WORLD HEALTH ORGANIZATION
ORGANISATION MONDIALE DE LA SANTÉ
REGIONAL OFFICE FOR THE WESTERN PACIFIC BUREAU RÉGIONAL DU PACIFIQUE OCCIDENTAL
REGIONAL COMMITTEE Sixty-fourth session Manila, Philippines 21–25 October 2013 Provisional agenda item 15 WPR/RC64/9 5 September 2013 ORIGINAL: ENGLISH
PROGRESS REPORTS ON TECHNICAL PROGRAMMES
As a follow-up to discussions at previous sessions of the WHO Regional Committee for the Western Pacific, progress reports on the following technical programmes and issues are presented in this document: 15.1 Review of health systems strategies 15.2 MDGs 4 and 5: maternal and child health 15.3 HIV/STI prevention and treatment 15.4 Asia Pacific Strategy for Emerging Diseases (2010) and the International Health Regulations (2005) 15.5 Civil registration and vital statistics 15.6 Tuberculosis prevention and control 15.7 Expanded Programme on Immunization 15.8 Malaria and artemisinin resistance. The Regional Committee is requested to note the progress made and the main activities undertaken.
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15.1 REVIEW OF HEALTH SYSTEMS STRATEGIES
1. BACKGROUND AND ISSUES
In collaboration with Member States, the WHO Western Pacific Secretariat has produced regional strategies and action frameworks related to health systems. The strategies cover human resources, health financing, essential medicines, laboratory services, traditional medicine and overall health system strengthening based on the values of primary health care. All the strategies have a common goal—to support health system functioning for progress towards universal health coverage (UHC) and greater equity in health outcomes. UHC is fundamental for achieving the Millennium Development Goals and is emerging as a central component for health in the post-2015 development agenda. To that end, the World Health Assembly in resolution WHA64.9 requested the
Director-General to establish a plan of action for the Secretariat to support Member States in moving towards UHC. The six regional health system strategies outline recommended actions for WHO and Member States, as well as indicators to review progress. Consultations conducted while developing the strategies facilitated setting realistic targets and motivating Member States to implement the strategies towards the achievement of the health-related Millennium Development Goals and sustainable progress on health outcomes and equity.
2. ACTIONS TAKEN
A comprehensive review was conducted to determine how effective the health system strategies and action frameworks have been in supporting countries in health system development. The review included results collected in 10 low- and middle-income countries: Cambodia, China, Fiji, the Lao People’s Democratic Republic, Malaysia, Mongolia, Papua New Guinea, the Philippines, Solomon Islands and Viet Nam. The review focused on four overarching issues: 1. Input by WHO, Member States and partners: A qualitative review of the implementation of actions included in each of the six regional health system strategies. The review also mapped actions by Member States and the WHO Secretariat in response to the Regional Committee resolutions that endorsed the strategies.
WPR/RC64/9 page 3 2. Trends on indicators: Examining data collected over 20 years on key health system performance and health outcome indicators, with disaggregation by social stratifiers, wherever possible, in order to properly examine equity issues. 3. Utility and lessons learnt: The utility of WHO health system strategies and related input to country actions, processes and health outcomes. 4. Future health systems work: An effort to identify emerging and future issues that will require adjustments to health system functioning and how the Secretariat works with Member States in support of UHC for achieving the health-related Millennium Development Goals and in the post-2015 development agenda for improved health outcomes and equity. With UHC as a common goal in strategies since 2008, the Region was ahead of the curve in considering the post-2015 development agenda. Most countries in the Region already include UHC or its components in their national health policies and plans, along with actions proposed in the health system strategies. Key informant interviews indicate that strategies are more likely to be known to policy-makers when WHO has country office staff in place with that specific expertise. interviews also showed that guidance from WHO is generally regarded highly. However, there is neither a systematic record of health systems development work nor a comprehensive overview of such work available for Member States, WHO staff or development partners. This lack of information may slow orientation to country contexts for new staff and consultants. The six regional strategies contain a total of 122 indicators. But data are available for only 85 indicators. The review recommends that the Secretariat reduce the number of core indicators to be most useful to Member States for adequate monitoring of UHC and equity. Monitoring indicators requires robust civil registration and vital statistics (CRVS) for accurate denominators, but CVRS are not strong in many of the 10 review countries. Trends on 33 health system performance indicators are mostly positive, although data are insufficient to adequately monitor equity. Though difficult to set, regional targets for the strategies on health financing and essential medicines have motivated countries to take appropriate action. As a percentage of the total health expenditure, government investment in health has increased and out-of-pocket expenditure has decreased in several countries. In six of the 10 review countries where data are available, however, The
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patients receiving antibiotics at outpatient facilities exceeds the 10% target by a large margin. Seven of the 10 countries report that antibiotics are still available without a prescription; the other three have not reported. In addition to concerns about effective individual treatment and system efficiency, the implications for antimicrobial resistance are worrisome. The demographic, socioeconomic and epidemiological transitions require that health systems engage more fully with all sectors so that health is reflected in all policies and the negative impacts of social determinants of health are mitigated. Furthermore, issues of climate change, food security, financial stability and human health are inseparable. There is a strong case for new organizing principles in working to meet these interconnected challenges. When considering future social risks, health issues feature highly and include unsustainable population growth, mismanagement of population ageing, rising rates of chronic diseases and vulnerability to pandemics. Another risk could be over-reliance on health technologies that are becoming unstable or uncertain, such as antimicrobial medicines, leading to major system and population vulnerabilities such as antimicrobial resistance. A high-level consultation in July 2013 was attended by 25 representatives from 18 Member States to discuss the review findings and summary report. The draft report is attached (Annex 1). The consultation confirmed that the six regional health systems strategies are valued by Member States, and used for evidence-based ideas and bench-marking as well as for advocacy. At the same time, the consultation stressed that strategies are context dependent and countries' own health and development plans, focused on the health of their populations, are of paramount importance. Therefore, all global and regional strategies must be adapted to the context of each country. WHO's work with Member States on health sector development could give more emphasis to a “whole-ofsystem” approach. The evidence base of policy options and technical information is dynamic, and countries request the support of WHO with timely information to stay current. During the consultation
countries emphasized that WHO should be more agile and adaptable in order to help Member States build a resilient health sector in the Western Pacific Region. An important future role for WHO is increased use of information technology to support networks for exchange of knowledge and lessons learnt within and between countries and subregions, such as Pacific island countries and areas, ASEAN, the Mekong countries and high-income countries. This progress report is accompanied by a more detailed report (Annex 1), which covers the review results in greater depth. Work on the review recommendations will contribute to ensuring that health is central to the post-2015 development agenda, as recommended by Member States at the Sixty-sixth World Health Assembly in May 2013.
WPR/RC64/9 page 5 3. ACTIONS PROPOSED
The Regional Committee is requested to note the review results and country progress on universal health coverage and equity in health outcomes. Member States are urged to: improve actions in areas of weakness identified by the review, such as: o o strengthening civil registration and vital statistics consistently collect data disaggregated by social stratifiers on a small set of key indicators to routinely monitor equity in health outcomes o o improving education and distribution of health workforce controlling the use of antimicrobial medicines
adjust the integration of health service delivery towards a seamless continuum of quality care for patients and greater efficiency in the use of health system resources
engage more fully with non-health sectors so that health is reflected in all policies to mitigate the negative impacts of social and environmental determinants of health
engage more fully with non-state sectors in health to harness their potential in contributing to national health objectives while also enacting sufficient controls to mitigate any negative effects on equity.
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15.2 MDG 4 AND 5: MATERNAL AND CHILD HEALTH
1. BACKGROUND AND ISSUES
Resolution WPR/RC58.R2 on Progress towards Achieving the Millennium Development Goals (MDGs), adopted in 2007 at the fifty-eighth session of the WHO Regional Committee for the Western Pacific, urged Member States to strengthen national commitment to achieving the health-related MDGs. The Western Pacific Region has seen improvement in MDG 4, which calls for a reduction in child mortality, and MDG 5, which targets improved maternal health. This progress reflects the commitment and leadership of Member States. With regard to MDG 4, China and Mongolia have achieved the targets, while Cambodia, the Lao People’s Democratic Republic, Malaysia, the Philippines and Viet Nam are likely to reach the targets by 2015. With regard to MDG 5, the maternal mortality ratio (MMR) has decreased in most countries; however, MMRs in the Lao People’s Democratic Republic and Papua New Guinea remain high. At the same time, progress towards MDGs 4 and 5 has been uneven both within countries and across countries in the Region. Member States advised a target of 90% for births attended by skilled attendants at the subnational level in 2020 in the draft Action Plan for Healthy Newborn Infants in the Western Pacific Region (2014-2020). Half of the countries met this target at the national level in 2012. The poorest groups tend to have the lowest access. Universal access to reproductive health has not been achieved. Some 54% of under-five child deaths occurred during the neonatal period (the first 28 days of life) in 2010.
2. ACTIONS TAKEN
2.1
Strengthening political momentum and leveraging wider stakeholder participation by facilitating policy dialogue on women's and children's health The Global Strategy for Women's and Children's Health launched in 2010 by the United
Nations Secretary-General has enhanced the commitment of Member States and development partners to work together on these issues. Following up on the global strategy in collaboration with the H4+
WPR/RC64/9 page 7 partners1 , WHO has been supporting Member States in implementing commitments to advance the global strategy, as well as the recommendations of the Commission on Information and Accountability for Women's and Children's Health. At the Sixty-sixth World Health Assembly in May 2013, resolution WHA66.7 on Implementation of the recommendations of the United Nations Commission on Life-Saving Commodities for Women and Children was endorsed urging countries to improve the quality, supply and use of life-saving commodities for women and children’s health. WHO was requested to work with national, regional and international regulators, H4+ partners, private sector actors and other partners to promote and assure the availability of safe, high-quality commodities. WHO with the Partnership for Maternal, Newborn and Child Health and other partners adopted the Manila Declaration in November 2012 during the Asia-Pacific Leadership and Policy Dialogue for Women's and Children's Health, which brought together ministers and senior officials from 17 countries. 2.2 Strengthening country-led, evidence-based policy-making by providing technical support and guidance In consultation with Member States, the draft Action Plan for Healthy Newborn Infants in the Western Pacific Region (2014–2020) (Annex 2) and the Regional Framework for Reproductive Health in the Western Pacific were developed. Both the action plan and the framework incorporated global and regional recommendations and scientific evidence, including nutrition and health system strengthening and focused on improving coordination among partners. Goals and targets were agreed upon in the action plan for elimination of preventable newborn mortality through the provision of quality early essential newborn care and increased coverage of births by skilled attendants.
3. ACTIONS PROPOSED
The Regional Committee is requested to take note of the progress made and the need to accelerate progress towards achieving MDGs 4 and 5. The Regional Committee is also requested to note the development of the draft Action Plan for Healthy Newborn Infants in the Western Pacific Region (2014–2020) and to urge Member States to implement the action plan. 1
H4+ Partners: Joint United Nations Programme on HIV/AIDS (UNAIDS), United Nations Children’s Fund (UNICEF), United Nations Population Fund (UNFPA), UN Women, WHO and the World Bank.
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15.3 HIV/STI PREVENTION AND TREATMENT
1. BACKGROUND AND ISSUES
The Asia Pacific region ranks second in terms of number of people living with HIV, after sub-Saharan Africa. In the WHO Western Pacific Region, 1.3 million people were living with HIV in 2011. Antiretroviral therapy (ART) is being rapidly scaled up with approximately 50% of people in need receiving treatment (310 000) in 2012, a 16% increase over the previous year (261 000 in 2011). In June 2013 WHO released a new guideline on the use of antiretrovirals for treating and preventing HIV. This will result in more people in need of treatment. Current levels of transmitted HIV drug resistance among previously uninfected individuals infected with a drug-resistant virus appear to be low in this region (<5%). However, as more HIV-positive individuals are maintained on ART for longer periods of time, HIV drug resistance will inevitably increase. The number of new HIV infections in the Region has stabilized. However there is no cause for complacency. HIV prevalence trends are increasing among men who have sex with men. For example, HIV prevalence has increased in this subpopulation from 1.8% in 2009 to 10.6% in Ulaanbaatar, Mongolia, and from 0.6% in 2003 to 16% in 2012 in Chengdu, China. Sudden “outbreaks” of HIV can occur. A recent survey showed a prevalence rate in Cebu, Philippines, of 54% among injecting drug users, compared to 0.59% in 2009. The most recent data available (2008) showed that the Western Pacific Region has the highest number of new cases of curable sexually transmitted infections (STI) in the world. There were 127 million new cases, including 42 million people infected with gonorrhoea, 40 million with chlamydia, 600 000 with syphilis and 46 million with trichomoniasis. At least seven countries in the Region reported syphilis prevalence in pregnancy of over 1%. STIs are major contributors to HIV
transmission, pelvic inflammatory disease, infertility and cervical cancer.
2. ACTIONS TAKEN
In 2013, the Regional Office and country offices facilitated midterm reviews of national HIV health sector strategic plans in Cambodia, Mongolia, Papua New Guinea and the Philippines. These reviews helped Member States adjust their strategic plans and mobilize national and external financial
WPR/RC64/9 page 9 resources, such as from the Global Fund to Fight AIDS, TB and Malaria, to sustain their response to HIV and STI. The Regional Office emphasized advocacy and the development of tools to support implementation of new WHO guidelines for the prevention and treatment of HIV and STI among key populations. A training package called “The Time Has Come” was jointly developed by WHO and the United Nations Development Programme. It provides support for access to services for men who have sex with men and transgender people. Initial steps to address the health needs of transgender people included the preparation of a technical brief, Regional Assessment of HIV, STI and other Health Needs of Transgender People in Asia and the Pacific. China and Malaysia have expanded harm reduction programmes for injecting drug users, resulting in a decrease of new HIV infections in those subpopulations. Efforts are under way to address the HIV and hepatitis C outbreaks among injecting drug users in Cebu, Philippines. Among countries with detention centres for people who use drugs, Malaysia and Viet Nam were the first to phase out compulsory detention in 2012. The new WHO guideline on the use of antiretrovirals for treating and preventing HIV contains new approaches. The Regional Office has engaged the WHO Network for HIV and Health in the Region, which involves WHO collaborating centres and technical partners to support its implementation. Increasing HIV testing rates and referring HIV-infected individuals to treatment and care are priorities. The Regional Office is developing a framework that will include a core set of indicators to monitor and evaluate the benefits of ART in various populations, including its utility in the prevention of mother-to-child transmission and TB/HIV co infections. Moreover, WHO, the United States National Institutes of Health, and Therapeutics Research, Education and AIDS Training in Asia jointly convened a meeting of countries to discuss implementation research to evaluate the prevention benefit of test and treat strategies in Asia. The Asia Pacific Treatment 2.0 Task Force was established to close the treatment gap. Efforts are under way to strengthen STI surveillance in China, Mongolia and Pacific island countries and areas. Several countries in the Western Pacific Region have begun to consider a combined approach for the prevention of paediatric HIV infections and congenital syphilis. China and Viet Nam are including their hepatitis B control efforts as part of a triple (congenital syphilis, paediatric HIV and hepatitis B) elimination initiative with the support of WHO, to benefit from integrated strategies for increasing uptake of screening and interventions.
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3. ACTIONS PROPOSED
The Regional Committee is requested to note the progress achieved and to urge Member States to consider adopting the new WHO guideline on the use of antiretrovirals for treating and preventing HIV. In addition, the Regional Committee is requested to urge Member States to increase efforts to strengthen STI surveillance, as part of a drive to better understand the STI epidemic and reinforce implementation of national STI prevention and control plans. Finally, the Regional Committee is requested to note progress towards the dual elimination efforts of mother-to-child transmission of congenital syphilis and paediatric HIV linked to hepatitis B control efforts.
WPR/RC64/9 page 11 15.4 ASIA PACIFIC STRATEGY FOR EMERGING DISEASES (2010) AND THE INTERNATIONAL HEALTH REGULATIONS (2005)
1. BACKGROUND AND ISSUES
The updated Asia Pacific Strategy for Emerging Diseases or APSED (2010) continues to serve as a regional tool to assist Member States in the Western Pacific Region in developing core capacities required by the International Health Regulations or IHR (2005). Despite good overall progress, a significant number of Member States (14 of 27 States Parties) in the Region requested and were granted two-year extensions of the initial IHR deadline in June 2012 (Annex 3). At the sixty-third session of the WHO Regional Committee for the Western Pacific in September 2012, Member States were urged to accelerate implementation of IHR (2005) through resolution WPR/RC63.R6. The emergence of two new viruses––the avian influenza A(H7N9) and the Middle East Respiratory Syndrome coronavirus or MERS-CoV––clearly indicated health security threats arising from emerging infectious diseases and the continuing need for enhancing national and regional capacities to prepare for and respond effectively to these emerging threats. Rapid and coordinated response to the avian influenza A(H7N9) demonstrated the value of investing in core capacity development under IHR (2005) through the implementation of APSED (2010) in the Region. The next deadline to meet the IHR core capacity requirements is fast approaching. Member States have been advised that further extensions to the 15 June 2014 deadline can only be granted by WHO in exceptional circumstances. Requests for extension must be submitted to the WHO Director-General at least four months before the deadline and must include a new implementation plan. The criteria for extensions in 2014 will be provided to the Executive Board at its 134th session in January 2014. In view of the current technical and financial investments, meeting the deadline of 15 June 2014 remains a significant challenge for some countries.
2. ACTIONS TAKEN
Effective implementation of national workplans is the key to successful achievement of IHR core capacities. Actions have been taken by Member States, WHO and partners to support
implementation of the national workplans and the common regional priority activities for 2012–2013, as recommended by the 2012 Asia Pacific Technical Advisory Group (TAG) Meeting on APSED (2010).
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The results of the 2013 IHR core capacity monitoring questionnaire and the annual progress review at the national and regional level show overall steady progress made towards fulfilling core capacity requirements by Member States. For example, in order to enhance readiness and operational capacity to respond to all acute public health events and emergencies, the process of establishing a functional emergency operations centre (EOC) within the ministry of health has been initiated in a number of countries, including the Lao People's Democratic Republic, Mongolia and Viet Nam. A new external quality assessment (EQA) for dengue and other emerging infectious diseases was established in 2013 in 19 public health laboratories in the Region. National and regional efforts have been made to strengthen IHR core capacities at designated points of entry. Over the past year in the Region, responses to a number of emerging disease outbreaks have been extensive, such as avian influenza A(H5N1) in Cambodia, the more recent avian influenza A(H7N9) in China, and dengue in the Lao People's Democratic Republic and Solomon Islands. The newly upgraded EOC in the WHO Regional Office for the Western Pacific provided a common operational platform to facilitate the coordinated response to these outbreaks in the Region. The Western Pacific Surveillance and Response (WPSAR), an online regional information-sharing journal, was accepted into the widely used biomedical database Medline/PUBMED, and rapid communication on public health events was initiated. The TAG meeting on APSED (2010) continues to serve as an effective regional mechanism to monitor progress and identify common priority activities. At the biregional TAG Meeting in
July 2013, the annual progress report on APSED (2010) implementation was reviewed and further commitments were made towards meeting the IHR core capacity requirements, including strengthening capacities to detect and respond to newly emerging threats, such as avian influenza A(H7N9) and MERS-CoV.
3. ACTIONS PROPOSED
The Regional Committee is requested to take note of this report. Member States are encouraged to provide input on the criteria to be used by the Secretariat when considering requests in 2014 for extensions to the deadline (Annex 4). Member States, WHO and partners should further invest and mobilize technical and financial resources to ensure effective implementation of updated national plans to fulfil the IHR core capacity requirements by June 2014.
WPR/RC64/9 page 13 15.5 CIVIL REGISTRATION AND VITAL STATISTICS
1. BACKGROUND AND ISSUES
Understanding population dynamics and levels, patterns and trends in mortality and causes of death is imperative for identifying emerging health trends and introducing effective public health programmes and policies. Civil registration records are the only effective and efficient source of continuous and universal vital statistics for administrative divisions and local areas, providing information on population, fertility, mortality and health. Civil Registration and Vital Statistics (CRVS) systems use data on the occurrence and characteristics of vital events pertaining to the population, primarily births and deaths, to generate vital statistics, including medically certified cause of death to accurately monitor the burden of diseases. In the Western Pacific Region, support for strengthening CRVS systems is growing not just in health systems but across sectors. CRVS systems have not been appropriately advocated as a crucial source of health data. Potential users must be convinced that there is no substitute for vital statistics derived through a wellfunctioning CRVS system. Multisectoral coordination mechanisms that are functional, sustainable and representative, with clear mandates and responsibilities, are needed to maximize the efficiency, effectiveness, completeness and quality of CRVS systems. Increased advocacy for improving CRVS systems is not sufficient. More investments are needed in CRVS to close the gap between estimation and accurately reporting progress on essentially every health policy, strategy or plan, including the Millennium Development Goals (MDGs) and universal health coverage.
2. ACTIONS TAKEN
Assessment, planning and implementation tools and data quality and analysis resources for CRVS have been developed by WHO in collaboration with the University of Queensland in Australia and implemented in collaboration with development partners. Beginning in 2010, nearly all Member States in the Western Pacific Region have conducted a rapid assessment of their CRVS system with multisectoral engagement by government officials in health, statistics and civil registration. Since 2011, training, implementation and/or completion of comprehensive assessment and planning in CRVS strengthening has occurred in Cambodia, Cook Islands, the Federated States of Micronesia, Fiji, the Lao People’s Democratic Republic, Malaysia, Mongolia, Nauru, Niue, Palau, Papua New
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Guinea, the Philippines, the Marshall Islands, Tonga, Samoa, Solomon Islands, Tokelau, Tuvalu, Vanuatu and Viet Nam. Under the direction of the Commission on Information and Accountability for Women's and Children's Health, and with support of the Health Metrics Network (HMN), WHO collaborated with the United Nations Economic and Social Commission for Asia and the Pacific (UNESCAP), the Secretariat of the Pacific Community (SPC), the United Nations Children’s Fund (UNICEF), the United Nations Population Fund (UNFPA), the University of Queensland and other partners to develop a regional action plan to assist countries in Asia and the Pacific to develop well-functioning CRVS systems by 2020. A subregional consortium of partners, referred to as the Brisbane Accord Group, is providing CRVS technical assistance to Pacific island countries and areas. In December 2012, a high-level interministerial meeting was jointly organized by UNESCAP, WHO and HMN to mobilize greater political will and leadership and issue a call to action for improvements of CRVS systems in Asia and the Pacific. In April 2013, a Global Summit on CRVS was held in Bangkok, Thailand, organized by HMN and WHO to advocate for CRVS as a development agenda priority. The 69th session of UNESCAP in May 2013 adopted a resolution calling for improved CRVS systems. Overall, there has been an acceleration of progress in CRVS strengthening in more than 20 countries in the Western Pacific Region.
3. ACTIONS PROPOSED
The Regional Committee is requested to note the importance of CRVS in achieving better health and the collaboration by regional development partners in recent years to increase visibility and progress in CRVS. The Regional Committee is also requested to consider urging Member States to strengthen efforts to improve their CRVS systems. .
WPR/RC64/9 page 15 15.6 TUBERCULOSIS PREVENTION AND CONTROL
1. BACKGROUND AND ISSUES
In its sixty-first session in 2010, the Regional Committee for the Western Pacific endorsed the Regional Strategy to Stop Tuberculosis in the Western Pacific (2011–2015) through resolution WPR/RC61.R4 as a guide to develop or update national tuberculosis (TB) strategic plans in the Western Pacific Region. The Region is on track to reach the Millennium Development Goal (MDG) targets for TB. Despite the significant progress, there are still 1.4 million people in the Region diagnosed with TB annually. Of that number, 130 000 people die each year from this curable disease. TB tends to concentrate in high-risk and vulnerable populations, such as migrants, the elderly and the poor. TB prevalence surveys, conducted with WHO support, have shown a higher TB burden in recent years than previous WHO estimates. The results illustrate the limitations of current diagnostic methods. Although the HIV burden is relatively low in the Region, HIV mortality is rather high, partially due to co-infection with TB. In addition, drug-resistant TB is on the rise in the Region, with an estimated 78 000 multidrug-resistant TB (MDR-TB) patients added annually and increasing numbers of patients with extensively drug-resistant TB (XDR-TB). The MDR-TB epidemic, which finds its origin in poor treatment practices, is spreading, posing major financial and technical challenges. WHO analysis shows that the vast majority of MDR-TB is found among newly diagnosed TB patients. Thus, strategies that focus on previously treated patients need to be revisited. Such a bold expansion of MDR-TB case-finding is necessary to control the MDR-TB epidemic and ensure a public health impact. Currently, only 6% of the estimated MDR-TB cases have been reported by national TB programmes (see Annex 5).
2. ACTIONS TAKEN
All countries with a high TB burden have aligned their national strategic plans with the Regional Strategy to Stop Tuberculosis in the Western Pacific (2011–2015) and are making progress towards its targets. WHO has supported this process and delivered technical assistance, with a focus on MDR-TB, surveillance, laboratory strengthening, new tools and new strategies for vulnerable groups, and TB/HIV co-infection. WHO organized several training-of-trainers activities in different
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fields to build national capacity and reduce dependency on international consultants. In close consultation with countries, WHO is also developing a guidance document on tuberculosis control in migrant populations. WHO established the Regional Green Light Committee to support countries with the scale up of the programmatic management of drug-resistant TB (PMDT). All high-burden countries received intensified country-based technical assistance and all introduced a novel easy-to-operate MDR-TB diagnostic tool that reduces the time of MDR-TB diagnosis from six to eight weeks to just two hours. Recognizing the important role of the private sector, WHO developed a private sector assessment tool, which was successfully piloted in the Philippines. Furthermore, WHO works with several governments on the responsible introduction of the first new TB drugs in four decades in an attempt to prevent the development of drug resistance.
3. ACTIONS PROPOSED
The Regional Committee is requested to take note of the progress made in TB control and to urge Member States to consider bold investments and actions to sustain current gains and move towards elimination of all forms of TB, while preventing catastrophic expenditures for both patients and health services.
WPR/RC64/9 page 17 15.7 EXPANDED PROGRAMME ON IMMUNIZATION
1. BACKGROUND AND ISSUES
The Western Pacific Region made remarkable progress towards achieving its 2012 measles elimination goal, with a 93% reduction in measles cases between 2008 and 2012 and the likely interruption of endemic measles transmission in 33 countries and areas. However, continued measles transmission in several countries and an increasing number of cases in two countries in 2013 highlight the urgency of achieving and maintaining high levels of measles immunity. The WHO Regional Committee for the Western Pacific in 2012 reaffirmed its commitment to eliminate measles and accelerate rubella control in the Region. Following consultations with Member States from 2010 to 2013, the Regional Verification Commission for Measles Elimination in the Western Pacific Region established the mechanisms to be used to verify measles elimination. Following the 2011 poliomyelitis outbreak in China, the Regional Commission for the Certification of Poliomyelitis Eradication in the Western Pacific Region highlighted the need to improve acute flaccid paralysis (AFP) surveillance in all countries. Papua New Guinea and the Philippines were noted to be at high risk of polio importation. In May 2013, the Sixty-sixth World Health Assembly endorsed the global Polio Eradication and Endgame Strategic Plan 2013–2018 in response to the Health Assembly resolution WHA65.5 on Poliomyelitis: intensification of the global eradication initiative. The global Polio Eradication and Endgame Strategic Plan 2013–2018 outlines parallel implementation of endgame activities to prevent the emergence and circulation of vaccinederived polioviruses. It includes synchronized replacement of attenuated oral poliovirus vaccines type 2 with inactivated poliovirus vaccines to mitigate the risk of vaccine-associated paralytic poliomyelitis in the Western Pacific Region. In October 2012, China validated the elimination of maternal and neonatal tetanus, leaving only four countries in the Western Pacific Region that still need to validate elimination. The Region as a whole and at least 30 countries and areas in the Region will likely reach the 2012 milestone of less than 2% hepatitis B infection prevalence in children. The Sixty-fifth World Health Assembly also endorsed the Global Vaccine Action Plan (GVAP) to reach the goals of the Decade of Vaccines: achieve a world free of poliomyelitis; meet global and regional elimination targets; meet vaccination coverage targets in every region, country and community; introduce new and improved vaccines and technologies; and exceed the MDG 4 target for
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child mortality reduction. The Health Assembly urged Member States to incorporate GVAP into their national health plans, to allocate adequate resources to achieve immunization goals and to report annually to the regional committees on GVAP implementation progress.
2. ACTIONS TAKEN
The Regional Office developed practical strategies and tools and provided training to assist Member States in closing measles immunity gaps, strengthening surveillance and rapidly responding to measles outbreaks. Communications were initiated with Member States to develop a regional implementation plan for the global polio strategic plan. Collaboration with Member States was initiated to develop a regional plan to implement GVAP in the Western Pacific Region.
3. ACTIONS PROPOSED
The Regional Committee is requested to note the progress in measles control and urge Member States with endemic measles virus transmission to implement intensified strategies to interrupt transmission and to take timely action in submitting progress reports on measles elimination and, for those Member States free of endemic measles transmission for at least 36 months, initiate verification processes. In addition, the Regional Committee is requested to note progress in polio eradication and urge Member States to sustain surveillance and, if polio is detected, implement recommended strategies to stop the outbreak within four months, and to consider the need to introduce at least one dose of inactivated poliovirus vaccine by November 2015 and withdraw the oral poliovirus vaccine type 2 by April 2016, and develop national plans for the implementation of the global Polio Eradication and Endgame Strategic Plan 2013–2018. Finally, the Regional Committee is requested to urge Member States to implement GVAP to strengthen national immunization programmes, facilitate introduction of new vaccines and accelerate regional disease elimination initiatives.
WPR/RC64/9 page 19 15.8 MALARIA AND ARTEMISININ RESISTANCE
1. BACKGROUND AND ISSUES
Malaria is endemic in 10 of the 37 countries and areas in the Western Pacific Region. The Regional Action Plan for Malaria Control and Elimination in the Western Pacific (2010–2015) endorsed by the WHO Regional Committee for the Western Pacific in 2009, remains the road map for these countries. The emergence of resistance by Plasmodium falciparum to artemisinin derivatives in the Greater Mekong Subregion (GMS) is now the biggest challenge to malaria control and elimination. Resistance was first confirmed in Cambodia in 2008 and has now also been detected in Myanmar, Thailand and Viet Nam. Artemisinin-based combination therapy (ACT) is partially responsible for the remarkable recent success in reducing the global malaria burden. The emergence of resistant strains of parasites in other regions could jeopardize global malaria control efforts.
2. ACTIONS TAKEN
WHO has been providing support for containment operations in affected countries, starting in 2009 in Cambodia and Thailand and in 2011 in Myanmar and Viet Nam. Major development partners, together with WHO, carried out an assessment of the response to artemisinin resistance in the GMS in 2011–2012. The assessment report became the basis of the Emergency Response to Artemisinin Resistance in the Greater Mekong Subregion: Regional Framework for Action 2013–2015, which was launched on World Malaria Day 2013. The response includes the establishment of a WHO regional hub in Phnom Penh, Cambodia, to support and coordinate containment efforts, with financial support from the Bill & Melinda Gates Foundation and the Australian Agency for International Development (AusAID). In addition, the Global Fund to Fight AIDS, Tuberculosis and Malaria announced the allocation of US$ 100 million to tackle artemisinin resistance over the next three years. WHO currently estimates that at least US$ 300 million to US$ 350 million of additional funding will be required
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between 2013 and 2015 to fully scale up malaria control and containment activities across affected countries. Therapeutic efficacy monitoring for antimalarial medicines has been intensified throughout the Region, including support through the new Pacific Malaria Drug Resistance Monitoring Network, which is modelled on the Mekong network. Malaria programme reviews were conducted or are ongoing in seven countries of the Region. The aim is to facilitate programme reorientation and update national strategic plans, including the response to artemisinin resistance. Intense regional and global advocacy efforts have been undertaken to consolidate political commitment and mobilize resources. Several high-level political undertakings were made in 2012 to support the fight against malaria and artemisinin resistance by the ministers of health of the Association of Southeast Asian Nations (ASEAN); by participants at Malaria 2012: Saving Lives in the Asia-Pacific, held in Sydney, Australia, in October 2012; and through the Declaration of the 7th East Asia Summit on Regional Responses to Malaria Control and Addressing Resistance to Antimalarial Medicines. Artemisinin resistance exemplifies the multisectoral dimension of a public health emergency affecting vulnerable population groups in border areas and beyond. The WHO regional offices for South-East Asia and the Western Pacific convened a high-level Biregional Meeting on Healthy Borders in the Greater Mekong Subregion in Bangkok, Thailand, in August 2013 to analyse the complexities of this multisectoral problem drawing upon the weaknesses in health systems, the inequitable access to health systems for the most vulnerable population groups in border areas, the impact of development projects in health and the need for consolidated action between various relevant sectors beyond health, such as trade, labour and agriculture. This meeting was organized to promote political commitment and collaboration among sectors capable of effective action.
3. ACTIONS PROPOSED
The Regional Committee is requested to note the progress in fight against malaria and artemisinin resistance and to urge Member States to capitalize on unprecedented political commitment to vigorously implement the Emergency Response to Artemisinin Resistance in the Greater Mekong Subregion: Regional Framework for Action 2013–2015.
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Draft Guiding health system development in the Western Pacific Summary of a review on the use and utility of six regional health strategies
WHO Regional Office for the Western Pacific Manila, Philippines
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Contents
Conclusions and Recommendations...........................................................................................27 A. Introduction .........................................................................................................................31 B. Review objectives and methodology......................................................................................33 Objectives .............................................................................................................................33 Methodology in brief.............................................................................................................33
Scope and limitations ..................................................................................................... 35 Economic progress and widening social gaps ................................................................ 36 Demographic transition .................................................................................................. 36 Epidemiological transition .............................................................................................. 37 Box 1. Proportion of deaths in Mongolia, both sexes, all ages, 2010 ............................ 37 Box 2. Universal health coverage and the health system .............................................. 38
C. Context of regional health system development ....................................................................36
D. Future health system challenges ...........................................................................................39 E. Review findings .....................................................................................................................41 E1. Findings on objective 1.....................................................................................................41
1.a Health Care Financing .............................................................................................. 42 Box 3. OOP as % THE 2005 - 2011 .................................................................................. 42 Box 4. Health-care financing expenditure (US$) in China 1995 – 2011 ......................... 42 1.b Access to essential medicines.................................................................................. 43 Box 5. % Outpatients receiving Antibiotics, 2012 .......................................................... 43 1.c Human Resources for Health ................................................................................... 44 Box 6. Skilled Birth Attendance ...................................................................................... 45 1.d Health system performance and health outcomes ................................................. 45 1.e Equity, gender and human rights ............................................................................ 46 1.f Key country actions or events ................................................................................. 46 1.g WHO Secretariat core functions (WHO Secretariat work) ...................................... 47 1.h Resource mobilization for health system development (WHO Secretariat work) .. 47 1.i Initiating global developments (WHO Secretariat work) ........................................ 48 Box 7. Health system levers to reduce maternal mortality in Cambodia ...................... 48 Figure 1. China key country events impacting on health system development ............ 49 Table 1. Snapshot of data on 33 of 47 indicators to monitor health system performance, most recent data from 1994-2003 ............................................ 50 2.a Usefulness of the regional health system strategies to countries ........................... 52 Box 8. Fiji’s aspirations ................................................................................................... 52 Box 9. The Philippines Health Care Financing Strategy .................................................. 54
E2. Findings on objective 2.....................................................................................................52
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2.b Usefulness of the regional health system strategies to WHO regional disease and programme based activities ....................................................................... 55 2.c Usefulness of the regional health system strategies to development partners ....... 55 Table 3. Summary regional health system strategy actions in national health plans .... 57 E3. Findings on objective 3 .................................................................................................... 59
3.a Gaps in “whole-of-system” approaches................................................................... 59 Box 10. “Whole-of-system” approaches ......................................................................... 60 3.b Gaps in guidance on policy options.......................................................................... 60 3.c Gaps in working with non-state and non-health sectors ......................................... 60 3.d Gaps in knowledge management ............................................................................. 61 3.e Gaps in information on strategy indicators ............................................................. 63 Table 4. Number and level of indicators in the six regional health system strategies ... 63 3.f Hospitals neglected .................................................................................................... 64 3.g Gaps in responsiveness to WHA and RCM resolutions ............................................. 64
F. Discussion on findings ........................................................................................................... 65 Framework arising from the Review ...................................................................................... 65 F1. Discussion: Knowledge about the country and context ..................................................... 68
Figure 2. Knowledge and processes for effective technical partnership ........................ 65 1.a 1.b 1.c 1.d Region sets context for the future ........................................................................... 68 Primacy of country context and country plans ........................................................ 68 Accelerate improving country health system trends ............................................... 69 A new country focus for WHO Secretariat’s information ........................................ 70
F2. Discussion: Technical knowledge and learning networks................................................... 71
2.a WHO’s breadth of health knowledge....................................................................... 71 2.b Meeting strategy gaps in future ............................................................................... 71 2.d Knowledge generation and learning networks ........................................................ 72 3.a WHO health system strategies and work valued by countries ................................. 73 3.b Coordinated health system work .............................................................................. 73 3.c Synthesizing health systems work in countries......................................................... 74 Box 11. Knowledge management: An urgent problem................................................... 74 3.d Supporting WHO staff ............................................................................................... 75 3.e Secretariat accountability to the Regional Committee............................................. 75
F3. Discussion: WHO Secretariat processes and work history in countries................................. 73
F4. Discussion: Effective technical partnership ....................................................................... 77 G. Summary of Review findings and implications for WHO ..................................................... 78 Appendices ........................................................................................................................... 83
Appendix 1. Review of Regional Health System Strategies Briefing Paper .................... 85 Appendix 2. Health system strategies Review work and documents ............................. 87 Appendix 3. Context of developing regional health system strategies and frameworks ....................................................................................................... 89 Appendix 4. Main goals, high-level objectives and strategic areas of action in each of the six regional health system strategies .......................................................... 91 Appendix 5. Quotes on UHC from national health plans of 10 Review countries .......... 93
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Appendix 6. Influence of WHO on health system policies or key events (motivation, development or implementation) reported by national Key Informant interviewees ..................................................................................................... 95 Appendix 7. Focus of Western Pacific WHO Regional and country office health system activities by WHO core functions ......................................................... 97 Appendix 8. Partial indication of country health system activities mapped against actions requested of Member States in World Health Assembly and Regional Committee Resolutions related to six regional health system strategies............... 99 Appendix 9. Partial indication of WHO country office health system activities mapped against activities requested of WHO in World Health Assembly and Regional Committee Resolutions related to the six regional health system strategies ......................................................................................................... 101 Appendix 10. Summary of links between WPRO disease programme strategies and six regional health system strategies ............................................................. 103 Appendix 11. Summary of links between strategies of five development partners and concepts in six health system strategies ................................................. 105 Appendix 12. Reference information on indicator fixed points used in Tables 1 and 2 in section E. Review Findings .......................................................................... 107 Appendix 13. Status of 10 Review countries on essential medicines, 2011 baseline .. 111 Appendix 14. Status of 10 Review countries on human resources for health indicators, most recent data from 2004-2011 ............................................... 113 Appendix 15. Status of nine Review countries on health financing indicators ............ 115 Appendix 16. Status of 10 Review countries on indicators recommended in the Traditional Medicine Strategy, 2011 .............................................................. 117 Appendix 17. Status of 10 Review countries on health equity, available data from 1993-2011 (WPRO HIIP and World Bank)....................................................... 119 Appendix 18. Proportion of deaths in the 10 Review countries, 2010 ........................ 123
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Conclusions and Recommendations The six Western Pacific regional health system strategies form a technical knowledge component of effective technical partnership (Figure 2). They are valued and used by Member States for evidence-based ideas, bench-marks and to support advocacy. Trust in the competence of technical staff, and soundness and evidence-base of advice offered, are also critical. Use and utility of the strategies cannot be considered in isolation from the systems and contexts in which they are used. During key informant interviews for this Review, it is WHO staff, rather than the strategies, that are considered most important in assisting progress in health system development. The Review found a general recognition that WHO is trusted by countries as a neutral ally in health sector development. Trust is gained through long-term presence in countries with staff being on hand to respond quickly to requests for support and advice across a wide spectrum of technical areas. The Review found several examples of direct use of the regional strategies in informing development of country health system policies or plans. Further, most of the national health plans of the ten Review countries include many of the recommended actions and principles from the strategies. Whether these are realistic and funded for implementation needs further monitoring that is not yet being undertaken by the WHO health system teams. Some activities requested by the Western Pacific Regional Committee in its resolutions endorsing the regional health system strategies have not been systematically undertaken or recorded by the WHO Secretariat or Member States. More robust monitoring and evaluation of the WHO secretariat health system work and country progress on core health system performance indicators could frame stronger mechanisms of accountability to the Regional Committee. Clearly, the challenges that Member States face in planning and developing health systems that are effective, universal, equitable and sustainable are complex and daunting. Despite this, indicators of health system performance show that many countries are making some progress, for example in increasing government expenditure on health, and reducing out of pocket payments as a percentage of total health expenditure. However insufficient improvements are being made on aspects of drug control that could have devastating consequences with anti-microbial resistance creating even more health problems for the future. Continuing inequities in distribution of health workers have progressively compounding negative effects on health outcomes. All the Review countries need better information disaggregated by key social stratifiers to properly monitor and take action on inequities in health. Although not their intended focus, the six regional health system strategies provide little guidance on integrated services or “whole-of-system” approaches on engaging with non-state sectors in health or with non-health sectors on mitigating negative effects of social and environmental determinants of health. The demographic, socio-economic and epidemiological transitions currently taking place require that health systems engage more fully with all sectors DRAFT REPORT – NOT FOR CIRCULATION OR CITATION – 04 Sept
WPR/RC64/9 page 28 Annex 1 that impact on health. It is becoming increasingly clear that the post-2015 agenda and anticipated challenges in health mean that future approaches to health system development will have to include these critical dimensions. Countries, in partnership with the WHO secretariat, should strengthen their stewardship capacity for working with non-state actors and non-health sectors in moving towards national health objectives. All of this underlines the need for the WHO Secretariat itself to be agile and resilient in order to help Member States build a resilient health sector in the Western Pacific Region. Countries are looking towards WHO to maintain (on their behalf) its leadership in health system development, and to strengthen it for the future. This Review offers many lessons and ideas on how this can be achieved. Faster and more efficient sharing of these lessons and ideas - and indeed of all health information - will depend crucially on Member States and the WHO secretariat together making optimum use of new information technologies. WHO has an essential future role in promoting and supporting a network of knowledge management and exchange within and between countries and subregions, for example Pacific Island countries, ASEAN and the Mekong countries. This summary of the Review has been revised and updated to reflect the discussions and recommendations of a high-level consultation on the Review, held in Manila on 22-24 July 2013 and attended by 25 representatives of 18 Member States as well as WHO secretariat staff. The consultation confirmed that the six regional health systems strategies are valued by Member States, and used for evidence-based ideas, bench-marking and advocacy. At the same time, the consultation stressed that all strategies are context dependent and countries' own health and development plans are of foremost importance to them. Therefore, all global and regional strategies must be adapted to the context of each country. The consultation considered that WHO Secretariat work with Members States on health sector development should support more practical application of “whole-of-system” approaches. The evidence base of policy options and technical information is dynamic, and countries request the WHO Secretariat to support timely availability of information in order that they can stay abreast of advances. During the consultation countries emphasized that the Secretariat should be more agile and adaptable in its efforts to work with Member States in building resilient health sectors in the Western Pacific Region.
Review recommendations for WHO Member States in the Western Pacific Region include: • Take active leadership in implementing national health plans to achieve ambitious though realistic progress on all components necessary for universal health coverage and equity in health outcomes. Progressively integrate health service delivery towards a seamless continuum of quality care for patients and greater efficiency in the use of health system resources – “whole-of-system” approaches. Improve actions in areas of weakness identified by the review, such as: o Strengthening civil registration and vital statistics
•
•
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WPR/RC64/9 page 29 Annex 1 o o o • • Consistently collect data disaggregated by social stratifiers on a small set of key indicators to routinely monitor equity in health outcomes Improving education and distribution of the health workforce Controlling the use of antimicrobial medicines
Engage more fully with non-health sectors so that health is reflected in all policies to mitigate the negative impacts of social and environmental determinants of health. Engage more fully with non-state sectors in health to harness their potential in contributing to national health objectives while also enacting sufficient controls to mitigate any negative effects on health equity.
Review recommendations for the WHO Secretariat in the Western Pacific Region include: A: • • With Member States Put more effort into enhancing countries’ stewardship role in health. Establish and support networks for knowledge generation and rapid sharing of lessons on health system development within and between countries and sub-regions in the Western Pacific. Enhance guidance for countries on contextualization of global and regional health system strategies. Work with countries to engage more fully with non-health and non-state sectors in health. Strengthen guidance for countries on effects of markets and the private sector on health. Support more regular monitoring of country progress on core health system performance indicators, disaggregated by relevant stratifiers. Strengthen WHO’s role in working with middle- and high-income countries on health system issues such as health equity, system efficiency, service quality and patient safety. Internally for the Secretariat New ways of working, better knowledge management, more focus on country plans and implementation. Adjust structure, processes and funding to be more agile and flexible. Strengthen capacity of WHO staff for health systems work, “whole-of-systems approaches”, and working in teams and networks. Improve and synthesize Secretariat knowledge on health system structure and functioning in each country, for use by all WHO staff and consultants. Ensure more regular monitoring and evaluation of WHO’s health system work in the Region. Establish mechanisms for stronger accountability of the Secretariat to the Regional Committee.
• • • • •
B: • • • • • •
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A. Introduction Over the past ten years, and in response to increasing questions and requests for support from countries, the Division of Health Sector Development (DHS) in the WHO Regional Office for the Western Pacific, has developed six health system strategies and action frameworks: • Regional Strategy for Improving Access to Essential Medicines in the Western Pacific Region 2005–2010, followed by Regional Framework for Action on Access to Essential Medicines in the Western Pacific 2011-2016 • Regional Strategy on Human Resources for Health 2006-2015, followed by Human Resources for Health Action Framework for the Western Pacific Region 2011-2015 • Health Financing Strategy for the Asia-Pacific Region 2006-2010, followed by Health Financing Strategy for the Asia-Pacific Region 2010-2015 • Asia Pacific Strategy for Strengthening Health Laboratory Services 2010-2015 • Western Pacific Regional Strategy for Health Systems Based on the Values of Primary Health Care (published 2010) • Regional Strategy for Traditional Medicine in the Western Pacific Region 2011-2020
The main goals, high level objectives, and strategic areas of activity in each of the current six health system strategies are summarised in Appendix 4. The strategies draw on international evidence and practice to guide objectives and actions to reach overarching health goals. They all have universal access or coverage as a goal, objective or principle. Collectively they aim to support health system development for better health, financial risk protection, and health equity in health outcomes all key components of universal health coverage. They are intended for use by WHO Member States, WHO staff and development partners. WHO in the Western Pacific Region was innovative in developing the health system strategies, generally in the absence of global strategies on the same subject (Appendix 3). The Regional Strategy on Human Resources for Health 2006-2015 was written before the World Health Report 2006, Working Together for Health. The first Regional Health Financing Strategy pre-empted the World Health Report 2010. There is no similar global strategy on Health Systems Based on the Values of Primary Health Care, which brings together bringing the details of two separate global documents on health systems 1 and primary health care 2 together into one overall document (TD4). The purpose of the Review from which this Summary Report has emerged was to provide feedback to the Regional Committee on progress in health system development and on the collective use of the strategies in the Region, with an overall health system perspective. There were several reasons for conducting the Review. First, the six health system strategies and frameworks have been endorsed by the Regional Committee for the Western Pacific, which requires progress reports on their use. Also, 1 2
WHO (2007). Everybody’s business: strengthening health systems to improve health outcomes. WHO (2008). World Health Report 2008. Primary Health care: Now More Than Ever.
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WPR/RC64/9 page 32 Annex 1 with the deadline for the Millennium Development Goals (MDGs) approaching and discussion on the post 2015 development agenda gathering momentum, it was felt timely to collectively review the strategies for reporting to the Regional Committee in 2013 (Appendix 1). In addition, the Review has been undertaken in the context of WHO global and regional reforms, which, among other objectives, aims to develop a stronger evaluation culture within the Secretariat. The wide-ranging Review has been conducted over the past year (since mid-2012), to assess the utility of the six regional strategies and action frameworks to Member States and partners across the Region. The Review also considers the history and status of the countries’ health system development, and likely future health system challenges.The countries involved were: Cambodia, China, Fiji, Lao PDR, Malaysia, Mongolia, Papua New Guinea, the Philippines, Solomon Islands and Viet Nam. An important aspect of this Review is the degree to which it gives voice to the views and concerns of senior national officials involved in the health sector, through 61 key informant interviews (KII), a rich source of insights. These interviews were conducted in eight of the ten Review countries. The aim was to gather information on the utility of WHO’s regional health system strategies from those most closely involved in country level health system policies and development processes. Ten senior WHO staff and 12 representatives from development partner organizations in the Western Pacific Region were also interviewed on their experience of policy dialogue and system development. This Summary Report presents the key findings of this extensive process, which is reported in full in the companion Technical Report. Based on consolidated findings and the high-level consultation held with 18 WHO Western Pacific Member States and Secretariat staff, this summary report also outlines some recommendations regarding possible "next steps" for both Member States and the Secretariat. By considering the use and usefulness of the strategies – and the regional health system context for which they have been developed – the Review provides a wealth of observations that Western Pacific Member States can use to strengthen their own health system development in order to meet the health challenges of the coming decades. In addition to the main body of this Summary Report, the appendices are offered as a valuable resource for Member States, partners and a wider readership. There are 18 appendices which give background to the basis and context of developing the strategies, their main goals, high-level objectives and strategic areas of action. The appendices also provide information on the status of the ten countries in the Review on essential medicines, health financing, human resources, traditional medicine and health equity indicators. In addition they show the proportion of deaths in the ten countries due to communicable diseases, noncommunicable diseases, and injuries. Tables 1 and 2 show country status on health system performance indicators across two time periods, including life expectancy, maternal and under-5 mortality, HIV and tuberculosis prevalence, alcohol consumption, tobacco use and out-ofpocket payments at the point of care. This summary of the Review has been revised and updated to reflect the discussions and recommendations of a high-level consultation on the Review, held in Manila on 22-24 July 2013 and attended by 25 representatives of 18 Member States as well as WHO secretariat staff.
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B. Review objectives and methodology Objectives The Review has had four main objectives that involve looking back and looking forward: 1. Review implementation of key policies and programmes related to the six regional health system strategies by countries, WHO and partners; 2. Assess the usefulness of the six Western Pacific Region health system strategies to countries, WHO and partners; 3. Identify gaps and future needs to inform appropriate Western Pacific Region health system development approaches ; and 4. Identify major lessons learnt regarding WHO support to health system development. The Review encompasses WHO, Member States and development partner activity relating to the areas of health system development covered by six Regional strategies: • Regional Framework for Action on Access to Essential Medicines in the Western Pacific 2011-2016 • Regional Strategy on Human Resources for Health 2006-2015, and Human Resources for Health Action Framework for the Western Pacific Region 2011-2015 • Health Financing Strategy for the Asia-Pacific Region 2010-2015 • Asia Pacific Strategy for Strengthening Health Laboratory Services 2010-2015 • Western Pacific Regional Strategy for Health Systems Based on the Values of Primary Health Care (published 2010) • Regional Strategy for Traditional Medicine in the Western Pacific Region 2011-2020 The Review takes a collective sector-wide view of the six health system strategies and activity relating to them. It was not the intention of the Review to assess the strategies individually or to arrive at recommendations relating to individual strategies.
Methodology in brief This was a mixed methods review, conducted in a pragmatic and iterative manner over a period of one year. It has been conducted with the active collaboration of Member States, development partners and WHO staff in regional and country offices. The Review also benefitted from the support, direction and oversight of a Steering Committee which comprised independent health system and evaluation experts drawn from across and outside the Region (TD1). 3 Methods of data collection, collation, synthesis and analysis, along with key limitations, are described in full in the Technical Report. The Review retrospective reference period is July 2004 to June 2012, the former date being the earliest introduction of any of the six WHO Regional Strategies. The prospective reference period for looking forward extends to around 2020.
3
(All numbers in italics and brackets throughout the text refer to numbered technical documents listed in Appendix 2.)
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WPR/RC64/9 page 34 Annex 1 Three linked dimensions guided the Review’s data collection and processes: 1. assessment of health sector development activities by WHO, countries and development partners; 2. assessment of health system performance and health outcome indicators from 1995 onwards in order to consider trends before and after regional and national strategy implementation; and 3. assessment of utility and implementation of the regional strategies, and identifying lessons learned and issues for the future. Ten low- and middle-income Member States in the Western Pacific Region were involved: Cambodia, China, Fiji, Lao PDR, Malaysia, Mongolia, Papua New Guinea, Philippines, Solomon Islands and Viet Nam. The countries were selected to represent the range of size and of economic and health system development in the Region. Methods for individual review elements included: desk review and analysis of relevant documentary sources (including WHO sources, national strategies and policy sources); key informant interviews (with national officials and health system personnel, development partners and WHO staff); extensive dialogue with relevant Western Pacific Region technical units; collation and analysis of indicator data (principally from the WHO World Health Statistics and Global Health Observatory, with other data sources used where appropriate). In order to elicit the richest information possible, the interviews considered policy and health system development in its broadest sense encompassing the health system strategies rather than focusing on them directly. Strategies and related work were considered on characteristics such as relevance, coherence, technical quality, usefulness, and sensitivity to local context. Evidence was synthesized and analyzed using methods designed to provide information and observations to fulfill the Review’s objectives. Observations drawn from these analyses were then combined to arrive at overall observations. Several research approaches have been adopted to ensure that the Review and its observations are as robust as possible. The Review process has at all stages been transparent, and all documents and raw data are available, though with confidentiality protected. The wide range of data sources allow for triangulation of the evidence, and where observations are supported by more than one source and type of evidence this is recorded explicitly. Gathering, synthesis and interpretation of evidence have been conducted by more than one researcher, usually working independently. Raw data and reports resulting from finished work strands have been independently reviewed and observations checked by members of the Review Steering Committee. A premise of the Review was that much of the information needed to answer the Review questions, particularly on strategy implementation, and previous health system work in countries, ought to have been readily available from the WHO Secretariat itself. However generally, this was not the case. The Draft Summary Report was reviewed at a high level consultation in Manila in July 2013 attended by 25 representatives from 18 Member States, eight WHO country office health system staff, six members of the Steering Committee, the Review team and many other Secretariat staff. The draft was subsequently revised as suggested by the consultation.
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Scope and limitations Several limitations in the Review’s scope and methodologies must be acknowledged. No high-income countries were included, which affects the ability of the Review’s analyses to consider differences between these and low- and middle-income countries. However, representatives from New Zealand, Japan and South Korea attended the High Level Consultation and commented on the Review and its findings. The two Pacific Island countries included in the Review, Fiji (multi-ethnic) and Solomon Islands (predominantly Melanesian) are not representative of Polynesian or Micronesian Pacific Island countries. On the advice of the Steering Committee at the outset, the Review has focused primarily on the regional strategies and frameworks on Essential Medicines, Health Care Financing, Human Resources for Health and Health Systems based on the Values of Primary Health Care, and less on Laboratory Services and Traditional Medicines. However, the latter are included in the strategy content analysis, and analyses of national health plans and strategy indicators. Much of WHO’s work on policy dialogue and influence is not easily measured or recorded. In other areas, inadequate and inconsistent WHO Secretariat recording practices, and staff shortages and turnover, especially in WHO country offices, limited the ability of the Review to assess health system development activities comprehensively in the ten countries. These issues contributed to the development of the framework in Figure 2. Identification of interviewees – national key informants and WHO and development partner staff – was purposeful, with the aim of interviewing knowledgeable people in order to elicit information of value to the Review. Selection was necessarily opportunistic to some extent, because the calibre of personnel sought meant that they were not always easily available for interview. These factors could be considered to have introduced some selection bias. The relatively limited numbers of interviewees, a result of resource and time limitations, may limit the strength of the evidence gathered. The date of latest data available for health system performance indicators varies from indicator to indicator and country to country. In addition, aggregated data have been used in the analysis, which can mask health inequity in service provision, access and use. The Review does not, and cannot, provide any attribution of links between the regional strategies and national health outcomes.
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C. Context of regional health system development The Western Pacific Region is home to approximately 1.6 billion people, around 28% of the world's population. One of the most diverse of the WHO regions, the Western Pacific has the largest continental country (China) and smallest island country (Niue) in the world, as well as some of the leastdeveloped nations and the most rapidly-emerging economies. It includes highly-developed countries such as Australia, Japan, New Zealand, the Republic of Korea and Singapore; and fast-growing economies such as China, Mongolia, the Philippines and Viet Nam. Challenges that are evident globally are also seen across the Western Pacific, where changes are unfolding with equal, if not greater momentum. Spurred in recent years by political reforms and dynamic economic development, most of the Region’s Member States that were formerly classified as low-income countries are now graduating to middle-income countries. 4 For example, in 2010, Viet Nam advanced from a low-income to a lower middle-income country status, with an annual average growth rate of 7.3% and a per capita income that has increased fourfold in the last twenty years. 5 Economic progress and widening social gaps Economic progress has had significant health benefits for the populations concerned. Although the Region has been less severely impacted by the recession and austerity measures required in many countries, notably in Europe, progress is unequally spread within and between countries, with rural and vulnerable groups being left behind. Health gaps between the richer and poorer sections of societies are growing ever wider. Large numbers of poor people are faced with difficult situation when illness strikes – they have little or no access to formal health care as they cannot afford to pay for it; or if they do manage to pay for it, and have no financial protection, they are faced with further descent into poverty. Inequity in access and in health outcomes is associated with social determinants of health such as nutrition, housing, geographical location, education, income, sex, gender and age. Persisting health inequities in many Western Pacific countries explain why the goal of universal health coverage (Box 2) is essential, and why it is receiving increasing attention and support. Demographic transition Demographics are also changing, with increasing life expectancies and growing proportions of elderly people. Regionally, overall life expectancy at birth for both men and women rose from 70 years in 1990 to 76 years in 2011.6 The increase in the proportion of people aged over 60 years is especially rapid in low- and middle-income countries. For example, while Japan, Australia and New Zealand took five decades to double their ageing population from 7% to 14%, Cambodia, Lao People’s Democratic Republic and Papua New Guinea are projected to achieve the same increase in less than 30 years. In 2010, 77% of the 235 million people aged 60 years and above in the Region lived in low- and middleincome countries. This situation has been accompanied by falling birth rates, especially in developed countries, and a continuous flow of rural-urban migration. These trends in part reflect the success of countries’ development and public health policies, but also present challenges to communities and health systems 4 5
http://data.worldbank.org/about/country-classifications/country-and-lending-groups#Lower_middle_income World Bank (2012). Viet Nam Development Report 2012: Market Economy for a middle-income Viet Nam. 6 WHO (2013). World Health Statistics 2013.
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WPR/RC64/9 page 37 Annex 1 as they aim to maximize the health and functional capacity of older people and their social participation and security. The fast rate of population ageing in low- and middle-income countries significantly narrows the window of time available for governments and societies to prepare and respond to the complex social, economic and public health implications. Epidemiological transition Economic, social and demographic transitions have been accompanied by an epidemiological transition: a shift from infectious diseases, which historically have been the main global challenge, especially their impact on children, to noncommunicable diseases (NCDs), which mainly affect adults. In the Western Pacific Region, four out of every five deaths are due to the most common NCDs – cancer, cardiovascular disease, chronic respiratory conditions and diabetes. Box 1. Proportion of deaths in Mongolia, The growth in prevalence of NCDs is driven in part by both sexes, all ages, 2010 the ageing population, but also by environmental and lifestyle factors associated with economic and social change, such as urbanization, pollution, changing diets, tobacco use and reduced exercise. Box 1 demonstrates the predominance of NCDs (blue) among the proportion of deaths compared to communicable diseases (red) and injuries (green) in Mongolia. Graphs showing the proportion of deaths in all 10 of the Review countries are in Appendix 18. shows the proportion relative to the total number of The rapid rise in the prevalence of NCDs and Area deaths. See Appendix 18 for explanation of abbreviations associated chronic disability poses major challenges Source: Institute for Health Metrics and Evaluation. for health systems and has wider economic and social implications: NCDs reduce productivity, negatively affect development trends, and increase individual and household poverty. Across the Region, the poorest people have the highest burden of NCDs, as they have greater exposure to risk factors and less access and use of preventive and therapeutic services. This is a major challenge for low- and middle-income Western Pacific countries.
It has been estimated that the average treatment cost for an elderly person is seven or eight times higher than the cost of treating a child 7. As treatment is often long-term as well as expensive, meeting these growing needs will require tremendous increases in resources and innovative approaches to service delivery 8. Recent reports have highlighted diabetes and cardiovascular epidemics in Viet Nam 9 and China 10 and the difficulties they present to health systems. “These changes will require an integrated government response to improve primary care and undertake required multisectoral action to tackle key risks. Analyses of disease burden provide a useful framework to guide policy responses to the changing disease spectrum in [countries]”. 11
7 8
UNFPA (2012). Ageing in the Twenty-First Century: A Celebration and A Challenge. Regional-Director’s speech, World Health Summit Regional Meeting, Singapore, 9 April 2013. 9 “Diabetes surges in Viet Nam”, International Herald Tribune, 5 June 2013. 10 “Under-diagnosis of hypertension reveals bigger health system gap in China”, South China Morning Post, 2 June 2013. 11 Yang G, Wang Y, Zeng Y, et al (2013). Rapid health transition in China, 1990-2010: findings from the Global Burden of Disease Study 2010. The Lancet, Volume 381, Issue 9882, Pages 1987 – 2015.
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WPR/RC64/9 page 38 Annex 1 It is in this context that the Western Pacific Region’s six health system strategies and frameworks were developed in order to guide health system development in Member States as well as the work of WHO staff.
Box 2. Universal health coverage and the health system The WHO health system framework* identifies and addresses six interconnected components of health system: service delivery, health workforce, information, medicines and equipment, financing, and governance. The major goals of the health system are to attain better health, increase responsiveness, ensure financial protection and equity, and improve efficiency. These health system components and goals are fundamental to the achievement of universal health coverage. Universal health coverage is defined by WHO** as ensuring that all people can use the promotive, preventive, curative, rehabilitative and palliative health services they need, of sufficient quality to be effective, while also ensuring that the use of these services does not expose the user to financial hardship. This definition embodies three related objectives: • • • equity in access: those who need health services should get them, not only those who can pay; that the quality of health services is good enough to be effective in improving health; and that people are protected from the risk of financial hardship due to the cost of using services
Universal health coverage is firmly based on the WHO constitution of 1948 declaring health as a fundamental human right. Achieving the health Millennium Development Goals and the next wave of targets beyond 2015 will depend largely on how countries strengthen their overall health system, both public and private, using “whole-of-system” approaches (Box 10), and engage with others sectors on social determinants of health and social protection, in a whole-of-government approach. * Everybody’s business: strengthening health system to improve health outcomes. WHO, 2007. ** http://www.who.int/healthsystems/universal_health_coverage
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WPR/RC64/9 page 39 Annex 1
D. Future health system challenges In order to plan effectively, it is essential to consider not only past and present activities, but also to look ahead to potential challenges and opportunities in the future. For this reason, the Review commissioned a paper to examine the challenges and opportunities for health system development in the Western Pacific Region, with particular reference to changing demographic, economic, epidemiological and political contexts (TD20 in Appendix 2). The paper takes the view that many factors that will be important in the future are already here but invisible, and that other elements of the future that are here and visible are not well distributed. Current trends suggest possible directions to follow but are unreliable. History has shown that unexpected turning points or bends in trends often occur, demanding resilience to cope with the unknown. Climate change, food security, financial stability and human health are all inextricably linked. There is a strong case for adopting new organizational principles if these interconnected challenges are to be met. When considering future social risks, health issues feature highly: they include unsustainable population growth, mismanagement of population ageing, rising rates of chronic diseases, and vulnerability to pandemics. A particular health risk could be over-reliance on technologies that are becoming unstable or uncertain, such as antibiotics, leading to major system and population vulnerabilities such as anti-microbial resistance. The question is not whether another emerging disease will give rise to a pandemic but when and where, and how serious the impact will be. The Western Pacific Region is particularly susceptible, and that vulnerability is likely to increase over the next 20 to 30 years. Historically, the Western Pacific has been a recipient of global strategies and approaches, much of which originated in the developed world. With the Region becoming increasingly dominant in terms of global population, the new middle class, and the main bearer of the global “disease burden”, there will be an increasing onus on it to inform health system development in other regions. Both regionally and nationally, the challenges facing those responsible for the planning and management of population health and services, including WHO, are vast and complex and may seem overwhelming. While many interventions to address the challenges ahead already exist, they are currently poorly distributed contributing to growing inequities. Health systems will be profoundly affected by the trends that are occurring as a result of the various transitions (demographic, epidemiological, urbanization). At the same time, health systems themselves are changing as a result of new technologies and patterns of care. WHO has long argued for more rationally balanced systems centered on people, not on specific institutions or professions or individual episodes of illness or ability to pay. The sociological and economic reality of the Western Pacific Region means there is little choice but to take a stronger preventive approach, and to use public health and primary care more effectively to address the challenges ahead. With continually increasing urbanization, health systems will need to meet the problems of emerging urban environments – the provision of basic services (safe water, food, housing), and addressing increasing and unhealthy slum development, violence, access to healthy recreational space, safe public transport and access to appropriate health services. Strong Ministry of Health engagement in areas DRAFT REPORT – NOT FOR CIRCULATION OR CITATION – 04 Sept
WPR/RC64/9 page 40 Annex 1 such as urban planning and social services will be essential to ensure the health needs of urban populations are met, particularly to address the large inequities between different groups in the cities. Noncommunicable diseases are driven by a rise in particular risk factors – smoking, over-nutrition, alcohol and lack of physical activity – all of which are amenable to preventive action on numerous fronts by several different sectors. System-wide approaches will be increasingly required within the health sectors of Member States and multi-sectoral approaches will become ever more important. Consensus is also growing, even among the private sector that greater emphasis needs to be placed on the demand side of health care rather than allowing an unregulated supply side market to drive up health expenditure and health inequities. Despite the evident promise of economic development, the issue of inequities within the countries will take greater prominence, as few countries in the Region have achieved economic growth that is well distributed across their populations. WHO’s role historically has been both developmental and normative. The developmental focus has been primarily on developing countries, with part of its workforce located there. The future will see a greater emphasis on the normative role of WHO as relevant to all countries’ health and health systems. WHO will focus more on standards and best practice for countries to use as they see fit, and provide less direct technical assistance which will be less needed. Country focus is likely to be on balancing levels of service for access and in relation to burden of disease; increasing standards and safety; reducing inequity; controlling costs and reducing wastage. To meet these challenges, WHO needs to work more with countries on their problems of implementation, taking into account the countries’ unique contexts. In the past, success has often been judged in terms of policies adopted or laws passed; in the future, greater attention needs to be paid to implementation and outcomes. Countries’ different points in the various transitions can be an advantage for the Region. For example, Japan and other countries’ experiences of how to care for an older population can be instructive for other countries in the years ahead, if lessons on what works and what does not work are documented and disseminated. A radical change is likely in terms of how knowledge is generated, disseminated and implemented. Technology will immensely facilitate the transfer of technical knowledge – information that previously would have come from a WHO “expert” is now readily sourced via the Internet even in the leastdeveloped countries. But not all knowledge is technical or written. The transfer of tacit knowledge occurs through extensive personal contact, trust and honest interaction. Tacit knowledge is also highly context-specific, developed through a deep understanding of the cultural and political economic setting in which the knowledge is used; the contextual differences between countries are extensive. The key to preparing for the future is to build resilient health sectors on a strong values base consistent with WHO’s founding principles. The core values of WHO will become more important in guiding actions to address the complexity of future challenges in the Western Pacific Region. Moving away from a hierarchical model of health development to a more networked one, which capitalizes on the growth
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WPR/RC64/9 page 41 Annex 1 of knowledge and experience across the Region and increases the flow of knowledge and lessons within and between Member States, will assist in enhancing health sector resilience.
E. Review findings This section of the Summary Report presents the main findings relating to each of the Review’s objectives. Objectives 1 and 2 are retrospective and consider previous health system development activities and the utility of the strategies, while Objective 3 considers gaps in strategies and future needs. Objective 4 is more prospective, aiming to consider lessons that can be applied in the future. Thus, the findings for Objective 4 are presented as discussion of the findings on the first three objectives and implications for future health system work. A set of 20 technical documents generated during the Review, referred to throughout this Summary Report, is presented in Appendix 2. These technical documents form the evidence base of the Review and reflect the breadth, depth and detail of the exercise. They provide details on the extensive and varied data collection and analyses conducted, and, along with comprehensive methodology, comprise the detailed Review Technical Report, companion to this Summary Report, available on the review SharePoint. 12
E1. Findings on objective 1 Objective 1: Review implementation of key policies and programmes related to the six regional health system strategies by countries, WHO and partners. The regional strategies are syntheses of the evidence on health system development and expressions of WHO’s values. Targets and strategic areas are summarized in Appendix 4. They inform the work of WHO staff and guide Member States on actions to improve health system functioning (TD1). 13 All the strategies contain indicators to monitor country progress and performance in each of the health system areas. Implementation of key actions in the regional strategies is examined through analysing country timelines, national health plans and trends on indicators. In the following sections, notable results are presented along with responses from key informant interviews related to the findings.
Summary of findings – objective 1 Country health system features: • gradual Increases in data available • overall progress on indicators • insufficient disaggregated data to fully monitor health equity, but data available show inequity in access to and use of services • some key events are linked to changes on indicator trends • generally increases in government expenditure on health, and decreases in OOP as a percentage of THE • EM and HRH data difficult and/or expensive to collect, but data available show inequities in access to EM and in HRH distribution • Outpatients receiving antibiotics exceeds 10% target in all six Review countries with data • Antibiotics available without prescription in all 8 Review countries with data
12
http://intranet.wpro.who.int/sites/health_systems_strategies_review/default.aspx, username: WPPRD75\wpro_review; password: Password123 13 All numbers in italics and brackets throughout the text refer to numbered technical documents listed in Appendix 2.
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1.a Health Care Financing The regional health financing strategy emphasises evidence-based policymaking, monitoring and evaluation. The strategy includes four key indicators and benchmarks: • out-of-pocket (OOP) spending not above 30%–40% of total health expenditure; • total health expenditure (THE) at least 4%–5% of the gross domestic product (GDP); • over 90% of the population covered by prepayment and risk pooling schemes; and • close to 100% coverage of vulnerable populations with social assistance and safety-nets (Appendix 4) Many countries used the health financing policy as a guiding document for high level policy dialogues to put health higher on the national development agenda and to raise the importance of multi-sectoral contribution to health (see also Box 9 in Findings on strategy usefulness). Analysis of national health and health financing plans reveals that seven of the ten countries have recognized the need for action to address OOP health expenditure and most are making some progress (Box 3). Fiji, Papua New Guinea and the Solomon Islands have mainly tax-based health system and have low OOP spending. WHO has been actively engaging countries to monitor and to evaluate progress through survey data and routine statistics on the key health financing indicators. Appendix 15 and Box 4 present annual data from the WHO global health expenditure database for 1995 to 2011 in the ten Review countries on THE, government health expenditure (GHE) as a proportion of THE, and OOP as a proportion of THE. All countries show some increase in THE over the period, and most also show some reduction in OOP as a proportion of THE.
Box 3. OOP as % THE 2005 - 2011
Box 4. Health-care financing expenditure (US$) in China 1995 – 2011
For example, in China increases in GHE can be linked with a decline in OOP as a percentage of THE since 2007 (Box 4). China has made concerted efforts over several years to extend staffing and quality for primary care services, in addition to enrolling more poor and rural people in various insurance schemes. Collectively, these policies with increased GHE could be said to have resulted in reduced OOP. However, increased total and government health expenditure does not always result in decreased OOP (Appendix 15). An increase in the proportion of OOP can accompany increased GHE and THE, for example where improving economies result in a growing middle class and increased use of private health care, as in Malaysia and the Philippines. During the Review process, Malaysia expressed a need for WHO support in regulating the private health sector.
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1.b Access to essential medicines Strategic action areas in the regional essential medicines framework include national medicines policy and medicines regulation; medicines procurement and supply system; substandard and counterfeit medicines; adequate financing and affordable prices; intellectual property rights and international trade agreements (Appendix 4). Key informant interviews show that WHO plays a strong role in helping countries develop their national medicines policies and is a source of technical guidance on pharmaceuticals – particularly emphasised in China, Malaysia and Viet Nam (TD5). 14 Five of the Review countries have national medicines policies that could be accessed: Cambodia, Fiji, Lao PDR, Malaysia and the Philippines. These country medicines policies cover training on drug issues, demand-side strategies and collaboration. However, areas recommended in the Regional Essential Medicines Strategy that are not well covered include: monitoring of the effects of trade policies, information on medicines financing, price monitoring, efficiency (including cost-containment and financing management), use of WHO pre-qualified products, pharmaceutical sector assessment and antimicrobial resistance (Table 3, pp31-32). For the other five Review countries, their national health plans were assessed for provisions relating to essential medicines. Mongolia’s national health plan mentions access to essential medicines, regulation and quality assurance, and rational use of medicines, as well as identifying related challenges. Access, regulation and rational use are mentioned only briefly in Viet Nam’s national health plan. Policy and access and rational use are discussed in China’s plan. Only policy and access are discussed in Papua New Guinea’s plan, while none are included in the plan of the Solomon Islands (TD5). Weaker areas identified in countries’ plans are also reflected in the essential medicines indicators (Appendix 13). Limited data are available relating to the availability of medicines, public procurement prices, rational use and compliance with standard treatment guidelines. This information has to be obtained through facility surveys that are expensive, not regularly funded and thus infrequently conducted. All countries providing data have some Box 5. % Outpatients receiving provisions in place for the regulation and Antibiotics, 2012 licensing of pharmaceutical production and 70 supply. Data that are available suggest that 60 most countries are implementing actions 50 related to financial coverage for essential 40 medicines. However, limited disaggregated data 30 are available on access to medicines. Data on 20 service access suggest that access to use of and 10 funding for medicines is inadequate for poor and 0 difficult to reach populations. For health MYS CHN MNG VNM KHM LAO PHL outcome indicators, where correct use of quality medicines are critical, such as maternal and child health and non-communicable diseases, available disaggregated data suggest that there is inequitable coverage (TD5). 14
All numbers in italics and brackets throughout the text refer to numbered technical documents listed in Appendix 2.
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% Outpatient prescriptions with antibiotics
WPR/RC64/9 page 44 Annex 1 Of those countries for which data are available, all but Mongolia report higher percentages of outpatient receiving antibiotics in excess of the 10% regional target. In the Philippines, Lao PDR and Cambodia percentages are 63%, 57% and 55% respectively (Box 5 and Appendix 13). Antibiotics are dispensed over the counter without prescription in all eight of the Review countries reporting on this issue. Only the Philippines’ National Medicines Policy includes approaches on antimicrobial resistance but the degree to which it is currently implemented is uncertain (TD5).
1.c Human Resources for Health The Human Resources for Health, Action Framework (2011-2015) outlines four key result areas for the health workforce: 1) response to population health needs; 2) education and continuing and competence; 3) deployment, management and retention; and 4) governance and partnerships for sustained health workforce contributions to improved health outcomes (Appendix 4). In Cambodia, Lao PDR and Papua New Guinea, 20 of 34 key informants expressed the view that capacity building in human resources for health is an important and valued part of the WHO Secretariat’s work, but it is also an area in which more could be done (TD17). Participants at the High Level Consultation (22-24 July, 2013) that formed part of this Review, requested more support for capacity building in health system development. Summary analyses of WHO Secretariat health system work suggest that 30% of reported activities at country office level and 13% at Regional Office level are associated with health worker capacity building (Appendix 7 and TD16). Notably successful WHO HRH work, such as the workforce retention initiatives in Lao PDR and the Pacific Open Learning Health Net (POLHN) continuing education initiative, have been characterized by common elements. These include close collaboration with national agencies and development partners that has been sustained over time; flexibility and responsiveness to local contexts, needs and capacities; and activities and methods that are in line with the HRH Strategy and Action Framework (TD14). Effective strategic planning and management of human resources for health depends upon good information and yet capacity to monitor the workforce in countries appears to be poor. Data on indicators recommended in the HRH Action Framework are presented in Appendix 14. Data are available for strategic response, staffing levels, education training and competence indicators in many countries, but not for indicators on workforce utilization, management, retention, governance, leadership and partnerships. The data available highlight inequities in access to and use of health care. In Lao PDR only 22% of health workers are rural, while 66% of the national population lives in rural areas. In Papua New Guinea the mismatch is even more marked, with only 18% of health workers being rural, while 88% of the national population lives in rural areas. In the Philippines the number of qualified health workers per capita is highest of the ten Review countries, and this is especially true of midwives. Yet the percentage of births attended by trained health professionals is lower than several countries with significantly fewer health workers and shows greater inequity than in other countries except Lao PDR (Box 6).
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WPR/RC64/9 page 45 Annex 1
Box 6. Skilled Birth Attendance By place of residence 99 100 85 77 67 68 48 80 60 40
Rural
Urban 98
By wealth quintile 97 81 49 98 100
Poorest Richest
By education level of mother
Lowest Highest
100 80 60 40 20 0
95
100
94
99 100 80
91 63 47
96 100 73
97
53 26 3
60
60 40 20 0
11
20 MNG PHL VNM
3 KHM LAO MNG
11 PHL VNM
KHM
LAO
0 KHM LAO MNG PHL VNM
KHM: DHS 2010 LAO: MICS 2006 MNG: MICS 2005 PHL: DHS 2008 VNM: MICS 2006 DHS= Demographic and Household Survey MICS= Multiple Indicator Cluster Survey, UNICEF MCH Community base data, http://www.unicef.org/statistics/index_24302.html Source: Regional Framework for Reproductive Health in Western Pacific, World Health Organization, 2013
1.d Health system performance and health outcomes The Review collated data on many of the indicators proposed in the six regional health system strategies in order both to describe the context for the review and to assess countries’ current status in health system strengthening and health outcomes. The data for access to essential medicines, human resources for health, health financing and traditional medicines are presented in Appendices 13-17 (TD10). In tables 3 and 4, information is presented on 33 of the 47 indicators proposed by WHO headquarters for monitoring health system performance 15 and universal health coverage. The two charts present data from 1994 to 2003 and 2004 to 2012, with the latest data for each country favoured in each time period. The strength of countries’ performance is illustrated by means of colour gradation, with darker shades indicating better performance. Country data on health system performance indicators have not been presented in this way previously. Fourteen of the 47 indicators are not included either because they could not easily be graded or because data are not available or not feasible to collect. These include indicators on quality, international health regulations and characteristics of national health planning processes (TD10). In Tables 1 and 2, the country columns are ordered horizontally according to total health expenditure (THE) per capita (top row), while vertically the indicators have been arranged in accordance with their visual matching to the top row ordering. Differences between the two time periods illustrate improving health system information, services and outcomes. Table 2 has both more data and more dark green than Table 1. However, even in the more recent chart many data are missing, often for the same countries and often relating to quality, reproductive health or child health indicators. In the upper rows of Table 2, countries with higher THE per capita appear to have better outcomes on indicators such as life expectancy and mortality, and service delivery such as skilled attendance at birth and DPT3 coverage. Patterns of shading in lower parts of the chart suggest that better outcomes may not be so influenced by THE. Lower prevalence of overweight in some countries with lower per capita 15
WHO and IHP (2011). Monitoring, evaluation and review of national health strategies.
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WPR/RC64/9 page 46 Annex 1 THE possibly reflects nutrition deficits or more rural subsistence lifestyles; while increased antiretroviral coverage among HIV-positive adults likely reflects increased aid programmes by development partners.
1.e Equity, gender and human rights WHO supports countries in building capacity to design and implement health policies, programmes and actions that integrate equity-enhancing, gender-responsive, and human rights-based approaches in health. One important factor in this regard is the inclusion of equity, gender and human rights in national health plans. A review of plans in the ten Review countries indicates that frequent reference is made to these values (Table 3 part 4), but with great variation. For example, "equity" is mentioned in all ten of the national health plans, and four include specific actions to address inequities. "Gender" is discussed in only half of the plans. Reference to "human rights" or "the right to health" is made in few national plans and without any specific actions identified. The health system performance and health outcomes data presented in Tables 1 and 2 are aggregated and can only therefore present an overall picture of a country’s status relating to any indicator. This often masks inequalities in the distribution of, access to and use of health care. Disaggregated data offer the potential to consider health service development and health outcomes amongst different subgroups of the population, defined, for example, by gender, sex, age, income, and rural or urban domicile. Published health statistics from eight of the Review countries shows countries collect disaggregated data on a diverse range of indicators. Most commonly they are stratified by subregion, rural/urban domicile, followed by sex and then age (TD12). However, disaggregated data are often not collected or published for the indicators recommended by WHO for assessment of health system performance and progress towards UHC. The disaggregated data that the WHO Secretariat has are scattered, and in order to assess equity in health system development the Review sought disaggregated data from multiple sources (Box 6 and Appendix 17). The data that are available suggest that inequity continues in health service delivery and health outcomes. In most of the Review countries for which data are available, infant and under-five mortality rates, skilled birth attendance, antenatal care coverage, immunization, stunted growth in children and access to improved water and sanitation are better in urban than in rural settings and for those in higher than lower income groups – Mongolia being a notable exception where greater equity is more evident (Box 6, Table 3, Appendix 17, TD5, TD12).
1.f Key country actions or events To review the implementation of policies and programmes related to the strategies, efforts were made to collect country information and WHO Secretariat’s work. The Review, with guidance from WHO country offices and technical units, collected information on key country actions and events that were associated with health system development or led to the creation of other policies. The main events were plotted on a timeline for each of the ten countries. The timeline for China is presented as Figure 1 as an example. The others can be found in TD8 as listed in Appendix 2. Country actions and events give an overview of strategy implementation and overall health system development. Events can be linked to changes in trends on indicators, but it is not possible to attribute causality. Almost invariably, improving trends in health indicators are affected by more than one policy or event, and several policies may be needed for sustained effects. Box 7 describes several actions
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WPR/RC64/9 page 47 Annex 1 taken by Cambodia to reduce maternal mortality. Although it is not possible to attribute these initiatives directly to the regional health system strategies, they are in line with recommendations in the strategies.
1.g WHO Secretariat core functions (WHO Secretariat work) In the period from 2010 to the end of 2012, the WHO Secretariat in the Western Pacific Region has invested an average of around US$ 24 million annually in health system work by the Regional Office (50%) and the country offices in the ten Review countries collectively (50%). This involves staff and the activities they support. The number of health system posts has increased from 24 in 2004 to 52 in 2012. While the reference period for the Review was intended to be 2004 to 2012, changes in procedures and staff and generally poor recording mean that the WHO Secretariat has limited information on its work prior to 2009 and even less prior to 2007. WHO health system work at regional and country offices is spread across all six Secretariat core functions, but not evenly. Appendix 7 provides a summary overview of the focus of regional and country office health system activities by WHO’s six core functions. Although there is broad consistency, there are also some notable differences. For example, the major emphasis for the Regional Office is on national health policies, strategies and plans, but for country offices it is on training and capacitybuilding in human resources for health. A key informant in Papua New Guinea expressed particular appreciation of capacity-building: “WHO works hard to develop local capacity rather than just to deliver support that cannot be sustained”. Work on norms and standards appears to receive more attention at country than at Regional Office level. From a health system development perspective, the analysis reveals a disappointingly low focus on multi-sectoral work by the health system teams at both regional and country office levels (TD16).
1.h Resource mobilization for health system development (WHO Secretariat work) At both regional and country office levels, WHO staff have helped countries mobilize large amounts of funding for health system strengthening. Since 2007, WHO staff have supported Joint Annual Health Reviews in Viet Nam. In 2010, the results of such a review were used in a successful application to the Global Alliance for Vaccines and Immunisation (GAVI) health system funding platform that secured US$ 24.4 million for health system strengthening (TD9). Between 2006 and early 2010 the health system teams supported Cambodia, China, Fiji, Lao PDR, Mongolia, Papua New Guinea and Solomon Islands to raise a total of US$25.7 million from GAVI for health system strengthening; and a further US$200 million for Viet Nam, China, Cambodia, Lao PDR, Fiji, Mongolia and PNG from The Global Fund to fight AIDS, TB and Malaria (GFATM) (TD9). In 2010/11 the Region again was successful is helping Viet Nam, Lao PDR and Solomon Islands to raise a total of US$ 28.9 million through the GAVI/GFATM joint health system funding platform where the two Global Health Initiatives (GHI) attempted to harmonize their application processes (TD9). WHO supports not only proposal development but also technical assistance for implementation, monitoring and reporting of these GHI-funded health system strengthening activities (TD9).
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1.i Initiating global developments (WHO Secretariat work) In developing the current and previous regional health system strategies, the Western Pacific Region has spearheaded work on a number of now accepted global issues. For example, in 2004 the Region launched a Rapid Alert System (RAS) as a portal to enhance surveillance of counterfeit medicines and facilitate exchange of information between countries. The RAS is a Western Pacific Region project that is now being implemented globally. Starting with Cambodia, Mongolia and the Philippines, by 2008 the RAS expanded to 40 countries in the Western Pacific and South-East Asian Regions. Some countries also developed national alert systems (TD14).
Box 7. Health system levers to reduce maternal mortality in Cambodia Cambodia has recorded one of the world’s biggest reductions in maternal mortality, with a fall in the number of deaths of about two-thirds since 1990. This compares to a global average drop of almost half over the last 30 years. While in 2000 only 39% of pregnant women had at least one antenatal check-up with a health-care provider, this figure was almost 90% by 2010. The policies and actions Cambodia used for this achievement resonate with recommendations of the six health system strategies. Elements of particular relevance are in italics in the text below. Rapid economic growth and improvements in health care in Cambodia help explain why fewer women are dying in or around childbirth. But an important specific factor is the strategic planning and implementation of innovative health policies. Among these, ensuring universal access to skilled birth attendants is essential in reducing maternal and newborn deaths. Cambodia has been pursuing this since the mid-2000s with support from WHO and other international agencies and partners. Health centres began operating 24 hours a day and other measures made maternity services more accessible. The Ministry of Health also adopted a strategy of increasing the training of midwives and their absorption into the health system through deployment based on population and need. Now all health centres nationwide have a primary midwife with one year of training, and more than half have a secondary midwife with three years of training. To increase further the proportion of births attended by a skilled midwife, the ministry offered financial incentives to staff. For every live birth at a health centre, the birth attendant receives a US$15 bonus, while every live birth at a referral hospital carries a $10 incentive. Skilled birth attendant-assisted deliveries rose from 46% in 2007 to 70% in 2010, and deliveries taking place in health facilities rose from 26% to 59% over the same period. The increase in facility-based deliveries occurred across the whole Cambodian population. The proportion doubled among the richest 20% of the population and quadrupled amongst the poorest 20% of the population. Source: http://www.wpro.who.int/about/administration_structure/dhs/story_cambodia_reduces_maternal_mortality
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E2. Findings on objective 2 Objective 2: Assess the usefulness of the six Western Pacific Region health system strategies to countries, WHO and partners 2.a Usefulness of the regional health system strategies to countries Summary of findings - objective 2 The regional health system strategies are:
Analyses of national health plans and health system • technical, evidence-based knowledge policies in the ten Review countries reveal that they reflect • expressions of WHO values many of the recommendations in the strategies (Table 3, • used by countries as bench marks, for evidence-based ideas, and advocacy Appendix 4, TD5). The ten national health plans also have for policy makers explicit or implicit references to universal health coverage • used in national health plans (UHC) and the associated values of equity, gender and • most useful when the country office human rights (Appendix 5). Country goals and aspirations has dedicated staff with the relevant skills reflect local need and capacity to ensure access to quality health services and financial risk protection for the whole • used in 14 WHO regional programme strategies and frameworks population, especially the poor and vulnerable. Box 8 gives an example from Fiji. It is difficult to attribute this directly to the regional health system strategies or to other WHO activity since the Secretariat has no systematic processes Box 8. Fiji’s aspirations “The Strategic Plan has been developed (so that) for recording its work or impact in countries (TD14). However, interviews with national key informants who have been involved in national health planning indicate that the WHO Secretariat’s health system work is highly valued. WHO is often regarded as the lead health sector partner, whose long-term presence and technical expertise are appreciated (TD17). communities (will) have access to effective, efficient and quality clinical health care and rehabilitation services … … Government has recognized the need to strengthen health care services and through the Peoples Charter has made a commitment to have an annual increase to the health budget.” Strategic Plan 2011-2015: Shaping Fiji’s Health, Ministry of Health.
Where national key informants were familiar with the strategies, they regarded them as useful sources of evidence-based ideas and bench-marks, as providing easy access to best practices, and as being valuable resources for evidence-based ideas, and for leverage in convincing governments to commit support and funding for health system development. There are several examples showing that WHO regional health system strategies and WHO staff advocacy for their recommendations have influenced Member States’ health system planning. In Malaysia, seven of the eight informants showed awareness of the six health system strategies, and generally regarded them and support from WHO as instrumental in health system development. Four interviewees commented that WHO’s evidence-based strategies had been used even without WHO staff or funding support. …” (TD17). 16 Interviewees in Malaysia specifically mentioned WHO as the key catalyst for development of their National Medicines Policy (2007). Two of the eight binterviewees in Papua New Guinea commented “WHO is the main source of evidencebased policies and advice” [for health system development], and highlighted the usefulness of the Health Financing Strategy for the Asia-Pacific Region 2010-2015 as a source of evidence for use in lobbying. “In the 16
All numbers in italics and brackets throughout the text refer to numbered technical documents listed in Appendix 2.
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WPR/RC64/9 page 53 Annex 1 past they [government] said we [the Department of Health] are just spending money, but I think the message is now getting to people that health is an investment. WHO can come with some good arguments.” (TD17) In China the 2005-10 Essential Medicines Strategy had been used as a principle reference in the development of national essential medicines policy and action plans. It was translated into Chinese and supplied to key departments in the Ministry of Health and to key provincial institutions (TD14). The financing strategy was regarded by one interviewee in China as having been directly useful, providing ideas on how to monitor government and out-of-pocket expenditure (TD17). Similarly in the Philippines, the WHO regional financing strategies have contributed to development of the national financing strategy and approaches to universal health coverage (Box 9). Despite these notable exceptions, the health system strategies are not usually the primary motivating factor for Member States in developing their policies or plans. Rather, national strategies most often stem from domestic political decisions (Appendix 6 and TD17), though external influences, such as the Millennium Development Goals (MDGs), global agendas (e.g. tobacco control) or WHO publications (e.g. the World Health Report) do play a part. In Malaysia, Viet Nam and the Philippines awareness of the regional strategies is mostly good, but in several other Review countries awareness is generally low. Dissemination of the strategies appears to have been neither systematic nor thorough. In PNG seven of the eight interviewees thought that general awareness of the strategies was low in the Department of Health, and four were unaware personally. In Lao PDR interviewees were frequently unaware of the strategies (TD14, TD17). Where awareness of the strategies is low, the role of WHO staff in spreading health system technical knowledge is crucial (TD14, 17, 18). In Lao PDR, for example, although many interviewees did not know of the strategies, the Review researcher reported that during the key informant interviews, the main strategy messages appeared to have been understood. A further view, expressed in China, and related to health financing, is that “the strategies themselves are less important than the WHO staff in the country and Regional Offices who helped shape the policies” (TD17). This is an important finding, reinforced by development partners and WHO staff themselves (TD18, TD19). While the regional health system strategies inform the work of WHO staff, it is the work of the staff themselves rather than the strategies that emerged from interviews as being more important in supporting the development of national policy (TD17, TD19). The Review shows that Member States, development partners and other stakeholders regard WHO as a technical agency (not a funding agency) playing a vital role in policy dialogue, advocacy, technical support and capacity building (TD17). As an interviewee in Viet Nam put it, “WHO is usually the first place we think to ask for help”. WHO was described by 26 of 56 interviewees in the Philippines, Cambodia, Papua New Guinea and Lao PDR as being primarily a technical support organization. “Technical advice … that is what they are known for”, “WHO has the best technical support, they have the experience and skills in these areas” (PNG KII). The key informant interviews suggest that WHO is generally trusted by countries as a neutral ally in health sector development, and that they regard WHO’s health system expertise as effective (TD17). “WHO was always helpful, always available, and nearly always present,” an interviewee in the Philippines said. An DRAFT REPORT – NOT FOR CIRCULATION OR CITATION – 04 Sept
WPR/RC64/9 page 54 Annex 1 interviewee in China commented: “For the past decade, the relationship has been very equal – WHO really respects member countries.” It is important that Member States have full ownership of the development of their health system plans and policies. None of the country key informants reported any difficulty with ownership and WHO is seen as a partner in health system development rather than as dictating what direction a country should take (TD17). WHO is also seen as bringing a broader perspective to health system support than some of its development partners, and its ability thereby to link together all parts and concepts of the health system is seen as an important advantage (TD13, 17, 18). Interviewees in Papua New Guinea and Cambodia commented that, although often timely and appreciated, support could be more effective if sustained over longer periods: “Just a consultant for a number of weeks ... helpful, but not sufficient”, “Often we need someone to help for longer – not just 7-21 days”, “less one-off things”. One interviewee in Papua New Guinea commented that “Although we [the Department of Health] reside together in the same building [with WHO], I think they assist us on a piecemeal, inconsistent basis….” While many external consultants were seen as very effective and helpful, it was highlighted that some consultants lacked understanding of developing country contexts and were therefore less effective. Some country interviewees feel that WHO could do better in setting an example and acting as a role model (TD17, 18, 19) particularly with regard to integrating services, linking better with disease programmes, using “whole-of-system” approaches and sharing health system lessons. One interviewee in the Philippines commented that “WHO needs to start reforming itself before it tells countries what to do … There are many strategies coming from many different offices within WHO that are not talking to each other or choose not to talk to each other.”
Box 9. The Philippines Health Care Financing Strategy A health care financing strategy for the Philippines was prompted by a WHO regional consultation in 2006 introducing the Health Financing Strategy for the Asia-Pacific Region 2006-2010. The Philippines participants’ take home plan was to develop a national health financing strategy to fix the country’s fragmented health financing. The Department of Health (DoH), with support from WHO, held a series of meetings, dialogues and consultations with key stakeholders. The WHO regional Health Care Financing Strategy was used as one of the primary references for deciding strategic areas, targets and benchmarks. The Philippine Health Care Financing Strategy 2010-2020 (PHL-HCF) provides a roadmap to increase overall health spending, promoting universal coverage, improving allocative efficiency and promoting technical efficiency. As the DOH Secretary Ona puts it, the “2010-2020 Health Care Financing Strategy of the Philippines: Toward Financial Risk Protection is the blueprint for meeting the challenge posed to us by President Benigno Aquino III “serbisyong pangkalusugan” on universal health coverage, with a goal to achieve health services for all within three years through PhilHealth.” (social health insurance) (PHL-HCF page 8).
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WPR/RC64/9 page 55 Annex 1 2.b Usefulness of the regional health system strategies to WHO regional disease and programme based activities The Review examined regional programme strategies or frameworks in several areas such as communicable disease control, tobacco control and reproductive health, for their linkages with health system actions promoted in the six WHO regional health system strategies. Many of the recommendations of the six health system strategies are reflected in the strategies and frameworks examined (Appendix 10 and TD6). For example, the current regional strategy on tuberculosis 17 adopts a diagram from the Human Resource for Health Action Framework 2011-2015. Similarly, the latest reproductive health strategy 18 completely follows the health system framework (Appendix 10 and TD6). However, although the disease programmes are integrating health system approaches in their work, one staff member commented “The current global vaccine strategies are difficult to understand, even for us, as they adopted a health system approach which we are very unfamiliar with”. Such remarks suggest that greater awareness and understanding of integrated services and “whole-of-system” approaches should be promoted within the WHO Secretariat (TD6). This was also noted by several key informants. 2.c Usefulness of the regional health system strategies to development partners The Review undertook three pieces of work regarding development partners: linkages between development partners’ health-related strategies and WHO health systems strategies (TD7;) summary of development partners’ health system work in the region (TD13); and key informant interviews (TD18). The five development partner strategies examined were linkages health system concepts promoted in the six WHO regional health system strategies and summarised in Appendix 11 were: • • • • • UNICEF Joint Health and Nutrition Strategy 2006-2015 World Bank’s Healthy Development (2007) ADB Strategy 2008-2020 Operational Plan JICA’s operation in health sector 2010-2015 USAID Global Health Strategic Framework 2012-2016
These five agencies link their plans with global agreements such as the MDGs, and three have timeframes that run until about the MDGs deadline in 2015. Each has its own particular health system focus related to their respective comparative advantage. The World Bank’s, for example, on health system financing and UNICEF’s on maternal and child health programmes and nutrition. UNIDO, though not having a specific health strategy, undertakes work on developing pharmaceutical and health technology industries in countries, an important factor in promoting affordable and sustainable access to care (TD13, TD18). All five of the agency plans have activities and support for health care financing and health information systems including research. Four include contents on governance and health system strengthening; two have essential medicines and laboratory services; only one has human resources; while three refer to equity, gender and human rights (Appendix 11 and TD7). For the most part, the content appears to be in line with the regional health system strategies.
17 18
WHO Western Pacific Region (2011). Regional Strategy to stop tuberculosis in the Western Pacific Region (2011-2015). WHO Western Pacific Region (2013). WHO Framework for Reproductive Health in the Western Pacific.
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WPR/RC64/9 page 56 Annex 1 Ten of the 12 development partners interviewed were aware of and use at least one of the six regional health system strategies (TD18). For example, AusAID in Papua New Guinea uses the six building blocks and the regional health system strategies: “absolutely we use them … all of our work is based on them” (TD18). Four development partner interviewees reflected that health system approaches require work beyond the health sector, and that this appears to be an area in which WHO is lacking knowledge and experience (ADB, JICA, UNIDO, World Bank). A World Bank interviewee stressed the need to work with both the private and public sectors in health, as the private sector plays a significant role in many countries (TD18). WHO health system strategies provide little advice to countries on the stewardship needed to overcome potential negative impacts of private sector activity on health equity, an omission that renders the strategies less useful.
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Table 3. Summary regional health system strategy actions in national health plans Table 3 Part 1. Publication dates of national health plans and sub-sector plans KHM National Health Plan National Health Care Financing plan National Health Accounts developed after 2006 National Human Resources for Health plan National Essential Medicines plan National Laboratory plan National Health Information System plan National Research Plan (d = draft)
CHN 2009
FJI 2011
LAO 2011 2011 d
MYS 2011
MNG 2005 2010
PNG 2010
2008 2008 Yes 2006 2010 2010 2008
PHL 2006/ 12 2010 Yes 2005 2012
SLB 2011
VNM 2010
Yes
Yes 1997 1994/ 07
Yes 2009 2003 2011 2009 2007
Yes
Yes 2009
Yes 2012 2011 d 2012
Yes
Yes
2007 2010 2011
2006
2011 2011 2008
2012 2010/ 12 2011
2011 d
Table 3 Part 2. Inclusion of strategic areas of health system strategies in national health plans and sub-sector plans Health system strategic areas Governance Health Workforce (HW) (see also Appendix 14) HW strategic response to evolving, unmet population health &health service needs HW education, training and continuing competence HW utilization, management and retention, including remuneration and incentives, monitoring and evaluation HW governance, leadership & partnerships for sustained HRH contributions to improved health outcomes Health care financing (see also Appendix 16) Increasing investment and public spending on health Improving aid effectiveness for health Improving efficiency by rationalizing health expenditures Increasing the use of prepayment and risk-pooling Improving provider payment methods Strengthening safety-net mechanisms for poor & vulnerable Improving evidence and information for policymaking Improving monitoring and evaluation of policy changes Essential medicines (see also Appedix 13) Policy and access to essential medicines Regulation and quality assurance Rational selection and use of medicines KHM CHN FJI LAO MYS MNG PNG PHL SLB VNM
* * *
*
* * *
* * * *
* * * *
*
*
* *
*
* *
*
* * * *
* * *
* *
* * *
* *
* * * *
*
*
*
*
*
* * *
* * *
* *
*
* * *
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WPR/RC64/9 page 58 Annex 1 Health system strategic areas KHM CHN FJI LAO MYS MNG PNG PHL * * SLB VNM *
Areas related to health service delivery (see also Appendix 12) Quality * Patient safety Accreditation of providers Patient-centred health care Antimicrobial resistance * Laboratory services Coherent national framework for laboratory services Sustainable financing for laboratory services Build capacity for laboratory services Quality assurance for laboratory services Rational use of laboratory services Improving safety of laboratory services Support research and ethics in laboratory settings Health information systems and research (HS-PHC values) # National health information system, strategy, plan or policy * Sufficient resources and technical capacity to manage system * Sufficient disaggregation of information Monitoring of health system performance * Research * * * * *
*
*
* * * *
* * *
* * * *
*
* * *
* *
*
*
*
# Areas for health information systems as in the Regional Strategy for Health Systems Based on the Values of Primary Health Care
* Challenges identified in this area:
No mention in the national health plan or national plan or no existing document Briefly mentioned but without further discussion, objectives, strategies, actions, budget, time plan and indicators Mentioned and with two or more of the following: discussion, objectives, strategies, actions, budget, time plan and indicators
Table 3 Part 3. Content of national health plans on universal health coverage (see also Appendix 5) Universal Health Coverage Mention of UHC Coverage with needed health services Coverage with financial risk protection Mention of Primary Health Care (Green indicates “yes”)
KHM
CHN
FJI
LAO
MYS
MNG
PNG
PHL
SLB
VNM
Table 3 Part 4. Content of national health plans on equity, gender and human rights Values Equity Gender Human rights Assessment Equity Gender Human rights
KHM
CHN
FJI
LAO
MYS
MNG
PNG
PHL
SLB
VNM
White No mention No mention No mention
Yellow Refers to “equity” and discusses equity issues Refers to “gender” and discusses gender issues Refers to “human rights” or “right to health” including discussion on right to health issues
Green Includes specific actions to improve equity Includes specific remedial actions that tackle gender inequalities or address gender needs Includes specific actions that explicitly apply a human rights-based approach to health
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E3. Findings on objective 3 Objective 3: Identify gaps and future needs to inform appropriate Western Pacific Region health system development approaches. Summary of findings – objective 3 Gaps: • a “whole-of-system” approach • guidance on country adaptation and sequencing of steps to take • explanation of policy options in specific contexts • working with non-state sector in health • links to social determinants of health • knowledge management • monitoring and evaluation frameworks • hospitals • health system work not systematically guided by RCM resolutions
3.a Gaps in “whole-of-system” approaches The regional health system strategies lack guidance on interconnectedness needed for “whole-of-system” approaches (Box 10) for optimal system functioning (TD5). Several of the strategies were developed prior to the growing discussion on “whole-of-system” approaches in health, and only the Strategy for Health Systems based on the values of Primary Health Care makes explicit reference to it. The other strategies relate only to single technical areas, although they all use the health system framework or refer to WHO’s six health system building blocks.
The WHO Secretariat itself is structured vertically in units focused on specific disease or technical areas that often do not consult each other sufficiently. Even the work of the health system technical teams is not integrated and this is not appreciated by countries. Three of eight key informants in the Philippines and four of eight in Papua New Guinea commented that the WHO Secretariat has a highly vertical structure, which undermines the system-wide message, and the separate health system strategies may also contribute to this problem (TD4, TD17). “Even the DHS Unit is part of that vertical structure” (PHL), “WHO is still working in programmes” (PNG) (TD17, 18).
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Box 10. “Whole-of-system” approaches Any system involves elements such as inputs, processes, flows, outputs and outcomes. Systems thinking is about the interconnectedness of all parts of the system. “Whole-of-system” approaches acknowledge the complexity of government systems within which the health system operates and the interrelationships between its elements. The objectives are balance, coordination and optimal system functioning to best achieve desired system outcomes. Systems in any area of functioning are nested and overlapping. For example, the system of health financing falls within whole government financing system, overlaps with social protection, national supply and regulatory systems, within the overall national economy. For a health decision-maker, “whole-of-system” approaches means assessing the impact of a decision or change in one part of the system on other parts of the system; for example, increased demand will require access to additional resources, the introduction of new equipment will have running and maintenance costs; will need staff skills for effective use and laboratory capacity to analyse results; patient acceptance of the new equipment may also be important. A “whole-of-system approach” in health also ensures that each facility and level of the system is used most effectively; for example ensuring primary care services are used when appropriate rather than more expensive hospital services if not necessary. For this to work, other systems are also needed, such as information, referral and management systems to achieve quality services in the most efficient manner. It also means ensuring sufficient funds are allocated to each level of service within the system. Paraphrased from: Western Pacific Regional strategy for health system based on the values of Primary Health Care. WHO, 2010.
3.b Gaps in guidance on policy options Although the WHO health system strategies are sources of evidence-based policy options, these need to be adapted to each country’s particular health, social and economic contexts. The health system strategies were regarded by ADB interviewees as standards that are not fully achievable, applicable or relevant to some lower-income countries. There is little guidance in the strategies on how they may best be adapted to these or any other contexts (TD18). There exist areas of dissonance between WHO’s health system approaches and policies and those of other development partners, as well as between different partners. Together, these potentially present policy options to Member States, but they can be confusing and decisions can be skewed if they are linked with funding, as they often are. The WHO health system strategies presently offer little advice to the countries on how to decide between different policy options (TD18).
3.c Gaps in working with non-state and non-health sectors Summary analyses of WHO regional and country office activities suggest that multi-sectoral approaches constitute less than 1% of reported activities at both levels (Appendix 7, TD16). The six health system strategies lack guidance on multi-sectoral working, social determinants of health and on the role of nonstate actors in health. Health system development and health outcomes depend not only on health-specific statutory bodies and actions, but on non-state actors such as the health-related private sector, civil society, non-governmental organizations and other sectors related to social determinants of health, such as nutrition, housing,
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WPR/RC64/9 page 61 Annex 1 environment, education, economy and employment. Thus moving towards improved health outcomes requires a multi-sectoral approach to health system development. Four development partner interviewees stressed the importance of looking in particular towards the nonstate sector in health, which plays a significant role in many countries. However, they felt that the WHO Secretariat currently has a lack of experience in engaging with sectors outside of state health system (TD18). This may be an area in which the WHO Secretariat should seek to develop its, evidence base, methods and capacities
3.d Gaps in knowledge management The Review found that while WHO is strong on technical knowledge, it is weak in gathering and synthesizing knowledge about each country’s particular health and socioeconomic context, and knowledge of previous health system development work, whether by the country, by the WHO Secretariat or by other partners. There is information everywhere, but not well enough synthesized to be practically useful. This was evident in the review process as it was hampered by a lack of systematic recording of Secretariat activities and their impact, and of countries health system development. The desk review of Secretariat activities at regional and country levels revealed some duplication, or activities that were poorly sustained or sequenced (TD5, TD10, TD14, TD15). Only a limited amount of the information the Secretariat has about a country is available on the country pages of the Western Pacific Region’s website. Instead, most country information is on the website pages of individual programmes or technical units. For example, the health financing country profiles 19 that the Western Pacific Region prepared over recent years are not on the country web pages but on the health care financing page. The recent NCD country profiles 20 are not on the country web pages, but on the NCD programme pages. Given that the institutionalization of national health accounts (NHA) has become a WHO priority globally and in the region, completion of NHA in countries had not been documented at the Regional Office in the Western Pacific. The two experienced technical staff comprising the health care financing team, and new to the office, were not able to find any summary overview on NHAs from previous WHO staff. Moreover, health system information available at the Secretariat is not comprehensive. For example, the Western Pacific Region does not have documented, or readily to hand, overviews of country health financial protection benefits packages, or laboratory services, or development partner work in the countries. Similarly, history of country health system development does not seem to exist, except to some extent in the recently-completed reviews in the series Health Systems in Transition 21, produced by the Asia Pacific Observatory on Health (presently available for four countries). One reason could be high staff turnover in WHO regional and country offices. Between 2004 and 2012, 49 new members of staff filled health system positions in the Regional Office and 54 in the ten country offices. This was a mix of replacements and new posts. Each year during 2004 to 2012r, an average of 29% (range 12% to 54%) of all the WHO health system positions in the Region had turnover with new staff. The tacit 19 20
WHO Western Pacific Region. HCF country profiles website: http://www.wpro.who.int/health_financing/en/index.html WHO Western Pacific Region. NCD country profiles website: http://www.wpro.who.int/noncommunicable_diseases/documents/ncd_in_wpr/en/index.html 21 Asia Pacific Observatory. Website: http://www.wpro.who.int/asia_pacific_observatory/hits/en/
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WPR/RC64/9 page 62 Annex 1 knowledge that is essential to inform health system work often resides with individual WHO staff members and is often lost when they leave. Despite this, there are no systematic means of recording work and handing over to facilitate orientation of new staff for the provision of consistent, continuous and seamless support (TD14). (F3e) The problem of poor knowledge management and institutional memory was also raised in key informant interviews. In Cambodia, an interviewee expressed frustration “…we spent a lot of time providing background and context of our health system [to consultants] but then the consultant has ended. A new TA [technical advisor] came in and we have to brief the TA on the context and background again. We are very tired of doing this and it is often a waste of our time.” An interviewee in the Philippines commented that the frequent turnover of WHO staff means that work is sometimes forgotten (TD17). The importance of personalities and staff orientation was also reflected. “The main frustrations stem from personalities rather than differences in strategies or approaches ” said an AusAID interviewee in Papua New Guinea. A UNICEF interviewee felt that “a lot of the problems, as well as a lot of the good work, are personality-led” (TD18). “For both WHO and UNICEF, there is a need for better oriented staff on our mandates and roles. There should be proper orientation for new staff before sending them to assignments” (UNICEF) (TD18).
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WPR/RC64/9 page 63 Annex 1
3.e Gaps in information on strategy indicators All six of the regional health system strategies recommend indicators that can be used to determine progress in implementation and towards health system strengthening. Monitoring these or similar indicators provides opportunities for countries to see their current status and progress in health system strengthening. However reliability of data on indicators requires robust civil registration and vital statistics (CRVS) for accurate denominators, but CRVS is not strong in many of the Review countries. Around 37 of the 122 indicators in the six strategies are not used by countries and neither are they collected by the WHO Secretariat (Table 4). Some strategies recommend qualitative indicators that may be difficult to collect or open to interpretation. Indicators most commonly used by the countries are two of the four in the finance strategy, and about 30 of the 40 in the Strategy on Health Systems Based on the Values of Primary Health Care, which are proposed globally by WHO as a set for monitoring health system performance. Out-of-pocket expenditure is the only indicator proposed in more than two of the strategies, albeit with different targets, emphasising its overall importance as a key indicator for monitoring universal health coverage and as a proxy for equity. Table 4. Number and level of indicators in the six regional health system strategies Strategy Level of Indicators Total Input * Output Outcome Impact Monitoring equity # In the HS-PHC list of 40 HS-PHC Values 40** 5 8 19 8 7 Health Financing ‡ 4 1 2 1 1 1 33 2 HR Framework 17 15 2 Laboratory Strategy ‡ 14 12 2 Essential Medicines Framework 26 15 10 1 2 3 25 Traditional Medicines Strategy 21 21
2 2 12
none none Not yet collected
none none 13
With up-to-date data available for most countries in the Region
‡ Cover Asia-Pacific (two WHO regions: South East Asia and Western Pacific) * Input, output, outcome and impact indicators are in line with the Health System Performance Framework – See Tables 1 and 2, and Appendix 12 for full list of indicators ** Review is using 47 health system performance indicators to measure universal health coverage, a list very close to the original 40. # Monitoring equity with disaggregation by any social stratifiers; or out-of-pocket payments (the health financing strategy suggests OOP should be no more than 30-40% THE; the essential medicines framework recommends less than 50%
Senior WHO staff working on information systems indicate that within countries health information is fragmented by function, disease or condition, donor, or global health initiative. There is little data integration and sharing with lack of clarity of data ownership. MDG, NCD, and other health indicator reporting is challenging, expensive and often incomplete. Thus while valuable data are often gathered, availability of useful information for decision-makers is poor. While the collection of data on Health System Performance remains fragmented in countries and linked to single strategic areas in the WHO secretariat, opportunities to identify system-wide opportunities for DRAFT REPORT – NOT FOR CIRCULATION OR CITATION – 04 Sept
WPR/RC64/9 page 64 Annex 1 improved health outcomes are lost. For example, data relating to access to essential medicines is linked to health care financing (prices and costs to patients; system expenditure) and health service delivery availability of drugs at facilities for care).
3.f Hospitals neglected WHO in the Western Pacific Region has provided surprisingly little support on hospital functioning or service delivery. Country office input has included assistance with MOH work on treatment guidelines; medicines and labs procurement systems; and management-related workshops for health professionals. There are significant opportunities for increased efficiency in health spending through reductions in hospital wastage in use of tests, more expensive procedures and drugs, and length of admission. With the increasing interest of the private sector in health there is a proliferation of hospitals which may not be the most effective or efficient way to meet population needs. Growing interests in medical tourism also has implications for the home population in terms of the use of health workers and access to services. Associated with these and other health system issues relating to hospitals, there is substantial scope for increased research and evaluation and for more assistance from WHO.
3.g Gaps in responsiveness to WHA and RCM resolutions The Regional Committee Resolutions that endorsed the six health system strategies list actions requested of the Member States (TD2) and WHO Secretariat (TD3). The number of actions requested in the resolutions ranges from two for essential medicines to 47 for human resources. Appendices 7 and 8 show summarised partial mappings of Member States and Secretariat health systems work against the resolution requests. The two strategies with the lowest number of requests for action, essential medicines (with two) and laboratory services (with six or seven), have the highest proportion completed and by more countries. For the other three strategies, action has been taken on less than 50% of the resolution requests, and for many resolution requests, no actions have been taken. However, the significant differences in level of detail in the resolution requests causes problems with this analysis. Work against Regional Committee Resolutions is also an example of an area that the Review team would have expected the WHO Secretariat to monitor on a regular basis. Instead, the analysis was inhibited by overall lack of recording. The partial information collected appears to indicate that WHO Secretariat accountability to the RCM is not specifically related to the resolutions (TD2, TD3).
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F. Discussion on findings This section addresses the Review’s fourth Objective: Identify major lessons learnt regarding WHO support to health system development. It considers the findings on the first three objectives and seeks to identify lessons and their implications for future health system work.
Framework arising from the Review Since its foundation, WHO has acquired an international reputation as a knowledge-based technical agency. “Technical support” is one of the Secretariat’s six core functions.22 The health system strategies present evidence-based technical information to assist policy dialogue and technical support. A key purpose of technical support is to help bridge the “know-do gap” between countries knowing something and the practical application of that knowledge in the specific country context. In Figure 2, effective technical partnership incorporates this along with all the Secretariat core functions and the working relationship between the Secretariat and Member States. A premise of the Review at its outset was that much of the information needed to answer the Review questions, particularly on strategy implementation, and previous health system work in countries, ought to have been available from the WHO Secretariat itself. Over the year of the Review, and with feedback from the steering group and representatives of WHO Secretariat and Member States, the framework in Figure 2 emerged as a result. Although developed while looking at use of regional health system strategies, the framework can be applied to WHO Secretariat work in general, and is hoped to be useful in the ongoing organizational reforms.
Figure 2. Knowledge and processes for effective technical partnership
This Review shows clearly how important the gathering, creation and use of knowledge is. Three aspects of knowledge - WHO’s technical knowledge and learning networks, knowledge about each country and its context, and knowledge about the WHO Secretariat’s processes and current and previous work in countries - are dynamically interlinked. For effective technical partnership between the WHO Secretariat and Member States, strength in all three spheres of knowledge is vital. 22
WHO (2006). Engaging for Health: 11th General Programme of Work 2006-2015, A Global Health Agenda.
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WPR/RC64/9 page 66 Annex 1 The three spheres also cover the three domains of the Review: a) inputs by countries, the WHO Secretariat and development partners; b) trends on indicators; and c) lessons for the future. All the findings presented in the previous section E, can also be arranged by this framework, and this Review process strongly indicates that all three spheres of knowledge and related processes, need to be strong for WHO regional health system strategies to be of optimum use to Member States. Each of the three areas of knowledge is explained below with a brief summary of related Review activities. The subsequent discussion on the Review findings follows the framework structure.
Sphere One: Technical knowledge and learning networks The six regional health system strategies covered by this Review are separate documents that crystallize and synthesize available evidence and technical knowledge on the topic area, as relevant to the Region, and as adjusted and agreed to by the Member States, through endorsement by the Regional Committee. Thus the strategies are not purely technical, but also politically adjusted and agreed. In looking to the future, there will be changing roles for Member States in the generation of technical and process knowledge that will inform progressive system development. Rapid sharing and wide dissemination of this knowledge and lessons in translation to country contexts is likely to be achieved through extensive learning networks and effective technical partnership between WHO Member States and Secretariat. In line with objective 2, the Review included a content analysis of the six health system strategies (TD4), 23 their use in national health plans (TD5), WHO disease programme strategies (TD6), and the strategies of several development partners (TD7). The use and application of a strategy in a specific country invariably requires adaptation to the country’s social, political and economic context as represented by the overlapping in Figure 2 of the technical sphere with the country sphere.
Sphere Two: Knowledge about the country and its context Adapting technical knowledge and planning effective technical partnership work needs information about the country and its socio-economic, political, demographic and epidemiological contexts, technical capacity, and development partner work (if any). In line with objectives 1 and 3, the Review examined information on several aspects of country health system development and performance including: timelines of key events that have impacted health system development (TD8); burden of disease (Appendix 18); information on indicators included in each of the strategies (Tables 1 and 2; Appendices 13 to 17; TD10 to 12); disaggregated data available in publications of national health statistics (TD12), health system assessments such as joint annual health system performance reviews (TD9), and summaries of partner work in the countries (TD13).
Sphere Three: WHO Secretariat processes and work history in the country In line with objectives 1 and 3, the health system work undertaken by WHO regional and country offices in the ten participating countries during 2004 to 2012 was explored through desk reviews and discussions with WHO staff (Appendices 6 and 7 and TD14 to 16). Key informant interviews were undertaken with 61 23
All numbers in italics and brackets throughout the text refer to numbered technical documents listed in Appendix 2.
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WPR/RC64/9 page 67 Annex 1 country officials, 12 development partner representatives and ten WHO staff (Appendix 6 and TD17, 18, 19). Information on the country and its context, along with what, when, why and to what extent previous work has been successfully undertaken (or not), both by the WHO Secretariat, and by partners (TD13) forms the basis for planning and sequencing future health system work in the country. This is represented by the overlap in Figure 2 between the country sphere and the WHO Secretariat work sphere. Lessons on what works and does not work in individual countries also influence future planning as well as being important to strengthen or extend technical knowledge generally, as represented by the overlapping of the technical sphere and the WHO Secretariat work sphere.
The center: Effective technical partnership Effective technical partnership acknowledges the role and capacity of Member States, and refers to all the WHO Secretariat core functions: leadership in global health, evidence based-policy options, norms and standards, technical support, monitoring health trends, research and knowledge generation. The key to preparing for the future is to build a resilient Regional health sector on a strong values base consistent with WHO’s founding principles. The core values of WHO will become more important in guiding actions to address the complexity of future challenges. Moving away from current hierarchical models of health development to more networked approaches, which capitalizes on the growth of knowledge and experience across the Region and increases the flow of knowledge and lessons within and between Member States, will assist in enhancing this resilience. The Review strongly indicates that all three spheres of knowledge and the related processes need to be strong for the regional strategies to be of optimum use to countries to build health system resilience to cope with future challenges and unpredictable bends in trends. Better knowledge management does not mean more data but more concise information, more useful for practical applications.
Organization of the discussion The discussion in the remainder of this section follows the framework presented in Figure 2, covering all three spheres of knowledge and related processes, as follows: 1. The findings on objective 1 (strategy implementation) fit with the two spheres on country and context, and Secretariat processes and work in countries. 2. The findings on objective 2 (usefulness of the strategies) fit with the two spheres on country and context, and on technical knowledge and learning networks. 3. The findings on objective 3 (gaps) also fit with the two spheres on country and context, and on technical knowledge and learning networks. 4. The discussion itself is related to objective 4 (lessons)
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F1. Discussion: Knowledge about the country and context 1.a Region sets context for the future The Western Pacific faces a multitude of health, social and environmental problems. The population is ageing and the Region is home to about one third of the world’s population and nearly half live in urban areas. 24 The health care and social security costs associated with noncommunicable diseases have the potential to overwhelm health systems already under stress, 25 as reflected by the Review findings in section E. In tandem, the need to address infectious and vector-borne diseases continues., and advances in medicine and health Summary of findings from section E: technologies are matched by rising public demand for Country health system features: better services and new treatments. • gradual Increases in data available The Region also grapples with mounting negative effects of climate change, on-going natural disasters, zoonoses and other public health risks and emergencies. These often hit hardest the poorest in societies, who have the least resilience to recover. The Region has experienced and learnt from the emergence of SARS (severe acute respiratory syndrome) and avian influenza, with the economic and international consequences of these outbreaks. Considered together, factors such as these present all countries, rich and poor, with serious, perhaps unprecedented, challenges for funding and equitable provision of health services. The rise of noncommunicable diseases, anti-microbial resistance and increasing inequities demonstrate failures in prediction, recognition and system actions, in health and other sectors, even in developed countries. • overall progress on indicators • insufficient disaggregated data to adequately monitor health equity • where there is data, considerable inequities are evident • some key events are linked to changes on indicator trends • generally increases in government expenditure, and decreases in OOP • EM and HRH data difficult and/or expensive to collect • outpatients receiving antibiotics exceeds 10% target in all 6 Review countries with data • antibiotics available without prescription in 8 Review countries WHO’s information on countries is: • not organised by country • located with programmes – both health system and disease • not easy to find • not comprehensive • weak on history of country health system development
These challenges and the extensive range of experiences also present opportunities as the capacity for knowledge generation within the Region has the potential to inform health systems development world-wide.
1.b Primacy of country context and country plans The regional health system strategies are considered of value by many, but several interviewees in countries and development partner agencies regard them as standards too difficult or not relevant for some countries, while others use them for evidence-based ideas, benchmarks and tools for advocacy World Health Statistics 2010. Geneva, World Health Organization, 2010. Bloom D E, Cafiero E T , Jané-Llopis E, et al (2011).The Global Economic Burden of Noncommunicable Diseases. Geneva: World Economic Forum. 25
24
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WPR/RC64/9 page 69 Annex 1 (TD17, TD18). Each country context must be considered and understood, and the strategy concepts and recommendations adapted accordingly – if indeed the country decides that any are appropriate and achievable in the coming timeframe. Yet the strategies provide little assistance on adapting to different country contexts. Advice in the WHO health system strategies on how countries can decide among various policy options is primarily in terms of key values and principles. WHO could assist countries better if it also acknowledged the policy choices put forward by other development partners when they differ from those of WHO. Explanations on arguments for and against different policy options, particularly in specific country contexts, would be useful for countries, which can experience the negative effects of partner competition,. Health policy reflects economic development, and policy support can only succeed when it is realistic (TD19). While Member States may endorse WHO health system strategies, they may be unable to adopt them, or may only do so in an aspirational way with the costs and practicalities of implementation not sufficiently considered (TD18, TD19). Table 3 (pp 31-32) shows that countries’ national health plans contain many of the health system strategies’ recommendations (TD5). Although this may suggest good awareness of the strategies, it does not necessarily demonstrate appropriate adoption or feasibility of strategy elements in the countries. Frank discussion with Member States on options for action is needed when planning and sequencing health system development in countries. Getting the right balance between extending population access to services and meeting demands for technological health-care advances is a challenge for all countries as they strive for both health equity and continuing progress towards universal health coverage. Achieving this balance is dependent upon contextspecific national health system planning and financing. The example from Cambodia in Box 7 emphasizes that country success often result from actions on multiple fronts. Health systems that emphasize primary care, public health and health promotion are best suited to provide the preventive and educational interventions and access to long-term support necessitated by ageing populations and noncommunicable diseases facing the region. Future health system work may need to focus more on supporting countries in developing comprehensive national health plans covering the whole health sector for integrated services delivery using whole-ofsystems approaches relative to the country context. Effectiveness mandates that health systems engage with sectors outside of health, such as social protection, education, employment, transport, urban design, housing, trade and agriculture. Broader health system work could guide countries on where to focus to benefit from wider sectoral engagement in each country context.
1.c Accelerate improving country health system trends A key health stewardship role is monitoring health system functioning and impact on health outcomes. Tables 1 and 2 and Appendices 13 to 17 present information collected by countries on health system status and progress. However, continued weaknesses in national civil registration and vital statistics put some of this data in doubt. Greater WHO support and country stewardship are needed to reduce fragmented data collection, often stimulated by donors. Stewardship needs good intelligence for policy and management.
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WPR/RC64/9 page 70 Annex 1 Using the data that is available, all countries have shown progress in health system performance. However, there are continuing problems with data quality and reliability. CRVS and data collection must be strengthened, and countries need to assess whether they are satified with their levels and speed of progress in health system development and health outcomes.
1.d A new country focus for WHO Secretariat’s information Despite being a knowledge-based organization and attempting to be country-focused, the WHO Secretariat’s knowledge management can be much improved. This is apparent not least in the organization’s websites. The Review found that while WHO is strong on technical knowledge, it is weak in gathering and synthesizing knowledge about each country’s particular health and socioeconomic context, and knowledge of previous health system development work, whether by the country, by the Secretariat, or by other partners. Difficulties in bringing this information together mean that WHO health system staff do not have a ready basis for adapting strategies or sequencing work for specific country contexts. The WHO Secretariat needs to put more effort into practical steps to being more country focused - not only bringing country information together, or making it searchable by country, but regularly synthesizing it for ready use by staff, consultants and the international community. Regular country focused briefings on individual countries, for all professional staff in the Regional Office would also be of benefit.
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F2. Discussion: Technical knowledge and learning networks 2.a WHO’s breadth of health knowledge WHO is mandated as the leading international technical agency for health, and aims for close working relationships with other UN agencies and development partners. It is unique in covering a wide range of diseases and programmes as well as health systems within the one organization. However, the Review findings show that the WHO Secretariat is not always a good role model for Member States. Integrating services, linking better across disease programmes and using “whole-ofsystem” approaches are areas of technical knowledge that WHO needs to crystalize and document, along with related lessons. Sharing and application of these areas of knowledge could help country accelerate progress in developing resilient health systems and positive health outcomes. Summary of findings from section E: The regional health system strategies are: • • • • • technical, evidence-based knowledge expressions of WHO values used by countries for evidence-based ideas and advocacy for policy makers used in national health plans used in 14 WHO regional programme strategies and frameworks A sense of cohesion or a “whole-of-system” approach explanation of policy options in specific contexts guidance on country adaptation sequencing of steps to take links to social determinants of health working with the non-state sector in health working with hospitals coherent monitoring and evaluation on health system strategy indicators
Gaps in strategies and health system work: •
2.b Meeting strategy gaps in future
The regional strategies are syntheses of evidence on • health system development and expressions of WHO values. The WHO Western Pacific Regional Office has • been proactive in strategy development. It responded • • promptly on the relationship between health costs • and poverty, and the first regional Health Financing • Strategy (2005 – 2010) included universal coverage • (Appendix 3). In response to the human resources crisis, the Western Pacific Regional Office developed its first regional human resources strategy when there was no WHO global strategy and while WHO HQ was preparing the World Health Report 2006, Working Together for Health. The Regional Strategy on Health Systems based on the Values of Primary Health Care brings the details of two separate global documents on health systems 26 and primary health care 27 together into one overall strategy. There is no similar WHO global strategy (TD4). 28 Despite these initiatives and innovations, the six Western Pacific regional health system strategies are separate documents, of different styles in their layout and content, and with significant gaps considering future needs. They do not form a coherent set, nor adequately support “whole-of-system” approaches (TD4). This latter concept may not have been strong when the strategies were developed, but “whole-ofsystem” approaches (Box 10) are considered to be important for resilience in future health system functioning (see section D). The Strategy for Health Systems based on the Values of Primary Health Care explicitly lists the values important to the WHO Secretariat in its guidance to Member States on health system development. Most 26 27
WHO (2007). Everybody’s business: strengthening health systems to improve health outcomes. WHO (2008). World Health Report 2008. Primary Health care: Now More Than Ever. 28 All numbers in italics and brackets throughout the text refer to numbered technical documents listed in Appendix 2.
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WPR/RC64/9 page 72 Annex 1 country national health plans include, and thus reaffirm these WHO values. One of the few unifying factors across the six strategies is the overarching goal of universal access or coverage and related health equity – the underlying WHO value being health as a human right. The core values of WHO will become more important in guiding actions to address the complexity of future health challenges. In many countries in the Region, the private sector plays a significant role. WHO health system strategies could provide more advice to countries on the stewardship needed to harness private sector potential in assisting with national health objectives and enacting sufficient controls to mitigate negative impacts on health equity. Currently, this technical knowledge is missing from the strategies. Even before the commission in 2008 on social determinants of health, 29 WHO has expressed an overall recognition of the importance of the social determinants of health. However, the six regional health system strategies contain little on interaction with other sectors or on promoting health in all policies. The ongoing transitions and anticipated challenges in health mean that future approaches to country health system development will not be able to overlook these critical social dimensions or engaging with the non-state sector in health. Transformative ways of working are needed to overcome the failures in forecasting, recognition and action that are represented by escalating problems such as non-communicable diseases, anti-microbial resistance and inequities in health.
2.d Knowledge generation and learning networks Some informants expressed a need for a stronger evidence-base for WHO’s health system strategies. More monitoring, evaluation and research in health system development is needed to assess which approaches really work and which do not in various country contexts. In 2010, the MOPAN review on WHO found that while WHO was just adequate in reporting on lessons learned, it was inadequate in sharing lessons from practical experience across the Organization. 30 So there is a significant area of improvement for the WHO Secretariat, which also presents an opening for different ways of working. The Western Pacific is increasingly significant in terms of global population and bearing a major part of the global disease burden. This poses both challenges and opportunities for the Region to inform health system development worldwide. In the future, more health system knowledge generation will emerge directly from within the Western Pacific Region and be shared directly between countries. This will be facilitated more by a networked model of health development rather than the current hierarchical one. Networked approaches can more adequately capitalize on the growth of knowledge and experience across the region. Increases the flow of information and practical lessons within and between Member States will assist in enhancing system development and resilience. Countries’ different points in the various transitions can be an advantage for the Region. For example, Japan’s experiences of how to care for an older population can be instructive for other countries in the years ahead, if lessons on what works and what does not work are documented and disseminated.
29 30
WHO, 2008, Closing the gap in a generation: Health equity through action on the social determinants of health MOPAN (2010). MOPAN Common Approach Institutional Report for the World Health Organization (Finding 19, page 45). http://www.mopanonline.org/upload/documents/WHO_Final-Vol-I_January_17_Issued1_1.pdf The Multilateral Organisation Performance Assessment Network (MOPAN) is a network of 17 donor countries with a common interest in assessing the organisational effectiveness of the major multilateral organisations they fund.
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WPR/RC64/9 page 73 Annex 1 WHO Member States and the Secretariat need to apply lessons learned from past work. The Secretariat has an imperative role to facilitate knowledge and learning networks among a wide range of stakeholders that generate, synthesize and use knowledge and information. Better knowledge management does not mean more data but more concise information, more useful for practical applications.
F3. Discussion: WHO Secretariat processes and work history in countries 3.a WHO health system strategies and work valued by countries The six Western Pacific regional health system strategies are valued and used by Member States for evidence-based ideas, bench-marks and to support advocacy. Trust in the competence of technical staff, and soundness and evidence-base of advice offered, are also critical. Use and utility of the strategies cannot be considered in isolation from the systems and contexts in which they are used. During key informant interviews for this Review, it is WHO staff, rather than the strategies, that are considered most important in assisting progress in health system development. The Review found several examples of direct use of the regional strategies in informing development of country health system policies or plans. Further, most of the national health plans of the ten Review countries include many of the recommended actions and principles from the strategies. Whether these are realistic and funded for implementation needs further monitoring that is not yet being undertaken by the WHO health system teams. Summary of findings from section E: WHO's health system work: • is valued by countries o supports resource mobilization o tackles sensitive issues o initiates global developments • is criticised as being vertical • does not cover actions in resolutions Secretariat mechanisms are needed to: • document and synthesise knowledge • avoid duplication, identify gaps or sequence activities • harvest tacit country knowledge before staff leave • orient staff to health system development in the country • maintain independence of advice
3.b Coordinated health system work As noted in 2.a above, the breadth of WHO knowledge and experience across all aspects of health programmes and system functioning can be considered a comparative advantage of WHO. The WHO health system framework notes the importance of interactions among system components, or “whole-of-system” approaches (Box 10).
• improve Secretariat accountability to Because programmes are involved in service delivery, how the Regional Committee health systems best incorporate programme approaches is an important aspect of technical knowledge. Yet this is not covered in the six health system strategies. The Review attempted to collect examples of health system work undertaken in countries by more than one of the health system teams together – but failed. This reinforces comments from both country and development partner interviewees that the WHO Secretariat works vertically and does not integrate its approaches , even within the health system team.
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WPR/RC64/9 page 74 Annex 1 The Review identifies that the WHO Secretariat could do more to assist countries in sequencing and implementing health system improvements in an integrated manner for all programmes in balance with the burden of disease, rather than continuing with vertical approaches . On a more positive note, and as mentioned earlier, disease programmes, being an integral part of the health system, often engage in health system work and are incorporating health system concepts into their own strategies.
3.c Synthesizing health systems work in countries Throughout this Review, it was found that recording and synthesis of the Secretariat’s health systems work is poor. It must be acknowledged and appreciated that much of what WHO staff do in terms of policy dialogue and influence is not easily recorded or measured. Even so, information on previous WHO Secretariat activities is not easily available for staff except at a high level, such as the Regional Director’s reports, or at a very detailed and disjointed level in the integrated computer reporting system. And neither of these forms of reporting is organized by country. With a lack of synthesized knowledge on previous health system work in a country, lessons learned can be easily lost. The efficiency of Secretariat work in that country is likely to be reduced, with potential duplication and gaps, or poor sequencing. This was noted repeatedly as the Review team attempted to follow work streams. This was corroborated by key informants who reflected that while WHO is strong in areas where there is a strong staff member, when that staff member leaves, programmes and work areas tend to falter and fail. Compounding this, the format for formal reporting on the Secretariat’s work and results in the integrated computer system has changed for each of the current and previous two biennia, meaning, for example, that information on countries included in baselines, targets and achievements in health system work across the biennia has not been adequately documented anywhere (Western Pacific Region senior staff).
Box 11. Knowledge management: An urgent problem In 2011, the WHO Executive Board acknowledged that “As a knowledge-based Organization, WHO’s ability to deliver results is dependent upon staff having rapid and easy access to information, evidence and experts. While considerable effort has been invested in improving access to administrative information, country-specific knowledge tends to be inadequately shared – contributing to the compartmentalization of WHO’s work. In an era of ever-more powerful means of communication, through electronic and other mass media, this is an urgent problem to address. Staff need to be able to access up-to-date information on what the Organization is doing, on a wide range of technical issues, and on how to access relevant expertise.”* * WHO reforms for a healthy future: Report by the Director-General. Executive Board Special session on WHO reform (Oct. 2011)
This general problem has been evident for some years 31 and was acknowledged by the WHO Executive Board in 2011 (Box 11). “The fragmented knowledge base, typical of international organisations, is reflected
31
Lucas A, Mogedal S, Walt G, et al (1997). Cooperation for Health Development: The World Health Organization’s support to programmes at country level, Summary Report.
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WPR/RC64/9 page 75 Annex 1 in WHO’s technical and organisational systems, structure and culture.” 32 Poor recording and knowledge management are compounded by staff turnover, as explained in the next section.
3.d Supporting WHO staff The regional health system strategies inform the work of WHO staff, but it is the work of the staff themselves rather than the strategies, that the key informant interviews indicate as being more important in supporting health system development. Key informants described long-term, trust-based relationships between Ministries of Health and WHO, resulting in adaption and adoption of strategy recommendations over time. The personal skills, strengths and weakness of individual staff, and their day-to-day relationships with counterparts and partner agencies, influence collaboration on health system work. Interviewees from seven development partner agencies commented on the importance of people and personalities in WHO’s work. However, over-reliance on individuals can also be a weakness. These comments are echoed in another recent WHO evaluation. 33 Staff turnover compounds loss of institutional memory of country context and WHO’s previous work in countries. Both the spheres of Secretariat knowledge related to countries (Figure 2) can be diminished by a high rate of staff renewal. This is especially so when there is not good information on the Secretariat’s work in countries, as well as that of partners and the countries themselves. This lack of information challenges proper orientation of new staff to continue moving work forward in the most appropriate manner for the country. WHO staff turnover also poses difficulties for development partners and national counterparts, in terms of maintaining effective communication and relationships between agencies. This points to a need for more Secretariat work in teams and networks, and less complete reliance on individuals. In summary, WHO staff can be supported by better technical (as distinct from administrative) orientation to country contexts; better information on Secretariat and country health systems work, progress and impact; and more team approaches to technical support and partnerships.
3.e Secretariat accountability to the Regional Committee An important political consensus is forged by WHO Member States when major strategies are endorsed and requirements for progress reporting are specified by the Regional Committee. A strategy that is both technically robust and has the backing of Member States is more valuable than a purely technical strategy. This political process also impacts on the technical advice – it is not only “evidence-based” but has been modified (appropriately) by a collective political process. For example, the current target agreed by Member States in the Western Pacific on OOP is less than 30% of THE, 34 even though best evidence indicates that less than 20% of THE is needed to mitigate negative impact on equity. 35
32
Barrett M, Fryatt B, Walsham G, et al (2005). Building bridges between local and global knowledge: new ways of working at the World Health Organisation, KM4D Journal 1(2): 31-46. (http://journal.km4dev.org/index.php/km4dj/article/viewFile/22/18) 33 WHO Western Pacific Region (2012). Placing Countries at the Centre: A report on a fresh approach to assessing WHO country performance in the Western Pacific Region. 34 WHO Western Pacific Region (2010). Health Financing Strategy for the Asia-Pacific Region 2010-2015. 35 WHO (2010). World Health Report 2010. Health systems financing: the path to universal coverage.
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WPR/RC64/9 page 76 Annex 1 Nevertheless, the Review found that the Regional Committee resolutions do not appear to guide either Member State or Secretariat health systems work (Appendices 8 and 9). However, this finding has to be treated with caution due to the lack of systematic Secretariat recordings as mentioned in E3.d and discussed above. WHO Secretariat mechanisms could support better monitoring and recording for stronger and more candid feedback and accountability to the Regional Committee, specifically on the actions the Committee requests of the Secretariat. This feedback could be coordinated across programmes and health system work, progress and impact, with a country-specific focus.
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F4. Discussion: Effective technical partnership All the discussion and issues so far influence this how WHO Member States and the Secretariat work together in developing and applying regional health system strategies for effective system functioning and better health outcomes – the central feature of the framework presented in Figure 2. A 1997 review in 12 countries across four WHO regions found that WHO was not strategic in its work at country level. 36 In 2012, an evaluation of three WHO country offices in the Western Pacific Region 37 came to the same conclusion, and further noted that WHO staffing is both a strength and a weakness; health system support is not strong enough; and the WHO Secretariat’s productivity is hampered by its own culture and systems. This review has made similar findings and further identified problems in the Secretariat’s internal knowledge management and weak accountability to the Regional Committee. Agility in both thinking and procedures is required to identify and capitalize on windows of opportunity. Significant concerns were repeatedly raised by country, development partner and WHO staff key informants, on the slow and cumbersome nature of WHO Secretariat procedures hampering smoothness and efficiency of WHO work. In this technological age, and in this rapidly-progressing region, WHO needs to be more agile. Further, excellent knowledge of the country, its context, and WHO’s previous work are also necessary for taking the most appropriate action to maximize impact when opportunities arise. As mentioned in F2.a, the breadth of WHO's knowledge and activity represents an opportunity that WHO can build upon. WHO’s expertise and experience in and across health system components is unique. By advocating for and supporting integrated services and system development through “whole-of-system” approaches (Box 10) relevant to each country and its context, the WHO Secretariat can more fully realize this potential comparative advantage. More support for health stewardship Development partners suggest that WHO could do more to strengthen ministries of health and health system governance. Indeed, governance is only briefly covered in the Regional Strategy for Health Systems Based on the Values of Primary Health Care (2010), with some components in the other strategies. On the other hand, it could be said that all six strategies and action frameworks are entirely about health sector governance. Two ADB interviewees felt that in countries the basic problem of poorly-functioning ministries of health is not being addressed: departments do not talk to each other, each having its own territory, and this issue of vertical areas of work undermines efforts in health system strengthening. WHO is ideally placed close to governments to address this, but it seldom happens effectively because of the “soft hand” approach preferred by WHO, not being explicitly critical of government or ministry actions when necessary (TD18).
36
Lucas A, Mogedal S, Walt G, et al (1997). Cooperation for Health Development: The World Health Organization’s support to programmes at country level, Synthesis Report. 37 WHO Western Pacific Region (2012). Placing Countries at the Centre: A report on a fresh approach to assessing WHO country performance in the Western Pacific Region.
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G. Summary of Review findings and implications for WHO Review findings Lessons and implications for WHO 1. Technical knowledge and learning networks • The regional health system strategies present technical, evidence-based knowledge, express WHO values, and have endorsement of the Western Pacific Regional Committee.
• • • • • • • • • • • • •
The strategies and WHO support are appreciated and used by countries for ideas and support for advocacy, Strategy recommendations or actions are widely found in national health plans, However, the strategies are also viewed by some as standards to aspire to, but too difficult for some countries to implement The strategies do provide guidance on adaptation to specific country contexts, nor sequencing of steps for implementation. In addition to the gaps in (e) above, the strategies do not provide a strong whole-of- system approach, and contain little or nothing on: explanation of advantages and disadvantages of different policy options in specific contexts working with the non-state sector in health links to social determinants of health hospitals Although all the strategies have suggested indicators, many are not used by countries and not collected by the WHO Secretariat. The strategies monitor and present information on their indicators in different ways, it is not a “linkedup” approach. A collective framework is not used to monitor strategy implementation or indicators. Strategy recommendations or actions are found in 14 WHO regional programme strategies
Future health system work could direct more efforts into frank discussion with countries on applicability of strategy recommendations and sequencing of steps for feasible implementation in the country context
Health system knowledge generation and sharing is likely to change in the future with more knowledge emerging directly from the Region and shared directly between countries. The WHO Secretariat has a role to facilitate such learning networks
Future health system strategies could provide more explicit advice and examples on working with other sectors on health. Health system strategies could provide more advice on working with the private sector to achieve national health objectives and to effectively mitigate associated negative impacts on equity. Countries will benefit from a more coherent WHO approach to monitoring progress in health system development in each country and focusing on indicators most useful to the country, with disaggregated data to monitor equity. The WHO Secretariat could benefit from mechanisms to obtain most up-to-date, or preferably “live” data on country health systems. This is a good basis for reducing verticality within the Secretariat and country programmes in a whole-ofsystem, balanced and coherent way across the health system components and their interactions with each other.
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Review findings 2. Knowledge about the country and context • • Extreme regional diversities
Lessons and implications for WHO
• • • •
• • • • • •
•
•
•
Work more with individual countries on their policies, plans and implementation taking into account the countries’ unique contexts. A greater normative role for the Secretariat in middle- and Few low-income countries in the region high-income countries, for example on balancing levels of service access in relation to burden of disease; increasing standards and safety; reducing inequity; controlling costs and reducing wastage. Support learning networks for more sharing lessons between countries at different stages in the various transitions. Most of the Review countries do not have systems Support countries to establish robust systems for civil for accurate and comprehensive civil registration and registration and vital statistics for accurate denominators vital statistics for indicators and social stratifiers. There is insufficient disaggregated data readily Support countries to collect and analyse disaggregated available in countries or WHO to monitor equity adequately. data on at least a small set of key health system Where there is data, considerable inequities are evident performance indicators to monitor equity. There are gradual Increases in data available and Continue to monitor a set of health system overall progress on indicators in the 10 Review performance indicators that the country finds useful. countries – However these positive trends cannot be Support countries to collect at least some standard attributed with any certainty to the regional health indicators on quality of care. system strategies or to WHO work. Data shows general increases in government expenditure on health, and decreases in OOP as a percentage of THE Essential Medicines and human resources data difficult and/or expensive to collect This has serious implications for Anti-microbial Outpatients receiving antibiotics exceeds 10% target resistance (AMR) and needs rapid and concerted in all six Review countries with data efforts by Member States. Antibiotics available without prescription in 8 Review countries Support countries to avoid or mitigate any further Fragmentation in health system undermining of health system coherence through unbalanced funding from global health initiatives Support countries to engage with the private sector Growing role of the private sector towards national health objectives, but regulate and control to mitigate negative effectives on equity. Technical and advocacy briefs to explain market failure in health to politicians. Regional health system work adapt global strategies to In the Western Pacific Region, WHO health systemspecific country contexts, for more country focus. related knowledge on countries is fragmented, Regular summaries of WHO health system work and scattered, submerged, not comprehensive, not progress in each country. Use these summaries for synthesized and not readily available to countries, orientation of all country office staff, and by all partners or WHO staff for orientation or to programmes in planning their country work – whether strategically plan health system work. by staff or consultants. Organize more of country information that the Most of the country information the Secretariat has Secretariat has, by country as well as by programme. is not organized by country, but is located with Combine the different Secretariat country web pages programmes – both health system and disease to one single comprehensive web page for each country. programmes. Systematically work with countries to improve Significant information on country health system is knowledge in more areas of health system structure missing. and functioning in each country, based on their priorities, e.g. laboratory and other diagnostic services, benefit packages, accreditation systems, and so on.
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WPR/RC64/9 page 80 Annex 1
Review findings • • complexity of future challenges health issues feature highly among future social risks
Lessons and implications for WHO
Work with countries on global and national emerging issues with broad engagement of stakeholders.
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WPR/RC64/9 page 81 Annex 1
Review findings Lessons and implications for WHO 3. Secretariat processes and history of work in the country a) Health system work is generally appreciated, but it is also criticized for functioning in a vertical manner.
b) The WHO Secretariat has no systematic processes for recording and synthesizing its health system work over time in an individual country.
The WHO Secretariat can act more as a role model and follow its own advice to Member States. By demonstrating that it can integrate itself across health system teams, and across different programmes, the Secretariat can provide a powerful message to countries
c)
The review found evidence that over the years WHO health system work in the Western Pacific Region has supported significant resource mobilization for country health system development; tackled sensitive issues and initiated some global developments. d) The way WHO works with ministries and development partners tends to depend on individual relationships, and work often falters when those individuals leave. Staff turnover reduces institutional memory of country context and WHO’s previous work. This contributes to poor staff orientation for work in countries, and creates the danger of not following through on or duplicating previous work. e) If WHO is too close to a ministry of health, it can lose its independence and its ability to advise the MoH on difficult or sensitive issues. Further, the special relationship with health limits work in other sectors on social determinants of health. f) g) There are mixed messages about WHO support in coordination of development partners’ work. The activities requested by the Western Pacific Regional Committee in its resolutions endorsing the regional health system strategies do not appear to be systematically followed by the WHO Secretariat or Member States.
WHO and Member States could benefit from improved Secretariat mechanisms that: i. document and synthesize the Secretariat’s previous and current health system work in countries; ii. avoid duplication, identify gaps and sequence WHO and country health system activities; and iii. support health system to become learning systems Countries could benefit from more Secretariat efforts in dissemination of success stories on effectively using funding from Global Health Initiatives in health system development.
WHO Secretariat mechanisms are needed to: i. harvest tacit country knowledge before staff leave; ii. orient staff to health system development in the country; and iii. work more in teams and networks to reduce reliance on individuals.
WHO Secretariat mechanisms are needed to: i. maintain independence and evidence-base of advice ii. ensure staff are capable of being both a friend and a critic to countries iii. have easier access for working with other sectors on social determinants of health WHO can put more effort into building countries’ capacity in their leadership and governance roles. WHO Secretariat mechanisms are needed to: ensure stronger and more candid feedback and accountability to the Regional Committee, specifically on the actions the Committee requests of the WHO Secretariat
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WPR/RC64/9 page 82 Annex 1
Review findings Lessons and implications for WHO 4. Effective technical partnership between WHO Member States and Secretariat • • Effective technical partnership needs all three spheres of knowledge as presented in Figure 1. WHO is most efficient with technical knowledge and less so at documenting, synthesizing and sequencing its own health system work in countries.
•
•
WHO agility and flexibility is essential for capitalizing on windows of opportunity – and excellent knowledge of the country, its context, and WHO’s previous work is also necessary for taking the most appropriate action when opportunities do occur. However, WHO agility is limited by its cumbersome and time-consuming procedures. The WHO Secretariat is also criticized for inadequate sharing of lessons learned.
i. Support health system changes for new technologies and patterns of care ii. more rationally balanced systems centered on people, with a stronger preventive approach, and use public health and primary care more effectively iii. Strong engagement by health ministries in other sectors such as urban planning iv. WHO can progress in strengthening all three spheres of knowledge in order to make its technical support more relevant to countries, effective and efficient, and with more sustainable impact. v. Strong engagement by health ministries in other sectors such as urban planning vi. System-wide approaches will be increasingly required within the health sectors of Member States and multi-sectoral approaches will become ever more important. Many WHO procedures are attempts to ensure efficiency, effectiveness and accountability. However, this Review demonstrates that these efforts may be counter-productive. It may be in the spheres of country knowledge and knowledge of WHO’s own work in countries where greatest gains in efficiency and effectiveness may be achieved. Bridging the “know-do gap“, an important purpose in technical support, is facilitated by sharing wellpresented lessons. More of the health system team’s work could be dedicated specifically to this. Move to a more networked model of health development, which capitalizes on the growth of knowledge and experience across the Region and increases the flow of knowledge and lessons within and between Member States
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WPR/RC64/9 page 83 APPENDICES
Appendices Appendix 1 is a short briefing paper developed at the beginning of the Review process to explain what the review was about. Appendices 3 to 18 are excerpts from the technical documents listed in Appendix 2, and which form the evidence base of this summary report and reflect the breadth, depth and detail of the Review exercise.
Appendix 1. Review of Regional Health System Strategies Briefing Paper Appendix 2. Health system strategies Review work and documents Appendix 3. Context of developing regional health system strategies and frameworks Appendix 4. Main goals, high-level objectives and strategic areas of action in each of the six regional health system strategies Appendix 5. Quotes on UHC from national health plans of 10 Review countries Appendix 6. Influence of WHO on health system policies or key events (motivation, development or implementation) reported by national Key Informant interviewees Appendix 7. Focus of Western Pacific WHO Regional and country office health system activities by WHO core functions Appendix 8. Partial indication of country health system activities mapped against actions requested of Member States in World Health Assembly and Regional Committee Resolutions related to six regional health system strategies Appendix 9. Partial indication of WHO country office health system activities mapped against activities requested of WHO in World Health Assembly and Regional Committee Resolutions related to the six regional health system strategies Appendix 10. Summary of links between WPRO disease programme strategies and six regional health system strategies Appendix 11. Summary of links between strategies of five development partners and concepts in six health system strategies Appendix 12. Reference information on indicator fixed points used in Tables 1 and 2 in section D. Review Findings Appendix 13. Status of 10 Review countries on essential medicines indicators, 2011 baseline Appendix 14. Status of 10 Review countries on human resources for health indicators, most recent data from 2004-2011 Appendix 15. Status of nine Review countries on health financing indicators Appendix 16. Status of 10 Review countries on indicators recommended in the Traditional Medicine Strategy, 2011 Appendix 17. Status of 10 Review countries on health equity, available data from 1993-2011 Appendix 18. Proportion of deaths in the 10 Review countries, 2010
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WPR/RC64/9 page 84 Appendices
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WPR/RC64/9 page 85 APPENDIX 1
Appendix 1. Review of Regional Health System Strategies Briefing Paper
Review of Regional Health System Strategies Six regional health system strategies under review
Over recent years the Division for Health Sector Development, in consultation with Member States of the WHO Region for the Western Pacific, has produced six regional strategies and action frameworks related to health system. All the strategies have one common goal – to support the attainment of universal coverage and equity in health outcomes. The timeframes for most of the strategies extend to 2015, the deadline for the Millennium Development Goals. This Review will examine the extent to which the health system strategies and action frameworks are effective in supporting countries to achieve universal coverage. Findings will be presented at the 64th Regional Committee Meeting in 2013. Review objectives
Six regional strategies and frameworks • Regional Framework for Action on Access to Essential Medicines in the Western Pacific 2011-2016 • Regional Strategy on Human Resources for Health 2006-2015 and Human Resources for Health Action Framework for the Western Pacific Region 2011-2015 • Health Financing Strategy for the Asia-Pacific Region 2010-2015 • Asia Pacific Strategy for Strengthening Health Laboratory Services 2010-2015 • Western Pacific Regional Strategy for Health Systems Based on the Values of Primary Health Care (2010) • Regional Strategy for Traditional Medicine in the Western Pacific Region 2011-2020
The Review will identify where progress has been made, where it has been slow, and why. Member States will be able to appraise their individual and collective progress on strengthening health system and use the evidence for decisions in their countries and for future guidance to the WHO Secretariat. 1. Review implementation of key policies and programs related to the six Key issues: regional health system strategies by countries, WHO and partners 2. Assess the usefulness of the six WPRO health system strategies to • Equity countries, WHO and partners • Services 3. Identify gaps and future needs to inform appropriate WPRO health • Efficiency system development approaches • Quality 4. Identify major lessons learned regarding WHO support to health system • Safety development • Financial protection Three dimensions of the Review
a. Identify inputs by WHO, countries and partners b. Establish trends on indicators
Qualitative review of progress on selected actions in each of the strategies and related RCM resolutions. Data for the past 15-20 years on key health system performance and health outcome indicators to see country and regional trends. Where possible, data disaggregated by social stratifiers will be used to appraise health equity.
c. Assess utility and identify lessons learned
Contribution and usefulness of the WHO strategies to country actions, processes and health outcomes. The focus will be on ways to enhance future health system work in support of universal coverage and health equity.
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WPR/RC64/9 page 86 Appendix 1 Timeframe
Data collection and analysis will be completed by May 2013. Findings will be presented at the 64th Regional Committee Meeting 2013.
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WPR/RC64/9 page 87 APPENDIX 2
Appendix 2. Health system strategies Review work and documents The following Technical Documents have been produced during the course of the Review. They report the methods and findings of individual Review elements. The numbers are used to cite these Technical Documents in this Summary Report Technical Documents WHO Western Pacific Region Health System Strategies Review initiation document Summary of WHA and Western Pacific RCM resolutions on health system development; actions for Member States (2004-2011) Summary of WHA and Western Pacific RCM resolutions on health system development; actions for WHO Secretariat (2004-2011) Content analysis of six current WHO Western Pacific regional health system strategies Analysis of national health policies and plans of 10 Review countries against six WHO Western Pacific regional health system strategies Comparison of Western Pacific regional disease programme strategies with Western Pacific regional health system strategies Comparison of Western Pacific regional health system strategies with development partner strategies Key events in 10 Review countries that significantly impacted on their health system development and functioning (1990-2011) Summary of health system assessment in four Review countries Analysis of health system performance indicators for 10 Review countries Data on health system performance indicators for 10 Review countries 1994-2012 Proportion of deaths in the 10 Review countries, 2010 Review of disaggregation in published national health statistics of eight Review countries 20002012 Overview of eight development partners’ health system work in the Western Pacific Region 2004June 2012 Desk review of WHO Western Pacific Regional Office health system work (2004-2012) Submission by eight WHO Western Pacific country offices of their health system work Summary of Western Pacific regional and country office health system activities by WHO’s six core functions Summary of key informant interviews in eight Review countries, 2013 Summary of key Informant Interviews with eight development partner agencies, 2013 Summary of five WHO Western Pacific staff interviews on policy dialogue experiences 2012 Future issues on health system, Don Matheson 2013 Number TD1 TD2 TD3 TD4 TD5 TD6 TD7 TD8 TD9 TD10 TD10 TD11 TD12 TD13 TD14 TD15 TD16 TD17 TD18 TD19 TD20
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WPR/RC64/9 page 88 Appendix 2
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WPR/RC64/9 page 89 APPENDIX 3
Appendix 3. Context of developing regional health system strategies and frameworks Context Regional health system strategies Traditional Medicines Strategy 2002 - 2010 Essential Medicines Strategy 2004 Existing WHO global strategy 2002 - 2005 Guide to develop national drug policy, 2001; World Medicines Situation, 2004 WHR 2000: HS improving performance; CMEH 2002 * Nursing and Midwifery Strategic Directions 2002-2010; WHR 2006: Working Together Persistent problem of insufficient access to medicines Assistance with access and poverty, and low investment in health HR crisis – need for effective strategies on health workforce production and retention Need to reduce fragmentation and progress on MDGs WHR 2010: HCF and UHC Everybody's Business 2007; WHR 2008: PHC Now More Than Ever Nursing and Midwifery Strategic Directions 2011-2020; 2010 Code of Practice World Medicines Situation, 2007 Embedding drug policy in the overall health care system Emphasis on universal coverage Other WHO global documents Demand from countries Innovation
2000 - 2003
Health Financing Strategy 2006 - 2010
No
Human Resource for Health Strategy 2006
No
Laboratory Strategy 2010-2015 Health Financing Strategy 2010 - 2015 Health Systems based on the Values of PHC 2010 Human Resources for Health Framework 2011 Essential Medicines Framework 2011 Traditional Medicines Strategy 2011 - 2020 WHR = World Health Report; WHA = World Health Assembly;
No
No No
2009 – no end date 2004 - 2007 2008 - 2013
Need operational perspective Need to control international recruitment Move from policy to action Extensive use of Traditional Medicine; challenges with quality, safety, efficacy
Laboratory services critical cross-cutting support integral to health system; Indicators Universal coverage; Indicators with target Brings together health system and PHC – not done elsewhere Indicators Traffic light presentation of indicators Indicators
Not current
UHC = Universal health coverage; HS = Health System;
PHC = Primary Health Care;
* Commission on Macroeconomics and Health 2002.
This table is table 2 in the Content analysis of six current WHO Western Pacific regional health system strategies (See Technical Document – 4 in Appendix 2 of this report).
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WPR/RC64/9 page 90 Appendix 3
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WPR/RC64/9 page 91 APPENDIX 4
Appendix 4. Main goals, high-level objectives and strategic areas of action in each of the six regional health system strategies Western Pacific Regional Strategy for Health Systems Based on the Values of Primary Health Care (2010) Core values Equity Social justice Universality People-centeredness Community protection Participation Scientific soundness Personal responsibility Self-determination Self-reliance Four goals of a health system Six Health System Building Blocks • health, both absolute across the entire population • leadership and governance and equity across socioeconomic groups • health-care financing • social and financial risk protection in health • health workforce • responsiveness and people-centeredness • medical products and technologies • efficiency • information and research • service delivery Health Financing Strategy for the Asia-Pacific Region (2010-2015) Four target indicators (1) out-of-pocket spending should not exceed 30%–40% of total health expenditure; (2) total health expenditure should be at least 4%–5% of the gross domestic product; (3) over 90% of the population is covered by prepayment and risk pooling schemes; and (4) close to 100% coverage of vulnerable populations with social assistance and safety-net programmes. Regional Strategy on Human Resources for Health (2006-2015) updated in 2010 by Human Resources for Health, Action Framework for the Western Pacific Region (2011-2015) Three Key result areas (KRA) KRA 1: Health workforce response to population health needs KRA 2: Health workforce education and continuing and competence KRA 3: Health workforce deployment, management and retention KRA 4: Health workforce governance and partnerships for sustained HRH contributions to improved health outcomes. Asia Pacific Strategy for Strengthening Health Laboratory Services 2010-2015 Seven key strategic elements 1. Establish a coherent national framework for laboratory services. 2. Finance laboratory services in a sustainable manner. 3. Build capacity for laboratory services. 4. Assure the quality of health laboratory services. 5. Promote the rational use of laboratory services. 6. Improve laboratory safety. 7. Support research and ethics in laboratory settings. Regional Framework for Action on Access to Essential Medicines in the Western Pacific (2011-2016) Strategic action areas National medicines policy and medicines regulation; medicines procurement and supply system; substandard and counterfeit medicines; adequate financing and affordable prices; intellectual property rights and international trade agreements Regional Strategy for Traditional Medicine in the Western Pacific Region (2011-2020) Five key strategic objectives 1. to include traditional medicine in the national health system; 2. to promote safe and effective use of traditional medicine; 3. to increase access to safe and effective traditional medicine; 4. to promote protection and sustainable use of traditional medicine resources; and 5. to strengthen cooperation in generating and sharing traditional medicine knowledge and skills.
This table is Appendix 2 in the Content analysis of six current WHO Western Pacific regional health system strategies (See Technical Document – 4 in Appendix 2 of this report). DRAFT REPORT – NOT FOR CIRCULATION OR CITATION – 04 Sept
WPR/RC64/9 page 92 Appendix 4
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WPR/RC64/9 page 93 APPENDIX 5
Appendix 5. Quotes on UHC from national health plans of 10 Review countries The Review examined the national health plans of the 10 participating countries for explicit or implicit references to universal health coverage – the uniting goal of the health system strategies. It found that all ten contained such references to UHC principles including access to quality services, equity, safety and financial protection. Cambodia: “The day-to-day activities of health managers and staff… should be guided by… social health protection, especially for the poor and vulnerable groups [and] client-focused approach to health service delivery.” Health Strategic Plan 2008-2015, Ministry of Health. China: “The implementation of the five priority reform programmes aims at effectively solving the problem of ‘difficult and costly access to health care services’.... efforts will be made to improve the service quality of public health care institutions and to meet the demand of the people to have ‘convenient and affordable access to health care services’.” Implementation Plan for the Recent Priorities of the Health Care System Reform 2009-2011, Ministry of Health (translation). Fiji: “The Strategic Plan has been developed [so that] communities [will] have access to effective, efficient and quality clinical health care and rehabilitation services…Government has recognized the need to strengthen health-care services and through the Peoples Charter has made a commitment to have an annual increase to the health budget.” Strategic Plan 2011-2015: Shaping Fiji’s Health, Ministry of Health. Lao PDR: “We have to…implement health strategy by giving priority to prevention and health promotion and at the same time, by giving importance to good quality in treatment and universal health service coverage.” The Seventh Five-Year Health Sector Development Plan 2011-2015 Ministry of Health. (Provisional Non-Official Translation). Malaysia: “Health sector development key result area – Health sector transformation towards a more efficient and effective health system in ensuring universal access to health care.” Country Health Plan 20112015: 1 Care for 1 Malaysia, Ministry of Health. Mongolia: “The mission of the Ministry of Health is the commitment to contribute to poverty alleviation and socio-economic development by ensuring the delivery of quality health care that is equitable, user -friendly, evidence-based and sector-wide, to improve the health status of all the people of Mongolia… especially to the poor and to areas in greatest need.” Health Sector Strategic Master Plan 2006-2015, Ministry of Health. Papua New Guinea: “The National Health Plan 2011-2020 [is a] demonstration of our commitment to strengthen primary health care for all, and improve service delivery for the rural majority and urban disadvantaged.” National Health Plan 2011-2020: Transforming our health system towards Health Vision 2020, Ministry of Health. Philippines: “Inequity is a pervasive problem in our country… We are now pursuing the goal of… universal health care to overcome inequities in our health system and delivery better health outcomes.” National Objectives for Health 2011-2016, Department of Health. Solomon Islands: “Universality – All residents of the country must be entitled to the health services provided by the nation’s health sector on uniform terms and conditions…the recent increase in funding for the health sector has been dramatic…. Both as a percentage of GDP and the percentage of government total revenues the allocations to health are high for a country… relative to countries of similar socio-economic levels.”.” National Health Strategic Plan 2011-2015, Ministry of Health and Medical Services. Viet Nam: “To promote preventive medicine and primary health care in the new situation, assuring people access to quality basic health services.” Five-Year Health Sector Development Plan 2011-2015, Ministry of Health. This is part of Analysis of national health policies and plans of 10 Review countries against six WHO Weston Pacific regional health system strategies (See Technical Document – 5 in Appendix 2 of this report).
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WPR/RC64/9 page 94 Appendix 5
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WPR/RC64/9 page 95 APPENDIX 6
Appendix 6. Influence of WHO on health system policies or key events (motivation, development or implementation) reported by national Key Informant interviewees During the semi-structured key informant interviews in eight Review countries, interviewees were asked to select key events or policies that they considered to have had significant influence on health system development. Their views were sought on whether WHO was involved or of influence in the chosen events or policies at three stages: the catalyst or motivation for the event or policy; its subsequent development; its implementation. In the third column of the table, diamonds represent the number of events or policies discussed by interviewees in eight event or policy areas. In subsequent columns the diamonds represent WHO involvement or influence at each of the three stages of the events and policies as perceived and reported by the interviewees. Health policy or event area KHM CHN LAO MYS PHL PNG SLB VNM LAO MYS PHL PNG VNM KHM LAO VNM VNM KHM CHN LAO PHL PNG VNM PHL VNM KHM MYS LAO PHL SLB VNM Number of policies/events discussed by interviewees Number of policies/events for which WHO was mentioned as catalyst or motivation Number of policies/events for which WHO was mentioned in development Number of policies/events for which WHO was mentioned in implementation
National Health Plans, general health system policy, Primary Health Care, quality & safety
Medicines / health technologies
Human Resources for Health Laboratories
Financing
Traditional medicines Health information / research Reproductive / Maternal & Child Health
This is Table 1 in Summary of key informant interviews in 8 Review countries (See Technical Document – 17 as listed in Appendix 2 of this report).
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WPR/RC64/9 page 96 Appendix 6
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WPR/RC64/9 page 123 APPENDIX 18
Appendix 18. Proportion of deaths in the 10 Review countries, 2010 The following graphs summarize the proportion of deaths in 2010 for the 10 countries covered by the WHO Review of six Western Pacific regional health system strategies. The diseases are grouped according to their main categories – communicable diseases (shades of red), noncommunicable diseases (shades of blue) and injuries (shades of green). The area of the Boxes refers to the proportion (per cent) relative to the total number of deaths. All data are based on the Institute for Health Metrics and Evaluation downloaded 12 July 2013 from: http://www.healthmetricsandevaluation.org Guide for disease categories used in graphs: Cancer = Neoplasms Cardio & Circ = Cardiovascular and circulatory diseases Chronic Resp = Chronic respiratory diseases Cirrhosis = Cirrhosis of the liver Diarr+LRI+Oth = Diarrhoea, lower respiratory infections, meningitis and other common infectious diseases Digestive = Digestive diseases (except cirrhosis) DUBE = Diabetes, urogenital, blood and endocrine diseases HIV+TB = HIV/AIDS and tuberculosis Intent Inj = Self-harm and interpersonal violence Maternal = Maternal disorders MSK = Musculoskeletal disorders Mental = Mental and behavioural disorders Neonatal = Neonatal disorders Neuro = Neurological disorders NTD+Malaria = Neglected tropical diseases & malaria Nutr Def = Nutritional disorders Oth NCD = Other noncommunicable diseases Oth Comm = Other communicable, maternal, neonatal, and nutritional disorders Transport = Transport injuries Unintent Inj = Unintentional injuries other than transport injuries Proportion of deaths in China, both sexes, all ages, 2010
Proportion of deaths in Cambodia, both sexes, all ages, 2010
Proportion of deaths in Fiji, both sexes, all ages, 2010
Proportion of deaths in Lao PDR, both sexes, all ages, 2010
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WPR/RC64/9 page 124 Appendix 18 Proportion of deaths in Malaysia, both sexes, all ages, 2010 Proportion of deaths in Mongolia, both sexes, all ages, 2010
Proportion of deaths in PNG, both sexes, all ages, 2010
Proportion of deaths in the Philippines, both sexes, all ages, 2010
Proportion of deaths in Solomon Islands, both sexes, all ages, 2010
Proportion of deaths in Viet Nam, both sexes, all ages, 2010
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WPR/RC64/9 page 125 ANNEX 2
Draft Action Plan for Healthy Newborn Infants in the Western Pacific Region (2014–2020)
WHO Regional Office for the Western Pacific Manila, Philippines
WPR/RC64/9 page 126 Annex 2
WPR/RC64/9 page 127 Annex 2
1. Introduction: Why do we need to focus on newborn infants? ............................................................... 129 2. What simple, cost-effective interventions would prevent newborn deaths? ........................................... 130 2.1 The First Embrace: A healthy start for every newborn baby ............................................................... 131 2.2 Prevention and care of preterm or low birth weight (LBW) babies ..................................................... 132 2.3 Prevention and care of sick newborn infants ....................................................................................... 133 3. If EENC interventions are available, why do newborn infants continue to die? ................................... 134 4. If constraints are prevalent, what can we do? ......................................................................................... 134 5. Regional Action Plan ............................................................................................................................. 135 Strategic Action 1: Ensure consistent adoption and implementation of Early Essential Newborn Care .................................................................................................................... 137 Strategic Action 2: Improve political and social support to ensure an enabling environment for Early Essential Newborn Care .................................................................................................................... 140 Strategic Action 3: Ensure availability, access and use of skilled birth attendants and essential maternal and newborn commodities in a safe environment ......................................................... 142 Strategic Action 4: Engage and mobilize families and communities to increase demand ......................... 144 Strategic Action 5: Improve the availability and quality of perinatal information .................................... 145 6. The way forward .................................................................................................................................... 147 APPENDIX 1: Early Essential Newborn Care (EENC) ............................................................................ 149
WPR/RC64/9 page 128 Annex 2
Acronyms ANC BFHI CoE CPAP DHS EENC EmOC HIV HMIS IMCI LBW MNCH MDG MICS NGO NMR PROM SBA UNICEF UNFPA WHA WHO antenatal care baby-friendly hospital initiative centre of excellence continuous positive airway pressure Demographic and Health Survey Early Essential Newborn Care emergency obstetric care human immunodeficiency virus Health Management Information System Integrated Management of Childhood Illness low birth weight maternal, newborn and child health Millennium Development Goal Multiple Indicator Cluster Survey Nongovernmental organization neonatal mortality rate prelabour rupture of membranes skilled birth attendant United Nations Children's Fund United Nations Population Fund World Health Assembly World Health Organization
WPR/RC64/9 page 129 Annex 2
1. Introduction: Why do we need to focus on newborn infants? While the arrival of a newborn baby should be cause for great happiness and hope, in the Western Pacific Region, one newborn infant dies every two minutes (Table 1). Table 1. Number of neonatal deaths and neonatal mortality rate in selected countries in the Western Pacific Region* Country Number of neonatal deaths (thousands) Neonatal mortality rate (deaths per 1000 live births) 8.7 12.2 11.9 19.4 22.6 17.5
China Philippines Viet Nam Cambodia Papua New Guinea Lao People’s Democratic Republic All other 31 countries and areas in the Region
143.4 28.7 17.3 6.2 4.7 2.5 6.0
37 countries and areas in the Western 209 Pacific Region * A neonatal death occurs within the first 28 completed days of life. Source: Levels and Trends in Child Mortality - Report 2012. New York, UNICEF, 2012.
9
Countries in the Western Pacific Region reduced under-five deaths by 75% between 1990 and 2010. However, neonatal deaths have declined at a slower rate than child deaths. Consequently, neonatal deaths represent an increasing proportion of child deaths (54% in 2010), mostly from complications of preterm birth, asphyxia and infection (Figure 1). Two thirds of deaths occur in the first three days of life. Deaths concentrate among poor, rural and disadvantaged groups who are less likely to receive quality care.
WPR/R RC64/9 page 130 Annex 2 Figure 1. Causes of under-five u dea aths in the Western W Pacifi ic Region, 201 10
Global Health h Observatory y. Geneva, WH HO, 2012. Source: G
e, cost-effe ective inte ervention ns would prevent p ne ewborn deaths? d 2. What simple Im mproving the e quality of care c during and a immediat tely after birt th, known as s Early Essen ntial Newbor rn Care (EE ENC), could d save an esti imated 47 00 00 lives in the e Region eac ch year (Figu ure 2). Central to EENC is "The Fir rst Embrace e"—a protect ted and prol longed skin-to-skin cudd dle between mother and d baby, whic ch allows p proper warm ming, feeding g and cord care. c EENC also includ des care of high-risk h new wborn infants focusing g on preventi ion and care of preterm and a LBW bab bies, and of sick s newborn n infants (Ap ppendix 1).
WPR/RC64/9 page 131 Annex 2 Figure 2. Priority EENC interventions*
* See Appendix 1, Table 1.1 for detailed interventions.
2.1 The First Embrace: A healthy start for every newborn baby Mothers left undisturbed will instinctively cuddle their babies and put them to their breast. Babies cuddled in skin-to-skin contact become calm, pink and alert. All babies benefit including those preterm, sick or born by caesarean section. Aside from the natural bond it fosters, the First Embrace helps transfer warmth, placental blood, protective bacteria, and through colostrum, essential nutrients, antibodies and immune cells to protect from infection. Babies adapt better to extra-uterine life.
WPR/RC64/9 page 132 Annex 2 The components of The First Embrace are: immediate and thorough drying; immediate skin-to-skin contact; clamping the cord after pulsations stop, cutting the cord with a sterile instrument; and initiating exclusive breastfeeding when cues occur (such as drooling, tonguing, rooting, biting hand).1 Many inappropriate practices interfere with the baby's ability to adapt and feed well. Too often, unnecessary suctioning, immediate cord cutting and delayed drying increase the risk of newborn infants to delayed fetal-to-newborn circulatory adjustments, infection, breathing problems, hypothermia, anaemia, acidosis, coagulation defects, brain haemorrhage and trauma. Too often, newborn infants are distressed, hypothermic and exposed to dangerous bacteria because of separation from the mother. The first breastfeed is usually delayed because of incorrect sequencing of actions immediately after birth. Routine care such as vitamin K, eye prophylaxis, immunizations, examination and weighing should be delayed until after the first breastfeeding. Bathing should be delayed until after 24 hours of life.
2.2 Prevention and care of preterm or low birth weight (LBW) babies Each year in the Western Pacific Region, more than 1.7 million babies (5%–7% of all births) are born preterm or low birth weight (LBW), contributing an estimated 81 600 neonatal deaths. These babies have 20 times the risk of death as those of normal gestation due to increased vulnerability to hypothermia, infection, and breathing and feeding difficulties. The WHO Comprehensive Implementation Plan on Maternal, Infant and Young Child Nutrition, adopted in at the Sixty-fifth World Health Assembly in 2012, has a global target to reduce LBW by 30% by 2025. Prevention and care for preterm or LBW babies during the intrapartum period and first 24 hours after birth that save lives includes: 1
eliminating induction of labour and caesarean section without medical indication; intrapartum antenatal steroids and tocolytics; antibiotics for preterm prelabour rupture of membranes (PROM); Kangaroo Mother Care (KMC);
Baby-Friendly Hospital Initiative: Revised, Updated and Expanded for Integrated Care. UNICEF/WHO, 2009.
WPR/RC64/9 page 133 Annex 2 feeding with breast milk; and monitoring for complications.
Preterm babies who breathe well will benefit from the warmth of their mother's body. As such, they should receive The First Embrace immediately after birth and KMC thereafter. KMC is a simple cost-effective intervention in which the mother wraps the preterm baby (or babies) in skin-to-skin contact on her chest so that the baby is kept warm, is able to breastfeed and is protected from infections. These interventions can reduce preterm mortality by half and be used in all settings. Opportunities to manage preterm babies are often missed. Mothers in preterm labour often do not receive antenatal steroids to help preterm babies breathe better; and KMC and appropriate feeding for preterm babies are often not incorporated into routine practice leading to increased risk of pneumonia, diarrhoea, necrotizing enterocolitis, malnutrition and death.
2.3 Prevention and care of sick newborn infants Approximately 10%–15% of newborn infants will require skilled case management for infection, asphyxia, birth trauma, and complications of prematurity and congenital malformations. Implementation of The First Embrace and interventions to prevent preterm and LBW will prevent many illnesses in newborn infants (Appendix 1). However, prevention of newborn sickness is not always possible. After drying and initial skin-to-skin contact with the mother, about 3% of babies will not start spontaneous breathing. Health workers cannot predict which babies these will be. Newborn infants suffer when the resuscitation bag and mask are not set up in advance or the equipment is faulty. Despite the best preventative care, about 10% of newborn infants will require management for infections, complications of prematurity and other conditions. Newborn infections require immediate antibiotic therapy and supportive care. Poor management of sick newborn infants is often due to failure to identify danger signs and incorrect use and stock out of antibiotics. Most sick newborn infants can be managed at the first level of care2, district hospitals and first referral hospitals.3 Severely sick babies need referral tertiary care after stabilization (Appendix 1, Table 1-2).
World Health Organization; UNICEF. IMCI chart booklet – standard. Geneva, World Health Organization, 2008. World Health Organization; Pocket book of hospital care for children: Second edition. Guidelines for the management of common childhood illnesses. Geneva, World Health Organization, 2013. 3
2
WPR/RC64/9 page 134 Annex 2
3. If EENC interventions are available, why do newborn infants continue to die? Many health workers are unaware that simple steps can protect newborn infants. Some feel no matter what they do, fragile newborn infants will die. Others were taught harmful and outdated practices. In-service and pre-service trainings usually do not include sufficient instruction on quality EENC. Furthermore, trainings were often not practical and clinical practice-based. Newborn infants are often not counted by health systems in most low and middle income countries. Health facilities often do not report newborn deaths. Vital registration and information systems for reporting newborn status are undeveloped. Newborn infants dying in the community are often not named and their deaths not reported. In many countries in the Region, newborn care services are limited by gaps in essential health systems.4 Newborn health programmes often do not have full-time staff or coordination bodies to manage implementation, and EENC interventions are often not included in plans, laws, policies and standards. High out-of-pocket costs, a lack of facilities and infrastructure, inadequate numbers of trained staff and geographic inaccessibility impede many from giving birth in a facility. Essential medicines and commodities may not include those needed for EENC, or the supplies or supply chains may not be adequate. Insufficient coordination between obstetric and paediatric care complicates newborn care. Violations of the International Code of Marketing of Breast-milk Substitutes and related World Health Assembly resolutions are rampant globally. The pervasiveness of infant formula marketing and promotion undermines breastfeeding in all countries. Ineffective traditional practices and reluctance to seek help also lead to higher risks for infant death.
4. If constraints are prevalent, what can we do? Understanding what motivates key stakeholders—such as mothers, families and health workers—is necessary to move from the current level of care to high-quality EENC. Understanding health worker beliefs and practices needs focus to change delivery and postpartum management. Formative research can bridge the gap between knowing and designing new environments that facilitate practice of EENC.
4
Comprehensive needs assessment of newborn care in selected countries: cross-country report. Bangkok, UNICEF East Asia and Pacific Regional Office, 2013; Maternal and Neonatal Health in East Asia and the Pacific: Country Profiles and Case Studies. Bangkok, UNICEF East Asia and Pacific Regional Office, 2013.
WPR/RC64/9 page 135 Annex 2 Practice of EENC requires universal access to essential drugs, commodities, trained health staff, effective supervision, referral, and monitoring. EENC needs to be incorporated into pre-service training curricula. Collaboration and coordination among stakeholders is needed to effectively plan and implement EENC. National plans, budgets, standards, laws, information systems, supply systems and platforms for advocacy need to address health system bottlenecks. Eliminating industry and health professional conflicts of interest requires ministries of health, professional associations and academe to recognize and stand against such entanglements. Appropriate legislation regulating marketing of breast-milk substitutes is needed to protect the rights of the child. Changing cultural beliefs and care-seeking practices, including how newborn infants are valued and managed in the home, requires effective health promotion.
5. Regional Action Plan Vision: Mission: A healthy start for every newborn infant To strengthen the health system and to cultivate an enabling environment where skilled providers of newborn care5 value and practise EENC at every birth Goal: To eliminate preventable newborn mortality by providing universal access to highquality EENC Target 1: At least 80% of facilities where births take place are implementing EENC by 2020 in all Member States Target 2: At least 90% of births in all subnational areas are attended by SBAs by 2020 in all Member States Target 3a*: Target 3b*: National neonatal mortality rate (NMR) is 10 per 1000 live births or less by 2020 Subnational neonatal mortality rate (NMR) is 10 per 1000 live births or less by 2020
* Countries that have already met the target should set the lowest possible target they can feasibly reach by 2020. Countries with higher baseline mortality should set a 2020 target that is two to three times the current annual rates of reduction.
5
Skilled providers of newborn care include SBAs, nurses, midwives, paediatricians and inter-professional teams.
WPR/RC64/9 page 136 Annex 2 Five strategic actions support full implementation of EENC (Figure 3): 1. Ensure consistent adoption of EENC 2. Improve political and social support to ensure an enabling environment for EENC 3. Ensure availability, access and use of SBAs and essential maternal and newborn commodities in a safe environment 4. Engage and mobilize families and communities to increase demand 5. Improve the quality and availability of perinatal information
Figure 3. Framework of strategic actions for implementation of EENC
Source: WHO, 2013, Manila, WHO Regional Office for the Western Pacific
WPR/RC64/9 page 137 Annex 2
Strategic Action 1: Ensure consistent adoption and implementation of Early Essential Newborn Care The Challenge: Improving health worker practices requires planning, budgeting, clinical standards, training, systems support and quality improvement and accreditation mechanisms to create conducive environments. Plans also need to address financial barriers to access to EENC. Operational Objective 1.1: To ensure Early Essential Newborn Care has been incorporated into national and subnational health agendas, plans, budgets and financing mechanisms Actions for countries and areas 1. 2. 3. 4. 5. Indicators for countries and areas 1. 2. Appoint a full-time ministry of health focal person/coordinator for newborn health/EENC Establish or expand a technical working/coordination group to include EENC Incorporate EENC into existing maternal and newborn health policies and strategies Prepare a costed implementation plan for EENC that includes social marketing Advocate for financial protection of all EENC services Full-time ministry of health focal person/coordinator for newborn health/EENC appointed Technical working group/coordination group established or existing working group has taken responsibility for advocating for and planning newborn health/EENC activities National implementation plan with associated costs for EENC developed EENC included in public funding, insurance schemes or performance-based financing schemes, free of charge or at low cost Develop planning and costing tools for EENC including social marketing based on formative research Support countries to plan for expansion of EENC Proportion of countries with functional coordination bodies for newborn health/EENC Proportion of countries with a costed implementation plan for EENC Proportion of countries with financial protection mechanisms in place for EENC
3. 4.
Actions for WHO, UNICEF and other partners Indicators for WHO, UNICEF and other partners
1. 2. 1. 2. 3.
WPR/RC64/9 page 138 Annex 2
Operational Objective 1.2: To enable providers of newborn care to practise Early Essential Newborn Care at every delivery by providing appropriate system support and training Actions for countries and areas 1. Support health workers to adopt and apply EENC at every birth using effective adult-learning methodologies, monitoring, supportive supervision and communication Create settings conducive to practising EENC, including incentives Integrate EENC into pre-service education for midwives, nurses and physicians Ensure that training methodologies for EENC are participatory and practice based
2. 3. 4.
Indicators for countries and areas Actions for WHO, UNICEF and other partners
1. Pre-service and in-service newborn training guidelines/materials for EENC developed for health professionals and integrated into existing curricula 1. Support Member States to conduct formative research on the needs of providers of newborn care to practise EENC at every delivery 2. Revise existing WHO training materials on EENC and support training programmes to ensure health workers master these key skills 3. Develop methodologies to evaluate and strengthen monitoring (including EENC signal functions), supportive supervision, and communications based on formative research and social marketing 1. Proportion of countries incorporating EENC standards in: a. in-service training b. pre-service training c. monitoring and supportive supervision 2. Proportion of countries that have evaluated and updated their monitoring and supervisory system
Indicators for WHO, UNICEF and other partners
WPR/RC64/9 page 139 Annex 2
Operational Objective 1.3: To ensure Early Essential Newborn Care has been incorporated in clinical protocols, quality improvement cycles and accreditation mechanisms Actions for countries and areas 1. 2. 3. 4. 1. Update clinical protocols to incorporate EENC at all levels of care Include EENC in quality improvement mechanisms of health facilities Establish standards for infection prevention and control Incorporate EENC in accreditation and regulatory mechanisms Clinical protocols and quality of care mechanisms in health facilities are updated to fully include EENC Develop model clinical protocols Develop model quality measurement tools for implementation of EENC, including clinical observation tools, client exit surveys and record review
Indicators for countries and areas Actions for WHO, UNICEF and other partners Indicators for WHO, UNICEF and other partners
1. 2.
1. Proportion of countries with updated clinical protocols that fully include EENC 2. Proportion of countries utilizing EENC quality improvement tools
Operational Objective 1.4: To scale up centres of excellence implementing Early Essential Newborn Care Actions for countries and areas 1. Issue standards for centres of excellence (CoE) 2. Support hospital administrators and health professionals to adopt and monitor implementation of national policies and standards and strengthen systems for EENC 3. Strengthen implementation of national standards and guidelines on hospital infection control 4. Monitor hospital-acquired infections and birth-weight-specific case fatality rates in CoE based on national standards and guidelines 1. Number of CoE established 2. Trends in annual rate of newborn hospital-acquired infections in CoE 3. Trends in annual newborn birth-weight-specific case fatality rates in CoE 1. Develop criteria for establishing CoE 2. Develop tools and models for measuring quality of intrapartum and newborn care practices 3. Undertake research and publish results to validate implementation of EENC and perinatal outcomes 1. Proportion of countries with at least one CoE established 2. Proportion of countries with declines in annual rates of newborn hospitalacquired infections in CoE 3. Proportion of countries with declines in annual newborn birth-weightspecific case fatality rates in CoE
Indicators for countries and areas
Actions for WHO, UNICEF and other partners
Indicators for WHO, UNICEF and other partners
WPR/RC64/9 page 140 Annex 2
Strategic Action 2: Improve political and social support to ensure an enabling environment for Early Essential Newborn Care The Challenge: Adoption of EENC requires political commitment, support of key stakeholders, and financial investment, as well as strengthened legislation, regulations and enforcement.
Operational Objective 2.1: To mobilize political commitment and social support of key stakeholders for policies, programmes and services for the implementation of Early Essential Newborn Care Actions for countries and areas 1. Organize a core EENC stakeholder group to engage key political leaders and champions to support EENC, including policy-makers, legislators, health providers, hospital administrators, civil society leaders, development partners, media practitioners, academia and health professional associations 2. Establish and strengthen mechanisms to ensure members of professional associations are implementing EENC 3. Advocate sustained funding and resources for EENC 1. EENC stakeholder core group established and functioning 2. Proportion of professional associations involved in newborn care that monitor their membership for implementation of EENC 1. Support the development of a country template for engaging key stakeholders 2. Develop communication tools, materials and methods for the components of EENC, including campaign and communication strategies 3. Monitor and evaluate: a. changes in awareness of key stakeholders b. resources mobilized to support EENC implementation 1. Proportion of countries with an EENC stakeholder group established 2. Proportion of regional professional associations supporting EENC
Indicators for countries and areas
Actions for WHO, UNICEF and other partners
Indicators for WHO, UNICEF and other partners
WPR/RC64/9 page 141 Annex 2
Operational Objective 2.2: To strengthen legislation, regulations and enforcement to meet international standards to support implementation of Early Essential Newborn Care Actions for countries and areas 1. Strengthen legislation, regulations, enforcement and financing to institutionalize key international standards,6 including: a. International Code of Marketing of Breast-milk Substitutes; (International Milk Code) and related World Health Assembly (WHA) resolutions b. Baby-Friendly Hospital Initiative (BFHI) 2. Support health facilities where births take place to fully achieve BFHI
Indicators for 1. Enforcement of a complete ban on marketing of products covered under the countries and areas International Code of Marketing of Breast-milk Substitutes and related WHA resolutions 2. Number of violations reported and acted upon 3. Rates of initiation of breastfeeding in the first hour 4. Exclusive breastfeeding rates for six months, percentage of infants (aged 0–5 months) who are exclusively breastfed Actions for WHO, UNICEF and other partners 1. Provide technical support and guidance to countries to meet targets for compliance with international standards for marketing of products for infant and young child feeding 2. Prepare and disseminate regional reports to monitor progress on legislation, regulation and enforcement of international standards 3. Support countries to institutionalize BFHI as a necessary component of EENC 1. Number of violations reported and acted upon by country 2. Rates of initiation of breastfeeding in the first hour by country
Indicators for WHO, UNICEF and other partners
6
Key international standards include International Labour Organization (ILO) Maternity Protection Convention, 2000 (No. 183); conventions of the Committee on the Rights of the Child; Global Newborn Action Plan; and Global Strategy for Women's and Children's Health.
WPR/RC64/9 page 142 Annex 2
Strategic Action 3: Ensure availability, access and use of skilled birth attendants and essential maternal and newborn commodities in a safe environment The Challenge: Overcoming barriers to access of EENC requires provision of acceptable services, availability of skilled birth attendants, essential medicines, equipment, supplies and infrastructure with accessibility by mothers and newborn infants.
Operational Objective 3.1: To ensure availability of a skilled birth attendant for every delivery Actions for countries and areas 1. Ensure national plans and budgets address availability and retention of skilled birth attendants (SBAs) 2. Strengthen and sustain efforts towards equitable distribution of SBAs 1. Rate of skilled attendance at birth at national and subnational levels (disaggregated by relevant social stratifiers to monitor equity) 1. Support countries to evaluate the availability and distribution of SBAs and to improve plans for availability 1. Rate of skilled attendance at birth at national and subnational levels (disaggregated by relevant social stratifiers to monitor equity) per country
Indicators for countries and areas Actions for WHO, UNICEF and other partners Indicators for WHO, UNICEF and other partners
WPR/RC64/9 page 143 Annex 2
Operational Objective 3.2: To ensure availability of equipment, supplies, essential medicines and infrastructure for EENC in routine and emergency situations Actions for countries and areas 1. Review and update national essential medicines and supply lists to ensure that they include those required to implement EENC 2. Incorporate essential EENC medicines, commodities and infrastructure into existing monitoring systems to track availability, quality and affordability7 3. Track availability of EENC medicines, commodities and infrastructure by conducting regular facility assessments—including routine skilled delivery care and emergency obstetrics care (EmOC) assessments8 4. Improve the availability of EENC medicines, commodities and infrastructure—through improved ordering, procurement, distribution and facility upgrades 1. Essential medicines and supply lists include key EENC medicines and commodities 2. Availability of selected life-saving medicines and commodities for maternal and newborn care in facilities where births take place9 3. Availability of basic and comprehensive obstetric care services: at least five health facilities providing EmOC, including one comprehensive EmOCproviding hospital, per 500 000 population 1. Support countries to evaluate availability of essential maternal and newborn commodities, technology and infrastructure 2. Engage experts to recommend standards for high-priority issues such as spacing between patients, sources of clean water and clean toilets in facilities where births take place 3. Engage experts to develop a framework for strengthening effective referral systems with specific focus on mothers and newborn infants 1. Proportion of countries with 100% of selected facilities where birth takes place with no stock-outs of selected, life-saving medicines and commodities for maternal and newborn care
Indicators for countries and areas
Actions for WHO, UNICEF and other partners
Indicators for WHO, UNICEF and other partners
Pregnancy, childbirth, postpartum and newborn care: a guide for essential practice. Geneva, WHO, 2006. Monitoring emergency obstetric care: a handbook. Geneva, WHO, 2009. 9 Priority life-saving medicines for women and children 2012: Improving health and saving lives by ensuring access to priority medicines. Geneva, WHO, 2012; UN Commission on Life-saving Commodities for Women and Children. Commisioners’ report, September 2012. New York, 2012. 8
7
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Strategic Action 4: Engage and mobilize families and communities to increase demand The Challenge: Mothers, families and communities need to manage newborn infants appropriately in the home, and to demand skilled birth care and optimal care of their newborn infants.
Operational Objective 4.1: To increase community demand for skilled birth and newborn attendance and Early Essential Newborn Care Actions for countries and areas 1. Review and update policies, plans and programmes targeting communities by government, national and community NGOs, development partners and civil society 2. Develop a communication strategy to create positive values toward newborn infants: a. seek skilled attendance at birth, prepare themselves for birth, demand The First Embrace, seek care for sick and low-birth-weight newborn infants early b. plan for and provide optimal postnatal at home care (Appendix 1, Table 1-2) 1. Communication strategy available with relevant costs 2. Percentage of mothers and babies who received timely postnatal care visits10 1. Support countries to develop communication strategy 2. Ensure maternal and newborn health incorporated in existing community initiatives 3. Support countries to review and update policies, plans and programmes targeting communities 1. Proportion of countries with a costed communication strategy developed 2. Rate of improved awareness of mothers in priority countries on EENC including The First Embrace
Indicators for countries and areas Actions for WHO, UNICEF and other partners
Indicators for WHO, UNICEF and other partners
10
If birth is in a facility, the mother and newborn baby should receive postnatal care during the first 24 hours after birth before being discharged. If birth is at home, the first postnatal contact should be as early as possible within 24 hours of birth. At least two additional postnatal contacts are recommended for all mothers and newborn infants on day 3 (48–72 hours after birth) and between day 7–14 after birth. The final postnatal contact is recommended at six weeks after birth. (WHO postnatal care guidelines, forthcoming)
WPR/RC64/9 page 145 Annex 2
Strategic Action 5: Improve the availability and quality of perinatal information The Challenge: More data are needed on newborn care practices at facilities and in communities through strengthened routine health information systems, facility quality of care assessments and household surveys. Data should be used for tracking progress and planning.
Operational Objective 5.1: To strengthen capacity of routine information systems to collect accurate data on perinatal health Actions for countries and areas 1. Include MDG 4 indicators and those recommended by the Commission on Information and Accountability for Women’s and Children’s Health11 in routine recording and reporting systems 2. Ensure civil registration includes all births, stillbirths, neonatal deaths and causes of neonatal deaths12 3. Establish, strengthen and scale up model surveillance systems monitoring selected EENC practices, stillbirths, neonatal deaths, causes of neonatal deaths, and case fatality rates for newborn sepsis, birth asphyxia, congenital malformations and per birth weight strata 1. National and subnational neonatal mortality rates 2. Incorporation of stillbirths and neonatal deaths in civil registration systems 3. Perinatal surveillance data reported from model surveillance system (stillbirths, neonatal deaths and causes of neonatal deaths) 1. Conduct analysis and publish results on current status of routine collection of perinatal data, barriers and capacity for improved recording system in the Region 2. Develop data-quality assessment tools for routine information systems 3. Support countries to conduct quality assessments of data periodically 4. Support countries to enhance/develop a comprehensive and functional civil registry system 1. Number of countries that have incorporated key perinatal measures into routine data systems 2. Number of countries with improved data quality of routine information systems and civil registration 3. Perinatal surveillance data reported from model surveillance system (stillbirths, neonatal deaths, and causes of neonatal deaths) per country
Indicators for countries and areas
Actions for WHO, UNICEF and other partners
Indicators for WHO, UNICEF and other partners
Commission on Information and Accountability for Women's and Children's Health. Keeping Promises, Measuring Results. Geneva, WHO, 2011. 12 Regional Strategic Plan for the Improvement of Civil Registration and Vital Statistics in Asia and the Pacific (DRAFT). New York, United Nations Economic and Social Council, (forthcoming).
11
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Operational Objective 5.2: Improve collection and use of data on perinatal health and practices through research, surveys and audits Actions for countries and areas 1. Periodically conduct EENC health facility surveys 2. Adopt perinatal death audits in selected health facilities 3. Ensure national and subnational health surveys (for example, Demographic and Health Survey [DHS] and Multiple Indicator Cluster Survey [MICS]) include neonatal and perinatal variables, disaggregated by social stratifiers to monitor equity 1. Proportion of facilities where births take place implementing EENC signal functions 2. Number of facilities with functional perinatal death audit systems in place 3. Neonatal and perinatal variable survey results at national and subnational levels 1. Support countries to conduct perinatal death audits 2. Develop and build consensus on facility-based measures of EENC practice for tracking quality of care 3. Support countries to improve presentation of data on EENC to facilitate country action 1. Proportion of facilities where births take place implementing EENC signal functions per country 2. Number of countries with functional perinatal death audit systems in place 3. Neonatal and perinatal variable survey results per country at national and subnational levels
Indicators for countries and areas
Actions for WHO, UNICEF and other partners
Indicators for WHO, UNICEF and other partners
WPR/RC64/9 page 147 Annex 2
6. The way forward This draft Action Plan for Healthy Newborn Infants in the Western Pacific Region (2014–2020) provides a systematic approach that can be applied to unique country needs and priorities. Close regional coordination is needed to allow sharing of tools, methods and approaches among countries and avoid unnecessary duplication of effort. In the early stages of implementation, the action plan emphasizes advocacy and social marketing approaches to generate critical stakeholder support required to achieve implementation of full EENC. Everyone—including other United Nations agencies and development partners and civil society— will have a major role in realizing the regional action plan. Advocacy is needed to encourage key non-health governmental departments to include the regional action plan in their development agenda, poverty reduction strategies and budgets—and to pass, regulate and enforce key legislation. Health-related NGOs should align their programmes and policies with the national adaptation of the regional action plan and coordinate implementation with government health services at all levels. Professional societies will play a critical role in ensuring that EENC standards are understood and used by practitioners. This regional action plan has been developed in consultation with country leaders and experts from the field. WHO and UNICEF will work with countries to ensure that the plan and subsequent actions are based on a thorough understanding of the needs of mothers and newborn infants, SBAs, other providers of newborn care and key stakeholders.
WPR/RC64/9 page 148 Annex 2
WPR/RC64/9 page 149 APPENDIX 1
APPENDIX 1: Early Essential Newborn Care (EENC) Table 1-1. Core EENC strategies for all and high-risk mothers and newborn infants All mothers and newborn infants 1) The First Embrace All mothers: maintain a supportive environment (e.g. companion and position of choice, elimination of unnecessary/harmful procedures) avoid environmental exposure to cold, draughts and infection maternal and fetal monitoring during labour including use of the partograph improved recognition of labour signs, care and referral of woman with risk factors (e.g. hypertension, diabetes, preterm labour); management of obstetric complications, especially pre-eclampsia/eclampsia set up newborn resuscitation area, including checking equipment for functionality organize delivery space postpartum care visits: counselling for routine newborn care and danger signs HIV and syphilis point-of-care rapid testing All newborn infants: immediate and thorough drying delayed bathing immediate skin-to-skin contact All newborn infants, if breathing: appropriately timed cord clamping; cut once exclusive breastfeeding when feeding cues occur rooming in/keeping warm routine care (e.g. eye care, vitamin K, immunizations and examinations) delayed until after a full breastfeed elimination of harmful practices including routine suctioning, placing substances on the cord stump, and pre-lacteal feeds postnatal care visits All mothers and newborn infants: avoidance of exposure to nosocomial pathogens through: hand hygiene and other infection prevention measures non-separation unless urgent care required High-risk mothers and newborn infants 2) Prevention and care of preterm and low-birthweight newborn infants High-risk mothers and newborn infants: elimination of unnecessary induction of labour and caesarean sections antenatal steroids (and tocolytics) antibiotics for preterm prelabour rupture of membranes Kangaroo Mother Care feeding with breast milk monitoring for complications 3) Prevention and care of sick newborn infants Newborn infants who are not breathing despite thorough drying (asphyxia) bag and mask ventilation post-resuscitation care (including aseptic cord trimming), monitoring and referral of cases with incomplete recovery/severe conditions Sick newborn infants and newborn infants with complications of delivery: standard case management of newborn sepsis and other newborn problems (e.g. pneumonia, meningitis, other infections, jaundice, malformations) identification of at-risk newborn infants stabilization (including prevention of hypothermia, hypoglycaemia, hypoxaemia, apnoea and infection) prior to timely referral oxygen and/or continuous positive airway pressure (CPAP) for those with respiratory distress care of the seriously ill newborn infants antiretrovirals for infants exposed to HIV and penicillin for those exposed to syphilis referral between levels of care and wards
WPR/RC64/9 page 151 ANNEX 3
ANNEX 3: STATUS REPORT ON IMPLEMENTATION OF IHR CORE CAPACITIES WESTERN PACIFIC REGION AS OF 1 AUGUST 2013* IHR extension to 2012 deadline Requested No and granted extension extension required (n=14, (n=13, 52%) 48%) O O O O O O O O O O O O O O O O O O O O O O O O O O O 14 13 O O O 21 O O O O O O O O O O Submission of IHR monitoring questionnaire 2010 (n=21, 77%) O O O O O O O O O O O O O O 2011 (n=19, 70%) O O O O 2012 (n=26, 96%) O O O O O O O O O O O O O O O O O O O O O O O O O O 26 2013 (n=26, 96%)** O O O O O O O O O O O O O O O O O O O O O O O O O O 26
Country (n=27)
Australia Brunei Darussalam Cambodia China Cook Islands Fiji Japan Kiribati Lao People's Democratic Republic Malaysia Marshall Islands Micronesia, Federated States of Mongolia Nauru New Zealand Niue Palau Papua New Guinea Philippines Republic of Korea Samoa Singapore Solomon Islands Tonga Tuvalu Vanuatu Viet Nam TOTAL
O O O O O O O O
O 19
* Data are updated as official confirmation is received from countries. ** In 2013, the WHO’s global deadline for submission of the questionnaires from countries was 1 August 2013. The regional deadline for the Western Pacific Region was 15 June 2013.
WPR/RC64/9 page 152 Annex 3
WPR/RC64/9 page 153 ANNEX 4
ANNEX 4: CRITERIA TO BE USED BY THE SECRETARIAT WHEN CONSIDERING REQUESTS IN 2014 FOR EXTENSIONS TO THE DEADLINE (EXCERPT FROM WORLD HEALTH ASSEMBLY DOCUMENT A66/16)
SIXTY-SIXTH WORLD HEALTH ASSEMBLY Provisional agenda item 15.1
A66/16 5 April 2013
Implementation of the International Health Regulations (2005) Report by the Director-General CRITERIA PROPOSED BY THE SECRETARIAT 36. Based on the requirements stated in the Regulations, the first criterion proposed by the Secretariat is that a State Party makes a formal request in writing to the Director-General at least four months in advance of the target date (which for most countries is 15 June 2014). This request must include a statement explaining the exceptional circumstances that have prevented the development and maintenance of the national International Health Regulations (2005) capacities. 37. Secondly any such request must be accompanied by a new implementation plan that includes the following elements: (1) a clear and specific identification of those capacity elements that are missing or inadequate; (2) a description of the activities and progress made in establishing those capacities up until that date; (3) a set of proposed actions that will be undertaken and a specified time frame to ensure the capacities are present; and (4) an estimation of the technical support and financial resources required to implement these activities; the proportion of these resources that will be invested from national budgets; and the extent of any external support required. 38. The Executive Board at its 132nd session concluded that, while there were no objections to the criteria proposed, they would benefit from the opportunity of further consideration by Member States through the mechanism of the regional committee meetings to be held in 2013, allowing the final criteria to be provided to the Executive Board at its 134th session in January 2014.
WPR/RC64/9 page 154 Annex 4