB Maternal and Child Health KRD MCH 002 FP Support for the MCH/PP Activities KRD OCH 001 RB Workers' Health KRD HEE 001 RB Gerontology KRD CEH 001 DP Control of Environmental Health Hazards KRD CEH 002 RB Control of Environmental Pollutants and Health Hazards KRD CLR 001 RB Laboratory Sciences and Techniques KRD DSE 001 RB Legislation and Drug Quality Control KRD TRM 001 RB Traditional Medicine KRD RHB 001 RB Rehabilitation KRD CAN 001 RB Cancer Control KRD CVD 001 RB Cardiovascular Diseases KRD NCD 001 RB Other Noncommunicable Disease Preventiod and Control Activities INDIA IND HSC 001 RB IND HST 003 RB IND HST 005 RB IND HST 006 VD IND WN 001 RB IND MPN 002 RB IND MPN 003 RB IND WN 200 RB IND HSR 001 RB IND HLE 001 RB IND PHC 001 RB/VD IND PHC 002 RB IND PHC 003 RB IND HMD 015 RB Training and Development of HFA Leadership Epidemiological Services Development and Training Development and Training of Health Information Services Field Epidemiology and Laboratory Support Services Country Health Planning Strengthening of Health Programming and Management Training and Development of HPA Leadership Managerial Process for National Health Development Health System Research and Development Health Legislation Organization of Health Systems based on Primary Health Care Tribal Health Care Strengthening of Medical Stores Organization Nursing Development and Research IND HHD 017 IND IEH 001 IND RPD 001 IND RPD 002 IND NUT 006 IND ORH 001 IND APR 001 IND MCH 003 IND MCH 004 IND MCH 005 IND OCH 001 IND HEE 001 IND ADA 001 IND MND 001 IND CWS 001 IND CWS 002 IND CEH 001 IND FOS 001 IND CLR 001 IND CLR 002 IND CLR 003 IND EDV 001 IND EDV 002 IND DSE 001 IND TRM 001 IND RIB 001 IND EPI 001 IND MAL 001 IND MAL 002 IND PDP 001 IND CDD 001 IND ARI 001 IND TUB 001 IND LEP 001 IND LEP 002 IND VPH 002 IND VDT 001 IND GPA 001 IND OCD 001 IND OCD 002 Health Management Assessment, Development and Training Development of National Health Education Services Biomedical Research Studies on Tribal Health Nutrition including Goitre Oral Health Prevention of Accidents Maternal and Child Health Promotion of Family Welfare Services and Research Family ~elfare/~CH Services in Urban Areas Workers' Health Health of the Elderly Prevention and Treatment of Problems related to the Abuse of Drugs Prevention and Control of Mental and Neurological Disorders Community Water Supply and Sanitation Rural Water Supply and Sanitation Control of Environmental Pollution Quality Control of Essential Food Blood Banking Laboratory Quality Control and Standardization Strenthening National Institute of Immunology using Modern Immunobiological and Biological Approaches Essential Drugs and Vaccines Strengthening of Medical Stores Organization Quality, Safety and Efficacy of Drugs and Vaccines Traditional Medicine (including Homoeopathy and Yoga) Rehablitation Expanded Programme on Immunization Malaria Eradication Research and Training in Malaria Control Control of Parasitic Diseases Diarrhoea1 Disease Control Programme Prevention and Control of Acute Respiratory Infections Tuberculosis Control Leprosy Control Approaches to Treatment and Prevention of Leprosy Zoonoses Control Prevention of Sexually Transmitted Diseases Prevention and Control of AIDS Prevention and Control of Viral Hepatitis Guineaworm Eradication Programme IND OCD 003 IND OCD 004 IND PBD 001 IND CAN 006 IND CVD 002 IND CVD 003 IND CVD 004 IND NCD 001 IND HBI 001 INDONESIA IN0 HSC 001 IN0 HST 101 IN0 HST 102 IN0 HST 103 IN0 HST 104 IN0 HST 105 IN0 HST 106 IN0 HST 107 IN0 HST 108 IN0 HST 109 IN0 MPN 101 IN0 MPN 102 IN0 MPN 103 IN0 MPN 104 Prevention and Control of Japanese Encephalitis Other Communicable Diseases Prevention and Control Activities, including Typhoid Prevention of Blindness Cancer (including Radiation Medicine) Prevention of Hypertension and IHD Prevention of Rheumatic PeverlRheumatic Heart Disease Prevention of Rheumatic Heart Diseases Other Noncommunicable Disease Prevention and Control Activities National Medical Library and Documentation Centre Health for All Strategy Coordination - Directo- rate General of Community Health Strengthening of Health Information System - Centre for Health Data Strengthening of Health Information System - Directorate General of Community Health Strengthening of Health Information System - Inspectorate General Strengthening of Health Information System - Directorate General of Medical Care Strengthening of Health Information System - Directorate General of CDC & EH Strengthening of Health Information System - Directorate General of Food and Drug Control Strengthening of FETP Training in Epidemiology - Directorate General of CDC & EH Strengthening of Disease Surveillance - Directorate General of CDC & EH Strengthening of Health Information System - Centre for Health Laboratory Services Strengthening of the Managerial Process for National Health Development - Bureau of Planning Strengthening of the Managerial Process for National Health Development - Bureau of Organization Strengthening of the Managerial Process for National Health Development - Bureau of Personnel Strengthening of the Managerial Process for National Health Development - Bureau of Finance IN0 MPN 105 RB IN0 MPN 106 RB IN0 MPN 107 RB IN0 MPN 200 RB IN0 HSR 002 RB IN0 HLE 001 RB IN0 PHC 004 DP IN0 PHC 101 RB IN0 PHC 102 RB IN0 PHC 103 RB IN0 PHC 104 RB IN0 HMD 015 DP IN0 HMD 101 RB IN0 HMD 102 RB IN0 HMD 103 RB IN0 HMD 104 RB IN0 HMD 106 RB IN0 IEH 101 RB IN0 IEH 102 RB Strengthening of the Managerial Process for National Health Development - Inspectorate- General Strengthening of the Managerial Process for National Health Development - Bureau of General Affairs Health for All by the Year 2000 Strengthening Government of ~ndonesia/~HO Collaboration Mechanism Health Systems Research at Centre of Health Service Research and Development, Surabaya - National Institute of Health Research and Development Strengthening of Health Legislation - Bureau of Legal Affairs and Public Relations Primary Health Care in Irian Jaya Strengthening of Health Care Delivery and Primary Health Care - Directorate General of Community Health Strengthening of Referral Hospital Nursing - Directorate General of Medical Care Hospital Sanitation - Directorate General of CDC &EH Strengthening of Community Participation - Directorate General of Community Health Development of Nursing Higher Education System including a Faculty of Nursing at the University of Indonesia Overall Development and Coordination of Human Resources for Health with emphasis on Paramedicals - Centre of Health Manpower Education - Pusdiknakes Development of Nursing Personnel - Centre of Health Manpower Education - Pusdiknakes Planning of Human Resources for Health - Bureau of Planning Human Resources for Health - Management Training - Centre for Personnel Education Training - Pusdiklat Development of Higher Education in Health Sciences - Consortium of Health Sciences, University of Indonesia Development of Public Health Education Systems - Faculty of Public Health, University of Indonesia Strengthening of Health Education - Centre for Health Education Strengthening of Public Relations - Bureau of Legal Affairs and Public Relations IN0 RPD 001 RB IN0 NUT 005 RB IN0 ORH 002 RB IN0 APR 001 RB IN0 TOH 001 RB IN0 MCH 003 RB IN0 ADH 001 RB IN0 OCH 001 RB IN0 HEE 101 RB IN0 HEE 102 RB IN0 ADA 001 RB IN0 MND 001 RB IN0 CWS 001 RB IN0 CWS 007 DP IN0 CWS 008 DP IN0 CWS 009 DP IN0 PCS 001 RB IN0 CEH 001 RB IN0 FOS 101 RB IN0 FOS 102 RB IN0 CLR 001 RB IN0 EDV 001 RBI IN0 DSE 001 RB IN0 DSE 002 DP IN0 TRM 101 RB Strengthening of National Health System Research and Development Capabilities - National Institute of Health Research and Development Nutrition Improvement Programme - Directorate General of Community Health Oral Health - Directorate General of Medical Care Accidents Prevention and Control - Directorate General of Medical Care Tobacco or Health Maternal and Child Health includinn Familv Health - - - Directorate General of Community Health Adolescent Health - Directorate General of Community Health Strengthening of Occupational Health - Directorate General of Community Health Health of the Elderly - Directorate-General of Community Health Care of the Elderly - Directorate General of Medical Care Prevention and Control of Alcohol and Drug Abuse - Directorate General of Food and Drug Control Protection and Promotion of Mental Health - Directorate General of Medical Care Strengthening of Environmental Health - Directorate General of CDC & EH Rural Water Supply and Sanitation, Bangkulu and Lampung Provinces Training in Pre-Investment Planning for Community Water Supplies and Sanitation Rural Water Supply and Sanitation Project, Fast Timor province Health Risk Assessment of Potentially Toxic Chemicals - Directorate General of Food and Drug Control Chemical Safety Food Sanitation - Directorate General of CDC & EH Food Safety - Directorate General of Food and Drug Control Health Laboratory Services - Centre for Health Laboratory Services 'VD Essential Drugs and Vaccines - Directorate- General of Food and Drug Control Drugs, Vaccine Quality, Safety and Efficacy - Directorate General of Food and Drug Control Manpower Development for the Implementation of National Drug Policies Utilization of Traditional Medicine - Directorate General of Food and Drug Control IN0 RHB 001 IN0 EPI 001 IN0 VBC 001 IN0 MAL 001 IN0 PDP 001 IN0 CDD 001 IN0 ARI 001 IN0 TUB 001 IN0 LEP 001 IN0 LEP 002 IN0 VPH 001 IN0 VDT 001 Utilization of Traditional Medicine Practitioners in PHC - Directorate General of Community Health Rehabilitation - Directorate General of Medical Care Expanded Programme on Immunization - Directorate General of CDC & EH Disease Vector Control - Directorate General of CDC & EH Malaria Control - Directorate General of CDC & EH Parasitic Diseases - Directorate General of CDC & EH Diarrhoea1 Disease Control - Directorate General of CDC & EH Control of Acute Respiratory Infections - Directorate General of CDC & EH Tuberculosis - Directorate General of CDC & EH Leprosy - Directorate General of CDC & EH Leprosy Control Veterinary Public Health (Zoonoses) - Directorate General of CDC & EH Sexually Transmitted Diseases and Yaws - Directorate General of CDC & EH IN0 VDT 002 RB Acquired Immunodeficiency Syndrome IN0 CPA 001 RB/FX Acquired Imnunodeficlency Syndrome - Directorate General of CDC & EH IN0 OCD 001 RB Communicable Disease Control with Community Participation - Directorate General of CDC & EH IN0 PBD 001 RB Prevention of Blindness - Directorate General of Community Health IN0 PBL 002 VD Primary Eye Care IN0 CAN 001 RB Cancer Control - Directorate General of of Medical Care IN0 CVD 001 RB Cardiovascular Diseases - Directorate General of Medical Care IN0 HBI 001 RB Scientific Information Network and Health Information Support to the National Institute of Health Research and Development MALDIVES MAV MPN 200 RB Managerial Process for National Health Development MAV PHC 001 RB/ Strengthening of Health Services Delivery VI/VD System based on Primary Health Care MAV HMD 004 RB Development of Human Resources for Health MAV MCH 002 FP Strengthening of Family ~ealthl~hild Spacing Servces MAV CWS 001 RB Water Supply and Sanitation MAV MAL 001 RB Malaria and Other Vector-borne Disease Control MAV LEP 001 VD Leprosy Control MAV PBL 001 VD Primary Eye Care MAV HBI 001 RB Development of Health Literature and Library and Information Services MONGOLIA MOG HST 001 MOG MPN 200 MOG PHC 002 MOG HMD 005 MOG RPD 001 MOG ORH 001 MOG MCH 002 MOG MCH 004 MOG CWS 001 MOG CLR 002 MOG EDV 002 MOG DSE 001 MOG TRM 001 MOG EPI 001 MOG ARI 001 MOG TUB 001 MOG VPH 001 MOG OCD 001 MCG NCD 001 Development of National Health Information System for improving the Health Planning and Management Process Managerial Proceas for National Health Development Management of Health Services Human Resources for Health Development and Strengthening of Research Capabilities Research Promotion and Development, including Research on Health Promoting Behaviour Development of Oral Health Maternal and Child Health Strengthening of MCHIFP Services Strengthening of Environmental Health Services Development of Clinical Laboratory Services Development of Genetic Engineering Hepatitis B Vaccine (Prepatory assistance) Improvement of Drug Supply and Vaccine Control Development of Folk's Medicine Expanded Programme on Immunization Acute Respiratory Infections Control Tuberculosis Zoonoses Communicable Diseases Prevention and Control Noncommunicable Diseases Prevention and Control MMR HST 001 RB Health Information Services MMR HST 002 RB Epidemiological Surveillance of Communicable Diseases MMR MPN 002 RB/VD Health Services Planning and Management MMR MPN 200 RB Managerial Process for National Health Development HEIR HSR 001 RB MMR PHC 001 RB MMR PHC 003 RB MMR PHC 004 RB MMR PHC 005 DP MMR HMD 008 RB MMR HMD 009 RB MMR HMD 010 RB MMR HMD 011 DP MMR HMD 014 DP MMR HMD 016 DP MMR HMD 017 FP MMR HMD 018 VD MMR HMD 019 VD MMR HMD 020 RB MMR IEH 001 RB MMR RPD 001 RB/VG MMR RF'D 002 RB MMR RF'D 003 RB MMR NUT 002 RB MMR NUT 003 VD MMR ORH 001 RB MMR APR 001 RB MMR MCH 004 RB MMR MCH 005 FP MMR ADH 001 RB MMR OCH 002 RB MMR HEE 001 RB MMR ADA 001 FD MMR MND 001 RB MMR CWS 001 RB MMR RUD 001 RB MMR CLR 001 RB MMR EDV 001 VD MMR EDV 002 DP MMR EDV 003 VD MMR DSE 001 RB Health Systems Research Primary Health Care and Basic Health Services Hospital Services Management Supply System and Maintenance and Repair Workshop for Health Equipment Reinforcement of the Instrumentation Division (Workshop) of the Department of Medical Research Development of Procedures and Staff Training Development of Medical Education Methodologies for the Training and Orientation of Health Teams, including Physicians, in support of People's Health Programme Development of Human Resources for Health Planning and Manpower Development for Primary Health Care and Basic Health Services Strengthening of the Nursing Services Human Resources Development for the Institutes of Medicine and Dental Medicine Strengthening of the Departments of Obstetrics and Gynaecology of the Institute of Medicine Health Manpower Planning and Information System Work Study on Divisions and Sections of Department of Health HFA Leadership Development Development of Health Education Health Research in Support of People's Health Programme Research Training Programme Development of Research Infrastructure Nutrition WHOlUNICEF Nutrition Support Programme Primary Oral Health Care Accident Prevention Family Health Care Strengthening of MCH Services Development of Physical Health Workers' Health Health Care for the Elderly UN/Burma Programme for Drug Abuse Control, Treatment and Research Component - Phase I1 Community-oriented Mental Health Care Programme Environmental Health Planning and Management Urban Environmental Health Promotion of Health Laboratories Essential Drugs Programme Development of Hepatitis B Vaccine Essential Drugs Development of Production and Quality Control of Biologicals and Pharmaceutical Products MMR FOS 001 MMR TRM 001 m TRM 002 MMR RHB 001 MMR EPI 001 MMR VBC 001 MMR CDD 001 MMR ARI 001 MMR ARI 002 M?4R TUB 001 MMR LEP 001 MMR VDT 001 MMR GPA 001 MMR GPA 002 MMR PBD 001 MMR PBD 002 MMR CAN 001 MMR CVD 001 MMR NCD 001 MMR HBI 001 NEP ISS 001 RB NEP HST 001 RB NEP MPN 001 RB/VK NEP MPN 002 RB NEP MPN 200 RB NEP PHC 001 RB/FB NEP PHC 003 RB NEP HMD 005 RB NEP HMD 008 RB NEP IEH 001 RB Development of Food and Drug Control Infra- structure (Pre~aratorv assistance) standardization,' ~ha~colo~ical and Toxicologi- cal Evaluation of Traditional Drugs and Herbal Medicine Development of 'Traditional Medicine Manpower Community-oriented Programme for Disability Prevention and Rehabilitation Expanded Programme on Immunization Vector-Borne Disease Control Control and Prevention of Diarrhoea1 Diseases Acute Respiratory Infections Control Programme Acute Respiratory Infections Control Tuberculosis Control Leprosy Control and Research Activities Control of AIDS Prevention and Control of AIDS Control of AIDS and other Sexually Transmitted Diseases Trachoma Control and Prevention of Blindness Programme Prevention of Deafness Cancer Control Cardiovascular Diseases Prevention of Deafness Development of Library and Information Services Development of Informatics Facilities in Support of Health System Development of Epidemiological Surveillance and Information System Country Health Programming Health Planning and Programming and Health Information System Managerial Process for National Health Development Community Health Development and Development of Referral System through Primary Health Care Alternative Approaches to Primary Health Care Development of Human Resources for Health Development of Nursing Personnel Planning and Management Public Information and Education for Health NEP RPD 001 NEP NUT 003 NEP NUT 004 NEP APR 001 NEP MCH 003 NEP MCH 005 NEP MND 001 NEP CWS 001 NEP CWS 003 NEP CLR 001 NEP DSE 002 NEP TRM 001 NEP RHB 001 NEP EPI 001 NEP VBC 001 NEP MAL 001 NEP CDD 001 NEP ARI 001 NEP TUB 001 NEP LEP 001 NEP VPH 001 NEP GPA 001 NEP VDT 001 NEP OCD 001 NEP PBD 001 NEP NCD 002 NEP HBI 001 SRI LANKA Research Promotion and Development Nutrition WHOIUNICEF Nutrition Support Programme Accident Prevention Programme Maternal and Child Health including Family Planning Centre for Family Health Protection and Promotion of Mental Health, including Alcoholism and Drug Abuse Community Water Supply and Sanitation Training of Manpower for Drinking Water and Sanitation Programme (Phase 11) Development of Laboratory Services based on PHC Drug Policy, Legislation and Information Promotion of Traditional Medicine Community-based Rehabilitation Expanded Programme on Immunization Vector Biology Control Control of Malaria Control of Diarrhoea1 Diseases Prevention and Control of Acute Respiratory Infections Control of Tuberculosis Control of Leprosy Control of Zoonoses and Food Safety Prevention and Control of AIDS Prevention and Control of Sexually Transmitted Diseases, including AIDS Control of Other Communicable Diseases Prevention and Control of Blindness Prevention and Control of Deafness Prevention and Control of other Noncommunicable Diseases Prevention and Control of Deafness Development of Health Literature and Library and Information Services SRL HST 001 RB Strengthening of Health Information System SRL HST 002 RB Strengthening of Epidemiological Surveillance SRL HST 003 DP National Health Information System SRL MPN 001 RB Country Health Programming SRL MPN 002 RB Strengthening of Planning and Management SRL MPN 200 RB SRL PHC 101 RB SRL PHC 102 RB SRL PHC 103 RB SRL PHC 104 RB SRL PHC 105 RB SRL m 011 RB SRL HMD 012 RB SRL HMD 014 RB SRL HMD 017 DP SRL HMD 018 RB SRL HMD 019 RB SRL HMD 020 DP SRL HMD 101 RB SRL HMD 102 RB SRL HMD 103 RB SRL HMD 104 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 MCH 010 FP SRL OCH 001 RB SRL ADA 001 FD SRL ADA 002 DP SRL MND 001 RB SRL CWS 001 RB SRL CWS 002 RB SRL FOS 001 RB SRL CLR 001 RB Managerial Process for National Health Development Development of Primary Health Care - PHC Management and Intersectoral Coordination Development of Primary Health Care - Traditional Medicine Development of Primary Health Care - Referral Hospitals (Secondary) Development of Primary Health Care - Tertiary Hospitals Development of Primary Health Care - Biomedical Engineering Services Nursing Education Postgraduate Medical Education Development of National Institute of Health Sciences National Institute of Health Sciences - Phase I1 Development of Human Resources for Health Development of Human Resources for Forensic Medicine Development of Regional Training Centres in Collaboration with the National Institute of Health Sciences Undergraduate Medical Education - University of Colombo Undergraduate Medical Education - University of Ruhuna Undergraduate Medical Education - University of Peradeniya Undergraduate Medical Education - University of Jaffna Health Education Research Promotion and Development Nutrition Community Oral Health Development of a National Programme on Accident Prevention Development of Family Health Programme Strengthening Family Planning Services Workers' Health Prevention and Treatment of Problems Related to the Abuse of Drugs Drug Abuse Monitoring System Mental Health Community Water Supply and Sanitation Training in Public Health Engineering Food Safety Strengthening of Laboratory Services SRL EDV 001 RB/VD Essential Drugs and Vaccines SRL TRM 002 DP Developnent of Traditional Medicine - Phase I1 SRL RHB 001 RB ~omnunit~ariented Rehabilitation Services SRL EPI 001 RB/VI Exoanded Pronrarme on Imunization SRL VBC 001 SRL MAJ, 001 SRL CDD 001 SRL ARI 001 SRL TUB 001 SRL LEP 001 SRL VPH 002 SRL VDT 001 SRL GPA 001 SRL PBD 001 SRL PBL 002 SRL CAN 002 SRL CVD 002 SRL CVD 003 SRL HBI 001 THA HST 001 THA MPN 001 THA MPN 200 THA PHC 002 THA PHC 003 THA HMD 015 THA IEH 001 THA RPD 003 THA ORH 001 THA APR 001 THA TOH 001 THA MCH 010 THA MCH 011 THA OCH 001 - Disease Vector Control Malaria Control Control of Diarrhoea1 Diseases Control of Acute Respiratory Infections Tuberculosis Control Leprosy Control Accelerated Rabies Control Campaign Control of Sexually Transmitted Diseases Prevention and Control of AIDS Prevention of Blindness Primary Eye Care Prevention and Control of Cancer Prevention and Control of Cardiovascular Diseases Prevention of Rheumatic Fever/Rheumatic Heart Disease Development of Health Literature and Library Network Health Situation and Trend Assessment Development and Strengthening of the National Decentralized Management System - RTG/wHO Executive Committee Managerial Process for National Health Development Support of Community-based Self-Managed Primary Health Care Development Health Systems Reorientation and Development in Support of PHC Development of Human Resources for Health Public Information and Education for Health Research Promotion and Development, including Research on Health Promoting Behaviour Preventive Oral Health Services Prevention of Accidents Smoking and Health Expansion of Family Planning Services Maternal and Child Health, including Family Planning Workers' Health THA HEE 001 THA PSF 001 THA CEH 001 THA EDV 001 THA DSE 001 THA TRM 001 THA VBC 001 THA MAL 001 THA PDP 001 THA CDD 001 THA ARI 001 THA TUB 001 THA LEP 001 THA VPH 001 THA VDT 001 THA RDV 001 THA GPA 001 THA OCD 001 THA PBL 001 THA PBL 002 THA CAN 001 THA CVD 001 THA CVD 002 THA NCD 002 THA HBI 001 RB Health of the Elderly RB Paychosocial Factors in the Promotion of Health and Human Development RB Control of Environmental Health Hazards RB/VD Promotion of Easential Drugs - Distribution and Rationalization of Drug Uses at the PHC Level RB Development of Pharmaceuticals and Biologicals RB Traditional Medicine RB Disease Vector Control RB Malaria Control RB Control of Parasitic Diseases RB Prevention and Control of Diarrhoea1 Diseases RB Prevention and Control of Acute Respiratory 000 RCO 103 RE 000 EXM 001 RB ICP DGP 001 RB 000 GPD 001 RB ICP GPD 002 RB ICP COR 001 RB 000 COR 100 AS ICP HSC 001 RB 000 ISS 001 RB 000 HST 001 RB 000 HST 002 RB Infections Tuberculosia Leprosy Rabies Control Sexually-Transmitted Diseases Vaccines Research and Development AIDS Prevention and Control Programme Disease Prevention and Control Activities Primary Eye Care Prevention of Blindness Prevention and Control of Cancer Cardiovascular Diseases Prevention of Rheumatic Fever/Rheumatic Heart Disease Prevention and Control of Noncommunicable Diseases Health Information Support Regional Committees Executive Management Regional Director's Development Prog~aInUe General Programme Development Staff Development and Training Liaison with ESCAP Coordination with other Organizations Health-for-All Strategy Coordination Informatics Management Strengthening of Epidemiological Surveillance System National Health Information Systems Development 000 HST 100 000 MPN 001 ICP MPN 003 ICP PHC 002 ICP PHC 009 000 PHC 100 000 HMD 014 ICP HMD 016 ICP HMD 017 ICP m 018 000 HMD 100 000 IEH 001 ICP IEH 002 000 IEH 100 000 RPD 001 ICP RPD 002 ICP RPD 003 000 RPD 100 ICP NUT 005 ICP NUT 006 000 NUT 100 ICP MCH 011 000 MCH 100 ICP HEE 001 000 PSF 100 ICP ADA 001 000 CWS 001 ICP CWS 002 ICP CWS 004 ICP CWS 005 000 CWS 100 ICP RUD 001 RBI VD/VK RB RBI AS/ST Health Situation and Trend Assessment Managerial Process for Health Development Strengthening Health Managerial Capabilities Promotion of Health for All with Primary Health Care as Key Approach including Appropriate Technology for Health Intensification of Action Programme for Primary Health Care Organization of Health Systems Based on Primary Health Care Development of Human Resources for Health HFA Leadership Development RB Staff Development and Training DP Development of Health Learning Materials RB Development of Human Resources for Health RB Public Information and Education for Health RB Promotion of Health Education RB Public Information and Education for Health RB Research Promotion and Development RB Collaboration in Research Programme RB Institutional Strengthening for Research RB Research Promotion and Development, including Research on Health-Promoting Behaviour RB/FB/ Nutrition Monitoring and Evaluation VD/VG WHOIUNICEF Nutrition Support Programme Nutrition Regional Advisory Team on Maternal and Child HealthIFamily Planning Maternal and Child Health, including Family Planning Health Care of the Elderly Psychosocial and Behavioural Factors in the Promotion of Health and Human Development DANIDA Training Course on Prevention and Management of Drug Abuse through PHC Community Water Supply and Sanitation GTZIWHO Cooperation Project for International Drinking Water Supply and Sanitation Decade Building up of Information Services in Environmental Health in South-East Asia Promotion of Support for Women's Participation in the IDWSSD Community Water Supply and Sanitation Environmental Health in Rural and Urban Develop- ment and Housing ICP CEH 001 ICP CEH 002 Control of Environmental Pollutants and Hazards Safety and Control of Pollutants and Toxic Chemicals Food Safety Standardization of Diagnostic Material and Laboratory Practices Preparation of Immunological and Immunodiagnostic Reagents by Institutions in SEAR Introduction of Quality Standards and Appropriate Technology for Laboratory Services in Support of Primary Health Care Clinical, Idoratory and Radiological Technology for Health Systems based on Primary Health Care Development of Essential Drugs: Legislation and Quality Control Drug Policies and Management Technical Cooperation in Pharmaceuticals among ASEAN Countries Regional Training in Rabies Vaccine Production and Prevention and Control of Human and Canine Rabies Disability Prevention and Rehabilitation Rehabilitation ICP FOS 001 ICP CLR 001 ICP CLR 002 ICP CLR 003 000 CLR 100 ICP EDV 001 ICP EDV 002 ICP EDV 004 ICP DSE 001 ICP RHB 001 000 RHB 100 ICP EPI 001 000 EPI 001 ICP VBC 001 000 VBC 100 ICP MAL 001 Expanded Programme on Imunization Expanded Programme on Immunization ise ease vector Control Disease Vector Control Malaria Control and Coordination of Antimalaria Activities in the Region Monltoring Sensitivity of Malaria Parasites to Antimalarial Drugs Malaria Parasitic Diseases Control Control of Visceral Leishmaniasis Strengthening of Biomedical Research Capability Prevention and Control of Diarrhoea1 Diseases Prevention and Control of Acute Respiratory Infections Acute Respiratory Infections Programme - Operations Leprosy Control Prevention and Control of AIDS in Asia and the Pacific AIDS Prevention and Control Programme Prevention of Blindness and Deafness Prevention of Blindness Control of Blindness (Primary Eye Care) ICP MAL 003 000 MAL 100 000 PDP 001 ICP PDP 002 000 TDR 100 ICP CDD 001 ICP ARI 001 ICP ARI 002 ICP LEP 001 ICP VDT 001 ICP GPA 100 000 PBD 001 ICP PBL 002 ICP PBD 004 ICP NCD 001 RB/FB A Community-oriented Approach to the Prevention and Control of Noncommunicable Diseases ICP NCD 002 VD Prevention and Control of Deafness 000 HBI 001 RB/AS Health Information Support 000 HBI 002 RB Health Literature, Library and Information Services 000 PER 001 RB Support Services - Personnel 000 PGS 001 RB/AS General Administration and Services 000 BFI 001 RB/AS Support Services - Budget and Finance 000 SUP 001 RB/AS Equipment and Supplies for Member States
Annex 2 PROJECTS IN OPERATION IN MEMBER COUNTRIES In the list of projects, the following abbreviations are used under "Source of Funds": AGFUND Arab Gulf Programme for the United Nations Development Organizations AS Special Account for Servicing Costs DL Standard Letter of Agreement Between Executing Agencies DM United Nations Development Programme/Special Measures DP United Nations Development Programme FA Trust Fund for the Special Programme for Research and Training in Tropical Diseases FB Associate Experts Other Than UNDP FD United Nations Fund for Drug Abuse Control FP United Nations Population Fund FX Voluntary Fund for AIDS RB Regular Budget ST Sasakawa Health Trust Fund VB Voluntary Fund for Prevention of Blindness VC Voluntary Fund for Diarrhoea1 Diseases Including Cholera VD Voluntary Fund - Other VG Voluntary Fund for Medical Research - Other (General) VI Voluntary Fund for Expanded Programme on Immunization VK Voluntary Fund for Training Courses (DANIDA) VL Voluntary Fund for Leprosy Programme VM Voluntary Fund for Malaria VN Voluntary Fund for Disasters and Natural Catastrophes Project Source number of funds Title BAN COR 001 BAN COR 002 BAN ISS 001 BAN HST 001 BAN HST 003 BAN MPN 002 BAN MPN 200 BAN HSR 001 BAN PHC 003 BAN PHC 004 BAN PHC 005 BAN HMD 007 BAN HMD 008 BAN HMD 010 BAN HMD 011 BAN HMD 014 BAN HMD 015 BAN HMD 016 BAN HMD 017 BAN IEH 001 BAN RPD 001 BAN RPD 002 BAN NUT 003 BAN ORH 001 BAN APR 001 BAN MCH 005 BAN MCH 006 BAN OCH 001 BAN HEE 001 BAN MND 001 BAN CWS 001 BAN FOS 001 Emergency Relief Operations Emergency Preparedness and Response Informatics Development Health Situation and Trend Assessment Field Epidemiological Surveillance and Disease Control Planning and Management of Health Services Managerial Process for National Health Development Health Systems Research Organization of Health Systems Based on Primary Health Care Repair and Maintenance of Electro-medical Equipment Community Participation and Health For All Leaderahip Development Nursing Advisory Services and Training Health Manpower Development Training of Senior Nurses Development of the Centre for Medical Education Human Resources Development - Training of Paramedical Workers Strengthening of Postgraduate Medical Education Undergraduate Medical Education Strengthening of National Institute of Preventive and Social Medicine Development of Health Education Services Research Promotion and Development Strengthening of Selected Institutions Community-baaed Nutrition Improvement Programme Oral Health Accident Prevention Family Planning Clinical Supervision Team Maternal and Child Health, including Family Planning Workers' Health Health of the Elderly Prevention and Treatment of Mental and Neuro- logical Disorders Community Water Supply and Sanitation Food Safety BAN CLR 002 BAN EDV 001 BAN EDV 003 BAN DSE 001 BAN TRM 003 BAN RHB 001 BAN EPI 001 BAN MAL 001 BAN MAL 002 BAN PDP 001 BAN CDD 001 BAN ARI 001 BAN TUB 001 BAN LEP 001 BAN VDT 001 BAN GPA 001 BAN PBD 001 BAN PBL 002 BAN CAN 003 BAN CVD 001 BAN NCD 001 BAN HBI 001 BHUTAN BHU HST 001 RB BHU MPN 001 RB BHU PHC 001 RB BHU HMD 001 DP BHU HMD 002 DP BHU HMD 003 RB BHU IEH 001 RB BHU MCH 002 FP BHU EDV 001 VD BHU OCD 001 RB BHU NCD 001 RB Clinical, Laboratory and Radiological Technology for Health Systems based on Primary Health Care Essential Drugs and Vaccines Essential Dmgs Production Drug and Vaccine Quality, Safety and Efficacy Development of Manpower in Traditional Medicine Rehabilitation of the Disabled Immunization Malaria Control Malaria Control Programme Parasitic Diseases Diarrhoea1 Diseases Control of Acute Respiratory Infections Tuberculosis Leprosy Sexually Transmitted Diseases Prevention and Control of AIDS Prevention of Blindness Primary Eye Care Prevention and Control of Cancer Cardiovascular Diseases Other Noncommunicable Disease Prevention and Control Activities Development of Health Literature and Library and Information Services Health Situation and Trend Assessment Country Health Programing Primary Health Care - Promotion and Health Infra- structure Development Development of Human Resources for Health strengthening and Development of Nursing Services Development of Human Resources for Health Strengthening of Health Education Programme Development and Strengthening of MCH and Family Health Services Essential Drugs Programme Prevention and Control of Specific Communicable Diseases Prevention and Control of Noncommunicable Diseases DEMOCRATIC PEOPLE'S REPUBLIC OP KOREA KRD MPN 001 RB Managerial Process for National Health Develop- ment KRD HMD 002 RB Development of Human Resources for Health KRD RPD 001 RB Promotion of Research KRD NUT 001 RB Nutritional Hygiene KRD ORH 001 RB Oral Health KRD MCH 001 RB Maternal and Child Health KRD MCH 002 FP Support for the MCH/PP Activities KRD OCH 001 RB Workers' Health KRD HEE 001 RB Gerontology KRD CEH 001 DP Control of Environmental Health Hazards KRD CEH 002 RB Control of Environmental Pollutants and Health Hazards KRD CLR 001 RB Laboratory Sciences and Techniques KRD DSE 001 RB Legislation and Drug Quality Control KRD TRM 001 RB Traditional Medicine KRD RHB 001 RB Rehabilitation KRD CAN 001 RB Cancer Control KRD CVD 001 RB Cardiovascular Diseases KRD NCD 001 RB Other Noncommunicable Disease Preventiod and Control Activities INDIA IND HSC 001 RB IND HST 003 RB IND HST 005 RB IND HST 006 VD IND WN 001 RB IND MPN 002 RB IND MPN 003 RB IND WN 200 RB IND HSR 001 RB IND HLE 001 RB IND PHC 001 RB/VD IND PHC 002 RB IND PHC 003 RB IND HMD 015 RB Training and Development of HFA Leadership Epidemiological Services Development and Training Development and Training of Health Information Services Field Epidemiology and Laboratory Support Services Country Health Planning Strengthening of Health Programming and Management Training and Development of HPA Leadership Managerial Process for National Health Development Health System Research and Development Health Legislation Organization of Health Systems based on Primary Health Care Tribal Health Care Strengthening of Medical Stores Organization Nursing Development and Research IND HHD 017 IND IEH 001 IND RPD 001 IND RPD 002 IND NUT 006 IND ORH 001 IND APR 001 IND MCH 003 IND MCH 004 IND MCH 005 IND OCH 001 IND HEE 001 IND ADA 001 IND MND 001 IND CWS 001 IND CWS 002 IND CEH 001 IND FOS 001 IND CLR 001 IND CLR 002 IND CLR 003 IND EDV 001 IND EDV 002 IND DSE 001 IND TRM 001 IND RIB 001 IND EPI 001 IND MAL 001 IND MAL 002 IND PDP 001 IND CDD 001 IND ARI 001 IND TUB 001 IND LEP 001 IND LEP 002 IND VPH 002 IND VDT 001 IND GPA 001 IND OCD 001 IND OCD 002 Health Management Assessment, Development and Training Development of National Health Education Services Biomedical Research Studies on Tribal Health Nutrition including Goitre Oral Health Prevention of Accidents Maternal and Child Health Promotion of Family Welfare Services and Research Family ~elfare/~CH Services in Urban Areas Workers' Health Health of the Elderly Prevention and Treatment of Problems related to the Abuse of Drugs Prevention and Control of Mental and Neurological Disorders Community Water Supply and Sanitation Rural Water Supply and Sanitation Control of Environmental Pollution Quality Control of Essential Food Blood Banking Laboratory Quality Control and Standardization Strenthening National Institute of Immunology using Modern Immunobiological and Biological Approaches Essential Drugs and Vaccines Strengthening of Medical Stores Organization Quality, Safety and Efficacy of Drugs and Vaccines Traditional Medicine (including Homoeopathy and Yoga) Rehablitation Expanded Programme on Immunization Malaria Eradication Research and Training in Malaria Control Control of Parasitic Diseases Diarrhoea1 Disease Control Programme Prevention and Control of Acute Respiratory Infections Tuberculosis Control Leprosy Control Approaches to Treatment and Prevention of Leprosy Zoonoses Control Prevention of Sexually Transmitted Diseases Prevention and Control of AIDS Prevention and Control of Viral Hepatitis Guineaworm Eradication Programme IND OCD 003 IND OCD 004 IND PBD 001 IND CAN 006 IND CVD 002 IND CVD 003 IND CVD 004 IND NCD 001 IND HBI 001 INDONESIA IN0 HSC 001 IN0 HST 101 IN0 HST 102 IN0 HST 103 IN0 HST 104 IN0 HST 105 IN0 HST 106 IN0 HST 107 IN0 HST 108 IN0 HST 109 IN0 MPN 101 IN0 MPN 102 IN0 MPN 103 IN0 MPN 104 Prevention and Control of Japanese Encephalitis Other Communicable Diseases Prevention and Control Activities, including Typhoid Prevention of Blindness Cancer (including Radiation Medicine) Prevention of Hypertension and IHD Prevention of Rheumatic PeverlRheumatic Heart Disease Prevention of Rheumatic Heart Diseases Other Noncommunicable Disease Prevention and Control Activities National Medical Library and Documentation Centre Health for All Strategy Coordination - Directo- rate General of Community Health Strengthening of Health Information System - Centre for Health Data Strengthening of Health Information System - Directorate General of Community Health Strengthening of Health Information System - Inspectorate General Strengthening of Health Information System - Directorate General of Medical Care Strengthening of Health Information System - Directorate General of CDC & EH Strengthening of Health Information System - Directorate General of Food and Drug Control Strengthening of FETP Training in Epidemiology - Directorate General of CDC & EH Strengthening of Disease Surveillance - Directorate General of CDC & EH Strengthening of Health Information System - Centre for Health Laboratory Services Strengthening of the Managerial Process for National Health Development - Bureau of Planning Strengthening of the Managerial Process for National Health Development - Bureau of Organization Strengthening of the Managerial Process for National Health Development - Bureau of Personnel Strengthening of the Managerial Process for National Health Development - Bureau of Finance IN0 MPN 105 RB IN0 MPN 106 RB IN0 MPN 107 RB IN0 MPN 200 RB IN0 HSR 002 RB IN0 HLE 001 RB IN0 PHC 004 DP IN0 PHC 101 RB IN0 PHC 102 RB IN0 PHC 103 RB IN0 PHC 104 RB IN0 HMD 015 DP IN0 HMD 101 RB IN0 HMD 102 RB IN0 HMD 103 RB IN0 HMD 104 RB IN0 HMD 106 RB IN0 IEH 101 RB IN0 IEH 102 RB Strengthening of the Managerial Process for National Health Development - Inspectorate- General Strengthening of the Managerial Process for National Health Development - Bureau of General Affairs Health for All by the Year 2000 Strengthening Government of ~ndonesia/~HO Collaboration Mechanism Health Systems Research at Centre of Health Service Research and Development, Surabaya - National Institute of Health Research and Development Strengthening of Health Legislation - Bureau of Legal Affairs and Public Relations Primary Health Care in Irian Jaya Strengthening of Health Care Delivery and Primary Health Care - Directorate General of Community Health Strengthening of Referral Hospital Nursing - Directorate General of Medical Care Hospital Sanitation - Directorate General of CDC &EH Strengthening of Community Participation - Directorate General of Community Health Development of Nursing Higher Education System including a Faculty of Nursing at the University of Indonesia Overall Development and Coordination of Human Resources for Health with emphasis on Paramedicals - Centre of Health Manpower Education - Pusdiknakes Development of Nursing Personnel - Centre of Health Manpower Education - Pusdiknakes Planning of Human Resources for Health - Bureau of Planning Human Resources for Health - Management Training - Centre for Personnel Education Training - Pusdiklat Development of Higher Education in Health Sciences - Consortium of Health Sciences, University of Indonesia Development of Public Health Education Systems - Faculty of Public Health, University of Indonesia Strengthening of Health Education - Centre for Health Education Strengthening of Public Relations - Bureau of Legal Affairs and Public Relations IN0 RPD 001 RB IN0 NUT 005 RB IN0 ORH 002 RB IN0 APR 001 RB IN0 TOH 001 RB IN0 MCH 003 RB IN0 ADH 001 RB IN0 OCH 001 RB IN0 HEE 101 RB IN0 HEE 102 RB IN0 ADA 001 RB IN0 MND 001 RB IN0 CWS 001 RB IN0 CWS 007 DP IN0 CWS 008 DP IN0 CWS 009 DP IN0 PCS 001 RB IN0 CEH 001 RB IN0 FOS 101 RB IN0 FOS 102 RB IN0 CLR 001 RB IN0 EDV 001 RBI IN0 DSE 001 RB IN0 DSE 002 DP IN0 TRM 101 RB Strengthening of National Health System Research and Development Capabilities - National Institute of Health Research and Development Nutrition Improvement Programme - Directorate General of Community Health Oral Health - Directorate General of Medical Care Accidents Prevention and Control - Directorate General of Medical Care Tobacco or Health Maternal and Child Health includinn Familv Health - - - Directorate General of Community Health Adolescent Health - Directorate General of Community Health Strengthening of Occupational Health - Directorate General of Community Health Health of the Elderly - Directorate-General of Community Health Care of the Elderly - Directorate General of Medical Care Prevention and Control of Alcohol and Drug Abuse - Directorate General of Food and Drug Control Protection and Promotion of Mental Health - Directorate General of Medical Care Strengthening of Environmental Health - Directorate General of CDC & EH Rural Water Supply and Sanitation, Bangkulu and Lampung Provinces Training in Pre-Investment Planning for Community Water Supplies and Sanitation Rural Water Supply and Sanitation Project, Fast Timor province Health Risk Assessment of Potentially Toxic Chemicals - Directorate General of Food and Drug Control Chemical Safety Food Sanitation - Directorate General of CDC & EH Food Safety - Directorate General of Food and Drug Control Health Laboratory Services - Centre for Health Laboratory Services 'VD Essential Drugs and Vaccines - Directorate- General of Food and Drug Control Drugs, Vaccine Quality, Safety and Efficacy - Directorate General of Food and Drug Control Manpower Development for the Implementation of National Drug Policies Utilization of Traditional Medicine - Directorate General of Food and Drug Control IN0 RHB 001 IN0 EPI 001 IN0 VBC 001 IN0 MAL 001 IN0 PDP 001 IN0 CDD 001 IN0 ARI 001 IN0 TUB 001 IN0 LEP 001 IN0 LEP 002 IN0 VPH 001 IN0 VDT 001 Utilization of Traditional Medicine Practitioners in PHC - Directorate General of Community Health Rehabilitation - Directorate General of Medical Care Expanded Programme on Immunization - Directorate General of CDC & EH Disease Vector Control - Directorate General of CDC & EH Malaria Control - Directorate General of CDC & EH Parasitic Diseases - Directorate General of CDC & EH Diarrhoea1 Disease Control - Directorate General of CDC & EH Control of Acute Respiratory Infections - Directorate General of CDC & EH Tuberculosis - Directorate General of CDC & EH Leprosy - Directorate General of CDC & EH Leprosy Control Veterinary Public Health (Zoonoses) - Directorate General of CDC & EH Sexually Transmitted Diseases and Yaws - Directorate General of CDC & EH IN0 VDT 002 RB Acquired Immunodeficiency Syndrome IN0 CPA 001 RB/FX Acquired Imnunodeficlency Syndrome - Directorate General of CDC & EH IN0 OCD 001 RB Communicable Disease Control with Community Participation - Directorate General of CDC & EH IN0 PBD 001 RB Prevention of Blindness - Directorate General of Community Health IN0 PBL 002 VD Primary Eye Care IN0 CAN 001 RB Cancer Control - Directorate General of of Medical Care IN0 CVD 001 RB Cardiovascular Diseases - Directorate General of Medical Care IN0 HBI 001 RB Scientific Information Network and Health Information Support to the National Institute of Health Research and Development MALDIVES MAV MPN 200 RB Managerial Process for National Health Development MAV PHC 001 RB/ Strengthening of Health Services Delivery VI/VD System based on Primary Health Care MAV HMD 004 RB Development of Human Resources for Health MAV MCH 002 FP Strengthening of Family ~ealthl~hild Spacing Servces MAV CWS 001 RB Water Supply and Sanitation MAV MAL 001 RB Malaria and Other Vector-borne Disease Control MAV LEP 001 VD Leprosy Control MAV PBL 001 VD Primary Eye Care MAV HBI 001 RB Development of Health Literature and Library and Information Services MONGOLIA MOG HST 001 MOG MPN 200 MOG PHC 002 MOG HMD 005 MOG RPD 001 MOG ORH 001 MOG MCH 002 MOG MCH 004 MOG CWS 001 MOG CLR 002 MOG EDV 002 MOG DSE 001 MOG TRM 001 MOG EPI 001 MOG ARI 001 MOG TUB 001 MOG VPH 001 MOG OCD 001 MCG NCD 001 Development of National Health Information System for improving the Health Planning and Management Process Managerial Proceas for National Health Development Management of Health Services Human Resources for Health Development and Strengthening of Research Capabilities Research Promotion and Development, including Research on Health Promoting Behaviour Development of Oral Health Maternal and Child Health Strengthening of MCHIFP Services Strengthening of Environmental Health Services Development of Clinical Laboratory Services Development of Genetic Engineering Hepatitis B Vaccine (Prepatory assistance) Improvement of Drug Supply and Vaccine Control Development of Folk's Medicine Expanded Programme on Immunization Acute Respiratory Infections Control Tuberculosis Zoonoses Communicable Diseases Prevention and Control Noncommunicable Diseases Prevention and Control MMR HST 001 RB Health Information Services MMR HST 002 RB Epidemiological Surveillance of Communicable Diseases MMR MPN 002 RB/VD Health Services Planning and Management MMR MPN 200 RB Managerial Process for National Health Development HEIR HSR 001 RB MMR PHC 001 RB MMR PHC 003 RB MMR PHC 004 RB MMR PHC 005 DP MMR HMD 008 RB MMR HMD 009 RB MMR HMD 010 RB MMR HMD 011 DP MMR HMD 014 DP MMR HMD 016 DP MMR HMD 017 FP MMR HMD 018 VD MMR HMD 019 VD MMR HMD 020 RB MMR IEH 001 RB MMR RPD 001 RB/VG MMR RF'D 002 RB MMR RF'D 003 RB MMR NUT 002 RB MMR NUT 003 VD MMR ORH 001 RB MMR APR 001 RB MMR MCH 004 RB MMR MCH 005 FP MMR ADH 001 RB MMR OCH 002 RB MMR HEE 001 RB MMR ADA 001 FD MMR MND 001 RB MMR CWS 001 RB MMR RUD 001 RB MMR CLR 001 RB MMR EDV 001 VD MMR EDV 002 DP MMR EDV 003 VD MMR DSE 001 RB Health Systems Research Primary Health Care and Basic Health Services Hospital Services Management Supply System and Maintenance and Repair Workshop for Health Equipment Reinforcement of the Instrumentation Division (Workshop) of the Department of Medical Research Development of Procedures and Staff Training Development of Medical Education Methodologies for the Training and Orientation of Health Teams, including Physicians, in support of People's Health Programme Development of Human Resources for Health Planning and Manpower Development for Primary Health Care and Basic Health Services Strengthening of the Nursing Services Human Resources Development for the Institutes of Medicine and Dental Medicine Strengthening of the Departments of Obstetrics and Gynaecology of the Institute of Medicine Health Manpower Planning and Information System Work Study on Divisions and Sections of Department of Health HFA Leadership Development Development of Health Education Health Research in Support of People's Health Programme Research Training Programme Development of Research Infrastructure Nutrition WHOlUNICEF Nutrition Support Programme Primary Oral Health Care Accident Prevention Family Health Care Strengthening of MCH Services Development of Physical Health Workers' Health Health Care for the Elderly UN/Burma Programme for Drug Abuse Control, Treatment and Research Component - Phase I1 Community-oriented Mental Health Care Programme Environmental Health Planning and Management Urban Environmental Health Promotion of Health Laboratories Essential Drugs Programme Development of Hepatitis B Vaccine Essential Drugs Development of Production and Quality Control of Biologicals and Pharmaceutical Products MMR FOS 001 MMR TRM 001 m TRM 002 MMR RHB 001 MMR EPI 001 MMR VBC 001 MMR CDD 001 MMR ARI 001 MMR ARI 002 M?4R TUB 001 MMR LEP 001 MMR VDT 001 MMR GPA 001 MMR GPA 002 MMR PBD 001 MMR PBD 002 MMR CAN 001 MMR CVD 001 MMR NCD 001 MMR HBI 001 NEP ISS 001 RB NEP HST 001 RB NEP MPN 001 RB/VK NEP MPN 002 RB NEP MPN 200 RB NEP PHC 001 RB/FB NEP PHC 003 RB NEP HMD 005 RB NEP HMD 008 RB NEP IEH 001 RB Development of Food and Drug Control Infra- structure (Pre~aratorv assistance) standardization,' ~ha~colo~ical and Toxicologi- cal Evaluation of Traditional Drugs and Herbal Medicine Development of 'Traditional Medicine Manpower Community-oriented Programme for Disability Prevention and Rehabilitation Expanded Programme on Immunization Vector-Borne Disease Control Control and Prevention of Diarrhoea1 Diseases Acute Respiratory Infections Control Programme Acute Respiratory Infections Control Tuberculosis Control Leprosy Control and Research Activities Control of AIDS Prevention and Control of AIDS Control of AIDS and other Sexually Transmitted Diseases Trachoma Control and Prevention of Blindness Programme Prevention of Deafness Cancer Control Cardiovascular Diseases Prevention of Deafness Development of Library and Information Services Development of Informatics Facilities in Support of Health System Development of Epidemiological Surveillance and Information System Country Health Programming Health Planning and Programming and Health Information System Managerial Process for National Health Development Community Health Development and Development of Referral System through Primary Health Care Alternative Approaches to Primary Health Care Development of Human Resources for Health Development of Nursing Personnel Planning and Management Public Information and Education for Health NEP RPD 001 NEP NUT 003 NEP NUT 004 NEP APR 001 NEP MCH 003 NEP MCH 005 NEP MND 001 NEP CWS 001 NEP CWS 003 NEP CLR 001 NEP DSE 002 NEP TRM 001 NEP RHB 001 NEP EPI 001 NEP VBC 001 NEP MAL 001 NEP CDD 001 NEP ARI 001 NEP TUB 001 NEP LEP 001 NEP VPH 001 NEP GPA 001 NEP VDT 001 NEP OCD 001 NEP PBD 001 NEP NCD 002 NEP HBI 001 SRI LANKA Research Promotion and Development Nutrition WHOIUNICEF Nutrition Support Programme Accident Prevention Programme Maternal and Child Health including Family Planning Centre for Family Health Protection and Promotion of Mental Health, including Alcoholism and Drug Abuse Community Water Supply and Sanitation Training of Manpower for Drinking Water and Sanitation Programme (Phase 11) Development of Laboratory Services based on PHC Drug Policy, Legislation and Information Promotion of Traditional Medicine Community-based Rehabilitation Expanded Programme on Immunization Vector Biology Control Control of Malaria Control of Diarrhoea1 Diseases Prevention and Control of Acute Respiratory Infections Control of Tuberculosis Control of Leprosy Control of Zoonoses and Food Safety Prevention and Control of AIDS Prevention and Control of Sexually Transmitted Diseases, including AIDS Control of Other Communicable Diseases Prevention and Control of Blindness Prevention and Control of Deafness Prevention and Control of other Noncommunicable Diseases Prevention and Control of Deafness Development of Health Literature and Library and Information Services SRL HST 001 RB Strengthening of Health Information System SRL HST 002 RB Strengthening of Epidemiological Surveillance SRL HST 003 DP National Health Information System SRL MPN 001 RB Country Health Programming SRL MPN 002 RB Strengthening of Planning and Management SRL MPN 200 RB SRL PHC 101 RB SRL PHC 102 RB SRL PHC 103 RB SRL PHC 104 RB SRL PHC 105 RB SRL m 011 RB SRL HMD 012 RB SRL HMD 014 RB SRL HMD 017 DP SRL HMD 018 RB SRL HMD 019 RB SRL HMD 020 DP SRL HMD 101 RB SRL HMD 102 RB SRL HMD 103 RB SRL HMD 104 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 MCH 010 FP SRL OCH 001 RB SRL ADA 001 FD SRL ADA 002 DP SRL MND 001 RB SRL CWS 001 RB SRL CWS 002 RB SRL FOS 001 RB SRL CLR 001 RB Managerial Process for National Health Development Development of Primary Health Care - PHC Management and Intersectoral Coordination Development of Primary Health Care - Traditional Medicine Development of Primary Health Care - Referral Hospitals (Secondary) Development of Primary Health Care - Tertiary Hospitals Development of Primary Health Care - Biomedical Engineering Services Nursing Education Postgraduate Medical Education Development of National Institute of Health Sciences National Institute of Health Sciences - Phase I1 Development of Human Resources for Health Development of Human Resources for Forensic Medicine Development of Regional Training Centres in Collaboration with the National Institute of Health Sciences Undergraduate Medical Education - University of Colombo Undergraduate Medical Education - University of Ruhuna Undergraduate Medical Education - University of Peradeniya Undergraduate Medical Education - University of Jaffna Health Education Research Promotion and Development Nutrition Community Oral Health Development of a National Programme on Accident Prevention Development of Family Health Programme Strengthening Family Planning Services Workers' Health Prevention and Treatment of Problems Related to the Abuse of Drugs Drug Abuse Monitoring System Mental Health Community Water Supply and Sanitation Training in Public Health Engineering Food Safety Strengthening of Laboratory Services SRL EDV 001 RB/VD Essential Drugs and Vaccines SRL TRM 002 DP Developnent of Traditional Medicine - Phase I1 SRL RHB 001 RB ~omnunit~ariented Rehabilitation Services SRL EPI 001 RB/VI Exoanded Pronrarme on Imunization SRL VBC 001 SRL MAJ, 001 SRL CDD 001 SRL ARI 001 SRL TUB 001 SRL LEP 001 SRL VPH 002 SRL VDT 001 SRL GPA 001 SRL PBD 001 SRL PBL 002 SRL CAN 002 SRL CVD 002 SRL CVD 003 SRL HBI 001 THA HST 001 THA MPN 001 THA MPN 200 THA PHC 002 THA PHC 003 THA HMD 015 THA IEH 001 THA RPD 003 THA ORH 001 THA APR 001 THA TOH 001 THA MCH 010 THA MCH 011 THA OCH 001 - Disease Vector Control Malaria Control Control of Diarrhoea1 Diseases Control of Acute Respiratory Infections Tuberculosis Control Leprosy Control Accelerated Rabies Control Campaign Control of Sexually Transmitted Diseases Prevention and Control of AIDS Prevention of Blindness Primary Eye Care Prevention and Control of Cancer Prevention and Control of Cardiovascular Diseases Prevention of Rheumatic Fever/Rheumatic Heart Disease Development of Health Literature and Library Network Health Situation and Trend Assessment Development and Strengthening of the National Decentralized Management System - RTG/wHO Executive Committee Managerial Process for National Health Development Support of Community-based Self-Managed Primary Health Care Development Health Systems Reorientation and Development in Support of PHC Development of Human Resources for Health Public Information and Education for Health Research Promotion and Development, including Research on Health Promoting Behaviour Preventive Oral Health Services Prevention of Accidents Smoking and Health Expansion of Family Planning Services Maternal and Child Health, including Family Planning Workers' Health THA HEE 001 THA PSF 001 THA CEH 001 THA EDV 001 THA DSE 001 THA TRM 001 THA VBC 001 THA MAL 001 THA PDP 001 THA CDD 001 THA ARI 001 THA TUB 001 THA LEP 001 THA VPH 001 THA VDT 001 THA RDV 001 THA GPA 001 THA OCD 001 THA PBL 001 THA PBL 002 THA CAN 001 THA CVD 001 THA CVD 002 THA NCD 002 THA HBI 001 RB Health of the Elderly RB Paychosocial Factors in the Promotion of Health and Human Development RB Control of Environmental Health Hazards RB/VD Promotion of Easential Drugs - Distribution and Rationalization of Drug Uses at the PHC Level RB Development of Pharmaceuticals and Biologicals RB Traditional Medicine RB Disease Vector Control RB Malaria Control RB Control of Parasitic Diseases RB Prevention and Control of Diarrhoea1 Diseases RB Prevention and Control of Acute Respiratory 000 RCO 103 RE 000 EXM 001 RB ICP DGP 001 RB 000 GPD 001 RB ICP GPD 002 RB ICP COR 001 RB 000 COR 100 AS ICP HSC 001 RB 000 ISS 001 RB 000 HST 001 RB 000 HST 002 RB Infections Tuberculosia Leprosy Rabies Control Sexually-Transmitted Diseases Vaccines Research and Development AIDS Prevention and Control Programme Disease Prevention and Control Activities Primary Eye Care Prevention of Blindness Prevention and Control of Cancer Cardiovascular Diseases Prevention of Rheumatic Fever/Rheumatic Heart Disease Prevention and Control of Noncommunicable Diseases Health Information Support Regional Committees Executive Management Regional Director's Development Prog~aInUe General Programme Development Staff Development and Training Liaison with ESCAP Coordination with other Organizations Health-for-All Strategy Coordination Informatics Management Strengthening of Epidemiological Surveillance System National Health Information Systems Development 000 HST 100 000 MPN 001 ICP MPN 003 ICP PHC 002 ICP PHC 009 000 PHC 100 000 HMD 014 ICP HMD 016 ICP HMD 017 ICP m 018 000 HMD 100 000 IEH 001 ICP IEH 002 000 IEH 100 000 RPD 001 ICP RPD 002 ICP RPD 003 000 RPD 100 ICP NUT 005 ICP NUT 006 000 NUT 100 ICP MCH 011 000 MCH 100 ICP HEE 001 000 PSF 100 ICP ADA 001 000 CWS 001 ICP CWS 002 ICP CWS 004 ICP CWS 005 000 CWS 100 ICP RUD 001 RBI VD/VK RB RBI AS/ST Health Situation and Trend Assessment Managerial Process for Health Development Strengthening Health Managerial Capabilities Promotion of Health for All with Primary Health Care as Key Approach including Appropriate Technology for Health Intensification of Action Programme for Primary Health Care Organization of Health Systems Based on Primary Health Care Development of Human Resources for Health HFA Leadership Development RB Staff Development and Training DP Development of Health Learning Materials RB Development of Human Resources for Health RB Public Information and Education for Health RB Promotion of Health Education RB Public Information and Education for Health RB Research Promotion and Development RB Collaboration in Research Programme RB Institutional Strengthening for Research RB Research Promotion and Development, including Research on Health-Promoting Behaviour RB/FB/ Nutrition Monitoring and Evaluation VD/VG WHOIUNICEF Nutrition Support Programme Nutrition Regional Advisory Team on Maternal and Child HealthIFamily Planning Maternal and Child Health, including Family Planning Health Care of the Elderly Psychosocial and Behavioural Factors in the Promotion of Health and Human Development DANIDA Training Course on Prevention and Management of Drug Abuse through PHC Community Water Supply and Sanitation GTZIWHO Cooperation Project for International Drinking Water Supply and Sanitation Decade Building up of Information Services in Environmental Health in South-East Asia Promotion of Support for Women's Participation in the IDWSSD Community Water Supply and Sanitation Environmental Health in Rural and Urban Develop- ment and Housing ICP CEH 001 ICP CEH 002 Control of Environmental Pollutants and Hazards Safety and Control of Pollutants and Toxic Chemicals Food Safety Standardization of Diagnostic Material and Laboratory Practices Preparation of Immunological and Immunodiagnostic Reagents by Institutions in SEAR Introduction of Quality Standards and Appropriate Technology for Laboratory Services in Support of Primary Health Care Clinical, Idoratory and Radiological Technology for Health Systems based on Primary Health Care Development of Essential Drugs: Legislation and Quality Control Drug Policies and Management Technical Cooperation in Pharmaceuticals among ASEAN Countries Regional Training in Rabies Vaccine Production and Prevention and Control of Human and Canine Rabies Disability Prevention and Rehabilitation Rehabilitation ICP FOS 001 ICP CLR 001 ICP CLR 002 ICP CLR 003 000 CLR 100 ICP EDV 001 ICP EDV 002 ICP EDV 004 ICP DSE 001 ICP RHB 001 000 RHB 100 ICP EPI 001 000 EPI 001 ICP VBC 001 000 VBC 100 ICP MAL 001 Expanded Programme on Imunization Expanded Programme on Immunization ise ease vector Control Disease Vector Control Malaria Control and Coordination of Antimalaria Activities in the Region Monltoring Sensitivity of Malaria Parasites to Antimalarial Drugs Malaria Parasitic Diseases Control Control of Visceral Leishmaniasis Strengthening of Biomedical Research Capability Prevention and Control of Diarrhoea1 Diseases Prevention and Control of Acute Respiratory Infections Acute Respiratory Infections Programme - Operations Leprosy Control Prevention and Control of AIDS in Asia and the Pacific AIDS Prevention and Control Programme Prevention of Blindness and Deafness Prevention of Blindness Control of Blindness (Primary Eye Care) ICP MAL 003 000 MAL 100 000 PDP 001 ICP PDP 002 000 TDR 100 ICP CDD 001 ICP ARI 001 ICP ARI 002 ICP LEP 001 ICP VDT 001 ICP GPA 100 000 PBD 001 ICP PBL 002 ICP PBD 004 ICP NCD 001 RB/FB A Community-oriented Approach to the Prevention and Control of Noncommunicable Diseases ICP NCD 002 VD Prevention and Control of Deafness 000 HBI 001 RB/AS Health Information Support 000 HBI 002 RB Health Literature, Library and Information Services 000 PER 001 RB Support Services - Personnel 000 PGS 001 RB/AS General Administration and Services 000 BFI 001 RB/AS Support Services - Budget and Finance 000 SUP 001 RB/AS Equipment and Supplies for Member States
ANNEXES Annex 1 ORGANIZATIONAL STRUCTURE 1 FIELD PROORAMME