WPRlRC53/SRl7 SUMMARY RECORD OF THE SEVENTH MEETING
Room A of the Kyoto International Conference Hall Thursday, 19 September 2002 at 2 p.m.
CHAIRPERSON: Dr Hideo SHINOZAKI (Japan)
CONTENTS
page
I.
Malaria, filariasis and other parasitic diseases (continued) ........................... . Antimicrobial resistance ................................................................................ . Ethical issues related to new developments in the health sector ................... . Essential public health functions: the role of ministries of health ................... .
190 192 198 201
2. 3. 4.
189
190
REGIONAL COMMIITEE: FIFTY-THIRD SESSION
1.
MALARIA, FILARIASIS AND OTHER PARASITIC DISEASES: Item 13 of the Agenda (Document WPR/RC53/8) (continued) Mr PARE (Cook Islands) endorsed the comments made by the representative of Fiji. It
was hoped that filariasis would be eliminated from Cook Islands by 2005, five years ahead of the target of 20 10 set by the Pacific Programme to Eliminate Lymphatic Filariasis (PacELF). He acknowledged the valuable support for that initiative received from WHO, and from G1axoSmithKline and the Japan International Cooperation Agency, which had donated supplies of albendazole and diethylcarbamazine, respectively. Cook Islands had welcomed the opportunity to host the fourth annual meeting of PacELF in August 2002. Much of the discussion had centred on vector control, and the conclusions and recommendations of the WHO informal consultation on the disease held in January 2002. It had been concluded that Member States should develop and implement more effective vector control strategies, methods and materials, as well as appropriate training for staff responsible for vector control operations. Cook Islands endorsed the resolution adopted by PacELF recommending that the New Zealand rugby star Jonah Lomu be approached with a view to inviting him to be designated PacELF international ambassador for the promotion of filariasis elimination in the Pacific. He looked forward to continued financial and technical support from WHO and hoped that the Organization would devote more resources to the elimination of the disease and to the treatment of long-term disabilities resulting from it. Dr TONG Ka 10 (Macao, China) reported that malaria in Macao (China) was limited to a few imported cases. Moreover, no case of lymphatic filariasis had ever been recorded and, thanks to the wholly covered wastewater drainage and treatment system and the cessation of agriCUltural activities, infections with soil-transmitted helminths had become uncommon. However, in 2001 Macao had experienced its first epidemic of dengue fever. In all there had been more than 1400 cases (3.2 per 1000), all but two of which had been of serotype 2; there had been no cases of dengue haemorrhagic fever and no fatalities. Causal factors were thought to include the movement of people to and from neighbouring areas where the disease was endemic, the abundance of mosquito breeding sites due to the increase in the number of abandoned lands and properties (owing to the economic situation), and inadequate environmental hygiene and mosquito control activities on the part of citizens. Increased rainfall had also contributed to the increase in mosquito breeding. As a consequence of the high population density, once the disease had appeared it had spread rapidly and widely. To
SUMMARY RECORD OF THE SEVENTH MEETING
191
prevent re-emergence in 2002, Macao had adopted integrated strategies covering breeding site elimination, health education, promotion of community participation, surveillance, early case detection, isolation and treatment, surveillance and research on vectors, chemical control, legislative measures, and communication. So far no case had been recorded. As outbreak control methods, such as space spraying with insecticides, were relatively ineffective, it was essential to motivate individuals to eliminate or clean containers in which mosquitoes could breed. He endorsed the proposed actions set out in the document and hoped that WHO would strengthen its dengue fever activities and enhance support to Member States in that area. Dr DA YRIT (Philippines) said that, in line with the global strategy, his Government hoped to complete endemic mapping of lymphatic filariasis by 2004. Treatment was being provided in endemic areas, thanks to donations of drugs from GlaxoSmithKline. Dr MANN (Papua New Guinea) supported the proposed actions set out in the document. Malaria continued to be a leading cause of morbidity and mortality in all age groups in his country, particularly in children and pregnant women. Moreover, the disease was re-emerging in high-altitude areas once free from it, as a result of climate change. Papua New Guinea was collaborating with various partners to implement malaria control measures using a two-pronged approach comprising use of an updated treatment protocol, which now included artemisinin and its derivatives, with a view to reducing mortality; and nationwide distribution of insecticide-impregnated bednets with the valuable support of Rotary International and a donation of bednets from the United States of America. Thanks were also due to WHO for valuable technical support, Australia for regular grants and a special grant for 2002 to fund drug purchases, and China, Japan, New Zealand and the Sasakawa Foundation for additional support. Collaboration with Australia and other partners on malaria vaccine research would continue. The REGIONAL DIRECTOR said that WHO would endeavour to provide additional support to Member States in their efforts to combat vectorborne diseases, within budget constraints. The encouraging PacELF initiative showed what could be achieved when countries worked together with commitment. He welcomed the proposal to designate an international ambassador for lymphatic filariasis elimination and hoped that PacELF participants would pursue the suggestion. The REGIONAL ADVISER, MALARIA said that thanks were due to the Government of Japan for its enduring efforts to ensure that parasitic diseases were placed on the
192
REGIONAL COMMITIEE: FIFTY -THIRD SESSION
international agenda, which it complemented with practical cooperation on the control of parasitic diseases in Asia, the Pacific and elsewhere. Moreover, on Japan's insistence,
malaria was included in the Global Fund, with a focus on the disease not only in Africa but also in Asia. The representative of China had clearly defined the relationship between malaria and poverty, especially rural poverty. Although the total number of cases of malaria was less than some other diseases, the importance of controlling malaria was much greater than indicated by morbidity and mortality figures, which were often underestimated because the disease occurred in remote areas. He drew attention to a new advocacy kit, packaged to resemble a bednet, which contained, among other items, a brochure on rapid diagnostic tests, an innovation that should help to control malaria in remote communities where microscopy facilities were lacking. It also contained a reprint of an article on counterfeit malarial drugs, a serious problem throughout South-East Asia and the cause of death in poor, isolated populations. More
international cooperation was needed to combat counterfeit drugs; WHO would need to focus more on that problem than it had done so far, but Member States would have to do their part too. With regard to soil-transmitted helminths, he pointed out the simplicity of control. People in most rural areas were affected, yet giving a cheap and simple treatment to schoolchildren twice a year would do much to alleviate the burden. It was a starting point that could be combined with education, communication and sanitation. Turning to dengue, he noted that the situation was worsening. It was largely
concentrated in the Western Pacific and South-East Asia Regions, and so far it had been difficult to raise funds for control. Fortunately, the main intervention consisted of education and actions that the community could undertake, rather than the spreading of insecticide. However, technical support was also needed, and the post of a high-level expert in dengue vector control was being funded in order to provide appropriate expertise to Member States. 2. ANTIMICROBIAL RESISTANCE: Item 14 of the Agenda (Document WPRlRC5319) The REGIONAL DIRECTOR said that in the past 50 years, WHO had achieved great success in reducing the impact of communicable diseases. Mortality from common
infections, such as respiratory infections and diarrhoeal diseases, had decreased remarkably
SUMMARY RECORD OF THE SEVENTH MEETING
193
and diseases like tuberculosis and malaria had become treatable. Much of that success had been due to new antibiotics and other antimicrobials. WHO was now facing a new challenge. Rapidly growing resistance to antimicrobials was a serious public health threat throughout the Region. Many common pathogens were already resistant to first-line drugs, which were readily available and usually much cheaper than new generation drugs. Some pathogens were already resistant to new antimicrobials. He reminded the Committee that, as they had heard earlier that week, multi drug-resistant tuberculosis was a major public health concern in many countries in the Region. Drugresistant malaria had also emerged. The number of hospital-acquired infections with resistant agents was also increasing. Drug resistance was spreading because antimicrobials were being misused or overused. In many countries, there was little control over the distribution or availability of antimicrobials. Patients were often ill-informed about antimicrobials and clinicians often had an economic incentive to prescribe unnecessary or expensive antimicrobials. Extensive use of antimicrobials in food-producing animals was also associated with the emergence of resistance. If WHO was to contain resistance effectively, it needed to involve everybody, including prescribers and dispensers, public health departments, public and private medical services, pharmaceutical industries, veterinary and agriculture sectors, the media and the general public. WHO's recent "global strategy for containment of antimicrobial resistance" described the interventions that could be implemented by each sector. It provided a strategic framework that Member States could use to develop national containment programmes. It aimed to reduce antimicrobial resistance by: • • • • • • reducing the disease burden and the spread of infection; improving access to appropriate antimicrobials; improving the use of antimicrobials; strengthening health systems and their surveillance capacities; enforcing regulations and legislation; and encouraging the development of appropriate new drugs and vaccines.
He believed that antimicrobial resistance was a problem WHO needed to address now. Once a micro-organism developed resistance, it would be difficult or impossible to reverse the
194
REGIONAL COMMITIEE: FIFTY-THIRD SESSION
process.
It was therefore essential that Member States establish effective containment Working together he believed WHO could still contain the
programmes immediately.
problem. However, if they delayed, the costs might become overwhelming for health services and for patients. Professor SMALLWOOD (Australia) warned that, if effective action were not taken in all Member States, there was a serious risk of creating a "post-antibiotics era", when formerly curable infections could no longer be treated. His Government strongly supported WHO's global strategy for the containment of antimicrobial resistance and the actions proposed in the document under review; it was already implementing activities along the lines proposed. National action with an intersectoral approach was fundamental for containment. Australia's programme included regulatory control, a monitoring and surveillance plan, strategies to prevent infection, and education and research. The coordination group comprised representatives from the health, agriculture and food sectors, among others. Expressing his support for the maintenance of a national essential drug list consistent with national treatment guidelines, he noted that would need to be adaptable to local conditions, such as different population groups and varying prevalences of particular antibiotic resistance. Dr TUKUITONGA (New Zealand) said that, although New Zealand had a low level of antibiotic resistance, it had designated activities to counter such resistance as a priority within its integrated approach to infectious diseases. The Antibiotic Resistance Working Group, set up in his country in 1998, comprised experts from such sectors as health, agriculture, environmental research, and pharmaceutical regulation, promoted appropriate use of antibiotics in the primary care setting. The Ministry of Health had set standards for infection control that were used to accredit hospitals and health care facilities, and had recently published guidelines on the management of methicillin-resistant Staphylococcus aureus. New Zealand supported the actions proposed in the document under discussion, although the question of the movement of infectious agents across borders could have been further expanded. Mrs LE THI THU HA (Viet Nam), endorsing the actions proposed in the document, said that the problem of antimicrobial resistance in Viet Nam was serious and worsening. A national antimicrobial resistance surveillance programme had been established in 1989 and covered most of the country. In addition, the National Committee on Rational Use of
SUMMARY RECORD OF THE SEVENTH MEETING
195
Antibiotics regularly issued treatment guidelines based on up-to-date resistance infonnation and undertook infonnation, education and communication activities. Viet Nam had adopted a number of measures to contain the rising trend of antimicrobial resistance, including prescription at community level, since the population lived predominantly in rural areas where most micro-organisms were still sensitive to common antibiotics; prescription of different drugs in hospitals, based on the resistant strains found among patients; continuing surveillance; regular review of guidelines; and further strengthening of intersectoral collaboration. Dr HOFSCHNEIDER (United States of America) observed that reducing the incidence of antimicrobial resistance would require better systems for monitoring not only drug resistance but also drug use and quality. Capabilities needed to be strengthened in the areas of drug regulation, quality assurance and post-marketing surveillance in order to contain the further development of resistance. Basic research was essential in order to understand the biological processes involved in resistance and to develop new control strategies, and more international collaboration was needed in that area. The use of antimicrobials had to be carefully planned and managed so that handling resistance became a routine matter that did not affect the availability of appropriate drugs to treat infectious diseases. The United States Interagency Task Force on Antimicrobial Resistance was a novel multi-partner approach, which included an array of government and private expertise. He welcomed contributions from the Region to the next meeting of the Task Force, to be held in September 2002 in San Diego, United States of America. Dr QI Xiaoqiu (China) said that his Government paid serious attention to antimicrobial resistance and had adopted appropriate measures. The Ministry of Health had prepared a tenyear programme on resistance to tuberculosis drugs and conducted surveillance in a number of provinces; it had also strengthened research on antimicrobial resistance. It was currently drafting a circular on the rational use of antibiotics at the clinical stage. He expressed his support for the proposals contained in the document, in particular raising awareness of misuse of antimicrobials among patients and health professionals. Medical education had to be strengthened, including moral values and better technical guidance had to be provided to clinicians and health workers in order to enhance their capacity to use antibiotics rationally. Education and guidance of patients and the general
196
REGIONAL COMMITIEE: FIFTY-THIRD SESSION
public should be intensified through use of the mass media so the harmful effects of misuse of antibiotics were better understood and misuse avoided. He proposed that guiding principles should be established for setting national treatment criteria, the management of prescription and nonprescription drugs should be improved, surveillance of antimicrobial resistance should be assured, and intervention measures to counter antimicrobial resistance should be extended. Dr THORNE (United Kingdom of Great Britain and Northern Ireland) agreed with previous speakers that antimicrobial resistance was a serious global health problem for which international collaboration was essential. Her Government was already implementing a
strategy to counter such resistance, which comprised surveillance, appropriate prescribing and infection control. She strongly supported the actions proposed in the document. Mr CHOI (Republic of Korea) said that his Government was managing the spread of antimicrobial resistance by forming a nationwide multisectoral task force. The import of
antimicrobial-resistant bacteria as a result of increasing international travel and trade was a cause of concern. The feeding of antibiotics to livestock and fish was also a problem, and the Republic of Korea was setting up a working group to establish maximum residue levels of antimicrobial agents and to draft guidelines for the use of antibiotics. In particular, hospital-acquired resistant microbes tended to be multi drug-resistant and difficult to treat; surveillance of major antimicrobial-resistant microbes was being conducted at each hospital in the Republic of Korea. The use of antibiotics in health care settings was also controlled. A new system that separated the prescribing from the dispensing of drugs had been successfully introduced two years ago; since then the use of prescription of antibiotics in hospitals and clinics had dropped considerably. Dr TANGI (Tonga) said that, as a practising physician, he had had first-hand experience of the evolution of resistance. Antibiotics, a relatively recent product, were crucial for the medical profession and were being abused. How could the medical profession
perform if antibiotics became ineffective? That was a problem that could not be ignored. He recalled how various generations of antibiotics had been promoted by pharmaceutical companies; barely 30 years later some of them were useless. Tonga had just experienced its first case of methicillin-resistant Staphyloccocus aureus, which required immediate action, and he stressed the importance of action on the part of all Member States.
SUMMARY RECORD OF THE SEVENTH MEETING
197
Dr ABDUL RAHMAN (Malaysia) agreed with previous speakers that antimicrobial resistance posed a serious global problem that required modifYing the use of antibiotics to treat infections. In Malaysia, methicillin-resistant Staphylococcus aureus and carbapenemresistant Acinetobacter species were major concerns. Committees had been formed to
recommend standard therapy for specific infections, but for guidelines to be useful appropriate implementation strategies were required. Implementation of guidelines needed to be set in a broader programme if it was to meet the objective of quality assurance. Managing resistance therefore required local epidemiological knowledge, understanding of the mechanisms of resistance, and appropriate choice of alternative drug therapy. Dr TONG Ka 10 ((Macao, China), expressing his agreement with all the actions proposed in the document, said that Macao hoped to receive technical support regarding surveillance methodology and an indicator system for antimicrobial resistance. Dr CHAN (Hong Kong, China), endorsing the views of previous speakers pointed out the significant role played by consumers and regulators. Consumer education was important, notwithstanding all the efforts made to raise the awareness of health and veterinary professionals. Consumers exerted pressure on physicians to prescribe antibiotics
inappropriately. Extensive self-medication brought into question enforcement of legislation and the ethical practices of certain dispensers; it was also linked to the issue of counterfeit drugs. There were more aspects involved than those indicated in the document and raised in the discussion. The REGIONAL DIRECTOR agreed that antimicrobial resistance was a cross-sectoral issue involving essential drugs, rational drug use, control of tuberculosis and malaria, legislation, regulation, and even ethics. Reflecting the importance accorded to antimicrobial resistance by Member States, several pages had been devoted in the previous Report of the Regional Director. The REGIONAL ADVISER, COMMUNICABLE DISEASE SURVEILLANCE AND RESPONSE said that one of the approaches to tackling the crossborder movement of antimicrobial-resistant microbes was to establish a mechanism for sharing information between countries. However, in a number of countries there was no surveillance system to monitor antimicrobial resistance. WHO would continue to provide support for monitoring resistance patterns to those countries with limited capacity to establish national systems. The CHAIRPERSON requested the Rapporteurs to prepare an appropriate draft resolution.
198
REGIONAL COMMITTEE: FIFTY-THIRD SESSION
3.
ETHICAL ISSUES RELATED TO NEW DEVELOPMENTS IN THE HEALTH SECTOR: Item 16 of the Agenda (Document WPRJRC53IINF.DOC.lI) Dr James BRYANT (president, Council of International Organizations for Medical
Sciences (CIOMS) and Emeritus Professor of the Aga Khan University, Karachi) introduced the subject of ethical issues related to new developments in the health sector on the basis of document WPRJRC531INF.DOC.ll. Dr OKAMOTO (Japan) commented that Dr Bryant's presentation had been challenging and thought-provoking; it had raised vital issues, posed critical questions and provided valuable information. He asked the Regional Director to describe the work he envisioned on the topic by the Regional Office. Dr TUKUITONGA (New Zealand) said that he had found the presentation interesting, consisting of a mix of issues. He wondered, however, whether the right questions were being asked. As a health official, he asked himself questions such as "If health is a basic human right, what are my ethical obligations when I have limited resources?", "Given my limited ability to fund even basic care, how do I ensure that the limited capacity to deliver care is fair and equitable?" and "Given that resources will always be limited, how do I ration care ethically and fairly?" In his view, the ethical questions to be addressed in the Region were still fundamental ones, such as whether it was ethical to place emphasis on access to care when the quality of that care could not be assured, so that more harm might be done than good. The ethical principles that had been described were predominantly biomedical, and the question arose of how traditional, local values and ethical considerations were to be incorporated into that otherwise predominantly Western view. He endorsed the request of the previous speaker for information on future work to be conducted on the issue in the Region, given that resources would always be limited and the demands endless. Dr MOHAMAD TAHA (Malaysia) said that new techniques and reforms in the health services had often raised ethical issues for all concerned parties and not only for public health officials. Ethical standards and codes of practice in various fields should be reviewed regularly to take into account technological developments and changing environments. Most issues could be handled at country level, but some developments required muIticountry or regional discussion. Gene therapy, stem-cell therapy and human cloning, for example, were issues that should be handled, not only at local or country level, but also globally. The Ministry of Health, academia and medical associations in Malaysia paid particular attention to
SUMMARY RECORD OF THE SEVENTH MEETING
199
ethical issues in health and health programme development, and annual seminars had been held in the past few years to discuss ethical issues. He also supported the request by the representative of Japan and urged the Regional Director to plan further discussion on the topic and perhaps to formulate a framework of action. Dr SADASIVAN (Singapore) said that medical progress in many countries of the Western Pacific Region had created practical ethical challenges. For instance, guidelines were necessary for research protocols, and ethical considerations were important in the field of transplantation. He supported the suggestion by the representative of Japan that the Regional Office address the issue and asked the Regional Director to consider developing guidelines for dealing with ethical problems, which took into consideration the cultural sensitivities of each country. Dr CHAN (Hong Kong, China) said that the integration of traditional Chinese medicine with Western medicine had long been a concern in Hong Kong. In view of the complexity of the topic of ethics in the health sector, she agreed with other speakers that
me
Western
Regional Office should take the lead role in developing a framework that could be used by each country or area as a basis for drawing up guidelines or a code of practice in accordance with its own cultural history. Dr POLYCARPE (France) commented that advances in technology and in medical case management and the legitimate demands of populations to benefit from those advances made it necessary to establish priorities, so that the resources available for health programmes were used optimally. In order to do so, a reliable information system should be available to allow evaluation of the impact of health programmes and the performance of care structures. Health professionals should seek greater collaboration and complementarity to improve the efficacy of the system and avoid waste. Health officials in French Polynesia and New Caledonia were formulating models of care that best met the needs of their populations, with equity of access and improved quality of care as the main objectives. An important aspect of the exercise was ensuring the active participation of users and patients in decision-making. That would require providing better information to users, respecting patients' choices and involving users in discussions and decisions.
200
REGIONAL COMMITTEE: FIFTY-THIRD SESSION
Mrs LE THI THU HA (Viet Nam) agreed with Dr Bryant that many countries were
facing the challenge of providing effective, equitable health care for their populations. The challenge was an even greater one for countries with limited resources. Primary health care was an essential basis for building health systems. The progress her country had made in respect of a number of health indicators over the past 10 years, despite its low per capita income, had been due to a vast network of primary health care facilities and the development of effective programmes for priorities such as malaria, tuberculosis and vaccine-preventable diseases. Nevertheless, Viet Nam was currently facing a double disease burden, with increasing incidences of noncommunicable diseases and persistently high incidences of communicable diseases. The new problems that had emerged included managing morbidity and ensuring the quality of care in the wake of a reduction in premature death and extension of life expectancy; ensuring equity of access to the network of health care services; and relieving the fmancial burden of the uninsured segment of the population. A number of policies had been adopted to address those problems. Viet Nam had a long history of traditional medicine, which was fully integrated into the existing health system. A national policy on traditional medicine had been approved in 1999. However, although traditional medicine had been proved to be effective in a number of conditions and diseases, an evidence-based approach would be needed to harmonize traditional and Western medicine, and quality standards and regulations should be developed for herbal medicines. The REGIONAL DIRECTOR was pleased to note that Dr Bryant had said that ethics were needed, not only in clinical medicine and research, but also in public health. As had been mentioned by the representative of New Zealand, issues such as equitable allocation of resources and socioeconomic determinants of health had to be addressed. He agreed that the Regional Office should pursue the subject further. Some issues were global and others should be addressed locally, taking cultural specificity into account He proposed that a wide consultation be undertaken with Member States, global bodies and experts in the field over a period of two years or more. Professor BRYANT thanked the representatives for their comments and commended the level of interest shown in the topic and the measures being taken in some Member States to tackle ethical issues. Replying to the question from the representative of New Zealand on what to do with a wealth of ethical principles and a shortage of resources, he said that equity
SUMMARY RECORD OF THE SEVENTH MEETING
201
was the foremost consideration. After that, benchmarks could help guide the thinking of policy-makers about items that are often neglected. On the complexity of dealing with ethical questions, he told the Committee that, in
1982, the Council of International Organizations for Medical Sciences (CIOMS) had published a proposal for ethical guidelines for research involving human subjects. In 1993, it had been lightly revised, but by 1999 ethical perspectives had changed completely and become much more complex. Experts from developing countries and from new disciplines such as social anthropology had been involved, and the results were posted on the Internet, which had attracted a large response. In relation to the Benchmarks of Fairness for Health Care Reform, he stated that some 16 countries in all regions were involved. The growth and interest in this tool required regional focal points to respond to issues rather than a few central persons. Those involved in working on ethical issues would have to understand the complexity of the problem, realize how to work on it locally, regionally and globally, and then build capacity at the local level. The CHAIRPERSON thanked Dr Bryant for his very interesting presentation and asked the rapporteurs to prepare an appropriate draft resolution. 4. ESSENTIAL PUBLIC HEALTH FUNCTIONS: THE ROLE OF MINISTRIES OF HEALTH: Item 15 of the Agenda (Document WPRJRC53/10) The REGIONAL DIRECTOR explained that document WPRJRC53110 systematically identified the essential public health activities or functions which were relevant to all societies. By doing so, it aimed to take the understanding of public health beyond general definitions or descriptions. These essential public health functions cut across different
vertical programme areas. They formed a generic and systematic basis for a comprehensive evaluation of both the strengths and the gaps and weaknesses at different operational levels within the current system. An analysis using this framework could serve as the basis for identifying options for strengthening essential public health functions in the future, and could help ensure that these functions were not forgotten during times of reform. The framework also facilitated a view across the whole of government, and not just those public health activities undertaken by specific ministries.
\
202
REGIONAL COMMITIEE: FIFTY-THIRD SESSION
He invited the Regional Committee to examine whether the Essential Public Health Functions concept would help Member States to ensure a comprehensive approach to public health in their countries. If the Committee considered that the Essential Public Health
Functions approach was worthwhile and useful, WHO could work with Member States to refme the nine essential public health functions. Working together, they could develop
further methods to identify an appropriate role for ministries of health to ensure that those functions were carried out comprehensively, effectively and efficiently. The REGIONAL ADVISER, HEALTH SYSTEMS DEVELOPMENT said that internationally, there had been increasing interest in arriving at a more systematic defmition of the content of public health. At the start of the project in the Region, WHO had drawn on a substantial amount of material that had been developed in the field by the US Department of Health and Human Services, the US Centers for Disease Control and Prevention, Centro Latino Americano de Investigacion en Sistemas de Salud, and the Pan American Health Organization, particularly the work done in relation to their "Public health in the Americas" initiative. An initial week-long meeting, involving researchers and policy-advisers from Fiji, Malaysia and Viet Nam, plus an international expert, had reviewed the material. It had then been decided to derive nine essential public health functions that would be suitable for health systems in the Region. The researchers then had taken the initial developments back to their countries for further discussions with relevant parties involved in public health, and the functions had been further refined. The resulting nine functions had then been used in a study in each country to examine the strengths, weaknesses and gaps of current systems and to develop options for strengthening those essential functions. The conceptual framework that WHO had developed in the Region, within which the functions were placed, enabled consideration of what was most appropriate at each administrative level of the health system for each function. It was not just policy-oriented, but also encompassed operational aspects critical to the effective implementation of those essential functions. That approach had strong and important connections with other key aspects, particularly human resources development. It would be possible for the framework to serve as a basis for identifying the public health competencies needed in the health workforce. The reviews that had been undertaken in each of the three countries, using a common framework, had provided a large amount of useful information and analysis. This had been
SUMMARY RECORD OF THE SEVENTH MEETING
203
useful, not only within the Ministry, but also at other levels. There had been several common fmdings of the studies. Although there had been considerable differences between the three health systems, all three had identified primary health care as one of the most critical ways of ensuring that many parts of the functions could be effectively delivered. Other common issues had included the need to improve both public health legislation and information systems. The most common critical challenge to the sustainable delivery of these functions had been identified to be the size and competence of the public health workforce. Many other more specific issues had been identified for each country. The report on these three case studies and the methods used in the study would be available soon from the Regional Office. WHO hoped it would provide some examples, both of the different ways in which an assessment of essential public health functions could be undertaken, and of different ideas for strengthening different aspects of health systems.
In summary, the nine essential public health functions outlined in the document had first been developed at the regional level, drawing on the best available international developments in that area. The framework had then been put to the test in three different health systems in different parts of the Region. Dr WAQA TAKIREWA (Fiji) referred to the importance of understanding the function of primary health care systems. Three years earlier, Fiji had begun reform of its health sector management, decentralizing for efficiency, effectiveness and patient choice. Market-driven reforms elsewhere in the Region had provided opportunities to improve personal health services, but public health services had deteriorated. Sound health reforms must not weaken public health structures and functions, which improved general health for all social and economic groups. Fiji saw the primary health care concept, as defined in Alma Ata in 1978, as combining a philosophy, an organizational structure, and a set of implementation programmes. Improving primary health care institutions had to be done in tandem with policy development and programme implementation in public health. That would secure primary health care in the new millennium. Fiji was planning to stage a primary health care conference for the Pacific island countries in June 2003, and he hoped that WHO would provide support so that representatives from less developed countries could attend. He asked WHO to explain the role and linkages of primary health care and the essential public health functions, and to outline the framework used in the review exercise. Dr TUKUITONGA (New Zealand) said that his was one of the few developed countries in the Region that had not carried out a review of functions, but had gone through a
204
REGIONAL COMMIITEE: FIFTY-THIRD SESSION
market-based reform. He advised other countries to take the opportunity to learn from some of the mistakes his country had made. He agreed that essential public health functions were public goods services and that they should be collectively paid for. He suggested that "diagnostic and clinical services", which apparently were not to be included within the essential public health functions, were actually a key area, in that all clinical services could be regarded as significant in terms of public health. Also "overall policy and mechanisms for public health financing" were surely relevant. He suggested, therefore, that a framework based on core functions plus options might be more appropriate than one which simply excluded certain areas. Mr CHOI (Republic of Korea) agreed that the roles and areas of health ministries should be more clearly defmed. His government was keen to defme essential primary health functions, and encouraged WHO to continue with that process, with assistance from his country. As regards the nine public health functions, more emphasis was needed on coordination, given the number of bodies involved in public health. Dr SMALL WOOD (Australia) regarded the set of functions as a useful tool, but cautioned against using them prescriptively. He agreed with the representative of Fiji that a clear distinction should be made between public health and primary health care. In his country, the National Public Health Partnership had produced its own set of core functions for implementation of public health work. It had been a useful framework, but it had been difficult to move beyond that stage. The WHO document would surely be very helpful for further refming that national set of functions. Dr HOFSCHNEIDER (United States of America) said that the proposed reflected two important goals: delineation of the role of public health for the Region, and identification of the tools needed to measure and assess the public health functions necessary to strengthen national health infrastructure. The United States Department of Health and Human Services had worked with the Pan American Health Organization on a similar project, for the Americas, and would be willing to collaborate with the Western Pacific Region. The focus on public health functions could be a cost-effective management and public health tool to help improve systems, public and private. As the initiative proceeded, it had to be viewed as a dynamic, scientific process, improving over time, and it needed support from policy-makers and technical experts. Resources would be needed over the long term. He thanked the Regional Office for moving the project forward, given the importance of public health infrastructure. Some of the proposed essential functions might lie outside the
SUMMARY RECORD OF THE SEVENTH MEETING
205
ministries of health, in education, drug regulation, and even in nongovernmental organizations. Member States, therefore, had to consider how best to use those various bodies to comprehensively support and implement the essential public health functions. The recent anniversary of the terrorist attacks on the United States was a reminder of the role that public health services played in domestic security, especially against bioterrorism. The public and private sides of the health sector had a prominent part to play in that area. Dr OKAMOTO (Japan) pointed out that many different partners were involved in the provision of public health services, for which demand was rising. The identification and adoption of the nine essential public health functions should help to ensure equity, a key requirement in such circumstances, and he commended the Regional Office on the development of the concept. Ministries of health must be strengthened, with long-term planning for capacity-building, to promote steady national health development. That was especially true in developing countries, where the situation was complicated by a variety of external development initiatives. In addition to differences in health status between the Member States of the Region, there were also differences within countries, for example between ruraJ and urban populations. Reforms should not exacerbate existing gaps or create new ones within countries. Indeed strengthening of essential public health functions should reduce such gaps. Mechanisms for fmancing the functions, usually the responsibility of ministries of fmance, had been excluded from the concept. While that was a reasonable decision, it was clear that functions could not be strengthened without basic public financing. Ministries of health must make every effort to obtain public support for the functions as the basis for acceptance of the need for public financing. The principle of equity should also extend to cost payment, and market mechanisms should not receive undue emphasis unless there was reasonable evidence that they did not conflict with that principle. Mr LIU Peilong (China) welcomed the inclusion of the agenda item. It was of particular relevance to China as the country moved from a planned to a market economy. Reforms in various sectors of Government, including the health sector, were being undertaken at all levels, and responsibilities were being decentralized. That process was giving rise to some difficulties, for example in defming the role and responsibilities of the Ministry of Health. The document prepared by the Regional Office would serve as a valuable reference. However, it represented only the start of a longer process, and WHO should continue to develop the concept. The relations between the nine essential public health functions should be further clarified and the roles and responsibilities at different levels further defined. The
206
REGIONAL COMMIITEE: FIFTY -THIRD SESSION
Regional Office should organize seminars on the subject for the benefit of various government sectors, which would provide the opportunity for an exchange of ideas. It should also prepare guidelines, after further analysis and consultation with Member States, which take into account the different conditions across the Region. It was important to define clearly the terms used in describing the concept. What precisely did the term "health sector" encompass, for example? He, therefore, proposed that WHO should prepare a glossary of public-health terms to ensure a common understanding of their meaning. Dr ARIF (Malaysia) said that his country had welcomed the opportunity of participating in the three-country case study of essential public health functions in the Region. It had been an enriching experience that had enabled Malaysia to take stock of its existing
public health programmes in relation to the nine functions. The country's relative success in health care was reflected in the health status indicators. While essential public health functions were not a new idea and had been implemented all along, the study had placed them more clearly in context and they would facilitate advocacy and partnerships. The list of functions and their detailed descriptions would also help public health specialists to assess the impact of future changes. As Malaysia tackled health care fmancing and structural reforms,.it would be important to maintain equity, protect vulnerable groups and ensure that individuals and communities had the opportunity to assess health care quality. The essential public health functions would be central to many decision-making processes in the course of those reforms. The list of functions had also been extensively used by the Ministry of Health in promoting professional standards among public health specialists, inter alia, through a two-day national meeting. Dr TONG Ka 10 (Macao, China) remarked that public health specialists in Macao welcomed the development of the essential public health functions, which they believed would be a valuable instrument in efforts to strengthen the health system and health service delivery, and in the process of health system reform. WHO should move the concept forward by strengthening advocacy for and promotion of the functions within the health sector, other government sectors and among the general public. The Organization should also develop practical instruments and guidelines for the evaluation of the functions and for their strengthening. Mr KALONTAS (Vanuatu) endorsed the nine essential public health functions, which
provided a valuable instrument for reviewing existing health system functions and delivery of health services at all levels. They might also prove useful for a reorientation of the current
SUMMARY RECORD OF THE SEVENTH MEETING
207
public health mandate, the prime function of which was to implement ministry of health policies, including implementation of national health programmes. The functions should help to revive and strengthen the primary health care concept and use of the indicators formulated in New horizons in health and the Healthy Islands initiative, which remained to be fully integrated into Vanuatu's health system. His Government had undertaken a comprehensive reform programme, with reorganization of all government departments, and was committed to transparency and accountability in service delivery. However, difficulties had been experienced, and the Ministry of Health was considering reviewing the changes in the light of the essential public health functions, in order to ensure a more systematic and holistic approach. Vanuatu would welcome WHO technical support to improve their understanding and use of the nine functions, and looked forward to sharing experiences in their use with other Member States. Mrs LE THI THU HA (Viet Nam) said that, as a result of participating in the threecountry case study on essential public health functions, her Government had come to a number of conclusions regarding the use of the functions in Viet Nam. The functions had been defined, and a list of concrete tasks had been formulated for each of them. However, they would contribute significantly to improving health only if implementation was of good quality and the role of the Ministry of Health was clearly delineated. Primary health care should be the main approach. The tasks and resulting fmdings should be used as a checklist for developing a set of national benchmarks for public health system evaluation. The benchmarks would be used to detect gaps in implementation and the reasons for them. The fmdings of that study should be used to review training and retraining curricula for relevant health workers. Over the past two years, the Ha Noi Public Health School had conducted further studies to explore the feasibility of using the primary health care system as a tool to strengthen essential public health functions in pilot areas and on a large scale. Over the same period, the Ministry of Health had formulated a number of important national policies, which had received Government approval, and had issued national benchmarks for health care at commune level. Despite considerable progress over the past decade, many challenges were being faced in proper delivery of essential functions under the current health system. A review of the current public-private mix of health care provision was being plarmed with a view to defming the role of the Ministry of Health more clearly and improving health system performance. WHO technical support for that effort would be welcome.
208
REGIONAL COMMITIEE: FIFTY-THIRD SESSION
Dr OTIO (Palau) endorsed the nine essential public health functions but suggested that
the they did not encompass all important areas of public health. For example, now public health was being placed at the core of human development and linked to alleviation of poverty. Moreover, WHO was currently involved in efforts to develop the proposed framework convention on tobacco control, an international treaty. Increasingly, public health was moving into areas of environmental politics and international trade, and recent events had introduced considerations related to terrorism. He therefore agreed with the representative of China that the functions should be further clarified and refmed and should take those aspects into account. At the invitation of the CHAIRPERSON, the representative of the World Federation for Mental Health made a statement to the Committee.
The meeting rose at 5.50 p.m.