Draft report of the Regional Committee

l , WORLD HEAL TH ORGANIZA TlON REGIONAL OFFICE FOR AFRICA

ORGANISATION MONDIALE DE LA SANTE BUREAU REGIONAL DE L'AFRIQUE

ORGANIZAÇÀO MUNDIAL DE SAUDE SEOE REGIONAL AFRICANA

REGIONAL COMMITTEE FOR AFRlCA

AFRlRC49118 3 September 1999 ORIGINAL: ENGLISH

Forty-ninth session Windhoek. Namibia, 3. August - 3 September 1999

DRAFT REPORT OF THE REGIONAL COMMITTEE

CONTENTS PARTI PROCEDURAL DECISIONS RESOLUTIONS AFRlRC49/Rl Nomination of the Regional Director AFRIRC491R2 Health sector refonn in the WHO African Region: Status ofimplementation and perspectives AFRlRC491R3 Regional strategy for mental health AFRlRC491R4 Integrated management of childhood illness (IMCI): Strategie plan for 20002005 AFRIRC491R5 Essential drugs in the WHO African Region: Situation and trend analysis AFRlRC491R6 Review of the implementation of the Bamako Initiative AFRlRC491R7 Regional Health-for-A11 Policy for the twenty-first century : Target 2020 Vote ofthanks

AFRlRC491R8

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.PART II Paragraphs OPENING CEREMONY .. .. .. . . ORGANlZATION OF WORK . ... .... . ... . . .. . ... 1 - 50

. ..... 51 -60 51 52 58 59 60

Constitution of the Subcommittee on Nominations ................... . .. . ....... Election of the Chairman, Vice-Chairmen and Rapporteurs . . . . . . . . . . . . . . . . . . . . . . . . Appointment of Members of the Subcommittee on Credentials . ...... . . . . ..... .. 53 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. Adoption of the Agenda . ...... ..... . .. . . . . . . .. Adoption of the hours ofwork ........

THE WORK OF WHO IN THE AFRlCAN REGION: ANNUAL REPORT OF THE REGIONAL DIRECTOR FOR 1998 .......................... . ...... 61 - 164 . . . . .. ..... ...... ...... . . . . ... .. . . . . ...... 61 - 67 Introduction ... . General programme development and management . . . ............ 68 - 91 Health services and systems development ... .. .. . . .. . .. .. . . 92 -104 105 - III Reproductive and family health .... ....... . '. . . . . . . . . . . . . . . . . . . . . Prevention and control of communicable diseases . . . . . .. .. .. . ... . . . . . . 1 12 - 126 Healthy environments and sustainable development ... . .... . . .. . . ... .. .. ... 127 - 131 Prevention and control of noncommunicable diseases . ... . ..... .. . ...... .. . . 132 - 148 Extemal coordination and programme promotion .. . . . . . . . . . . . . . . . . . . . . . . .. 149 - 157 Administration and finance ....... ..... ....... . . . . . . . . . . . . . . . . . . . . . . .. 158 - 164 NOMINATION OF THE REGIONAL DIRECTOR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 165

CORRELATION BETWEEN THE WORK OF THE REGIONAL COMMITTEE, THE EXECUTIVE BOARD AND THE WORLD HE AL TH ASSEMBL y . . ... .. Ways and means of implementing resolutions ofregional interest adopted by the World Health Assembly and the Executive Board Agendas of the one hundred and fifth session of the Executive Board and the Fifty-third World Health Assembly: Regional implications . . ........ . Method ofwork and duration of the World Health Assembly REPORT OF THE PROGRAMME SUBCOMMITTEE

166-176

.... 167 - 169

170 - 172 173 - 176 177 - 249

Health sector reform in the African Region: Status of implementation and perspectives . ..... .... ... . ... . ..... . . . . . . . . . . . . . . . . . . . . 181 - 193 Regional health-for-all policy for the 21" century ... . ............ . ........ 194 - 202

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•• Paragraphs CONTENTS Regional strategy for mental health ................ . . . ..... . .. . . . .. .... Integrated management of childhood ilIness (IMCI): ............ . ............... . .. .. . Strategic plan for 2000-2005 Essential drugs in the WHO African Region : Situation and trend analysis . ...... . . ............ . Hea1th technology policy in the African Region . . . .. . . .. Review of the implementation of the Bamako Initiative : . . .. .. . . ... REPORT ON THE TECHNICAL DISCUSSIONS .. 203 • 208 209 - 216 217 - 224 225 - 235 236 - 249

. ....... . ... ' 250 -254

Choice of Subject for Technical Discussions in the Year 2000 . . .. . . .. .... . ... . 255 Nomination of the Chairman and the A1temate' Chairman of the 2000 256 Technical Discussions DATES AND PLACES OF THE FIFTIETH AND FIFTY-FIRST SESSIONS OF THE REGIONAL COMMITTEE .. . ... . . . .. . .. . . . ....... . .. .. . . . .. . . ... . 257 Nomination of Representatives of the African Region to the Policy and Coordination Committee (pCC) of the Special Programme ofResearch, Development and Research Training in Human Reproduction (HRP) . .. . .... . ... .. ..... . . . .. .. . .. 258

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PROCEDURAL DECISIONS Decision 1: Composition ofthe Subcommittee on Nominations The Subcomrnittee on Nominations met on Monday, 30 August 1999 and was composed of the representatives of the following Member States: Angola, Botswana, Comoros, Republic of Congo, Côte d' Ivoire, The Gambia, Liberia, Mozambique, Rwanda, Senegal, South Africa and Zambia. The Subcommittee elected Dr Léon Alfred Obirnbat, Minister of Health, Solidarity and Humanitarian Action of the Republic of Congo, as its Chairperson.

Decision 2: Election of the Chairman, Vice-Chairmen and Rapporteurs After considering the report of the Subcommittee on Nominations, and in compliance with Rule 10 of the Rules of Procedure and resolution AFRlRC23/R l, the Regional Committee unanimously elected the following officers:

Chairman:

Dr Libertina Amathila Minister ofHealth and Social Services Namibia Mr Faustin Boukoubi Minister of Health and Population Gabon Mme Diakite Fatoumata N'diaye Minister of Health, the aged and solidarity Mali Dr Salih Meky Minister of Health Eritrea Mme Prof. Ratsirnbazafimabefa Rahantalalao Henriette Minister of Health Madagascar Mme Rosa Maria Silva Director-General of Health Cape Verde

First Vice-Chairman:

Second Vice-Chairman:

Rapporteurs:

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Decision 3:

Composition of the Subcommittee on Credentials

The Regional Committee, in accordance with Rule 16 of the Rules of Procedure, appointed a Subcommittee on Credentials consisting of representatives of the following 12 Member States: A1geria, Benin, Cameroon, Democratic Republic of Congo, Malawi, Mauritius, Niger, Sao Tome & Principe, Swaziland, Seychelles, Togo and Uganda. The Committee on Credentials met on 30 August 1999. Delegates of the foUowing Member States were present: A1geria, Benin, Cameroon, Democratic Republic of Congo, Malawi, Mauritius, Niger, Sao Tome & Principe, Swaziland, Seychelles, Togo and Uganda. It elected Mr Jacquelin Dugasse, Minister of Health of Seychelles, as its Chairperson. Decision 4: Credentials

The Regional Committee, acting on the proposaI of the Subcommittee on Credentials, recognized the validity of the credentials presented by representatives of the following Member States: A1geria, Angola, Benin, Botswana, Burkina Faso, Burundi, Cameroon, Cape Verde, Central African Republic, Chad, Comoros, Republic of Congo, Côte d'Ivoire, Democratie Republic of the Congo, Equatorial Guinea, Eritrea, Ethiopia, Gabon, The Garnbia, Ghana, Guinea, Guinea Bissau, Kenya, Lesotho, Liberia, Madagascar, Malawi, Mali, Mauritania, Mauritius, Mozambique, Namibia, Niger, Nigeria, Rwanda, Sao Tome & Principe, Senegal, Seychelles, Sierra Leone, South Africa, Swaziland, Togo, Uganda, United Republic ofTanzania, Zarnbia and Zimbabwe, and found them to be in order. Decision 5: Replacement of members of the Programme Subcommittee

The term of office of the following countries wiU expire with the c10sure of the forty-ninth session of the Regional Committee: Rwanda, Sao Tome & Principe, Senegal, Seychelles, Sierra Leone and Swaziland. They will be replaced by Angola, Benin, Botsy ·ana, Burkina Faso, Burundi and Cameroon. Decision 6: Agenda of the fiftieth session of the Regional Committee

The Regional Committee approved the Provisional Agenda of the fiftieth session of the Regional Committee. Decision 7: Agendas of the I05th session of the Executive Board and the Fifty-third session of the World Health Assembly

The Regional Committee took note of the provisional agendas of the 105th session of the Executive Board and the 53rd session of the World Health Assembly.

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• 3 Decision 8: Method of work and duration of the Fifty-second World Health Assembly

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President of the World Health Assembly 1. The Chairman of the forty-ninth session of the Regional Committee for Africa will be designated as the President of the Fifty-third session of the World Health Assembly to be held in May 2000. The last time the African Region designated a President of the World Health Assembly was in May 1994.

Main committees of the World Health Assembly 2. The Director-General, in consultation with the Regional Director will, if necessary, consider before each World Health Assembly, the delegates ofMember States of the African Region who rnight serve effectively as: Chairpersons of the Main Committees A and B (Rule 34 of the Health Assembly's Rules of Procedure); Vice-Chairpersons and Rapporteurs of the main committees.

Members entided to designate persons to serve on the Executive Board 3. Following the usual English alphabetical order, Chad, Comoros, Republic of the Congo and Côte d'Ivoiredesignated persons to serve on the Executive Board starting from the session ofEB 104, immediately after WHA52, joining Burundi, Cape Verde and Central African Republic from the African Region. 4. The term of office of Burundi will expire with the closure of WHA53 . Burundi will be replaced by Equatorial Guinea which will attend the 106th session of the Executive Board. 5. The Member State entitled to designate persons to serve on the Executive Board (Equatorial Guinea) should confirm its availability at least six weeks before the Fifty-third World Health Assembly. 6. By Resolution WHA51.26, the Fifty-first World health Assembly decided that Member States entitled to designate a representative to the Executive Board should designate them as government representatives, technically qualified in the field of health.

Informai meeting of the Regional Committee 7. The Regional Director will convene this meeting on Monday, 15 May 2000, at 08.00 a.m. at the Palais des Nations, Geneva, to confirm the decisions taken by the Regional Committee at its forty-ninth session.

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Decision 9: Choice of Subject for the Technical Discussions in 2000 The Regional Committee decided at its forty-seventh session, to continue to hold Techrùcal Discussions alongside its sessions. The Regional Committee, therefore, chose "Reducing maternai mortality: A challenge for the twenty-first century" as the subject for the Techrùcal Discussions in 2000. Decision 10: Dates and places oftbe fiftietb and fifty-first sessions oftbe Regional Committee The Regional Committee, in accordance with the Rules of Procedure, accepted to hold its fiftieth session in Ouagadougou, Burkina Faso, in August 2000. Concerning the fifty-first session, the Republic of the Congo made an offer to host the meeting. The Regional Committee will take a decision on this invitation at its fiftieth session. Decision Il: Nomination of Representatives of the African Region to the Polieyand Coordination Committee (PCC) of the Special Programme of Research, Development and Research Training in Human Reproduction (HRP)

The term of office of Angola and A1geria will come to an end on 31 December 1999. According to the English alphabetical order, they will be replaced by Burkina Faso and Burundi, which willjoin Benin and Botswana as members of the PCC from 1 January 2000 for a term ofthree years.

Forty-ninth session Windhoek, Namibia, 30 August - 3 September 1999

AFRlRC491R1 1 September 1999 ORIGINAL: ENGLISH

NOMINATION OF THE REGIONAL DIRECTOR

The Regional Committee, Considering Article 52 of the Constitution, and In accordance with Rule 52 ofits Rules of Procedure, 1.

NOMINATES Dr Ebrahim Malick Samba as Regional Director for Africa, and

2. REQUESTS the Director-General to propose to the Executive Board the appointment of Dr Ebrahim Malick Samba for a period of five years from 1 February 2000.

Fourth meeting, 31 August /999

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~~', :,~~~ ~~( \-lt l,I>

Forty-ninth session Windhoek, Namibia, 30 August - 3 September 1999

AFRlRC491R2 1 September 1999

ORIGINAL: ENGLISH

HEALTH SECTOR REFORM IN THE WHO AFRICAN REGION: STATUS OF IMPLEMENTATION AND PERSPECTIVES The Regional Committee, Recalling that the adoption of the African Health Development Framework and the Bamako Initiative by the Regional Committee in 1985 and 1987, respective!y, marked the lirst regional efforts to reorient and strengthen national health systems in the Region which had been !arge!y weakened by the economic reforms undertaken in response to the economic crisis of the 19805; Noting that most countries of the Region have, since the beginning of the decade, further embarked on reforming their health sectors to enhance their capacity to dea! with the increasing health problems and ultimately improve the health status of the population; Concerned that efforts in this regard are mostly piecemeal rather than comprehensive and that in sorne countnes the efforts are spearheaded by extemal partners rather than governments; Recognizing that for heaJth sector reform to achieve its set goal ofimproving the heaIth status of the population, it must lirst produce changes that will lead to health systems development and strengthening as prere',. '.isites for improving the performance of health services; Having exarnined the Regional Director's report as conta.ined in document AFRIRC4917 on the status of implementation and perspectives ofhealth sector reform in the countnes of the Region; Noting also with satisfaction the efforts that the UN agencies have made, under the leadership of the World Health Organization and the World Bank, to organize intercountry meetings that have enabled all countnes of the Region, which are at varying stages of the health sector reform process, to share expenences on this important subject; 1. 2. ADOPTS the report of the Regional Director; CALLS UPON Member States: (i) to intensify their efforts to undertake appropriate health sector reforms that are in conformity with national health policies;

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AFR/RC49!R2

page 2 (ii) to actively involve ail stakeholders - the private sector, civil society, communities, external partners and government agencies outside the nùnistry of health;

(iii) to ensure that government assumes leadership at every stage of the reform process and secures the necessary support of national and international partners; (iv) to cooperate with one another, within the context of technical cooperation among deve\oping countries, in designing and implementing their he~lth sector reforrns; (v) 3.

to advocate for and promote reforrns on other health-related sectors such that health sector reforms willlead to sustainable health deve\opment.

REQUESTS the Regional Director: (i) (ii) to make a synthesis of the experiences on health sector reforrns as reported by countries of the Region and dissenùnate 1t widely to Member States; to develop, on the basis of the synthesis of experiences, a framework that will guide Member States in designing, implementing and evaluating their health sector reform;

(Îii) to put in place effective mechanisms for providing timely and appropriate support to Member States and for contributing to the strengthening ofnational capacities, infrastructure and technology management in order to ensure sustainable health development; (iv) to take steps to further intensifY the collaboration between World Health Organization, the World Bank, the African Development Bank, and other UN agencies concemed so as to ensure that the implementation of the health component of the UN Special Initiative on Africa facilitates the health sector reforrn process in the individual countries; (v)

to report to the fifty-second session of the Regional Cornrnittee on the progress achieved in implementation of health sector reforrns in Member States and the added value of the implementation of the health component of the UN Special Initiative on Africa;

4. APPEALS to the African Development Bank, bilateral donors and UN agencies including the World Bank, to provide greater support to govemment-Ied health sector reforrn efforts in the countries of the Region. Fi/th meeting, 1 September 1999

Forty-ninth session Windhoek Namibia. 30 August - 3 September 1999

AFRfRC491R3 1 September 1999 ORIGINAL: ENGLISH

REGIONAL STRATEGY FOR MENTAL HEALTH

The Regional Committee, Aware of the magnitude and the public health importance of mental, neurological and psychosocial problems which have been aggravated by the stigma attached to them; Concemed about growing poverty, the increasing frequency of natural disasters, and the escalation of wars and other forms of violence and social disruption which are causing growing psyhosocial problems such as alcohol and drug abuse, prostitution, the phenomenon of street children, child abuse and domestic violence; RecalIing World Health Assembly resolutions WHA28.81 (1975) on the assessment of problems relating to alcohol abuse, WHAJ0.45 (1977) on the creation of the African Mental Realth Action Group, Regional Committee resolution AFRlRC40/R9 (1990) which ca1Jed on Member States to implement community mental health care based on the district health system approach and AFRlRC441R14 (1994) on accelerating the development of mental health in the African Region; Appreciating the efforts already made by Member States and their partners to improve the mental health of their people and prevent and control substance abuse; Recognizing the need to review existing approaches in this area and develop a comprehensive strategie framework for mental health and the prevention and control of substance abuse in the countries of the African Region; Raving carefully examined the report of the Regional Director as contained in document AFRIRC49/9which sets forth WHO 's regional strategy for mental heaIth; 1. APPROVES the proposed strategy aimed at strengthening the capacity ofMember States to improve the quality of life of their people by promoting healthy lifestyles, and preventing and controlling mental, neurological and psychosocial disorders; 2. REQUESTS Member States: (i) to take into account mental health concems in their national health policies and strategies; recognize the need for the multisectoral approach and integrate mental health into their general health services, particularly at the district level, with adequate cornmunity participation;

. AFRfRC49!R3 page 2 (ii) to establish or update national prograllunes and plans of action for the implementation of activities on mental health and the prevention and control of substance abuse, according to their priorities; to promote mental health and healthy behaviour using the commemoration of the World Mental Health Day (10 October). to formulate or review legislation in support of mental health and the prevention and control of substance abuse; to designate a focal point in the ministry of health to manage the mental health programme thus established; to provide financial resources for the implementation of the related activities and consider introducing cost-sharing schemes where appropriate; to intensiiY capacity building, taking into account the mental health dimension, when drawing up national human resources development plans and to use regional health training institutions; to ensure that a research culture is built into their national programmes; to undertake community-based psychosocial rehabilitation interventions, targeting vulnerable and high-risk groups, especially displaced persons, refugees, victims of land mines, health workers and people with chronic mental and neurological conditions as weil as people living with HlV/AIDS;

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(iii) (iv) (v) (vi) (vii)

(viii)

(ix)

3.

REQUESTS the Regional Director: (i) to pro vide technical support to Member States for the development of national policies and programmes on mental health and the prevention and control of substance abuse as weil as elaboration or revision of me'ltal health legislation; to take appropriate measures to enhance WHO' s capacity to provide timely and effective technical support, at regional and country levels, to national programmes on mental health and the prevention and control of substance abuse; to increase support to the training of health professionals in mental health at different levels of the health system and promote the use of traditional medicine within the context of African realities;

(ii)

(iii)

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AFRlRC491R3 page 3 (iv) (v) to facilitate the mobilization of additional resources for the implementation of the mental health strategy in Member States; to elaborate operational plans for implementation of the regional strategy for the period 2000-2001; to report to the 51 st session of the Regional Committee on the progress made in the implementation of the regional strategy for mental health.

(vi)

Fifih meeting, 1 September 1999

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Forty-ninth session Windhoek, Namibia, 30 August - 3 September 1999

AFRlRC491R4 1 September 1999 ORIGINAL: ENGLISH

INTEGRATED MANAGEMENT OF CIIILDHOOD ILLNESS (IMCn: STRA TEGIC PLAN FOR 2000-2005 The Regional Committee, Recalling World Hea1th Assembly resolution WHA48.12 which adopted IMCI in May 1995 as a cost-effective strategy for child survival and development; Recalling the regional Poliey Frameworkfor Teehnieal Cooperation with Member States. in which IMCI was confirmed as an appropriate and effective strategy that should be implemented in the Region; Considering that 70% of childhood deaths are due to acute respiratory infections, diarrhoeal diseases, measles, malaria and malnutrition and that IMCI is an appropriate strategy for controlling these childhood killer diseases; Bearing in mind the spirit of international events such as the 1978 Alma-Ata conference on primary health care, the adoption of the Convention on the Rights of the Child in 1989, and the 1990 World Summit for Children during which government leaders committed themselves to giving the child a better future; Aware of the high infant and child mortality rates in the countries of the Region and the need to support health sector development in a broad setting which provides opportunities for implementing preventive, promotive, curative and rehabilitative interventions; Acknowledging that the integrated strategy to childhood ilIness will help reduce under-five morbidity and mortality and that the strategy is capable of er.hancing cost effectiveness; Considering the present status of implementation ofIMCI in the African Region and the need to give more intensive support for the implementation ofthis strategie plan; Recognizing the invaluable support that multilateral and bilateral cooperation partners have given to the countries to date for IMCI implementation,

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1

1. APPROVES the regional strategie plan for the integrated management of childhood illness (IMCI) as presented in document AFRlRC49/10. 2. CALLS VPON Member States: (i) (ii) to inc\ude the IMCI strategy in national health policies and plans of action; to accelerate !MCI implementation, maintaining a stêp-wise approach and paying attention to quality, particularly dunng the expansion phase; to take the necessary steps to ensure greater availability of human and financial resources, and to strengthen district health systems, for sustainable implementation of the IMCI; to revise their essential drug list in order to facilitate the implementation of the !MCI strategy; to strengthen the nutntional rehabilitation of sick children ;

(iii)

(iv)

(v) 3.

REQUESTS the Regional Director: (i) to provide support to Member States to strengthen and accelerate the implementation ofthe strategie plan; to develop human resources and mobilize regular budget and extrabudgetary resourees to support the implementation of the strategie plan; to monitor the implementation of the strategie plan in the eountnes and faeilitate the shanng of expenenees and lessons learned among the Member States; to report to the fifty-first session of the Regional Committee on the progress made in the implementation of the strategic plan;

(ii)

(iii)

(iv)

4. REQUESTS international and other partners concerned with the implementation ofIMCI in the Afncan Region to intensify their support to the countnes for the implementation of the !MCI strategie plan. Fifth meeting, 1 September 1999

Forty-ninth session Windhoek. Namibia. 30 August - 3 September 1999

AFRlRC491R5 1 September 1999 ORIGINAL: ENGLISH

ESSENTIAL DRUGS IN THE WHO AFRICAN REGION: SITUATION AND TREND ANALYSIS

The forty-mnth Regional Committee, Recalling World Health Assembly resolutions WHA39.27, WHA41.l6, WHA43.20, WHA45.27, WHA47.12, WHA47.I3, WHA47.16, WHA47.17, WHA49.14, WHA52.19, on the WHO revised drug strategy; Regional Committee resolution AFRlRC37/R6 on essential drugs and vaccines; AFRlRC38/R18 on the Bamako Initiative; and AFRIRC38/R19 on local production of essential drugs; Recalling World Health Assembly resolutions WHA22.54, WHA31.33, WHA4 l.l 9, WHA42.43 , WHA44.33 and Regional Cornrnittee resolutions AFRlRC28fR3, AFRIRC33fR3, AFR/RC361R9 on the use of traditional medicines; Concerned about the present situation where over 50% of the population in the Region lack regular access to essential drugs despite the fact that national drug policies exist; Concerned further that prevailing economic difficulties and the effects of structural reforms "ln the social sector ar ' Idversely affeeting access to essential drugs; Noting with satisfaction the establishment for the African Region of the Intensified Essential Drugs Programme to help address present and future challenges in the pharmaceutical sector; Reaffirming the commitment of the Member States to developing, implementing and momtoring national drug polieies and programmes for improving the availability and accessibility of drugs of proven quality and to ensuring their rational use; 1. APPROVES the report of the Regional Director on essential drugs in the WHO African Region;

• AFRlRC49fRS page 2

..

2.

URGES Member States: (i)

to establish mechanisms for consultation between the ministry of health and other relevant ministries on monitoring the impact on access to essential drugs of the globalization of trade, international trade agreements, economie reforms, and health sector reforms; to review, and enforce legislation and regulations pertainipg to the control of the illieit trade in pharmaceuticals and the use oftraditional medicines and recognize generic drug substitution rights of pharmacists wherever applicable; to collaborate with one another, particularly at subregional level, coordinate efforts for local production of essential drugs and implement joint bulk purchasing; to strengthen national drug regulatory authorities an drug quality assurance mechanisms and, where feasible, establish national quality controllaboratories and make effective use of existing regionallaboratories; to collaborate actively with WHO and other partners in the implementation of the Intensified Essential Drugs Programme for the African Region;

(ii)

(iii) (iv)

(v) 3.

REQUESTS the Regional Director: (i) to continue to support Member States in their efforts to deve10p and implement pharmaceuticaJ legislations and regulations, national drug policies and essential drug programmes; to collaborate with Member States in the development of tools, guidelines and methodologies for monitoring and evaluating programmes; to support Member States: (a) in monitoring and analysing the pharmaceutical and public health implications of globalization, regional and international trade agreements such as those in the World Trade Organization (WTO) and on the Trade-Related Aspects of InteUectual Property Rights (TRIPS); in promoting intercountry coUaboration on local production, particularly of generic essential drugs; in undertaking the joint bulk purehasing of drugs; in developing their human resources in the area of pharmaceuticals; in mobilizing resources for the implementation of the Intensified Essential Drugs Programme for the Afiican Region at country level; in carrying out research on medicinal plants and promoting their use in the health care delivery systems;

(ii) (iii)

(b) (e) (d) (e)

(t)

AFRIRC49/RS page 3 (iv) to report to the fifty-first session of the Regional Committee on progress made and problems encountered in the implementation of the Intensified Essential Drugs Programme for the Afiican Region. Fifth meeting. 1 September 1999

Forty-ninth session Windhoek. Namibia. 30 August - 3 September 1999

AFRlRC491R6 1 September ) 999 ORIGINAL: ENGLISH

REVIEW OF THE IMPLEMENTATION OF THE BAMAKO INITIATIVE

The Regional Committee, Recalling Regional Committee resolution AFRlRC371R6 on the improvement of the health of women and children through essential drugs financing and management at the community level; Recalling also the request that the 47th session of the regional Committee made to the Regional Director to undertake a review of the progress made after a decade ofimplementation of the Bamako Initiative; Taking into account the recommendations made during the review of the implementation of the Bamako Initiative in the Afiican Region at the meeting jointIy organized by the Govemment of Mali, WHO and UNICEF in Bamako, Mali, ITom 8 to ) 2 March 1999; Considering the appeal made at the Bamako Initiative review meeting for the provision of support to Member States for continuing the implementation ofthe Initiative; Acknowledging the crucial role of the Bamako Initiative as a pertinent strategy for realizing the goals of primary health care and improving the accessibility and coverage of health services; Having carefully exarnined the report of the Regional Director contained in document AFRlRC49/ 13 : review of the implementation of the Bamako Initiative; 1. 2. RECOGNIZES the significant achievements made by Member States; NOTES the constraints encountered and the lessons learnt in implementing the Bamako Initiative;

3. APPROVES the report of the Regional Director and the proposai to develop an implementation framework for strengthening the community dimension of health sector reform; 4. INVITES Member States: (i) to include the Bamako Initiative in their agenda for health sector reform, and to implement the Initiative as the community dimension of the reform;

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AFRJRC491R6 page 2 (ii) to ensure that national policies and strategies have a strong community focus, empower individuals and farnilies to improve their own health and well-being and develop the capacity of communities to co-manage essentiaJ health services; to develop a new national framework for the implementation of the Bamako Initiative, including an essential package of care adapted to CUITent priority areas such as Roll Back Malaria, the Integrated Management of Childhood Illness, the Safe Motherhood Initiative, HIV/ AIDS and TubercuJosis prevention and control; to enhance equity by promoting national and local solidarity mechanisms for health care financing, especially for the most vulnerable groups such as women, children, adolescents, people living with HIV/AIDS and those living in remote areas; to improve coordination among actors, especially governments, communities and partners, in the implementation, monitoring and evaluation of the Bamako Initiative;

(iii)

(iv)

.

(v)

5.

REQUESTS the Regional Director: (i) to develop a new implementation framework in which the Bamako Initiative will be linked with income-generating activities at the community level, and, with the support of governments, to operationalize the framework by contributing to poverty alleviation and sustainable development; to further promote community and home-based health interventions for priority public health programmes and initiatives, e.g. Roll Back Malaria, Integrated Management of Child Illness, the Safe Motherhood Initiative, TubercuJosis and HIV1AIDS prevention and control; to set up a mechanism with other partners, particularly UNICEF, for improving coordination and support to Member States for the implementation, monitoring and evaluation of the Bamako Initiative; to report to the 52"d session of the Regional Committee on the progress made in the implementation of the new framework for the Bamako Initiative;

(ii)

(iii)

(iv)

6. APPEALS to partners to intensif)< their support to Member States for the implementation of the Bamako Initiative in the context of the overall development of the national health sector.

Fifth meeting, 1 September 1999

Forty-ninth session Windhoek, Namibia, 30 August - 3 September 1999

AFRlRC491R7 1 September 1999 ORIGINAL: FRENCH

REGIONAL HEALTH-FOR-ALL POLICY FOR T~ 21ST CENTURY TARGET 2020 The Regional Committee, Confirming the relevance of the principles and values underpinning the primary health care approach to the irnplernentation of the health-for-all policy and the fact that they are a source of inspiration for African countries; Considering the magnitude and persistence of health problems created by communicable diseases, particularly HIV/AIDS, complications of pregnancy and childbirth, the numerous childhood diseases, mental health, environrnents that adversely affect health, risky lifestyles and behaviours, ineffectiveness of health services, complex emergencies, armed conflicts and their tragic impact on African populations; Convinced, at the dawn of the third millennium, about the need to propose to African nations a frame of reference for national health development policies capable of providing lasting solutions to the various health problems that the countries are facing; Considering the adoption by the World Health Assembly in May 1998, of the "World Health Declaration" which affirms the need to give effect to the Global Health-for-All Policy for the 21 st century through implementing relevant regional and national policies; Having considered the proposed regional Health-for-All Policy for the 21st century and Health Agenda 2020 (document AFRlRC49/8(b), 1. COMMENDS the Regional Director for efforts made in this regard, the indepth analysis of the health development process in the Region over the past decades and for the futures studies covering the period up to the year 2020. 2. NOTES with satisfaction the progress made by the Region in the formulation of a Regional health development policy that focuses on regional priorities and recommends to Member States to carry out further consultations at the nationallevel bringing together other sect ors and all actors and partners so as to obtain the widest possible contribution to the formulation of the Regional Health-for-All Policy, 3. REQUESTS the Regional Director, (i) to reflect as from now, in the 2000-2001 programme of cooperation with Member States the following regional priorities: malaria, HlVIAIDS and tuberculosis prevention and control, child survival, safe motherhood, response to complex emergencies and epidemics, health sector reform, health promotion and poverty aIJeviation;

• AFR/RC491R7 page 2

(ii) to organize an intersectoral and multidisciplinary meeting to which will be invited international institutions and agencies interested in health development of the Region on the proposed Regional Health-for-All Policy for the 21 st century; (iii) to submit for adoption by the fiftieth session of the Regional Committee the regional health-for-all poliey for the 21st eentury and a strategie framework for action up to the year 2020. Fifth meeting, 1 September 1999

Fortv-ninth session Windhoek. Narnibia. 30 August - 3 September 1999

AFRlRC491R8

3 September 1999 ORIGINAL: ENGLISH

VOTE OF THANKS

The Regional Committee, Fully aware of the time, effort and resources expended by the Government of Narnibia to ensure the successful conduct of the forty-ninth session of the Regional Committee; Appreciating the exceptionally warm and friendly welcome accorded to ail the representatives of Member States and other participants by the Government and the people of Narnibia; Fully conscious of the fact that this was the first time that Narnibia was so intimately involved in the planning and organization of the Regional Committee; 1. THANKS mos! sincerely His Excellency Dr Sam Nujoma, President of the Republic of Narnibia, and his Government for hosting the Regional Committee meeting; 2. EXPRESSES its deep appreciation to His Excellency President Sam Nujoma for graciously agreeing to preside over the opening session of the Regional Committee and dehvering an inspiring inaugural address: 3. EXTENDS its gratitude to the Honourable Minister of Health of Narnibia, Dr Libertina Amathila, for her tireless efforts in making extensive preparations for the Regional Committee session, and the efficient manner in which she conducted the proceedings of the meeting; 4. EXPRESSES ilS sincere thanks to the Government and the people of Narnibia for their warm hospitality; and 5. REQUESTS the Regional Director to convey this motion ofthanks to His Excellency Dr Sam Nujoma and the Government and the people ofNarnibia. Tenth meeting, 3 September 1999

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• OPENING CEREMONY

1.

The forty-ninth session of the WHO Regional Committee for Africa was opened in the

Safari Conference Centre, Windhoek, Namibia, on Monday, 30 August 1999, by His Excellency Dr Sam Nujoma, President of the Republic of Namibia. Among the distinguished dignitaries present on the occasion were: Cabinet ministers of the Government ofNamibia; Ministers of Health and Heads of delegation ofMember States; Mr E. Ngatjizeko, Mayor of Windhoek; Dr Gro Harlem Brundtland, Director-General of WHO; Dr Ebrahim M~ Samba, WHO Regional Director for Africa; members of the Namibian Parliament; representatives of United Nations agencies and nongovernmental organizations, and members of the diplomatie corps. 2. The Master of Ceremonies, Dr K. Shangula, Permanent Secretary, Ministry of Health and

Social Services, Namibia, welcomed the delegates and others present at the opening ceremony.

3.

In her address, Honourable Minister of Health and Social Services, Narnibia, Dr L.

AmathiIa, welcomed the delegates and recalled with gratitude the support that Member States had given to Narnibia during its struggle for independence. 4. She recounted that, since independence, efforts had been made to improve the health

services in Namibia under the able and distinguished leadership ofH. E. President Sam Nujoma. The national health system had been reorganized to make it responsive to the needs of the people. 5. She invited the delegates to utilize the opportunity of being in Windboek to leam more

about the country by visiting places of interest. She concluded that her govemment and the people ofNamibia would do everything possible to make them feel at home.

6.

Dr T. Stamps, Chairman of the forty-eighth session of the Regional Committee for Africa,

while addressing the meeting, requested those present to observe silence in the memory ofthose who had lost their lives recently due to: civil strife in Bujumbura, Burundi; a cyclone in Cape Town, South Africa; and an earthquake in Turkey.

7.

Dr Stamps said that since the CUITent session of the WHO Regional Committee was the

last one to be held in this millennium, it provided an opportunity to reflect on the past, to consolidate the present, and to plan for the future.

• 2 8. He recounted the achievements in health development in the past which included: the

virtual elimination of poliomyelitis from al\ but a few countries in the Afiican Region; the putting in place of the fabric around which to build a sustainable mechanism to Rol\ Back Malaria, whereby national efforts would translate into regional achievement and for which Dr Brundtland and Dr Samba should be commended; a greater awareness ofthe gravity of the AIDS pandemic; acceptance of the importance of the primary health care strategy with its eight components; the growing acceptance of the need to adopt a sector'wide approach for health development; and a greater recognition of the vicious cycle of ignorance, ill-health and underdevelopment.

9.

Dr Stamps observed that the changes that had occurred in recent years had given cause

for both hope and caution. One such change related to new developments in biomedical sciences. Ucùike in the past, it was important that research undertaken in Afiica should respond to Afiica' s priority health issues.

10.

The future challenges in Afiica included the negative impact of the growing globalization,

migration, travel, tourism and communication, and changes in the demographic and epidemiological profiles of countries which can lead to problems of poverty and affluence.

II .

Dr Stamps cautioned that at a time when social and geopolithal environments were

changing rapidly, leadership at national and international levels should not be changed unnecessarily. Changes in leadership should be made ocùy for the betterrnent of the people and not for fashion or any other external concept.

12.

He underscored the need to guard against divisive forces and urged aU to move towards

unity for health by emphasizing the common goal and discounting aU differences.

13.

In his address, the Regional Director, Dr Ebrahim M. Samba, thanked the President of

Namibia, His Excellency Dr Sam Nujoma, for inviting WHO to Windhoek for its last Regional Committee meeting in the 20th century and for the excellent arrangements made to ensure its success.

•

3

14.

Dr Samba also expressed his sincere gratitude to His Excellency President Robert

Mugabe and the government and people of Zimbabwe for the refuge given to the staff of the Regional Office who were forced to move temporarily from Brazzaville. He noted that the WHO staff members were still refugees with ail the stresses and strains that go with that status.

15 .

The Regional Director gave a detailed catalogue of the events that had led the Regional

Office to move from Brazzaville and how the office came to be temp~rarily relocated in Harare. He re-emphasized that the stay of the Regional Office in Harare was only temporary .

16.

In spite of the difficult circumstances under which AFRO staffmembers were working,

their performance was most encouraging and relations with and support from WHO Headquarters were getting better. In addition, development partners such as multilateral and bilateral agencies and NGOs were doing ail they could to provide the necessary support. As a result, voluntary funding had increased live-fold during the past four years - from US $30 million in 1995 to US $156 million in July 1999.

17.

Dr Samba stated that collaboration with Member States had improved, and, with support

from the Director-General, greater authority had been delegated to the WHO country offices, especially with regard to personnel and linancial matters. This had resulted in speedier and more effective response to the needs of countries.

18.

The Regional Director briefly highlighted the progress that had been made in the areas

of health sector reform within the context of the United Nations Special Initiative on Africa (UNS lA), the African Initiative for Malaria Control together with Roll Back Malaria, HIV lAIDS, eradication of poliomyelitis, reproductive health, gender balance, human resource development, institutional strengthening, and health research in Africa.

19.

In conclusion, Dr Samba said that in spite of the enormity of the problems being faced

today, considerable progress could still be made to improve the health and quality of life of the African people in the 21 st century. To achieve this objective, the following ingredients of success were already present: full cornmitment of the Member States, support of the Director-

4

General and other Headquarters staff, the confidence of development partners in WHO' s capacity to deliver, and the highly motivated and devoted staff in the Region.

20. In her speech, Dr Gro Harlem Brundtland, Director-General of WHO, thanked the Govemment and the people of the Republic ofNamibia for hosting the forty-ninth session of the Regional Committee for Afiica.

21. She said that she would take this opportunity to share with the Regional Committee the direction that the work of the Organization had taken after a year of change.

22. The Director-General underscored the fact that in order to make a difference in global health, WHO must make a difference in Africa. While aspiring to leadership in international health development, WHO must demonstrate its real leadership in the Afiican Region. She also stressed the need to combine vision, commitment, successfulleadership, effective organization, and working together as one WHO to reduce the burden of premature death and excessive disability in the Afiican Region.

23 . Dr Brundtland enumerated the four global strategie directions of WHO. These were: (1) reducing the burden of excess mortality and disability, especially that suffered by the poor and marginalized populations; (2) countering the potential threats to health that result from economic crisis, unhealthy environments and risky behaviour; (3) helping countries to develop their health systems which would contribute to the reduction of health inequalities, which were responsive to peoples's legitimate needs, and which were financially equitable; and (4) working towards placing hea1th at the core of the development agenda. 24. National policies and budgets must give priority to the cost-effective interventions that were known to work: multi-frontal fight against the main childhood killer diseases and the HIVI AIDS epidemic; implementation of the Stop TB, the Roll Back Malaria, and the Making Pregnancy Safer Initiatives. The development and implementation of a global TB research agenda that would truly respond to the needs of the people, families and communities; and the successful implementation of the plan of the Global Alliance for Vaccines and Immunization, would be important steps to address the first of the aforementioned global strategie directions.

•

5 2S . The emerging epidemic of tobacco consumption that was about to hit developing countries would be addressed through global tobacco control efforts thal had already been started. She added Ihat representatives from Afiica would be welcome to the planned meeting ofthe Working Group on the WHO Framework Convention on Tobacco Control. 26. With regard to health systems, Dr Brundtland indicated that the challenge was to ensure health care coverage for aIl. This would involve deciding what senjces govemments should coyer and how health care should be financed, spelling out goals that health systems were expected to achieve, and how to assess their performance. 27. On placing health at the core of the development agenda, the Director-General pointed out that one of the areas where WHO would be more active and vocal in the years to come would be debt relief WHO would argue for both new resource flows and debt relief Also, WHO would argue that specifie and core health investments should he protected while reshaping the budgets and debt relief flows . 28. She noted that in view of the increasing number of players in health development, WHO would need to refine its role and see how best it could be of use to Member States. WHO would need to define where it had a comparative advantage, what function s should be left to other organizations or govemments and what work WHO collaborating centres should be called upon to undertake. WHO would function more effectively as a catalyst at national and international levels. Put differently, WHO would adopt a strategic approach in its work and focus more on achieving concrete outcomes at nationallevel. 29. Dr Brundtland described the achievements in Afiica in the past which included : the building of a remarkable disease surveillance system; the control of complex diseases such as onchocerciasis; and the reduction in infant mortality in many cou nt ries before the AIDS pandemie began to erode the health gains ofmany decades. These were good examples ofhow regional cooperation and donor assistance could lead to improved health conditions.

30. The Director-General concluded her speech by paying tribute to the tremendous efforts that were being made by hea1th workers under difficult conditions. She added that many other countries could learn valuable lessons from Afiica' s innovative health poli ci es and practices, particularly those drawing on broad networks of community involvemen!.

•

6 31 . The Regional Director of UNICEF for West and Central Africa, Mrs Rima Salah, expressed her appreciation for WHO 's invitation to her to attend and address the Regional Committee. 32. She drew the attention of the Committee to the fact that despite significant progress made in most other areas, not much improvement had been made in the areas of infant, clùld and maternai mortality. She also Iùghlighted the effect of mViAlOS on the rising morbidity and mortality as weil as the danger of infection of youths, especially girls. 33 . Mrs Salah reported on the lessons learnt from the review of the Bamako Initiative wlùch was conducted in March 1999, with the participation of 43 African countries. Worthy of note was the realization of the need to empower communities to adopt healthy lifestyles and take charge of their own health, and also of the need to focus on priority health problems, including HIViAIOS, in the minimum health package. 34. She recounted areas of successful collaboration between UNICEF and WHO such as the Expanded Programme on Immunization, the Bamako Initiative, the eradication of guinea worm, polio eradication, Roll Back Malaria, and the Integrated Management of Clùldhood Illness (WCI), among others. She pledged continued collaboration of her organization for as long as the health of mothers and clùldren remained a problem. She ended on a note of hope and optimism for the health and well-being of women and clùldren in Africa. 35 . Dr P. Piot, Executive Director ofUNAIDS, expressed appreciation of the close collaboration between him and Dr Samba and looked forward to continuing to work together in the fight against mV/AIDS in the Region .. 36. Based on the speech of His Excellency the President ofNamibia, the report of the Regional Director, and the interventions of delegates, il was clear that the Committee considered AIDS as a burning issue in Africa, an issue that required continued and urgent action. 37. Dr Piot told the Committee that there was a growing mobilization against AlOS in Africa, as weil as a real change in terms of awareness about AIDS and political commitment to respond to the epidemic. The International Partnership against AlOS in Africa had built up a broad coalition of governments, multilateral organizations, bilateral development agencies, NGOs and the private sectoL Through the UNAIDS Theme groups at country level which were chaired mainly by WHO country representatives, the co-sponsors were making it a reality that AIDS was

7 an institutional priority for aU of them, a situation that augured weil for expanding the resource base in support of the fight against illV/ AIDS. 38. He reported that the UN Secretary-GeneraI, Mr Koti Annan, had become personaUy involved in this combat. 39. Dr Piot appealed for intensified efforts against stigmatization and discrimination associated with AIDS as it had become a major obstacle to the prevention and càntrol activities. 40. He said that the level of inequity in access to antiretroviral drugs had become unacceptable. UNAIDS had continued to work with other partners and the pharmaceutical industry to facilitate wider access to antiretroviral drugs. These drugs were however not be seen as a panacea for the epidemic; much more effort needed to be put on prevention, and on improving access to effective treatment of opportunistic infections. He concluded his statement on the positive note that negotiations with sorne pharmaceutical laboratories were continuing to progress and that everyone was on the same wavelength in tackIing the complex problem ofillV/AIDS which threatened the future of Africa. 41. In his speech, His Excellency Dr Sam Nujoma, President of the Republic of Namibia, welcomed delegates and other guests to the Regional Committee meeting. when he paid astate visit to that country in 1993. 42. He noted that the meeting was taking place at a time when the health care deIivery systems in Africa were faced with many challenges. He indicated that bis Government recognized the very important linkage between health and development and, consequently, about sixteen per cent of the Government' s operational budget had consistently been aUocated to health-related activities. 43 . President Nujoma remarked that achievements relating to the improvement of the health status of the people under WHO leadership inc\uded: the eradication of smallpox; the near elimination of poliomyelitis; effective control of sorne of the other life-threatening diseases, and the dissemination of health information. Challenges still being faced, however, included the illV/ AIDS pandemie which had reversed sorne of the gains of the past, posed the greatest challenge to science, put additional burden on health care delivery systems, produced a negative impact on socioeconomic development, and threatened the very survival of the family unit. He specially welcomed Dr Gro Harlem Brundtland, Director-General, who was Prime Minister of Norway

•

8 44. He noted that the AIDS pandemie caUed for innovative strategies to deal with its prevention, and for new approaches to deal with those infected as weil as with those widowed and orphaned. Political commitment and coordinated efforts to fight the pandemie head on were also required . He added that given the disproportionate burden of disease that Africa, with only 20 per cent of the world' s population, carried, there was need for ail stakeholders to intensify their efforts to address the deteriorating health conditions in Afiica. 45 . The Govemment of the Republic ofNamibia subscribed to the principle ofhealth as one of the fundamental rights of every human being and this had formed the basis of national health development in the country. 46. President Nujoma underscored the fact that peace and stability were necessary prerequisites for health development. For that reason, the ongoing civil strife in many Afiican countries was a cause for concem, particularly because of their effects which included numerous refugees and displaced persons, weakened health systems, dislocation of families, and disruption of hea1th services. He commended WHO for the successful immunization campaign undertaken in the Democratic Republic of Congo, and added that it was evident that health workers were always ready to assist the people even during times of conflict. 47. He expressed concem about land-mines and added that innocent people had become victims. There was therefore a need to eliminate the production, stock-piling and use of land-mines. Namibia had taken steps to support this position by signing and ratifying the Ottawa Convention on land-mines. 48 . ln order to achieve the health goals set for the year 2000, he advised that countries should build on their achievements and review their shortcomings with a view to identifying why targets were not being met . 49 . The President added that the Heads of State and Govemment in Africa had always been interested in addressing important hea1th issues during their annual summits. In addition, they had been working tirelessly to bring a peaceful end to the conflicts that had ravaged Afiica and caused untold human suffering. 50. In conclusion, President Nujoma wished the delegates fiuitful deliberations, and formally declared the forty-ninth session ofthe Regional Committee open.

f

9

ORGANIZATION OF WORK Constitution of the Subcommittee on Nominations 51. The Regional Committee appointed a Subcommittee on Nominations, made up of representatives of the following 12 Member States: Angola, Botswana, Comoros, Republic of Congo, Côte d'Ivoire, The Gambia, Liberia, Mozambique, Rwanda, Senegal, South Africa and Zambia. The Subcommittee elected Dr Leon-Alfred Opimbat, Minister ofHealth, Solidarity and Humanitarian Action of the Republic of Congo, as its Chairman. Election of the Chairman, Vice-Chairmen and Rapporteurs 52. After considering the report of the Subcommittee on Nominations, and in compliance with Rule 10 of the Rules of Procedure and resolution AFRlRC401R1 , the Regional Committee unanimously elected the following officers: Chairman: lst Vice-Chairman:

Dr Libertina Amathila Minister ofHealth and Social Services, Namibia Mr Faustin Boukoubi Minister of Public Health and Population, Gabon Mme Diakité Fatoumata Ndiaye Minister ofHealth, the Elderly and Solidarity, Mali Mr Saleh Meky

2nd Vice-Chairman: Rapporteurs:

Minister of Health, Eritrea Prof. Henriette Ratsimbazafimaohefa Minister of Health, Madagascar Dr Rosa Maria Soares Silva Director-General of Health Services, Cape Verde Rapporteurs of the TechnicaI Discussions: Dr Saidi M . Egwaga (Tanzania) Dr Gagara Magagi (Niger) Dr Aida Libombo (Mozambique)

• lO

Appoiotmeot of Members orthe Subcommittee 00 Credentials S3. The Regional Committee appointed representatives ofthe following 12 countries as members of the Subcommittee on Credentials: A1geria, Benin, Camereon, Democratic Republic of Congo, Malawi, Mauritius, Niger, Sao Tome and Principe, Seychelles, Swaziland, Togo and Uganda. 54. The Subcommittee on Credentials, which met on 30 August 1'199, elected Mr Jacquelin Dugasse, Minister of Health, Seychelles, as its Chairman. 55. The Subcommittee examined the credentials presented by the delegates of the following Member States: A1geria, Angola, Benin, Botswana, Burkina Faso, Burundi, Cameroon, Cape Verde, Central African Republic, Chad, Comores, Republic of Congo, Côte d'Ivoire, Democratic Republic of Congo, Equatorial Guinea, Eritrea, Ethiopia, Gabon, Gambia, Ghana, Guinea, Guinea Bissau, Kenya, Lesotho, Liberia, Madagascar, Mali, Mauritania, Mauritius, Mozambique, Namibia, Niger, Nigeria, Rwanda, Sao Tome & Principe, Senegal, Seychelles, Sierra Leone, South Africa, Swaziland, Togo, Uganda, United Republic ofTanzania, Zambia, and Zimbabwe, and found them to be in order and recommended their acceptance. 56. The Subcommittee was unable to examine the credentials of Malawi. 57. The Subcommittee on Credentials, however, decided that its Chairman should examine the credentials of Malawi on behalf ofthe Committee and report directly to the Regional Committee. 58 . Thereafter, the Chairman examined the credentials presented by the delegates from Malawi and found them to be in order. He recommended their acceptance by the Regional Committee. The Regional Committee adopted the report.

Adoption of the Agenda 59. The Chairman of the forty-ninth session of the Regional Committee, Dr L. Amathila, Minister of Health and Social Services, Namibia, tabled the provisional agenda (document AFR/RC49/ 1 Rev.3), which was adopted without amendment.

Adoption of the ho urs ofwork 60. The Regional Committee adopted the following hours ofwork: 9.00 hours to 12.30 hours and 14.00 hours to 17.30 hours, inclusive oftea breaks.

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THE WORK OF WHO IN THE AFRICAN REGION: ANNUAL REPORT OF THE REGIONAL DIRECTOR FOR 1998: (document AFRfRC49f2) Introduction 61. In his introduction, the regional Director, Dr Ebrahim M . Samba, undedined the fact that the report was the result of team work involving staff from the Regional Office and the country offices, under the leadership of the new Director of Programme Management, Dr L. G. Sambo . 62. Dr Samba explained that he had decided to cover the situation of the Regional Office in sorne detail in his opening address for the benefit of His Excellency President Sam Nujoma, and sought the permission of the Committee for the directors of the various divisions in AFRO to present parts of the report which were relevant to their respective programme areas. 63 . Delegates from severa! Member countries raised questions about the retum of the Regional Office to Brazzaville.

64. The Congolese delegation presented a video film showing the progress that had been made towards restoring normalcy in the country. The delegation stressed that the retum of the Regional Office to Brazzaville was to be guided by resolution AFRfRC48fR6 and indicated that the Govemment of the Republic of Congo would make, and had in fuct commenced, full reparation for the damage and losses suffered by WHO and its staff. 65 . ln response, the Regional Director stated that he \Vas heartened to note from the video that the current situation in Brazzaville had apparently improved from what it was a month earlier when a team from the Regional Office had visited the city in the company of the Minister. He re-emphasized that the official seat of the Regional Office was still Brazzaville and that its current location in Harare had never been anything but temporary. 66. The WHOfHQ Legal Counsel, Mr Topping, staled that the Executive Board, al its ninth session in 1952 took a decision for Brazzaville to be the site of the WHO Regional Office for Africa, and no other decision had been taken since then te change that position. ln 1997, the Regional Director and the then Director-General took an administrative decision in view of the situation in the Congo, to evacuate WHO staff from Brazzaville and temporarily relocate the Regional Office tirst to Geneva and then to Harare. That action was reported to a private meeting of the heads of delegation during the session of the Regional Committee held in Sun City, South Africa, in 1997, but no formai resolution \Vas adopted. ln 1998, the 48th session of the Regional Committee adopted resolution AFRlRC481R6 which provided the gcneral policy for the retum of the Office, but left the implementation measures to the Secretariat,

12

including the need for adherence to the UN security standards. That resolution was still relevant. He reminded the Committee that Brazzaville was still in Phase Four, which ooly permitted UN staffinvolved in emergency and humanitarian missions. 67. Lastly, Mr Topping mentioned that the Director-General had established a high-level Task Force, made up of the Regional Director and other senior staff members of the Regional Office and Headquarters to monitor the temporary relocation of the Office to Harare and its retum to Brazzaville as soon as circumstances permit.

General programme development and management 68. In his presentation of this section of the report, Dr L. G. Sambo, Direetor, Programme Management, WHO! AFRO, indicated that the Regional Office had made changes in its structure and funetions in order to align itself with the reforms at the WHO Headquarters. The changes were also in response to the pressing problems encountered in health development in the African Region.

69. As a result, the Regional Office now had seven Divisions comprising the following programme areas: (a) Health systems and services development (b) Reproductive and family health (c) Prevention and control of communicable diseases (d) Healthy environment and sustainable development (e) Prevention and control of noncommunicable diseases (f) External coordination and programme promotion

(g) Adnninistration and finance . 70. Dr Sambo said that the main thrusts of collaboration with Member States were: health sector

reform to improve the functioning of health systems and the health status of the populations; development of human resources for health; prevention and control of communicable diseases; response to emergencies and epidemics; reproductive health; acceleration of child survival strategies and initiatives; health promotion and advocacy; and fostering greater coordination among health development partners at country and regionallevels.

13 71. The Director, Programme Management, informed the Committee that the results of the evaluation of the implementation of the 1996-1997 programme budget were used as a basis for detailed planning and implementation of the 1998-1999 programme budget. 72. He reported progress in the areas of health in socioeconomic development; research policy and coordination; interagency resource management; emergency and humanitarian action; and production of documents on health issues. 73. Highlighting the Organization's limited capacity to finance requests from Member States, Dr Samba suggested that WHO should focus more on the normative needs and on national priorities in the quest for more tangible results under the leadership of Governments, in collaboration with other partners. 74. Many delegates commended the quality of the report of the Regional Director and a1so the increased decentralization and delegation of authority to WHO representatives which had made it possible for the Organization to respond to country requests and needs more speedily. They added that the strengthening of the unit ofTechnical Cooperation with Countries at AFRO will further facilitate appropriate and timely response. 75. In response to a comment on the presentation of the report of the Regional Director by the Divisional Directors, many delegates commended the method ofpresentation of the report which reflected a style of management characterized by team spirit. 76. Many delegates commended the inspiring speech of Dr Gro Harlem Brundtland, DirectorGeneral of WHO . They particularly welcomed the reforms she had introduced since she assumed office as weIl as the four new global strategic orientations of WHO that she presented. The delegates feIt that countries in the Region wou Id greatly benefit from the implementation of these new strategic orientations. 77. The Committee requested WHO to: document and disseminate good practices in various aspects of the ongoing health sector reforms in countries; provide support to Member States to better understand the sector-wide approaches (SWAps) with a view to adopting such approaches for health development; support countries in their advocacy efforts aimed at securing greater budgetary allocations for health and also developing sustainable health care financing strategies including prepayment schemes; strengthen the capacity of countries to improve the allocative efficiency in resource allocation; ensure that greater debt relief was provided and the savings used to support poverty reduction programmes and services; and influence donors to provide timely financial support to countries to implement their priority health programmes.

14 78. Sorne delegates requested copies of the document on Innovative Health Care Financing Schemes in the Afiican Region that was being finalized by the Regional Office. 79. While recognizing and cornmending the assistance WHO had provided in coping with emergencies in countries of the Region, delegates requested WHO to help countries not oruy to prepare for emergencies but to respond to them more effectively. 80. Since diseases did not recognize political boundaries, many delegàtes stressed the need for neighbouring eountries to plan together to deal with emergencies, and urged WHO to play an active role in coordinating such efforts. 81 . Delegates carnmended the manner in which politicaJ eonflicts in the Region were being resolved by Afiican leaders themselves, and hoped that similar efforts would be made to pursue health development. 82. It was widely felt that missions by WHO to cauntries should be in response to the needs and priorities of the countries, rather than to promote the needs or priorities of specifie programmes of the Organization. 83 . It was felt that while Afiica had been used as a laboratory for undertaking many research programmes, Afiican countries had not always benefited from this researeh. This trend would need to be reversed .

84. The Regional Director reminded delegates about a resolution of the 45th session of the Regional Cornmittee which had urged countries to increase their budgetary allocation for health to at least Il %. Namibia was, therefore, cornmended for allocating as much as 16% ofits budget to health-related activities.

85 . With regard to the increasing frequency of emergencies in Member countries, the Regional Director reminded delegates that WHO was always in countries berore, during and after any emergency. He promised that WHO would help strengthen the capacity ofMember States to prepare for and respond to emergencies.

15 86. Dr L.G. Sambo, Director, Programme Management, informed delegates that research activities were being carried out in the area of each technical division or unit at AFRO . He admitted, however, that enough research had not been done and that was one of the reasons the African Advisory Committee on Health Research and Development had been reactivated.

87. He reminded the Committee that the creation oftwo new divisions at the Regional Office (the Division of Healthy Environment and Sustainable Developm~nt

and the Division of

Prevention and Control of Noncommunicable Diseases) was also in response to recommendations of the 48th session of the Regional Committee.

88. He assured delegates that the documents on innovative health care tinancing in the African Region contained experiences ITom Member States and that the publication would be available to countries by the tirst quarter of the year 2000.

89. The Director-General Dr H. G. Brundtland, thanked delegates for their remarks on her address and added that one of the themes that had come through was the need to develop a functioning health system to provide equitable, affordable and qUality services.

90. She noted the need to build alliances for health sector refonn and promised that WHO would

develop concrete activities to support Member countries in their health sector refonn efforts. She agreed that WHO, should work together as one to support national governments who have the responsibility for health development. Efforts would therefore be made to stop any inconsistency in WHO's approach to providing support to countries.

91. Dr Brundtland assured delegates that WHO would improve the documentation and dissemination of best practices, inc\uding the tinancing of health services.

Health services and systems development 92. Dr B. K. Nguyen, Acting Director, Health Services and Systems Development reported to the Committee that, in 1998, the activities of that division had contributed to national capacitybuilding through support for: the strengthening of institutional and technical capacity in matters concerning the organization and management of health systems; the deve10pment of human resources for health and the strengthening of the capacity of communities to participate

16

adequately in health development; the development ofhealth technology policies matched to the needs, norms and standards, the programme of quality of care; and national capacity- building in research and in the production and use of health information to support policy development and evidence-based management. 93. Under health systems development, Dr Nguyen indicated that emphasis was placed on reviewing the Regional Health-for-A11 Policy for the 21 st century, support to countries for policy formulation and the preparation of strategie national health development plans. with particular attention to their efl'ects on district health systems. 94. Dr Nguyen further explained that the production of evidence-based information for policymaking and management had prompted the expansion of health systems research activities and furthered cooperation in the strengthening of information systems based on the choice of essential health indicators made by the national authorities. 95. He infonned the Committee that the Regional Office had produced guidelines and tools to he\p Member States in policy analysis and formulation. Concerning fellowships, WHO continued to implement the relevant Regional Committee resolutions by encouraging placement offellows in training institutions in Afiica, including the fellow ' s own country. 96. Dr Nguyen concluded by informing the Committee about the achievements made in the local production of essential drugs in the Afiican Region a.,d the promotion of quaIity of care programmes. He indicated that there was significant institutional development in traditional medicine from both programmatic and human resources points of view. 97. The Committee considered that following the intercountry meetings on health sector reform, the next phase of WHO support should be targeted at countries, taking into account specifie country aspirations. In this regard, there was a need to move from policies and strategies to action. Special emphasis should be placed on health care financing strategies, including prepayment schemes, with preferential allocation of resources to primary health care, in order to ensure sustainability and equity. 98. In the health sector reform process, national policies and strategies should be translated into local-Ievel activities and interventions in order to ensure the strengthening of district health In this endeavour, WHO took cognizance of the ongoing health sector reforms in Member countries,

17

systems with effective community involvement. Best practices at district and community levels should be properly documented with support !Tom WHO and the experiences shared within the Region. 99. There was a need to develop and implement strategies to address issues concerning human resource for health, particularly the problem of staff attrition, including brain drain. WHO and other development partners should work with countries on motivational and incentive packages necessary to attract and retain qualified health personnel. 100. The referral system should be strengthened, particularly in countries recovering !Tom

conflict situations. Special emphasis should be placed on assisting public health laboratories for the provision of services and for research. 10 J . There was more work to be done to improve communication systems in support of the

health information system. WHO should support Member countries in the use of telemedicine and telehea\th, particularly where there was a shortage of specialists, 102, Concerted efforts should be made to improve access to quality essential drugs at

affordable cost in the countries of the Region, In this regard, local production of drugs should be supported by establishing industries 10 serve sub-regional blocs, WHO could provide support in this effort, 103 , Given its importance in providing access to health care in the Region, the need to accord

greater priority to traditional medicine, especially in the area of research, was underscored by delegates. 104, Dr B. K Nguyen of the Secretariat Ihanked delegates for their valuable comments,

particularly in the areas of human resources development, financing of health services, and documentation ofbest practices on district health systems and community approaches, He added that traditional medicine would be accorded the needed attention, and announced that the Regional Office had arranged for an African forum on traditional medicine scheduled for February 2000,

18

Reproductive and family bealtb 105. Dr T. R. Tshabalala, Director, Division of Reproductive and Family Health, introduced

the relevant section of the report. 106. She indicated that six out of the ten countries wlùch had initiated the Safe Motherhood

Needs Assessment process had completed the exercise. The information gathered would be used for comprehensive programming on reproductive health in district plans. 107. She informed the Committee that, in collaboration with UNICEF and UNAIDS, WHO

would be assisting several of the countries hardest lùt by the AIDS epidernic to plan for the prevention ofmother-to-clùld transmission ofHlV infection. 108. Dr Tshabalala reported that the formulation of the Regional Strategy on Adolescent

Health had been initiated and would be completed in time for presentation during the next session of the Regional Committee. 109. She reported that WHO had provided financial and technical support to ten countries in

the Region for the development of national plans on the elirnination of female genital mutilation. Progress had also been made in defining the magnitude and types of violence against women and children. It was evident trom country studies that the prevalence of clùld abuse could be as lùgh as 30% in sorne countries. 110. Outlining sorne of the constraints, Dr Tshabalala mentioned weak intersectoral planning

and coordination of inputs trom various partners, inadequate adaptation of the reproductive health concept in training institutions, disruption of public health systems due to conflict situations, and the lack of adequate resources. Ill . The Regional Committee commended the progress made in the promotion of

reproductive health and safe motherhood as one of the priority programmes, and underscored the need to document the best practices in the development of district models and the establishment of effective referral systems in order to address the problem of maternaI mortality. Delegates welcomed the initiatives taken on the prevention of mother-to-clùld transmission of available in Member countries.

mv

infection, and emphasized the need for WHO assistance to make relevant anti-retroviral therapy

•

19 Prevention and control of communicable diseases 112. Dr A. Kabore, Acting Director of the Division of Prevention and Control of

Communicable Diseases, introduced the relevant section of the report. 113. He eommeneed his presentation by stating the mission of the division which was to

provide technical onentation and support to Member States in the area of communicable diseases. 114. He reported that the division had been re-organized in 1998 into four functional areas

of: (i) surveillance and response; (ii) prevention and control; (iii) eradieation and elimination; and (iv) research and development. In addition, there were the two major programmes of Roll Back Malaria and HIV/AIDS . 115. Dr Kabore pointed out that epidemiologieal surveillance as a tool for preventing

outbreaks of epidemies had led to one major aceomplishment - improvement in the early deteetion of epidemie-prone diseases and organization of prompt and well-coordinated response. A new programme - Integrated Disease Surveillance (IDS) - had been established to accelerate the implementation of the regional strategy adopted by the forty-eighth session of the Regional Committee. 116. Within the Polio Eradication Initiative whieh had the aim to eradicate poliomyelitis (b) holding national

worldwide by the year 2000, the following strategies were being used : (a) sustaining high levels of routine immunization coverage with oral polio vaccine (OPV); immunization days (NIDs); (c) establishing effective surveillance of acute flaccid paralysis (AFP); and (d) conducting mopping-up activities. The NIDs had been suecessful in terms of the coverage attained, creation of national interagency coordination committees, an improvement in social mobilization efforts. They had also helped with the refurbishment of logis tics, improvement in cold chain, and in accessing population groups never reached before. At the end of 1998, ail the endemic countries except one had conducted at least one series of NIDs. 117. Dr Kabore concluded his presentation on the gnm situation ofHIV/AIDS in the Region

which continued to receive prionty attention. A joint WHO/UNAIDS plan for the 1998-1999 biennium had been developed and a total joint contribution of US $1,250,000 had been provided for its implementation. Guidelines were developed and field-tested for equitable, safe and

20 effective ways ofproviding anti-retroviral (ARY) therapy, blood safety, and home care. National project officers (NPOs) had been appointed in eight countries. 118. The delegates underlined the imponance of the initiative called "Health for Peace" involving The Gambia, Guinea-Bissau and Senegal, and the necessity to support it and extend it to other countries in the Region. The imponant role of epidemiological blocs and of the availability of good communication systems for epidemic control was also recognized. 119. The Regional Committee noted the progress made towards the eradication of poliomyelitis with the implementation ofnational immunization days (NIDs) and the surveillance of acute flaccid paralysis (AFP) by Member States. The implementation of the polio eradication strategies had demonstrated how weil African countries could perform when the health interventions were focused, well-targeted and adequately financed . 120. The Committee felt that more work needed to be done to improve national immunization systems that would routinely deliver quality immunization services and integrate new vaccines. The newly-created Global Coalition for Vaccines, which was in the process of setting up the Children' s Vaccine Fund, raised hopes of funher support so that increased protection could be provided to all children in the Region. 121 . The Regional Committee noted the importance attached to the problem of malaria in the

Region, and the continuation of WHO support to Member countries within the context of the Roll Back Malaria Initiative. They, however, expressed concern over the efforts that were being made to ban DDT, and asked for strong advocacy so that affordable and appropriate alternatives could be found before any measure was taken to ban DDT. 122. The delegates urged WHO to redouble its efforts in order to: make anti-retroviral drugs affordable to those in need in the African Region; improve the performance of laboratories to enable them to monitor anti-retroviral therapy; extend community-based care services to people living with AIDS in the countries of the Region; and take appropriate action to provide guidance on confidentiality with regard to HlV1AlDS. 123 . ft was requested that an orientation workshop on Integrated Management ofChildhood Illness (IMCI) be organized for Portuguese-speaking countries in the Region. Sao Tome and Principe offered to host such a workshop . 124. In response to the interventions by delegates, the Regional Director reaffirmed that AFRO would continue to support intercountry cooperation as weIl as strengthen communications for epidemic control. Efforts would be made to ensure that stopping the use of DDT for malaria

2l control would be phased so that altemate products could be developed and made available to countries in the Region. 125. Dr Kabore, of the Secretariat, assured the Committee that AFRO would actively work in collaboration with HQ and UNAIDS to: make anti-retroviral drugs affordable for those in need; improve laboratory support for the treatment of mV/AIDS; and disseminate the recommendations on confidentiality made by a consultation which was recently organized in Windhoek, Namibia. 126. He also informed the Regional Committee that an orientation workshop on !MCI was being planned for Portuguese-speaking countries during the first quarter of2000, and thanked Sao Tome and Principe for offering to host it. Healthy environment and sustainable development l27 . Mrs E. Anikpo, Acting Director of the Division of Healthy Environments and Sustainable Deve\opment, recalled that the division had been created in recognition of the fact that the health status of the people could be improved considerably by acting on the physical, social, economic and cultural environments. 128. The mission of the new division was to support countries in the identification, monitoring, prevention, and control of the adverse effects of the environment on health, and to put health high on the agenda of sustainable development. 129. She informed the Committee that the core function in the area of Protection ofHuman Environment was to pursue health promotion and health protection against a large number of risk factors . The Regional Office runs three programmes in tbis area, namely: (i) Environmental Risks Assessment (ERA), including chemical safety. Activities carried out in 1998 covered the management of hospital wastes, development of national chemical safety profiles, prevention of marine pollution, establishment of anti-poison centres, awareness campaign on the adverse health impact of desertification in Africa, and organization of a workshop on chemical safety. (ii) Water, Sanitation and Health (WSH): The Regional Office provided financial and technical support for promoting the Africa 2000 Initiative, and organized preparatory missions for national workshops on the operation and maintenance of water supply and sanitation systems. lt also helped prepare plans of action on Participatory Hygiene and Sanitation Transformation; draw up national environmental health policies; and assess the situation ofwater supply and sanitation in cholera-affected areas. Furthermore, the Regional Office took part in the preparation and holding of the First Consultative Forum

22 in Abidjan, Côte d'Ivoire, and organized the Second Regional Consultation on the Afiica 2000 Initiative in Harare, Zimbabwe. (iii) Healthy Cities, Healthy Villages and Healthy Islands (RUE): This programme adopts an integrated approach to health protection and promotion in human settlements. Its strategie objective is to undertake health promotion based on community participation, inter-sectorality, and partnership. Urban crisis in the Afiican continent will continue to be a major challenge in the neld century. That was why the programme was revitalized in the last quarter of 1998 through intensive preparation for healthy cities planning workshops for French-speaking countries in the African Region. Similar workshops were to be organized by the end of 1999 for English-speaking countries and countries with Portuguese as the official language.

130. Mrs Anikpo filfther indicated that two programmes had been developed under this area of work; namely: long term health development (LHD) which focused on capacity-building in long-term planning, health future studies, and the development of the capacity to anticipate changes in national and international environments that were becoming complex and volatile. 131 . The other, poverty and ill-health (PŒ) was to assist break the vicious cycle of poverty, environmental degradation and iIl-health, and thereby foster sustainable development. Prevention and control of noncommunicable diseases 132. Dr M. Belhocine, Acting Director, Division of Prevention and Control of Noncommunicable Diseases, introduced the relevant part of the report. 133 . He indicated that the mission ofthis new division was to promote healthy lifestyles and assist Member States to reduce their burden of noncommunicable diseases. 134. To indicate the magnitude of the disease burden that noncommunicable diseases (NCDs) contributed, Dr Belhocine mentioned that, by 2020, NCDs could be responsible for 60% of the total disease burden (as compared to 41% in 1990) and 73% of the total mortality. 135. Four major groups of diseases were singled out which accounted for three-quarters of the total burden attributable to NCDs. These were: (i) psychiatrie and neurological disorders; (ii) cardiovascular diseases and diabetes; (iii) cancer; and (iv) respiratory diseases. Sorne genetic diseases of public importance in the Region such as sickle ceIl anaemia, were also mentioned. 136. He mentioned that except the last group, the other groups shared common risk factors such as obesity, hypertension, and diabetes. 137. Dr Belhocine said that a variety ofactivities had taken place in the area ofmental health, the Tobacco-Free Initiative, management of diabetes and cardiovascular diseases, as weIl as setting up of a system of surveillance in gynaecological cancers. Activities had also been undertaken in community-based rehabilitation, nutrition, and oral health.

,

23 He reported that a regional strategy for the prevention and control ofnoncommunicable diseases would be submitted to the fiftieth session of the Regional Cornmitlee. 138.

139. Dr Belhocine concluded by saying that sorne countries had received support in the areas of health of the elderly and occupational health. 140. Delegates expressed their appreciation of WHO' s policies with regard to tobacco control as tobacco consumption in the Region was taking an epidemic dimension. 141 . The need was expressed to have a betler assessment of the magnitude of al! aspects of the problem of tobacco in the Region. In order to counter the powerful propaganda machinery of trans-national tobacco companies, there was a need to develop new, strong and effective information and advocacy strategies. 142. Member countries as weIl as WHO should move away from the traditional negative prescriptions (don'ts) of education messages in relation to tobacco control, to more positive ones wbich encouraged healthy behaviours. 143. It was recognized thatthe fight against tobacco was a hard one and long-term endeavours

were necessary wbich called not orny for political cornmitment from governments but also for building large coalitions comprising all interested stakeholders including communities themselves. It was noted that legislations and regulations aimed at curbing tobacco consumption were 144. being developed and implemented in several countries of the Region. 145. WHO was requested to provide technical support to countries with a view to creating conditions which helped people who wanted to quit smoking. 146. Substance abuse should be given priority and community-based-strategies should be designed for prevention, treatment and rehabilitation. 147. Mental health was recognized as a very important problem in the countries of the Region and community-based approaches must be adopted to address tbis concem. There was also a need to address the mental health ofhealth workers themselves who often operated in very difficult situations throughout the Region. 148. Attention should be given to chronic diseases such as hypertension, diabetes and sickle cell anaemia. Research in these areas should be promoted and programmes with clear objectives designed .

24 External coordination and programme promotion 149. Dr N . Nhiwatiwa, Director, Division of External Coordination and Programme Promotion, introduced this section of the report. 150. She reported to the Committee that the major thrust of the division in 1998 had been to improve the dissemination of health information and capacity-building of health communicators and promoters in Member States. 151 . She mentioned that 22,000 copies oftheHealth Information Package entitled Coping with common diseases had been distributed to Member countries. The package was also being translated into local languages. The second package on Reproductive Health was now being distributed. 152. Dr N . Nhiwatiwa reported that the Blue Trunk Library, designed to meet the basic information needs of district health workers, had been supplied to most French-speaking countries, and its distribution in the English-speaking countries had commenced. 153. In the area of capacity-building, she reported that four workshops had been organized for representatives of the mass media in Member States to provide the generaI public with essential health information. A total of92 joumalists and radio and television producers had participated in these workshops. 154. Dr Nhiwatiwa also reported that the AFRO Home Page had been established on the Internet. 155. While commenting on the Regional Director's report, one delegate said that the Blue Trunk library was extremely important and wanted to know when it would be made available in Portuguese. 156. Another delegate, while commenting on the Director-General's statement, said that HIV/AIDS was difficult to control in Africa due to lack ofhealth information and education on it. 157. Dr Nhiwatiwa of the Secretariat informed delegates that the Portuguese version of the Blue Trunk Iibrary was almost ready and would be sent to the countries very shortly. Administration and finance 158. Mr Bernard Chandra, Director of Administration and Finance, introduced himself and spoke on the relevant section of the report.

25 159. He reported that the Personnel Unit had been reorganized and several important posts were being filled to complete (his exercise. 160. Mr Chandra informed the Cornrnittee that the General Administration was currently very busy preparing to relocate the Regional Office to another area in Harare, in premises offered by the Government of Zimbabwe, which would allow all the staff to be under one roof Presently they were housed in two separate buildings. 161. He said that the Budget and Finance Unit had been thoroughly reorganized. A number of additional posts had been created which would strengthen the internai controls and checking functions. In order to strengthen the capacity of senior administrative staff in the WHO country offices, a series of intensive training workshops oftwo weeks ' duration had been started at the Regional Office. The first workshop was held in July 1999 for 26 participants and the second would be held in November 1999 for a similar number of staff. Thereafter, the workshops would be continued on a quarterly basis. Il was hoped that this type of training wou!d be extended to other categories of staff, both at the Regional Office and country offices. Compulsory visits of up to one week duration to the Regional Office by al! newly-appointed Professional staff had been started so that they could receive technical and administrative briefing. 162. In order to provide guidance and support to WR offices, Mr Chandra reported that a programme was being started which would ensure that every WR office in the Region would be visited once a year by senior administrative staff from the Regional Office to assist them in their work and to review their adherence to WHO rules and regulations. The levels of imprest funds, particularly for important activities such as NIDs, had been reviewed . WHO representatives had also received further delegation of authonty to enable !hem recruit short-term staff. 163 . In conclusion, he said that with the implementation of these measures, he was very confident that the accounting and financial services would improve and that there would be less queries from auditors as weil as a greater delegation of authority and support to WR offices. He assured the ComrnÏttee that the Administration and Finance Division was cornrnitted to improving the quality and method of work in the Region. 164. Having carefully examined the annual report of the Regional Director section by section, the ComrnÏttee adopted the entire report as contained in document AFR/RC49/2.

26 NOMINATION OF THE REGIONAL DIRECTOR 165. Meeting in c10sed session on 31 August 1999, the Regional Committee, in accordance with Article 52 of the Constitution of WhO and Article 52 of the Committee's Rules of Procedure, nominated Dr Ebrahim Malick Samba as Regional Director for Africa. The Committee adopted the resolution AFRlRC49/R1 . CORRELATION BE1WEEN THE WORK OF THE REGIONAL COMMITfEE, THE EXECUTIVE BOARD AND THE WORLD HEALTH ASSEMBLY 166. On behalf of the Regional Director, Dr N. Nhiwatiwa, Director of Extemal Coordination and Programme Promotion, introduced documents AFR/RC49/3, AFR/RC49/4 and AFRlRC49/S relating to agenda items 8.1, 8.2 and 8.3 respectively Ways and means of implementing resolutions of regional interest adopted by the World Health Assembly and the Executive Board (document AFRlRC49/3) 167. Document AFRIRC4913 was the report of the Regional Director on ways and means ofimplementing resolutions ofregional interest that were adopted by the Fifty-second World Health Assembly and the One-hundred-and-third session of the Executive Board. 168. The report contained paragraphs drawn !Tom the operative parts of resolutions adopted at the Fifty-second World Health Assembly. Each resolution was accompanied by a proposaI conceming the measures to be taken or information about actions already in progress. 169. The Committee was invited to examine and comment on the proposed strategies for implementing resolutions of interest to the African Region and provide guidance for the implementation of the regional programmes of WHO. Allendas of the One-hundred-and-fifth session of the Executive Board and the Fiftythlrd World Health Assembly: Regional implications 170. Document AFRlRC49/4 Rev.1 was the Report of the Regional Director on the draft provisional agendas for the One-hundred-and-fifth session of the Executive Board (EB 105) which would be held in January 2000, and of the Fifty-third World Health Assembly which would be held in May 2000. Also included with the report was a draft provisional agenda for the fiftieth session of the Regional Committee in September 2000. 171 . The report was submitted pursuant to Regional Committee resolution AFRlRC33/R6, which approved this procedure for coordinating the agendas of the goveming bodies at global and regional levels. The Committee was invited to note the correlation already existing between the work of the Regional Committee, the Executive Board and the World Health

27 Assembly in relation to the following items which appeared on the agendas of ail the three bodies: (a) mV/AIDS/STI (b) Proposed programme Budget for 2002-2003 (c)Method ofwork and duration of the Fifty-third World Health Assembly (d) Health promotion (resolution WHA51.12). 172. The Cornrrùttee was invited to consider the provisional agenda of its fiftieth session

and decide on issues that should be recommended to the One-hundred-and-fifth session of the Executive Board and the Fifty-third World Health Assembly in tine with Article 50 ofthe Constitution, operative paragraph 4 (3) ofResolution WHA3 3 .17, and Recommendation 116 of the Executive Board Working Group. Method ofwork and duration of the World Bealth Assembly (document AFRlRC49/5) 173. Document AFRlRC49/5 was designed to facilitate the work of the Fifty-third World Health Assembly in accordance with the relevant decisions of the Executive Board and the World Health Assembly concerning the method ofwork and duration of the Assembly. 174. The Comnùttee was informed that the African Region would designate a candidate for the post of President of the World Health Assembly in the year 2000. 175. Equatorial Guinea will replace Burundi whose term of office as member of the Executive Board will expire with the closure of the Fifty-third World Health Assembly. Equatorial Guinea was expected to attend the 106th session of the Executive Board, and was invited to confirm this. 176. The Regional Cornrrùttee noted the information contained AFRlRC49/3, AFRlRC49/4 and AFRlRC49/5 as presented. In

documents

REPORT OF THE PROGRAMME SUBCOMMITTEE (document AFRlRC49/6)

177.

Dr Malick Niang (Senegal), Chairman of the Programme Subcommittee (pSC),

informed the Regional Cornrrùttee that eleven of the twelve countries who were members of the PSC attended the meeting which took place in Harare from 14 to 18 June 1999.

28

178.

Members of the WHO Executive Board !Tom Burundi, Cape Verde and the Central

African Republic participated in accordance with an earlier decision of the Regional Committee.

179.

Dr Niang reported that the PSC had decided that only a single presentation be made

by the Chairman on their behalf

180.

After expressing the gratitude of the members of the PSC to the Regional Director

and his staff for the quality of the documents, Dr Niang went on to report on each of the working documents:

Health sector reform in the African Region: Status ofimplementation and perspectives (document AFRlRC4917) 181 . Dr Niang reported that the Subcommittee endorsed the operational definition

provided for health sector reform; the way health sector reform had been characterized; the frarnework provided in the document for Iinking health sector reform to improvement in health status; the major lessons learnt as weil as the key success factors highlighted; and the future challenges and perspectives that had been identified. 182. While welcoming the adoption of sector-wide approaches (SWAps) to health sector

reform, the Subcommittee cautioned that adequate attention would need to be paid to priority health programmes, sorne of which had hitherto been successfully implemented as vertical programmes. 183 . The need for WHO to assist countries to lay down common strategies that could be

adopted in order to ensure that donors accepted and followed national health priorities and development plans was stressed. 184. ln the discussion of this aspect of the Programme Subcommittee' s report, the

Committee noted with satisfaction the definition of health sector reforrns as contained in the report . It was acknowledged that the pro cess of reform should be backed with the development of explicit national bealth poli ci es; and translated into practice at health district and community levels.

,>

29 185. The Regional Committee stressed the facl that hea1th seclor reforms in isolation Consequently, the Regional would not be sufficient to guarantee sustainability and achieve expected results, particularly the improvement of the hea1th status of the population. Committee recommended the involvement of other relevant sectors in the building of consensus for, and implementation of health sector reform programmes. 186. It was observed that while the decentralization of health services management and

of decision making in regard to health development has become a sine qua non today, in many instances decentralization of health services had not been undertaken concomitantly with admirustrative decentralization. This had led to incongruencies between boundaries of admirustrative and health districts. deve!opment. 187. The Committee considered it the role of the State to give greater commuruty focus The Regional Committee therefore requested the Regional Office to undertake studies that would look into problems created by this

to decentralization. In addition, the State should continue to play a normative and regulatory role and affirm its will to implement public hea1th interventions that would benefit the entire populations. The experience with subcontracting of services which is gairung wide currency should help to provide a legal framework for the relations between the State, the commuruties and the different for-profit andlor not-for-profit private care providers. 188. Human resources management posed a major constraint that should be taken into

account in the reforms particularly the availability of staff with proper techrùcal and managerial skills and the retention ofhealth workers. 189. The Regional Office was requesled to assist countries to develop equitable alternative

financing strategies capable of guaranteeing the sustainability of services and their accessibility to the majority of the population. 190. Il was noted that country experiences in financing and resource management within

the context of implementation of reforms show that the conditionalities of partners and inadequate national budget allocation to the health sector had contributed greatly to the low rate of implementation of programmes. The Committee requested WHO to organize a regional consultation on this issue, bringing together officiais of Mirustries of Finance, the finance uruts of the mirustries ofhealth as weil as multilateral partners including the World Bank and the International Monetary Fund to address this problem.

30

191.

Given the advantages that the countnes could denve by leaming from the successful

expenences of other countnes, the Regional Committee requested the Regional Office to produce and disseminate to countnes a summary document on regional expenences in reforms; and provide opportunities during future Regional Committee meetings for the exchange of documents among countnes, on their experiences in the various domains of health development. 192. The Secretariat noted the comments, suggestions and requests 'Of the Committee for

subsequent action. 193. The Regional Committee adopted resolution AFRfRC491R2.

Regional health-for-all potiey for the 21st eentury (document AFRlRC49/8(a) and (b» 194. Dr Niang reported that the Subcommittee noted that the document was too long as

a policy paper and that it was too complex to understand. Sorne inconsistencies were also pointed out in the document. 195. The Subcommittee emphasized the need for multisectoral, multidisciplinary and

multiagency consultations to develop an appropriate long-term health development po1icy, given the limited role of Ministries of Health in sorne of the determinants of health. 196. The Subcommittee therefore proposed a new structure and content for the document

as weil as the process that could be followed in finalizing il. 197. In discussing this aspect of the report of the Programme Subcommittee, the Regional

Committee approved the stages proposed for the process of reviewing the policy document and stressed the need to reach a broad consensus. To that end, the Committee recommended that national, subregional and regional consultations be organized. 198. For the policy document to serve effectively as a frame ofreference to which other

partners can also refer, the Regional Committee emphasized the need to organize, after the proposed national consultations, a forum at the regionallevel bringing together the various institutions and partners at regional (OAU, ADB, ECOWAS, SADC, etc.) and international (UNICEF, UNDP, UNFPA, World Bank, !MF and the European Union, etc) levels.

31 199.

The Regional Committee noted the efforts that sorne countries were making to give

a long term planning perspective to the health development process and commended the efforts of the Regional Office to develop a policy framework for the long term health planning exercise. lt called on WHO to intensify its efforts in this direction. 200. The Regional Committee also noted that the problem ofIDV/AIDS and its impact

on life expectancy, as weil as increasing mental health problems should be explicitly mentioned in the situation analysis section of the draft policy document. 201. Dr L. G. Sambo ofthe Secretariat assured the Committee that the various suggestions

and requests made had been noted for action. 202. The Regional Committee adopted resolution AFRlRC491R7. •

Regional strategy for mental health (document AFRlRC49/9) 203. Dr Niang informed the meeting that the Subcommittee welcomed the document

which addressed a growing health problem which unfortunately had not been given adequate attention. Increasing drug addiction, high frequency of civil strife and wars, deteriorating economic and social conditions, domestic violence against women and children, and rising unemployment, particularly among school drop-outs, had contributed to the growth ofmental health problems. 204. The Subcommittee noted the need to: revise existing legislation on the management

of mentally iII patients; explore the role that traditional healers and practitioners could play in the implementation of the new regional strategy; and also explore the possibility of earmarking tax collections on commodities that constituted health risks for financing health services in general and mental health in particular. 205. In its discussion of this aspect of the Programme Subcommittee's report, the

Regional Committee welcomed the document and stressed the need to consider mental health among the regional priorities.

•

32 206. The Committee further highlighted the following as key areas that should be

addressed: mental health of health workers (prevention and control of stress related problems); mental health of the child and adolescent (early childhood psychosocial development and prevention and control of substance abuse in young people); community-based psychosocial rehabilitation in post -conflict countries; formulation or revision of national policies and programmes as weil as legislation supporting mental health and prevention and control of substance abuse; training of adequate personnel using the existing Regional institutions; definition of mechanisms for multisectoral collaboration with other government departments, NGOs etc. study of sorne earlier experiments that integrated the role of traditional medicines and practices in the treatment of mental patients (e.g Aro hospital in Nigeria) with a view to developing strategies for effectively collaborating with traditional healers in this domain. 207. The Secretariat informed the Regional Cornrruttee that the exercise ofjoint planning

for the period 2000-2001 had already started and that countries would be supported in their efforts to strengthen mental health programmes taking into account their priorities and available resources.

208.

The Regional Committee adopted resolution AFR/RC491R3.

Integrated management of childhood iIIness (!MCI): Strategie plan for 2000-2005 (document AFR/RC49/10) 209. Dr Niang reported to the Regional Committee that the Subcommittee noted that

IMCI was an important strategy (not a programme) that should be included in health sector reform agendas for reducing under-five mortality and morbidity.

33 210. The need to introduce IMCI as a part of the basic curriculum for training health

workers as a way of institutionalizing the strategy was stressed. The Subcommittee also identified sorne key factors for the successful implementation of IMCI. 211 . Given the importance of IMCI, the Subcomnùttee stressed the need to extend its

implementation to al! countries in the Region. 212. In its discussion of this aspect of the Programme Subcomnùttee's report, the

Regional Comnùttee stressed that the lntegrated Management of Childhood Illness (IMCl) is a good strategy that could save resources and also serve as a model for integrating health services. For the successful implementation of the strategy, the importance ofavailability of drugs and human resources, effective referral systems and adequate community involvement were stressed . WHO was requested to support countries to put in place these enabling conditions. 213 . Delegates suggested that the strategy should be adapted to local realities. For

example, where IllV1 AIDS prevalence is high as is the case in many countries of the Region,

lllV/AIDS should be part ofIMCI given the increasing number of children infected. Sorne delegates also requested for various kinds of technical support for the introduction and/or acceleration of the implementation of the strategy in their countries. 214. Dr A. Kabore of the Secretariat reaffirrned that IMCI is a strategy intended to

integrate, coordinate and optirnize on-going country interventions benefiting children below five years of age. He added that with a view to extending the IMCr approach to Portuguesespeaking countries, an orientation workshop had been planned for them during the early part of the year 2000. 215. He agreed that the strategy should be adapted to the epiderniological and

sociocultural contexts of each country. In recognition of the importance of community involvement in the implementation of IMCr, he inforrned the Committee that the Regional Office had strengthened its capacity in the community aspects ofIMCI. 216. The Regional Committee adopted resolution AFRlRC491R4.

34 Essential drugs in the WHO African Region: Situation and trend analysis (document AFRlRC49/11) 217. Dr Niang reported to the Regional Committee that the Subcommittee recounted the various dimensions of the drug issue that were of great concern, namely, limited availability of essential drugs; Jack of reguJar access to quality essential drugs; inappropriate drug use; Jack of standards, regulations and relevant legislation; fake or illicit. 218 . The Subcommittee stressed the need to encourage joint bulk purchasing to reduce cost of drugs; undertake more systematic quality control of drugs; make coordinated efforts with relevant partners to address the problem of fake and iIIicit drugs; and assure the avaiJability of essential drugs at all JeveJs of the health systems. 219. WHO was invited to develop a strategy on the role of traditional medicine in health care delivery and also to pJay a more active role in support of research on medicinal pJants. 220. It recommended!hat countries should review their tax. policies with a view to reducing the impact of international trade agreements on local manufacture of drugs; and high proportion of Împ(}rted drugs that were

cost barriers to wider access to essential drugs. Delegates al50 requested WHO to support the Association of Central Medical Stores in carrying out joint bulk purchasing of essential drugs. 221. It was felt that the magnitude and seriousness of the trade in illicit and fake drugs was a public health threat and called for a concerted regional- wide carnpaign for its speedy resolution. WHO was th~refore

called upon to develop a regional strategy to combat the menace of illicit and fake drugs.

222. The Committee called for an expanded irnplernentation on the Intensified Essential Drugs Programme for the African Region, and requested for the active participation of WHO in the forthcoming WTOrrRlPS negotiations, the outcome of which would have significant influence on the price of essential drugs . 223. - The Secretariat assured the Cornmittee that, as requested, specifie attention would be given to traditional medicine in the following areas:

research on and application of knowledge of

medicinal plants; production and supply of traditional remedies of proven efficacy; and ways and means ofintegrating the practice oftraditional medicine in health care services. 224. The Committee adopted resolution AFRlRC49fR5 .

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Health technology poticy in the African Region (document AFRlRC49/12) 225. Dr Niang reported to the Regional Committee that the Subcommittee welcomed the document and saw it as a major contribution in the Region since most countries did not have c1early defined policies or coherent strategies on health technology management. 226. Potential areas for technical cooperation among countries in the ~egion with regard ta health technology were identified, as was the need to develop a maintenance culture in this domain. 227. In their discussion ofthis aspect of the Programme Subcommittee's report, delegates noted that the greatest challenge was for countries to effectively cooperate on issues related to purchasing, utilizing and maintairùng health technologies. WHO could play an important role in facilitating the much needed cooperation by developing appropriate guidelines in this domain. 228. The need for better management on the part of govemment was stressed. For example, orders for equipment should not be placed without an explicit plan to train those who would operate and maintain the equipment. 229. Delegates noted with concem the donation ofhealth equipments that had not taken into consideration the technical and economic capacities as weIl as the epidemiological situation in countries. In addition, they noted that sorne donated equipment was at times ohsolete. WHO was, therefore, requested to provide guidance to countries to ensure that donations were appropriate to country needs. 230. The Essential Health care Technology Package linked identified essential c1irùcal procedures at various levels of health care delivery system with required technologies and indicated their life cycle cost implications, requirements in human resources and support structures. rt was noted that a package was ofinterest ta ail countries and that, forthis reason, WHO should continue its support to countries in defirùng essential health technology packages for various types of health facilities or levels of health care delivery systems. 231. Dr M. Belhocine of the Secretariat recalled that in 1994 the Regional Committee adopted a resolution on health technologies which recommended, among other things, the preparation and dissemination of guidelines for use by the countries and the defirùtion of an essential package of technologies. Since then, the Regional Office had worked on three main thrusts: improving WHO guidance to countries, strengthening country institutionai capacity and responding to country requests.

36 232. In collaboration with WHO Headquarters and other partners, the Regional Office set up a group of experts at the end of 1996. The group produced a guide for the formulation of a national policy on biomedical equipment. The finalization of the guide had been delayed to sorne extent by the relocation of the Regional Office. The guide however would be ready towards the end of the year for distribution to countries. 233 . He added that the problem of equipment donations had been discussed in detail at WHO Headquarters since other regions had similar problems. A guide that hac1 been prepared with the involvement of African experts had been sent for printing and should be available shortly. 234. To strengthen institutional capacity, WHO had been encouraging the development ofa methodology for the choice of essential equipment packages. This work was assigned to a WHO collaborating centre in South Africa. The methodology is currently available in the form of a comprehensive computer-based too1. 235. He added that the training of technicians and senior managers was being encouraged by the Regional Office and conc1uded that the suggestions and recommendations made by the Cornrnittee would be taken into account in the preparation of future plans of actions and progranunes of cooperation with countries.

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Review orthe implementation ofthe Bamako Initiative (document AFRlRC49/13) 236. Dr Niang reported ta the Regional Cornrnittee that the Subcommittee noted that although the Bamako Initiative had been found ta be relevant for addressing health problems, particularly at the community level, governrnents should not abdicate their responsibility to make essential health services available to ail their populations. In other words, community efforts should be seen only as complementary to the efforts of governrnents. 237. The Subcornrnittee identified constraints in the implementation of the Initiative, which the document had not brought out. 238. The Subcommittee underscored the need for WHO to provide a new framework for implementing the Initiative within the context of the ongoing health sector reforms. 239. In discussing this aspect ofthe Programme Subcommittee' s report, delegates stated that Governrnents should not be seen as the onJy providers of hea1th care but communities should participate actively in the development of their own health and weil being.

37 240. The Regional Director was requested to move speedily and propose the new operational framework for implementation of the Bamako Initiative in countries as recommended by the Subcommittee. 241 . WHO should assist countries to conduct an assessment of the impact of the Bamako Initiative after a decade of its implementation and to promote exchange of experiences. 242. At the community level, there was need to bring the Essential Drugs Programme doser to the Bamako Initiative, and develop new approaches to enable people to take ownerslùp of their own health. 243 . There was need to link the Bamako Initiative to the macro-econornic issues in countries. In that regard, Ministries ofHealth should work c10sely with Ministries ofFinance to develop the linkage. 244. In response, Dr Sambo of the Secretariat rerninded the Committee that health was a fundamental Human Right wlùch had to be guaranteed by the state, with active participation of communities in their own health and well-being. He stressed that the issue of poverty and low purchasing power of communities should also be taken into account. 245 . He conduded that WHO/AFRO, in consultation with UNICEF, would convene a technical working group meeting of nationals and technical officers to develop the new operational framework for implementation of the Bamako Initiative. In that regard, the linkage of BI and income generating activities would be further developed to address the issues of sustainability. 246. The Regional Committee adopted resolution AFRlRC491R6. 247 . At the conclusion of its debate on the various parts of the Programme Subcommittee report, the Regional Committee thanked the members of the Programme Subcommittee for a job weil done and approved its report. 248. The Chairman reminded the Committee that Rwanda, Sao Tome and Principe, Senegal, Seychelles, Sierra Leone and Swaziland would drop out of the Programme Committee and would be replaced by Angola, Benin, Botswana, Burkina Faso, Burundi and Cameroon. The new members would be required to designate the nationals who would serve on the Programme Subcommittee.

38 249. The Regional Committee therefore elected Algeria, Angola, Benin, Botswana, Burkina Faso, Burundi, Cameroon, Tanzania, Togo, Uganda, Zambia and Zimbabwe to serve on the Progranune Subcommittee whose first meeting would take place in Harare in June 2000. The exact dates would be communicated by the Secretariat at a 1ater date . TECHNICAL DISCUSSIONS (Documents AFRlRC49/TD/l and AFRlRC49/TD/2) Presentation of the report of the Technical Discussions (document AFRlRC49114) 250. Along side with the work of the Regional Committee, the Teclutical Discussions were held on

the theme Disease Control in the African Region in the 21 st century. 251. The report of the Teclutical Discussions was presented by its Chairman, Professor Peter

Ndumbe. 252. The Committee expressed appreciation for the excellent quality of the report and the

pertinence of its recommendations which were addressed to WHO, the Member States and their partners. 253. The Regional Director thanked the President, the Vice President and the participants for their

contribution to the success of these Teclutical Discussions. He added that the recommendations would be implemented. 254. The Committee took note of the report, which would be included as an annex in the Report of

the Regional Committee. Choice of subject for Technical Discussions in year 2000 (document AFRlRC491l5) 255. The Regional Committee chose the following subject for the Technical Discussions

at its fiftieth session: REDUCING MATERNAL MORT ALITY: A CHALLENGE FOR THE TWENTY-FIRST CENTURY. Nomination of the Chairman and the Alternate chairman of the 2000 Technical Discussions (document AFRlRC49/ 16). 256. The Committee appointed Professor Kelsey Atangamuerino Harrison (Nigeria) as

Chairman, and Dr Maria do Rosario de Fatima Madeira Rita (Angola) as the Altemate Chairman for the Technical Discussions at the fiftieth session of the Regional Committee for Africa in the year 2000.

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DATES AND PLACES OF THE 50TR AND 51ST SESSION OF THE REGIONAL COMMITTEE (document AFR/RC49/16) 257. In accordance with the Rules of Procedure, the Regional Cornmittee accepted the

offer of Burkina Faso to host the 50th session in Ouagadougou beginning on the 25th of August 2000. Conceming the 51 st session, Congo made an offer to host the meeting. A decision will be taken at the fiftieth session of the Regional Committee. PROCEDURAL DECISIONS Nomination of Representatives of the Arrican Region to Policy and Coordination Committee (PCC) of the Special Programme of Research, Development and Research Training in Ruman Reproduction (HRP). 258. The term of office of Angola and Algeria will come to an end on 31 December 1999.

According to the English alphabetical order, they will be replaced by Burkina Faso and Burundi which will join Benin and Botswana from 1 January 2000 for a term of three years.

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