Volume 10, Number 2, 2006
REGIONAL HEALTH FORUM WHO South-East Asia Region
Regional Health Forum WHO South-East Asia Region
Volume 10, Number 2, 2006
REGIONAL HEALTH FORUM WHO South-East Asia Region
ISSN 1020 4237 © World Health Organization 2006 Publications of the World Health Organization enjoy copyright protection in accordance with the provisions of Protocol 2 of the Universal Copyright Convention. For rights of reproduction or translation, in part or in toto, of publications issued by the WHO Regional Office for SouthEast Asia, application should be made to the Regional Office for South-East Asia, World Health House, Indraprastha Estate, New Delhi 110002, India. The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the Secretariat of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. The views expressed in this publication are those of the author(s) and do not necessarily reflect the decisions or stated policy of the World Health Organization; however they focus on issues that have been recognized by the Organization and Member States as being of high priority. Printed in India
Editorial The main objective of the Regional Health Forum is the exchange of information and ideas on any aspects of public health. It is thus a platform where health professionals at all levels can express their views, observations and experiences rather than a scientific journal (although we do, of course, fully encourage submission of health research). We are currently examining possibilities to make the RHF more interesting and interactive. Such possibilities could include increasing the frequency of RHF issues (e.g. bringing it out every quarter); wider participation of and dialogue among readers, and devoting RHF issues to interesting and stimulating themes. Please, therefore, do not hesitate to send us your fresh ideas and contributions (addressed to editor@searo.who.int) in the form of articles or essays. These may be published in our new “Letters to the Editor” page. The next issue of the Forum will be devoted to the theme of World Health Day 2007 – Health and Security.
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Contents Communicable Diseases The Role of Traditional Medicine in the Treatment of Multidrug-resistant Pulmonary Tuberculosis, Myanmar Paing Soe, Than Lwin, Khin Chit, Thaw Zin and Ti Ti
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Noncommunicable Diseases Integrated Community-based Intervention against the Risk Factors for Noncommunicable Diseases − Early Lessons from the Demonstration Project Undertaken at Ballabgarh, India Anand Krishnan, Chandrakant S. Pandav, Suresh K. Kapoor, Jerzy Leowski
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Primary Health Care Capacity Assessment of the Primary Health Care System to Manage Reproductive Tract Infections Sanjay Chauhan, Arvind Mathur, Beena Joshi, Vikas Bhadoria 22
Comment Notes and News Publications Corner 35 41
Guidelines for Contributors
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Communicable Diseases The Role of Traditional Medicine in the Treatment of Multidrug-resistant Pulmonary Tuberculosis, Myanmar Paing Soe*, Than Lwin**, Khin Chit*, Thaw Zin* and Ti Ti*** Abstract Extracts of reputed medicinal plants used in Myanmar for treatment of suppurative lung disease were screened for in vitro activity on Mycobacterium tuberculosis (H37 RV strain). Plants showing satisfactory efficacy were further subjected to phyto-chemical characterization and acute and sub-acute toxicity testing before having approval from the National Ethical Committee, Department of Medical Research (Lower Myanmar). Five out of 11 medicinal plant extracts, coded as PTBOO2, PTBOO3, PTBOO5, PTBOO7 and PTBOO9, were found to possess significant in vitro anti-mycobacterial activity. Chemical screening did not indicate any presence of toxic organic constituents. Acute and sub-acute toxicity tests in mice and rats showed no significant abnormalities in biochemical, haematological and histopathological changes in both the control and the test groups. With due consideration to medical ethics in human trials, the above-mentioned five promising plant extracts were allowed for clinical trials, on selected culture-proven multidrug-resistant tuberculosis (MDR-TB) patients from the Aung San Tuberculosis Hospital who had not shown satisfactory response to the routinely-administered second-line anti-TB drugs up to a minimum of two years. Also, for ethical reasons, the plant extracts were only allowed to be given in addition to the second-line anti-TB drugs already being administered (kanamycin, thiacetazone or quinolones), to which the patients had shown no response. A dose-finding study was conducted, starting from the minimal dose used by traditional practitioners, and slowly increasing it to its maximum tolerable level. All plant extracts were found to be well tolerated and all patients showed significant improvement after three to 12 months of treatment. This study indicated that the reputed indigenous medicinal plants of Myanmar can become potentially valuable anti-TB drugs in the future.
Introduction Over the last decade, interest in drugs of plant origin and their use in various diseases has increased in many industrialized countries since plants used in traditional medicine are more likely to yield pharmacologically active compounds than developing new drugs synthetically1. Myanmar uses a large number of traditional medicinal plants for the
treatment of various diseases including infectious diseases. Among these are plants with a long history of use and reputation of having beneficial effect in the treatment of respiratory symptoms, especially suppurative lung diseases2-5. Tuberculosis (TB) is a major health problem in developing countries6. Since tubercle bacilli readily develop drug resistance
* Department of Medical Research (Lower Myanmar), Yangon, Myanmar ** Aung San Tuberculosis Hospital, Department of Health, Yangon, Myanmar *** Reference Laboratory, Union Tuberculosis Institute, Department of Health, Yangon, Myanmar Regional Health Forum – Volume 10, Number 2, 2006 1
with monotherapy, drug combination regimens have to be used in the treatment of TB. The disease had been controlled in developed countries since the introduction of rifampicin in 1966, but its association with HIV infection caused its resurgence7. In 1991, the outbreak of multidrug-resistant TB (MDR-TB) alarmed the global population as a result of which WHO declared TB a global emergency. MDR-TB became resistant to at least two major drugs – isoniazid and rifampicin – and thus, little chance of survival was to be expected without appropriate treatment8. Treatment of MDR-TB with second-line and newer drugs is both difficult and less cost-effective. Compared to the first-line drugs, they are inferior in efficacy, more toxic, and have to be given for at least three times as long and at a hundred times the cost of basic short-course chemotherapy regimens. Since the impact of TB is greatest among the poor, their compliance to treatment remains highly questionable9 and most eventually seek alternative regimens, including traditional medicine10. Although MDR-TB, in most cases, was assumed to be a sign of poor programme performance, one must also be aware of the highly virulent strains spreading rapidly. Susceptibility-testing for second-line anti-TB drugs has not yet been standardized. It therefore needs to be systematically evaluated for individual clinical management and outcome in developing countries9,11. Recently, the finding regarding in vitro efficacy of traditional medicines in Myanmar against Mycobacterium tuberculosis has sparked new hopes for treatment of MDR-TB since drugs derived from traditional medicinal plants are less expensive and readily available locally12-14. The principal objectives of the present study were to: • Conduct in vitro efficacy screening for anti-mycobacterial activity of reputed medicinal plants in Myanmar which are used for the
treatment of suppurative lung diseases, and • Select and conduct controlled clinical trials on multidrug-resistant pulmonary tuberculosis patients at the Aung San Tuberculosis Hospital, using extracts of these plants showing satisfactory in vitro efficacy.
Material and methods Preparation of plant extracts Specified parts from the reputed 11 plants (001 to 011) were dried and powdered before they were extracted with 50% alcohol. The plant extracts were coded as PTB-001 to PTB-011 as shown in Table 1. Table 1: Preparation of plant extracts No. 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. Plants extracts PTB-001 PTB-002 PTB-003 PTB-004 PTB-005 PTB-006 PTB-007 PTB-008 PTB-009 PTB-010 PTB-011 Part of plant used Fruit Bark Leaf Whole Plant Rhizome Leaf Rhizome Whole Plant Rhizome Whole Plant Leaf
In vitro testing for anti-mycobacterial activity Sputum of smear-positive pulmonary TB patients was collected for culture and sensitivity testing15,16.
Preparation of drug/plant extract medium The drug/plant extract medium (PEM) was a mixture of drug solution with 1% plain Ogawa medium. The drug solutions in differ-
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ent dilutions included plants’ extracts (10−150 µg/ml), isoniazid (0.1−5.0 µg/ml), rifampicin (10−60 µg/ml) and control (no drug).
Resistant strains Resistant strains were those showing nonpigmented, buff-coloured cauliflower growth with a positive niacin test and resistant to 5 µg/ml isoniazid and 60 µg/ml of rifampicin.
Cultivation of mycobacterium and testing of activity on tubercle bacilli Sufficient quantities of mycobacterium colonies from the growth were cultivated from the sputum specimen and prepared into bacillary suspension of 1 mg/ml concent-ration. Further dilutions were made using distilled water and 0.1 ml of 0.01 µg/ml bacillary suspension, which were then introduced into each of the Ogawa media comprising 103−104 viable units. All test samples were then kept at 37 °C in a dark room. Reading of acid-fast bacilli was carried out after three to four weeks when countable colonies had appeared on drug-free media (control). The growth was recorded as: (−) = No growth (+) = 1-200 colonies (++) = One half of the medium was covered with partially confluent growth (corresponding to 200−500 colonies) (+++) = Three quarters of the medium were covered with almost confluent growth (approximately 500−2000 colonies) (++++) = The medium was covered entirely with confluent growth (2000 colonies or more).
Chemical screening The chemical screening of plant extracts was carried out using standard methods14,15. The procedure involved detection of organic constituents such as alkaloids, tannins, flavanoids, saponins, quinones and triterpene steroids.
Acute toxicity study A total of 30 albino mice of ddY strain (15 males and 15 females) weighing 30-35 g were fasted overnight. Water was allowed ad libitum. They were divided into three groups of 10 (five males and five females). Two drug dose levels of each plant extract − high (100 times the human dose) and low (50 times the human dose) – were selected for calculation of LDs. Five plant extracts (Table 2) were administered orally, both separately and in combination. The mice were continuously observed, and their behavioural responses recorded after 48 hours, and thereafter once daily until the 14th day.
Sub-acute toxicity study A total of 18 rats (Wister strain; nine males and nine females), weighing 200−250 g were subjected to sub-acute toxicity testing. They were divided into three groups of six (three males and three females). Two drug dose levels of the combination of five plant extracts (Table 2) were administered orally. The rats were continuously observed and their behavioural responses and toxic symptoms recorded daily for three months.
Criteria for sensitive and resistant strains of Mycobacterium tuberculosis Sensitive strains Sensitive strains were considered to be those showing non-pigmented, buff-coloured, cauliflower growth with a positive niacin test and susceptible to 0.1 µg/ml of isoniazid and 10 µg/ml of rifampicin.
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They were then sacrificed humanely and blood samples and internal organs collected for haematological, biochemical and histological examinations.
• Agreed to sign an informed consent, and • Agreed to be admitted to the Aung San TB hospital for a specified duration. Exclusion criteria • Patients with other conditions such as HIV, corpulmonale, diabetes mellitus, chronic renal failure, cirrhosis of the liver, valvular heart disease and heart failure, and • Pregnant or lactating women. Withdrawal criteria • Subjects without regular follow-up or compliance to protocol specifications, and • Any uncontrollable or serious adverse effects to drugs. Ethical approval was obtained from the "Ethical Committee on Medical Research involving Human Subjects"; Letter No. ii/Ethics 2000, Department of Medical Research (Lower Myanmar), Yangon, Myanmar, 3 August 2000.
Clinical trial of five medicinal plants from Myanmar on MDR-TB patients Preparation of plant drug Five of the 11 plant extracts (PTB 002, PTB 003, PTB 005, PTB 007 and PTB 009), which showed significant anti-mycobacterial activity, were chosen for the clinical trial. All plants were collected from a pre-defined area and identified by a competent botanist. They were all extracted and subsequently formulated into tablet form (Figure 1). Table 2: The dose levels of plant extracts used for the sub-acute toxicity study No. 1. 2. 3. 4. 5. Plants PTB 002 PTB 003 PTB 005 PTB 007 PTB 009 50 times human dose 1.5 g/kg 1.5 g/kg 0.6 g/kg 0.2 g/kg 0.75 g/kg 25 times human dose 0.75 g/kg 0.75 g/kg 0.3 g/kg 0.1 g/kg 0.375 g/kg
Baseline data Subject selection Fifteen MDR-TB patients admitted to the Aung San TB Hospital, who had remained sputum-positive for two to four years in spite of appropriate treatment with both the firstand the second-line anti-TB drugs, were selected according to the following criteria: Inclusion criteria • Culture-proven MDR-TB/polyresistant TB/chronic TB; • Males and non-pregnant females; • Age range between 15 and 60 years; Standard history, clinical examination and appropriate laboratory investigations were carried out on all subjects, including a complete blood examination; liver function tests; and urea, creatinine, sugar and electrocardiogram (ECG) tests. All patients were monitored closely. Direct sputum-smear examination for acid-fast bacilli (AFB), bodyweight, and erythrocyte sedimentation rate were conducted. Chest X-rays were checked every three months, while AFB culture was conducted after nine months of treatment. All investigations were repeated after regular intervals until the completion of the trial (two years).
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Criteria for improvement Major criteria 1. Negative direct smear for AFB; 2. Radiological improvement, and 3. Negative sputum AFB culture at the end of treatment.
Results Anti-mycobacterial activity of medicinal plants Fifty samples of plant extracts (10 each for five different concentrations) were tested in each batch. The experiments were repeated three times, amounting to 150 samples being tested for each plant extract (Table 3).
Minor criteria Clinical improvement and feeling of wellbeing as scored by the patient in the questionnaire assessment.
Chemical screening Chemical screening of plant extracts revealed the presence of alkaloids, flavanoids, triterpene steroids, quinones, tannins and saponins. Results of the screening are shown in Table 4.
Trial implementation Phase I During this phase the outcomes of MDR-TB patients treated either with kanamycin (750 mg), ofloxacin (400 mg), thiacetazone (150 mg) or chlofazimine (200 mg) were compared with the regimens comprising isoniazid (300 mg), rifampicin (450 mg), pyrazinamide (1500 mg) and ethambutol (800 mg). These second-line anti-TB drugs are standard, and given routinely for MDR-TB because they are readily available and affordable for most patients.
Acute toxicity test Neither of the dose levels of the combination of 95% alcoholic extracts of the 11 plants produced any mortality in the mouse model, when observed up to 14 days of drug administration. Furthermore, the extracts of the five plants showed no significant in vitro antimycobacterial mortality or side-effects.
Sub-acute toxicity test Neither dose levels of alcoholic extracts of medicinal plants administered orally produced any mortality in the rat model when administered over three months. There were no apparent signs of toxicity (toxic symptoms) in the control or test group. Also, there were no significant changes in the per cent weight gain in either the control or test group. Haematological parameters were within normal limits in the three groups examined. Biochemical parameters indicated no significant abnormalities in urea and creatinine, or ALT and AST values, in the control and test groups. The weight of vital organs was within normal limits and both gross and histopathological examinations of the organs did not indicate any significant abnormalities.
Phase II This phase included a prospective study on 15 MDR/Category II failure patients. These patients were treated with five plant extracts, which were combined with the three least expensive of the western drugs (kanamycin, ofloxacin and thiacetazone) readily available under the National TB Programme. The total duration of treatment before the final assessment was two years. The dose levels of plant drugs administered to MDR-TB patients comprised PTB 002 at 3 g/day; PTB 003 at 3 g/day; PTB 005 at 1.2 g/day; PTB 007 at 400 mg/day, and PTB 009 at 1.5 g/day.
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Table 3: Growth of Mycobacterium colonies in tested media (sensitive and resistant strains) Drug and plant extracts Isoniazid Rifampicin PTB 001 PTB 002 PTB 003 PTB 004 PTB 005 PTB 006 PTB 007 PTB 008 PTB 009 PTB 010 PTB 011 ++ − − Sensitive strains 0.1 µg − 1 µg − 5 µg − − ++++ ++ +++ ++++ +++ ++++ ++++ +++ ++++ ++++ ++++ + ++ ++++ ++ ++++ − ++++ ++ ++++ ++++ ++++ − − ++++ − ++++ − ++++ + ++++ ++++ − ++++ − − ++++ − ++++ − ++++ − ++++ ++++ ++++ − − ++++ − ++++ − ++++ − ++++ ++++ 10 µg 25 µg 50 µg 60 µg 100 µg 150 µg
Resistant strains Isoniazid Rifampicin PTB 001 PTB 002 PTB 003 PTB 004 PTB 005 PTB 006 PTB 007 PTB 008 PTB 009 PTB 010 PTB 011 + − − +++ +++ ++ ++ ++ ++++ ++ +++ ++++ +++ ++++ − ++++ +++ ++++ ++++ ++++ + ++ ++++ ++ ++++ − ++++ ++ ++++ ++++ ++++ − − ++++ − ++++ − ++++ + ++++ ++++ ++ ++++ − − ++++ − ++++ − ++++ − ++++ ++++ ++++ − − ++++ − ++++ − ++++ − ++++ ++++
(–) = no growth; (+) = 1−200 colonies; (++) = 200−500 colonies; (+++) = 500−2000 colonies; (++++) = more than 2000 colonies
Clinical trial of medicinal plants on MDR-TB patients The trial was conducted on 15 MDR pulmonary tuberculosis patients attending the Aung San Tuberculosis Hospital who showed persistent positive sputum smear for two to four years in spite of proper treatment with both the first- and second-line anti-TB drugs. All patients were given five plant extracts for two years, in addition to the standard and rou6
tinely administered second-line western antiTB drugs to which no satisfactory response had been seen. Table 5 shows the treatment outcome of 21 MDR-TB patients in Phase 1 treated exclusively the first- and second-line western antiTB drugs, one of which showed a curative response.
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Table 4. Results of chemical screening of active plant extracts Name of plant PTB 001 PTB 002 Type of extract Alcohol H 2O P. Ether CHCL3 Alcohol H 2O P. Ether CHCL3 Alcohol H 2O P. Ether CHCL3 Alcohol H 2O Alcohol H 2O P. Ether CHCL3 Alcohol H 2O Alcohol H 2O Alcohol H 2O Alcohol H 2O Alcohol H 2O Alkaloids − − + + + − + + + − + + + − + + + + + − + + + − + + + − Flavanoids + − + + − − − + + − + + − − + + − + + − − − + + + + − − Triterpene steroids + − + + + − + + + − + + + − + + + + + − − − − − + + + − Quinones − − + − ~ − − − − − + − ~ + + − + − − − + + − − − − Tannins + + + + + + + + + + + + + + + + + + + + + + ~ ~ + + − + Saponins − − ~ ~ ~ − ~ ~ ~ + ~ ~ ~ − − − ~ ~ ~ − + + + + + + + +
PTB 003
PTB 005
PTB 006 PTB 007
PTB 008 PTB 009 PTB 010 PTB 011
(+) = detected; (–) = not detected; (~) = not done
Table 5: Treatment outcome of MDR patients treated exclusively with western medicine in a retrospective study Previous regime HRZE “ “ “ “ Added drugs Thiacetazone Ofloxacin Thiacetazone + ofloxacin Clofazemine + ofloxacin Clofazemine + ofloxacin + kanamycin Ofloxacin + thiacetazone + kanamycin Total patients Number of patients 1 5 8 1 5 Outcome Failed 1 5 8 1 4 Cured 0 0 0 0 1
“
1
1
0
21
20
1
The Phase II trial consisted of two groups of subjects (Table 6). The first group consisted of eight patients who were treated with plant extracts combined with quinolone, thiacetazone and kanamycin for two years. Six of these patients completed the treatment and remained sputum-negative at the end of the trial. One patient expired after one year and another failed to show a satisfactory response after two years of treatment. The second group consisted of seven patients who were treated with plant extracts combined with quinolone and kanamycin also for two years. Five patients completed the treatment and remained sputum-negative at the end of the trial. The other two patients were only treated for five to six months and thus could not be assessed. All patients tolerated
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the treatment regimen well with no serious side-effects. Table 6: MDR/Cat II failure patients treated with western medicine and five plant extracts Western drugs Thiacetazone + kanamycin + quinolone Number of patients assessed 8 Duration of therapy Two years Remark
already reported to possess anti-mycobacterial activity in vitro17. However, no reports are available for the plant extracts tested in the present study. In the Phase II trial conducted at the Aung San Tuberculosis Hospital, 13 out of 15 patients who had received full doses of the five plant extracts, had sputum conversion to negativity after three months of treatment and remained negative throughout the trial period of two years. Since these patients had shown no satisfactory response to full treatment with the second-line anti-TB drugs, the outcome seen in the present study could be attributed at least to the efficacy of the added plant drugs. The two patients who did not show a satisfactory response, may be due to a sub-optimal dosage during the dose-finding period or to the higher virulence of the strains in these patients, but this will need further verification. This is the first extensive scientific report on the anti-mycobacterial properties of reputed medicinal plants from Myanmar which have been tested according to the required phases of traditional drug development guidelines in Myanmar21,22. Although further in-depth evaluation and multi-centre clinical trials may be needed before the therapeutic utility of these plants becomes fully established, their efficacy in respect of clinical and laboratory parameters is such that the Aung San Tuberculosis Hospital will seriously consider this form of integrated treatment on seemingly hopeless MDR-TB patients. Weight gain, and feelings of well-being and satisfaction as a result of treatment were acknowledged by all patients, even those showing comparatively slow or little response to treatment. The study included some patients who were highly educated and financially stable, and who had been disappointed with their previous treatment with the second-line antiTB drugs.
Six patients – sputumnegative One patient failed One patient died
Clofazemine + kanamycin + quinolone
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Two years
All seven patientssputum conversion after three months
Discussion Drugs such as ethionamide, cycloserine, amikacin/kanamycin and ofloxacin are unaffordable for most patients in a developing country like Myanmar11. The current trend therefore points to an increasing use of medicinal plants for treatment of various diseases. Myanmar is one of the countries in the WHO SEA Region which has a large number of traditional medicinal plants. But even with reputed plants, scientific evaluation is essential. In the present study, all biologically active extracts showed anti-mycobacterial property at specific concentrations. Generally, plant extracts using polar solvent media such as chloroform or alcoholic extracts, were found to possess significant biological activity13-15. Some medicinal plants tested for anti-mycobacterial activity were found to be effective even on multidrug resistant strains of AFB which indicated the potential role of medicinal plants in MDR-TB13. Essential oils of Alpinia galanga and Acarus calamus are 8
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The present study did face a problem in recruiting eligible MDR-TB patients fulfilling the entry criteria. The prolonged period of study; admission period; frequency of followup visits and tests, and strict protocol specifications made some less educated and financially unstable patients reluctant to join the study. Some of these patients, when explained the protocol and requirement regarding their informed consent to join the study, felt that herbal medicines were to be administered as a last resort for hopeless cases. Only after experiencing clinical improvements did they realize the efficacy of these medicines. These findings indicate the need for education, counselling and socio-
economic studies to integrate western and traditional medicine towards a common goal.
Conclusion The present study indicates that traditional medicines from Myanmar could be of great value as adjunct therapy in MDR-TB cases. They may even find a place as alternatives to extremely expensive drugs like macrolides and beta-lactam antibiotics. However, longterm studies and follow-up observations for relapses are mandatory before their role in treating MDR-TB can become fully established.
References 1. World Health Organization Regional Publications (1990). Medicinal Plants in Viet Nam. Institute of Materia Medica, Hanoi. WHO Regional Office for the Western Pacific, Manila, Philippines. Ministry of Agriculture, Yangon, Myanmar, Burmese Medicinal Plants, 1980: 205-208, 257, 260, 411-417. Translation of Ashin Naga-thein Bi-Wuntha's Compilation of Myanmar-Ayuveda Medicinal Plant Atlas/illustrations, past and present era, extracted from Materia medica Say A-bidan, Thetka-ta Scripts. Volume 2, Mingalar Press, Kandaw-galay, Yangon, 1956. Translation of U Mya Win. Thawda Win's Medicinal uses of vines, shrubs and Plants, text and illustrations, Baya-say-abidan, volume 1-3, December, 1964. San Khin. Some medicinal and useful plants by indigenous and exotic of Burma. Ed. Thiripyanchi U Tha Myat, Published by Khin Khin Aye, 120th Street, Yangon, Myanmar, 1970, 2-9. Dolin PJ, Roviglione MC, Kochi A. Global tuberculosis incidence and mortality during 19902000. Bulletin of World Health Organization, 1994, 72: 213-220. WHO, TB/92.164. (1992). HIV-associated tuberculosis in developing Countries. Epidemiology and strategies for prevention. Tuberculosis Programme and Global Programme on AIDS. Geneva, Switzerland. WHO, TB/92.167. (1992). Report of a WHO review and Planning meeting. Tuberculosis Programme and Global Programme on AIDS. Geneva, Switzerland. 9. Pectro Guillermo-Suarez. First required for Control of multi-drugs-resistant TB. Bulletin of WHO2002 80(6): 496. Marcos A, Spinal Z & Zaleski R. TB Control and access to second line drugs: better model needed. Bulletin of WHQ_2002, 80 (6): 495. Than LWin, Ti Ti & Saw Aung. Study of Primary and acquired anti- TB resistant state among patient of U. T.I. Programme and Abstracts, Myanmar Health Research Congress 1992, P 21. Khin Chit. Antimycobacterial activity of biologically active Plants Desmodium triquetrum. MMedSc (Pharmacology), Thesis, Institute of Medicine (1) Yangon,' 1996: Lwin-Ko, Hla-Naing, Ti Ti, Thaung Nyunt. In-vitro activity of Azadtrachta indica on mycobacterium tuberculosis and animal toxicity study. Journal of Myanmar Military Medicine, 1994, 003(2): 5-7 Ti Ti, Lwin Ko, Khin Chit, Win Myint, Than Swe, Aung Naing, Hla Naing & Sein Kyi. In- vitro sensitivity of Azadirachta Indica extract on Mycobacterium tuberculosis. Program and Abstracts, Myanmar Health Research Congress 1995, PP 9. Fujiki A. Japan Anti-tuberculosis Association, Ogawa and Lowenstein-Jensen Media, Illustrated Tuberculosis Examination Procedure 1993: 32. Fujiki A. The Japan International Co-operation Agency preparation of egg medium (Ogawa medium). Minimal Essential Laboratory Procedure for Tuberculosis Control 1986: 48. Pablos-Mendez A, Decpthiman K, Gowda T, Frieden R. Controlling multi-drug resistant tuberculosis and access to expensive drugs: a rational
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framework. Bulletin of WHO, 2002, 80(6): 489494 18. Ikhin K, Bouremia D, Dankoulodo D. Chemical screening of medicinal plants used in the traditional pharmacopoeia of Niger. International Journal of Pharmacognosy 1992, 3(4): 251-262. UNDP/MYA/81/O28 and WHO-TRM/MED (1989). Myanmar Traditional Medicine Formulary. Pharmacology Research Division, Department of Medical Research, Yangon, Myanmar, p 45-47. Chopra IC, Khajuria BN, Chopra CL. Antibacterial properties of volatile principles from Alpinia galanga and Acorus calamus. Antibiotic Chemotherapy 1957; 7: 378.
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MOH/DMR(LM)/DTM. General guidelines for research and evaluation of traditional medicine in Myanmar (Draft report). Committee on Pharmacological and Toxicological Evaluation of Traditional Remedies, Department Traditional Medicine and Department of Medical Research (Lower Myanmar), Yangon, 2002. Government of Union of Myanmar/UNDP/ WHO. Report of the Joint Evaluation Mission of the Government of Myanmar/WHO/UNDP on the project, "Standardization, Pharmacological and Toxicological Evaluation of Traditional Medicine Formulations used in Myanmar", April 1991.
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Noncommunicable Diseases Integrated Community-based Intervention against the Risk Factors for Noncommunicable Diseases − Early Lessons from the Demonstration Project Undertaken at Ballabgarh, India Anand Krishnan*, Chandrakant S. Pandav**, Suresh K. Kapoor** and Jerzy Leowski***
Abstract Despite the increasing burden of noncommunicable diseases (NCDs) in WHO’s South-East Asia (SEA) Region due to changing lifestyles, community-based interventions and health promotion efforts with regard to their risk factors have not kept pace. In order to generate evidence on the effectiveness of community-based interventions and to learn lessons related to their implementation, a demonstration project was initiated in Ballabgarh, India in January 2004. This paper describes the experience gained and the lessons learnt during the the first two years of the project. A coalition of community members called “Friends of City” was formed. Schools and industries were identified as the prime stakeholders of interventions along with others that included private and public health sectors, nongovernmental organizations (NGOs), traders and the media. A survey was conducted to document the baseline levels of risk factors, the results of which were shared with all stakeholders. Furthermore, an educational “Live healthy” campaign was launched with the help of all involved. Regular meetings are organized by the “Friends of City” team to review the progress of the project and plan its activities. The challenges being faced include leadership; development of ownership by the community; building on previous efforts to guide on technical issues; linkages with other interventions, and mobilization of resources for the campaign. In this context, a process and impact evaluation will guide future orientation of the project.
Introduction Chronic noncommunicabe diseases (NCDs) contribute to a high proportion of deaths and disability globally. In the South-East Asia (SEA) Region of the World Health Organization, they accounted for 51% of deaths and 44% of the disease burden in 2002. Based on available trends, by the year 2020
NCDs are predicted to account for 73% of deaths and 60% of the disease burden.1 It is estimated that in India, coronary heart disease cases will double to about 61million cases in 2015. Similar forecasts have been made for stroke and diabetes.2,3 The socioeconomic burden of these diseases is also poised to increase concomitantly.2
*Associate Professor, Centre for Community Medicine, All India Institute of Medical Sciences, New Delhi, India; E-mail: kanandiyer@yahoo.com/anand.drk@gmail.com; Telephone: 91-11-26594253; Fax: 91-11-26589815 ** Professor and Head ** Former Professor
****Regional Adviser, Noncommunicable Diseases, World Health Organization, Regional Office for South-East Asia, New Delhi, India
}
Centre for Community Medicine, All India Institute of Medical Sciences, New Delhi, India
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Most of the increase in NCD cases will result from an increasing life expectancy at birth, a reduction in the number of cases of communicable diseases and changing lifestyles. Behavioural risk factors such as tobacco use, alcohol consumption, low consumption of fruit and vegetables and a lack of physical activity lead to the intermediate risk factors such as obesity, hypertension, raised blood glucose and cholesterol levels, and contribute to cardiovascular diseases, cancer, chronic lung diseases and diabetes
mellitus. The World Health Report 2002 reiterated the evidence available on preventability of NCDs through risk factor reduction and health promotion. Even a modest reduction in the population-level risk factors through adoption of more healthy lifestyles could bring about a huge public health benefit. The Report revealed that five of the top ten global risk factors to health are high blood pressure; high cholesterol; alcohol consumption; tobacco use, and obesity.4
Box 1. Misunderstandings about noncommunicable diseases 1. NCDs mainly affect high-income countries. The reality is that four out of five chronic disease deaths are in lowand middle-income countries. 2. Low-and middle-income countries should control infectious diseases before NCDs: In reality, low- and middle-income countries are at the centre of both old and new public health challenges. While they continue to deal with the problems of infectious diseases, they are experiencing a rapid upsurge in NCD risk factors and deaths, especially in urban settings. These risk levels foretell a devastating future burden of NCDs in these countries. 3. NCDs mainly affect rich people: The truth is that in all but the least developed countries of the world, poor people are much more likely than the wealthy to develop NCDs, and are more likely to die as a result. Moreover, NCDs cause substantial financial burden, and can push individuals and households into poverty. 4. NCDs mainly affect old people: We now know that almost half of chronic disease deaths occur prematurely. One quarter of all chronic disease deaths occur in people under 60 years of age. 5. NCDs primarily affect men: The truth is that chronic diseases, including heart disease, affect women and men almost equally. 6. NCDs are the result of unhealthy “lifestyles”: Many people believe that if individuals develop a disease, they have no one to blame but themselves. The truth is that individual responsibility depends on equitable access to a healthy life and healthy choices. Governments have an important role to play in improving the health and wellbeing of populations, and in providing special protection for vulnerable groups. This is especially true for the poor children who cannot choose the environment in which they live, their diet and their passive exposure to tobacco smoke. They also have limited access to education and health care. 7. NCDs cannot be prevented: Some people believe that there is nothing that can be done, anyway. In reality, the major causes of NCDs are known, and if these risk factors are eliminated, at least 80% of all heart diseases, stroke and type 2 diabetes can be prevented; over 40% of cancer cases are preventable. 8. NCD prevention and control is too expensive: Some people believe that the solutions for NCD prevention and control are too expensive for low-and middle-income countries. In reality, a full range of NCD interventions are very cost-effective. Many of these solutions are also inexpensive to implement. 9. “My grandfather smoked and was overweight - and he lived to 96”: In any population, there will be a certain number of people who do not demonstrate the typical patterns seen in the vast majority. 10. “Everyone has to die of something”: Certainly yes, but death does not need to be slow, painful, or premature. Most NCDs are likely to cause people to become progressively ill and debilitated, especially if their illness is not managed correctly. Death is inevitable, but a life of protracted ill-health is not. NCD prevention and control helps people to live longer and healthier lives.
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However, efforts for prevention of NCDs have not taken off in most countries of the SEA Region. The reasons for this are many and include: continued preoccupation with the unfinished agenda of maternal and child health and communicable disease control; misconceptions related to NCDs (See Box 1), and inadequate evidence on the feasibility and effectiveness of prevention strategies. This is especially true in developing countries where local evidence is lacking and appropriateness of models used by developed countries for community-based interventions is justifiably questioned. The WHO Global Strategy for the Prevention and Control of Noncommunicable Diseases recommends the establishment of pilot prevention programmes using an integrated risk factor approach. This is based on the fact that unhealthy behaviours are very common and deeply rooted in the community – in its social, cultural and economical environments. Thus addressing the determinants of ill-health and their risk factors in the community should supplement a generally practised but less cost-effective approach of identifying and treating individuals at the highest risk. The aim is to work together with the community to change the community, so that healthier behaviours become easier, more natural and therefore more sustainable.5 Community-based interventions for NCDs have been attempted with variable success in developed countries. These provide important lessons for developing countries.6 Community-based intervention projects have been initiated with WHO support in several countries of the SEA Region. This paper documents the experience in India and shares some of the lessons learnt during the early phase of intervention.
intervention for an integrated prevention of major NCDs.
Project area Ballabgarh block of district Faridabad, near New Delhi (Fig. 1) The total population of Faridabad district in the state of Haryana is two million with a sex ratio of 839 females per thousand males. The population density of Faridabad district is 1020/sq. km. The urban block of Ballabgarh had a population of about 145 000 as recorded in the census of 2001. It is mainly an industrial and a trading town. The primary health concerns of the government continue to be prevention and control of communicable diseases and provision of maternal and child health services. The intervention project was facilitated by the Comprehensive Rural Health Services Project, a project run by the All India Institute of Medical Sciences, New Delhi in collaboration with the State Government of Haryana. The project runs a sixty-bed secondary-level hospital in Ballabgarh and provides outpatient, inpatient and emergency services.
Pilot phase This covered the period 2001- 2002 and was conducted in an urban colony of Ballabgarh with an estimated population of 35 000. The objective of the pilot phase was two-fold. The first was to pilot-test the protocol in order to measure the level, prevalence and pattern of select, modifiable risk factors for NCDs, and the second was to assess the acceptability and readiness of the community for a community-based intervention against NCD risk factors. The experience of the pilot phase of projects implemented in Ballabgarh as well as in two other areas (one each in Bangladesh and Indonesia) was discussed at a consultation meeting organized by the WHO Regional Office, New Delhi, which recommended that the Demonstration Phase be started.7
Objective of the project The objective of the project was to explore the feasibility of mobilizing civil society, the administration and other local partners to plan, initiate and sustain a community-based Regional Health Forum – Volume 10, Number 2, 2006
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Fig. 1: Site of the demonstration project on community-based intervention in Ballabgarh, India
Demonstration phase The aim of this phase was to evolve and execute a model for a community-based intervention for NCD risk factor control in urban Faridabad with the long-term goal of empowering the community to take over NCD prevention and control a routine activity. This phase lasted for two years from July 2003 to June 2005.
levels of risk factors were estimated using the Faridabad urban census 2001 population structure. The summary of results for urban Ballabgarh are shown in Table 1. The results of the survey have been shared with the district and block-level administrative and health authorities and also with the community.
Identification of stakeholders The relevant stakeholders were identified by the intervention team. These included educational institutions (schools/colleges), industries, nongovernmental organizations, trader organizations, government and community members, women groups and public and private health sectors. The activities undertaken with each stakeholder are briefly discussed below and summarized in Table 2.
Baseline survey A baseline cross-sectional study of NCD risk factors was carried out from April 2003 to January 2004 in Ballabgarh Block of Faridabad district. The survey methodology was based on the WHO STEPS approach.8 A total of 5151 individuals aged 15-64 years were randomly selected for the study with approximately equal numbers from slums and non-slum areas. The population
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Table 1: Summary of age-adjusted* NCD risk factor levels in population aged 15-64 years in urban Ballabgarh Block, Faridabad Variable Area Prevalence of current daily smoking Prevalence of smokeless tobacco use Prevalence of current (last one year) alcohol consumption Percentage consuming >5 servings of fruits and vegetables/day Prevalence of physical inactivity (not doing moderate or vigorous activity at all) Percentage reporting more than 150 min. exercise per week Mean body mass index (BMI) Prevalence of overweight (BMI>25) Prevalence of overweight (BMI>23) Mean waist circumference (WC) Prevalence of central obesity (WC >102 cm for males and >88 cm for females) Mean systolic blood pressure (BP) Mean diastolic BP Prevalence of hypertension (≥140/≥90) Urban slum 36.5% (33.7-39.1) 10.2% (8.5-11.9) 25.9% (23.5-28.3) 7.9% (6.3-9.3) 14.8% (13.9-17.9) 67% (64.9-69.5) 20.9 (20.6-21.1) 16% (13.9-17.9) 26.7% (24.2-29.1) 79.0 (78.3-79.3) 3.5% (2.4-4.5) 122.7 (121.8-123.6) 75.6 (75.0-76.1) 17.27% (15.1-19.3) Males (95% CI) Urban 22.2% (20.0-24.6) 12.0% (10.3-14.0) 28.9% (26.4-31.5) 8.6% (7.1-10.2) 23.2% (20.9-25.6) 57.8% (55.0-60.5) 22.4 (22.7-22.6) 25.4% (23.0-27.9) 40.8% (38.1-43.6) 82.6 (81.9-83.3) 6.4% (5.1-7.9) 126.8 (125.9-127.7) 79.1 (78.6-79.8) 23.0 (20.7-25.4) Urban slum 7.0% (5.5-8.3) 2.7% (1.7-3.5) − 5.4% (4.1-6.5) 55% (52.4-57.8) 22.8% (20.4-25.0) 21.9 (21.7-22.1) 21.9% (19.6-24.1) 34% (31.4-36.6) 76.2 (75.5-76.9) 20.6% (18.3-22.8) 117.8 (116.7-118.7) 74.2 (73.5-74.7) 15.82% (13.8-17.8) Females (95% CI) Urban 1.4% (0.9-2.2) 1.1% (0.6-1.9) − 4.4% (3.4-5.7) 52.4% (49.7-55.1) 26.9% (24.5-29.3) 23.4 (23.1-23.7) 34.9% (32.3-37.6) 48.6% (45.8-51.4) 79.2 (78.5-79.9) 27.6% (25.1-30.1) 119.0 (118.1-120.0) 75.6 (75.0-76.2) 15.7% (13.8-17.8)
* Age adjusted to urban Faridabad population structure as per Census 2001.
Community Community members felt that in addition to lifestyles, issues related to environment and cleanliness were also important. A loose coalition of community members was formed called “Friends of City” with the objective of making Ballabgarh a healthy town.
This informal group, which met about 15 times over the last year is carrying out various community-based activities. One volunteer from each colony/cluster would be identified and trained to carry out NCD prevention activities.
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Table 2: Description of roles and activities of different stakeholders for NCD control at Ballabgarh Stakeholders Local administration Identified Roles Creating enabling environment Providing facilities Legislation enforcement Progress Achieved District and sub-divisional magistrates sensitized Initial commitment received Free site for hoardings provided Problems identified Very busy and frequent transfers Health is a low priority and within health, NCDs are a low priority Misperception that NCDs are lifestyle-related and lifestyles are an individual’s choice Busy with their own work Lack of technical manpower and infrastructure
Government and private health sector
Service provision – preventive, promotive and curative
Sensitized Management guidelines for disease management disseminated Starting of NCD clinic Meeting among teacher groups Activity-based learning among schoolchildren poster competition, health talk etc. Link with an existing platform – Hriday SHAN Sensitized Keen to get involved Training programme for volunteers developed
Educational institution
Spread messages to peer group Facilitate change within family Create supportive environment in schools Provide necessary skills to schoolchildren to adopt healthy habits Dissemination of information Act as change agents
Examinations and vacations Not the target group for surveillance Lack of facilities – e.g. playgrounds
NGO and women groups and volunteers
Nonavailability of NGOs in the area of health Lack of capacity Worried about production time Focus on curative aspects Inability to use available national platform
Industrialists and traders
Awareness-generation among employees Formulating and implementing NCD-friendly policies and guidelines Awareness-generation in community Provision of services Resources
Participated in meetings Link with Faridabad Industries Association established Baseline information on factories and employees being collected
Media (Press / Cable)
Carry messages regularly Act as a pressure “group”
Sensitized to the importance Seen as “value” addition
Inadequate media communication skills
Schools Schoolchildren were included as many unhealthy behaviours develop during this age period. Using the modality of a postgraduate thesis, the knowledge about risk factors re-
lated to NCDs, as well as their prevalence among middle-school children were studied.9 The thesis documented the then current status of risk factors among schoolchildren. The results showed a lower use of tobacco
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among children but a heavy household exposure to tobacco use, and low levels of physical activity and diet intake. The assessment of the school environment revealed easy availability of tobacco near school despite legislation, lack of playgrounds, easy availability of unhealthy foods etc. A total of 16 school-level meetings and exhibitions were held covering about 10 000 children. The purpose was to generate awareness about unhealthy lifestyles among children and the school management. Schoolchildren were also given some holiday home work in the form of developing information, education and communication (IEC) materials and slogans. These were subsequently used in community meetings. As the schools were keen to continue this work they were linked to Hriday-SHAN, an NGO working with youth and schools.10 Industries Faridabad has about 400 industrial establishments. Results of the survey conducted among employees of three conveniently sampled industrial establishments as part of the postgraduate thesis enabled us to highlight the need for addressing NCDs.11 This survey documented the high prevalence of risk factors in both manual and non-manual workers. These included smoking and alcohol consumption rates among men, high-fat diet and low fruit and vegetable intake, and high rates of physical inactivity especially among non-manual workers. A gap was also seen between the intention to change their risk status and their ability to do it; for example cessation of tobacco use. The Faridabad Industries Association (FIA) was contacted and showed interest in addressing issues related to NCD prevention. A group meeting was held with human resource development managers of industries to sensitize them to the need to address NCDs at the industry level, and explore ways of integrating NCD prevention issues into regular industrial health safety training. However, efforts by the Association to link its acti-
vity with the “Healthy Workplace” initiative of the Confederation of Indian Industries (CII) could not fructify due to its internal differences. With the help of FIA, a survey of the industries is being conducted to document the presence or absence of policies and guidelines regarding issues, such as tobacco and alcohol consumption, provision of food in canteens and facilities for physical activity. Local government Results of the baseline survey were shared with the district and block administration. They agreed to support the activities of “Friends of City” and allowed us the use of hoardings in government buildings that are visited by a large number of people. Health sector District and block-level health authorities were also present during the meeting. Private medical practitioners were addressed under the umbrella of the Ballabgarh Medical Association and meetings were held to train them on the management guidelines for hypertension and ischemic heart disease. An NCD clinic was also started at the Ballabgarh Hospital for management of NCDs based on a standard protocol for these diseases at secondary level. Others The meetings and events were well covered by the local media. An NGO working on tobacco control in Faridabad district was identified and involved in IEC activities. An effort is now being made to identify and enrol other NGOs who can be our potential partners in this exercise.
Launching a campaign Development of IEC materials Many IEC materials such as posters and slogans were developed as part of the campaign. The people involved in preparation of 17
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IEC materials included school teachers and children, members of the community and doctors. A book on NCD prevention and control in Hindi was also written by the project team and distributed to different stakeholders.
Monitoring and evaluation plan The need for a good and reliable monitoring and evaluation system for continuous monitoring of the change process and for more comprehensive summary evaluation has been emphasized by Nissinen et al.6 Guidelines are being developed by WHO for monitoring the community-based risk factor intervention projects. These would be used to monitor the progress of the project. The second round of the NCD risk factor survey is in preparation (three years after the baseline date). While it is too early to expect major changes in behaviours, this mid-term survey will help in documenting the trends. It is also proposed to evaluate the IEC campaign in terms of its reach and effectiveness.
Branding In order to improve its visibility, it was decided to have a logo and a slogan for the campaign. A communication campaign is being launched with the support of different stakeholders. (Fig. 2). Fig. 2: Logo and slogan for a “Live Healthy” media campaign at Ballabgarh
Lessons learnt Demonstration projects are meant to guide subsequent efforts at national level.6 It is important, therefore, to share the lessons learnt and challenges faced so that others can learn from them.
*
Identification and empowerment of stakeholders **
* Live Healthy ** Adopt Everyday – Healthy Lifestyles
Resource generation Funds needed for a full-scale campaign need to be generated. Some potential sources have been identified and efforts are being made to convert “Friends of City” into a registered body so that it can receive donations/grants from the government, national and international agencies and private organizations.
It is important to identify relevant stakeholders who can assist in planning and implementing the project. In this intervention, industries and schools became the primary focus for intervention apart from the community. More however needs to be done to increase the involvement of existing stakeholders, identify and involve new partners, and more importantly to sustain this partnership. For this, there is need for a strategy to empower stakeholders through regular advocacy, information sharing, and skills development of all the stakeholders.
Generate local information While information from other parts of the world and even from other parts of the
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country does serve a purpose, one often comes across a perception among stakeholders that this reported information is not applicable or relevant to them. In order to address this perception, it is important to generate local information. In the absence of a structured surveillance and routine local health reporting system, this could be done through scientific studies (as in this case for community, schools and industries) or even through anecdotal evidence. Information should cover the magnitude of the problem, effectiveness of preventive measures and the cost of the intervention. Such baseline information is essential for evaluation of the intervention at a later stage.
tity, so that people remember the campaign and its objectives. Subsequent evaluations will show the usefulness of this strategy.
Multiple settings or multipronged approach While the community appears as a single entity, it often has many sub-entities. In order to reach a larger section of the community, a multi-pronged approach is needed. This not only ensures a wider reach of the intervention but continuously reinforces messages, which is a prerequisite to change the behavioural “norms” in a community.
Technical support While many stakeholders were willing to put in some efforts in the initial period, the project team had inadequate technical resource or capacity to address their concerns or guide their actions. It highlighted the lack of technical documents/manuals on the communitybased approach. While the project team did prepare some of the background documents, these need to be shared and improved upon and made easily available. It is also pertinent to mention that much work needs to be done in the areas of monitoring and evaluation of community-based interventions for health promotion.
Role of research agencies The community-based intervention is primarily about project development and implementation. Yet it is important to involve academic/ research institutions as they could provide essential technical back-up in terms of knowledge sharing and tools and methods for sound planning, monitoring and evaluation.
Need for documentation The project also highlights the need for documentation and sharing of the experience as is being done through this article. This not only brings such experience to a global public domain but also helps in the advocacy efforts for NCD prevention. Documentation of experiences and advocacy for strengthening community-based interventions against NCD risk factors are of particular importance in developing countries and regions of the world where the burden of illness due to NCDs continues to rise.
Link to established or existing mechanisms and systems While efforts should be made to involve the stakeholders in the community, it is essential to look at other related initiatives in the area and link them together. This helps in getting more resources and technical support. In the case of our project, success was achieved regarding schools, but it was a failure in the case of industries.
Strategic challenges for implementation and sustainability Leadership All new initiatives need strong leadership. In the initial stages, the project investigators 19
Branding/visibility As a marketing strategy for any IEC campaign, it is important to create a brand idenRegional Health Forum – Volume 10, Number 2, 2006
provided this leadership and it was hoped that the baton would soon pass to someone else identified by the community. In the case of this project, this is yet to take place. In the larger sense, the issue would be whether such initiatives are to be led by the health sector or the non-health sector, the government or the private sector, or by the community, academicians or programme managers. While the right solution may differ from area to area, it is important to have a group rather than an individual leading the initiative to ensure its sustainability.
Ownership by community and community mobilization There is a perception of ownership in the community in that they feel this is important and much-needed work. They also appreciate the efforts of the project team. However, we feel that the community is currently not yet ready to assume full responsibility for the initiative. One of the reasons for this is the lack of established mechanisms or forums for carrying out this kind of activity at the community level. In such a scenario, the start-up leadership becomes a crucial determinant of success.
a similar nature. As for vertical links, many of the major interventions for NCD prevention and control are executed at higher levels, such as legislation and policy-making. Without support from the higher echelons, there is a limit to what can be achieved through community mobilization alone. Communitybased interventions might create lobbies or pressure groups. Thus, there is need to build synergy in demonstration projects by involving higher authorities including local, state and national governments. WHO can play an effective role in forging these vertical and horizontal links by sharing information, and getting different groups together on a regular basis.
Resource mobilization Resources are required for IEC campaigns. However, the related costs should be absorbed by routine activities of the agencies involved. Of course, this would require significant efforts and it is easier said than done.
Conclusion Integrated community-based interventions against the risk factors for NCDs are a feasible, and perhaps, the major way forward to change behaviours at the community level. Such efforts need to be supported technically and the experience shared at national, regional and global levels in order to promote further initiatives.
Technical capacity As already stated above, lack of technical capacity among members of the project team, and the absence of documented experiences of this kind of initiative, meant that the project was primarily a process of learning by doing and developing technical capacity to address the evolving needs. This was only possible because of involvement of a team from a premier medical institution in this initiative. However, this area needs strengthening for future sustainability of the programme.
Acknowledgements The project would not have been possible without the active involvement of all members of “Friends of City”, and all stakeholders mentioned in the paper. We also thank the Ministry of Health and Family Welfare, Government of India and WHO’s India Country Office for their technical and financial support. Comments made by Dr Cherian Varghese, National Professional Officer, WHO India Country Office, on the manuscript are deeply appreciated. Regional Health Forum – Volume 10, Number 2, 2006
Vertical and horizontal links Horizontal links are not only between different stakeholders, but between different projects of 20
References 1. Health Situation in the South-East Asia Region 1998–2000. World Health Organization, Regional Office for South – East Asia, New Delhi 2002. NCMH Background Papers. Burden of Disease in India. National Commission on Macroeconomics and Health (NCMH). Ministry of Health & Family Welfare, Govt. of India, New Delhi September 2005. Assessment of Burden of Non – Communicable Diseases. Indian Council of Medical Research, New Delhi, 2004. The World Heath Report 2002: Reducing Risks, Promoting Healthy Life. World Health Organization. The protocol for the WHO study on the effectiveness of communitybased programmes for NCD Prevention and control (COMPASS). NMH/NPH/NCP/03/09. Geneva 2003. Nissinen A, Berrios X, Puska P. Communitybased noncommunicable disease interventions: lessons from developed countries for developing ones. Bull World Health Organization. 2001;79(10):963-70 10. 7. World Health Organization. Report of Integrated Community-based prevention of major Noncommunicable diseases in SEAR. 27-31 January 2003, New Delhi. SEA-NCD-59, WHO SEARO, New Delhi 2003. The WHO STEPwise approach to chronic diseases risk factor surveillance. World Health Organization, Geneva 2005 Vivek Gupta. A study of the knowledge and the risk factors for NCDs among middle school children in Ballabgarh Block, Haryana, India. MD. Thesis submitted to All India Institute of Medical Sciences, New Delhi June 2005. Reddy KS, Arora M, Perry CL, Nair B, Kohli A, Lytle LA, Stigler M, Prabhakaran D. Tobacco and alcohol use outcomes of a school-based intervention in New Delhi. Am J Health Behav. 2002 May-Jun;26(3):173-81. Biplab Jamatia. A Study of Prevalence of Risk Factors for Non Communicable Diseases among Factory Employees. MD. Thesis submitted to All India Institute of Medical Sciences, New Delhi, June 2003.
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Primary Health Care Capacity Assessment of the Primary Health Care System to Manage Reproductive Tract Infections Sanjay Chauhan*, Beena Joshi*, Vikas Bhadoria* and Arvind Mathur**
Abstract Reproductive Tract Infections (RTIs) are one of the integral components of the National Reproductive and Child Health (RCH) Programme in India. Rural primary health care centres are expected to have the requisite facilities in terms of personnel and infrastructure to provide quality RTI services. However, little is known about service delivery aspects such as current RTI management practices, training status and technical competence of the health functionaries, and essential facilities for quality service provision. Information on these aspects is needed to assess the feasibility of the primary health care system in providing preventive, diagnostic, and curative services for RTIs. A study conducted during 2003-2004 carried out a situational analysis of the primary health care system in a district of India’s Maharashtra state on its capacity to provide quality services for reproductive tract infections among women. The data revealed inadequate facilities at the primary health centres and sub-centres and incomplete knowledge on RTI management among medical officers, laboratory technicians and auxillary nurse midwives (ANMs). The study concluded that with specific training and facility upgrades, RTI services, integrated with the family welfare services, could be operationalized in the primary health care system.
Introduction Reproductive tract infections (RTIs) including sexually transmitted infections have existed since long and caused suffering to innumerable men and women around the world. Their consequences, however, have been far more devastating and widespread among women than among men. RTIs often go undiagnosed and untreated among women. When left untreated they lead to complications such as infertility, ectopic pregnancy and cervical cancer. Pelvic inflammatory disease and infertility arising from RTIs pose *Assistant Director *Research Officer *Project Investigator
major public health problems and adversely affect the reproductive health of poor women who do not receive treatment. Management of RTIs is greatly neglected particularly in rural and urban slum areas of India. In the public sector, the treatment for RTIs is limited with most services provided only through STD clinics in urban areas. Most clients, and women in particular, avoid seeking treatment at STD clinics because of the perceived stigma attached to the same. Thus most clients at STD clinics tend to be men while their partners may remain untreated.
**Coordinator, Family and Community Health, WHO Representative’s office, 534, “A” Wing, Nirman Bhavan, Maulana Azad Road, New Delhi-110 011, India; E-mail: mathura@searo.who.int
}
National Institute for Research in Reproductive Health, Jehangir Merwanjee Road, Parel, Mumbai, India; Tel.: 91-22-24192042
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Research on RTIs in India has so far concentrated on studies estimating the prevalence of various RTIs and the healthseeking behaviour(1-6) of women. Little is known about the service delivery aspects such as training status and training needs of the health functionaries and the essential facilities for provision of quality service. For programme and policy purposes it is critical to have this information in order to assess the feasibility of the primary health care system in providing preventive, diagnostic, treatment and counselling services for RTIs. A WHOfunded situational analysis study was conducted during 2003-2004 in Thane district of India’s Maharashtra state to assess the primary health care system’s capacity to provide quality services in treating reproductive tract infections among women. The specific objectives of the study were to: (i) assess the knowledge, skills and attitudes of health functionaries towards RTIs in the primary health care system; (ii) assess their training needs and available infrastructural facilities for provision of RTI services in the primary health care system, and (iii) recommend the provision of essential facilities in the primary health care system for the management of RTIs.
Setting Thane district, located to the north of Mumbai, spreads over an area of 9558 sq. km and ranks 19th in size among the 35 districts of Maharashtra state. The major part of the district is hilly with more than 37% of the total geographical area being forested and with tribal settlement. The list of public health institutions operating in the rural areas of the district and the facilities covered by the survey are provided in Table 1.
Institutional Ethics Committee. Thane district has 10 rural hospitals; 77 primary health centres (PHCs); and 470 sub-centres. Since rural Thane consists of two-thirds tribal and one-third non-tribal inhabited areas, a stratified multistage random sampling design was adopted. Two rural hospitals (RHs), 14 PHCs and 42 sub-centres were randomly selected from the tribal belt and one rural hospital, six PHCs, and 18 sub-centres from the non-tribal belt. All service providers serving the posts of medical officers (MOs), auxillary nurse midwives (ANMs) and laboratory technicians were selected for interviews. The tools used to collect data were pre-tested, semi-structured interview schedules for MOs, ANMs and laboratory technicians and facility checklists for rural hospitals, PHCs and sub-centres. The service providers were interviewed for an assessment on their socioeconomic background, knowledge, attitudes, perception and management practices regarding RTIs, their training status, and the services provided by them including counselling in relation to RTIs. In the survey of facilities, availability of essential equipment and reagents to carry out simple laboratory tests for RTI was noted. In addition, facilities available at the centres in terms of infrastructure including medical examination, staffing, educational (IEC) material, and activities related to RTIs were also recorded. Table 1: Rural health infrastructure in Thane district S. No. 1. Health infrastructure in Thane No. of PHCs Tribal Non-tribal No. of SCs Tribal Non-tribal No. of RHs Tribal Non-tribal Existing 77 50 27 470 324 146 10 6 4 Covered by survey 20 (26%) 14 6 60 (13%) 42 18 3 (30%) 2 1
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Methodology The study was initiated after obtaining the necessary permission from the Government of Maharashtra and the approval of the Regional Health Forum – Volume 10, Number 2, 2006
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Results 23
A total of 20 PHCs and 24 constructed subcenters were covered for the facility survey in the study (60% of the sub-centers in the sample had not been constructed). The data further pertains to interviews of 39 MOs, 60 ANMs and 18 laboratory technicians.
Current service provision and clientele for RTIs General curative services and services related to family planning, maternal and child health and immunisation were available at all PHCs whereas only 23% of PHCs provided services
for first trimester termination of pregnancy. The PHC MOs reported that on an average 30 women and 23 men attended the centre per day for general curative problems but the attendance was found to be very poor (one man and five women per month) for RTI/STI services. The majority of men seeking treatment for any problem related to RTI mainly complained of burning micturition, followed by pruritus, urethral discharge and genital ulcer. Most women patients complained of vaginal discharge and lower abdominal pain (Figure 1).
Figure 1: Major RTI complaints of care-seekers
Men Others Signs and symptoms Burning micturition Pruritus Scrotal pain Genital ulcers Urethral discharge 0 20 0 9 24 40 60 29 3 56 Signs and symptoms Others Burning micturition Pruritus Lower abdominal pain Genital ulcers Vaginal discharge 0
Women 0 50 50 74 9 88 20 40 60 80 100
Percentage
Percentage
The majority of MOs reported management practices based on symptoms alone and non-responsive cases were referred to the rural or district hospital. For example, asked how they would manage a client with complaints of vaginal discharge, 75% responded saying that they would seek to know of the duration, type and odour of discharge and then treat it with antibiotics while 21% said they would simply refer such cases to the higher facilities. As denoted in figure 2, the most common drugs used by MOs to treat RTIs were norfloxacin (77%); metronidazole (74%); and ciprofloxacin (53%); and co-trimoxazole (50%). Only about one-third of MOs re24
ported delivering counselling services on RTI/STI/HIV/AIDS. Treatment of the sexual partner was not found to be a part of totally lacking in the management practice of MOs. ANMs reported catering to nine men and 16 women per day for general and family welfare consultations at the sub-centre. In case of RTI-related services the poor attendance levels at the sub-centres reflected that of PHCs. The common complaints among women were vaginal discharge, lower abdominal pain, burning micturition and pruritus. About 18% of ANMs reported providing treatment for RTIs to women with co-trimoxazole and metronidazole; the rest said that they would refer such cases to the PHC. Regional Health Forum – Volume 10, Number 2, 2006
Figure 2: Drugs used by medical officers to treat RTIs
availability of IEC material, record keeping and accessibility of services.
Norfloxacin Ciprofloxacin Metronidazole Septran
Infrastructure and accessibility The basic infrastructure facilities such as space for waiting clients, functioning water source, working toilets for clients at the PHC, and electricity facilities were found to be adequate, whereas 73% of the constructed sub-centres had inadequate facilities. Electrical energy was available in 65% of the sub-centres. Almost all the PHCs were found to have sufficient space for noting the history of patients and conducting examination. But 60% of PHCs did not have a separate room for counselling and conducting examinations to maintain audiovisual privacy and confidentiality of clients. It was also almost non-existent at all the subcentres (Figure 4). The PHCs and sub-centres reported to be functional six days a week and for nine hours a day. Only 15% of the PHCs and four per cent of the sub-centers had signage at their premises indicating availability of RTI/STI services. Figure 4: Availability of basic infrastructure for provision of RTI services SC Adequate water Adequate light Facilities Cleanliness Visual privacy Audio privacy
Antibiotics
0
20
40
60
80
100
Percentage
Common tests carried out by laboratory technicians serving at PHCs include those for tuberculosis (acid-fast bacilli), urine for sugar and albumin, haemoglobin, peripheral smear for malaria, VDRL for syphilis, and Widal test for typhoid fever (Figure 3). It was observed that gram staining was carried out for RTIs/STIs at only five per cent of PHCs while 45% of the PHCs reported to be conducting VDRL tests for syphilis as a part of antenatal care for women. Fifteen per cent of PHCs referred the patients for laboratory testing of RTIs to district hospitals or private facilities. Figure 3: Tests carried out by laboratory technicians HIV RTI (VDRL only) Malaria
PHC
Women Men
Tests done
Widal Bile/Pigment Hb
0
20
40
60
80
100
Percentage
Urine (Sugar/albumin) TB
Staff position 0 20 40 60 80 100 Percentage
Capacity of facilities to provide RTI services Data was collected on infrastructure, availability of equipment, supplies and drugs,
About 82% of sanctioned strength of MOs and 94% of ANMs were placed at PHCs and sub-centres. The availability of laboratory technicians was 78% of the sanctioned strength in the PHCs. Among MOs, there was
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a shortage of female doctors, who comprised only 16% of the total.
Equipment, drugs and supplies The availability of equipment and supplies required for clinical examination and laboratory diagnosis of RTIs was looked into. The availability of equipment such as uterine sound, speculam, tenaculum, microscope,
glass slides, examination table, refrigerator and sterilizing instruments was adequate at the PHCs. However, other essential equipment and supplies for carrying out laboratory diagnosis of RTIs such as burner lamps, centrifuge machine, gynaecological torch, specimen collection swabs etc. were not available or not in working condition in about 90% of PHCs (Figure 5).
Figure 5: Availability of basic equipment and supplies for RTI treatment at PHCs
Glass slides/cover slips Ayers spatula Bacteriology loop Specimen collection swabs Burner Lamps Centrifuge machine Facilities Microscope Examination table Refrigerator Antiseptic lotions Gynecology lamps/ torch Sterilizing equipment 5 0 0 0 10 15 90
95
Working Available
95 100 100
100
0
20
40
60
80
100
% of PHCs
The availability of reagents and supplies required for laboratory diagnosis of RTIs such as PAS staining reagent, Thayer’s martin media, blood culture media, cell culture, Sabouraud’s glucose agar and 10% potassium hydroxide was poor or inadequate.
Only 20% of PHCs had gram-staining reagents available for laboratory diagnosis of RTIs. Of these, only five per cent of PHCs carried out laboratory diagnosis for RTIs/STIs using these reagents. Forty five per cent of PHCs conducted syphilis tests during ante-
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natal care using RPR/VDRL kits. However, testing facility for HIV infection was not available with the PHCs at all. The availability and supply of oral antibiotic drugs in the PHCs was found to be adequate. Drugs such as norfloxacin, ciprofloxacin, doxycyline, metronidazole, ampicillin and co-trimoxozle were available in all the PHCs. Other oral drugs such as flucanozole and tinidazole were available in 40% of PHCs. However, local anti-microbial vaginal creams and pessaries were not available in the PHCs. The PHC dispensaries also did not stock separate drugs for RTIs.
IEC and resource material The availability of IEC material on related issues such as family planning, maternal and child health and nutrition were available in 70% to 90% of PHCs and sub-centres. Flip charts, brochures, posters and written messages, or either of them, on HIV/AIDS were available in 90% of PHCs and 73% of subcentres. However, such material on RTIs focusing on women was available in only 16% and those focusing on men in five per cent of PHCs. Resource material such as treatment guidelines and protocols were not available at any of the facilities.
sory rural service of one year and were in the younger age-group of 24-30 years. Sixty two per cent of the MOs had received training for three days under the Family Health Awareness Campaign (FHAC) in April 2003. The majority of MOs called for an effective training course on RTI/STIs to update them with the latest practices and expressed the need for provision of resource material and protocols for their ready reference. In comparison with MOs only 20% of ANMs were aged below thirty years and the majority had 11-20 years of experience. Sixty two per cent of the ANMs had received two days of training on RTIs/STIs during FHAC. They were, however, not very clear as to what extent their training helped them to manage RTIs. Majority of laboratory technicians (79%) were science graduates with a diploma in medical laboratory technology. Forty two per cent of Laboratory technicians received training for a day on RTI/STI laboratory diagnosis during RCH training in the year 1999. All of them expressed the need for effective training that includes current methods for diagnosis of RTIs by microscopic examination and the provision of reference material and laboratory protocols.
The concept of reproductive health and its components was not clear to the majority of MOs. About 79% of MOs perceived it as maternal and child health, family planning Record keeping and nutrition. Only nine per cent of MOs mentioned RTI/STIs as a component of reproDue to information gaps in the Reproductive ductive health. Regarding their knowledge on and Child Health (RCH) database, 95% of RTIs/STIs, only 15% knew the difference bePHCs did not maintain separate records for tween RTIs and STIs. The majority (85%), clients with RTIs. however, knew that RTIs could exist in the absence of signs or symptoms. All MOs surTraining status, knowledge and technical veyed knew of HIV/AIDS as an STI. The percompetence of staff centage of MOs familiar about various RTI/STIs was varied: Candidiasis (71%) syphiHalf of the MOs had an allopathic (MBBS) lis (59%), gonorrhoea (32%), and bacterial degree while the other half were ayurvedic vaginosis (15%) were known to many. doctors (BAMS). The majority of MBBS docChancroid and hepatitis B were the least tors had an experience of less than a year as known STIs with only three per cent of MOs most of them were completing the compulbeing familiar with them (Figure 6). Figure 6: Types of RTIs/STIs known to medical officers
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Chancroid Hepatitis B Bacterial vaginosis LGV RTIs/STIs Gonorrhoea Chlamydia trachomatis Syphilis Candidiasis AIDS 0 20 40 60 Percentage 80 100 120
Asked about the consequences of the absence of treatment for RTIs/STIs, all the MOs mentioned HIV transmission, 35% mentioned infertility, 15% cited pelvic inflammatory disease, nine per cent mentioned cancer and six per cent vertical transmission. Indepth knowledge such as on the use of condoms for dual protection of STIs and pregnancy and management of ‘at risk’ family planning client was found to be lacking among more than 20% of MOs. Their knowledge on syndromic management of RTIs was also found to be inadequate. ANMs were not able to differentiate between RTI and STI but could name the different types of RTIs/STIs such as AIDS, syphilis, candidiasis and gonorrhoea. ANMs were found to have a little better knowledge about the dual protection provided by condoms and the management of ‘at risk‘ family planning client. The laboratory technicians knew of the different types of RTIs such as AIDS, gonorrhoea, syphilis and candidiasis. All of them also knew that RTIs can create complications if left
untreated and can even increase chances of HIV transmission.
Discussion The primary health care infrastructure in India is one of the largest networks of three-tier facilities reaching out to the rural community. The National AIDS Control Organization (NACO) implements the RTI/STI treatment programme only at the tertiary level and at the district-level public health facilities located in urban areas. At the primary care level in the rural regions, the RTI/STI control programme is administered by the Department of Family Welfare and has to compete with other programmes such as family planning, child survival and maternal health, resulting in low priority being accorded to it. The existing RCH programme includes RTI/STI care along with family planning and maternal & child care. To provide these services and ensure quality requires a capable health infrastructure with both trained man-
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power and equipment in position. The study findings are an eye-opener on the ground realities of the existing scenario on RTI service delivery in the primary health care system. The findings indicate that the concept of reproductive health has not been correctly and fully comprehended by MOs and that their knowledge on RTIs was inadequate, as was reflected in their RTI diagnostic and treatment practice. Most of the MOs were not aware of the syndromic management of RTIs. They treated symptoms suggestive of RTIs using available drugs such as norfloxacin, ciprofloxacin, co-trimoxazole and metronidazole. It is well documented that Neisseria gonorrhoea has developed resistance to fluoroquinolones such as ciprofloxacin and norfloxacin across the South Asian Region(7) and has therefore been excluded from many of the syndromic management guidelines. Third generation cephalosporins such as cefixime and ceftriaxone are the newly recommended drugs for treatment of gonorrhoea(8). These drugs were not available and neither prescribed by the MOs to treat vaginal discharge or urethral discharge syndrome. Moreover, doxycycline though available in all the PHCs was not known to MOs as a recommended drug to treat chlamydial infection and was therefore not utilized for the same. The treatment of the partner is a cornerstone of the RTI case management approach as it prevents re-infection of the index patient and helps in reducing the burden of infection in the community. Counselling RTI patients on their diagnosis, the mode of transmission and the need to treat all partners is an important part of partner notification. This aspect of RTI management was totally lacking among MOs as well as ANMs. This also reflects poor application of the existing knowledge about the dual protection offered by the condom. Though about one-fifth of ANMs were treating RTIs with available drugs such as co-trimoxazole and metronidazole, they also totally lacked the knowledge and skills for need for appropriate RTI client
management and appropriate referral. This gap in knowledge and practice reflected the need for training in clinical diagnosis and treatment and provision of standard RTI management guidelines most suitable to the PHC set up. Overall training needs identified in the study pertains to clinical diagnosis, including RTI history-taking and physical examination, individual counselling, health education, follow-up and partner management. Guidelines need to be developed that can be used as a reminder and an easy source of reference for health functionaries. Such guidelines should be able to guide providers in adopting standard approaches to patient management. In India, STD management guidelines developed by NACO are available(9). However, it needs to be adopted or modified to integrate in the RCH programme which entails that national RTI/STI treatment and operational guidelines need to be developed for the primary health care system. Diagnostic tests are the most clinically accurate way to identify and confirm specific RTI pathogens. Laboratory tests and microscopy can strengthen both clinical diagnosis and syndromic algorithms to improve the diagnosis, treatment, and surveillance of STIs. In the district under study though the laboratory technicians were carrying out routine pathological tests such as blood, urine, malaria and TB sputum tests, it was found that the majority of them were not skilled to perform wet mounts and gram staining for RTI detection. However, it was an encouraging sign that almost all the health functionaries did acknowledge their limitations and were very receptive about undergoing the RTI training for quality service delivery. It could be fairly stated that in the district being studied the existing PHC laboratory can undertake simple microscopy procedures to diagnose some RTIs such as trichomoniasis, candidiasis and bacterial vaginosis with the help of saline wet mounts. Other infections such as syphilis and gonorrhoea could also be diagnosed at
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the PHC or RH with some research inputs (kits, stains and reagents). The facilities in the study district have the requisite facilities in terms of basic infrastructure and personnel. However, since the majority of PHCs do not fare well on audiovisual privacy, attention needs to be paid to ensure that separate counselling or examination rooms are available at all facilities to safeguard privacy during client/provider interactions. This might need an improvement in the physical structure of the facilities in order to provide RTI acceptable services. Laboratory support services are inadequate at the PHCs rendering patient management based on history-taking and clinical examination. Besides, laboratory services are also essential for an accurate assessment of RTI epidemiology, including antimicrobial resistance patterns, and for detecting asymptomatic infections(10). General drug availability and supply is good, though, some antibiotics which have become resistant to gonococci need to be replaced. IEC material which is important for informing, educating and communicating with clients about RTIs were lacking in most facilities. In contrast, the IEC material on HIV/AIDS was available in almost all the facilities, reflecting a need to develop and provide such material on RTIs. Also, few facilities displayed prominent signs announcing the availability of RTI services. The poor attendance for RTI-related services is a cause for great concern and needs to be analysed by assessing the magnitude of the RTIs in the community and their treatment seeking behaviour for the same. Though precise data on prevalence of RTIs in the rural areas of Thane district are not available, the Rapid House-hold Survey(11) revealed that 45% of the eligible women have at least one symptom of RTI/STI over reference period of the last three months. About eight per cent of females suffered abnormal vaginal discharge and among them 54% sought treatment for their problems, mostly from private doctors, and only 12% reported to have availed of government facilities. The reasons for not
availing of public sector services include their poor quality followed by inconvenient location (23%), overcrowding (14%) and unsuitable timings (8%). The primary reason for not availing of public sector services could be the lack of RTI service availability as indicated by the study. The problem with the facilities where some services are being delivered could be accessibility and quality of services delivery that depends on infrastructure, technical competence and also on the attitude and behaviour of service providers. Studies have found that a common complaint of clients attending clinics for STD care is lack of privacy and confidentiality(11,12). The judgmental and unsympathetic attitudes of providers have also been found to have a profound impact on patients’ opinion on the services. Therefore, community members often report a preference for private practitioners and traditional healers who are perceived as sympathetic and caring. Provider discomfort and unwillingness to counsel clients about sexual practices and reproductive tract infections is a barrier to quality RTI services. Though the gender of the providers is biased towards male doctors at the PHCs and female ANMs at the sub-centres as observed in the study, its effect on RTI service up-take by clients is not clear as the majority of the providers reported to be comfortable in discussing sexual behaviour with the client of the opposite gender.
Conclusion The study concludes that with specific training and facility up-gradation, RTI services integrated with the family welfare services could be operationalized in the primary health care system.
Recommendations Policy and programme Integrate dual protection strategies by reviewing the policy guidelines between NACO
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and the Department of Family Welfare with respect to integrating RTI/STI management services with the family welfare programme at the primary and secondary care level. This policy change needs to be supported by development of National Guidelines for Management of RTIs most suitable to the primary health care system.
Demand for services A demand for RTI services needs to be generated by promoting treatment-seeking through information, education and communication; involving local institutions, and using lessons learnt from FHAC. For this the availability of simple, culture friendly IEC material is crucial and need to be provided. Specific strategies needs to be devised for provision of RTI services to other groups such as non-pregnant women, adolescents and men.
Upgrade facilities The primary health care facilities in the district observed need to be upgraded by: (i) improving/improvising physical structure of facilities to provide separate counselling/ examination rooms to safeguard privacy during client-provider interaction in order to make RTI services more acceptable; (ii) the provision of minimum necessary equipment, stains and reagents for laboratory diagnosis. The existing PHC labs can undertake simple microscopy to diagnose common RTIs – trichomoniasis and candidiasis by saline wet mounts – and with some resource inputs such as stains and reagents they could be made functional for diagnosing other RTIs such as bacterial vaginosis, and (iii) the provision of effective drugs such as Azithromycin and Cefixime for treatment of RTIs. The provision of syndrome-specific drug kits with condoms and information material could also be explored.
Monitoring and evaluation Routine monitoring mechanism should be evolved not only for staff performance but also for client satisfaction.
Surveillance laboratory If possible, a surveillance laboratory should be established for an accurate assessment of RTI epidemiology, drug resistance patterns, and for detecting asymptomatic infections
Study limitations The study had a major limitation for not being able to assess the quality of RTI services provided by using standard tools such as ‘onthe-job observation’ and ‘exit interviews’ of clients. Such an exercise was planned to be carried out but could not be executed because of uncertainty over client availability due to poor attendance levels.
Training The MOs need to be trained for RTI management. Major areas the training should address include: (i) risk assessment, clinical and laboratory diagnosis; (ii) utilizing opportunities such as during antenatal care, IUD insertion for detection of asymptomatic RTIs; (iii) RTI transmission, control and treatment approach; (iv) confidential counselling services and prevention education, and (v) partner management and follow-up. The ANMs need to be trained in counselling, appropriate referral and followup. The laboratory technicians also need to be trained for provision of diagnostic services for RTIs.
Acknowledgements The assistance provided by Miss Namrata Aggarwal and Mr Haresh Jadhav in management of data is hereby acknowledged.
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References 1. Bang, RA. et al (1989): High Prevalence of Gynaecological Diseases in Rural Indian Women, The Lancet- 85-88, January, 14. Bhatia, J. C. et al (1997) : Levels and Determinants of Gynaecological Morbidity in a District of South India - Studies in Family Planning, Vol.28, No.2, June 1997. Brabin, L; at al (1998): Reproductive tract infections, Gynaecological Morbidity and HIV. Seroprevalence among women in Mumbai, India. WHO Bulletin,1998, 76(3). Pp 277-287. ICMR (1997): A Baseline Survey of Reproductive Health Services in 23 Districts (14 States) of India - a component of Modified District Project. Lata K., et al (1997): Prevalence of clinically detectable gynaecological morbidity in India: Results of Four Community based studies by Baroda Citizens Council, Baroda., Child in Need Institute, West Bengal., SEWA - rural and Streehitakarini, Bombay-The journal of family Welfare, Vol.43, No. 4. National Family Health Survey – 2 Report (199899) International Institute for Population Sciences, Mumbai. 7. Ray K, Bala M, Kumari S, Narain JP. Antimicrobial resistance of Neisseria gonorrhoeae in selected World Health Organization Southeast Asia countries: an overview. Sexually Transmitted Diseases. 2005 March; 32(3):178-84. WHO (2005). Sexually transmitted and other reproductive tract infections- A Guide to essential practice, p-117. National AIDS Control Organisation, India, Sexually transmitted infections- Treatment guidelines. Family Health International (2005), Control of sexually transmitted diseases, chapter 12, The STD Laboratory. Rapid Household Survey RCH Project, (2002), Thane district, International Institute of Population Sciences, Mumbai. Saifur Rahman, et al (2001), Operational Aspects of Syndromic Management of RTIs/STIs at a Primary Healthcare-level Clinic, Centre for Health and Population Research, Bangladesh, ICDDR,B Working Paper No. 151.
2.
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12.
6.
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Errata This is with reference to the article: “District-level Variations in Infant Mortality in Sri Lanka: A Challenge to Achieving the Millennium Development Goal on Child Survival”, published in the Regional Health Forum (RHF) (Volume 10, Number 1, 2006)*. Please note that references to the infant mortality rate (IMR) on Pages 96-98 of the abovequoted issue of RHF have been incorrectly mentioned in percentages instead of in numbers (1000 live births etc.). Hence the sentence (Page 96): “The IMR declined by over 88% from 140% in 1945 to 16.3% per 1000 live births in 1997” should read: “The IMR declined by over 88% - from 140 per 1000 live births in 1945 to 16.3 per 1000 live births in 1997.” Similarly, the sentence (Page 96) following the one quoted in the preceding paragraph should read ”However, Sri Lanka still needs to reduce its IMR by at least two thirds: from 19.5 per 1000 live births in 1990 to 6.6 per 1000 live births in 2015, in order to meet the MDG on child survival by 2015.” Furthermore, the figures of 19.0% (Line 4 – Page 97); and 1.6% and 2.7% (Line 7 – Page 97) 16.3% (Line 8 – Page 97); 4.9% (Line 10 – Page 97); and 18.8% (Line 11 – Page 97) should be read as 19.0; 1.6; 2.7; 16.3; 4.9 and 18.8 per 1000 live births respectively. Also, the figures of 1.7%; 2.7% and 16.3% (Lines 10 and 11 – Page 98) should be read as 1.7; 2.7 and 16.3 respectively. Lastly, please replace the list of “references” published on Page 103 with the following list: 1. 2. 3. 4. 5. Millennium Development Goals www.undp.org/mdg/ Sri Lanka Demographic and Health Survey 2000. Department of Census and Statistics, in collaboration with Ministry of Health, Nutrition and Welfare. Annual Health Bulletin. Ministry of Health, Sri Lanka 2000. National Human Development Report 1998. United Nations, Sri Lanka 1998 Luther N. De Silva S, Gaminirathna K H W, Retherford RD. Consistent Correction of International Migration Data for Sri Lanka. International Migration Review, Vol. XXI No.4 winter 1987: Center for Migration Studies. Darmstadt GL. Lawn JE, Costello A - Advancing the state of the world's newbornsBulletin of WHO -2003 ;.( 81): 3: 224-225). Child and Maternal Mortality in Sri Lanka 1992-1995. Ibrahim GJ. Malaria during pregnancy. Journal of Tropical Pediatrics 1996;42:6263 9. De silva NR, Sirisena JLG, Gunasekera DP, Ismail MM, de Silva SJ. Effect of mebendazole therapy during pregnancy on birth outcome. Lancet 1999;353: 11451149
6. 7. 8. 9.
*
Authors: Rafiqul Huda Chaudhury; Prasanna Gunasekera, and Dulani Gunasekera.
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10. Amarasinghe WI. Influence of prenatal rest to house work on birth weight. 26th Annual Scientific Sessions. Sri Lanka College of Obstetricians and Gynaecologists. July 1993 11. Caesey et al Effects on birth weight and perinatal mortality of maternal dietary supplements in rural Gambia; 5 year randomized controlled trial; British Medical Journal 1997:315:786-790 12. Commentary-reducing perinatal and maternal mortality in the world: the major challenges. British Journal of Obstetrics & Gynaecology 1999; 106:877-880 13. Child Health Research Project, special Report 1999 - "Reducing Perinatal and Neonatal Mortality", Meeting in Baltimore, Maryland, USA 1999 ;3 (1): 10 14. Participatory Nutrition Improvement Project(pNIP) Ministry of Plan Implementation, Sri Lanka, 1997 15. Study on LBW and neonatal morbidity and mortality, Family Health Bureau, Ministry of Health and women's affaires Colombo 1992 16. Gunasekera PC, Chandrasena LG, Gunasekera DP, Sirisena JL- Time we increased Folic Acid consumption in Sri Lanka -Ceylon Medical Journal 1997;42: 159-163 We deeply regret the above-mentioned errors and omissions – Ed.
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Comment
Notes and News World Health Day 2006 “For strong, responsive and equitable health systems, what is needed is political will. Today, there is a global crisis in human resources, a chronic shortage of well-trained health workers. There is an urgent need for countries to invest in their health workforce, which is a vital part of the health systems,” said Dr Samlee Plianbangchang, Regional Director, WHO South-East Asia Region. Speaking on the theme of World Health Day 2006 “Working together for health,” Dr Samlee focused on the need for public private efforts to redress these shortages. He said the way to improve the performance of the health system depends ultimately on improving the knowledge, skills, motivation and availability of human resources. The danger is that even recent health gains would be at risk with a dwindling workforce. Privatization and market economies have eroded free public health care systems. Investment in health is important and unless this is increased, one can expect little improvement in the health workforce. WHO’s South-East Asia Region, with a quarter of the world’s population, has a health workforce of only 12% of the global total. On an average, there are 29 health service providers per 10 000 population in the Region, which is well below the global average of 62. According to Dr Samlee, the key human resource challenges for countries in the Region include a shortfall in the numbers of trained health workers and an imbalance in their distribution, mainly between urban and rural areas. In some countries of the Region, only about 20% of posts for rural physicians are filled compared to 96% in urban areas. The availability of health workers for primary health care varies from a low of three per 10 000 population in India and Myanmar to 25 per 10 000 population in the Maldives. “The media has an important role to play. Journalists can help to place human resources for health (HRH) issues high on the public agenda and generate a debate on the vital importance of the people who make the health systems work,” Dr Samlee added. Recent outbreaks and public health emergencies have demonstrated the critical importance of a robust health system. It is essential for the overall health security of any nation. Only a strong and efficient health system can secure the benefit of progress in new treatments and new technologies. Public health capacity is only as good as the people who constitute it. Increased public knowledge accompanied by a well-trained health workforce could help reduce the burden of diseases, Dr Samlee added. WHO has already taken several steps to rectify this situation in the Region, following the call by the WHO Regional Committee for South-East Asia for developing appropriate national policies in the production, utilization and development of human resources for health.
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WHO has also launched the ‘Public Health initiative: 2004-2008’ and the Ministers of Health in the Region made a commitment in 2005 to prioritize public health in their national agenda. Many Member countries have initiated steps to renew health care skills and medical education.
Strategic health operations centre A Strategic Health Operations Centre (SHOC) was inaugurated at SEARO by the Regional Director, Dr Samlee Plianbangchang, on 20 February 2006. With its state-of-the-art information and communication technology, collaborative workspace and the dedicated team to support operations, the SHOC room is wellequipped to support WHO in responding to public health crises. It is intended as a Regional Alert and Response Coordination Centre. The global public health information and mapping facilities allow dynamic access to health data during an emergency. The plasma screen video-conferencing facilities allow smooth real-time interaction with WHO country offices, WHO headquarters in Geneva, technical partners, other UN agencies, donors and international organizations. With SHOC, coordination of activities by WHO/SEARO will improve sharply following outbreak of an epidemic. SHOC will serve as the 24-hour / 365 day operations support, helpdesk and communications hub for daily briefings allowing real-time information exchange, operations planning and virtual networking, particularly during a crisis.
Briefing on avian influenza pandemic Experts at the WHO Regional Office for South-East Asia last week briefed some members of the international community, including donor agencies, about the situation of avian influenza in the Region. The briefing was held in response to requests from several missions based in Delhi to better understand the situation and to assess the overall risk from avian flu to other countries in the Region. Dr Samlee Plianbangchang, Regional Director, said the Organization was very concerned that if the avian influenza virus underwent mutation or reassortment, it could be the start of an avian influenza pandemic. This would have a devastating impact on the health of millions of people around the globe, with catastrophic implications for global economies. Dr Samlee said the worstaffected would be developing countries where the health infrastructure was not ready or strong enough to tackle the situation. For the past one year, WHO has been working with its 11 Member States in the Region to enhance their preparedness plans to meet the threat of avian influenza. Several intersectoral consultations have been held where experts in areas of animal and human health discussed practical measures that countries could take. On the basis of these consultations, all countries now have preparedness plans, which need to be implemented in order to effectively and efficiently respond to this crisis.
The World Health Assembly mourns the death of Dr LEE Jong-Wook The Fifty-ninth World Health Assembly opened on a sombre note on 22 May 2006 following the death early the same morning of Dr LEE Jong-wook, Director-General of the World Health Organization. Dr LEE, who was 61 and had been in his post since July 2003, died following a sudden illness. Opening the formal proceedings of the Health Assembly, the Minister of Health of Spain, Elena Salgado, said Dr LEE “was an exceptional person and an exceptional Director-General”. The Assembly observed a
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two-minute silence and was suspended for 30 minutes following the announcement of Dr LEE’s death. Dr LEE became Director-General of the World Health Organization on 21 July 2003. Before that, he had worked for more than 20 years for the Organization, first battling leprosy in the South Pacific islands, then tackling vaccine preventable diseases including polio. At WHO Headquarters in Geneva, he also pioneered new ways for people to gain access to tuberculosis medicines and antiretroviral drugs for the treatment of HIV.
Avian influenza and pandemic preparedness The Regional Conference of Ministers of Health, Agriculture and Livestock on Avian Influenza and Pandemic Preparedness opened in New Delhi on 28 July 2006. Speaking on the occasion, Dr Samlee Plianbangchang, Regional Director said, “Today, there is a formidable challenge of emerging diseases. During recent years, we have witnessed the outbreaks of Nipah and SARS. And now, we are facing the threat posed by avian influenza. Basically, avian influenza affects animals, particularly birds and poultry. This virus has been found highly pathogenic, and entrenched in the poultry of several countries in this part of the world.” The Regional Director continued, “These plans are only the blueprints for action. They will remain on paper, unless we implement them. I am glad to report that our Member States have already started implementing their plans. And we have learnt various lessons. It is clear, among others, that, to be successful in implementing the plans, intersectoral collaboration, especially between agriculture and health is of paramount importance. In the countries where these two sectors have collaborated well, the outbreaks in animals and in humans have been contained. We have also learnt that we have to act promptly and effectively in a transparent manner. Member States have re-affirmed the Regional Health Forum – Volume 10, Number 2, 2006
need for transparency in sharing information concerning avian influenza. They have also agreed to voluntary compliance with the relevant provisions in the revised International Health Regulations. To implement the pandemic preparedness plan, an adequate number of trained staff are needed. And we need to have sufficient resources. Today, we are at a critical juncture in the history of human infectious diseases. The influenza virus has been known to have caused major pandemics, with severe health and economic consequences. No one can precisely predict its occurrence. But now, we have some clue of the features of a virus with pandemic potential. If the H5N1 virus undergoes mutation and/or reassortment, it could cause a major devastating pandemic. This is because very few people would be adequately immune against the disease.” Dr Samlee cautioned. “It is believed that, if an avian influenza pandemic begins, there will be a window of only few weeks to take action to contain it. It is really a very short timespan. Therefore, we need to be really well prepared now. The catastrophic impact of not preparing or of inadequate preparation for this pandemic is beyond human imagination. Countless deaths will occur, there will be disruption of travel and commerce, and our major activities will come to a grinding halt. There will also be a tremendous psychosocial impact on the affected population. The participation in this meeting of honourable ministers and partners from diverse areas reflects a clear commitment and dedication to the cause. I wish the Conference all success,” Dr Samlee concluded.
Two important meetings The Fifty-ninth session of the WHO Regional Committee for South-East Asia was held in Dhaka, Bangladesh, from 22 to 25 August 2006. It was attended by representatives of all the eleven Member States of the Region, United Nations and other agencies, non-
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governmental organizations having official relations with WHO, as well as observers. Addressing the joint inaugural session of the Twenty-fourth meeting of Ministers of Health and the Fifty-ninth session of the Regional Committee for South-East Asia in Dhaka on 20 August 2006, H.E. Begum Khaleda Zia, Prime Minister of the People's Republic of Bangladesh, called for stronger and more enduring cooperation among Member countries of the Region to ensure greater equity in delivery of health care. The Prime Minister urged delegates to introduce innovative financing methods to make health care affordable and within reach of all households. The Prime Minister underlined the need for developing countries to be supported in evolving new technology and methods, including technology transfer and revision of patent laws, to ensure availability of cheap and high-quality medicines. While recounting the steady progress in the health sector made by Bangladesh, H.E. Begum Khaleda Zia acknowledged the important contribution made by WHO in supporting the key national health programmes. In his address, Dr Samlee Plianbangchang, Regional Director, WHO South-East Asia Region, singled out the spread of avian influenza throughout the world as the most daunting health challenge. Stating that efforts to control it could not be made in isolation, without the cooperation of neighbouring countries and the international community, the Regional Director called for continued vigilance by all for every hint and sign of the virus changing its behaviour. Dr Samlee emphasized the importance of addressing the Millennium Development Goals (MDGs) towards achieving poverty reduction. He underlined the importance of strengthening the public health infrastructure by producing a balanced health workforce,
paying attention to health promotion and focusing on disease prevention and control. He emphasized that placing health services at the grassroots level would ensure that the health benefits reached the poor, the marginalized and the underprivileged. In his welcome address, H.E. Dr Khandaker Mosharraf Hossain, Minister of Health and Family Welfare, Government of Bangladesh committed, on behalf of the health ministers, to advance regional cooperation in health, and to take steps to ensure that the health-related MDGs can be achieved by 2015. Besides discussing the Regional Director’s Annual Report, the Regional Committee deliberated upon several important issues having regional implications including: Regional strategy for health promotion: Follow-up of sixth global conference on health promotion; Alcohol consumption control: Policy options in the South-East Asia Region; Regional initiatives for eradication/ elimination of tropical diseases; Strengthening health workforce in SEAR countries; International trade and health; Regional Strategic Plan for Human Resource Development and Proposed Regional Programme Budget 2008-2009.
Global patient safety challenge A meeting on Global Patient Safety Challenge 2005-2006: Clean Care is Safer Care was held in Dhaka, Bangladesh, on 17 September 2006. The WHO Representative to Bangladesh, Dr Duangvadee Sungkhobol delivered the Regional Director’s opening remarks. “T h e theme, Clean Care is Safer Care is very appropriate indeed. Health careassociated infections are also known as nosocomial infections. These infections constitute a major issue of patient safety worldwide. At any given time, more than 1.4 mil-
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lion people around the world become seriously ill from health care-associated infections. In industrialized nations, it is estimated that 5–10% of hospitalized patients acquire these infections. Overcrowding and understaffing in health care facilities contribute to the perpetuation of this problem. In some developing countries, the proportion of patients affected by health care-associated infections can exceed 25%. Such infections contribute to patient deaths and disability; and delay the recovery of patients,” Dr Samlee said. “We need to introduce proper concepts on patient safety in all pre-service, in-service and continuing education programmes for all health staff, including community health workers. Patient safety should be an integral component of training in medical ethics. Patients and communities must be engaged as active partners in the process to ensure patient safety,” Dr Samlee added. “In closing, I would like to commend Bangladesh for committing to this Challenge; and setting a powerful precedent for other countries in the Region. I would like to reiterate WHO’s full support to Bangladesh in taking forward the patient safety movement. Let us work together to prevent healthcareassociated infections − a big step towards making patient care in our Region safer,” concluded Dr Samlee.
tality. The burden of maternal and neonatal morbidity and mortality including stillbirths is enormous. In absolute numbers, approximately 510 000 maternal deaths are reported every year globally, of which the South-East Asia Region accounts for 171 000. About 37 million children are born in the South-East Asia Region every year. Unfortunately, over 3.1 million do not live to see their fifth birthday. Nearly half of these i.e. 1.4 million, die in the first four weeks of life, while an equal number of stillbirths go unnoticed. About 30% of newborns in the Region weigh less than 2500 grams. Poor maternal nutrition, short birth-intervals and inadequate care during pregnancy are some of the reasons for this. Mortality rates in lowbirth-weight babies are significantly higher than in the normal weight babies. The Region needs to address these issues seriously.” “I am convinced that we are moving in the right direction and that with our collective efforts we would be able to make a difference in the lives of mothers and their babies. I wish you a successful and satisfying training experience at the end of which, I am sure, we will have a pool of experts in the Region to take the agenda of newborn health successfully forward in our Member States,” Dr Samlee concluded.
Declaration of yaws elimination from India A meeting was organized on 19 September 2006 in New Delhi for the “Declaration of Yaws Elimination from India.” Speaking on the occasion, the Regional Director, Dr Samlee Plianbangchang, congratulated the Government of India on the laudable achievement. “It is indeed an important milestone in the field of public health in India,” he said, to a host of dignitaries including Dr Anbumani Ramadoss, Honourable Minister of Health and Family Welfare, Government of India.
Training of trainers on the WHO essential newborn care course A Training of Trainers on the WHO Essential Newborn Care Course for Bangladesh, Bhutan, DPR Korea, Nepal and Timor-Leste was held in Dhaka, Bangladesh, from 10-14 September 2006. The WHO Representative to Bangladesh, Dr Duangvadee Sungkhobol delivered the Regional Director’s address. “Many countries in the Region are grappling with high maternal mortality – one pervasive consequence of which is high neonatal morRegional Health Forum – Volume 10, Number 2, 2006
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The Regional Director also stated that the achievement of yaws eradication in India will serve as a model to other endemic countries in the South-East Asia Region. In addition to the health impact, this success will contribute significantly to poverty reduction. This is because yaws is predominantly a disease of extreme poverty, affecting the most marginalized groups, in remote and hard-toreach-areas. The other control programmes, particularly those for neglected diseases, like kala-azar, lymphatic filariasis, and trachoma, can benefit from these lessons.
“The Fifty-ninth session of WHO’s Regional Committee for South-East Asia in August 2006 adopted a resolution calling for intensified efforts of all stakeholders to eliminate or eradicate tropical diseases from the Region. This resolution is another springboard for WHO and its Member States in this Region to further strengthen their collaboration in the fight against these diseases,” Dr Samlee concluded.
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Publications Corner Children’s health and the environment: developing action plans [ISBN/Document No. 9289013745; Ind. Rs. 840] Investing in children’s health is essential to ensure human and economic development. Healthy children have the best chance for healthy, productive lives. At the Fourth Ministerial Conference on Environment and Health in 2004, the countries in the WHO European Region committed themselves to building a healthy future for the Region's children by adopting the Children's Environment and Health Action Plan for Europe. It provides a framework for action by the 52 diverse countries in the Region. This book was written to provide the guidance and tools that countries need to carry out the Action Plan at local and national levels and Region-wide. The aim is to transform the framework document into national action plans suited to each country’s circumstances, priorities and resources. The book has three parts. Part I provides the scientific evidence on children's susceptibility to environmental risk factors, and an overview of environmental risk factors and their effects on children's health. Part II is the core of the publication: tables proposing child-specific actions and therefore concrete ways in which a country can work to reduce children's exposure to environmental risk factors and improve their health. This gives countries the opportunity to act on their own national priorities, while still addressing Region-wide environmental risk factors. Part III focuses on the tools required to ensure implementation of national action plans: setting priorities; building partnerships; taking a precautionary approach to uncertain risks; carrying out strategies for advocacy and information, education and communication; and using indicators to monitor progress at national and regional levels. This publication is intended to act as a handbook for countries to use in building a safe and healthy future for all of Europe's children.
Atlas: Epilepsy care in the world, 2005
[ISBN/Document No. 9241563036; Ind. Rs. 600] This atlas is one of the most comprehensive compilations of available resources for epilepsy ever attempted, providing an illustrative presentation of information on the current status of epilepsy services and care available from 160 countries covering 97.5% of the world’s population. The data confirm what professionals in the field of epilepsy have known for a long time that epilepsy care is grossly inadequate compared with the needs in most countries: “When it comes to epilepsy care, most countries are developing countries.”
The World Health Report 2006 - Working Together for Health Geneva: World Health Organization, 209 pages. ISBN: 9241563176 ISBN: 9789241563178 ISSN: 1020-3311 Hardcopy available on loan at: SEARO Library The World Health Report 2006 - Working Together for Health contains an expert assessment of the current crisis in the global health workforce and ambitious proposals 41
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to tackle it over the next ten years, starting immediately. The report reveals an estimated shortage of almost 4.3 million doctors, midwives, nurses and support workers worldwide. The shortage is most severe in the poorest countries, especially in subSaharan Africa, where health workers are most needed. Focusing on all stages of the health workers' career lifespan from entry to health training, to job recruitment through to retirement, the report lays out a ten-year action plan in which countries can build their health workforces, with the support of global partners. Table of contents Overview Chapter 1: Health workers: a global profile Health workers are people whose job it is to protect and improve the health of their communities. Together these health workers, in all their diversity, make up the global health workforce. This chapter gives an overview of what is known about them. It shows that there is a substantial shortage of health workers to meet health needs, but that shortages are not universal, even across low income countries. The chapter then considers how much it would cost to scale up training to meet this shortfall and pay health workers subsequently. Chapter 2: Responding to urgent health needs This chapter identifies some of the most important performance challenges facing health systems and the global health workforce today, examines the ways in which the health workforce is meeting them, and suggests how these responses can be improved. These challenges are, first, to scale up interventions to attain the health-related MDGs; second, to shift successfully to communitybased and patient-centred paradigms of care for the treatment of chronic diseases; third, to tackle the problems posed by dis-
asters and outbreaks; and fourth, to preserve health services in conflict and postconflict states. Chapter 3: Preparing the health workforce The previous chapter provided an overview of the enormous challenges facing the health workforce. Chapter 3 and the following two chapters deal with many of these challenges, using the framework of strategies to train, sustain and retain the workforce. This chapter is about preparation: getting it right at the beginning; giving the right training to the right people to create an effective workforce for the delivery of health care. Chapter 4: Making the most of existing health workers A country’s health workforce is made up of health workers who are at many different stages of their working lives; they work in many different organizations and under changing conditions and pressures. Whatever the circumstances, an effective workforce strategy has to focus on three core challenges: improving recruitment, helping the existing workforce to perform better, and slowing the rate at which workers leave the health workforce. Chapter 5: Managing exits from the workforce Each year, substantial numbers of health workers leave the health workforce, either temporarily or permanently. These exits can provoke shortages if workers who leave are not replaced, and such shortages compromise the delivery and quality of health services (1, 2). Chapter 3 discussed the routes new workers take into the workforce; this chapter examines the other end of the spectrum – the various ways in which workers depart active service. Finally, it reviews and analyses the factors that influence exits and proposes strategies for managing them.
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Chapter 6: Formulating national health workforce strategies The ultimate goal of health workforce strategies is a delivery system that can guarantee universal access to health care and social protection to all citizens in every country. There is no global blueprint that describes how to get there – each nation must devise its own plan. Effective workforce strategies must be matched to a country’s unique situation and based on a social consensus. Chapter 7: Working together, within and across countries There are five broad areas of concern that impel countries to look beyond their borders and work together with others in order to address issues of human resources for health more effectively.
water and quality; treatment efficiency; monitoring water quality in storage and distribution; surveillance and investigation of contamination events and waterborne outbreaks; and analytical methods.
SARS: How a gobal epidemic was stopped
WPRO Nonserial Publication [ISBN 92 9061 213 4; CHF 40.00 / US$ 36.00, Developing countries: CHF 20.00] SARS caused more fear and social disruption than any other disease of our time. While it killed a relatively small number of people, it nevertheless buckled economies, crippled international trade and travel, and emptied the streets of some of the world’s most prosperous cities. Where did this frightening disease come from? How did it spread? And will the world be any better prepared if it returns? For the first time, these and other questions are answered in this remarkable inside account of what really took place in those fateful months of 2003 when Severe Acute Respiratory Syndrome threatened to engulf the world. Written largely by public health experts and scientists who were in the thick of the battle, this book traces the ways in which the virus spread, how close it came to bringing public health systems to their knees and how, in the end, an unprecedented global coalition stopped it in its tracks. For health specialists, this book will serve as an indispensable guide to the science of SARS providing a detailed account of the clinical symptoms associated with the disease, the unravelling of the genetic secrets of the SARS coronavirus and the development of vaccines and diagnostics. This book is published by the World Health Organization’s Regional Office for the Western Pacific, the geographical zone where 95% of the more than 8000 global
Assessing microbial safety of drinking water, improving approaches and methods [ISBN 92 4 154630 1; Ind Rs.945/-] Inadequate drinking water and sanitation are among the world’s major causes of preventable morbidity and mortality. This book provides a state-of-the-art review on approaches and methods used in assessing the microbial safety of drinking-water. It supports the rapidly emerging trend towards preventive management and a broader, system-wide outlook. It supports a framework for water safety which extends from resource to consumer and is based on rigorous risk assessment and risk management. The book offers guidance on the selection and use of available indicators alongside operational monitoring to meet specific information needs. It looks at potential applications of “new” technologies and emerging methods. The book includes chapters by eminent authorities/recognized experts dealing with aspects of: parameters for assessing water quality; assessment of risk; catchment characterization and source
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SARS cases occurred and where 12 countries or areas were hit, some with devastating force.
Evaluation of certain food contaminants Sixty-fourth report of the joint FAO/WHO expert committee on food additives WHO Technical Report Series, No 930
The Guidelines are used by countries worldwide as a scientific basis for standardsetting and regulation and are used extensively by professionals and local decisionmakers. They supersede five editions of guidelines and of previous International Standards. This fully-revised third edition includes expanded coverage on systematic drinking water safety assessment and management. It describes a “Water Safety Framework” encompassing complementary functions of national regulators, water suppliers and independent surveillance agencies. The “Water Safety Plan” provides a comprehensive approach to assist suppliers in water safety management.
[ISBN 92 4120930 5 Order No.11000930; Price CHF 40.00 / US$ 36.00; Developing countries: CHF 28.00] This report represents the conclusions of a Joint FAO/WHO Expert Committee convened to evaluate the safety of various food contaminants with the aim to advise on risk management options for the purpose of public health protection. The first part of the report contains a general discussion of the principles governing the toxicological evaluation of contaminants and assessments of intake. A summary follows of the Committee’s evaluations of technical, toxicological and intake data for certain food contaminants (acrylamide, ethyl carbamate, inorganic tin, polybrominated diphenyl ethers and polycyclic aromatic hydrocarbons). Cadmium was assessed to determine the impact of different maximum limits on intake. Annexed to the report are tables summarizing the Committee s recommendations for intakes and toxicological evaluations of the food contaminants considered and a description of the statistical methods for dose-response modelling that were applied at this meeting.
Researching violence against women: a practical guide for researchers and activists [ISBN 92 4 154647 6; CHF 50.00 / US$ 45.00] This practical manual has been developed in response to the growing need to improve the quality, quantity, and comparability of international data on physical and sexual abuse. It outlines some of the methodological and ethical challenges of conducting research on violence against women and describes a range of innovative techniques that have been used to address these challenges. It will be useful for those interested in pursuing research on violence against women, particularly in developing countries and other resource-poor settings. This manual is written for ‘those interested in the application of social science and public health research methods to the study of gender-based violence. It is designed for researchers who want to know more about adapting traditional research techniques to the special case of investigating physical, sexual and emotional abuse. And it will also be relevant to activists, community workers and service providers
Guidelines for drinking-water quality, Vol. 1: Recommendations; 3rd edition
[ISBN/Document No. 9241546387; Ind. Rs. 1225; Order no. 1150567] This new edition of WHO’s Guidelines for Drinking Water Quality provides a state-ofthe art perspective on issues of water quality and health and on effective approaches to water safety management.
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who want to become conversant in methodological issues.
national Decade for Action, Water for Life: 2005-2015.
WHO drug information, Vol. 20, No. 1 2006 [Order Number 11902001; Price CHF 33.00 / US$ 29.70; Developing countries: CHF 23.10] WHO Drug Information communicates pharmaceutical information that is either developed and issued by WHO or transmitted to WHO by research and regulatory agencies throughout the world. The journal also includes regular presentations of newly proposed and recommended International Nonproprietary Names (INN) for Pharmaceuticals Substances.
Cancer control: knowledge into action. WHO guide for effective programme planning: Nonserial publication [ISBN-13 9789241546997 ISBN-10 9241546999; Order Number 11500674; Price CHF 15.00 / US$ 13.50; Developing countries: CHF 10.50] The World Health Organization estimates that 7.6 million people died of cancer in 2005 and 84 million people will die in the next 10 years if action is not taken. More than 70% of all cancer deaths occur in lowand middle-income countries, where resources available for prevention, diagnosis and treatment of cancer are limited or nonexistent. Yet cancer is to a large extent avoidable. Over 40% of all cancers can be prevented. Some of the most common cancers are curable if detected early and treated. Even with late cancer, the suffering of patients can be relieved with good palliative care. Cancer control: knowledge into action, WHO guide for effective programmes is a series of six modules offering guidance on all important aspects of effective cancer control planning and implementation.
WSH CD-ROM Water, sanitation and health electronic library, Fourth edition, A compendium of WHO information on water, sanitation and health [ISBN 92 4 056024 6; Order Number 09904013] The Water, Sanitation and Health Electronic Library, Fourth Edition, includes more than 220 documents of new and current publications. The documents provide information on water supply and sanitation, recreational/ bathing waters, achieving the Millennium Development Goals on water, sanitation and hygiene, drinking-water quality, water resources management and health-care waste. Included are full text books and guidelines, facts sheets, facts and figures, posters, advocacy materials and other information products. The CD ROM is intended to assist all those interested in water, sanitation and health by providing them with comprehensive up-to-date information. Users include public health specialists, scientists, policymakers, practitioners, academics, and nongovernmental organizations in developing and developed countries. By assisting these and other user groups the electronic library is intended to contribute towards the Inter-
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Guidelines for Contributors THE Regional Health Forum seeks to inform and to act as a platform for debate by health personnel including policy-makers, health administrators, health educators and health communicators. Contributions on current events, issues, theories and activities in all aspects of health development are welcome. Contributions should be original and contain something of interest to those engaged in health policy and practice, some lesson to be learned, some idea, something that worked, something that didn't work, in fact anything that needs to be communicated and discussed on a broader scale. Articles, essays, notes, news and views across the spectrum of health development will be published. Every year, the April issue of the Forum is dedicated to the World Health Day theme of the year. Readers may send contributions relating to the theme for inclusion in the special issue. Papers for submission should be forwarded to the Editor, Regional Health Forum, World Health Organization, Regional Office for South-East Asia, World Health House, Indraprastha Estate, Mahatma Gandhi Road, New Delhi 110002, India (E-mail address: editor@searo.who.int). Contributions should: • • • • be in English; be written in an anecdotal, informal, lively and readable style (so that sophisticated technologies, for example, may be easily understood); be in MS Word and sent on-line to editor@searo.who.int not normally exceed 3 000 words with an abstract (approx. 250 words) and a maximum of 30 references. Letters to the editor should normally be between 500-1000 words with a maximum of six references.
Responsibility of the Authors Authors are responsible for: • • • ensuring that their contributions contain accurate data and references (and are requested to check the accuracy of both before submission); obtaining permission to use copyrighted material (if used). The letter granting such permission should be attached to the manuscript when submitted; obtaining permission from appropriate governmental authorities if the contribution pertains to a government programme/project and contains material/statistics/data derived from government sources; ensuring that all abbreviations (if used) are explained; Regional Health Forum – Volume 10, Number 2, 2006
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• • •
giving their full names, the name and address of their institutions, and an exact description of their posts; declaring sources of funding for the work undertaken, and disclosing at the time of submission, information on financial conflict of interest that may influence the manuscript. They may also choose to declare other interests that could influence the results of the study or the conclusions of the manuscript. Such information will be held in confidence while the paper is under review, and if the article is accepted for publication the editors will usually discuss with the authors the manner in which such information is to be communicated to the reader.
Tables and Illustrations • • • • • The use of tables and illustrations should be restricted to those that clarify points in the text. All illustrations and tables should be numbered consecutively and should be lightly marked on the back with the figure number, and the author's name indicated. Graphs and figures should be clearly drawn and all data identified. Photographs should be on glossy paper, preferably in black and white. Each table should be submitted on a separate sheet of paper.
References • • • References should be numbered consecutively as they occur in the text. Journal titles should be written out in full (i.e. not abbreviated). A reference to a contribution in a book should include the chapter title and page range.
Reprints Reprints of contributions are not produced but five printed copies of the issue will be supplied to the respective authors. An electronic version of the article in PDF format may also be made available to authors if they provide their e-mail addresses.
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How to order WHO Publications New WHO publications are issued frequently. Requests for information about WHO publications and orders should be addressed to the nearest sales agent (listed below) or to WHO, New Delhi. Orders sent to New Delhi must be accompanied by payment in the form of a demand draft/Indian postal order/money order (prices include handling and postage charges). Orders from countries other than India can be addressed to the Sales agent or WHO Representative in that country and are payable in local currency: INDIA Southern India M/s New Century Book House (P) Ltd. 136 Anna Salai Chennai 600 002, TAMIL NADU Western India M/s Consumer Communications 52, Shafi Estate, Amar Mahal Chembur Mumbai 400 089, MAHARASHTRA M/s K.M. Varghese & Company Medical Book Distributors & Publishers 104 Hind Rajasthan Building Dadasaheb Phalke Road, Dadar Mumbai 400 014, MAHARASHTRA Eastern India M/s Insales India (P) Ltd. 1C/1&2, Camac Court 25-B, Camac Street Calcutta 700 016, WEST BENGAL BANGLADESH Ahsania Mission Book Distribution House House No. 1/A, Road No. 13, Dhanmondi R.A. (Mirpur Road) 1st Floor, Dhaka - 1209 Email: dam@drik.bgd.toolnet.org INDONESIA M/s C.V. Sagung Seto Jalan Pramuka No. 27 P.O. Box 4661 Jakarta 10001 NEPAL Everest Media International Services (P) Ltd. Shanti Nagar-34 Block No. Kha-1-248 New Baneswar, Kathmandu THAILAND Suksit Siam Co. Ltd 113, 115 Fung Nakhon Road Opp. Wat Rajbopith Bangkok 10200
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