(WPR/RC32/SR/8)
SUMMARY RECORD OF THE EIGHTH MEETING Hotel Shilla. Seoul Monday. 28 September 1981 at 9.00 a.m. CHAIRMAN; Mr Doo-Ho Rhee (Republic of Kor~a)
CONTENTS
1. 2.
Address by the Director-General
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142 142
Consideration of draft resolutions
3.
Statements by representatives of the United Nations, the Specialized Agencies and intergovernmental and nongovernmental organizations in official relations with WHO ....................................................... .
142 143 143 143
4.
Adoption of the report of the Committee Resolution of appreciation Closure of the session
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5. 6.
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1.
ADDRESS BY THE DIRECTOR-GENERAL:
Item 3 of the Agenda.
At the invitation of the CHAIRMAN, the DIRECTOR-GENERAL addressed the Regional Committee (see Annex 1 for copy of his statement). 2. OONSIDERATIONOF DRAFT RESOLUTIONS The Committee considered the following draft resolutions: 2.1 Action Pro ramme on EssentialDru s Document WPR/RC32/Conf. Paper' No. 17) Decision: The draft resolution was adopted without comment (see resolution WPR/RC32.R17). 2.2 Topic of Technical Presentation in 1982 (Document WPR/RC32/Conf. Paper No. 18) Decision: The draft resolution was adopted without comment (see resolution WPR/RC32.R18). 2.3 sessions of the Regional Committee No. 19 • Decision: The draft resolution was adopted without comment (see resolution WPR/RC32.R19). 3. STATEMENTS BY REPRESENTATIVES OF THE UNITED NATIONS, THE SPECIALIZED AGENCIES AND INTERGOVERNMENTAL AND NONGOVERNMENTAL ORGANIZATIONS IN OFFICIAL RELATIONS WITH WHO.
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At the invitation of the CHAIRMAN, statements were presented on behalf of the following: 3.1 United Nations and related organizations United Nations Children's Fund United Nations Development Programme 3.2 Nongovernmental organizations International Dental Federation International Federation of Health Records Organizations International Hospital Federation International Committee of Catholic Nurses International Council of Nurses International Federation of Ophthalmological Societies International planned Parenthood Federation International Federation of Pharmaceutical Manufacturers Association Rehabilitation International International College of Surgeons
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4.
ADOPTION OF THE REPORT OF THE COMMITTEE: (Document WPR/RC32/l9).
Item 25 of the Agenda
The CHAIRMAN presented the draft report of the thirty-second session of the Regional Committee for comment. Dr MINNERS (Uni ted States of America), re ferring to section 3, Part VII of the report, asked that. in the first sentence of the third paragraph of the section, the phrase "and the United States of America" should bf> deleted. since in fact the United States had only accepted the Guiding Principles subject to certain modifications. The sentence would then read " ••• the representatives of Australia ••• Singapore and Tonga ••• ". In the fourth sentence of the paragraph. the phrase "notably the United States of America" might be added after "by some representatives". but he had no strong feelings on the matter. Decision: The draft report, as amended. was adopted (see resolution WPR/RC32.R20). 5. RESOLUTION OF APPRECIATION Dr TANAKA (Japan) presented a draft resolution of appreciation. Decision: The draft resolution was adopted unanimously (see resolution WPR/RC32.R2l). 6. CLOSURE OF THE SESSION: Item 26 of the Agenda
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The CHAIRMAN thanked representatives for their cooperation and declared the thirty-second seSSlon of the Regional Committee closed.
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The meeting closed at 11.35 a.m.
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ANNEX 1
ADDRESS BY DR H. MAHLER DIRECTOR-GENERAL OF THE WORLD HEALTH ORGANIZATION TO THE THIRTY-SECOND SESSION OF THE REGIONAL COMMITTEE FOR THE WESTERN PACIFIC Seoul, 22 - 28 September 1981
PARTNERSHIP FOR HEALTH FOR ALL
Mr Chairman, honourable representatives, ladies and gentlemen, colleagues and friends, 1. The unanimous adoption by the recent World Health Assembly of a Global Strategy for Health for All by the Year 2000 constitutes a real milestone in international cooperation in health. It clearly crystallizes the efforts set in motion by the Declaration of Alma-Ata and a number of decisions by subsequent Health Assemblies. In response to these, a large number of countries have formulated genuine national strategies and all WHO regions have started formulating regional strategies. The Global Strategy does no more than to reflect these national and regional strategies, thereby adding the important dimension of international coherence to WHO's work. 2. But we must not become euphoric nor lulled into a sense of complacency just because we now have an agreed Strategy. The Strategy will only be useful to the extent that it is really used. We have spent enough time on conceiving it. We must now devote all our energies to delivering it. 3. It was in this spirit that the Health Assembly asked the Executive Board to prepare a plan of action for the immediate implementation of the Strategy. You have a draft of that plan of action before you. As you can see, it is only a skeleton. It is for you and your people to bring that skeleton to life and give it flesh and blood, and it is WHO's duty to help you do so. For, when the Health Assembly adopted the Global Strategy, it called it a solemn agreement - a social contract - between three partners governments, people and WHO. 4. I shall start with WHO's duties as one of the partners, because I hope T am in a position to assure you that your Organization is more than ready to support you in converting your plans into realities, to genuinely cooperate with you in doing so, and to help mobilize the resourCes you require.
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5. But what of you? What are you ready to do? I ask you as representatives of your governments, realizing fully well that the answers do not depend on you alone. - Are you really ready to adopt the Strategy at the highest political level, to ensure the means for implementing it in your country and to fight any resistance you may encounter to its introduction? - Are you really ready to continue an agonizing reappraisal of your health systems, and to strengthen your health infrastructures with primary health care as their central functions and main focuses whatever the obstacles you will have to face? - Are you really ready to reconsider the health technology you are using so that it becomes really appropriate in your socioeconomic circumstances? - Are you really ready to mobilize all possible human, financial and material resources to ensure the implementation of your national strategy? - Are you really ready to reinforce your managerial capacity to give effect to your Strategy, to monitor progress and to report on it openly and unashamedly to all your colleagues in the regional committee so that all can learn from your experience? - Are you also ready to cooperate with one another 1n other ways to ensure that the Strategy is fully implemented? 6. As for your people, are you ready to give them the right to assume growing responsibility for their own health and to help them do so? - Are you ready to help them understand what your national health strategy is all about, so that individuals, families, communities, associations and non-governmental organizations can increasingly take an active part in developing your health system, in carrying out part of its functions, and in exercising social control over it and the technology used in it, and so that they can know where to seek appropriate help when they feel they need it? 7. If you are ready, and if your p~ople are ready, as I hope WHO is ready, what can possibly hold us back from fulfilling the social contract? It would be foolish to ignore the obstacles, whether these stem from political, social, economic, managerial or technical issues in your countries, or whether they stem from the very cold international political and economic climate. However, it would be even more foolish to allow these obstacles to deflect us from our path. The solidarity you have displayed in' determining international health policy and promoting its adaptation to your national health strategies shows that you have been able to overcome no less formidable obstacles in thp past. Nevertheless, we must be realists, and must work hard together to solve those problems that we know so well will plague us. 8. Two and a half years ago I had the privilege of visiting our host country, and of seeing at very close quarters just how much realism is requirpd in order to put into practice a new set of health policies. I had
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the opportunity of observing closely the New Community Development Movement - a striking example of intersectoral action for health at the community level. I should like to mention in particular the Korea Institute for Population and Health, because it illustrates a concept that has been discussed in WHO for a number of years, yet does not seem to be properly understood. Indeed, it has given rise to much disquiet in a number of ministries of health for fear that a super-structure was being imposed upon them. Nothing could be further from the intentions of those who proposed such mechanisms. To prepare and implement national strategies for health for all, some sort of permanent mechanism is required to develop and apply the national managerial process for health. This could include planning units in ministries of health themselves, as well as individuals and institutions in the health and other sectors, in order that they all share the managerial research, development and training efforts required. The important thing is that all potentially useful human resources have to be mobilized to make sure that the national health strategy is properly carried out and is effective through a continuing correction along its bumpy road. Bureaucratic handling of the situation has no chance whatsoever of succeeding in this. 9. Yet, such mechanisms cannot function in a vacuum; they do require stimulation, support and coordination by the outreach of that part of government that most closely represents the national health policy. That outreach is undoubtedly what is most commonly known as the ministry of health, whatever name is given to it by each country and whatever additional functions it may have, such as health and social affairs in this country, health and the environment in some countries, and health and human resources in others. Unfortunately, in too many countries ministries of health have become relics of a past in which health goals and ways of attaining them were far less defined than they are now. I am not at all sure that eVen in those days the predominantly bureaucratic nature of most ministries of health was permissible. Today, however, if national strategies for health for all are to have any chance of success, the way ministries of health function will have to change radically. 10. One way that has proved itself over and over again of succeeding in any endeavour is to entrust the endeavour to a highly dedicated individual or group. That is what a ministry of health should be in relation to the national strategy for h~alth for all. No other group can he expected to be as dedicated. In recognition of this, in spite of sneering comments from some sceptics, the Global Strategy for Health for All describes in quite some detail how a ministry of health could discharge the role assigned to it by the World Health Assembly, namely the directing and coordinating authority on national health work. This consists in essence of acting on behalf of the government as a whole in order to channel activities into the national strategy for health for all and to spearhead action for implementing the strategy through all the appropriate mechanisms in the health and other sectors. So I heg of you, please use the wealth of ideas spelled out in the Global Strategy to decide how best to reshape your ministries of health in order to make thpm more capable than ever of fulfilling the vastly wider and more decisive roles in the life of your country that historical events have bestowed on them. We have dared to take great strides in arriving together at the desired profile of your ministries of health; we must now take even greater strides in working together to make them really conform to the profile.
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11. One of the first tasks of any ministry of health that truly wants to implement a national strategy for health for all would be to review how best to reorganize the health system so that it is based on primary health care. In so doing, they can do no better than follow the directives you have given in your regional strategy. I shall quote selected extracts: "The ,overnment must lead and assume initial responsibility for build1ng community capability to plan, organize and implement health development activities ••• The government must permit and promote the adaptation of approaches or technology to suit the needs or the situation in the community ••• The government must provide communities with resources in terms of manpower skills, technology, information and funds for the planning, implementation and monitoring of health development activities."
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12. So, in full compliance with the strategy that you yourselves have devised, I can only urge you: Give your people a chance! They cannot do much worse than the bureaucracies have done in so many countries in the past. And by giving people this chance, you can be certain that at least whatever sinks in will remain the intellectual and emotional property of your people - and surely, health for all is for them. 13. This emphasis on people is the fundamental difference between basic health services and primary health care. The aim of basic health services was to provide the type of care considered necessary by health professionals; so they emphasized medical institutions organized in the conventional three-tiered hierarchy, starting from the central level, continuing with the intermediate level, and reaching out to the peripheral level. They did not pay any but scant attention to the political, social, economic and environmental factors that influence peoples' health, and to the action in sectors other than the health sector that can make or mar health. Nor did they consider people as individuals, families and communities whose health needs are determined by varying specific combinations of the factors I have just mentioned, as well as by biological and psychodynamic factors inherent in people themselves and in the families and communities in which they lived. They certainly did not take into account that, if properly supported, people could assume much greater responsibility for their own health. 14. Primary health care has changed ~ll that in theory. I will not repeat what has been described adequately in the Alma-Ata Report, the Global Strategy for Health for All, and your own regional strategy; they are all there for you to use and to brandish in order to get your message across to a wide audience. But I would like to illustrate just how some of your major health problems could be dealt with more effectively through the primary health care approach.
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15. In your regional strategy you point out that the countries of the Region vary widely in their socioeconomic environment and have widely different health problems. This accounts for the high prevalence you mention of both communicable and chronic diseases. I shall start with the communicable diseases. These have all too often been dealt with through what we call in our jargon "vertical programmes", that is each programme with its own infrastructure, each working separately, and rarely, if ever, involving people or communities in agreeing on what should be done and in! taking part in doing it. How could this be different? 16. Let us look at a few diseases .that still take a heavy toll in this Region, such as malaria, diarrhoeal diseases, tuberculosis and leprosy; and then let us look by way of illustration at a few ways in which they could!be dealt with differently. We have to start by, and it is not being done, . getting individuals and communities to understand how these diseases are caused, how they can be prevented, and how they can be treated. I am not implying full scie~tific comprehension of the control of these diseases; that clearly would be utopian. However, experience has clearly shown that it is perfectly possible to explain to people in their own language and culture what such diseases are all about and how they can be controlled. 17. But what action can be taken by individual families and communities? Well, take mothers in the control of diarrhoea. Their education is half the battle - education concerning breastfeeding, drinking water, disposal of excreta, sanitation in and around the home and the use of oral rehydration in case of severe attacks. But this type of education, which we know has been successful in many countries, could be extended in scope as well as to the family as a whole, so that its members genuinely act as a health team; for example, in making sure that those who need it receive the food they require, or get the specific drugs they require for tuberculosis, leprosy or malaria in the right dose and at the right time. There have been successful experiences in a number of countries of individuals, in particular mothers, taking over responsibility for the chemoprophylaxis of malaria in the fnmily. Also, thp distribution of chloroquine has been dealt with very succ('s~dlllly as part of a more general system of distribution of commodities outside the formal health system. I have just seen some very successful pxamples of this in a number of African and Asian countries.
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18. As for community measures, community involvement implies that these measures be taken £I the community, r~ther than for the community by outsiders. Thus, to take malaria as an example again, residual insecticide spraying has a much greater likelihood of being efficient if it is carried out as a community enterprise, accompanied by educational activities that take into account the power structure, social organization and cultural pattern of the community concerned. Many aspects of water management and draining for malaria control have a much greater chance of being effective in the long run if they are carried out by the community itself, or at least with the full understanding and commitment of the community, and this is certainly the case for drinking water and related sanitation. After all; once more water and sanitation seem to be for people, not for pipes. If only this principle was more widely applied, the strategy for the water decade wOllld become much clearer.
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19. Even from the very skimpy illustrations I have given of involvement in the control of some communicable diseases by people themselves, it is very clear that radical changes would have to take place in the way health workers function and are trained so that they can guide and support people in such efforts. Bringing about these changes could be the key to reshaping the whole health infrastructure so that it genuinely supports primary health care. I do not want to take up your time with a dissertation on primary health care, but to illustrate its scope. Let me just mention action in sectors other than the health sector. In country-wide programmes for controlling the diseases I have just referred to, it is not difficult to identify very pragmatically the action required in such sectors as education, agriculture, distribution of food and other goods, housing, and water resource development. 20. In most countries where cardiovascular diseases, cancer and other so-called chronic noncommunicable diseases are the main problem, there are not even vertical programmes to control them; there are no programmes at all, and problems are dealt with on a "come-and-get-it-if-you-can" basis. The alternative approach of encouraging individual, family and community action with the support of the health and other sectors is hardly conceived of. I refer to such action as reasonable behaviour to protect health and prevent some of these diseases, whether as regards eating, drinking, smoking, driving, exercise and the like, all of which can be promoted or thwarted by national political and economic decisions and by action in various economic and social sectors. 21. Much of the action I have referred to depends on the availability of essential drugs. You made a good beginning in this Region when the Pacific Islands got together for bulk purchase of a number of these drugs. We have all been boasting of your efforts. But I am disappointed that all of you have not picked up this idea with the enthusiasm it deserves. As for drug production, I have just been reading a report on a country in a neighbouring region which, with external support, built a factory, bought equipment, and secured training for local managers at a cost of just over 4 million dollars, which is peanuts as compared with what most countries spend on buying drugs - not to speak of arms. Through this activity alone the country I am referring to hopes eventually to supply about 25% ~f its needs in essential drugs at prices one third to one half lower than those of existing products - a notable result. 22. However, in the country I have just referred to the problem of efficient internal distribution of drugs still remains. So this brings me to the efforts required to build up the right kind of health infrastructure based on primary health care. Where are they, these health generalists, these doctors and nurses with a sense of dedication, a flair for simple epidemiological analysis, an ability to plan and get things going, to organize and improvise, and to influence people and health workers, community leaders and politicians? Today there are far too few of them. I should like to suggest that you make every effort to spot bright candidates. Then, through joint efforts, we could find ways of encouraging them to enter and to stay in this field by providing them with proper incentives and the right kind of training, and above all with exciting
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experience. Surely there must be enough young women and men in this Region with some adventurous spirit who, if given the right encouragement, would enjoy and not hate working in primary health care, organizing it, and providing guidance and training in it, and who would eventually graduate to become the Region's hea 1 th leaders 0 f tomorrow! I see th e cleve lopmen t 0 f such people as a very high priority for the use of WHO's resources and I am convinced that with a bit of imagination we could work out concrete proposals to bring this about. 23. I h~ve just referred to the use of WHO's resources. You have at your disposal an unusually flexible and pragmatic mechanism for programme budgeting WHO's resources in your countries. You could at least use these resources to ensure the progressive improvement of primary health care where it is most needed and for those specific elements that are most needed. I would also beg of you to use WHO to identify those parts of your primary health care strategy that could benefit from more massive external support and to secure the commitment of the appropriate authorities to ask for such support. You will have to be absolutely ruthless in ensuring that external support is channelled into your urgent primary health care needs, because that is one sure way of redressing imbalances in the distribution of your health budget, and it will lead sooner or later to increased national investments in these same areas. 24. As you know, WHO has set up on a trial basis, in the face of much resistance from the Board, a Global Health Resources Group for primary health care whose aim is to match needs with resources to the extent that these can become available. Your Regional Committee can be of great value in identifying needs, but you must realize that there will be ferocious competition for funds, so you will have the difficult and delicate task of screening and guaranteeing the authenticity of requests. 1~ese requests come through you, and the ways they are dealt with by the Global Health Resources Group or any other mechanism, will be reviewed by the Executive Board and World Health Assembly, so this is another example of WHO's coordinating role being used to help you in a way that goes far beyond the possihilities of its own limited funds. But here I have to ask you another qu£>stion: Are you really ready to use your Regional Committee as a peer group for reviewing objectively your needs for external resources in support of your strategies, so ·that the regional committees, the. Executive Board and the Health Assembly can correlate their work in such a way as to ensure that all available resources are effectively and efficiently used in support of well-defined strategies for health for all? If this process for mobilizing resources for your health strategies is to succeed, there can be no answer to this question other than a positive one. 25. Mr Chairman, Excellencies, honourable representatives, I cannot end without mentioning in sorrow the status of the so-called North/South Dialogue, because unless something drastic happens soon to change the situation, I am afraid it has to be considered as nothing less than a breakdown. Have we any chance of succeeding in our efforts in this cold international climate? At the risk of being called yet again a starry-eyed romantic, I think we have, because, under the aegis of WHO, dialogue between North and South and Ea·st and West with regard to health has never been so
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intimate and with so many concrete results. Our collective aims and policies transcend political philosophies and economic dogmas. I even believe that through our success, as succeed we will, others will take heart and will renew the dialogue in specific fields until a wide spectrum of social and economic issues is covered. This is an additional reason for us to pursue our aims very resolutely. 26. It is in this spirit of dialogue and cooperation that I should like to end. I beg of you to feel that I am talking with you and not at you. I shall know if I have succeeded in this by your-response.
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