SEA/RC65/2
in the South-East Asia Region
WHO Biennial Report of the Regional Director 1 January 2010 – 31 December 2011
The Work of
WHO Library Cataloguing-in-Publication data Biennial report of the Regional Director, 1 January 2010 – 31 December 2011. 1. Regional Health Planning. 2. Communicable Diseases. 3. Delivery of Health Care. 6. Tobacco Use Cessation. 9. Food Safety. 12. Budgets. ISBN 978-92-9022-420-4 4. Family Health. 7. Ageing. 10. Health Policy. 13. South-East Asia. (NLM classification: WA 540) 5. Reproductive Health. 8. Disasters. 11. Environmental Health.
© World Health Organization 2012 All rights reserved. Requests for publications, or for permission to reproduce or translate WHO publications – whether for sale or for noncommercial distribution – can be obtained from Publishing and Sales, World Health Organization, Regional Office for SouthEast Asia, Indraprastha Estate, Mahatma Gandhi Marg, New Delhi 110 002, India (fax: +91 11 23370197; e-mail: publications@searo.who.int). The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by the World Health Organization to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization be liable for damages arising from its use. Printed in India
Contents Preface. ........................................................................................ v Executive summary of key achievements .................................. vii 1. Communicable diseases. .......................................................1 Overview........................................................................................... 1 Member States’ achievements and WHO’s contributions .......................... 2 Lessons learnt.................................................................................. 15
2.
HIV/AIDS, tuberculosis and malaria. ..................................17 Overview......................................................................................... 17 Member States’ achievements and WHO’s contributions......................... 18 Lessons learnt.................................................................................. 31
3.
Noncommunicable diseases. ...............................................33 Overview......................................................................................... 33 Member States’ achievements and WHO’s contributions......................... 34 Lessons learnt.................................................................................. 43
4.
Maternal and child health, reproductive and sexual health, and healthy ageing......................................45 Overview......................................................................................... 45 Member States’ achievements and WHO’s contributions......................... 46 Lessons learnt.................................................................................. 56
5.
Health in emergencies, disasters, crises and conflicts........57 Overview......................................................................................... 57 Member States’ achievements and WHO’s contributions......................... 58 Lessons learnt.................................................................................. 63
6.
Tobacco, alcohol, psychoactive substances, unhealthy diets, physical inactivity and unsafe sex............65 Overview ........................................................................................ 65 Member States’ achievements and WHO’s contributions......................... 66 Lessons learnt.................................................................................. 73
7.
Social and economic determinants of health. .....................75 Overview......................................................................................... 75 Member States’ achievements and WHO’s contributions ........................ 77 Lessons learnt.................................................................................. 83
The Work of WHO in the South-East Asia Region
iii
8.
Healthy environments and environmental threats to health. ................................................................85 Overview......................................................................................... 85 Member States’ achievements and WHO’s contributions......................... 86 Lessons learnt.................................................................................. 94
9.
Nutrition, food safety and food security. .............................95 Overview......................................................................................... 95 Member States’ achievements and WHO’s contributions......................... 96 Lessons learnt................................................................................ 101
10. Health services, governance, financing, staffing and management.................................................103 Overview....................................................................................... 103 Member States’ achievements and WHO’s contributions....................... 104 Lessons learnt................................................................................ 116
11. Access, quality and use of medical products and technologies..............................................................119 Overview....................................................................................... 119 Member States’ achievements and WHO’s contributions ...................... 120 Lessons learnt................................................................................ 124
12. Leadership, governance, partnership and country collaboration. ................................................127 Overview ...................................................................................... 127 Member States’ achievements and WHO’s contributions....................... 128 Lessons learnt................................................................................ 131
13. An efficient and effective WHO.........................................133 Overview....................................................................................... 133 Member States’ achievements and WHO’s contributions ...................... 134 Lessons learnt ............................................................................... 137
Annexes 1. List of strategic objectives and Organization-wide expected results............................................. 139 2. List of active WHO collaborating centres in the SEA Region. ............ 148 3. Budget implementation by strategic objective. .............................. 154 4. Budget implementation by budget centre. .................................... 155
iv
The Work of WHO in the South-East Asia Region
Preface This report on The Work of WHO in the South-East Asia Region, covering the period 1 January 2010 to 31 December 2011, highlights WHO’s collaborative activities in relation to Member States’ achievements in public health and WHO’s contributions in the context of current health developments. Each chapter covers a technical area which directly addresses a related strategic objective of the Organization. It describes the scope, salient strategies / main strategic approaches and lists key partners and stakeholders. The Report also underscores key lessons learnt and priorities for each area of work. The 11 Member States of WHO’s South-East Asia Region are making concerted efforts to improve the health status and quality of life of the 1.72 billion people who live in the Region. Substantial efforts are underway to strengthen health systems based on primary health care for ensuring universal health coverage as a means for achieving the goal of health for all so that people may live socially and economically productive lives. The substantial investments made in health systems strengthening are yielding results. Member States have made substantial progress in promoting health and combating illnesses. Some of the notable achievements include the elimination of guineaworm disease and leprosy from the Region. Poliomyelitis is on the verge of eradication. Extensive immunization has reduced mortality due to measles by almost 50 %. An effective public health response was mounted by countries in combating an influenza pandemic and all countries had national influenza preparedness plans in place. The Region has contributed significantly towards the global achievement of MDG 6. The prevalence and mortality of tuberculosis is declining. The HIV epidemic is being contained, with a decline in the number of cases in India, Myanmar and Nepal, and a reverse in Thailand. Malaria deaths have also shown a significant decline. Several countries recorded significant declines in their maternal and child mortality rates. However, much more attention to intersectoral initiatives addressing the social determinants of health are needed to achieve MDGs 4 and 5. The Region has also advanced its pharmaceutical and biotechnological manufacturing capacity. It is well recognized for making low-cost but quality antiretroviral drugs and vaccines available all over the world. The burgeoning burden of noncommunicable diseases (NCDs) poses an additional public health challenge in the Region. The increase in NCDs can be attributed to globalization, demographic transition, rapid unplanned urbanization and unhealthy lifestyles. Primary prevention of NCDs and health
The Work of WHO in the South-East Asia Region
v
promotion are key in addressing this challenge. Countries will need to adopt the public health approach to control and contain the NCD epidemic. The NCD epidemic underscores the need for intersectoral action for health. Indeed, this is an opportune time to work towards “health in all policies”. WHO-SEARO stands by to work with Member States in this vital area. Strong, well-managed and adequately funded public health systems, efficient intersectoral coordination, planned urbanization, preservation of the environment, along with effective core competencies as enunciated in the International Health Regulations, will assist in appropriate control of biological, chemical and radioactive substances and aid global health security by restricting the spread of diseases and protecting travel and trade. The Region continues to be prone to natural disasters. This necessitates sustained and advance planning and preparation as well as strengthening of the disaster management cycle in order to prevent, mitigate, and respond to various events. In the area of environmental threats to health, work focused on building capacity of Member States to create healthier environments, through implementation of health impact assessments as part of healthy public policy. Member States worked relentlessly to strengthen health systems based on primary health care to meet the challenges posed by the rising burden of noncommunicable diseases, communicable diseases and inequities in health outcomes within and across countries. Revitalization of primary health care will need further focus on community-based approaches and community empowerment. Health funding constraints and the shortage, mal-distribution and inappropriate skills-mix of human resources for health remain a challenge. Appropriate and urgent action is needed to address issues related to human resources for health. Countries are making efforts in ensuring availability of quality medicines through better functioning of their National Regulatory Authorities and pharmaceutical industry. Member States’ achievements during the biennium 2010-2011 were made possible due to close collaboration with all health partners and effective intersectoral collaboration at country, regional and global levels. It is hoped that this Report will be found useful by those interested in health development and in WHO’s work, future challenges and priorities in the South-East Asia Region.
Dr Samlee Plianbangchang Regional Director
vi
The Work of WHO in the South-East Asia Region
Executive summary of key achievements*
Communicable diseases Member States’ achievements: Diptheria, Tetanus, Pertussis 3 doses (DTP 3) coverage in SEAR increased from 76% in 2008 to 77% in 2010. This 1% increase represents an additional 372 282 children vaccinated The last wild poliovirus case detected in the Region was on 13 January 2011 All countries have eliminated leprosy as a public health problem All SEAR countries now have specific units designated for surveillance of public health risks, including a component of ‘event based surveillance’
WHO’s contributions: Supported performance assessment surveys and training workshops on immunization Supported preparation of Global Alliance for Vaccines and Immunization (GAVI) applications Led aggressive mop-up campaings for polio eradication Funding for leprosy scale-up Monitoring of protective chemotherapy Guidelines, training and technical support to build International Health Regulations (IHR) core capacities
HIV/AIDS, tuberculosis and malaria Member States’ achievements: HIV prevalence has been reduced in 10 of the 11 countries. 717 000 HIV+ people in SEAR now receive anti-retroviral therapy (ART), an additional 140 000 since 2009
*See Annex 1 – List of strategic objectives and Organization-wide expected results.
The Work of WHO in the South-East Asia Region
vii
Early case detection and appropriate treatment lowered malaria mortality and case fatality rates Use of rapid diagnostic tests for malaria reached 15.2 million in 2010, up from 1.4 million in 2005 Availability of long lasting insecticide nets / insecticide-treated mosquito nets (LLINs/ITNs) increased to 17 million, up from 4.3 million in 2005 Progress was made in containment of malaria drug resistance in Myanmar and Thailand Tuberculosis (TB) case-notification and treatment success rate is >85% for the Region All SEA countries have successfully transitioned from grants to direct procurement of First-Line Drugs (FLDs) for TB
WHO’s Contributions: External reviews of health sector response to HIV/AIDS Various normative documents and tools for HIV, TB and malaria Technical assistance for proposal development, strategy development, programme reviews, training, entomology, microscopy, monitoring and evaluation (M & E) and drug resistance studies Support for development of Global Fund to fight AIDS, Tuberculosis and Malaria (GFATM) proposals and planning and implementation of related activities Organization and support for participation by Member States in meetings and workshops
Noncommunicable diseases Member States’ achievements: Nine countries have integrated noncommunicable diseases (NCDs) into national policy National guidelines and plans on NCDs were updated to reflect integrated approaches Primary Health Care (PHC)-based screening and management of NCDs using Package of Essential Noncommunicable Disease Interventions for Primary Health Care (PEN) approach began in Bhutan, Sri Lanka and Myanmar.
viii
The Work of WHO in the South-East Asia Region
WHO’s contributions: Advocacy, technical and financial support for conducting WHO STEPwise approach to surveillance (STEPS) survey and for participation by Member States in regional consultations and high level meetings on NCDs and for incorporation of trauma care into health care systems Normative manuals, guidelines, handbooks and training materials on tobacco control, mental health, primary health care, violence and injuries, trauma care, rights of persons with disabilities National workshops/training on injury prevention, surveillance and care, prevention of blindness, epidemiology of ear health and community care Situation analyses on prevention of blindness and communitybased rehabilitation (CBR) Regional framework for CBR for people with disabilities
Maternal and child health, reproductive and sexual health, and healthy ageing Member States’ achievements: Child mortality declined in most countries Bangladesh and Nepal won UN Secretary-General (UNSG) awards for their achievements in improving child and maternal health and survival Millennium Development Goal 5 (MDG 5) targets have already been met by Thailand and Sri Lanka
WHO’s contributions: Advocacy, technical and financial support for: improving universal access, improving skilled birth attendance, emergency obstetric care, access to safe abortion, care of elderly populations, maternal death review studies, operational research and programme management Normative guidelines, tools and manuals including regional strategic directions on improving adolescent health, fact sheets on child health, family planning and on adolescent health and pregnancy, continuum of care guidelines, home based care guidelines, and quality and coverage assessment tools
The Work of WHO in the South-East Asia Region
ix
Workshops, meetings, joint reviews and training on: child health, early childhood development, birth defects, scaling up of adolescent health programmes Reproductive health programme reviews Support to WHO Collaborating Centres
Health in emergencies, disasters, crises and conflicts Member States’ achievements: Emergency response operations conducted with WHO support included: –– –– DPR Korea – torrential rains and floods, June 2011; Indonesia • Mt Merapi eruption (October, 2010) – South-East Asia Regional Health Emergency Fund (SEARHEF) support provided; continued support to Padang earthquake recovery (September, 2009);
• –– –– ––
Myanmar – cyclone Giri; Sri Lanka – continued support for the recovery efforts in the post-conflict area in Vavuniya/Menik Farm; floods; Thailand – floods, August to December, 2011
WHO’s contributions: Convening of partners, provision of resource persons during emergencies and serving as Health Cluster Coordinator Operational platform for surge capacity for funding, logistics, human resources and capacity building Guidance materials including: framework for primary health care approach in emergencies, package on community resilience, nursing in emergencies Technical, financial, emergency supplies, training and operational support Establishment of South-East Asia Disaster Health Information Network (SEADHIN)
x
The Work of WHO in the South-East Asia Region
Tobacco, alcohol, psychoactive substances, unhealthy diets, physical inactivity and unsafe sex Member States’ achievements: Ten countries have completed at least one round of risk factor survey similar to the WHO STEPS survey Nine countries have adopted tobacco control legislation and cessation clinics are operational in four Ten countries completed first and second rounds of the Global Youth Tobacco Survey (GYTS) Seven countries have multisectoral strategies and plans on healthy diets or physical activity
WHO’s contributions: Technical, financial and training support for: awareness campaigns, proposal development, conduct of surveys, adaptation and amendment of tobacco control legislation, harmful use of alcohol and inter-country collaboration Normative materials, scientific documents and advocacy materials
Social and economic determinants of health Member States’ achievements: Changing public policies in Thailand and Indonesia illustrate efforts being made to tackle social and economic determinants of health Integrated national health statistics exist and health information in most countries is aggregated by age, sex, income and health conditions. Countries are therefore able to clearly identify disparities.
WHO’s contributions: Key indicators of social and economic determinants of health were integrated into surveys, studies and interventions of SEARO technical units
The Work of WHO in the South-East Asia Region
xi
Regional Strategic Framework to address social determinants of health was developed and regional consultations held on a Framework for Public Health, Innovation and Intellectual Property and on the Consultative Expert Working Group on Research and Development Financing and Coordination (CEWG) Training materials and workshops on inter-sectoral action in relation to social determinants, intellectual property rights and HHR Collation and dissemination of country experiences Normative work and tools development, and technical assistance to analyze health equity and responses
Healthy environments and environmental threats to health Member States’ achievements: Nine SEAR countries implemented activities for the Global Plan of Action on Workers’ health Chemical safety programmes implemented in Indonesia, Sri Lanka and Thailand Phased banning of asbestos agreed in Sri Lanka and Thailand Analysis and assessment of sanitation and drinking water in nine countries and water safety plans implemented in six countries Healthy Settings programmes implemented as part of World Health Day (WHD) activities on urbanization and health Primary prevention interventions
WHO’s contributions: Advocacy documents, normative guidance and tools including: water quality guidelines and standards, chemical profiles and standards, vulnerability assessment tool on the impacts of climate change Technical support for: monitoring of water safety, management of chemicals, occupational health Training activities on workers health and chemical safety
xii
The Work of WHO in the South-East Asia Region
Nutrition, food safety and food security Member States’ achievements: National capacities to assess environment-related contaminants and foodborne disease outbreaks were strengthened Member States established national programmes in undernutrition, diet-related chronic disease, micronutrient deficiencies and infant and young child nutrition Increased participation of Member States in Codex Alimentarius Commission and the International Food Safety Authorities Network (INFOSAN)
WHO’s contributions: Development of Regional Nutritional Strategy Organization of regional consultation on street foods, bi-regional meeting on scaling up of nutrition and technical consultation on sodium intake, iodine deficiency and cardiovascular problems Dissemination of guidelines, standards, protocols, recommendations and communication materials Technical assistance and training on severe childhood malnutrition
Health services, governance, financing, staffing and management Member States’ achievements: The health workforce increased and the quality and relevance of health personnel education improved Health personnel educational institutes and teachers were strengthened and quality assurance mechanisms established Health information systems and MDG monitoring improved Development of national human resources for health strategic plans
The Work of WHO in the South-East Asia Region
xiii
WHO’s contributions: Health system rapid assessments Training including Health Information System (HIS), human resources for health (HRH) and Global Learning Programme – National Health Policy and Strategy Planning (NHPSP) Policy, strategic and operational support for HIS Regional meetings and consultations on quality assurance in medical education and national health planning Improving health coordination, convening of partners and resource mobilization Technical support for HRH, HIS, health financing, health planning, Tools, norms, standards and guidance materials including guidelines for health workforce planning, health financing policy development, patient safety, hand hygiene and safe surgery Regional strategies such as the Asia-Pacific Health Financing Strategy 2010-15, Regional Strategy for Universal Health Coverage (UHC).
Access, quality and use of medical products and technologies Member States’ achievements: Member States updated Essential Medicines Lists and standard treatment guidelines and revised national drug policies 10 Member States have national policy/legal framework for blood safety India, Indonesia and Thailand made significant progress to comply with National Regulatory Authorities (NRA) regulatory requirements for a vaccine producing country and Thailand was assessed to be functional Progress in improving detection and reporting of adverse events following immunization (AEFI) was recorded
WHO’s contributions: Technical advice and support for updating essential medicines lists, clinical guidelines, rational use of medicines, revision of
xiv
The Work of WHO in the South-East Asia Region
national drug policy, safe blood, and the strengthening of drug supply and regulation Regional consultations and training programmes Baseline survey on health technologies
Leadership, governance partnership and country collaboration Key achievements Meetings of governing bodies including the Regional Committee and the Sub-committee on Policy and Programme Development and Management were successfully organized. Briefings for Member States’ representatives were organized prior to the Executive Board and World Health Assembly meetings. Communication, media relations and advocacy between the Organization and Member States were strengthened through utilization of appropriate technology. WHO country offices were briefed on the United Nations Development Assistance Framework (UNDAF) development process and were engaged with Common Country Assessment (CCA) and the UNDAF through the Peer Support Group of the UNDG-Asia Pacific. A Conference of Partners for Health in South-East Asia was organized. A new WHO liaison link with United Nations Economic and Social Commission for Asia and the Pacific (UN ESCAP) was created in 2011. A Memorandum of Understanding (MoU) between SEARO, WHO Western Pacific Regional Office (WPRO) and the Association of Southeast Asian Nations (ASEAN) on specific modalities for the implementation of shared workplan was signed in 2010. Nine communication training programmes and seven media workshops were conducted with the participation of 153 ministry of health officials, 147 media personnel, 31 UN staff and 60 WHO staff.
The Work of WHO in the South-East Asia Region
xv
An efficient and effective WHO Key achievements The increased involvement of Member States in WHO planning was achieved through participation in the development of 2012-2013 programme proposals based on national and regional challenges, Country Cooperation Strategies (CCSs), Regional Committee resolutions and ministerial declarations. Monitoring of operational plans and the programme budget was conducted. Improved income management procedures were implemented to enhance resource mobilization efforts. Training of WHO country office personnel was delivered on sound financial management practices. 100% reconciliation of financial records was achieved. Selection guidelines were revised to make recruitment processes simpler, more qualitative, time-effective and transparent. The staff induction programme was developed and implemented, and staff profiling exercises conducted in six WHO country offices. The technology infrastructure of the Region was upgraded and new tools introduced for knowledge-sharing. Global Management System (GSM) was fully rolled out. The Regional Information and Communication Technology (ICT) office was restructured for better services. All procurement personnel were trained on the process of establishing catalogues. Security evaluations were conducted in five WHO country offices and recommendations made to improve compliance with UN security standards.
xvi
The Work of WHO in the South-East Asia Region
Communicable diseases Overview 1. Public health issues addressed in this chapter include vaccine-preventable and neglected tropical diseases which are targeted for elimination and eradication along with zoonotic and epidemic-prone diseases including vector-borne diseases. Efforts to strengthen national and regional laboratory capacity to support public health functions, surveillance, response and disease prevention, control and elimination and eradication are also included in this area of work as are polio eradication efforts and emerging infections including pandemics, and implementation of the International Health Regulations (IHR-2005). 2. Various strategies were employed to combat communicable diseases including: the Asia Pacific Strategy for Emerging Diseases, Asia Pacific Strategy for Strengthening Health Laboratory Services, the Regional Strategic Framework for Prevention and Control of Zoonoses, and the Bi-regional Strategic Plan for the Prevention and Control of Dengue in Asia Pacific. 3. Major stakeholders involved in collaborative efforts to combat communicable diseases included ministries of health and other relevant government and nongovernmental sectors, the United Nations Children’s Fund (UNICEF), Food and Agriculture Organization (FAO), World Organization for Animal Health (OIE),
1
Centers for Disease Control and Prevention – Atlanta (CDC-Atlanta), United States Agency for International Development (USAID), the Australian Agency for International Development (AUSAID), European Commission, Canadian International Development Agency (CIDA), South Asian Association for Regional Cooperation (SAARC), ASEAN, Global Network for Neglected Tropical Diseases (GNNTD), the Nippon/Sasakawa Foundation, GAVI and GFATM among others.
Member States’ achievements and WHO’s contributions Maximizing equitable access to vaccines 4. DTP 3 coverage for the Region increased from 76% in 2008 to 77% in 2010 (Table 1.1). This one percent increase required immunizing 372 282 children in addition to the 28.3 million vaccinated up to 2008. India expanded Hepatitis B vaccine to all States and initiated pentavalent vaccine in two States. Three GAVI-eligible countries (DPR Korea, Myanmar, and Timor-Leste) received GAVI approval for financial assistance to introduce pentavalent vaccines and will be introducing pentavalent vaccine in 2012 in their national immunization programmes. Bangladesh received GAVI approval for financial assistance to introduce pneumococcal vaccine and will be introducing it in 2014. Table 1.1: DTP3 Coverage (percent) estimates* by country, SEAR, 2006-2010 Country Bangladesh Bhutan DPR Korea India Indonesia Maldives Myanmar Nepal Sri Lanka Thailand Timor-Leste SEAR 2006 93 95 89 66 72 98 82 94 98 98 63 71 2007 95 95 92 70 81 98 86 91 98 98 70 75 2008 95 96 92 72 77 98 85 96 98 99 79 76 2009 96 93 93 72 82 98 90 89 97 99 72 77 2010 95 91 93 72 83 96 90 82 99 99 72 77
*WHO-UNICEF estimates 2010
2
The Work of WHO in the South-East Asia Region
5. India completed the first round of the measles catch-up campaign in 45 districts covering 12 million children between nine months and ten years of age in 2010 and commenced the second phase covering 144 districts targeting 38.3 million children in the same age group. Indonesia completed a measles follow-up campaign in November 2011 covering 17 provinces targeting 12 million children. In 2011 alone, 11.5 million children in Indonesia and 40.7 million children in India were immunized against measles through supplementary immunization activities (Figure 1.1). These regional achievements contributed to global progress on reducing measles deaths by 74% in 2010. Figure 1.1: Measles-Containing Vaccine first dose (MCV1) coverage* and measles cases**, SEAR 1980-2010
*WHO/UNICEF estimated coverage Updated on 26 December 2011 **WHO vaccine-preventable diseases: monitoring system 2011 global summary
6. WHO-SEARO’s contributions to these achievements included support to India to conduct a performance assessment survey of health workers on routine immunization (RI), routine support for the Reaching Every District Strategy in Bangladesh, India, Indonesia, Myanmar and Nepal and training workshops for selected middle-level health managers in all countries. Support was also provided from the Regional Office by providing consultants for monitoring during the measles catch-up campaigns conducted in India, Indonesia and Myanmar. A workshop was organized to support eligible countries to prepare their applications to GAVI and
Communicable diseases
3
for the screening of necessary documents. Bhutan and Indonesia were assisted to hold consultative workshops on strengthening National Technical Advisory Groups on Immunization (NTAGI). In August 2011, a high-level ministerial meeting drew commitments from Member States, development partners, civil society and immunization stakeholders through the Delhi Call for Action. This advocacy initiative led to the WHO Regional Committee adopting a resolution in September 2011 declaring 2012 as the Year of Intensification of Routine Immunization in the South-East Asia Region.
Achieving certification of poliomyelitis eradication 7. The last case of wild poliovirus in the Region was detected in India on 13 January 2011. This date represents an important milestone for the Region, marking the starting point for the longest polio-free period ever recorded. With the exception of Nepal which experienced active transmission through importation from India in 2010, all other countries of the Region have remained polio-free for more than five years. With the tremendous progress in India, the Region is now on a certification track. The certification process is the responsibility of the Regional Certification Committees (RCC), which will certify the Region to be polio-free based on convincing evidence presented by the National Certification Committees (NCC). The RCC certifies WHO Regions and not individual countries to be polio-free. The RCC will only consider certification three years after the last indigenous wild poliovirus case is detected in any country in the Region in the presence of high-quality acute flaccid paralysis (AFP) surveillance. The South-East Asia Regional Certification Committee has a projected certification for January 2014. All countries in the Region are currently using trivalent oral polio vaccine in their routine immunization programmes. The polio end-game strategy and timeline for stopping the use of oral polio vaccine will need to carefully consider the different vaccine options and mitigate risk as one progress towards global polio eradication. 8. In support of polio eradication work, WHO-SEARO formulated and pursued strategies towards an overall improvement in the quality of polio immunization campaigns and AFP surveillance. These strategies included programme intensification in high-risk areas focusing on migrant populations; aggressive mop-up campaigns in response to wild poliovirus detection; and, the introduction and use of bivalent oral polio vaccine (bOPV).
4
The Work of WHO in the South-East Asia Region
Towards polio eradication in India India has made tremendous progress towards polio eradication. As a result of concerted efforts over the previous 12-24 months, the number of polio cases decreased by over 99% as compared to 2009. In 2011, there was only one wild poliovirus case detected – the lowest since surveillance was initiated in 1997. Success and lessons learned in building a highly sensitive surveillance network for polio have been expanded to include strengthening surveillance for other vaccine-preventable diseases and monitoring routine immunization activities. Strategies adopted to stop polio transmission in India represent a multi-pronged approach. Eradication challenges have been approached systematically with specific programmes: the 107 high-risk block initiative in historically polio-endemic areas of western Uttar Pradesh and central Bihar has focused on rapid improvement in sanitation, availability of clean water, hygiene and prevention/control of diarrhoea; migrant populations that have played an important role in sustaining and spreading polio have been targeted for surveillance and immunization activities; and, the introduction of bivalent oral polio vaccine (bOPV) has provided an additional tool for epidemiological based supplemental immunization activities. With continued, sustained efforts in 2012-2013, one can look forward to certifying the Region polio-free in 2014.
Preventing, controlling, eliminating and eradicating neglected tropical diseases 9. All 11 countries of the Region have achieved elimination of leprosy as a public health problem by reducing prevalence rates to less than one case per 10 000 population at the national level. Treatment coverage of Lymphatic Filariasis (LF) in Bangladesh, India, Indonesia, Nepal, Myanmar, and Thailand showed a marginal decline due to shortage of albendazole and operational cost. Because of achievements in reducing microfilaria rate to less than 1%, 287 implementation units stopped Mass Drug Administration (MDA) (Bangladesh, Maldives, Myanmar, Nepal, Sri Lanka and Thailand). 203 implementation units mainly in India reached a microfilarial rate of less than 1% and are planning for transmission assessment surveys. Two
Communicable diseases
5
countries (Maldives and Sri Lanka) initiated verification for elimination of LF. Both countries also initiated post-MDA surveillance. Soil Transmitted Helminthiasis (STH) treatment coverage in 11 Member States showed an increase from 137 million children (37%) in 2009 to 143 million (38%) in 2010. Myanmar reduced prevalence of active trachoma from 43% to less than 5% by implementing SAFE strategy (surgery for trichiasis, antibiotics to treat inflammatory disThe last case of wild poliovirus in the Region was ease, face washing and detected in January 2011. environmental activities) by 2011 and preparing for assessment. Nepal reduced the prevalence rate of active trachoma from 13% to 8% (2011) and nine districts completed an impact survey and were found to be meeting the criteria of elimination. A total of 69 433 new cases of kala-azar (Bangladesh, India, Nepal) were recorded and all received treatment during the biennium. The mortality rate in kala-azar decreased from 0.5% (2007) to 0.3% (2011). Indonesia, Nepal, Myanmar and Timor-Leste developed a national five-year plan for integrated control of neglected tropical diseases. 10. All countries of the Region now have a coordinating mechanism and national focal points in place for the detection of and response to zoonotic events. Ten of the Member States have developed and implemented a specific policy or strategy for surveillance and response to such events, including a community-level component in nine countries. In addition, 10 countries have established a mechanism for joint human / animal sector response to zoonotic events and for access to laboratory diagnosis of priority zoonotic events.
6
The Work of WHO in the South-East Asia Region
11. WHO-SEARO support to Member States included the organization of two national leprosy programme meetings. Timely funding from SEARO, WHO/HQ, USAID and GNNTD was used for Regional Programme Review Group (RPRG) and LF programme managers, meetings. Funds were also used to scale-up LF-MDA, to initiate verification of LF elimination in Maldives and Sri Lanka and to provide technical assistance to monitor preventive chemotherapy. 12. The WHO Global Leprosy Programme works under the leadership of the Regional Director. A total of 130 countries submitted reports to WHO on their country/territory situation. The number of new leprosy cases detected in the WHO Regions from 2004 to 2010 continues to show a decline in all Regions except for the Eastern Mediterranean Region (Table 1.2). The Enhanced Global Strategy and Operational Guidelines for Further Reducing the Disease Burden due to Leprosy 2011-2015 is being implemented in leprosy endemic countries. Drugs required for multidrug therapy have been made available to all Member States of WHO. Table 1.2: Trends in the detection of new cases of leprosy, by WHO regions. 2004-2010 WHO Regiona African Americas South-East Asia Eastern Mediterranean Western Pacific Total a
No. of new cases detected 2004 46 918 52 662 298 603 2005 45 179 41 952 201 635 2006 34 480 47 612 174 118 2007 34 468 42 135 171 576 2008 29 814 41 891 167 505 2009 28 935 40 474 166 115 2010 25 345 37 740 156 254
3392
3133
3261
4091
3938
4029
4080
6216 791 407
7137 299 036
6190 265 661
5863 258 133
5859 249 007
5243 244 796
5055 228 474
Reports from the European Region are not available
Source: Country Reports
13. Support was also provided to organize a national training workshop on clinical recognition, case management and control of emerging diseases including zoonoses in Maldives. The training of health professionals in Indonesia on the application of intradermal rabies vaccination and on leptospirosis case management was also included. Sri Lanka was supported
Communicable diseases
7
to organize a meeting of major stakeholders and to develop a national plan for rabies elimination based on the Regional Strategic Framework. 14. Technical support was also provided for adopting the Enhanced Global Leprosy Strategy and Operational Guidelines (2011-2015) that are in place in all Member States. The Regional Office organized a RPRG-LF meeting to approve the free supply of albendazole for the MDA programme. LF and kala-azar programme managers’ meetings were also organized to review achievements, identify bottle-necks and find solutions; as were informal consultation meetings to develop the Regional Strategic Plan for LF Elimination, 2010-2015 and a regional strategic plan for integrated neglected tropical diseases (NTD) control, 2012-2016. 15. A Regional Strategic Framework for Elimination of Human Rabies Transmitted by Dogs in the South-East Asia Region was developed and finalized through a consultative process. Technical support was also provided to Bangladesh, Bhutan and Indonesia to finalize national guidelines for rabies prophylaxis including intradermal rabies vaccination. India was supported to prioritize zoonoses and to strengthen prevention and control of zoonoses at state and district levels in the 12th Five Year Plan. Other activities included support to enhance networking between animal and human sectors and between countries. Finally, guidelines for the prevention and control of Nipah virus infection were initiated and media materials were developed on emerging infectious diseases (EID) / zoonoses as were public awareness materials on rabies, scrub typhus, toxoplasmosis and leptospirosis.
Enhancing surveillance and monitoring of communicable diseases 16. All 11 countries of the Region have specific units designated for surveillance of public health risks, including a component of ‘event-based surveillance’. In addition, 10 Member States report that surveillance data on epidemic-prone and priority diseases are analyzed at least weekly at national and sub-national levels. The majority of countries of the Region have reports or other documentation showing that surveillance alerts (i.e. values exceeding defined thresholds) spur action at the primary public health response level. The capacity of Member States to diagnose emerging infectious diseases and carry out surveillance of antimicrobial resistance have been enhanced. All Member States of the Region have surveillance systems for vaccine-preventable diseases in place. These systems transmit
8
The Work of WHO in the South-East Asia Region
information through the WHO country office to the Regional Office and then to Headquarters on a weekly and monthly basis. All Member States of the Region are also reporting annually through the WHO / UNICEF joint reporting form for immunization surveillance and monitoring. 17. WHO-SEARO support to these achievements included training on event-based and indicator-based surveillance and other such training programmes in India, Indonesia, Myanmar and Thailand. Technical support was provided to Bangladesh, Bhutan, Nepal, Sri Lanka and Thailand to establish and maintain expanded sentinel site surveillance for influenza. In addition, support was provided to build capacity in surveillance at camps for migrant and displaced persons in Thailand. Furthermore, technical support was provided to DPR Korea for the assessment of national response to pandemic hemagglutinin1/neuraminidase1 (H1N1) virus 2009 in the context of IHR including the surveillance component. Facilities for polymerase chain reaction (PCR)-based diagnosis of emerging infectious diseases including influenza were established in all Member States. A regional workshop on event-based surveillance and risk assessment was conducted in Indonesia involving participants from both public health and aninmal health sectors of 10 Member States. As a result, key technical staff from these countries received training that is expected to strengthen (1) defensible evidence-based decision-making (2) prioritization of control measures (3) faster implementation of appropriate control measures (4) more effective operational communications and (5) more effective risk communications. In addition, the workshop has contributed to increased understanding and the formation of an informal network between the two sectors involved.
Developing new knowledge and tools for prevention and control of communicable diseases 18. Eleven small grant research proposals funded in four Member States during the biennium are showing good progress. A study to assess the impact of Hepatitis B vaccination was initiated in Bangladesh. Research on climate change and its impact on human health was also initiated. A strategy for communicable diseases research was also developed during the biennium. 19. Sustained technical assistance and funding was provided by WHOSEARO for small research grant projects to five Member States. Workshops
Communicable diseases
9
on developing research protocols and on operational research on kala-azar were organized. A workshop to develop a regional “public health agenda for influenza research” was also organized at the Regional Office.
Strengthening of core capacities required by IHR (2005) 20. While significant progress has been made in strengthening core capacities for the implementation of the International Health Regulations by the end of 2011, no country of the Region has achieved full compliance. It is therefore expected that the majority of countries in the Region will apply for an IHR implementation extension until June 2014. The most significant measure of progress in IHR implementation was the ongoing response to pandemic influenza H1N1 2009 through to 2010, during which all Member States continued to operationalize their pandemic response plans and exchange surveillance data through IHR focal points on a regular basis. Eight Member States completed the assessment and developed a national action plan to achieve core capacities for surveillance and response in line with their obligation under the IHR 2005. 21. Technical support was provided to DPR Korea during the biennium for the assessment of the regional response to pandemic H1N1 2009 in the context of IHR. Assessments of ‘points of entry’ were conducted in Bhutan Figure 1.2: Implementation of IHR core capacities (percent) in the SEA Region by technical area, 2011
Source: Member States’ reports / standard reporting.
10
The Work of WHO in the South-East Asia Region
and Timor-Leste and support given to the revision of national legislation in Timor-Leste. Support was also provided to field epidemiology programmes in India, Indonesia and Thailand. Significant support was also provided to strengthening capacity for surveillance, laboratory services and zoonotic diseases. At the regional level, the third and fourth regional workshops on implementation of IHR (2005) were also organized in Bangladesh and Thailand. These meetings provided an opportunity for WHO-SEARO to realign support to Member States and develop a regional plan to support national IHR implementation extension plans. In addition, an international workshop to strengthen capacities for sound chemical management in the South-East Asia Region was supported, bringing together national IHR focal points and focal points for chemical safety. Support was provided to strengthen capacity for surveillance, laboratory services, risk communication and zoonotic diseases as outlined above.
Detecting, assessing and responding to epidemics 22. All Member States of the Region have national influenza preparedness and response plans in place, which were activated during the pandemic H1N1 2009. All Member States found their plans to be resilient, many documented lessons learnt and some have already begun a process of revision. However, none of the Member States report having generic national public health emergency plans for multiple hazards and “points of entry” tested in an actual emergency or in a simulation. During the biennium dengue-endemic Member States implemented the Asia-Pacific Dengue Strategy and made progress in implementing integrated vector management guidelines. 23. An evaluation of the Asia-Pacific Strategy for Emerging Diseases (APSED 2005) undertaken in Indonesia and Sri Lanka in 2010 showed satisfactory progress. Support was also provided for the development of country plans in Indonesia and Timor-Leste for the Asia Pacific Strategy for Emerging Diseases. In the area of risk communication, media and spokespersons’ trainings were held in Bhutan, Maldives and in Sri Lanka. Training on Communications for Behaviour Change (COMBI) was also conducted in Maldives. A bi-regional consultation and a Technical Advisory Group Meeting were organized in collaboration with WHO’s Western Pacific Regional Office leading to finalization of the new, updated Asia Pacific Strategy for Emerging Diseases (2010). A further Technical Advisory
Communicable diseases
11
Member States are strengthening vector control methods in the Region.
Group meeting was held in July 2011, where an APSED work-plan was presented and endorsed. A tool was developed by SEARO to facilitate assessment of national responses to pandemic H1N1 2009. A strategic framework for integrated diarrhoeal diseases and acute respiratory infection prevention and control programmes (IDRPCP) was also developed and a regional strategy for viral hepatitis was drafted. Guidelines on the clinical management of priority emerging diseases were also developed and a package of training materials on respiratory infection prevention and control was finalized and approved. A comprehensive regional guideline on dengue prevention and control was distributed and training in integrated vector management (IVM) for vector control officers of all the endemic Member States was organized.
Coordinating alert and response to epidemics and other public health emergencies 24. Field epidemiology training programmes supported by WHO-SEARO are active in India, Indonesia and Thailand. Global Outbreak Alert and Response Network (GOARN) partners in the Region participated in international outbreak responses (for example, Queen Sirikit National Institute of Child Health supported the response to dengue outbreaks in Pakistan and International Centre for Diarrhoeal Disease Research
12
The Work of WHO in the South-East Asia Region
Partnership and horizontal collaboration in outbreak response – Maldives A dengue outbreak was reported in Maldives in early June 2011 with markedly higher number of cases as compared to the previous years. From 26 December 2010 to 27 September 2011, 2432 dengue cases were detected across 44 islands and resorts resulting in 12 deaths. The majority of cases occurred in the capital Male’. A national dengue control task force was established through a presidential decree to boost the country’s efforts to fight the epidemic. WHO, in its effort to support the Government initiative, rapidly mobilized resources from all levels of the Organization to enhance the capacity of the Ministry of Health for the prevention and management of dengue. The approach addressed different components of the dengue prevention and management. The following technical assistance was provided: conducting a review of the dengue situation and the outbreak and assistance in developing a national plan for dengue prevention and control; introduction and dissemination of the new edition of the WHO Comprehensive Guidelines for the Prevention and Control of Dengue and Dengue Haemorrhagic Fever; training sessions were organized on the clinical management of dengue for doctors and nurses of public and private clinics facilitated at the central level by the team of experts from Thailand and behaviour change communication for prevention and control of dengue using Communication for Behavioral Impact (COMBI) approach. Dengue diagnostic kits were provided, and testing of blood samples was undertaken at a specialized laboratory in Thailand to confirm the type of dengue virus and procurement of essential supplies for dengue prevention and management was assisted. In collaboration with the Ministry of Health, WHO supported concerted efforts for communication of information on dengue prevention and control to the public as well as led efforts to raise awareness on the disease among the UN staff in the country. The most important features of the actions were: a comprehensive approach which recognized the importance of involving a range of strategies targeting service delivery, information management, communication strategies; working with multisectoral actors – the
Communicable diseases
13
high-level dengue task-force, ministries of housing and environment, tourism, media, the general population in addition to the ministry of health; and significantly, the ability to respond rapidly by utilizing Organizational resources beyond the WHO country office, which included unprecedented financial and technical support from the WHO Regional Office (procurement of dengue kits, coordination of technical assistance, analysis of reports) SEARO Information Disease Analysis System (SIDAS), COMBI, the horizontal collaboration with the WHO Country Office, Nepal, and technical collaboration with experts, institutions and laboratory services from Thailand (clinical management training and laboratory services).
(ICDDR), Bangladesh provided support to the response to flooding in Pakistan). All 11 Member States report that resources for rapid response during outbreaks of national or international concern are accessible and that rapid response teams are available in the country. In addition, nine countries report that management procedures are established for command, communications and control during public health emergency response operations, together with a functional, dedicated command and control operations centre. Eight countries successfully vaccinated high-risk groups following the occurrence of H1N1. 25. Work has begun to strengthen regional alert and response capacity, including support to training and the development of appropriate standard operating procedures and guidelines. Regional workshops on risk assessment and management were organized and inputs provided to the development of global guidelines. A South-East Asia Regional Expert Network Database and related manuals in Thai and English were also developed and identification of regional experts continued. Standard operating procedures and training of communicable diseases surveillance and response focal points were provided. The regional stockpile in Bangkok demonstrated it’s usefulness during the H1N1 pandemic, when between 24 April 2009 and 10 September 2010, a total of 115 000 courses of Tamiflu (Oseltamivir) 75 mg were deployed to Member States. Other essential items in bulk quantities in the Region include personal protective equipment (PPE), real-time reverse transcriptase-PCR (RRT-PCR), rapid test kits, sample collection kits and transport solutions. The Bangkok regional stockpile has assisted all 11 Member States of the Region. Direct technical support was also provided to Thailand for the investigation of clusters of
14
The Work of WHO in the South-East Asia Region
Guidelines and training to strengthen alert and response capacity are being promoted in the Region.
unexplained deaths in Chiang Mai. Extensive technical and operational assistance was provided to six countries for H1N1 vaccines. Following the epidemic, vaccine deployment plans were updated in five countries. Training materials on logistics have also been developed in collaboration with WHO Headquarters and regional offices and training conducted. Assessments have also been carried out in a number of Member States and drills conducted to check procedures for deployment.
Lessons learnt 26. The difficulties inherent in increasing and sustaining routine immunization coverage were underscored during the biennium. Consequently, 2012 has been declared the “Year of Intensification of Routine Immunization in the South-East Asia Region”. Efforts to assist countries prepare applications to GAVI for supporting new vaccines were deemed very useful. Provision of consultants for monitoring measles catchup campaigns and conducting consultative workshops were also crucial to the achievements of expected results. 27. AFP surveillance needs to be intensified to ensure that countries achieve and maintain global certification standards. Populations at high-
Communicable diseases
15
risk for importation and spread of poliovirus need to be identified and immunity against polio maintained through high routine immunization and polio vaccination campaigns where necessary. Risk assessment should be conducted in all countries of the Region regularly to ensure that high-risk areas are identified and appropriate risk mitigation activities are planned and executed. 28. Simplified, timely case detection and putting cases on WHO prescribed fixed duration multidrug therapy (MDT) treatment have proved very effective in leprosy. In other NTD areas, timely funding and drug supply and sustained technical support were key. In zoonoses, definition of priorities, development of strategic approaches, support for, and dissemination of best practices in inter-sectoral work were deemed important to progress. 29. For some Member States, strengthening surveillance requires strengthening human resource capacity. More needs to be done to advocate for and deliver additional training. Despite significant progress in some countries (mostly those affected by Avian Influenza H5N1), mainstreaming inter-sectoral work between animal and human health and tackling related issues that transcend health continue to present obstacles in some countries. 30. Considerable work remains to be done to adequately strengthen the core capacities required for full IHR implementation and it is expected that most Member States will request a two-year implementation extension in 2012. An examination of regional data on progress in IHR capacity building reveals that it is uneven across capacities, with the lowest implementation rates being seen for chemical (33%) and radio-nuclear hazards (35%). To strengthen capacities in these areas, it will be especially important to further engage and strengthen collaboration with other sectors responsible for energy, industry and environment. 31. Member States appear to be prepared for a sustained response to pandemic influenza, to assess their responses and to consider revision of preparedness and response plans. In some cases, this should include broadening the scope to encompass an ‘all hazards’ approach. Regional networks linked to GOARN need to be developed and training in international outbreak response is required, as is development and testing of standard operating procedures to facilitate rapid deployment of experts.
16
The Work of WHO in the South-East Asia Region
HIV/AIDS, tuberculosis and malaria Overview 1. This area of work focuses on scaling up and improving HIV/ AIDS, TB and malaria prevention, treatment, care and support interventions to achieve universal access, including among high-burden populations, women, infants, children, adolescents, poor and vulnerable groups. Also, included herein are initiatives to advance related research; address key bottlenecks that are impeding access, use and quality of interventions; and contribute to the strengthening of health systems. In HIV/AIDS, ART coverage increased from 32% in 2009 to 34% in 2010; this means an increase in the number of persons receiving ART from 577 000 in 2009 to 717 000 in 2010 (Figure 2.2). In 2010, both TB prevalence and mortality rates decreased by about 40% compared to the 1990 level. These results were achieved through good case-notification and treatment success rate of TB cases of more than 85% for the Region since 2005. In malaria, remarkable increase in scaling-up interventions was observed; in 2010, the cumulative number of available and effective LLINs/ ITNs was 17 million as compared to 4.3 million in 2005 (Figure 2.1). The estimated malaria cases per 1000 population at risk were reduced by almost one-third from 30/1000 in 2005 to 22/1000 in 2010.
2
2. Strategies to tackle these three important diseases are also vital to achieve the Millennium Development Goals, and to promoting universal access and delivery of essential interventions for prevention, treatment, care and support. The Regional Health Sector Strategy on HIV 2011 – 2015 suggests approaches to HIV/AIDS challenges, such as a timely diagnosis of HIV infection, its prevention and care, high cost of drugs for treating the disease, and health system capacity. The Regional Strategic Plan for TB Control 2006 – 2015 intensified action to add impetus to current efforts and promote additional interventions through the New Stop TB Strategy. The Malaria Control and Elimination Strategy in SEA Region 2011 – 2015 is in draft form. It addresses early case detection and prompt treatment, integrated vector management, containment of focal epidemics and options for malaria control according to risk. 3. National Programmes, other government and non-governmental sectors in Member States are key stakeholders for this work. In the HIV/AIDS area, partner UN agencies such as UNICEF and UNAIDS, CDC-Atlanta, partners of Asia-Pacific-Task Force on Prevention of Mother-to-Child Transmission of HIV and syphilis at the regional level, and USAID, AUSAID, Department for International Development (DFID), The US President’s Emergency Plan for AIDS Relieve (PEPFAR) and the GFATM at various levels are the main stakeholders. In the area of TB, WHO Stop TB Partnership, USAID TB Care, international and regional NGOs and partners like KNCV, Tuberculosis Foundation, International Union Against Tuberculosis and Lung Disease, DFID and Programme for Appropriate Technology in Health (PATH) are the main stakeholders. In the area of malaria, UNICEF, the World Bank, Japan International Cooperation Agency (JICA), USAID, Three Diseases Fund, the GFATM, President’s Malaria Initiative and the Bill and Melinda Gates Foundation are major stakeholders.
Member States’ achievements and WHO’s contributions Developing tools for prevention, treatment and care HIV/AIDS 4. All SEAR countries have HIV/AIDS policies and medium-term strategic plans in place. Myanmar and Timor-Leste updated their strategic plans in 2010, while Bhutan, Maldives and Nepal developed new plans in 2011.
18
The Work of WHO in the South-East Asia Region
5. Technical assistance was provided for external reviews of the health sector response to HIV/AIDS in Bhutan, Indonesia and Sri Lanka and also to develop the five-year national strategic plans. WHO-SEARO also provided financial support to organize the Indonesian National AIDS Conference. Fifteen participants from nine Member States of the SEA Region were supported to participate in the Twelfth International Union Against Sexually Transmitted Infections (IUSTI) World Congress. WHO-HQ and SEARO organized a session on antimicrobial resistance in Neisseria gonorrhoeae – impact on maternal and child health. A meeting of WHO-SEAR national AIDS programme managers was held in WHO-SEARO in 2010. A regional training in early infant diagnosis on HIV for SEAR Member States was conducted in collaboration with the WHO Collaborating Centre in Pune, India in 2011. Four publications were finalized, printed and distributed: (i) Regional Guidelines on Management of Sexually Transmitted Infections; (ii) Training Modules on Planning of Health Sector Response to HIV/ AIDS; (iii) HIV/AIDS in South-East Asia: A Progress Report, 2010; and (iv) A Strategy to Halt and Reverse the HIV Epidemic Among People who Inject Drugs in Asia and the Pacific, 2010-2015. Health personnel in Member States were trained to use the Training Manual on Planning of Health Sector Response to HIV/AIDS. A regional training workshop on STI surveillance was also conducted to strengthen the capacity of STI surveillance in SEAR countries.To ensure that Member States are kept abreast of global and regional technical issues, three symposiums were cosponsored at the Tenth International Congress on AIDS in Asia and the Pacific (ICAAP): (i) Towards a roadmap to Treatment in Asia and Pacific; (ii) Eliminating new pediatric HIV infections and congenital syphilis in Asia-Pacific; and (iii) Engaging the health sector for scaling up services for men having sex with men and trans-genders.
Tuberculosis 6. All countries have developed national five-year TB plans. A national TB programme (NTP) manual on multidrug-resistant TB (MDR-TB) management was made available in all countries. TB Infection control guidelines were also made widely available. Technical assistance was provided by WHO to countries in updating and revising national strategic plans; guidelines for improved TB control services; integrating programmatic management of drug-resistant TB (PMDT); advocacy, communication and social mobilization (ACSM); infection control (IC) and practical approach to lung health (PAL).
HIV/AIDS, tuberculosis and malaria
19
7. The Regional Office convened various meetings and workshops in line with the new Stop TB strategy, such as the Regional Workshop on Laboratory Diagnosis of MDR-TB and extra drug-resistant TB (XDRTB); Meeting of Technical Working Group on TB; Regional Workshop on Public and Private Mix/Practical Approach to Lung Health in TB Control; Meeting of Country Focal Points on Programmatic Management of MDR-TB; Informal Consultation on Roll-out of Xpert MTB/RIF Diagnostic Test* and Expanding Laboratory Services for TB Control, and Meeting of National TB Control Programme Managers and Partners. Policy guidance was provided on adopting and applying the revised WHO policies and guidelines. The Regional ACSM Strategic Framework was published and its copies distributed. Step-by-step guidelines on health system rapid assessment have been finalized.
Malaria 8. Coverage of malaria interventions increased during the biennium. This included long lasting insecticide bed nets (LLIN), insecticide-treated bed nets (ITN), rapid diagnostic test (RDT), and artemisinin-based combination therapy (ACTs). Significant progress was made in containment of drug resistance in two countries where artemisinin resistance was detected (Myanmar and Thailand). All malaria-endemic countries (all SEAR countries except Maldives) have trained many primary health care workers and volunteers who are contributing to improved delivery of malaria control services in hard-to-reach areas. These efforts led to an overall improvement in the malaria situation. Maldives remains malaria-free. Bhutan, DPR Korea, Nepal, Sri Lanka and parts of Indonesia and Thailand are now in the preelimination phase; while in Bangladesh and Thailand, cases are limited to a few districts. Malaria control activities have also been intensified in India, Indonesia, Myanmar and Timor-Leste. Four endemic countries achieved their national intervention targets for preventing malaria. 9. All malaria-endemic countries have at least one technical staff (either national or international) providing technical support to the national malaria control programme. Short-term consultants were also provided to countries to perform specific work such as proposal development, strategy development, programme reviews, training, entomology, quality * Xpert MTB/RIF is an automated, cartridge-based nucleic amplification assay for the simultaneous detection of TB and rifampicin resistance directly from sputum in under two hours.
20
The Work of WHO in the South-East Asia Region
assurance/quality control (QA/QC) microscopy, M & E, drug resistance studies, etc). Meetings of technical working strategy groups facilitated by WHO helped improve national response against malaria. Administrative and management support was also provided for implementation of Three Diseases Fund (3DF) and the GFATM, TB and Malaria (GFATM) grant in Myanmar and GFATM grant in DPR Korea. Figure 2.1: Cumulative availability of effective LLINs and ITNs in the SEA Region, 2005-2010
Note: LLINs are effective within three years after distribution; ITNs are effective only for one year Source: MAL/CDS/SEARO estimates based on National Malaria Control Programme Reports
10. Technical support was provided to all endemic countries in planning, implementation and monitoring of activities supported by GFATM, USAID, 3DF, WHO and other partners. Generation of evidence on artemisinin resistance was supported, technical meetings were convened, plans developed, resources mobilized and technical support provided for containment of drug resistance in Myanmar and in Thailand. Programme reviews were facilitated in six countries. This provided the opportunity to improve the managerial and technical aspects of the programme. Technical assistance was provided to countries aiming for malaria elimination (Bhutan, DPR Korea, Nepal and Sri Lanka). All endemic countries scaled up the use of LLINS/ITNs, RDTs and ACTs.
HIV/AIDS, tuberculosis and malaria
21
Supporting prevention, treatment and care interventions HIV 11. Member States’ programmes on STI/HIV prevention, treatment and care for all populations groups were strengthened by the availability of updated new treatment guidelines on HIV and capacity building. 12. In Bhutan, advocacy for recent approaches adopted by WHO and relevant international partners on the health sector response to the drug use prevention programme and on care and treatment of drug users was supported. Components of drug use prevention and harm reduction of the National Strategic Plan for HIV/AIDS were also revised. The technical review of the Opioid Substitution Therapy Programme and the external review of the health sector response to HIV in Indonesia were also technically supported. For Myanmar, reviews of areas that might need WHO support such as Early Warning Indicators for ART resistance; ART resistance survey within the Global Fund Round 9 grant; biennium 20112012 planning; was conducted. Figure 2.2: Scale-up of antiretroviral treatment programme in the South-East Asia Region, 2003-2010
Source: 1. Towards Universal Access Progress Report, 2010 2. UNGASS Country Progress Reports, 2010
22
The Work of WHO in the South-East Asia Region
13. Prevention of mother-to-child transmission (PMTCT) including breast-feeding guidelines were disseminated. The PMTCT review with recommendations for quality PMTCT services linked with quality antenatal care for elimination of congenital syphilis and paediatric HIV infection was undertaken, and a review and development workshop on methadone guidelines was organized in Myanmar with WHO support. In Nepal, streamlining of ART regimen, and preparation of a future one-year plan for ART procurement were supported. Thailand have already achieved 80% coverage for both antiretroviral therapy and the prevention of mother-tochild transmission services. 14. Activities funded by the GFATM including scaling up of ART services within the context of universal access, PMTCT services within the context of “Zero HIV in newborns”, and strengthening of STI and HIV surveillance systems within the context of improving evidence for action were supported. Sri Lanka was supported in the implementation of elimination of congenital syphilis (ECS) and PMTCT following the WHO strategy on zero HIV infections among infants in collaboration with the MaternalNewborn-Child Health (MNCH) Programme. The Regional Office provided technical assistance by updating national manuals, guidelines, plans and training materials for strengthening the implementation of HIV prevention, treatment, and care and support activities. It also assisted in planning/ proposal development, grant negotiations and implementation of the GFATM grants. To observe the World AIDS Day in 2010, SEARO produced three posters and a monthly planner that were distributed to the SEAR Member States to be disseminated to respective ministries. A poster competition was conducted among Member States, and the best three posters were awarded prizes at the World AIDS Day 2011.
TB 15. In 2010, both TB prevalence and mortality rates decreased by about 40% compared with the 1990 levels (Figure 2.3). These results were achieved due to good case-notification and treatment success rate of more than 85% for the Region since 2005. The overall case notification increased and the treatment success rate of 88% was achieved in 2010. 16. Technical support was provided to countries to facilitate implementation of country workplans in line with the six components of the Stop TB strategy, especially in pursuing high-quality DOTS expansion and enhancement ensuring earlier and higher case detection and universal coverage of all
HIV/AIDS, tuberculosis and malaria
23
forms of TB. No treatment interruption for drug susceptible TB has been reported at treatment sites by SEAR Member States since 2010. Qualityassured smear-microscopy is functioning well in all eleven countries. Culture and first-line drug susceptibility testing (DST) have been established in nine countries; culture and second-line DST in India and Thailand; culture and DST in six countries (for first- and second-line drugs supported through Supranational reference laboratories through agreements) have been established. Ten countries have established programmatic interventions for TB/HIV and four countries are scaling up these interventions nationwide. GLC approved MDR-TB management projects were established in nine countries. National MDR-TB guidelines were available in all countries. Nine countries are reporting on MDR-TB case management under national programmes. Capacity building in technical areas was undertaken in eight countries, in planning and budgeting, MDR-TB management, laboratory strengthening, tuberculin testing, MDR-TB management, monitoring and evaluation. Several national workshops were also needed, and monitoring and evaluation, MDR-TB management, laboratory training and supply chain management, several national workshops including MDR-TB management were also conducted. Figure 2.3: Tuberculosis incidence, prevalence and mortality, 1990-2010, SEA Region
Source: Country reports, 2011
24
The Work of WHO in the South-East Asia Region
17. WHO-SEARO provided technical assistance to all countries for updating national manuals, guidelines, plans and training materials for strengthening implementation of all interventions under the Stop TB strategy. It also assisted with planning/proposal development, grant negotiations and implementation of the GFATM. A Regional Response Plan 2011-2015 on MDR-TB was developed after a consultative meeting with WHO country office staff.
Malaria 18. All malaria-endemic countries have national strategies that served as the basis for resource mobilization and operational planning. Most countries also have functional partnerships that provide technical and operational oversight. Bi-regional and intercountry collaboration to address malaria, including drug resistance were strengthened. The WHO Mekong Malaria Programme based in Bangkok is an example of bi-regional collaboration in prevention and control of malaria. 19. Full time WHO international staff are posted in DPR Korea, Myanmar, WHO-Mekong Malaria Programme (based in Bangkok), Indonesia and Timor-Leste. Short-term consultants were also provided to most countries. Meetings of technical working (strategy) groups were facilitated which helped improve the national response against malaria. In Myanmar and DPR Korea, WHO was involved in providing technical and managerial support to implement the GFATM grants (as well as Three Diseases Fund in Myanmar). An informal consultation was organized to review drug policy and to set-up a network for drug resistance monitoring. Technical support was provided to several countries through WHO staff missions and through consultants. Involvement of WHO in bi-regional and intercountry collaboration has been proactive. Assessments of intercountry needs to address malaria (e.g. Bhutan-India; the Mekong countries) were also carried out.
Promoting equitable access to essential medicines, diagnostic tools and commodities HIV 20. All countries were provided technical updates and information on quality medicines and the rational use of drugs. DPR Korea and Myanmar
HIV/AIDS, tuberculosis and malaria
25
were supported financially and technically to procure HIV medicines and reagents. A regional training on early infant diagnosis of HIV was conducted in 2011 in collaboration with the WHO Collaborating Centre in Pune, India where laboratory staff from 10 Member States participated.
TB 21. All countries in the Region have successfully transitioned from the Global Drug Facility (GDF) grant support to direct procurement for firstline drugs (FLDs) with governments and/or other external donors (mostly GFATM) funding. Ten countries of the Region have access to quality-assured and concessionally priced second-line drugs (SLDs). Four of these countries, namely India, Myanmar, Nepal and Timor-Leste continue benefiting from the GDF grant for SLDs, funded by UNITAID. All Member States with the exception of Maldives and Timor-Leste, initiated treatment of TB in children by accessing the paediatric formulations, which are made available to countries through the GDF grant mechanism.
No interruption in anti-TB drug supply has occurred in the SEA Region since 2010.
22. Technical support and assistance missions were conducted in countries to strengthen capacity of programmes in drug procurement and supply chain management. A global procurement and supply chain management workshop was organized and was attended by national TB control programme representatives from ten countries. Eight countries of the Region were provided with regular assistance missions and two received country-specific assistance (planning, forecasting and budgeting for Bangladesh and rapid assessment for Maldives) to further improve or strengthen the supply chain management systems.
26
The Work of WHO in the South-East Asia Region
Malaria 23. The massive-scale up of RDTs and ACTs was noted in all Member States endemic to malaria. Rational use of malaria drugs also improved through training, supportive supervision and confirmation of diagnosis by either RDT or microscopy. 24. Technical support was provided to all malaria-endemic countries in building their capacities (training) for case management of malaria. Quality assurance/quality control of microscopy was strengthened through development of standard operating procedures, training and internal and external competency assessment in various countries (Bangladesh, DPR Korea, Myanmar, Thailand, Timor-Leste). Technical and administrative support in procurement of quality-assured products (RDTs and ACTs) was also provided to all endemic countries. At regional level the global policy to ban the use of artemisinin monotherapies was promoted.
Strengthening surveillance, monitoring and evaluation HIV 25. Training needs assessments of district-level staff were conducted in seven countries for surveillance and a surveillance database for ten Member States was regularly updated. Training in HIV estimations and projections was conducted in collaboration with UNAIDS for all countries in 2010. Annual Universal Access reporting and United Nations General Assembly Special Session on HIV/AIDS (UNGASS) reporting were undertaken in all 10 endemic countries with technical assistance from SEARO. 26. Participants from ten Member States were trained on surveillance of sexually tranmitted infections (STIs). Country support for surveillance and estimations through site visits/emails was provided to most countries. Technical support was provided to India and Indonesia on HIV drug resistance monitoring; training support was provided for HIV and STI sentinel surveillance. A two-week Field Epidemiology Training Programmes (FETP) curriculum and a strategy document on HIV surveillance in lowprevalence countries were developed. Annual Regional Progress Reports were also produced, published and disseminated to Member States and a M&E toolkit for sex workers was completed.
HIV/AIDS, tuberculosis and malaria
27
TB 27. All countries have maintained routine reporting on TB. Impact assessments were carried out in four countries and technical assistance for TB surveillance including drug resistant surveillance (DRS) was also provided to four countries. Monitoring missions and joint reviews were carried out in five countries during the biennium. 28. Assistance for surveillance, including DRS was provided to several countries. Technical assistance for improving data and software management was also provided and impact assessment completed in Bangladesh, Bhutan, India, Indonesia, Myanmar and Nepal.
Malaria 29. The publication of World Malaria Reports contributed to maintain high interest in malaria control and elimination. Continuous monitoring and evaluation improved programme performance. 30. Technical support was provided to countries to strengthen monitoring and evaluation activities and enable national programmes to fulfil their reporting commitments to GFATM and 3DF (in Myanmar) as well as for preparation of the World Malaria Report. Drug resistance surveillance activities were also supported in five countries. 31. Malaria programme reviews were conducted in six countries. Workshops on monitoring and evaluation were also supported in Myanmar. Surveillance systems were assessed in several countries and regional guidelines were updated. The protocol for disease burden estimates was adapted and utilized. Countries were supported in contributing data for the World Malaria Report. The bi-regional document on M & E was drafted in collaboration with the WHO Regional Office for the Western Pacific, while the regional network for drug resistance surveillance was supported.
Sustaining political commitment and ensuring mobilization of resources and partnerships HIV 32. Advocacy, networking and collaboration and coordination of resources were supported in all Member States. Indonesia, Myanmar
28
The Work of WHO in the South-East Asia Region
and Thailand participated in the rapid testing-rapid results workshop: increasing access to HIV-testing results and services, conducted by the AIDS support and technical resources (AIDSTAR-One). The Country Coordinating Mechanism Members from five SEAR Member States (DPR Korea, Indonesia, Myanmar, Thailand, Timor-Leste) participated in the East Asia and Pacific (EAP) CCM regional workshop of the GFATM held in Kuala Lumpur. Participants from India, Indonesia, Maldives, Myanmar, Nepal, and Thailand attended the regional multi-stakeholders meeting; to discuss the Asia-Pacific Regional Learning Site Phase 2 for HIV/AIDS and sex work at country level. Bhutan, Indonesia, Nepal, Maldives and Myanmar developed Round 10, and Round 11/Round 9 integration proposals. Technical support was provided to countries for development of Global Fund Round 10 proposals. Myanmar was supported to develop Round 11 and Round 9 integration. The Regional Office mobilized about US$ 990 000 to provide technical support to Member States for the GFATM related activities in 2011. The GFATM proposal development and review workshops were conducted for all countries.
TB 33. TB services were scaled up involving several sectors and diverse providers. Most Member States have a number of community-based initiatives in place. Success stories with private-public partnerships and involvement of communities were documented in all countries. Collaboration and coordination with various stakeholders in the Region were noticeably strengthened. 34. All countries with the exception of Bhutan and DPR Korea, reported on private-public partnership initiatives and outcomes during the biennium. Coordination and collaboration were strengthened with the GFATM, USAID, Regional Development Mission for Asia (RDMA) and other regional partners like USAID-TBCARE. Global Fund Round 10 proposal development assistance was provided to Bhutan, Indonesia, Sri Lanka, Thailand and Timor- Leste and grant negotiations were successfully completed in DPR Korea and Myanmar. Assistance was provided to countries for development of TBCARE and USAID proposals and for Global Fund Round 11 proposal development. 35. A regional strategic framework on advocacy, communication and social mobilization (ACSM) was developed by the Regional Office. It also
HIV/AIDS, tuberculosis and malaria
29
convened a regional workshop on public-private mix (PPM) and practical approach to lung health (PAL) for TB control.
Malaria 36. All malaria-endemic countries showed strong support for malaria control with some aiming for either national or sub-national elimination of malaria. Increased financial resources were made available both from partners as well as from governments of endemic countries. Communities are being empowered and are contributing actively malaria control. 37. Technical and financial support was provided for observation of World Malaria Day, proposal development, advocacy to donors and in preparation of reports for donors. The World Malaria Day 2011 focused on the roles and contributions of community volunteers, and a video was developed and disseminated. Community mobilization and training of community volunteers was also supported in several countries.
Developing new knowledge, intervention tools and strategies HIV 38. A five-day operational research training was conducted and HIV research ethics guidelines were drafted in India. Technical inputs were also provided to India for HIV research ethics guidelines. A training manual on scientific writing was developed and a five-day training programme in scientific writing was resourced by SEARO. Review of research protocols from countries was carried out. The Regional Office also supported, participated and coordinated sessions of the South-East Asia Regional Conference on Epidemiology in 2011.
TB 39. Seven countries submitted proposals for operational research through TBREACH. A new diagnostic tool was deployed in Bangladesh, India, Indonesia and Myanmar with support from Global Laboratory Initiative (GLI). 40. Technical support was provided for operational research (OR) aimed at addressing programme needs including innovative approaches in India.
30
The Work of WHO in the South-East Asia Region
Although funding for OR has been mobilized through the GFATM for almost all countries in the Region, the capacity to undertake quality research is still weak in most countries.
Malaria 41. Documentation of drug resistance and initiation of containment activities in Myanmar and Thailand were the product of joint efforts across the three levels of the Organization, Member States and partner agencies. Studies published on malaria in the SEA Region were reviewed and a research agenda was drafted. In each Member State, a study on malaria was supported.
Lessons learnt 42. Having dedicated technical staff was key to mobilizing resources and for planning, implementation, monitoring and evaluation of malaria control activities. 43. Updated and continuous knowledge and availability of WHO information on quality reagents and drugs, as well as the opportunity to mobilize resources from the GFATM grants for the procurement of quality-assured supplies for HIV control. Having technical staff in country offices and close collaboration across the three levels of the Organization facilitated good support to countries. 44. The joint monitoring missions and their recommendations to improve the performance of the malaria control programme proved very useful for revising and updating programme plans for malaria prevention and control. 45. Proposal development workshops and reviews facilitated development of sound proposals and limited duplication of efforts. 46. In the area of operational research for malaria, working through WHO collaborating centres and promoting horizontal collaboration worked well. Technical assistance in development of operational research protocols was also key to success.
HIV/AIDS, tuberculosis and malaria
31
32
The Work of WHO in the South-East Asia Region
Noncommunicable diseases Overview 1. Noncommunicable diseases (NCDs) are the leading cause of mortality in the SEA Region. NCDs account for an estimated 7.9 million deaths each year in the Region, exceeding deaths due to all other causes put together. The major NCDs in the Region are cardiovascular diseases, cancer, diabetes and chronic respiratory diseases (Figure 3.1). In some countries, thalassaemia, liver diseases and kidney diseases are also significant public health problems. Oral health is also a major public health concern in most countries of the Region. Mental and neurological disorders, and tobacco and substance abuse have received due recognition as significant causes of morbidity in the last decade. Furthermore, road traffic injuries, drowning, burns, falls, assaults, violence and child injuries are the major causes of mortality. Deafness, blindness and physical disabilities are closely related to poverty. With increasing awareness of the significant suffering caused by these conditions to the community more countries are initiating programmes to address them. 2. The salient strategies for work in this area include the Regional Framework for the Prevention and Control of NCDs, The Strategic Action Plan for Tobacco Control in 2011 – 2015, and the Regional Framework on Community-Based Rehabilitation 2012-2017. The RC Resolution on injury prevention and safety
3
promotion 2010 and the strategic approach to injury prevention and control in the South-East Asia Region (2011) form the backbone and foundation for injury prevention and control programmes. The Global Vision 2020: the Right to Sight has been used in the Region for the prevention to blindness. The regional plan of action for human health focuses on strengthening the primary health care (PHC) system to deliver care for mental and neurological disorders. 3. Major stakeholders and partners for work relating to NCDs during the period under review were ministries of health, transport and communications, industrial ministries, home ministries, personnel from the social development, human security, welfare, commerce and insurance departments, other UN and international agencies, i.e. UNICEF, United Nations Economic Commission for Europe (UNECE), UN ESCAP, International Agency for Prevention of Blindness (IAPB), Society for Sound Hearing, and Asia-Pacific Development Centre on Disability (APCD), etc. With regard to mental and neurological disorders, and substance abuse, partners included the ministries beyond health (such as education, labour, social welfare, justice, information, and women’s affairs, etc). Other partners included academic institutions where research and training are conducted, NGOs, and civil society.
Member States’ achievements and WHO’s contributions Providing advocacy and support for tackling noncommunicable diseases 4. Member States acknowledge that NCDs have emerged as the leading cause of death and need to be addressed through multisectoral approaches. As a result, all Member States of the Region now have a unit in the ministry of health, dedicated staff and budgets, for the prevention and control of chronic noncommunicable diseases, and seven countries have adopted a multisectoral national policy on chronic noncommunicable diseases. In September 2011, the Twenty-ninth Health Ministers’ Meeting discussed and adopted 10 key messages for the UN High Level Meeting from the SEA Region Health Ministers, and recommended that NCDs be taken up as a technical subject at the next session of the Regional Committee. In September 2011, the High-level Meeting of the UN General Assembly was
34
The Work of WHO in the South-East Asia Region
well attended by SEAR, with heads of state participating from Bangladesh and Maldives, along with health ministers from India, Indonesia, Maldives, Thailand and Sri Lanka and high-level delegates from other countries. As regards tobacco work, tobacco cessation clinics in Bhutan, Myanmar and DPR Korea have been established. All Member States also have a focal point for injury and violence prevention in their respective ministries of health. By the end of 2011, as a result of the joint efforts of Member States, the Secretariat and other partners, five Member States had established an injury unit in the ministry of health to implement and coordinate prevention activities with multisectoral organizations. Figure 3.1: Percentage of NCD deaths in population aged <60 years by cause, 2008
Source: WHO Global Health Observatory 2011 http://apps.who.int/ghodata/
5. In January 2011, WHO-SEARO supported a regional civil society meeting on NCDs in Kathmandu, which culminated in the Kathmandu Call for Action on NCDs and drew attention to the serious health and socioeconomic impacts of NCDs. The Regional Office also supported the participation of several Member States in the First Global Ministerial Conference on Healthy Lifestyles and Noncommunicable Diseases Control, in Moscow; in all, six ministers from SEAR participated in the Moscow conference. With WHO support, 10 out of the 11 countries in SEA Region conducted national meetings to advocate for multisectoral actions for NCD prevention and control at country level. WHO-SEARO developed a manual on tobacco cessation for doctors and dentists and a manual on tobacco
Noncommunicable diseases
35
cessation for nurses and health workers. A regional training workshop for training of trainers was also organized. WHO-SEARO supported Member Sates to conduct national tobacco cessation training workshops and helped in establishing tobacco cessation clinics in Bhutan, Myanmar and DPR Korea. Technical and financial support was provided to organize national workshops and trainings on injury epidemiology, prevention and care in Myanmar, Indonesia and Sri Lanka. Several normative publications and advocacy material were also produced and disseminated to Member States and partners, including the fact-sheet – The Silent Epidemic of Road Traffic Injury in the South-East Asia Region (2011).
Guiding the development and implementation of policies, strategies and regulations for NCDs 6. Countries are moving towards integrated prevention and control by addressing NCDs as a cluster of diseases rather than individual NCDs. Nine Member States reported having national integrated NCD policy. Nine countries in the SEA Region have national plans on violence and injury prevention and/or road safety. 7. Technical support was provided to various countries for the development and updating of national policies, plans or strategies on NCDs. Internationally accepted guidelines on identification and treatment of the most common mental and neurological disorders have been made available to Member States to be reviewed and considered for inclusion in their mental health plans. Technical expertise was also provided on request. Technical and financial support was provided for awarenessraising, multisectoral collaboration in planning and implementing the plan of action for road safety in the Decade of Action for Road Safety 2011-2020. Technical and financial support was provided to implement the intervention model for road safety in India. National workshops were supported technically and financially in Myanmar, India and Indonesia to increase awareness and commitment (Figure 3.2). 8. Technical discussions on the subject of ‘Injury Prevention and Safety Promotion’ were held at the Sixty-Third Session of Regional Committee and a resolution on the subject was adopted. There was a decrease in estimated prevalence of blindness from 12.5 million cases in 2002 to 12 million cases in 2010. Ten countries have national plans for blindness prevention, and all
36
The Work of WHO in the South-East Asia Region
countries have national committees on prevention of blindness. A model to integrate prevention of blindness and deafness together into the health system is being developed in India and Indonesia. Support was provided by WHO-SEARO to evaluate ‘Vision 2020’. Revision of national plans is under way in Bhutan, Indonesia, India, Nepal and Myanmar. Technical support was also provided to organize the Mid-term Review of Vision 2020: The Right to Sight Workshop in Kathmandu. A National Committee strategy paper on need assessment was also developed and used as framework for organizing the India National Workshop for Strategic Planning. A regional workshop on prevention of blindness was also conducted in co-sponsorship with International Agency for Prevention of Blindness (IAPB) and in collaboration with the Arvind Eye Care Centre, Tamil Nadu, India. Figure 3.2: Proportion of road traffic deaths according to types of road users in selected countries of the South-East Asia Region, 2009-2010
Source: Bangladesh – Police MAAP (Micro Analysis Accident Package), 2009 Bhutan – Traffic Division, Royal Bhutan Police, 2010 India – Road Accidents in India, 2010, Ministry of Road Transport and Highways, Transport Research Wing Indonesia – Indonesia National Police, 2010 Maldives – Maldives Police Service, 2010 Myanmar – Myanmar Police Force, 2010 Thailand – National Injury Surveillance System, MOPH, 2009
Noncommunicable diseases
37
Strengthening the primary health care system to deliver care for mental and neurological disorders Mental and neurological disorders have not received adequate attention to date in health-care delivery systems. This is because of lack of trained manpower, lack of appropriate services that reach out to the people even in remote and rural areas, shortage of psychotropic medications, and stigma against patients in the community. An indicator of this lack of services is the treatment gap (i.e. the number of people who need treatment but are not getting treatment). The treatment gap can be as high as 95% depending on disease and geographical location. To address this issue, SEARO has developed a strategy to train villagebased health workers in the identification of the most common mental and neurological disorders, using a validated screening questionnaire. Once identified, the patients are taken to the nearest PHC-based doctor who has been trained to provide appropriate treatment. Pilot projects, using epilepsy treatment gap as an example, have been extremely successful in Member States where they have been implemented (Bangladesh, Bhutan, Myanmar and Timor-Leste). Impact assessments of these pilot projects have shown that the treatment gap can be substantially reduced as shown in the following table: Impact assessment of intervention for epilepsy through PHC in pilot projects in defined geographic area No 1 2 3 4 Country Bangladesh Bhutan Myanmar Timor-Leste Treatment gap before intervention (%) 87 40 95 93 Treatment gap after intervention (%) 5 26 5 54
These pilot projects clearly demonstrate that not only people who need treatment can get it through the existing primary health care system with additional investments in training. In addition, the programmes are sustainable as they become part of the existing health-care delivery system. Member States will benefit greatly from scaling up these projects where they have been implemented and adapting them to conditions in other countries.
38
The Work of WHO in the South-East Asia Region
Improving capacity for NCD data collection, analysis and use 9. Availability of data on major behaviour and some metabolic risk factors for NCDs has improved. Ten of 11 countries have conducted at least one round of risk factor survey similar to the WHO STEPS survey (Figure 3.1). Table 3.1: Percentage of current smokers ≥15 years old who received health-care provider advice in the past 12 months, in selected Member States of the Region Sample size (number of smokers in each category) Unweighted Bangladesh India Thailand 2233 11 596 4907 Asked history of smoking by health-care provider % 56.6 53.2 59.1 95% CI (51.1, 61.9) (50.4, 55.9) (55.5, 62.6) Advised by health-care provider to quit smoking % 53.2 46.3 50.6 95% CI (47.9, 58.5) (43.6, 49.1) (47.0, 54.1)
Visited healthcare provider 95% CI (34.5, 40.9) (45.1, 49.3) (32.1, 36.6)
% 37.7 47.2 34.3
Source: Global Adult Tobacco Survey Reports: Bangladesh 2009; India 2009-2010; Thailand 2009
10. Ten Member States submitted assessment reports of their national road traffic injuries (RTI) prevention status to WHO during the Second Global Survey on status of road safety. Countries also invested more in injury surveillance and related information systems. Most countries were able to report road safety data. Eight countries conducted rapid assessments and national surveys on blindness over the last five years. New data on blindness in the over-40 years population is available in ten countries. There is greater awareness of the burden of disability and increased national investment to comply with the rights of persons with disability. Bhutan, India, Maldives and Thailand have made national data on prevalence of disabilities available. 11. WHO-SEARO provided technical assistance to Bangladesh, Bhutan and Timor-Leste in developing the initial protocol for strengthening the primary health care system to deliver care for mental and neurological
Noncommunicable diseases
39
Advocacy for healthy diet is being promoted in the Region.
disorders. The objective of the project was to reduce the treatment gap of epilepsy. Training manuals for community-based doctors and health-care workers on identification of epilepsy (generalized tonic clonic seizures) were provided. 12. Technical and financial support was provided for conducting STEPs survey, for collation of epidemiological data and for preparation and dissemination of the 2009 STEPS survey report. Training for secondary data collection of road safety status was provided to staff concerned in all Member States of the SEA Region to be used for national, regional and global reports. Several publications were also developed and disseminated to Member States and partners including Profile of Child Injury in the Asia-Pacific and a fact sheet on The silent epidemic of road traffic injury in the South–East Asia Region. An update of the situation analysis of prevention of blindness in the Region was prepared and a situation analysis on community based rehabilitation was conducted in collaboration with Asia-Pacific Development Center on Disability (APCD), Thailand. Technical support was also provided for conducting a national workshop on community-based rehabilitation and the launch of the World Disability Report in Indonesia, as well as for the national launch of the World Disability Report in Myanmar.
40
The Work of WHO in the South-East Asia Region
Promoting mental health and preventing violence, injuries, and hearing and visual impairment 13. Suicide prevention is being addressed by countries through a multi-dimensional approach including promotion of mental well-being, identification and management of depression, and identification and management of alcohol abuse. Four Member States have initiated community-based projects to reduce suicides. 14. Technical and financial support was provided for model development in integrating injury and violence prevention for children under five years of age into the Maternal Child Health Handbook and programme. Technical and financial support was also provided for a regional training of trainers on injury epidemiology, prevention and care. A draft curriculum for shortcourse training on injury prevention and care for emergency room (ER) chief nurses of tertiary care hospitals in the SEA Region is being developed. Moreover, with the WHO Collaborating Centre in Thailand (Khon Kaen Regional Hospital), WHO conducted an expert group (multisectoral) meeting on preventing motorcycle injuries in children, the first such event in the world in this context. The recommendations of the meeting were shared with those concerned in the Region and also globally. With regards to normative work, a publication Injury prevention and control: A handbook for undergraduate medical curriculum was developed and disseminated to Member States and partners.
Improving the ability of health and social systems to prevent and manage NCDs 15. Social and health systems were strengthened through multisectoral collaboration in areas of blindness and deafness. Most countries are implementing community-based rehabilitation (CBR) for people with disabilities. Governments are increasing investment to decrease environmental barriers for people with disabilities to participate in social activities. Children with intellectual disabilities have received substantial attention not only from technical experts but also high-level policy-makers including the First Ladies of many Member States. The strategy is to
Noncommunicable diseases
41
develop a community-based programme to identify children who have any kind of intellectual disability including autism, then provide them with the services of expert clinicians. A PHC-based screening for CVD risk factors and management of NCDs using the WHO-promoted PEN approach was initiated in three countries with WHO’s technical support. 16. Trauma care training was conducted and WHO Trauma Care Guidelines were used in the intercountry training of trainers in epidemiology prevention and care. Advocacy and support (both technical and financial) were provided to incorporate trauma-care services for victims of injuries or violence into countries’ health-care systems, based on the WHO TraumaCare Guidelines. The Society for Sound Hearing and Christoffel Blinden Mission (CBM) worked in partnership with WHO to promote the prevention of deafness and management including rehabilitation for hearing loss. The situation analysis of prevention of blindness in the Region was updated in collaboration with the L.V. Prasad Eye Institute (a WHO collaborating center) and is ready for publication in 2012. The situation analysis on CBR was conducted in collaboration with APCD, Thailand. SEARO provided technical support for the Strategic Planning Meeting of Vision 2020: The Right to Sight Forum and for Vision 2020 at the All India Ophthalmic
Member States are incorporating trauma-care services into their health-care system.
42
The Work of WHO in the South-East Asia Region
Society’s Annual Congress. A number of advocacy and training activities on prevention of blindness and deafness were conducted by WHO-SEARO. An intercountry training on epidemiology of ear health and community care was completed in collaboration with Otological Centre, Siriraj Hospital (WHO Collaborating Centre in Thailand) and posters were developed in collaboration with the Society for Sound Hearing and the Christoffel Blinden Mission. Technical support was extended for sound hearing at the Second International Deaf Expo organized by a number of deaf persons’ organizations. A regional workshop on Prevention of blindness was conducted in co-sponsorship with IAPB and in collaboration with the Arvind Eye Care Centre (a WHO collaborating center). National launches of CBR guidelines and the World Report on Disability were supported in several countries. A regional strategic framework on community-based rehabilitation was developed. A situation analysis of community-based rehabilitation in the Region and a review of CBR practices were conducted. A handbook for policy-makers in the health sector in implementing the UN Convention on Rights of Persons with Disability (UNCRPD) was also published and disseminated.
Lessons learnt 17. A successful engagement of sectors beyond health is challenging, especially owing to conflicts of interest. High-level political commitment is required to ensure that vested interests in the private sector do not impede gains in health. The key obstacles in prevention and management of blindness and deafness are inadequate technical and financial support, and the limited resources provided by countries. 18. Civil registration systems remain weak in most countries of the SEA Region making it difficult to generate good mortality and morbidity statistics. This increases the reliance on disease-burden estimates. National data on incidence and prevalence of NCDs can, however, be estimated, with both technical and financial support. 19. Impact evaluation of pilot projects in Bangladesh, Bhutan and TimorLeste have shown that empowering the existing primary health-care delivery system of a country can have a significant positive impact on delivery of community-based care for mental health and neurological disorders.
Noncommunicable diseases
43
44
The Work of WHO in the South-East Asia Region
Maternal and child health, reproductive and sexual health, and healthy ageing Overview 1. The following public health issues and challenges are addressed under this area: newborn and child morbidity and mortality; adolescent health; maternal morbidity and mortality; family planning; reproductive health and healthy ageing. Work in these areas focuses on enhancing health and development to identify, develop, implement and evaluate approaches and interventions that foster healthy development across the life course. 2. Salient strategies for work in this area include: Strategic Directions for Improving Adolescent Health, A Framework for Implementing the Reproductive Health Strategy in the SouthEast Asia Region and A Strategic Framework for Healthy Ageing in the South-East Asia Region. The Region has adopted a life cycle and multisectoral approach with equity and quality as the main principles. For example, addressing improvement in child health and development in the Region involves a multisectoral approach for appropriate nutrition, universal immunization
4
coverage in addition to care and management of common diseases and illnesses, targeting individuals, families, and communities. Improving newborn and maternal health and survival involves improving access to quality skilled care linked to timely obstetric care services at the level of individuals, families, communities and health facilities across the continuum of care. While ‘Regional Strategic Directions for Improving Adolescent Health’ were disseminated in October 2011, a Regional Strategic Framework for Newborn and Child Health is being developed in partnership with UNICEF. The Regional Strategy for Early Childhood Development was developed and disseminated in 2010. A framework for implementing the reproductive health strategy in the South–East Asia Region provides guidance to countries in implementing the Global Reproductive Health Strategy considering the regional context, country situation and needs. A Strategic Framework for Active Healthy Ageing in the South–East Asia Region is available to the countries in developing strategies and practices for healthy ageing. 3. WHO worked closely with UN agencies in particular UNICEF, UNFPA, the World Bank, other development partners including bilateral donors, civil societies, professional bodies and institutions in this important area of work.
Member States’ achievements and WHO’s contributions Scaling-up implementation towards universal access to effective interventions 4. SEAR commitment to achieve MDGs 4 and 5 and accelerate achievements of related targets in the Region was recognized as the UN Secretary-General awarded Bangladesh and Nepal for having made significant progress in respect of the Millennium Development Goal (MDG) 4, for “reducing infant and child mortality and expanding life-saving health services”. Countrylevel reviews were conducted and maternal and newborn health policies and strategies were updated in DPR Korea, Maldives, Myanmar, and Nepal. Advocacy for adolescent health has resulted in the identification of focal points for adolescent health in ministries of health in most countries of the Region. A strategy for adolescent health has been developed for the
46
The Work of WHO in the South-East Asia Region
Strengthening of National Menstrual Regulation Programme in Bangladesh Bangladesh is committed to achieving MDG 5 and reducing maternal mortality; good progress is being made as a result through several related initiatives. One such initiative is the menstrual regulation (MR) programme started by the government in 1974, which later received funding from donors to complement the services provided by the government especially for the poor and hard-to-reach. In 2008, funding was provided by the Ministry of Development Cooperation of The Netherlands to implement the “Strengthening of National MR Programme for Reduction of Maternal Mortality and Morbidity in Bangladesh”. The project was evaluated; the findings are positive and encouraging. What has contributed to the success of this challenging initiative? These can be summarized as follows: Clear objective that addresses a real and quantified felt need – to ensure availability of quality MR services, development of standards for MR services and post-abortion care to the poor and hard-to-reach, through public-private partnership; Clearly defined components: (i) scaling-up delivery of quality MR services, (ii) enhancing rights-based demand generation for safe MR services, (iii) improving the knowledge and evidence base on unsafe abortion, MR and other sexual and reproductive health and rights issues and (iv) strengthening the policy response; Good management with clearly defined roles and responsibilities of the three major players; The use of civil society organizations as implementing agencies is a successful model for the public-private partnership approach; and Sustainable funding from donors from the start of the initiative. The maternal mortality ratio in Bangladesh declined remarkably between 1990 and 2010. While several factors have contributed to this, it cannot be denied that the MR programme has played a role in it.
Region and capacity for programme review and management for adolescent health has been strengthened. Significant progress in ensuring universal access to reproductive health including maternal health has been made.
Maternal and child health, reproductive and sexual health, and healthy ageing
47
All Member States have reproductive health policy and strategies to use and implement the Global Reproductive Health Strategy endorsed by the World Health Assembly in 2004, and several countries have updated and revised their national strategies such as Bhutan, Maldives, Myanmar, Nepal and Sri Lanka. Eight Member States have developed a policy on achieving universal access to sexual and reproductive health. A regional workshop was held in which a tool designed for scaling up interventions, called ExpandNet, was introduced to countries of the Region. 5. Capacity for conducting short programme review (SPR) for national/ sub-national child health programmes was developed in Bangladesh, India, Maldives, Myanmar and Sri Lanka. Technical support was provided for developing an integrated SPR tool for maternal and child health in Sri Lanka and India. Rapid programme review (RPR) tool on adolescent health was adapted in India and state-level RPRs were held in two states followed by a national meeting to develop an integrated framework on adolescent health involving different ministries and stakeholders. Support was also provided for conducting RPR in Bhutan with an aim to develop a national strategy on adolescent health. Regional meetings were organized during the biennium to share experiences and deliberate on scaling-up of evidence- based interventions in countries and share recent technical updates: regional network meeting on newborn health; regional meeting to promote coordinated approaches for prevention and management of pneumonia and diarrhoea; regional programme managers’ meeting for adolescent health; regional programme managers’ meeting for child health; regional expert group meeting on prevention and control of birth defects. At a regional workshop on scaling up of best practices, each country made plans for scaling up identified best practices to achieve universal access. Bangladesh and Nepal provide good examples of having policies in place to increase access to safe abortion by allowing mid-level health workers to provide the service. An evaluation of the national RH programme in Bhutan was carried out with support from the Regional Office. Also, the donor-funded menstrual regulation (MR) programme in Bangladesh was evaluated in the mid-term in 2010 and at end-of-term. 6. Recognizing the static level of contraceptive prevalence rates in almost all the countries in the Region, with a high unmet need for family planning in some of them, a regional meeting on family planning updates was held, and country profiles on family planning are being updated for better programme planning.
48
The Work of WHO in the South-East Asia Region
Strengthening national research capacity 7. Bangladesh, India and Indonesia conducted research in child and adolescent health during the biennium. A study was conducted in five Member States (India, Indonesia, Myanmar, Nepal and Sri Lanka) on the extent of implementation of maternal death audits/reviews. 8. Technical assistance was provided to develop research proposals on adolescent / youth friendly health services in Bangladesh. Research projects were supported to study adolescent pregnancy / Sexual and Reproductive Health (SRH) service needs, early childhood development services and improving the performance of trained community health workers (CHWs) and study on effectiveness of adolescent health orientation programme package and adolescent job aids in improving knowledge and practice of health care providers in India. Support was provided for a research study on comparison of Integrated Management of Childhood Illness Computerized Adaptation and Training Tool (ICATT) with conventional IMCI training methodology. Review of laws and policies related to Adolescent Sexual and Reproductive Health (ARSH) and HIV services has been supported in India in partnership with UNICEF. Technical support was also extended to India to develop a research proposal on large Randomize Control Trials (RCT) for ferrous sucrose in pregnant women. The Regional Office supported the WHO multi-country survey on maternal and newborn health and supported the Indian Council of Medical Research in coordination and organization of activities at different sites and supported this in Nepal and Thailand too. WHO-SEARO also supported work in the area of strategic information: country fact sheets on child health and newborn health are at an advanced stage of development and key equity differentials for newborn and child health in the Region have been identified for further analysis. Country fact sheets on adolescent health and HIV in young people are also being updated. New and emerging areas of reproductive health began to be addressed in 2010-2011; while excess fertility remained a priority issue, several countries, especially India, have expressed concern over the issue of infertility. Work was initiated by the Regional Office with the four WHO Collaborating Centres in India in the area of infertility, in which research was conducted to estimate the burden of the problem and the existing activities being carried out to manage infertility. As a result, guidelines have been developed on prevention and management of infertility, focussing on the primary health care level.
Maternal and child health, reproductive and sexual health, and healthy ageing
49
Improving maternal care at country level 9. The number of women dying due to complications during pregnancy and childbirth decreased by 34% from an estimated 546 000 in 1990 to 358 000 in 2008 according to latest data. Such progress is notable, yet the annual rate of decline is less than half of what is needed to achieve the MDG target of reducing the maternal mortality ratio by 75% between 1990 and 2015. Achievements in selected key indicators related to maternal and newborn health in Member States are reflected in Table 4.1. Table 4.1: Selected indicators for maternal and newborn health in SEA Region, 2010 Antenatal care coverage (%) At least 1 visit 52 88 97 75 93 99 80 44 99 99 84 At least 4 visits 21 NA 95 50 82 85 43 29 93 80 55 Birthsskilled health personnel (%) 18 72 97 47 73 95 37 19 >=99 >=99 30 Unmet need for family planning (%) 16.8 NA NA 12.8 9.1 NA 19.1 24.6 7.3 3.1 3.8
SEAR countries
CPR (%)
Bangladesh Bhutan DPR Korea India Indonesia Maldives Myanmar Nepal Sri Lanka Thailand Timor-Leste
55.8 NA 68.6 56.3 61.4 34.7 41 48 68 81.1 22.3
Source: World Health Statistics 2011 *SRS MMR Bulletin, 2011
10. All Member States are implementing strategies for increasing coverage with skilled care for childbirth. Achievements in this area are attributed to several factors, including special efforts by Member States. Bangladesh, while strengthening its in–service training programme for community–based midwives also developed and initiated a direct entry midwifery programme, thus creating a new cadre and a broader base of skilled attendants. India continued to strengthen its in–service competencies enhancement training for Auxiliary Nurse Midwives (ANMs) and revised the pre–service curriculum and duration of ANMs training to sustain gains. DPR Korea continued to
50
The Work of WHO in the South-East Asia Region
improve service delivery points through rehabilitation and equipping the district and provisional hospitals with extensive training of health care providers in child birth and emergency obstetric care. Similar capacity building and quality improvement efforts were on-going in other Member States. In Timor-Leste, a curriculum review of nurse-midwifery training was conducted by external experts. In all these efforts the Regional Office provided technical and financial assistance. 11. WHO extended technical and financial support to Member States to strengthen emergency obstetric care, make quality improvements in maternal health care and conducted a review of maternal programme management through training and use of tools developed by WHO. Efforts were also made to address the quality of services. Preceding the research in five countries on maternal death reviews, several interactions were held with Member States in this biennium as a continuation of efforts in the previous biennia, to strengthen capacities in maternal death audits including the use of the guide ”Beyond the Numbers – Reviewing Maternal Deaths and Complications to make Pregnancy Safer” (WHO, 2004). Several countries selected maternal health as the theme of their scaling-up project – Bangladesh and Nepal selected the use of misoprostol at community level for the prevention and management of post-partum haemorrhage.
Improving neonatal survival and health at country level 12. Considering that newborn mortality has remained high in the Region, WHO-SEARO worked with Member States to improve neonatal health. Community-based approaches were strengthened to improve coverage of interventions through trained community health workers (CHWs) at community level along with improvement in facility-based interventions. DPR Korea and Maldives initiated a scaling up programme for essential and advanced care for sick newborns. A critical pool of experts and network of institutions have been developed in a few countries (DPR Korea, India, Sri Lanka). Nepal started a community–based newborn care programme with support from WHO, UNICEF and Save the Children. India has initiated implementation of home–based newborn care in selected states. Bangladesh has incorporated components of community–based management of the sick child in IMCI training control for basic health workers including newborn care.
Maternal and child health, reproductive and sexual health, and healthy ageing
51
13. Efforts to review and map policies were initiated and programmes implemented for home based newborn care. “Healthy mother, healthy newborn: a guide to homebased care” was developed. Re v i e w o f p o l i c i e s a n d programme implementation for home-based newborn care in Member States was completed in collaboration with WHO and UNICEF country offices. The tools, packages and guidelines on home-based newborn care through community health workers have been shared with the programme managers of Member States for national adaptation. 14. In cooperation with the essential care for newborns. HIV/STI programme, and with other UN partners, a framework for the Asia Pacific Region was developed for the elimination of mother-to-child transmission of HIV and syphilis with focus on the maternal service component. Member States are scaling up programmes for
Improving child health and development, taking into consideration international and human rights norms and standards 15. All Member States have developed plans for scaling up efforts for further improvement of child health and survival. Data-based planning has been adopted by Member States for child health. Continuum of care for child health across home and community to first level health facilities and referral level health facilities were strengthened and integrated approaches promoted in Member States. More attention to relatively new areas related to early childhood development and prevention of birth defects has also been paid by Member States. 16. Information on the status of implementation of Child Health programmes and IMCI was collected from all Member States to identify 52 The Work of WHO in the South-East Asia Region
strengths and weaknesses. Six Member States have expanded coverage of the IMCI to more than 75% of target districts. Support was provided to strengthen Integrated Management of Neonatal and Childhood Illness (IMNCI) implementation including scale-up of pre-service IMCI training in medical and nursing education. Capacity building for conducting short programme review for child health and programme management for child health was supported in Member States. A proposal was supported by The Bill and Melinda Gates Foundation for introducing the Global Action Plan for Pneumonia (GAPP) and diarrhoea in South-East Asia for which a regional workshop on integrated approaches to prevent and manage pneumonia and diarrhoea for achievement of MDG 4 was organized. A regional programme managers` meeting reviewed progress of child health programmes in the Region and recent technical updates to scale-up child health interventions were shared to accelerate progress in achieving MDG4. WHO-SEARO initiated work in two new areas this biennium: early childhood development (ECD) and Prevention of birth defects. A Regional Strategy for Early Childhood Development was developed and shared with countries and partner agencies. The report of the WHO/UNICEF regional meeting on ECD was also disseminated. Funds were mobilized to support a pilot on ECD in India. To support prevention and control of birth defects in the Region, a regional experts group meeting was organized. Funds have been mobilized from US CDC to develop regional strategy, guidelines and tools to build capacity of Member States for prevention of birth defects.
Evidence-based policies and strategies on adolescent health and scaling-up interventions 17. Member States moved from project level approaches to a programmatic mode for scaling up adolescent health and development programmes during this biennium. In Bangladesh, implementation guidelines to operationalize adolescent and youth friendly health services (AFHS / YFHS) standards were developed and the adolescent health training package was updated and strengthened. National training of trainers on adolescent health has been supported in Maldives. In India, adolescent job-aids were adopted for auxiliary nurse midwives (ANMs) and field-tested. A study to assess the sexual and reproductive health (SRH) service needs of adolescents including preventive care and abortion services has been initiated in India. 18. Support was provided for development of national strategies for adolescent health in Bhutan and Myanmar. A regional programme managers’ meeting on scaling-up adolescent health programmes was organized in collaboration with UNFPA. Recently released global guidelines on prevention of adolescent pregnancy were shared with Member States. Information on the status of implementation of adolescent health programmes in Member Maternal and child health, reproductive and sexual health, and healthy ageing
53
Standards-based approach for Adolescent Friendly Health Services WHO has supported Member States to follow a standards-based approach for delivering adolescent health services. Adolescent Friendly Health Services (AFHS) can be distinguished by well-known physical and functional attributes of the health facility, the methods adopted by healthcare providers for provision of services and by the approaches for creating demand for such services. The criteria of friendliness can be paraphrased and grouped as ‘standards’ of quality for the adolescent health services. Implementation and maintenance of such standards is likely to improve access to services and their utilization by adolescents, especially by those most at risk. Bangladesh, Bhutan, India, Indonesia, Sri Lanka and Thailand have developed national standards for AFHS through a consultative process. Considering that the standards contribute to quality of services, their assessment also provides the means for systematic verification of the quality of services from the perspectives of the clients, providers and the health system. WHO developed tools for assessment of quality and coverage of AFHS and has supported Member States (Bangladesh, Bhutan, India, and Indonesia) to carry out the assessments. The figure below shows that implementation of standards improves the quality of services at AFHS sites as compared to the nonimplementation health facilities. Compliance with national standards of AFHS at implementation sites
SC: Sub-center; PHC: Primary Health Center; AFHS: Adolescent Friendly Health Services Source: Ministry of Health and Family Welfare, Government of India, WHO Country Office India, 2010
54
The Work of WHO in the South-East Asia Region
States was collected and shared during the joint review and planning meeting. Evidence on weekly iron-folic acid supplementation for prevention and management of adolescent anaemia was finalized and disseminated.
Implementing strategies to attain reproductive health goals and targets 19. All Member States recognize the need to continue to address excess fertility and the consequences of unplanned pregnancies. A renewed emphasis on family planning is in evidence in several countries. Member States developed country-specific action plans and re-emphasized the need for continued and enhanced advocacy for family planning while support for both basic and implementation research for family planning was promoted. 20. To improve universal access, the regional meeting on family planning conducted a review of family planning in all countries which included the participation of partners such as UNFPA, the Implementing Best Practices (IBP) initiative, USAID, Johns Hopkins Programme for International Education in Gynecology and Obstetrics (JHPIEGO), International Planned Parenthood Federation (IPPF), Family Planning Association (FPA) and Pathfinders. India shared repositioning family planning to increase the use of post partum intra uterine contraceptive device (IUCD). The tool for family planning “the four cornerstones” publications were shared with Member States, many of which translated or adapted them for local use. The Medical Eligibility for Contraceptive (MEC) wheel was also translated and widely applied in Member States. Family planning fact sheets for all Member States were revised and updated. The Regional Offices provided fellowships and study tours to health personnel in these countries on prevention and management of cervical cancer. Cervical cancer control was strengthened in DPR Korea and Maldives. India was also supported in its effort to review the evidence for medical abortion and revising their guidelines to prevent unsafe abortions which were disseminated widely.
Ageing as a public health issue 21. Life expectancy continued to increase in all SEA countries. The number of people needing care and services is also increasing. Efforts are being made in all countries to develop the capacity to provide services beyond medical care. Six Member States have a functioning active healthy ageing programme consistent with World Health Assembly resolution WHA 58.16 “Strengthening active and healthy ageing”.
Maternal and child health, reproductive and sexual health, and healthy ageing
55
22. Assessment of the regional situation was completed and awareness campaigns carried out to include the support and care for elderly populations as a priority in national development agendas. Policy, strategic and technical support was provided to governments to develop multisectoral programmes. Capacities of national institutions were built through training and technical support. A multi-disciplinary task group was formed to address the issue of support and care for elderly populations and regional workshops were held bringing high government officials, NGOs, UN agencies and development partners together for advocacy, strategy development and national evidence-based plans for healthy ageing.
Lessons learnt 23. The renewed global thrust on MDG 4 & 5 through the UNSG’s Global Strategy on Women’s and Children’s Health and establishment of the Commission on Information and Accountability has been an important development. Sustained advocacy with Member States has led to political commitment and increased investment for MDG 4 and 5 in the countries. Partnerships with WHO collaborating centres was very useful as was the collaboration with UN and other international agencies including UNFPA, UNICEF, IBP, JICA, USAID and JHPIEGO for sustaining the momentum. Sustained advocacy with national and sub-national governments in Member States has resulted in development of national policies, strategies and plans for reporductive, maternal, newborn, child and adolescent health (RMNCAH). However, the technical and managerial capacity to scaleup plans for effective and equitable implementation of evidence-based interventions in Member States needs to be strengthened. 24. Close monitoring of the Global Reproductive Health Strategy is important for success in this area. Countries of the Region, with support from the Regional Office, submit reports on the progress of its implementation every two years to be presented at the World Health Assembly. One important lesson learned is the “failure” in the scaling-up of effective evidencebased interventions, and the reasons for this “failure”; and how targeted approaches such as using a tool (Expandnet) can make a difference. 25. Another important lesson is the use of research at regional and country level to generate evidence, or confirm evidence generated by HQ, so that responses can be made locally applicable, as was done in the study on infertility, maternal death reviews and prenatal death profiles in India.
56
The Work of WHO in the South-East Asia Region
Health in emergencies, disasters, crises and conflicts Overview 1. Salient public health issues and challenges in this area include efforts to reduce risks against all hazards. This entails strengthening of the disaster management cycle in all phases in order to prevent, mitigate, prepare, respond and recover from various events. Work is conducted within health systems as well as with government agencies in disaster management (e.g. national disaster management authorities) and with the other stakeholders (e.g. transport, infrastructure). 2. Strategies include the Hyogo Framework for Action 20052015, The Global Campaign for Safe Hospitals (2008-09) and the health cluster approach for humanitarian response. At the regional level common approaches include: (1) South-East Asia Region Benchmarks for Emergency Preparedness and Response (for risk reduction and preparedness); (2) Primary Health Care Approach in Emergencies; (3) The Kathmandu Declaration by Health Ministries for Protecting Health Facilities from Disasters; and (4) The South-East Asia Regional Health Emergency Fund (SEARHEF) and standard operating procedures (SOPs) for emergencies.
5
3. The primary partners in this area are ministries of health and their disaster and emergency management units. Other stakeholders and partners government agencies and sectors include national disaster management authorities and water-related groups and agencies. Amongst agencies, the United Nations International Strategy for Disaster Reduction (UNISDR), United Nations Office for the Coordination of Humanitarian Affairs (UNOCHA), UNICEF, UNFPA, and the Federation of the Red Cross and Red Crescent are key partners. Disaster Preparedness European Community Humanitarian Office (DipECHO), The Korean Foundation for International Health and United Nations Central Emergency Response Fund (UN CERF) are major donors. At country level several NGOs, both international and national, have been partners with WHO in delivery of these activities. Merlin, Handicap International, Sarvodaya Sri Lanka, Sulabh Academy (India), are some agencies who have worked with WHO. In terms of training, SEARO has a MoU with The Asian Disaster Preparedness Center based in Bangkok, to train the Member States in the area of Public Health Emergency Management.
Member States’ achievements and WHO’s contributions Strengthening of national emergency preparedness plans and programmes 4. A tool for assessing preparedness and response was completed using SEAR Benchmarks and was applied during the biennium in Bangladesh, Indonesia, Myanmar and Nepal. An advocacy campaign for safe hospitals using social media was conducted by all countries. All countries also have plans to manage multiple types of hazards and some have completed updating their existing plans. 5. A regional meeting on primary health care in emergencies was conducted and a framework for primary health care approach in emergencies was developed. This meeting aimed to identify best practices and to develop a framework to improve application of the primary health care approach in emergencies. Regional expert consultation to define strategic options for nursing in emergencies and disasters was conducted. Countries began to scale-up nursing programmes in emergencies and disasters in an organized
58
The Work of WHO in the South-East Asia Region
manner based on global competency standards. Draft guidelines for essential public health needs in emergencies and primary care providers (e.g. workers, volunteers, professionals) were put to practical use in emergencies (e.g. Thailand floods).
Responding to disasters associated with natural hazards and conflict-related crises 6. The capacity to respond to emergencies was enhanced with the establishment of the regional operational platform for surge capacity which all countries draw from and share. Post-conflict work in Sri Lanka; the fire accident in Bangladesh; Mt. Merapi eruption in Indonesia; floods in Sri Lanka; torrential rains in DPR Korea and the floods in Thailand were all responded to during the biennium. The operational platform for surge capacity includes components of funding, human resources, logistics stockpile and capacity building. Funding of US$ 1.3 million was released to support emergencies in the Region during the biennium. The response to these events were supported using the SEARHEF. As part of strengthening the capacity of human resources, a focal points’ meeting was conducted to further coordinate and work cohesively. Regional plans and approaches were discussed and will be taken forward. For emergencies that have occurred in the biennium (seven Member States), specific health plans have been implemented in the humanitarian action plans. 7. Two stockpiles of essential emergency health kits are stored and managed in Bangkok and Delhi. Stocks were released as per need in acute emergencies or for pre-positioning for monsoon floods. Operational readiness workshops were conducted in WHO country offices in Nepal and Sri Lanka and plans were revised in who country offices in Indonesia and Thailand. Guidelines were provided as required and were always available via the web.
Assessing needs and planning interventions during transition and recovery phases 8. Countries affected by sudden onset emergencies developed plans for the health sector response. This included countries that have contingency plans for expected events (e.g. cyclones, floods). As for recovery strategies, countries experiencing major emergencies have developed dedicated
Health in emergencies, disasters, crises and conflicts
59
strategies. For all such events WHO-SEAR provided financial support, emergency supplies, technical and operational support as required on request.
South-East Asia Disaster Health Information Network (SEADHIN) — www.seadhin.org In order to utilize lessons of past disasters in the future, there was an urgent need to establish a system of collecting and storing information. With this in mind, the South-East Asia Disaster Health Information Network (SEADHIN) was created as a repository of “good practices” and documentation of various types in different countries and compilation and sharing of information between scientists, practitioners, technical institutions and end users through existing medical and public health library networks. Organizing such information allows for analysis and drawing lessons from events. Information that is stored systematically allows for: availability of the evidence base for review, adaptation and revision of guidelines; improved management and operations for future emergencies; and Improved planning processes and interventions for recovery and rehabilitation.
Controlling communicable diseases in natural disasters and conflict situations 9. All emergencies require establishment of early warning, surveillance and reporting systems for diseases with epidemic potential. Countrylevel mechanisms are in place to activate early warnings systems in the aftermath of an emergency, and are usually integrated within existing routine surveillance and reporting systems. 10. Communicable disease surveillance systems in ministries of health were supported to develop preparedness and response contingencies. A set of guidelines and SOPs in setting early warning and response systems were drafted.
60
The Work of WHO in the South-East Asia Region
Strengthening national preparedness, alert and response mechanisms for food-safety and environmental health emergencies 11. Bangladesh, Bhutan and Sri Lanka have established plans on chemical, biological, radiation, nuclear (CBRN) emergencies and are also working on environmental emergencies (e.g. climate change-related emergencies). WHO-SEARO collaborated in the development of a vulnerability analysis methodology of climate change, health and disasters. This was piloted and completed in selected districts in Haryana, India, focusing on drought and flood scenarios. This will be used for disaster risk management processes especially planning.
Member States are ensuring continuity of basic public health services in emergencies.
Developing effective communications, partnerships and coordination 12. The cluster approach was applied during major emergencies and public health aspects of emergencies were addressed during the biennium. These included:
Health in emergencies, disasters, crises and conflicts
61
DPR Korea – torrential rains and floods, June 2011; Indonesia –– –– Mt Merapi eruption (October, 2010) – SEARHEF support provided; continued support to Padang earthquake recovery (September, 2009);
Myanmar – cyclone Giri; Sri Lanka – continued support for the recovery efforts in the post-conflict area in Vavuniya/Menik Farm; floods; Thailand – floods, August to December, 2011.
13. Countries of the Region are highly vulnerable to natural disasters The magnitude of disasters and their effects have considerable impact on the morbidity and mortality of the Region where 25% of the world’s population resides. As per disaster statistics, SEAR Member States accounted for 46% of the global total of deaths from disasters in the decade 2001 to 2010 as seen in the figure below. Figure 5.1: Total number of people reported killed by disasters by country and territory 2001 to 2010
Source: World Disaster Report 2011
62
The Work of WHO in the South-East Asia Region
14. The Regional Office engaged in advocacy for the cluster approach in Member States. This included regular provision of booklets and manuals to support better implementation of the cluster approach.
Implementing acute, ongoing and recovery operations 15. The operational platform for surge capacity in the Regional Office has been established with components of funding, human resources, logistics stockpile and capacity building. 16. These four components are contingent to major events in Member States. WHO supported emergency response in five countries (DPR Korea, Indonesia, Myanmar, Sri Lanka and Thailand). 17. Activities were funded by emergency funds from SEARHEF, UN mechanisms (eg CERF, Flash Appeal) or direct donor contributions (Republic of Korea to DPR Korea). SEARHEF and the regional stockpiles in Delhi and Bangkok for emergency health supplies have helped tremendously in the speedy WHO response in the Region.
Lessons learnt 18. Use of the SEAR Benchmarks for emergency preparedness and response proved very useful. Coordination in the deployment and set-up of early warning and surveillance systems worked well in Member States. Morevover, working towards building the evidence base for the work in emergency risk management in health will be a crucial contribution of WHO for the Region. 19. Building links with partners beyond the health sector such as the national disaster management authorities and other key sectors such as the private sector (where most health facilities are being developed and managed) is very beneficial.
Health in emergencies, disasters, crises and conflicts
63
64
The Work of WHO in the South-East Asia Region
Tobacco, alcohol, psychoactive substances, unhealthy diets, physical inactivity and unsafe sex Overview 1. Unhealthy diet, tobacco and alcohol use and the lack of sufficient physical activity are the key risk factors for noncommunicable diseases (NCDs). The SEA Region has 250 million adult smokers and the same numbers of adults are users of smokeless tobacco. Nearly 80% of adults do not consume at least five servings of fruits and vegetables daily and nearly half do not engage in sufficient physical activity. As a result, NCD-related morbidity and mortality is on the rise. 2. Salient strategies in this area include an updated Regional Strategy on Tobacco Control 2011-2015 . Cost-effective interventions to tackle these risk factors (tobacco use, harmful alcohol use, unhealthy diet and physical inactivity) include creating awareness, school-based programmes, legislative measures to reduce tobacco use, eliminating trans fat from diet, reduction of salt and free sugars and promoting physical activity through schools and the workplace, and enabling an environment for physical activity. In the context of the Global Strategy to Reduce the Harmful Use of Alcohol, the regional
6
strategic approaches focus on community action to reduce harm from alcohol use while the Regional Strategy On Tobacco Control advocates implementation of different provisions of the Framework Convention on Tobacco Control and MPOWER policy package (MPOWER package consists of Monitoring tobacco use and prevention policies, Protecting people from tobacco smoke, Offering help to quit tobacco use, Warning about the dangers of tobacco use, and Enforcing bans on tobacco advertising, promotion and sponsorship). 3. Major stakeholders and partners for this work include ministries of health, finance, education, labour, social welfare, justice, information and women’s affairs in respective Member States of the Region; national and international NGOs, academia, research institutes, public health undertakings, international partners such as other UN partners; Center for Disease Control and Prevention, Atlanta, USA; CDC Foundation, Atlanta, USA; Thai Health, Thailand; Bloomberg Philanthropies; Confederation of Indian Industries (CII); Kobe Centre, Japan; and The Indian Public Health Association, India.
Member States’ achievements and WHO’s contributions Promoting health and preventing or reducing major risk factors 4. Several SEAR countries have recorded significant progress in multisectoral and multidisciplinary collaboration to promote health and prevent priority diseases. Member States have recognized the need to work with a broad range of development sectors especially due to the recent increase of public interest and health-related actors in noncommunicable diseases. Multisectoral approaches to prevent noncommunicable diseases are being widely accepted to bring about individual behaviour change, community support, and public policies to contribute to positive impacts on health behaviour. A number of countries are looking for innovative financing for health promotion. The Thai Health Promotion Foundation is a leading example of such innovative measures and has been requested by partners in Member States to share experiences in the management of the Thai Health Fund. Six Member States have evaluated and reported on the action areas and commitments of the Global Conference on Health Promotion.
66
The Work of WHO in the South-East Asia Region
5. WHO-SEARO provided technical support to countries and promoted inter-country collaboration to strengthen capacities in the Region. Maldives received support from collaboration with Thailand to develop national health promotion policies and strategies. Cross–country sharing of experience and expertise was valuable. A group representing health and civil society organizations from Bangladesh made a field visit to The Thai Health Promotion Foundation to gain experience and learn how to engage multisectoral partners and build community interest in health promotion and disease prevention.
Campaigns to reduce major risk factors in NCDs are being promoted in the Region.
6. WHO provided support for core staff of the health promotion and communication units from the Ministry of Health, Bhutan, to attend a certificate training course on health promotion at the Institute of Health and Family Welfare, New Delhi, India. An evaluation of a decade of The Thai Health Promotion Foundation which brought concrete evidence of achievements and lessons learnt of the health promotion activities was also supported. A regional situational analysis on health promotion, education and professional development was conducted and core capacities for health promotion were identified.
Tobacco, alcohol, psychoactive substances, unhealthy diets, physical inactivity and unsafe sex
67
Strengthening national systems for surveillance of major risk factors 7. There is increased availability of data on major behavioural risk factors for NCDs, as well as for some of the metabolic risk factors for NCDs. Ten SEAR countries have conducted at least one round of risk factor survey similar to the WHO STEPS survey (Figure 6.1). In some countries trends in risk factor data are available. However, routine reporting of NCD morbidity and mortality remains low in all countries. Figure 6.1: Smoking and smokeless tobacco use prevalence among adults aged 15+ years in selected Member States of the Region
Source: Bangladesh, India and Thailand, Global Adult Tobacco Survey Report, 2009
8. Several documents and advocacy materials were prepared by WHOSEARO such as: Evidence on NCD risk factors in SEA Region; Regional NCD Status Report; Regional Profile on Gender and Tobacco, 2010; Report of the Global Youth Tobacco Survey (GYTS) and Global School Personnel Survey (GSPS), Bangladesh 2010; Report of the Global Health Professions Student Survey (GHPSS), Bangladesh, 2010; Brief Profile of Tobacco Control in Bhutan, 2010; Tobacco Cessation in Schools in Myanmar, 2010; Brief Profile on Tobacco Control in Nepal, 2010; Profile on Implementation of WHO Framework Convention on Tobacco Control in the South-East Asia Region; The WHO FCTC Indicators: GYTS 2011; The WHO FCTC Indicators:
68
The Work of WHO in the South-East Asia Region
GSPS 2011; The WHO FCTC Indicators: GHPSS 2011; Noncommunicable Diseases Risk Factor Survey, Myanmar report, 2011; Indian Journal of Public Health, one special issue on tobacco control, 2011. Guidance and support to strengthen national systems for monitoring early-age risk factors were provided through regional workshops on development of evidence-based school health programmes utilizing results from the global school-based health survey. The workshop supported joint action plans and implementation between the ministries of health and ministries of education in the Region.
Tackling or preventing tobacco use 9. Bhutan showed very strong commitment to tobacco control including approval and enactment of national tobacco control legislation. India strengthened its tobacco control policy by amending regulations on pictorial health warning and smoke–free movies. Indonesia adopted sub-national legislation and declared 11 cities smoke–free with people’s order and 17 cities with executive order. Maldives enacted national tobacco control legislation. Myanmar reported the formation of a Central Tobacco Control Committee with inclusion of multisectoral partners and stakeholders. Nepal adopted strong and comprehensive tobacco control legislation and developed regulation especially on tobacco use in public places and pictorial health warnings. In Thailand, progress was made to amend the current legislation to fully comply with the WHO FCTC. 10. Ten countries have completed the first and second rounds of Global Youth Tobacco Survey and six countries have tobacco control units with dedicated staff. All Member States enhanced their advocacy and awareness campaigns. Cessation clinics have been initiated in Bhutan, DPR Korea, Myanmar and Indonesia. 11. WHO-SEARO supported Bangladesh, Bhutan, Myanmar, Nepal and Sri Lanka in the production of Information, Education and Communication (IEC) materials. Member States were also supported to conduct awareness campaigns. Advocacy workshops were conducted in Bangladesh, Bhutan, Maldives, Myanmar and Nepal. SEARO also provided technical support to Bangladesh, Bhutan, Maldives and Nepal for adoption and amendment of tobacco control legislation. Efforts were made to collect scientific evidence on smoking and smokeless tobacco products used in Member States of
Tobacco, alcohol, psychoactive substances, unhealthy diets, physical inactivity and unsafe sex
69
Smoke-free in Indonesia There is no safe level of exposure to second-hand smoke (SHS), and even brief exposure can cause serious damage including heart disease, respiratory illness, and lung and other cancers. Each year, approximately 600 000 non-smokers are killed by exposure to SHS. Only a total ban on smoking in all indoor public places can protect people from the harms of SHS. Evidence shows that the ban on smoking in public places help smokers quit and can reduce youth smoking by changing social norms about tobacco use. WHO has been concerned for long about the dangers of SHS, and continues to provide guidance and technical support to countries to help them implement strong and effective measures to eliminate this exposure. Although some countries have implemented such measures at the national level, other countries such as Indonesia, have achieved success by focusing on sub-national, smoke-free initiatives. As early as 2005, some initial local smoke-free regulations were passed. However, it is in more recent years that progress has accelerated. In 2010-2011, a number of concerted actions took place including a series of training workshops on smoke-free implementation. In 2011, a Mayors’ Alliance was launched to accelerate smoke-free action at the local level. Many of the cities going smoke-free also issued regulations to ban tobacco advertising in outdoor media. In Padang Panjang, one of the first cities to go smoke-free, the integration of smoke-free initiatives with its ongoing Healthy Cities project was one strategy that helped in its success. There was also a total ban on smoking in the Mayor’s office and in any event involving the Mayor. Community and cultural leaders worked together and spoke out to say that smoking should not be part of the local tradition and promoted smoke-free lifestyles and alternative ways to celebrate events. The media was engaged as a partner in this initiative, writing articles highlighting the importance of tobacco control. Local radio stations discussed the dangers of tobacco use and instituted a policy refusing cigarette advertising. As of December 2011, Indonesia had eight smoke-free cities: Padang Panjang, Payakumbuh, Bogor, Jakarta, Palembang, Kota Tangerang, Pontianak and Surabaya. This is particularly significant due to the challenges faced in Indonesia including high smoking rates (over 60% of men smoking) and strong tobacco industry influence.
70
The Work of WHO in the South-East Asia Region
the Region and were disseminated through publication of reports, fact sheets and articles in peer reviewed journals. 12. Inter-country expert group consultations were held at the Regional Office on smokeless tobacco use and its implications in SEA and on innovative financing from tobacco taxation for health promotion. SEARO also mobilized resources to conduct surveys under the Global Tobacco Surveillance System and provided technical support in developing training proposals for field implementation and quality control issues. Field work was completed for the first round of GATS (2011) in Indonesia and repeat GATS in Thailand, (2011). GYTS and GSPS were completed in Maldives, Myanmar, Nepal, and Sri Lanka; GHPSS was repeated in Myanmar, Nepal, Sri Lanka and Thailand (2011). SEARO developed a manual on Tobacco Cessation for Doctors and Dentists and a Manual on Tobacco Cessation for Nurses and Health Workers and organized a regional training workshop for training of trainers. SEARO provided support to conduct national tobacco cessation training workshop and helped in establishing tobacco cessation clinics in some countries.
Combating or preventing burden of disease caused with alcohol, drugs and other psychoactive substances 13. Reducing harm from alcohol is a complex inter-sectoral issue. A diverse range of innovative community-based programmes have been developed to reduce harm from alcohol use. Various Member States are also making efforts to control harm from psychoactive substance use. Six Member States have developed strategies, plans and programmes for combating or preventing public health problems caused by alcohol, drugs and other psychoactive substance use. 14. The Regional Office assisted Member States to develop technical material for training community members in identification of the harm being done to the community from use of alcohol. Communities have realized the complex and diverse nature of the harm from alcohol. Communities were facilitated to find their own unique solutions to the problem of harm from alcohol use and implement them. WHO-SEARO also supported pilot projects in Member States to address various solutions to the problem of harmful use of alcohol.
Tobacco, alcohol, psychoactive substances, unhealthy diets, physical inactivity and unsafe sex
71
Reducing economic harm from alcohol use In recent years, harm from alcohol use is increasingly recognized as a matter of public health concern. Alcohol use leads to a diverse range of harm which affects not only the individual but the family and the community. Types of harm include medical, social, psychological and economic harm. WHO has developed a strategy entitled “Reducing harmful use of alcohol”. This strategy has been adopted by the World Health Assembly. It recommends ten evidence-based strategies to reduce harm from use of alcohol. SEARO has focused on working with Member States to develop alcohol control policies and also conducting pilot projects in some Member States to reduce harm from alcohol use. Specific impact indicators have been developed to assess each project. One of the indicators is reducing economic harm from alcohol use. Pilot projects to reduce economic harm have been conducted in Bhutan, Sri Lanka and Thailand. The economic benefit from reduction in alcohol use is summarized in the following table: Country Bhutan Strategy Prohibition of serving alcohol and meat during funerals Creating awareness in a community about the real cost of alcohol use Economic benefit The cost of each funeral decreased by 30 000 Nu. The people of Bhutan would save an estimated sixty crores Nu in one year. The community realized that with the money saved from reduced use of alcohol, they could build new roads in the village rather than depend on the government. The village saved 60 000 baht in six months from reduced alcohol consumption.
Sri Lanka
Thailand
Encourage alcohol users to deposit the cost of one bottle of alcohol into a money box
The community is often not aware of the economic implications of alcohol consumption. Awareness and knowledge about the real economic cost of alcohol use combined with motivation and methods to reduce harm from alcohol use can be very successful. Moreover, since these actions are taken by community members at their own initiative, they are likely to be sustainable.
72
The Work of WHO in the South-East Asia Region
Addressing unhealthy diets and physical inactivity 15. Member States developed action plans on healthy diets and physical activity. Bhutan, Indonesia, Maldives, Myanmar, Nepal, Sri Lanka and Thailand have adopted multisectoral strategies and plans for healthy diets or physical activity in the context of their national NCD strategies and programmes. Three of these received WHO-SEARO support to develop action plans and guidelines on healthy diet and physical activity.
Lessons learnt 16. Inter-country sharing of experience and expertise, particularly with field visits, provided positive results for further collaboration among countries across sectors. Multisectoral approaches worked well when priorities and policies were set for health promotion programmes and activities. Gaining commitment from multiple stakeholders and coordination among all partners is challenging and monitoring of progress in different areas of work in health promotion across sectors and issues is difficult. 17. Strengthening the capacity of national officers and focal points in monitoring progress and providing effective and timely technical assistance to partners are crucial and urgently needed. Coordination mechanisms at country and regional levels to develop health promotion, particularly on health in all policies and healthy settings, need to be developed. Another key lesson is that harm from alcohol use is best addressed through community action.
Tobacco, alcohol, psychoactive substances, unhealthy diets, physical inactivity and unsafe sex
73
74
The Work of WHO in the South-East Asia Region
Social and economic determinants of health Overview 1. The level of socioeconomic development in countries of the WHO SEA Region is quite varied. Despite efforts to provide universal health coverage and pro-poor health policies, health equity remains a challenge. Growing urban populations and urban slums; cross-border migration; unfair trade of agricultural products, pharmaceutical and intellectual property rights violations; increasing unhealthy commodities and advertising; internal political conflicts; and other factors increasingly pose barriers to achieve health. Rapid urbanization has contributed to weakening of community ties and changed the health-seeking behaviour of urban populations, thereby influencing their access to health care and information. The increasing number of females completing secondary education has created a positive impact on maternal and child health on the one hand, but exposed them to the world of work and other health risks on the other. 2. Human rights and health have been advocated throughout the SEA Region, However, they need to be built into health policies and implemented within the health sector. The existing health information in most countries is disaggregated by basic
7
indicators on social determinants of health, which focus on individual health behaviours and factors. However, the evidence and information on broader factors related to health inequities still needs to be generated. 3. Following the Colombo Call of Action 2009, the Regional Strategic Framework to address the social determinants of health was drafted (Figure 7.1). The World Conference on Social Determinants of Health held in Rio de Janeiro, Brazil called the attention of high-level officials from SEA Region to deepen their understanding of the complexities of underlying health issues beyond the health sector. Exchange of experiences and dialogue among Member States, international partners and civil societies on the global platform stimulated interest in the issues related to health, human rights, trade, equity, governance and social participation to address health equity in a more concrete manner. United Nations Development Programme (UNDP), UNICEF, International Labour Organization (ILO) and UNFPA are the key stakeholders among UN agencies. The ministries of finance, foreign affairs, education and social welfare are the key stakeholders at country level. Regarding NGOs or civil society groups, the Global Health Alliance and the Voluntary Health Association of India are the key stakeholders. Figure 7.1: Regional strategic framework on intersectoral actions addressing social determinants of health
76
The Work of WHO in the South-East Asia Region
Member States’ achievements and WHO’s contributions Recognizing social and economic determinants of health 4. Member States of the SEA Region recognized social and economic determinants of health as important factors to prevent and control communicable and noncommunicable diseases. India, Indonesia, Maldives, Sri Lanka and Thailand made significant progress in addressing social determinants of health through intersectoral collaboration, community participation and civil society engagement. Changes to public policies in Thailand and in part of Indonesia demonstrated the efforts being made to tackle underlying social and economic determinants of health. Decentralization and universal health were widely discussed among countries of the Region to better address health and inequity. Engagement of multisectoral partners in health policies development served to strengthen collaboration among various partners. Thailand addressed health inequity at national and grassroots level through the National Health Assembly, as well as throughout the process of policy development where the National Health Commission built networks of local health assemblies across the country. The Social Inequity Reduction Network (SIRNet) was initiated in Thailand as a mechanism to tackle the health and inequity problems. Sri Lanka, as part of the “lighthouse” project as initiated in collaboration with WHO headquarters and the regional and country offices, has been successfully addressing social determinants of health through multisectoral partnership and collaboration among various sectors in the country, as well through intercountry collaboration. 5. WHO-SEARO’s contribution to this work included organizing a regional consultation on health of the urban poor intersectoral actions and the primary health care approach in addressing health of the poor in urban settings. This attracted potential partners from international organizations, nongovernmental organizations and civil society to address the social determinants of health. WHO-SEARO also worked to integrate the key indicators of social and economic determinants of health in surveys, studies and health interventions across technical units. WHO country offices worked closely with national and international partners through dialogue and advocacy. A series of regional consultations and workshops addressing social determinants of health were conducted in collaboration with technical units, such as on tuberculosis, immunization, leprosy, and noncommunicable diseases, as well as on the health system using the primary health care approach to address health of the urban poor.
Social and economic determinants of health
77
The “Lighthouse Project” – addressing social determinants of health in Sri Lanka In collaboration with the WHO-SEARO, WHO headquarters, and the WHO Country Office, as well as the Ministry of Health, Sri Lanka, the “Lighthouse Project” was launched in 2011 to assist the country to document and pilot intersectoral actions to address underlying causes of health concerns in Sri Lanka. Studies on social determinants and risk factors related to acute myocardial infarction, diabetes mellitus, and dengue were conducted. Stigma attached to mental health was investigated among services providers and multisectoral team interventions to reduce stigma and increase awareness on mental health were documented. A community approach to tackle social determinants was implemented using estate, rural, and urban settings. In the estate setting, primary health care facilities in Nuwera Eliya Division Secretariat Areas in the Central Province of Sri Lanka were strengthened to address the social determinants of health related to noncommunicable diseases. A districtlevel steering committee for NCD–social determinants of health (SDH) projects was set up through social mobilization of elderly, women, youth groups, sport clubs, civil society groups and the communitybased rehabilitation team, to address the issue of social determinants. Healthy village was introduced to MoH and nutrition coordination division. Also, NCD prevention through pre-school education was introduced through teacher training and parental guides. The rural setting approach to address SDH was implemented in the Alawwa Divisional Secretariat Area of Kurunegala district, in the North Western province of Sri Lanka. The approach was used to identify disparities and inequities in health service delivery and utilization of health outcomes in relation to NCDs, malnutrition, tobacco, and harmful use of alcohol. Social determinants and causes of disparities (namely income, education, gender, and social exclusion) were analysed and the potential pathway interventions were determined. The health-in-all policy approach was introduced in combination with the PHC model in rural setting to reduce and mitigate the inequalities. The urban setting approach was used to investigate the role of “social capital” in determining health and livelihood of poor women in underserved urban settlements in Colombo. Social capital was found to be the major factor in safeguarding family health and in supporting livelihood activities of poor women. It also contributed on determining disease patterns and health-care utilization practices among families living in poor settlements.
78
The Work of WHO in the South-East Asia Region
SIRNet: Social Inequity Reduction Network, Thailand Actions to address social determinants of health need multisectoral and multidisciplinary approaches involving numerous groups of actors, social networks, academics and policy-makers. The mainstreaming of social determinants of health must focus on advocacy to generate common understanding and a sense of responsibility to act together. The Social Inequity Reduction Network (SIRnet), Thailand, is a network of academics, policy-makers and civil groups working together to address health issues of vulnerable groups such as people living with disability, elderly persons, farmers, labourers, women and others. The network started with core technical individuals who foresee health as broad responsibilities of all sectors. They work together to produce evidence and advocate for policy change. Learning from Thailand’s experience, health must be put at the heart of the whole health system with a holistic approach encompassing physical, mental, social and spiritual well-being. A holistic health system includes health care services, individual conditions, and the whole social, political, economic and natural environment. The SIRNet is also a network of networks where research in different areas is conducted through networks with support from governmental organizations and partners in the country. The network synergizes individuals and network of people through their existing commitment on the issues.
Addressing social and economic determinants of health, including public health implications of trade and trade agreements through intersectoral collaboration 6. During the biennium, countries of the SEA Region have been increasingly engaged in dialogue and have moved towards greater intersectoral collaboration within and across countries to address the social and economic determinants of health. The issue of international partnerships to address social determinants of health through the MDG Framework was discussed in countries and among the Member States at the Regional Consultation on Intersectoral Actions addressing Social Determinants of
Social and economic determinants of health
79
Health. Issues of health system strengthening and universal coverage have been the primary focus in the Region for addressing health equity. However, economic and political crises as well as natural disasters during this period have hindered Member States` ability to reduce the gap and address health implications of social and economic changes.
Social and economic determinants of health play an important role in health and development in the Region
7. National workshops on intersectoral actions and collaborations were supported by WHO-SEAR to address social and economic determinants along with noncommunicable disease prevention, and to address health inequity. Multisectoral workshops were also supported to address social determinants of health. Country experiences were published and disseminated and a regional consultation on intersectoral actions addressing social determinants of health was organized to facilitate regional sharing of intersectoral actions. Technical assistance was also provided to Member States on emerging issues, such as implications of the Convention on Biological Diversity and the Nagoya Protocol on Access and Benefit-sharing of Medical Products, such as for pandemic influenza preparedness and standard material transfer agreements. In addition, training was provided for competition, intellectual property and trade issues in public health. WHO-SEARO also provided technical and policy support to Member States for framing related national policies, laws and regulations.
80
The Work of WHO in the South-East Asia Region
8. Technical assistance was provided for developing the Royal Thai Government (RTG) – WHO initiative that included an International Trade and Health Programme as one of the five priority areas for action in 2011-2015. In India, technical assistance provided included public health concernes in FTAs, such as EU-India Free Trade Agreement (FTA) and IndiaTurkey FTA, which also incorporated information on quality laboratories accreditation for certification of medical products. 9. The First Regional Consultation for Development of a Regional Framework on Public Health, Innovation, and Intellectual Property identified specific action points in eight elements and twenty five sub-elements of the 108 action points for implementing the World Health Assembly resolution WHA61.21. The intellectual property aspects for developing a tool to meet the specific requirements of the SEA Region and its Member States were identified. Pursuant to the World Health Assembly resolution WHA63.28, WHO-SEARO facilitated the identification of regional experts for a working group on research and development, financing and coordination (CEWG). The regional consultation examined the appropriateness of different research and development (R&D) financing approaches under review by the CEWG, and also the feasibility of using these approaches in the SEA Region. The consultation enabled the adoption of regional priorities in the report of the CEWG presented to the World Health Assembly.
Monitoring the social and economic data relevant to health 10. Health information in most countries in South-East Asia has aggregated data on age, sex, income and health conditions. Countries are able to identify disparities in the health among different age groups, sexes and income of populations by various health conditions and health outcomes. Integrated national health statistics also exist. Health inequity assessments in urban areas using Urban HEART (health equity assessment and response tool) were piloted in two cities (Indore and Bally, India). Moreover, evaluations of projects conducted in the pilot cities that participated in Urban HEART development (Jakarta and Colombo) were completed during the biennium. A study on mortality in urban areas in South-East Asia (in selected cities of five countries) was conducted utilizing existing data for longitudinal analysis. The study discovered a significant lack of disaggregated data for social determinants of health in urban settings.
Social and economic determinants of health
81
Thailand begun documenting the measurement of health inequity from the entire health system perspective. Bhutan integrated the analysis of determinants of health into the Gross National Happiness index. Five Member States published their experiences in tackling social determinants for health equity. 11. Technical support was provided to several countries to analyse health equity as well as the existing measurement tools for determinants of health. Sri Lanka was supported in addressing the social determinants of health and in utilizing existing health information systems to identify target areas for response.
Promoting ethics and rights-based approaches to health 12. Health as a human right is already expressed in national policies, constitutions and agendas of most countries of the SEA Region. However, implementation of human right principles and human-rights based approach to health need to be further strengthened in medical schools and healthcare facilities, and in health programmes and planning. 13. Ethics and rights-based approaches have been promoted at the regional level through various advocacy and capacity-building efforts, such as organization of trainings and orientations on health and human rights (HHR), creation of a HHR website, creation and distribution of advocacy materials and through giving technical support to countries. An HHR training was also organized at WHO-SEARO. Baseline tools on neonatal health and human rights were developed in Indonesia. An HHR factsheet and a factsheet on TRIPS Agreement and human rights compatible with patient protection was produced in Maldives. A factsheet on the right to health in Thailand was also produced. In Indonesia, WHO and the Ministry of Health jointly participated in a workshop on Human Rights and Gender Equality in Health Sector Strategies. A study on the right to health as established in constitutions of SEAR countries was also conducted. Three training workshops were organized for the benefit of WHO country offices and focal points were active in strengthening capacities for advocating and disseminating knowledge and practices, and for implementing the HHR tools.
82
The Work of WHO in the South-East Asia Region
Formulating gender responsive policies and programmes 14. Most SEAR countries have gender-disaggregated data and integrate gender into normative programmes. All countries commemorated 2011 16 Days of Activism Against Gender Violence Campaign and 10 country factsheets and 1 regional factsheet on gender-based violence were produced. Regional and country profiles on gender and women’s health were also developed. 15. Technical support was provided to Bhutan and Nepal to mainstream gender perspectives into normative programmes, particularly the HIV/ AIDS programme. A tool to assess the country situation on gender-based violence was also developed and utilized among SEAR Member States. Support was also provided to Sri Lanka and Thailand for formulation of gender-responsive policies and programmes in the SEA Region. Gender mainstreaming activities supported by WHO were conducted in ten Member States.
Lessons learnt 16. WHO-SEARO commissioned two investigations into the existing data and information on social determinants of health and health inequity in the Region. The studies revealed significant gaps in information on social determinants of health in urban settings and the limited analysis of health equity in South-East Asia. 17. Multisectoral approaches and intersectoral actions encouraged other sectors to recognize the important roles they play in the health of populations on the one hand and changing the health sectors to take roles in advocacy and seek participation from other partners, on the other. Ensuring the quality of information and reliability of sources for health equity analysis remains a challenge. The linkage among social and economic development, health and human rights needs to be integrated into national health policies. Most countries do not yet have plans of actions to address health inequity and reduction of poverty and social gaps.
Social and economic determinants of health
83
18. Quality and reliable disaggregated data are crucial for the accurate analysis of health equity at national and subnational levels. Regular monitoring and assessment of social and economic indicators and health outcomes is necessary to provide evidence for priority-setting in countries where resources are limited. Target populations could be identified through qualitative research showing the context of inequity and justice in the broader areas of social determinants of health especially on trade, human rights, and public policies influencing health. 19. Advocacy raises the awareness of Member States on gender and health, and the need for sex-disaggregated data. Publications on gender and in particular on health issues provide good examples on how a country can tackle gender issues, as well as on the linkage between gender and health outcomes or accessibility to health services. Support in implementing the global strategies on gender and women’s health or activities related to gender and women’s health need to be carried out through multidisciplinary and multisectoral approaches.
84
The Work of WHO in the South-East Asia Region
Healthy environments and environmental threats to health Overview 1. This area of work aims to build the capacity of Member States to create healthier environments, support primary prevention and promote healthy public policies to address the root causes of ill-health resulting from unsafe drinking water, climate change, exposure to chemicals, poor sanitation and workplace hazards. Major public health challenges related to this work include diarrhoeal diseases, respiratory infections, injuries and ill-health resulting from hazards in the workplace, malaria, dengue, cancers or related diseases from ingestion and exposure to chemicals. The rise of communicable and noncommunicable diseases and malnutrition due to the impacts of climate change on health, and strengthening the resilience of the most vulnerable people and the health systems to the impacts of climate change are also addressed. 2. The salient strategies for work in this area include the Regional Strategy for Protecting Health from Climate Change. Strategic approaches include: integration of workers’ health into
8
primary health care through close collaboration between ministries of health and ministries of labour and industries. The other strategic approaches are capacity-building of national staff on development of water safety plans; developing sanitation and health-care waste management practices; recognizing the harmful effects of exposure to chemicals; and developing healthy workplace initiatives was supported. Strategic approaches are also employed to tackle other challenges such as prevention of drinking water contamination through the implementation of water safety plans; household water treatment and safe storage; hygiene promotion; safe and sound management of health-care waste; promotion of various types of affordable and sustainable sanitation technologies; and safe reuse of waste water in agriculture and aquaculture. Workers’ health is being promoted through developing mechanisms for measurement of the extent of ill-health and injuries among workers and building capacity of Member States to deliver workers’ health programmes. 3. Working with the Ministry of Labour has made it possible to develop standards for strengthening the capacity of national organizations to regulate workers’ health. Collaborative work with United Nations Environmental Programme (UNEP) and ministries of environment has enabled mobilization of resources for implementation of chemical safety programmes. The other key stakeholder is UNDP.
Member States’ achievements and WHO’s contributions Assessment and normative work on major environmental hazards 4. Six Member States conducted assessment of specific environmental threats to health or quantified the environmental burden of disease. Myanmar and Sri Lanka conducted assessments on environmental threats while Timor-Leste carried out water quality assessment to understand the safety of drinking water both in terms of chemical as well as microbiological safety. Assessment of environmental conditions (water, sanitation and waste management) of health facilities was also completed in India and Timor-Leste and an arsenic epidemiological study was completed in
86
The Work of WHO in the South-East Asia Region
Bangladesh. Drinking water quality standards and guidelines were also developed in Timor-Leste. Global analysis and assessment of sanitation and drinking water were carried out in nine countries. Indonesia received funds for implementing the Strategic Approach to International Chemicals Management and under this programme, Sri Lanka and Thailand developed profiles of chemicals and of the evidence generated to implement the programme on elimination of asbestos-related diseases. 5. Member States were assisted by WHO-SEARO to develop tools to assess the vulnerability of people and health systems to the impacts of climate change, and to develop strategies to strengthen the adaptive capacity of people and the health sector to manage the health impacts of climate change. Member States were also supported to attend a high-level meeting held in Dhaka, to orient Member States’ focal points on their participation in the Conference of Parties of United Nations Framework Convention on Climate Change (UNFCCC) in international negotiations, and in obtaining funds for assessing the vulnerability of populations in developing and implementing related plans. Technical support was provided for developing studies and assessment protocols, implementing assessments, analysing data and preparing reports. In addition to supporting the execution of the chemical safety project, WHO also provided technical guidance to countries to develop chemical profiles and standards as well as guidelines on drinking water.
Implementing primary prevention interventions 6. All Member States implemented several primary prevention interventions such as promotion of sanitation, health-care waste management and ensuring water safety to prevent water-borne diseases. Water safety plans were introduced and implemented in six countries (Bangladesh, Bhutan, India, Myanmar, Nepal, Timor–Leste). A regional workshop on health-care waste management resulted in development of a five-year action plan for the sound management of medical waste in each Member State. A healthcare waste management pilot project in Nepal and training on health care waste management (HCWM) were conducted in Bangladesh and Indonesia, and sanitation technologies were piloted in Bhutan, Nepal. The improper management of wastes generated in health-care facilities can severely affect the health of care-givers, patients and individual members of the community. Additional health hazards occur from scavenging on waste
Healthy environments and environmental threats to health
87
disposal sites and from manual sorting of waste at health-care facilities. WHO supported Member States to address issue by providing training, developing policies and guidelines, conducting baseline studies, introducing sound health-care waste management systems and advocating use of mercury-free medical equipment. A summary of the developments in this area are provided in Table 8.1. Table 8.1: Health-care waste management status – Member States of the SEA Region, 2011 BAN BHU DPRK IND HCWM legislation HWCM policy Guidelines on HCWM HCWM programe at national level Baseline study on HCWM Guidelines for management of waste from immunization activities Yes Yes Yes Yes Draft Yes drafted Yes Draft Yes Yes Yes
INO MAL MMR NEP Yes Yes Yes No Draft Draft Yes Yes Yes No Yes Yes
SRL Yes Yes Yes
THA TLS * Yes Yes Yes No No No
Yes
Yes
Yes
Yes
Yes
No
Yes
Yes
Yes
Yes
Yes
Yes
No
No
Yes
Yes
Yes
No
Yes
Yes
Yes
Yes
Yes
No
Yes
Yes
Yes
No
Yes
Yes
Yes
Yes
No
HCWM activities In probeing imcess plemented Phasing of mercurybased devices in health facilities
Yes
In process
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Partly
No
No
started
Yes
In Bali
No
No
Yes
PlannPiloted ed
No
Source: Country Reports, 2011 * BAN – Bangladesh, BHU – Bhutan, DPRK – DPR Korea, IND – India, INO – Indonesia, MAL – Maldives, MMR – Myanmar, NEP – Nepal, SRL – Sri Lanka, THA – Thailand, TLS – Timor-Leste
7. Good progress was made to increase awareness on risks and strategies through the Strategic Approach to International Chemicals Management
88
The Work of WHO in the South-East Asia Region
(SAICM) project in Sri Lanka and Thailand. Additional funding received from SAICM led to further progress in promoting chemical safety in the Region. In Nepal, public health service in urban settings was enhanced through capacity building and networking, while in Myanmar good progress was made in applying the healthy setting approaches. In Nepal, an evaluation of healthy city projects was carried out. Moreover, indicators and guidelines for healthy cities were developed for municipalities. All Member States of the Region implemented the healthy settings programme as part of the World Health Day activities on the theme of “urbanization and health”. These resulted in a number of advocacy initiatives for raising awareness of the impact on health of rapid urbanization. The National Environmental Health Action Plans (NEHAP) and demonstration programmes were strengthened in Indonesia, Maldives and Thailand to implement the primary prevention interventions aimed at reducing the environmental hazards to health, especially in local settings and among vulnerable groups. 8. Technical support was provided for monitoring of water safety projects in six countries, and for implementing the strategic approach to management of chemicals. The concept of basic occupational health services was introduced and technical assistance provided to Bhutan, Sri Lanka and Thailand for implementing such health services and integrating workers’ health into primary health care. Regional workshops, review meetings, a meeting of parliamentarians on climate change, training for researchers in SEARO, specialized trainings on water sanitation, study visits and national workshops were organized to enhance the skills of relevant staff in Member States. The Regional Office also organized an International Meeting on Healthy Workplaces that led to developing guidance on how to establish healthy workplaces.
Strengthening national occupational and environmental health risk management systems 9. Nine Member States implemented national activities towards achieving the objectives of the Global Plan of Action (GPA) on Workers’ Health. These same countries also reported on their activities at the regional consultation organized to update the occupational health strategy. Countries identified new strategies for implementing the GPA, the most important being integration of basic occupational health services into health systems.
Healthy environments and environmental threats to health
89
Multi-sectoral support for Occupational Health in Bhutan In 2010-2011 WHO-SEARO supported the Ministry of Health of Bhutan in its efforts to collaborate with the Ministry of Labour and Human Resources. WHO-SEARO provided technical support to the Ministry of Labour and Human Resources to conduct a review of the existing situation of the working environment and recommended appropriate occupational health and safety standards. A number of different products resulted from this review. The first was a revision of the Regulation on Occupational Health Safety and Welfare. This regulation contains legal requirements that must be met by all workplaces within the coverage of the Labour and Employment Act, 2007 that come under the inspection jurisdiction of the Department of Labour, Ministry of Environment. The purpose of these regulations was to establish standards on occupational health safety and welfare on premises, instruments, vessels, appliances, apparatus, tools, devices, electrical safety and other hazardous conditions. This is to ensure the safety, health and welfare of employees as well as other persons at workplaces, from work-related risks to their health, safety and well-being. WHO also supported the Ministry of Labour and Human Resources to develop six different manuals on occupational health and safety in the manufacturing, iron and steel, hotel, cement and construction industries and mining operations. These manuals defined standards for safe levels for the work environment, operations and exposures according to WHO standards. The process of developing the guidelines was participatory, with health, labour and other sectors working together to agree on regulations that can be implemented, manuals that are simple to use by industries and inspectors, and in turn developed the capacity of labour inspectors to implement the health and safety programme.
Sri Lanka and Thailand made significant progress in this regard, particularly with respect to setting up healthy workplace initiatives and engaging with the enterprise community. Progress was made in developing the National Occupational Health Profile and the health and safety standards and manuals. In Bhutan, training modules for workers’ health were also developed and applied at a training course. National programmes for addressing priority occupational risks and diseases were developed and
90
The Work of WHO in the South-East Asia Region
implemented in most countries. In Sri Lanka, training programmes for medical and public health inspectors were implemented. 10. In preventing exposure of workers to risks including chemical risks, funds obtained through the SAICM enabled successful implementation of chemical safety programmes in Indonesia, Sri Lanka and Thailand and initiatives for phased banning of asbestos in Sri Lanka and Thailand. Resource mobilization carried out by SEARO assisted six countries (Bangladesh, Bhutan, India, Nepal, Sri Lanka, Thailand) in receiving funds for occupational and environmental health work. At the regional level, efforts to develop guidelines for healthy workplaces resulted in a tool for action. The Regional Office hosted the International Conference on Healthy Workplaces, which increased the awareness of business community workers, occupational health experts and policy-makers about the benefit of adopting a comprehensive approach to improve worker’s health.
Reducing environmental hazards to health and enhancing safety 11. WHO-SEAR contributed to the preparation of the Report of the Joint Monitoring Programme on Water Supply and Sanitation that was published in 2010 by WHO and UNICEF. Consultations with Member States were held to validate data for the 2012 report. Policies and strategies conducive to workers’ health were advocated through country-level reviews. Significant among these was the stakeholders` meeting to integrate workers’ health into primary health care as well as on water quality in the SEA Region. Advocacy documents on water and sanitation were prepared and disseminated to all Member States as part of World Water Day. 12. One of the key factors for preventing water-related diseases is ensuring safe drinking water supply. The fourth edition of WHO Drinking Water Quality Guidelines recommends a preventive management approach to ensure safety of drinking water taking into account the characteristics of drinking water supply from the catchment to the consumer. With support from AusAID, WHO supported three Member States to advocate for the concept of water safety plans, to build capacity of nationals in implementing water safety plans, to develop guidelines, manuals and quality assurance tools and finally in implementation of water safety plans in several communities, urban areas and schools.
Healthy environments and environmental threats to health
91
13. Countries that implemented the water safety plans (WSPs) for their drinking water supply systems during the biennium are shown in Table 8.2. Table 8.2: Implementation of water safety plans for drinking water supply systems; selected Member States, 2010-2011 Country Bangladesh Bhutan Nepal India TOTAL WSPs=Water Safety Plans Source: Country Reports, 2011
City WSPs – – – 1 1
Small Town WSPs 10 5 20 – 35
Rural WSPs 15 61 20 – 96
Population Covered 1 550 000 85 000 360 000 2 400 000 4 395 000
Enhancing health-sector leadership for creating healthier environments 14. Health sector leadership was clearly demonstrated during WHO’s urbanization and health campaign. All countries of the Region engaged in the process that brought together many other sectors. Maldives updated its NEHAP, while Myanmar is in the process of doing so. In Sri Lanka, the Occupational and Environmental Heath (OEH) department has prioritized capacity building in occupational and environmental health through Training of Trainers (TOTs) and working with other sectors and universities. Policies and guidelines in other sectors, for instance in relation to the programme on elimination of asbestos-related diseases, are advocated through the leadership role of ministries.
Addressing health problems resulting from climate change 15. Most Member States have developed national adaptation plansprogrammes of action based on the UNFCCC. Most Member States also developed health sector plans for environmental health that included a chapter on climate change and health. Bangladesh and Sri Lanka developed intersectoral strategy documents on climate change and health. Bangladesh has also established an office in the health sector solely for on managing
92
The Work of WHO in the South-East Asia Region
Member States recognize human health as the central issue in climate policy.
climate change impacts on health. It has also embarked on development of a health sector strategy on climate change. 16. WHO-SEARO organized and funded meetings on climate change and health of high-level officials, parliamentarians, and the ministries of health and environment at regional level in Dhaka and Thimphu. The Dhaka meeting recognized human health as the central issue in climate policy and advised that reference to health should remain prominent in negotiating texts. It also urged countries to consider health interventions as an integral part of adaptation policy and planning, and advised that appropriate technology should be ensured to protect health from climate change. It also urged that research support should be provided to assess the scale and nature of the vulnerability of health to climate change. 17. The Thimphu Meeting for Parliamentarians recommended efforts to increase awareness on the health consequences of climate change; strengthening health and education systems; capacity; adequate resources; policies for reducing emission of greenhouse gases; addressing health concerns in other sectors; enacting necessary legislation; and strengthening the existing legal mechanisms.
Healthy environments and environmental threats to health
93
Climate change and health in Bangladesh The Health Promotion and Climate Change unit at the Ministry of Health has brought out two manuals on the health impacts of climate change for high school students and teachers, which have been incorporated in the curriculum. One manual for health professionals including doctors was also produced and used for training them on the impacts of climate change on health. A health impact and vulnerability study and an area-specific baseline survey on the health impact of climate change have been carried out in the coastal areas of Bangladesh. The Health Promotion and Climate Change unit has now started an FM radio station for enhancing the knowledge and information of coastal people including fishermen on the impacts of climate change, and on ways to respond to such impacts.
Lessons learnt 18. Assessments of healthy city initiatives and the application of the concept of basic occupational health services highlighted the importance of the “settings” approach and the opportunities the approach provides for intersectoral work. Collaborative work is not only a requisite for occupational health but also facilitated increased effectiveness. Engaging WHO Collaborating Centres also served to produce better results. 19. Water, sanitation, waste management and hygiene are implemented by various sectors such as urban water and sanitation, rural water and sanitation, ministry of health, municipalities, NGOs, other UN agencies, etc. In the biennium, multisectoral collaboration among various partners helped in implementing the planned activities on time and effectively. Such collaborations will continue and be further strengthened. 20. Developing healthy workplace initiatives and integrating workers’ health into primary health care have been found to be particularly effective. 21. With such a large proportion of workers in the informal sector, it is apparent that strategies focusing on informal sector workers are required. National stakeholder collaboration and established collaborative mechanisms between ministries of health and the environment are key to enabling multisectoral collaboration. 22. WHO’s “1000 Cities 1000 Lives” campaign created a healthy spirit of competition between and among countries and regions, which was reflected in the momentum and success of the campaign.
94
The Work of WHO in the South-East Asia Region
Nutrition, food safety and food security Overview 1. Public health challenges in this area include: malnutrition in all its forms in infants, children, adolescents, adults and the elderly; micronutrient deficiencies, over-nutrition and obesity, food safety and public health implications; and household food insecurity through a life-course, integrated and intersectoral programmatic approach. 2. The main strategy in this area is the Regional Nutrition Strategy: Addressing Malnutrition and Micronutrient Deficiencies (2011-2015). Strategic approaches include establishment and strengthening integrated nutrition and food safety policies and plans of action; adoption of the global strategies on infant and young child feeding, food safety, diet, chronic diseases and health and the global strategy on noncommunicable diseases. They also include SEAR regional nutrition strategy, adoption of WHO Nutrition Guidance Advisory Group (NUGAG) & Inter-agency Standing Committee (IASC) recommendations on malnutrition and micronutrient deficiencies, assistance to Member States to participate in Codex Alimentarius and INFOSAN activities, strengthening capacities of national food analyses laboratories, and development of an evidence-based regional strategy for food safety.
9
Landscape analysis on readiness to act in nutrition A ‘Landscape Analysis’ project initiated by WHO builds on the experiences of Member States in developing and implementing national nutrition plans and policies. The ‘Landscape Analysis’ aims to identify gaps, constraints and opportunities for new and existing effective nutrition actions leading to intersectoral action for improving nutrition. The first analysis in SEAR was undertaken in Timor-Leste jointly by the national health authorities, WHO and UNICEF. The second took place in Indonesia followed by Sri Lanka. Nepal and India have also expressed interest to undertake the “Landscape Analysis”. Overall findings from these exercises indicated that while commitment to promote nutrition of the population exists in Member States, the capacity to act for nutrition needs to be strengthened. Preventive activities related to improved mother, infant and young child nutrition and intersectoral coordination of programme interventions also need to be reinforced. These issues have been articulated along with appropriate interventions in the Regional Nutrition Strategy: Addressing Malnutrition and Micronutrient Deficiencies (2011-2015) which has been shared with Member States. 3. Major stakeholders and partners in this area of work include managers from the national nutrition, child health, food safety, agriculture, veterinary sciences and disease surveillance programmes and international and bilateral organizations – UNICEF, World Food Programme (WFP), Food and Agriculture Organization (FAO), Micronutrient Initiative, International Council for the Control of Iodine Deficiency Disorders (ICCIDD), International Centre for the Control of Diarrhoeal Diseases-Bangladesh (ICDDRB), Global Alliance for Improving Nutrition (GAIN) and WHO Collaborating Centres.
Member States’ achievements and WHO’s contributions Promoting partnerships and coordination for intersectoral actions, increased investment and research 4. Several Member States, some with funding support from WHO, participated at different standard-setting meetings of the Codex Alimentarius
96
The Work of WHO in the South-East Asia Region
Commission. Currently other than one Member State (Thailand), the other ten Member States of the Region are entitled to receive financial support from the Codex Trust Fund. 5. The Regional Office has continued to update the information-base on the national Codex and INFOSAN focal points in SEAR Member States, thereby enabling better identification of national participants for attending the various Codex meetings. Communication with the INFOSAN headquarters and the national INFOSAN focal points continued to be interactive and strong. For example, relevant information from the Fukushima nuclear accident and radionuclide contamination of food was promptly disseminated to all national focal points in Member States. A bi-regional meeting to strengthen information sharing and INFOSAN was also organized. 6. In order to strengthen national capacities to accurately assess environment-related contaminants and foodborne disease outbreaks, the Regional Office arranged training in Bhutan and the Maldives on pesticide residues and heavy metals contamination of food. Equipment and supplies were provided to the national food analyses laboratory in the DPR Korea to improve its functioning. 7. A regional consultation on street foods was organized which enabled a review of the status of safe street foods in Member States, the existing laws and legislation for ensuring safe street foods and the development of road-maps to promote safe street foods in Member States. Concepts and principles of the draft Comprehensive Implementation Plan on Maternal, Infant and Young Child Nutrition prepared by WHO were reviewed at a bi-regional consultation. Promoting community and facilitybased management of children with malnutrition was achieved through partnerships with Member States, bilateral and international partners. Various WHO recommendations on micronutrient deficiencies, malnutrition and diet-related chronic diseases were disseminated to Member States. Six Member States have formulated national food-based dietary guidelines (FBDG), while work continues in the others with technical assistance provided by WHO and partners.
Nutrition, food safety and food security
97
Street foods in Member States are available from a wide range of vendors; safety of street food is a critical issue.
Producing norms and standards for assessment and response to malnutrition, and zoonotic and non-zoonotic foodborne diseases 8. Member States benefited from WHO documents in the formulation of national operating procedures for various interventions. Eight Member States have initiated a plan for the reduction in the incidence of at least one major foodborne zoonotic diseases. 9. Communication materials providing basic information on different aspects of food safety in a simple format were developed for use by the general public. Draft versions were under review in several Member States and by partner agencies. A photograph data-base on food safety was also compiled to assist Member States develop effective communication strategies on food safety. 10. With the establishment of the Nutrition Guidelines Advisory Group (NUGAG) at WHO-HQ, the process of dissemination of guidelines, standards and recommendations is simpler. WHO recommendations on vitamin A supplementation were disseminated to the programme managers of child health and nutrition in Member States. Consensus protocols for the management of severely malnourished children were developed based on WHO guidelines and recommendations. WHO also served as a member of NUGAG and provided assistance in the collation and compilation of Regional-level data.
98
The Work of WHO in the South-East Asia Region
Strengthening monitoring, surveillance, assessment and evaluation of nutrition 11. The global survey on nutrition policies showed that all Member States have established national programmes in four key areas: undernutrition, diet-related chronic diseases, micronutrient deficiencies and infant and young child nutrition. However, the extent of interventions varied among Member States. The growth standards developed by WHO for children under five years have been accepted in ten Member States. Although all Member States monitor national nutrition programmes, comprehensive integrated nutrition surveillance systems do not yet exist in most Member States. 12. Technical assistance was provided to finalize under-five growth charts in Bhutan and DPR Korea. The Regional Nutrition Strategy: Addressing Malnutrition and Micronutrient Deficiencies (2011-2015) was introduced to align with the activities of the comprehensive implementation plan for maternal, infant and young child nutrition in Member States. Support was provided to Sri Lanka to undertake ‘Landscape Analysis’ to map stakeholders in nutrition programme activities (see Box). Indonesia, Sri Lanka and Timor-Leste have undertaken this analysis. The global launch of an electronic library of evidence for nutrition action (eLENA) and the global database on the implementation of nutrition action (GINA), two important sources of information on food and nutrition, took place in the Region.
Developing, strengthening and implementing nutrition plans, policies and programmes 13. All Member States have established a national nutrition policy or plans of action that include programmes covering most aspects of a lifecourse approach. Bangladesh, Bhutan, Maldives, Nepal, Sri Lanka and Timor-Leste also revised or updated their national guidelines dealing with infant and young child nutrition and micronutrient deficiencies emphasizing a multisectoral approach to nutrition programming and support to programmes at the provincial and district levels (Figure 9.1). Nine Member States have functional institutionalized coordination mechanisms
Nutrition, food safety and food security
99
to promote intersectoral approaches and actions in the area of food safety, food security or nutrition. 14. WHO-SEARO contributions included the formulation of a consensus protocol for managing severely malnourished children at hospitalsettings along with a Regional training workshop on managing severe childhood malnutrition. The new WHO recommendations on vitamin A supplementation in different age groups were presented to the national child health programme managers and nutrition programme managers. A technical consultation on hospital nutrition examined the status of nutrition care provided to patients in hospitals. Available information indicated that the quality of nutrition to enhance cure and recovery remained poor in most hospitals of the Region. A key finding of the consultation was the need to establish a nutrition support team at every hospital to ensure the maintenance of proper nutrition to the admitted patients. A technical consultation to review sodium intake among the populations of the WHO South-East Asia Region was organized. The consultation indicated an urgent need to obtain more data on the sodium and salt consumption patterns of the populations of South-East Asia and to develop closer linkages with the national iodine deficiency disorders (IDD) control and prevention programme managers for an effective salt iodization programme using less salt. Figure 9.1: Key nutrition areas in Member States of SEA Region involved in the coordination of policies and programmes
Source: Global Nutrition Policy Review (2010), WHO Geneva.
100
The Work of WHO in the South-East Asia Region
Emphasizing surveillance, prevention and control of zoonotic and non-zoonotic foodborne diseases, food-hazard monitoring and evaluation 15. Infrastructural development of the national food analyses laboratories was undertaken in Bhutan, DPR Korea and Maldives. National capacities to detect pesticide residues in food and other environment-related contaminants was improved in Bhutan and Maldives, while the assessment of burden of diseases from foodborne illnesses was initiated in Thailand. 16. The attention of Member States was drawn to the emerging food safety issues related to street foods and international trade and food safety. The Regional Office continued to update the information-base on the national INFOSAN and Codex Committees.
Setting international standards and developing national food-control systems 17. All Member States have adopted and implemented the WHO Child Growth Standards. A Total Diet Study was undertaken in India while capacity-building for analyses of food contaminants in the food chain was carried out in Bhutan, DPR Korea and Maldives. 18. Member States of the Region were assisted to participate in the first Global and bi-regional INFOSAN meetings. The Regional Office prepared an overview of the national Codex Committees and INFOSAN units. Streamlining the funding process of the Codex Trust Fund and advocacy for additional funding was achieved. Technical networking to strengthen the activities of national INFOSAN and GFN (Global Foodborne Infection Network) units also took place.
Lessons learnt 19. Direct technical input and assistance at country level had a good impact on food legislation, management of severe malnutrition, developing growth charts, food labelling and laboratory training in pesticide analysis. Effective communication with national counterparts and sharing of information with partner agencies reduced overlap of activities and allowed better utilization
Nutrition, food safety and food security
101
of resources. With WHO-HQ coordinating the development of technical guidelines, recommendations and standards, the development of guidelines and standards was streamlined and dissemination became easier. However, the development of guidelines and recommendations on technical issues remains a time-consuming process. Such delays compel Member States to turn to agency-based recommendations and standards. 20. Development of new communication and information materials should exploit existing information and country-specific considerations to make them more cost-effective. As core components of a national food and nutrition policy already exist in all Member States, improving the range and quality of programmes should be possible through the improvement of managerial skills and competencies. Another key lesson is that competing vertical nutrition programmes introduced by international partner agencies can interfere with the activities of the national nutrition programmes. Effective food safety monitoring and surveillance remains a complex task as it involves coordination and collaboration of many stakeholders. 21. Overall, the national food safety programmes in Member States remained compartmentalized with limited collaboration and cooperation between the different sectors. In addition, the domestic food safety programmes were not subjected to appropriate monitoring and enforcement of legislation and laws. The Regional Office needs to continue to support Member States in addressing the ever-increasing public health burden of environment-related contaminants entering the food chain and foodborne illnesses.
102
The Work of WHO in the South-East Asia Region
Health services, governance, financing, staffing and management Overview 1. The diversity of social, political and economic conditions prevailing in Member States of the Region is reflected in their respective health systems. Member States worked to strengthen health systems and meet the challenges posed by the rising burden of noncommunicable diseases, some communicable diseases and inequities in health outcomes. The challenges imposed by climate change as well as natural and man-made disasters and emergencies were also important. Such challenges were exacerbated by health funding constraints and the shortage, maldistribution and inappropriate skills-mix of human resources for health (HRH), particularly in the rural and remote areas. Expenditure on health by Member States of the Region varied from 1.9% to 13.6% of GDP. 2. Salient strategies of relevance to this area of work include the Regional Strategy for Universal Health Coverage, Regional Strategic Plan for Health Workforce Development in the SEA Region, Regional Strategy for Strengthening Health Information Systems and Regional Strategy on Research for Health. Such
10
strategies are intended to strengthen capacity for policy or strategy formulation and health planning including a multisectoral approach to address the socio-cultural determinants of health and strengthen HRH management to increase the availability of public health professionals. More resources for health are also required and there is an urgent need to explore alternative methods of health financing to facilitate universal coverage in which everyone is entitled to a set of health services as per need regardless of the ability to pay. Ensuring good quality, affordable and safe primary care supported by well-functioning referral care is also a priority as is ensuring that health services employ effective and safe technology in health care delivery. Improving access to good quality and safe drugs and medicines for all is also crucial. 3. Major stakeholders and partners in this area or work include the ministries of health, education, planning, finance, planning commissions, GFATM and GAVI, UN agencies and development partners.
Member States’ achievements and WHO’s contributions Improving management and organization of integrated, population-based health-service delivery 4. Countries are implementing health systems strengthening based on primary health care by: focusing on primary care; improving the balance between public health and medical care; improving people-centred care and engaging the private sector for improvement in health services coverage. Increased interest in universal health coverage has been noted. India has produced a comprehensive document on UHC strategy. Some countries received funds from GAVI and the GFATM for health systems strengthening. 5. To improve country capacity for policy dialogue on national policy and strategies Global Learning Programme workshops were conducted in all Member States of the Region. Health systems rapid assessment guidelines, which will be useful for resource mobilization purposes were also finalized.
104
The Work of WHO in the South-East Asia Region
Building national capacity for governance and leadership 6. A regional consultation on Strengthening National Health Planning was convened by WHO in Indonesia. The consultation provided a basis for discussing a framework for assessing national health plans and key gaps in current practices were identified. The following actions were recommended: inclusion of stakeholders beyond the Ministry of Health; accounting for contextual issues beyond health (political, economic and social determinants of health) in national health plans; and use of relevant tools and techniques for evidence-based planning; using national planning more strategically to strengthen leadership of ministries of health in health particularly with ministries of finance; and, strengthening the use of evidence in developing plans including on broader contextual issues (social determinants of health, economic and political). Bhutan, Thailand and Sri Lanka conducted evaluation of progress including implementation of their national health plan, based on a commonly agreed performance assessment of their health system. In collaboration with Mahidol University, WHO-SEARO initiated the development of a training course on essential skills for national health planning including priority setting, costing and impact evaluation. The capacity of WHO country offices was enhanced through a Global Leadership Programme – National Health Policy Strategic Planning (NHPSP) and training modules to build NHPSP capacity in Member States were developed.
Improving coordination mechanisms to achieve national targets for health system development and global health goals 7. Countries enjoying robust donor support have established a coordination mechanism (in Bangladesh, Nepal and Timor-Leste). Countries receiving donor support from GAVI and GFATM have their own specific coordination mechanism. WHO country offices played an important role in improving health coordination efforts at country level.
Strengthening country health information systems 8. Health Information Systems (HIS) and monitoring of MDGs are improving. Bangladesh realigned its HIS national strategies using the
Health services, governance, financing, staffing and management
105
Health Metrics Network (HMN) country assessment reports. India improved the HIS developed under National Rural Health Mission (NRHM). Maldives has fairly good health statistics and monitoring of health-related MDGs that meet agreed standards. The health action plan and progress in MDG achievement is monitored and reported in Sri Lanka. Consultative meetings were held at national and sub-national levels to draft a country HIS policy. Thailand’s health information system focusing on monitoring of quality health care services and health resource mapping was established.
Telemedicine project in DPR Korea Telemedicine is increasingly being used to provide equitable access to high-level medical service for populations in remote and unreachable areas. In view of the geographical characteristics of DPR Korea where 80% of its territory is mountainous, telemedicine is being seen as an optimal solution to bridge the gap. The Ministry of Public Health, in close collaboration with WHO, has embarked on a plan to extend telemedicine in the medical service system on a step-by-step approach. An initial situational assessment on the country’s need and infrastructure readiness was undertaken in November 2007 which was followed by a pilot project in 2008. In 2009, the pilot system was launched in three sites representing the central, provincial and county levels to assess the adaptability and functionality of the system. All monitoring indicators were satisfied. During 2011, through funding provided by WHO-SEARO, technical support and equipment for establishing 60 new sites, for the Central Maternity hospital and upgrading three sites was made possible. Now, all province-level hospitals and 60 county hospitals are connected through the telemedicine system for tele-consultation for diagnosis and treatment of cases whose symptoms are not so common or appropriate to be handled at the provincial level with the central level where highly professional specialists are available. The telemedicine system is also utilized for tele-education through which in-service medical staff are trained or re-trained on advanced technology and scientific developments in the field of medicine by professors and scientists from the central level. Development of a National Policy on Telemedicine and e-Health and study tours for capacity building of national telemedicine program managers and practitioners are being planned for the near future.
106
The Work of WHO in the South-East Asia Region
E-health strategy development and telemedicine have been supported in some Member States.
9. MDG data sheets were updated based on the new monitoring framework and disseminated to countries for concurrence on data. The Health Situation and Trend Assessment (HST)-SEARO website was reviewed and reorganized. Health updates from countries were obtained, collated and published on the HST website. Country MDG reports of the last five years have also been uploaded. The telemedicine project was expanded in DPR Korea and equipment delivered in over 60 county hospitals (see Box). Introduction of the telemedicine project in Bhutan was reviewed and an e-health strategy developed.
Assuring better knowledge and evidence for health decision-making 10. Country profiles with core health data are not yet available in all countries. However, based on the second Global e-health survey in 2009, South-East Asia has the second highest telemedicine potential (50%) after the European Region. Eight Member States have regularly updated databases on numbers and distribution of health facilities and health interventions offered. 11. WHO supported Member States in introducing Global Positioning Systems (GPS), realigning national strategies using the Health Metrics Network and providing e-facilities for health information management.
Health services, governance, financing, staffing and management
107
Mapping and compilation of laboratories in the health sector, strengthening data management capacity and improve quality of health information system, training on verbal autopsy and completion of assessment of the coverage and completeness of the vital registration systems were also supported. In addition, policy support for multi- and intersectoral action, technical advice for strategy development and operational research, and HIS stakeholder meeting and workshops to strengthen the capacity of central and provincial health information units and strengthening capacity of the staff on computerized health information system were focused on.
Strengthening national health research for development of health system 12. Most countries of the Region have established a national body to coordinate health research. In the last biennium, Bhutan, Maldives and Timor-Leste established national research bodies. Countries also established ethical review boards and strengthened research capacity. 13. WHO-SEARO developed a Regional Strategy on Research for Health, endorsed by the 32nd South East Asia Advisory Committee on Health Research. The regional strategy has six Strategic Directions, namely: (a) prioritization on research for health, (b) capacity building on health research, (c) research ethics, (d) enhancing management of research, (e) managing research knowledge to bridge research policy-gap, and (f) monitoring and evaluation on research for health. The 31st and 32nd sessions of the South-East Asia Advisory Committee on Health Research (SEA-ACHR) made recommendations to strengthen research capacity in Bhutan, Maldives and Timor-Leste and to develop benchmarks to measure the progress. In the other eight countries, WHO supported individual capacity building of researchers, institutional capacity building, and promoting networking among health researchers. List of active WHO collaborating centres in the SEA Region (as of 18 April 2012) is in Annex 2.
Developing and implementing knowledge management to strengthen health systems 14. Establishment of new health information portals with equitable access facilitated public awareness in public health. Training in development of information portals and access to information services were organized
108
The Work of WHO in the South-East Asia Region
by Member States of the Region. Four Health InterNetwork Access to Research in Health (HINARI) training workshops for health professionals, health librarians and researchers were conducted in Bhutan, DPR Korea, Sri Lanka, and Timor-Leste. Two portals of national online health journals were developed in Indonesia and Thailand whereas 29 portals on institutional repositories in Bhutan, DPR Korea, Indonesia, Myanmar, Sri Lanka and Thailand have been developed, maintained and sustained. As a result, national health information and literature has become increasingly visible and accessible. Indonesia and Sri Lanka also have eHealth policies, strategies and regulatory frameworks. 15. In support of this work, WHO-SEARO provided technical support mainly in the form of training workshops with hands-on guidelines for sustainable development in information management and dissemination at partner institutions in Bangladesh, Bhutan, DPR Korea, Indonesia, Myanmar, Sri Lanka, Thailand and Timor-Leste. Fellowships and study tours were awarded to Health Literature, Library and Information Services (HELLIS) librarians and policy makers in Bangladesh, Bhutan and DPR Korea. Financial and infrastructural support was also provided whenever feasible.
Strengthening health–workforce information and knowledge 16. Capacity for policy analysis, planning and implementation was enhanced in several countries. National human resources for health (HRH) strategic plans were developed in nine SEAR countries and are under development in Nepal and Timor-Leste. All countries of the Region are aware of the need to improve their HRH information system. In Indonesia and Nepal, with support from the Global Health Workforce Alliance and WHO, active participation of other related sectors in the development of comprehensive national HRH development plans was fostered. Moreover, the education and training of health workers was further strengthened. 17. Technical support was provided to institutionalize quality assurance mechanisms in health professional educational schools (e.g. medical, nursing and paramedical schools) in Bangladesh, DPR Korea and India. Support was also given to further strengthen the capacity of teachers of health professional schools to enable them to provide quality education in Bangladesh, Bhutan, DPR Korea, India, Myanmar, Nepal, Sri Lanka, and
Health services, governance, financing, staffing and management
109
Timor-Leste. The capacity of teachers of traditional medicine in Bhutan was also further developed. Support was given to Bhutan to develop and implement the two-year Bachelor of Public Health programme for experienced health assistants to further build their capacity as well as for their career advancement. Household doctors in DPR Korea, and various categories of community-based health workers (e.g skilled birth attendants, senior assistant health workers, auxilliary nurse-midwives, MCH workers and female community health volunteers) in Nepal were trained.Training programmes and consultations were carried out in Sri Lanka to enhance monitoring and evaluation of HRH, while in Indonesia a help desk for HRH information was established. Standardized competency-based training for a public health course was developed in India. The capacity of the Nepal Medical Council was enhanced to effectively function as the Secretariat of the Network of Medical Councils in the Region. Member States continued to use fellowships for capacity building of their health workforce. During the period under review, 756 awards were issued as per details given in Table 10.1. Table 10.1: Fellowships awarded during the biennium 2010-11 Member State Bangladesh Bhutan DPR Korea India Indonesia Maldives Myanmar Nepal Sri Lanka Thailand Timor-Leste Total Number of fellowships awarded 43 39 185 162 7 48 151 41 67 11 2 756
Source: WHO-SEARO, Department of Health Systems Development, 2012.
18. SEARO accorded high priority to supporting Member States in strengthening their public health infrastructure and workforce. In this regard, WHO advocates the development of more and more public health
110
The Work of WHO in the South-East Asia Region
professionals and thus the emphasis on supporting more training and studies related to public health disciplines. Of the 756 awards issued during 2010-11, 442 (58%) were for study/training in public health vis-à-vis 314 (42%) in clinical areas (Figure 10.1). This highlights the continued efforts of Member States to build capacity and competence in public health. There was an encouraging number of nominations of female candidates for fellowships. Of the 756 candidates who were awarded fellowships during 2010-11, 471 (62%) were males and 285 (38%) females (Figure 10.2). Figure 10.1: Distribution of fellowships – public health discipline vs. clinical area
Figure 10.2: Fellowships awarded – by gender
Source: WHO-SEARO, Department of Health Systems Development, 2012.
Health services, governance, financing, staffing and management
111
19. Support was provided by WHO to strengthen the Nepal Nursing Council and for the accreditation of nursing education. WHO-SEARO also provided continuous technical support to countries in HRH policy development with advocacy and developed a regional guideline for health workforce planning. A training module for development of an HRH strategic plan was developed with a facilitators’ guide. Support was also provided to countries to prepare HRH country profiles to provide sound evidence for informed decisions. A regional meeting on implementation of quality assurance in medical education was also convened.
Supporting production, distribution, skill mix and retention of health workforce 20. Intensified support was provided to strengthen education and training of the health workforce in all countries of the Region, especially those facing an HRH crisis (Bangladesh, Bhutan, India, Indonesia, Myanmar and Nepal). In DPR Korea the model of collaboration between nursing education and services was revisited to improve the quality of nursing education and practice. Support was also given to further strengthen the capacity of teachers of health professional schools to enable them to provide quality education in eight Member States.
Member States are strengthening education and training of the health workforce.
112
The Work of WHO in the South-East Asia Region
Bhutan launches the Bachelor in Public Health course for health assistants A community-based health workforce is the backbone of a PHCbased health system. In Bhutan the trained community-based health assistants have provided primary health care services for years. Over time it was realized that the workload of the health assistants was increasing and becoming more complex. At the same time community expectations were growing. To address this the government decided to help the Health Assistants to upgrade their skills and increase their numbers. A training needs assessment supported by WHO was conducted in February 2009, at the request of the Ministry of Health. It found that health workers lacked skills in leadership, planning and management, critical thinking, problem solving and analytical abilities. The Ministry planned to create a new course for them – a Bachelor in Public Health (BPH), to improve the quality of health care services and to ensure more efficient and effective management. At the same time this additional training and qualification would enhance the image and morale of the workforce and importantly, enhance their career prospects. WHO-SEARO provided technical assistance to the Royal Institute of Health Sciences (RIHS), Bhutan to develop the Bachelor in Public Health programme. Mahidol University, Thailand was requested to assist in curriculum development and the South-East Asia Public Health Network for providing technical support for the programme. WHO supported the faculty of RIHS to build capacity for meeting the teaching and training needs of the programme. In addition, library and IT resources were also strengthened. WHO-SEARO reviewed the curriculum, which was finally validated by the Royal University of Bhutan. The BPH programme, launched in April 2010, is a step towards professionalizing the community-based health workforce and a significant step towards revitalization of primary health care in Bhutan.
Health services, governance, financing, staffing and management
113
21. Support was provided to build the capacity of the National Institute of Health Sciences in Sri Lanka to develop it as a national and regional centre of excellence for education and training of community-based health workers. Research to better understand the issues in health workforce development and management was also supported. Health workforce availability and development needs were assessed and the outcomes were utilized in developing local health plans in Bangladesh. A study of nursing and midwifery education in India was conducted so that appropriate interventions could be taken to increase the production and improve the quality of education. A regional consultation on quality assurance in continuing medical education was organized and countries were urged to organize a national meeting to further disseminate the information. Special attention was given to strengthen the public health workforce. Technical discussions prior to the Sixty-fourth session of the Regional Committee dealt in-depth on how to strengthen the roles of community-based health workers in the context of revitalization of primary health care. Subsequently, the Regional Committee further endorsed the recommendations of the technical discussions to further strengthen the roles of community-based health workers.
Improving health system financing 22. Countries of the Region are adopting different health financing mechanisms and are at different levels in terms of social protection and equity. Significantly, in most countries of the Region, the highest proportion of total health expenditures is from out-of-pocket payments—the most regressive form of health financing, which is associated with high catastrophic spending on health as well as impoverishment. Total health expenditure as a percentage of Gross Domestic Product / Gross National Income (GDP/ GNI) varies from 2.3% (Indonesia and Myanmar) to 13.7% (Timor-Leste), while government health expenditure varies from 7.5% (Myanmar) to 84.6% (DPR Korea) in the Region. Per capita health expenditure (in international dollars / Purchasing Power Parity (PPP) exchange rate) varies from 44 (Bangladesh) to 769 (Maldives) in the Region. 23. WHO-SEARO has been providing support and collaborating with Member States to address and reduce out-of-pocket expenditures. A Health Financing Strategy for the Asia Pacific Region, 2010-2015, was developed. Member States were provided with technical and policy support to raise additional funds for health; to reduce financial barriers to access,
114
The Work of WHO in the South-East Asia Region
and to reduce incidence of financial catastrophe, and impoverishment linked to health payments; or to improve social protection and the efficiency and equity of resource use. Policy briefs were prepared, disseminated and their use supported. These briefs document best practices on revenue-raising, pooling and purchasing, including contracting, provision of interventions and services, and handling of fragmentation in systems associated with vertical programmes and inflow of international funds.
Tracking resources and monitoring the cost and effectiveness of interventions 24. Key tools, norms and standards to guide policy development and implementation were developed and disseminated in eight countries according to expressed need. These included tools for resource tracking and allocation, budgeting, financial management, estimating the economic consequences of disease and social exclusion, organization and efficiency of service delivery, including contracting, or the incidence of financial catastrophe and impoverishment. Six Member States were supported by WHO-SEARO to conduct health systems assessments including health financing assessments. Another key achievement was development of the South-East Asia Regional Strategy for Universal Health Coverage.
Framing health financing policy and interpretation 25. Countries are reviewing their health financing strategies as a key area for improving equity and efficiencies in health for universal health coverage (UHC). Considerable experience has been gained on what has worked and why in extending UHC both within and outside the Region. Member States of the Region requested that these lessons be documented in a systematic manner as a practical guide to framing national policies on UHC through resolution SEA/RC63/R5 at the Sixty-third Session of the Regional Committee for South-East Asia. A draft final document was presented to the Sixty-fourth Session of the Regional Committee and, based on recommendations made, this was finalized for submission to the Sixty-fifth Session of the Regional Committee. 26. Nine Member States were provided support in the formulation of health financing policies and strategies and the interpretation of financial data, or with key information on health expenditures, financing, efficiency and
Health services, governance, financing, staffing and management
115
equity. Capacity building workshops on strategic purchasing for social protection were organized in Bangkok and a regional consultation was held on national health planning.
Enhancing patient safety 27. A strategic framework and package of interventions for strengthening patient safety was adopted in the Region. Maldives launched a national hand hygiene campaign and Thailand piloted a set of research tools for estimating adverse events. Patient safety quality committees were established at national level in India, Indonesia, Sri Lanka, Thailand and Maldives. Bangladesh piloted WHO draft Hand Hygiene Guidelines at Chittagong and started to manufacture alcohol-based hand rub according to WHO formulation. St Stephen’s Hospital in Delhi was a pilot site to introduce the Safe Surgery Checklist. The checklist was also implemented at the All India Institute of Medical Sciences, New Delhi. Patient Safety champions collaborated with the college of general practitioners in Sri Lanka to develop educational materials and patient and provider rights and responsibilities. In India, the Director-General of Health Services established patient safety programmes in all central government hospitals and patient safety concepts were introduced in medical education and training. WHO’s patient safety curriculum guide for medical students was successfully piloted in medical colleges in Nepal and in New Delhi. 28. Documentation of country experiences in the form of reports and case studies was completed during the biennium. Regional workshops on priority topics in patient safety were also organized. Support was provided to several national and sub-national initiatives on 1st and 2nd Challenges Clean Care is Safer Care, Safe Surgery Saves Lives. By the end of 2011, 1052 hospitals in eight SEAR countries had registered with the global “Save Lives: Clean Your Hands” programme.
Lessons learnt 29. Multisectoral improvements to health planning including the involvement of key stakeholders in formulating national health plans can reap benefits to countries’ health development, as shown in Bhutan, Thailand, Sri Lanka and India.The Global e-health survey in which eight
116
The Work of WHO in the South-East Asia Region
countries from the Region participated showed that e-health including m-health (mobile health) has great potential to contribute to improving health systems. Greater collaboration among development partners facilitated provision of coordinated and concerted support to countries to address HRH challenges. Strong government leadership was essential for the success of the programme. 30. Another key lesson is that it is crucial to keep knowledge of information workforces up to date so as to make the best use of emerging technologies and new information resources in response to ever-changing information needs. 31. It is very important to work with ministries of finance and national planning commissions to convince higher level policy makers regarding better financing options to achieve UHC. It is also important to work with local experts and centres of excellence of the Region. 32. Linkages between patient safety activities at the hospital level and health systems strengthening based on PHC need to be strengthened. The patient safety initiatives at national level need to be developed down to district level to improve effective referral care. Patient safety issues also need to be introduced in pre-service and in-service training.
Health services, governance, financing, staffing and management
117
118
The Work of WHO in the South-East Asia Region
Access, quality and use of medical products and technologies Overview 1. Medicines are a fundamental part of health care and a wellcontrolled functional pharmaceutical sector is a pre-requisite for a good health system. Many challenges in this area still persist. There is evidence in the Region that drug policies are often not implemented, drug supply systems are poor, drug quality cannot be assured in the market, drug regulation is weak and irrational use of medicines is rampant. Moreover, few donors are interested in funding this important area. 2. Building infrastructure and capacity within Member State health systems to ensure adequate availability and use of good quality medicines are key areas of WHO’s support. Main strategic approaches of relevance to this area include: the development of an adequate policy framework, development or updating of national essential medicines lists and standard treatment guidelines, provision of technical support to improve drug supply and use and building the capacity of regulatory authorities to regulate medicines and vaccine safety, quality and efficacy.
11
3. Major international partners and stakeholders include WHO Collaborating Centres in Newcastle/Australia on drug policy, Harvard-Boston/USA on drug policy and rational use of medicines and Bureau of Drug and Narcotic Department of Medical Sciences/Thailand on drug quality. Major partners in countries are the drug regulatory authorities and the departments in ministries of health responsible for drug supply. The identification of more potential WHO Collaborating Centres and donors is a major challenge for the next biennium.
Member States’ achievements and WHO’s contributions Supporting access, quality and use of essential medical products and technologies 4. Member States have continued to update their Essential Medicines Lists and standard treatment guidelines and revise their national drug policies with the support of international partners. WHO provided technical support to nine Member States to update Essential Medicines Lists and clinical guidelines, revise national drug policy and to strengthen drug supply and regulation. A situational analysis, as recommended by the Sixty-fourth Session of the Regional Committee (SEA/RC64/R5), was undertaken in seven countries and recommendations for drug policy were formulated.
Member States are improving access, quality and use of essential medical products and technologies
5. Resources made available at country level from international developmental partners such as the GFATM have helped to improve blood
120
The Work of WHO in the South-East Asia Region
transfusion management and strengthen health systems, especially as safe blood is intricately linked with HIV. Support provided by WHO and other actors resulted in ten Member States developing a national policy and legal framework for blood safety. Technical support and advocacy was also provided for improving quality, availability and utilization of safe blood, and strengthening systems for providing quality assured screening of blood for transfusion transmissible infections (HIV, hepatitis B and hepatitis C), improving national blood transfusion services, development and implementation of national blood policy and celebration of World Blood Donor Day (June, 2011) to enhance the voluntary non-remunerated blood donations. 6. WHO undertook a study to examine factors promoting access to technology and innovation in small and medium-sized Indian pharmaceutical, traditional, dental and medical technology enterprises and to identify policy options on technology access, innovation and research & development in these enterprises for sustainable supply of the aforementioned medical products worldwide. Two regional consultations were also organized and a Regional Framework for the Global Strategy and Plan of Action on Public Health, Innovation and Intellectual Property (GSPA) was developed for submission to the Sixty-first World Health Assembly. These consultations outlined inter alia regional and national strategies to promote innovative capacity and management of intellectual property (GSPA elements 3 and 5) to contribute to innovation and promote public health. Countries of the Region are following up on recommendations made in the GSPA as stipulated in World Health Assembly resolution WHA61.21.
Developing and implementing international norms for quality, safety, efficacy and cost-effective use of medical products and technologies 7. Nine Member States from the Region participated in the 14th International Conference of Drug Regulatory Authorities in 2010. ASEAN country drug regulatory authorities continued to work on drug harmonizsation and SAARC countries started to discuss setting up a process whereby drug harmonization may be achieved in South Asia. Member States have also continued to strengthen their drug supply and
Access, quality and use of medical products and technologies
121
regulatory systems with the support of international partners. A first major conference, called the Global Forum on Medical Devices was held in Thailand. The conference enabled Member States in the South-East Asia Region to understand and initiate work for addressing health technology needs and challenges. Technical input was provided to the Ministry of Health and Family Welfare, Government of India on transfer of technology in the India-European Union bilateral free trade agreement. In 7 Member States, the functionality of the national regulatory authorities has been assessed or supported. 8. Thailand is now producing measles vaccine which is pre-qualified for UN procurement increasing significantly the availability of this vaccine from assured quality sources. India in partnership with the Canadian Food and Drugs Authority has significantly strengthened the market authorization procedure through a parallel review of meningococcal vaccine and Thailand did a similar exercise with the Australian FDA for the market authorization of JE vaccine. Indonesia which is also a major source of WHO pre-qualified vaccine is in the process of implementing a quality management system. To the end of the biennium all major vaccine producing countries in SEAR had an assessed and functional NRA. In the non-producing countries significant progress to improve detection and reporting of Adverse Event Following Immunization (AEFI) were achieved. National AEFI committees were constituted and training workshops on AEFI monitoring and causality assessment were conducted in Bangladesh, Bhutan and India. In Bangladesh a major programme was initiated to upgrade the National Control Laboratory to meet requirements aligned with government policy to produce vaccine and drugs. Countries’ capacity to regulate vaccine was greatly enhanced in the Region. There are now a pool of national experts in different aspects of vaccine regulation who actively participate with WHO in the NRA assessments and other NRA capacity building to facilitate training or to participate in “hands-on” training. 9. Approximately US$ 1 million of laboratory equipment and supplies were procured by WHO with funds from the World Bank. WHO conducted a revision of the NRA assessment tool and methodology with experts from low-, middle- and high-income countries. In addition AEFI training material was updated with the participation of post-marketing experts from WHO Regions.
122
The Work of WHO in the South-East Asia Region
Situational analyses of the pharmaceutical sector in seven Member States Selected key findings of the situational analyses were as follows: Over half of all patients with upper respiratory tract infection received antibiotics inappropriately. Public sector use of essential drugs was over 80%-99% in countries where government procured drugs but much less than this in countries with decentralized purchase and only 36%-57% in the private sector. Prescribing by generic name was 54%-90% in the public sector but only 0%-68% in the private sector and less in hospitals as compared to primary care centres. 11%-59% of patients were prescribed vitamins inappropriately (mostly vitamin B complex or multivitamins). All countries in which governments supplied drugs to the public sector complained of stock-outs and were hampered in stock management by manual systems and lack of monitoring. Common solutions identified included: establishing a unit dedicated to promoting rational use of medicines in the ministry of health; monitoring drug use and consumption; establishing an electronic drug inventory system for better stock management; and better resourcing of drug regulatory authorities to regulate the markets.
Promoting scientifically sound and cost – effective use of medical products and technologies by health workers and consumers 10. All Member States were using national lists, updated within the past five years, of essential medicines, vaccines or technologies for public procurement or reimbursement. In July 2010, an intercountry meeting was held in SEARO and attended by nine countries. This meeting recognized the multi-factorial nature of irrational use of medicines and the need for a coordinated health system approach to the problem. It recommended undertaking situational analyses of the pharmaceutical sector in order to develop contextualized, coordinated national action plans to promote rational use of medicines. A situational analysis with a particular focus on
Access, quality and use of medical products and technologies
123
promoting rational use of medicines, as recommended by Regional Committee resolution SEA/RC64/R5, was undertaken in seven SEAR countries and recommendations on how to promote rational use of medicines were made (see above Box). 11. Additional technical support was provided to Member States on how to promote rational use of medicines and in India a project on Better Medicines for Children, funded by the Gates Foundation, was undertaken. Seven SEAR countries participated in the third International Conference on Improving the Use of Medicines and in the intercountry meeting on rational use of medicines. Six countries of the Region participated in the Global Baseline Survey on Medical Devices, first round in 2010. An additional three countries participated in the second round in 2011. 12. Traditional medicine is widely used in all Member States. The main focus of work in the biennium was on sharing information on the use of herbal medicines in primary health care. In collaboration with WHO Country Office, India and Gujarat Ayurved University, a book entitled Traditional Herbal Remedies for Primary Health Care was published. It aims to promote the rational, safe and appropriate use of herbal medicines and mainstreaming of traditionally used herbal remedies. WHO assisted the Ministry of Health, Indonesia, in translation and publication of a book entitled Guidelines for the Use of Herbal Medicines in Family Health Care. In Bhutan, preparation and publication of a monograph on the Use of Traditional Medicine in Primary Health Care was supported. HerbalNet, a WHO website, was established, to promote multi-institutional collaboration in the area of herbal medicine and to also promote the safety, efficacy and quality of herbal medicines by exchanging information on national norms and standards.
Lessons learnt 13. WHO’s technical and financial support are crucial in making progress since few other partners are working in this field. In the area of essential medicines, country visits to undertake situational analyses followed by a national stakeholder workshop to plan future activities worked well especially because the outlay of staff and time was minimal. However, lack of human resources with expertise in pharmaceuticals and a lack of
124
The Work of WHO in the South-East Asia Region
funds at country and regional levels is a major impediment to progress and results in lack of follow-up on recommendations made during the situational analysis. 14. In the area of immunization and vaccine development (IVD), NRA progress was significant to improve standards and comply with international standards for vaccine safety, quality and efficacy. However, sustainable achievement is still fragile. WHO must attempt to better align WHO vaccine pre-qualification requirements and NRA capacity building programmes with priority to pre-qualified vaccine producing countries. In IVD, countries have experienced a significant increase of AEFI reports in the last couple years. This increase although due to improved detection and reporting, has raised unnecessary concerns about vaccine safety. It is critical for WHO, in providing support to countries to also improve detection and reporting of AEFI and build capacity to conduct rigorous and scientific causality assessment of sub-quality standard vaccines.
Access, quality and use of medical products and technologies
125
126
The Work of WHO in the South-East Asia Region
Leadership, governance, partnership and country collaboration Overview 1. This area of work aims to enhance the capacity of the Organization to advance the global health agenda as set out in WHO’s 11th General Programme of Work. 2. During the 2010-2011 biennium, the Regional Office contributed to all four Organization-wide expected results identified in WHO’s Medium-Term Strategic Plan 2008-2013. The key strategic approaches used were: Facilitating the provision of a forum to exchange experiences and continuous dialogue among Member States and to support them to take united positions on health issues of common concern and interest. Strengthening governance through active engagement of Member States in the preparation and conduct of the Regional Committee and other high-level meetings in the Region as well as at the World Health Assembly and the Executive Board. Ensuring documentation of policies and decisions, documenting lessons learnt from Member States and regional experiences and enhancing communication.
12
Building consensus and capacity of Member States for improved engagement within the global development agenda including UN reform, as well as the harmonization and alignment agendas. Promoting and strengthening interregional and interagency cooperation and coordination with the UN system organizations, donor agencies, intergovernmental bodies and regional groups. Conducting a regular and systematic review of the Organization’s policies and encouraging decision-making through an inclusive process.
3. The Regional Office also contributed to WHO-headquarter’s global governance initiatives while intensifying focus on country activities and aligning actions with national and regional priorities identified in the WHO country cooperation strategies (CCS) and reports of regional consultative meetings. Mechanisms have also been established within countries to lead the national heath development agendas through fostering of effective partnerships.
Member States’ achievements and WHO’s contributions Exercising effective leadership and direction of the Organization 4. The Regional Office’s contributions to effective leadership and direction of the Organization have been exercised through enhancement of governance and improved coherence, accountability and synergy of WHO’s work. The Regional Office strengthened WHO’s leadership and management at regional and country levels, while ensuring the Regional Office’s participation in policy dialogue at global level in order to ensure that SEAR challenges, issues and concerns are adequately reflected in global policy directions and guidance. It has also enabled global governing bodies to include and synchronize regional and country priorities with the global health agenda. 5. WHO-SEAR successfully organized meetings of governing bodies, including the Regional Committee and the Sub-committee on Policy and Programme Development and Management (SPPDM) to discuss programme budget and other technical issues. Effective preparation of Member States representatives for these meetings has enabled all countries to adequately contribute to the regional health agenda. 128 The Work of WHO in the South-East Asia Region
6. Briefings organized prior to the session of the Executive Board and the World Health Assembly for representatives of all Member States of the Region helped ensure that issues of relevance to the Region were adequately represented at global governing body meetings. Work over the past biennium also witnessed strengthening of communication, media relations and advocacy between the Organization and its Member States as well as with other development partners through capacity strengthening and utilization of appropriate technology. Contributing to the WHO reform process was another key focus of activity in this area.
Implementing WHO country cooperation strategies 7. WHO-SEAR is in the process of updating several CCSs to ensure alignment with country health challenges and harmonization and alignment with national development plans and the contributions from other development partners. WHO staff in the UNDAF roll-out countries increasingly assumed leadership roles and led the health sector. Countries were supported in their engagement with CCA and UNDAF through the Peer Support Group of the UNDG-Asia Pacific, of which WHO is a member. Country offices were briefed on the UNDAF development process through the dissemination of UNDAF guidelines and procedures including the 2010 UNDAF Guidance for WHO Country Offices, developed by WHO-HQ with the active contribution of SEARO. Four WHO Country Offices reviewed and adjusted their core capacity in accordance with their country cooperation strategy. 8. SEARO also provided WHO country offices and representatives of Member States with training on harmonization and alignment as part of the Global Learning Programme, to help ensure that the health component of the UNDAF is aligned with CCS, and with national development strategies and priorities. In all Member States, WHO is leading or actively engaged in health and development partnership (formal and informal) including in the context of reforms of the United Nations system.
Providing sustained and predictable technical and financial resources for health 9. The 2010-2011 biennium witnessed continued and strengthened collaboration with health development stakeholders including UN system organizations, intergovernmental organizations, regional groups and donor
Leadership, governance, partnership and country collaboration
129
agencies at country and regional levels. In spite of the global financial downturn, Member States of the Region have successfully maintained a steady level of development aid. The two SEAR countries that practise Sector Wide Approach (SWAp), namely Bangladesh and Nepal, were able to further strengthen donor forums, while the only International Partnership (IHP +) country in the Region, Nepal, has been successful in showing improvement towards achievement of MDGs. 10. In an effort to promote regional collaboration for health, and encourage effective and sustainable partnerships between the various stakeholders working in health in the Region, SEARO organized a Conference of Partners for Health in South-East Asia in 2011, which provided highlevel representatives of donor and recipient countries, multilateral and intergovernmental organizations and civil society organizations from Member States, an opportunity to discuss health priorities for the Region, the challenges ahead, and the opportunities for partnering to advance regional health priorities. 11. In order to strengthen opportunities for improved synergy and alignment among the United Nations agencies with regional mandates, WHO has actively engaged in regional coordination mechanisms and initiatives such as the United Nations Development Group Regional Directors Team (UNDG-AP), and the United Nations Economic and Social Commission for Asia and the Pacific (UNESCAP), establishing official responsibilities in 2011 for liaison with ESCAP. 12. The Regional office continued to engage with regional intergovernmental groups including SAARC and ASEAN, with which it agreed, on specific modalities for the implementation of a shared workplan following the signing of an MoU between SEARO, WPRO and ASEAN in 2010. Support was also given to WHO country offices to strengthen coordination and collaboration with development partners and global health partnerships, including the IHP+ in Nepal.
Exchanging and sharing knowledge effectively 13. WHO-SEARO has focused on disseminating essential health knowledge and advocacy material to Member States, health partners and other stakeholders. SEARO has also ensured and further developed the quality of WHO’s documents and publications from the Region and countries
130
The Work of WHO in the South-East Asia Region
during the biennium. It has expanded the distribution of WHO publications through sales and/or free distribution to academia, policy-makers, other health sector stakeholders and the general public, and contributed to the upgrading and updating of health and medical knowledge in the Region through management support and by providing equipment, books and publications, including e-library to Member States and other health stakeholders. As a step to further strengthen the relationship between ministries of health, WHO and the media, WHO adopted a proactive strategy to build the capacity of health experts and the media to communicate and report better on health issues. Nine communication training programmes and seven media workshops were conducted including the participation of 153 ministry of health officials and programme managers, 147 media personnel, 31 UN staff and 60 WHO staff.
Lessons learnt 14. Proactive involvement of all Member States, intense preparation for regional governing body meetings and other briefings for Representatives of Member States attending the Executive Board sessions and the World Health Assembly, have contributed to bringing a regional perspective to these meetings. 15. Building capacity at country level is the key to ensuring effective WHO country presence. Such capacity ensures that the CCSs are designed and planned in full alignment with the health and development agendas of Member States and harmonized with agendas of the UN country team and other development partners. The proactive involvement of governments, stakeholders, national institutions and other partners using an inclusive and a participatory approach during development of CCSs has helped some WHO country offices sharpen the focus of their strategic agendas. 16. Building national capacity as well as WHO’s own capacity at WHO country level is the key to ensuring that national and regional mechanisms are established to provide sustained and predictable technical and financial resources for health on the basis of a common health agenda, that responds to the health needs and priorities of Member States.
Leadership, governance, partnership and country collaboration
131
132
The Work of WHO in the South-East Asia Region
An efficient and effective WHO Overview 1. The purpose of this area of work is to provide services that enable the Organization to execute its work, both in terms of strategic direction and in operational execution of strategic plans. Such work is primarily performed internally by the Organization, or through vendors who provide administrative products and services. 2. One important challenge during the biennium was the implementation of the Global Management System (GSM) and conversion of business processes and data from legacy systems to the new integrated environment. 3. For GSM implementation, a project oversight committee was established, all staff underwent GSM training, and senior management throughout the Region provided a clear commitment to the GSM project and the need for SEAR to fully convert to the new system as quickly as possible. On the administrative side, the Director of Administration and Finance, as well as new managers in four of the administrative units started work at SEARO in 2011 and were obliged to quickly becoming acquainted with regional business practices, culture and priorities. All new managers realigned their respective offices to increase efficiencies and accountability for service delivery to reduce costs wherever feasible.
13
4. The 2012-2013 planning processes begun during the biennium included development of a set of programme proposals based on national and regional health challenges identified in CCS, regional meeting reports, Regional Committee resolutions, and ministerial declarations etc.
Member States’ achievements and WHO’s contributions Planning and monitoring performance, and evaluating results of the Organization’s work 5. Increased Member State involvement in programme planning was achieved through ministry of health engagement in the development of 2012-2013 programme proposals. Improved priority-setting and sharpened focus of CCS were also achieved in some countries. The programme proposals were peer reviewed at a regional meeting and subsequently costed. The programme proposals then provided the foundation for workplan development. The technical workplans were subjected to peer review by respective technical units, while the human resources plans for the 2012-2013 biennium of the 20 Budget Centres were subjected to a comprehensive review by the Regional Office. 6. The implementation of operational plans was subjected to regular technical and financial monitoring. Progress status has been updated within the established time frames for periodic reporting in 94% of all Office Specific Expected Results (OSERs). Detailed reports were prepared in a timely manner, validated, and submitted to WHO-HQ. In-house reviews were arranged to identify areas to improve implementation. Detailed evaluations of specific technical programmes, such as for malaria, were also undertaken. Budget implementation by strategic objective and by budget centre (as on 31 December 2011) is in Annexes 3 and 4.
Achieving sound financial practices and efficient management of financial resources 7. Accounting records were fully reconciled, financial reporting kept current, and sound financial management were improved upon and maintained. Improved income management procedures that were implemented during the biennium are expected to have a positive impact on resource mobilization efforts across the Region.
134
The Work of WHO in the South-East Asia Region
8. Training was provided to country office personnel on sound financial management practices. This helped ensure that country offices achieved 100% reconciliation of financial records. Close monitoring and management of financial transactions of the Region also ensured full and appropriate utilization of funding. Efforts were initiated to establish a compliance office. This office will be tasked with regular monitoring of compliance with financial rules and regulations at country and regional levels, sound business practices, and implementation of audit findings.
Implementing human resource policies and practices 9. Gains recorded in this area during the biennium included increased alignment of staff functions to Organizational work plans and increased efficiencies in hiring personnel. To make recruitment processes simpler, qualitative, time-effective and transparent, selection guidelines were revised with a view to efficiently and effectively implement WHO programme activities. Rosters of experts in different technical and administrative areas were developed to ensure qualitative selection and accelerate the recruitment of temporary staff. Staff profiling exercises were conducted in six country offices, resulted in updating of position descriptions and improved alignment of Organizational structure and staffing to country work plans. 10. Targeted problem-based learning programmes were introduced for development of staff members’ knowledge and skills. WHO-SEARO also developed and implemented staff induction programmes. Ninety-seven percent of all staff complied with the cycle of the Performance Management Development System for the 2011 evaluation cycle. Health promotion and awareness campaigns for WHO personnel were also executed. This increased the ability of staff to learn and get engaged in managing factors that impacted their own health.
Enhancing efficiency and effectiveness of management information systems 11. The technology infrastructure of the Region was upgraded during the biennium. New tools were introduced for knowledge-sharing and evaluations were performed to improve the efficiency and effectiveness of technology services and infrastructure for the next biennium. The GSM was
An efficient and effective WHO
135
also fully rolled out in SEAR during the biennium and all personnel were trained in its use. Outdated infrastructure was updated and service levels for internet access improved. The Regional Information and Communication Technology (ICT) office was also restructured to provide better services, with fewer personnel and a significantly reduced budget.
Efficient functioning of managerial and administrative support services 12. Administrative services for mail delivery and transport were provided in an effective manner. Procurements were conducted in a timely fashion, providing goods and services for support of technical programmes as and when needed. Long-term agreements were established in many offices to reduce procurement processing time and minimize cost escalation of goods. Training of procurement personnel on sound procurement practices and use of GSM was also supported during the biennium. 13. Day-to-day operations for procurement of goods and services were performed smoothly throughout the Region, with competitive procurement conducted regularly as prescribed by the Organization’s rules. Measures were taken at the Regional Office to reduce the environmental impact of the building and its use, such as installation of light sensors and solar panels.
Protecting the well-being and safety of staff 14. Some buildings were upgraded and staff relocated to more appropriate facilities during the biennium. Security evaluations were performed and appropriate measures taken to ensure compliance of all SEAR locations to the UN-established security standards. 15. Various security measures were implemented as a result of evaluations conducted by the Regional Security Officer to ensure compliance with UN security standards. Security evaluations were conducted in five country offices and recommendations made for actions to improve compliance with UN security standards. 16. The responsiveness of building management services to meet the needs of staff for workable space was considered to be good during the biennium.
136
The Work of WHO in the South-East Asia Region
Lessons learnt 17. The collaborative involvement of all staff and the commitment of senior management to implementation of GSM throughout the Region ensured its successful roll-out. Strong involvement of the Regional Budget and Finance Office helped to ensure that the accounting records of all country offices were fully reconciled to the GSM system. Good collaboration among the Budget and Finance, Programme, Planning, Administration and Technical personnel was the key to establishing, reviewing, finalizing and updating the human resources workplans. 18. It was recognized that building renovations or office relocations are needed for more effective WHO space allocations. Improving the environmental footprint of WHO buildings is a lengthy process requiring large investments of staff time and is very costly. 19. As regards programme management, the improved focus on outcomes and outputs during the biennium is a positive development allowing for improved clarity throughout the result chain. A better distinction between these results which are achieved collectively versus those which can be directly attributed to WHO has also been important, especially for monitoring purposes.
An efficient and effective WHO
137
138
The Work of WHO in the South-East Asia Region
Annex 1
List of strategic objectives and Organization-wide expected results
Strategic objective 1 To reduce the health, social and economic burden of communicable diseases 1.1 Policy and technical support provided to Member States in order to maximize equitable access of all people to vaccines of assured quality, including new immunization products and technologies, and to integrate other essential child health interventions with immunization. Effective coordination and support provided in order to achieve certification of poliomyelitis eradication, and destruction, or appropriate containment, of polioviruses, leading to a simultaneous cessation of oral poliomyelitis vaccination globally. Effective coordination and support provided to Member States in order to provide access for all populations to interventions for the prevention, control, elimination and eradication of neglected tropical diseases, including zoonotic diseases. Policy and technical support provided to Member States in order to enhance their capacity to carry out surveillance and monitoring of all communicable diseases of public health importance. New knowledge, intervention tools and strategies that meet priority needs for the prevention and control of communicable diseases developed and validated, with scientists from developing countries increasingly taking the lead in this research. Support provided to Member States in order to achieve the minimum core capacities required by the International Health Regulations (2005) for the establishment and strengthening of alert and response systems for use in epidemics and other public health emergencies of international concern. Member States and the international community equipped to detect, assess, respond to and cope with major epidemic and pandemic-prone diseases (e.g. influenza, meningitis, yellow fever, haemorrhagic fevers, plague and smallpox) through the development and implementation of tools, methodologies, practices, networks and partnerships for prevention, detection, preparedness and intervention. Regional and global capacity coordinated and made rapidly available to Member States for detection, verification, risk assessment and response to epidemics and other public health emergencies of international concern. Effective operations and response by Member States and the international community to declared emergency situations due to epidemic and pandemic-prone diseases.
1.2
1.3
1.4
1.5
1.6
1.7
1.8
1.9
List of strategic objectives and Organization-wide expected results
139
Strategic objective 2 To combat HIV/AIDS, tuberculosis and malaria 2.1 Guidelines, policy, strategy and other tools developed for prevention of, and treatment and care for patients with, HIV/AIDS, tuberculosis and malaria, including innovative approaches for increasing coverage of the interventions among poor people, and hard-to-reach and vulnerable populations. Policy and technical support provided to countries towards expanded gender sensitive delivery of prevention, treatment and care interventions for HIV/AIDS, tuberculosis and malaria, including integrated training and service delivery; wider service-provider networks; and strengthened laboratory capacities and better linkages with other health services, such as those for sexual and reproductive health, maternal, newborn and child health, sexually transmitted infections, nutrition, drug dependence treatment services, respiratory care, neglected diseases and environmental health. Global guidance and technical support provided on policies and programmes in order to promote equitable access to essential medicines, diagnostic tools and health technologies of assured quality for the prevention and treatment of HIV/AIDS, tuberculosis and malaria, and their rational use by prescribers and consumers, and, in order to ensure uninterrupted supplies of diagnostics, safe blood and blood products, injections and other essential health technologies and commodities. Global, regional and national systems for surveillance, evaluation and monitoring strengthened and expanded to keep track of progress towards targets and allocation of resources for HIV/ AIDS, tuberculosis and malaria control and to determine the impact of control efforts and the evolution of drug resistance. Political commitment sustained and mobilization of resources ensured through advocacy and nurturing of partnerships on HIV/AIDS, tuberculosis and malaria at country, regional and global levels; support provided to countries as appropriate to develop or strengthen and implement mechanisms for resource mobilization and utilization and increase the absorption capacity of available resources; and engagement of communities and affected persons increased to maximize the reach and performance of HIV/AIDS, tuberculosis and malaria control programmes. New knowledge, intervention tools and strategies developed and validated to meet priority needs for the prevention and control of HIV/AIDS, tuberculosis and malaria, with scientists from developing countries increasingly taking the lead in this research.
2.2
2.3
2.4
2.5
2.6
Strategic objective 3 To prevent and reduce disease, disability and premature death from chronic noncommunicable diseases, mental disorders, violence and injuries and visual impairment 3.1 Advocacy and support provided to increase political, financial and technical commitment in Member States in order to tackle chronic noncommunicable diseases, mental and behavioural disorders, violence, injuries and disabilities together with visual impairment, including blindness. Guidance and support provided to Member States for the development and implementation of policies, strategies and regulations in respect of chronic noncommunicable diseases, mental
3.2
140
The Work of WHO in the South-East Asia Region
and neurological disorders, violence, injuries and disabilities together with visual impairment, including blindness. 3.3 Improvements made in Member States’ capacity to collect, analyze, disseminate and use data on the magnitude, causes and consequences of chronic noncommunicable diseases, mental and neurological disorders, violence, injuries and disabilities together with visual impairment, including blindness. Improved evidence compiled by WHO on the cost-effectiveness of interventions to tackle chronic noncommunicable diseases, mental and neurological and substance-use disorders, violence, injuries and disabilities together with visual impairment, including blindness. Guidance and support provided to Member States for the preparation and implementation of multisectoral, population-wide programmes to promote mental health, and to prevent mental and behavioural disorders, violence and injuries, together with hearing and visual impairment, including blindness. Guidance and support provided to Member States to improve the ability of their health and social systems to prevent and manage chronic noncommunicable diseases, mental and behavioural disorders, violence, injuries and disabilities together with visual impairment, including blindness.
3.4
3.5
3.6
Strategic objective 4 To reduce morbidity and mortality and improve health during key stages of life, including pregnancy, childbirth, the neonatal period, childhood and adolescence, and improve sexual and reproductive health and promote active and healthy ageing for all individuals 4.1 Support provided to Member States to formulate a comprehensive policy, plan and strategy for scaling up towards universal access to effective interventions in collaboration with other programmes, paying attention to reducing gender inequality and health inequities, providing a continuum of care throughout the life course, integrating service delivery across different levels of the health system and strengthening coordination with civil society and the private sector. National research capacity strengthened as necessary and new evidence, products, technologies, interventions and delivery approaches of global and/or national relevance available to improve maternal, newborn, child and adolescent health, to promote active and healthy ageing, and to improve sexual and reproductive health. Guidelines, approaches and tools for improving maternal care applied at the country level, including technical support provided to Member States for intensified action to ensure skilled care for every pregnant woman and every newborn, through childbirth and the postpartum and postnatal periods, particularly for poor and disadvantaged populations, with progress monitored. Guidelines, approaches and tools for improving neonatal survival and health applied at country level, with technical support provided to Member States for intensified action towards universal coverage, effective interventions and monitoring of progress. Guidelines, approaches and tools for improving child health and development applied at the country level, with technical support provided to Member States for intensified action towards universal coverage of the population with effective interventions and for monitoring progress, taking into consideration international and human-rights norms and standards, notably those stipulated in the Convention on the Rights of the Child.
4.2
4.3
4.4
4.5
List of strategic objectives and Organization-wide expected results
141
4.6
Technical support provided to Member States for the implementation of evidence-based policies and strategies on adolescent health and development, and for the scaling up of a package of prevention, treatment and care interventions in accordance with established standards. Guidelines, approaches and tools made available, with provision of technical support to Member States for accelerated action towards implementing the strategy to accelerate progress towards the attainment of international development goals and targets related to reproductive health, with particular emphasis on ensuring equitable access to good-quality sexual and reproductive health services, particularly in areas of unmet need, and with respect for human rights as they relate to sexual and reproductive health. Guidelines, approaches, tools, and technical assistance provided to Member States for increased advocacy for consideration of ageing as a public health issue, for the development and implementation of policies and programmes aiming at maintaining maximum functional capacity throughout the life course and for the training of health-care providers in approaches that ensure healthy ageing.
4.7
4.8
Strategic objective 5 To reduce the health consequences of emergencies, disasters, crises and conflicts, and minimize their social and economic impact 5.1 Norms and standards developed, capacity built and technical support provided to Member States for the development and strengthening of national emergency preparedness plans and programmes. Norms and standards developed and capacity built to enable Member States to provide timely response to disasters associated with natural hazards and conflict-related crises. Norms and standards developed and capacity built to enable Member States to assess needs and for planning interventions during the transition and recovery phases of conflicts and disasters. Coordinated technical support provided to Member States for communicable disease control in natural disaster and conflict situations. Support provided to Member States for strengthening national preparedness and for establishing alert and response mechanisms for food-safety and environmental health emergencies. Effective communications issued, partnerships formed and coordination developed with other organizations in the United Nations system, governments, local and international nongovernmental organizations, academic institutions and professional associations at the country, regional and global levels. Acute, ongoing and recovery operations implemented in a timely and effective manner.
5.2 5.3
5.4 5.5 5.6
5.7
Strategic objective 6 To promote health and development, and prevent or reduce risk factors for health conditions associated with use of tobacco, alcohol, drugs and other psychoactive substances, unhealthy diets, physical inactivity and unsafe sex 6.1 Advice and support provided to Member States to build their capacity for health promotion across all relevant programmes, and to establish effective multisectoral and multidisciplinary collaborations for promoting health and preventing or reducing major risk factors.
142
The Work of WHO in the South-East Asia Region
6.2
Guidance and support provided in order to strengthen national systems for surveillance of major risk factors through development and validation of frameworks, tools and operating procedures and their dissemination to Member States where a high or increasing burden of death and disability is attributable to these risk factors. Evidence-based and ethical policies, strategies, recommendations, standards and guidelines developed, and technical support provided to Member States with a high or increasing burden of disease and death associated with tobacco use, enabling them to strengthen institutions in order to tackle or prevent the public health problems concerned; support also provided to the Conference of the Parties to the WHO Framework Convention on Tobacco Control for implementation of the provisions of the Convention and development and implementation of protocols and guidelines. Evidence-based and ethical policies, strategies, recommendations, standards and guidelines developed, and technical support provided to Member States with a high or increasing burden of disease or death associated with alcohol, drugs and other psychoactive substance use, enabling them to strengthen institutions in order to combat or prevent the public health problems concerned. Evidence-based and ethical policies, strategies, recommendations, standards and guidelines developed and technical support provided to Member States with a high or increasing burden of disease or death associated with unhealthy diets and physical inactivity, enabling them to strengthen institutions in order to combat or prevent the public health problems concerned. Evidence-based and ethical policies, strategies, interventions, recommendations, standards and guidelines developed and technical support provided to Member States to promote safer sex and strengthen institutions in order to tackle and manage the social and individual consequences of unsafe sex.
6.3
6.4
6.5
6.6
Strategic objective 7 To address the underlying social and economic determinants of health through policies and programmes that enhances health equity and integrates pro-poor, gender responsive, and human rights-based approaches 7.1 Significance of social and economic determinants of health recognized throughout the Organization and incorporated into normative work and technical collaboration with Member States and other partners. Initiative taken by WHO in providing opportunities and means for intersectoral collaboration at national and international levels to address social and economic determinants of health, including understanding and acting upon the public health implications of trade and trade agreements, and to encourage poverty-reduction and sustainable development. Social and economic data relevant to health collected, collated and analyzed on a disaggregated basis (by sex, age, ethnicity, income, and health conditions, such as disease or disability). Ethics- and human rights-based approaches to health promoted within WHO and at national and global levels. Gender analysis and responsive actions incorporated into WHO’s normative work and support provided to Member States for formulation of gender responsive policies and programmes.
7.2
7.3 7.4 7.5
List of strategic objectives and Organization-wide expected results
143
Strategic objective 8 To promote a healthier environment, intensify primary prevention and influence public policies in all sectors so as to address the root causes of environmental threats to health 8.1 Evidence-based assessments made, and norms and standards formulated and updated on major environmental hazards to health (e.g. poor air quality, chemical substances, electromagnetic fields, radon, poor-quality drinking-water and wastewater reuse). Technical support and guidance provided to Member States for the implementation of primary prevention interventions that reduce environmental hazards to health, enhance safety and promote public health, including in specific settings (e.g. workplaces, homes or urban settings) and among vulnerable population groups (e.g. children). Technical assistance and support provided to Member States for strengthening national occupational and environmental health risk management systems, functions and services. Guidance, tools and initiatives created in order to support the health sector in influencing policies in other sectors to allow policies that improve health, the environment and safety to be identified and adopted. Health-sector leadership enhanced for creating a healthier environment and changing policies in all sectors so as to tackle the root causes of environmental threats to health, through means such as responding to emerging and reemerging consequences of development on environmental health and altered patterns of consumption and production and to the damaging effect of evolving technologies. Evidence-based policies, strategies and recommendations developed, and technical support provided to Member States for identifying, preventing and tackling public health problems resulting from climate change.
8.2
8.3 8.4
8.5
8.6
Strategic objective 9 To improve nutrition, food safety and food security, throughout the life-course, and in support of public health and sustainable development 9.1 Partnerships and alliances formed, leadership built and coordination and networking developed with all stakeholders at country, regional and global levels, in order to promote advocacy and communication, stimulate intersectoral actions, increase investment in nutrition, food-safety and food-security interventions, and develop and support a research agenda. Norms, including references, requirements, research priorities, guidelines, training manuals and standards, produced and disseminated to Member States in order to increase their capacity to assess and respond to all forms of malnutrition, and zoonotic and non zoonotic food borne diseases, and to promote healthy dietary practices. Monitoring and surveillance of needs and assessment and evaluation of responses in the area of nutrition and diet-related chronic diseases strengthened, and ability to identify best policy options improved, in stable and emergency situations. Capacity built and support provided to target Member States for the development, strengthening and implementation of nutrition plans, policies and programmes aimed at improving nutrition throughout the life-course, in stable and emergency situations.
9.2
9.3
9.4
144
The Work of WHO in the South-East Asia Region
9.5
Systems for surveillance, prevention and control of zoonotic and non-zoonotic food borne diseases strengthened; food-hazard monitoring and evaluation programmes established and integrated into existing national surveillance systems, and results disseminated to all key players. Capacity built and support provided to Member States, including their participation in international standard-setting in order to increase their ability to assess risk in the areas of zoonotic and non-zoonotic food borne diseases and food safety, and to develop and implement national food control systems, with links to international emergency systems.
9.6
Strategic objective 10 To improve health services through better governance, financing, staffing and management, informed by reliable and accessible evidence and research 10.1 Management and organization of integrated, population-based health-service delivery through public and non public providers and networks improved, reflecting the primary health care strategy, scaling up coverage, equity, quality and safety of personal and population-based health services, and enhancing health outcomes. National capacities for governance and leadership improved through evidence-based policy dialogue, institutional capacity building for policy analysis and development, strategy based health system performance assessment, greater transparency and accountability for performance, and more effective intersectoral collaboration. Coordination of the various mechanisms (including donor assistance) that provide support to Member States in their efforts to achieve national targets for health system development and global health goals improved. Country health-information systems that provide and use high-quality and timely information for health planning and for monitoring progress towards national and major international goals strengthened. Better knowledge and evidence for health decision making assured through consolidation and publication of existing evidence, facilitation of knowledge generation in priority areas, and global leadership in health research policy and coordination, including with regard to ethical conduct. National health research for development of health systems strengthened in the context of regional and international research and engagement of civil society. Knowledge management and e Health policies and strategies developed and implemented in order to strengthen health systems. Health workforce information and knowledge base strengthened, and country capacities for policy analysis, planning, implementation, information sharing and research built up. Technical support provided to Member States, with a focus on those facing severe health workforce difficulties in order to improve the production, distribution, skill mix and retention of the health workforce. Evidence-based policy and technical support provided to Member States in order to improve health-system financing in terms of the availability of funds, social and financial-risk protection, equity, access to services and efficiency of resource use. Norms, standards and measurement tools developed for tracking resources, estimating the economic consequences of illness, and the costs and effects of interventions,
10.2
10.3
10.4
10.5
10.6 10.7 10.8 10.9
10.10
10.11
List of strategic objectives and Organization-wide expected results
145
financial catastrophe, impoverishment, and social exclusion, and their use supported and monitored. 10.12 Steps taken to advocate additional funds for health where necessary; to build capacity in framing of health-financing policy and interpretation and use of financial information; and to stimulate the generation and translation of knowledge to support policy development. Evidence-based norms, standards and measurement tools developed to support Member States to quantify and decrease the level of unsafe health care provided.
10.13
Strategic objective 11 To ensure improved access, quality and use of medical products and technologies 11.1 11.2 Formulation and monitoring of comprehensive national policies on access, quality and use of essential medical products and technologies advocated and supported. International norms, standards and guidelines for the quality, safety, efficacy and cost effective use of medical products and technologies developed and their national and/or regional implementation advocated and supported. Evidence-based policy guidance on promoting scientifically sound and cost-effective use of medical products and technologies by health workers and consumers developed and supported within the Secretariat and regional and national programmes.
11.3
Strategic objective 12 To provide leadership, strengthen governance and foster partnership and collaboration with countries, the United Nations system, and other stakeholders in order to fulfill the mandate of WHO in advancing the global health agenda as set out in the Eleventh General Programme of Work 12.1 12.2 Effective leadership and direction of the Organization exercised through enhancement of governance, and the coherence, accountability and synergy of WHO’s work. Effective WHO country presence established to implement WHO country cooperation strategies that are aligned with Member States’ health and development agendas, and harmonized with the United Nations country team and other development partners. Global health and development mechanisms established to provide more sustained and predictable technical and financial resources for health on the basis of a common health agenda which responds to the health needs and priorities of Member States. Essential multilingual health knowledge and advocacy material made accessible to Member States, health partners and other stakeholders through the effective exchange and sharing of knowledge.
12.3
12.4
146
The Work of WHO in the South-East Asia Region
Strategic objective 13 To develop and sustain WHO as a flexible, learning organization, enabling it to carry out its mandate more efficiently and effectively 13.1 Work of the Organization guided by strategic and operational plans that build on lessons learnt, reflect country needs, are elaborated across the Organization, and used to monitor performance and evaluate results. Sound financial practices and efficient management of financial resources achieved through continuous monitoring and mobilization of resources to ensure the alignment of resources with the programme budgets. Human resource policies and practices in place to attract and retain top talent, promote learning and professional development, manage performance, and foster ethical behaviour. Management strategies, policies and practices in place for information systems, that ensure reliable, secure and cost-effective solutions while meeting the changing needs of the Organization. Managerial and administrative support services necessary for the efficient functioning of the Organization provided in accordance with service-level agreements that emphasize quality and responsiveness. Working environment conducive to the well-being and safety of staff in all locations.
13.2
13.3
13.4
13.5
13.6
List of strategic objectives and Organization-wide expected results
147
Annex 2
List of active WHO collaborating centres in the SEA Region (countrywise)*
Institution name
Title of WHO Collaborating Centres Bangladesh
International Centre for Diarrhoeal Disease Research, Bangladesh (ICDDR) Bangladesh Institute of Research & Rehabilitation in Diabetes, Endocrine & Metabolic Disorders (BIRDEM) National Institute of Preventive and Social Medicine (NIPSOM)
Diarrhoeal Diseases Research Research and Rehabilitation in Diabetes, Endocrine and Metabolic Disorders Training and Development of Public Health Workforce
DPR Korea Institute of Public Health Administration, Ministry of Public Health Development of Primary Health Care at District Level
India National Institute for Research in Reproductive Health, Indian Council of Medical Research (ICMR) Department of Obstetrics and Gynecology, All India Institute of Medical Sciences (AIIMS) Department of Obstetrics and Gynecology, Postgraduate Institute of Medical Education & Research (PGIMER) Radiation Standard Section Health Safety and Environmental Group, Bhabha Atomic Research Centre Dr. Rajendra Prasad Centre for Opthalmic Sciences, All India Institute of Medical Sciences (AIIMS) Research and Training in Reproductive Health Human Reproduction
Research in Human Reproduction Secondary Standard Radiation Dosimetry Prevention of Blindness
*as of 18 April 2012
148
The Work of WHO in the South-East Asia Region
Institution name National Institute of Cholera & Enteric Diseases (NICED), Indian Council of Medical Research (ICMR) National Institute of Occupational Health, Indian Council of Medical Research (ICMR) Vector Control Research Centre (VCRC), Indian Council of Medical Research National Tuberculosis Institute (NTI) Tuberculosis Research Centre Tata Memorial Hospital National Institute of Communicable Diseases (NICD) Centre for Biomedical Engineering, Indian Institute of Technology Aravind Eye Hospital and Post Graduate Institute of Opthalmology, Aravind Eye Care System Department of Food and Nutrition, Faculty of Home Sciences, M. S. University of Baroda National Institute of Nutrition (NIN), Indian Council of Medical Research (ICMR) Genetics Unit, Department of Paediatrics, All India Institute of Medical Sciences (AIIMS) Schizophrenia Research Foundation (SCARF) Epidemiology Division, National Institute of Communicable Diseases (NICD) National Institute of Epidemiology Division of Neonatology, Department of Paediatrics, All India Institute of Medical Sciences (AIIMS) Indian Institute of Health Management and Research Cardiothoracic Centre, All India Institute of Medical Sciences (AIIMS) L.V. Prasad Eye Institute
Title of WHO Collaborating Centres Research and Training on Diarrhoeal Diseases Occupational Health Research and Training in Lympahtic Filariasis and Integrated Methods of Vector Control Tuberculosis Research and Training Tuberculosis Research and Training Cancer Prevention, Screening and Early Detection Rabies Epidemiology Research and Training in Safety Technology Prevention of Blindness Anaemia Control and Diet Related Non-Communicable Diseases Nutrition Science in Primary Health Care Training in Clinical and Laboratory Genetics in Developing Countries Mental Health Research and Training Epidemiology and Training Leprosy Research and Epidemiology Training and Research in Newborn Care District Health System based on Primary Health Care Epidemiology and Prevention of Cardiovascular Diseases Prevention of Blindness
List of active WHO Collaborating Centres in the SEA Region
149
Institution name Prof. M. Viswanathan Diabetes Research Centre, Diabetes Research Centre and M.V. Hospital for Diabetes College of Nursing, Christian Medical College and Hospital National Institute of Nursing, College of Nursing, Post Graduate Institute of Medical Education & Research (PGIMER) Department of Epidemiology, National Institute of Mental Health and NeuroSciences (NIMHANS) Department of Health Services Studies, Tata Institute of Social Sciences Department of Neurovirology, National Institute of Mental Health and Neurosciences (NIMHANS) Regional Medical Research Centre, Indian Council of Medical Research (ICMR) National AIDS Research Institute (NARI), Indian Council of Medical Research (ICMR) Department of Obstetrics and Gynaecology, All Indian Institute of Medical Sciences (AIIMS) Department of Environmental Health Engineering, Sri Ramachandra Medical College and Research Institute National Drug Dependence Treatment Centre, All Indian Institute of Medical Sciences (AIIMS) Society for Applied Studies Postgraduate Institute of Medical Education and Research Dr. Sushila Nayar School of Public Health, Mahatma Gandhi Institute of Medical Sciences Dr Mohan’s Diabetes Specialities Centre Geo-Environmental Management Division, National Eenvironmental Engineering Research Institute
Title of WHO Collaborating Centres Research, Education and Training in Diabetes Nursing and Midwifery Development Nursing and Midwifery Development
Injury Prevention and Safety Promotion Health Policy Research and Training Reference and Research in Rabies Diagnosis, Reference, Research and Training in Leptospirosis HIV Diagnosis and Monitoring of Antiretroviral Human Reproduction Research and Training in Occupational Health and Environmental Health Substance Abuse Research, Community based Action and Programme Development in Child Health Reference and Research on Fungi of Medical Importance Research and Training in Community Based Maternal, Newborn and Child Health Noncommunicable Diseases Prevention and Control Water and Sanitation
150
The Work of WHO in the South-East Asia Region
Institution name Institute of Palliative Medicine Department of Physical Medicine and Rehabilitation, Christian Medical College Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research Central Bureau of Intelligence, Directorate General of Health Services, Ministry of Health & Family Welfare Centre of Community Medicine, AIIMS Trivandrum Institute of Palliative Science (TIPS) National Institute of Virology, Pune
Title of WHO Collaborating Centres Community Participation in Palliative Care and Long Term Care Development of Rehabilitation Technology, Capacity Building and Disability Prevention Research and Capacity Building in Chronic Respiratory Diseases Family of International Classifications Capacity Building and Research in Community-based Non Communicable Diseases Prevention and Control Training and Policy on Acess to Pain Relief Strengthening Capacity for Emerging Infectious Diseases Indonesia
Centre for Family Planning and Reproductive Health, National Family Planning Coordination Board (BKKBN) Department of ENT, Dr. Cipto Mangunkusumo National Hospital, Faculty of Medicine, University of Indonesia
Research and Training in Human Reproduction Prevention of Deafness and Hearing Impairment
Myanmar Department of Medical Research (Lower Myanmar), Ministry of Health University of Nursing, Yangon, Myanmar SAARC Tuberculosis and HIV/AIDS Centre Research and Training on Malaria Nursing and Midwifery Development TB and TB/HIV Research and Training Thailand Urban Environmental and Management Programme, Asian Institute of Technology Department of Obstetrics and Gynaecology, Siriraj Reproductive Health Research Centre, Siriraj Hosptial Bureau of Occupational and Environmental Diseases, Department of Disease Control, Ministry of Public Health Water Supply and Waste Disposal
Research in Human Reproduction
Occupational Health
List of active WHO Collaborating Centres in the SEA Region
151
Institution name Division of Radiation and Medical Devices, Department of Medical Sciences, Ministry of Public Health Department of Obstetrics and Gynaecology, Faculty of Medicine, Chulalongkorn University Drug Dependence Research Centre, Institute of Health Research, Chulalongkorn University Bureau of Drug and Narcotic, Department of Medical Sciences, Ministry of Public Health ASEAN Institute for Health Development, Mahidol University Otological Centre Bangkok Unit, Faculty of Medicine, Mahidol University Medical Education Unit, Faculty of Medicine, Chulalongkorn University Queen Saovabha Memorial Institute, Thai Red Cross Society Institute for Population and Social Research (IPSR), Mahidol University at Salaya Institute of Nutrition, Mahidol University (INMU) Centre for Health Economics, Faculty of Economics, Chulalongkorn University Faculty of Nursing, (Siriraj), Mahidol University Department of Nursing, Faculty of Medicine, Ramathibodi Hospital, Mahidol University Bamrasnaradura Infectious Diseases Institute Queen Sirikit's National Institute of Child Health (Children's Hospital) Bureau of Epidemiology, Ministry of Public Health Saovabha Memorial Institute, Thai Red Cross Society
Title of WHO Collaborating Centres Secondary Standard Radiation Dosimetry Research in Human Reproduction Research and Training in Drug Dependence Quality Assurance of Essential Drugs Primary Health Care Development Prevention of Deafness and Hearing Impairment Medical Education Research on Rabies Pathogenesis and Prevention Research in Human Reproduction Community Nutrition and Food Safety Health Economics Nursing and Midwifery Development Nursing and Midwifery Development Training and Research on HIV/AIDS Clinical Management and Counselling Case Management of Dengue Fever (DF)/Dengue Haemorrhagic Fever (DHF)/Dengue Shock Syndrome (DSS) Field Epidemiology Venomous Snake Toxicology and Research
152
The Work of WHO in the South-East Asia Region
Institution name Trauma and Critical Care Centre, Khon Kaen Regional Hospital Department of Clinical Tropical Medicine, Faculty of Tropical Medicine, Mahidol University Faculty of Nursing, Chiang Mai University National Blood Centre, Thai Red Cross Society Armed Forces Research Institute of Medical Sciences (AFRIMS) Miscellaneous Bacteriology Section, National Institute of Health, Department of Medical Sciences, Ministry of Public Health International Centre for Environmental and Industrial Toxicology, Chulabhorn Research Institute Prosthetics and Orthotics Unit, Sirindhorn National Medical Rehabilitation Centre Bureau of Laboratory Quality Standard, Department of Medical Sciences, Ministry of Public Health Inter-country Centre for Oral Health, Department of Health, Ministry of Public Health Bangkok Biomaterial Centre College of Public Health Sciences, Chulalongkorn University Centre for Research and Training on Gender and Women's Health, Faculty of Nursing, Khon Kaen University, Khon Kaen, Thailand Department of Medicine, Neurovirology Division, Faculty of Medicine, Chulalongkorn University Clinical Epidemiology Unit, Faculty of Medicine, Khon Kaen University
Title of WHO Collaborating Centres Injury Prevention and Safety Promotion Clinical Management of Malaria Nursing and Midwifery Development Training in Blood Transfusion Medicine Diagnostic Reference, Training and Investigation of Emerging Infectious Diseases Antimicrobial Resistance Surveillance and Training Capacity Building and Research in Environmental Health Science and Toxicology Training in Medical Rehabilitation and Prosthetics - Orthotics Strengthening Quality System in Health Laboratory Promoting Community-based Oral Health Models Research and Training in Tissue Banking Research and Training in Public Health Development Research and Training on Gender and Women's health (CRTGWH)
Research and Training on Viral Zoonoses Research Synthesis in Reproductive Health
List of active WHO Collaborating Centres in the SEA Region
153
Annex 3
Budget implementation by strategic objective (as on 31 December 2011) Budget Strategic Ojective Approved budget Funds available Funds available (% of approved budget) 91 77 67 45 54 76 74 86 48 73 69 92 95 78 Utilization (Expenditure plus Encumbrances) 141 855 832 61 208 455 10 026 575 14 744 592 26 834 722 9 063 781 2 945 222 8 647 149 4 658 861 29 835 482 6 187 167 15 020 200 41 460 058 372 488 094 Utilization (% of approved budget) 79 68 66 40 49 71 70 81 48 72 66 91 94 71 Utilization (% of funds available) 86 88 98 90 91 94 94 95 101 98 95 99 99 91
AC 7 348 000 6 520 250 6 611 750 7 664 500 4 262 000 3 627 250 1 088 500 5 419 250 2 073 250 21 234 250 3 330 250 10 255 500 22 353 750 101 788 500
VC 173 129 000 83 158 000 8 667 500 28 838 000 50 292 000 9 114 500 3 132 000 5 221 000 7 557 000 20 431 000 6 065 000 6 187 000 21 792 000 423 584 000
1 2 3 4 5 6 7 8 9 10 11 12 13 Grand Total
180 477 000 89 678 250 15 279 250 36 502 500 54 554 000 12 741 750 4 220 500 10 640 250 9 630 250 41 665 250 9 395 250 16 442 500 44 145 750 525 372 500
164 108 625 69 410 496 10 243 666 16 412 377 29 469 524 9 621 490 3 118 129 9 120 924 4 598 896 30 592 863 6 489 743 15 130 387 41 957 794 410 274 914
154
The Work of WHO in the South-East Asia Region
Annex 4
Budget implementation by budget centre (as on 31 December 2011) Budget Budget Centre AC Bangladesh Bhutan India Indonesia DPR Korea Maldives Myanmar Nepal Sri Lanka Thailand Timor-Leste Country Total Communicable Diseases Administration and Finance Office of Director Programme Management Office of Deputy Regional Director Emergency and Humanitarian Action Family and Community Health Health Systems Development Immunization and Vaccine Development Noncommunicable Diseases and Mental Health Office of Regional Director Sustainable Development and Healthy Environments RO Total Grand Total 10 829 667 2 979 800 13 302 504 9 987 094 4 378 500 3 291 539 7 364 500 8 571 300 5 633 502 6 539 300 2 131 000 75 008 706 3 720 372 4 879 581 VC 28 515 000 3 622 000 111 504 000 41 209 000 31 246 000 2 489 000 38 169 000 24 022 000 7 211 000 11 927 000 5 861 000 Approved budget Funds available Funds available (% of approved budget) 66 60 96 72 57 65 75 76 66 67 60 77 74 101 Utilization Utilization (Expenditure (% of plus Encum- approved brances) budget) 23 562 608 3 880 999 105 024 580 32 362 889 19 751 469 3 774 227 29 811 028 22 719 531 8 386 975 12 131 825 4 663 722 266 069 853 23 834 251 20 521 328 60 59 84 63 55 65 65 70 65 66 58 70 66 99 Utilization (% of funds available) 91 97 88 88 97 100 87 92 98 98 97 90 90 97
39 344 667 6 601 800 124 806 504 51 196 094 35 624 500 5 780 539 45 533 500 32 593 300 12 844 502 18 466 300 7 992 000
25 932 119 3 991 390 119 363 397 36 906 672 20 280 593 3 778 700 34 176 028 24 825 029 8 534 404 12 378 137 4 791 906 294 958 375 26 455 135 21 086 097
305 775 000 380 783 706 32 199 000 15 939 000 35 919 372 20 818 581
848 200
2 467 000
3 315 200
3 014 240
91
2 992 508
90
99
880 900
918 000
1 798 900
1 651 067
92
1 652 817
92
100
454 200
10 747 000
11 201 200
8 563 409
76
6 693 277
60
78
3 479 355
13 102 000
16 581 355
8 449 206
51
8 351 456
50
99
4 588 623 613 250
7 579 000 16 800 000
12 167 623 17 413 250
9 435 357 15 211 391
78 87
9 084 376 13 164 206
75 76
96 87
2 232 822
5 984 000
8 216 822
6 891 174
84
6 471 042
79
94
1 625 700
4 506 000
6 131 700
5 274 831
86
4 648 018
76
88
3 456 791 26 779 794 101 788 500
7 568 000
11 024 791
9 284 632 115 316 539 410 274 914
84 80 78
9 004 962 106 418 241 372 488 094
82 74 71
97 92 91
117 809 000 144 588 794 423 584 000 525 372 500