REGIONAL COMMITTEE Sixty-sixth Session SEARO, New Delhi, India 10–13 September 2013
Provisional Agenda item 4.2 SEA/RC66/7 18 July 2013
Selection of a subject for the technical discussions to be held prior to the Sixty-seventh Session of the Regional Committee The attached document lists the subjects of the technical discussions held since 2001 in conjunction with the respective sessions of the Regional Committee. It also provides a list of proposed subjects for technical discussions to be held prior to the Sixty-seventh Session of the Regional Committee in 2014. The rationale for each proposed subject has been provided. The High-Level Preparatory (HLP) Meeting held in the Regional Office in New Delhi from 1 to 3 July 2013 reviewed the attached document and made the following recommendations: Actions by WHO-SEARO (1) The topic of “Covering every birth and death: improving civil registration and vital statistics” is recommended as the subject for the technical discussions to be held prior to the Sixty-seventh Session of the Regional Committee in 2014. The recommendation for this topic will be submitted for the consideration of the Sixtysixth Regional Committee in September 2013. (2) To provide guidance on health issues related to civil registation and vital statistics to Member States. (3) To prepare and conduct the technical d iscussions on “Covering every birth and death: improving civil registration and vital statistics” prior to the Sixty -seventh Session of the Regional Committee in September 2014. The working paper and the HLP Meeting recommendations are submitted to the Sixtysixth Session of the Regional Committee for its consideration.
SEA/RC66/7
Selection of a subject for the technical discussions to be held prior to the Sixty-seventh Session of the Regional Committee to be held in 2014 1. The following subjects have been dealt with in the technical discussions held in conjunction with the sessions of the Regional Committee since 2001: 2001: Mental health and substance abuse, including alcohol 2002: Management of decentralization of health care 2003: Social health insurance 2004: Emergency health preparedness 2005: Skilled care at every birth 2006: Promoting patient safety at health care institutions 2007: Nutrition and food safety 2008: Revitalizing primary health care 2009: Protecting human health from climate change 2010: Injury prevention and safety promotion 2011: Strengthening of community-based health workforce in the context of revitalization of primary health 2012: Noncommunicable diseases, including mental health and neurological disorders 2013: Universal health coverage 2. In selecting a subject for the technical discussions to be held prior to the Sixty-seventh Session in 2014, the Committee may wish to consider the following subjects: (1) (2) (3) (4) (5) Neglected tropical diseases; Drug-resistant tuberculosis; Moving from coverage to quality in maternal and reproductive health; Covering every birth and death: improving civil registration and vital statistics; Community-based rehabilitation: reaching the unreached.
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3.
The rationale for each proposed subject has been provided below.
1. Neglected tropical diseases Background
Neglected tropical diseases (NTDs) are diseases anchored tropical/subtropical countries and encompass 17 diseases.
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Among the WHO regions, the South-East Asia Region bears the second-highest burden of NTDs, although not all NTDs are prevalent. Priority NTDs in the Region include: dengue fever, rabies, leprosy, lymphatic filariasis, kala-azar (visceral leishmaniasis), trachoma and yaws (endemic treponematoses).
Regional perspectives
Leprosy: Leprosy has been eliminated as a public health problem at national level from the Region. However, much work remains to be done at subnational levels. Lymphatic filariasis: Three countries (Maldives, Sri Lanka and Thailand) have reached the point of elimination and more than 50% of endemic districts reduced microfilaria rate to less than 1%. Kala-azar: Cases and deaths reduced to 23 000 and 30, respectively, in 2012, from 33 600 and 106 in 2010. Rabies: Production of rabies vaccine of nerve tissue origin has been discontinued and cost-effective intradermal vaccination promoted. Human mortality reduced in Sri Lanka and in Thailand. Yaws: Yaws was eliminated from India in 2006. Cases show a declining trend in Indonesia. Dengue fever: Case-fatality rate reduced to less than 0.5%. Regional Strategic Plans are in place for integrated NTDs control, lymphatic filariasis, rabies and dengue fever.
Issues
Scaling-up due to funding gaps and limited technical capacity in countries. Targeted research in diagnostics, immunoprophylaxis and chemotherapy. Population growth and migration, movements of livestock and vectors, and climate change. Sustaining political and financial commitments at global, national and subnational levels.
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Way forward
The Sixty-sixth World Health Assembly resolution WHA66.12 on NTDs urges Member States to: – – – – –
ensure country ownership of prevention, control, elimination and eradication of NTDs; expand and implement interventions and advocate for predictable, long-term international financing for activities related to control and capacity strengthening; integrate control programmes into primary health-care services; ensure optimal programme management and implementation; achieve and maintain universal access to interventions and reach the targets.
Resolution WHA66.12 reinforces the growing commitment of Member States to defeating NTDs.
Need for technical discussion
Given the high burden of NTDs in the Region, the need to scale-up integrated interventions against NTDs, and for implementation of resolution WHA66.12, it is proposed to have technical discussions on this subject in 2014.
2. Drug-resistant tuberculosis Background
The Sixtieth World Health Assembly endorsed resolution WHA60.19 on “Tuberculosis control: progress and long-term planning”. Health ministers from countries with a high burden of multidrug-resistant and extensively drug-resistant tuberculosis (M/XDR-TB) made a ”Call for Action” in April 2009, to scale-up national plans to address M/XDR-TB. The Sixty-second World Health Assembly endorsed resolution WHA62.15 on “Prevention and control of multidrug -resistant and extensively drug-resistant tuberculosis”. This is based on the concern that M/XDR-TB could potentially replace drug-susceptible tuberculosis; reverse gains made in reducing tuberculosis prevalence, incidence and mortality, and; substantially increase costs for tuberculosis control.
Regional perspectives
Well-functioning national tuberculosis control programmes in the Region, achieving high treatment success rates, have resulted in maintaining a slow but steady decline in tuberculosis incidence rates during the past decade. This has also led to low levels (2.1%, range: 1.8–2.5%) of multidrug-resistant tuberculosis (MDR-TB) among newly detected cases. Among previously treated cases in the Region, MDR-TB rate is estimated to be higher (around 16%, range: 12–19%). However, given the large numbers of tuberculosis cases in the South-East Asia Region, this translates to a total 89 000 estimated MDR-TB cases.
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Issues
Slow progress in scaling-up programmatic management of drug-resistant tuberculosis. Overstretched national public health-care systems: gaps in human resources, surveillance and monitoring, procurement and logistics management systems. Inadequate national laboratory capacity. Limited capacity tuberculosis. for programme management, particularly of drug-resistant
Unregulated over-the-counter sales of tuberculosis drugs in many countries. Limited availability of quality-assured second-line drugs; small numbers of pre-qualified manufacturers; delays in procurement. Uncertain long-term funding, particularly for MDR-TB.
Need for technical discussion
Drug-resistant tuberculosis is a major challenge in our fight against tuberculosis. The issue is assuming greater importance day-by-day. Technical discussions will provide the way forward in scaling-up national efforts, alongside implementation of the Executive Board resolutions.
3. Moving from coverage to quality in maternal and reproductive health Background
Population-based surveys, such as demographic and health surveys and multiple indicators cluster surveys, are documenting coverage of maternal and reproductive health interventions. Routine health information systems in many countries are not providing representative and adequate data on the health situation, a problem which is being addressed in the country approaches under ”Every woman, Every child” (Commission on Information and Accountability workshops). However, even where coverage increases the quality of care is an obstacle to reaching good health outcomes, which has been documented in several studies and surveys. People have a good perception where they receive quality of care, and bypass the public system, leading to low utilization.
Regional perspectives
Several surveys in countries of the South-East Asia Region documented problems with the quality of care. The Regional Office can play a prominent role in setting appropriate standards, documenting approaches, sharing success stories, and promoting quality improvement initiatives.
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Issues
Quality of care is not measured by routine indicators, as standards of care are often poorly defined. Maternal (and perinatal) death reviews are a way of documenting shortcomings in care that result in a maternal or newborn death. Promoting essential components of care packages (family planning, antenatal care, delivery care, postnatal care) in pre- and in-service training and service delivery is important for achieving quality care; simple tools and clinical guidelines can help to achieve this. Established approaches to quality assurance, such as accreditation of services and hospitals, and linking them to disbursement, is a method to be further explored. The role of professional societies as guardians of quality, who are able to sanction breaches of conduct, should be strengthened further.
Need for technical discussion
Member States need to discuss ways to promote quality of care and explore possibilities to document shortcomings through instituting routine mechanisms, such as maternal death reviews and intermittent surveys of the quality of care, which can identify problems to be addressed. Studies in successful methods of quality improvement might be considered for gaining and sharing information. Quality of care for regions and subgroups might need to be defined, keeping equity in mind.
4. Covering every birth and death: improving civil registration and vital statistics Background
The health sector has a particularly strong need for functional civil registration and vital statistics (CRVS) systems. Civil registration and vital statistics are two very important areas, usually bundled together as one rhyming phrase. There is much interdependence between the two areas. Civil registration systems create a permanent record and provide citizens with legal proof of vital events such as birth, death, cause of death (COD), adoption, marriage and divorce. Birth, death and COD are most important for health policy. The data from these civil registration records form the basis of the vital statistics system of a country. Vital statistics are used to derive the fundamental demographic and epidemiological measures that are needed in national planning across multiple sectors, such as education, labour and health. However, CRVS systems are often weak and incomplete in developing countries. Therefore, alternative data sources to generate vital statistics such as population census, household sample surveys, demographic surveillance in sentinel sites and sample registration systems have to be used. These alternative data sources are costly methods and do not provide a continuous, complete and cost-effective means to obtain real-time vital statistics.
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All births and deaths, as well as COD, must be registered for producing vital statistics, as many health indicators use these as denominators and numerators. Globally, one in three births are not registered, two in three deaths are not registered, and two-thirds of the global population do not have reliable COD. As a result, we are dealing with less reliable health indicators.
Regional perspectives
The first of the 10 recommendations of the Commission on Information and Accountability for Women’s and Children’s Health is that by 2015 countries have made significant steps for improving their CRVS systems to register births, deaths and COD. Since end 2010, with technical support from the Regional Office, comprehensive assessment of CRVS systems using the WHO tool has been completed or is in progress in seven of the 11 Member States, and strategic plans for improvement of CRVS systems are being developed. The Regional Office is in discussion with the remaining four Member States to also undertake the comprehensive assessment. In December 2012, the United Nations Economic and Social Commission for Asia and the Pacific (UNESCAP) in collaboration with WHO hosted a high-level meeting on the improvement of CRVS. High-level representatives across health, civil registration and statistics from 10 of the 11 Member States of the Region attended this meeting. In April 2013, WHO in collaboration with the Health Metrics Network hosted a global summit on CRVS, to bring together development partners and government representatives, to collaborate and pledge political commitment to strengthening CRVS systems in their countries. Ten of the 11 Member States of the South-East Asia Region participated at this summit.
Issues
Inadequate coverage and completeness of birth and death registration. Need for better quality COD data. – – –
For community deaths: use of verbal autopsy to capture the most probable COD. For health facility deaths: medically-certified COD using the International Death Certificate. For unnatural deaths: incorporation of police data on the COD.
Inadequate implementation of the International Statistical Classification of Diseases and Related Health Problems, Tenth Revision (ICD-10) tool, improper International Classification of Diseases (ICD) coding of COD data, inadequate training of coders, etc. Lack of regular quality audits to improve data quality, analysis and compilation of vital statistics from civil registration data. Use of innovative approaches and information and communications technology (ICT) to render improvements in CRVS data within a short span of time.
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Need for technical discussion
Decision-makers in health need up-to-date understanding of mortality statistics. Tracking the progress of strategies to reduce the levels of child, maternal and diseasespecific mortality, reduce the spread of noncommunicable diseases and to address inequalities in all these areas requires reliable, continuous and timely data on age- andcause-specific mortality. This can only be achieved with reliable civil registration systems that count all deaths and reliably certify their causes. We need to prioritize CRVS as a development issue in the global post-2015 development agenda.
5. Community-based rehabilitation: reaching the unreached Background
Most persons with disabilities (PWD) are poor, generally face stigma and discrimination, and experience a lack of appropriate rehabilitation facilities. Institutionbased rehabilitation services are only available at a few centres, which are able to reach out to only a limited population. Community-based rehabilitation (CBR), initiated by WHO, is based on the principles of primary health care. The principle of mobilizing local resources in the community through CBR gives scope for wider community development and to further reduce poverty. The 2010 CBR guidelines were produced jointly by WHO, the International Labour Organization (ILO), United Nations Educational, Scientific and Cultural Organization (UNESCO) and civil societies such as the International Disability and Development Consortium (IDDC), and are based on the principles of the UN Convention on the Rights of Persons with Disabilities (CRPD). They incorporate fundamental principles of empowerment, the mainstreaming of disability in the developmental agenda, human rights and social justice. They delineate key development initiatives/programmes such as health, education, livelihood and social sectors, inclusive of people with disabilities and their families.
Regional perspectives
CBR is currently being implemented in all countries of the WHO South-East Asia Region in varying forms, to different degrees and with varying national commitments. Specific reference to CBR exists in laws and policies of Bhutan, India, Indonesia, Myanmar, Sri Lanka, Thailand and Timor-Leste. The responsibility for disability rests with differing nodal ministries such as health, social affairs, justice, welfare, etc. They also have different coordinating mechanisms and varying financial commitments. Civil societies also play an important role in promoting and supporting CBR. These have resulted in different models of CBR in different countries. In all countries there is scope for improvement and further development of CBR, especially by multisectoral collaborations and through a participatory approach.
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Issues
Poverty, illiteracy, low levels of awareness, poor affordability and accessibility to health and rehabilitation services. Lack of knowledge and insufficient numbers of trained personnel on CBR. Underutilization of available services and benefits within the community. Inadequate multisectoral commitment and collaboration of key sectors (health, education and livelihood), partner organizations and PWD. Inadequate understanding of CBR, PWD rights-based and participatory approaches. Promoting disability-inclusive health policies and legislation. Promoting access to quality health and rehabilitation services in a barrier-free environment.
Need for technical discussion
CBR is the main strategy for disability issues, but still faces major challenges at both national and local level. There is a need to understand the important components according to the new CBR guidelines, as well as a need for multisectoral collaborations, a rights-based approach and also for advocacy to strengthen national programmes. Unless CBR is promoted, PWD in the community will continue to be unseen, unheard and unreached.