THE WORI< OF WHO 1980-198 I
THE WORI< OF WHO 1980-1981 Biennial Report of the Director-General to the World Health Assemb!J and to the United Nations
WORLD HEALTH ORGANIZATION GENEVA
•
The texts of the World Health Assembly and Executive Board resolutions referred to in this report can be found in the Handbook of Resolutions and Decisions of the World Health Assemb!J and the Executive Board, Volume I, I94S-I972, and Volume II,fourth edition (I97}-I9So). Resolutions adopted in 1981 can be found in WHO documents EB67/1981jREcj1, WHA34/1981jRECj1, and EB68j1981jRECji. The abbreviations used m this report include the following: ACC ACMR A SEAN CIDA CIOMS DANIDA ECA ECDC ECE ECLA ECWA ESCAP FAO GTZ Administrative Committee on Coordination Advisory Committee onMedical Research Association of South-East Asian Nations Canadian International Development Agency Council for International Organizations of Medical Sciences Danish International Development Agency Economic Commission for Africa Economic cooperation among developing countries Economic Commission for Europe Economic Commission for Latin America Economic Commission for Western Asia Economic and Social Commission for Asia and the Pacific Food and Agriculture Organization of the United Nations Gesellschaft fur Technische Zusammenarbeit (Agency for Technical Cooperation, Federal Republic of Germany) International Atomic Energy Agency International Agency for Research on Cancer International Civil Aviation Organization International Labour Organisation (Office) Inter-Governmental Maritime Consultative Organization Organization of African Unity Organisation for Economic Co-operation and Development OPEC - Organization of Petroleum Exporting Countries PAHO Pan American Health Organization Swedish International Development SIDA Authority TCDC Technical cooperation among developing countries UNCTAD- United Nations Conference on Trade and Development UNDP United Nations Development Programme Office of the Disaster Relief Coordinator UNDRO UNEP United Nations Environment Programme UNESCO- United Nations Educational, SCientific and Cultural Organization UNFDAC- United Nations Fund for Drug Abuse Control UNFPA United Nations Fund for Population Activities Office of the United Nations High UNHCR Commissioner for Refugees UNICEF United Nations Children's Fund UNIDO United Nations Industrial Development Organization US AID United States Agency for International Development World Food Programme WFP World Health Organization WHO OECD -
IAEA IARC ICAO ILO IMCO OAU -
©
ISBN 92 4 1j6073 8 World Health Organization 1982
Publications of the World Health Organization enjoy copyright protection in accordance with the provisions of Protocol2 of the Universal Copynght Convention. For rights of reproduction or translation of WHO publications, in part or tn toto, application should be made to the Office of Publications, World Health Organization, Geneva, Switzerland. The World Health Organization welcomes such applications. The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the Secretariat of the World Health Organization concerning the legal status of any country, territory, ciry or area or of its authorities, or concerning the delimitation of its frontiers or boundanes. Where the designation "country or area" appears in the heading of tables, it covers countries, territories, cities or areas. The mention of specific companies or of certain manufacturers' products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters.
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IV
Contents page
Strategy for health for all by the year zooo: Resolutions of the Thirty-fourth World Health Assembly . Introduction . . . . . . 1.
rx XIII
Policy basis: World Health Assembly, Executive Board, and Strategy for health for all by the year zooo . . WHO's structures in the light of its functions Health and politics . . . . . . . . . . . . . . .
regi~nal
committees
2.
General programme development and management Managerial process for national health development Managerial process for WHO's programme. Information systems support.
16 r6
3. Coordination . . . . . . Extra budgetary sources of funds. . . United Nations system . . . . . . . . United Nations Development Programme (UNDP) United Nations Children's Fund (UNICEF). World Food Programme (WPF). Emergency relief operations . . . United Nations Volunteers . . . . Nongovernmental organizations . Cooperative programmes undertaken with Member States .
26 z6 27 29 29 30 3I 33 33 34
4· Research promotion and development Global developments. . . . . . . . . Regional developments . . . . . . . .
35 35 37
5. Health services development Primary health care. . . . . . . . . . Health services planning and management Appropriate technology for health. Health services research . .
42 43 45 48
49 5I 54
6. Family health . . . . . Maternal and child health Nutrition . . . . . . . . . Health education . . . . . Special Programme of Research, Development and Research Training in Human Reproduction .
59
6z 64
v
7· Mental health . . . . . . . . . . . . . . . . . Development of community health services. . . . . . . Safe use of narcotic and psychotropic substances . . . . Psychosocial aspects of health promotion (including drug dependence and alcohol-related problems) Promotion of biomedical and health practice research . . . . . . . . . . . . . Monitoring and other mechanisms for programme development and support. . . . . . . . . . . . .
75 75 77 78 82
84
8. Diagnostic, therapeutic, and rehabilitative technology Pharmaceuticals. . . . . . . . . . . . . Action programme on essential drugs . Biologicals . . . . . . . . . . Health laboratory technology Radiation medicine . . Rehabilitation. . . . . Traditional medicine . Essential surgical care Prevention of road traffic accidents Care of the aged . . . . . . . . . . .
86 86 88
90 92 93 95
97 98
99 roo
9· Communicable disease prevention and control . . . . . . . . . . . . . . . . . . . Post-eradication activities in smallpox and epidemiological surveillance of communicable diseases. Malaria . . . . . . . . . Other parasitic diseases. Diarrhoeal diseases . Leprosy. . . . . . . . . Tuberculosis . . . . . . Other acute bacterial diseases Acute respiratory infections . Virus, rickettsial, and related diseases . Safety measures in microbiology. Hospital infections . . . . . . Sexually transmitted diseases . . . Prevention of blindness . . . . . Expanded Programme on Immunization Veterinary public health . . . . . . . . . Vector biology and control . . . . . . . Special Programme for Research and Training in Tropical Diseases .
I02
ro2 I05 I I I I I
7
119 122 126 I 27
128
' 31 1 32 1 32 I 33 I 34 1 37 I41
146
IO.
Noncommunicable disease prevention and control . Cancer . . . . . . . . . . . . . . . . . . . . . International Agency for Research on Cancer. Cardiovascular diseases. . . . . . . . . . . Other chronic noncommunicable diseases . Oral health . . . Workers' health Immunology . .
I
55 Ijj
157 I6o I64
I66
167 170
II.
Promotion of environmental health . . . . . . . . . International Drinking Water Supply and Sanitation Decade. Control of environmental hazards . Promotion of food safety . . . . . . . . . . . . . . . . . . . VI
I 2.
Health manpower development . . . Programme planning and general activities . . Health manpower planning and management . Promotion of training . . . . . . . . . . . . . Educational development and support . . . . Examples of health manpower activities in other programmes .
I
3. Health information. . . . . . . . . . . . . . . . . . Health statistics. . . . . . . . . . . Health and biomedical information legislation) . . . . . . . . . . . . Health information of the public . . . . . . . (including . . . . . . . . . . . . . . . . . . . . . health literature . . . . . . . . . . . . . . . . . . . services, WHO publications, and health . . . . . . . . . .
2I3 2I
3 7
2I
222
I4.
Constitutional, legal, and administrative developments . . . Constitutional and legal matters . Administration . . .
225 22j 227
I
5. Regional trends . . . African Region . . . . . Region of the Americas South-East Asia . . . . European Region. . . . Eastern Mediterranean Region. Western Pacific Region . . . .
Annex Annex
I.
Members and Associate Members of the World Health Organization at 3 I December I981. . . . . . . . . . . . . . . . Organizational and related meetings, I980-I98I . Intergovernmental organizations that have entered into formal agreements with WHO approved by the World Health Assembly, and nongovernmental organizations in official relations at 3I December I98I . . . . . . . . Structure of the World Health Organization at 3I December I98I (charts).
257 2
2.
59
Annex 3·
26o
Annex 4· Index . . .
VII
Strategy for Health for All by the Year 2000 The two following resolutions were adopted by the Thirty-fourth World Health Assemb!J in Mt!J I98I.
Global Strategy for health for all by the year The Thirty-fourth World Health Assembly,
2ooo
Recalling WHO's constitutional objective of the attainment by all peoples of the highest possible level of health, the Declaration of Alma-Ata, and resolutions WHA30.43, WHA32.30, and WHA33.24 concerning health for all by the year 20oo and the formulation of strategies for attaining that goal, as well as resolution 34/5 8 of the United Nations General Assembly concerning health as an integral part of development; Having reviewed the Strategy submitted to it by the Executive Board in the document entitled "Global Strategy for health for all by the year 20oo" ; 1 Considering this Strategy to be an invaluable basis for attaining the goal of health for all by the year 2ooo through the solemnly agreed, combined efforts of governments, people and WHO; 1. ADOPTS
the Global Strategy for health for all by the year
2000;
2. PLEDGES WHO's total commitment to the fulfilment of its part in this solemn agreement for health; 3· DECIDES that the Health Assembly will monitor the progress and evaluate the effectiveness of the Strategy at regular intervals;
I Global Strategy for health for all lry the year 2000. Geneva, World Health Organization, 198 r ("Health for All" Series, No. 3).
IX
4·
Member States: (I) to enter into this solemn agreement for health of their own volition, to formulate or strengthen, and implement, their strategies for health for all accordingly, and to monitor their progress and evaluate their effectiveness, using appropriate indicators to this end; (2) to enlist the involvement of people in all walks oflife, including individuals, families, communities, all categories of health workers, nongovernmental organizations, and other associations of people concerned; INVITES REQUESTS the Executive Board: (I) to prepare without delay a plan of action for the immediate implementation, monitoring and evaluation of the Strategy, and submit it, in the light of the observations of the regional committees, to the Thirty-fifth World Health Assembly; (2) to monitor and evaluate the Strategy at regular intervals; (3) to formulate the Seventh and subsequent General Programmes of Work as WHO's support to the Strategy; REQUESTS the regional committees: (I) to review their regional strategies, update them as necessary in the light of the Global Strategy, and monitor and evaluate them at regular intervals; (2) to review the Executive Board's draft plan of action for implementing the Strategy and submit their comments to the Board in time for it to consider them at its sixty-ninth session in January I982;
5.
6.
7.
the Director-General: (I) to ensure that the Secretariat at all operational levels provides the necessary support to Member States for the implementation, monitoring and evaluation of the Strategy; (2) to follow up all aspects of the implementation of the Strategy on behalf of the Organization's governing bodies, and to report annually to the Executive Board on progress made and problems encountered; to present the Strategy to the United Nations Economic and Social Council (3) and General Assembly in I98I, and report to them subsequently at regular intervals on progress made in implementing it, as well as United Nations General Assembly resolution 34/5 8. REQUESTS
WHA34·37
Resources for strategies for health for all by the year 2ooo
The Thirty-fourth World Health Assembly, Recalling resolution WHA30.43, which defined the goal of health for all by the year zooo, resolutions WHAp.3o and WHA33.24, which endorsed the Declaration of Alma-Ata and urged Member States to formulate national strategies for attaining health for all through primary health care as part of a comprehensive national health system, and X
STRATEGY FOR HEALTH FOR ALL
resolution 34/5 8 of the United Nations General Assembly concerning health as an integral part of development; Also recalling resolutions WHA27.29, and WHA29.32, which requested the DirectorGeneral to strengthen WHO's mechanisms for attracting and coordinating an increased volume of bilateral and multilateral aid for health; Noting with satisfaction the decision taken by the Executive Board at its sixty-seventh session concerning the establishment of a Health Resources Group; A ware that some countries have encountered difficulties in developing and implementing their national strategies for health for all, and convinced that these countries urgently require special support to enable them to overcome their difficulties; 1. WELCOMES the efforts being made by Member States to prepare and implement national strategies for health for all through the development of health systems based on primary health care; 2. URGES all Member States to allocate adequate resources for health and, in particular, for primary health care and the supporting levels of the health system;
3· URGES Member States that are in a position to do so to increase substantially their voluntary contributions, whether to WHO or through all other appropriate channels, for activities in developing countries that form part of a well-defined strategy for health for all, and to cooperate with these countries and support them in overcoming the obstacles impeding the development of their strategies for health for all; 4· INVITES the relevant agencies, programmes and funds of the United Nations system, as well as other bodies concerned, to provide financial and other support to developing countries for the implementation of national strategies to achieve health for all by the year zooo;
5. URGES those Member States that, for the implementation of their strategies for health for all, require external sources of funds in addition to their own resources, to identify those needs and report thereon to their regional committees; 6. INVITES the regional committees to review regularly the needs of Member States in the region for external resources in support of well-defined strategies for health for all, and report thereon to the Executive Board; 7. REQUESTS the Executive Board to review regularly the international flow of resources in support of the strategy for health for all, to ensure that such resources are effectively and efficiently used for that purpose, and to report thereon to the Health Assembly; 8. DECIDES that the Health Assembly shall review from time to time the international flow of resources for health, and encourage those Member States that are in a position to do so to ensure an adequate level of transfer; XI
9·
the Director-General: to support developing countries as required in preparing proposals for external funding for health; (z) to take appropriate measures for identifying external resource requirements in support of well-defined strategies for health for all, for matching available resources to such needs, for rationalizing the use of such resources, and for mobilizing additional resources if necessary; (3) to report regularly to the Executive Board on the measures he has taken and the results he has obtained. REQUESTS
( 1)
XII
Introduction The way strategies for health for all ry theyear 2000 were developed ry WHO's Member States in I9So and I93I was, ry atry standards, remarkable. When the International Conference on Primary Health Care met in Alma-Ata in I9JS it did not content itself with a paper plan of action; instead it urged governments to develop strategies for attaining health for all through health systems based on primary health care. And the response in a large number of countries throughout the world has been phenomenal. On the basis of national strategies WHO's regions developed regional strategies, and from them a Global Strategy was prepared reflecting the national and regional strategies. It was adopted ry the Health Assemb!J in Mcry I93I. The Global Strategy provides practical guidance to governments on how to develop health systems based on primary health care so as to suit wide!J differing health, social, economic, cultural, and political situations. It shows how cooperation between countries can be improved. It defines the role of WHO-a necessary act, for it must be stressed that while WHO's role is important it is ry no means that of guarantor of the implementation of the Strategy. Implementation will depend first and foremost on the action of Member States themselves, individual& and joint!J. As the Health Assemb!J requested, the Executive Board has worked out a plan of action to implement the Strategy and this is beingfinalized as the present report goes to press. It spells out what is expected of every Member State, of the governing bodies of WHO, and of the Director-General and Regional Directors. The burning question now is how to make sure that Member States will have adequate resources to carry out the Strategy. True, the World Health Assemb!J passed a resolution in which it urged all Member States to allocate adequate resources in furtherance of the Strategy; and it called on the more fortunate countries and the bilateral, multilateral, and voluntary agencies to increase their support to the less affluent countries to help them carry out strategies for health for all if these are well defined. But we in WHO do not live within a political and economic vacuum. At a time when national and international political instability is spreading, when the world's leaders right!J or wrong!J feel that its economy is floundering and see no easy wcry of reversing the situation in the near future, and when the developing countries have to run harder in order to stand still, it is not easy for programmes of human development to gain acceptance and the financial support thry require. Yet those are the very circumstances in which such programmes are most needed. Recent international political and economic proposals have large!J been made in an atmosphere ofpessimism and inconsistency, and the forecasts have not shown even a glimmer of hope of emerging from the confusion before the end of the century. No clear policies that have atry chance of being universal& accepted have emerged, let alone atry world strategy that, startingfrom countries themselves, has been built up block ry block. Unique!J, that is what has taken place within WHO. Not on!J that, but the consistent health XIII
THE WORK OF WHO, 198o-198I
policies and mutuai!J reinforcing national and international strategies for their implementation reach far beyond the health sector; they show how the struggle for health can be used effective!J as a springboardfor human development in general. Admitted!J the cost is far from negligible, b~t it is much lower than present expenditure on what, to put it mild!J, are far less lofty ideals. The effort to mobilize world opinion in favour of the health-for-all movement has not been totai!J in vain. Thus, following the resolution adopted~ the United Nations General Assemb!J towards the end of 1979 declaring that health is an integral part of development, the Economic and Social Council proposed another resolution that was adopted ~ the General Assemb!J in December Ig8I. This resolution endorses the Global Strategy for health for all~ the year 2000 and recognizes it as a mqjor contribution to the fulfilment of the International Development Strategy for the Third United Nations Development Decade. But is this any more than lip-service--the ea!J adoption of a resolution ~ consensus because it does not seem to do anybotfy any harm? When it came to the real test-the inclusion in government plaiforms and in the NorthfSouth dialogue of the poliry of giving human development pride of place over mere economic growth as an alternative approach to solving the world's current dilemma-there was regrettab!J no one even reatfy to entertain the possibility. This was unfortunatelY true not on!J in the organizations of the United Nations !)'Stem but also at the last Summit Conference of Non-aligned Countries and at the International Meeting on Cooperation and Development held in Cancun. This should not and will not deter WHO from going on trying to get its message across,for it is precise!J when an apparent impasse is reached that daring!J innovative concepts are most required and have a chance of taking root in people's imagination. To make the Organization fitter than ever to carry out the new roles devolving upon it in relation to the Strategy for health for all, a managerial stutfy of unusual magnitude for any organization, national or international, took place during the biennium-a stutfy of WHO's structures in the light of its functions. These functions now include taking positive action for health in addition to mere!J indicating how such action should be carried out. Action for health can be effective on!J if it is pursued consistent!J-derived from countries' needs, based on policies and principles that have been agreed upon collective!J, and applied~ governments and~ WHO in accordance with that collective agreement. To achieve such unity of action, the democratic government of the Organization as envisaged in its Constitution has been !)'Stematicai!J strengthened. National representatives in regional committees and the World Health Assemb!J are taking a much greater part in the affairs of the Organization than ever before. The Executive Board has never been so active in guiding the Health Assemb!J and in carrying out its policies. The debates in all these organs during the biennium were refreshinglY frank. Relationships between Member States and their Organization began to change, the notion of technical assistance where~ WHO gave "assistance" to countries being replaced~ that of technical cooperation where~ the Organization cooperates with Member States in a genuine partnership. This evolution has not been to everybotfy' s liking. Many voices have been heard bemoaning the diminution in action in countries as the old technical assistance prqjects began to fade out and new forms of technical cooperation were slow to replace them. For, I regret to have to admit it, the change in poliry from passive acceptance of assistance to active cooperation to stimulate the growth of national selfreliance in health matters has not yet gained universal recognition where it matters most-within the countries themselves. This was evident, for example, in relation to the International Drinking Water Supp!J and Sanitation Decade, which started in Ig8I. There were too many instances where the XIV
INTRODUCTION
impression was given that countries were waiting for funds to come from outside before taking action rather than rising to the challenge ofworking out local solutions, plunging into the thick of things without waiting for external support, and thus demonstrating the will to reach the target of safe water and sanitation for all fry 1990. It is on!J fry such bold endeavour that self-reliance will rise above the level ofan empty political slogan. As for the International Drinking Water Supp!J and Sanitation Decade, so for technical cooperation among developing countries. TCDC for health remained embryonic. It was more talked about than acted upon. It was often confused with passive acceptance of WHO support in intercountry activities, not seen as a genuine getting together of countriesfor joint health action, using WHO to help if and as necessary. This is as true of the developed as of the developing countries, although the Organization took great pains to point out to the former that thry have much to gain fry working together in joint endeavours with their Organization. There are growing signs that these countries have come to realize that thry cannot continue to spend more and more on their health services for the little additional health benefit received. So thry too are turning to the Strategy thry helped to put together in WHO. In the Secretariat as well there were ma'!Y who could not understand the evolution that was taking place in the Organization. Some resented what thry felt to be a threat to the influence of the permanent staff But as time went on, and as thry became involved in preparing the Organization's next General Programme of Work, which the Executive Board decided should represent WHO's support to the Strategy for health for all, most of them came to realize that what was involved was not a diminution of their power but a challenge to their ability to app!J their vast accumulation of knowledge in a different wcry and to use it as a springboard for national health personnel to develop their capacities. The emphasis on action for health of a more fundamental nature than the execution of different prf!!ects frequent!J brought its own counteraction or, as I would dare to call it, reaction. One such example is the International Code of Marketing of Breast-milk Substitutes. This has to be seen in its proper context, that of ensuring an acceptable level of health for all in the foreseeable future. Instead, it was considered in isolation and, because of the controver{Y created around it and the impassioned interventions of the advocates of opposing opinions, it received undue publicity of too sensational a nature. A similar storm is being artificiai!J brewed over the marketing of medicinal drugs. I take this opportunity of making it clear that WHO has no machiavellian schemes against af!Ybotfy genuine!J concerned with medicine and health. Those who are honest in their practices have nothing to fear. But WHO will never aijure its constitutional obligation to provide the world, without fear or favour, with the best available information on all matters relating to health. That is the crux of its constitutional position as directing and coordinating authority on international health work. The Health Assemb!J called upon ministries of health, or equivalent bodies acting on behalf of the minister responsible for health, to become directing and coordinating authorities on national health work. This did not go unnoticed and uncriticized. The main criticism was that the intersectoral nature of primary health care makes it impossible for af!) one ministry to be able to develop and implement it, and the ministry of health is particular!J unsuitable since in maf!Y countries it is considered of secondary importance. It is true that m_inistries of health have rare!J been given much weight in the affairs of state and have often been too deep!J engrossed in the dcry-to-day tasks of administering the health sector, and sometimes on!J the governmental parts of it. However, the need to modify their role in ma'!Y countries stems not from af!Y desire for greater prestige for the health sector but from the needfor a single botfy to direct and coordinate--not necessari!J to administer-all the interrelated activities in all the sectors concerned. XV
I
To the criticism that most ministries of health are too weak for that role and that more powerful ministries should be appointed as focal point, I would retort that nobot!J can look after a bafry so well as its parents. By taking on challenges requiring direction and coordination, ministries of health will progressivelY become directing and coordinating authorities. Integrated planning and administration for the totaliry of sectors in complex societies have proved to be a task bryond human capabilities; selective intersectoral action is therefore mandatory. As far as health is concerned there is no alternative but for a ministry of health or equivalent bot!J to identify what needs to be done, fry whom, how, when, where, with what resources, and through what mechanisms-in short, to elaborate a strategy for health. If such a ministry then reciprocates fry being reat!J to accept coordination of those of its activities that influence other social and economic endeavours, we have a good recipe for the best kind of intersectoral action. At the international/eve/, too, there is more than enough room for others to be active in the field of health. It is a pleasure to record the contribution to health made during the period under review fry such organizations as-to mention on!J afew-UNICEF, UNDP, UNFPA, and the World Bank, as well as fry ma'!} bilateral and voluntary organizations. Differences of interest or emphasis can be turned to advantage rather than be made a matter of contention, suiject to one condition of overriding importance: that the policies and principles decided upon collective!J in WHO fry its Member States are adhered to. WHO's constitutional role makes it the guardian of those policies and principles. A comment frequent!J heard throughout this transitional period was that WHO, in its attempts to inspire action for health, was becoming too politicized, to the detriment of its technical programmes. I believe that this report, which abounds in accounts of technical activities over a very wide range of endeavours, belies this accusation sufficient!J. I98o and I93I were most excitingyet controversialyears. I think that the controver!J contributed to the excitement. The years of germination of ideas nurtured fry worldwide debate bore fruit in the conversion of policies into strategies and the beginnings of plans of action for implementing them. The democratization of WHO's structures moved steadi!J forward. All these are continuing processes and the essential is that thry have started-! believe in the right direction. In spite of those who cannot see the wood for the trees, I submit that thry are all developments that have given greater solidiry and sense of purpose to the work of WHO. If that is the case, half the battle for health for all fry theyear 2000 is won. To win the other half we shall have to continue with the same determination we started with, never allowing cold international political and economic winds to deflect us from our path.
Director-General
XVI
Chapter
I
Policy Basis: World Health Assembly) Executive Board) and Regional Committees DURING the biennium I98o-I98I the governing bodies of WHO paid particular attention to two major issues-the Global Strategy for health for all by the year 2000 and the structures of WHO in the light of its functions. The Strategy defined the long-term health objectives of Member States and of WHO as well as action to attain them on the basis of policies and principles agreed upon by the governing bodies in previous years. The study of WHO's structures was undertaken to ensure that the Organization is optimally geared to its role in support of the Strategy. I. I
of comprehensive health services; health science and technology; and promotion and support. An implementation schedule includes objectives for I 990 related to immunization, water supply and sanitation, and the fight against hunger and malnutrition. The Regional Committee for Africa, in adopting the regional strategy, invited Member States to formulate detailed national plans of action with emphasis on primary health care and to put their strategies into effect with the support of WHO, OAU, and other organizations or institutions. It requested the setting up of mechanisms to evaluate the progress of the work every two years and the effectiveness of the work every six years. I ·4 The Regional Committee for the Americas (the Directing Council of PAHO) considered the regional strategy together with developments in the health sector in the decade I97I-I98o (the period covered by the Ten-Year Health Plan for the Americas). It agreed that primary health care and its components constitute the basic strategies for attaining the goal and that they include: the extension of health service coverage and environmental improvement; community organization and participation; better mechanisms for intersectorallinkages; development of research and appropriate technologies; and the development of human resources. It then adopted a plan of action to implement the strategy. This includes technical and admin-
Strategy for health for all by the year 1.2
2ooo
More than half of WHO's Member States have formally prepared national strategies for health. Many others have reviewed and updated their national health policies without giving the outcome of their review the official title of a national strategy for health for all. I. 3 In the African Region a newly formed African Advisory Committee on Health Development reviewed the regional strategy for health for all, which is a synthesis of the national strategies and a practical manifestation of the regional health charter. Specific objectives were taken from national strategies and classified into three groups: development
THE WORK OF WHO, '98o-1981
istrative support measures, means for identifying and mobilizing resources, research promotion, development of appropriate technologies, and information exchange; and it provides for further intrasectoral and intersectoral coordination as well as an overall system for monitoring and evaluation. I. 5 The Regional Committee recognized the need for the regional plan of action to be linked with the PAHO and WHO programming/budgeting cycles and the monitoring and evaluation periods in a manner that would enable PAHO's resources to be fully committed to the plan of action by I984. Member governments were urged to introduce the necessary adjustments in their national plans, and in their monitoring, evaluation, and information systems. The Regional Director was requested to review and orient PAHO's technical cooperation programme to support national efforts towards health for all by the year 2ooo, and to strengthen the catalytic role of the Organization.
the implementation of national strategies, including the establishment of high-level national councils and committees for coordinated implementation of the strategies and the specific objectives and targets that had been included in countrywide health programmes. It felt that, although there was increasing evidence of intersectoral coordination within countries, the national plans of action to implement the strategies with internal and international support needed to be vigorously pursued. It adopted a resolution (sEA/RC34/R4) urging Member States to strengthen national mechanisms for monitoring and evaluating the implementation of the Global Strategy and requesting the Regional Director to collaborate in the revision and updating of national and regional strategies. I. 7 In the European Region a Regional Health Development Advisory Council, composed of members of the Consultative Group on Programme Development and experts in the fields of political science, economics, and sociology, proposed a comprehensive long-term strategy for the Region. In I98o the Regional Committee endorsed the proposed strategy, with minor changes. It agreed that the main programmes should include: promotion of lifestyles conducive to health; reduction of preventable conditions; and reorientation of the health care system to cover the whole population with comprehensive health care to the maximum degree possible for each country according to its stage of development. Attention was also drawn to the importance for all programme areas of reducing poverty, and to the significance in this respect of the establishment of the New International Economic Order. The Regional Committee recommended that regional as well as national targets be set, with an annual review of progress. The importance of accurate indicators-relating not only to disease but also to health care systems-for monitoring progress and achievements was
1.6 The regional strategy for South-East Asia incorporates the national strategies of the Member States in the Region and is an operational expression of the regional health charter. When it adopted the regional strategy in I98o the Regional Committee urged Member States to develop a plan of action and commit themselves fully to its implementation. It also urged them to take individual and collective steps to update the national and regional strategies annually and to set up mechanisms at national level to monitor and evaluate the implementation of the strategy. It further requested the Regional Director to work out a regional plan of action and to take the steps required to ensure that WHO's technical cooperation with Member States was in consonance with the national and regional strategies. The following year the Regional Committee noted with satisfaction the progress reported by Member countries in 2
POLICY BASIS
fully recognized. The Regional Committee felt that monitoring as a continuing process during the implementation of the regional strategy was essential and that the strategy would need constant updating, the health for all movement being a dynamic process. Community involvement, more humanized care, and health education were other issues the Regional Committee considered should be given attention. 1.8 In 1981 the Regional Committee reviewed the progress made since its adoption of the regional strategy and noted that, in collaboration with experts working in different disciplines, work was now well under way in setting targets at both national and regional level. It advocated that an evaluation system based on relevant indicators should be developed. It also stressed the need for studies on the cultural and social forces contributing to lifestyles hazardous to health; for the strengthening of regional activities in health education and health promotion; for increased attention to the role of the family and the socioeconomic environment; and for examination of the way the health system and other sectors could respond to both present and future trends with a bearing on health. In the area of prevention, identification of the most important diseases was required, and also recognition of the emergence of highrisk groups such as the elderly, migrants, and the unemployed. This should lead to a reanalysis of the various systems of health care, particularly at primary health care level, including the concept of self-help and "alternative" health care. A re-examination of the present system of hospital care and of material and human resources in Europe would benefit not only countries in the Region but also those in other regions at different stages of development. 1 ·9 The Regional Committee, in considering the plan of action for implementing the Global Strategy, agreed that clarification
was needed on a number of key elements, such as the support that WHO should give to Member States in developing their national strategies, the means of mobilizing human and financial resources for their implementation, and the commitment of the United Nations system as a whole to the support of the Global Strategy. More specific targets would have to be set and information provided on the resources necessary for implementation. I. IO In the Eastern Mediterranean Region a number of Member States are actively pursuing their national strategies for health for all by the year zooo. Following subregional meetings held in Kuwait, Somalia, and the Syrian Arab Republic, draft regional strategies were formulated. These were taken into account in preparing the Global Strategy.
I. I I The Regional Committee for the Western Pacific in 1980 unanimously adopted a regional strategy for health for all by the year zooo, confident that it would be strengthened as countries made progress towards the goal through the acquisition of new knowledge and the application of that already existing. The strategy calls for three basic courses of action: laying the foundation for health (providing adequate food, water, and shelter); developing individual and community self-reliance in health; and providing appropriate and affordable health technology for the sick, the disabled, the chronically ill, and the socially maladjusted. The strategy focuses on primary health care as one of the principal approaches. The Regional Committee urged Member States to implement, monitor, and evaluate their national strategies, reviewing and updating them as required. It considered that commitment at all levels was of utmost importance and that managerial expertise would have to be strengthened. At its session in I98I, the Regional Committee adopted a revised reg-
3
THE WORK OF WHO, 198o-1981
ional strategy as well as a plan of action for implementing it. Liz In May I98I the Thirty-fourth World Health Assembly adopted a Global Strategy for health for all by the year zooo (resolution WHA34·36).1 It was based on the report of the International Conference on Primary Health Care and the Declaration of Alma-Ata 2 and on guiding principles for formulating strategies that had been prepared by the Executive Board.3 The Global Strategy reflects the national and regional strategies as seen from a global perspective, and responds to United Nations General Assembly resolution 34/5 8 concerning health as an integral part of development. I. I 3 The main component of the Strategy is the development, starting with primary health care, of the health system infrastructure for the delivery of countrywide programmes reaching the whole population that include measures for health promotion, disease prevention, diagnosis, therapy, and rehabilitation. The Strategy entails the specifying of measures to be taken by individuals and families in their homes, by communities, by the health service at the primary and supporting levels, and by other sectors. It also involves the selection of technology that is appropriate for the country concerned in being scientifically sound, adaptable to local circumstances, acceptable to those for whom it is used and to those who use it, and maintainable with resources the country can afford. It is crucial to the Strategy that social control of the health infrastructure and 1 Global strategy for health for all by theyear 2000. Geneva, World Health Organization, 1981 ("Health for All" Series, No. 3). 2 Alma-Ata I9J9: primary health care. Geneva, World Health Organization, 1978, reprinted 1981 ("Health for All" Series, No. r). 3 Formulating strategies for health for all by the year 2000 : guidingprincrples and essentialrssues. Geneva, World Health Organization, 1979, reprinted 198r ("Health for All" Series, No. z).
technology should be ensured by a high degree of community involvement. The Strategy also presupposes international action to support national action through the exchange of information, the promotion of research and development, technical support, training, coordination within the health sector and between the health and other sectors, and the fostering and support of the essential elements of primary health care in countries. I.I4 An inseparable part of the Strategy is the action required to promote and support it. This includes strengthening the ministry of health, or whatever authority represents the whole health sector, as the focal point for the national strategy. It is necessary to ensure political commitment at the highest level nationally and internationally, as well as the support of economic development planners. Professional groups inside and outside the health sector have to be enlisted. An appropriate managerial process for national health development has to be developed and applied, 4 and biomedical, behavioural, and health systems research oriented to support the Strategy. Policy, technical, and popular information to ensure acceptance of and involvement in the Strategy has to be widely disseminated. I. I 5 Another inseparable part of the Strategy is action to generate and mobilize all the resources possible. Not only health personnel but all human resources have to be mobilized, and all types of health personnel must be motivated. The best use has to be made of the human and fmancial resources available, and investments in health have to be increased if necessary. The international transfer of resources from developed to
4 Managerial process for national health development: guiding principles for use in support of strategies for health for all by the year 2000. Geneva, World Health Organization, 1981 ("Health for All" Series, No. 5).
4
POLICY BASIS
developing countries has to be rationalized and, if necessary, increased. I. I 6 Cooperation between countries is an essential feature of the Strategy, because few countries will be able to formulate and implement their strategies independently. This involves both technical and economic cooperation among countries (TCDC and ECDC) and the use of WHO's regional arrangements to facilitate such cooperation. I. I 7 To monitor progress in implementing the Strategy and to evaluate its effectiveness, suitable monitoring and evaluation processes 1 will be set up by countries as part of national health development management. At the international level WHO mechanisms will be used to report progress and assess the impact of the Strategy. Indicators will be used at the global level that are useful first of all at the national level; a list of such indicators has been prepared, based on national and regional strategies.z
the involvement of people in all walks of life, including individuals, families, communities, all categories of health workers, nongovernmental organizations, and other associations of people concerned. It requested the Executive Board to prepare without delay a plan of action for the immediate implementation, monitoring, and evaluation of the Strategy, for review by the regional committees before being finalized. It requested the DirectorGeneral, inter alia, to present the Strategy to the United Nations Economic and Social Council and General Assembly in I98I, and report to them subsequently at regular intervals on progress made in implementing it as well as United Nations General Assembly resolution 34/5 8. (See also paragraphs 3. I 2 and 1.28.) I. I 9 The governing bodies devoted much attention to the mobilization of resources for implementing the Strategy. Thus, in resolution WHA34·37 the Health Assembly urged all Member States to allocate adequate resources for health and, in particular, for primary health care and the supporting levels of the health system. It urged Member States that are in a position to do so to increase substantially their voluntary contributions, whether to WHO or through all other appropriate channels, for activities in developing countries that form part of a welldefined strategy for health for all, and to cooperate with those countries and support them in overcoming the obstacles impeding the development of their strategies for health for all. It invited the relevant agencies, programmes and funds of the United Nations system, as well as other bodies concerned, to provide financial and other support to developing countries for the implementation of national strategies to achieve health for all by the year 2000. It urged Member States that, for the implementation of their strategies for health for all, require external sources of funds in addition to their own resources, to identify those needs and report thereon to
I. I 8 When the Health Assembly adopted this Strategy it considered it to be an invaluable basis for attaining the goal of health for all by the year 2ooo through the solemnly agreed combined efforts of governments, people, and WHO. It pledged WHO's total commitment to the fulfilment of its part in the agreement. It invited Member States to enter into this solemn agreement for health of their own volition; to formulate or strengthen--and implement-their strategies for health for all accordingly; and to monitor the progress and evaluate the effectiveness of those strategies using appropriate indicators for the purpose. It also invited them to enlist
1 Health programme evaluation: gu1dmg principles for its application in the managerial process for national health development. Geneva, World Health Organization, 1981
("Health for All" Series, No. 6). 2 Development of indicators for monitoring progress towards health for all by the year 2000. Geneva, World Health
Organization, 1981 ("Health for All" Series, No. 4).
THE WORK OF WHO, r98o--r98r
their regional committees. It then invited the regional committees to review regularly the needs of Member States in their regions for external resources in support of well-defined strategies for health for all, and to report on them to the Executive Board. It requested the Executive Board to review regularly the international flow of resources in support of the strategy for health for all, to ensure that such resources are effectively and efficiently used for that purpose, and to report on those matters to the Health Assembly. It decided that the Health Assembly would review from time to time the international flow of resources for health and encourage Member States in a position to do so to ensure an adequate level of transfer. Finally, it requested the Director-General to support developing countries as required in preparing proposals for external funding for health; and to take appropriate measures for identifying external resource requirements in support of well-defined strategies for health for all, for matching available resources to such needs, for rationalizing the use of such resources, and for mobilizing additional resources if necessary.
1.21 It has been estimated that an additional $z 5oo million per year 1 will be required to implement the regional strategy for Africa, a sum that includes $zooo million for drinking-water and sanitation, $55 million for the Expanded Programme on Immunization, and $2 5 million for malaria control. This sum amounts to $7-$1o per inhabitant per year. External funding will be necessary, and an African Regional Health 2ooo Resources Group was therefore set up. It includes representatives of Member countries, of organizations of the United Nations system, and of intergovernmental, governmental, and nongovernmental organizations. Its terms of reference include advising on how best to secure extrabudgetary support, stimulating the mobilization of resources for health development, and promoting the exchange of information on health needs and resources. 1. 22 The Regional Committee for the Americas advocated the establishment of national systems for fmancing the health strategies and reorientation of international cooperation. A mechanism has been established not only to identify needs and possible sources of external funds for countries but also to help countries draw up suitable proposals for the programmes that have a high likelihood of being financed. Discussions have been held in particular with the Inter-American Development Bank. In the European Region the feasibility of setting up a regional health resources group is under discussion. In the Western Pacific Region a resource mobilization committee composed of staff members reviews the regional programme to identify needs for extrabudgetary resources and initiate approaches to funding agencies.
1.20 One of the measures taken by the Director-General was to invite representatives of bilateral, multilateral, and nongovernmental agencies as well as of developing countries to meet in a Health Resources Group for Primary Health Care. The aim of this Group is to promote the rationalization of the flow of resources required for primary health care activities in developing countries, and to stimulate the mobilization of new resources (see also paragraph 3.6). This conforms to the directive given by the Executive Board that the Health Resources Group should function under the aegis of WHO and in accordance with its constitutional mandate--a directive that was noted with satisfaction by the Thirty-fourth World Health Assembly.
I Throughout this volume the $ stgn denotes US dollars.
6
POLICY BASIS I. 2 3 Political support is essential for implementing the Strategy for health for all. Such support needs to be sought and promoted, and the regional committees have been active in doing so. Among the sources of political support are the geopolitical groupings of countries, an example being OAU. WHO is inviting OAU to include health for all by the year 2000 as an agenda item at one of its forthcoming summit meetings. I .24 Another example is ASEAN. The cooperative spirit characteristic of ASEAN has permeated the health sector and reinforced international health cooperation, particularly with WHO. A meeting of ASEAN health ministers (from Indonesia, Malaysia, the Philippines, Singapore, and Thailand), held in Manila, accepted among its regional priorities WHO's goal of health for all by the year 2ooo through primary health care. The ministers signed a declaration of collaboration in health affirming "their agreement to strengthen and coordinate regional collaboration in health among ASEAN countries". They adopted guidelines to ensure that collaboration should contribute directly or indirectly towards regional selfreliance and self-determination; to emphasize health as an integral part of overall socioeconomic development; to aim at making health care accessible to the whole population, priority being given to the underserved and depressed areas; to promote health manpower development consistent with the needs of the ASEAN member countries; to continue with international collaboration in health while striving to be self-reliant in the delivery of health services; and to emphasize primary health care in the overall development strategy. The ministers also agreed to develop a formal mechanism within ASEAN to facilitate effective collaboration in the areas of: primary health care; disease control; health planning, management, and information systems; nutrition; health manpower development; environmental and occupa-
tional health; pharmaceuticals, biologicals, and traditional medicine; and mental health. 1.25 A third example is the movement of non-aligned countries. The Fourth Meeting of Ministers of Health of the Non-aligned and Other Developing Countries (Geneva, I98o) adopted a resolution supporting the goal of health for all by the year 20oo and calling on all countries in the movement to develop an appropriate programme of action. The ministers agreed to use WHO mechanisms for bilateral and multilateral exchanges of the experience obtained in this direction; to exchange information; to request or send consultants and advisers, in line with each country's possibilities; to coordinate research in biomedical and health matters; and to request or offer material, technical, human, and financial support for implementing the priorities of the programme of action adopted at the Sixth Summit Conference of Nonaligned Countries (Havana, I979) in line with possibilities and needs. 1.26 The adoption of regional charters for health development is a welcome event, indicative of widespread political support for WHO's policies and acceptance of the concept of technical cooperation. The official signing by certain countries of the Charter for the Health Development of the African Region was of major importance, marking a decisive step in reaffirmation of the individual and collective determination of Member States to attain a reasonable level of health. The objectives of the Charter include improvement in primary health care, manpower development and training, provision of safe water and sanitation, promotion of maternal and child health, and control of communicable diseases. The Charter affirms the commitment of Member States in areas they jointly consider important for health development. By collectively binding governments to ideals they already hold individually, the Charter can be an effective instrument for peace, progress, and cooperation.
7
1.27 The countries of the South-East Asia Region have signed the Asian Charter for Health Development. The Charter is a means for the countries of the Region to cooperate in building up individual selfreliance and collective self-sufficiency. Its aim is to promote intercountry consultation and collaboration, foster close international cooperation, and provide a common basis for formulating health plans, programmes, and projects in the best way possible, within the framework of national, regional, and global development policies. I. 2 8 Political support was also forthcoming at the global level. Following the adoption by the United Nations General Assembly of resolution 34/5 8 on health as an integral part of development, the Economic and Social Council recommended to the General Assembly the adoption of a resolution on the Global Strategy for health for all by the year 2000. The General Assembly subsequently adopted resolution 36/43, in which it recognized that the implementation of the Global Strategy would constitute a valuable contribution to the improvement of overall socioeconomic conditions and thus to the fulfilment of the International Development Strategy for the Third United Nations Development Decade. The General Assembly endorsed the Strategy and urged all Member States to ensure its implementation as part of their multisectoral efforts to implement the provisions contained in the International Development Strategy, and to cooperate with one another and with WHO to that end. It requested all appropriate organizations and institutions of the United Nations to collaborate fully with WHO in carrying out the Strategy, and asked the Director-General of WHO to ensure that measures to implement the Strategy are taken into account in the review and appraisal of the implementation of the International Development Strategy for the Third United Nations Development Decade.
1.29 In compliance with its constitutional functions the Executive Board embarked on the preparation of the Seventh General Programme of Work covering the period I984-I989 inclusive. It decided that this Programme of Work should constitute WHO's support to the Global Strategy for health for all, being the first of three such general programmes of work up to the target date 2000. Draft material for the Programme was considered and commented on by the regional committees at their I98I sessions. For example, the Regional Committee for the Americas decided to consider its plan of action for the implementation of the regional strategy as the Region's contribution to the preparation of the Seventh General Programme of Work. The Regional Committee for South-East Asia stressed that the Programme should be relevant to the particular needs of the countries of the Region. These, as well as the comments and recommendations of the other regional committees, were brought to the attention of the Programme Committee of the Executive Board, which took them into account when it prepared a draft of the Programme for the consideration of the Executive Board in January I982. (See also paragraphs 2.3I2·3 3·)
WHO's structures in the light of its functions 1.30 A managerial study of unprecedented magnitude on WHO's structures in the light of its functions took place under the direction of the Executive Board during I 98o and I 98 I. Following wide consultation throughout the Organization, the matter was reviewed extensively and intensively by the regional committees and the Executive Board. The high point of the study was the adoption by the Health Assembly in May I98o of resolution WHA33·I7, in which it decided that WHO should concentrate its 8
POLICY BASIS
activities on support to strategies for attaining health for all, and that its role in promoting action for health, in addition to indicating how such action might be carried out, should be strengthened. The Health Assembly felt that the functions of the regional offices and WHO headquarters should be redefined and organizational structures and staffing adapted so as to ensure the provision of adequate and consistent support to Member States. The engagement of national staff and of international WHO field staff should be reviewed to ensure the full involvement of both kinds of staff in collaborative national programmes. The Health Assembly considered that the Executive Board should strengthen its role in giving effect to the decisions and policies of the Health Assembly and in advising it; become increasingly active in presenting major issues to the Assembly; and correlate its own work with that of the Assembly and the regional committees, monitoring the way in which the regional committees reflect the Assembly's policies in their work. The regional committees, in the view of the Health Assembly, should intensify their efforts to develop regional health policies and programmes in support of health for all, support technical cooperation among all Member States, support the establishment or strengthening of multisectoral national health councils, and increase their own monitoring, control, and evaluation activities. The Health Assembly also urged Member States themselves to take action. They should review the role of their ministries of health, establish multisectoral national health councils, and mobilize all possible resources that could contribute to health development. In addition, they should improve their coordinating mechanisms in support of their health development strategy and technical cooperation, and coordinate their representation within WHO and in the United Nations and the specialized agencies concerned with development. The Health Assembly requested the Director-General to 9
take all the measures within his constitutional prerogatives that he considered nec,essary to ensure the provision of timely, adequate, and consistent support to Member States. I. 3 I In this context the regional committees, the Executive Board, and the Health Assembly reconsidered the nature of WHO's international health work as mentioned in the Constitution. The Thirty-fourth World Health Assembly (resolution WHA34.24) welcomed the changed climate in WHO and among its Member States that has given rise to the rejection of the concept of "technical assistance", whereby aid was provided by socalled "donors" to "recipients", and its replacement by the concept of "technical cooperation" founded on the common and mutual interest of all, whereby Member States cooperate with their Organization, as equal partners, to define and achieve their health . goals through programmes that are determined by their needs and priorities and that ptomote their self-reliance in health development. The Health Assembly reiterated that WHO's unique constitutional role in international health work comprises in essence the inseparable and mutually supportive functions of acting as the directing and coordinating authority on international health work and ensuring technical cooperation between WHO and its Member States, essential for the attainment of health for all by the year zooo, making no distinction between these integral functions carried out at country, regional, and global levels, whether financed from the WHO regular budget or from other sources. It affirmed that coordination in international health work is the facilitation of the collective action of Member States and WHO to identify health problems throughout the world, to formulate policies fqr solving them, and to define principles and develop strategies for giving effect to these policies; and that technical cooperation in international health work is the joint action of Member States cooperating among themselves and
THE WORK OF WHO, r98o-r98r
with WHO, as well as with' other relevant agencies. to achieve their common goal of the attainment by all people of the highest possible level of health by implementing the policies and strategies they have defined collectively. It urged Member States to act collectively in order to ensure the most effective fulfilment by WHO of its constitutional functions and the formulation by the Organization of appropriate international health policies, principles, and programmes to implement them; to formulate their requests for technical cooperation with WHO in the spirit of the policies, principles, and programmes they have adopted collectively in WHO; and to take full account of the experience of technical cooperation between WHO and its Member States when deciding collectively on policies, principles, and programmes in WHO. The Health Assembly also requested the Director-General to emphasize WHO's unique constitutional role in inter-. national health work in all appropriate forums, and particularly in the United Nations system and in other international or bilateral organizations. 1.32 In the course of 1981 the regional committees, the Executive Board, and the Health Assembly reviewed a plan of action that had been prepared by the Director-General for implementing resolution WHA33.17. In this plan of action particular emphasis is given to the proper fulfilment by WHO of its role in supporting Member States at country level, including the role of the WHO programme coordinators. In the African Region more than 30% of all WHO programme coordinators are nationals of the country concerned, and the proportion is increasing yearly. A global strategy to strengthen WHO's role of facilitating technical cooperation among developing countries (TCDC) has been prepared, and all regions are developing plans of action to implement this strategy in a manner appropriate to their own circumstances. IO
Particular attention was paid to TCDC in Africa and the Americas. In the African Region, for example, work has been organized through three subregional groupings of countries with the aim of supporting TCDC within each of them. 1. 3 3 The Regional Committee for the Americas recommended that Member governments should play a more active individual and collective role in the work of WHO and enhance the continuity, preparation, and coordination of their delegations to the governing bodies ofPAHO and WHO. It subsequently requested that the regional structures should take into account the requirements of the plan of action for the regional strategy for health for all. The Regional Committee for South-East Asia endorsed the plan of action prepared by the Director-General for implementing resolution WHA33.17. It urged Member States to initiate action as recommended in this resolution, especially in regard to the strengthening of the role of ministries of health ; and also to ensure the highest level of representation at its sessions in order to strengthen the role of the Regional Committee. It again emphasized the overriding importance of strengthening operations at country level, including the work of the WHO programme coordinators. 1. 34 The Regional Committee for Europe revised its methods of work to ensure more effective conduct of the proceedings. Thus in even-numbered years, when there will be shorter Health Assemblies and when the regional programme budget proposals for the forthcoming biennium are considered, the Regional Committee will be held in Copenhagen and the working sessions will be somewhat extended to make it possible to complete the agenda without undue haste. The Regional Committee for the Western Pacific felt that WHO had been particularly successful in that Region in implementing many of the measures identified as themes of
POLICY BASIS
the study. Despite this, the Regional Committee wished to achieve an even deeper relationship with the Health Assembly and the Executive Board and decided to include a review of mechanisms for improving this relationship on the agenda of a future session. It invited representatives who are also members of the Executive Board to comment during sessions of the Regional Committee on issues of special interest for regional activities. The Regional Committee adopted a resolution recommending that consideration should be given to devising a means of increasing the number of members from the Western Pacific Region serving on the Executive Board. I. 3 5 Regional committees have undoubtedly responded to the challenge to take a more active part in the work of the Organization. The following are some of the ways that have been adopted to facilitate this: - The letter inviting Member States to attend the Regional Committee requests them (i) to coordinate their representation at regional committees and the Health Assembly and to designate representatives to the regional committees and delegates to the Health Assembly who will later be in a position to influence national health policy so as to make it consistent with collective health policy adopted in WHO; and (ii) to take into account as far as possible the multidisciplinary nature of health activities when forming their delegations to the Health Assembly and the Regional Committee (African Region). - An advisory group of members of the Regional Committee who have attended the Health Assembly prepares material for the Regional Committee on the Health Assembly's resolutions (European Region). - Regional committees have established various advisory bodies: programme committees (African and Western Pacific Regions); consultative groups on programme development and on budgetary
questions (European and Eastern Mediterranean Regions); a standing committee or subregional committee on TCDC (African and Western Pacific Regions); a regional advisory committee on medical research (all regions); and a regional health development advisory council (African, European, and Eastern Mediterranean Regions). - Consultations with Member States on given subjects take place through groups of experts who report to the Regional Committee (European Region). - Biennial seminars of representatives of Member States are being organized to discuss the letter of consultation on preparing the programme budget proposals (European Region). - Relations between the regional committees/regional offices and the United Nations regional economic commissions, as well as with subregional geopolitical groupings of Member States, are being strengthened (all regions). - A regional plan of action has been formulated for implementing resolution WHA33.I7 (Western Pacific Region). - The synchronization of PAHO's and WHO's planning cycles is under consideration, as well as of the sessions of the Regiqnal Committee (i.e., the Executive Committee or the Directing Council of P AHO) with those of the Executive Board and the Health Assembly, in order to strengthen PAHO's contribution to these organs (Region of the Americas). 1.36 Much attention was also paid to improving methods of work in regional committees. For example, in the African Region the work of the Regional Committee has been greatly facilitated not only by the establishment of consultative mechanisms of the type indicated above but also by a new presentation of the material for the Committee's consideration, in which fundamental questions are posed at the end of the documents. I I
THE WORK OF WHO, r98o--r98r I. 37 There has been greater correlation of the work of the regional committees, the Executive Board and the Health Assembly. Agendas are better coordinated, and to facilitate this move appropriate action is taken at every session of the Global Programme Committee of the Secretariat, which consists of the Director-General, the Deputy Director-General, the Regional Directors, and the Assistant Directors-General. The following are further examples of the ways in which the work of the governing bodies is being better correlated: - Resolutions of the preceding Health Assembly and sessions of the Executive Board are reviewed, particularly with respect to their regional implications (all regions). - A document submitted to the Regional Committee containing a summary of the resolutions of the Health Assembly and Executive Board permits that Committee to expand and deepen its analysis of the regional and national implications of those resolutions (African Region). - The provisional agenda for the session of the Regional Committee is examined at the preceding session, taking into account the regional implications of decisions of the governing bodies at other levels (African Region). - A regional plan of action for implementing the resolutions is adopted by the Regional Committee (African Region).
sembly in May I981. The Regional Committee for the Americas decided that the programme budget framework of PAHO for I984-I98 5 should conform not only to the regional plan of action for the strategy for health for all, but also to the classified list of programmes to be established by WHO under the Seventh General Programme of Work. Moreover, in order to improve the correlation between the health programmes of individual countries and those of WHO, the Regional Committee decided to develop a new set of criteria for the allocation of resources among country programmes. These criteria should reflect the relative health needs of the countries and their relative capacities to implement global and regional priority programmes within their national health systems. 1.39 The issues that were discussed by the regional committees, the Executive Board, and the Health Assembly during I98o and I 98 I illustrate further how the work of the governing bodies was correlated and indicate the specific matters that were considered by one or other of these bodies in the light of their particular interests. Reference has already been made to the interaction between the regional committees, the Board, and the Assembly for the development of the strategies for health for all, the Seventh General Programme of Work, and the study of WHO's structures in the light of its functions. The consideration by the Health Assembly in I98o of the development and coordination of health research, which led to resolution WHA3 3.2 5, was followed by discussions on this matter in the Regional Committee for Africa in I98o (resolution AFR/RC3o/R5) and I98I (resolution AFR/ RC 3 I /R 5) and in the Regional Committee for the Western Pacific in I98I (resolution WPR/ RC32/RI4). Intense debate on infant and young child feeding in the Health Assembly in I98o (resolution WHA33·32), the Board in 198I (resolution EB67.RI2), and again in the 12
I. 38 Certain issues to be discussed at the Health Assembly are first reviewed in the regional committees. For example, in I 98 I the Regional Committee for Africa reviewed the subject of alcohol consumption and alcohol-related problems in preparation for the Technical Discussions during the Thirtyfifth World Health Assembly in May I982. Again, the Regional Committee for the Western Pacific discussed health systems support for primary health care, which was the subject of the Technical Discussions during the Thirty-fourth World Health As-
POLICY BASIS
Assembly in I98I (resolution WHA34.23), led to the adoption of the International Code of Marketing of Breast-milk Substitutes (resolution WHA34.22). This was subsequently considered by the Regional Committees for South-East Asia (resolution SEA/RC34/R8), Europe (resolution EUR/RC3 I/R5), and the Western Pacific (resolution wPRjRcpjRII).
I .40 Disability prevention and rehabilitation were considered by the Regional Committee for the Western Pacific in I98o (resolution WPR/RC3I/R2o). In I98I the Executive Board considered the International Year of Disabled Persons (decision EB67 (I 2)) as did the Health Assembly (resolution WHA34·3o). This was followed in the same year by discussions on the subject in the Regional Committee for the Americas (resolution XLIII). The Technical Discussions at the Regional Committee for Europe in I98I were devoted to the medical and social problems of disabled persons (resolution EUR/RC 3I /R I 3). The International Drinking Water Supply and Sanitation Decade was considered by the Regional Committees for South-East Asia and the Western Pacific in I98o (resolutions SEA/RC33/R9 and WPR/ RC3J/R2I respectively), by the Health Assembly in I98I (resolution WHA34.25), and following this by the Regional Committee for Europe (resolution EUR/RC3 I/R9) as well as by the Regional Committee for Africa as part of its review of programmes with I 990 as deadline (resolution AFR/RC3I/RI4). The Technical Discussions at the I98I session of the Regional Committee for the Western Pacific had as their subject "Health education and rural water supply and sanitation". A decision of the Executive Board in I 98 I concerning health care of the elderly (decision EB67 (13)) was followed by consideration of the matter in the Regional Committees for the Americas (resolution XLI) and the Western Pacific (resolution WPR/Rcp/RI5)·
L4I The organizational studies of the Executive Board dealt with (i) the role of WHO expert advisory panels and committees and collaborating centres in meeting the needs of WHO regarding expert advice and in carrying out technical activities in WHO, and (ii) the role of WHO in training in public health and health programme management. Both were prepared by working groups of the Board, considered by the Board itself (resolutions EB65 .RI4 and EB67.RI4 respectively), and subsequently reviewed by the Health Assembly (resolutions WHA33.20 and WHA34.I4). The Executive Board carefully reviewed the evidence concerning the global eradication of smallpox (resolution EB65 .RI7) and its review was followed by the resolutions of the Health Assembly (wHA33·3 and WHA 33.4) solemnly declaring the eradication of the disease and indicating the measures to be taken to ensure that it did not reappear. I .42 As for matters of particular interest to one or other of the governing bodies, the Thirty-third World Health Assembly reviewed the programme on workers' health, the programme on smoking and health, and the strengthening of the health legislation programme, adopting resolutions WHA 33. 3I, WHA33·35, and WHA33.28 respectively. Of specific interest to the Regional Committee for Africa, for example, were the Charter for the Health Development of the African Region, national liberation and health (resolution AFR/RC3o/RI4), and the regional antimalaria strategy (resolutions AFR/RC 30/R 17 and AFR/RC3 I /R I I). The Regional Committee for the Americas reviewed malaria control in I98o (resolution XIII) and the problem of Aedes aegypti in I98I (resolution xxi). It gave particular attention to the question of women in development both in I98o and I98I (resolutions xvn and xv respectively). It also reviewed alternatives for the full capitalization of the Revolving Fund of the regional Expanded Program on Immunization (resolution xx, I 98 I). The Regional Committee for
South-East Asia reviewed the Expanded Programme on Immunization itself (resolution SEA/RC34/R2) as did the Regional Committee for Africa as part of its review of programmes with I99o as deadline (resolution AFR/RC3 I/RI4)· The Regional Committee for South-East Asia paid particular attention to health manpower and community participation in primary health care and also to the managerial process for national health development (resolution SEA/RC34/R5)· The Regional Committee for Europe studied the assessment of medical technology, health education, and the promotion of health and prevention of disease through the adoption of appropriate lifestyles (resolution EUR/ RC3 I/R6). The Regional Committee for the Western Pacific took a particular interest in the programme of acute respiratory infections (resolution WPR/RC3 IjR23). It carried out an evaluation in the Region of the fellowships programme (resolution WPR/RC32/Rq), a subject to be reviewed by the Executive Board in January I982. Finally, all regional committees, followed by the Board and the Health Assembly, gave great attention to reviewing the programme budget proposals for I982-I983, which were described by the Director-General as "progressive programming and conservative budgeting". 1.43 The World Health Assembly did not leave its own structures untouched: it launched an Organization-wide debate on the periodicity, duration, and method of work of Health Assemblies. Following wide discussions by Member States in the regional committees and a thorough review in the Executive Board, the Thirty-fourth World Health Assembly finally resolved to maintain the practice of annual Assemblies for the time being (resolution WHA34.28). It also decided that, commencing in I982, the duration of the Health Assembly would be limited to not more than two weeks in even-numbered years, when there is not a proposed programme budget to consider. It requested the 14
Executive Board to work out the necessary methods of work for implementing this decision on a trial basis at the Thirty-fifth World Health Assembly in May I982 and asked the Director-General and the Executive Board to submit a report on the results of the trial, in respect of both the methods of work and the duration of the Health Assembly, for the consideration of the Thirty-sixth World Health Assembly in May I98 3 (resolution WHA34.29).
The above developments and what I ·44 led to them have been carefully considered within the Secretariat by the regional, headquarters, and global programme committees, as well as by an independent review group that was set up by the Director-General and that consists of a currently serving and an emeritus regional director. In addition, a working group of the Executive Board has been reviewing the work of the Secretariat and will report to the Executive Board in January I982.
Health and politics 1.45 Even if the attainment of health is the least controversial of social aspirations, its pursuit is fraught with political hurdles. These were not lost on the governing bodies during the biennium I980-I981. For example, the Regional Committee for Africa, considering that the political and economic liberation of the totality of African countries is indispensable for social and health progress in the Region, requested the Regional Director to organize a conference on apartheid and health (resolution AFR/Rqo/R4)· This took place in Brazzaville in November I 98 I in collaboration with the African liberation movements, the front-line countries, and the OAU Committee for the Liberation of Africa. Both in I 980 and in I 98 I the Health Assembly adopted a number of resolutions aimed at intensifying cooperation with newly
POLICY BASIS
independent and emerging States in Africa as part of their struggle for liberation, in particular by providing health assistance to front-line States, to Zimbabwe, to Namibia, and to refugees in Africa (resolutions WHA33·33, WHA33.34, WHA34.3J, WHA34.34,
including Palestine (resolutions WHA 3 3. 1 8 and WHA34·I9)· 1.47 The Health Assembly also considered general issues for maintaining world peace. In a resolution on "The role of physicians and other health workers in the preservation and promotion of peace as the most significant factor for the attainment of health for all" (resolution WHA34.38), the Health Assembly appealed to Member States to multiply their efforts to consolidate peace in the world. It gave instructions for the creation of an international committee composed of eminent experts in medical science and public health to study the contribution that WHO could make to economic and social development and to facilitate the implementation of the United Nations resolutions on strengthening peace and in particular preventing thermonuclear conflict.
and WHA34·35)·
I .46 The two subcommittees of the Regional Committee for the Eastern Mediterranean did not hold sessions during the biennium. In each of these years, the Health Assembly called for intensified health assistance to refugees and displaced persons in Cyprus (resolutions WHA33.22 and WHA34.2o), health and medical assistance to Lebanon (resolutions WHA33.23 and WHA34.21), and continued efforts to improve the health conditions of the Arab populations in the occupied Arab territories,
Chapter
2
General Programme Development and Management Managerial process for national health development DURING 198o-I981 WHO continued to improve the methodology of an integrated managerial process for national health development and to collaborate with countries in its application. This was in response to the real need of countries for a managerial process that would strengthen their capacity to formulate and implement their strategies and plans of action for achieving health for all by the year zooo. The strategy developed by WHO to this end comprises the following elements: promotion of the concept, technical cooperation, training, material support, further development of the methodology, and strengthening of WHO's support capacity. 2.1 2. 2 The plan of action that was developed in 198o-I981 to implement the strategy covers all these elements and concentrates primarily on providing the relevant support to countries in the remaining years of the Sixth General Programme of Work (1982-1983), bearing in mind the need for an extension into the Seventh General Programme of Work (1984-1989). It is being carried out by the entire WHO Secretariat (i.e., staff at country level, in the regional offices, and at headquarters) and entails close working relations and mutual support
between the various levels. In its support to health authorities it applies the principles of technical cooperation among developing countries (TCDC). 2.3 During the biennium WHO published guiding principles for the tlMlnagerial process for national health development, in support of the strategies for achieving health for all.l They set out the concepts and principles that can serve as a basis for more specific national guidelines. The managerial process, with all its components, is shown schematically in Figure 2. 1. 2-4 Guiding principles for health programme evaluation as part of this managerial process were also published,z to assist countries in developing evaluation activities that will permit the monitoring of progress towards health for all. , 2. 5. Problem-based learning material to illustrate the main issues arising in the application of the managerial process is in preparation. Such material constitutes a conceptual framework for the training process and provides an opportunity to learn the 1 World Health Organization. Managerial process for national health development: gutding principles. Geneva, I 98 I ("Health for All" Senes, No. 5). 2 \X' orld Health Orgamzauon. Health programme evaluatzon: gutding pnnciples. Geneva, I 98 I ("Health for All" Series, No. 6).
GENERAL PROGRAMME DEVELOPMENT AND MANAGEMENT
strategies of bringing about change; the techniques of planning, programming, programme implementation, and monitoring; and the skills required for teaching others. 2.6 In 198o-r98r most countries were engaged in formulating their national strategies and plans of action for achieving health for all by the year 2000 and in so doing used some form of the managerial process that was relevant to their political, social, economic,
and administrative situations. Most of them determined their long-term plans of action during this period and are now implementing countrywide priority programmes, using the managerial process for this purpose. A common characteristic of such plans is that they aim at a comprehensive national health system encompassing the entire population and include components both from the health sector and from other sectors whose interrelated action contributes to health develop-
Figure 2.1
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THE WORK OF WHO, I98o-I98I
ment. Many countries specifically foresee the development and application of an integrated managerial process and the establishment of a well-coordinated infrastructure for the delivery of countrywide programmes using appropriate technology and providing complete coverage. 2. 7 In the African Region all countries formulated national strategies for health for all during I98o--I98I, again with the help of the managerial process for national health development. An interministerial conference on the planning and management of health services was held in Dakar (I98o) with the participation of the ministers of health and economic planning of Benin, Mali, Mauritania, and Senegal.
2. Io Several intercountry workshops on country health programming were organized. National training workshops were held in most countries of the Region, with WHO support. In Zambia, for example, a national strategy and plan of action for health for all and primary health care was elaborated, material support being given by the Government of the Netherlands for its implementation.
2. I I In the Region of the Americas, all countries have formulated national strategies and plans of action for health for all, using appropriate managerial processes.
2.8 The first consultation in that Region on the development of health management training was held in Arusha (United Republic of Tanzania) in I98o, its object being to promote and strengthen such training in the African Region by establishing national networks of institutions. Participants came from health and management training institutions and from ministries of health and social welfare. Prior to the meeting, questionnaires had been sent out to ascertain what management procedures were being followed in certain institutions in Africa so that they could be reviewed at the meeting along with those used by ministries and by WHO. The relevance of existing courses to the goal of health for all by the year 2ooo was discussed, together with ways in which existing training programmes could be strengthened at all levels. 2.9 Following the recommendations of an interregional consultation, an African network of health management training and development programmes was set up in I981. This network is open to all national institutions.
2. I 2 To supplement the existing 49 regular courses in health care administration, a new phase of the PAHOJWHO programme in health administration was initiated with the support of the W. K. Kellogg Foundation. Literature was prepared and workshops organized as part of a strategy to improve the educational process and the content of courses in three areas : (i) economics and finance, (ii) organizational methods, and (iii) health assessment and planning. The participating institutions were the Regional Library of Medicine and Health Sciences (BIREME), the Latin American Center for Educational Technology in Health, the Case Western Reserve University (USA), and the London School of Hygiene and Tropical Medicine. 2. I 3 Two further important activities were an advanced programme in health administration training for the Central American countries and an international course on planning for the development of health service systems at the School of Public Health, Mexico City. 2. I4 In South-East Asia a regional plan of action for support to the managerial process was drawn up, based on national medium-term programmes developed in I 979 and updated in both I98o and I981. These
GENERAL PROGRAMME DEVELOPMENT AND MANAGEMENT
programmes clearly spell out the needs of countries and the type of cooperation required for implementing national priority programmes. 2. I 5 Burma, India, and Sri Lanka took part in a study of training programmes to improve manpower management in primary health care. Burma carried out a systems analysis of its management problems and, on the basis of that analysis, began work on a training programme for managers of primary health care services at all levels. India and Sri Lanka initiated similar action. In Thailand the National Economic 2.16 and Social Development Board established a macrosocial development subcommittee, with task forces concerned with (i) health, (ii) education and culture, and (iii) social welfare and security. Five ministries were involved. At the request of the subcommittee the Development Board formulated long-range objectives and strategies and indicated the mechanisms for achieving them through a 2o-year development plan, the first five years of which (I982-I986) coincide with the national social development project. The three task forces will devise medium-term plans for those five years. The objectives, initially established on the basis of past trends, will be refined with experience; indicators will be selected and expressed in terms of targets agreed by all the agencies concerned. Progress will be monitored throughout the period and evaluated before the next five-year planning cycle begins. Fundamental and supportive strategies in the main sectors will be defined, future resources will be estimated, and delivery of services will be planned accordingly. This broad approach is well in line with WHO's recommendations, and progress in Thailand will be watched with great interest by many Member countries. 2. I 7 Training material and modules have been prepared by training institutions in the
various countries of the Region in support of national planning and management activities, particularly in the evaluation of health services research. 2. I 8 In Europe, the Regional Health Development Advisory Council at its first meeting (March I 98o) discussed the development of regional strategies for the preparation of national and regional targets-strategies that were reviewed by the Council in I 98 I and circulated to all countries. Several projects in health planning and management were supported-in Algeria, Denmark, Morocco, Portugal, and Spain. 2.I9 Two international workshops on country health programming and related managerial processes were held in the United Kingdom in I98o and I98I-at the Usher Institute (Edinburgh) and the Nuffield Centre for Health Services Studies (University of Leeds). Participants came from several European countries and from countries of other regions, namely the Bahamas, Botswana, Democratic Yemen, Kuwait, Pakistan, Saudi Arabia, Sierra Leone, and Sudan. Country health programming was introduced into the workshops held in Amsterdam and Antwerp, in I98o and I98I, for participants from developing countries in Africa, South-East Asia, and the Eastern Mediterranean. 2.20 A regional workshop on the control of health care costs in social security systems (Vienna, I98I) laid stress on the need to coordinate primary health care and strengthen health care measures both within and outside the health sector. Another workshop (Munich, I98I), on the cost-effectiveness of standard patterns of long-term health care, focused on the quality of that care. 2.2I In the Eastern Mediterranean Region, a document to guide national authorities in introducing or strengthening the
THE WORK OF WHO, I98o-I98I
managerial process for national health development was issued in 198I and has been distributed to all countries of the Region. 2.22 The managerial process for national health development was used in preparing the five-year plans in Iraq, Somalia, Sudan, and Yemen. In Democratic Yemen, Sudan, and Yemen, the process was used in elaborating the national health policies, strategies, and plans of action for health for all. 2.23 The first workshop on the strengthening of health management in the Eastern Mediterranean Region (Mogadishu, 1980) was attended by participants from Democratic Yemen, Somalia, Sudan, and Yemen. The emphasis was on training needs, and use was made of local case material adapted to the requirements of the participants and the country concerned. A national workshop on health management was held in Israel in I 98 I for 24 key nationals from health and social security agencies. 2.24 In the Western Pacific Region, countries made use of the managerial process for national health development in updating their policies and strategies for primary health care and the achievement of health for all. The process was, for example, used in preparing five-year plans in the Cook Islands, Fiji, Papua New Guinea, Samoa, the Solomon Islands, and Tonga. In Kiribati, using a broad programming methodology, the plan for the country was updated and translated into priority programmes. In Malaysia, the preparation of the five-year plan was facilitated by a national workshop for senior health administrators. In the Republic of Korea the economic and financial aspects of the next five-year plan were worked out. In Malaysia, Papua New Guinea, the Philippines, and the South Pacific countries national strategies and plans of action for achieving health for all were elaborated, with the technical support of staff of the Regional Office. In China, a
course on management in national health development was held (1981), in which 50 senior public health administrators from throughout the country took part. 2.25 The establishment of national centres for health development was promoted in China, Fiji (for the South Pacific), Malaysia, Papua New Guinea, the Philippines, and the Republic of Korea. A regional network of centres is being established, to ensure technical cooperation among countries in the application of the managerial process for national health development.
Managerial process for WHO's programme 2.26 During 198o-198I WHO's own process of programme development focused on continuing the impetus given by the Thirty-first World Health Assembly (I978), which in resolution WHA3 1.43 requested that "managerial methods for health development [should be] devised and applied by WHO in an integrated manner", and by the Executive Board in elaborating the Seventh General Programme of Work (I984-I989 inclusive). 2.27 In recent years WHO has sought to promote an approach to health programme development and management that is relevant, practical, economical, and comprehensive. However, the components of this process have tended to develop at different speeds, and during the period 198o-I98I efforts were made to harmonize them more closely. There is now a systematic, unified managerial process in operation at all levels of WHO, whereby its general programmes of work are formulated on the basis of the Organization's policies and strategies and are then converted into medium-term programmes, which in turn form the basis of the biennial programme budgets. A process of monitoring and evaluation tracks the course 20
GENERAL PROGRAMME DEVELOPMENT AND MANAGEMENT
of the programmes as they are implemented and assesses their efficiency and effectiveness with a view to improvement where necessary. Ensuring that information both for and from the above-mentioned components is readily available is an integral part of this managerial process (see paragraph 2.39 to end of chapter). 2.28 A summary describing this integrated process has been issued. 1 It gives a short account of WHO's methods of programme development and is used for providing information both within and outside the Organization. 2.29 Whereas the preceding biennium was characterized by the development of methods for the management of WHO's programmes, the period now under review has seen a shift from the developmental phase to a phase in which the process is utilized to improve the content of programmes and their implementation. 2. 30 The regional committees, the Programme Committee of the Executive Board, the Executive Board itself, and the Health Assembly were all actively concerned with the periodic review and consequent reorientation of the process. 2. 3 I
The Board therefore classified individual programmes into (I) those that are required for the direction, coordination, and management of the Organization's act1v1ttes; (2) those that are required for the establishment of a sound health system infrastructure based on primary health care; (3) programmes of science and technology to ensure the appropriateness of the technology used by that health system; and (4) programmes designed for the practical and administrative support required by these three groups. 2. 32. At the same time, the Board requested the Programme Committee to prepare a draft of the Seventh General Programme of Work for its sixty-ninth session. Preparatory work was carried out in all regions and at headquarters, on the basis of the guidance given by the Board and its Programme Committee, and the material prepared was presented to the regional committees, whose comments were then taken into consideration by the Programme Committee (November I98I) in preparing its draft. 2. 33 The Seventh General Programme of Work is the first of the three such programmes that will be required up to the year 2ooo; its targets, for the period I984-I989, are therefore intermediate. It represents the Organization's response to the individual and collective needs of its Member States in implementing the strategies for health for all. It is moreover the first general programme of work to have been prepared on the basis of information on long-term strategies emanating directly from Member States and from the regions, thus enabling firm long-term trends to be established.
At its sixty-seventh session (January
I98I) the Executive Board considered the
report of its Programme Committee on the preparation of the Seventh General Programme of Work covering a Specific Period ( 1984-1989 inclusive) and confirmed that the latter should constitute support to the Global Strategy for health for all by the year zooo. The Strategy's emphasis is on developing health systems based on primary health care for the integrated delivery of health services to the entire population, using appropriate technology. 1 The managerial process for WHO's programme development (WHO document MPWPD/8I.I), 1981.
2.34 In I98o the medium-term programmes pertaining to the Sixth General Programme of Work were completed, all of them based on information and requests from Member States. Although their objectives, ap2I
proaches, and actlvttles originally derived from the Sixth General Programme of Work, the programmes formulated were greatly influenced by the new policy directives enunciated by the governing bodies of WHO in the context of health for all; medium-term programmes developed earlier were revised in the light of those directives. Moreover, now that these medium-term programmes have entered the implementation phase, they are providing further evidence of the usefulness of the process. 2.. 3 5 The experience gained during the Sixth General Programme of Work is being used in developing medium-term programmes pertaining to the Seventh General Programme. Because of the need for testing methodology, the medium-term programmes relating to the earlier General Programme were developed at different times, thus making it more difficult to ensure the necessary correlation. The medium-term programmes for the Seventh General Programme will all be worked out at the same time with a view to proper linkage. They will then form the basis of the biennial programme budgets.
2.. 37
With the programme budget for
I98o-I98I WHO adopted a new and more
2..36 Guidelines for joint medium-term programming and programme budgeting were issued in I 98 I to ensure the homogeneous development of the Seventh General Programme of Work into medium-term programmes, and the progressive translation of the latter into the three programme budgets that will cover I984-I989. To ensure that the activities described in the programme budget are consistent with the medium-term programmes, individual summaries of the latter will be included in the global programme statements in the budget document presented to the Executive Board and the Health Assembly in 1983. The guidelines also emphasize evaluation as an integral component of this medium-term programming/programme budget sequence (see paragraph 2..38). 2.2.
flexible approach to programme budgeting and the management of WHO's resources at country level, intended to strengthen the relevance and impact of WHO's support to governments and facilitate the Organization's role as the international partner of every Member State in developing and implementing the health policies and strategies that countries have adopted for the attainment of health for all by the year zooo. In many countries however this new approach has not yet come up to expectation. In some cases the potential for collaboration between WHO and the country concerned has not been fully utilized; in others the continuation of traditional practices and procedures has proved a constraint on the new approach. Accordingly in I98I studies were initiated in countries in two regions to determine- how WHO can give better support to Member States, including more effective programme budgeting and better use of WHO resources at country level. The conclusions drawn from these studies should help in establishing the programme budget for I984-I985 and in strengthening the relevance and effectiveness of WHO support to Member States. 2.. 38 Programme evaluation is an integral part of the managerial process for WHO's programme development and the Organization's internal mechanisms (including the regional and headquarters programme committees) continued their periodic reviews of WHO-supported projects and programmes. Although progress has been made in applying the evaluation process, significant lacunae still remain. For example, the proper dissemination to the various levels of the Organization of the results of evaluation, and the consequent utilization of its findings in order to achieve change, has not been fully realized; in other words, the synthesis and interpretation of evaluation results-and the feedback of the conclusions drawn-need to
GENERAL PROGRAMME DEVELOPMENT AND MANAGEMENT
be improved. One way of achieving such improvement is to relate evaluation results more closely to medium-term programmes and to programme budgets, e.g., by including a short assessment of previous activities under the various headings of the proposed programme budget.
services; and-most important of allsupport to Member States in the development and operation of their information services. 2.42 Direct services in support of the planning, programming, implementation, monitoring, evaluation, and coordination of WHO's collaborative programmes with Member States differ, depending on the nature of the technical programme, its mode of operation, and its management. For example, in 1980-1981 support to the Special Programme of Research, Development and Research Training in Human Reproduction included (i) a management information system providing financial and administrative data on projects, grants, and collaborating institutions or scientists, and (ii) dataprocessing services for multicentre studies on various fertility regulation methods. Another example is the assistance given to the Special Programme for Research and Training in Tropical Diseases in basic management studies, development of an information service on collaborating institutions or scientists, and provision of computer support. In addition, a text analysis system was developed for documents produced by the Expanded Programme on Immunization to ensure that the terminology used would be familiar to readers. Experience such as the above is providing a basis--and in part the tools-for information systems support to the relatively new diarrhoeal diseases control programme and to the action programme on essential drugs. 2.43 Direct services were also continued to the administrative and financial side of WHO's activities. The computerized administration and finance information system was of assistance inter alia in preparing, consolidating, and finalizing the operations required in establishing the biennial programme budget. This system was improved during 1980-1981. Moreover its main components (related to budget control, expendi-
Information systems support 2.39 Information systems support to the managerial process falls into two main areas: (1) operation and development of WHO's own information system in relation both to management of WHO programmes and to international exchange of health information and experience ; and ( 2) direct and indirect support to Member States in developing certain aspects of their national health information systems, particularly as regards methodology and technology. 2.40 During 1980-1981, the main activities carried out and the systems developed were reviewed by an interregional advisory group. As a result of this review, the Director-General decided that responsibility for the internal reporting system at headquarters should be transferred to the programme managers. This system has been in operation since January 1978 and incorporates such useful features as an organizationwide compatible format for the recording, reporting, storage, and retrieval of information on programmes and projects; sixmonthly and annual reporting-by-exception; and an information flow geared to the Organization's managerial process for programme development. 2.41 As from January 1981 therefore the information systems programme concentrated on methodological and technological support for information systems throughout the Organization; the provision of compatible data-processing and text-processing
ture accounting, general ledger entries, and payment of claims) were adapted for use in regional offices on a minicomputer. The system is running to the satisfaction of the Regional Office for Europe, which agreed to be the pilot regional office in this respect and to train staff from other regions. Plans were developed for introducing the system in 1982-1983 in the Regional Office for Africa (which already uses a minicomputer for training purposes) and a start was made with relatively simple applications related to personnel, supplies, fellowships, budget, and country health information. 2.44 The use of the fully compatible word-processing equipment installed at headquarters and in the Regional Offices for the Americas, South-East Asia, Europe, and the Western Pacific was strengthened in 1980-1981 by training new operators, developing new applications, and making the equipment available to a larger number of programmes. A feasibility study was carried out in the Regional Office for the Eastern Mediterranean with a view to the acquisition of similar equipment early in 1982. 2.45 Computer services at headquarters continued to be provided by the Genevabased International Computer Centre. But throughout 1980-1981 the policy was to decentralize electronic data-processing and word-processing services to the regional offices. This is reflected in the fact that the relevant expenditure has been more or less stabilized at headquarters, whereas it has increased in the regional offices, all of which now have electronic data-processing or wordprocessing installations, and in some cases both. 2.46 The following are examples of methodological and technological support to national health information systems during the biennium, and there were many others:
- A review of Bahrain's health information system and a proposed strategy for its improvement. The first phase of the latter aimed at establishing users' requirements for both manual and computerized components of the system. It is expected that the experience, and in part the tools, developed for Bahrain will be shared by other Member States in the Gulf area. - Support to China in developing a strategy for a computerized information network to strengthen the biomedical information centre of the Academy of Medical Sciences, Beijing. The first phase aimed at familiarizing key staff with the support that can be given to routine library operations by simple microcomputers, and training them to develop the software applications needed. - Support to Egypt in revising its datacollection forms and in establishing key health indicators and the outline for subsequent reports. Six types of microcomputer were selected and, after development of the software, were field-tested in six provinces of the country. - Support to Kuwait in establishing a strategy for a largely computerized health information system as part of an integrated health care system, but starting initially with five relatively new hospitals. - Support to Thailand in a health management information system for central, provincial, and district level. During the first phase, users' requirements were established; studies were carried out on the information flow from the district level and on storage and processing facilities at that level; and additional computer support for the Ministry of Public Health from other government institutions was negotiated. 2.47 Experience acquired from the type of project described above can be drawn upon in the context of technical cooperation among developing countries. To help to meet increasing demands, WHO also called upon
GENERAL PROGRAMME DEVELOPMENT AND MANAGEMENT
its collaborating centres in medical (health) informatics, of which there are at present two, in Paris and Uppsala (Sweden). 2.48 There was a considerable training element in most of the activities. Where appropriate, it covered the utilization of upto-date systems and computer-supported techniques. For example, to follow up the support given to the Malaysian health information system in I978-I979 a workshop was held (Malaysia, I98o) which benefited from a demonstration and evaluation of the improvements introduced. 2.49 Since microcomputers, if properly selected and utilized, often constitute the "appropriate technology" required, WHO maintains comparative data on some of the more suitable models available, and on their applications in health work. Two studies were initiated in I 98o-I 98 I (both involving
the WHO collaborating centres) to develop such applications and test their practical and economic implications; the first study related to processing of tabular material, the second to retrieval of health ·literature. 2.50 The years I98o-I981 saw a major evolution in the methodology and technology of information systems that will have an impact in the health sector. It was accompanied by a significant increase in Member States' requests to WHO for assistance with their health information systems. To enable the Direcor-General to take full advantage of the opportunities opened up by informatics, an international consultationon informatics applications in health-was convened (November 1981) to advise on priorities for 1984-1989 and on ways and means of meeting them in consonance with the strategies for health for all by the year 2000.
Chapter J
Coordination
COORDINATION activities in 1980-1981 moved into higher gear in response to certain factors: (i) the nature of primary health care, which requires multisectoral support and has thus brought to the fore the need to engage the interest of other agencies and disciplines; (ii) the growing production by countries of national health plans, calling inevitably for more external resources of all kinds; (iii) the translation into practical terms of WHO's constitutional role as the coordinating body for international health activities by way of a completely new approach, that of rationalizing the flow of international health resources in accordance with WHO's priorities and with nationally perceived requirements; and (iv) the atmosphere of deepening financial crisis, which has made it more difficult to mobilize those resources at the very time when the need for them is increasing. 3.1
198o-1981, the sum of $75 789 67o was contributed to WHO's Voluntary Fund for Health Promotion. By the end of 1981 a further $29 697 695 had been pledged but not yet received.
3. 3 This channelling of funds through WHO was accompanied by a similar increase in direct bilateral support to the health sector and in loans and grants from development banks and funds. A noteworthy development has been the express wish of donors to increase their mutual collaboration under the aegis of WHO, in order to avoid wastage or duplication and to ensure that every dollar for development is used to the best effect. WHO is increasingly consulted for guidance as regards bilateral health programmes. This trend has given rise to a more formalized collaboration with the main traditional donors that includes annual review meetings in addition to the routine daily contacts. 3·4 During the biennium substantial contributions were received by the Organization from the traditional donors, notably Belgium, Denmark, France, the Federal Republic of Germany, Kuwait, the Netherlands, Norway, Sweden, Switzerland, the United Kingdom, the United States of America, and the USSR. The Japan Shipbuilding Industry Foundation (Sasakawa Memorial Health Foundation) maintained a substantial contribution to selected programmes. 26
Extrabudgetary sources of funds 3. 2 The period under review was characterized by continued recognition on the part of donor countries, foundations, nongovernmental organizations, and others concerned with health development that an acceptable level of health for all by the year 2ooo can be achieved only by channelling substantial resources-human, financial, and materialinto the health sector. During the biennium
COORDINATION
3. 5 The development banks increased the proportion of their grants and loans to the health sector. In I98o the Inter-American Development Bank provided $244 million in loans related to public health or environmental health. The agreement between WHO and the Islamic Development Bank led to the funding by the latter of important health projects in different countries, including a health network in southern Sudan, a primary health care network for refugees from Ogaden (Somalia), equipment for a hospital and wells for drinking-water in Pakistan, a primary health care network in the United Republic of Cameroon, and hospital equipment for Uganda. The funding of these projects to date has totalled $4 million, and further projects are under study. 3.6 The Director-General established the Health Resources Group for Primary Health Care as a forum where all those interested in supporting the global health effort could discuss the international transfer of resources for health work. The Group met in December I 98o and decided upon an initial approach that includes in particular a review of resource utilization in those countries whose primary health care programme is at a stage where external support can be absorbed and effectively used. The aim is to provide an authenticated document that can form the basis on which external support is provided by a group of donors acting in unison with the country concerned. At a meeting in December I981 the results of the first reviews-in Benin, Ecuador, Gambia, Sri Lanka, and Sudan-were presented by the representatives of the ministries of planning and health of those countries to a wide group of governments and organizations interested in supporting health development. This approach is proposed as an appropriate mechanism for achieving more effective use of existing resources for health and encouraging the allocation of a larger proportion to the health sector. The planning authorities of 27
each of the countries where reviews were made will convene a meeting of interested external partners in health development during I982. In addition, the exchange of information is being intensified. WHO programme coordinators and other staff are being made more aware of the possibilities for obtaining a due proportion of external resources for health work at country level. 3. 7 A trust fund-the Primary Health Care Initiative Fund-has been set up to provide a ready source of financing for "seed" and catalytic activities connected with primary health care, particularly in the developing countries. Contributions have been received, notably from Greece and the Netherlands, and a number of pledges have been made. 3.8 A particularly intensive effort was made during the period to enhance collaboration with the Arab banks or funds assisting socioeconomic development. Contacts were made with the OPEC Fund for International Development, the Arab Fund for Economic and Social Development, the African Development Bank, the Islamic Development Bank, the Club du Sahel, the Gulf Arab Development Foundation for the United Nations, the Aga Khan Foundation, the Organization of the Islamic Conference, and the Health Department of the League of Arab States.
United Nations system 3·9 Coordination within the United Nations system continued to be an important concern, particularly in view of the resolution adopted by the United Nations General Assembly in I979 entitled "Health as an integral part of development" (resolution 34/5 8). 3. I o In response to that resolution, and as part of the follow-up required by the Inter-
THE WORK OF WHO, 198o-I981
national Conference on Primary Health Care (Alma-Ata, I978), the Director-General undertook a study of the various components of primary health care in relation to the work programmes of the United Nations itself and of the specialized agencies in its system. The report was presented to the March I 98o session of the Consultative Committee on Substantive Questions (Programme Matters) of the Administrative Committee on Coordination. It helped to create a greater awareness of the extent to which sectors other than health were concerned in the implementation of primary health care. The discussion in the Consultative Committee served as a basis for a study submitted to the Thirty-fourth World Health Assembly when it considered the contribution of health to socioeconomic development and peace. This study was subsequently brought to the attention of other organizations and institutions of the United Nations system.
3. I 2 This promotion of concerted action within the United Nations system was complemented in I 98 I by the submission to the Economic and Social Council (at its second regular session in I 98 I) of the Global Strategy for health for all by the year 2ooo. The Director-General presented the Global Strategy in plenary meeting and it was subsequently discussed in committee. On the recommendation of the Council, the United Nations General Assembly at its thirty-sixth session endorsed the Strategy as "a major contribution to attaining the worldwide social goal of health for all by the year zooo", and requested all appropriate organizations and institutions of the United Nations system to collaborate fully with WHO in carrying it out (General Assembly resolution 36/43). 3. I 3 WH 0 took part in three crossorganizational programme analyses undertaken by the United Nations Secretariat at the request of the Committee for Programme and Coordination. The studies focused on science and technology, activities related to young people, and public administration and finance. A number of other contributions were made to United Nations reports dealing with such subjects as: exchange of information on banned hazardous chemicals and unsafe pharmaceutical products; protection of consumers; human rights; and disarmament and its relationship to socioeconomic development and to operational activities for such development. Much of the collaboration took place within the framework of the Administrative Committee on Coordination (ACC) but certain matters were coordinated through ad hoc interagency meetings in which WHO continued to ensure that health concerns and WHO programmes are thoroughly related to the broader work of the United Nations system. 3. I 4 The Director-General ensured WHO's full participation in the work cif ACC and its subsidiary bodies. As in earlier years, a 28
3. I I In connexion with the Technical Discussions held during the Thirty-third World Health Assembly on "The contribution of health to the New International Economic Order", publications and other written material were solicited from the United Nations system and served as a basis for the documentation for the debate. No less than I4 organizations contributed. Several organizations were also represented at the Technical Discussions and this helped to bring into better focus the health sector's contribution to a more equitable social and economic order. The results of the Technical Discussions were brought to the attention of the United Nations in the Director-General's report to the eleventh special session of the General Assembly (September I98o), which met to consider a new International Development Strategy and to assess the progress made in implementing the Programme of Action on the Establishment of a New International Economic Order.
COORDINATION
very wide range of subjects came under review by ACC, including rural development, information systems, science and technology, water resources, disarmament questions, and the role of women in socioeconomic development. 3. I 5 Specific attention was given by WHO to the International Year of Disabled Persons (I98I), the Organization hosting an interagency meeting in this connexion in August I98o. There was also close cooperation with the United Nations in preparations for the World Assembly on Aging (I982). Work was instituted with the International Telecommunication Union in preparation for World Communications Year in I983. 3.I6 WHO took an active part in the preparations for and the proceedings of the United Nations Conference on the Least Developed Countries (Paris, September I 9 8 I), the Director-General emphasizing in his address the total interdependence and indivisibility of health and economic development.
mentioned sessions emphasized the need for the specialized agencies to be involved in the development of activities for this third programming cycle. They particularly stressed the use of UNDP country programming as a flexible frame of reference for the operational activities to be carried out by governments through their planning, programming, and coordinating processes. The designation of resident coordinators serving the United Nations system at country level is now well advanced. 3. I 9 An innovative step was the joint programming of WHO activities under the UNDP regional programme for Asia and the Pacific, involving three WHO regions; similar steps were taken for Africa and Europe. 3.20 Continued support was given under UNDP's global and interregional programmes to the UNDPfWorld Bank/WHO Special Programme for Research and Training in Tropical Diseases; negotiations were undertaken for the third phase of this support, in an amount of $8.6 million. Increased financial support was also assured for the Expanded Programme on Immunization, the quality control of vaccines, the control of diarrhoeal diseases, and work in connexion with the International Drinking Water Supply and Sanitation Decade. Preliminary assistance was given to the new programme on health learning materials.
United Nations Development gramme (UNDP)
Pro-
3.17 The key issue of the I 98o and I 98 I sessions of the UNDP Governing Council was the third cycle of programming and planning, I982-I986. The preliminary pledges so far made by donor governments for that period-some $5 Ioo million-fell short by 24% of the target of $6 700 million required for implementing the programme planned, and efforts are being made to bridge the gap. The Council decided that So% of the total allocations available for countries should be allotted to those with a per capita gross national product of less than $ 5oo.
United Nations Children's Fund (UNICEF) 3.2I The biennium I98o-I98I saw encouraging and fruitful developments in the cooperation between WHO and UNICEF. Primary health care was the main area of collaboration. This took the form of development of methodology, organizing of regional and national workshops, and collaboration
3. I 8 Various interagency meetings and the UNDP Governing Council at its above-
with governments in the implementation of primary health care at country level. Certain of the main components of primary health care were developed, at least in their services aspect, as joint UNICEF /WHO programmes. The most important of these relate to the Expanded Programme on Immunization and include development of the cold chain; control of diarrhoeal diseases and national production of oral rehydration solutions; and work on essential drugs. 3.22 A significant achievement-with which UNICEF was closely associated as part of the promotion of proper infant and young child feeding-was the International Code of Marketing of Breast-milk Substitutes, approved by the Health Assembly in May I98I (paragraphs 6.7-610). 3.23 In November I98o the DirectorGeneral of WHO and the Executive Director of UNICEF met to explore ways of achieving even closer collaboration, particularly between field offices. It was agreed that WHO and UNICEF should make a special effort to accelerate the development of primary health care in those countries that were ready for such an undertaking. 3.24 The UNICEF/WHO Joint Committee on Health Policy met in February I 98 I. It considered a study carried out by the two organizations on country decision-making for the achievement of the objectives of primary health care (see paragraph p) and recommended it to the UNICEF Executive Board for approval. The Joint Committee also agreed to a proposed new study, provisionally entitled "Implementation of primary health care, with emphasis on the most effective support that WHO and UNICEF could give jointly to governments" (paragraph 5.2). Other subjects considered were the Expanded Programme on Immunization, essential drugs, leprosy control, schistosomiasis, the joint UNICEFJWHO programme
on childhood disabilities, control of diarrhoeal diseases, and infant and young child feeding. UNICEF and WHO are also collaborating in a joint plan of action on nutrition covering the years I98I-I985. The activities of the Joint Committee were warmly commended by the UNICEF Executive Board.
World Food Programme (WFP) 3.25 Since the ever-increasing demands for emergency food aid are now being met in part by special donor financing, the World Food Programme (WFP) was again able to devote most of its regularly pledged resources to food aid for socioeconomic development, particularly for rural development projects in the least developed countries. WHO, as health adviser to WFP, 3.26 contributed directly to enhancing the nutritional value of some of the commodities supplied by the latter. An example of this was vitamin-A-enriched dried skim milk, where WHO's recommendations were generally accepted by WFP and also by governments providing food aid bilaterally. Likewise the European Economic Community, which makes a substantial contribution of dried skim milk, acted on these recommendations when taking over WFP's support to India's "Operation Flood", a remarkably successful dairy development project. One WHOdeveloped technique was widely used in the field by nongovernmental and voluntary organizations to check the presence of vitamin A in batches of dried skim milk. WHO's guideline for the measurement of the nutritional impact of supplementary feeding programmes aimed at vulnerable groups was re-issued, t the English version being supplemented by UNICEF-financed translations in French and Spanish. 1
WHO document FAP/79.1 (1979).
COORDINATION
3.27 To increase the impact of rural development projects funded by WFP commodity grants, WHO worked to develop appropriate technology, e.g., control circuits for rural water tanks and solar-powered electric water pumps. This stimulated WFP to grant$ I 5. 5 million in food aid to the Republic of Korea to help in extending the rural selfhelp water supply system to the entire country, an exemplary enterprise that should be of benefit to many other developing countries. 3.28 Finally, WHO advised on the development projects being considered for funding by WFP with a view to minimizing any adverse effects on health or, in extreme cases, recommending postponement or cancellation of a project. This advice is crucial in the case of large-scale projects such as dams and irrigation systems that may have profound ecological and health effects but whose economic or prestige value renders them irresistibly attractive. In one such instance, WHO's analysis of the adverse impact on health was sufficiently convincing to persuade the project's sponsors to defer their
support until the necessary precautions were taken. 3.29 The allotment ofWFP resources to projects most directly related to health promotion is summarized in Table 3. I.
Emergency relief operations 3.30 The I98o-I98I biennium saw a considerable expansion of WHO's action in emergencies. The Organization continued its traditional response to emergency situations caused by natural or other disasters, consisting mainly of immediate aid in the form of urgently needed medical equipment, drugs, vaccines, and other services. Steps were taken concurrently to strengthen disaster preparedness and disaster management within WHO and in Member States.
Disaster preparedness 3. 3I Technical cooperation with disasterprone countries was increasingly aimed at
Table 3.1
World Food Programme: commitments to projects, 1980-1981
Nature of project
Projects approved from 1 July 1979 to 30 June 1980 Number Amount US$
Projects approved from 1 July 1980 to 30 June 1981 Number Amount US$
All projects Development aid . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Emergency aid . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49 67 410000000 148600000 558600000 59 91 502000000 192 600 000 694600000
-----------------------------------116 150
Health-related projects Health promotion . . . . . . . . . . . . . . . . . . . . . Institutional feeding . . . . . . . . . . . . . . . . . . . . Teaching institutions . . . . . . . . . . . . . . . . . . . . . . . . . . . . Community housing and development . . . . . . . . . . . . . . . . . .
8 4 2
3 ------------------------------17 179 900 000 26 282500000
42500000 94000000 14000000 29400000
4 10 3 9
129 000 000 106400000 14100 000 33000000
THE WORK OF WHO, 1980-1981
improving national capacity both to take preventive measures and to remain effective in emergency situations. This involved WHO in activities related to the public health management of emergencies, research on the epidemiology of disasters, study of populations at risk, assessment of needs and priorities in the event of there being mass casualties, case studies of catastrophes, investigation of patterns of disease following disasters, and study of the disease control measures required. Two resolutions (EB67.RII and WHA34.26) were adopted by WHO's governing bodies in 1981 underlining the importance of the matter. 3. 32 A collaborating centre was established at the Centre for Research on the Epidemiology of Disasters, University of Louvain, Belgium. This was made possible by a generous grant from the Government of Belgium. 3·33 The first major WHO course on health management in natural disasters (October 198o) brought together senior officials from 2 3 developing countries; in view of the interest shown, similar courses will be held regularly in disaster-prone developing countries. In collaboration with UNHCR and the London School of Hygiene and Tropical Medicine, a multidisciplinary seminar on health problems in refugee communities was conducted in 1980 and 1981 and will be repeated annually in different regions. 3·34 Under WHO's impetus several universities have established undergraduate and postgraduate programmes on health management in disasters. This has already resulted in better-trained personnel becoming available for field work in emergencies. 3. 3 5 Several organizations of the United Nations system are establishing disaster units at senior level and the system's capacity to deal with disasters is being seriously studied.
WHO's considerable experience in these matters has enabled it to make a valuable contribution. It has maintained close relations with UNDRO, UNHCR, UNICEF, UNEP, and other organizations of the United Nations system, taking part in all the major multi-agency missions on disaster situations; and with the International Committee of the Red Cross, the League of Red Cross Societies, and other nongovernmental organizations. WHO was increasingly involved in 3.36 the health problems of refugees and in other disasters of a sociopolitical nature. In collaboration with UNHCR and the University of London, a manual on health in refugee camps was prepared and is being tested in the field. 3. 37 Lists of essential drugs for mass emergencies are being formulated. Specifications for a standard UNHCRJWHO kit of emergency drugs and supplies have been established.
Emergenry relief 3-38 WHO participated fully in the provision of emergency assistance by the United Nations system, the regional offices in particular increasing their contribution. The joint appointment of UNHCRJWHO senior coordinators for the health of refugees, as in Somalia and Thailand, set a new pattern of cooperation. 3·39 Technical cooperation among developing countries found concrete expression in the case of emergencies, with WHO in the position of coordinator of such cooperation. The experience of the Algerian earthquake disaster is but one example. 3.40 made Particularly high demands were on WHO's resources during I 98o-1 981. Some $zo million were mobil-
COORDINATION
ized, mostly from extrabudgetary sources. It is significant that emergencies requiring international assistance are increasing in both frequency and seriousness: during the biennium WHO conducted more than Ioo emergency operations, some of which are listed below. 3·4 I African Region. Angola (health aspects of liberation activities of the SouthWest Africa People's Organization); Burundi (influx of refugees); Central African Republic (national reconstruction); Chad (strife, reconstruction work); Comoros (supply of drugs); Ethiopia (drought, rehabilitation work); Gambia (disturbances, emergency surgery); Ghana (yaws); Madagascar (cyclones); Mali (cerebrospinal meningitis); Mauritius (cyclone); Mozambique (cholera); Uganda (drought, sleeping-sickness); United Republic of Cameroon (influx of refugees); Zaire (influx of refugees, diarrhoeal diseases); Zimbabwe (general humanitarian assistance, national reconstruction). Region of the Americas. El Salvador 3.42 (population movement); Jamaica (floods); Nicaragua (rehabilitation work); Saint Lucia (hurricane). 3·43 South-East Asia Region. Bangladesh (floods); Burma (devastating fires); Indonesia (influx of refugees, earthquake); Nepal (earthquakes); Thailand (influx of refugees). 3·44 European Region. Algeria (earthquake); Italy (earthquake); Turkey (malaria); Yugoslavia (rehabilitation work). 3·45 Eastern Mediterranean Region. Cyprus (reconstruction work, thalassaemia); Djibouti (drought); Iran (floods); Lebanon (strife); Pakistan (influx of refugees); Somalia (influx of refugees); Sudan (influx of refugees, drought, cholera); Yemen (floods). 33
3.46 Western Pacific Region. Democratic Kampuchea (national reconstruction); Fiji (cyclone); VietNam (typhoon). 3·4 7 N ationa/ liberation movements. In collaboration with other agencies in the United Nations system, WHO provided urgently needed health assistance to the national liberation movements recognized by the Organization of African Unity.
United Nations Volunteers 3.48 Close cooperation with the United Nations Volunteers programme has made possible the greater use of qualified professionals for middle- and upper-level operational services in WHO-executed projects. Between July I98o and July I98I the average monthly number of United Nations volunteers working in the health field was 200. Since 75% of the volunteers currently in service are nationals of developing countries and are working in other developing countries, they are a good example of technical cooperation among developing countries in action.
Nongovernmental organizations 3·49 Collaboration has continued with the I 24 nongovernmental organizations in official relations with WHO, the latest of which-the International Council of Women-was admitted during the biennium. A complete list of these nongovernmental organizations will be found in Annex 3 to this report. Working relations, or more informal contacts of an ad hoc nature, were maintained with a considerable number of them. 3. 5o A more integrated approach to such collaboration has been sought, wherever possible specific activities being undertaken within a jointly agreed framework. Efforts
were made to ensure WHO's full participation in the various international congresses and technical meetings organized by the nongovernmental organizations, and the Organization agreed to sponsor or cosponsor a number of those that were of direct interest to its programmes. Possibilities were explored for strengthening collaboration at national level, where it can be particuarly effective.
tinued to expand and its joint coordinating committee, meeting annually, reviewed or programmed the support being provided by WHO (at both regional and headquarters level), UNDP, UNICEF, UNFPA, and various multilateral or bilateral sources. The appointment in 1981 of a WHO programme coordinator in Beijing has been of significant help in planning and monitoring this complex programme. 3. 52 Meetings were held with the authonues in Bulgaria, China, the German Democratic Republic, Hungary, and Yugoslavia for the continuation of cooperative efforts in training, collaborative research, and exchange of experience, particularly for workers from developing countries.
Cooperative programmes undertaken with Member States 3·5 1 The cooperative programme launched in 1978 by WHO and China con-
34
Chapter 4
~esearch JDro~otion
and 4.1
Develop~ent
poLICIES and programmes in the field of health-whether for the control of disease, the development of community health services, or the promotion of environmental health--are constantly evolving. This is both the result of and the rationale for the continual development of biomedical research in its widest sense. But a proper balance must be reached between research and services, between the acquisition of new knowledge and the utilization of what already exists. To attain this balance, the social function of biomedical research, i.e., its practical application, must always be kept to the fore. Only thus can the allocation of resources to biomedical research and its various components be rationalized. 4.2 In May 1980 the Health Assembly restated the contribution to be made by biomedical, health services, and health promotion research towards attaining health for all by the year 2000 (resolution WHA33.25). It urged Member States to intensify their cooperation in health research and to give high priority to research training and institution-strengthening.
viewed the progress made in WHO's current research efforts, including the special programmes on research and training; it also discussed the action taken on the recommendations made at its previous session, especially in relation to nutrition, control of diarrhoeal diseases, and ethical review procedures for research involving human subjects. ACMR reviewed the work of its subcommittees on information, health services research, research on mental health and human behaviour in primary health care, research administration, and research career structures. It recommended that the subcommittees on information and on research administration should continue their work; that a subcommittee should be established to study the research component of WHO's cancer programme; that the subcommittee on health services research should, after its November 198o session, be transformed into a scientific planning group; and that scientific planning groups should also be established for the programmes in (i) nutrition and (ii) mental health and human behaviour in primary health care. When reviewing the work of the regional ACMRs, the global ACMR noted that one of the main constraints on effective action by certain of them was lack offunds. It proposed that all regional offices should earmark a minimum of 5% of their regional budgets for research. It also noted that the 4·4 35
Global developments 4· 3 The global Advisory Committee on Medical Research (ACMR) at its twentysecond session (Geneva, October 198o) re-
THE WORK OF WHO, I980-198I
disparity between the capabilities of the various regions, and also between countries in those regions, prevented some regional ACMRs from instituting relevant countrybased studies. Since the practical implementation of research programmes at country level depends not only on the availability of resources but also on effective communication, ACMR suggested that efforts should be made to achieve better interdigitation between national research priorities and those of WHO at regional and global level. Certain projects might be funded partly by WHO and partly by Member States; others might benefit from experience acquired at interregional level. 4· 5 ACMR also discussed research career structures, including a recommendation that, rather than promote research career structures per se, WHO should support research as a basic component of health plans and programmes. It was stressed in the discussion that research opportunities and career structures were essentially a national matter and that careers in research could not be viewed separately from those in other government services or institutions. The general view was that appropriate systems of peer approval and opportunities for interaction between young scientists and their colleagues constituted a stimulus to research workers. At its twenty-third session (Geneva, 4.6 October 1981) the global ACMR noted with appreciation the considerable progress made at regional level in coordinating and developing health research. It considered the advances in health services research (particularly in maternal and child health), in diarrhoeal disease research, and in general promotional activities (e.g., training in research management and research methodology) to be of particular importance. Regional offices had gone a long way in strengthening the links between medical research councils in their regions. The global
ACMR encouraged the further creation of focal points for coordinating research in those countries where formal bodies did not exist. 4· 7 The final report on ethical review procedures for research involving human subjects was examined; progress reports were received from the subcommittees on cancer, information, research administration, health services research, and mental health; and specially commissioned papers-on the formulation of research activities in gerontology and on the utilization and protection of nonhuman primates and other animals required for research-were discussed.
Research training 4.8 By enabling individual scientists to obtain additional training, WHO research trammg grants complement institutionstrengthening. The emphasis is on postgraduate education, although grants are also awarded for training other health, laboratory, and support personnel from developing countries and, in some cases, for training in research management. A wards are also made to promote the exchange of scientific knowledge by enabling investigators working on subjects of relevance to WHO programmes to visit scientists in other countries working in similar or related fields. 4·9 These two types of grants are funded by the special programmes for research and training as well as by the regular budget. Nearly 200 grants for research training, and some 5o grants to enable scientists to visit other institutions, were funded by those programmes during the biennium. In general, grants are increasing in number as well as in duration of the period of training. Particular attention is given to ensuring the relevance of the training to regional and national health research priorities and to providing it within the context of technical cooperation among developing countries.
RESEARCH PROMOTION AND DEVELOPMENT
Regional developments African Region
4· Io Member States of the Region are increasingly aware of the contribution that research can make to health development and 22 of them have medical research councils. Thirty-one of WHO's collaborating centres are in the African Region and there are also 4 5 national centres recognized by WHO. 4· I I The Special Programme for Research and Training in Tropical Diseases continued to expand in the Region, reaching a total of 206 projects since its inception; 7 I of these were in research and development, I I9 in research training, and I6 in institutionstrengthening. Onchocerciasis research, carried out mainly in the Volta River basin area, focused on: vector biology and control; environmental studies; clinical, epidemiological and parasitological investigations; and chemotherapy.
4· I 5 In relation to the Special Programme of Research, Development and Research Training in Human Reproduction, an African study group was set up and met in Antananarivo (June I98I). The four priorities of the Special Programme in the Region relate to pregnancy and delivery, male and female infertility, fertility regulation, and gynaecological disorders. 4· I6 The regional ACMR at its fifth session (Nairobi, April I98I) dealt with three broad areas. One was evaluation of the regional research programme since I 976: it was felt that health policy-makers, including those from countries that have not established medical research councils, should be brought together at regular intervals; and it was recommended that at least 5% of the regular budget for the Region should be allocated to research. The second was strengthening of research information systems: following the meeting of medical librarians from the African Region (Belgrade, September I98o), the establishment of an African Index Medicus and the intensification of bibliographical services in the Region were approved. The third area was the integration of applied research in primary health care: it was considered that ministries of health and faculties of medicine should collaborate in the development and management of health services research and that technical discussions should be organized to this effect during the Regional Committee.
4· I 2
Research diseases covered food safety, oral between Burkitt's
in the noncommunicable cardiovascular diseases, health, and the relation lymphoma and malaria.
4· I 3 In nutrition, investigations were continued to determine simple indicators of nutritional status, surveillance methods, postweaning dietary regimes, and appropriate technology for the storage of foodstuffs. In health services research, a training course on methodology was held in Ouagadougou (August-September I98o); a workshop on financing of health services was organized in Botswana (October I98o); and a multidisciplinary group on health services research met (February I98I) to study problems of evaluation, information systems, and financing. 4· I4 37
Region of the Americas
4· I 7 Research in this Region has two main objectives: (i) to develop and strengthen national capabilities for bringing research to bear on the country's health problems, and (ii) to give a lead in developing those areas of research that are critical for the achievement of health of all by the year 2000. Meetings were held in all five subregions with a view to
THE WORK OF WHO, 198o-I98I
a Pan American conference on research policy that will assist countries in setting research priorities, focusing research more sharply on the problems encountered, establishing reference systems, and formulating ethical codes for research involving human subjects. 4.I8 The PAHO Advisory Committee on Medical Research continued to promote research in nutrition, diarrhoeal diseases, health services, and the social sciences as related to health. A bibliography of social science research was completed, and specific attention is being given to the social factors that are critical in the control of malaria. Six scientific meetings on health services research were held.
South- East Asia Region
At its sixth and seventh sessions (New Delhi, April I98o and April I98I) the South-East Asia Advisory Committee on Medical Research considered several issues. At its seventh session it evolved a format for reporting progress in WHO-supported research in the Region, essentially by evaluating the catalytic role of the research programme in generating national activities and by assessing its impact on health care systems in Member States. 4.22
4· I 9 An extensive study of the impact of research on health development was in its final stage. It includes an analysis of the human and material resources directed to research in the Region, which indicates that the majority of projects are for applied research, mainly in public health, social medicine, microbiology, and parasitology. There are Io Pan American centres carrying out research in nutrition, perinatology, epidemiology, the zoonoses, environmental health and sanitary engineering, ecology, and educational technology. PAHOfWHO also coordinates the work of the I63 WHO collaborating centres in the Region. The Regional Library of Medicine (BIREME) continues to perform an important task, its 2 35I journal titles constituting the major reference source in Latin America. The Index Medicus Latino-Americano which it publishes complements the Index Medicus of the National Library of Medicine, United States of America. 4.2o
A subcommittee of the regional ACMR developed a conceptual basis for orienting research towards the objectives of health for all and enabling the Regional Office to screen the research activities that would contribute to national strategies. Similarly, a subcommittee on health services research provided a conceptual description of such research and a regional plan for promoting it in relation to national priorities. 4.23
Planning proceeded for a unique research programme on snake-bite, which is of particular interest to this Region. Efforts are also being made, at the WHO collaborating centre in Thailand, to develop a dengue vaccine. Under the global programme for diarrhoeal diseases control, a scientific working group was set up for implementing operational studies. 4· 24
4· 2 I The Special Programme for Research and Training in Tropical Diseases has supported over 300 projects in the Americas through grants to individual scientists or to strengthen institutions.
Since the meeting of directors of medical research councils or analogous bodies in I979, Member countries have been active in developing a coordinated managerial process for research on priority problems, using all the available national potential. A second such meeting (I98I) discussed progress and identified the specific issues to which the Regional Office should address itself during the Seventh General Programme of Work (I984-I989). 4.25
RESEARCH PROMOTION AND DEVELOPMENT
European Region The Regional Committee for Europe at its thirtieth session reviewed the work of the European ACMR and recommended that meetings dealing with research in the different countries of the Region should bring research workers into closer touch with the problems of individual countries; and that the programme, even though adapted to the requirements of a region predominantly composed of industrialized countries, should not neglect the continuous surveillance of communicable diseases. 4.26
4· 2 7 Planning groups of the European ACMR reviewed in depth problems of health care delivery; standardization of methods, measurements, and terminology; and evaluation of therapeutic and diagnostic substances. At its sixth session (Copenhagen, September I98o), the European ACMR itself discussed the latest recommendations of its planning groups in five priority areas: (I) health services research programmes (mental health, hypertension as related to health care, and health economics); (2) national organization and management of health research, and development of information systems; (3) participation of the Regional Office in the international programme on chemical safety; (4) the role of WHO collaborating centres; and (5) the need to develop research manpower by way of a training grants scheme. In general, the European ACMR approved the recommendations of its planning groups, but it emphasized that in the areas studied by all these groups research should be oriented towards services, as a prerequisite for achieving health for all. 4.28 4.29 The European ACMR stressed the importance of drug-related problems in studies on self-care, and the need for more specific recommendations on research into
the effect of drugs on the behaviour of drivers. It recommended priority for a study of the economic aspects of recent developments in primary health care, and the continuation of studies on the economic aspects of health care of the eyes, which could also be used as a model for the interdisciplinary approach. In mental health, it underlined the need for continuing research on etiology in addition to health services research, and for further studies in child psychology and early prevention of disorders. It also stressed the need for expanding the activities of the planning group on standardization into various biomedical areas and for collaborating closely with national centres working on standardization. Recognizing the great need for research training, it urged that funds be used primarily for training the research workers involved in large regional studies and for stimulating training in health services research. Lastly, it advocated additional voluntary funding to permit a further expansion of the Regional Office's work on research. 4.30
In I98I eight new Member States were represented on the European ACMR, bringing the total to I 7. Among the main concerns at its session in that year were the research implications, in the European context, of the strategy for health for all by the year zooo, particular emphasis being given to the sociological aspects.
Eastern Mediterranean Region The research activities sponsored by the Regional Office, under the guidance of the Eastern Mediterranean Advisory Committee on Biomedical Research, are now increasingly aimed at supplementing national research activities in the Member States of the Region. The regional ACMR met twice during the biennium. It reviewed ongoing activities, including those in nutrition, malaria, mental health, cancer, maternal 4,3 I
39
THE WORK OF WHO, 198o-I98'
health, and diarrhoeal diseases. It also advised on the research needs of the various technical programmes. 4· 32 Health services research continued to receive special attention. A training course in the methodology of such research was organized at the Department of Community l::lealth, University of Nottingham, United Kingdom (July I98o), and was attended by I8 nationals from five countries of the Region. The learning material used in the course is being adapted for use by the participants in organizing national workshops and courses. 4· 33 A health coverage study was initiated and completed during I98o-I98I in Bahrain, Egypt, andY emen, aimed at providing the three countries with information necessary to develop alternative strategies for achieving health for all through effective primary health care coverage of the population. The findings indicate that the three countries are committed to a policy of total coverage but that their present strategies emphasize physical rather than functional aspects. Self-care support by the informal health system, including traditional healers, is still the main source of primary health care. Community involvement in the provision and management of the health services is generally lacking. Through taking part in this study, a large number of health personnel in the three countries were trained in the concepts, methods, and management of health services research. Guidelines were developed on the basis of the experience gained and will be of use to other countries undertaking similar coverage studies. 4· 34 In order to refine the regional research priorities in health services manpower development, a consultation was held (September I98I). It resulted in research proposals that will be further developed into projects to be carried out by selected institutions in the Region.
4· 3 5 To build up national expertise in managing research programmes and research centres, a workshop (Islamabad, April I98I) was devoted to: organization of research at national and institutional level; research planning; evaluation of research proposals and scientific activities; staff promotion and development; research information; and management techniques applicable to medical research. A manual was in preparation as an aid to conducting similar workshops at national level, some of them in the form of research programme exercises at which ongoing activities are evaluated and future plans established.
Western Pacific Region
4.36 The general objective of the regional programme is to achieve selfsufficiency in health research (biomedical, health services, and health behaviour research) with particular relation to the major health problems of Member States. The specific objectives during the biennium were (I) to strengthen national research capability; (2) to increase technical cooperation among research institutions in the Region; and (3) to promote research management and coordination mechanisms at national level. 4· 37 To advance objective (I), resources were used to strengthen institutes in Malaysia for research on tropical diseases; in Papua New Guinea for research on acute respiratory infections; and in the Republic of Korea for research on parasitic diseases and health services. A working group was convened (Manila, February I98o) to encourage Member States to establish health research councils or national focal points with a view to better research management. Training in research methodology received increased attention, and a WHO-supported national workshop on the subject was conducted in China (May I98I).
RESEARCH PROMOTION AND DEVELOPMENT
4· 38 In relation to objective ( z) a number of themes were promoted as part of WHO's programmes of technical cooperation, the following being considered priority areas by the regional ACMR: health services research; diarrhoeal disease control; acute respiratory infections; application of modern immunological techniques; vector control methods; occupational health; cardiovascular diseases (including diabetes in the Polynesian and
Micronesian islands); and clonorchiasis and paragonimiasis. 4·39 As for objective (3), a redistribution of resources has taken place since 1979, increasing the responsibility of regional programme managers for programming the research component as an integral part of health development activities and thus relating it more closely to the solution of regional and national health problems.
41
Chapter J
Health Services Development
RESULTS of the study on national decision-making for primary health care carried out by the UNICEF/WHO Joint Committee on Health Policy were published in I981. 1 Seven countries politically committed to the goal of health for all by the year zooo had studied how the principles of primary health care were being put into practice, tracing the factors determining the initial political decision, the steps followed in the implementation of policies, the progress made, and the problems or constraints encountered. The study is intended to contribute to the formulation of policies for international cooperation through UNICEF and WHO and to clarify for participating and other countries the main issues involved and different ways of moving forward. Participating countries were requested to designate a national multidisciplinary team and a national coordinator, and these were supported by UNICEF and WHO staff and consultants. The fact that the studies were carried out by national teams not only improved the countries' understanding of the issues investigated but also provided an opportunity for nationals to acquire valuable experience in the development and implementation of primary health care, including reasses&ment of policies and planning mechanisms. 5-I I World Health Organization. National decision-making for primary health care. Geneva, 1981.
THE
5.2 Following the promising outcome of the study, the Joint Committee recommended at its February I 98 I session that the I98I-I982 UNICEF/WHO study should be on the implementation of primary health care. The two main aims of the study, which will be a longitudinal process rather than a retrospective analysis, are to further the development of primary health care in countries where a serious commitment is evident and there is reasonable chance of success, and to ascertain how UNICEF and WHO can best support such development. It will be a multinational endeavour with responsibility taken by countries as part of their efforts towards achieving health for all by the year 2ooo. A plan of action was formulated with UNICEF in I98I; four countries were selected for the study initially (Burma, Democratic Yemen, Ethiopia, and Nepal) and others will be included later. UNICEF and WHO held joint briefing sessions for those at headquarters, regional, and country level engaged in reviewing strategies and drawing up plans of action in support of primary health care.
5. 3 Activities carried out during the biennium to strengthen national health development networks were of four categories: (I) promotion of the concept by making relevant information available and creating the opportunity for exchange of experience and ideas; (2) participation in the formulation and implementation of national plans of
HEALTH SERVICES DEVELOPMENT
action and in the development of a framework for monitoring and enlisting the contribution of the networks to the health development process; (3) promotion of the orientation and training of national staff in the management of institutions and of the health development process; and (4) collaboration with countries in the mobilization of the resources necessary for the proper functioning of networks and centres, ensuring that financial and other support for projects and the strengthening of institutions are available for sufficiently long periods to produce an impact. These activities were carried out, in collaboration with other agencies of the United Nations system, in Algeria, Burma, Colombia, Costa Rica, Democratic Yemen, Ethiopia, Jamaica, Malaysia, Morocco, Nepal, Nicaragua, Pakistan, Papua New Guinea, Republic of Korea, Sri Lanka, Sudan, Thailand, and Zimbabwe. 5·4 Workshops on primary health care in the Caribbean area were sponsored by the Caribbean Community (CARICOM), UNICEF, and WHO in support of the national health development networks programme. SIDA has provided financial aid for WHO activities in this field.
inherited an economic infrastructure severely weakened by years of armed struggle, a massive refugee problem with thousands of displaced people, an economy ill adapted to the needs of the whole population, a health care system characterized by a grossly inequitable distribution of resources as between the urban and rural areas, and a type of health care providing predominantly curative medicine, with expensive and sophisticated facilities available only to a minority. In short, the distribution of the resources available for health improvement bore little relation to the health needs of the majority. Following a WHO-supported symposium (Salisbury, December I98o), a primary health care programme was developed with emphasis on community participation and the village health worker, and on legislation to ensure more equitable hospital services. Support is being provided to strengthen national capabilities, particularly in the planning and programming of health services and manpower development. Studies on the role of women in health development, particularly in relation to primary health care, were begun in I 98o, covering nine countries of the Region. 5.6 In the Region of the Americas special emphasis was placed on ascertaining the needs of underserved groups, promoting intersectoral cooperation and community participation, developing appropriate technology for administering and delivering services, and updating the training of health personnel. Efforts were made-e.g., in Bolivia, Colombia, Costa Rica, and Ecuador-to organize health care so that the requirements of primary care are met and the quantity, quality, and accessibility of secondary and tertiary levels of care are improved. 5. 7 In countries of the South-East Asia Region activities were focused on the training and utilization of community health workers and supporting staff, and manuals for this purpose were prepared 1n Bangladesh, 43
Primary health care 5. 5 In the African Region interministerial coordination committees, or similar mechanisms to promote intersectoral activities within the primary health care programme, have been set up in Botswana, Gambia, Ghana, Kenya, Lesotho, Liberia, Malawi, Mauritius, and Zambia, and national action programmes for primary health care were formulated during I98o and I98 I in Benin, Burundi, Comoros, Congo, Gambia, Upper Volta, United Republic of Cameroon, and Zambia. Priority attention has been given to newly independent nations. Zimbabwe's newly elected Government, for example,
THE WORK OF WHO, 1980-1981
Indonesia, and Nepal. Mechanisms for intersectoral coordination at all levels were developed-as reflected in the establishment of village health committees in Bangladesh and of a "basic minimum needs" steering committee in Nepal, and in the plans of other ministries as well as the health ministry in India. The increase in the health budget in India, the reorganization of the health care delivery system in Sri Lanka, the review of the national health system in Indonesia (where an assessment was made of activities carried out by traditional birth attendants), and the improvement of the indigenous system of medicine in Burma, all reflected increased attention to primary health care. 5.8 The main emphasis in the European Region was on self-care, community partici' pation, the integration of primary, secondary, and tertiary care, and particular attention to underserved and vulnerable groups. The Regional Advisory Committee on Primary Health Care, which met for the first time in Copenhagen in August I98o to review proposed activities, accorded highest priority to action to combat social inequalities in health, clarification of the concept of primary health care in industrialized countries, analysis of the relative contributions to primary health care of various health care sectors and groups of personnel, and research and training. The completion in I 98o of the first phase of a regional study resulted in an inventory of primary health care management problems. The Government of Algeria, which is firmly committed to the development of primary health care, decided to implement a demonstration project in one province; and in Turkey a plan of action was prepared, with the collaboration of UNICEF, to demonstrate how the solution of a major problem-malaria-can benefit from an integrated primary health care approach. 5·9 In the Eastern Mediterranean Region further countries incorporated primary health 44
care programmes as an integral component of their health development plans, or are in the process of doing so. Many of them (the Libyan Arab Jamahiriya, Oman, Pakistan, Somalia, Sudan, and Yemen) have requested WHO cooperation in the formulation, implementation, or evaluation of primary health care programmes. In January I 98 I Bahrain, Democratic Yemen, Lebanon, Saudi Arabia, the Syrian Arab Republic, and Yemen were represented at a meeting of a working group, organized by UNICEF with WHO collaboration, to review the current status of primary health care programmes and pinpoint the essential elements for converting the AlmaAta commitment into action. 5. I o In the Western Pacific Region attention was focused on the promotion of national commitment to primary health care and its translation into action plans. Studies were carried out in Papua New Guinea and the Philippines to determine the most appropriate way of organizing community health development. 5. I I Interregional trammg courses on primary health care were organized in China in I98o, with visits to three centres which were later designated as WHO collaborating centres. UNDP-supported courses for administrators were held at these centres (three in I98o, one in I98I). Staff of the centres visited Malaysia, the Philippines, and Thailand to observe primary health care activities, with a view to introducing improvements in the courses. The aim has been to encourage 5. I 2 countries to exchange views and work together on common issues in health development. Two UNICEF /WHO workshops on primary health care--in Mozambique (English-language, February/March I98o) and in Senegal (French-language, February I98I)-dealt with a number of political, managerial, and technical issues. Following a
HEALTH SERVICES DEVELOPMENT
two-year interval during which the countries represented at the workshops will seek to introduce any necessary modifications in their primary health care programmes, representatives of the same countries will meet and compare experience. 5. I 3 If present trends continue, by the end of the century 5o% of the world's population will be living in cities, at very high density and in appalling squalor. Cities in general receive the lion's share of health resources but many of them have large and rapidly growing slum areas whose population rarely benefits from health care programmes. A WHO consultation was held on primary health care in urban areas, with emphasis on the urban poor (Geneva, January I98I), and similar action was initiated in the Region of the Americas and in the South-East Asia and Western Pacific Regions; a number of cities have expressed interest in participating in this programme, in which UNICEF and various other United Nations and nongovernmental organizations are collaborating. 5.14 Community involvement is one of the prerequisites for successful implementation of primary health care, and social control of the health infrastructure and technology through such involvement is essential for achieving the goal of health for all. Moreover, community self-reliance requires that people participate in the planning and implementation of their health care. Technical collaboration with countries to increase community involvement in primary health care was therefore intensified, and in I98I preparations were made for a comprehensive review of approaches and experience in different national settings. p 5 A UNICEF /WHO interregional study on the training and utilization of community health workers, begun in I979, was completed, and a workshop held in Jamaica in February I98o was attended by 45
representatives of the participating countries (Botswana, Bulgaria, China, Ethiopia, Honduras, India, Iran, Jamaica, Papua New Guinea, the Philippines, Sudan, Thailand, and Turkey). A set of recommendations was drawn up on the training of community health workers as an integral part of the public health programme, and on their selection, functions, and support. Follow-up activities, relating especially to training and support, are under way. 5. I 6 With regard to intersectoral action, WHO is collaborating in an intercountry study (being carried out initially in Colombia, India, Jamaica, Norway, Sri Lanka, and Thailand) to review concepts and experience regarding the contribution of other sectors to health development. It is also cooperating with F AO and other organizations in the United Nations system in connexion with regional integrated rural development programmes, with a view to practical action in this area. 5. I 7 The problem of financing primary health care at the local level has caused concern in many countries. An interregional study on the subject was carried out in I I countries, and the findings were discussed at a UNICEF/WHO workshop (Geneva, December I98o).
Health services planning and management 5. I 8 Most countries directed their main efforts to extending coverage of their populations with essential health care by reorienting their health services in line with the primary health care approach. A study on the measurement of coverage, effectiveness, and efficiency of various patterns of health care was carried out in Burma, Costa Rica, Egypt, Finland, Malaysia, Nigeria, the Republic of Korea, and Senegal, and the results were
consolidated in preparation for publication. Some of these countries proceeded, with WHO collaboration, to develop monitoring schemes to be tested at national and local level. 5. I 9 "Health system support for primary health care" was the subject of the Technical Discussions held during the Thirty-fourth World Health Assembly and an informal consultation was organized on the concepts, processes, and implications of health systems reorientation (Geneva, June I98I). The related documentation was circulated for use by countries in analysing and reorienting their health systems. 5. 2.0 An interregional course (the third in English) on the planning, organization, and management of health care delivery in support of primary health care was held in Sofia (October I98o). 5. 2. I In the Region of the Americas national health plans were formulated in Dominica, Grenada, Honduras, and Peru. The Organization cooperated in implementing the health plan and project for extended service coverage in Guatemala and provided technical advice on the extension of coverage in Paraguay (with the financial support of the Inter-American Development Bank in both countries). An agreement was concluded with the Colombian Government on a programme, to be funded by the Netherlands, to develop the primary health care aspects of the national integration plan. Projects on health system design were supported in Chile, Peru, and Uruguay. Previously vertical programmes are being integrated into comprehensive services in several countries. Social security is playing an increas5.2.2. ingly important role in health care, and the Organization collaborated with the social security institutes of Ecuador, Peru, and Costa Rica in the development of activities in the health field.
In South-East Asia assistance was 5.2.3 given to Indonesia in finding alternative patterns for reorganization of the national health system; and in the Eastern Mediterranean WHO gave support to Democratic Yemen, Egypt, and Sudan in their efforts to increase the equity of their health systems through social and economic reforms and administrative decentralization. 5. 2.4 As regards the organization of health services, in the Region of the Americas assistance was provided to improve regionalization and management (budget, personnel, and supplies) in Bolivia, Costa Rica, the Dominican Republic, Ecuador, El Salvador, Guatemala, Guyana, Haiti, Nicaragua, and Paraguay. Studies on drug supply management in health units were carried out in Ecuador and Panama; analyses of financing, accounting, cost control, and budgets were intensified in Guyana and Jamaica; a broad project for administrative development was started with UNDP financial support in Colombia; and organizational behaviour studies were initiated in Brazil and Chile. In addition, assistance was provided to many countries for training in the collection of health information and for the development of improved health information systems. 5. 2. 5 The organization of health services was reviewed in several countries of the South-East Asia Region, and a workshop on health management was held in Bangladesh for senior government officials. 5.2.6 In the Western Pacific Region WHO-supported national workshops for managers of health services were held in six countries, the role of front-line health staff was studied in three, and manuals for rural health units were revised or adapted with WHO collaboration in two. The Asian Development Bank and WHO cooperated with Papua New Guinea in a study on the strengthening of the rural health services.
HEALTH SERVICES DEVELOPMENT
5. 2 7 As part of a WH 0-supported interregional study being carried out with a view to increasing the relevance of health care facilities to local needs and possibilities, national case studies on the planning, construction, and operation of such facilities within the context of national health systems were completed in Algeria, Cuba, Senegal, Sudan, Venezuela, and Zambia. The reports included analyses of the health care systems and management in those countries, and the process led to national recommendations on how to improve the situation. A WHOsponsored meeting on health care facilities in developing countries was held in Geneva in November I98o. Volume 4 of Approaches to planning and design of health care facilities in developing areas was prepared in I98I for
ing hospital facilities suited to local conditions. 5. 30 Health service planning and management projects, with emphasis on primary health care, were supported in nine countries in the Western Pacific Region. Under an intercountry project on hospital management, design and maintenance, support was given to courses in New Zealand, the Philippines, and at the University of the South Pacific, and for strengthening hospital services in the Republic of Korea and the Trust Territory of the Pacific Islands. 5. 3I To promote the use of epidemiology as a tool in implementing the preventive and community aspects of primary health care, an interregional workshop was held in Malaysia (March I98o), attended by senior health managers and epidemiologists from Botswana, Burma, Ecuador, Indonesia, Malaysia, Morocco, the Philippines, Sudan, the United Republic of Tanzania, Thailand, and Zambia. 5. 32 In the European Region the need for improved communication between producers and users of health information was stressed in the recommendations of a workshop on the use of health indicators (Brussels, November I98o), and a consultation on indicators for health for all by the year zooo was held in April I981. 5. 33 Following an interregional seminar on the economic aspects of health services (Mexico, 1979) and on the basis of experience gained during an intercountry training course in the African Region (Botswana, 198o), a manual providing guidance for surveys of health financing was finalized.
publication.t 5.28 In the Americas a subregional seminar on the planning and maintenance of health facilities (Venezuela, April I 980 ), organized in collaboration with UNDP and the secretariat of the Hipolito Unanue Agreement, was attended by 7 2 health officers from I4 countries. Assistance with project preparation was provided to the Andean countries and to Guatemala, Guyana, and Trinidad and Tobago. Cooperation in teaching and research was initiated with the Health Facilities Research Center of the University of Buenos Aires.
5. 29 In the Eastern Mediterranean Region technical support was given to Lebanon, Sudan, and the Syrian Arab Republic in the design and management of health facilities, and a survey was made of national capabilities for health facility development in the Region. In South-East Asia assistance was given to Mongolia in designt Kleczkowski, B.M. & Pibouleau, R., ed. Approaches to planning and design of heath care faciltties in developtng areas, Volume 4 (in preparation). Geneva, World Health Organization. Volumes r, 2, and 3 were published as Offset Publications Nos 29, 37, and 45 in 1976, 1977, and 1979 respectively.
5. 34 In the South-East Asia Region a study of the financial aspects of health care delivery in Bangladesh was completed. In Thailand alternative strategies for health development were analysed and compared. 47
THE WORK OF WHO, r98o-r98r
5. 3 5 In the European Region the reports of two meetings on health economics (the economic aspects of health care, and those of eye health care) were issued. Guidelines for national health accounting were simplified and tested in six countries during I 980. A multinational study on the influence on health of economic factors such as unemployment and economic instability was initiated by a planning meeting (Copenhagen, November I 98o ). At a workshop on the control of health care costs in social security systems (Vienna, May I98I) stress was laid on the need for cost containment to extend beyond the health care system, encompassing, for instance, environmental pollution and self-imposed risks. 5. 36 In the Western Pacific Region WHO cooperated with the Republic of Korea in a review of new systems for financing health care, and with Singapore in the development of modules for teaching health econom1cs.
elements of primary health care listed in the Declaration of Alma-Ata.l The scope of this long-term activity is to be extended through participation in the SATIS network (Socially Appropriate Technology Information System) based in the Netherlands, which publishes thematic bibliographies having a bearing on health. The Regional Offices for the Americas, South-East Asia, and the Eastern Mediterranean have already identified national institutions interested in collaborating in this programme. 5·39 Following the recommendations made at a consultation in Manila at the end of I979 regarding the establishment of an information system for appropriate technology, efforts were made in some countries, notably Thailand, to set up an integrated information service. 5.40 The ATH Newsletter-a means of disseminating information to health workers at the periphery-was widely distributed and well received. A new edition of the directoryz of organizations, institutions, groups, and individuals concerned with appropriate technology was issued in I98o, after careful assessment of their activities.
Appropriate technology for health 5. 37 The emphasis in this area was on promoting the concept of appropriate technology and developing integrated information services. On the basis of country studies, two interregional workshops were held (French-language, Washington, December I98o; and English-language, New Delhi, March I98I) to review the experience of the participating countries and progress in the development of appropriate technology for the different elements of primary health care, and to identify areas for WHO collaboration. These workshops served to sensitize participants to options suitable for their specific national situations. 5. 38 An inventory of the in-house documentation related to appropriate technology for health is being made with a view to issuing annotated bibliographies on the eight
5.4I To overcome certain specific problems in developing countries, support was provided for research to develop prototypes of a solar heater, a "Sahelian" cooker, a vapour-sterilizer, a dry-heat sterilizer, a water distiller, and a portable tester for thermal sensation in the clinical examination of leprosy. 5.42 The maintenance and repair of equipment are considered of vital importance
1 Alma-Ata 1978: primary health care. Geneva, World Health Organization, 1978, reprinted r98r ("Health for All" Series, No. r), p. 4· 2 WHO document ATH/8o.z (August 198o).
HEALTH SERVICES DEVELOPMENT
in this programme. In the Americas special stress was placed on the establishment or expansion of services for the maintenance of health facilities and equipment in Colombia, Costa Rica, Ecuador, El Salvador, Mexico, and Venezuela. The Eastern Mediterranean and African Regions have also been active in this subject, particularly as regards training. Work in the African Region centred 5·43 on the exchange of information with many countries throughout the world, particularly with regard to traditional medicine. 5-44 In the Americas a regional symposium on appropriate technology for health and three area seminars-for countries of Central America, the Andean region, and the Caribbean-were held during the biennium. 5·45 In the South-East Asia Region, Bangladesh, India, Indonesia, and Thailand gave increased emphasis to research on appropriate technology as support for primary health care, and several seminars and workshops on the subject were organized, both at interregional level (New Delhi, October I98o) and at country level (India, Sri Lanka, and Thailand, I 9 8 I). 5.46 A meeting at the European Regional Office (May I98I) reviewed possible systems of technology assessment. Its recommendations covered: establishment of the national organizational base; identification of needs; involvement of decision-makers, the information media, and the general public; the multidisciplinary approach; and the need for international cooperation. In the Eastern Mediterranean 5·4 7 Region, Pakistan and Sudan are playing a leading role in the establishment of a regional information service on appropriate tech-' nology for health. Both countries are also implementing national projects f6r the provision of low-cost spectacles. 49
5.48 Technical and financial support was given to a number of countries in the South Pacific for the construction of ferro-cement water tanks, and to the Philippines for the development of pilot biogas digesters in small communities.
Health services research 5·49 Health services research, with emphasis on support for national strategies for achieving health for all based on primary health care, was carried out as part of WHO's various programmes at both regional and global level. 5. 5o In the African Region there was increased emphasis ·on training in health services research. Workshops held in Gambia, Mali, and Upper Volta were attended by participants from Benin, Congo, Guinea, Mali, Mauritania, Niger, Senegal, and the United Republic of Cameroon. A study group on health services research was established; its tasks included the formulation of a regional programme for I98I-I983. 5. 5I Countries of the Americas have made specific recommendations for promoting and using health services research. Despite the constraints-lack of competent investigators, unsatisfactory communication between health workers and researchers, inadequate definition of research needs, and scarcity of funds-progress was made in implementing the recommendations, and the Organization initiated a health services research programme with emphasis on the strengthening of local capabilities. It collaborated in various surveys and studies on drug administration in hospitals, development of supply administration, infection control centres in hospitals, and appropriate technology for maintenance of health facilities. A regional workshop (Washington, January I98I) was attended by specialists in
epidemiology, sociology, systems engineering, economics, health administration, teaching, and research. 5·52 In South-East Asia WHO-supported health services research was carried out in Bangladesh, Burma, India, and Thailand. Seminars on methodology for such research were organized at the Centre for Research Development in Health Services, Surabaya, Indonesia (a WHO collaborating centre), as well as in Sri Lanka and Thailand. 5. 53 The European ACMR approved the proposals of its planning groups on the problems of health care delivery and on the economic aspects of health care, emphasizing the importance of orientation towards services. WHO supported studies on health service accounts, management of primary health care, and hospital administration. An international course on research in primary health care was organized for postgraduate research workers (Kuopio, Finland, May 198o).
5. 55 Increased emphasis was placed on health services research in the Western Pacific Region, where the task force on the subject was designated as a subcommittee of the regional ACMR and a draft plan for 1981-1983 was formulated. WHO supported studies related to primary health care (in Malaysia, Papua New Guinea, and the Philippines) and to the immunization and diarrhoeal disease control programmes. 5. 56 A workshop on health services research was held at the Korea Development Institute, Seoul (October 198o), and the Public Health Institute in Kuala Lumpur was designated as a lead agency for health services research in Malaysia. A regional information system on health services research is being established. 5. 57 At global level, two meetings of the ACMR subcommittee on health services research were held-one in Manila, when it focused attention on the strengthening of national capabilities, and the other in Addis Ababa, when it considered the potential contribution of health services research to the strategy for health for all, taking maternal and child health care as a concrete example. 5. 58 With a view to ascertaining training requirements, a review is being made of the initiatives undertaken by countries and WHO to orient and train people in the principles and practice of health services research.
5. 54 In the Eastern Mediterranean Region, where a quarterly newsletter- The health services researcher-is published, a health services coverage study was completed in Bahrain, Egypt, and Yemen. Research proposals were prepared during a course in health services research held in the United Kingdom (see paragraphs 4·32 and 4.33).
Chapter 6
Fami!J Health
THE FAMILY is the basic unit of health care, and the emphasis given to it in primary health care is a recognition of that fact. Its role is vital to health promotion and to the prevention, early' diagnosis, and treatment of disease since the bulk of health action is carried out in the home before any contact with health workers. It is the family-in general the mother-that rears the children, cares for the sick and the elderly, determines the diet, maintains the immediate environment, transmits attitudes and lifestyles, and decides when to have recourse to the health services. 6. 2 The indicators of the health of the family in Table 6. I show the wide disparity Table 6.1
6. I
that exists between developed and developing countries, and suggest the extent to which the health of members of the family depends on a whole range of social and economic factors and requires for its improvement the intersectoral and integrated approach embodied in primary health care. 6.3 WHO's programme in I98o-I98I focused on managerial, technical, and research support to family health programmes in over 90 countries. The trend throughout all regions was towards an integrated approach, combining maternal and child health, family planning, immunization, diarrhoeal disease control, and many other components. These national family health programmes
Indicators of family health
Developing countries Typical value Infant mortality rate' Percentage of newborn weighing less than 2500 g• .. Fertility rate' . . . . . . . . . . . . . . . . . . . . . . . . Percentage of pregnant women who are anaemic• .. Maternal mortality per 100 000 live births' . . . . . . . • Without China this figure would be 120. Range of values
Developed countries Typical value Range of values
109. 18
5.3 60 about 400
13-217 6-50 1.8-7.4 15-77 13-600
20 7 2.0 20 21
7-39 4-12 1.4-4.2 5-22 1.5-37.3
Sources 'Population Reference Bureau Inc., Washington, 1981 data sheet. • See footnote to paragraph 6.20. • United Nations Demographic Yearbook, 1918, for developed countries; data for developing countries are WHO estimates.
THE WORK OF WHO, I98o-I98I
came closer to making family and community involvement, and the intersectoral approach,. a reality. One important aspect was community-oriented training for health workers, community development workers, schoolteachers, traditional health practitioners, and women's groups. Information tools such as family health records and children's growth charts were developed in parallel. UNFP A's financial support, channelled through WHO, contributed significantly to these developments. 6.4 Activities relating to research on human reproduction, and institution-strengthening for such research, received financial support from the Governments of Australia, China, Cuba, Denmark, Finland, the Federal Republic of Germany, India, the Netherlands, Nigeria, Norway, Sweden, Thailand, the United Kingdom, and the United States of America, as well as from UNFP A. Joint activities were carried out with UNICEF, F AO, the International Children's Centre, and the United Nations University; with the International Federation of Gynecology and Obstetrics, the International Paediatric Association, the International Planned Parenthood Federation, the International Union of Health Education, and the International Union of Nutritional Sciences; and with the Swedish Agency for Research and Cooperation with Developing Countries.
and education. In Africa concern was also expressed at the proportion of infertility in certain population groups. Fertility was viewed as a main indicator not only of health but also of the interrelationship of health and socioeconomic development. The analyses in the World Fertility 6.6 Survey and the reviews of WHO's own programmes pointed to the large unmet need for family planning and to the demands for greater emphasis on the "users' perspective" and on community-based services. On the basis of experience over the past I o years in providing services, training, and research in family planning, WHO reinforced its activities in I 980-I 98 I (see paragraph 6.67 to end of chapter).
Infant and young child feeding 6. 7 WHO made headlines in the world's press in I 98o-I 98 I with its work on infant and young child feeding. Joint work with UNICEF had highlighted the severity of malnutrition in this age group and the negative impact on feeding practices of certain social and economic forces, in particular as related to the declining trend in breastfeeding in some parts of the world. The subsequent drafting of an International Code of Marketing of Breast-milk Substitutes 1 and its adoption by the Thirty-fourth World Health Assembly (I98I) were historic events, since it was the first code of its kind. Its aim is "to contribute to the provision of safe and adequate nutrition for infants, by the protection and promotion of breast-feeding, and by ensuring the proper use of breast-milk substitutes, when these are necessary, on the basis of adequate information and through ap-
Fertility 6. 5 The importance given to fertility trends in national and regional strategies for achieving health for all by the year zooo reflects the more open recognition by Member States of the health aspects of fertility and of population issues. In the Western Pacific, for example, fertility reduction is among the objectives of the regional strategy, and all regions gave a clear priority to expanding family planning care, research,
1 World Health Organization. International code of marketing of breast-milk substitutes. Geneva, 1981.
FAMILY HEALTH
propriate marketing and distribution". The Code covers: the information to be provided on infant and young child feeding; the advertising or other forms of promotion of breast-milk substitutes; the presentation and quality of such substitutes; and the responsibilities of health authorities and of health workers. 6.8. The process leading to the adoption of the Code was in itself an innovation: extensive consultations were held with all interested parties, including the governments of more than 8o countries, organizations in the United Nations system, the scientific community, nongovernmental organizations, consumer advocate groups, and industry. The WHO/UNICEF Meeting on Infant and Young Child Feeding (Geneva, October I979) was followed in I98o by six meetings to discuss its recommendations and to review the draft of the Code. 6.9 The Thirty-third World Health Assembly (resolution WHA 33. 32) endorsed the recommendations of the WHO/UNICEF Meeting that a final Code should be developed; the Executive Board (January I98I) unanimously resolved that it should be adopted as a recommendation; and it was so adopted by the Thirty-fourth World Health Assembly. In resolution WHA34.22 the Health Assembly urged all Member States: (I) to give full and unanimous support to the provisions of the International Code in its entirety as an expression of the collective will of the membership of the World Health Organization; (z) to translate the International Code into national legislation, regulations or other suitable measures; (3) to involve all concerned social and economic sectors and all other concerned parties in the implementation of the International Code and in the observance of the provisions thereof; 53
(4) to monitor the compliance with the Code. 6. I o Meetings were held in each region to examine in detail how infant and young child feeding practices could be improved. Regional and global plans of action were established that cover the full recommendations of the WHO/UNICEF Meeting, namely: (i) encouragement and support of breast-feeding; (ii) promotion and support of appropriate weaning practices; (iii) strengthening of education, training and information; (iv) improvement of the health and social status of women; and (v) appropriate practices for marketing breast-milk substitutes. Guiding principles to help Member States in monitoring progress and determining the kind of cooperation they require were discussed by the regional committees at their I 9 8 I sessions.
Women in relation to health and development1 6. I I The midway point in the United Nations Decade for Women was marked by the United Nations Conference on Women (Copenhagen, I98o) and the World Congress of Women (Prague, I 98 I). Despite pessimism as to progress, there was agreement that at least it was now recognized that socioeconomic development, including health development, cannot be achieved without significant changes in the condition of women, whose unequal status inhibits or distorts development. 6.I2 WHO's whole programme can be considered as contributing to the aims of the Decade, in the sense that all the programme areas relate in some way to women. The Organization has however specifically at-
1 For study on women as providers of health care, see paras 12.38-rz.39·
THE WORK OF WHO, 198o-I981
tempted to define the interrelationship between the status of women and health development, in order to create awareness of the health priorities of women and their roles in health care, by asking how the social, educational, employment, and political factors influencing the status of women affect, or are affected by, health; how women's involvement in health care can be made more equitable and more effective; how women's organizations can be mobilized to promote primary health care; and what kinds of societal, community, and family action are needed to ensure equity for woman as mothers and a better balance of men's and women's responsibilities. 6. I 3 In the African Region support was given to increase the effectiveness of villagebased women's organizations for health care; in the European Region, the importance of women's self-help movements was stressed; in the Western Pacific, women's participation in primary health care was analysed; in the Eastern Mediterranean a plan of action was formulated to discourage negative traditional practices such as female circumcision; in South-East Asia national focal points for information exchange were designated; and in the Americas a five-year plan of action on women in health and development was adopted at the Regional Committee's I98I session. 6. I4 WHO cooperated with nongovernmental organizations in strengthening the health components of their intersectoral programmes for improving women's status. An international meeting in Geneva (I 98 I) brought together women representing nongovernmental organizations and women's groups at community level; they radically questioned the "male-dominated health establishment", urging that more serious account should be taken of women's views when health programmes are being developed. 54
Maternal and child health Infant mortality and health
6. I 5 Progress in lowering the mortality and morbidity rates for infants and young children was unsatisfactory in most countries. Infant mortality rates have traditionally been linked to inadequate socioeconomic development but the complex conditions of today's world require a more precise analysis of these links if intersectoral action is to be effective. WHO initiated several studies in I 98 I on the social correlates of infant mortality. Joint activities were undertaken with various organizations and institutes to explain the vulnerability of children to certain situations of poverty, e.g., those related to the abuse of child labour, abandoned children, urban squatters, or the "fourth world"-the pockets of destitution that exist even in affluent societies. 6.I6 WHO's work in child health cannot be seen in isolation from other activities described in this report. The major causes of infant and child mortality and morbidity are infectious diseases-including diarrhoeal diseases and acute respiratory infectionscombined with malnutrition. During I98oI98I joint work with programmes in those fields was intensified. The children's growth chart is used by the Expanded Programme on Immunization; material on breast-feeding is utilized both by that programme and by the diarrhoeal diseases control programme; activities were undertaken in common with the programme on acute respiratory infections.
Maternal mortality
6. I 7 There has been a tendency to underestimate the relative magnitude of preventable maternal mortality. However, a global review in I 98o-I 98 I showed that in many developing countries the figures for maternal
FAMILY HEALTH
deaths are from 5o to 200 times higher than in developed countries. Maternal mortality is thus a key health indicator that highlights disparities. Numerous interrelated biological and social factors contribute to that mortality. The immediate causes are induced abortion, hypertensive disorders of pregnancy, infections, multiparity, malnutrition (especially anaemia), and parasitic diseases; they are closely linked to lack of care in pregnancy and childbirth, and to the heavy burden of women's work. In the Eastern Mediterranean Region, a scientific working group on maternal health (November I98o) proposed new initiatives, including a system of confidential inquiries into maternal deaths. Studies on such a system are under way in Afghanistan, Democratic Yemen, Egypt, Kuwait, Pakistan, and Sudan. 6. I 8 An increase of knowledge on the direct or indirect causes of maternal deaths (including predisposing factors) has significance for programmes in family planning, maternal nutrition, and health care of women, as well as for those in the broader perspective of the status of women. The perinatal and intergenerational aspects of women's health are crucial for the survival and the healthy growth and development of children. This interaction was further analysed at a joint International Paediatric Association/WHO workshop on the effects on the offspring of nutrition during pregnancy (September I98o).
conditions in rural or urban peripheral areas. This requires not only better_ tools but also new knowledge, based on epidemiological studies. In I 98 I a collaborative research project on hypertensive disorders of pregnancy-a main cause of maternal deathswas instituted in I I countries, involving some 40 ooo women. Its outcome is expected to be the development of intervention techniques for the prevention and management of such disorders as part of primary health care. 6.20 Birth weight was selected as an indicator for monitoring progress towards health for all by the year 2000; it is valuable in that it reflects the mother's reproductive capability (and thus her health and nutritional status) and predicts the chances of the infant's survival and subsequent growth and development. The estimates made in I98o of the incidence of low birth weight 1 show how little is known about the problems related to birth in developing countries. WHO is attempting to define those problems, to investigate the determinants of low birth weight, and to examine the effects of intervention strategies, especially at home and village level. In I980-I98I reviews were made of methods of neonatal heat regulation (e.g., simple types of incubator or techniques suitable for home use) and of the possible utilization of the gravidogram and the partogram outside hospital settings. 6.2I Data on the distribution of birth weight, collected as part of the collaborative study on hypertensive disorders of pregnancy (paragraph 6. I9), laid the groundwork for a system of surveillance of perinatal problems, to be coordinated through WHO's collaborating centres, of which the latest (in Athens) was designated in I981.
Perinatal health and health care
6. I 9 Many technologies are available in affluent countries for such aspects of maternal health as safe childbirth, some of them sophisticated in the extreme. But there are fewer of them for the care of the mother and her baby during the perinatal period, especially technologies that are suitable for the home level and can be adapted to local 55
1 The incidence oflow birth weight: a critical review of available information. World Health Statistics Quarterly, 33: 197-224 (r98o). Also available as offprint.
THE WORK OF WHO, 198o-198I
6.22 PAHO's Latin American Center for Perinatalogy and Human Development continued its research and training in this field, work being directed towards simplifying perinatal care.
Support to national maternal and child liealthj jami!J planning programmes
community groups were involved in the programmes. In the Eastern Mediterranean Region many of the pilot projects were reformulated and expanded into nationwide programmes. In the Americas links were strengthened with other sectors of socioeconomic development, e.g., education, agriculture, and labour. 6.24 Technical cooperation with China was expanded during I 98o-I 98 I ; it covered research in perinatology, work in relation to family planning services, and training. Several study tours were organized to enable health workers from China to go abroad and. those from other countries to study various aspects of China's maternal and child health/ family planning programmes. An interregional meeting (Shanghai, I98o), with participants from all WHO regions, reviewed policies for maternal and child health care and ways of improving it in the context of primary health care. . 6. 2 5 In all regions the emphasis was on integrating the priority components of primary health care and strengthening the managerial aspect. A method of rapid programme assessment for the maternal and child health and immunization components was developed in I 98 I ; it was used in Somalia and Sri Lanka at village, health centre, and central government level. Country case studies on the integration of family planning at different levels of care were organized in Algeria, Morocco, Portugal, Tunisia, and Turkey. A workshop, complemented by field visits, for the exchange of experience between the United Republic of Tanzania and Zimbabwe (November-December I98I) made recommendations on maternal and child health policy and on practice within the context of primary health care. 6.26 Training received high priority in WHO's support to national programmes, and there was a marked shift towards community-
6.23 Technical and managerial back-up was provided to some 8o family health programmes in different countries, funded mainly by UNFPA (see Table 6.2). Services coverage, training, and health services research were increased, and progress was also made in promoting community participation and the intersectoral approach. In several African, European, and Western Pacific countries, for example, women's bureaux and
Table 6.2 Maternal and child health/family planning country projects receiving UNFPA support as at December 1981 African Region Benin, Botswana, Central African Republic, Congo, Gambia, Guinea-Bissau, Lesotho, Liberia, Malawi, Mali, Mauritania, Mauritius, Mozambique, Nigeria, Sierra Leone, Swaziland, Zambia Region of the Americas Antigua and Barbuda, Bolivia, British Virgin Islands, Cayman Islands, Chile, Colombia, Cuba, Dominica, Ecuador, El Salvador, Guatemala, Haiti, Honduras, Jamaica, Mexico, Nicaragua, Panama, Peru, Saint Lucia, Saint Vincent and the Grenadines, St Kitts, Uruguay South-East Asia Region Bhutan, Mongolia, Nepal, Sri Lanka, Thailand European Region Bulgaria, Czechoslovakia, Hungary, Malta, Portugal, Turkey Eastern Mediterranean Region Afghanistan, Bahrain, Democratic Yemen, Jordan, Pakistan, Somalia, Sudan, Syrian Arab Republic, Yemen Western Pacific Region China, Cook Islands, Fiji, Kiribati, Malaysia, Papua New Guinea, Samoa, Solomon Islands, Tonga, Tuvalu, Vanuatu, Viet Nam
FAMILY HEALTH
oriented training of a wide range of health and other workers. Practical methods of problem definition and task analysis at local level enabled primary health care workers in maternal and child health/family planning to acquire their knowledge in real situations; training centres were situated in the rural communities with which they were directly involved. This approach was followed in Papua New Guinea, Sudan, and the United Republic of Cameroon, and was reviewed at a meeting of teachers from African and Arab countries (Barakat, Sudan, I98I). The emphasis was on improving the pre-service and in-service training of health workers with a view to transferring responsibilities to the appropriate level and promoting the use of such resources as traditional birth attendants and community development workers. Support was given to developing curricula suitable for community-oriented programmes and to producing teaching/learning material. International and regional training of teachers ensured a more rap~d build-up of capabilities. Support was given! to a regional training centre in Singapore; preparations were made for a regional centre in Mauritius; and numerous study tours and courses were organized (see paragraphs I2.144-I2.I47). 6.27
the point of view both of the community and of the family or individual, and the subsequent design oflocal strategies to ensure the best allocation of human, material, and financial resources according to the level of risk. 6.29 The risk factors are not only biological: they can be socioeconomic, environmental, or cultural and they thus call for intersectoral and community action in addition to individual treatment. Studies and training in this approach were carried out in all regions during I98o-I98I (see paragraph I 2. I44), reinforced by methodology prepared at global level. Studies in Burma, Cuba, Czechoslovakia, the Dominican Republic, India, Malaysia, Nicaragua, the Republic of Korea, Sri Lanka, Thailand, and Turkey strengthened national capabilities for research and development. An annotated bibliography was issued.l 6.30 The preliminary results of many of the studies indicate the changes in programmes and~policy that the risk approach requires at both local and national level: redistribution of tasks; training of traditional birth attendants and their incorporation into the health care structure; improved data collection; introduction of family health records; and community involvement. The risk approach is being used in one country as a basis for nationwide primary health care, and in the Americas as a basis for the regional strategy for achieving health for all by the year 2ooo.
Risk approach 6.28 All mothers and all children require some form of care throughout the cycle of growth, development, and reproduction, but the traditional model for such care prescribes methods and tasks that are often inappropriate to local problems or resources and never come anywhere near adequate coverage. In response to Health Assembly resolution WHA32.42 health services research, including research training in the field, was carried out on the development and utilization of the "risk approach", i.e., the identification and quantification of risk factors from
6. 3I A meeting of the global ACMR subcommittee on health services research (Addis Ababa, November I98o) reviewed experience in maternal and child health care in Burma, China, Congo, Cuba, Ethiopia,
1 Rtsk approach for maternal and child health: a selected annotated bibliography (WHO document MCHfRAj8LI), 1981.
57
THE WORK OF WHO, 198o--198r
Sweden, and Upper Volta as well as in the Gaza Strip. In the Americas, demonstration areas were set up that combined primary care, training, and epidemiological and health services research; various national studies were supported to improve the research design of existing programmes. An approach was devised for assessing community processes and encouraging community participation.
6. 34 Guidelines were prepared to facilitate changes in hospital and maternity clinic practices, and a review of legislation was initiated with reference to provision for maternity leave, breaks during working hours, day nurseries, or other arrangements at places of employment to allow women the time and a place for breast-feeding. To facilitate the monitoring of patterns and trends, a document on surveillance techniques z was prepared and was given a preliminary testing in two countries. 6. 3 5 Educational material was produced-e.g., an audiovisual presentation; a handbook on how to organize workshops and evaluate follow-up action; and a series of clinic posters and calendars on the themes of breast-feeding, immunization, and diarrhoeal diseases. The WHO brochure on breastfeeding3 is now available in seven languages.
Breast-feeding 6. 3 2 That the natural biological process of breast-feeding, whose importance for infant health is universally recognized, should require scientific, promotional, and educational action by WHO may be thought paradoxical. But there are a number of constraints associated with breast-feeding, and the practice is declining in many countries.l One of the efforts to prevent this decline was the adoption of the International Code of Marketing of Breast-milk Substitutes (see paragraphs 6.7-6.10). 6. 3 3 The promotion of breast-feeding was intensified during the biennium by the organizing of workshops, scientific groups and symposia (in 1980 in Antigua, Chile, Colombia, Fiji, Ghana, Grenada, Hong Kong, Indonesia, Papua New Guinea, Saint Lucia, Samoa, and Thailand; in 1981 in the Caribbean area, Congo, Ethiopia, Guyana, Nigeria, Peru, Saudi Arabia, Sri Lanka, Tunisia, and Zaire). These meetings contributed to increased awareness of the importance of breast-feeding and to the introduction of measures for its support. (See also paragraph 15.95.)
6.36 A WHO report on the status of women and breast-feeding,4 distributed to women's organizations and to policy-makers, outlines the factors that affect women's circumstances and their options as regards breast-feeding, and indicates areas for future action, both at political and at grass-roots level.
Growth and development of children 6. 37 One of the main concerns in maternal and child health is, through preventive, promotive and rehabilitative care, to ensure the healthy physical growth and psychosocial development of children. The aim of WHO's programme is that families should be able to contribute to the monitoring of their own 2 Methodology for determination of breast-feeding patterns (WHO document MCHJBFJSURJ8r.r), 1981. 3 World Health Organization. Breastjeeding. Geneva, 1979· 4 WHO document FHEj81.1 (r98r).
I
World Health Organization. Contemporary patterns of
breast feeding: report on the WHO collaborative stutfy on breastjeeding, Geneva, 1981; Infant andyoung child feeding: current issues, Geneva 1981.
FAMILY HEALTH
children's health and thus prevent problems from arising or ensure their early diagnosis. A publication on the consequences for adulthood of health problems during the period of growth and development 1 shows how the foundations for healthy maturity are laid in the earliest stages of human life, the growth and development of girls being especially crucial for future generations.
Adolescence 6. 38 Adolescence is a critical period in growth and development; the importance of preparing adolescents for their role as parents is recognized, and the risks of teenage pregnancies or abortions are viewed with particular concern. During 198o-198I meetings were held in the European, South-East Asia and Western Pacific Regions, with a global meeting in Mexico City (April-May I 98o) at which health authorities from numerous developing countries described the health and social problems of adolescents, their demographic potential, and the contribution they could make to primary health care. 6. 39 The regional strategy for attaining health for all in the Western Pacific Region includes a specific objective for reducing the number of adolescent pregnancies, and a regional plan of action was prepared covering services and educational research. In the Caribbean area, the Organization gave support to activities to reduce the incidence of teenage pregnancies. 6.40 At global and regional level studies were carried out on growth and sexual development during puberty (Hong Kong,
Hungary, Israel, Kenya, Nigeria, Sri Lanka, and Switzerland). These indicate inter alia that age at menarche may be a useful indicator of health in the female population. Studies on the use of prenatal and family planning services by adolescents are under way, or being developed, in Bangladesh, India, Malaysia, Nigeria, Portugal, the Republic of Korea, Sri Lanka, and Turkey. A series of family life education programmes, both in school and elsewhere, was developed in several Caribbean, European, and South-East Asia countries. Much of this work was carried out in collaboration with the International Planned Parenthood Federation (IPPF). On the basis of these programmes, guidelines for health services research on adolescent reproductive health are being prepared.
Nutrition Malnutrition is recognized as one of the most serious problems in the world today, and the situation in Africa in particular has deteriorated. A sustained improvement in the nutritional status of populations will not be achieved in isolation from socioeconomic development, including a more equitable distribution of products. Thus the health sector alone cannot be expected to correct the basic causes of malnutrition. However, in addition to the impact that nutritional work can have at primary health care level, the health sector can provide information on the extent and nature of malnutrition as a spur to multisectoral action. During 198o-198I WHO deployed its efforts in this direction. In Africa, for example, it participated in the joint F AOJWHOJOAU Regional Food and Nutrition Commission, which, with ECA, is testing new approaches. Other regions also collaborated in multisectoral efforts to develop and implement adequate food and nutrition policies. 6.41
1 Falkner, F., ed. Prevention in childhood of health problems in adHit life. Geneva, World Health Organization, 1980.
59
THE WORK OF WHO, 198o-I981
6.42 An Expert Committee on the Role of the Health Sector in Food and Nutrition met in I 980 1 to reassess the contribution of the health sector to the fight against malnutrition, both through its direct work and in collaboration with other sectors. Following extensive analysis of the situation in a number of countries, a meeting (Dacca, December 198o) defined the structure and functions of central-level nutrition units within ministries of health. In several regions, e.g., South-East Asia, analyses of the nutrition component of primary health care were carried out. 6.43 Without political will and a new approach to the production, storage, and distribution of food, the health machinery cannot go beyond certain limits. Yet sound nutrition is paramount for health, and the synergistic effects of malnutrition and infections are particularly serious for infants and young children. WHO's main concern in I98o-1981 was therefore to ensure the proper integration of nutrition within primary health care, which offers unique opportunities for improving nutritional status, and to develop the related components of primary health care-maternal and child health/family planning, water supply and sanitation, immunization, and disease control, particularly In relation to diarrhoeal diseases. 6.44 The role of community-level or primary health care workers as a crucial element in nutrition work makes their training and supervision particularly important. A manual for the training of such workers was published 2 after four years of preparation involving nutrition specialists and teachers from institutions in all regions and including field testing. It contains a methodology for
tratning that can be adapted to local situations and covers the basic content of nutrition work as part of primary health care. Training in nutrition was supported through educational programmes, e.g., in the Americas, as part of the programmes of the Caribbean Food and Nutrition Institute and the Institute of Nutrition of Central America and Panama (IN CAP); and in Africa at the Regional Health Development Centre (Cotonou) and the Pan African Development Institute (Douala, United Republic of Cameroon). In the latter Region, a network of national centres for research and training in nutrition was established.
Child nutrition 6.45 Attention focused on the nutritional status of pregnant and lactating women, and on feeding patterns in young children. As epidemiological evidence clearly shows, it is the under-threes who suffer most acutely from malnutrition, especially during the weaning period; this is not only the critical period in terms of morbidity, mortality, and long-term consequences but the stage at which proper dietary and feeding practices must be established if lasting improvements are to be made. 6.46 A consultation on child nutrition in primary health care (New Delhi, February I 98 I) reviewed activities and identified needs for operational resarch. In Africa, the Americas, and South-East Asia assessments of regional needs in research were made and plans developed. Studies were conducted in Congo on the incorporation of child nutrition into rural health programmes, and in Upper V alta on nutritional status and diet in young children. In Colombia, determinants of feeding practices for infants and young children were studied, including opportunities for and
1 2
WHO Techmcal Report Series, No. 667, 1981.
World Health Orgamzatlon. Gmdelmes jur tratnii(R commumty health workers m nu!rttion. Geneva, 198 I (WH() Offset Publication No. 59).
Go
FAMILY HEALTH
constraints on improvement. INCAP, in collaboration with the child nutrition agency of Guatemala, instituted a system for the early diagnosis, prevention, and correction of malnutrition in children or pregnant women in poor urban areas; it includes community participation and coordination with local primary health care services. In the Eastern Mediterranean similar studies were s_upported in Democratic Yemen, Egypt, and Pakistan. In the Western Pacific a study was carried out in Papua New Guinea on beliefs and attitudes of mothers regarding the feeding of infants and young children. In the South-East Asia Region studies on child nutrition were initiated in all countries. 6.4 7 One of the questions to be answered by certain of the above studies was how available resources, including local foods, can best be used for combating malnutrition, particularly as concerns weaning, one of the key areas in the WHO programme on infant and young child nutrition. In I 98 I the Health Assembly (resolution WHA34.2.3) asked for a report on the nutritional value and safety of products specifically intended for infant and young child feeding, and this was prepared after a meeting on the subject (October I 98 I). 6.48 Since the work in I 97 I of a Joint FAOfWHO Expert Committee on Energy and Protein Requirements 1 new information has become available on the specific requirements of infants and young children, and a joint FAO/WHO/United Nations University consultation met in I98I to evaluate it. In the same year WHO published a manual2 on treatment and rehabilitation in cases of severe protein-energy malnutrition, for use by workers in health centres.
Surveillance of nutritional status 6.49 Methodological aspects of nutritional surveillance were further developed. Collaboration continued with the Tanzanian Food and Nutrition Centre in setting up a trial community-based surveillance system in the Iringa district, and with INCAP in the retrospective identification of indicators of nutritional status and their field testing. There was collaboration with the United Nations Research Institute for Social Development on the inclusion of indicators of nutritional status in its project for measurement of social change at local level in southern India. To review experience since the F AO/ UNICEF/WHO Joint Expert Committee on Methodology of Nutritional Surveillance met in I 97 5, 3 an international workshop was organized.(Cali, Colombia, I98I) on behalf of the ACC Subcommittee on Nutrition and was attended by more than 6o participants from five WHO regions. Another workshop--on nutrition monitoring and evaluation-was organized in the South-East Asia Region. 6. 5o The collection of published data on anthropometric indicators of health and nutritional status was started. A simple infant-length measuring board that could be constructed at village level was developed in collaboration with the Appropriate Health Resources and Technologies Action Group.
Specific nutritional deficiencies 6. 5I Technologies exist for the control of certain specific nutritional deficiencies and WHO endeavoured to ensure that they were used effectively. 6. 52. Together with UNICEF and the World Food Council, control programmes
WHO Technical Report Series, No. 522, I973· World Health Organization. The treatment and management of severe protein-energy malnutrition. Geneva, I 98 I. I 2
3
WHO Technical Report Series, No. 593, 1976.
6I
THE WORK OF WHO, r98o-r98r
for endemic goitre were promoted in countries where, together with endemic cretinism, it is a major public health problem (several countries of Africa and Asia). Work was carried out with UNIDO in a number of African countries to determine the feasibility of salt iodization as a control measure. 6. 53 Work on xerophthalmia included identification of the countries where the disease is prevalent. Very little information is available for the Eastern Mediterranean and African Regions. Reports established in collaboration with USAID indicate that in some countries the prevalence has hitherto been underestimated, and control programmes were planned. Research needs were identified and priorities for WHO studies were recommended by a consultation (Manila, 1980). 6. 54 Cooperation continued with the International Vitamin A Consultative Group, (IV ACG) of which WHO is a member, to develop and coordinate control activities. In addition to a meeting held in Cebu (Philippines), a joint WHO/UNICEF/USAID/ Helen Keller International/IV ACG meeting reviewed progress in the institution of measures to control vitamin A deficiency and xerophthalmia (Jakarta, October 198o).l Programmes for fortification of sugar with vitamin A were evaluated in several Central American countries. Ampoules containing o.o 55 g of water-miscible retinol palmitate for intramuscular injection were provided free of charge to all countries that requested them. 6. 55 Applied research on nutritional anaemia centred on practical control measures. A simple methodology for screening and models for the fortification of food with iron were developed. Studies on the feasibility and
the effectiveness of fortification schemes were carried out on sugar (Guatemala) and fish sauce (Thailand). Experience in several countries shows that the iron preparations at present distributed have a number of sideeffects that jeopardize the success of control programmes; field trials were therefore conducted, in Indonesia and the Philippines, to test new preparations. 6. 56 Two meetings of the International Nutritional Anaemia Consultative Group were held, in Bangkok and Santiago (Chile), to ensure coordinated activities. 6. 57 WHO is emphasizing the importance of controlling nutritional anaemia, which contributes significantly to maternal morbidity and mortality and is estimated to affect nearly two-thirds of pregnant and onehalf of non-pregnant women in developing countries. 6. 58 In reappralSlng its nutrition programmes during 198o-1981 WHO clearly recognized that their impact would remain inadequate, given present resources. While there has been a promising reorientation in approach, much more is required in the way of large-scale action at country level. A fiveyear plan was developed with UNICEF, in close collaboration with several other agencies, as a step towards meeting these needs.
***
Health education 6.59 The Declaration of Alma-Ata (1978), by emphasizing the need for individual and community participation, gave a new meaning and direction to the practice of health education. The dynamic definition of health education would now be: a process to promote a situation in which people want to be healthy, know how to achieve that wish, do what they can individually or collectively,
1
WHO Technical Report Series, No. 672, 1982.
FAMILY HEALTH
and seek help when needed. As distinct from the paternalistic approach of the past, the new slant requires people's active, voluntary, and sustained involvement in their own health care, in partnership with the providers of health services. It also presupposes a symbiosis of health education and information, with links between the mass communications media, political opinion-makers, health educators, community development workers, and the various community-oriented organizations at all levels. Communication has to be intensified, evolving between the different levels rather than filtering down from the top.
Self-care Jself-help 6.6I Health education has traditionally been associated with disease prevention but two emerging themes are self-care and health promotion. The European Region embarked on a radically new programme based on activities in health promotion, prevention, and care that can be carried out by the layman. Studies are under way to explore health promotion through sport and creative leisure activities. 6.6z All regions concerned themselves with health education in family health. In the Americas it was included in I 8 national maternal and child health programmes. In the Western Pacific a special effort was made in relation to intersectoral community development, including the involvement of women's groups (Malaysia, the Philippines, the Republic of Korea, and seven countries in the South Pacific).
6.6o In I98o-I98I WHO's programmes were geared to reorienting health education in this way, within primary health care. In the African Region, work in I 7 countries emphasized inter alia the organization of community awareness campaigns and the creation of village health committees; a regional meeting was held on this subject (Dakar, February I98I). In the Americas, community health education was the topic of the Technical Discussions held during the Regional Committee in I98o; studies were made in 23 countries to determine the present status of health education and indicate new strategies and techniques. In the Eastern Mediterranean Region, new approaches to health education were made in Lebanon, Pakistan, and Yemen. Community participation was the object of several activities in the Western Pacific Region-in relation for example to leprosy/ tuberculosis control (throughout the Region), development of water supply and sanitation activities (Kiribati), and malaria control (Papua New Guinea). Communication strategies, including use of media facilities, were strengthened in the Cook Islands, the Lao People's Democratic Republic, Malaysia, the Philippines, Samoa, and the Solomon Islands. Radio broadcasts were used as a medium for health education in many African countries.
Sociocultural research 6.63 Increased attention was given to the sociocultural determinants of health and health behaviour. Intercountry meetings on research needs in this area were held in the South-East Asia and Western Pacific Regions; in the African Region cooperation was established with the International Institute for Social Studies. Studies in the United Republic of Tanzania focused on improving the distribution and use of antimalaria tablets. Applied social research in primary health care was carried out in Niger and the United Republic of Cameroon. In the Republic of Korea, research was directed towards determining patterns of communication and adoption of health practices.
Health education for children 6.64 In collaboration with USAID and the University of the West Indies, school
THE WORK OF WHO, 198o--198I
health curricula were reshaped in a number of Caribbean countries. Similar work was carried out in Africa (Benin, Botswana, Congo, Ghana, Guinea, Swaziland, Togo, the United Republic of Tanzania, and Zambia), in SouthEast Asia (India and Mongolia); and in the Western Pacific.
carried out in Bihar and Uttar Pradesh. Other activities took place in the context of the International Drinking Water Supply and Sanitation Decade. Collaboration continued with ILO, FAO, and UNESCO, especially in relation to family well-being in the context of rural development. UNFP A collaborated with WHO in providing support for more intensive family life education.
Training 6.65 Training in the health education aspects of primary health care was intensified in all regions by way of institutional support, workshops, seminars, etc. In South-East Asia an intercountry workshop was held with participants from Bangladesh, India, Indonesia, and Thailand; in the Western Pacific the focus was on training peripheral health and allied workers, e.g., in Kiribati, Papua New Guinea, the Solomon Islands, and Tuvalu. In Africa, the regional centres for health education (University oflbadan, Nigeria), health development (Cotonou), and training of health workers (Lome and Lagos) were also active in this direction. A practical manual for teaching the essentials of health education to primary health workers, prepared with WHO support by the Department of Preventive and Social Medicine, University of lbadan, was issued. (See also paragraphs I 2. 148-I 2. I 52.)
Special Programme of Research, Development and Research Training in Human Reproduction 6.67 The Special Programme is WHO's major resource for research in family planning, including infertility. In the Global Strategy for health for all by the year zooo, the special research programmes are seen as the "main instruments for promoting and coordinating the international research and development required for the successful implementation of the Strategy" and thus for supporting countries "in strengthening their capacities for organizing and conducting biomedical, behavioural and health systems research related to the implementation of their strategies" .1 6.68 Family planning was recognized in the Declaration of Alma-Ata as a basic component of primary health care, and the Special Programme's research activities are oriented to "the provision of guiding principles and training material for its delivery in the most efficient way through health infrastructures". 2
Involvement of other organizations 6.66 A number of United Nations agencies and nongovernmental organizations stepped up their work in health education and collaborated to increase the impact of programmes. Notable among the latter were the International Union for Health Education and the League of Red Cross Societies, which devised an interesting programme for primary health care. UNICEF and WHO worked together in several countries, e.g., in Nepal and India; an investigation of behavioural attitudes to rural water supply was
1 Global strategy for health for all by the year 2000. Geneva, World Health Organization, 1981 ("Health for All" Series, No. 3), part VIII, para. 12. 2 Op. cit. part VIII, para. 20.
FAMILY HEALTH
6.69 Through the Special Programme governments and scientists are able to collaborate in both research and institutionstrengthening; they jointly identify priorities, plan strategy, conduct activities, assure quality, and disseminate results. In 1981, So countries were involved, 54 of them developing countries. 6. 70 World efforts on service and psychosocial research in family planning, studies on the safety and efficacy of current methods of birth control, development of new methods, and research on infertility-all these are at present very limited. Apart from the WHO programme, they are concentrated in the United States of America and one or two other developed countries. As to institutionstrengthening in developing countries for service and biomedical research in family planning, it is virtually confined at international level to the Special Programme. 6. 71 A full report on the Special Programme's activities is published each year and widely disseminated. 1 The main trends in 198o-I981 are illustrated below.
6. 73 Community partiCipation. Research under the Special Programme is exploring how to involve the community in family planning in the primary health care contextas a whole and also through its particular elements, e.g., schoolteachers, housewives, local religious leaders, or practitioners of traditional medicine.
Health services research and psychosocial research 6. 7 z Research is increasingly used by governments to improve the availability and utilization of family planning services. This was reflected in the large number of requests for collaboration in the past two years. They related mainly to manpower for family planning in primary health care, integration of family planning with other activities, impact of services and of psychosocial factors on family planning practices, field trials of contraceptives, and definition in different communities of the need for services. 1 World Health Organization. Special Programme of Research, Development and Research Training in Human Reproduction: ninth annual report, Geneva, I 980; tenth annual report, Geneva, 198 I.
6. 74 The first phase of a study in two rural areas of Kenya, designed to enable the community to define its family planning needs and the type of services it desires, and to secure its participation in the provision of such care, showed clearly the conflict between (i) the high esteem in which fertility is held and (ii) the realization of the economic constraints that large families impose and of the health hazards of grand multiparity. Family planning to space pregnancies or avoid the dangers of grand multiparity was acceptable, whereas current slogans such as "two [or even four] children are enough" met with general laughter or incomprehension. The communities had been left in a state of confusion by the introduction of the concept of planning their families without any attention being given to other aspects of their lives. This had confirmed them in the opinion that family limitation was in the interest of "other people" with ulterior motives, not in their own interest.
6.75 Another factor which emerged was the acceptance within the family circle of extramarital children and of the children of other relatives, brought in to "fill out" the smaller families. These practices weaken the economic rationale for limiting family size, since the family that has adopted birth control merely spends more of its resources on other children. The need for group acceptance and group practice of family planning emerged very clearly from the studies and also the fact that the community, rather than the in-
THE WORK OF WHO, 198o-I981
dividual or the family, should be the target for information and education. 6. 76 Manpower training. To respond to the growing interest of governments in experimenting with the training, reorientation, and deployment of various members of the community and different categories of health personnel for family planning care, support was given to developing protocols for studies, preparing training manuals, elaborating post-training evaluation criteria, and evolving mechanisms for surveillance and supervision, in addition to the financial and technical support common to many parts of the programme. 6. 77 Educational material for tratntng nonmedical personnel in any culture to teach natural family planning methods was developed in the course of a three-year project and evaluated in six countries. This "learning package" deals with the two methods at present most widely practised-the ovulation method and the symptothermal. The package includes simple visual aids that can be used without any equipment and are suitable for teaching couples, groups, or individuals. 6. 78 One of the criticisms of health services research is that it is difficult to replicate at national level the findings of pilot studies. The national extension of two pilot studies (Thailand and Turkey) for training midwives or nurses to provide the clinical family planning services hitherto provided only by physicians is showing this criticism to be unfounded. In Thailand the pilot project showed that operating-room nurses could be trained to perform post-partum tubal ligations as competently as surgeons, and with equally low morbidity rates. In the national extension, in 3000 procedures the immediate complication rate (o. 2% ), the percentage of women satisfied with the result (99· 2% ), and the rates and types of complication detected at the six-week follow-up visit were highly 66
satisfactory and in line with the data reported · during the pilot project. 6.79 Integrated care. Resolution WHA3 1.37, which urged the Director-General to intensify health services research under the Special Programme, focused particularly on the role of such research in facilitating "the complete integration of services for fertility regulation into the primary health care systems of the countries concerned". Projects of this type were developed in India, Indonesia, Kenya, Peru, the Republic of Korea, and Sri Lanka. The most advanced of these--that in Sri Lanka-is testing two such integrated approaches in different regions of the country and comparing them with control areas that have normal government services. In one area midwives who normally provide maternal and child health services are involved in a streamlined management and referral system that enables them to provide family planning services as well. In the second area, midwives and district medical officers of health concerned with prevention are brought in to the same management process but are in addition provided with certain drugs for curative purposes. The setbacks encountered in this project exemplify the difficulties of conducting large-scale field research projects: an epidemic of cholera in one area, a typhoon in another, transfer of field staff and their replacement by inexperienced personnel, and power cuts affecting data processing. Nevertheless, the results of introducing the curative care package have already been so positive that a national conference on the restructuring of the health services (August 1981) recommended its inclusion on a national scale. 6.8o Health rationale for jami(y planning. Many countries have changed their legislation on family planning as a result of local studies showing the effect on mortality and morbidity, and the ensuing cost to health services, of lack of access to family planning
FAMILY HEALTH
services or failure to use them. Studies on illegal abortion were completed in Ankara, Ibadan (Nigeria), Kuala Lumpur, Caracas and Valencia (Venezuela). The cost of illegally induced abortion was found to be considerable both in human and in health services terms: of the hospitalized cases in Ibadan nearly one woman in twenty died, while in Ankara and Kuala Lumpur there was one death for every 2 5o such admissions. The cost of providing hospital beds, drugs, blood transfusions, and other scarce services for cases of illegally induced abortion was enormous, amounting to over one million dollars a year for the two cities in Venezuela alone. 6.81 Studies were carried out in Colombia, Egypt, Pakistan, and the Syrian Arab Republic 1 on the effects on maternal and child health of the timing, spacing and number of pregnancies, and of environmental and behavioural variables. As was the case with earlier WHO studies (in India, Iran, Lebanon, the Philippines, and Turkey) they showed the risk of poor pregnancy outcome to be lower for low parity groups at maternal ages 20-29 and for pregnancy intervals of 3-5 years. It is interesting to note that, although completed fertility ranged from 5.6live births in Colombia to 9· 1 in Egypt, the ideal family size as seen by the same women ranged from 3.2 to 6.5. 6.82 Institution-strengthening for health services and p!]chosocial research. The greatest single constraint on the development of services and psychosocial research in family planning continues to be the shortage of trained manpower, and governments are acutely aware of this. Research training courses held during the biennium are listed in Table 6-3-
Table 6.3 Courses in health services and psychosocial research in family planning, 1980-1981
Title of course and country from which trainees came Health services research in family planning (1980) India, Bangladesh, Egypt, Indonesia, Nepal, Republic of Korea, Thailand, Turkey Application of epidemiology to research in fertility regulation (1980) India, Kenya, Nepal, Sudan, Thailand, Turkey WHOIESCAP workshop on psychosocial research (1980) Bangladesh, China, India, Indonesia, Japan, Malaysia, Nepal, Pakistan, Papua New Guinea, Philippines, Republic of Korea, Singapore, Sri Lanka, Thailand Health services research in family planning (1980) Turkey Health services research in family planning (1981) Bangladesh, Bra2il, Egypt, India, Indonesia, Kenya, Nigeria, Sri Lanka, Tunisia, United Republic of Cameroon Application of epidemiology to research in fertility regulation (1981) Bangladesh, China, Colombia, Mexico, Thailand, Yugoslavia
Duration
3 weeks
6 months
2 weeks
2 months
3 weeks
6 months
Safety and efficacy of current methods of fertility regulation 6.83 Investigations on the safety and efficacy in developing countries of current methods of fertility regulation were conducted at the request of national authorities concerned at having to use, in their own population, birth control methods that had been tested only in developed countries. For some methods, e.g., pills and intrauterine devices, guidance was requested as to which preparation or device was best suited to the particular population. In other instances controversy in developed countries on the safety of certain products, e.g., the injectable depot-medroxyprogesterone acetate
I Omran, A.R. & Stllndley, C.C. Further studies on fami!J formation patterns and health. Geneva, World Health Organization, 1981.
THE WORK OF WHO, 198o-r98r
(DMPA), spilled over into the developing countries, which turned to the Special Programme for analysis of the situation and for further research. Some problems, particularly those relating to possible long-term effects such as cancer, are still of concern to developed as well as to developing countries. The Special Programme's research 6.84 in this direction represents the largest world effort to answer such questions as they relate to the population of the developing countries. It is conducted mainly through the network of WHO collaborating centres, using common protocols so that not only are data of immediate local relevance obtained but interpopulation comparisons can also be made and sufficiently large numbers of subjects can be accumulated to find an answer to the questions rapidly. Some examples of recent findings are given below. 6. 8 5 Oral contraceptives. A bewildering number of oral contraceptives are available: as many as 68 different ones were being marketed in I978, under 228 trade names. A comparative study was therefore conducted in I 2 countries to cover the commonly used range of dosages and combinations of progestogens and estrogens. Over 34 ooo cycles were observed in about 3000 women. Preparations containing 30 to 3 5 Jlg ethinylestradiol were found to be as effective as those containing the higher dose of 5o Jlg, but those containing 20 !lg could not be recommended. Discontinuation because of bleeding was more common with preparations containing norethisterone, and discontinuation because of nausea and vomiting with those containing norgestrel. The local "acceptability" of these two side-effects will have a bearing on the choice of preparations for national programmes. 6.86 For conditions such as malaria or other parasitic diseases that barely exist in developed countries, few data are available as 68
to possible interaction with contraceptive methods. Studies are continuing in areas where malaria and schistosomiasis are endemic, and studies on liver fluke infection have been completed. Clonorchis sinensis, for which there is no safe effective therapy, affects the biliary system and is widespread in Asia. Liver function was compared in infected and non-infected women using oral contraceptives or intrauterine devices; no significant differences were found after one year of pill use.
6.87 Intrauterine devices ( IU Ds ). There is also a wide variety of IUDs available-plain plastic, copper, or hormone-releasing-but little in the way of comparative clinical data, particularly from developing countries, to help in choosing the most appropriate type. National authorities sought guidance on the effectiveness of IUDs inserted immediately after delivery, and on their safety when inserted after an induced or a spontaneous abortion. More than I 3 ooo women participated in the studies on these questions, and by October I98I more than 2I7 ooo womanmonths of data had been collected in 22 countries.
6.88 In all the studies, the Copper T 22oC intrauterine device was found to be better than either the Lippes Loop or the Copper 7, pregnancy and medical removal rates being lower and continuation rates higher. IUD insertion following first-trimester induced or spontaneous abortion carried no greater risk of perforation or infection than if the device had been inserted during or immediately after the menses. IUD insertion following second-trimester abortion is not recommended however, in view of the high expulsion rates revealed by the studies. Insertion immediately after delivery was associated with even higher expulsion rates.
FAMILY HEALTH
6.89 I'!}ectable contraceptives. Two longacting progestogen preparations, depotmedroxyprogesterone acetate (DMP A) and norethisterone enantate (NET-EN), are used widely throughout the world. Clinical and epidemiological studies on their safety and effectiveness were conducted and also field trials on their provision by health services. DMP A has for a number of years been the subject of controversy and on two occasions the Special Programme has issued guidelines for national authorities on its use. 6.90 The controversy was further fuelled in the latter part of 1980 by an article in a United States consumer magazine which gave a somewhat one-sided account of adverse effects of DMP A. This led to renewed demands for guidance from various governments, UNFP A, and other technical cooperation agencies. Guidelines were therefore prepared at a meeting (October 1981) bringing together members of the programme's Toxicology Review Panel, representatives of the drug regulatory agencies of India, Mexico, Sweden, Thailand, the United Kingdom, and the United States of America, representatives of the manufacturers of these products, and scientists working in this field.l The meeting found no reason to recommend discontinuing the provision of either DMP A or NET-EN. The guidelines are being widely distributed. z 6.91 One finding from WHO studies in Mexico and Thailand that has considerable health, cost, and acceptability implications is that the three-monthly dose of DMP A at present administered- I 5o mg-may be larger than is required to achieve protection against pregnancy in the smalier women of 1 Facts about injectable contraceptives: memorandum from a WHO meeting. B11/letin of the World Health Organization, 6o (2), 1982. 2 Injectable contraceptives: technical and safety aspects. Geneva, World Health Organization, 1982 (WHO Offset Publication No. 65).
these developing countries. The larger dose may moreover account for some of DMPA's undesirable side-effects in these women. Studies on a xoo mg dosage will now be conducted.
Female sterilization. Some of the 6.92 many procedures for female sterilization require only the most basic general surgical and anaesthetic skills and facilities; others demand special skills and relatively complex equipment. In a study of the various procedures in xo countries, minilaparotomy was found to be the best suited to primary health care since it requires only minimal surgical skills and basic facilities.
New methods of fertility regulation 6.93 The need for improved and new methods of fertility regulation was repeatedly stressed during the biennium by national authorities and in international meetingsfor example, by the Parliamentary Conference on Population and Development in Africa (July 1981), the International Conference on Family Planning in the 198os (Jakarta, April 1981), and the United Nations Economic and Social Council (May 1981), which in resolution 1981/28 urged "international organizations, including the United Nations Fund for Population Activities and the World Health Organization, and national Governments to give high priority to research on human reproduction and the development of more acceptable, safer, and more effective means of fertility regulation". 6.94 The development of better methods of fertility control has always received high priority within the Special Programme, which has shown its ability to marshal from both developed and developing countries the resources required for the many types of research involved-from basic reproductive biology through chemistry and bioengineer-
ing to animal toxicology, clinical studies and product development. Such research and development are however very costly, and owing to funding constraints fewer of the promising leads are being pursued than merit it. 6.95 Some of the products under development are nearing the stage at which they will be available to family planning programmes, some are at an earlier stage of clinical assessment, while others are still at the stage of studies in animals. 6.96 Intrauterine devices. The steroidreleasing IUD developed by WHO has been shown to reduce the bleeding associated with currently used IUDs, which is a main reason for women discontinuing their use and which is demonstrated by WHO studies to be a health hazard for anaemic women in developing countries. The WHO device has an intended life-span of 10 or more years, and during the biennium it successfully completed the clinical trials in small numbers of women that precede large-scale clinical testing. 6.97 Vaginal rings. At a similar stage of development is the WHO steroid-releasing vaginal ring. Its advantage over the IUD is that a woman can insert and remove the ring herself; and over barrier methods, that it can be left in place for periods of up to three months. WHO studies have shown it to be acceptable in different cultural groups. Machinery for mass production is being developed by the Special Programme. 6.98 Female sterilization. A method that has reached an advanced state of clinical testing is a non-surgical method of female sterilization-chemical occlusion of the fallopian tubes-that can be performed by either physicians or non-physicians on an outpatient basis. If its final testing proves successful it will represent an important logistic and
economic advance for family planning programmes in those developing countries that provide sterilization services. 6.99 Prostaglandins. Similarly, drugs for the termination of pregnancy have reached the final stage of testing. During the biennium, a number of clinical trials were completed on prostaglandin analogues, which have a high degree of effectiveness and relatively minor side-effects. 6.100 Determination of the fertile period. Technical difficulties were encountered in the development of simple methods to enable women themselves to predict the fertile phase of the menstrual cycle. Such methods should permit a reduction of the period of abstinence required by present methods. The two main lines pursued were: (i) chemical tests in the form of simple kits for home use, and (ii) automated devices for taking, recording, and interpreting basal body temperature. From the start of work on do-it-yourself kits, it was understood that alternative laboratory methods, too sophisticated for home use but easier, quicker, safer, and less expensive than radioimmunoassays, would be an intermediate step in their development; this is well on its way to being accomplished. The methods developed are a significant improvement on existing methods for measuring plasma hormones, especially in places or conditions where blood sampling is not acceptable or where long-term monitoring is desired. They have already been adopted by more than half the collaborating centres working with the programme, but methodological constraints make it unlikely that onestep methods suitable for home use can be developed within the next few years. 6.101 However, an automated electronic device for detecting ovulation and the postovulatory infertile phase of the menstrual cycle is at the prototype stage. There is great public interest in it: in 1981 reports appeared
FAMILY HEALTH
in the press all over the world, the terms "sexometer" and "intelligent thermometer" being used to describe the device. 6. I02. ltljectable contraceptives. The demand remains great from developing countries for injectable or implantable contraceptives that would have significantly fewer side-effects than the two injectable compounds at present available and would provide greater choice in terms of duration of action. Efforts were concentrated in three areas: development of biodegradable implants with a one-year lifespan, synthesis of new long-acting compounds, and improvement of monthly injectable preparations. 6. I03 The biodegradable implant, a way of delivering a drug at a constant rate for a long period of time, involves highly innovative polymer chemistry. Local irritation problems were, however, encountered in the first human trials and further animal studies are required. Synthesis and biological screening were completed of more than 2.00 new injectable compounds produced by university laboratories in I 2. countries, of which seven were developing countries. Patents have been applied for in the case of the two most promising compounds; for the more promising of these, pre-clinical toxicological studies are beginning. 6. I04 Plants for fertility regulation. A systematic study of plants used for fertility regulation aims at exploring their merits scientifically in order both to discover new compounds or extracts and to discourage ineffective or harmful practices. At present the emphasis is on identifying agents that could be taken if a period is missed or immediately after coitus. Some work has started on orally active agents for men that ~ould inhibit spermatogenesis or sperm maturation. A computerized data base has been established for selection of the plants to be tested. Over Ioo plants have been pro7I
cured, I46 different extracts prepared, and 175 bioassays performed. In addition, about I4 extracts have been fractionated and significant progress has been made in elucidating the structure of two promising pure compounds. 6. I05 Newer approaches. A number of other leads are being followed that have not yet reached the stage of clinical testing. The aim in each case is simplicity of use in the primary health care setting. They include drugs that could be taken immediately after intercourse; when a woman notices that her period is late; or regularly once a month. All three approaches are intended to limit bodyexposure to drugs and obviate the need for daily pill-taking. 6. I o6 Birth control vaccines would also make an important contribution to family planning programmes. They would provide long-term protection, could be administered by paramedical personnel at low cost and, in view of the acceptance of vaccination in general in developing countries, might be a popular method, particularly since they are not likely to disrupt the menstrual cycle or cause the metabolic disturbances associated with most currently used drugs. Work on a vaccine is well advanced and should reach clinical testing in I982..
6. I07 Research on methods of male fertility control has been conducted mainly through the collaborating centres in China. A major part of it was concerned with chemical work and animal studies on gossypol, a substance derived from cotton-seed oil.
Research on infertility 6. I o8 Research on infertility is of particular interest to countries in the African Region. A simplified questionnaire has been prepared, the answers to which will give a
reasonable estimate of the prevalence of primary and secondary infertility, pregnancy wastage, and infant and child mortality. It consists of about 25 to 30 questions, to be answered by community samples of 300 to 5oo couples, and is designed to be processed by hand under field conditions. The original prototypes were developed, pre-tested, and modified after field testing in rural areas of Nigeria, Sudan, and the United Republic of Cameroon. In the surveys of primary and secondary infertility conducted, some very high rates of infertility were found, e.g., 40% of women aged 30 to 44 in a Sudanese population showed primary infertility. Wide variation was also found in different population groups in the same country. 6. I09 The techniques used for the investigation of the infertile couple vary widely from one centre to another. In some cases the male partner is never examined at all, and in many centres urologists have little interest in male infertility. This has resulted in incorrect diagnoses, inappropriate treatment, and erroneous comparisons of the frequencies of various forms of infertility and of results of treatment. The WHO manual for the investigation and diagnosis of the infertile couple is now being used in the 34 centres taking part in research on infertility. A total of 2 53 7 couples have to date entered the standardized study. Other studies are evaluating com6. I I o monly used diagnostic and therapeutic procedures, several of which appear of questionable value, and are developing less expensive and more appropriate methods. Others are determining the etiology in the large proportion of infertile cases previously classified as of unknown cause. Institution-strengthening
research institutions was reflected in the greater emphasis placed during the biennium on this part of the programme. There was an increase in the number of requests by Member States for institution-strengthening, and a concomitant rise in the related expenditure. 6. I I 2 The distinction frequently made between institution-strengthening and research is in fact a false dichotomy as regards the Special Programme, whose fundamental principle and practice it has been to strengthen institutions through research. Collaboration involves, from the very outset, developing a research plan, assisting in the elaboration of research projects, introducing the required research training and purchase of equipment, and helping to establish methods and implement projects by regular visits to the institution. At the same time scientists from the institutions take part in the collaborative research of task forces and in the planning and reviewing activities of steering committees. 6. I I 3 Although on the one hand institution-strengthening activities are localized and aim at achieving national self-reliance in research, on the other hand they mobilize the capabilities of many countries for both research training and consultant expertise and are thus interregional. This dual character is also evident in the outcome of institutionstrengthening: in the immediate it provides resources for the solution of research problems of local importance, yet at the same time it promotes collaboration among scientists of different countries, interests the developed countries in the problems of the developing countries, and increases the world's pool of knowledge and technology. The following paragraphs give only a few examples of activities in the past two years. 6.1t4 African Region. Activities have hitherto been limited, since for most of the countries in the Region research in human
6. I I I The priority given by all WHO policy-making bodies to the strengthening of
FAMILY HEALTH
reproduction was not a high priority. However, attitudes are changing rapidly. A study group on human reproduction met (Madagascar, June I 9 8 I) to develop research activities in conjunction with the Special Programme and to link research to training and service activities.
psychosocial research both in Bangkok and in rural areas; it also acts as a base for a national scheme for standardizing clinical chemistry methods and provides courses on advances in family planning and methodology of clinical research for teachers in medical schools and public health workers. 6. I I9 European Region. The collaborating centres of this Region played an important role in strengthening the institutions of developing countries by providing training and consultants. In the USSR the Moscow research and training centre in human reproduction has begun to strengthen research institutes in Tashkent and Erevan. The collaborating centre for research and research training on service aspects of family planning, Ankara, has served to expand significantly health services research on family planning in Turkey and to train health scientists in this area.
6. I I 5 The major project in Africa under the Special Programme is the Nairobi centre for research in reproduction, which is conducting research on clinical problems of pregnancy, infertility, and family planning and, in local animal species, on models for research in human reproduction. 6. u6 Region of the Americas. A new collaborating centre for clinical research in human reproduction was designated in Colombia. The collaborating centres in Cuba and Mexico are developing other centres in their own countries. One of the hoped-for outcomes of institution-strengthening is the multiplier effect by which centres, once strengthened, take on similar responsibilities for other institutions. 6.II7 South-East Asia Region. In India, institution-strengthening focused mainly on three key national institutions-in Bombay, Chandigarh, and New Delhi-which were expected to have a multiplier effect at national level. The Special Programme's activities have now been extended to the network of centres of the Indian Council of Medical Research, which has restructured its administrative mechanisms relating to research in fertility regulation, using the Special Programme as a model.
6. I 20 Eastern Mediterranean Region. A research centre for the national family planning programme was established in Tunis. The Special Programme collaborated in building up its laboratories and in training personnel in laboratory and epidemiological methods. 6. I 2 I Western Pacific Region. During the biennium there was collaboration with China in the development of two large institutes for research in family planning, one in Shanghai and the other (UNFP A-funded) in Beijing. In I98I, and on a smaller scale, support was given to institutes in Nanjing and Wuhan. Research training, although concentrating mainly on the Beijing and Shanghai institutes, also included scientists from other parts of China. Some 58 research training or "visiting scientist" grants 1 were awarded, usually coupled with intensive language tuition. Three national courses were held in China on radioimmunoassay techniques and on male 1
6. I I 8 The two collaborating centres in Bangkok are a good illustration of how academic institutions can work closely with national authorities by giving advice and conducting research on problems encountered in the family planning programme. One of them is active in health services and 73
See paras 4.8-4.9·
THE WORK OF WHO, 198o-198I
reproduction, as well as a major symposium on advances in fertility regulation, the proceedings of which appeared in Chinese and English. 6. I 22 Research training grants. Some 2 5o research training and "visiting scientist" grants were awarded during I98o-I98I, nearly twice the number awarded in the previous biennium; they went mainly to staff of the institutions that are being built up in collaboration with the Special Programme, in order to achieve research groups of a viable size rather than disperse available resources. 6. I 2 3 The 20 research training courses organized (nearly three times as many as in the previous biennium) covered health services and psychosocial research, epidemiology, pharmacology, andrology, and laboratory techniques. Eight of them were held in the collaborating centres of developing countries. 6. I 24 Standardization and quality control. To ensure comparability of results in multicentre trials and other collaborative studies, a major effort was made in the standardization and quality control of laboratory procedures. This has also had a significant institutionstrengthening impact, since the provision of well-validated methodologies, reagents, and the means for assessing assay performance enabled many investigators to pursue research projects that would otherwise have been difficult to undertake. There are now I42 laboratories, in 48 countries, participating in these schemes.
exchange of information on agencies' activities and plans, identification of possible areas of overlap or neglect, and discussion of obstacles to progress.
Dissemination of information 6. I 26 In addition to providing guidelines, responding to numerous requests for information, and issuing manuals, as mentioned above, the Special Programme undertook a variety of activities to disseminate information to policy-makers, programme administrators, providers of services, scientists, and the general public. Twelve symposia or seminars were organized (in China, Colombia, India, Israel, Malaysia, the Republic of Korea, and Thailand) to present an overview of recent advances in research on fertility regulation or to focus on the results of studies in specific areas, e.g., female sterilization, regulation of male fertility, plantderived products, prostaglandins, immunological approaches to fertility regulation, termination of pregnancy, synthesis of new compounds, psychosocial aspects of family planning, and infertility.
6.127 The main channel for dissemination to the scientific community of the results of studies supported by the Special Programme is through articles in professional journals, of which over 700 appeared in the biennium. Access to the scientific literature is still a problem in many countries, and journal subscriptions were provided to 8 5 institutions in developing countries.
Coordination 6. I 2 5 In its coordinating capacity the Special Programme brought together on three occasions the main international, national, and nongovernmental agencies conducting or directly supporting research in family planning. The meetings focused on biomedical, health services and psychosocial research. They provided the opportunity for 74
Funding 6.128 The Special Programme is largely financed by voluntary contributions. For I98o-I98I the donors were Australia, China, Cuba, Denmark, Finland, the Federal Republic of Germany, India, the Netherlands, Nigeria, Norway, Sweden, Thailand, the United Kingdom, the United States of America, and UNFP A.
Chapter 7
Mental Health
GLOBAL Coordinating Group for Mental Health at its fourth session (New Delhi, October 1981) gave particular attention to evaluating the progress achieved and the problems encountered during the period covered by the Sixth General Programme of Work (1978-1983) and agreed on the adjustments necessary to ensure a smooth transition into the Seventh General Programme. The scope of the mental health programme 1 was considered and specific recommendations for action were made with reference to the prevention and treatment of mental and neurological disorders; alcohol and drugrelated problems; better use of mental health knowledge in improving general health care; and prevention of the untoward psychological consequences of socioeconomic change. Two regional advisory groups on mental health also met in 1981, those for the South-East Asia and European Regions. 7.1
THE
(Brazil, Colombia, Egypt, India, the Philippines, Senegal, and Sudan) continued a collaborative study on ways and means of incorporating mental health components into primary health care. Representatives from the countries met twice during 198o-1981 to consider the results of repeat observations demonstrating that it is possible for staff with only simple training to recognize and deal efficiently at primary health care level with serious mental disorders, and that attitudes of staff and the community can be positively influenced through well-defined intervention.
Development of community health services 7.z At national level, mental health was included by a number of countries in their national strategies for achieving health for all by the year zooo. Teams from seven countries I
World Health Organization. Social dimensions for
mental health. Geneva, 1 98 r.
7. 3 The report of the study was presented to the Study Group on Mental Health Care in Developing Countries (Geneva, 1981), which concluded that recent evaluative research had produced evidence of the feasibility of introducing mental health care into primary health care settings. The Study Group recommended ways of doing so, and identified the following as priority subjects for research: psychosocial factors affecting health care; management of common disorders; protection and promotion of mental life; and evaluation of the general health services' contribution to mental health care. The Study Group also made recommendations on the role that WHO can play in facilitating developments at country level. The information gained in the study was widely 75
THE WORK OF WHO, 198o-r98r
disseminated through publications, national seminars, and professional contacts. 7·4 In the African Region, a project of technical cooperation in mental health in southern African countries, initiated in I977 at the request of the five countries forming the African Mental Health Action Group (Botswana, Rwanda, Swaziland, the United Republic of Tanzania, and Zambia) made considerable progress during I98o-I981. The Action Group, which meets annually in Geneva during the Health Assembly, was joined by two more countries, Kenya and Lesotho; its meetings during the biennium were attended by representatives from neighbouring countries and from developed countries supporting this action. 7. 5 The problems pinpointed by these countries include the psychosocial effects of population uprooting and movement; disrupted family life; adverse effects of urbanization; delinquency; alcohol and drug abuse; and mental retardation in children. Since the main constraint in dealing with these problems is the lack of trained personnel at all levels, activities in I98o-I98I concentrated on postbasic training. Workshops were organized in the United Republic of Tanzania (I98o) and in Lesotho (I98I); an analytical report was prepared on selection criteria for the intake of nurse trainees and on the status of training institutes; and recommendations were made for strengthening the postbasic training of nurses in mental health. Manuals were prepared and translated into Swahili, and other material was tried out in several countries. For example, flow-charts (paragraph I 2. I 8) for the diagnosis and management of common mental disorders were prepared and field-tested in Lesotho mainly for their use by general nurses, and some modifications were made for this specific setting. The training capability of the WHO collaborating centre for research and training in mental health, in Aro (Abeokuta,
Nigeria), was strengthened with a view to using this centre inter alia for the postbasic training of nurses from other parts of Africa. The countries of the Action Group 7.6 sent participants to the meeting in Zambia which considered the first phase of a research project on community response to alcoholrelated problems (see paragraph 7·37)· This provided an opportunity for a detailed discussion of ways and means of carrying out similar work in their own countries. 7· 7 A review of the supply, distribution, monitoring and control of psychotropic drugs in Botswana, Lesotho, Swaziland, and Zambia led to recommendations on measures to overcome the difficulties encountered in obtaining drugs, e.g., bulk purchasing to reduce costs. 7.8 National coordinating groups were established or strengthened in the countries of the Action Group, involving all sectors concerned with the implementation of national plans (for example, health, labour, education, justice, and internal affairs). Other organizations in the United Nations system, e.g., UNICEF, were approached with a view to including a mental health component in their projects in the countries of the Group. The financial and technical support of countries such as Belgium, Denmark, and Norway is an important element in this project, for which further financial support is being sought. 7·9 In the Region of the Americas, a working group (Washington, March I98o), with participants from Bolivia, Brazil, Colombia, Guatemala, Honduras, Panama, Peru, the United States, and Venezuela, discussed the functions of the primary health worker as a mental health agent and made recommendations on training material. A simple manual on mental health for the primary health worker was drafted in I 98 I
MENTAL HEALTH
and will be field-tested in a rural sector adjacent to the city of Cali (Colombia). 7· IO The Organization cooperated in planning and organizing community services for the care and rehabilitation of chronic mental patients in Barbados, Colombia, the Dominican Republic, Grenada, Saint Vincent and the Grenadines, and the United States of America. A seminar on mental health at the primary level of health care was held in Chile and its recommendations served as a basis for the planning of a national programme. (For training programmes in the Americas, see paragraph I2.I53·) 7· I I In the European Region, a workshop on mental health planning for the city of Rotterdam (August I98o) provided an opportunity for introducing in a practical setting the principles and objectives of community mental health care developed by the Region over the past decade. A similar activity was the consultation on architecture and mental health organized at the WHO collaborating centre for psychosocial factors and health, Brussels. (For training programmes in the European Region, see paragraph I2.154.) 7. I 2 In the Eastern Mediterranean Region, the results of studies in Egypt and Sudan on the extension of mental health care, and in Kuwait on the monitoring of needs, were appraised; they were considered as making an important contribution to the provision of wider coverage and the improvement of the quality of care. The Region has made sustained efforts to develop training programmes in this field to equip general health workers with the necessary knowledge and skills for providing optimal mental health care at the primary health care level. 7. I 3 Current collaborative work to promote training in psychological medicine has enabled some countries of the Region, par77
ticularly Saudi Arabia, to establish a countrywide network of psychiatric services and to move from isolated, insitution-based care towards community-oriented services. 7· I4 In the Western Pacific, collaborative activities with China were developed in I98o-I981. They concentrated on training (see paragraph I 2. I 55) and on preparations for a major epidemiological investigation of mental health problems in the country. 7·15 Study missions enabled Chinese psychiatrists to visit WHO collaborating centres in Europe (the Netherlands, Switzerland, the United Kingdom, and Yugoslavia). Fellowships were awarded. Four institutes, in Beijing and Shanghai, were designated as WHO collaborating centres for research and training in mental health and the neurosciences. Plans were made for the designation of other centres.
Safe use of narcotic and psychotropic substances 7. I 6 In the context of the Convention on Psychotropic Substances, I97I, and the Single Convention on Narcotic Drugs, I96I, the evaluation of the benefit/risk ratio of narcotic and psychotropic drugs continued. The United Nations Commission on Narcotic Drugs (February I98I) reviewed WHO's recommendations on the control of anorectic drugs and agreed to include benzphetamine, mazindol, phendimetrazine, and phentermine in the schedules of the I97I Convention. The Commission also approved the termination of the exemption of certain preparations containing a controlled psychotropic substance, submitted in notifications by the Governments of Bulgaria and Mexico. 7. I 7 Two groups of psychotmpic substances-benzodiazepines, and opiate agonists and antagonists-were reviewed in
THE WORK OF WHO, 198o-198I I 98 I, resulting in specific recommendations concerning the level of control of these groups.
7.I8 WHO continued to develop the methodology for the scheduling of psychotropic substances. The Expert Committee on Implementation of the Convention on Psychotropic Substances 1 reviewed the methodology for assessing the public health and social problems associated with the use of psychotropic drugs.
plant origin, and to support such programmes by the development of appropriate guidelines". A project was initiated in six countries (Kuwait, Malaysia, Morocco, Nigeria, Panama, and Thailand) to gather the information required for formulating such guidelines, which should enable countries to derive maximum benefit from psychoactive drugs with minimum harm. The Government of the Netherlands, together with UNFDAC, has given financial support to this programme.
7· I9 The role of drugs in modifying the behaviour of drivers was reviewed in collaboration with the National Institute for Drug Abuse (USA). 7.20 Four seminars (one national, two regional, and one interregional) were held on the subject of safe use of narcotic and psychotropic substances, involving participants from about 40 developing countries.
Psychosocial aspects of health promotion Work in this area focused on: (I) the mental health sequelae of social and economic processes ; ( 2) the psychosocial aspects of public health programmes; (3) social support systems relevant to health, e.g., self-help and mutual aid schemes; (4) modification of lifestyles and the prevention of disease; and (5) training material for the primary health care worker. 7.2 3
7. 2 I In the Western Pacific Region, a workshop on psychotropic drugs was convened (Manila, August I98o). It concluded that, although certain countries of the Region already applied controls in keeping with the I97I Convention on Psychotropic Substances and provided information on an informal basis, all countries should work towards proper ratification of the Convention; and, further, that all countries should review combination drugs in the spirit of that Convention. 7.22
The Thirty-third World Health Assembly (resolution WHA33.27) asked WHO "to promote the initiation and strengthening of national and international programmes for the assessment, scheduling, control and appropriate use of narcotic and psychotropic substances, including those of
One example of collaborative research to assess the psychosocial implications of public health action was the multicentre study on the p!]chosomatic sequelae of female sterilization carried out under family planning programmes. Some 2000 women in five different countries were followed up for a year after tubal ligation. The aim was to identify those at risk of developing psychosomatic symptoms, assess the need for specific pre-operation psychological counselling, and evaluate the psychosocial effects of this form of family planning on the woman and on the family unit. 7.24 7.25 The effect that modification of community attitudes or behaviour may have on the
t
WHO Technical Report Series, No. 656, 1981.
prevention of various diseases or disorders was examined by a working group, which formulated strategies for community-based trials on the relationship between mental
MENTAL HEALTH
health action and the control of physical disease. Another working group focused on the potentialities of self-help and mutual aid as an important resource of primary health care.
7.26 As part of WHO's programme of health care for the elderly (see paragraphs 8.92.-8.96) new emphasis was laid on psychogeriatrics. A project was launched to evaluate different models of health care for the elderly and to assess the relation between place of care, psychological factors, and efficacy of treatment. The study compares two groups of patients, one admitted to the general hospital and the other to the geriatric hospital. Standardized data are being gathered on the quantity and quality of hospital care, and on the attitudes and vocational adjustment of health personnel towards the elderly sick. The effect of care and of the treatment environment on the physical and mental health of the patient and on his or her social functioning is also being evaluated.
7.2.9 A booklet on care of the mentai!J retardedl was prepared under contract by the Joint Commission on International Aspects of Mental Retardation, a nongovernmental organization in official relations with WHO, and was widely circulated. On the basis of the comments received, one of the constituent bodies of the Commission-the International League of Societies for the Mentally Handicapped-issued a brochure2 discussing the implementation of the major recommendations of the United Nations Declaration on the Rights of Mentally Retarded Persons (I97I).
Drug dependence 7.30 Projects atmmg to strengthen the capacity of national authorities for the treatment and prevention of drug dependence and to develop models for the training of primary health care workers are under way in nine countries. One such model, developed in the hill tribes area of Thailand, has recently been expanded to cover a larger area of population.
7. 2 7 A task force on neuroendocrinology' and behaviour was constituted in I 98 I and a research protocol was drafted for a series of neurobehavioural tests and neurohormone titratio,ns in aging persons. Field research centres in Canada, Italy, and Nigeria were selected for participation in the study. Meetings were held to agree on the protocol for a multicentre study of the epidemiology of senile and presenile dementia. 7.2.8 The collaborative study on the assessment of "dangerousness" of individuals by use of mental health expertise was completed in mid- I 98 I, when representatives of the six participating countries (Brazil, Denmark, Egypt, Swaziland, Switzerland, and Thailand) met to discuss the results. A report on the study is in preparation. 79
7. 3I A centre was established in Bangkok for training physicians, social workers and nurses to work as a team in the management of drug dependence. Similar models will be developed in other countries, e.g., Burma and Pakistan.
7. 32 A number of potentially useful technologies became available during the biennium, e.g., on the methodology of student
t Mental retardation: prevention, amelioration and service delivery. Brussels, Joint Commission on International Aspects of Mental Retardation, 1980. 2 Step fry step: implementation of the rights of mentally retarded persons. Brussels, League of Societies for the Mentally Handicapped, 1980.
THE WORK OF WHO, 198o-r981
drug-use surveys, 1 drug-abuse reporting systems, 2 general population surveys of drug abuse,3 drug use among non-student youth,4 and evaluation of treatment for drug dependence. 7· 33 One project nearing completion was an assessment of treatment methods for drug dependence in developing countries, in which investigators in 10 countries took part. 7·34 A study on the sociocultural aspects of drug problems,s by investigators in 15 countries, analysed the epidemiology of the drug problem, patterns of drug abuse, health care approaches, treatment, and prevention. It was based on 40 case studies of different forms of drug dependence in widely differing settings. The study emphasizes the importance of sociocultural considerations in selecting the approach to be adopted and demonstrates the practical implications of that approach for policy and programme formulation.
strengthening both national and international programmes. It was facilitated by financial support from the Nordic countries. Activities have focused on methods of investigating the nature and extent of alcohol problems and on technologies for their prevention and management at both commmunity and national level. 7. 37 Reports on the first phase of a project on community and national response to alcohol problems were presented at meetings in the collaborating countries-Mexico, the United Kingdom, and Zambia. These meetings were also attended by several neighbouring countries in each region that were considering the possibility of similar activities. A second phase of the project involved the three collaborating countries in monitoring the implementation of the proposed policies and programmes. The Thirty-second World Health Assembly (resolution WHA32.4o) requested WHO to encourage collaboration in "reviewing existing trade practices and agreements relating to alcohol". A project on the public health aspects of the international production, marketing, and distribution of alcoholic beverages was subsequently launched. 7.38 7·39 The consequences of excessive alcohol consumption are damaging not only for the heavy drinker but also for the family. During 1981 work started on a project concerned with the prevention and management of alcohol problems in the family setting. 7.40 Moreover, the consequences of drinking among the work force at all levels, both in industry and in other forms of employment, are extremely costly. Studies on alcohol problems in the employment setting were started during 1981 in cooperation with ILO and the International Council on Alcohol and Addictions.
7· 3 5 The Organization collaborated with Bolivia, Burma, Colombia, Ecuador, Egypt, and Peru in other UNFDAC-financed projects for control of drug dependence, which included clinical, epidemiological, and operational research, and training of personnel.
Alcohol-related problems 7.36 The expanded programme on alcohol-related problems derives from resolution WHA32.40, which stressed the need for
WHO Offset Publication No. jO, Geneva, 198o. WHO Offset Publication No. 55, Geneva, 1980. 3 WHO Offset Publication No. j 2, Geneva, r 980. 4 WHO Offset Publication No. Go, Geneva, 1981. 'Edwards, G. & Arif, A., ed. Drug problems in the sociocultural context: a basis for poltcies and programme plannmg. Geneva, World Health Organization, 1980 (Pubhc Health Papers, No. 73). 2
1
So
MENTAL HEALTH
7-4I In the European Region a workshop on the epidemiology and prevention of alcohol- and drug-related problems was held in Dublin (I98o). In the Western Pacific a working group on prevention and control of alcohol-related problems met in Tokyo (I 98 I). In the Americas, surveys on the prevalence of alcohol-related problems were carried out in Ecuador, Honduras, and Mexico. The Organization cooperated with the Governments of Brazil, Chile, and Ecuador in running courses for health professionals. 7.42 The report of the Expert Committee on Problems related to Alcohol Consumption was published in I98o.l A review of preventive measures, policies and programmes, compiled with the help of contributors from more than 8o countries in all six WHO regions, was published on behalf of the Organization by the Alcoholism and Drug Addiction Research Foundation, Toronto, Canada, a WHO collaborating centre for research and training on alcohol and drug dependence problems. 2 Another report published by this Foundation records the outcome of an international study, in collaboration with WHO, of alcohol control experience in seven countries (Canada, Finland, Ireland, the Netherlands, Poland, Switzerland, and the United States of America).3 7·43 A study was completed on the social factors that have a bearing on alcohol-related problems in a number of countries. It pro-
vides basic information on the role of such factors in increasing alcohol consumption, identifies the high-risk groups in the population, and suggests practical preventive measures.
Mental health of children 7·44 More than half the population of the developing world are children, and epidemiological investigations show that at least one child in 20 is liable to suffer from a mental disorder. Available resources for mental health care are not always used to the full advantage of children and their families. In I 9 8 I seven countries-Costa Rica, Egypt, France, Greece, Nigeria, Singapore, and Sri Lanka-completed national studies on the nature of these disorders and on the possibility of programmes for their control. Once analysed, this information will form the basis of specific recommendations for action at national and international level. 7-4 5 In the Americas, the findings of various regional studies on the influence of malnutrition and certain environmental factors on child development were discussed by a study group (Washington, I98o) attended by specialists from Chile, Colombia, Guatemala, Jamaica, Mexico, the United States of America, and Uruguay. The subject was also discussed at the I 98o meeting of the regional Advisory Committee on Medical Research (Costa Rica). The documentation and recommendations of those meetings were w.idely distributed. 7.46 The Organization also cooperated with the Governments of Chile and Venezuela in the provision of services for the psychologically impaired child. 8I
1 2
WHO Technical Report Series, No. 65o, 198o. Moser, J. Prevention of alcohol-related problems: an
international review of preventive measures, policies and programmes. Toronto, Alcoholism and Drug Addiction Research Foundation, 1980. 3 Makela, K. eta!. Alcohol, society and the State. Toronto,
Alcoholism and Drug Addiction Research Foundation, 1981.
THE WORK OF WHO, 198o-t981
Promotion of biomedical and health practice research 7·47 The Subcommittee on Mental Health and Neuropsychiatry of the global Advisory Committee on Medical Research, in its report to the Committee in I 98o, gave high priority to (i) research on the detection and treatment of mental disorders by primary health care workers and the use of behavioural science principles in improving the effectiveness of primary care; (ii) institutionstrengthening for the purpose of ensuring long-term commitment and continuity in mental health research, development, and training; and (iii) research on related health education. There was agreement that WHO's research in mental health in developing countries should primarily be addressed to those aspects on which practical measures could be taken at primary health care level. In relation to the report of its 7.48 Scientific Planning Group, the global ACMR considered detailed options for mental health research in the I98os and I99os, produced in consultation with WHO's collaborating centres and leading scientists. Similar developments took place at 7·49 regional level. In the Eastern Mediterranean the regional ACMR at its fifth session (September I98o) reviewed the regional research programme in mental health, discussed options and priorities, and accepted in principle the proposals submitted for future research, which were later scrutinized and redefined by a scientific working group (Karachi, Pakistan, June I98 I). The Western Pacific ACMR (April I98o) recommended that a subcommittee on mental health should be established or that a representative of this discipline should be co-opted on to the Committee. The European ACMR (June I98I) particularly emphasized research on lifestyles and on the psychosocial factors influencing health and health behaviour.
7.50 WHO continued to coordinate cross-cultural multicentre studies aiming to provide a data base for planning mental health services, evaluating care, and developing new technologies for prevention and management. One of these studies ascertained for the first time the incidence of schizophrenia and other severe mental disorders in Io countries representing five of the WHO regions. A longitudinal study on the impairments and social disabilities consequent on an episode of mental disorder was carried out in seven countries. The preliminary results of the above-mentioned studies give reason for cautious optimism as to the possibility of providing effective care for these conditions and preventing their severer sequelae by means of community-based services, without recourse to costly technology or the custodial type of care that is now regarded as completely obsolete. 7. 5I Depression--one of the most common mental disorders, and frequently undiagnosed or misdiagnosed-was studied in several countries by examining a series of persons consulting the health services for other reasons. The study confirmed that a large number of mental disorders (including depression) are encountered in general health care, and it raised such important questions as the psychiatric training of general physicians and the capacity of primary health care workers to detect and handle mental health problems.
Biological p{Jchiatry and p{Jchopharmacology 7·52 WHO's work in biological psychiatry took three principal directions: collaborative research, training, and exchange of information. A network of 3 I centres in various countries collaborate in this programme and can be said to constitute an "international institute" of biological psychiatry. Activities were concentrated on the
MENTAL HEALTH
search for biological approaches to the prevention and control of mental disorders, on new methods of treatment, and on improving the classification of psychiatric illnesses. 7. 53 The last two years have produced new findings on the biological markers of functional psychoses that can be used to identify groups at high risk of mental disorder. Studies continued on other possible types of biological marker (ABO blood groups in affective disorders, dexamethasone suppression test in depressive illness). Important results (e.g., the effect of naloxone on verbal hallucinations) were obtained in collaborative research on the involvement of internal opioid systems in the pathogenesis of schizophrenia. 7. 54 Several meetings were held. At the Third World Congress of Biological Psychiatry (Stockholm, June-July 1981), which WHO co-sponsored, symposia were organized by WHO with participants from 14 countries. The methodology of multicentre trials in psychopharmacology was discussed at a WHO symposium held in connexion with the congress of the Collegium internationale Neuro-psychopharmacologicum (Goteborg, Sweden, June 198o). A training course and travelling seminar on biological psychiatry and psychopharmacology was also organized, for both English- and French-speaking countries. 7· 55 A project on the effects of psychotropic drugs in different populations (involving 1 2 countries) aims at determining the optimal dosage of drugs taking into account cultural, climatic, nutritional, and other considerations.
pathies was implemented. Baseline data were collected in the participating countries (Canada, China, Federal Republic of Germany, Italy, Japan, Mexico, Nigeria, Portugal, Senegal, and Spain) and the results are being prepared for publication. The second phase--devoted to pharmacological control of diabetic neuropathies-was also initiated. 7. 57 Data on the incidence and prevalence of neurological disorders are urgently needed by Member States : a protocol for international studies was prepared and a pilot study was carried out in China and Nigeria. Field research centres were selected in several countries of Africa, and in China, Italy, Mexico, and Spain. (For training in neurology, see paragraphs 12.156 and 12.157·)
7. 58 The need for better control of epilep[J in all parts of the world, especially in the developing countries, is generally recognized. A protocol was prepared for an international collaborative study to find safe and efficacious pharmacological means for such control. This project will also introduce health authorities in different countries to new views on the prevention and management of epilepsy. 7· 59 Several international symposia were organized in collaboration with nongovernmental organizations, the subjects including peripheral neuropathies, biological membranes in growth and development, phagocytosis, immunogenetics, neuronal aging, and cerebrovascular disorders. Two round-table discussions on peripheral neuropathies were organized by WHO: the first on the occasion of the Fifth Biennial General Meeting and Conference of the Pan African Association of Neurological Sciences (Nairobi, April 1981), the second related to the Twelfth World Congress of Neurology (Kyoto, Japan, September 1981).
Neurological disorders 7· 56 The first phase of an international collaborative study on peripheral neuro-
***
THE WORK OF WHO, '98o--198I
7.6o It is hoped that the survey of prospective longitudinal research with mental health implications 1 published in I 98 I will focus interest on the potential value and the limitations of long-term research for primary prevention of chronic psychological disorders.
Monitoring and other mechanisms for programme development and support 7.6I Work continued on the evaluation of the psychopathological, psychological, and social components of health programmes and health services. Seven countries (Bulgaria, Ghana, Kuwait, Panama, Papua New Guinea, Thailand, and the United States of America) completed work on a method to monitor mental health needs and assess the burden on general and specialized health services attributable to patients with psychopathological problems. These countries then went on to use the method in various parts of their own services. Other countries plan to use similar models for monitoring the psychiatric component of their health services, and the WHO regional offices are developing resource centres to facilitate collaboration and exchange of experience, e.g., in Kuwait, for countries of the Eastern Mediterranean Region. In the European Region such methods have been tested and utilized in 2 I pilot areas in I 6 countries. 7.62 Social and psychological problems are frequently the reason, or at least one of the reasons, for patients contacting the primary health care services. However, data registration and problem classification schemes are at present almost exclusively somatic.
During the biennium seven countries began collaboration in a project to develop and field-test methods for a triaxial (physical, psychological, and social) classification and registration of primary health care contacts. A further aim of this work-which is being carried out in centres in Brazil, Canada, Colombia, Malaysia, Thailand, the United States of America, and Zambia (and is envisaged in Cuba)-is to assess the extent to which such information can be used in planning health and social services and allocating multisectoral resources. 7. 6 3 A review of the indicators of mental health service utilization as reported in official national publications demonstrated the utility of such indicators for medium and long-term projections. Work has now started on establishing indicators to assess the psychological implications of primary health care programmes and the determinants of their effectiveness. In parallel, indicators are being compiled and tested that will permit the evaluation of social development programmes and their impact on health. 7.64 The systematic assessment of people's behaviour is a frequent prerequisite for neuropsychiatric (in particular clinical and epidemiological) research. Developing countries have hitherto been severely hampered in the evaluation of findings by the lack of facilities for analysing data. Microcomputers may provide the answer, and a feasibility study was launched on the use of microcomputer methodology and technology in mental health surveys. Four countries are participating or plan to participate: China, Colombia, India, and Nigeria. 7.65 In the Western Pacific Region, systems of reporting cases of drug abuse were reviewed in Australia, Hong Kong, the Philippines, and Singapore. The need was assessed for a network of centres to facilitate the exchange of information in this field.
1 Mednick, S. A. & Baert, A. E. Prospective longitudinal research: an empirical basis for the primary prevention of p.rychological disorders. Oxford University Press (published on behalf of the WHO Regional Office for Europe),
1981.
MENTAL HEALTH
7.66 In the Americas, the feasibility study on the establishment of a drug abuse monitoring system in Argentina, Mexico, and Peru was continued. One of its main aspects is the feeding of data on drug and alcohol abuse into existing national health information systems.
7. 67 The general increase in research in to the causes of mental disorders has necessitated a re-examination of the approach to their diagnosis and classification. WHO, in cooperation with the Alcohol, Drug Abuse and Mental Health Administration, Institute of Mental Health (USA), launched a new programme in which scientists from some 4 5 countries review scientific knowledge with a view to translating the advances made in a number of disciplines into a coherent "common language" for use in diagnosing
and classifying mental health problems. In the first phase of this programme, nine working groups were convened. They identified the need for further work in such areas as child mental health; psychosocial aspects of aging; stress-related conditions; neurotic and personality disorders; alcohol- and drug-related problems; functional psychoses; organic psychosyndromes, including those associated with tropical and parasitic diseases; and mental health problems in primary health care. Task forces were set up for the development of assessment instruments, the standardization of terminology and nomenclature, and the measurement of personality variables in different cultures. The conference in which the programme will culminate (April 1982) should result in a global plan of activities and the development of improved diagnostic methods, evaluation technologies, and classification tools for mental health care.
Chapter 3
Diagnostic) Therapeutic) and Rehabilitative Technology THIS chapter brings together important aspects of clinical and technological support for the delivery of health care both at the level of first contact between the community and the health professional and at that of referral services. It includes such newcomers to WHO programmes as traditional medicine and essential surgical care, which are destined to play an increasingly important role in the future. It also includes the two programmes for which the· Regional Office for Europe has world-wide responsibility, namely: prevention of road traffic accidents, and care of the aged. 8.1
the Twenty-eighth World Health Assembly (resolution WHA28.65), provides that the health authorities of exporting countries should supply a certificate for each product stating that it is authorized for sale in the exporting country and that the manufacturer is subject to regular inspection. By the end of 1981, 71 Member countries had agreed to participate in the scheme and had designated responsible national authorities.t 8.4 Basic tests for over 2 5o essential pharmaceutical substances were endorsed by the WHO Expert Committee on Specifications for Pharmaceutical Preparations (December 1981). They are simplified laboratory procedures designed primarily to confirm the identity of pharmaceutical substances and to ensure that gross degradation has not occurred. 8. 5 Volume 2 of the third edition of the International Pharmacopoeia 2 was published on the basis of advice offered by the WHO Expert Advisory Panel on the International Pharmacopoeia and Pharmaceutical Preparations. It contains revised monographs for substances essential to primary health care. Monographs are in preparation for other
Pharmaceuticals 8.2 WHO continued its efforts to increase the availability of essential drugs of adequate quality, particularly in developing countries, where technical facilities for the assessment of pharmaceutical products are limited. To strengthen national capability for quality control, the Eastern Mediterranean Region provided specialist advice to countries and awarded fellowships. A subregional workshop sponsored by the Western Pacific Region in Kuala Lumpur in 1980 considered drug quality control and management.
8.3 A revised certification scheme on the quality of pharmaceutical products moving in international commerce, adopted in 1975 by 86
1 See WHO Chronicle, 34: 427-432 (1980). World Health Organization. The International Pharmacopoeia, Third Edition, Vol. 2,Q~~ality specifications. Geneva, 1981. 2
DIAGNOSTIC, THERAPEUTIC, AND REHABILITATIVE TECHNOLOGY
essential drugs and will be included in Volume 3· 8.6 The WHO collaborating centre for chemical reference substances in Sweden distributed more than z6oo samples of international reference materials required for analytical methods described in the International Pharmacopoeia to laboratories in some 5o Member States. Nine new reference substances were established, bringing the total number maintained at the centre to 98. Secondary reference standards are now being developed on a subregional ba'sis within the A SEAN group of countries, an initiative that is likely to be followed elsewhere. 8. 7 New international nonproprietary names for pharmaceutical substances were selected on the basis of requests by national nomenclature authorities and by pharmaceutical manufacturers. During the biennium new names were proposed for 340 substances, bringing to 5I 2 I the total number of nonproprietary names so far established by WHO. A sixth cumulative list containing all names published up to May I98I will be published in I982. 8.8 Information sheets on essential drugs intended for prescribers at various levels of the health care system in developing countries are in preparation, in accordance with the recommendations of the Expert Committee on the Selection of Essential Drugs.t Consultations on the content and format of these sheets were held in January and November I98I, and the material will subsequently be field-tested to ascertain its relevance to national needs. 8.9 Information on the safety and efficacy of widely used drugs, evaluated in the light of recent decisions by national drug registration authorities, was provided in the quarterly 1 WHO
bulletin Drug Information. An international conference of drug registration authorities, co-sponsored by WHO and the Food and Drug Administration of the United States of America, convened in I 979, had stressed the need for international exchange of information on regulatory decisions and harmonization of national registration procedures. 8.Io The WHO collaborating centre on international drug monitoring, Uppsala (Sweden), became fully operational during the biennium, and 22 countries continued actively to contribute data.
8. I I The series of 'annual symposia on clinical pharmacological evaluation in drug control, organized by the Regional Office for Europe in collaboration with the Government of the Federal Republic of Germany, continued in I98o and I981. 8. I 2 A symposium on clinical pharmacology held in the Federal Republic of Germany (I98o) dealt with drug treatment of the elderly. It was designed to complement an ad hoc technical group on the use of medicaments by the elderly in relation both to clinical management and to regulation. Another symposium, in I 98 I, was on problems associated with drug treatment for infants and children (see also paragraphs I 5.69 and 15·70). 8. I 3 The work of the WHO drug utilization research group continued to be organized by the Regional Office for Europe. 2 A working relationship was established with the Nordic Council on Medicines working group, which has devised a classification of drugs and designed a system of defined daily
Technical Report Series, No. 6Ij, 1977.
2Bergman, U. eta!., ed. Studies in drug utilization: methods and applications. Copenhagen, World Health Organization, 1979 (WHO Regional Publications, European Series, No. 8).
THE WORK OF WHO, r98o-r98r
doses as units of measurement that are considered suitable for measuring drug use and conducting international comparative studies. It has been widely agreed to present drug utilization data in terms of the number of defined daily doses per Iooo inhabitants per day; for hospital utilization the number of defined daily doses will be per Ioo bed days. International collaborative studies on antihypertensives, antidiabetics, and antimicrobials will be studied within the group.
Action programme on essential drugs 8. I 5 In conformity with resolutions
EB6I.RI7, EB63.R20, WHA31.32, and WHA32.4I, WHO established an action programme on essential drugs in February I981.
8. I4 The second meeting on technical cooperation among ASEAN countr1es on pharmaceuticals (Manila, August I98o) developed a plan of action for exchange of information; training and exchange of expertise; reference substances; an essential drug list; practical guidelines for implementing good manufacturing practice; drug evaluation; and control and quality assurance. An initial meeting on the establishment of secondary reference materials was held in Bangkok in November I98o and a further meeting in Malaysia in December I981. A training programme for the preparation of standard substances began in Sweden in September I981. A subregional workshop on quality assurance was held in Kuala Lumpur in February and March I98o. In September I98o the UNDP project for a national drug standardization centre in China was implemented; it strengthens national drug assurance capability by providing laboratory equipment and arranging study missions and fellowships. In August and September I 98 I, under the programme agreed by the China/ WHO joint coordination committee, a study tour on clinical pharmacology and the evaluation and authorization of new drugs was made to Japan and the United States, and a seminar on methodological approaches in clinical pharmacology was arranged. WHO monitored adverse drug reactions so as to strengthen national drug assurance systems in the Philippines.
Its major objective is to support governments in increasing the availability and utilization of drugs at the lowest possible cost for primary health care, particularly through the formulation and implementation of national drug policies. Some of the major deficiencies in developing countries can be remedied by using drugs rationally, by maximizing the use of limited manpower and financial resources, and by ensuring the availability of the least expensive and most effective drugs. 8.I6 The WHO model list of essential drugs 1 was the basis for cooperation with Member States; more than 40 countries have developed a national list. Cooperation took place with many Member States, for example in the selection of essential drugs, the quantification of drug needs, the development of national distribution systems (including storage facilities and logistic support), quality assurance, drug legislation and regulatory control, early feasibility studies for the establishment of a formulation plant, and manpower development. Fact-finding missions were undertaken in more than 20 countries-jointly with the pharmaceutical industry in four-for an exchange of views and analysis of the problems experienced by developing countries. As a result, valuable experience has been gained which could be applied in a more general way to other countries. 8. I 7 In the African Region the paucity of drugs is a major problem. However, the situation has been analysed in at least I 2
t
See WHO Techmcal Report Series, No. 64r, I979·
88
DIAGNOSTIC, THERAPEUTIC, AND REHABILITATIVE TECHNOLOGY
countries and a list of some 40 essential drugs has, in principle, been accepted by 33 Member States of the Region. This list is intended to form a basis on which these countries can pool procurement facilities, in collaboration with UNICEF. TCDC activities in local production and quality control are only in the initial process of development in this Region. 8. I 8 In the Americas, resolution XXIII of the thirty-second session of the Regional Committee (I98o) requires study of mechanisms for, among other things, the collective purchase of drugs. An interdisciplinary operational research project was undertaken to assess the management and use of drugs in selected health centres, hospitals, and health posts; in five countries deficiencies were apparent at various levels of the pharmaceutical supply system. The need to strengthen health infrastructures to provide patients with drugs at primary health care level is also to be studied. 8.19 A m<.:<.:ting on drug policies and management was convened in late 1981 with the participation of countries in the Region. Regular information in Spanish on the safety and efficacy of drugs has been provided in a special quarterly section of the Boletfn de Ia Oficina Sanitaria Panamericana. A revolving fund for the procurement and distribution of essential drugs among Member States has just started to function. Professional staff were recruited for the Caribbean regional drug testing laboratory in Jamaica to ensure the quality of essential drugs.
8.2I In the field of quality control and distribution, Burma, Indonesia, Sri Lanka, and Thailand obtained technical support from WHO and financing from the Government of Japan, the Asian Development Bank, and UNDP. 8.22 As an example of interregional collaboration, Indonesia and Thailand have joined the TCDC programme among A SEAN countries (paragraph 8. 26).
8.23 The main areas of interest in the European Region are clinical pharmacology, drug evaluation, and drug utilization (see paragraphs 15 .69-I 5. 72). A survey of the pharmaceutical supply system was carried out in Morocco. 8.24 In the Eastern Mediterranean Region utilization studies for more rational prescribing and use of drugs were carried out in Democratic Yemen and Sudan. The formulation of national drug policies was initiated in Sudan. A drug licensing scheme was introduced in Bahrain. 8.25 In the Western Pacific Region emphasis was placed on the development of a joint purchasing system for the South Pacific countries. 8.26 The second meeting on technical cooperation among ASEAN countries on pharmaceuticals was hosted by the Regional Office for the Western Pacific in August I98o and a third meeting took place in Kuala Lumpur in December I98I to discuss how such cooperation could be achieved. The implementation phase of this programme is funded by UNDP.
8.20 In the South-East Asia Region the various components of a pharmaceutical supply system were assessed, in collaboration with Member States. In the field of production, Bangladesh, Burma, Indonesia, Mongolia, Nepal, and Sri Lanka received WHO support. Progress was made in the development of national drug policies in Indonesia and Thailand.
8.27 Negotiations are under way with China for the supply of some essential drugs for developing countries. Collaboration with the Lao People's Democratic Republic and VietNam consisted mainly in the provision of drugs.
8.28 At global level, action was begun to prepare manuals for important areas of drug policies and management. A consultation was arranged with a view to preparing different kinds of information sheets on essential drugs, some aimed at professional workers at various levels of education and skill, others at nonprofessional primary health care workers. This consultation obtained the reaction of potential users of the information sheets and assessed the relevance of the sheets to the various levels of expertise available in Member States. Guidelines and recommendations for the establishment of a low-cost pharmaceutical formulation plant in developing countries were produced. 1 The basic elements of drug legislation and of regulatory control for developing countries were defined with the help of a consultative group meeting in June I981. Guidelines are under preparation on the formulation of national drug policies and drug distribution and management, as well as on the proper use of the most widely used medicinal plants. 8.29 The International Federation of Pharmaceutical Manufacturers Associations and the World Federation of Proprietary Medicine Manufacturers have offered, on behalf of member companies, to provide training for government-sponsored technicians in various aspects of drug quality control. To date six individuals from developing countries have been trained, and six more are being trained. 8.30 An interregional working group (New Delhi, December I98o) formulated a global strategy for the action programme on essential drugs. This strategy includes the development of appropriate national drug policies linked with country health programmes for the achievement of the goal of
health for all by the year 2ooo through health systems based on primary health care. It also. envisages technical cooperation among Member States and greater coope-ration with the pharmaceutical industry, without whose help drugs cannot be provided. Further cooperation is also proposed with a number of organizations in the United Nations system, including UNICEF, UNCTAD, UNIDO, UNDP, the World Bank, and with the regional development banks.
Biologicals 8. 3 I The need for biological reference materials continues to increase. In the past two years 2 5 new or replacement reference materials were established, bringing the total to I 8 5 for international reference materials and I8o for reference reagents. About 12 500 reference materials are distributed every year, more than half of them to developing countries. As the distribution is accompanied by the transfer of technical information on their correct use, the service continues to assist primary health care. 8. 32 The new requirements for biological substances approved at the 1980 meeting of the Expert Committee on Biological Standardization 2 include: rabies vaccine for veterinary use; hepatitis B vaccine; thromboplastins and plasmas used to control oral anticoagulant therapy; and immunoassay kits used on a wide scale in the standardization of pregnancy test kits. The requirements that have been revised in order to take modern technology into consideration are: rabies vaccine prepared in cell cultures and intended for human use; poliomyelitis vaccine (oral); meningococcal polysaccharide vaccine; and antibiotic susceptibility tests.
1WHO
document DPMf8o.z (r98o).
2WHO Technical Report Series, No. 658, 1981.
DIAGNOSTIC, THERAPEUTIC, AND REHABILITATIVE TECHNOLOGY
8. 33 In addition to these requirements, guidance on the national control of vaccines and sera was published.l This will be of particular assistance to Member States contemplating the establishment of quality control. Guidelines for the quality assessment of antitumour antibiotics were also published.z The original procedure for the 8.34 approval by WHO of yellow fever vaccines was established some 30 years ago, since when the technology of production has advanced and new manufacturers are now requesting recognition. In reviewing the procedures the opportunity was taken to record the history of all the yellow fever virus strains derived from the Rockefeller Foundation strain qD and used throughout the world. 8.35 At its 1981 meeting the Expert Committee on Biological Standardization 3 approved the requirements for Rift Valley fever vaccine and completely revised the requirements for antibiotic susceptibility tests to take into consideration antimicrobial agents other than antibiotics. The Committee noted that the research programme (supported from extra budgetary sources) to improve the stability of measles vaccines has now been completed. As a result of the findings WHO has been able to devise a stability test to be applied to each batch of vaccine in order to ensure that only the most stable vaccines are distributed in countries with high ambient temperatures. Similar action is now being taken to improve the stability of oral poliomyelitis vaccine. 8.36 Surveillance of the production and control of oral poliomyelitis vaccine has continued, with particular reference to the test for neurovirulence. A single test has been
accepted by all the countries involved and variations in results between countries, which presented problems in the past, have now decreased. International reference materials for inclusion in the test were approved at a meeting of the manufacturing and national control laboratories. Two countries continue to be assisted by WHO in establishing consistency in the production of this vaccine. Developments in the technology of 8.37 production of inactivated poliomyelitis vaccine have led to culture of the virus in a nontumorigenic cell line grown in large tanks. These techniques give a greater virus yield and so a greater yield of the purified antigens. The requirements for the production and testing of the vaccine were revised to take account of the new technology and the revised requirements 4 were approved by the Expert Committee on Biological Standardization. 8.38 Problems that have occurred in the expression of biological activity of some classes of immunoglobulins were discussed at a meeting of a small group of experts particularly involved in such work. 8. 39 Within the activities of the blood programme, four groups of scientists considered plasmapheresis practices and the uses and misuses of blood coagulation factors, albumin, and immunoglobulins. Their views will be of assistance to countries either importing these biologicals or contemplating their production with national resources. 5
8.40 It has been suggested for some years that WHO should play a role in ensuring future supplies of nonhuman primates, which are vital for biomedical research and drugOp. cit. (Annex z). World Health Organization. The collection, fractronation, quality control, and uses of blood and blood products. Geneva, 1981. 4 5
tOp. cit. (Annex II). z Op. cit. (Annex 9). 3
WHO Technical Report Series, No. 673, 1982.
THE WORK OF WHO, 198o-I981
testing programmes. An international primate resources programme has accordingly been formulated and appropriate action was discussed at an international meeting. 8.41 Individual and group training programmes in the quality control of vaccines continue, with financial assistance from UNDP. Although the number of candidates for individual training is increasing, there are still fewer than were originally anticipated. During the biennium 10 candidates from seven countries in three regions were trained, and two training courses were arranged in another region. 8.42 In the Western Pacific Region largescale modern vaccine production started in Alabang Serum and Vaccine Laboratories (Philippines), and other vaccine production centres in the Region are contemplated. The establishment of quality control laboratories in the Region and quality control programmes linked with other international laboratories is also being considered. 8.43 A course on quality control of viral vaccines was held in May 1980 at the Commonwealth Serum Laboratories, Parkville, Australia.
8.45 The need. to improve the reliability of health laboratory results was clearly demonstrated by a worldwide laboratory proficiency testing programme organized by WHO. The Organization accordingly intensified its training programme in laboratory techniques and its cooperation with countries in the development of national quality control schemes. It organized seminars and workshops, inter alia on: laboratory safety, particularly in the field of microbiology, since infections continue to be frequently reported; local production and control of biological reagents with the objective of establishing self-reliance; and hospital cross-infection. 8.46 WHO collaborated with eight countries in seeking the best way to organize peripheral laboratories, the aim being to improve the quality of health care and to integrate all laboratory services at the peripheral level to achieve the control of all major diseases. With the aid of DANIDA and the Centers for Disease Control, Atlanta (USA) WHO organized a laboratory management course to strengthen the managerial capabilities of central and intermediate-level laboratory directors. In this course great importance is attached to low-cost supervision and the organization of supplies to prevent demoralizing shortages. A training course for laboratory tutor technicians was arranged in Nepal. At this course the students individually prepare a curriculum structure for teaching laboratory tests used at the peripheral level. Emphasis is also given to stimulating enthusiasm and strengthening the responsibilities of the peripheral laboratory worker. 8.47 To make simple, sturdy, low-cost laboratory equipment available to developing countries is a matter not merely of designing and producing a prototype in research centres in industrialized countries but also of finding a country where the equipment can be produced at low cost. This can only be a
Health laboratory technology 8.44 WHO collaborated with countries in the different regions in developing their health laboratory infrastructure through the strengthening of central reference laboratories and the expansion of the national network to meet the needs of primary health care. Emphasis was given to the public health aspects of laboratory activities and support to the communicable diseases surveillance programme. Particular attention was also given to increasing the efficiency of the national laboratory system and improving logistic support and supervision.
DIAGNOSTIC, THERAPEUTIC, AND REHABILITATIVE TECHNOLOGY
developing country where both the technology for production and the market are present. The patent on the robust and simple MONA colorimeter designed at the Clinical Research Centre, Harrow (United Kingdom) does not cover any of the countries where WHO is likely to be interested in producing it. This will make it easier to promote local production or assembly in developing countries. With the aid of the laboratory equipment research sections of the Clinical Research Centre and the Centers for Disease Control, WHO cooperated with developing countries in the evaluation of locally produced equipment. Technical information was provided to local industry for the improvement of its equipment. WHO is also cooperating with 8.48 countries in the African and South-East Asia Regions in the local production of bloodgrouping reagents, and with countries in North Africa and the Western Pacific Region in the production of quality control sera. 8.49 In an effort to improve the quality of the services given by the health laboratories, nine training courses were organized-in Burma, China, Morocco, Nepal, Pakistan, the United Republic of Tanzania, and Viet Nam. They were mainly financed by DANIDA. With the same objective WHO intensified its international proficiency testing programme in clinical chemistry, haematology, and bacteriology, with the technical support of collaborating centres in Belgium and the United Kingdom. It is estimated that only 40% of the laboratory results in clinical chemistry and 1 5% of those in bacteriology are of an acceptable quality in developing countries.
Kingdom and the United States of America and was widely distributed. This should assist national central laboratories in the preparation of national reference material and in the assessment of local methods and equipment. A protocol for the evaluation of reagent kits has also been tested in the field. 8. 51 It has been estimated that there is $6ooo-$8ooo million worth of biomedical equipment in developing countries. However, most of this equipment is not adapted to withstand the prevailing environmental conditions. In some countries up to 6o% of the equipment lies idle because of the lack of suitable facilities for maintenance and repair. With a group of experts, a programme for improving the utilization of laboratory equipment has been set up, and guidelines for the establishment of a national laboratory equipment maintenance and repair service have been prepared.
Radiation medicine 8. 52 The concept of basic radiological services continues to be promoted, and in the course of four consultations a WHO advisory group prepared technical specifications for a basic X-ray machine and a manual for the training of machine operators. Substantial progress was also made in the preparation of a manual on film interpretation for general practitioners. Two WHO consultations, one on radiology in Africa (Nairobi, November 198o), the other on radiology in Europe (Copenhagen, December 198o) discussed basic radiological services, problems related to radiotherapy, and the comprehensive development of radiological services at country level. 8. 53 An exhibition on basic radiological services was held during the Thirtyfourth World Health Assembly and at the XV International Congress of Radiology 93
8. 5o One of the rna jor reasons for this is the poor quality of the reagents. Reference material with assigned values for some of the essential components was prepared with the aid of collaborating centres in the United
(Brussels, June-July I98I), where the problems of radiology in developing countries were discussed with the International Society of Radiology and the International Society of Radiographers and Radiological Technicians. A round-table discussion on radiology in the developing world held during that Congress was attended by participants from developing and developed countries. It reviewed the present situation of radiotherapeutic and radiodiagnostic services and the problems and possible solutions. 8. 54 Four prototypes of basic radiological machines have been produced, two of which have been tested under clinical conditions in Copenhagen and Lund (Sweden), the results serving to improve the design of the tube cassette holder. The quality of the radiographs produced with mediumfrequency X-ray generators powered by lead acid batteries compared favourably with that obtained by high-powered three-phase generators. The Regional Offices for South-East Asia and the Eastern Mediterranean have made progress towards the implementation of basic radiological services projects in Cyprus, Egypt, and Yemen, and more recently in Burma, Indonesia, and Nepal. 8. 55 With the support of the Federal Republic of Germany,WHO organized two workshops on quality assurance in diagnostic radiology and in nuclear medicine in October and November I98o. The reports give practical guidance on the planning and implementation of quality assurance programmes. Again with the support of the Federal Republic of Germany, a meeting on the efficacy and efficiency of radiological and nuclear medicine procedures was held in Munich-Neuherberg (November I98I). It reviewed studies on this subject and prepared rational referral criteria.
nescent dosimetry intercomparison, aimed at improving the dose delivery to patients in radiotherapy, was continued: a total of 2 3 5 dosimeter sets were processed in I98o-I981. Some of the results were analysed at a joint symposium on dosimetry in biology and medicine (Paris, October I98o). Action was taken to expand the intercomparison to orthovoltage machines and to high-energy photons used in radiotherapy. 8. 57 Other joint IAEA/WHO activities were: two courses and study tours on nuclear medicine (USSR, I98o and I98I); an international symposium on medical radionuclide imaging (Heidelberg, Federal Republic of Germany, September I98o), at which a panel on quality assurance was held; an international seminar on quality assurance in nuclear medicine (Bogota, May I 98 I), with the collaboration of the Government of Colombia; and a seminar on prospective methods of radiotherapy in developing countries (Kyoto, Japan, September I98I). The outcome of the meetings on quality assurance in nuclear medicine was an internationally coordinated study to evaluate the performance of nuclear medicine imaging devices, which began in September I98I in collaboration with the College of American Pathologists and the Physics Department, Westminster Hospital, London. Another study brought out the need for an internationally coordinated quality assurance programme to improve radiotherapy.
There was close collaboration be8.56 tween IAEA and WHO. The thermolumi-
8. 58 Radiation protection activities continued in relation to the medical use of ionizing radiation. Film badge services were provided to I4 Member States in four regions. These services are provided free of charge by the Service central de Protection contre les Rayonnements ionisants, France, and the Gesellschaft fiir Strahlen- und Umweltforschung, Federal Republic of Germany. In addition, WHO participated in the redrafting of publications of the Inter-
94
DIAGNOSTIC, THERAPEUTIC, AND REHABILITATIVE TECHNOLOGY
national Commission on Radiological Protection dealing with the medical use of ionizing radiations. It also participated in the work of the International Commission on Radiation Units and Measurements and the International Electrotechnical Commission on standards for electromedical equipment. 8.59 In South-East Asia pilot projects were set up in selected countries to study basic radiological services as an integral part of primary health care. Radiation health protection was promoted through a regular supply of films to Bangladesh, Burma, Mongolia, and Nepal for personal dosimetric measurement. Standardization of radiotherapy was furthered through the increasing participation of radiotherapy departments in the IAEAfWHO dosimetry intercomparison programme (see paragraph 8.56). The development of nuclear medicine was promoted through advisory services to the Democratic People's Republic of Korea and India. In the Region of the Americas 8.6o efforts were made to develop a basic X-ray system for health centres and front-line hospitals. Clinical field trials of the basic radiology system are being carried out. Quality assurance in radiotherapy was promoted through intercomparison studies for cobalt-Go teletherapy units, carried out in collaboration with IAEA. In nuclear medicine quality assurance was furthered through cooperation with regional and national nuclear medicine soc1et1es in Brazil, Colombia, and Uruguay. Radiation protection services have been established within the ministries of health in 1 3 countries, with the assistance of the Regional Office. They cover instrumentation and methods for radiation measurement, calculation of radiation shielding, personal dosimetry services for workers, radiation control regulations and inspections, training of personnel, and prevention of radiation accidents. 95
Rehabilitation 8.61 In response to resolutions WHA29.68 and WHA34·3o, WHO embarked on a programme (i) to design and evaluate schemes aimed at minimizing disability through prevention and rehabilitation, (ii) to develop and test training packages and learning material, (iii) to promote innovative approaches to rehabilitation and support the planning, implementation, and evaluation of projects, and (iv) to cooperate with other organizations in the United Nations system, nongovernmental organizations, and other interested parties in the development and implementation of the new policies and programmes in rehabilitation. 8.62 Emphasis was placed on refining and further developing the concept of disability prevention and rehabilitation within the context of primary health care. Guidelines were prepared on community-based disability prevention and rehabilitation as a part of health and development systems at all levels. A manual on training the disabled in the community was prepared and distributed for trial, evaluation, and adaptation to local settings. Field testing of the manual was carried out in Botswana, Burma, India, Indonesia, Mexico, Nepal, Nigeria, the Philippines, Saint Lucia, and Sri Lanka. The programme was endorsed by 8.63 the WHO Expert Committee on Disability Prevention and Rehabilitation (February 1981). 1 UNICEF actively supported the programme and substantial extrabudgetary resources were obtained for it. 8.64 National and intercountry workshops on community-based rehabilitation were organized in Botswana, India, Nigeria, and Saint Lucia, to foster implementation of the programme and assist in the development t
WHO Technical Report Series, No. 668, r98r.
THE WORK OF WHO, •98o--I981
of the necessary manpower. Development projects for training, research, and service delivery were started in Botswana, India, Mexico, Nigeria, and Saint Lucia. Support was given to disability studies in five countries. 8.65 WHO hosted an interagency meeting in Geneva and actively collaborated at meetings in Paris and Vienna as well as in regional technical meetings on the International Year of Disabled Persons, I 98 I. It played an active role in a meeting on the prevention of disablement organized by the Government of the United Kingdom (November I 98 I) and attended by a large number of international experts, including representatives of many intergovernmental and nongovernmental organizations. The meeting particularly emphasized the prevention of disability due to age, to accidents, and to communicable diseases against which immunization is effective. Its outcome was the Leeds Castle Declaration on the Prevention of Disablement, which clearly defines the areas where impairment is preventable and sets out an action programme as part of the follow-up to the International Year of Disabled Persons. 8.66 In the African Region the National Orthopaedic Hospital, Lagos, was designated as a WHO collaborating centre for training and research in orthopaedics and rehabilitation. Its activities in community-based programmes were supported. 8.67 In the Americas a programme of simplified rehabilitation at community level was introduced in Mexico and the Caribbean area and was promoted by a training workshop held in Saint Lucia in May-June I981. Support in prosthetics and orthotics was given to Bolivia, Colombia, Ecuador, El Salvador, and Peru.
8.68 In South-East Asia aid was provided to countries, in connexion with the International Year of Disabled Persons, to assess the social and health status of the elderly in the community. Participants from Bangladesh, India, Nepal, and Thailand attended regional and global preparatory meetings organized in Melbourne, Australia, in December I98o. 8.69 Pilot demonstration projects were established in collaboration with the Medical College, Trivandrum (India) to train health and allied personnel in disability prevention and rehabilitative services through primary health centres affiliated to the College. In collaboration with UNICEF, national meetings were sponsored for planning and implementing rehabilitation programmes for the different categories of disabled in the community. Community-oriented disability prevention and rehabilitation training centres were set up in Burma, with ILO and WHO as the executing agencies. A national sample survey of the disabled was sponsored in Nepal and technical assistance was provided to India and Indonesia for the analysis of WHO-aided disability surveys. Research and development were promoted to meet the national demand for orthotic and prosthetic appliances by utilizing appropriate technology and local resources.
8. 70 In the European Region the Institute of Physical Medicine and Rehabilitation, Hercegnovi, Yugoslavia, was designated as a collaborating centre. A working group on disability in the elderly (Cologne, Federal Republic of Germany, November I 9 8 I) established guidelines and priorities for disability prevention programmes. 8. 7 I In the Eastern Mediterranean Region support was given to national actlvltles in Iraq, Israel, Jordan, Lebanon, Pakistan, Saudi Arabia, and the Syrian Arab Republic, with the aim of assisting in the development of national programmes of
DIAGNOSTIC, THERAPEUTIC, AND REHABILITATIVE TECHNOLOGY
disability prevention and rehabilitation, including prosthetic and orthotic services. A research project on community-based rehabilitation was started in Pakistan. 8. 7 2 In the Western Pacific Region a working group on rehabilitation and disability prevention (Manila, December I98I) formulated recommendations and guidelines on WHO's collaborative role in the development of regional and national programmes on disability prevention and rehabilitation and outlined practical ways for the implementation of such programmes.
8. 7 5 The WH 0 expert advisory panel on traditional medicine now has over 40 members from a wide variety of health and allied health disciplines with geographical representation of all six WHO regions. The wide range of disciplines is necessary in view of the role of traditional medicine in such fields as fertility regulation, treatment of infertility, control of tropical endemic diseases, drug dependence, anaesthesia, and analgesia. 8. 76 Some African and Asian countries have already created departments for traditional medicine in ministries of health and universities. In the Western Pacific Region training courses in acupuncture and study tours on traditional medicine were organized in China, with participants from four WHO regions. In Kiribati, Papua New Guinea, and the Philippines medicinal plants and traditional medicine were studied. An interregional meeting on the standardization and use of medicinal plants was held in Tianjin (China) in I98o. With UNDP support, WHO collaborated with China in the development and establishment of a research centre in traditional medicine. It cooperated with Viet Nam in relation to the cultivation, preparation, distribution, and use of medicinal plants as well as in the preparation of a pharmacopoeia of traditional medicine. A meeting of ASEAN ministers of health (Philippines, I 9 So) to promote technical cooperation called for collaboration in primary health care and traditional medicine. Advisory services were provided by WHO at the request of the Government of China for a cooperative programme on the nomenclature of standard acupuncture points.
Traditional medicine 8. 73 During the period under review increasing interest in traditional medicine was shown by several countries and recognition was given by some governments to traditional and indigenous health care systems.l Collaborating centres for traditional medicine were established in Africa, the Americas, Asia, and Europe to carry out research in the evaluation of medicinal plants and herbal remedies, in the mechanisms of acupuncture, in the training of potential scientists from developing countries, and in the collection and analysis on a global basis of information relating to traditional medicine. 8.74 A coordinating meeting of directors of WHO collaborating centres for traditional and indigenous systems of medicine was held in Geneva (November I 98 I). It indicated the need for additional collaborating centres, particularly in the developing countries, reviewed and compared the research carried out, and established future strategies for research and training.
1 See paragraphs birth attendants.
12.20
and
12.87-12.89
for traditional
8.77 In August I98o the Regional Office for Africa, with support from DANIDA, organized a meeting at Accra at which 2 5 participants from Ethiopia, Kenya, Lesotho, Nigeria, Sierra Leone, Uganda, the United Republic of Tanzania, and Zambia considered collaboration between practitioners
97
of traditional and of allopathic medicine, collaboration that should ultimately lead to improved health coverage of the population. The first meeting organized by Angola on traditional medicine with the participation of healers and doctors was supported by WHO. Some countries in the African Region have already drawn up legislation and regulations governing traditional medicine and its allied activities. Four WHO collaborating centres for traditional medicine were established, in Ghana, Mali, and Nigeria; and there are plans for further centres in the Region in the near future. 8. 78 Three collaborating centres for traditional medicine were established in the Americas in I98I, two in the United States of America (Chicago and New York) and one in Mexico. WHO participated in a meeting on medicinal plants and traditional herbal remedies held in Mexico in I981. 8. 79 In South-East Asia two collaborating centres for traditional medicine are now in operation in India, one in Jamnagar and the second in V aranasi. Centres will be established in other countries as soon as the formalities have been concluded. An intercountry meeting on the development of research protocols on priority areas in traditional medicine was held in V aranasi in I98o. Advisory services were provided to a number of countries in the Region: to Burma and Sri Lanka, for example, which are developing national programmes on traditional medicine. A national workshop on the promotion and development of traditional medicine was held in Dacca in I98o and on the basis of its recommendations advisory services are being provided by WHO to assist in the development of a systematic programme. The Government of Burma, with the support of WHO and UNDP, plans to strengthen the Institute of Indigenous Medicine in Mandalay as well as existing traditional medicine hospitals and
dispensaries by establishing another 30 dispensaries. WHO also provided assistance in the development of medicinal herbs and ayurvedic drugs. The Government of Maldives is planning to train practitioners of traditional medicine for primary health care. In Sri Lanka a Ministry of Indigenous Medicine has now been established. WHO co-sponsored the Seventh World Congress on Acupuncture held in Colombo in I 98 I. 8.8o In the Eastern Mediterranean Region formalities are under way for the establishment of two WHO collaborating centres and other centres are under review. WHO collaborated with the International Organization of Islamic Medicine in connexion with the Second International Conference on Islamic Medicine, to be held in Kuwait in I982. 8.8I A handbook for health administrators and practitioners on traditional medicine and health care coverage is in preparation. It will be of use to health administrators and practitioners in understanding the variety of health care facilities available to and used by local populations. It will contain information on the present state of the law in relation to traditional medicine and its practitioners and there will be a chapter on the role of WHO.
Essential surgical care 8.82 The programme of essential surgical care was established on I February I981. Its aim is to assess the basic surgical facilities at primary health care level and to draw up a list of the essential minimum equipment for use at first referral hospital level. For that purpose liaison is being established with nongovernmental organizations in the field of surgery, surgical specialties, anaesthesia, nursing, and first-aid care.
DIAGNOSTIC, THERAPEUTIC, AND REHABILITATIVE TECHNOLOGY
8. 83 Contact has been made with surgical societies in Member States through the International Federation of Surgical Colleges and the International College of Surgeons. Comments have been received about the programme itself and about a list of surgical equipment circulated to them that was the product of an earlier consultation between WHO and the International Federation. Informal consultations were held with the World Federation of Societies of Anaesthesiologists and steps are being taken for a joint review of anaesthetic literature, equipment, and drugs. Consideration is being given to the quality control of surgical instruments, implants, and other bioengineering equipment extensively used in surgery at present. Preliminary discussions were held with a group of bioengineers belonging to the International Society for Prosthetics and Orthotics.
On the basis of its recommendations, proposals were made on ways in which WHO could support national and regional strategies. The Conference was the first worldwide review of accident prevention policies. 8.85 WHO participated with the International Children's Centre (Paris) in community surveys of accidents in Benin, Brazil, Senegal, and Turkey with the aim of preparing a manual on injury prevention and treatment for use by primary health workers. In cooperation with the United States National Institute for Drug Abuse, guidelines were drawn up on international cooperation and research on the role of drugs in accidents. Guidelines were also prepared in the framework of the International Year of Disabled Persons and presented to national committees for the International Year; they emphasize the need for education on pedestrian and driver safety in schools and industrial undertakings. The national programmes for the International Year attracted attention in several Member States to road accident prevention. In Africa various projects in mental 8.86 health, workers' health, disability prevention, and rehabilitation have highlighted the toll of disability and death exacted by road traffic accidents. The role of alcohol consumption in road traffic accidents was studied in Zambia as part of a WHO-supported project on the community response to alcohol problems (paragraphs 7.6 and 7·37)· In collaboration with ILO, meetings were held on problems of workers' health and safety in three Member States. At these meetings control of the work environment, improved knowledge on safety, and reduction of drug and alcohol consumption were emphasized as essential steps in the prevention of accidents at work, on the roads, and in the home. 8.87 In the Americas, where road accident cases occupy up to 30% of hospital 99
Prevention of road traffic accidents 8.84 In many developing countries industrialization and urbanization are rapidly changing lifestyles and creating environmental hazards, among which road traffic accidents rate as one of the most harmful to health, especially among the young. The initial, and main, focus of the programme has been to assess the extent of this problem in developing countries, to draw the attention of governments to its health and socioeconomic consequences, and to promote intersectoral cooperation in dealing with it. A survey in 4 I developing countries provided epidemiological information and highlighted some of the main human and environmental features of transport accidents in those countries. The findings were presented at an Interregional Conference on Road Traffic Accidents in Developing Countries (Mexico City, November 1981) at which 50 countries, including the 41 mentioned above, met to formulate national strategies for prevention.
THE WORK OF WHO, r98o-r98r
surgical beds, a regional plan of action is being developed to support national prevention programmes. 8. 8 8 In South-East Asia a regional profile of the accident problem was prepared for the Interregional Conference on Road Traffic Accidents (paragraph 8.84). WHO cooperated with India, Sri Lanka, and Thailand in relation to the implementation of national plans for accident prevention. 8.89 The European Region continued to promote intersectoral cooperation on road accidents at national level and guidelines on the role of health services were drawn up. In cooperation with the Government of Belgium, a document was issued on psychosocial factors relating to accidents in children that provides guidelines for health service intervention and for further research. In the framework of the International Year of Disabled Persons, a symposium on the epidemiology of accident injuries and resulting disabilities identified priorities for intervention and research (see also paragraphs I 5. 73 and I 5. 74). A review of major national road safety policy issues was also begun, in cooperation with Finland, France, and the United Kingdom. The first WHO collaborating centre for the accident prevention programme was designated in the United Kingdom, at the Transport and Road Research Laboratory, London. 8.90 In the Eastern Mediterranean an assessment, completed by I 6 countries and analysed by the above-mentioned collaborating centre, demonstrated the urgent need for appropriate measures to prevent road accidents. It called for intersectoral cooperation between ministries and departments at national level. 8.9I A multidisciplinary meeting on road traffic accidents was organized in Kuwait in March I98I, with WHO support, by the IOO
Secretariat-General of the Council of Ministers of Health of the Arab Countries of the Gulf Area. The meeting set the frame for coordinated action and highlighted the main national issues to be considered. The conclusions of this meeting were thoroughly discussed at the Interregional Conference described in paragraph 8.84. The Western Pacific Region used its programme to make a contribution to that Conference.
Care of the aged 8.92 WHO participated in the preparations for the United Nations World Assembly on Aging, to be held in I982. It was represented at an interagency meeting on the elderly and the aged (Vienna, SeptemberOctober I98o) to coordinate the contributions of the various agencies. A preparatory conference for the World Assembly was convened by WHO in December I98o in Mexico City. 8.93 The orientation of the programme on care of the aged towards health service development was manifest in the work of a meeting on services and systems of care for the elderly (Helsinki, October I98o) and of another on appropriate levels of continuing care (Berlin (West), November I98o). A book was published on the provision of services for care of the aged.l There was also a trend towards closer consultation with national policy-makers and directors of national gerontological institutes. WHO reports appeared on nutrition, the education of physicians, and the role of nursing in relation to care of the aged. (For work in psychogeriatrics, see paragraphs 7.26 and 7.27.)
1 Kinnaird, J. et al., ed. The provision of care for the elder!y. Edinburgh and London, Churchill Livingstone, r98r.
DIAGNOSTIC, THERAPEUTIC, AND REHABILITATIVE TECHNOLOGY
8.94 The technology component of the programme was not overlooked. A meeting was held on the use of medicaments by the elderly (paragraph 8. 12); a three-volume book on scientific and social aspects of aging was published on behalf of WHO ;1 and a WHO study group reported on neuronal aging and its implications in human neurological pathology in December 198o.2
WHO co-sponsored a symposium in Hamburg, Federal Republic of Germany, on aging in developing countries. In the Western Pacific a working group on health care of the elderly met in Manila (August 1981). Advisory services were provided to Bangladesh, Burma, India, Indonesia, and Thailand. 8.96 In the African Region WHO endeavoured to promote the use of epidemiological data and knowledge of lifestyles and general environmental conditions to identify factors harmful to the health of the elderly. Preliminary studies began in that Region to assess mortality and morbidity and the environmental conditions of the aged. Traditionally the aged were cared for within the family, but the migration of young workers is now leaving them in social isolation and without economic support. The aim of the studies is not only to obtain precise data but also to make governments aware of the growing problem.
The geographical coverage of the programme was greatly expanded during the biennium. An interregional working group on the care of the elderly in the developing countries of Asia and the Pacific met in Melbourne, Australia (December 198o). 8.95
1 These three volumes were published under the general title Aging: a challenge to science and society. Vol. 1 : Biology, ed. Danon, D. & Shock, N.W. Vol. 2: Medicine and social science, ed. Gilmore, A.J.J. et a!. Vol. 3: Behavioural sciences and conclusions, ed. Birren, J .E. et a!. London, Oxford University Press, 1981. 2 \1\'HO Techntcal Report Senes, No. 665, 1981.
101
Chapter 9
Communicable Disease Prevention and Control cOMMUNICABLE diseases, complicated by malnutrition and other adverse socioeconomic factors, continued to contribute to the inordinately high levels of mortality, morbidity, and disability in all developing countries, particularly in the under-five age group. Member States and WHO intensified their activities against major killers such as malaria and other parasitic diseases, acute diarrhoeal and respiratory infections, tuberculosis, and early childhood infections. Significant developments also took place in science and technology, in several cases promoted by an impressive expansion in global and regional collaborative research. 9· I her I98I to develop guidelines for contingency planning and establish requirements for national emergency services and criteria for regional and global collaboration.
Post-eradication activities in smallpox and epidemiological surveillance of communicable diseases 1 The case recorded in October I977 in Somalia remains the last known case of endemic smallpox in the world and, in May I98o, the Thirty-third World Health Assembly solemnly decl~red that smallpox eradication had been achieved throughout the world (resolution WHA33·3) and that there was no evidence that it would return as an endemic disease. The Health Assembly endorsed the recommendations on posteradication policy made by the Global Commission for the Certification of Smallpox Eradication (resolution WHA33.4), activities in I98o and I98 I being the implementation of those recommendations. In May I98I the Thirty-fourth World Health Assembly excluded smallpox from the list of diseases subject to the International Health Regulations (I969). 9·3 For training in epidemiology, see paras
9.2 Epidemics and pandemics of viral, bacterial, parasitic, and toxic origin occurred and will continue to present a threat because epidemiological surveillance is inadequate, preventive measures are deficient, and man continues to disturb his environment. Acquired resistance and natural insensitivity to chemotherapeutic agents, hospital infections, and vector resistance to chemical pesticides impede progress against disease and increase the costs of control. To review emergency situations in the light of WHO's past experience of epidemics, an informal consultation on strategies for the control of emergencies caused by epidemics of communicable disease was organized in NovemIOZ
1
I2.I6o--
I2.I62.
COMMUNICABLE DISEASE PREVENTION AND CONTROL
Vaccination poliry 9·4 The Health Assembly recommended that routine smallpox vaccination should be discontinued in every country except for investigators at special risk. At the end of I 979 routine smallpox vaccination was still continuing in 5I countries; however, by December I98I it had been officially discontinued in I44 Member States. In six countries it remains obligatory and in another six countries information about the situation is being sought. WHO is making every effort to discourage the continuation of vaccination and, except in Chad, a smallpox vaccination certificate is no longer required from international travellers.
laboratories have transferred or destroyed their stocks of virus and, in October I98I, only the five laboratories listed in Table 9· I retain stocks. These laboratories have been inspected periodically by a WHO team of experts to ensure that the variola virus stocks are being kept under strict control.
Table 9.1 Laboratories retaining variola virus as at 1 October 1981
Laboratory Centers for Disease Control * National Institute of Virology Research Institute of Viral Preparations* Rijksinstituut voor de Volksgezondheid * Centre for Applied Microbiology and Research*
City/country Atlanta, Georgia, USA Sandringham, South Africa Moscow, USSR Bilthoven, Netherlands Parton Down, United Kingdom
Reserve stocks of smallpox vaccine 9· 5 WHO has established two refrigerated depots for vaccine storage in Geneva and New Delhi. In I98o and I98I, 5ooooooo doses of smallpox vaccine were donated by the USSR, 6 030 ooo doses by India, and 2 ooo ooo doses by Belgium for the emergency reserve. WHO stocks are now sufficient to vaccinate more than 200 million people using the bifurcated needle. A timetable has been prepared for vaccine sampling at the WHO collaborating centre in the Netherlands during the next Io-year period to monitor the potency of the vaccine. Seed lots of vaccinia virus suitable for the preparation of smallpox vaccine and reference vaccine for potency testing are being maintained in designated WHO collaborating centres. In addition, many national producers retain their own batches of seed virus.
* Laboratories acting as WHO collaborating centres.
Investigation of suspected cases of smallpox 9· 7 The Organization has maintained surveillance of suspected cases of smallpox in collaboration with countries where the cases have been reported. Since January I98o, 55 rumours from 29 countries have been reported to WHO and found to be false alarms consisting of misdiagnosed cases of chickenpox, measles or other diseases, or errors in recording. A document1 has been prepared and widely distributed to facilitate appropriate investigation of any rumour of smallpox reported to national health authorities. It is important to note, as stressed in the
Variola virus stocks in laboratories 9.6 At the end of I979 seven laboratories retained variola virus. WHO has continued to discourage its retention. Since then, two 1 Management of suspected cases of smallpox in the post-eradication era (WHO document SE/So. I 57 Rev. I), I980.
document, that vaccination should not be done unless the presumptive diagnosis of smallpox is confirmed through examination by a physician with extensive experience in the clinical diagnosis of smallpox and demonstration of poxvirus particles by electron microscopy. WHO collaborating centres in Atlanta (USA) and Moscow have participated in the laboratory diagnosis of suspected cases of smallpox as required during the surveillance activities.
Laboratory investigation and research
Human monkrypox
9.8 The Thirty-third World Health Assembly specifically recommended special surveillance of human monkeypox. In I98o and I98I six cases of the disease were reported from Zaire and one from the Ivory Coast. Since human monkeypox was first identified in Zaire in I 970, 57 cases of the disease have been detected. In April I98o a seminar with participants from I 3 countries in Africa was held at the Regional Office for Africa, Brazzaville, to coordinate surveillance activities in countries where human monkeypox had occurred or its presence was suspected. Detailed guidelines were developed to establish a monkeypox surveillance system. Accordingly, in I98o and I98I WHO organized and assisted special surveillance programmes on human monkeypox in Congo, the Ivory Coast, Sierra Leone, and Zaire. Medical personnel from hospitals and health units in tropical rainforest areas of those countries were trained to recognize and report the disease. In addition, serological surveys to determine the prevalence of orthopoxvirus antibodies in unvaccinated children were conducted in those areas. A total of I 2 ooo serum specimens were collected and will be screened for poxvirus antibodies, then tested for antibodies specific to monkeypox, so as to estimate the prevalence of the disease and its public health importance in the posteradication era. I04
9·9 WHO continues to encourage and coordinate research on orthopoxviruses, which is essential to promote post-eradication surveillance activities. It includes the development of simple and reliable screening tests for orthopoxvirus antibodies and tests for the detection of antibodies specific to monkeypox virus or other species of orthopoxvirus. Further development of these methods involves the production of monoclonal antibodies specific to different species of poxvirus. These studies will enable WHO to estimate the effectiveness of the special human monkeypox surveillance programme. Increasingly detailed studies of DNA from monkeypox and variola viruses and of the persistence of monkeypox virus in various animals are needed. In I98o and I98r virologists from WHO collaborating centres met to discuss the technical aspects of research related to WHO smallpox post-eradication strategies and agreed on the direction orthopoxvirus research should take for the next five-year period.
Committee on orthopoxvirus infections
9· Io A committee on orthopoxvirus infections has been established to review regularly the Organization's activities and ensure that they meet the recommendations made by the Thirty-third World Health Assembly for smallpox post-eradication policy.
Documentation
9· I I Publications supported by WHO include books on the eradication programmes in Bangladesh, Ethiopia, India, and Somalia. All relevant scientific, operational, and administrative data of the smallpox eradication programme are now being catalogued with a
COMMUNICABLE DISEASE PREVENTION AND CONTROL
view to their retention for archival purposes. Preparations were begun for the publication of a monograph on smallpox and its eradication.
malaria. In IO countries the risk of malaria is minimal, while in large parts of the remaining 9 3 the risk is moderate to high. 9· I 5 Approximately I 8oo million people living in I03 countries or areas are exposed in varying degrees to the risk of malaria (see Figure 9· I and Table 9.2). In I98o more than 2 I o million people were chronically infected or suffered from acute malaria. In Europe malaria transmission is recorded only in Turkey, where 35 ooo cases were detected in I98o, mostly from the Asian part of the country. In Europe malaria contracted abroad (3 500 cases per year) is a cause of significant mortality because of inadequate prophylaxis and, often, late diagnosis. In Africa north of the Sahara the incidence is less than I ooo cases a year.
Vaccination requirements for international travel
9· I 2 Because no traveller now needs to be vaccinated against smallpox, the opportunity was taken in the I98I edition to change the format and increase the scope of the booklet on vaccination certificate requirements for international travel so as to provide more general health advice.! The booklet is addressed to national health administrations, which have the responsibility (coopting as necessary the aid of the medical profession, tourist agencies, shipping companies, airline operators, and other bodies) for advising travellers on the risks they might encounter when visiting other countries. 9· I 3 In addition to providing information on malaria, which is being increasingly reported among travellers, the booklet covers a number of health hazards and indicates where they most frequently occur. It also mentions the precautions that should be taken against certain diseases.
Strategy of malaria control
Malaria During I98o-I98I malaria in individual countries or areas generally followed the trend observed in the period I978-I979· Although in some countries a noticeable reduction in the number of cases was observed, in most no such progress was reported. Out of I43 countries or areas wholly or partly malarious, 40 have been freed and continue to be free from autochthonous 9·I4 1 World Health Organization. Vaccination certificate requirements for international travel, and health advice to travellers: situation as on I January I98I. Geneva, 198 r.
The period I98o-I98I marked the finalization and implementation of the global medium-term programme for malaria, its objectives being to prevent and control malaria epidemics, prepare long-term malaria control programmes, train personnel to meet present and future manpower requirements, and promote research primarily to develop better instruments and methods for malaria control. The main approach is through a worldwide strategy requiring the development of realistic national plans based on malaria endemo-epidemicity levels and available manpower and financial resources. 9.I6
pursuance of resolution the Director-General submitted a progress report on malaria control strategy to the Executive Board at its sixty-fifth session and to the Thirty-third World Health Assembly. The Executive Board decided to undertake a more detailed study of the implementation of the malaria action programme. This was carried out in I98o by the WHA 31.4 5,
9· I 7
In
Figure 9.1
Epidemiological assessment of
CAPE VERDE
D
AREAS IN WHICH MALARIA HAS DISAPPEARED,
D
AREAS WITH LIMITED RISK
•
AREAS
106
COMMUNICABLE DISEASE PREVENTION AND CONTROL status of malaria, December 1 980
MAC40
/Q 60 !\ ·~.r·
I
HONGKONG
J MALDIVES
~~ • •'111 "4'~
~
0
...
_____.
COMOROS
,P
MAURITIUS
VANUATU
... \
BEEN ERADICATED, OR NEVER EXISTED
WHERE MALARIA TRANSMISSION OCCURS
WHO li11Ul7
THE WORK OF WHO, 198o-198I
Table 9.2
Global malaria situation in 1980
Zone
Number of countries or areas affected
Population at risk (millions)
Estimated number of infections
Africa south of the Sahara Asia and Oceania Central America South America Africa north of the Sahara, and Europe* • Including the Asian part of Turkey.
45 31 10 11 6
313 1400 21 22 40
160000000 50000000 1 300000 1 300000 36000
Board's Programme Committee, whose report to the sixty-seventh session of the Board endorsed the line of action proposed by the Director-General for the implementation of the malaria control strategy in endemic countries showing a clear commitment. 9· I 8 A strategy for malaria control within primary health care for Africa is being developed with the aim of reducing mortality and incapacity by making antimalarial drugs available and of protecting the populations in urban and rural communities so as to improve productivity and reduce maternal, fetal, and neonatal mortality. The programme design is guided by the social target of health for all by the year 2ooo and, as it is based on the primary health care approach, is in keeping with the reorientation of the malaria strategy ap~roved by the Thirty-first World Health Assembly. It has been formulated to meet ecological, epidemiological, and socioeconomic criteria, and Member States have been invited to give priority to their national malaria control strategies, which when combined are expected to lead to the adoption of a regional strategy. Malaria control must be intensified to save human lives and enable the population to benefit from the socioeconomic advantages control brings. 9· 19 The global Malaria Advisory Committee met in I98o and again in 1981. In 1980
the Committee felt that most countries with active malaria control or eradication programmes were preoccupied with controlling epidemics and preventing the further spread of the disease, little attention being paid to an epidemiological approach. It was also noted that an acute shortage of trained and experienced personnel was hampering the reorientation of control. In I 98 I the Committee emphasized the need to maintain a nucleus of specialized persons to plan, supervise, and evaluate antimalaria activities, through horizontal services wherever these proved to be effective enough to secure the necessary coverage of the population at risk. The Committee also stressed the need for a better information system to provide the malaria action programme with reliable data, which would greatly facilitate planning of the global programme and assessment of its progress.
9.20 A second Indian Ocean inter-island seminar on malaria and other communicable diseases was convened in Reunion under the auspices of the health authorities of Reunion and WHO. It stressed the need to develop regional programmes based technically and financially on intercountry and multilateral cooperation and to develop appropriate antimalaria strategies based on the local situation or take effective steps to prevent the reintroduction of malaria.
108
COMMUNICABLE DISEASE PREVENTION AND CONTROL
Position in the regions 9.21 In the African Region there were 42 malarious countries or areas and approximately 300 million persons live in areas at risk of malaria. In addition to causing high mortality among infants and young children, the disease also affects the output of workers and inhibits socioeconomic development. Malaria is one of the five leading causes of mortality and morbidity in tropical Africa and accounts for 15-20% of all hospital admissions. Lesotho, Seychelles, St Helena, the western Sahara, and the major part of South Africa are naturally free of malaria. Reunion was officially registered as having eradicated malaria. In Mauritius, however, cyclones have contributed to the recent reestablishment of malaria transmission.
9.23
In the South-East Asia Region malaria continues to be a problem in eight of the 10 Member countries. The problems of vector resistance to insecticides and of parasite resistance to drugs have yet to be solved. Nevertheless, the shift in strategy from eradication to control has shown encouraging results in some areas. There is however an urgent need to strengthen some of the programmes. During the period under review the resistance of Plasmodium falciparum to sulfonamide and pyrimethamine combinations emerged and is threatening progress in control. Efforts are being made to prevent the spread of resistance through intersectoral coordination and cooperation in border areas and a drug resistance monitoring programme. 9· 24 In the European Region a conference on the coordination of antimalaria activities in south-east Europe (Brice, Sicily, October 1979) emphasized the need for additional efforts to adjust the nature and intensity of vigilance to the risk of transmission, and for periodic review of activities in the light of environmental and social change. In countries where malaria transmission exists a special effort is needed to strengthen cooperation with neighbouring countries by exchanging technical information and conducting appropriate antimalaria activities in border areas. The role and participation of European countries in the fight against malaria in the world were discussed at another conference held in the Region (Cagliari, Sardinia, October 198o). 9.25 In the Eastern Mediterranean Region, as far as can be ascertained from the available information, the malaria situation and malaria control in Afghanistan and Iran have considerably deteriorated. In parts of other countries conflicts have hampered normal antimalaria acttvttles and surveillance. Refugees in several countries of the Region pose a special problem and efforts have been
9.22 In the Region of the Americas, the countries of which differ widely in the relative intensity and distribution of malaria and in resources and general development policies, a continental plan was formulated for the promotion and support of malaria programmes. To date, 12 countries of the Region have reformulated their plans of action and five more have requested programme review teams in 1981. As a general principle programmes aim at preserving effective operational capacity based on precise timing and coverage, and at mobilizing community and government resources for all activities. Most programmes need funds for new human and material resources and for the structural changes required for the implementation of new strategies. As an essential part of the continental plan, it is proposed that experience in countries should be analysed and collated with a view to guidelines of regional or global applicability. A special effort is being accorded to the development of primary health care systems in interaction with the malaria programmes. The plan includes a continental training programme to be carried out through a coordinated network of institutions.
THE WORK OF WHO, 198o-1981
made to prevent or contain serious malaria outbreaks among them. 9.2.6 In the Western Pacific Region Australia was officially certified malaria-free by WHO, thus bringing the number of countries or areas registered to 2.4. Singapore's certification is still under consideration. The Regional Committee urged Member States to prevent the establishment of imported malaria vectors, to provide adequate diagnostic and treatment facilities, to coordinate antimalaria operations along common borders, and to disseminate and exchange information. A comprehensive review was made of antimalaria programmes in countries with endemic malaria. Considerable progress has been achieved in some countries, especially Malaysia, but in others there have been setbacks owing to adverse climatic conditions, budgetary constraints, and other factors. 9.2.7 WHO cooperation was obtained by 10 Member countries for the assessment and planning of antimalaria activities (Algeria, Democratic Kampuchea, India, Indonesia, Maldives, Mauritius, Pakistan, Sri Lanka, the Syrian Arab Republic, and the United Republic of Tanzania).
therapy of malaria was published in I981. 1 It reflects the therapeutic progress made during the past three decades and provides practical guidance in this increasingly difficult field.
Training and research 9.2.9 Once countries have defined their priorities and approaches, estimated their resources, and determined their training requirements, it is of paramount importance that they should develop and maintain national training facilities to provide the necessary expertise for the planning, implementation, and evaluation of malaria control programmes. For this purpose, a permanent secretariat for coordinating the malaria training programme in Asia is being developed as a cooperative effort of national training centres and WHO, with possible bilateral contributions. Its task is to cooperate with national centres in the development of curricula, the provision of teaching aids and consultant teachers as necessary, and the organization of courses for the training of teachers. Funds were provided from the Director-General's Development Programme for the establishment of the permanent secretariat and the Government of Malaysia has agreed to house it. 9· 30 The malaria action programme is accelerating the development of the skills necessary for malaria control and promoting greater national expertise through specially arranged fellowships tailored to the needs of individuals and countries. This programme was slow in starting because of difficulty in finding suitable candidates, but it has now gained impetus.
Dissemination 9.2.8
of information
WHAI0.32., WHAI
application of resolutions 3·5 5, and WHA2.2..48, yearly reviews of malaria were published in the Week!J Epidemiological Record, and information regarding risks and advice on prophylaxis for travellers were made available to national health administrations, the medical profession, institutions, and bodies dealing with international travel (see paragraphs 9· I z-9. I 3). A second, entirely revised edition of the WHO monograph on the chemoIIO
In
I Bruce-Chwatt, L.J ., ed., et al. Chemotherapy of malaria, second edition. Geneva, World Health Organization, 1981 (WHO Monograph Series, No. 27).
COMMUNICABLE DISEASE PREVENTION AND CONTROL
9· 3I A seminar on the planning and execution of applied malaria research was conducted in Shanghai in I98o with the participation of staff from malaria control services and scientific institutions. It was followed by a workshop on malaria epidemiology and mathematical modelling. An international course on continuous in vitro cultivation and its application in malaria research was held in Moscow in I98o. 9· 32 In view of the increasing problem of drug-resistant P. falciparum in large parts of eastern Asia and South America and the serious threat it poses to other malarious areas of the world, further efforts were made to train national personnel in the standard techniques of drug sensitivity testing. Four regional workshops were held-in Cotonou, Geneva, Kuala Lumpur, and Sennar (Sudan) -and several subregional or country courses were held in the American, European, SouthEast Asia, and Western Pacific Regions. Most were supported by the Special Programme for Research and Training in Tropical Diseases, which also supported most of malaria research. This research, which is reviewed in paragraphs 9·233-9.237, is a coordinated activity of the Special Programme and the malaria action programme.
in cooperation with the Government of Turkey, is developing a pilot project and demonstration area in the south of Turkey, where a primary health care system will be developed simultaneously with antimalaria activities and the control of waterborne diseases. 9·34 After an II-year gap the Seventh Asian Malaria Conference was convened in Manila in November I 980. Participants from 25 Member countries in four WHO regions discussed the current malaria situation, emphasizing the need for planning, supervision, evaluation, and specialized training. The Conference examined the link between malaria control strategies and primary health care. It recommended the inclusion of specific malaria control targets within national strategies for health for all by the year 2000 and the clear defmition within the health plans of each country of the functions and responsibilities of the persons to be involved in the delivery of primary health care services. Cooperation between countries for the optimum utilization of available training resources, and continuing and increasing support for basic and applied field research in malaria were considered to be essential.
Malaria control and primary health care 9· 33 Representatives from UNICEF, USAID, the United States Public Health Service, and WHO at a malaria coordination meeting concluded that long-term malaria control should be an integral part of primary health care, since it requires a high degree of coverage in space and time, which could be provided through this approach. Experience from the implementation of antimalaria programmes should be taken into consideration when planning appropriate systems. In this regard the malaria action programme, through the Regional Office for Europe and II I
Other parasitic diseases 9· 3 5 Parasitic diseases remain among the most ubiquitous and serious public health problems in developing countries, with a depressingly high prevalence of the major protozoan and helminthic infections.
Schistosomiasis 9· 36 In many countries agricultural reliance on irrigation techniques has led to increases in the incidence, prevalence, and intensity of schistosomiasis. The construction
THE WORK OF WHO, r98o-r98r
of various types of dam, from small village ponds to large manmade lakes, has aggravated and will aggravate the situation in endemic areas. Schistosomiasis is a social and economic scourge and, paradoxically, one that is frequently created by man in his development efforts. 9· 37 In collaboration with national and nongovernmental organizations, WHO continued to promote awareness of the importance of schistosomiasis and of the need for appropriate control measures. In I98o-I98I emphasis was on the further collection, evaluation, and dissemination of data on the medical, social, and economic importance of schistosomiasis. The collection of statistical data on the geographical distribution and prevalence of schistosomiasis in 7 3 Member States for the period I970-I98o was completed. These data provide a basis for the preparation of an atlas on the geographical distribution of schistosomiasis in the world. 9.38 In response to resolution WHA28. 53, a survey of the schistosomiasis problem in the world was made using information on schistosomiasis control programmes provided by I03 Member States in reply to a questionnaire circulated by WHO. This was published in the Bulletin of the World Health Organization. 1 According to the estimated prevalence and the size of the endemic areas, the most severely affected countries were: in Africa: Angola, Central African Republic, Chad, Egypt, Ghana, Madagascar, Malawi, Mozambique, Nigeria, Senegal, Sudan, United Republic of Tanzania, Zambia in South America: Brazil in South-East Asia: Philippines in South-West Asia: Iraq, Yemen.
9· 39 WHO collaborated in the evaluation and planning of schistosomiasis control in Benin, Brazil, Egypt, Ghana, Mozambique, the Philippines, Tunisia, the United Republic of Tanzania, and Zambia. Technical cooperation in the development of control programmes was established with Botswana, Congo, Gabon, Morocco, and Zimbabwe.
9.40 Of the different control techniques, effective chemotherapeutic treatment of infected persons remains the cornerstone. WHO continued to collaborate with the pharmaceutical industry in the development and evaluation of the effectiveness in the field of a new drug, praziquantel (see paragraphs 9.238-9.239). This compound was used in extensive field trials in Brazil, Egypt, Kenya, Mali, Nigeria, the Philippines, Senegal, Sudan, the United Republic of Cameroon, the United Republic of Tanzania, and Zambia. The data on praziquantel show that it can now be used effectively within the primary health systems of endemic countries.
1 Bulletin of the World Health Organization, 59: (r98r).
IIj-127
9·4 I A consultant team reported on disease prevention and control in water resources development schemes. An informal consultation on health protection in such schemes was held in Geneva in I 98 I with the aim of emphasizing the need (i) to establish a network of WHO collaborating centres for monitoring data on epidemiological situations in large water resources development schemes causing serious public health problems, (ii) to increase the manpower in developing countries by providing training for planners, engineers, and technicians dealing with implementation of such schemes, and (iii) to prepare a manual on health protection in water resources development schemes. In I 98 I a consultant team reported on regulations on health protection in water development schemes, based on a review of national legislation and world literature on the subject. II2
COMMUNICABLE DISEASE PREVENTION AND CONTROL
clature of influenza viruses, now based on I 2 haemagglutinin and nine neuraminidase subtypes; assessment of the role of the newer molecular and biochemical methods for virus strain characterization; studies on influenza ecology; and support for the development of both inactivated and live attenuated vaccines. 9· I 30 Hepatitis. Serological tests are now available to detect infections with viral hepatitis A and B, and hence, by exclusion, nonA/non-B. However, much information is lacking on their incidence and trend in developing countries and, particularly, the mode of transmission of hepatitis B and nonAjnon-B hepatitis. The role of mother-toinfant transmission of hepatitis B is the subject of collaborative research in Burma, the aim being to show whether vaccine or early administration of immunoglobulin halts transmission. In view of the high cost of laboratory reagents and the need for standardizing reference material and techniques, WHO has set up a network of 35 national centres, mainly in developing countries, which will be supported through workshops and a coordinated scheme for the regional production of reagents with the cooperation of the four designated collaborating centres. 9· I 3 I Acute respiratory infections. In support of the WHO programme on acute respiratory infections, a simple rapid technique based on the detection of viral antigens by immunofluorescence was established and reagents of high quality were obtained. Two collaborating centres provide reference services to maintain the quality of tests carried out in countries participating in the programme. 9· I 32 Poliomyelitis. Recent studies on the virus have led to the use of highly strainspecific absorbed sera and biochemical procedures and shown that the outbreaks caused by poliovirus type I in Canada, the Netherlands, and the United States had a
common origin and that all recent poliovirus type 3 isolates in the United Kingdom were related to the same vaccine strain (Sabin). The ability to characterize strains serologically and biochemically is of considerable epidemiological significance and has called for a better system of nomenclature, which was published in late I981.1 9· I 33 With the implementation of the Expanded Programme on Immunization, laboratories are called upon for surveillance, evaluation of the effectiveness of immunization, estimation of the impact of immunization programmes, studies of individual cases or outbreaks, and quality control of vaccines. To bring up to date the technical knowledge of laboratories in their regions, the Regional Offices for the Western Pacific and the Eastern Mediterranean conducted workshops on the laboratory diagnosis of poliomyelitis. 9· I 34 Measles. As the control of measles vaccine presents the same problems as that of poliomyelitis, both being live vaccines, techniques for the quality control of measles vaccines were included in the abovementioned workshops on poliomyelitis diagnosis. 9· I 35 Haemorrhagic cotljunctttlltts. Extensive outbreaks of acute haemorrhagic conjunctivitis occurred in I98I in Africa, Asia, and, for the first time, the Americas. WHO virus collaborating centres were involved in the identification of the causative agent. Enterovirus type 70 was confirmed in one outbreak. Other possible agents known to cause this kind of outbreak, adenovirus type I I and coxsackievirus A type 24, were not identified.
1 Bulletin of the World Health Organization, 59: 8 53-8 54 (1981).
THE WORK OF WHO, 198o-198I
9· I 36 Yellow fever. A large number of cases occurred in I98o, mainly in Africa, where Ghana, affected for two years consecutively, set up an intensive vaccination programme with WHO support. Ecological studies in West Africa showed that epizootics can develop in monkey populations and move along riverine forests in waves lasting three to four years. This may result in periodic epidemics among local human populations, as in Gambia in I978-I979· In the Americas the upward trend of jungle yellow fever since I972 was arrested in I98o, but a gradual spread to previously unaffected areas occurred; the vector Aedes aegypti is widespread and there is an increased risk of urban transmission. The I 7D yellow fever vaccine in use is still remarkably effective, but its mode of preparation does not allow for production on a scale to meet the demand. New techniques for vaccine production are being studied in the Americas and production facilities in Brazil and Colombia improved. 9· I 37 Dengue haemorrhagic fever. All four serotypes of dengue virus are now prevalent in the dengue endemic areas of Asia and America. Serotype 4, which was introduced in many islands of the South Pacific in I979-I98o, was for the first time isolated in the Americas in I 98 I and caused several outbreaks in the Caribbean. Haemorrhagic and fatal cases were also recorded for the first time in the Americas in I 98 I, in a violent outbreak in Cuba. In the endemic areas of Asia, Thailand had the highest number of cases ever in I98o and Indonesia remains highly endemic, while in China and VietNam the disease seems to be increasing. In other areas where the virus is known to be prevalent the disease is either silent or present mainly as the milder classical dengue fever. The pathogenesis of the severe forms is still largely unknown and further clinical, immunological, epidemiological, and virological studies are required. Vaccine development has high priority; strains for a quadrivalent qo
vaccine have been selected by the WHO collaborating centre in Bangkok and are being cultured by serial passage to achieve attenuation. Research and vaccine development were reviewed at interregional meetings held in Delhi in March I98o and March I981. 9· I 38 Rift Valley fever. Following its dramatic appearance in Egypt in I977, Rift Valley fever continues to arouse concern in the Mediterranean and Middle East. An informal consultation in Geneva in I98I stressed the general lack of preparedness for dealing with any extension of this hitherto purely African disease. It listed the effective epidemiological surveillance mechanisms available, reviewed control measures, indicated areas where the vaccine could be used in humans and livestock, and outlined national contingency plans applicable both in countries that had experienced the disease and in countrie_s potentially receptive to its introduction.l 9· I 39 Rickettsial diseases. The present status of rickettsial diseases was reviewed and guidelines for the development of national control programmes were prepared by a working group convened in Geneva in I 98 I. An additional WHO collaborating centre for rickettsial reference and research was established at the Gamaleya Institute of Epidemiology and Microbiology, Moscow, in order to increase the availability of reagents for diagnosis and control. Specific antigens and antisera were distributed to national laboratories.
Diseases restricted to circumscribed geographical areas
9· I40 Viral haemorrhagicfevers. The spread ofhaemorrhagic fevers seems to be limited to 1 World Health Organization. Rift Va/lry fever: an emerging human and animal problem. Geneva, 1982 (WHO
Offset Publication No. 63).
COMMUNICABLE DISEASE PREVENTION AND CONTROL
endemic zones, but they carry the threat of infection in any part of the world. A meeting was convened in New Delhi in March I98o to consider research in viral haemorrhagic fevers in the Eastern Mediterranean, SouthEast Asia, and Western Pacific Regions. It outlined measures and research that could be undertaken if the diseases appeared in a new country. 9·I4I Although no epidemic occurred in I98o-I98I, epidemiological research by the
9· I44 With the advent of selective antiherpes drugs, the prospects for effective chemotherapy of viral diseases look promising. To play an active part in this rapidly developing area of research, WHO has established an expert advisory panel on virus diseases (antivirals and interferon). 9·I45 Exchange of information. WHO has maintained a virus reporting system since I963, the total number of reports now exceeding Ioo ooo per year and the number of reports from the participating laboratories in developing countries being almost one and a half times as many in I98o-I98I as in I 978-I 979· The reporting system, by keeping laboratories in developing countries in contact with the network of virus laboratories throughout the world, has been of value to those countries in assessing the progress they have achieved in laboratory diagnosis.
WHO collaborating centres in Africa has continued on Lassa, Marburg, and Ebola viruses, in coordination with monkeypox surveillance. These viruses were found to be present in larger areas of Africa south of the Sahara than was suspected. 9· I42 The Regional Office for the Americas and UNDP supported a project to develop a vaccine against the Junin virus, the causative agent of Argentine haemorrhagic fever. In I98I a possible seed virus was developed as a vaccine candidate.
Safety measures in microbiology 9· 146 Various collaborating centres and national authorities were assisted in relation to the biosafety requirements of diagnostic and research laboratories working with dangerous pathogens. Biosafety guidelines in microbiology have been developed by an international working group for use, as they are, by individual laboratories or national governments, or for adaptation to local or national conditions. A number of other guidelines have been prepared or are under preparation, and those for the management of accidents involving microorganisms have been published.l 9·I47 WHO participated with the Universal Postal Union and the International Air Transport Association in the revision of their regulations for the safe and expeditious 1 Bulletin of the World Health Organization, 58: 24 5-2 56 (198o).
Research and information
9· I43 Research on antiviral agents. A WHO/National Institute of Allergy and Infectious Diseases workshop on DNA recombinant interferon cloning held in Washington in I98o devised a system for the orderly nomenclature of interferons. DNA recombinant techniques are expected to provide large quantities of relatively cheap highly purified interferons. To determine the significance of different types and subtypes in the treatment of certain diseases and to prevent duplication and wastage of interferon, international cooperation is necessary. A WHO informal meeting in Rotterdam, Netherlands, in I 98 I discussed approaches to such international collaboration in relation to the clinical use of interferon. I3J
THE WORK OF WHO, 198o--198I
shipment of diagnostic specimens and agents. It is currently involved with ICAO and IMCO in the revision of their requirements
for the transport of the same agents. 9· I48 An international consultation on training programmes in biosafety was held and model training programmes and trainers' manuals were developed for use at regional, national, and local level. The first training course was held in Brazil. 9· I49 Active liaison has been maintained with the Committee on Genetic Experimentation of the International Council of Scientific Unions and with several national programmes regarding assessment of the risk of laboratory procedures associated with R-DNA research. Recommendations were made in relation to laboratory facilities.
particularly in developing countries; there 8o-8 5% of the inhabitants do not have even minimum health care for sexually transmitted diseases, which are frequently present in 5-I 5% of the adult population. To diagnose and treat the diseases as early as possible before the appearance of complications, cooperative research was carried out to develop simplified and rapid diagnostic techniques for use by non-specialized personnel; this would obviate the need for cumbersome, expensive, and sophisticated laboratory methods. Research was carried out at the same time on the development of simplified rapid diagnostic techniques for bacterial infections. 9· I 5z The emergence of gonococcal strains that are highly or totally resistant to penicillin or to a range of drugs is a serious problem. WHO organized a worldwide resistance surveillance programme, in line with the recommandations of resolution WHA 3I. 57 and of various scientific groups. This problem is compounded by the indiscriminate use of antimicrobial agents in man and animals and by their wide use in food preservation. A scientific working group in I 98 I proposed methods of dealing with the problem, which particularly affects countries that find it difficult to meet the cost of the new antibiotics required to deal with resistance. 9· I 53 In many regions of the world genital ulcers of diverse bacterial and viral origin are responsible for a great many sexually transmitted diseases. A multinational research project on methods of diagnosis, treatment, and '·control has been coordinated by WHO. Research was also carried out to identify the antigens responsible for the attachment to and penetration of gonococci into cells and tissues and to elucidate the mechanism of antibody production. The findings have helped in the identification of vaccine candidates and opened the way to promising diagnostic technology.
Hospital infections 9· I 5o Larger hospitals, particularly in the developing countries, increased specialization, modern diagnostic and curative techniques, and various newly developed drugs that affect immunoresistance contributed to higher morbidity and mortality rates from hospital infections. To define the magnitude and nature of such infections, WHO initiated a prevalence study in selected countries. Surveillance will be carried out by a collaborating centre for reference and research on hospital infections that has now been established at the Public Health Laboratory, Colindale, London.
Sexually transmitted diseases 9· I 5I WHO's objective, in close cooperation with countries, research centres, and nongovernmental organizations, is to make effective control services available to an increasing percentage of the population,
COMMUNICABLE DISEASE PREVENTION AND CONTROL
9· I 54 Endemic treponematoses. A review 1 of the epidemiological situation shows that yaws and endemic syphilis still constitute a considerable health hazard to the child population in medically underserved areas, particularly in West and Central Africa and, to a lesser extent, in South-East Asia and the Americas. The incidence of endemic syphilis (bejel) in the sub-Saharan region approaches that of yaws in the savanna and rain forest region of West Africa. Recent WHO surveys in the Sahel found that approximately 2.8 million of the region's 30 million inhabitants were at risk of endemic syphilis. Reports suggest, however, that pinta has virtually disappeared from countries of Latin America. WHO cooperated with national health administrations and bilateral agencies in assessment of the problem in a number of countries of West and Central Africa and in the implementation and evaluation of control. 9· I 55 A WHO Scientific Group on Treponema! Infections (October I98o) updated and simplified the treatment schedules recommended for use in treponematoses control programmes. 2 A field manual on the clinical and control aspects of endemic treponematoses for health workers in primary health care areas is in preparation.
9·I 57
The WHO Advisory Group on the Prevention of Blindness met in Ouagadougou in I98o at the headquarters of the Onchocerciasis Control Programme, and in I98I in New Delhi. The latter meeting was attended by representatives from all the regional offices with a view to achieving coordination of the programme. The economic implications of the prevention of blindness were reviewed by a small expert group in I98o in which the World Bank participated. Useful guidelines for eye care within the framework of primary health care were elaborated by another working group in Geneva in I 980.
9· I 58 Contributions through the Voluntary Fund for Health Promotion, in particular from the Netherlands, Norway, Sweden, and the Japan Shipbuilding Industry Foundation, have considerably strengthened activities in several countries, e.g., the prevention of blindness programme in Nepal, operational since I98o. Advisory services for the formulation of national programmes were provided by WHO to more than 30 countries during I98o-I98I.
Prevention of blindness 9· 15 6 Work proceeded in several countries on the assessment of blindness and its causes and on the planning of preventive measures and provision of essential eye care at peripheral level. A resolution on the prevention of blindness was adopted by the Regional Committee for Africa in I98o. The first meeting of the PAHOJWHO advisory committee on prevention of blindness took place in Brazil in I98o. Week!J Epidemiological Record, 56: 241-244 (1981). Report to be published in the WHO Technical Report Series, 1982. t 2
9· I 59 Close collaboration was mamtained with several nongovernmental organizations, in particular the International Agency for the Prevention of Blindness. Funds provided by the Royal Commonwealth Society for the Blind and the Asian Foundation for the Prevention of Blindness permitted the employment of a full-time WHO programme coordinator for the prevention of blindness in South-East Asia for a two-year period. 9· I6o Several seminars and workshops on the prevention of blindness were held at the intercountry and national levels. The training of auxiliary health personnel, particularly community health workers, in eye care was the subject of two meetings in I98o in the African Region, sponsored jointly by I33
THE WORK OF WHO, 198o-1981
WHO and the International Eye Foundation. Following those meetings, the possibility of strengthening the training of health personnel in eye care within the framework of TCDC was investigated in six neighbouring countries in Africa. Intercountry cooperation in the surveillance and prevention of blindness was discussed in a seminar in Uruguay in I 98 I at which five Latin American countries were represented. 9.I6I Support was given to training in eye care at the national level for various categories of health personnel. A regional workshop on the prevention of blindness in the Western Pacific Region focused on training and its interrelation with the establishment of blindness surveillance systems. The organization of cataract relief services was considered by a workshop in South-East Asia, as well as by several seminars at the national level. The use of residual vision by visually disabled persons was reviewed in a multidisciplinary meeting in the European Region in I98I, convened within the context of the International Year of Disabled Persons.
collection of data on blindness and applied field research. Additional technical staff have been recruited for this work, which has so far been carried out in two African countries. 9· I64 Two publications have appeared, one on applied survey techniques,! the other on the prevention and control of trachoma.z A standard eye examination record, which was developed and field-tested for surveys on blindness, is adapted to computer data analysis and will be available in several languages. A blindness data bank has been established, with periodic updating of available information on blindness throughout the world. A pamphlet giving general information about the programme has been prepared.
Expanded Programme on Immunization 9· I65 At the time of the Alma-Ata Declaration in I978, which included immunization against the major infectious diseases of childhood among the eight elements necessary to provide primary health care to all the world by the end of the century, no training programmes for the management of immunization programmes had been developed; no consensus was to be found on the type of information needed to monitor and evaluate progress; no routine reporting existed of immunization coverage and vaccine quality, particularly in the developing countries; and few efforts were being made to provide immunization within the framework of comprehensive health services. Now all developing countries or areas in the six WHO regions are in the process of implementing immunization programmes in accordance with WHO recommendations that include 1 World Health Organization. Methods of assessment of avoidable blindness. Geneva, 1980 (WHO Offset Publication No. 54). 2 Dawson, C.R., Jones, B.R. & Tarizzo, M.L. G11ide to trachoma control in programmes for the preventton of blindness. Geneva, World Health Organization, 1981.
9· I 62 The network of WHO collaborating centres for the prevention of blindness has been strengthened and at present comprises Io institutions. The training and research programmes of these centres were reviewed at the annual meetings of the Advisory Group on the Prevention of Blindness in I98o and I98I and priorities for applied research were established. Training courses for medical personnel in the epidemiology and public health aspects of ophthalmology are being arranged by some collaborating centres. 9· I63 The lack of reliable data on disorders causing blindness and their effect is in certain areas an obstacle to systematic prevention or treatment. A grant in I98o from the National Eye Institute, National Institutes of Health (USA) through the Voluntary Fund for Health Promotion is being used for the
COMMUNICABLE DISEASE PREVENTION AND CONTROL
specific targets for both immunization coverage of the infant population and disease reduction. 9· I 66 Programme management. The target for DPT, poliomyelitis, and measles immunization in I983 is to cover 50% of the newborn, and for BCG 7 5%. However at present coverage can be stated regionally only by three of the WHO regions: for exemple, for DPT, the most frequently given antigen, coverage is 37% in the Americas, 2.2% in the Eastern Mediterranean, and I 5% in SouthEast Asia. Specific coverage surveys in geographical areas where phased development of the immunization programme is starting are more encouraging. In the period I979-I98I such surveys were carried out in 49 countries and showed more than 50% coverage in 3 5% of the surveys for DPT, 3o% of those for polio vaccine, and 54% of those for measles vaccine. 9.I67 Following the pattern of developed countries in the past two decades, a reduction in poliomyelitis, measles, and tetanus has already been recorded in limited areas of the developing world, particularly in the Americas, where immunization and recording systems are more advanced. At global level it is too early to discern any meaningful trends. 9.I68 External resources. Of the multilateral funding bodies UNICEF continued to be the major supporter of the programme, primarily with vaccines and cold chain equipment. UNDP continued to provide funds for the improvement of vaccine quality control and intercountry activities in the African and South-East Asia Regions. Considerable extrabudgetary funds were channelled through the Voluntary Fund for Health Promotion. All activities relating to cold chain development were funded through contributions received from Denmark, Finland, the United Kingdom, and the Japan Shipbuilding I
Industry Foundation, and the extended training activities during this period would not have been possible without significant contributions from the Netherlands and Sweden. Contributions of vaccine were made by Finland, the Netherlands, and the USSR. 9· I69 Vaccines. Figure 9.2 summarizes the information available on countries that use vaccines conforming to WHO requirements. A system of certification of laboratories qualified to test individual vaccines for their conformity with WHO requirements is now being initiated. 9· I 70 The Regional Office for the Americas established a successful rotating fund for the purchase of vaccines and other selected materials. The Regional Office for the Western Pacific is considering establishing a regional procurement system for vaccines and drugs, and WHO and UNICEF have been collaborating closely to satisfy national vaccine requirements. The global information system continues to suffer from weaknesses in forecasting vaccine needs, but is improving as national planning capacity improves.
Training
9· I7I The emphasis has been on management at all levels; senior health officials from I 20 countries were trained in immunization planning, and staff from 7 3 countries participated in national and intercountry courses for mid-level supervisory personnel. Courses in cold chain management and cold chain equipment repair were held for technicians from 52 countries.
Research
9· I 7 2 Work was completed or is progressing in ~4 target research areas, notably: the 35
Figure 9.2 Quality of Expanded Programme vaccines being used (Percentage of countries/areas, by WHO region)
AFRICA (46)
.................... ....... . .... . ... . .. .... . .. .. .......... .. . .... ...... .... ... .................... ... ...... . .... .. . . . . ...... .. ... .. ..... .. . .... ..... ... .. . . . . .. .. ... .... . . . . . . . . .. .. . . .... ..... ... .... .. . ....................... ..... . .. . .. . ....... .... . .. ..... .. ... . . .... .. .. ..................... ....................... . . . .. .. .. . .. ..... .. .. . . .. . .. .. ... .... ... ... . . .. . . . . ............ .. . .
AMERICAS (47)
... . ..... ......... .... . .. ......... ... . . .. ... . . . . .... . . ... ... .. . . .. ..... SOUTH-EAST ASIA :·: ·: ·: ·: ·: ·: ·: ·: ·: ·: ·: ·: ·: ·: ·: ·: ·: ·: ·: ·: ·: ·: ·: ·: ·: ·: ·: ·: ·: ·: ·: ·: ·: ·: ·: · (11) :::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: ..................................... . . . . . ..... . . .... . . . . .. .. . . . . . . . . . EUROPE (37)
..... ... . . ...... .. ..... ... .. ............ .. .. .. .. .. .. .. . .. ............................... ....................... . .. .... .. . . .. ... . . . .. . .... . . ... . . .... .. . .. .......... .. .. ... . . . . . . . . . . . . .... .. ..... .... .. ........ . ..... . . . ............ . . . . . . . . . . .. . ................................ ..... . . . . . . . .. . .. .. .. .. .. .. .. .. .. .. . .. . .. . . .. .. .. . . . . . . . . . .. . . . . . . . ... . . . . .. . . . .. . . . .. .. .. . . . ... . ... . ... .. .... .. . .. . . . . . . . . . . . . . . . . . . . . . . . ..... . ... . .. .. .. .. .. . .... .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. . .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. . .. .... . . .... . . ... .. .. .. .. .. .. .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..
EASTERN MEDITERRANEAN (24)
WESTERN PACIFIC:::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: (32)
.... ...
:::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: ~~~~~~~~~~~~~~~~~~~~~
.... .... co
0
0
10
20
30
70 40 50 60 Percentage of countries
80
90
100
~ ~
Countries/areas in which vaccines conform to WHO requirements Countries/areas in which one or more vaccines do not conform to WHO requirements Countries/areas using vaccines of quality unknown to WHO
(00)
Number of countries/areas in the region
COMMUNICABLE DISEASE PREVENTION AND CONTROL
epidemiology of neonatal tetanus, measles, and poliomyelitis; the development of costing guidelines; the preparation of diagnostic materials; the development of more stable measles vaccines; and the development and commercial production of a wide range of cold boxes, refrigerators, freezers, and temperature indicators. 9· I 7 3 Satisfactory progress has not been achieved with respect to pertussis, for which an improved vaccine and improved diagnostic methods are needed. Basic research in this field is being pursued, particularly in the American, European, and Western Pacific Regions. Little progress has been made in better defining the geographical distribution of diphtheria but, although this is technically feasible, it is not at present considered to be a matter of priority.
9· q6 Despite the considerable improvement in information systems in recent years, much remains to be done. Reports on the incidence of all the target diseases were received from only 83 countries or areas for the year ending December I98o, and the quality of vaccines being used was not known for 75 countries or areas. 9· I77
An increasing number of countries are conducting national programme reviews, 17 having been completed in I979 and I98o and seven in I 9 8 1. The methods used are adapted to the needs of the country concerned. The current emphasis is on broadening the review process to include other elements of primary health care than immunization, with particular emphasis on maternal and child health care.
Veterinary public health Evaluation 9·I74 Using data obtained from the global information system and regional and global narrative reports, the programme's advisory group conducts an annual review and issues a report. The group met in Geneva in I98o and in Washington in I981. 9·I78 The WHO Expert Committee on Bacterial and Viral Zoonoses that met in Geneva in I98I 1 with the participation of F AO reviewed the socioeconomic aspects and the factors influencing the prevalence of zoonoses and recommended measures for surveillance, prevention, control, and possible elimination. It dealt particularly with the need for intersectoral and interdisciplinary collaboration and for comprehensive national programmes to ensure the mobilization of resources in the different sectors concerned with health-the environment, food, safety of animal products, and wastes. It placed special emphasis on surveillance and control of emerging zoonoses and immediate improvement of rural economic development services.
9· I 7 5 The Regional Office for the Americas started a newsletter in May I979 which has received wide circulation inside and outside the Region. The Western Pacific Region includes information on the incidence of the programme's target diseases in its monthly epidemiological bulletin. One or more countries in each region either have special newsletters or periodic reports concerning the programme or include information on immunizable diseases in their epidemiological records or bulletins. Wider circulation of this information is given by the Weekry Epidemiological Record.
1 Report to be published in the WHO Technical Report Series, 1982.
THE WORK OF WHO, 198o-1981
Zoonoses centres 9· I 79 The veterinary public health programme and the zoonoses control centres are supported in their activities by WHO collaborating centres. The Pan American Foot-andMouth Disease Center in Rio de Janeiro and the Pan American Zoonoses Center ,in Buenos Aires continued to cooperate with the national authorities and institutions of several countries in the Americas in planning new control and prevention programmes for zoonoses and exotic diseases. They conducted applied research on vaccines and diagnostic procedures and trained staff in various fields of veterinary public health and animal health. Several countries, with close technical cooperation from the Zoonoses Center, carried out control programmes for brucellosis, bovine tuberculosis, echinococcosis/hydatidosis, leptospirosis, and rabies. 9· I So The Mediterranean Zoonoses Centre (UNDPfWHO) extended its services to almost all the Mediterranean countries, particularly for rabies, echinococcosis/hydatidosis, and improvement of the hygiene of food products of animal origin. It organized or took part in meetings that provided practical guidelines on echinococcosis/hydatidosis control (Morocco, I 98o), intersectoral and interprofessional cooperation (Portugal, . I98I), and Rift Valley fever (Geneva, I98I) (see also paragraph 9·138). 9.I8I The various WHO collaborating centres also hosted a world congress on foodborne infections and intoxication in Berlin (West) (I98o), a seminar .on milk hygiene (Hanover, Federal Republic of Germany, I98o), a seminar on environmental hygiene dealing with the hygienic aspects of animals in urban areas (Hanover, I98I), a symposium on the comparative aspects of leukaemias, lymphomas, and papillomas (Munich, I98o), and a symposium on the microbiology of prospective biological products for viral diseases (Munich, I98I).
Control of zoonoses and Joodborne diseases 9· I 82 In line with resolution WHA3 1.48, emphasis continued to be placed on the development of national, regional, and global strategies and methods for the surveillance, prevention, and control of zoonoses and foodborne diseases attributable to animal products. Guidelines on echinococcosis/ hydatidosis control were issued t and other guidelines were in preparation. 9· I 8 3 Rabies. WHO developed regional and global strategies specifically for the control of rabies in dogs in developing countries since, with the improvement of vaccines and immunoglobulins for the treatment in man, the elimination of the disease in its animal reservoirs is being neglected. Information was collected from all regions on successful dog rabies control projects and a model comprehensive national programme was developed and used in collaboration with Member States. WHO has become directly involved in national programme planning and execution, since rabies calls for the coordination of activities in adjacent countries. 9· I 84 Research was carried out on dog ecology in selected areas of the Americas, North Africa, and the Philippines. The recommendations of the WHO Expert Committee on Rabiesz were reviewed and amendments proposed at informal meetings in I98o in Lyon, France (co-sponsored by the Pasteur Institute) and in I98I in Nancy, France (organized jointly with the French National Rabies Research Centre). An international research programme on natural barriers to wildlife rabies was given guidance at a WHO
I 2
WHO document VPH/81.28 (1981). WHO Technical Report Series, No. j23, '973·
q8
COMMUNICABLE DISEASE PREVENTION AND CONTROL
meeting in I 98 I in Vienna (co-sponsored by the Austrian Government). Specific aspects of modern cell culture vaccines for humans were discussed and vaccine schedules defined at a meeting held in I98o in Essen, Federal Republic of Germany (co-sponsored by the University of Essen). 9· I 8 5 Echinococcosisff?ydatidosis. Following a remarkable expansion of interest in this subject, programmes were launched successfully in Cyprus, the Falkland Islands (Malvinas), New Zealand, and Tasmania, representing island models, and in Argentina, Bulgaria, Chile, Peru, Uruguay, and parts of the USSR, representing continental models. Experience gained from these programmes highlighted the important steps in control and their sequence and clearly showed that a reduction in echinococcosis in all age groups of the human population as well as in food animals can be rapidly achieved by relatively simple control measures. However, traditions, habits, inadequate meat inspection, access of dogs and other animals to infected offal, inadequate intersectoral cooperation, and the absence of suitable programmes remain obstacles to successful control in many Member States.
9· I 87 Salmonellosis. The WHO/World Association of Veterinary Food Hygienists Round Table Conference on the Present Status of the Salmonella Problem (Prevention and Control), held in the Netherlands in I 980, noted that salmonellosis from food of animal origin is the most common food borne disease in the world and causes great morbidity and economic loss. Guidelines were prepared to assist public health and veterinary authorities and food and feed industries in taking practical measures to prevent and control salmonellosis. 9.I88 Surveillance of joodborne diseases. An international surveillance programme to aid national programmes for control of foodborne diseases was established in the European Region, mainly by the FAOJ WHO collaborating centre for research and training in food hygiene and zoonoses, Berlin (West). Fifteen European countries agreed to participate and in nine a contact point was designated to provide relevant information. A manual on surveillance of foodborne diseases is being prepared to advise countries on how to organize programmes at national level. 9· I 89 More than 2 5o requests for information on food virology were received from 40 Member countries. Two centres, one in the United States of America (Madison, Wisconsin), the other in Czechoslovakia (Brno ), actively collaborated in the food virology programme. 9· I90 Training. Two international courses on zoonoses management in which WHO closely collaborated were convened in I98o and I98I in the USSR. Rabies, brucellosis, leptospirosis, echinococcosis/hydatidosis, taeniasis/cysticercosis, and food borne disease control were subjects in the courses, in which 45 students from five WHO regions participated.
9· I 86 In cooperation with F AO and UNEP, WHO in I98I formulated research requirements for future decades and collaborated with an increasing number of Member States in planning, executing, and evaluating national programmes. Fresh knowledge has accrued on host-parasite relationships, sociocultural factors modifying them, strain differences, and the dynamics of transmission. Serological diagnosis in man can now be applied with a high degree of sensitivity in some areas and highly effective drugs are available for the large-scale treatment of dogs. Some drugs were identified as having larvicidal activity in animals and are being evaluated in man. I39
THE WORK OF WHO, 198o-t981
9·I9I A WHO workshop on veterinary public health was conducted by the FAO/WHO collaborating centre for research and training in food hygiene and zoonoses. The participants were senior public health and veterinary public health officers from the Eastern Mediterranean and SouthEast Asia. 9· I 92 Four international training centres in Europe coordinated international postgraduate courses in food microbiology for students from developing countries.
ment of programmes for monitoring critical control points. 9· I95 Meat hygiene. Work was carried out jointly with F AO on an international code of principles for ante-mortem and post-mortem judgement of slaughter animals and meat, and a code of hygienic practice for game. They were discussed by the Codex Committee on Meat Hygiene (London, I98I) and the Codex Alimentarius Commission itself (Geneva, I98I). 9· I96 In developing countries slaughterhouses and meat-handling practices contribute greatly to poor health and the spread of animal diseases. Two guidelines-on the design and construction of simple slabs where modern facilities are lacking and on slaughter and meat-handling where there are few slaughter facilities-were the subject of an informal consultation with F AO in Geneva in April I981. 9·I97 Fish and shelfish hygiene. Work on fish hygiene was carried out jointly with F AO within the framework of the Codex Committee on Fish and Fishery Products. Several codes of hygienic practice for fish products were discussed at the meeting of the Committee in Bergen, Norway, in I98o, including microbiological specifications for frozen, cooked, and ready-to-eat shrimps and prawns, which are widely available in international trade. In view of the public health importance of intoxications caused by shellfish, particularly in tropical areas of the world, a guide on paralytic shellfish poisoning was begun.
Microbiological criteria for food 9· I 9 3 An FA 0 /WH 0 working group on microbiological criteria for dried milk products and natural mineral water met in Washington (November I98o) and inter alia finalized general principles for the establishment and application of microbiological criteria for food. These were adopted at the fourteenth session of the FAOfWHO Codex Alimentarius Commission (Geneva, I98I). 9· I 94 Effective control over pathogenic microorganisms and their toxins in food must be exercised not only during the processing of the food but also during its distribution, wholesale and retail storage, and final consumption either in food service establishments or at home. The hazard analysis and critical control point system is an approach to these problems. This system, originally developed for use in food processing establishments in the United States of America, has the full support of WHO. The first meeting of experts in this field was convened in Geneva in I 980 to discuss further development of the system, including: assessment of the health and spoilage risks associated with processing and marketing a given food product; determination of critical control points in the manufacturing process; and the establish140
Comparative medicine 9· I 98 Emphasis was laid on studies in cancer therapy from which results can be extrapolated to man. The classification of tumours in domestic animals by extent,
COMMUNICABLE DISEASE PREVENTION AND CONTROL
condition of lymph nodes, and presence or absence of distant metastases (TNM) was issued. 1 It is as close an adaptation as possible to the TNM classification of malignant tumours in man, published by the International Union against Cancer and in international use. The purpose of the animal tumour classification is to provide an unambiguous method of reporting clinical observations and a guide to prognosis and therapy. 9· 199 In international clinical trials carried out in conjunction with the WHO collaborating centre for comparative oncology, the Department of Clinical Veterinary Medicine, University of Cambridge (United Kingdom), the TNM classification was already being used. The trials covered the use of radiotherapy in spontaneous osteosarcoma in dogs, with and without a hypoxic cell sensitizer, and the immunotherapy of spontaneous canine mammary tumours. The results will be directly relevant to human cancer.
Vector biology and control 9.201 Greater efforts were made to develop training facilities, particularly at the advanced level, and to collaborate with national professional staff in improving control of insect vectors, rodent reservoirs, and snail intermediate hosts of disease.
Vector resistance 9.202 Insecticide resistance in important vectors of disease continued to spread, appearing in additional species and in additional geographical areas. With the appearance of resistance to DDT in the sandfly Phlebotomus papatasi in Bihar State, India, the tsetse remains the only important vector group in which resistance has not been reported. The most serious challenge to a large-scale programme has been the development in the Ivory Coast of resistance to temephos in two species of the Simulium damnosum complex, S. soubrense and S. sanctipauli. First noted in the south in May 198o, resistance to this organophosphorus insecticide has since spread, so that the Onchocerciasis Control Programme has had to shift to alternative insecticides; in October 1981, cross-resistance was detected to one of these alternatives, chlorphoxim. The further spread of resistance to organophosphorus insecticides among important vectors of malaria has greatly increased the technical and financial problems these programmes face. Multiple resistance has been reported in nine additional species of anophelines, including Anopheles sacharovi in Turkey, A. culicifacies and A. stephensi in India, and A. arabiensis in Sudan. The appearance of resistance in populations of Aedes aegypti in the Americas may increase operational problems in the intensified programmes against this vector of yellow fever, dengue, and dengue haemorrhagic fever. Cross-resistance to synthetic pyrethroids in DDT-resistant A. aegypti is of great concern, 141
Laboratory animal health 9.200 Cooperation with Member States in laboratory animal health was expanded and WHO, together with the International Council for Laboratory Animal Science, drafted a medium-term programme covering: guidelines on husbandry, breeding methods and quality, rational use, experimental techniques, and transportation; education and training; and research. The programme was adopted at a meeting of the Council's Governing Board (Dusseldorf, Federal Republic of Germany, 1981).
1
WHO document VPH/CMO/So.zo (198o).
THE WORK OF WHO, 198o-198I
since this is the newest group of insecticides available for use against resistant vectors. All in all, by 1980, 54 different species of anopheline and 42 species of culicine mosquitos had developed resistance to one or more insecticide compounds used in vector control programmes. This increases the urgency of the need to develop alternative pesticides and alternative methods of vector control that can be integrated with, or at least in part substituted for, the use of chemical pesticides and so reduce the selection pressure.
Pesticide production and safe use 9.204 WHO carried out trials of new formulations of existing insecticides in Indonesia, the I vary Coast, and Thailand and the information provided on them to manufacturers has resulted in marked improvements in the performance, stability, and packaging of formulations. 9.205 Some of the alternative compounds under trial are less safe for spraymen and inhabitants of treated houses than the insecticides they must replace. Safety protocols were developed in collaboration with national authorities, the manufacturer being invited to participate in field trials by providing the insecticide, analysis equipment, and technical staff, particularly toxicologists, to carry out safety assessment of the compound. Such a trial was carried out in Indonesia. Continued concern about the possible enhanced toxicity of malathion waterdispersible powders as a result of defective or prolonged storage led to frequent requests for assessment of the toxicity of suspect batches. A course on the safe use of pesticides adaptable to national needs was started in the Republic of Korea and Sudan, and Spanish and Portuguese texts for it are being prepared.
Testing and evaluation of new insecticides 9.203 To overcome vector resistance to insecticides, especially where alternative methods are difficult to implement or are not available, it is necessary to shift to insecticide compounds that involve no cross-resistance to existing groups. The industry was encouraged to provide such candidate compounds for field tests, and WHO organized or participated in collaborative trials in Colombia, Indonesia, Nigeria, and Venezuela of compounds against several different vector species, including mosquitos and triatomid bugs. Unfortunately, the number of new compounds submitted to WHO for testing remains low. Testing has been intensified to expedite the screening of the new compounds made available and to ensure that they reach the essential large-scale field trial stage with the least delay. The industry also increased its collaboration by requesting WHO to comment on the protocols of its own trials. Representatives of the industry visited the WHO collaborating centres in the Ivory Coast, United Kingdom, and United States of America as well as the WHO field testing unit in Indonesia. The results of field trials have been rapidly disseminated to the Member States through unpublished documents issued by WHO.
Testing and evaluation of insecticide application equipment 9.206 Laboratory and field tests were carried out with a new type of sprayer and it was then tried out in a national malaria programme in Saudi Arabia. The results of the tests were communicated to the manufacturer and weak points in the construction have been remedied. Draft specifications for mist blowers and aerosol generators were drawn up and are being tested at the WHO collaborating centre for equipment testing, Silwood Park, United Kingdom. Tests were
COMMUNICABLE DISEASE PREVENTION AND CONTROL
also carried out wtth an electrostatic sprayer at this centre and the initial results were encouraging, though the dispersal patterns must be improved.
Biology and control of specific vectors 9.207 Malaria vectors. Studies on the ecology of Anopheles balabacensis in Thailand and A. sundaicus, A. aconitus, and A. sacharovi in Turkey were carried out in collaboration with national malaria programmes. A seminar on the biology and control of A. sinensis was held in China in I 9 8 1. Field trials of new insecticides, new insecticide formulations, and new approaches were carried out by the WHO research unit, Semarang, Java. Large field tests of an organophosphate, a carbamate, and a pyrethroid were undertaken in a number of villages. Selective spraying of fenitrothion (OMS-43) on the lower portion of walls where most A. aconitus rest provided acceptable and much more economical control than total house coverage. 9.208 An interregional seminar in Adana (Turkey) reviewed environmental management methods and their application to malaria vector control. WHO collaborated with the Government of Burma in its vectorborne disease control programme, which was aimed primarily at control of malaria and its vectors. 9.209 Vectors of filariasis. Longitudinal studies on the biology, ecology, and distribution of vectors of Brugian and Bancroftian filariasis in Java and Sumatra (Indonesia) were completed and the vectorial capacity of the mosquito vectors was determined. Entomological, parasitological, and control studies were carried out in Sulawesi in collaboration with the Ministry of Health. Studies on the control ofBancroftian filariasis in Sri Lanka were carried out in collaboration with the Government. The efficacy of insect growth inhibitors and biological control I43
agents against the main urban vector of filariasis, Culex quinquefasciatus, was examined by several different collaborating laboratories. The South-East Asia and the Western Pacific Regional Offices provided expertise, material for susceptibility tests, and insecticides for field trials against vectors of filariasis. 9.2Io Vectors of yellow fever and dengue. With funds from the Government of the Netherlands, an intensive study was initiated on the biology and distribution of Aedes aegypti in Colombia. There are already indications that it has spread to parts of the country in which it was never found before. Because of a major outbreak of dengue and the first appearance of dengue haemorrhagic fever in Cuba, WHO collaborated with the Government in emergency vector control measures. Trials of vehicle-mounted insecticide application equipment against A. aegypti were carried out by a reference laboratory in Thailand. Following a yellow fever outbreak in Angola, a collaborative study was made of the distribution and population density of A. aegypti in Lunda; another was carried out in the United Republic of Cameroon. A grant was provided to a laboratory in Dakar for research on the vectors of yellow fever in Central and West Africa; these studies are providing more data on the transovarial transmission of yellow fever virus.
9· 2 I I Vectors of onchocerciasis. Following the appearance of insecticide resistance in two Simulium species in the areas of the Onchocerciasis Control Programme in West Africa, efforts to develop and field-test chemical and biological pesticides as alternatives to temephos were intensified. WHO cooperated with Guinea, Guinea-Bissau, Mali, Senegal, and Sierra Leone in a feasibility study on onchocerciasis control. Through its research unit in Kaduna it cooperated with Nigeria in the preparation of a national
THE WORK OF WHO, 198o-I981
onchocerciasis control campaign. DANIDA funded an onchocerciasis pilot scheme in the United Republic of Tanzania with which WHO cooperated. WHO also participated in missions to evaluate onchocerciasis and its vectors in Guatemala and Mexico, and in planning in Ecuador in relation to the newly discovered onchocerciasis vectors there.
for control. In Malaysia WHO assessed potential rodent reservoirs of plague and advised on control. A two-week interregional training course on rodent control was held in Rangoon. 9.2I4 Snail intermediate hosts and schistosomiasis control. In collaboration with GTZ, missions were undertaken to Congo, Malawi, and Mali to prepare collaborative support for schistosomiasis control programmes. A similar mission was carried out in Rwanda, and another, combined with a teaching course, in Gabon. In view of the worldwide shortage of persons trained in medical malacology, support was given to the development of regional centres for applied malacology. In association with the Special Programme for Research and Training in Tropical Diseases, assistance was given to many research projects in the prevention and control of major trematode diseases. Reviews, manuals, and practical field guides on such subjects as plant molluscicides, biological control, and snail host taxonomy by regions were prepared. The prospects for biological control of snail hosts at virtually no cost in integrated control schemes are now promising. A programme for the development of biocontrol agents, mainly competitor andfor predator snails, was begun in I98I, involving WHO collaborating centres in several Member States.
Vectors of trypanosomiasis. With the Special Programme for Research and Training in Tropical Diseases, research programmes were carried out on tsetse vectors of sleeping sickness (see paragraphs 9·2439.248). Studies in the Ivory Coast and Kenya on the biology, ecology, and population dynamics of tsetse provided a basis for control activities. Improved trapping methods for sampling and controlling tsetse have been developed and give hope that simple traps and insecticide-impregnated screens can be used by villagers for their own protection in sleeping sickness endemic areas. WHO participated in meetings organized by F AO and OAU on the planning of tsetse control programmes. A long-term feasibility study on the genetic control of tsetse vectors of sleeping sickness in Upper Volta has been completed and the results are being assessed. 9.212
9· 2 I 3 Rodent andflea control. Studies at the WHO rodent control demonstration unit in Rangoon were completed. A large-scale trial carried out by the Burmese Government and WHO staff using new rodenticides and application and evaluation systems demonstrated the practicality of a high level of cost-effective control of rodent populations. The establishment of laboratory facilities for work on agents of rodent-borne diseases will enable studies on plague and murine typhus to continue. Susceptibility tests on flea vectors of plague and murine typhus in Burma and Java showed high levels of DDT resistance, and field trials of insecticide compounds formulated as dusts demonstrated the availability of effective alternative chemicals I44
9· 2 I 5 Cyclops and dracunculiasis control. In connexion with the International Drinking Water Supply and Sanitation Decade, WHO collaborated with the agencies involved in the reduction or elimination of guinea-worm infection, especially in West Africa, through the provision of safe drinking-water supplies.
Biological control 9· 2 I 6 Research on the biological control of vectors, supported largely by the Special Programme for Research and Training in
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clature of influenza viruses, now based on I 2 haemagglutinin and nine neuraminidase subtypes; assessment of the role of the newer molecular and biochemical methods for virus strain characterization; studies on influenza ecology; and support for the development of both inactivated and live attenuated vaccines. 9· I 30 Hepatitis. Serological tests are now available to detect infections with viral hepatitis A and B, and hence, by exclusion, nonA/non-B. However, much information is lacking on their incidence and trend in developing countries and, particularly, the mode of transmission of hepatitis B and nonAfnon-B hepatitis. The role of mother-toinfant transmission of hepatitis B is the subject of collaborative research in Burma, the aim being to show whether vaccine or early administration of immunoglobulin halts transmission. In view of the high cost of laboratory reagents and the need for standardizing reference material and techniques, WHO has set up a network of 35 national centres, mainly in developing countries, which will be supported through workshops and a coordinated scheme for the regional production of reagents with the cooperation of the four designated collaborating centres. 9· I 3 I Acute respiratory infections. In support of the WHO programme on acute respiratory infections, a simple rapid technique based on the detection of viral antigens by immunofluorescence was established and reagents of high quality were obtained. Two collaborating centres provide reference services to maintain the quality of tests carried out in countries participating in the programme. 9· I 32 Poliomyelitis. Recent studies on the virus have led to the use of highly strainspecific absorbed sera and biochemical procedures and shown that the outbreaks caused by poliovirus type I in Canada, the Netherlands, and the United States had a
common origin and that all recent poliovirus type 3 isolates in the United Kingdom were related to the same vaccine strain (Sabin). The ability to characterize strains serologically and biochemically is of considerable epidemiological significance and has called for a better system of nomenclature, which was published in late I98I.I 9· I 33 With the implementation of the Expanded Programme on Immunization, laboratories are called upon for surveillance, evaluation of the effectiveness of immunization, estimation of the impact of immunization programmes, studies of individual cases or outbreaks, and quality control of vaccines. To bring up to date the technical knowledge of laboratories in their regions, the Regional Offices for the Western Pacific and the Eastern Mediterranean conducted workshops on the laboratory diagnosis of poliomyelitis. 9· I 34 Measles. As the control of measles vaccine presents the same problems as that of poliomyelitis, both being live vaccines, techniques for the quality control of measles vaccines were included in the abovementioned workshops on poliomyelitis diagnosis. 9· I 3 5 Haemorrhagic corijuncttvttts. Extensive outbreaks of acute haemorrhagic conjunctivitis occurred in 198I in Africa, Asia, and, for the first time, the Americas. WHO virus collaborating centres were involved in the identification of the causative agent. Enterovirus type 70 was confirmed in one outbreak. Other possible agents known to cause this kind of outbreak, adenovirus type I I and coxsackievirus A type 24, were not identified.
1
Bulletin of the World Health Organization, 59: 85 3-854
(1981).
THE WORK OF WHO, r98o--r98r
9.136 Yellow fever. A large number of cases occurred in I98o, mainly in Africa, where Ghana, affected for two years consecutively, set up an intensive vaccination programme with WHO support. Ecological studies in West Africa showed that epizootics can develop in monkey populations and move along riverine forests in waves lasting three to four years. This may result in periodic epidemics among local human populations, as in Gambia in I978-I979· In the Americas the upward trend of jungle yellow fever since I972 was arrested in I98o, but a gradual spread to previously unaffected areas occurred; the vector Aedes aegypti is widespread and there is an increased risk of urban transmission. The I 7D yellow fever vaccine in use is still remarkably effective, but its mode of preparation does not allow for production on a scale to meet the demand. New techniques for vaccine production are being studied in the Americas and production facilities in Brazil and Colombia improved. 9· I 37 Dengue haemorrhagic fever. All four serotypes of dengue virus are now prevalent in the dengue endemic areas of Asia and America. Serotype 4, which was introduced in many islands of the South Pacific in I979-I98o, was for the first time isolated in the Americas in I 98 I and caused several outbreaks in the Caribbean. Haemorrhagic and fatal cases were also recorded for the first time in the Americas in I98I, in a violent outbreak in Cuba. In the endemic areas of Asia, Thailand had the highest number of cases ever in I98o and Indonesia remains highly endemic, while in China and VietNam the disease seems to be increasing. In other areas where the virus is known to be prevalent the disease is either silent or present mainly as the milder classical dengue fever. The pathogenesis of the severe forms is still largely unknown and further clinical, immunological, epidemiological, and virological studies are required. Vaccine development has high priority; strains for a quadrivalent qo
vaccine have been selected by the WHO collaborating centre in Bangkok and are being cultured by serial passage to achieve attenuation. Research and vaccine development were reviewed at interregional meetings held in Delhi in March I98o and March I98 1. 9·13 8 Rift Valley fever. Following its dramatic appearance in Egypt in I977, Rift Valley fever continues to arouse concern in the Mediterranean and Middle East. An informal consultation in Geneva in I 98 I stressed the general lack of preparedness for dealing with any extension of this hitherto purely African disease. It listed the effective epidemiological surveillance mechanisms available, reviewed control measures, indicated areas where the vaccine could be used in humans and livestock, and outlined national contingency plans applicable both in countries that had experienced the disease and in countries potentially receptive to its introduction. 1 9· I 39 Rickettsial diseases. The present status of rickettsial diseases was reviewed and guidelines for the development of national control programmes were prepared by a working group convened in Geneva in I981. An additional WHO collaborating centre for rickettsial reference and research was established at the Gamaleya Institute of Epidemiology and Microbiology, Moscow, in order to increase the availability of reagents for diagnosis and control. Specific antigens and antisera were distributed to national laboratories.
Diseases restricted to circumscribed geographical areas
9· I40 Viral haemorrhagicfevers. The spread of haemorrhagic fevers seems to be limited to 1 World Health Organization. Rift Valley fever: an emerging human and animal problem. Geneva, 1982 (WHO Offset Publication No. 63).
COMMUNICABLE DISEASE PREVENTION AND CONTROL
endemic zones, but they carry the threat of infection in any part of the world. A meeting was convened in New Delhi in March 1980 to consider research in viral haemorrhagic fevers in the Eastern Mediterranean, SouthEast Asia, and Western Pacific Regions. It outlined measures and research that could be undertaken if the diseases appeared in a new country. 9· 141 Although no epidemic occurred in 198o-1981, epidemiological research by the
9· 144 With the advent of selective antiherpes drugs, the prospects for effective chemotherapy of viral diseases look promising. To play an active part in this rapidly developing area of research, WHO has established an expert advisory panel on virus diseases (antivirals and interferon). 9· 145
WHO collaborating centres in Africa has continued on Lassa, Marburg, and Ebola viruses, in coordination with monkeypox surveillance. These viruses were found to be present in larger areas of Africa south of the Sahara than was suspected. 9· 142 The Regional Office for the Americas and UNDP supported a project to develop a vaccine against the Junin virus, the causative agent of Argentine haemorrhagic fever. In 1981 a possible seed virus was developed as a vaccine candidate.
Exchange of information. WHO has maintained a virus reporting system since 1 96 3, the total number of reports now exceeding 100 ooo per year and the number of reports from the participating laboratories in developing countries being almost one and a half times as many in I98o-1981 as in 1978-1979· The reporting system, by keeping laboratories in developing countries in contact with the network of virus laboratories throughout the world, has been of value to those countries in assessing the progress they have achieved in laboratory diagnosis.
Safety measures in microbiology 9· 146 Various collaborating centres and national authorities were assisted in relation to the biosafety requirements of diagnostic and research laboratories working with dangerous pathogens. Biosafety guidelines in microbiology have been developed by an international working group for use, as they are, by individual laboratories or national governments, or for adaptation to local or national conditions. A number of other guidelines have been prepared or are under preparation, and those for the management of accidents involving microorganisms have been published.! WHO participated with the Universal Postal Union and the International Air Transport Association in the revision of their regulations for the safe and expeditious 9· 147 1 Bulletzn of the World Health Organization, 58: 245-256 (198o).
Research and information
9· 143 Research on antiviral agents. A WHO/National Institute of Allergy and Infectious Diseases workshop on DNA recombinant interferon cloning held in Washington in 1980 devised a system for the orderly nomenclature of interferons. DNA recombinant techniques are expected to provide large quantities of relatively cheap highly purified interferons. To determine the significance of different types and subtypes in the treatment of certain diseases and to prevent duplication and wastage of interferon, international cooperation is necessary. A WHO informal meeting in Rotterdam, Netherlands, in 1981 discussed approaches to such international collaboration in relation to the clinical use of interferon.
THE WORK OF WHO, 198o-I981
shipment of diagnostic specimens and agents. It is currently involved with ICAO and IMCO in the revision of their requirements for the transport of the same agents. 9· I48 An international consultation on training programmes in biosafety was held and model training programmes and trainers' manuals were developed for use at regional, national, and local level. The first training course was held in Brazil. 9· I49 Active liaison has been maintained with the Committee on Genetic Experimentation of the International Council of Scientific Unions and with several national programmes regarding assessment of the risk of laboratory procedures associated with R-DNA research. Recommendations were made in relation to laboratory facilities.
particularly in developing countries; there 8o-8 5% of the inhabitants do not have even minimum health care for sexually transmitted diseases, which are frequently present in 5-15% of the adult population. To diagnose and treat the diseases as early as possible before the appearance of complications, cooperative research was carried out to develop simplified and rapid diagnostic techniques for use by non-specialized personnel; this would obviate the need for cumbersome, expensive, and sophisticated laboratory methods. Research was carried out at the same time on the development of simplified rapid diagnostic techniques for bacterial infections. 9· I 52 The emergence of gonococcal strains that are highly or totally resistant to penicillin or to a range of drugs is a serious problem. WHO organized a worldwide resistance surveillance programme, in line with the recommandations of resolution WHA 3 I. 57 and of various scientific groups. This problem is compounded by the indiscriminate use of antimicrobial agents in man and animals and by their wide use in food preservation. A scientific working group in I 98 I proposed methods of dealing with the problem, which particularly affects countries that find it difficult to meet the cost of the new antibiotics required to deal with resistance. 9· I 53 In many regions of the world genital ulcers of diverse bacterial and viral origin are responsible for a great many sexually transmitted diseases. A multinational research project on methods of diagnosis, treatment, and control has been coordinated by WHO. Research was also carried out to identify the antigens responsible for the attachment to and penetration of gonococci into cells and tissues and to elucidate the mechanism of antibody production. The findings have helped in the identification of vaccine candidates and opened the way to promising diagnostic technology.
Hospital infections 9· I 5o Larger hospitals, particularly in the developing countries, increased specialization, modern diagnostic and curative techniques, and various newly developed drugs that affect immunoresistance contributed to higher morbidity and mortality rates from hospital infections. To define the magnitude and nature of such infections, WHO initiated a prevalence study in selected countries. Surveillance will be carried out by a collaborating centre for reference and research on hospital infections that has now been established at the Public Health Laboratory, Colindale, London.
Sexually transmitted diseases 9· I 5I WHO's objective, in close cooperation with countries, research centres, and nongovernmental organizations, is to make effective control services available to an increasing percentage of the population,
COMMUNICABLE DISEASE PREVENTION AND CONTROL
9· I 54 Endemic treponematoses. A review 1 of the epidemiological situation shows that yaws and endemic syphilis still constitute a considerable health hazard to the child population in medically underserved areas, particularly in West and Central Africa and, to a lesser extent, in South-East Asia and the Americas. The incidence of endemic syphilis (bejel) in the sub-Saharan :egion approaches that of yaws in the savanna and rain forest region of West Africa. Recent WHO surveys in the Sahel found that approximately 2.8 million of the region's 30 million inhabitants were at risk of endemic syphilis. Reports suggest, however, that pinta has virtually disappeared from countries of Latin America. WHO cooperated with national health administrations and bilateral agencies in assessment of the problem in a number of countries of West and Central Africa and in the implementation and evaluation of control. 9· I 55 A WHO Scientific Group on Treponema! Infections (October I98o) updated and simplified the treatment schedules recommended for use in treponematoses control programmes.2 A field manual on the clinical and control aspects of endemic treponematoses for health workers in primary health care areas is in preparation.
9· I 57 The WHO Advisory Group on the Prevention of Blindness met in Ouagadougou in I98o at the headquarters of the Onchocerciasis Control Programme, and in I98I in New Delhi. The latter meeting was attended by representatives from all the regional offices with a view to achieving coordination of the programme. The economic implications of the prevention of blindness were reviewed by a small expert group in I98o in which the World Bank participated. Useful guidelines for eye care within the framework of primary health care were elaborated by another working group in Geneva in I98o. 9· I 58 Contributions through the Voluntary Fund for Health Promotion, in particular from the Netherlands, Norway, Sweden, and the Japan Shipbuilding Industry Foundation, have considerably strengthened activities in several countries, e.g., the prevention of blindness programme in Nepal, operational since I98o. Advisory services for the formulation of national programmes were provided by WHO to more than 30 countries during I980-I98I.
Prevention of blindness 9· I 56 Work proceeded in several countries on the assessment of blindness and its causes and on the planning of preventive measures and provision of essential eye care at peripheral level. A resolution on the prevention of blindness was adopted by the Regional Committee for Africa in I98o. The first meeting of the PAHOJWHO advisory committee on prevention of blindness took place in Brazil in I98o. t Week!J Epidemiological Record, 56: 241-244 (1981). z Report to be published in the WHO Techmcal Report Senes, 1982.
9· I 59 Close collaboration was mamtained with several nongovernmental organizations, in particular the International Agency for the Prevention of Blindness. Funds provided by the Royal Commonwealth Society for the Blind and the Asian Foundation for the Prevention of Blindness permitted the employment of a full-time WHO programme coordinator for the prevention of blindness in South-East Asia for a two-year period. 9· I6o Several seminars and workshops on the prevention of blindness were held at the intercountry and national levels. The training of auxiliary health personnel, particularly community health workers, in eye care was the subject of two meetings in I98o in the African Region, sponsored jointly by
THE WORK OF WHO, I98o-I98I
WHO and the International Eye Foundation. Following those meetings, the possibility of strengthening the training of health personnel in eye care within the framework of TCDC was investigated in six neighbouring countries in Africa. Intercountry cooperation in the surveillance and prevention of blindness was discussed in a seminar in Uruguay in I98I at which five Latin American countries were represented. 9· I 6 I Support was given to trammg in eye care at the national level for various categories of health personnel. A regional workshop on the prevention of blindness in the Western Pacific Region focused on training and its interrelation with the establishment of blindness surveillance systems. The organization of cataract relief services was considered by a workshop in South-East Asia, as well as by several seminars at the national level. The use of residual vision by visually disabled persons was reviewed in a multidisciplinary meeting in the European Region in I98I, convened within the context of the International Year of Disabled Persons. 9· I 62 The network of WHO collaborating centres for the prevention of blindness has been strengthened and at present comprises Io institutions. The training and research programmes of these centres were reviewed at the annual meetings of the Advisory Group on the Prevention of Blindness in I98o and I98I and priorities for applied research were established. Training courses for medical personnel in the epidemiology and public health aspects of ophthalmology are being arranged by some collaborating centres. 9· I63 The lack of reliable data on disorders causing blindness and their effect is in certain areas an obstacle to systematic prevention or treatment. A grant in I98o from the National Eye Institute, National Institutes of Health (USA) through the Voluntary Fund for Health Promotion is being used for the I34
collection of data on blindness and applied field research. Additional technical staff have been recruited for this work, which has so far been carried out in two African countries. 9· I64 Two publications have appeared, one on applied survey techniques, 1 the other on the prevention and control of trachoma.z A standard eye examination record, which was developed and field-tested for surveys on blindness, is adapted to computer data analysis and will be available in several languages. A blindness data bank has been established, with periodic updating of available information on blindness throughout the world. A pamphlet giving general information about the programme has been prepared.
Expanded Programme on Immunization 9.I65 At the time of the Alma-Ata Declaration in I978, which included immunization against the major infectious diseases of childhood among the eight elements necessary to provide primary health care to all the world by the end of the century, no training programmes for the management of immunization programmes had been developed; no consensus was to be found on the type of information needed to monitor and evaluate progress; no routine reporting existed of immunization coverage and vaccine quality, particularly in the developing countries; and few efforts were being made to provide immunization within the framework of comprehensive health services. Now all developing countries or areas in the six WHO regions are in the process of implementing immunization programmes in accordance with WHO recommendations that include 1 World Health Organization. Methods of assessment of avoidable blindness. Geneva, I98o (WHO Offset Publication No. 54). 2 Dawson, C.R., Jones, B.R. & Tarizzo, M.L. Gutde to trachoma control in programmes for the prevention of blmdness. Geneva, World Health Organization, I 98 I.
COMMUNICABLE DISEASE PREVENTION AND CONTROL
specific targets for both immunization coverage of the infant population and disease reduction. 9· I66 Programme management. The target for DPT, poliomyelitis, and measles immunization in I983 is to cover 50% of the newborn, and for BCG 7 5%. However at present coverage can be stated regionally only by three of the WHO regions: for exemple, for DPT, the most frequently given antigen, coverage is 37% in the Americas, 22% in the Eastern Mediterranean, and I 5% in SouthEast Asia. Specific coverage surveys in geographical areas where phased development of the immunization programme is starting are more encouraging. In the period I 979-I 98 I such surveys were carried out in 49 countries and showed more than 50% coverage in 3 5% of the surveys for DPT, 3o% of those for polio vaccine, and 54% of those for measles vaccine.
Industry Foundation, and the extended training activities during this period would not have been possible without significant contributions from the Netherlands and Sweden. Contributions of vaccine were made by Finland, the Netherlands, and the USSR. 9· I69 Vaccines. Figure 9.2 summarizes the information available on countries that use vaccines conforming to WHO requirements. A system of certification of laboratories qualified to test individual vaccines for their conformity with WHO requirements is now being initiated.
9· I 67 Following the pattern of developed countries in the past two decades, a reduction in poliomyelitis, measles, and tetanus has already been recorded in limited areas of the developing world, particularly in the Americas, where immunization and recording systems are more advanced. At global level it is too early to discern any meaningful trends. 9· I 68 External resources. Of the multilateral funding bodies UNICEF continued to be the major supporter of the programme, primarily with vaccines and cold chain equipment. UNDP continued to provide funds for the improvement of vaccine quality control and intercountry activities in the African and South-East Asia Regions. Considerable extrabudgetary funds were channelled through the Voluntary Fund for Health Promotion. All activities relating to cold chain development were funded through contributions received from Denmark, Finland, the United Kingdom, and the Japan Shipbuilding
9· I 70 The Regional Office for the Americas established a successful rotating fund for the purchase of vaccines and other selected materials. The Regional Office for the Western Pacific is considering establishing a regional procurement system for vaccines and drugs, and WHO and UNICEF have been collaborating closely to satisfy national vaccine requirements. The global information system continues to suffer from weaknesses in forecasting vaccine needs, but is improving as national planning capacity improves.
Training
9· I 7 I The emphasis has been on management at all levels; senior health officials from I 20 countries were trained in immunization planning, and staff from 7 3 countries participated in national and intercountry courses for mid-level supervisory personnel. Courses in cold chain management and cold chain equipment repair were held for technicians from 52 countries.
Research
9· I 7 2 sing in
i4 target research areas, notably:
Work was completed or is progresthe
THE WORK OF WHO, 198o-198I
Figure 902 Quality of Expanded Programme vaccines being used (Percentage of countries/areas, by WHO region)
AFRICA (46)
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AMERICAS (47)
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SOUTH-EAST ASIA ::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: ::.~:::::::::::::::: ::::::::::::::::::::::::::::::::::::::::: (11) ........... . ... . .. .. .. .. .. . . .. .. .. ..................................... 0 :::::::::: 0
EUROPE (37)
..................... .. . . . . . . . . . . . . . . . . . .. .. .. . .. .. .... .... .. .... . . .. . . .. .. . . . . . . .... . .. .. . . .................................. . . . .. ...... .. . . . .. . ... . . . . . .. . .. ..... ..... . . .. • 0 • • • • • • • • 0 0 • • • • • • • • • • • • • • • 0 • • • • • • • • • • • • • •
EASTERN ................................. MEDITERRANEAN • • • • • • • 0 • • • • • • • • • • • • • • • • • • • • • • • • • 0 0. 0 • • • • • • • • • • • • • • • 0 ••• 0. 0 0. 0
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WESTERN PACIFIC :::::::::::::::::::::::::::::::::::::::::::. ·::::::::::: ·::::::::::: (32) : 0: ·: 0:·:·:o:• : 0:.:.: 0: 0:· :·:. :·: ·:· :· :·:.:. :·:·: .·.:.:.: 0: :. :. : o:•
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Percentage of countries Countries/areas in which vaccines conform ~ to WHO requirements ~
Countries/areas in which one or more vaccines do not conform to WHO requirements Countries/areas using vaccines of quality unknown to WHO
(00)
Number of countries/areas in the region
COMMUNICABLE DISEASE PREVENTION AND CONTROL
epidemiology of neonatal tetanus, measles, and poliomyelitis; the development of costing guidelines; the preparation of diagnostic materials; the development of more stable measles vaccines; and the development and commercial production of a wide range of cold boxes, refrigerators, freezers, and temperature indicators. 9· I 7 3 Satisfactory progress has not been achieved with respect to pertussis, for which an improved vaccine and improved diagnostic methods are needed. Basic research in this field is being pursued, particularly in the American, European, and Western Pacific Regions. Little progress has been made in better defining the geographical distribution of diphtheria but, although this is technically feasible, it is not at present considered to be a matter of priority.
9· q6 Despite the considerable improvement in information systems in recent years, much remains to be done. Reports on the incidence of all the target diseases were received from only 8 3 countries or areas for the year ending December I98o, and the quality of vaccines being used was not known for 75 countries or areas. 9· I 77 An increasing number of countries are conducting national programme reviews, 17 having been completed in I979 and I98o and seven in I981. The methods used are adapted to the needs of the country concerned. The current emphasis is on broadening the review process to include other elements of primary health care than immunization, with particular emphasis on maternal and child health care.
Veterinary public health
Evaluation 9·I74 Using data obtained from the global information system and regional and global narrative reports, the programme's advisory group conducts an annual review and issues a report. The group met in Geneva in I98o and in Washington in I981.
9· 175 The Regional Office for the Americas started a newsletter in May I979 which has received wide circulation inside and outside the Region. The Western Pacific Region includes information on the incidence of the programme's target diseases in its monthly epidemiological bulletin. One or more countries in each region either have special newsletters or periodic reports concerning the programme or include information on immunizable diseases in their epidemiological records or bulletins. Wider circulation of this information is given by the Week!J Epidemiological Record.
9· q8 The WHO Expert Committee on Bacterial and Viral Zoonoses that met in Geneva in I 98 I 1 with the participation of F AO reviewed the socioeconomic aspects and the factors influencing the prevalence of zoonoses and recommended measures for surveillance, prevention, control, and possible elimination. It dealt particularly with the need for intersectoral and interdisciplinary collaboration and for comprehensive national programmes to ensure the mobilization of resources in the different sectors concerned with health-the environment, food, safety of animal products, and wastes. It placed special emphasis on surveillance and control of emerging zoonoses and immediate improvement of rural economic development services.
1 Report to be published in the WHO Technical Report Series, 1982.
THE WORK OF WHO, I98o-I98I
Zoonoses centres 9· I 79 The veterinary public health programme and the zoonoses control centres are supported in their activities by WHO collaborating centres. The Pan American Foot-andMouth Disease Center in Rio de Janeiro and the Pan American Zoonoses Center ,in Buenos Aires continued to cooperate with the national authorities and institutions of several countries in the Americas in planning new control and prevention programmes for zoonoses and exotic diseases. They conducted applied research on vaccines and diagnostic procedures and trained staff in various fields of veterinary public health and animal health. Several countries, with close technical cooperation from the Zoonoses Center, carried out control programmes for brucellosis, bovine tuberculosis, echinococcosis/hydatidosis, leptospirosis, and rabies. 9· I So The Mediterranean Zoonoses Centre (UNDP(WHO) extended its services to almost all the Mediterranean countries, particularly for rabies, echinococcosis/hydatidosis, and improvement of the hygiene of food products of animal origin. It organized or took part in rpeetings that provided practical guidelines on echinococcosis/hydatidosis control (Morocco, I 980), intersectoral and interprofessional cooperation (Portugal, I98I), and Rift Valley fever (Geneva, I98I) (see also paragraph 9· 13 8). 9· I 8 I The various WHO collaborating centres also hosted a world congress on foodborne infections and intoxication in Berlin (West) (I98o), a seminar .on milk hygiene (Hanover, Federal Republic of Germany, I98o), a seminar on environmental hygiene dealing with the hygienic aspects of animals in urban areas (Hanover, I98I), a symposium on the comparative aspects of leukaemias, lymphomas, and papillomas (Munich, I98o), and a symposium on the microbiology of prospective biological products for viral diseases (Munich, I 98 I).
Control of zoonoses and Joodborne diseases 9· I 82 In line with resolution WHA3 1.48, emphasis continued to be placed on the development of national, regional, and global strategies and methods for the surveillance, prevention, and control of zoonoses and foodborne diseases attributable to animal products. Guidelines on echinococcosis/ hydatidosis control were issued t and other guidelines were in preparation. 9.I83 Rabies. WHO developed regional and global strategies specifically for the control of rabies in dogs in developing countries since, with the improvement of vaccines and immunoglobulins for the treatment in man, the elimination of the disease in its animal reservoirs is being neglected. Information was collected from all regions on successful dog rabies control projects and a model comprehensive national programme was developed and used in collaboration with Member States. WHO has become directly involved in national programme planning and execution, since rabies calls for the coordination of activities in adjacent countries.
9· I 84 Research was carried out on dog ecology in selected areas of the Americas, North Africa, and the Philippines. The recommendations of the WHO Expert Committee on Rabies2 were reviewed and amendments proposed at informal meetings in I98o in Lyon, France (co-sponsored by the Pasteur Institute) and in I98 I in Nancy, France (organized jointly with the French National Rabies Research Centre). An international research programme on natural barriers to wildlife rabies was given guidance at a WHO
1
WHO document VPH/8L28 (1981). z WHO Techmcal Report Series, No. 523, 1973·
q8
COMMUNICABLE DISEASE PREVENTION AND CONTROL
meeting in I 98 I in Vienna (co-sponsored by the Austrian Government). Specific aspects of modern cell culture vaccines for humans were discussed and vaccine schedules defined at a meeting held in I98o in Essen, Federal Republic of Germany (co-sponsored by the University of Essen). 9· I 8 5 Echinococcosisfrydatidosis. Following a remarkable expansion of interest in this subject, programmes were launched successfully in Cyprus, the Falkland Islands (Malvinas), New Zealand, and Tasmania, representing island models, and in Argentina, Bulgaria, Chile, Peru, Uruguay, and parts of the USSR, representing continental models. Experience gained from these programmes highlighted the important steps in control and their sequence and clearly showed that a reduction in echinococcosis in all age groups of the human population as well as in food animals can be rapidly achieved by relatively simple control measures. However, traditions, habits, inadequate meat inspection, access of dogs and other animals to infected offal, inadequate intersectoral cooperation, and the absence of suitable programmes remain obstacles to successful control in many Member States. In cooperation with F AO and UNEP, WHO in I981 formulated research requirements for future decades and collaborated with an increasing number of Member States in planning, executing, and evaluating national programmes. Fresh knowledge has accrued on host-parasite relationships, sociocultural factors modifying them, strain differences, and the dynamics of transmission. Serological diagnosis in man can now be applied with a high degree of sensitivity in some areas and highly effective drugs are available for the large-scale treatment of dogs. Some drugs were identified as having larvicidal activity in animals and are being evaluated in man. 9.186 1 39
Salmonellosis. The WHO/World Association of Veterinary Food Hygienists Round Table Conference on the Present Status of the Salmonella Problem (Prevention and Control), held in the Netherlands in 198o, noted that salmonellosis from food of animal origin is the most common food borne disease in the world and causes great morbidity and economic loss. Guidelines were prepared to assist public health and veterinary authorities and food and feed industries in taking practical measures to prevent and control salmonellosis. 9.I87
Surveillance of foodborne diseases. An international surveili:lpce programme to aid national programmes for control of foodborne diseases was established in the European Region, mainly by the F AO/ WHO collaborating centre for research and training in food hygiene and zoonoses, Berlin (West). Fifteen European countries agreed to participate and in nine a contact point was designated to provide relevant information. A manual on surveillance of foodborne diseases is being prepared to advise countries on how to organize programmes at national level. 9. I 8 8 9· I 89 More than 2 5o requests for information on food virology were received from 40 Member countries. Two centres, one in the United States of America (Madison, Wisconsin), the other in Czechoslovakia (Brno ), actively collaborated in the food virology programme. 9· I9o Training. Two international courses on zoonoses management in which WHO closely collaborated were convened in 1980 and I98 I in the USSR. Rabies, brucellosis, leptospirosis, echinococcosis/hydatidosis, taeniasis/cysticercosis, and foodborne disease control were subjects in the courses, in which 45 students from five WHO regions participated.
THE WORK OF WHO, 1980-1981
9· I9I A WHO workshop on veterinary public health was conducted by the F AOJWHO collaborating centre for research and training in food hygiene and zoonoses. The participants were senior public health and veterinary public health officers from the Eastern Mediterranean and SouthEast Asia.
ment of programmes for monitoring critical control points.
Four international training centres in Europe coordinated international postgraduate courses in food microbiology for students from developing countries. 9· I92
Meat hygiene. Work was carried out jointly with F AO on an international code of principles for ante-mortem and post-mortem judgement of slaughter animals and meat, and a code of hygienic practice for game. They were discussed by the Codex Committee on Meat Hygiene (London, I 98 I) and the Codex Alimentarius Commission itself (Geneva, I98I). 9· I95
Microbiological criteria for food 9· I93 An FAOJWHO working group on microbiological criteria for dried milk products and natural mineral water met in Washington (November I98o) and inter alia finalized general principles for the establishment and application of microbiological criteria for food. These were adopted at the fourteenth session of the FA 0 JWH 0 Codex Alimentarius Commission (Geneva, I98I).
9· I 96 In developing countries slaughterhouses and meat-handling practices contribute greatly to poor health and the spread of animal diseases. Two guidelines-on the design and construction of simple slabs where modern facilities are lacking and on slaughter and meat-handling where there are few slaughter facilities-were the subject of an informal consultation with F AO in Geneva in April I98I. 9· I 97 Fish and shelfish hygiene. Work on fish hygiene was carried out jointly with F AO within the framework of the Codex Committee on Fish and Fishery Products. Several codes of hygienic practice for fish products were discussed at the meeting of the Committee in Bergen, Norway, in I98o, including microbiological specifications for frozen, cooked, and ready-to-eat shrimps and prawns,- which are widely available in international trade. In view of the public health importance of intoxications caused by shellfish, particularly in tropical areas of the world, a guide on paralytic shellfish poisoning was begun.
9· I 94 Effective control over pathogenic microorganisms and their toxins in food must be exercised not only during the processing of the food but also during its distribution, wholesale and retail storage, and final consumption either in food service establishments or at home. The hazard analysis and critical control point system is an approach to these problems. This system, originally developed for use in food processing establishments in the United States of America, has the full support of WHO. The first meeting of experts in this field was convened in Geneva in I 980 to discuss further development of the system, including: assessment of the health and spoilage risks associated with processing and marketing a given food product; determination of critical control points in the manufacturing process; and the establish140
Comparative medicine 9· I98 Emphasis was laid on studies in cancer therapy from which results can be extrapolated to man. The classification of tumours in domestic animals by extent,
COMMUNICABLE DISEASE PREVENTION AND CONTROL
condition of lymph nodes, and presence or absence of distant metastases (TNM) was issued. 1 It is as close an adaptation as possible to the TNM classification of malignant tumours in man, published by the International Union against Cancer and in international use. The purpose of the animal tumour classification is to provide an unambiguous method of reporting clinical observations and a guide to prognosis and therapy. In international clinical trials carried out in conjunction with the WHO collaborating centre for comparative oncology, the Department of Clinical Veterinary Medicine, University of Cambridge (United Kingdom), the TNM classification was already being used. The trials covered the use of radiotherapy in spontaneous osteosarcoma in dogs, with and without a hypoxic cell sensitizer, and the immunotherapy of spontaneous canine mammary tumours. The results will be directly relevant to human cancer. 9· r 99
Vector biology and control 9.201 Greater efforts were made to develop training facilities, particularly at the advanced level, and to collaborate with national professional staff in improving control of insect vectors, rodent reservoirs, and snail intermediate hosts of disease.
Vector resistance 9.202 Insecticide resistance in important vectors of disease continued to spread, appearing in additional species and in additional geographical areas. With the appearance of resistance to DDT in the sandfly Phlebotomus papatasi in Bihar State, India, the tsetse remains the only important vector group in which resistance has not been reported. The most serious challenge to a large-scale programme has been the development in the Ivory Coast of resistance to temephos in two species of the Simulium damnosum complex, S. soubrense and S. sanctipauli. First noted in the south in May 1980, resistance to this organophosphorus insecticide has since spread, so that the Onchocerciasis Control Programme has had to shift to alternative insecticides; in October 1981, cross-resistance was detected to one of these alternatives, chlorphoxim. The further spread of resistance to organophosphorus insecticides among important vectors of malaria has greatly increased the technical and financial problems these programmes face. Multiple resistance has been reported in nine additional species of anophelines, including Anopheles sacharovi in Turkey, A. culicifacies and A. stephensi in India, and A. arabiensis in Sudan. The appearance of resistance in populations of Aedes aegypti in the Americas may increase operational problems in the intensified programmes against this vector of yellow fever, dengue, and dengue haemorrhagic fever. Cross-resistance to synthetic pyrethroids in DDT-resistant A. aegypti is of great concern,
Laboratory animal health 9.200 Cooperation with Member States in laboratory animal health was expanded and WHO, together with the International Council for Laboratory Animal Science, drafted a medium-term programme covering: on husbandry, breeding guidelines methods and quality, rational use, experimental techniques, and transportation; education and training; and research. The programme was adopted at a meeting of the Council's Governing Board (Dusseldorf, Federal Republic of Germany, 1981).
1
WHO document VPH/CMOJSo.zo (198o).
THE WORK OF WHO, 1980-I98I
since this is the newest group of insecticides available for use against resistant vectors. All in all, by 1980, 54 different species of anopheline and 42 species of culicine mosquitos had developed resistance to one or more insecticide compounds used in vector control programmes. This increases the urgency of the need to develop alternative pesticides and alternative methods of vector control that can be integrated with, or at least in part substituted for, the use of chemical pesticides and so reduce the selection pressure.
Pesticide production and safe use 9.204 WHO carried out trials of new formulations of existing insecticides in Indonesia, the Ivory Coast, and Thailand and the information provided on them to manufacturers has resulted in marked improvements in the performance, stability, and packaging of formulations. 9.205 Some of the alternative compounds under trial are less safe for spraymen and inhabitants of treated houses than the insecticides they must replace. Safety protocols were developed in collaboration with national authorities, the manufacturer being invited to participate in field trials by providing the insecticide, analysis equipment, and technical staff, particularly toxicologists, to carry out safety assessment of the compound. Such a trial was carried out in Indonesia. Continued concern about the possible enhanced tox1c1ty of malathion waterdispersible powders as a result of defective or prolonged storage led to frequent requests for assessment of the toxicity of suspect batches. A course on the safe use of pesticides adaptable to national needs was started in the Republic of Korea and Sudan, and Spanish and Portuguese texts for it are being prepared.
Testing and evaluation of new insecticides 9.203 To overcome vector resistance to insecticides, especially where alternative methods are difficult to implement or are not available, it is necessary to shift to insecticide compounds that involve no cross-resistance to existing groups. The industry was encouraged to provide such candidate compounds for field tests, and WHO organized or participated in collaborative trials in Colombia, Indonesia, Nigeria, and Venezuela of compounds against several different vector species, including mosquitos and triatomid bugs. Unfortunately, the number of new compounds submitted to WHO for testing remains low. Testing has been intensified to expedite the screening of the new compounds made available and to ensure that they reach the essential large-scale field trial stage with the least delay. The industry also increased its collaboration by requesting WHO to comment on the protocols of its own trials. Representatives of the industry visited the WHO collaborating centres in the Ivory Coast, United Kingdom, and United States of America as well as the WHO field testing unit in Indonesia. The results of field trials have been rapidly disseminated to the Member States through unpublished documents issued by WHO.
Testing and evaluation of insecticide application equipment 9.206 Laboratory and field tests were carried out with a new type of sprayer and it was then tried out in a national malaria programme in Saudi Arabia. The results of the tests were communicated to the manufacturer and weak points in the construction have been remedied. Draft specifications for mist blowers and aerosol generators were drawn up and are being tested at the WHO collaborating centre for equipment testing, Silwood Park, United Kingdom. Tests were
COMMUNICABLE DISEASE PREVENTION AND CONTROL
also carried out with an electrostatic sprayer at this centre and the initial results were encouraging, though the dispersal patterns must be improved.
Biology and control of specific vectors 9.207 Malaria vectors. Studies on the ecology of A11opheles balabacensis in Thailand and A. sundaicus, A. aconitus, and A. sacharovi in Turkey were carried out in collaboration with national malaria programmes. A seminar on the biology and control of A. sinensis was held in China in I 98 1. Field trials of new insecticides, new insecticide formulations, and new approaches were carried out by the WHO research unit, Semarang, Java. Large field tests of an organophosphate, a carbamate, and a pyrethroid were undertaken in a number of villages. Selective spraying of fenitrothion (OMS-43) on the lower portion of walls where most A. aconitus rest provided acceptable and much more economical control than total house coverage. 9.208 An interregional seminar in Adana (Turkey) reviewed environmental management methods and their application to malaria vector control. WHO collaborated with the Government of Burma in its vectorborne disease control programme, which was aimed primarily at control of malaria and its vectors. 9.209 Vectors of filariasis. Longitudinal studies on the biology, ecology, and distribution of vectors of Brugian and Bancroftian filariasis in Java and Sumatra (Indonesia) were completed and the vectorial capacity of the mosquito vectors was determined. Entomological, parasitological, and control studies were carried out in Sulawesi in collaboration with the Ministry of Health. Studies on the control ofBancroftian filariasis in Sri Lanka were carried out in collaboration with the Government. The efficacy of insect growth inhibitors and bielogical control I43
agents against the main urban vector of filariasis, Culex quinquejasciatus, was examined by several different collaborating laboratories. The South-East Asia and the Western Pacific Regional Offices provided expertise, material for susceptibility tests, and insecticides for field trials against vectors of filariasis. 9.2Io Vectors of yellow fever and dengue. With funds from the Government of the Netherlands, an intensive study was initiated' on the biology and distribution of Aedes aegypti in Colombia. There are already indications that it has spread to parts of the country in which it was never found before. Because of a major outbreak of dengue and the first appearance of dengue haemorrhagic fever in Cuba, WHO collaborated with the Government in emergency vector control measures. Trials of vehicle-mounted insecticide application equipment against A. aegypti were carried out by a reference laboratory in Thailand. Following a yellow fever outbreak in Angola, a collaborative study was made of the distribution and population density of A. aegypti in Lunda; another was carried out in the United Republic of Cameroon. A grant was provided to a laboratory in Dakar for research on the vectors of yellow fever in Central and West Africa; these studies are providing more data on the transovarial transmission of yellow fever virus. I Vectors of onchocerciasis. Following the appearance of insecticide resistance in two Simulium species in the areas of the Onchocerciasis Control Programme in West Africa, efforts to develop and field-test chemical and biological pesticides as alternatives to temephos were intensified. WHO cooperated with Guinea, Guinea-Bissau, Mali, Senegal, and Sierra Leone in a feasibility study on onchocerciasis control. Through its research unit in Kaduna it cooperated with Nigeria in the preparation of a national
9.2 I
THE WORK OF WHO, 198o-I981
onchocerciasis control campaign. DANIDA funded an onchocerciasis pilot scheme in the United Republic of Tanzania with which WHO cooperated. WHO also participated in missions to evaluate onchocerciasis and its vectors in Guatemala and Mexico, and in planning in Ecuador in relation to the newly discovered onchocerciasis vectors there.
for control. In Malaysia WHO assessed potential rodent reservoirs of plague and advised on control. A two-week interregional training course on rodent control was held in Rangoon. 9.2I4 Snail intermediate hosts and schistosomiasis control. In collaboration with GTZ, missions were undertaken to Congo, Malawi, and Mali to prepare collaborative support for schistosomiasis control programmes. A similar mission was carried out in Rwanda, and another, combined with a teaching course, in Gabon. In view of the worldwide shortage of persons trained in medical malacology, support was given to the development of regional centres for applied malacology. In association with the Special Programme for Research and Training in Tropical Diseases, assistance was given to many research projects in the prevention and control of major trematode diseases. Reviews, manuals, and practical field guides on such subjects as plant molluscicides, biological control, and snail host taxonomy by regions were prepared. The prospects for biological control of snail hosts at virtually no cost in integrated control schemes are now promising. A programme for the development of biocontrol agents, mainly competitor andfor predator snails, was begun in I98I, involving WHO collaborating centres in several Member States. 9.2I 5 Cyclops and dracunculiasis control. In connexion with the International Drinking Water Supply and Sanitation Decade, WHO collaborated with the agencies involved in the reduction or elimination of guinea-worm infection, especially in West Africa, through the provision of safe drinking-water supplies.
Vectors of trypanosomiasis. With the Special Programme for Research and Training in Tropical Diseases, research programmes were carried out on tsetse vectors of sleeping sickness (see paragraphs 9.2439.248). Studies in the Ivory Coast and Kenya on the biology, ecology, and population dynamics of tsetse provided a basis for control activities. Improved trapping methods for sampling and controlling tsetse have been developed and give hope that simple traps and insecticide-impregnated screens can be used by villagers for their own protection in sleeping sickness endemic areas. WHO participated in meetings organized by F AO and OAU on the planning of tsetse control programmes. A long-term feasibility study on the genetic control of tsetse vectors of sleeping sickness in Upper Volta has been completed and the results are being assessed. 9.2 I 2
9· 2 I 3 Rodent andflea control. Studies at the WHO rodent control demonstration unit in Rangoon were completed. A large-scale trial carried out by the Burmese Government and WHO staff using new rodenticides and application and evaluation systems demonstrated the practicality of a high level of cost-effective control of rodent populations. The establishment of laboratory facilities for work on agents of rodent-borne diseases will enable studies on plague and murine typhus to continue. Susceptibility tests on flea vectors of plague and murine typhus in Burma and Java showed high levels of DDT resistance, and field trials of insecticide compounds formulated as dusts demonstrated the availability of effective alternative chemicals I44
Biological control 9· 2 I 6 Research on the biological control of vectors, supported largely by the Special Programme for Research and Training in
COMMUNICABLE DISEASE PREVENTION AND CONTROL
Tropical Diseases, has reached the stage at which some agents, in particular some entomopathogenic spore-forming bacteria, can be put into operational use in the near future. This is shown by the successful field trial of Bacillus thuringiensis H-I4 against blackfly in the Ivory Coast. Research is now under way to determine the optimum particle size spectrum and suspensibility characteristics of B. thuringiensis H-I4 formulations for blackfly and mosquito control. All trials confirm that B. thuringiensis H-I4 is a highly specific larvicide with virtually no effect on nontarget fauna. Links were established with industry and several United Nations agencies to ensure the practical application of research information so as to strengthen vector control in tropical countries. Field trials against mosquito larvae have been carried out with strain I 59 3 of B. sphaericus, isolated from Indonesia. This organism sometimes persists and recycles, particularly in polluted water, a characteristic that makes it a promising agent for the control of Culex quinquefasciatus. Mammalian toxicity tests show no hazard to man, but considerable development work has still to be carried out. 9· 217 To facilitate the evaluation of candidate biological agents in field trials in Member States, data sheets detailing all laboratory and field background on the most prom1smg agents were prepared and disseminated. A WHO Expert Committee on Biological Control of Vectors of Disease (December I 9 8 I) 1 reviewed available and potentially available agents and made recommendations to expedite their use in vector control programmes. An informal consultation on fish for mosquito control (October I98I) considered the potential of different larvivorous fish species for mosquito control and made recommendations for field trials and operational use of the fish alone or in combination with other methods. 1 Report to be published in the WHO Technical Report Series, 1982.
Environmental control
9.2I8 A joint WHO/FAOfUNEP panel of experts on environmental management for vector control was established and a meeting was held in Geneva in September 1981. The aim is to facilitate interagency collaboration, promote integrated development strategies with due consideration for the protection of human health, provide technical guidance, and recommend priorities for financial support to projects and activities within this field. 9.219 As a follow-up to the recommendations on the subject of the WHO Expert Committee on Vector Biology and Control,2 steps were taken to integrate appropriate, simple, inexpensive environmental management methodologies for vector control into large-scale vectorborne disease control programmes as well as into primary health care systems. In several programmes, including those in Sudan and Turkey, operational trials and staff training were started. The Blue Nile health project in Sudan, an example of integrated control strategy, utilizes environmental management as appropriate in the control of a group of water-related diseases, notably malaria, schistosomiasis, and diarrhoeal diseases. The project has made good progress and outside funding is forthcoming on an increased scale. 9.220 A seminar on integrated control of mosquito vectors (Adana, Turkey, November 198I) provided information on new methods and approaches. Participants from several professional disciplines had an opportunity for intersectoral exchanges of views.
Vector control in international health
9.221 The risk of exotic vector species crossing international boundaries continues z WHO Technical Report Series, No. 649, 198o.
145
THE WORK OF WHO, 198o-I98I
to increase. Freon-based aerosols were recommended for use in disinsecting aircraft following experiments indicating that propane-based and isobutane-based aerosol formulations pose a greater potential fire hazard in aircraft. New and more effective methods of disinsecting, including residual contact insecticides, continue to be sought.
Training and dissemination of information 9.222 A special effort was made to organize and support a series of M. Sc. courses in medical entomology and vector control, in close collaboration with national authorities and the Special Programme for Research and Training in Tropical Diseases. Courses were established in Africa-in Nairobi, Jos (Nigeria), and Bouake (Ivory Coast)-and support was given to universities in Bogor (Indonesia) and Bangkok. The Regional Office for South-East Asia collaborated in a national intersectoral seminar held in Burma on integrated vectorborne disease control in connexion with dam construction. 9.223 A short training course in vector biology and control funded by DANIDA was held in Ciloto, Indonesia, and a joint OAUJFAOJWHO seminar on trypanosomiasis and Glossina research and control was held in Arusha, United Republic of Tanzania. The Regional Office for the Western Pacific, in collaboration with the Government of China, organized a course on low-toxicity insecticides in Shanghai as well as several general national training courses. The Regional Office for South-East Asia held a workshop in September I98I in Sri Lanka on manpower requirements in entomological aspects of malaria control programmes. Several courses were held in the Americas on the maintenance and use of insecticide application equipment and on emergency measures for the control of Aedes aegypti.
9.224 Detailed information on vector biology and control is lacking in many parts of the world. A number of issues in the WHOJVBC series of documents summarized new developments in control, the subjects covered including the vectors, reservoirs, and control of leishmaniasis; urban filariasis vectors in Africa; and the biology and control of human lice. In all 77 documents were issued in this series, among them a special report on the use of pesticides in public health, I 978-I 979, and a forecast of the demand for I98o-I984 that includes data from I03 developing countries.
Special Programme for Research and Training in Tropical Diseases 9.225 From its inception in I975 until 3 I December I 98 I the Special Programme supported I368 projects; over 2300 scientists
from I I 8 Member States participated in its planning, implementation, and evaluation; and more than $7o million were spent on direct support to national scientists and institutions. The percentage of funds for project support going to developing countries affected by the tropical diseases rose from 29% in I977 to 63% in I981. 9.226 Progress was made in: the drug treatment of malaria, schistosomiasis, and filariasis; biological control of the disease vectors of malaria and onchocerciasis; the development and testing of a possible vaccine against leprosy; the fundamental knowledge required to develop a vaccine against malaria; and simple and accurate diagnostic field test kits for malaria, leprosy, and African trypanosomiasis. Most of the results obtained in research and development were intermediate, in the sense that it will take time before the new information, valuable though it is, can be applied in the control of disease. Many years of systematic work are required for the development of a new agent, whether it is a
COMMUNICABLE DISEASE PREVENTION AND CONTROL
drug or a vaccine, and the need for longsustained effort is recognized. 9.227 Up to mid-1981 over 11oo scientific papers had been published describing the results of work supported by the Special Programme. 9.228 To achieve optimal effectiveness, the Special Programme remained in close touch with research sponsored by other agencies, including the pharmaceutical industry, and whenever appropriate it undertook a catalytic or coordinating role. Some promising activities initiated by other agencies before the Special Programme was established were also supported. For example, in collaboration with the Walter Reed Army Institute of Research, Washington, and the pharmaceutical industry, the Special Programme supported research on the potential antimalarial agent mefloquine, including studies on the bioavailability of different formulations and its clinical evaluation 1n endemic areas in three continents. 9.229 By funding work on standardization, safety testing, and field trials, the Special Programme contributed to the rapid development of Bacillus thuringiensis H-14 as a biological agent for the control of vectors. Although this agent was discovered before the start of the Special Programme, its potential usefulness was recognized and its development and evaluation were accelcrated. The agent will be ready shortly for application 1n national disease control programmes. 9.230 The other objective of the Special Programme, the strengthening of the research capability of the developing countries, was also pursued vigorously, especially through the promotion of technical cooperation among those countries. For example, through institutional and research training grants and other forms of support, insti147
tutions in developing countries are now increasing their capability for research and for the training of scientists from their own and neighbouring countries. Over 2 5o individual training grants have been awarded and 26 institutions are being strengthened through long-term support, while 26 others have received shorter-term support. 9· 2 31 The Special Programme continues to lay great emphasis on evaluation, from the level of individual projects up to the Special Programme as a whole. As recommended by its Scientific and Technical Advisory Committee, each component undergoes in-depth review and evaluation by a scientific and technical review committee at least once every four years.
Research and development 9.232 The planning, implementation, and evaluation of the Special Programme are carried out by collaborating national scientists. Thus research and development are carried out by scientists working in their own institutions, whose activities are coordinated by the steering committees of the Special Programme's scientific working groups. This network approach is proving productive and cost-effective and has overcome some of the constraints that in the past have limited research on tropical diseases. Basic scientists have been able to contribute their specialized skills in disciplines such as immunology, molecular biology, and biochemistry, and the scarce biological materials they require are provided by the networks of scientific working groups. For example, the Scientific Working Group on Immunology of Leprosy provided scientists throughout the world with leprosy bacilli, and other groups provided freeze-dried worms for schistosomiasis research and sera from patients and controls for research on Chagas' disease. The network has made it possible to tackle problems affect-
'
ing many countries, using standard protocols (e.g., for the epidemiology of leishmaniasis) and standard diagnostic kits (e.g., for in vitro testing of the sensitivity of malarial parasites to drugs) to conduct experiments and trials wherever the local ecological situation is most suitable. Thus natural onchocercal infection in cattle in Australia was discovered to be an excellent tertiary and definitive model for the human disease, which occurs only in tropical Africa and Central America. Malaria. Up to 31 December 1981, 87 projects had been supported on chemotherapy and drug development, 68 on immunology, and 57 on field research. Work continued on the development of kits to perform the microtest for the sensitivity of malaria parasites to drugs, and prototype kits were evaluated in endemic countries. Research priorities for the development of tissue schizonticidal drugs were established and work continued on metabolic pathways in malaria parasites, with comparisons among strains that differ in their response to drugs. 9.233
sensitivity to pyrimethamine was developed in collaboration with the Centers for Disease Control, Atlanta, USA. 9.23 5 Immunological research received a major stimulus through the introduction of the cell fusion (hybridoma) technique for the production of monoclonal antibodies. Several of these antibodies proved to have parasiteinactivating or growth-inhibiting properties. A particularly promising monoclonal antibody inactivating sporozoites of P. berghei was found to interact with a sporozoite surface antigen and to confer complete resistance in mice to infection with P. berghei. The system is now being applied to P. falciparum in order to obtain inhibitory monoclonal antibodies and use them for isolating the relevant pure antigen, with a view eventually to reproducing and mass producing the protective antigen through modern methods of genetic engineering. As a result of these developments the concept of malaria vaccination has shifted from the use of crude whole-parasite vaccines to that of specific protective antigens, which are more acceptable from the aspect of vaccine safety. A solid-phase radioimmunoassay for the detection of low numbers of malaria parasites has been adapted from a rodent model to P. Jalciparum; it detects malaria infection at a level of 8 parasites per 106 erythrocytes. Current work is aimed at adapting the test to an enzyme-linked immunosorbent assay (ELISA) system. 9.236 In basic biology, support of chemotherapeutic and immunological research continued. Progress was made with continuous in vitro cultivation of various primate plasmodia and with mass production techniques for P. Jalciparum. The availability of viable gametocytes of P.Jalciparum from in vitro culture now permits the production of great numbers of sporozoites, which are much needed in chemotherapeutic and immunological research. Other current studies
Chemotherapeutic research and development received substantial support through the Special Programme. Phase I clinical trials of mefloquine, a highly active blood schizonticide, were completed in Brazil and Zambia, Phase II trials in Brazil and Thailand, and Phase III trials in Brazil, Thailand, and Zambia. Progress was made with the preclinical development ofQinghaosu (artemisinine) and its derivatives. Another blood schizonticidal candidate compound was selected for further development. Certain aminoacid derivatives of primaquine proved to be more active and better tolerated than the parent compound. The microtest system for in vitro assessment of the drug sensitivity of Plasmodium Jalciparum (to chloroquine, amodiaquine, quinine, and mefloquine) was further developed and large-scale validation studies were implemented in countries of all regions. A microtest for the assessment of 9.234
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concern the structure and function of parasite and erythrocyte membranes in relation to parasite invasion, material and energy transport, and antigenic components. 9.237 In applied field research high priority was given to the implementation or further development of studies on drug resistance of malaria parasites, especially P. jalciparum. These studies are carried out with the close cooperation of the malaria services of the countries concerned. Besides the establishment of baselines and the monitoring of drug sensitivity levels, which are essential prerequisites to the use of drugs in control measures, major efforts are being made to develop and strengthen methods for the containment of drug-resistant malaria. Other essential research is on the operational use of antimalarial drugs 1 community participation in antimalaria measures, vector control in areas with exophilic or insecticide-resistant anophelines, and the epidemiological basis for rational planning and evaluation of malaria control. Special efforts are being made in research training and in the improvement of the field research capabilities of national antimalaria services and scientific institutions in tropical malarious countries. 9.238 Schistosomiasis. One hundred and five projects were funded in applied field research, including vector biology and control, chemotherapy, and immunology. Integrated approaches to the control of schistosomiasis in manmade bodies of water were studied at Lake V alta, Ghana, and the findings will shortly be published. Studies were carried out on focal mollusciciding based on ecological conditions in Sudan and on the dynamics of snail transmission in different irrigation systems. Eleven physicians participated in a worskhop on the population epidemiology of Schistosoma japonicum in the Philippines. Research was sponsored on the intermediate snail hosts of schistosomiasis, and a slow-release formu149
lation of a molluscicide is being tested. Projects complementing the work of the pharmaceutical industry were supported on the chemotherapy of schistosomiasis, and basic biochemical studies were designed to elucidate the mode of action of schistosomicidal drugs as well as their pharmacological effects on man. Clinical trials on praziquantel, a drug developed by the pharmaceutical industry in collaboration with WHO, were supported. 9.239 A collaborative study of immunodiagnosis involving eight laboratories was recently completed. Immunology research was also promoted by the provision of parasite material to investigators, e.g., lyophilized adult worms and S. mansoni eggs. The immunological responses of the mammalian host to infection are being studied, including work on the mechanism of resistance to infection.
9· 240 Filariasis. Priority continued to be given to onchocerciasis, and work on lymphatic filariasis was expanded. The aim is to improve the use of existing filaricides, find new ones, and seek means of reducing the inflammatory reactions that occur in the human host in response to the presence and death of filarial worms. Over 6ooo compounds have been tested; those showing activity in primary screening were subjected to further evaluation and the promising ones were tested in Australian cattle infected with Onchocerca gibsoni and 0. gutturosa. So far three compounds have shown high macrofilaricidal activity, and they are being developed further for eventual testing in man. New chemical compounds are also being screened for antifilarial activity. 9.241 Microfilarial density was reduced by 88% in patients treated with mebendazole in combination with levamisole. Mebendazole alone or in combination with levamisole has a chemosterilizant effect, as shown
THE WORK OF WHO, 198o-1981
by nodules examined after treatment. Studies using radiolabelled diethylcarbamazine have provided new information on the metabolism of this drug in the human body. Work continued on the identification and characterization of antigens for serodiagnosis. In addition, models were designed for the study of the pathogenesis of ocular lesions in onchocerciasis; progress was made with regard to the vectors of both lymphatic ftlariasis and onchocerciasis; and some epidemiological studies were funded. An onchocerciasis mathematical model for predictive simulations of control strategies was developed. 9.243 African trypanosomiasis. Recent results led to a greater understanding of the epidemiology of this disease. Several game animals were shown to harbour trypanosomes, some of which appear to be identical with the human stock of Trypanosoma b. gambiense. This complements the earlier finding of similar infection in pigs and dogs. Further confirmation was obtained of the finding that tsetse flies travel over much longer distances than had been assumed in the past. A second field trial of the ion-exchange minicolumns for parasitological diagnosis was carried out, this time in a T.b. rhodesiense endemic area. The direct card agglutination test for trypanosomiasis was improved to achieve better fixation of the antigen to the card, and comparison with three other tests is planned. A longitudinal study of trypanosomiasis was started in Zambia. 9.244 In drug development, work was carried out on compounds that can disrupt threonine metabolism and those which affect the parasite enzyme ornithine decarboxylase. Screening of potential trypanocides continues at two centres, one in Kenya, the other in the Federal Republic of Germany. Pharmacological studies continued on the drugs in current use, antrypol and organic arsenicals. 150
9· 24 5 Although immune complexes are found in the sera of patients with and without cerebral complications, they were found in the cerebrospinal fluid only in the meningoencephalitic stage. Work continued on antigenic variation in the parasites. American trypanosomiasis. Field research on the prevalence and distribution of Chagas' disease began in several endemic countries with standard protocols and diagnostic methods. A field evaluation of paint containing a slow-release insecticide showed promising results, with effective control of the insect vector for nine months. Work continued on the study of the mode of action of organophosphates on Triatoma itifestans larvae. 9.246 9.247 A comparative serological study started in July 1980 with the collaboration of reference laboratories in three countries. In a project based in Brazil, reference sera from patients and uninfected controls were collected and are being made available to scientists for standardization of their tests. The mechanisms of pathogenesis of the lesions of Chagas' disease are being elucidated; of particular interest are the correlation of parasite strains with clinical manifestations and the role of antibodies in endocardial, vascular, muscular, and peripheral nerve lesions. 9.248 Work on antigenic analysis and purification is making good progress ; specific antigenic components are being identified by the use of monoclonal antibodies. A successful animal model for chronic lesions of the disease has been developed in inbred rabbits.
Leishmaniases. To increase knowledge of the geographical distribution and varieties of this group of diseases the existing literature was reviewed and is being summarized on a country-by-country basis. 9.249
COMMUNICABLE DISEASE PREVENTION AND CONTROL
Epidemiological surveys are in progress in 17 countries and the preliminary data are being analysed. The animal reservoirs of both the cutaneous and mucocutaneous and the visceral forms are being identified in different geographical locations. 9· 2 5o Type collections of sandflies from many different parts of the world are being catalogued for taxonomic purposes and for the training of scientists. Blood meal identification is being widely used to pinpoint the local vectors and efforts continue to obtain a more exact typing of leishmania! strains. In addition to the standard serological, biochemical (enzymological), and biological characteristics, a new technique using radiorespirometry could prove valuable in the classification of reference material. 9.251 Clinical evaluation of promising drugs again confirmed that nifurtimox has some effect in mucocutaneous leishmaniasis but, when used alone, does not achieve a high cure rate. In combination with meglumine antimonate, it improved the results obtained by treatment with either drug alone. Allopurinol, which had shown in vitro activity, has so far proved disappointing in visceral leishmaniasis in clinical trials. The observation in experimental animals that entrapment in liposomes enhances the therapeutic activity of some antileishmanial drugs is being pursued in the hope of applying the finding in human disease, and biological screens for cutaneous and visceral disease are being evaluated. Standardized protocols for drug trials-including the selection of patients, identification of the parasites, treatment schedules, follow-up, and criteria of cure--were developed. 9· 2 52 Work was supported on diagnosis with modern techniques of antigenic analysis and specific monoclonal antibodies. Mechanisms of immunity are being studied, the demonstration of cross-reacting antigens
between Leishmania enriettii and L. tropica having opened up the possibility of using the former, a non-pathogenic species, as a potential vaccine. 9· 2 53 Leprory. Work on the development of a vaccine continued to make progress. Experiments in mice confirmed the protective effect of four different preparations of killed Mycobacterium leprae; the preferred procedure produces a high yield, with minimal damage to bacteria and minimal contamination. It is proposed to test the immunogenic potential of this preparation in human beings with and without BCG, as the first step in trials of the vaccine. 9.254 Immunodiagnostic tests were further developed. An ELISA test of sensitivity comparable with that of the radioimmunoassay test to M. leprae and a method for the early detection of systemic infection in armadillos were established. Monoclonal antibodies are being evaluated for their specificity for M. leprae.
9· 2 55 Clinical trials of drug combinations continued. Detailed protocols for field trials of chemotherapy of lepromatous leprosy were drafted and two trials will start soon. In drug development, analogues of thalidomide and of rifampicin failed to yield promising leads but preliminary trials with analogues of ethionamide and prothionamide continued. Prolonged-release preparations of dapsone are under development and surveys are being carried out on the frequency of primary dapsone resistance in endemic countries. 9.256 Biomedical sciences. The Special Programme continued actively to stimulate the further application of basic biomedical sciences to the study of tropical parasitic and infectious diseases, with particular emphasis on innovative approaches. It supported projects on the use of recombinant DNA technology for the study of kinetoplast DNA in
THE WORK OF WHO, r98o-r98r
Trypanosoma lewisi and of the variant antigen sequences of trypanosomatids. Work is progressing on the gene organization and function of parasitic protozoa. The role of factors under genetic control in relation to susceptibility to infection is being investigated with regard to G-6-PD deficiency and P.Jalciparum infection in man. Two studies in animal models are investigating genetic factors in relation to leishmania! infections. The metabolic pathways of parasites were studied, including purine metabolism in trypanosomes and the role of oxygen reduction products in the killing of parasites. The exchange of scientific information was encouraged through co-sponsorship of courses and workshops with national institutions. Biological control of vectors. Collabor9.2 57 ation continued with national scientists and industrial firms in the testing and development of biological agents for vector control. The tests for efficacy and safety of the agents followed the scheme developed by WHO expert committees.
pathogenic for larvae of Culex and certain species of Anopheles, but much less effective against certain species of Aedes, in particular A. aegypti. 9.260 Of the non-microbial agents, high priority was assigned to the fish Gambusia affinis. The use of this and other larvivorous fish was reviewed at a special consultation in October I 981. A variety of other agents are being systematically examined according to the standard scheme for investigating potential biological agents. 9· 261 Epidemiology. A multidisciplinary longitudinal epidemiological study in Zambia is providing useful information about the health status of the population in rural areas. Analysis of the data has shown correlations suggesting interaction between malaria and schistosomiasis infection. A field study was started and about IOoo persons were examined during the initial survey. Collaboration continued in the strengthening of training courses at key institutions in developing countries. In collaboration with the Regional 9.262 Office for the Western Pacific, a regional workshop was held for teachers of epidemiology. The activities of the 26 participants will be followed up in 1982. Other activities in support of training in epidemiology include the preparation of a field manual. Social and economic research. The 9.263 Special Programme aims at increasing the effectiveness of disease control programmes through the incorporation of human behavioural factors into the design and management of programmes, behaviour being defined so as to include social, cultural, and economic factors. Most of the projects funded related to the intermediate objective of defining the relationship between those factors and the transmission and control of diseases and, as far as possible, they were developed in 152
9· 2 58 Of the microbial agents, the highest priority has been assigned to Bacillus thuringiensis, serotype H-14, which has now reached the stage of large-scale testing for the control of mosquito and blackfly larvae. Tests have shown that it is a potent non-residual larvicide of these larvae, with a large safety margin in relation to man and other nontarget organisms. The activity of the agent is not affected by salinity, a pH within reasonable limits, or water temperature, but it is less effective in polluted than in clear water. The delta endotoxin is stable under tropical conditions. 9· 2 59 Work continued with another bacterial agent, B. sphaericus. Safety tests showed that this agent is innocuous for mammals under normal conditions of exposure, and environmental studies show no harmful effects on non-target organisms. The agent is
COMMUNICABLE DISEASE PREVENTION AND CONTROL
assoc1at10n with ongoing epidemiological research or disease control programmes. 9.264 A preliminary report was made on knowledge, attitudes, and behaviour with regard to malaria, where the reasons were sought for the decline in the collaboration of the population in the indoor spraying of DDT in a programme of control. In another study the role of the school in the control of locally endemic diseases was examined through a questionnaire administered to primary school children.
or most of their training in developing countries other than their own. The host countries were Brazil, Ethiopia, the I vary Coast, Kenya, Malaysia, Singapore, Thailand, Venezuela, and Zambia. 9.267 Interaction between scientists from developing countries also occurs through short-term workshops and seminars and long-term courses. All such group learning activities took place in developing countries and were planned and carried out by local scientists; and all included participants from other developing countries. Seven of the institutions receiving long-term support are engaged in group training activities involving nationals from other developing countries. 9.268 Activities were expanded to provide for collaboration among the institutions supported so as to build up a network of research and research training institutions in countries where tropical diseases are endemic. Accordingly, training workshops in research management were developed for scientists with a managerial role in institutional development programmes; the first was held at global level, but plans have been made to hold others at regional level. Plans were made for technical meetings of scientists working in developing countries, so that they can exchange information that has not yet been formally published and also exchange experiences in institutional development. Other ~ promotional action includes the development of training programmes in endemic countries and the development of research manpower in institutions on the basis of nationally approved explicit long-term plans.
Strengthening of research capability 9.265 The strategic plan for this area of the Special Programme, which was formulated and implemented in 1979, was reviewed in depth by a scientific and technical review committee. The development of a durable network of institutions in endemic countries, an objective of the plan, involves the shifting of resources to less developed institutions when those which initially received support no longer require it. In this context, the Government of Zambia assumed responsibility for the management of the Ndola Tropical Disease Research Centre, formerly a Special Programme activity, and a Zambian physician/scientist was appointed as the first director. The Centre continues to collaborate with the Special Programme on research in epidemiology and clinical pharmacology and is also playing an important role in the training of scientists from other developing countries. 9.266 Most promotion of technical cooperation among developing countries took place through training activities, which can lead to the forging of links among institutions in developing countries. Of the 53 scientists supported by research training grants and visiting scientist grants between 1 July 198o and 30 June 1981, 21 received all
Financing of the Special Programme 9.269 By 31 December 1981, 25 governments (including those of ro developing countries) and six other organizations,
THE WORK OF WHO, r98o-r98r
together with UNDP, the World Bank, and WHO, had contributed over $95 million to the Special Programme. The Joint Coordinating Board (the Special Programme's top management body) approved a maximum budget of $61.64 million for the 1982/1983 biennium, an amount that would permit
the Special Programme to maintain its momentum but a decrease of 5.2% in real terms over the previous biennium. The Joint Coordinating Board urged governments and agencies to contribute to the Special Programme so that the very real opportunities which it presented could be realized.
/
I
54
Chapter ro
Noncommunicable Disease Prevention and Control 10.1 DURING the biennium the concept
of a comprehensive integrated programme for the prevention and control of chronic noncommunicable diseases was further developed, as opposed to the traditional specialty-oriented approach. As an outcome of a number of consultations and meetings (Geneva, June 198o; Zurich, October 198o; Kaunas (USSR), November 1981), an experimental programme was designed and a few target centres and countries, both developed and developing, were selected for the testing and implementation of the proposed programme.
spare incurable cancer patients unnecessary pain as widely as possible. Priority is given to those cancers that can be prevented. 10.3 The outlines of this programme were drawn up by the first meeting of the Subcommittee on Cancer of the global ACMR (September 1981), the Scientific Group on Prevention Strategies in Cancer (October 1981), and the Programme Committee of the Executive Board (November 1981) when it discussed a progress report by the Director-General on long-term planning of international cooperation in the field of cancer. 10.4 The Director-General's Coordinating Committee on Cancer, which includes representatives of WHO, IARC, and the International Union against Cancer (UICC), has held regular yearly meetings to discuss policy matters and coordination. One result has been a clearer division of work between WHO and IARC: WHO concentrates on cancer control, including prevention, early diagnosis, therapy, rehabilitation, and operational research, IARC on carcinogenesis, epidemiology, and laboratory and field research. During the biennium the Coordinating Committee promoted cooperation with countries in the formulation of national cancer policies and programmes as part of their health programming process. Three countries, Finland, Sri Lanka, and Sudan,
Cancer 10.2 WHO's activities in the field of cancer were given a more pragmatic orientation in 198o-I981 so as to ensure: effective cooperation with Member countries in designing and implementing national cancer control programmes, in line with the Global Strategy for health for all by the year zooo; efficient coordination of cancer activities between headquarters, the regional offices, and IARC; and research on appropriate technologies for cancer prevention and control. The main targets of the programme are, by way of existing knowledge and parallel goal-directed research, (i) to prevent up to one-third of the cancers at present encountered, (ii) to cure up to one-third, and (iii) to
THE WORK OF WHO, 198o-I981
were selected for that purpose to provide experience for future policies. 10.5 The programme in Sri Lanka was based on a situation analysis by a team including representatives of WHO, IARC, and UICC. It was followed by a pilot study to determine whether primary health workers could be effectively used in a cancer control programme integrated with the general health care system. Oral cancer-one of the most frequent neoplasms in the countrywas selected for the early detection study that started in I 98 I. In Sudan, where cancer is among the most important health problems, the formulation of priorities was begun with WHO cooperation: a national cancer control policy and programme was formulated at a meeting in December I981. In view of the crucial lack of qualified specialists in all areas of cancer control and the paucity of economic resources, an approach emphasizing professional education was chosen as a first step. The situation is very different in Finland, which has well developed cancer control facilities. A report on the organization of the national cancer control programme in this country is available for the planning of national programmes in countries with a similar level of development.
countries (Region of the Americas); for the detection of oral cancer using primary health care workers (South-East Asia Region); and for a project on self-examination for breast cancer detection (European and Eastern Mediterranean Regions). Experts from both developed and developing countries met in Geneva in October I98I to formulate proper strategies for cancer prevention. They reviewed existing knowledge and analysed the approaches that might be adopted in individual countries. 10.7 A reappraisal of the present situation in the prevention and control of lung cancer, one of the most common tumours in many countries, was made at a "state of the art" meeting in November I981. The participants were directors of medical services, whom the reappraisal will help in their policymaking, and generalists. Io.8 At a meeting held in I98I in Japan to discuss prevention and cancer statistics for developing countries, the data from different countries were analysed. The United States National Institutes of Health generously agreed to provide, for selective distribution by WHO, the 50 ooo-6o ooo abstracts of cancer literature appearing each year.
Prevention, treatment, and after-care Io.6 The prevention component of the cancer programme includes an energetic antismoking programme in the Eastern Mediterranean Region, a campaign against tobaccochewing in South-East Asia in collaboration with the Government of Sri Lanka, and a health education programme for the prevention of skin cancer in the African Region. The early detection aspect of the programme stresses community involvement and the use of primary health care workers. Realistic guidelines are being prepared for the early detection of cervical cancer in developing
10.9 One goal of the programme is to develop simple, safe, inexpensive methods of therapy for common cancers that can be used in developing as well as in developed countries. For this purpose WHO collaborating groups for the assessment of the essential minimum of treatment for breast and lung cancer are being formed. A project has been started to identify and disseminate information on the relief of pain. Io. Io The work of the collaborating centres is being aligned with the aims of the newly oriented cancer programme. Accordingly, they are preparing succinct practical manuals on specific forms of cancer,
q6
NONCOMMUNICABLE DISEASE PREVENTION AND CONTROL
for use at the district hospital level. A WHO collaborating centre for biostatistics was established to provide quantitative expertise for WHO field projects in Member countries and develop methods of teaching cancer control suitable for developing countries.
Histological classification of tumours Io. I I The work on the International Histological Classification of Tumours, which had been coordinated by WHO for over 20 years, came to a close. The last two publications of the 25-volume series went to press during the biennium. In the future such highly technical standardizations of methodologies will be contracted out to the WHO collaborating centres.
Io.q In collaboration with WHO an analysis was carried out of differences in coding practices relating to some 5o diagnostic terms, which could affect the comparability of cancer registry data. A critical review of observed time-trends in cancer incidence was begun, taking into account the effect of changes in population age structure and other competing causes of death. IO.I4 Following the observation that the incidence of malignant melanoma is increasing by about 5% per annum in many populations, an international collaborative study was started into all forms of malignant melanoma; 33 cancer registries will contribute to a retrospective study and 29 to a prospective study.
Alcohol consumption and cancer International Agency for Research on Cancert IO.I2 The I98o and I98I editions of the Directory of on-going research in cancer epidemiology were published, continuing the annual volumes that have been prepared jointly with the Cancer Research Centre, Heidelberg (Federal Republic of Germany), since I976. The latest volume 2 contains I 3 I 3 projects reported from So countries and includes an index of chemicals for which human exposure has been recorded and studied. In the preparation of Volume IV of Cancer incidence in five continents, cancer registry data for the quinquennium I973-I977 were collected from 9 I registries covering I I 6 ethnic groups. 1 For a more detailed description ofiARC's activities, see: International Agency for Research on Cancer, Annual report, r98o, Lyon, 198o; Annual report, r98r, Lyon, 1981. 2 Muir, C.S. & Wagner, G., ed. Dmctory of on-going research in cancer epidemiology, r98r. Lyon, International Agency for Research on Cancer, 1981 (!ARC Scientific Publications, No. 38).
Io. I 5 The association between the consumption of alcohol and cancers of the digestive and upper respiratory tract has now been demonstrated in a number of studies. Oesophageal cancer, in particular, is strongly associated with both drinking and tobacco consumption, and a detailed case-control study is being completed in Calvados and Orne (France), where the mortality rates exceed 30 per Ioo ooo inhabitants in both males and females. Concurrent experimental studies in which Wistar rats were given samples of apple brandy in their drinkingwater failed to show any excess of tumours or precancerous lesions in the animals.
Oesophageal cancer Io. I6 The prevalence of oesophagitis has been studied in a population at high risk of oesophageal cancer in Lin Xian, China, and for comparison in a low-risk population in Jiao Xian. Oesophagitis, identified by endoscopy, was seen approximately twice as I
57
THE WORK OF WHO, I98o-1981
often in the high-risk population of Lin Xian, both male and female, as in Jiao Xian. These findings support the hypothesis that this lesion is a precursor of oesophageal cancer, a finding that should prove of considerable importance in epidemiological studies of the causation of the cancer. The study was carried out with the collaboration of the Beijing Cancer Institute, the Honan Medical College and Honan Cancer Institute, China, and the Regina Elena Institute, Rome.
confirmed by a-fetoprotem determmatwn, since no histopathological confirmation is available. IO.I9 A cohort study to determine the risk of developing primary liver cancer among carriers of hepatitis B surface antigen is being carried out in the Chinese population of Singapore, in collaboration with the University and the Blood Bank. Of a total of 929 people in the cohort, 65 (7%) were positive for the surface antigen. Io.2o A study is in progress in the Philippines, in collaboration with the Department oflnternal Medicine, Philippines General Hospital, to determine the rate of perinatal transmission of hepatitis B virus and subsequent development of a carrier state among children born to "carrier" mothers as compared with "non-carrier" mothers. Blood was taken from the children after the first month of life and they will be followed up until the age of one year.
Cancer of the large bowel I o. I 7 The international study of cancer of the large bowel has largely confirmed the hypothesis regarding the protective role of dietary fibre. The results so far suggest that the risk is determined by a complex interaction of dietary factors and it is postulated that dietary fat and protein promote cancer by increasing the output of bile acid. The action of dietary fibre appears to be to increase the faecal bulk and thus reduce the concentration of any carcinogen or cocarcinogen that may be present in the stool and in contact with the bowel mucosa. In a study of the distribution of various lesions of the colon and rectum in populations in Europe, it was shown that the prevalence of polypoid lesions was higher in areas of high incidence of cancer of the large bowel, and that the polyps also tended to be larger.
Hazards of man-made mineral fibres I0.2 I The follow-up study of the health risks associated with mineral fibre production has reached its final phase. The collection of data from I 3 factories in seven countries is now complete, and the results of the environmental survey carried out by the Institute of Occupational Medicine, Edinburgh (United Kingdom), at each of the factories have been sent to the Agency, so that estimations of exposure to airborne fibres can be made for individual work stations. Cancer morbidity and mortality will be compared among groups of workers with differing degrees and lengths of exposure. I0.22 In the study of a localized high incidence of mesothelioma in central Turkey, zeolite fibres were found in higher concentration in some of the samples of air from the
Cancer of the liver Io.I8 In collaboration with FAO and UNEP, the Agency is assessing the effect of measures to decrease aflatoxin contamination of foodstuffs on the prevalence of liver cancer in Swaziland. At the Agency's laboratory in Swaziland, more than 1000 specimens have so far been analysed for mycotoxins. In order to strengthen the data collected from the cancer registries, cases of liver cancer are being
q8
NONCOMMUNICABLE DISEASE PREVENTION AND CONTROL
village affected, but the overall fibre concentrations were too low for a definite assessment. A case-control approach is now being made to ascertain the frequency of zeolite deposits in the houses of cases as compared with those of controls. Rock samples are being analysed at the Medical Research Council Pneumoconiosis Unit, Penarth, United Kingdom.
of which occupational exposures are typical examples, was a new departure in the series. I o. 2 5 The ninth information bulletin in the survey of chemicals being tested for carcinogenicity included reports on 970 chemicals in 99 institutes in I 8 countries. 2
Long-term effects of pesticides on human health I0.23 A cohort of 9ooo workers in Colombia engaged in floriculture is being followed to determine the health hazards arising from long-term exposure to pesticides. In the first phase a prevalence survey was carried out of congenital malformations among children born to women engaged in floriculture or to women whose husbands were so engaged. A case-control study will follow in an effort to establish reproductive histories and details of occupational exposure.
Io.26 Laboratory studies were devoted to methods of monitoring human exposure to environmental carcinogens and identifying individuals at higher risk. The preparation of monoclonal antibodies against carcinogenDNA adducts has provided a method that may make it possible to determine an individual's exposure to a given carcinogen. Pilot studies were carried out on oesophageal tissues collected in Lin Xian, China, to identify adducts indicating exposure to carcinogenic nitrosamines. I0.27 The differences between individuals in levels of carcinogen-metabolizing enzymes may indicate differences in susceptibility to given carcinogens. For example, the differences in susceptibility to cigarettesmoking between individuals might be attributable to differences in the activity of the enzymes responsible for metabolizing benzo(a)pyrene, one of the carcinogens present in cigarette smoke. Benzo(a)pyrene metabolism was therefore studied in lung tissue and mucosal specimens from lung cancer patients, and compared with the metabolic levels observed in cancer-free individuals. Io.28 Methods have been developed in experimental animals to permit quantitative estimation of the in vivo formation of nitrosamine. The safety of the methods having been confirmed, they have been used
Chemical carcinogens I o. 24 During the biennium five international working groups met in Lyon to evaluate the published literature relating to 53 chemicals and 8 industrial processes. Their proceedings were included in the IARC monographs on the evaluation of the carcinogenic risk of chemicals to humans, of which the first four were published. 1 The evaluation of risks associated with complex exposures,
1 International Agency for Research on Cancer. !ARC monographs on the eval~~t~tton of the carcinogenic risk of chemicals to humans: Volume 24, Miscellaneous pharmaceutical drugs, Lyon, 198o; Volume 2J, Wood, leather and some associated industries, Lyon, 1981; Volume 26, Some antineoplastic and immunosuppressive agents, Lyon, 1981; Volume 27, Some aromatic amines, anthraquinones and nitroso compounds, and inorganic fluorides used in drinking-water and dental preparations, Lyon, 198 r.
2 Ghess, M.J ., Wilbourn, J.D., Bartsch, H. & Tomatis, L. Information bulletm on the survry of chemicals being tested for carcinogenicity, volume !I· Lyon, International Agency for Research on Cancer, 1981.
THE WORK OF WHO, 198o-I981
to determine the levels of in vivo nitrosamine formation in humans. Techniques of chemical analysis of nitrosamines have also been applied to the measurement of these P~!tative carcinogens in urine samples collected in areas of high and low risk of oesophageal cancer. I0.29 The development continued of short-term tests based on methods of measuring mutagenic activity and capable of indicating possible carcinogenic substances. Tests employing bacterial colonies, and others in which mammalian cell lines were used, were applied to screening for active substances and to the study of mechanisms of carcinogenic activity by the identification of active metabolites.
Cardiovascular diseases I0.33 Changes appear to be occurring in the incidence of cardiovascular diseases that may require the strengthening of WHO activities in developing countries. For instance, the figures from Malaysia show that, while cardiovascular diseases rated fourth among all causes of mortality in I965 and third in I97o, they were first in I975 and accounted for I 3% of all deaths. There was a similar development in Mauritius, where in I979, if cerebrovascular diseases are included, more than 30% of all deaths were attributable to cardiovascular diseases. On the other hand, several countries that previously had rising death rates have shown a levelling off or even a decrease in the rates (e.g., Australia, Finland, New Zealand, and the United States of America). Planning for an international study to monitor the trends and determinants in cardiovascular diseases was therefore started in I98o. A protocol was prepared in I 98I and tested in a feasibility study in three centres in Europe-North Karelia (Finland), Kaunas (USSR), and Copenhagen. The first meeting of investigators in the multicentre study was held in October I98r. The study will start in 1982 and, over a Io-year period, will measure trends in cardiovascular disease mortality and coronary heart and cerebrovascular disease morbidity and assess the extent to which the trends in defined communities are related to changes in known risk factors, health care, or major socioeconomic features. This project might serve as a model for monitoring morbidity trends in other diseases and should lead to the development of a permanent system for the collection of data on morbidity from chronic disease.
Training 10.30 Seven short courses were held. Two in the Agency were devoted to epidemiological aspects of occupational cancer and one to chemical carcinogenesis. A course on the utilization of primates in cancer research was held in Sukhumi (USSR), and three on epidemiology were organized in Bogota, Limassol (Cyprus), and Ndola (Zambia). There were approximately 40 participants in each course. I0.3I Twenty-five fellowships were awarded during the biennium to postdoctoral scientists studying epidemiology or aspects of environmental carcinogenesis. Of these, seven were tenable at the Agency. 10.32 An international symposium on host factors in human carcinogenesis was organized with the support of the Commission of the European Communities and the Greek Government. A training component was included that enabled I2 promising young postdoctoral scientists to participate. I6o
Primary prevention 10.34 An Expert Committee on the Prevention of Coronary Heart Disease held in Geneva in November-December I98I
NONCOMMUNICABLE DISEASE PREVENTION AND CONTROL
reviewed the available data, discussed alternative approaches to prevention, and made practical recommendations on strategies for population-based approaches to prevention in countries with a high as well as a low incidence of coronary heart disease. In the former the most effective approach is the mass approach aimed at reducing the levels of different risks; in the latter it is primordial prevention of the development of unfavourable lifestyles and risk factors. Io. 3 5 The results of the follow-up study on primary prevention of ischaemic heart disease were published in the Lancet.l In this trial a lipid-lowering substance, clofibrate, was administered in a double-blind trial to middle-aged male volunteers whose serum cholesterol levels were within the upper third of the distribution in their respective populations (Budapest, Edinburgh, Prague). After an average of 5. 3 years of observation, the initial serum cholesterol level having been reduced by about 9%, the incidence of ischaemic heart disease had fallen by 20% in the intervention group as compared with the placebo group (which received olive oil), thus demonstrating the preventive value of lowering this plasma lipid. However, there was a significant increase in total mortality and in non-cardiovascular mortality in the group that received clofibrate, a trend that seems to be continuing, as evidenced by follow-up studies. The explanation for this trend is not clear, but several possible mechanisms are being considered, including the long-term toxic effect of clofibrate, the possible consequences of reducing body cholesterol pools in middle-aged men, and even chance. Close monitoring of all the volunteers in the centres that took part in the trial is being carried out and will continue for several years.
10.36 To stimulate research in the prevention of ischaemic heart disease in early life, WHO is coordinating pilot programmes on the study of risk factors in childhood and youth. After descriptive epidemiological investigations in Geneva and northern Italy had ended, intervention programmes in schoolchildren started in Finland, the German Democratic Republic, the Federal Republic of Germany, Israel, and Norway to assess the most appropriate health education methods for healthy low-risk ways oflife. To study the origins of coronary heart disease, preparations were made for a morphological study to assess structure and structural changes in the coronary arteries of children. I o. 37 Within the context of prevention, a new concept, primordial prevention, is receiving special attention. This is primary prevention in its purest sense-prevention of the development of risk factors in populations still free from most of the cardiovascular diseases. A project was started to see if, in selected developing countries, cardiovascular diseases can be prevented from reaching the epidemic proportions experienced in industrialized countries by removing risk factors. The design was further elaborated by a group of consultants in February I98r. Initially the main emphasis will be on the control of tobacco smoking and the development of healthy nutritional habits.
Community control Io.38 The WHO-coordinated study on comprehensive cardiovascular community control programmes, which started in I974 and is carried out by centres in all parts of the world, was the subject of two meetings during the biennium, one in Prague in September I98o, the other in Nairobi in October I981. Experience from this study is being used in developing the programme on integrated noncommunicable disease prevention and control (paragraph I o. I).
10.39 A WHO-coordinated 1o-year study on the community control of hypertension ended in 1980. The preliminary results were discussed at the final meeting of investigators in December 1980 in Geneva. One of the most important outcomes of this cooperative project is the experience gained in organizing and operating hypertension control programmes in different social and health care settings. The preliminary report covered the setting up, management, and evaluation of a hypertension project; cooperation with and motivation of the health services; and the need to make hypertension control an integral part of basic health care. The conclusion was that pilot programmes for the community control of hypertension are feasible and effective and a useful tool for acquiring new knowledge of hypertension control methods in populations. However, when formulating plans for hypertension control in total populations, the sociopolitical environment in its widest sense should be taken fully into consideration. A report on the whole study will be prepared after analysis of the outstanding data. 10.40 Following a meeting of investigators held in New Delhi in November 1979, which marked the end of a long-term study on the community control of rheumatic fever and rheumatic heart disease, a report was issued emphasizing the feasibility and practicality of early prevention measures. Experience from the multicentre cooperative project showed that control projects as outlined in the WHO protocol 1 are feasible in developing countries. Regular surveillance can be difficult, but the gains are considerable even with a followup rate of 5o% and only half of those followed up on regular prophylaxis. Although it was not possible to measure the direct health benefits quantitatively, the benefits in terms 1 WHO Chronicle, 34: 336-345 and 389-395 (r98o); Bulletin of the World Health Organization, 59: 285-294 (I 98 I).
of health care expenditure were such that the direct health benefits can be assumed to be great indeed. An essential requirement for success is for the programme to be part of the national health policy. Rheumatic fever control should be at national and local community level, with full cooperation between the cardiological, paediatric, and school health ser':ices within the framework of primary health care. The elaboration, publication, and dissemination of strategies for the community control of rheumatic fever and rheumatic heart disease are under way, with special reference to developing countries.
Research and information 10.41 A research project on the standardization of tests to assess abnormal tendencies to thrombosis began in centres in London, Prague, and Krakow (Poland). It will form the basis for prospective studies in which an assessment will be made of their predictive value in ischaemic heart disease events. As a first step a feasibility study was started (i) to demonstrate the feasibility of collecting large numbers of samples for haemostatic function tests in a fairly short time, and (ii) to see whether within each centre there are similar relationships with age, smoking, and other risk factors in the population samples studied. 10.42 The role of nutritionai!J induced trace element imbalance in the occurrence of myocardial infarction and hypertension has been studied for the past ten years in collaboration with IAEA and a network of collaborating pathology institutes and analytical laboratories. The project has now ended and the results are being evaluated. 10.43 Physical activity to prevent coronary heart disease is continuing to attract worldwide interest. After the publication of a
NONCOMMUNICABLE DISEASE PREVENTION AND CONTROL
monograph in 1978, 1 another on physical activity in disease prevention and treatment is in preparation.
Nomenclature and classification 10.44 WHO and the International Society and Federation of Cardiology (ISFC) continued to collaborate closely. Joint WHOJISFC task forces prepare recommendations for the standardization of classification, nomenclature, and diagnostic criteria for different cardiovascular diseases. Task forces on nomenclature and classification of arrhythmias and on nomenclature of ischaemic heart diseases have published reports in previous years.2 The task force on definition and classification of cardiomyopathies published its report in 1980.3 A task force on haemodynamics is finalizing its recommendations. A task force on nomenclature in echocardiography has been organized. It is planned that WHO, ISFC, and CIOMS will eventually publish a compendium of all the recommendations of these task forces.
10.46 A course in cardiovascular diseases epidemiology was held in Singapore in September 1980. It was organized by the Regional Office for the Western Pacific and was a follow-up of the course held in 1978 in Wellington.
Smoking and health 10.47 An international clearing-house for information on smoking and health became operational in May 1981. Its purpose is to collect (i) statistics on national tobacco and cigarette production, per capita consumption, smoking prevalence by age, sex and race, etc.; and (ii) information on smoking control activities, including legislation, public information, educational approaches, health warning labels, statements of tar, nicotine, and carbon monoxide yield, advertising restrictions, and other action or voluntary agreements for the purpose of reducing smoking. These data are widely scattered in the literature and in reports, many of which are not easily available; they will be collated and issued by WHO in special reports. The dearing-house is partly funded by the United States Department of Health and Human Services. 10.48 A project on the analysis of tar, nicotine, and carbon monoxide yields of cigarettes collected in selected developing countries has begun. The analyses are being carried out at WHO collaborating centres. 10.49 An international conference on tobacco and youth was held in Venice in November 1981 with WHO co-sponsorship. 10.50 Tobacco report, a WHO newsletter, appeared twice in 1981 and is expected to be issued quarterly in 1982. Five thousand copies in English and three thousand in French of each issue were distributed worldwide and have been well received.
Training 10.45 Annual ISFC 1o-day international teaching seminars on cardiovascular epidemiology and prevention, held in collaboration with WHO, were organized in Kaunas (USSR) in August 1980 and in Heidelberg (Federal Republic of Germany) in August 1981.
1 Lange Andersen, K. et a!. Habitual pf!ysical activity and health. Copenhagen, World Health Organization,
1978 (WHO Regional Publications, European Series, No.6). 2 American Heart Journal, 95: 796-8o6 ( 1978) and 98: 263-267 (1979); Circulation, 59: 607-609 (1979). 3 British Heart Journal, 44: 672-673 (198o).
THE WORK OF WHO, 198o-1981
Io.p The theme of World Health Day I98o, "Smoking or health-the choice is
yours", aroused a great deal of interest and resulted in intensified anti-smoking campaigns in many countries. Io. 52 The first of two workshops on smoking and health issues in developing countries, organized in collaboration with SIDA and national authorities, was held in Colombo in November I98I; a second will be held in I982 in Swaziland.
Io. 55 During the biennium two national research centres were designated as WHO collaborating centres: the Institute for Diabetes, Endocrinology and Metabolic Diseases, Zagreb (Yugoslavia), as WHO collaborating centre for the development of appropriate technology in the control of diabetes mellitus; and The Royal Southern Memorial Hospital, Caulfield, Victoria (Australia) as WHO collaborating centre for the epidemiology of diabetes mellitus, to assist WHO in training and the organization of epidemiological studies on diabetes in the Western Pacific.
Other chronic noncommunicable diseases Diabetes mellitus 10. 53 The WHO Expert Committee on Diabetes Mellitus, the second report of which was published in I98o,1 drew particular attention to the need to involve the community as well as the patient. The main health services for diabetics, it considered, should be at community level; preventive, promotive, curative, educational, and research activities should all have their basis in primary health care; and national diabetes programmes should be developed. 10.54 Following those recommendations, planning for a national diabetes programme in Malta was begun in I98o; it covered an epidemiological study, an educational programme for health personnel, patients, and the public at large, and the development of health services. A collaborative epidemiological study on diabetes as related to malnutrition was started in which a number of developing countries are participating.
10. 56 Cooperation with nongovernmental organizations such as the International Diabetes Federation was further developed. The training of health personnel and the dissemination of information to front-line health workers were promoted. WHO, along with the Federation and the national authorities, organized the first international seminar on clinical epidemiology and public health aspects of diabetes in Cambridge (United Kingdom) in July I981. I0.57 The follow-up stage of the WHO multinational study of vascular disease in diabetics was continued. In this study I4 research centres from I 3 countries are collaborating.
Chronic respiratory diseases 10. 58 Stronger emphasis was placed on the involvement of the community in chronic respiratory disease prevention and control, and closer cooperation was developed with the scientific committee on respiratory diseases of the International Union Against Tuberculosis. A joint meeting (Geneva, February I 98 I) identified priorities for epidemiological and operational research within the framework of an overall WHO programme on respiratory diseases.
1 WHO Technical Report Series, No. 646, 1980.
NONCOMMUNICABLE DISEASE PREVENTION AND CONTROL
Chronic rheumatic diseases I o. 59 Guidelines for the further development of a rheumatic diseases programme were drawn up at a joint meeting in Geneva (January I98I) with the International League against Rheumatism. 1 The Philippines was selected as the target country for a community-oriented rheumatic diseases prevention and control programme, jointly coordinated by the national authorities, the International League, and WHO.
Io.6o In the Americas collaborative studies are being carried out on the profile of patients with chronic rheumatic diseases who seek care in rheumatology and allergy clinics. Particular emphasis is placed on the degree of disability and dependency caused by these diseases, including their effect on functional and working capacity and, in allergic diseases, their relation with risk factors in the environment. The use of medical facilities for both groups of diseases is also being investigated.
incidence of hereditary anaemias and related conditions were collected in Bali (Indonesia), Nigeria, and the USSR, and the molecular base of their heterogeneity was investigated. With WHO assistance a programme on community control of thalassaemias was carried out by the University of Ferrara, Italy, in which a sharp downward trend in the birth rate of affected children was observed. To review experience in other countries, assess recent advances, and gauge the possibilities of support for a worldwide attempt to control hereditary anaemias, an ad hoc WHO meeting was held in Cagliari (Italy) in June I 9 8 I in association with an international symposium on thalassaemias. It considered that the preventive approach to hereditary anaemias could be integrated into the health care programmes of the communities where the diseases are common, and that WHO could be of assistance to the Member States concerned by providing guidance and establishing standards. To explore the subject further a working group on the community control of hereditary anaemias was held in Geneva (November I98I). Io.63 The Organization continued to support the development of international repositories for genetic disorders. The seventh and eighth listings in the Repository of chromosomal variants and anomalies in man have been produced.z Io.64 Two international meetings were given support: the annual meeting of the European Society of Human Genetics held in Dubrovnik (Yugoslavia) in I98o and the VII International Workshop on Human Gene Mapping held in Oslo in I981. Eight WHOassisted research centres concentrated their activities on the genetic approach in the
Hereditary diseases and those where there is genetic predisposition Io.6I In human genetics the programme concentrated mainly on international collaboration in the management of some common genetic disorders and the application of genetic knowledge and further development of the genetic risk approach in the prevention and control of certain communicable and noncommunicable diseases. Io.6z Five research centres in four regions collaborated on the management of certain genetic disorders (hereditary anaemias and thalassaemias in particular, highly prevalent in the areas where malaria was formerly common). New data on the distribution and
1
WHO document NCDJOND/ RHEUM/8I.I (1981).
2 Repository of chromosomal variants and anomalies in man. Seventh listing, June 1980, Denton, North Texas State University. Eighth listing, August 1981, Wilmington Medical Center, Delaware (USA).
prevention and control of noncommunicable and infectious diseases. Genetically determined differences in susceptibility to infectious diseases were further studied in India, the USSR, and Zambia with a view to developing methods for the utilization of genetic markers in the prevention and treatment of communicable and parasitic diseases. In addition to the markers previously studied, a complex of genetic, anthropometric, and clinical characters were found to be correlated with non-specific lowered resistance to disease such as childhood pneumonia. A new project was also initiated on the genetic nature of differences in response to vaccination, and a WHO-assisted feasibility study is under way in Bulgaria. New data were collected on the distribution of HLA-DR antigens in normal populations of the USSR and on the association of some HLA antigens with diseases in Romania (ankylosing spondylitis, Behc;et's. syndrome, and lupus erythematosus). Research on the genetic component of common chronic diseases and on genetic epidemiology was coordinated with the assistance of the WHO collaborating centre for the processing of human genetic data (University of Hawaii, USA). 10.65 A review of the programme on human genetics took place during the biennium and a WHO task group met in November 1981 to consider the action required. The working group on the community control of hereditary anaemias (paragraph 1 o.62.) inter alia assessed their suitability as model genetic disorders in the development of WHO's human genetics programme.
visited the countries of the Region, assessed the facilities for treatment available, and prepared a draft medium-term programme for the prevention and control of deafness.
Oral health 10.67 Emphasis was given to the development of standard methods for analysing the oral health situation and coordinating planning, and WHO published a guide for both developed and developing countries.! The major activity in all regions continued to be technical cooperation in the integrated planning of oral health services. The concept of demonstration, training, and research centres for oral health is now well accepted. The first such centre was officially opened in Thailand and agreement has been reached with the Syrian Arab Republic for the development of a similar centre. Further centres are under consideration in China and in Africa. These centres will develop and strengthen technical cooperation between countries at different levels of development and provide a focus for the dissemination of standard methodology on integrated planning and for the improvement of teaching and of technology. They will help in international collaborative research on, for example, the intake and metabolism of fluoride in different cultural and nutritional settings or the evaluation of alternative health care delivery systems. They will also provide field demonstrations of preventive measures and delivery systems. 1o.68 To assist countries in the monitoring of their oral disease trends, WHO collaborated in studies of the epidemiology of oral diseases and continued to monitor the global oral health programme. A new standard methodology, the community peri1 Planning oral health services. Geneva, World Health Organization, 1980 (WHO Offset Publication No. 53).
Preventable deafness 1o.66 In the South-East Asia Region it was concluded, on the basis of preliminary data from rural areas, that preventable deafness attributable to otitis media was a health problem requiring attention. A consultant 166
NONCOMMUNICABLE DISEASE PREVENTION AND CONTROL
odontal treatment needs index, was developed for assessment of the periodontal status and treatment needs of populations and was tested in an international collaborative study involving I 3 countries. This index, which will now be used as an international standard, provides a reliable method for the planning, monitoring, and evaluation of periodontal disease prevention and control programmes. Io.69 The first of a series of field demonstrations of preventive programmes and measures was completed in one country, and similar programmes are in progress in three other countries. These field demonstrations are supported by the Voluntary Fund for Health Promotion. 10.70 Annual coordination meetings continued, with the help of extrabudgetary funds, to coordinate essential research. In the international collaborative study on dental manpower systems, I 3 sets of data from I I countries are now being prepared for analysis.
Workers' health 10.7 3 Resolution WHA 33. 31, endorsing the programme of action on workers' health for the years I979-I984, urged Member States to pay special attention to the provision of health care to working populations, particularly "underserved" workers, and requested the Director-General to "support the developing countries in ensuring safe working .conditions and effective protective measures for workers' health in agriculture, mining and industrial enterprises by using experience available in this field". This resolution was followed by intensified efforts (i) to identify the major occupational health problems of underserved working populations in developing countries, (ii) to initiate country projects in occupational health services and training, and (iii) to develop occupational health knowledge and technology in cooperation with WHO collaborating centres in various parts of the world.
Following reports of the development of new and more efficient preventive procedures, a system of review and assessment of preventive materials was instituted. The detailed information obtained will be used to advise administrators on the choice of such materials. Io. 7I 10.72. The trend towards decreased oral disease in highly industrialized countries, accompanied by a continuing high level of production of oral health personnel, has reached the stage at which dental manpower surpluses of considerable proportions are imminent in a number of countries. Consideration is being given by WHO to the possibility of deploying the surpluses to ease the worsening manpower situation in developing countries until their own oral health manpower training facilities are sufficiently developed to provide adequate numbers of trained personnel.
Identification of problems
10.74 WHO collaborated with 15 Member States in field surveys to identify occupational health problems and develop practical methods for the detection, evaluation, and control of various occupational health risks. Cross-sectional studies of workers' health problems in agriculture and small industries were made in Burma, Egypt, the Philippines, Sudan, the United Republic of Tanzania, and several other countries. Miners' health problems, particularly pneumoconiosis, were investigated in Bahrain, Botswana, and the Republic of Korea. A research programme on the monitoring of occupational exposure and the effects on health of chemical and physical hazards was carried out in Brazil, Bulgaria, Czechoslovakia, Poland, Switzerland, and the USSR. An epidemiological study correlating various working conditions, workload, and health of
THE WORK OF WHO, '980-198'
workers was undertaken in the German Democratic Republic. A review of the findings of investigators of occupational health problems in developing countries was made by the Permanent Commission and International Association on Occupational Health at a meeting in Colombo (April I98I)-cosponsored by WHO. I o. 7 5 In Thailand, a new feasibility study was initiated in June I98I to introduce primary health care in workplaces, particularly in small-scale industries where no other health systems are available. One of the aims of the study is to produce guidelines on primary health care in workplaces for examination in regional workshops. A similar study started in Sri Lanka in November I981.
the ILOJWHOJUNDP project on central and regional occupational health laboratories in Indonesia included the development of primary health care for workers in rural areas and the introduction of modern control technology in large industrial establishments. WHO assisted the Ministry of Health in Malaysia in the development of an occupational health unit, which will become the national reference centre on occupational health matters. The aim of a WHOJUNDP project in Mauritius is to develop a unit for the training of occupational health and safety personnel, and of one in Singapore to set up a national institute of occupational health and safety. 10.78 Occupational health manpower is in short supply in most countries. The Joint ILOJWHO Committee on Occupational Health at its meeting in March I98I developed guidelines on training and education in occupational health, safety, and ergonomics.! WHO also organized or coordinated several regional or interregional courses and seminars on various occupational health subjects. The third interregional workshop on the organization of occupational health services took place in Sofia in June I98I and was attended by I 5 participants from I 5 different countries. It emphasized the multidisciplinary approach to the control of occupational health hazards and recommended methods for their assessment and control and for the integration or coordination of occupational health with national health services. 10.79 In May I98I WHO assisted the fourth international course in occupational and environmental toxicology in Belgrade, which was attended by I 7 participants from developing countries----chemists, physicians, and other health personnel--and provided
Technical cooperation 10.76 The number of countries involved in technical cooperation with WH 0 increased to some 30, in all regions. Preliminary surveys to assess health problems and develop occupational health units and laboratories were assisted by WHO consultants in Bangladesh, Botswana, Burma, China, Greece, Jordan, Kenya, Macao, Mauritius, Mozambique, Qatar, Saudi Arabia, Somalia, Yemen, Zambia, and Zimbabwe. A main purpose was to assist the health authorities in developing workers' health programmes that are integrated or fully coordinated with the national health services. Some projects also included the training of personnel and the preparation of plans for the development of occupational health institutes. WHO assisted in the development of an industrial health service centre with occupational hygiene laboratories in a newly industrialized district in Burma. In collaboration with UNEP, Io. 77 WHO assisted in the development of the national centre for occupational and environmental health near Cairo. The second phase of I68
1
WHO Technical Report Series, No. 663, 1981.
NONCOMMUNICABLE DISEASE PREVENTION AND CONTROL
instruction in basic knowledge and practical methods. It organized an international seminar on the risk assessment of chemicals, with 27 participants from Europe, in Lodz (Poland) in September I98o, and an international course on occupational health in agriculture, particularly emphasizing pesticide intoxications, in September and October I98o at the same institute. The latter course was attended by I o participants from different countries. An advanced course on biological monitoring of exposure to industrial chemicals was coordinated by the Regional Office for Europe at the Institute of Occupational Health, Helsinki, in August I98o. WHO and ILO co-sponsored an international symposium on occupational cancer in Helsinki in April I98I and an international symposium on education and training policies in occupational safety and health and ergonomics in Sandefjord (Norway) in August I981. Io.8o WHO initiated a study on the organization of occupational health services in Cuba, Egypt, Greece, Sudan, Thailand, the United States of America, and the USSR, and prepared a working document for a joint ILOfWHO project on institutional arrangements for occupational health at national level. The responsibilities of different government agencies and mechanisms will be identified to ensure coordination and cooperation among them.
agriculture, as a first step towards guidelines for the detection and control of occupational hazards in agricultural work and for the health education of workers in agriculture. A meeting of the Joint ILO/WHO Committee on the Health of Seafarers took place in September I98I to revise and update the International medical guide for ships, a joint WHO/ILO/IMCO guide for the diagnosis and treatment of emergencies and diseases affecting seafarers, published in I 967. Io.82 In the field of occupational hygiene, guidelines were produced on the evaluation of airborne particulates in the work environment. Two consultations helped with their preparation, the second meeting during the biennium (Alexandria, September I98I). These guidelines will provide occupational hygienists with simplified methods for the evaluation of the different airborne dusts. WHO also organized an interagency consultation on guidelines in occupational health for the establishment and operation of specific industries (June I98I), bringing together participants from UNDP, UNEP, ILO, the World Bank, IAEA, and WHO. Two main industries were selected as a priority: (i) iron and steel, and (ii) pesticides (manufacture, formulation, and use). I0.83 Two study groups were convened to recommend occupational exposure limits, one in June I98o for the commonly used solvents carbon disulfide, toluene, trichloroethylene, and xylene,l the other in June I98I for the pesticides malathion, carbaryl, lindane, and dinitro-o-cresol.2 Io.84 Guidelines on the early detection of health impairment in occupational exposure to vegetable dusts were finalized in I98o. In the same year a consultation was held 1 WHO Technical Report Series, No. 664, 1981.
Occupational health technology I0.8I In relation to occupational health technology, WHO organized a meeting in Copenhagen to prepare a manual on occupational health epidemiology that will become self-instruction reference material and also be used in training courses. This project is supported by the National Institute for Occupational Safety and Health (USA). A consultation was also held in April and May I98o on a manual on occupational health in
To be published in the WHO Technical Report Series in 1982. 2
THE WORK OF WHO, 198o-I981
on the preparation of a manual whose aim will be to help occupational physicians with the early diagnosis of occupational diseases in periodic health examinations of workers. I0.85 In view of the importance of synergism in the health hazards of the work environment, WHO convened an expert committee on the subject in December I 98o 1 to review research on combined exposure to multiple factors, physical, chemical, and biological, and their effects on health. It also reviewed existing knowledge on the influence of smoking, alcohol and drug consumption, malnutrition, and parasitic diseases on the health effects of occupational hazards. It identified gaps in knowledge and made recommendations on further research and the application of occupational hygiene standards in combined exposure.
programming and harmonization. An interagency meeting took place with ILO, UNEP, and other bodies in Rome (September I98o) for the preparation of a medium-term plan for occupational health and safety identifying the main areas of concern for each agency or body in the improvement of the working environment.
Immunology Io.88 During the biennium the network of WHO immunology research and training centres was expanded by the addition of a new centre in Beijing at the Institute of Basic Medical Sciences, Chinese Academy of Medical Sciences. The centre organized a four-week course on immunology in I981. The training programme of the centre at Lausanne/Geneva, supported largely by the Swiss Government, was enlarged by the granting of six-month fellowships to enable two students to stay on for further studies after the annual course in English. The number of students accepted for the course in French was increased from five to seven. A complementary programme was also established to help ex-students to set up their own research and training programme on their return to their home institutions. These extensions of the programme were made possible by an increased donation from Switzerland. The PAHO/WHO immunology research and training centre organized a course in I 98o in Sao Paulo, Brazil. Io.89 The WHO immunology research and training centre for advanced studies in Rehovot (Israel) organized a course on molecular and cellular aspects of antigenicity. The centre in Singapore organized a symposium on hybridoma technology. Assistance was provided for a symposium on clinical inimunology in Caracas.
New areas of concern Io.86 Consultations took place in the second half of I 98 I to prepare a detailed programme of work on psychosocial factors and ergonomics. A new programme on injury prevention, assisted financially and technically by the National Institute for Occupational Safety and Health, USA, was initiated by a consultation in November I98I dealing with human aspects in the control of occupational injuries.
Coordination with other organizations Io.87 Coordination with UNEP, UNIDO, ILO, and other agencies continued during the biennium. The Joint ILOfWHO Committee on Occupational Health (paragraph 10. 78) also reviewed ILO and WHO work in occupational health with a view to joint
t
WHO Technical Report Series, No. 662, 1981.
NONCOMMUNICABLE DISEASE PREVENTION AND CONTROL
10.90 Under the programme for the production of immunological reagents, a course was organized in Bangkok and a collaborating centre was established in Birmingham (United Kingdom). The centre will provide the standard reagents needed for the production of good-quality immunological reagents in different countries, train technical personnel, and control the quality of the material produced. A regional centre for the production of immunological reagents was established in Islamabad and a request for the establishment of a similar centre in Bangkok is being considered. 10.91 Interregional collaboration for the development of a vaccine against dengue haemorrhagic fever is progressing according to schedule. Attenuated strains of all four serotypes were obtained.
Union of Immunological Societies, WHO conducted a critical review of some of the most frequently used tests in clinical immunology with the aim of reducing the cost of patient care. The results of the meeting were published 1 and steps are being taken to bring this source of economy to the attention of ministries of health. With the same committee, WHO reviewed the effectiveness of gammaglobulin in preventing some infectious diseases and treating immunological disorders. In collaboration with the standardization committee of the International Union, a standard anti-human IgG labelled with horseradish peroxidase was produced and is being considered for acceptance as an international reference reagent. The work was made possible by a grant from the United States National Institutes of Health. 10.94 A meeting on the immunity of the mucous membrane reviewed the present state of knowledge and made recommendations for further research.
A programme to assess the socioeconomic importance of allergic diseases in developing countries started in Kuwait, Thailand, and Venezuela. 10.92 10.93 Together with the clinical immunology committee of the International
1
Bulletin of the World Health Organization, 59: 717-728
( 1981 ).
Chapter
II
Promotion of Environmental Health International Drinking Water Supply and Sanitation Decade II.I THE INTERNATIONAL Drink-
ing Water Supply and Sanitation Decade, I98I-I990, was launched by the United Nations General Assembly in November I98o, the aim being to provide all people with adequate supplies of safe water and sanitation by I99o, if possible. For the launching of the Decade, the Secretary-General of the United Nations prepared a comprehensive report t on the drinking-water supply and sanitation situation. WHO had a principal role in the analysis, collation, and interpretation of the data and in the preparation of the report. II.2 In May I98I the Thirty-fourth World Health Assembly, in resolution WHA 34· 2 5, emphasized safe drinking-water and adequate sanitation as basic elements of primary health care and listed the principles through which the Decade will contribute to the improvement of health as part of the Global Strategy for health for all by the year 2ooo. The Health Assembly recommended that Member States propose relevant water supply and sanitation programmes and projects for external support with the objective 1 Development and international economic co-operation, International Drinking Water Supp!J and Sanitation Decade: present sit11ation and prospects. Report of the Secretary-General (United Nations document A/35/367).
of reaching underserved populations, fostering coordinating mechanisms, focusing on national health priority problems, associating the community with all stages of the programmes and projects, and strengthening national agencies. Multilateral and bilateral agencies were invited to support national plans. I I. 3 The launching of the Decade stimulated wide interest in national planning to extend and improve water supply and sanitation services. Some 6o countries have formed national action committees, and national Decade plans are being prepared in a number of countries. Increasing attention is being given to projects that will benefit underserved rural and urban fringe populations. WHO helped more than 30 countries in four regions in Decade planning, using its own resources as well as resources from UNDP, GTZ, and SIDA. The World Bank/ WHO cooperative programme played an important part in this work. WHO organized I 5 national planning workshops, in the course of which national officials clarified the issues, agreed on urgent measures, and formulated a policy for Decade planning. In addition, a number of specialized workshops were held on the economic and financial, technology transfer, and data management aspects of Decade planning. The results of WHO's experience were summed up in the document referred to in paragraph I 1. 1. WHO also
PROMOTION OF ENVIRONMENTAL HEALTH
published guidelines for the application of the principles of the Decade in the preparation of national plans. 1 WHO strategy is to cooperate with the governments that have the will to give effect to the principles of the Decade and to help in the mobilization of resources; to cooperate in national efforts with other internatiomil organizations, particularly UNDP, UNICEF, and the World Bank; to advocate forcefully and consistently the orientation of the Decade towards the priority health problems of Member States; and to give precedence to technical cooperation at country level. I I ·4 A review of the progress achieved in the provision of drinking-water supply and sanitation during the I 97os showed that the targets set for the I o years prior to the Decade were not fully met. Only about two out of five persons had access to safe drinking-water and only one out of four had some kind of sanitary facility. A rough comparison between the situation in I970 and in I98o showed a modest improvement in water supply but practically no progress in sanitation. Since the United Nations Water Conference at Mar del Plata (Argentina) in I977, however, changes have occurred; Member States are increasingly aware of the potential of the Decade as a means of improving people's health and the quality oflife, and new programmes are being initiated. Big differences nevertheless occur from country to country in political commitment, in government planning mechanisms, and in the experience of government planners. Whereas in some countries the governments have clear ideas about the Decade and are taking strides towards the establishment of national plans, others have needed WHO help in planning and preparing projects. WHO's present concern is to ensure that the momentum created at the start of the Decade should not be lost and that WHO support for 1 World Health Organization. Drinkzng-water and sanitation, I98I-I990: a wery to health. Geneva, 198 r.
efforts in countries should be appropriate and consistent. I 1. 5 It is recognized that many of the water supply and sanitation systems built by governments at considerable expense have not achieved any lasting improvement of health. This is the result partly of inadequate planning but more often of neglect in the operation and maintenance of the systems. To help remedy this situation, WHO has given greater attention to the development of infrastructures and the strengthening of manpower at the community level. Throughout the biennium it supported national sector agencies, national action committees, and UNDP in identifying and formulating projects, solving institutional problems, and designing appropriate equipment. It devoted increasing resources to (i) the development, in cooperation with other organizations in the United Nations system and nongovernmental organizations, of methods and models for strengthening national, institutional, financial, and human resources; (ii) the creation of systems for the exchange of information on Decade technology, financial and technical resources, and projects in need of external support; and (iii) the devising of global and national evaluation mechanisms for assessing the impact of Decade efforts, especially on human health. I 1.6 In its work with governments and with sister agencies, WHO has always recommended sanitary collection and disposal of household and community wastes as a necessary complement to the provision of clean water. The bulk of current investment projects only give better service to communities already served by public systems. WHO seeks to persuade governments and lending agencies that rational and comprehensive projects to ensure safe water supply and sanitation for underserved communities must be implemented on a very large scale during the next IO years. I73
I I. 7 Contiguous communities or districts seldom recognize the economies of scale they might enjoy by cooperative water systems; hence they may resist centrally planned regional schemes. WHO has shown that such schemes can be made self-reliant and selfsustaining through careful on-site planning and implementation of projects calling for the maximum participation of the communities concerned, and has promoted this approach in all its field activities. I I .8 The choice of plant and equipment, at the production and especially at the consumer end of the system, and of institutional mechanisms for getting them properly installed and used is very large. Through the programme for the exchange and transfer of information on water supply and sanitation (POETRI) initiated by the Netherlands Government, WHO is bringing the choice to the attention of experts and decisionmakers in national water supply and health agencies; in consulting firms, in international agencies, and in nongovernmental organizations. WHO also emphasizes health education and community action, activities that were included in a number of investment projects prepared through the World Bank/ WHO cooperative programme. I I ·9 During the biennium WHO considerably developed its collaborative work with the organizations in the United Nations system: with ILO and UNESCO in human resources development methodology; with FAO in the prevention of water-related diseases; and with the World Bank in the formulation of development projects with positive health benefits. The cooperative programme with the World Bank was continued, with increased emphasis on infrastructure development; in addition to activities at headquarters, 36 missions to countries were carried out during the biennium. The steering committee for cooperative action for the Decade, consisting of the United Nations
agencies concerned with the Decade (the United Nations itself, UNDP, UNEP, the United Nations Centre for Human Settlements, UNICEF, ILO, F AO, WHO, UNESCO, and the World Bank) met five times in the period I98o-I981. The committee, which is chaired by the Deputy Administrator of UNDP (WHO providing secretariat services), promotes a coordinated approach to implementation of the Decade. Task forces have been set up to deal with public information, information exchange, project formulation, and human resources development. (For training activities, see also paragraphs I2.66 and 12.67.) I I. IO Under the sponsorship of the steering committee, a second consultative meeting involving donor governments, the United Nations and other international organizations, nongovernmental organizations, and representatives from countries was held at WHO headquarters in June I98o. It reviewed progress during the preparatory phase of the Decade, issues related to its launching and implementation, and ways of furthering cooperation with a view to increasing the flow of resources to the sector.
Progress in Member States I I. I I The information available indicates that, since the start of the Decade, most Member States have intensified their efforts to increase the provision of safe water supplies and sanitation facilitaties. WHO is helping them to overcome weaknesses in current practices. Coordination mechanisms have been established at national and international level, communication between supporting agencies and countries has been improved, allocations for water supply and sanitation have been increased at national and international level, arid a public information campaign covering developed and developing countries is being implemented to promote the Decade and its objectives.
I74
PROMOTION OF ENVIRONMENTAL HEALTH I I. I 2 In the African Region substantial progress has been made in organizing Decade activities. Of the 4 5 countries in the Region, 22 have established some form of national action committee for intersectoral coordination in relation to water supply and sanitation. In 29 countries a technical support team has been organized, including staff from WHO and other international agencies. WHO is executing interregional cooperative projects supported by UNDP, GTZ, and SIDA in I 7 countries, projects that are all concerned with national planning and programming for the Decade. WHO also participated in technical cooperation in three other countries for the development of a national plan, and in seven national workshops concerned with the development of intersectoral planning and programming for the Decade. I I. I 3 An intercountry TCDC project in basic sanitary measures has been implemented. Sanitary engineering posts have been established in each of the three subregions to ensure more direct support to countries in respect of the water supply and sanitation aspects of TCDC.
age authority in Barbados; the setting up of administrative, operation, and maintenance systems for water service in Haiti; the development of rural water supply programmes in Guatemala and Paraguay; and institutional development in Costa Rica. Institutional development was also supported by the inclusion of human resources development as a component in technical cooperation with countries, examples of which were the Caribbean area water management project to develop a self-sustaining training system, and projects for the development of drinkingwater and sanitation institutions in the Andean subregion and in Central American countries. The Pan American network of national focal points for information and documentation on sanitary engineering and environmental sciences was further developed and a start was made in coordinating it with the international collaborating centre information programme. The Pan American Center for Sanitary Engineering and Environmental Sciences, Lima, carried out studies on waste-water stabilization ponds, biogas, and the development of a new type of chlorinator. The regional programme providing help with analysis to water and wastewater laboratories was continued.
I 1. I4 WHO helped in the Economic Commission for Africa meeting (Addis Ababa, August I98o) concerning national water supply and sanitation action related to the Decade. The World Bank/WHO cooperative programme also gave support to water supply and sanitation activities in a number of countries. I I. I 5 Institutional development was an important feature of programme activities in the Region of the Americas. The Organization collaborated with some I 2 countries in organizing information systems for national and local institutions. The projects assisted included: the strengthening and development of water and sewerage agencies in Brazil; the establishment of a national water and sewer-
I I. I 6 The Organization collaborated with countries in support of their strategies for the Decade. This included work under the cooperative programme with the World Bank, and with the Inter-American Development Bank and GTZ. The work with GTZ focused on national planning and infrastructure development in Bolivia, Haiti, and Paraguay, and the establishment of a centre for training in the operation and maintenance of water and sanitation services for Central America and Panama. Cooperation also continued with several countries to assure water quality and continuity, UNDP, CIDA, and the Caribbean Development Bank providing support.
175
I I. I 7 Most of the countries in the SouthEast Asia Region have given high priority to water and sanitation and have established mechanisms to coordinate policy and action for the Decade with UNDP resident representatives. Several activities in the countries of the Region are now mainly concerned with the preparation of a national plan and the implementation of projects during the Decade. WHO held two intercountry workshops on Decade planning and Decade support programmes, including information systems, health education, behavioural studies, operation and maintenance, manpower development, and water quality surveillance. National plans were completed for Bangladesh, Nepal, and Sri Lanka and will shortly be prepared for other countries in the Region. I I. I 8 In the European Region particular effort was directed towards accelerating activities in water supply and sanitation in Algeria, Morocco, and Turkey (paragraph I 5. 77), where WHO sanitary engineers have been stationed to provide technical support to the UNDP resident representative. While the programme under WHO's regular budget focused on rural sanitation, large-scale action took place within the framework of the UNDP country programmes. In Algeria a large-scale project related to solid wastes collection and disposal for 6o medium-sized cities was begun. In Morocco a seminar on appropriate technology for rural sanitation was held in Rabat in December I98o as a preparatory activity for a pilot project. I I. I 9 In the Eastern Mediterranean Region consultations or workshops bringing together representatives from departments and organizations concerned were conducted with WHO assistance in Egypt and Sudan (through a UNDP-funded interregional cooperation project), in Somalia (through a similar GTZ-funded project), and in Pakistan (with UNDP support). These meetings
focused on technical cooperation with countries in their preparation of national sector plans for the Decade. A sector study in Yemen executed through the World Bank/ WHO cooperative programme identified a number of projects requiring external resources. In Lebanon a WHO/UNDP national waste management project prepared a draft master plan and, despite some problems, is proceeding with the preliminary engineering and feasibility studies for four priority areas. I I. 20 Training and human resources development were important aspects of water supply and sanitation activities in the Western Pacific Region. Two workshops considered the financial and economic aspects, another was held on regional strategies for the Decade, and a number of courses dealt with technical subjects such as surveillance of drinking-water quality. The Region administers more than 30 projects concerned with basic sanitary measures, largely supported from UNDP funds. A new UNDP/WHO project began in I 98o for the training of water supply and sewerage personnel for countries of the South Pacific area. Summary reports were completed by July I98 I for all countries and areas except Brunei, Democratic Kampuchea, and Macao. An assessment was prepared of the situation in the Region and of the strategies and approaches to be followed.
Control of environmental hazards I I. 2 I While the International Drinking Water Supply and Sanitation Decade is generally seen as directed mainly towards developing countries, many related problems remain unresolved in developed countries, such as the contamination of drinking-water by chemicals and the widespread pollution of rivers, lakes, and groundwater. In the past, too, serious toxic wastes were often disposed
!76
PROMOTION OF ENVIRONMENTAL HEALTH
of in an uncontrolled manner and have become a serious public health problem in a number of countries. In four WHO regions there are programmes on ways and means of dealing with those problems.
International programme on chemical safety I I. 22 The international programme on chemical safety was put on a broader footing during the biennium. At the international level, ILO and UNEP have joined the programme as cooperating agencies. At the national level, I 2 Member States have formally adhered to the programme by a memorandum of understanding. Twelve national institutions have been designated as lead institutions for specific programme areas. IARC is the lead institution for carcinogenesis. UNEP has established an international register for the collection, retrieval, and dissemination of information on potentially toxic chemicals. An interregional research unit was established at the National Institute of Environmental Health Sciences, North Carolina, USA. Another is being set up in the Environmental Protection Agency, Washington. I 1.23 A programme advisory committee was set up to advise the Director-General and the executive heads ofiLO and UNEP on the overall aspects of the international programme. The committee met twice during the biennium and established four priorities: evaluation of the effects of pesticides, food additives, household chemicals, and selected industrial chemicals; dissemination of information; training of toxicologists; and development of methodologies, especially for monitoring exposure from various sources and for validating tests for the detection of mutagenicity, carcinogenicity, and teratogenicity. It developed guidelines for designating lead institutions and for ensuring that the work they perform corresponds to the
international character of the programme. It also dealt with the question of unpublished proprietary data and the participation of nongovernmental organizations in the programme. It reviewed the special needs of developing countries and made recommendations on the training of manpower, the dissemination of information, and the drafting of basic guidelines on the safe use of chemicals. I 1.24 The Regional Office for Europe was active in the field of chemical safety (paragraph I 5. 78). It has developed plans for dealing with emergencies and accidents involving the release of toxic chemicals, plans that could be adapted for global application. It is also implementing a UNDP-supported project on European cooperation on environmental health aspects of the control of chemicals that aims at the strengthening of national capabilities in this area.
I 1.25 The preparation of environmental health criteria documents on chemicals constitutes an important part of the programme. Three documents were published in the biennium and a fourth is in press.t Under the new arrangements in the programme the lead institutions take the responsibility for the preparation of the criteria documents under the guidance of the central unit. The drafts go to countries for review and comments and the revised draft is finally reviewed by a group of international experts. Twelve lead institutions have begun the preparation of I 8 additional documents on I 8 chemicals or groups of chemicals. In all, 3 I criteria documents on chemicals are at various stages of preparation and I6 are already in print. Guidelines on the preparation of the criteria 1 World Health Organization. Tin and organotin compounds: a preliminary review, Geneva, 1980 (Environmental Health Criteria, 15); Manganese, Geneva, 1981 (Environmental Health Criteria, 17); Arsenic, Geneva, in press (Environmental Health Criteria, 1 8); Hydrogen sulfide, Geneva, 1981 (Environmental Health Criteria,
19)·
I77
documents have been prepared. Work has begun in relation to methodology on: principles and methods for evaluating the toxicity of chemicals; general principles in epidemiological methods for environmental health studies; assessment of the effects of chemicals on reproductive function; short-term tests to predict the mutagenic and carcinogenic potential of chemicals; integrated evaluation of acute and chronic prenatal toxicity of chemicals; and evaluation of neurobehavioural toxicity. Environmental health planning I 1.26 A guide on environmental health planning was finalized and distributed to a wide range of users at country level. An analysis was also published 1 of a study conducted in 2 I countries at various stages of development. It makes comparative information available for the first time on the different approaches adopted to deal with the complex issue of intersectoral coordination and health in environmental management. The Western Pacific Regional Centre for Promotion of Environmental Planning and Applied Studies and the Pan American Center for Sanitary Engineering and Environmental Sciences continued to give the highest priority to this subject. In the Eastern Mediterranean Region studies continued on the establishment of a similar regional centre for environmental health activities. The Regional Office for Africa organized a consultation on the establishment of a regional network of national environmental sciences institutes (Dakar, June-July I98I), attended by participants from I I countries in the Region. The meeting agreed that, as a first step, a feasibility study should be begun on the establishment of a regional environmental health centre. 1 Schaefer, M. lntersectoral coordznation and health in environmental management: an examination rif national experience. Geneva, World Health Organization, 1981 (Public Health Papers, No. 74).
Monitoring and control of pollution I 1.27 During the biennium WHO continued its UNEP-supported air and water quality monitoring projects, which aim at initiating or strengthening national monitoring programmes and at obtaining information on pollution levels on a regional and global scale. Some So countries now participate in the air quality monitoring programme. New approaches are being developed and tested so as to improve the information base for assessment of the impact of air pollution on human health. Pilot studies were initiated in Toronto (Canada) and Zagreb (Yugoslavia) in I98o, and arrangements were made to initiate similar studies in China and India. By the end of I98I data under the water quality monitoring project were being collected and analysed routinely from more than 30 countries. The last two regional training courses in the initial series on water quality monitoring were held in Dakar and Nairobi in collaboration with UNESCO. A training course on the quality assurance aspects of water quality monitoring was organized in Nagpur, India, for participating countries in the South-East Asia and Eastern Mediterranean Regions. I 1.28 A relatively simple method2 has been developed and tested over the past few years for the identification and assessment of air, water, and land pollution sources in a given city, region, or even country. Its application will yield an industrial waste profile and indicate the most urgent control problems and the problems that may be emerging. I I .29 The revision and merging of International standards for drinking-water and European standards for drinking-water proceeded well in I98I, with a view to their 2 World Health Organization. Rapid assessment of sources ofair, water, and land poJJution. Geneva, 198 2 (WHO Offset Publication No. 6z).
PROMOTION OF ENVIRONMENTAL HEALTH
publication as WHO guidelines for drinkingwater quality. During the biennium a number of working groups were convened by WHO to prepare sections of the guidelines dealing with the contamination of drinking-water by biological organisms and chemical and physical constituents and to set forth recommended limits. This project is supported financially by DANIDA and by a number of WHO collaborating centres and focal points for the environmental health criteria programme. I 1.30 For the UNEP industry and environment programme, WHO participated in a review of the environmental aspects of nonferrous metal industries by providing information on the known health effects. Also, as a follow-up to UNEP's review of the environmental problems caused by motor vehicles, WHO together with UNEP sponsored two workshops on motor vehicle emissions, the first at the Western Pacific Regional Centre for Promotion of Environmental Planning and Applied Studies in I98o with the participation of representatives from countries in the Western Pacific and South-East Asia Regions, the second in Moscow in I 98 I with the participation of representatives from countries in the African, European, and Eastern Mediterranean Regions. The Regional Office for Europe initiated a project on the assessment of toxicological problems associated with specific industries, and a planning meeting was held in I981.
held in Nashville, USA, in I 981. The symposium placed special emphasis on methods of quantification, comparison, and analysis of health risks; the development of epidemiological parameters for the evaluation of the health impact; and cost/benefit analysis. The health impact of various components of nuclear fuel cycles and the environmental health implications of the disposal of highlevel radioactive waste were reviewed by a working group organized by the Regional Office for Europe in cooperation with the Belgian Government. I I. 32 During the biennium a pilot project on the assessment of human exposure to pollutants through biological monitoring for selected metals and for organochlorine compounds was carried out with the participation of some I 5 countries and the support of UNEP. The measurement of concentrations in human tissues and fluids is an excellent means of estimating the uptake and deposit of these substances in the body. This type of monitoring is technically difficult, and most of I98o-I98I was devoted to strengthening the analytical capabilities of participating laboratories and instituting a vigorous analytical quality assurance programme. By the end of I98I most of the participating laboratories had either begun or made plans to begin monitoring selected populations. Under this pilot study, lead and cadmium are being measured in the blood, cadmium in the kidney cortex, and organochlorine compounds such as DDT, DDE, and polychlorinated biphenyls in breast milk. I I. 33 Monitoring of environmental radiation was continued through the WHO collaborating centre at the Service central de Protection contre les Rayonnements ionisants, Le Vesinet, France. Under this programme some 30 national laboratories in 2 I Member States and four WHO collaborating centres participate by providing information on radiation levels in air, water, milk, and bone.
Ever-increasing demands for I I. 3 I energy have made it necessary to evaluate and compare the health risks of different sources of energy (wood, coal, oil, nuclear power, etc.). Approaches to a comparative assessment of detriment to health from energy production were considered at a WHO meeting organized jointly with the Federal Republic of Germany. The problem was further discussed at a WHO/UNEP/IAEA symposium on health impacts of different sources of energy 179
THE WORK OF WHO, 1980-1981 1 1. 34 Technical cooperation activities were undertaken through the regional offices. Countries in the Eastern Mediterranean actively participated with the Regional Office in the planning and implementation of marine pollution control programmes as part of both the Mediterranean and the Kuwait action plans. In the South-East Asia Region technical cooperation activities in air and for water quality management were carried out in India, Indonesia, and Thailand. The Regional Office for the Americas supported a series of projects in countries concerned with the development of environmental control programmes, research, and the collection and exchange of information. The European Region was involved in the promotion of assessments of environmental impact, the improvement of systems for the collection and disposal of solid wastes, and the development of environmental pollution control programmes. In the Western Pacific Region cooperation continued with the Republic of Korea in the development of air and water pollution control measures. In China UNDPsupported projects were initiated on the monitoring and control of pollution. In the African Region a pilot project on the development of a control programme for air and water pollution was carried out in Abidjan. The results of this study will serve as a model for use in conjunction with the guidelines on environmental pollution assessment (paragraph 1 1.28). 1 I. 3 5 WH 0 continued to participate in the work of UNEP's coordinated regional seas programme by providing specific information on the human health aspects. Work was continued in the Mediterranean, Caribbean, and other regional seas. In addition, WHO coordinated the development of training material for a projected series of workshops on assessment of the environmental impact of coastal area development. This work was carried out with the participation of the United Nations, the United Nations Centre
for Human Settlements, FAO, UNESCO, IMCO, and UNIDO, and resulted in 1981 in an instructor manual, a student manual, and an illustrative case studies manual.
Protection against radiation and other pl!Jsical factors 1 I. 36 The health risks associated with exposure to non-ionizing radiation and other physical factors are undergoing evaluation; during the biennium environmental health criteria documents were issued on noise and on radiofrequency and microwaves. 1 Additional criteria documents are in preparation on lasers, ultrasound and extremely low frequency, and power line electromagnetic fields. The Regional Office for Europe is completing preparation of a manual on protection from non-ionizing radiation.
1 1. 37 A number of guidelines on various aspects of radiation protection have been developed or updated to assist Member States in the management of national services. Among these, mention should be made of Basic safety standards for radiation protection, which was revised jointly by IAEA, ILO, WHO, and the OECD Nuclear Energy Agency on the basis of the recommendations of the International Commission on Radiological Protection (ICRP), 2 and the IAEA/ WHO code of practice on basic requirements for personnel monitoring.3 The application of radiation protection standards was the
1 World Health Organization. Noise, Geneva, 1980 (Environmental Health Criteria, I2); Radiojrequency and microwaves, Geneva, I 981 (Environmental Health Criteria, I 6). 2 Basic safety standards for rad1at10n protectiOn: report of an advisory group ;ointly sponsored by IAEAJWHOJ ILOJNEA. Vienna, International Atomic Energy Agency, I98r. 3 Basic requirements for personnel monitoring: a code of practice sponsored by the International Atomic Energy Agency and the World Health Organization. Vienna, International Atomic Energy Agency, I98o (Safety Series, No. I4).
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subject of a joint WHOfiAEAfOECDNEAfiCRP symposium held in Madrid on the application of the dose limitation system in nuclear fuel cycle facilities and other radiation practices. A joint IAEA/WHO booklet on low-level radiation was issued 1 to provide information to the general public. I r. 38 To improve the preparedness of public health authorities for possible radiation accidents, in addition to the system for mutual assistance in radiation accidents devised by IAEA, WHO, FAO, ILO, UNDRO, and the International Radiation Protection Association,2 two WHO collaborating centres for radiation emergency medical assistance were designated in Paris and Oak Ridge (USA) to assist all the regions in the handling of radiation accidents and the treatment of radiation injuries. The rationale for public health action in case of possible radiation accidents was considered at a WHO meeting organized in cooperation with the Belgian authorities. Regional training seminars on general procedures for the management of persons receiving whole-body or part-body radiation were jointly organized by the Regional Office for the Americas and the Brazilian Atomic Energy Commission.
acceptable daily intakes and maximum residue limits in foods, of pesticides used extensively in agriculture and public health. At its I98o meeting 4 it included items of a general nature such as general principles for establishing acceptable daily intakes, the quality and validation of toxicological data, and proposals for maximum residue limits for food groups. Among the specific problems discussed were delayed neurotoxicity as a hazard posed by some organophosphorus insecticides, impurities in technical pesticides, and pesticide residues in stored products. I I .40 Two meetings of the Joint F AOJWHO Expert Committee on Food Additives were held in I98o 5 and I98r. 6 The report of the I98o meeting dealt with the approach followed by the Expert Committee in evaluating food additives claimed to be free from cariogenic activity; the need, under certain circumstances, for impurities or transformation products of food additives to be tested separately; the special problems posed by toxicological evaluation of modified food ingredients; and the nutritional significance of reactions between additives and normal food components. Particular attention was given to the implications of temporary acceptance of food additives: the time limits proposed for the completion of further investigations on some food additives would, in the Committee's view, create no public health hazards. I 1.4 I The I 98 I meeting examined a number of colouring agents, carrier and extraction solvents, flavouring agents, enzyme preparations, sweeteners, and miscellaneous food additives. Special attention was given to: the use of hormones in stockraising and the problems posed by their 4
Promotion of food safety 3 Food additives and contaminants IL39 In I98oand I98I the Joint Meeting of the F AO Panel of Experts on Pesticide Residues and the Environment and the WHO Expert Group on Pesticide Residues provided toxicological evaluations, in terms of 1 Facts about low-level radiation. Vienna, International Atomic Energy Agency, 1981. 2 Mutual emergency assistance for radiation accidents. Vienna, International Atomic Energy Agency, 1980 (IAEA-TECDOC- 2 37). 3 For food safety in relation to veterinary publtc health, see paras 9.182-9.197·
F AO Plant Production and Protection Paper No. 26,
1981.
s WHO Technical Report Senes, No. 65 3, 1980. 6WHO Technical Report Series, No. 669, 1981.
I8I
THE WORK OF WHO, r98o-r98r
residues in food; the safety aspects of plastic materials in food packaging; antibiotics as direct food additives; and enzymes used in food processing. The Committee also examined its current approach to the evaluation of natural and nature-identical food additives. It reviewed the work it had carried out for 2 5 years and the benefits developing countries could derive from it. I 1.42 A Joint FAOfiAEAfWHO Expert Committee on the Wholesomeness of Irradiated Food was convened in I98o.l It considered that the irradiation of food commodities up to an overall average dose of Io kGy presents no toxicological hazard, that toxicological testing of foods so treated is no longer required, and that such irradiation introduces no special nutritional or microbiological problems; but it emphasized that attention should be given to the significance of any changes in relation to each particular irradiated food and to its role in the diet.
reviewed and assessed the results of its work. One of the important issues dealt with was that of nutrition. Many draft and existing Codex standards either contain specific nutrition provisions or help to protect the nutritional quality of the food supply by controlling the composition and distribution of foods passing into trade. The Commission concluded that nutritional considerations had not been neglected in its work, either past or present, which had considerable nutritional impact. I 1.45 Following recommendations of its committee on general principles, the Commission adopted revised procedures for the elaboration of worldwide and regional Codex standards aimed at simplifying and speeding up the mechanism for acceptance by Member States.
Technical cooperation with Member States I I .46 Technical cooperation in market and food sanitation was provided in the African Region as part of the general sanitation programme. Preparatory work began in connexion with a proposed regional expert committee on the development of food safety policy. The FAOfWHOfiARCfUNEP project on control of fungal contamination of food and human health, initiated in Swaziland, has been extended until the end of
Food standards programme I 1.43 The primary objective of the joint FAOfWHO food standards programme under the aegis of the Codex Alimentarius Commission, which now has a membership of I 2 I countries, is to protect consumers from the health hazards related to food and from fraudulent practices. It attempts to do so by establishing international or regional standards and drawing up codes of practice for the safe handling of food. During the biennium I 7 commodity and general subject committees were convened, and meetings were held of the coordinating committees for Africa, Europe, and Latin America. I I ·44 The fourteenth session of the Codex Alimentarius Commission took place in Geneva in I 98 I, when the Commission
I982. I I ·4 7 In the Americas technical cooperation was undertaken with a number of countries. In I98o the ministers responsible for health in the Caribbean countries began planning and developing strategies for a subregional food protection (food safety) programme. The Andean countries have also voiced interest in the development of a subregional food safety programme. Training continued under the regional education programmes for food protection based in
I
WHO Technical Report Series, No. 659, r98r.
I82
PROMOTION OF ENVIRONMENTAL HEALTH
Colombia. At the thirty-third session of the Regional Committee (September I98I) the subject of the Technical Discussions-the sanitary control of food-resulted in an action plan that will guide future regional activities. I 1.48 In South-East Asia country projects on a range of food safety topics were undertaken in India, Indonesia, Sri Lanka, and Thailand. The need for the systematic development of national food safety programmes in the Region is being increasingly recognized. I I.49 The Regional Office for Europe published Food safety services, 1 the result of a survey of national food safety services in the countries of the Region; it is intended to be used as background material for working groups, e.g., on food inspection principles, sampling programmes, the training of food inspectors, and selected coordination problems. Preparatory work relating to food safety in mass catering continued, with the collection of material for proposed studies and working groups. A working group on health examination of food-handling personnel met in I98o. A surveillance programme for foodborne infections and intoxications in Europe became operational. II. 5o Basic sanitary measures, with special emphasis on the improvement of food safety and hygiene, are recognized as vital in the socioeconomic and climatic conditions of the Eastern Mediterranean Region. Collaboration continued with governments and with international organizations such as F AO, as well as with the Arab Organization for Standardization and Metrology, on improving food control and hygiene activities. A sixweek programme for training food inspectors was organized in Amman in October I981. 1 Johnson, R., ed. Food safety services. Copenhagen, World Health Organization, 1981 (Public Health in Europe, No. 14).
II. 5I In the Western Pacific Region country projects included the initiation of a project on food safety in China, with UNDP support. National seminars were held in Fiji and the Republic of Korea to develop national food control systems. A working group on the public health aspects of marine food poisoning was convened in cooperation with the South Pacific Commission.
Information and monitoring I 1. 52 WHO is further emphasizing its food safety activities by providing information and health education programmes for schoolchildren, food-handling personnel, and the general public. I 1.5 3 The UNEP-supported joint F AO/ WHO food contamination monitoring programme aims at providing information on environmental pollutants in food (organochlorine pesticides, polychlorinated biphenyls, cadmium, lead, and aflatoxins) in order to assess the health risks to man from exposure to such pollutants and to determine priorities for developing pollution control strategies at the national, regional, or global level. Under this programme F AO/WHO collaborating centres in 2I countries contribute monitoring data on contaminants in foods and in total diet. These data are being evaluated to determine trends and potential health hazards and a summary of data received up to July I98o was prepared. In almost all cases the estimated dietary intakes of the organochlorine pesticides are low and reflect the decreased utilization of these pesticides in certain countries. Cadmium dietary intakes indicate that this contaminant should be monitored closely. An analytical quality control programme was implemented. The second session of the technical advisory committee of the joint F AO/ WHO programme was convened in April I98I to review progress and problems and to advise on the future operational phase of the programme.
Chapter
I2
Health Manpower Development
REVIEW of present health manpower systems reveals a number of problems arising from the absence or inadequacy of national health manpower policies. The neglect of coordinated training and utilization of health personnel results, among other things, in a shortage of such personnel; an uneconomic utilization of the health team; an imbalance between different categories of staff; inequities in geographical distribution, aggravated by the migration of qualified personnel; and in many cases the absence of a clear definition both of functions and of required competencies for the various categories of health worker. There is often no wellconceived manpower system operating as an integral part of the health system. The most frequent problem is the lack of coordination of the three main elements of the health manpower development process-planning, production (i.e., training), and management. A related problem is the lack of coordination between the health manpower development process and other sectors, e.g., general education, social security, labour, and agriculture. I 2. I I2.2 The first element in the health manpower development process is planning. In many countries there are no health manpower plans at all, or if they do exist they are often exclusively quantitative in character. Where there is no proper planning of health
A
teams, the result is an undue emphasis on the training of certain conventional categories of health personnel-particularly physicians and nurses--at the expense of other categories. 12.3 In health manpower production the main problem is the shortage of facilities for training the required type and number of health personnel needed by the national health services. This includes a shortage of teachers of health sciences, especially of teachers competent to plan, implement, and evaluate the teaching/learning process, using a systems approach and ensuring that what students learn is relevant to the demands that will be made upon them on completion of their training. Only too frequently there are wide divergencies between academic training goals and the requirements of the health services. Curricula, methods, and systems of evaluation are often unsuitable for training health workers to meet the real health needs of the community and to work in teams. Moreover the absence of collaboration between those responsible for training staff and those responsible for health care delivery is liable to result in educational programmes that develop in isolation from the changing needs of health care. 12.4 Problems in health manpower management include unattractive working conditions, e.g., insecurity of tenure, limited
HEALTH MANPOWER DEVELOPMENT
promotion prospects, and inadequate financial or other incentives. Very often there is no provision for continuing education and this in itself is a severe limitation on maintaining and improving the level of competence and performance of health workers.
Medium-term pro,f!,ramme I 2. 5 During the biennium, the basis of work was the medium-term programme for I978-I983, endorsed by the Thirtyfirst World Health Assembly (resolution WHA3 1.36). A partial revision of this programme was undertaken to ensure that it remained relevant to the changing health priorities of Member States and was in line with the principles adopted at the Alma-Ata Conference and the Global Strategy for health for all.
"Health Manpower News", that provided information on health manpower plans, programmes, and processes; teaching/learning materials; processes and tools for programme evaluation; and training institutions and other learning facilities. Nine newsletters in all appeared up to January I981. Since that date, owing to the reduction in periodicity of the Chronicle (paragraph I 3.30), the newsletter has been discontinued although information on health manpower development is still carried by the Chronicle.
Research I 2. 8 During the biennium, an analysis was made of health manpower development policy in WHO from its inception (I948) up to I98o. 1 The intention was to document the relationship between expressed policy, implementation by way of programme, and final outcome. The study set out to identify the main policies and objectives of the programme and the factors (political, social, economic, cultural, health, etc.) that shaped them; to determine to what extent policy was implemented; to find out which factors influenced the successes or failures of the programme; and to ascertain what changes, if any, in WHO's Member States could be attributed to the influence of WHO's health manpower development programme. I 2.9 The methods used to carry out the study included an analysis of United Nations and WHO official documents; a statistical analysis ;2 the canvassing of expert opinion; case studies in six countries (Barbados, Costa Rica, Ethiopia, Gabon, Indonesia, and
I2.6 In I98o-I98I an attempt was made to assess progress after three years' experience of implementing the medium-term programme. It was found that many of the problems inherent in a first effort had been solved in the course of implementation; but, as with any programme extending over a long period, it was necessary to revise, add, or discontinue activities because national health priorities had changed. In general however the targets set in I977 remain essentially the same. A final assessment will be made in I 98 3 to determine to what extent targets have been met by the end of the six-year period. The progress made can be seen from the following pages.
Programme planning and general activities Information service 12.7 The WHO Chronicle was hitherto the vehicle for publishing a newsletter,
1 Fiilop, T. & Roemer, M.I. International development of health manpower. Geneva, World Health Organization, 1981 (WHO Offset Publication No. 61). 2 Fiilop, T. & Reinke, W.A. Statistical analysis of interdependence of country health resource variables, with special regard to manpower-related ones. Bulletin of the World Health Organization, 59: 129-141 (1981).
THE WORK OF WHO, r98o-r98r
Malaysia) to assess the relationship between WHO's programme and the status of health manpower development in the country; and an analysis of the literature on WHO's work in health manpower development. I2.IO In the conclusions of the study, guidelines for the future are discernible. 1 It is clear that further progress in health manpower development depends on the political will at national level to seek and apply proper solutions to manpower problems that have been properly diagnosed in relation to the need for health services based on the primary health care approach. Moreover it emerges clearly from the study that it is WHO's role to act as an agent of change, to stimulate the right political response without which even the best technical solution may end in failure, and to promote the political will that alone can ensure an effective development process. I 2. I I To produce "effective" health manpower, i.e., appropriately trained manpower that is able and willing to care for the entire population of a country, requires active research on all aspects of the manpower development process: policy formulatwn, planning, production, and management. During the biennium WHO launched several activities to promote research of this kind.
I 2. I 3 Eight WHO collaborating centres in seven countries are collecting epidemiological information on the nursing care needs of elderly and elective surgical patients, data being drawn from 30 health care institutions in I 3 countries. Participating nursing personnel attend in-service training programmes on the process required (assessment of health needs, planning and implementation of nursing care, and evaluation of its effectiveness). A meeting (Switzerland, I98o) discussed the importance of records in carrying out this process.
I 2. I4 In collaboration with the International Council of Nurses and the World Federation for Medical Education, a study was made on the concept and practice of a competency-based curriculum that could be used to promote a shift from the subjectcentred or discipline-oriented curriculum to a problem-solving approach. Part of this study consists in examining the experience of educational programmes that have defined and used learning objectives. I 2. I 5 In the Region of the Americas, the Latin American Center for Educational Technology in Health (Rio de Janeiro) is developing research projects on a curriculum and didactic planning model based on the health needs of primary health care programmes, including communication with the supervisory level.
I 2. I 2 In the South-East Asia, European, and Eastern Mediterranean Regions, several meetings were held on research in manpower development. In the South-East Asia Region, a consultant visited five countries (Bangladesh, Burma, Indonesia, Sri Lanka, and Thailand) to determine research needs. A consultative group on the organization and scope of research in education for the health professions (Prague, I 98 I) met to decide what action should be taken to promote research in the European Region that would enable Member States to develop plans and activities to attain health for all. 1
I 2. I 6 Procedures for assessing the performance of health workers and students were worked out by investigators in six countries: Bahrain, Kenya, Mozambique, Poland, Sri Lanka, and the United Republic of Cameroon. The theoretical basis for this research and its practical aspects were published in the form of guidelines. 2 2 Katz, F.M. & Snow, R. Assessing health workers' performance: a manual for training and supervision. Geneva,
WHO Chronicle, 36: 3-6 (r98z).
World Health Organization, 1980 (Public Health Papers, No. 72).
I86
HEALTH MANPOWER DEVELOPMENT I 2.17 The important matter of how to select suitable applicants for training as health workers was studied with the support of UNFP A. A working group met in Geneva (I98o) and in Maputo (I98I) to provide alternatives to the most commonly used practices, such as the almost universal reliance on scholastic achievement as a criterion for selection. The procedures recommended by the working group will be disseminated in the form of guidelines.
coincided with the results of epidemiological surveys. Such an approach could prove even more useful in the national managerial process, of which manpower planning is an element. I 2.20 Although there is still some opposition to the utilization of traditional birth attendants in the health services, those countries that do use them commend their contribution to the extension of coverage and are continually seeking ways to increase it. Research has begun in Thailand to determine what additional role the traditional birth attendant can play in primary health care. A study has also begun in Burma to determine the ability of the traditional birth attendant to function as a first-level health worker in maternal and child health care and to detect women and newborn infants at special risk; its outcome will serve as a basis for guidelines on the training of teachers of traditional birth attendants in such screening. In Sierra Leone, where 70% of deliveries are attended by traditional birth attendants, a training programme was initiated as early as I974 to improve their skills and practices. A countrywide study began in I98I to assess the impact of their work on health care services. It includes the development and testing of evaluation tools and of a methodology for assessing the effectiveness of training programmes. I 2.2 I Research is an integral part of all health manpower development activities and futher examples will be found throughout this chapter.
I 2. I 8 A flowchart for decision-making in patient management, for use especially in primary health care but also as a training device, was tested in a number of countries. The flowchart project was extended to other areas of health care, e.g., mental health, where a problem-oriented method was developed to determine the appropriate management of mental illness in cross-cultural primary care settings. The method is designed for use by intermediate-level health workers in developing countries and was tested by psychiatric field workers in Colombia, India, and Lesotho. In preliminary reports from Lesotho the diagnosis made on the basis of the flowchart showed a 76% agreement with the consultant psychiatrist's diagnosis in 6o cases. Reports from India showed agreement in 28 out of 30 cases. The method is currently being evaluated in Colombia and Egypt. WHO also sponsored the preparation and field testing of a manual to teach instructors and learners how to adapt and use the flowchart method. It outlines the basic clinical skills that must be acquired before the method can be used. The manual is being adapted for use by village health workers. I 2. I 9 The failure to assess health manpower requirements in terms of health needs is an obstacle to realistic planning. An approach was devised for eliciting information from health workers, health administrators, and the community (see paragraph I 2. 36). It was found that what they perceived to be the main health problems usually
Health manpower planning and management
Coordination between health services and manpower development institutions I 2.22 To improve the planning of health manpower, the proper deployment of health
workers, and the relevance of training programmes to community health needs, WHO continued to promote the integrated development of health services and of manpower. Virtually all regions promoted discussion and organized meetings on the subject, and the concept was adopted by an increasing number of Member States. I2.23 In the European Region, a working group on communication and collaboration between and· within the health and educational systems reviewed the promotional work of WHO and Member States in that connexion. Case studies were presented from different systems of health care-in Poland, Sweden, and Switzerland. At the request of the health authorities of Montenegro, Yugoslavia, a visit was made to the area in I 98 I to discuss the organization of health services and health manpower training. I 2.24 The recognition that health development requires both an intersectoral approach and community participation has led to the establishment of national health councils and health development networks that include a health manpower component. This is occurring in Burma, Colombia, Democratic Yemen, Ethiopia, Papua New Guinea, and Sudan.
lines can be used as a basis for one-week workshops; they indicate the steps to be followed in formulating manpower plans, as should routinely be done after the workshop to reinforce learning by doing. 12.26 In the Americas, regional courses to train personnel in project planning were conducted in Colombia and Peru. An intercountry workshop was held (Lima, November I98I) to promote manpower planning in the countries represented, test the procedural steps outlined in the guidelines, and adapt them for a Spanish version. I2.27 In the South-East Asia Region, Bangladesh, Burma, Nepal, and Thailand held national workshops on the guidelines, followed by the formulation of manpower plans. In I98o Bangladesh formed a steering committee and a working group for a health manpower study that was undertaken in 1981. Indonesia is carrying out health manpower planning as part of its national health planning. 12.28 In recent years the countries of the South-East Asia Region have shown increasing interest in health manpower planning, an interest stimulated in great part by the Regional Office. The Technical Discussions at the thirty-third session of the Regional Committee (Maldives, 198o) were on the subject of health manpower planning and community participation for primary health care. An intercountry workshop on the I2.29 methodology of health manpower planning (Colombo, December 198o/]anuary I98I) brought together senior administrators and educators from the South-East Asia and Eastern Mediterranean Regions with a view to their guiding health manpower planning in their countries and training other health workers. Sri Lanka's approach to manpower planning was more specific in that limited 188
Planning of health manpower I 2.2 5 Cooperative activities to strengthen the health manpower planning capability of Member States as part of the managerial process for national health development continued. Guidelines for health manpower planning were field-tested in country and intercountry workshops and were published with the financial aid of UNFP A.t These guide1 Hornby, P. et a!. Guidelines for health manpower planning: a course book. Geneva, World Health Organization, r98o.
HEALTH MANPOWER DEVELOPMENT
studies directly related to the expressed needs of the decision-makers were conducted, e.g., a study on norms and standards for the staffing of health institutions. 12.30 In the European Region an intercountry workshop on health manpower planning (Copenhagen, October 1981) was faced with a situation peculiar to that Region-the oversupply and overspecialization of physicians. The workshop did not provide readymade solutions but attempted to show possible alternatives based on the exchange of information and experience. 12.31 A study on nursing services and education was made in nine countries of the Region. The resulting information, compiled at the end of 1981, will be of use to all European countries in developing policies and plans. It will also be a useful contribution to international statistics on nursing personnel. 12.32 Member States in the Eastern Mediterranean Region gave particular attention to the forecasting of health manpower requirements. The guidelines for health manpower planning (paragraph 12.2 5) were adapted to the conditions of countries in the Region and will be translated into local languages. A workshop on their use was held in Democratic Yemen (December 1981) and will be followed by the formulation of a national manpower plan.
in planning the development of the health services. 12.34 WHO has produced a number of learning modules-for example, on setting of health priorities-which are currently being field-tested. 12.35 In keeping with the recommendations of the Global Strategy for health for all, t work began on an interregional project to stimulate the establishing of national manpower projections for the year 2000, especially for the categories of health worker that will be directly involved in primary health care. A preparatory meeting was organized to decide on national plans of action; participants came from Bangladesh, Democratic Yemen, Dominica, Gambia, Hungary, the Philippines, the United Kingdom, Vanuatu, and Zimbabwe. In addition, Burma and Indonesia are participating in the project. 12.36 A simple way of obtaining information for such manpower projections is to ask selected health workers, administrators, and community representatives what they consider to be the health needs of the community and its manpower requirements. This approach, which has been field-tested in Colombia, obviates the need for large-scale surveys over a long period of time. The results are promising but need to be tried out in other countries; further testing is being undertaken in the Philippines in relation to the role and functions of primary health workers. 12.37 The need for updated inventories of health workers, particularly primary health care workers, and for the development of country-specific indicators of health man1 Global strategy for health for all by the year 2000. Geneva, World Health Organization, 1981 ("Health for All" series, No. 3), part III, paragraph r6.
12.3 3 Most countries in the Western Pacific Region have national health plans and a number of them carried out initial studies of health manpower, using the guidelines. In the Republic of Korea a review was made of requirements in the categories of health manpower trained in junior health colleges, and of their utilization. In Guam, a review was made of nursing manpower and nursing education. In Vanuatu an analysis of the health manpower situation was made to help
THE WORK OF WHO, 198o--198I
power development is gradually gaining acceptance in Member States. In the Region of the Americas, the Organization cooperated with several countries on information systems to determine the availability of personnel and the training needed to meet future demands.
World Health Assembly (May I98I). The Assembly adopted resolution WHA34. I4, which recognized the importance of management training in reorienting health systems towards the attainment of health for all, and endorsed the recommendations of the study. I 2.4 I The study concluded that management training should form part of national strategies for health for all. It should be clearly oriented towards the managerial process for health development and be capable of responding to the evolving health needs of the community. It should form an integral part of basic, postbasic, and continuing education programmes; be available to personnel at all levels; be team-oriented and promote community participation; and rely on the learning-by-doing approach, with particular emphasis on problem-solving and the use of locally available resources. WHO's role in helping to develop coordinating mechanisms in the form of national health development networks that include management training resources was underlined. The establishment of such networks-whose aim is self-reliance in management trainingwould require WHO to collaborate in mobilizing extrabudgetary resources, provide fellowships and equipment, and cooperate on request in the formation of the national group that would assume overall responsibility for management training. The strategy recommended in the study includes the promotion of career mobility and of incentives to those prepared to invest in continuing education and management development. I 2.42 Member States showed a growing interest in management training of national staff responsible for the health services. A consultation on health management training and work studies in June I98I brought together representatives from a number of national projects currently under way (Benin, Burma, Costa Rica, India, Sri Lanka, Thailand, and the United Republic of Tanzania).
Women as providers of health care 12.38 WHO has initiated a multinational study on women as providers of health care, funded by UNFPA. Its purpose is to stimulate action on the part of all individuals and groups who are (or should be) concerned to facilitate and enhance the work of women in health development; it aims at providing information and guidance for the formulation of policies and the implementation of practical action within the next few years. The outcome of the study will have implications for governments, international agencies (governmental and nongovernmental), women's organizations, and organizations of health professionals. 12.39 More specifically the project will describe in statistical terms the situation of women as providers of health care; analyse statistical and other information to show how that situation is related to economic, political, social, or cultural variables; and propose intervention strategies to improve it. The study, to be completed in I982, will include contributions from Brazil, Colombia, Egypt, Ethiopia, France, Hungary, India, Indonesia, Jamaica, Mali, Nigeria, the Philippines, Poland, and Thailand.
Training in health mancW'llli'lll I 2.40 The Executive Board's organizational study on the role of WHO in training in public health and health programme management! was submitted to the Thirty-fourth 1
WHO document EB67/I98I/RECfi, Annex
j.
HEALTH MANPOWER DEVELOPMENT
These projects promote the basic training and the continuing education needed for managing health services, especially in primary health care. The meeting assessed the progress made, noted the constraints, and agreed on ways of expanding the projects in line with the recommendations of resolution WHA34. I4. It also discussed the basic elements for an interregional network of health management training projects; the role of work studies in health manp0wer management, training for management, and educational and manpower planning; methods of carrying out such studies; and ways of obtaining extrabudgetary support. I 2.43 A growing number of countries in the African Region have asked WHO to collaborate in health planning and in developing health information systems for management. Workshops were held in five countries (Gambia, Liberia, Nigeria, Upper Volta, and Zambia). I 2.44 A meeting in Arusha, United Republic of Tanzania (July I98o), with participants from I 5 countries, discussed the functions of a training network, teaching methods, and the role of health development centres. On its recommendation, I 3 selected teaching establishments will each organize a workshop on how to integrate management training into the curriculum. 12.45 In the Region of the Americas, a programme for advanced training in health administration for Latin America and the Caribbean area has been under way since I 979 with the support of the W.K. Kellogg Foundation. The network of training programmes is being continuously expanded and at present numbers 49· I 2.46 During the biennium regional workshops were held on (i) education in organizational behaviour, (ii) education in health economics, finance, and costs control,
and (iii) health planning. Their reports are being prepared for issue, in addition to two bibliographies on health administration. 12.47 A programme of training for supervision and consultation in local health service units is being supported by the Organization in Bolivia, Brazil, Costa Rica, El Salvador, Guatemala, Honduras, Nicaragua, Panama, and Peru. A meeting coordinated by the Latin American Center for Educational Technology in Health (Rio de Janeiro) was held in Lima to organize the work in Bolivia, Brazil, and Peru. Similarly, a community health training programme coordinated the work of the countries of Central America and Panama in implementing a process for training in supervision at country level. An evaluation of programme activities was carried out in the countries that had been participating for two years (Costa Rica, El Salvador, Guatemala, Honduras, and Nicaragua) and was presented to a meeting in Guatemala City, which agreed that WHO's continued support was essential to the future of the programme. I 2.48 In the European Region, collaboration fontinued with several teaching institutions, including the Central Institute for Advanced Medical Studies, Moscow; the latter runs annual international courses for public health administrators for which WHO provides lecturers and fellowships. At the fifth scientific session of the I98o course (Budapest, June I98o) the theme was primary health care and the role of outpatient departments in increasing the effectiveness of such care. A third meeting of the joint committee to evaluate the courses was also held.
12.49 The Regional Office for the Eastern Mediterranean sponsored a series of workshops on training in management (Somalia, I 980, and Israel, I 98 I) and is continuing its efforts to promote similar meetings in other countries of the Region.
THE WORK OF WHO, r98o-r98r
Continuing education 12.50 Continuing education is an essential element in good health manpower management. It is of particular importance in retaining primary health personnel where their services are most needed and in reducing the migration of trained personnel. I 2. 5I A programme on continuing education in the Region of the Americas has been jointly supported since I978 by PAHOJ WHO and CIDA in seven countries-Bolivia, Colombia, Cuba, the Dominican Republic, Ecuador, Guatemala, and Hondurasjoined in 1980 by Nicaragua. The community health training programme for Central America and Panama has been designated as reference centre for the programme. An evaluation carried out in April I981 (San Jose, Costa Rica) showed that each country had adapted the programme to its own needs. The programme's main aim is the continuing education of auxiliary and middle-level technical health personnel but it would be desirable for it to cover the entire health team; a proposal for its expansion has therefore been made to CIDA. I 2. 52 A set of standards for primary health care services, which can also be used in the continuing education of health service administrators, is being developed in the Region.
health services and professional associations can promote a systematic programme of continuing education that will reorient and reinforce primary health care services in line with the regional strategy, and (ii) what are the best methods and mechanisms to implement that strategy at country level, particularly as regards the promotion of lifestyles conducive to health, the provision of adequate and accessible health care services, the contribution of the various levels of management, and the relationship of those levels in a system of continuing education.
Fellowships 12.54 Fellowships continue to play an important part in WHO's manpower development programme. The emphasis is on training fellows in an environment and with a study programme similar to that of their home country. During the biennium WHO awarded 702 I fellowships (see Table I 2. I). It also provided travel and subsistence allowances to enable some 7570 participants to attend educational meetings or national courses organized by WHO. 12.5 5 In the African Region, the exchange of instructors between countries of the Region continued. In I98o four students from Liberia and the United Republic of Tanzania studied in Nigeria and Kenya, and in I98I two Tanzanian students took courses in Nigeria. I 2. 56 The administration of fellowships is being decentralized in the Region of the Americas, the process beginning with Colombia and countries of the Caribbean area . Seminars were held in Brasilia, Lima, and Mexico City, to plan further decentralization. To facilitate this planning, a new administrative manual and a directory of training programmes were prepared.
12.5 3 In the European Region a consultative meeting to review recent developments in continuing education (Copenhagen, May I98o) stressed the importance of teacher training. It prepared the programme outline for a seminar on the continuing education of . health workers in primary health care (San Remo, Italy, I98I), which brought together administrators responsible for planning such programmes and representatives of national health services and health training institutions. The discussion centred on (i) how
HEALTH MANPOWER DEVELOPMENT Table 12.1 Distribution of fellowships, by subject of study and by region, 1980-1981 SouthEast As1a Reg10n Eastern Med1terranean Reg1on
SubJect of study
Afncan Reg1on
Reg1on of the Amen cas
European Region
Western Pac1fic Reg1on
Total
Public health admm1slrat10n Hosp1tal and med1cal care ad minas!ratiOn . . . . . . . ConstructiOn of health mstllullons Medical libranansh1p Subtotal Environmental san,tal10n Food control Subtotal Nursmg and m1dw1fery Public health nursmg Med1cal soc1al work Subtotal Maternal and child health. Paed1atncs and obsletncs Subtotal Mental health Health education . Occupational health Nutnt1on. Health stat1st1cs Oral health . Rehabilitation . . . . Control of pharmaceutical and biOlog1cal preparat1ons Subtotal Total
513 11 3 527 101 4 105 79 55 134 31 27 58 13 82 3 20 6 18 21 6 169
141 27 4 9 181 54 22 76 57 25 1 83 120 26 146 53 14 9 14 60 30 15 20 215
265 32 4 301 204 20 224 42 16 58 97 26 123 39 115 37 31 58 34 14 31 359
26 6 1 33 162 8 170 12
67 28
117 16 4 137
1129 120 8 24 1 281 647 78 725 274 121 6 401 494 134 628 181 246 103 91 179 130 94 122 1146
102 49 10 59 31 6 1 38 62 31 93 24 11 22 10 18 19 30 22 156
77 14 91 53 19 4 76 78 14 92 17 21 15 14 16 24 7 27 141
12 106 10 116 35 3 17 2 21 5 7 16 106
-
HEALTH ORGANIZATION AND SERVICES
993
701
1 065
437
448
537
4181
Percentage
71% 26 9 11 87 41
62Y. 38 9 17 103 72 2 241
56% 85 8 41 115 171 3 423
72% 3 8 3 8 23 20 65
44% 61 8 22 61 76 4 232
56% 77 7 18 41 55 1 199
60% 290 49 112 415 438 30 1 334
. . . Malana . . Sexually transmitted d1seases Tuberculosis Other commumcable d1seases Laboratory serv1ces. Chemotherapy, ant1b10t1cs Total - COMMUNICABLE DISEASES Percentage Surgery and medicine Anaesthes1ology . Rad1ology Haematology Other med1cal and surg1cal specialties Subtotal Bas1c med1cal sc1ences Med1cal and allied educa11on Undergraduate medical stud1es . Subtotal Total - CLINICAL MEDICINE, BASIC MEDICAL SCIENCES, AND MEDICAL AND ALLIED EDUCATION
174
13% 11 4 85 5 27 132 43 6 43 92
21%
22% 37 3 28 8 89 165 57 203 3 263
11% 28 2 5 8 35 78 13 13 26
23% 34 27 91 12 59 223 47 51 7 105
20Y. 6 11 27 4 40 88 53 62 26 141
19% 120 47 245 43 286 741 232 454 79 765
9 6 36 55 19 119 138
224
193
428
104
328
229
1 506
Percentage GRAND TOTAL
16% 1 391
17% 1135
22Y. 1 916
17% 606
33% 1 008
24% 965
21% 7 021*
• Of wh1ch 3 504 dunng 1980 and 3 517 dunng 1981
1 93
THE WORK OF WHO, r98o-r98r
12.57 Fellowships in the South-East Asia Region accounted for more than 22% of the regional budget for I98o-I981. The trend towards placing fellows in their own region has continued: of the I005 fellowships awarded in I98o, 57% were for study within the Region as compared with 27% of the I 546 fellowships in the previous biennium. Procedures for evaluating the knowledge and experience gained by fellows are being improved. In the European Region the subI 2. 58 jects studied by WHO fellows reflect the health problems of their countries of origin and the emphasis placed by WHO on certain of those problems. The third meeting of European national fellowships officers (Bratislava, Czechoslovakia, August 198o) discussed the purpose of WHO fellowships, the use made of them by Member States, the way in which fellows were utilized on their return, and how administrative procedures could be improved. The meeting was partly financed by voluntary contributions from Austria and Czechoslovakia. The Regional Office continues to promote the organization of international courses for the benefit of fellows. There were four such courses in I98o, three concerned with health services and one with teacher training. 12.5 9 In the Eastern Mediterranean Region the trend towards a reduction in the total number of fellowships continued-497 were awarded in I98o as against 5 IO in I979 and 562 in I978. One reason for this is the tendency to support training in other ways: for example, during the biennium all the WHO-sponsored training of community health workers for primary health care, and that of their teachers, took place within the countries concerned. At other levels-even that of teacher training for medical schoolsincreasing use is being made of workshops, courses, seminars, etc., at country level,
where WHO's contribution is indirect and does not require the granting of fellowships. I2.6o A selective study on the utilization of ex-fellows was presented to the Regional Committee for the Western Pacific in September I 98 I. Almost all countries and areas of the Region benefit from the fellowships programme, China now being one of the major beneficiaries. Study tours to that country are also being increasingly organized; in addition to the established courses in acupuncture, China provides short courses and workshops in primary health care. I 2.6 I Increasing cooperation at regional level and greater recourse to TCDC is particularly evident in the case of fellowships. The policy of placing fellows either within their own region or in countries with comparable socioeconomic conditions has been made even more imperative by the recent sharp increase in the costs of training in certain European and other industrialized countries. I 2.62 In response to requests made at the Thirty-third World Health Assembly, a report was prepared for the Executive Board, t which at its sixty-ninth session (January I982) was to review the use of WHO fellowships. The report describes the objectives of the fellowships scheme as set by the Health Assembly and traces its operation from I947 up to the present day. It examines the administration of fellowships in the different regions, the responsibility of Member States for nominating fellows, and the contribution of the host country and its institutions. The evidence gathered confirms that fellowships have made an important contribution to WHO's work. More than 70 ooo fellowships were awarded from I947 to I98o, almost all the fellows were able to utilize the new skills acquired, and Member States expressed their 1
WHO document EB69jz6 (r98r).
HEALTH MANPOWER DEVELOPMENT
satisfaction at the contribution made by fellowships to the development of health manpower. Among a number of suggestions for action by Member States and WHO, one recommendation stresses the need for countries to have a manpower plan, in line with the national policy for health development, which would inter alia be the principal point of reference for the nomination, selection, and evaluation of fellows. To carry out national strategies for achieving health for all, more fellowships should be awarded to those who will be directly involved in primary health care programmes.
tries, organized by ECWA (Beirut, 1980). 2 A study of the case of the United States of America, sponsored by the Sandoz Foundation, was prepared by WHO on the basis of the overall study.3 Details of the case of Latin America, also prepared by WHO, were included in a study supported by the Fogarty International Center (USA). 4 Several Member States have shown interest in adopting measures to control undesirable migration of health manpower in line with the conclusions of the report. Colombia, Jamaica, the United States of America, and several countries in the Eastern Mediterranean Region have begun to study the problem on a national basis and to take the necessary steps.
Development of career structures I 2.6 3 The absence of appropriate career structures for health workers is frequently a cause of lack of motivation. But career structure policy often spans the whole civil service and is thus difficult to change in the health sector alone. In the South-East Asia Region, studies on the conditions of employment of sanitarians and auxiliary sanitarians were carried out in both Indonesia and Thailand. The reports prepared by the national investigators are being discussed with ILO before recommendations are made to Member States on the training and management 'f environmental health staff at primary health care level.
International Drinking Water Supp!J and Sanitation Decade I 2.66 · The development of human resources is a prominent component of the activities related to the International Drinking Water Supply and Sanitation Decade (I98I-I99o). WHO proposed a two-phase strategy for international action. During the first three years the international agencies would support the efforts of some 5o countries to assess and meet their most pressing needs for manpower in the water and sanitation sector; they would then support I 2 of those countries in testing and utilizing various methods of planning, producing, and 2 Zahlan, A. B., ed. The Arab hrain drain :proceedings of a seminar organized hy the Natural Resources, Sciences and Technology Division of the United Nations Economic Commission for Western Asia, Beirut, 4-8 February rg8o. London, Ithaca Press, 1981. 3 Mejia, A., Pizurki, H. & Royston, E. Foreign medical graduates: the case of the United States. Lexington, MA, D. C. Heath, 1980 (Sandoz Institute of Health and SocioEconomic Studies). 4 Mejia, A. Health manpower migration in the Americas. In: Kidd, C. V., ed. Biomedical research in Latin America: background studies. Washington, National Institutes of Health, 1980 (NIH Publication 8o-zo5 1).
Migration of health manpower 2.64 The findings of the WHO multinational study on physician and nurse migration 1 were widely circulated and aroused considerable interest. They were presented at a seminar on the brain drain in Arab counI 1 Mejia, A., Pizurki, H. & Royston, E. Physician and nurse migration: analysis and poliry implications. Geneva, World Health Organization, 1979.
THE WORK OF WHO, 198o-r98r
managing the human resources required for the Decade. In the second phase the approaches that had proved most fruitful would be applied on a broader scale within those I 2 countries and also extended to others. I 2.67 Several WHO regions are devising strategies and action for developing human resources for the Decade, and the South-East Asia Region is at an advanced stage in its plans.
was to evolve strategies that would increase the contribution of nursing/midwifery personnel to national plans of action and emphasize the reorientation towards primary health care of nursing education, nursing services, and continuing education. It outlined the technical support that would be required at national, regional, and global level and from WHO collaborating centres and nongovernmental organizations. I2.7I WHO also collaborated with countries in revising basic nursing education programmes in order to produce graduates who could work effectively in primary care. Guidelines were developed and field-tested in I98I showing how curricula should be revised so that the focus of nursing education became care of health rather than care of sickness. The guidelines were initially tried out at the School of Nursing of Chulalongkorn University, Bangkok, and proved helpful to teachers in all aspects of curriculum development. The trial was repeated in other countries: Colombia, Israel, Jamaica, Malaysia, Nigeria, the Philippines, the Republic of Korea, Spain, Switzerland, Thailand, and Zimbabwe. National and regional workshops were organized to facilitate the reorientation of basic nursing education programmes towards primary health care.
Promotion of training I2.68 During I98o-I98I activities were geared to developing and promoting a variety of training strategies for all categories of health staff. Close collaboration was maintained with Member States in their efforts to train the health teams required for primary health care (in particular auxiliary and intermediate-level personnel working at the periphery) and traditional birth attendants.
Educational programmes for primary health care I2.69 Work was carried out with the International Council of Nurses (ICN) to implement the recommendations made at the I979 ICN/WHO workshop on the role of nursing in primary health care. Information was gathered on how national nursing associations are supporting primary health care and how they will collaborate in developing and implementing their countries' strategies for achieving health for all. The ICN congress in I 98 I, attended by 6ooo nurses, promoted awareness of this concept. Its theme was "Health care for all-Challenge for nursing". 12.70 An informal working group, representing national personnel, WHO collaborating centres, and nongovernmental organizations, was sponsored by WHO. Its aim
1 In the European Region, Member States showed increasing interest in the nursing/midwifery programme (see also paragraph I2.8I), which is designed to ensure the participation of nationals through a network of collaborating and participating centres in I 8 countries. Eight nursing research centres are now collaborating directly with the WHO nursing programme, in Belgium, Denmark, Finland, France, Poland, Switzerland, and the United Kingdom (England and Scotland). The centres take part in multinational studies using standardized research instruments and report the results achieved by following the I 2. 72
HEALTH MANPOWER DEVELOPMENT
methodology outlined in WHO's mediumterm programme. 12.73 In the Western Pacific Region several countries and territories-the Cook Islands, Fiji, Guam, Papua New Guinea, and Vanuatu-have with WHO collaboration undertaken the revision of their basic nursing education programmes to bring them into line with the primary health care approach. WHO is collaborating with Samoa and Vanuatu in preparing nurses to assume greater responsibilities in the primary health care services of rural areas ; the training will cover community assessment, diagnosis and treatment of disease, midwifery, health promotion and disease prevention, environmental health, and management of rural health facilities. I 2. 74 Training ofphysicians in the African Region was carried out in 48 institutions in I 98o; several of them have been organized as university centres of health sciences and their first physicians are now graduating. In Burundi, the Faculty of Medicine of Bujumbura introduced the second phase of its medical curriculum-clinical studies. During the biennium 32 country and I 3 intercountry projects were supported in the Region, the training whenever possible being carried out by nationals.
the Americas in recent years prompted the Organization's collaboration with the Pan American Federation of Medical School Associations in setting minimum requirements for the establishment of new schools. Regional meetings were held in Brazil and Venezuela to define basic principles for such requirements and in I98o work was carried out with national medical school associations. A guide to the assessment of existing schools was prepared for use at a first national meeting, in Lima. Meetings were subsequently held in Colombia and Mexico. In the Eastern Mediterranean Region, continued support was given to the medical schools in Bahrain and Yemen, still in their planning stage, and to those in Gezira and Juba (Sudan), only recently established, to ensure that training programmes are relevant to the health needs of the communities where graduates will serve and that the methods used are educationally sound. 12.78 In the Western Pacific Region, WHO cooperated with Fiji in training medical graduates and with faculties of medicine in the Lao People's Democratic Republic, Malaysia, and Singapore. Viet Nam, whose health system was totally disrupted, is now regularly receiving supplies and equipment for its faculties of medicine. I 2. 79 The International Conference on Primary Health Care (I978) drew attention to the need to review the training and clarify the functions of community health workers, emphasizing the importance of exchange of experience on their training, utilization, and deployment. In response, WHO and UNICEF undertook an interregional study to collect information on such experience and to define the critical issues, e.g., selection, functions, tasks, and remuneration. Workshops for the analysis of experience were held in Kingston (February I98o) and in Dakar (February I98I). The reports on the findings
12.75 A regional seminar on the teaching and delivery of health care in Africa (December I98o) brought together 4I deans and directors of medical schools or university centres of health sciences from 26 countries. The seminar reiterated the need for training the health team, promoting the teaching of management and educational methodology, and establishing coordination between the health and education sectors and other development sectors. 12.76 The explosive growth in the number of medical schools in the Region of I97
THE WORK OF WHO, 198o-I981
should help decision-makers and health workers to improve the training and use of community health workers as part of the primary health care approach. Follow-up activities are being carried out at country level and will be reviewed at an interregional workshop. 12.8o In the Region of the Americas the advisory commitee to the community health training programme for Central America and Panama, at its meeting in 1980, approved a plan of action covering nine subprogrammes. It included the production of new models for extension of primary health care coverage and for in-service training, and the development of educational technology. The main emphasis in the Region has been on intermediatelevel and auxiliary personnel, in line with the priorities of primary health care. 12.81 Support continued to be given to Member States of the European Region in developing a nursing/midwifery subsystem of the overall health staffing system that will enable them to plan for, train, and efficiently utilize this type of personnel. Two workshops for nurse managers at national, regional, and local level were followed by a working group (1980) to study the training and use of auxiliary nursing/midwifery personnel. The group considered that the proliferation of categories of auxiliary personnel would inhibit the development of efficient and costeffective nursing services. It recommended that all categories of nursing staff should receive appropriate training before entering the health services; that the content of programmes for the training of nursing auxiliaries should be better defined; that the minimum level of general education required before nursing education could be undertaken should be raised to correspond to any rise in a country's general level of education; and that the definition of different categories of auxiliary nursing personnel throughout the Region should be standardized.
12.82 A considerable effort has been made in the Eastern Mediterranean Region to reorient the education of health personnel towards the primary health care concept, with particular emphasis on the training of middlelevel and rural health workers. WHO support focused on teacher training, the development of task-based, community-oriented curricula, and the preparation of learning materials. There has been growing cooperation between countries of the Region and an increasing number of institutions are now able to provide training for nationals of other countries. The regional directory of education and training programmes for health personnel (paragraph 12.86) facilitates such cooperation. 12.83 In the Western Pacific Region WHO has worked with countries to establish their requirements in various types of middlelevel health worker. The training of medical assistants is being promoted in a number of countries. Tonga, where a training programme is being implemented, has developed an infrastructure that facilitates inter alia the training and use of such staff. WHO has collaborated with Fiji in revising training curricula. 12.84 An important member of the health team is the medical technician, whose responsibilities include the maintenance and repair of medical equipment. In the African Region, the training centre at Freetown has been operating at full capacity since April 1980 for students from English-speaking countries, while the centre in Lome receives students from French-speaking countries. (See also paragraph q.102.)
Information on training institutions 12.85 WHO regularly publishes directories of medical schools and schools of public health. A French version of the fifth
HEALTH MANPOWER DEVELOPMENT
edition of the World directory of medical schools 1 was published in 1980. Information on the training of primary health workers is being collected at the request of Member States in order to maintain a source of up-to-date basic data for the promotion of training programmes and the planning of facilities. 12.86 In the Region of the Americas a directory of training programmes in Latin America and the Caribbean area was prepared in 1980. In the Eastern Mediterranean Region the next issue is being prepared of the biennial directory of education and training programmes for health personnel, which contains information on programmes for all levels of health worker. The fifth edition of the registry of training courses available for health personnel in the Western Pacific Region was completed.
traditions, customs, and resources and in keeping with the background of the trainees, who for the most part are illiterate or semiliterate. A manual has therefore been prepared for instructors of traditional birth attendants; it consists of a practical description of training strategies, an indication of simplified technologies that can be used in maternal and child health care and family planning, and a guide to the production of low-cost teaching/learning materials.z After wider field testing, these manuals will be distributed to all countries that ask for them. 12.89 A joint effort is being made w1th UNESCO to integrate literacy skills into the training of traditional birth attendants. Both India and Thailand have expressed interest in this activity which, if it is successful, should make the traditional birth attendant a more effective member of the community as well as a better health worker and educator. Work in the training of traditional birth attendants was supported by UNFP A.
Traditional birth attendants 12.87 A number of countries in the South-East Asia and Western Pacific Regions (Bangladesh, India, Indonesia, Malaysia, Maldives, the Philippines, and Thailand) are developing strategies to train traditional birth attendants and utilize them in their maternal and child health carejfamily planning services. There are programmes in 52 countries to train such staff but few to ensure their supervision and evaluate their work. A study has begun in Sierra Leone to develop and test methods for assessing the extent to which trained traditional birth attendants contribute to an improvement in community health. I 2.88 The atmosphere in which traditional birth attendants are able to work has improved, but there are still impediments to their training-chiefly the absence of methods and teaching material based on local
Postgraduate and postbasic education 12.90 In 1981, the ninth interregional meeting of directors and representatives of schools and departments of public health was held in Cotonou, attended by participants from 33 countries in the African, South-East Asia, Eastern Mediterranean, and Western Pacific Regions. The meeting defined the role of schools of public health and of centres or national networks for health development in carrying out priority programmes for achieving health for all by the year 2ooo. Emphasis was given to the integrated training of the health team, collaboration among all levels of the health delivery system, self-sufficiency in health development, and teaching methods and research in health development and health management. 2 World Health Organization. A TBA trainer's kit . London, British Life Assurance Trust Centre, 1982.
1 World Health Organization. World directory of medical .rrhool.r. fifth edition. Geneva, 1979.
1 99
THE WORK OF WHO, 198o-1981
12.9I For over a decade surveys of postbasic nursing education programmes have pointed to the shortage of qualified nurse educators and nurse administratorsthe key personnel not only in training nurses and other health personnel but also in reorienting basic nursing education. In preparation for an expert committee in I 98 3, a global survey was made of post basic nursing education programmes; its purpose was to clarify the nature, characteristics, and progress of changes in training programmes, determine the extent to which those changes are oriented towards primary health care, and examine the factors impeding their realization. Questionnaires were sent to I 8 2 schools (in all regions) offering postbasic programmes for the preparation of nurse teachers and managers. Analysis of the data began in late I981. This type of curriculum reform is part of the response to Health Assembly resolution WHA30.48, which calls for nursing/midwifery staff to be given the opportunity to develop the skills required for effective participation in the planning, management, and execution of primary health care programmes. 12.92 In the African Region a working group on postgraduate education discussed the training of specialists and recommended the establishment of a regional network of specialized training centres. The sixth meeting of deans and directors of health sciences faculties, schools, and university centres (Brazzaville, I 980) reviewed the recommendation and approved the establishment of I 3 sub-networks, each specializing in the teaching of one priority discipline. 12.93 The regional postbasic nursing education centre at Dakar introduced the teaching of primary health care in I 98 I, and the centre at Yaounde is to follow suit. The centre in Luanda has based its programme on the principles of primary health care. At a workshop on teaching methodology for 200
nurse educators from French-speaking countries (Lome) discussion centred on the teaching of primary health care and the tasks to be carried out by nurses and midwives, indicating the duties that could be performed by auxiliaries. A similar workshop was held at Banjul for nurses working in the hospitals and health centres of three English-speaking countries (Gambia, Liberia, and Sierra Leone). 12.94 As part of technical cooperation among developing countries, Cuttington University College, Liberia, introduced a postbasic nursing education course attended by students from Gambia and Sierra Leone as well as from Liberia. 12.95 In the Region of the Americas the emphasis in collaboration with schools of public health was on the decentralization of programmes by means of regional basic courses that include in-service training. The Latin American Association of Public Health Schools, which is responsible for graduate programmes in public health and social medicine, continued to receive support from WHO; at the eleventh regional meeting of the Association, in I 98 I, the main topic discussed was public health training on a regional basis. Postbasic training courses were organized at national and regional level in nursing, dentistry, mental health, and veterinary medicine. I 2.96 A group of experts in the SouthEast Asia Region (October I98o) examined the possibility of a network of national public health training institutes that would share their facilities and expertise. A regional meeting at the All India Institute of Hygiene and Public Health, Calcutta (I98I) discussed what activities such a network could undertake.
12.97 In the European Region, WHO continued to support four university pro-
HEALTH MANPOWER DEVELOPMENT
grammes in nursing education-in Belgium, Iceland, Italy, and Berlin (West). The projects in Belgium and Italy came to an end and were evaluated; the others are continuing, visiting professors being provided to teach in those areas of clinical medicine for which national teachers are being trained abroad. I 2.98 In the Eastern Mediterranean Region, the resources of the WHO-supported medical education projects in Pakistan and Sudan were mainly used for postgraduate and continuing education. Over the past two years WHO has been closely associated with the development and activities of the Arab Board for Medical Specialization. I 2.99 Support was given to a regional course in anaesthesiology to serve the need of developing countries in the Western Pacific Region. In the Philippines, WHO collaborated with the Institute of Public Health, Manila, to upgrade the training of the managers and administrators required for health care systems based on primary health care.
team leader at project level, one related to Liberia and the other to the Netherlands. Methodologies will be proposed for the design of curricula and learning materials to prepare physicians and other health personnel for a leadership and supervisory role in primary health care. Further case studies will be published to guide Member States in developing training programmes suited to local conditions. Continuing education programmes intended for physicians already in practice will also be examined. I 2. IOI The regional health development centre in Cotonou, which since June I98o has had a national director, has trained 8 5 students from French-speaking countries of the African and other regions. During the biennium 40 of the students came from I 7 countries of the African Region, including for the first time two Portuguese-speaking countries. The training covered most members of the health team-physicians, nurses, midwives, social assistants, health, medical, and sanitary technicians, sanitary engineers, dental surgeons, pharmacists, nutritionists, administrators, and sociologists. The centre offers a diploma, a master's degree, and a doctorate in public health.
Development of the health team 12. I oo Work continued on promotion of the health team approach, with special emphasis on the team leader. A study begun in I98o on the role and tasks of leaders of primary health care teams will be used as a basis for a review of training, beginning with training programmes for physicians. Three nongovernmental organizations were associated with the study-the International College of Surgeons, the International Federation for Hygiene, Preventive Medicine and Social Medicine, and the World Medical Association--and their national chapters undertook surveys at country level. The findings were analysed, reviewed, and used in preparing two case studies on the role of
I2.I02 In the South-East Asia Region, a group of experts met in I98o to clarify the concept of teamwork as it applies to the Region, define its essential components, and develop guidelines for training. A subsequent consultative meeting, with participants from Bangladesh, India, Indonesia, Maldives, Mongolia, Nepal, Sri Lanka, and Thailand, was in general agreement with the recommendations made; it also agreed on the design of case studies in those countries to determine what primary health care teams are already in action and what are the factors facilitating or impeding their functioning. A training programme for health teams will be based on the findings of the study.
20I
Teaching/ learning materialsfor primary health care I2.I03 The preparation of teaching/ learning materials for primary health care workers continued to receive high priority. A revised edition of The primary health worker, with new chapters on record-keeping, reporting, and participating in community development, together with new illustrations, was published during the biennium. 1 This publication has been in constant demand and has also been translated into the local language, after adaptation where necessary to local conditions, in about 20 countries. I 2. I04 Experience shows that the success of health auxiliaries and village health workers depends on the support and supervision they receive. To meet the need for teaching/learning materials for middle-level managers in primary health care--public health nurses, midwives, sanitarians, and in some instances physicians--a guide has been published entitled On being in charge. 2 It is intended to help health workers who have to organize, supervise, administer, and provide technical or administrative support to primary health care programmes at intermediate level. The publication is being widely promoted. I2.I05 The scarcity of educational resources in both printed and non-printed form, especially those designed to permit selfinstruction, is a serious constraint on the preparation of personnel for primary health care.
training nursing staff in the WHO network of collaborating and participating centres; so far one module, on the nursing process, has been prepared. Studies were carried out on (i) communication and collaboration between health professionals, (ii) legislation on nursing services and training, and (iii) legislation on midwifery services and training. Nine basic documents and workbooks were completed and distributed throughout the network, some of them prepared on the basis of these three studies, others as part of various activities in the nursing/midwifery programme. 12. I07 In the Western Pacific a regional module bank went into operation in I98I to meet the need of nursing/midwifery schools for learning modules that have already been tested. Modules are also being developed on primary health care, both for instructors and for health workers. Reports on the use of the modular approach to learning in Papua New Guinea and the Philippines indicate that it is successful in fostering the student's own responsibility for learning and his or her active participation in the learning process. I 2. 108 Books and other teaching materials to promote self-instruction are being supplied to schools of nursing/midwifery in the South Pacific.
Educational development and support
Educational planning In the European Region, a teaching/learning package, to consist of seven interrelated modules, is being developed for I 2.106 1 The primary health worker: working guide, guidelines for training, guidelines for adaptation, revised edition. Geneva, World Health Organization, 1980. 2 McMahon, R., Barton, E. & Piot, M. On being in charge: a guide for middle-level management in primary health care. Geneva, World Health Organization, 1980.
I 2. I 09 Among the acttvtttes to ensure that training programmes adopt the primary health care approach is the promotion of a network of community-oriented educational institutions for health sciences. This network is now two years old and operates as an independent entity, WHO continuing to lend support on request. It provides participating
202
HEALTH MANPOWER DEVELOPMENT
institutions with an opportunity for mutual assistance in developing problem-based training programmes. One of the task groups established by the network has examined the organizational requirements for a community-oriented educational programme. Among the reasons for the success of the network are a capable secretariat (University of Limburg, the Netherlands) and the enthusiasm of its member institutions. I 2. I IO WHO is collaborating with several Member States in producing detailed job specifications for different categories of staff, especially primary health care workers. Methods are being worked out for determining easily and economically the tasks to be carried out by the members of the health team. A world survey of task-centred (competency-based) curricula is being jointly undertaken in nursing and medical schools by WHO, the International Council of Nurses, and the World Federation for Medical Education. Data collected so far indicate that, in spite of their proven qualities, methodologies for the preparation of task-centred curricula are not widely accepted by teaching staff. It is hoped that the information produced by the survey will encourage the planning of more effective educational programmes, based on actual professional tasks and responding to the real needs of the community. I 2. I I I In the African Region, the planning of training programmes for all categories of health personnel, particularly those directly concerned with primary health care, is an important part of WHO's work with Member States. In Mozambique, for example, the Organization helped to develop an overall plan for training the manpower needed in that country. I 2. I I 2 In the Region of the Americas, collaboration was channelled through the Latin American Center for Educational Technology in Health, Rio de Janeiro, which
provides a wide range of courses and advisory services, e.g., in Central America and Panama, where it has collaborated with the community health training programme. It is expected that in the future this programme will be able to coordinate all educational activities in the subregion. I 2. I I 3 In the European Region, a workshop on educational planning was organized (Copenhagen, I98o) to develop skills in formulating objectives, identifying determinants of planning, and evaluating competence. Participants stated the goals they wished to achieve during the I 2 months following the workshop and prepared plans of action as a basis for self-evaluation at the end of that period. The Regional Office took part in a seminar on curriculum development for health professionals (I98o) held at the Institute for Research in Education and Evaluation, Berne. I 2. I I 4 In the Eastern Mediterranean Region, the 26 participants in the tenth regional workshop on educational planning (Amman, I98o) came from Jordan, Somalia, and Sudan. All were professional educators in key posts, for whom this was the first experience of modern techniques of planning and evaluation. A workshop on educational planning and evaluation at the High Institute of Public Health, Alexandria (I98o) brought together I 8 faculty members, also without previous experience of such work, and prepared them to carry out the overall evaluation of an institutional programme. 12. I I 5 In the Western Pacific Region a workshop on medical education was conducted in I98o for deans and senior faculty members of the institutions participating in the regional teacher-training centre, Sydney, Australia. Senior nurse educators from the South Pacific attended a workshop on learner-centred curricula (Suva, I 9 So) and discussed current trends in educational meth-
THE WORK OF WHO, 1980-1981
odology. Schools are being encouraged to introduce learner-centred activities and to develop teaching materials appropriate to the health needs of the South Pacific.
~eacher
training
I 2. II 6 During the biennium acuvrtles focused on preparing teachers of primary health care workers and others to plan curricula relevant to national strategies for achieving health for all. In Papua New Guinea, Sudan, and the United Republic of Cameroon, courses on primary health care in rural areas for supervisors and teachers were carried out in those rural areas where primary health care was being organized. I 2. I I 7 To help teachers to recognize their own strengths and weaknesses, a guide was prepared and widely circulated for comment, with a view to its revision for publication. In the same context, the widely distributed educational handbook for health personnel was thoroughly revised after continuous field testing and use at teachertraining workshops.t The revision is available in English, French, Italian, and Spanish.
I 2. I I 9 The Latin American Center for Educational Technology in Health offered several courses in teacher training during the biennium. They covered the use of audiovisual aids in nursing education; group dynamics in education; didactics as applied to health sciences; and use of computer programming techniques in education. The Center continued to take part in the master's degree programme in educational technology offered by the Federal University, Rio de Janeiro.
I 2. I 20 The two regional teacher-training centres in South-East Asia, at Peradeniya (Sri Lanka) and Bangkok, continued to support improvements in educational planning and methodology. The centres have organized a wide range of short courses on such subjects as design of self-learning packages, professional attitudes and their measurement, clinical evaluation techniques, and the concept of the health team. India established a second national teacher-training centre at the postgraduate Institute of Medical Education and Research, Chandigarh, and Indonesia now has a network of five such centres.
I 2. I I 8 In the African Region, the regional training centres at Lagos and Lome continued to strengthen health systems in the countries of western and central Africa. The courses offered by the centres are planned in cooperation with the countries and are especially geared to the training or retraining of teachers who will go on to organize education and training programmes in their own countries. The Lagos centre has trained 24 5 students from I 8 countries, and the Lome centre 58 I (including I 76 laboratory technicians).
I 2. I 2 I In the Eastern Mediterranean Region teacher-training activities are entirely carried out by nationals, mainly trained at the regional centre, Shiraz (Iran).
1 Guilbert,].-]. Educational handbook for health personnel. Geneva, World Health Organization, 1977, revised 1981 (WHO Offset Publication No. 35).
I2.I22 In the Western Pacific a number of activities were carried out with the support of the WHO regional teacher-training centre, Sydney (Australia). In Hong Kong, a curriculum was developed for occupational therapists; medical education workshops were organized in China; faculty development was undertaken at the Institute of Health Sciences, Tacloban (Philippines); an integrated curriculum was developed at the universities in Kuala Lumpur and Penang
HEALTH MANPOWER DEVELOPMENT
(Malaysia); a review was made of the multiple-choice questions used in instruction; and a medical education unit was established at the University of Singapore. I 2. I 2 3 In Malaysia a national teachertraining centre has been set up at the Public Health Institute, Kuala Lumpur, the faculty being given WHO fellowships for their training, most of it at the regional teachertraining centre, Sydney. In the Philippines WHO helped to establish a programme for a master's degree in education of health personnel at the national teacher-training centre in Manila. In the Solomon Islands a project is under way to develop a cadre of nurse teachers by contract with Armidale College, Australia: faculty members from the College visit Honiara periodically and assignments are set for students to complete before the next visit; the students also spend some time in Armidale for training and teaching practice.
Learning materials I 2.126 The aim of WHO's interregional programme in this area, which is complemented by two regional programmes, is to promote national self-reliance in the production of teaching and learning materials that are relevant to health services and community needs. Such materials are urgently required for all categories of health personnel at all stages of their careers-as students, practitioners, or teachers-and for their continuing education. This UNDP-supported programme provides an excellent opportunity for technical cooperation among countries by the sharing of their expertise in the production, adaptation, and distribution of learning materials. Six countries are participating: Kenya, Morocco, Nepal, Peru, the Philippines, and Sudan. A meeting to determine strategies and define the role of the interregional network (Geneva, I 98 I) was attended by representatives of organizations that have practical experience of producing learning materials in or for countries of the Third W odd. I2.I27 In the African Region, attempts are being made to establish a network of national centres for the production and distribution of learning materials. A preliminary survey was carried out in five countries (Ghana, Mozambique, Nigeria, Senegal, and the United Republic of Cameroon) and was followed up at the sixth meeting of deans and directors of health sciences faculties, schools, and university centres (Brazzaville, I98o). A regional programme to complement the interregional work is based on a network of country projects linking the health science centres in Benin, Mozambique, Nigeria, and Rwanda. I2.128 A workshop on the production and use of audiovisual material (I 98 I) brought together teachers from the centres for higher education in nursing (Dakar,
I2.I24 Work began during the biennium on guidelines to assist administrators of training programmes in selecting trainees. These guidelines are being tested in a number of countries to ensure that the procedures really meet the requirements, namely the selection of the candidates most likely to benefit from training for primary health care.
I 2. I 2 5 As a guide to teachers on how to make students more effective members of the instructional team, two documents were prepared. The first, Students learning from students,l is currently being tested in a number of training institutions in developing countries. The other, Students helping in the teaching/ learning process,2 is a review of peer-learning experience and includes a bibliography.
t WHO document HMD/8o.3 (198o). ZWHO document WHOfEDUCf8I.I81 (1981).
THE WORK OF WHO, 198o-I98'
Luanda, and Yaounde) and from national schools of nursing and midwifery. Its aim was that participants should be able to produce their own material for use in teaching primary health care. I 2. I29 In the Region of the Americas, the textbooks and instructional materials programme was expanded to provide highquality material for health personnel at all levels, with emphasis on primary health care workers. A meeting of the community health training programme for Central America and Panama, with the participation of ministries of health, defined priorities and requested WHO support for the preparation of instructional manuals for auxiliary personnel. One such manual prepared ' as a result of this meeting deals with maternal and child health.
I 2. I 32 The preparation, production, and distribution of learning materials have received full support in the Eastern Mediterranean Region. A number of training manuals were translated into Arabic, relating inter alia to management of obstetric emergencies in health centres, basic techniques for health laboratories, prevention and emergency care of common oral diseases, and a guide for teachers of health staff. I 2. I 33 Following a meeting in Alexandria (April I98o) it was decided to develop a library for the medical assistant (or equivalent) during training and service. Production of learning materials at country level was further accelerated by a regional programme (complementary, as in the African Region, to the interregional programme) involving projects in Democratic Yemen, Somalia, the Syrian Arab Republic, and Yemen.
I 2.130 With the support of the Rockefeller Foundation, instructional material on epidemiological principles was prepared for the use of professional personnel in the health services and in other training programmes. Manuals on clinical laboratory work and on the training of primary health workers in eye care are under way. WHO has sponsored the preparation of a set of instructional modules for training health workers in communicable disease and immunization strategies and procedures.
I 2. I 34 WHO continued to collaborate with training institutions of the Region in field-testing various teaching/learning materials for relevance and suitability. Primary health care manuals were prepared and reproduced for local adaptation (even more than most learning materials, such manuals need to be country-specific). Plans are under way to collaborate with Member States in training nationals to prepare educationally sound and relevant teaching/learning materials, with particular emphasis on teacher-training material. I 2. I 3 5 The educational communication project that has been in operation in Sudan since I978 was terminated at the end of I981. It developed a methodology by which health workers can enlist the participation of the community in solving its own health problems, making use of available resources and local methods of communication. The methods and learning materials developed in the course of the project are now being utilized in Sudan's primary health care programme.
I 2. I 3 I The Latin American Center for Educational Technology in Health cooperated with the Expanded Programme on Immunization in producing educational material for regional and national training programmes. The Center offers two types of programme: faculty development workshops, and special courses in education. More than 500 professors of health sciences have participated in these programmes through fellowships offered by PAHOfWHO and the Center.
206
HEALTH MANPOWER DEVELOPMENT
Evaluation processes I 2.13 6 Programme evaluation as a means of improving the quality of health manpower programmes has received increasing attention from Member States, for example in the Eastern Mediterranean Region. The approaches used range from evaluation of national programmes to assessment of programmes of key institutions, such as was carried out at the Centre for Educational Technology in the Health Sciences, Cairo, in I981. The Centre had for many years received WHO support and the assessment was intended to determine the extent to which it had attained its objectives and suggest possible modifications in its work. I2.I37 WHO collaborated with Bahrain and Egypt in setting up a unit in the ministry of health to evaluate health manpower development on a continuing basis and to plan, implement, and monitor programmes in relation to the health services. The staff charged with this task in the two countries were given initial training in Geneva and will continue to receive support in carrying out the evaluation, which includes a review of organization, structure, and mechanisms. To reinforce this work, health manpower development indicators are being formulated and will be tested in different Member States. I2.138 Evaluation of the efficiency, ef. fectiveness, .and impact of educational programmes· by those responsible for them continues to be promoted. WHO's guidelines 1 are now being utilized in a number of institutions. Two workshops on programme evaluation were organized by the King Faisal University Faculty of Medicine, Dammam, Saudi Arabia-one at the Health Training Institute in Mogadishu, for sanitarians and 1 Katz, F.M. Guidelinesfor evaluating a trainingprogramme for health personnel. Geneva, World Health Organization, 1978 (WHO Offset Publication No. 38).
laboratory technicians, the other for the staff of the Faculty of Medicine and Surgery, Somali National University, Mogadishu. I 2. I 39 These activities are a continuation and extension of the regional teacher-training programme. Over the last I o years training institutions for health personnel have been established in a number of countries, and they are now in a position to examine their educational programmes critically and revise their curricula to make them more relevant to the needs of the population.
I 2. I40 During the biennium an evaluation was made of the quality of nursing care in hospitals, using methodology and criteria field-tested in Kuwait, Sudan, and Yemen. The results were examined at a working group organized with WHO support in Khartoum (I 98 I). Similar evaluation exercises but on a larger scale will be carried out elsewhere in the Region. 12. I4I With the support of WHO and the Association of Schools of Public Health in the European Region, the Academy of Public Health, Dusseldorf (Federal Republic of Germany), organized a workshop on the evaluation of educational programmes for public health personnel. This was in relation to the establishment of a network of collaborating institutions for training in modern aspects of public health.
I 2. I42 Assessment of performance. In view of the importance of assessment in guiding the work of students and supervising the performance of health workers, WHO has published a manual on the subject.2 A catalogue has been widely distributed listing the methodologies for performance assessment compiled at headquarters) 2 Katz, F.M. & Snow, R. Assessing health workers' performance: a manual for training and supervision. Geneva, World Health Organization, 1980 (Public Health Papers, No. 72). 3 WHO document HMD/8r.6 (1981).
207
THE WORK OF WHO, 198o-I98I
I 2. I43 A working group in the European Region (Varna, Bulgaria, I98o) considered trends in the assessment of the competence of students of the health professions, discussed the issues arising at all stages of training, and established principles for the selection and implementation of assessment procedures.
for instructors in nursing and midwifery given in collaboration with the National Research Institute for Mother and Child, Warsaw; and (iii) a postgraduate course for instructors from developing countries. Interregional courses on fertility management and maternal and child health were also organized. I2.I47 In the European Region, modern methods of learning requiring the active participation of students and group work were the main features of a seminar on the planning and organi-zation of maternal and child health (Bulgaria, I 98 I). In the African Region, the reI 2.148 gional health education centre at the University of Ibadan, Nigeria, continued to provide training in health education for three categories of health worker: (i) an advanced course, leading to a diploma, for people already engaged in health education work in departments of health; (ii) a course leading to a degree of master of public health with specialization in health education; and (iii) a new programme for a doctor's degree in public health with specialization in health education. In I98I there were 40 students from I 6 countries following these courses. Health education was also part of the training of health workers at the regional health development and training centre, Cotonou. I 2. I 49 The first All Africa Conference on Health Education was organized in I98I by the Federal Ministry of Health, Nigeria, with the collaboration of WHO and the International Union for Health Education. In addition to the health educationalists a number of other health professionals participated, including practitioners of traditional medicine. The Conference constituted inservice training in health education for a number of the participants. I 2.15 o In the South-East Asia Region, an intercountry workshop on health education 208
Examples of health manpower activities in other programmes Training of manpower for specific tasks
I 2. I44 Regional workshops or meetings of national task forces were used during the biennium to train researchers and health administrators in the concept, methodology, and application of the risk approach in maternal and child care and fami!J planning (see paragraph 6.28). Interregional workshops to prepare the participants for research or intervention strategies were held in Bogota, Geneva, Manila, Nairobi, and Nottingham (United Kingdom); they contributed to the production of a workbook on the risk approach that can be used as a training tool. National task forces in Cuba, the Republic of Korea, and Turkey further advanced training in the risk approach. WHO collaborated with the I2.I45 Ministry of Public Health, China, in organizing interregional study tours on maternal and child health and family planning. These study tours, financially supported by UNFP A, included training programmes in French and English for health personnel and other community workers. I 2. I46 Three interregional courses on family health and family planning took place in I 980: (i) a course for health and social workers organized jointly with the International Children's Centre, Paris; (ii) a course
HEALTH MANPOWER DEVELOPMENT
was organized in I98o as part of the strategy for achieving health for all. Members of the faculties of six institutions attended: the Central Health Education Bureau, New Delhi; the All India Institute of Hygiene and Public Health, Calcutta; the Gandhigram Institute of Rural Health and Family Welfare, Madurai (India); the National Institute of Preventive and Social Medicine, Dacca; the Faculty of Public Health, University of Indonesia, Jakarta; and the F acuity of Public Health, Mahidol University, Bangkok. The discussions centred on the changes, modifications, and improvements that are required to meet the new challenges of primary health care. I 2. I 5 I India and Sri Lanka have introduced health education into the basic training of their medical, nursing, and midwifery students. In Mongolia, health education has become part of the curriculum in secondary schools and teachers' colleges; a manual on sex and family life education was prepared as part of the instructional material. I 2. I 52 The training of health education specialists was strengthened in the Western Pacific Region, where WHO collaborated with Malaysia in reviewing the curriculum of postgraduate courses in health education at the Public Health Institute, Kuala Lumpur. Special attention was given to developing health education models for use in hospitals and for education of patients. In Papua New Guinea, the diploma course in health education at the College of Allied Health Sciences was improved by linking up classroom teaching with field practice. In the Philippines, an intensive three-month course was organized for the in-service training of provincial health educators who have had little formal training in health education.
Dominican Republic; the Organization subsequently collaborated in running the courses. In IO countries of the Americas short courses for general practitioners were conducted in psychiatry, behaviour therapy, child psychiatry, management of alcoholism and drug dependence, and neurology. In the Dominican Republic and Ecuador, the Organization took part in the introduction of new programmes for resident training in psychiatry. I2.154 In the European Region, an evaluation was carried out of the seven courses in mental health organized by the Regional Office from I97I to I978, the results of which were highly positive. A UNDPsupported project on rehabilitation of the handicapped in Romania began during the biennium with a training course in Bucharest and Ia§i. Fellowships were given for participation in the continuing programme of education and training in rehabilitation in the United Kingdom. I 2. I 5 5 In the Western Pacific, collaborative activities with China included training in mental health. WHO took part in workshops on the epidemiology of mental disorders and on recent advances in the teaching of psychiatry in medical schools. Training courses covered psychopharmacology, control of nervous diseases, and control and management of cerebrovascular disorders.
I 2. I 56 As part of the training programme in neurology, a series of courses on clinical and basic neurology was organized in Beijing, Durango (Mexico), Marseilles (France), and San Miniato (Italy).
I 2. I 53 Work in mental health included the revision of curricula in psychiatric nursing in Argentina, Barbados, Colombia, and the
I2.I57 WHO and the National Institute of Neurological and Communicative Disorders and Stroke (USA) both continued to award fellowships. Candidates from China, Nigeria, and the Philippines received training in neurology.
I 2. I 58 As part of the training work in radiology, WHO and IAEA jointly organized a workshop and training seminar on quality assurance in nuclear medicine (for Latin American countries) and an interregional training course and study tour on the application of nuclear methods in medicine. In collaboration with the Federal Republic of Germany, workshops on quality assurance in diagnostic radiology and nuclear medicine were held whose reports will serve as guidelines for programme implementation. I 2. I 59 The programme for medical physicists from developing countries continues to provide training on a biennial basis. A course on the dosimetry of radiotherapy, jointly organized with IAEA, was held in I981. WHO is currently indicating medical facilities that can provide practical training for radiotherapists and medical physicists from developing countries.
I 2. I62 Where not enough physicians are available for training in epidemiology, auxiliary staff require adequate instruction and experience. The Government of Fiji, in collaboration with WHO and the Centers for Disease Control (USA), has conducted courses in epidemiological surveillance for such health personnel in the South Pacific.
I 2. I 6 3 The malaria action programme is accelerating the development of manpower for malaria control work and increasing national expertise by acquainting health workers with different ecological situations or specific techniques by way of fellowships tailored, to the needs of the individual or to local requirements. This programme was slow to begin owing to difficulties in finding suitable candidates, but it is now progressing satisfactorily.
Go Training in epidemiology is most effective when carried out in the framework of a career development scheme and this type of training, utilizing an in-service, learningby-doing approach, was emphasized at both regional and national level. The approach has been adopted in Thailand and is being developed in Indonesia. I 2. I I 2. I6I The interregional epidemiology courses have continued to the extent that they are needed to reinforce regional activities. They were given in English in Prague, Moscow, and the United Republic of Cameroon; and in French in Paris, Abidjan, and Bobo Dioulasso (Upper Volta). In Ivory Coast, the United Republic of Cameroon, and Upper Volta, field training is linked to communicable disease control programmes. In the Americas, in addition to the regional course in Venezuela, assistance was given to the strengthening of epidemiological courses in national schools of medicine and public health throughout the Region.
I 2. I 64 In the South-East Asia and Western Pacific Regions, WHO is setting up a secretariat to coordinate training programmes in malaria control as part of a cooperative effort involving WHO, national trammg centres, and possibly bilateral agencies. WHO's responsibility will relate to design of curricula, provision of consultant teachers, supply of teaching aids, and organization of teacher-training courses. The Government of Malaysia has agreed to provide accommodation for the coordinating secretariat.
I2.I65 A seminar on the planning and execution of field-applied malaria research (Shanghai, I98o), with participants from malaria control services and scientific institutions, was followed by a workshop on malaria epidemiology and mathematical modelling. An international course on continuous in vitro cultivation and its application in malaria research was held in Moscow (I98o).
2IO
HEALTH MANPOWER DEVELOPMENT I 2. I66 In view of the increasing problem of drug-resistant Plasmodium Jalciparum in large parts of eastern Asia and South America, and the serious threat it poses to other malarious areas of the world, training in standard techniques for testing drug sensitivity was continued. Four regional workshops were held-in Cotonou, Geneva, Kuala Lumpur, and Sennar (Sudan)-and also several subregional or national courses in the Americas, Europe, South-East Asia, and the Western Pacific. Most of these activities were supported by the Special Programme for Research and Training in Tropical Diseases. I 2. I 67 Training in the epidemiology and control of tuberculosis was given to health personnel from different regions at an annual course in Tokyo, sponsored by WHO and the Government of Japan. A subregional course for South Pacific countries was organized in the Solomon Islands. International courses on the management of tuberculosis programmes were sponsored in Argentina, Brazil, Chile, Cuba, and Mexico; a course in bacteriology is held annually in Argentina. With support from DANIDA, training in the production and quality control of BCG vaccine was given at the State Serum Institute, Copenhagen. I 2. I 68 A workshop on veterinary public health was organized by the FAOfWHO collaborating centre for research and training in food hygiene and zoonoses, Berlin (West), for senior public health and veterinary public health officers from the South-East Asia and Eastern Mediterranean Regions.
12. qo Four training centres-two in France, one in the Netherlands, and one in the United Kingdom-are running postgraduate courses in food microbiology for students from developing countries. I 2.17 I The cancer programme in the South-East Asia Region included training sessions on the recognition of cancerous and precancerous lesions of the oral cavity in adults and a workshop on the standardization of histological criteria for diagnosis of liver disease (Karachi). A seminar on the histopathological diagnosis of tumours took place in the Western Pacific.
12. I 72 Courses in immunology continued at the WHO immunology research and training centres in Brazil, China, Egypt, and Switzerland. A course on hybridoma technology was given in Singapore and a course on molecular and cellular aspects of antigenicity in Israel. 12.17 3 The teaching of environmental health to sanitary engineers and other health workers was continued in the African Region through five national and three intercountry projects. An agreement between the Federal Polytechnic School, Lausanne (Switzerland), and the Ecole inter-Etats d'Ingenieurs de l'Equipement rural, Ouagadougou, made it possible to offer a one-year programme in sanitary engineering. WHO cooperated with UNDP in establishing a training programme in sanitary engineering at the Faculty of Technology, University of Addis Ababa. Postgraduate programmes in environmental health were established at the University of Ife (Nigeria) and at the University of Nairobi; and the objectives of a training programme in sanitary engineering were defined for the Higher Institute of Technical Training and Research, Nairobi. I2.I74 As part of work in relation to the International Drinking Water Supply and
I2.I69 WHO collaborated closely in organizing two international courses on zoonoses management in the USSR. Twentytwo students from five WHO regions took part in the courses, which covered rabies, brucellosis, leptospirosis, echinococcosis/ hydatidosis, taeniasis/cysticercosis, and foodborne diseases.
211
THE WORK OF WHO, I98D-I98I
Sanitation Decade, an investigation has been in progress since I 978 of institutions offering training in the water and sanitation sector in countries of western Africa-Gambia, Ghana, Ivory Coast, Liberia, Mali, Niger, Nigeria, Senegal, Sierra Leone, Togo, the United Republic of Cameroon, and Upper Volta. This investigation should assist the planned development of health manpower at national and regional level. I 2. I 7 5 In the Americas, the Regional Library of Medicine (BIREME) ran courses for the training of librarians to enable them to provide the information needed for health care.
Teaching/learning materials I 2. I 77 To strengthen national information .rystems and provide guidance for health workers, particularly at primary health care level, WHO has prepared a series of booklets on the practical aspects of community surveys: how to gather, process, and present information, and how to use it in routine work as well as in the management of health care.
Teacher training I 2.176 Training in health statistics and related subjects continued with a series of workshops in various regions for teachers of health statistics, epidemiology, and health records systems. Several handbooks were prepared, e.g., a guide for teachers 1 that provides a systematic approach to the teaching of health statistics to medical undergraduates. As recommended by the interregional conference on teaching of statistics to medical undergraduates (Karachi, I978), a standard teaching programme was worked out covering the essential minimum of subjects. A similar programme for the teaching of statistics to postgraduate medical students was initiated. 1 Lowe, C.R., ed. Health statistics and medical students: a gutde for teachers. Karachi, 1981 (A handbook sponsored
I 2. 17 8 Different types of instructional material on infant and young child feeding were prepared, including a handbook on the organization of workshops, an audiovisual presentation for training health administrators, and a brochure on breast-feeding for middle-level health workers and educators.
I 2. I 79 In the Region of the Americas, an informal working group discussed the current status of teaching materials in Latin America and designed a textbook on p.rychiatry on the basis of material prepared by Latin American specialists.
by the World Health Organization and the Government of Pakistan).
I 2. I So Further teaching/learning materials in diagnostic radiology were produced for the basic radiological services programme (see paragraphs 8. 52-8. 54). The operator's manual on patient positioning was revised, a chapter being added on patient care, first aid, and hygiene. A general practitioner's manual on the interpretation of radiographs was drafted and should be ready for field testing in early I982.
2I2
Chapter
I}
Health Information
Health statistics 13.I NATIONAL authorities in the de-
cation between those who provide the information and those who use it.
veloping countries realize that, if the goal of health for all is to be attained by the year zooo, their health programmes must be based on statistical information that faithfully reflects the country's health problems and the needs of its population. In particular, the new strategy has highlighted the serious lack of statistical support at the primary health care level. Even in developed countries the statistical services may not be flexible enough to cope with evolving requirements, and health planners and administrators may lack the skill to exploit fully those statistics that are available. 13.2 I98o-I98I was the period in which a conceptual frame was evolved for information support in monitoring progress towards health for all. Preparatory work was undertaken in collaboration with national experts, in particular with a view to establishing indicators suitable for regional and global monitoring (see paragraph 1. q). Technical cooperation with Member States to strengthen their health information systems and services was reoriented in the light of the new developments. Priority was given to training of staff; data generation at the periphery; data processing, flow, and analysis; and utilization of the information produced. Emphasis was on better communi213
Development of health statistical services I 3. 3 As work on the Global Strategy for health for all progressed, the information support that it required was clarified. Intercountry and interregional workshops or consultations were held to define concepts and principles and to develop action programmes. They included a working group on the counting of births and deaths and a consultation on potential uses of statistics in health management (both held in Rijeka, Yugoslavia, September I98I), and a workshop on health records and health statistics practice at family, community, ~nd primary health care level (Papua New Gu~nea and the Philippines, October-November I 98 I), followed by a consultation in Sri Lanka to prepare guiding principles on the same subject. All these meetings centred on the generation of a least a minimum of essential statistical data and their utilization at community and primary health care level.
I 3·4 Work in relation to national health information systems focused on improving national capabilities for monitoring and utilizing vital and health statistics and health records. WHO cooperated with a number of countries in this respect. Several workshops
THE WORK OF WHO, 1980-I981
were held to exchange experience and to identify the technical problems encountered in devising information systems to support the planning, management, and evaluation of health development programmes. Most of them were concerned with primary health care programmes. I 3. 5 Since any improvement in national systems for health information depends on better communication between the producers of information and its users, WHO continued to promote broadly-based national committees on vital and health statistics as forums for such communication. A document was issued reviewing the activities of national committees over the last 30 years and emphasizing the importance of their role, whatever the stage of development of the country.!
cation of Diseases, Injuries, and Causes of Death (ICD),2 the International Classification of Procedures in Medicine,3 and the International Classification of Impairments, Disabilities, and Handicaps. 4 Developmental work was carried out on classifications that have hitherto been neglected, priority being given to health problems in primary health care and lay reporting. The above work was financed in part by contributions to the Voluntary Fund for Health Promotion. Meetings were organized for countries of the South-East Asia Region (New Delhi, October I98o) and of the African Region (Nairobi, September I98I), with the aim of initiating or promoting the use of lay reporting systems in obtaining information for the planning, monitoring and evaluation of community and primary health care services. 13.8. Work started on the next (tenth) revision ofiCD, which, as recommended by a meeting of experts, will be based upon a thorough evaluation of the Ninth Revision as utilized in Member States. To permit that evaluation, the Director-General sought the opinion of Member States as to the desirability of postponing the Tenth Revision for five years, i.e., submitting it to the Health Assembly in I 990 instead of in I 98 5 as a decennial revision would require. Almost all Member States were in favour of deferment. The preparatory work is being organized accordingly. I 3·9 Valuable technical contributions were made by the six WHO collaborating centres for classification of diseases (Caracas,
13.6 The preparation of several methodological guidelines was undertaken-on health situation analysis, health surveys, health expenditure statistics, measurement of outcome of health action, health manpower statistics, hospital statistics, and vital statistics. Guidelines were also completed on the keeping of medical records-a subject on which a joint programme was instituted with the International Federation of Health Records Organizations. (For training of teachers in health statistics, see paragraph I2.176).
International Classification of Diseases and related classifications I 3. 7 Among the basic tools for the recording, processing and analysing of health information are the internationally adopted classifications of health problems. Member States were given support in introducing the Ninth Revision of the International Classifi-
t WHO (198o).
document
WHO/HSjNAT.COM/8o.369
2 World Health Organization. Man11al rif the international statistzcal classification of dzseasts, in;uries, and causes of death, IfJ7 f revision, Volume I, Geneva, 1977; Volume 2 (Alphabetical mdex), Geneva, 1978. 3 World Health Organization. International classification rif procedures in medicine, Volumes I and 2. Geneva, 1978. 4 World Health Organization. International classification of impairments, disabilities, and handicaps: a manual of classification relating to the consequences of diseases. Geneva,
1980.
2I4
HEALTH INFORMATION
London, Moscow, Paris, Sao Paulo, and Washington) in training staff to use the Ninth Revision of ICD, assisting Member States with coding problems, updating computer software, and adapting ICD and the related classifications into national languages. A new centre was established in I98I in Beijing.
use in the assessment of progress towards health for all by the year 2000. The World Health Statistics Annual, r 3. I 3 the main WHO statistical publication, was for many years published in three volumes; for reasons of economy it was reduced during the biennium to two. The volume dealing with vital statistics and causes of death will continue to appear annually, but the second volume will in one year contain statistics on cases of infectious diseases and in the alternate year statistics on health personnel and hospital establishments. To improve the appearance of the Annual, it was decided to go over to photocomposition for its production. 13. I4 The World Health Statistics Quarter(y continued to emphasize analytical studies on special subjects of public health interest. During I 9 So- I 9 8 I it carried articles on cancer mortality (projections and socioeconomic implications); health manpower; primary health care; prevalence of low birth weight; infant, child, and maternal mortality in relation to fertility patterns; and physical and mental disabilities. Five ad hoc surveys on infant and I 3. I 5 early childhood mortality in relation to fertility patterns were made in the I97os, the report on Afghanistan being published in I978. Detailed tabulations for the latter were issued during the biennium, as were the reports on the surveys in Algeria, Sierra Leone, and Sudan in cooperation with the respective governments (the report on Trinidad and Tobago should be issued in 1982). Data collected in a special cohort study of infant mortality in Mauritius were analysed with a view to publication. Three volumes on maternal and child health statistics were in preparation: a study of maternal mortality, a symposium on adolescent reproductive health, and a study of infant mortality in the socialist countries of Eastern Europe. The English editions of the manual of mortality 2I5
Dissemination of statistical information 13. IO Following adoption of the Global Strategy for health for all in I 98 I, the Secretariat began assembling data on global indicators for the monitoring of health progress from available national reports. Plans were made for updating the information in the headquarters data bank. The regional offices initiated similar action with respect to regional and national indicators. At the Regional Office for the Americas a new computerized data base was designed and new methods of data collection were devised. The Regional Office for the Western Pacific plans to establish a data bank on indicators for all countries in the Region.
I 3. I I Studies were undertaken to improve the general information base and to generate new data. A number of projects for improving the data base at national level were planned as a complement to the projects of the regional offices. 13.I2 The Sixth report on the world health situation, 1 covering the years I973-I977• was published in I98o in two parts. The first describes global health problems and the measures taken to solve them, indicating the success or failure of such measures at national, regional, and international level. The second part reviews the situation country by country. This report was the first attempt to provide Member States with baseline information for 1 World Health Organization. Sixth report on the world health situation, I97J-I977· Part 1, Global anafysis; Part 2, Review by country and area. Geneva, 1980.
THE WORK OF WHO, r98o-r98r
analysis 1 and the life table and its application 2 were revised and were adapted for translation into French. A manual of fertility analysis was also in preparation. I 3. I 6 The Regional Office for the Western Pacific completed country health information profiles, based on I979-I98o data, for all but two countries of the Region. The Regional Office for the Eastern Mediterranean issued a directory of selected institutions actively engaged in biomedical research. The European Regional Office published a manual on standard definitions and methods of measurement for use in health statistics. Among the P AHO publications were Hospitals in the Americas and Health conditions in the Americas, I!J77-If)3o. I 3. I 7 In addition, the regional offices carried out or were associated with a number of new studies. In South-East Asia these covered perinatal mortality in five countries, the impact of improved water supply in India, and hospital distribution and utilization in Burma. The Regional Office for the Western Pacific introduced a statistical type of reporting that can form the basis for projections of health trends when planning future requirements. In the European Region I 3 Member States are taking part in establishing similar projections; I 5 Member States are collaborating in a study of demographic trends in Europe and their implications for health.
Committee for International Coordination of National Research in Demography (CICRED)-dealt with socioeconomic differential mortality in industrial societies. The meeting in Manila-sponsored by WHO and ESCAP-focused on mortality in Asia. Meetings on data bases (Bangkok, I98I) and on sex differentials in mortality (Canberra, I98I) were sponsored by the United Nations and WHO as part of joint United Nations/ WHO mortality studies. There were also meetings on family life cycles (Wiesbaden, Federal Republic of Germany, July I98I) and on cancer statistics in developing countries (Nagoya, Japan, August I98I), the latter the fourth of its kind. I3.I9 A project for monitoring the requirements of countries as regards mental health statistics was completed during the biennium.
Health statistical methodology I 3. 20 The work of the health statistics programme in providing statistical support for other WHO programmes was reoriented to ensure integration with the Seventh General Programme of Work, I984-I989, and to serve the particular needs of the strategies for attaining health for all by the year 2000. Such support covers the statistical or methodological basis for the planning and execution of projects; the analysis and evaluation of field data; operational research and systems analysis as applied to epidemiological investigations or the improvement of health delivery systems; and the use of computer facilities or other aspects of medical informatics.
13 . I 8 A special health demo graph y programme financed by UNFP A was expanded with interragency collaboration. Two meetings were convened (Geneva and Manila, I98o). The Geneva meeting-sponsored by WHO, the United Nations, and the 1 Mortality analysis: a manual on methods of analysis of national mortality statisticsfor public health purposes. Geneva,
World Health Organization, 1977 (reprinted 198o). 2 Chin Long Chiang. Life table and mortality analysis. Geneva, World Health Organization, 1978 (out of print; revision in preparation). 2I6
I 3. 2 I Much of the basic statistical processing was transferred to country level. WHO was however increasingly involved in general planning, coordination, and promotion of statistical operations in countries that have
HEALTH INFORMATION
the necessary professionally qualified staff. The consequent increase in interpretative and evaluative work was particularly evident in multicountry projects, where countries often felt the need for independent planning, review, and appraisal of comparative findings - a role to which WHO is particularly suited. In addition, statistical support was provided for specific programmes (health delivery systems, parasitic disease control, projection of health trends, etc.), emphasis being given to innovative methods of data collection and methodologies for primary health care. 13.22 Close contact was maintained with several intergovernmental and nongovernmental organizations working in the general field of medical informatics and medical computing. General systems methodology was also promoted through continued and close liaison with the International Institute of Applied Systems Analysis, Vienna.
consolidated list of the periodicals held by health sciences libraries in Africa that should develop into a major resource-sharing tool. The Regional Office for South-East Asia sponsored regional and national meetings for the establishment of national focal points, cooperative national health library networks, and a regional network of health literature, library, and information services. In the Eastern Mediterranean the Regional Office carried out a second survey of health libraries and issued a revision of the "List of sources for a basic medical faculty library". In the Western Pacific a survey was made of the health literature situation and plans were drawn up for a regional library network. I 3. 2 5 The agreement between WH 0 and the United States National Library of Medicine for the provision of MEDLARS searches and related photocopy services was renewed up to the end of I981. The Regional Office for the Western Pacific entered into an agreement with the Government of Australia for the supply of MEDLARS material to developing countries in that Region; this service operates through a system of national focal points.
Health and biomedical information Health literature services 13.23 During the biennium WHO took vanous initiatives in the health literature programme, providing advice at regional and country level and placing increased emphasis on the strengthening of health libraries, information services, and documentation centres. Direct technical cooperation focused on the establishment of a national health literature project in Egypt and a biomedical information centre and network in China; strategies were formulated and UNDPfinanced activities began.
I3.26 During I98I WHObeganissuinga monthly list of its technical documents with a view to improving access to the information it produces. Two new studies were under way to determine how best to collect, process, and disseminate the health-related literature emanating from the developing countries. Much of this "fugitive", often unconventional, literature could be of considerable interest to other countries with similar health problems. I 3. 2 7 Three regions drew up initial plans for indexing the health and biomedical periodicals of developing countries. A planned African Index Medicus was discussed and casted. The Regional Office for SouthEast Asia held a two-week workshop to train
The Regional Office for Africa sponsored a first meeting of African medical librarians, which prepared the ground for a consortium of health libraries in Africa. WHO cooperated in the production of a 13.24 2I7
THE WORK OF WHO, 1980-1981
librarians of the Region in indexing (using the medical subject headings of the United States National Library of Medicine) and issued a first experimental index to South-East Asian health literature. 13.28 A number of training plans were made. For their implementation assistance was obtained from certain other WHO programmes, notably the Special Programme for Research and Training in Tropical Diseases, which is prepared to finance the training of librarians in institutions receiving long-term support from the Special Programme. WHO promoted the part1c1pation of medical librarians from developing countries in the Fourth International Congress on Medical Librarianship (Belgrade, September I98o), a meeting that provided an occasion for them to follow continuing education courses. A subsequent meeting in Geneva of WHO librarians from headquarters, five regional offices, and IARC laid the basis for improved intra-organizational cooperation in the health literature field.
I 3. 30 The Forum was financed without any overall increase in the publications budget. This meant some reduction in other publications: notably the issues of the WHO Chronicle, which is published in the same six languages, were reduced from 12 in I98o (Volume 34) to six in I98I (Volume 35). Within those limitations the Chronicle continued to perform its task of keeping the health professions informed about WHO's activities and publications. There was no change in the frequency of publication of WHO's scientific journal, the Bulletin of the World Health Organization, which is published in a bilingual English/French edition and in a Russian edition; six issues (Volume 58) and a supplement appeared in I98o, and six issues (Volume 59) in I981. I 3. 3 I An important development was the initiation of a new series of non-periodical publications-the "Health for All" S crieswhich is published in Arabic, Chinese, English, French, Russian, and Spanish. This series is a medium for the publication of fundamental texts on policies, strategies, and processes that will assist countries in planning, implementing, and evaluating their own programmes for attaining health for all by the year 2ooo. The report of the Alma-Ata Conference (I978) and the document prepared by the Executive Board on formulating strategies for health for all (I979) were included, retroactively, as Nos I and 2 in this series. The other volumes issued up to the end of I 98 I were: Global strategy for health for alll!J the year 2000 (No. 3), Development of indicators
WHO publication.r 13.29 In 1980 an experimental issue of World Health Forum: an international journal of health development (Volume I, Nos I and 2
combined) was produced in English and French versions. This issue was widely circulated and the replies to the questionnaire that accompanied it revealed almost universal approval of the proposed new journal. In January I98I the Executive Board discussed the Forum and was in favour of its regular production in Arabic, Chinese, English, French, Russian, and Spanish. During I98I four issues (Volume 2, Nos I-4) appeared and were given an encouraging reception. The journal is directed principally at those responsible for health policy, at health planners and administrators, and at teaching staff in schools of public health and similar institutions. 2I8
for monitoring progress toward.r health for alll!J the year 2000 (No. 4), Managerial process for national health development (No. ;), and Health programme evaluation: guiding principles (No. 6). I3·32 The two volumes of the Sixth report on the world health situation, I97J-I9J7,
prepared in accordance with resolution WHA29.22, appeared in a new format in I98o (see paragraph J3.12).
HEALTH INFORMATION
I 3. 33 Among the numerous other books published during the biennium, the following give some indication of the wide range of topics covered by WHO's publishing programme: the second edition of Chemotherapy of malaria (WH 0 Monograph Series, No. 2 7), which has been completely revised to present the latest information at a critical time for malaria control; the report on the first phase of the WHO collaborative study on breastfeeding (Contemporary patterns of breastfeeding) and the text of the International Code of Marketing of Breast-milk Substitutes adopted by the Thirty-fourth World Health Assembly (see paragraphs 6. 7-6.10); the Manual of basic techniques for a health laboratory, which describes in detail but in simple terms (each step being illustrated) all the techniques that a health laboratory will need to perform in support of primary health care; and a completely new version of the annual Vaccination certificate requirements for international travel that endeavours to increase security against the international spread of diseases by incorporating health advice to travellers (see also paragraphs 9.I2-9.I3).
The health aspects offood and nutrition: a manual for developing countries in the Western Pacific Region of WHO. Regional publishing programmes also covered some topics of global interest, as witness the P AHO publication Emergenry health management after natural disaster and the European Regional Office glossaries on air pollution and on solid waste. 13.36 An indicator of the success of WHO publications is provided by the growing number of requests from national bodies (governmental or other) to reprint them for distribution among professional associations or to issue translations into languages in which WHO does not regularly publish. While the greatest number of requests concerned German, Japanese, and Portuguese, permission was granted for translations into numerous other languages-among them Bengali, Indonesian, Italian, Korean, Turkish, and Vietnamese.
WHO technical documentation I 3. 37 An ad hoc working group met in Geneva (October I98o) to discuss methods for improving the relevance and quality of documents prepared by WHO for use by countries. It made a number of recommendations concerning documentation for meetings, handbooks and manuals, bibliographies, and other types of technical documentation. These recommendations were implemented in 1981.
3. 34 The strengthening of the regional publications programmes, noted in the previous biennial report, was particularly marked during the period under review in the Eastern Mediterranean Region, where a large number of texts were issued as part of the regional Arabic programme. Some of these originated in the Region, while others were translations of WHO publications issued in other languages; all were selected for their particular relevance to regional needs and conditions. I
Health legislation 13.38 Work continued during the biennium to implement resolution WHA30.44, concerning the reorientation of the health legislation programme in accordance with the overall strategies of WHO and Member States. The sixty-fifth session of the Executive Board in January I98o fully en2I9
I 3. 35 Publications suited to regional concerns elsewhere may be illustrated by the following, which were issued by the appropriate regional offices: two volumes of Health development in Africa; The eradication of smallpox from Bangladesh; The planning of health services: studies in eij!,h! huroperm 1 o1mtries; and
THE WORK OF WHO, r98o--r98r
dorsed the Director-General's report on measures taken to strengthen the programme (resolution EB65.RI3), and in May I98o the Thirty-third World Health Assembly strongly supported the proposed strategies for technical cooperation and information transfer in this sector; in resolution WHA 33. 28 it requested the Director-General to proceed with the formulation of a detailed programme based on these strategies. I3·39 The groundwork was laid for the preparation of such a programme, and many components are already operative; an informal global network of sources of expertise was further developed during the biennium. There was enhanced technical cooperation between WHO and Member States in the preparation of new legislation in key areas of both personal and environmental health services. An unprecedented number of requests for information, sometimes on policy issues and sometimes on highly detailed matters, was received from Member States. WHO was able to respond to these requests with the generous assistance of many national and international institutions and experts. The Regional Office for SouthI 3.40 East Asia promoted the holding of national seminars on health legislation issues; a seminar on law and health for development (Chonburi, Thailand, August I98o) was one outcome of this endeavour. A firm basis for programmes in the European Region was ·established by a regional advisory committee on health legislation, which held its first meeting in Dresden, German Democratic Republic (June I98I). The Regional Office for the Eastern Mediterranean carried out an in-depth study of the legal status of primary health care workers that will undoubtedly also be of interest to health administrators in other parts of the world. Technical cooperation activities in I 3·4 I health legislation, as in many other fields, 220
must be based on up-to-date and reliable information. WHO provides such information in its quarterly journal, the International Digest of Health Legislation. In resolution EB65 .Rq the Executive Board reaffirmed the criteria established for the selection of material for publication in the Digest and emphasized "the need for priority to be given to legislation in support of Member States' strategies for attaining health for all their people". Accordingly a reoriented Digest, with legislative texts arranged by subject rather than by country and with more analytical, comparative, and bibliographical material than hitherto, was introduced in I 98 I and was favourably received. During the biennium the Digest reported on new legislation in Member States on such topics as breast-milk substitutes and breast-feeding, disabled persons and the elderly, workers' health, food and drug safety, and environmental health. The proportion of international as opposed to national texts was increased, and for the first time bilateral treaties between developed and developing countries for cooperation in the health sector were covered.
I 3.42 In line with the provisions of resolution WHA30.44, collaboration with other specialized agencies concerned with health legislation was strengthened. Thus WHO cooperated with FAO in systematically compiling national legislation governing foods for infants and young children. It played an active role in the preparations for, and was represented at, the Ad Hoc Meeting of Senior Government Officials Expert in Environmental Law, held under the auspices of UNEP (Montevideo, November I98I).Cooperation with nongovernmental organizations was intensified; for example, there was particularly close cooperation with the Council for International Organizations of Medical Sciences (CIOMS) in regard to legislation on human experimentation.
HEALTH INFORMATION I 3·4 3 By its very nature health legislation is intersectoral, and an increasing number of WHO technical programmes (concerned with such matters as traditional medicine, essential drugs, control of smoking, drug dependence, control of alcohol abuse and alcoholism, care of the elderly, and chemical safety) undertook activities that have a health legislation component but are dealt with in other sections of this report.
House, Beijing, under an agreement with the Ministry of Health, China (for Chinese); with the Medicina Publishing House, Moscow, under an agreement with the Ministry of Health, USSR (for Russian); and at the PAHO/WHO Publications and Documentation Service in Mexico (for Spanish). I 3·4 5 In I 98 I the Council of Arab Ministers of Health decided to establish a centre for Arabic health documentation and publications in Kuwait and requested the cooperation of WHO. The Organization gave its full support to this centre as exemplifying the principles of technical cooperation among developing countries. It is expected that in due course it will contribute significantly to the WHO Arabic language programme.
Language services I 3·44 The new policies and approaches of WHO had their impact on the language services during the period under review. The reduction in the number of permanent staff in response to resolution WHA29.48 was completed. There was however a steady increase in translated material in all languages. In order to cope with this situation several approaches were used, including:
Technical terminology I 3.46 As in the previous biennium, the need for clear and unambiguous terminology continued. A study indicated that the establishment of a central computer terminology bank would be unjustifiably costly. Accordingly terminology work was reorganized so as to make maximum use of electronic text-processing equipment. Thanks to the use of special text-processing programmes for the preparation of multilingual glossaries and lists of terms, this has led to an increase in efficiency that is conservatively estimated at zoo%. A further development was an agreement with the Terminology Bureau of the Commission of the European Communities, in Luxembourg, under which it enters and maintains all WHO-developed terminology in its large, multilingual computer term bank, all of which is made available ro WHO free of charge.
- contracting out, under supervision, a significant proportion of the required translation work; and promoting a policy of selfrevision among the permanent language staff while maintaining only for certain documents, of a legal, political, or regulatory nature, the more elaborate process of revision by a senior translator. - exchanging translators/revisers between headquarters and regional offices during peak periods, in the interest of quality of translation and uniformity of terminology. The number of such exchanges increased substantially during the biennium. - strengthening collaboration and coordination between central, regional, and country level, with increasing decentralization and delegation of functions. Examples were the activities carried out as part of the Arabic language programme of publications of the Regional Office for the Eastern Mediterranean; with the People's Medical Publishing 22I
13·47 Numerous glossaries and other terminological documents were prepared, primarily to ease the increasing termin-
THE WORK OF WHO, 198o-I981
ological problems faced by technical and linguistic staff. They covered such subjects as food hygiene, nutrition, health statistics, and nomenclature of pathogenic microorganisms. Of particular interest is a multilingual glossary of managerial terms, prepared in separate Arabic, Chinese, English, French, Russian, and Spanish versions with a view to publication as a volume in the "Health for All" Series. The Regional Office for Europe completed preliminary work on a thorough revision of its glossary of health care terminology. The Regional Office for the Eastern Mediterranean continued to support the preparation of English/ Arabic and French/Arabic medical dictionaries by the Special Working Committee on Medical Arabic Terminology, these dictionaries being scheduled for publication in 19!!2. 13.48 WHO continued its part in the joint CIOMSJWHO project on the International Nomenclature of Diseases, for which CIOMS is the executing agency. However, owing to lack of funds, progress on this project was slower than had been foreseen, although one volume (on mycoses) was readied for publication 1 and another (on viral diseases) was prepared in draft form.
of flexibility--and eventually of feedback from recipients-should be completed by April I982. 1 3. 5 I The policy was continued of actively seeking facilities in various countries, particularly developing countries, where WHO's publications could be printed on more advantageous terms. The consequent reduction in printing costs was reflected in the sale price of publications. As a result of this and other factors, revenue from sales decreased from $5 07 I I 6 3 in the biennium I 978-I 979 to $4 670 9 I 3 in I 980-I 98 I.
I 3. 52 The bulk of sales continued to be made in western Europe (46%) and North America (3 I%).
Health information of the public I3·53 The Thirty-fourth World Health Assembly, in adopting the Global Strategy for health for all by the year 2ooo, called upon Member States to "enlist the involvement of people in all walks of life" in this historic movement. The challenge to the health information programmes during the biennium was therefore to create an understanding of the issues underpinning the Global Strategy and a willingness to become involved in and support the primary health care process. I 3· 54 As the Director-General acknowledged in an article in World Health magazine,3 the concept of health for all had aroused scepticism. "How do you define health?" "What do you mean by all?" These were the questions asked. By means of the printed word, audiovisual methods, and common efforts with the mass communication media,
Distribution and sales I 3·49 Promotional efforts were continued to make WHO publications more widely known; they were exhibited at technical and medical congresses and also at bookfairs. A new catalogue was issued in English and French,2 and a Spanish edition is in preparation.
I 3. 5o The computerization of mailing lists that has been undertaken in the interests CIOMSJWHO. Internatronal nomenclature of diseases. 2: Mycoses. Geneva, CIOMS, 1982. 2 World Health Organization. W flO publications: catalogue 1947-1979, Geneva, 198o; Supplement 19S0-19SI, Geneva, 1981. Vol. II, Part 1
3 What is health for all? World Health, November 1979, pp. 3-j.
222
HEALTH INFORMATION
the nongovernmental organizations, and the information departments of Member States, WHO set out to answer these questions and to demonstrate by numerous examples and case histories that the principles adopted in the Declaration of Alma-Ata were more than abstract theories. As a counterpoint to this global effort to form public opinion on complex and often controversial issues, the Organization sought to create a greater awareness of the advantages of living a healthy life by providing material for local campaigns to promote attitudes and behaviour conducive to health. I 3. 55 Among a number of events utilized to direct world attention to the work of Member States and WHO was the ceremony at the Thirty-third World Health Assembly (May I98o) that marked the eradication of smallpox. This was the occasion for radio broadcasts and television coverage, a transatlantic news conference, the production of a film, and the dissemination of information kits. Newspapers often critical of the United Nations system commented on the eradication of smallpox as demonstrating the value of international institutions. I 3. 56 Two central themes of the primary health care approach-maternal and child health, and provision of clean water and adequate sanitation-provided an opportunity to demonstrate the role of WHO as the directing and coordinating authority on international health work. Cooperating with UNDP and UNICEF, WHO undertook a global public information campaign to build up support for the International Drinking Water Supply and Sanitation Decade. Similarly, an intensive two-year campaign of information and education of the public, jointly conducted with UNICEF, preceded the adoption by the Thirty-fourth World Health Assembly (May I98I) of the International Code of Marketing of Breast-milk Substitutes. The campaign included national
and international seminars for the mass media and nongovernmental organizations, and wide dissemination of printed and audiovisual material. The groundwork was laid for support to Member States in their health education campaigns to protect and promote breast-feeding. 13·57 World Health Day, 7 April I98o, took as its subject "Smoking or health: the choice is yours". The theme was used to illustrate the roles of personal behaviour and community action in the primary health care process. Almost all Member States mounted health information and education campaigns and many found it opportune to introduce legislative or administrative curbs on the tobacco habit. I 3. 58 The information campaign to promote the new health doctrines reached a peak with World Health Day I98I, which was devoted to the theme "Health for all by the year zooo". Declarations of support were issued by many heads of state or ministers of health and WHO material was used as the basis for national information campaigns in most Member States.
1 3. 59 In the Global Strategy for health for all, information is seen as the "permanent operational arm of national and international strategies to mobilize political, financial, managerial, technical, and popular support" .1 Member States, nongovernmental organizations, and the mass media look to WHO to popularize the aims and benefits of the Strategy and to bring the process alive by reporting on the progress made and the problems encountered. This requirement guided the work of WHO's information officers in responding to day-to-day inquiries and in producing publications and audiovisual material. 1 Global strategy for health for all by theyear 2000. Geneva, World Health Organization, 1981 ("Health for All" Series, No. 3), part IV, para. 26.
223
THE WORK OF WHO, 198o-1981
13.60 During the biennium two new documentary films were produced, bringing to six the number in the series entitled "Health for all-Aspects of primary health care". They dealt with the primary health approach in Ghana and in Thailand. Other documentaries had as their subjects smoking, eradication of smallpox, health of the aged, and the continuing fight against tuberculosis-the latter to commemorate the discovery by Koch of the tuberculosis bacillus. WHO also joined with other organizations in the United Nations system in producing films on the International Drinking Water Supply and Sanitation Decade, the International Year of Disabled Persons, and the plight of African refugees. Work began on a film describing primary health care in the Western Pacific, to be financed by a contribution from the Australian Government. Some 950 copies of WHO films were sold.
With a monthly circulation of some I 5o ooo in English, French, Portuguese, Russian, and Spanish, and with quarterly issues in Arabic and Persian, not only is World Health widely read but its articles are frequently reprinted in the daily press. 13.63 In addition to collaborating with the United Nations system on specific issues, WHO continued to furnish material for the monthly newspaper, Development Forum.
q.61 The WHO radio service provided some 240 radio stations or networks with regular monthly programmes in English, French, and Spanish. q.62 The 20 issues of World Health magazine published in 198o-I981 reflect the broad spectrum of WHO's activities.
q.64 Measures were taken to increase the relevance of reports on health by the mass media and to ensure that health information was popularized with accuracy. In Geneva, 40 scientific journalists were briefed on the latest developments in tropical disease research. The Regional Office for the Western Pacific cooperated with the Malaysian Ministry of Health in running a workshop on health reporting for journalists. A regional workshop on information, education, and communication for health was held in Manila (1981). A working group on information and health (Luxembourg, November 198o) recommended that WHO and Member States should foster greater access by journalists to health information and should seek their advice in formulating health education and information campaigns.
224
Chapter I4
Constitutional) Legal) and Administrative developments Constitutional and legal matters five new Members joined the World Health Organization: Dominica, Equatorial Guinea, Saint Lucia, San Marino, and Zimbabwe (formerly an Associate Member under the name of "Southern Rhodesia"). The Organization thus maintained its virtually universal character, which is vital to the fulfilment of its objectives. A list of Members (at present I 57) and Associate Members (at present one) is given in Annex I. I98o-I98I, I4.2 The amendments to Articles 24 and 2 5 of the Constitution, adopted in I 976 by the J4.I DURING
of acceptances thus reached 53 at the end of I98I. I4·4 The amendment to Article 74, providing for the inclusion of an Arabic version of the Constitution among the authentic texts, which had been adopted in I978 by the Thirty-first World Health Assembly, had received a total of I 6 acceptances by the end of I981. I4·5 The Thirty-fourth World Health Assembly (May I98I) considered proposals for a transition from annual to biennial Health Assemblies but felt that this change in periodicity should take place only in association with other structural reforms, such as changes in the composition and size of the Executive Board and in the role and functions of all bodies of the Organization. It therefore resolved to maintain the practice of annual Health Assemblies for the time being. However, it decided that, beginning in I982, the duration of the Health Assembly should be limited to not more than two weeks in even-numbered years, when there is no proposed programme budget to consider (see paragraph 1.43). I4.6 The Thirty-fourth World Health Assembly also adopted Additional Regulations amending the International Health Regulations (I969) in order to exclude smallpox, in view of its global eradication, from the 225
Twenty-ninth World Health Assembly and providing for an increase in the membership of the Executive Board from 30 to 3 I, were accepted by I 3 Member States during the biennium, bringing the total number of instruments of acceptance so far deposited to 58 ; a further 4 7 acceptances were still required for the entry into force of the amendments, which under Article 7 3 of the Constitution must be accepted by two-thirds of the Members. I4·3 One instrument of acceptance was deposited for the amendment to Article 7 of the Constitution, adopted by the Eighteenth World Health Assembly in I965 ;1 the number 1
See resolution
WHAI8.48.
THE WORK OF WHO, 198o-I981
diseases subject to the International Health Regulations. The Additional Regulations came into force on I January I982, and States bound by them may now no longer require smallpox vaccination certificates from international travellers (see also paragraph 9·4). I4·7 Basic agreements on technical advisory cooperation were concluded during the biennium by WHO with Djibouti, Equatorial Guinea, Kiribati, Vanuatu, Viet Nam, and Zimbabwe; and by PAHO with Bolivia and El Salvador.
14· 8 The Protocol for the Protection of the Mediterranean Sea against Pollution from Land-based Sources, which had as a startingpoint the studies and first drafts prepared by WHO at the request ofUNEP, was signed on I7 May I98o in Athens by I2 Mediterranean coastal States and by the European Economic Community. It was published in the International Digest of Health Legislation. 1 I4·9 On 20 May I98o the Thirty-third World Health Assembly, having regard to proposals to remove the Organization's Regional Office for the Eastern Mediterranean from Alexandria, requested an Advisory Opinion of the International Court of Justice on the question whether the negotiation and notice provisions of the Agreement concluded with Egypt on 2 5 March I 9 5I were applicable in the event of such transfer. In paragraph 5I of its Opinion of 20 December I 98o, the Court advised that the Organization and Egypt have a duty: (a) to consult together in good faith as to the question under what conditions and in accordance with what modalities a transfer rna y be effected;
(b) in the event of a transfer being finally decided, to consult together and to negotiate regarding the arrangements needed to effect the transfer in an orderly manner and with a minimum of prejudice to the work of the Organization and the interests of Egypt; (c) to give a reasonable period of notice taking account of all the practical arrangements needed to effect an orderly and equitable transfer. On I8 May I98I the Thirty-fourth World Health Assembly accepted the Advisory Opinion of the Court and recommended to all parties concerned to be guided by it. The Assembly further requested the DirectorGeneral: (I) to initiate action as contained in paragraph 5I of the Advisory Opinion and report the results to the sixty-ninth session of the Executive Board in January I982 for consideration and recommendation to the Thirty-fifth World Health Assembly in May I982; (2) to continue to take whatever action he considered necessary to ensure the smooth operations of the technical, administrative, and managerial programmes of the Regional Office for the Eastern Mediterranean during the period of consultation. As a result of the action initiated by the Director-General with regard to the Advisory Opinion, a meeting was held (Cairo, November I98I) between the representatives of the Government of Egypt and of the Director-General. I4. Io Questions of patent rights and the protection of the public sector with regard to inventions resulting from cooperation of the Organization with research institutions or industry raised increasingly complex issues. A study of these issues was initiated in I 98 I and a document was prepared for consideration by the Executive Board in January I982 and by the Health Assembly in the following May.
I International Digest of Health Legislation, 31: 950-95 8 (198o).
226
CONSTITUTIONAL, LEGAL, AND ADMINISTRATIVE DEVELOPMENTS
Administration t Establishment
I4.II On 30 November I98I the total staff (excluding staff of the Pan American Health Organization) was 43 77 as compared with 4378 on 30 November I979 and 432I on 30 November I98o. The number of professional or higher graded staff fell from I 6 3o in November I979 to I57I in November I 98 I, whereas that of general service staff rose slightly-from 2748 to 28o6-in the same period, this being mainly due to an increase in general service project staff.
and communication skills of field staff were developed. In all, close on 5o programmes were conducted or sponsored in managerial and related skills alone. A number of them focused on priority issues in health development, e.g., strategies for the International Drinking Water Supply and Sanitation Decade. 14. I4 To maintain their technical proficiency, a total of 42 staff members were granted individual study leave for varying periods of time. 14·15 Secretarial development was expanded, some 450 staff members taking part in programmes for this purpose at headquarters or in regional offices. 14· I 6 Language training continued to absorb greater resources owing to demands for proficiency in German and Portuguese, as well as in the traditional official languages (Arabic, Chinese, English, French, Russian, and Spanish). 14· 17 WHO played a major role in fostering interagency cooperation in staff training within the United Nations common system. Documentation in relation to career development, management training, and evaluation of staff training was prepared for consideration by a subcommittee of the ACC Consultative Committee on Administrative Questions. Other agencies were invited to participate in WHO training programmes.
Staff development and training
I 4· I 2 Development and training of staff were intensified, the main expansion taking place in the three regional offices that have staff and established training programmes for this purpose (the Americas, Europe, and the Western Pacific). I 4· I 3 Particular emphasis was given to training both WHO and national staff in the implementation of strategies and plans of action for national health development, and to introducing new technical and managerial approaches in the various programme areas. This is well demonstrated by the European Region, where four training programmes were conducted, two in advanced health services management and two in country health programming and managerial processes for national health development. Twenty-eight WHO staff members and many more nationals took part in these programmes. Similarly, in the Western Pacific, over So staff members took part in management workshops. In the Americas programmes for strengthening the management 1 Budgetary and financial data are presented separately in the annual financial reports.
Office accommodation
14· I 8 At the Regional Office for the Western Pacific, two additional floors were added to the annex building in I981. Improvements to the main building were undertaken, including warehouse and covered parking space. 227
THE WORK OF WHO, r98o-r98r
14· I 9 At headquarters, part of the V Annex building (I 8 offices) was demolished to make way for a road that has been constructed by the authorities of the Canton of Geneva (the building stands on land owned by the Canton).
laboratory instruments to several collaborating centres and national institutes for research in various fields (regular budget and UNDP, $5o869I5)· I 4· 2 3 Emergency assistance following natural or other disasters was provided to Algeria, Burma, Gambia, Italy, and Lebanon in the form of drugs, vaccines and other medical supplies ($214 215 ).
Supp!J services Supply operations during I98o9 8 I showed a certain stabilization of centralized procurement and a steady increase in procurement at regional and country level, in the spirit of technical cooperation among developing countries. Inflation in the major industrialized countries was reflected in commodity prices and in freight transport costs, both by sea and by air. I4.20 I
I4.2 I The cost of supplies and equipment purchased by the Organization reached a record figure of $8I 898 3 I4, not including the $12 284 747 required to cover freight and insurance charges. Line items ran to 126 797, necessitating some 22 86o purchase orders. 14.22 Approximately two-thirds of all purchases were financed by extrabudgetary funds. Operations during the period included the provision of medical supplies and equipment to Democratic Kampuchea, the Lao People's Democratic Republic, and Viet Nam (extrabudgetary resources and regular budget, $5 213 465); and continuation of the long-term programme of United Nations humanitarian assistance to Cyprus (funded by UNHCR, $I 400 52I). Under an expanded programme of technical cooperation with China, WHO provided capital equipment and
14.24 The Regional Office for Europe gave technical advice on the purchase and erection of prefabricated buildings for one hospital and five health centres in the earthquake-stricken area of El Asnam, Algeria. Funds came from a grant of one million European units of account by the Commission of the European Communities. The Regional Office also arranged for the purchase and dispatch to El Asnam of emergency supplies and equipment in the amount of $100 500. I 4· 2 5 In contrast to a decline in the previous biennium, there was an increase in purchase of supplies against reimbursement during I98o-I98I, mainly in the Eastern Mediterranean Region. The total amount of such purchases, including those made under the Revolving Fund for Teaching and Laboratory Equipment, was $6 I23 6q.
I4.26 Large quantities of vaccines and drugs donated by various countries to the Voluntary Fund for Health Promotion were received in Geneva and redistributed later to developing countries for their immunization programmes. The estimated value of these donations in I980-I98I was $z4I8 352·
228
Chapter
If
Regional Trends
Mrican Region 15. I MEMBER STATES of the Region 1 have shown their determination to ensure that, through primary health care, individuals, families, and communities achieve a level of health that will permit them to lead a socially and economically productive life by the year 2000. In the years I98o and I98I virtually all those Member States signed the Charter for the Health Development of the African Region (paragraph 1.26) and made efforts to attain national self-reliance with a view to achieving the social objective of health for all by the year 2ooo. This objective is neither a pious hope nor a publicity slogan; rather it is the expression of a general political will to combat social injustice, which is incompatible with the establishment of a new international economic order. 15.2 Health is an inalienable and fundamental right. States have a duty to ensure, with the full participation of their people, that the essential needs of those people are met and that the quality of their life is improved. To this end they must exercise over the national health system, and the technology it adopts, the social control that is essential for rational
implementation of national and regional health development strategies. I 5. 3 Far from being utopian, the strategy of the African Region, which is an integral part of the Global Strategy, is a reality to which the health revolution has only to give shape. The Lagos Plan of Action, adopted by OAU in April I98o, provides for implementation of the strategy contained in the Monrovia Declaration (I979) on the basis of the relevant guiding principles and the practical measures required for attainment of national and collective self-reliance in the social and economic fields.
1 Figure I j. I delineates the six WHO regions and shows the location of regional offices.
15 ·4 In I 980 the Regional Committee devoted its attention to the subject of health for all by the year 2ooo. It concluded that the objective was both justified and relevant, as it offered a means of combating social injustice and cultural alienation, the principal causes of political instability and economic underdevelopment. The social liberation of the African peoples is dependent on integrated, multidisciplinary, multisectoral social and health development. A simplistic approach to the problem of health must be avoided, for the problem is essentially multidimensional and complex, and there should be no slavish copying of health systems that do not fit national requirements. The search for alternative paths to health development should be based on critical reflexion and open the way
Figure 1 5.1
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REGIONAL TRENDS
to other acqulSltlons in the field of social practice; for health practice cannot exist in isolation from the social setting. The implementation of measures arising from a proper approach must lead to the social and health liberation of communities and contribute to their physical, mental, and social well-being. That is the meaning of the objective of health for all by the year zooo, which has now been translated into a regional strategy. The main concern of this strategy is development of the health infrastructure on the basis of primary health care, with the object of ensuring that social and health measures reach the entire population.
I 5. 7 A plan of action for implementation of the resolutions adopted is drawn up after each session of the Regional Committee. This plan is given wide distribution in order to facilitate supervision and monitoring of the implementation of the regional programme in accordance with the guidelines laid down by the governing bodies. I 5. 8 Governments receive, through the WHO programme coordinators, periodic situation reports on the use of WHO regular budget funds allocated to them. They are also informed of the situation with regard to extrabudgetary funds. Free and frank use of the supervision and monitoring machinery has created a climate of mutual confidence and established close contacts between the Regional Office and Member States.
Supervision and monitoring I 5. 5 The supervision and monitoring mechanisms are instruments of collaboration between Member States and the Regional Office. The Regional Committee is responsible for monitoring regional programme budget policy and strategy. The periodic reports of the Regional Director on the work of WHO in the African Region are mainly concerned with reviewing the implementation of national and regional development strategies, with particular emphasis on primary health care.
Regional structures I 5·9 In order to increase efficiency, the Regional Office structures have been reorganized in accordance with resolution WHA33.I7. The experiment of having national coordinators for WHO's programme at country level is continuing and they report directly to the Regional Director. Programme coordinators are participating increasingly in the international cooperation activities of ministries of health. In this capacity, they are often included in national delegations to meetings and sessions of WHO's governing bodies.
1 5.6 The co-management mechanisms, such as the Programme Subcommittee, the Standing Committee on TCDC, and the regional ACMR, have been strengthened. Other mechanisms have been introduced, in particular: (i) participation of members of the Programme Subcommittee in other meetings concerned with programming; (ii) study visits by representatives of health services to other countries of the Region, in accordance with the Regional Committee's decision at its thirtieth session; (iii) the establishment of an advisory committee on health development; and (iv) increased use of regional experts.
Special cooperation programmes I 5. I o The International Conference on Apartheid and Health (Brazzaville, November I98I) provided an opportunity for discussion on action to put an end to an inadmissible injustice. The particularly disturbing health situation in Chad and in Equatorial Guinea led to the establishment of
THE WORK OF WHO, 198o-198I
special programmes of technical cooperation. A mission headed by the Chairman of the thirty-first session of the Regional Committee studied the social and health situation created by armed aggression in Angola and proposed an emergency programme of technical cooperation.
Technical cooperation among developing countries (TCDC) I 5. I I Subregional working groups concerned with TCDC met in I98o and in I98I, and their reports were considered by the Standing Committee on TCDC and then by the Regional Committee. In I 9 8 I, for the first time, the countries of each subregion studied topics chosen by themselves. The priority projects recommended were included in the list drawn up by WHO with a view to seeking extrabudgetary funds. I 5. I 2 The African Health/ 2ooo Resources Group, composed of I 2 countries that are members of the Standing Committee on TCDC and a number of technical cooperation agencies, met in June I98o and reviewed all the projects in the list. It made recommendations and issued an urgent appeal to the international community for funds. I 5. I 3 The accession of Zimbabwe to independence has made possible a concentration of the efforts to increase support to the national liberation movements recognized by OAU and to the front-line States, whose social and health situation remains precarious because of South African aggression.
nation of information, and trammg of research workers. Material facilities have been improved by grants, and collaborating centres have been designated. Project formulation and coordination have been strengthened through meetings of subcommittees on nutrition, diarrhoeal diseases, and health services research. The regional ACMR has played a decisive role in promoting and coordinating research.
Health services development 15 . 15 The African Health Charter I 97 52ooo gave priority to activities aimed at improving peripheral services and the Charter for the Health Development of the African Region (resolution AFR/RC29/RI I) confirmed that priority. The regional development strategy, which is a consolidation of the national strategies, places special stress on primary health care and calls for continuing creative effort, improvement of the management process, and community participation. The strategy has two main components: (i) the training of health personnel, with particular emphasis on country health programming, and (ii) technical cooperation at country level for the implementation of country health programming. I 5. I6 The food and nutrition situation in the Region continues to be disturbing, particularly in the arid zones, and conflicts, migration, and inflation are aggravating factors. During the biennium emphasis was placed on nutrition as an element of primary health care.
Research promotion and development I 5. I 4 Regional research has been reoriented in the light of the objective of health for all by the year zooo. The main thrusts are promotion of research activities, dissemi-
Disease prevention and control I 5. I 7 Disease prevention and control form part of the strategy for attainment of the social objective of health for all. The Regional Committee at its thirty-first session (Sep-
REGIONAL TRENDS
tember I98I) adopted a plan of action for implementation of the regional strategy. National control strategies are emphasizing the role of primary health care in the treatment of disease and the protection of vulnerable groups, the training of health personnel, public information and education, and the participation of the international community. The Onchocerciasis Control Programme in the Volta River Basin Area is continuing satisfactorily. Control programmes have been planned for the new zones of infection in Nigeria and the United Republic of Tanzania.
Region of the Americas I 5. 20 The major developments in I98o-I98I were the decisions and action taken to achieve health for all by the year 2ooo. At Punta del Este, Uruguay, in I96I the decision had been taken to improve health as an integral part of socioeconomic development. In I972 the results of the preceding IO years' efforts formed the basis of the Ten-Year Health Plan for the Americas (I97I-I98o), which was adopted at the Third Special Meeting of Ministers of Health. At the end of that period a regional evaluation of the Plan was carried out, based on reviews by 2 5 governments of the progress made toward the goals and objectives set in I972. It showed that life expectancy at birth in the Region has risen to 67 years-63.6 for Latin America, 69.9 for the Caribbean, and 71. I for Canada and the United States. Infant mortality in Latin America dropped from more than I05 deaths per 1000 live births in I970 to less than 65 per 1000 in I98o. Mortality among children I -4 years old declined from 8. 5 to 4· 3 per 1000 during the decade. Yet perinatal deaths still account for about 5% of all deaths, an indication of the vulnerability of the neonate. In communicable disease control, which had high priority during the decade, several countries showed progress; in others mortality from preventable diseases, especially among children under 5, is still a source of concern. Communicable diseases and diseases associated with hostile environments and overcrowding are still problems in all countries, reflecting deficient social and economic conditions and extreme poverty. Levels of health are decisively influenced by two phenomena: population growth and increasing urbanization. Undernutrition remains a serious problem, but some governments have started to take intersectoral measures to solve it. A determined effort was made to provide water supply and waste disposal services covering So% of the urban and 50% of the rural population. By the end of the decade 7I% of
Promotion of environmental health I 5. I 8 The countries of the Region have begun the planning of water supply and sanitation programmes and, with the cooperation of GTZ, SIDA, UNDP, and WHO, have mobilized resources for part of the planned action. Nevertheless, the success or failure of the International Drinking Water Supply and Sanitation Decade in Africa depends essentially on the extent of participation in national efforts by the international community as a whole.
Health manpower development I 5. I 9 The training of health manpower at all levels, an essential element of the regional strategy for attainment of health for all, has been given fresh urgency by new programming approaches and the increase in health and social services, which have led to a growing need for personnel with management capability. Training is provided by a network of national centres supported by regional centres to which they can refer. The TCDC approach has played a major role in this activity.
the urban population and 34% of the rural population had access to sanitary drinking water supplies ; 42% of the urban and 3% of the rural population benefited from adequate sewerage and excreta disposal facilities.
National and regional strategies for health for ail I 5.2 3 In I 98o Member governments reaffirmed or revised their national strategies for attaining health for all, and the regional strategies based on them were adopted by P AHO's Directing Council at its XXVII Meeting (the thirty-second session of the Regional Committee) in September I 980. The regional strategies reflect the situation and experience of the countries in the Region and provide a common reference point for reorienting national policies and plans. In adopting the regional strategies in terms of level of health and coverage by health services, the governments set minimum goals for health structures and levels and undertook to pool their resources and energies so that no country would fall short of them two decades hence. Among the minimum goals the governments proposed that in no country should life expectancy at birth be less than 70 years, infant mortality be more than 30 deaths per 1000 live births, or mortality among children under 5 years of age be more than 2.4 deaths per 10oo. Other goals are: immunization services against diphtheria, tetanus, whooping cough, tuberculosis, measles, and poliomyelitis; the provision of drinkingwater supplies and sanitation facilities to 100% of the population by I99o, in accordance with the aims of the International Drinking Water Supply and Sanitation Decade, overall coverage being sustained through to the year 2ooo; and access to health services for the entire population. I 5.24 The regional objectives set were: reorganization and expansion of health systems to make them more efficient, equitable, and effective; intersectoral linkages; and promotion and improvement of regional and interregional cooperation. Certain important features in the regional strategies were stressed. The first is the need to adopt innovative solutions to health problems, inasmuch as the essential determinants of
15.2 I The main objective in the Region was to extend health service coverage to the entire population. The few valid indicators available for gauging the extent to which the coverage increased show that about half of the countries have made substantial gains. Nevertheless, the organization of the health sector and the development of human resources did not keep pace with the growth of facilities. Some countries made substantial efforts to promote intrasectoral coordination, particularly between the public health sector and the social security agencies. Several attempts were made to create intersectoral linkages in local projects within integrated rural development programmes and major economic and regional development. Regionally also, a close link was forged between the Regional Office and ECLA. Despite considerable investment in the health infrastructure, to which the Inter-American Development Bank contributed substantially, the growth of public expenditure for health care appears to have been slow and often to have lagged behind the general economic growth.
I 5.zz In short, while the countries in the Region made real gains, the gains in some cases fell short of expectations, because national economic development was unequal, economic structures and development measures were not always conducive to attaining the goals, or the time allowed for reaching them was too short. In addition, countries encountered difficulties in translating their goals into targets, and the will to attain the goals was not always as strong or sustained as it should have been.
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health status largely lie outside the health sector's traditional sphere of action. This means changes in the environment, in styles of socioeconomic development, and in living conditions. Just what changes are to be made depends on what is done in the various sectors to contribute to comprehensive community development and improved wellbeing. The second feature stressed is the urgency of revising traditional practices and methods so that health services are accessible to all the population and especially to the groups at greatest risk. Promotion and prevention programmes should be developed in combination with programmes for health restoration and rehabilitation and in close coordination with improvement of the physical and social environment. I 5. 2 5 It should be emphasized that the strategies also call for the reorientation of health systems so that services are extended to as much of the population as possible through the primary health care approach. This reorientation is to be accomplished by basic measures for enhancing the efficiency of the systems and increasing the public's use of the services. Their operating capacity must be improved, resources must be made more productive, and budgetary programming, control, and evaluation must be tightened up so as to guarantee that the system will be efficient. The strategies emphasize the redirection of resources to the established goals and full mobilization of all national resources. International cooperation must be intensified, particularly in relation to TCDC.
mittee's Subcommittee on Long-term Planning and Programming. The proposed regional plan, which was approved by the Directing Council of P AHO at its XXVIII Meeting (the thirty-third session of the Regional Committee) in September I98I, outlines the responsibilities and tasks assigned to governments and to the Organization. 15.2 7 This regional plan of action is the intermediate stage between the statement of regional objectives, goals, and strategies, and their translation into concrete programmes. For governments it serves as a guide and frame of reference for adjusting national health plans so they make their contribution to the regionwide effort by solving priority national problems. For the Organization it is the basic source of guidance for adjusting its cooperation policies, procedures, and programmes. At the world level it represents the input of the Americas to the global plan of action and to WHO's Seventh General Programme of Work. I 5.28 The aim of the regional plan is to satisfy the health needs of the entire population, and especially of those groups development has bypassed; priority is given to rural and marginal urban groups and, within them, to special population groups, namely women, children, workers, the elderly, and the disabled. The plan calls for the organization of services to maximize their equity and efficiency. New technologies, procedures, and methods will have to be devised to improve productivity and strengthen planning and administration. The plan makes restructuring of the health sector an essential requirement and involves the incorporation of social security systems, the refocusing of financing mechanisms, and the participation of the community in improving its health.
Regional plan of action 15.26 The regional strategies later became the basis for the health component of the new regional development strategy adopted by ECLA in Uruguay in May I981. A plan of action was drawn up with the participation of the PAHO Executive Com-
I 5.29 The plan clearly establishes that primary care entails much more than the extension of basic health servi<;:es: it is an
integral constituent of social development, and as such will lead countries to strengthen their social policies and harmonize their intersectoral plans and measures. I 5. 30 One of the plan's most notable and innovative features is its establishment of a regional monitoring and evaluation system closely coordinated with those of countries. The regional system is called on to supply to Member governments and PAHO(WHO the information necessary for gauging progress and making decisions about new methods and adjustments of policies, strategies, goals, and objectives at national, regional, and global level.
being established to follow up the implementation of the strategies in all their aspects and reports will be made to the Regional Committee--annually in the initial years. I 5. 33 Political commitment to health development was reinforced at the first meeting of ministers of health of Member States of the Region (] akarta, September I 98 I). The ministers affirmed that the action to follow on their commitment would be not only at political but also at executive and technical level. Recognizing the importance of technical cooperation among developing countries, they decided that time-limited plans of action for cooperation and collaboration should be prepared by meetings of government representatives, WHO fulfilling its coordinating and supporting role. The health ministers agreed to meet again immediately after the Regional Committee in
15.3 I To implement the plan of action, the Directing Council has asked governments to assess, in the light of the national situation, the compatibility of their priorities and strategies with regional goals and priorities and make the adjustments found to be necessary. Governments will also have to devise mechanisms for improving international and intercountry programming and coordination.
I982.
Health services development I 5. 34 A deeper appreciation of the need for equity in the allocation of health resources is evident and its result is a greater emphasis on the primary health care approach. Besides extending the network of primary health centres and subcentres, and retraining present single-purpose health workers as multipurpose workers, Member countries are also training and deploying a large number of community health volunteers, particularly in rural areas. A number of promotional activities have been planned that give increased attention to urban primary health care. In all countries multisectoral action is being taken to combat malnutrition, improve maternal and child health, and cover a number of other fields. Current initiatives, which span the entire health system and reach all levels, will improve the system's capacity to deliver a variety of services through skilled manpower; they also give reason for con-
South-East Asia Region I 5. 32 Regional and national strategies for attaining health for all by the year zooo were formulated after intensive consultation and were endorsed by the Regional Committee at its thirty-fourth session, in I981. High-level national councils or committees with responsibility for directing and coordinating their implementation were set up in almost all countries of the Region. Steps are being taken for the mobilization of resources for health development; for example, a study of resource utilization (in collaboration with the Health Resources Group for Primary Health Care) has been completed in one country. Mechanisms are
REGIONAL TRENDS
tinued optimism as to a rapid improvement in health throughout the Region.
ating centres were established, in Bogor (Indonesia) and Dacca. I 5. 37 With the rapid extension of primary health care services, especially in rural communities, health education is being reoriented to meet the educational and community participation needs of those services. In consequence, health behaviour studies, health education programmes, and appropriate educational methods and materials are being developed while at the same time mass communication is being utilized as an integral component of health education. WHO action supports national efforts and emphasizes health education as a process for influencing health behaviour, attitudes, and values.
Fami(y health I 5. 35 In the family health programme the main emphasis continues to be on extension of coverage to underserved populations, particularly those groups at greatest risk. In line with this, support has been given to several countries for studies on the risk approach in the delivery of maternal and child health care; the guiding principles developed by WHO for monitoring and evaluating such programmes were tested in this Region. As regards manpower, training curricula for all levels of health workers are being remodelled to meet changing health needs; and national self-reliance in education and training is being fostered by means of regional teachertraining programmes and institution-strengthening. WHO continues to advocate the small family as the norm. I 5. 36 The integration of nutrition work into primary health care and the development of a coordinated approach with other disciplines in planning, programming, and research are the main elements of the comprehensive nutrition programme. Surveillance of nutritional status and research-cumaction projects in priority areas were successfully introduced in several countries of the Region. Evaluation of ongoing nutrition work in primary health care programmes was undertaken under the research priorities, and the preliminary results were discussed at a meeting of principal investigators; the results of this evaluation are being utilized for improvement of programmes. The regional food and nutrition strategies were discussed in a consultative meeting and clear indications for future activities were given. As part of the network being developed to provide training and research facilities as supportive mechanisms for government activities, two collabor-
Mental health I 5. 38 The programme in mental health focused on extending population coverage by the appropriate training of primary health care workers. Community involvement and self-help were promoted, with successful results in some countries, e.g., community participation in the drug-abuse control programme in Burma, and the self-help groups for the mentally handicapped in some parts of India.
Diagnostic, therapeutic and rehabilitative technology I 5. 39 Countries of the Region are at different stages of developing pharmaceutical supply systems. Lists of essential drugs for primary health care have been prepared but systems of procurement, distribution, and utilization need further strengthening. The trend at present seems to be towards improving the separate components of the pharmaceutical system; WHO has, however, assisted countries in developing a coordinated approach as well as in tackling specific
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THE WORK OF WHO, 198o-I981
aspects. There is greater emphasis on achieving self-reliance in the production of essential drugs and on improving quality assurance. In the coming years WHO will cooperate with Member countries in further strengthening the technical, managerial, and administrative aspects of their drug policies and management.
treatment regimens. Multidrug regimen trials were started in India, Indonesia, and Thailand. The results of the rifampicin trial in Burma are expected to be available at the end of I982. I5 ·43 In diarrhoeal diseases the essential is to decrease, through oral rehydration, the high mortality from acute diarrhoea in children under 5 years of age. Regional training centres were established in Bangladesh and India, and preparations were completed for establishing a third centre in Indonesia, to train programme managers who will transmit their knowledge and skills to those working in primary health care. I 5·44 In the control of dengue haemorrhagic fever, early diagnosis and treatment was emphasized. Research on production of a vaccine is progressing satisfactorily at the WHO collaborating centre in Bangkok. Research studies on the pathogenesis and the epidemiological and entomological aspects of dengue haemorrhagic feverfdengue shock syndrome were conducted in Indonesia, Sri Lanka, and Thailand, with the support of the Regional Office.
Disease prevention and control I 5.40 Epidemiological surveillance services are being improved in order to make them an effective tool in controlling prevalent communicable diseases. The emphasis is on training programmes in field epidemiology.
Antimalaria work continues to receive priority owing to the persistence of the disease and its explosive potential. Despite the expansion of operations, which absorb a major part of the public health funds of most countries, there was a levelling out of the sharp decline in incidence recorded during the past five years. In particular, the incidence of Plasmodium falciparum infection showed an overall regional increase of I4% between I979 and I98o. In the face of these discouraging indications national control programmes are being revised; applied field research to overcome technical and operational constraints is being carried out with the help of the Special Programme for Research and Training in Tropical Diseases; national malaria coordinating committees are being strengthened by the participation of sectors other than health; and countries with common borders and similar problems are coordinating their approach by holding joint meetings. I5 .42 In leprosy, field studies to improve case-finding and treatment are in progress in several institutions. Research priorities have been identified and protocols developed, particularly in regard to drug resistance and
I 5.4I
I 5·4 5 The Expanded Programme on Immunization is being rapidly developed. Surveys have been carried out in most countries to measure baseline incidence rates in the target diseases, evaluate immunization coverage in the target age groups, and assess community participation. Thailand was selected as a demonstration and training area for the global programme. Newly developed cold-chain equipment (including solarpowered refrigerators and freezers) are being field-tested, and several countries have begun the local manufacture of cold boxes and vaccine carriers. The expansion of the programme is however hampered by two factors: the inadequacy of the cold chain, and the less than optimal community participation as reflected in the high drop-out rate.
REGIONAL TRENDS I 5.46 The principal trend in vector biology and control is the emphasis on comprehensive integrated programmes, increasingly employing bioenvironmental methods. Intersectoral collaboration is being promoted in order to reduce the prevalence--particularly in agricultural and industrial development areas--of malaria, filariasis, dengue haemorrhagic fever, Japanese encephalitis, leishmaniasis, and plague. The introduction of a health component at the planning stage of major development projects in most Member countries is a welcome step forward.
Promotion of environmental health I 5·49 The launching of the International Drinking Water Supply and Sanitation Decade greatly influenced the nature and type of environmental health work. WHO gave its support to coordinated policies and action to meet the requirements of a vastly increased programme in water and sanitation that includes the implementation of specific projects and various support programmes (appropriate technology, manpower development, and community education based on sociobehavioural studies). The very size of the Decade programme has aroused an interest in managerial aspects, information systems, and programme monitoring and evaluation.
I 5·47 Most countries are developing programmes for the control of zoonotic diseases of public health significance, particularly rabies. WHO is helping to strengthen facilities for the production of rabies vaccine and to train national personnel in production technology and in modern methods of zoonosis control.
I 5. 5o Greater emphasis is being given to low-cost sanitation for the small towns and urban fringe areas that have hitherto been neglected. Sociobehavioural studies, using the multidisciplinary approach, are providing new insights into people's attitudes. I 5. 5I In spite of their low per capita income, a few countries of the Region have undertaken considerable work in control of air and water pollution. WHO has cooperated in assessing the environmental impact.
5.48 As regards noncommunicable diseases, there has been greater emphasis on training peripheral workers to identify high-risk groups and on providing facilities for early diagnosis and treatment (including rehabilitation) in the case of cancer, cardiovascular diseases, diabetes, blindness, and deafness, and for treatment and rehabilitation in the case of injuries resulting from accidents. Community-oriented activities in disability prevention and rehabilitation have been promoted through national surveys and through training programmes for the disabled, for members of their families, and for health workers. Health services for the working population have improved with the provision of better laboratory facilities and the availability of trained manpower; the hazards to agricultural workers as a result of the increasing use of pesticides and chemical fertilizers will receive continued attention. I
I 5. 52 Food safety programmes are at present mainly confined to urban centres with central laboratories. WHO's role is now seen as that of promoting comprehensive food safety programmes in which veterinary and public health aspects are integrated with sanitation.
Health manpower development I 5. 53 Cooperation between WHO Member States was directed towards planning of health manpower and more effective coordination of planning, training, and utilization of personnel.
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THE WORK OF WHO, 198o-I98I I 5. 54 Progress was made in clarifying the nature and dimensions of teamwork as related to primary health care. This work will form the basis for a series of descriptive case studies of the health team in countries of the Region that will later be used to improve training programmes. I 5. 55 Teacher-training programmes for health personnel also made progress. Many countries now have formal structures for providing such programmes and these are being used to reorient the training towards community needs and primary health care.
all. A group of scientists from Member countries worked out a framework for actionoriented health services research, and projects in this context have already begun in several countries. 15 .6o In view of the need for a multisectoral approach to research, the Regional Office has taken action to associate medical research councils, analogous bodies, and research foci in ministries other than the health ministry with its promotion and development of research. At national level also, coordination and management of research will be enhanced by greater contact with medical research councils. Training in research management and methods is being developed. Centres of excellence in the Region are being identified and networks of collaborating centres are being established to permit greater participation by national scientists and institutions in WHO programmes.
I 5. 56 Intensive efforts were made to redesign or reorient programmes of basic nursing education and to incorporate on a large scale the training of traditional birth attendants and similar workers. WHO cooperated in evolving a systematic approach to continuing education that should make it more relevant and accessible for a maximum number of health personnel, particularly at primary health care level. I 5. 57 Progress was made in organizing a regional health literature, library, and information system. It is being used for the training of staff and for research programmes, and is expected to contribute to the Region's capacity for technical cooperation.
Programme planning and development · q.6I The planning, development, and delivery of programmes have been facilitated by the streamlining of internal management information systems, frequent government and WHO reviews of programme implementation (in two countries by joint governmental/WHO bodies), and the increased financial responsibility delegated to WHO programme coordinators. WHO's programme budget as it relates to the country concerned is being used by ministries of health to coordinate and make better use of external resources. I 5.62 A programme budgeting exercise carried out in Thailand has led to a better understanding of national and WHO procedures and should ensure that the programme budget for that country is closely related both to national objectives and strategies and to WHO's General Programme of
I 5. 58 The trend towards awarding fellowships for study within the Region continued; 57% of fellowships were of this type in I98o as compared with 47% in I979· The monitoring and evaluation process to ensure that fellowships meet the requirements of Member countries has been improved.
Research promotion and development I 5. 59 The research programme was reoriented towards support of national and regional strategies for achieving health for
REGIONAL TRENDS
Work. A mechanism for the Thai Government's management of the WHO country programme is being designed, to be set up in early I982. 15 .6 3 There has been close collaboration with several organizations in the United Nations system, particularly UNICEF, m consultative programme formulation at country level. An increasing number of missions relating to health, water, and sanitation in the Region are being jointly supported by WHO and the Asian Development Bank. This augurs well for further collaboration in defining the health component of Bank-assisted rural development programmes.
in education and public information, changes in social and economic conditions, and even regulatory controls to ensure food safety and halt illegal imports. The deteriorating economic climate, however, is likely to take its toll on the health of the less fortunate socioeconomic groups. Preliminary studies have shown that unemployment has particularly deleterious and long-term effects on health; those caused by poverty are better known. The failure to recognize the extent to which health policy is dependent on that of other sectors-in particular the economic-has in the past militated against the optimum use of resources. The new strategy attempts to correct that tendency. I 5.66 The new strategy is designed to encourage policy-makers to lead rather than to follow; it is therefore vitally important to develop regional targets to promote its implementation. Work in this sense has begun and takes into account both technological and economic possibilities and constraints. To monitor achievements, indicators are now being developed, due regard being paid to the different levels of development of health information systems in countries of the Region and to the WHO list of I2 indicators for monitoring progress at globallevel. 1 The regional indicators fall into four categories: health status; factors affecting health; health care provision; and policy measures. These were in the course of I98I subjected to analysis by national administrations and various international bodies with a view to finalizing a document on regional targets in I982. Several Member States of the Region have held seminars and meetings on the subject to stimulate interest among their health professionals.
European Region I 5.64 The biennium saw the steady development of a European strategy for health for all by the year zooo. One of the elements of the strategy is prevention, another the improvement of health care systems. The former covers a wide spectrum, from genetic counselling and immunization through food control and the provision of adequate drinking-water supplies and sanitation to the reduction of accidents, including road traffic accidents, and their consequences. Improvement of health care systems in accordance with the principles of the Declaration of Alma-Ata will, in many countries of the Region, entail major changes in professional practice and in the organization and financing of health care. I 5.6 5 Other elements of the strategy, of immediate concern to the European Region, are the promotion of healthy lifestyles and minimization of the detrimental effects on health of poverty and unemployment. Healthy lifestyles are both an individual and a community responsibility, requiring efforts
1 Global strategy for health for a/1/ry theyear 2000. Geneva, World Health Organization, 1981 ("Health for All" Series, No. 3), part VII, para. 6.
THE WORK OF WHO, 1980-1981
Technology and quality assurance of health services
I 5.67 The Regional Office developed a new medium-term programme in I98o, on model health care programmes and quality assurance of services. Many current quality assurance programmes aim at obtaining maximum instead of optimum quality because they over-emphasize the scientific and technical aspects. In the attempt to provide the best possible care for everybody the costs become prohibitive. The new programme, with the aim of making the most efficient use of available resources, suggests solutions to the problem such as routine quality assurance mechanisms and standard patterns of care.
and administrative practices; others have influenced the clinical study and utilization of drugs. I 5. 70 The I 98o symposium concentrated on drugs for the elderly. The I98I symposium, the tenth in the series, was on the use of drugs in infants and children. It considered the factors to be taken into account both in the choice of drugs and in the establishment of precautions to be taken by investigators and regulatory agencies to ensure the safe and efficacious use of drugs in the young, especially the very young. Since the beginning of the I 97os, a I 5. 7 I drug utilization research group has dealt with methodological problems in the measurement and comparison of drug utilization, working closely with the Nordic Council on Medicines (paragraph 8.13). Marked differences in drug utilization in different countries have been found and the group is now studying the extent to which these differences are attributable to disease patterns or traditions of treatment, or both. I 5. 72 To improve the efficiency of pharmaceutical supply systems, the Regional Office has provided Member States with information on the role therein of regulatory agencies, health professions, universities, social security schemes, regional economic groupings, industry, and the consumer. The aim is to enable Member States to formulate the drug policies most appropriate to their own traditions and needs. I 5. 7 3 International Year of Disabled Persons. According to population surveys and
Research promotion and development
I 5.68 The work of the European ACMR at its sessions in I 980 and I 98 I is described in paragraphs 4.26-4.30.
Diagnostic, therapeutic, and rehabilitative technology
15 .69 I 980 was the first full year of operation of the new regional programme on prophylactic, diagnostic, and therapeutic substances, which at present deals mainly with chemical and pharmacological evaluation in drug control, research on drug utilization, and the development of national drug policies. Symposia held every year since I972 in the Federal Republic of Germany have made recommendations on the investigation and regulation of drugs-on their efficacy, safety, quality, indications, and use. The broader themes discussed have included national drug policies and the utilization of specific groups of pharmaceuticals. Many of the recommendations of the symposia have been accepted by the European governments concerned and incorporated into their national legislation
other data, the number of disabled people is alarmingly high in many countries of the European Region, amounting to at least 10% of the population. The Regional Office contributed to the WHO programme on disability prevention and rehabilitation by convening meetings on the use of residual
REGIONAL TRENDS
vision by visually impaired persons 1 and on ways of preventing disability in the elderly. In addition, over the last five years, the European programme for the prevention of road traffic accidents has reviewed all the related public health issues, with emphasis on the action required on the part of the authorities not only in the health sector but also in the other public sectors concerned. In March I98I a symposium reviewed the characteristics of accident injuries, analysed disability patterns and their consequences for the health services, and considered the problem of indicators of the level of severity of injuries. I5·74 At the thirty-first session of the Regional Committee (Berlin, September I98I) the Technical Discussions had as their theme the medical and social problems of disabled persons. These were discussed in the light of the International Classification of Impairments, Disabilities, and Handicaps (paragraph I3.7). The aim was to provide guidance to Member States in formulating health and social policies to integrate the disabled into society. It was concluded that the severely disabled have special needs that should be carefully assessed and appropriately met by the rehabilitation services; that social problems are often the major determinants of handicap resulting from an impairment or a disability; and that, because structural and other physical barriers still prevent many disabled from becoming socially integrated, more attention should be given to the encouragement of barrier-free design. Appropriate preventive measures should be taken by way of legislation, and rehabilitation should whenever possible be carried out using the primary health care approach. Services should be community-based, with
appropriate systems for supervtston and referral, and should provide total coverage of the population. The administration and organization of disability prevention and rehabilitation services should be restructured to reflect the new approaches; and there should be concerted action by the authorities concerned with health, social affairs, and labour. Research, particularly health services research, should be encouraged and measures should be taken for the full participation of the disabled in community activities.
Cancer I 5. 7 5 A working group (Luxembourg, October I98I) reviewed the extent of development of cancer centres in Europe; the structure and functions of community-based cancer control programmes within the general health care system; and cancer registration and its role in cancer control. Proposals were made for a further expansion of the Regional Office's programme in this field to include the systematic development of national cancer control programmes.
Cardiovascular diseases I 5. 76 In I 967, when the Region embarked on its long-term programme in this field, cardiovascular diseases were already the cause of some 5o% of the deaths in Europe2 5% of them due to coronary heart disease alone. The sharp decline in mortality from cardiovascular diseases in the USA since the mid-sixties has recently attracted interest. In Europe, however-except for Belgium, Finland, and Norway--coronary heart disease mortality, according to available data, is static or is continuing to rise, in the latter case particularly in the younger age groups. During the biennium work proceeded on a publication to evaluate the results of the longterm programme.
1 The use of residual vision by visual(y disabled persons. Copenhagen, World Health Organization, 1981 (EURO Reports and Studies, No. 41).
243
THE WORK OF WHO, 1980-1981
Promotion of environmental health I 5. 77 Continuous support has been given to Member States in water supply and waste disposal programmes, a major component of the support being the work undertaken by WHO as executing agency for UNDP. In Algeria, Morocco, Portugal, Turkey, and Yugoslavia pre-investment projects have been completed, the results of which have been used by the governments in successful applications for loans to the World Bank. The cost of the studies undertaken by the Regional Office in these projects has been about $5 . 5 million, amounting to some 2% of the loans generated. These figures do not include national investments based on project recommendations, which are considerable. The work of the Regional Office in recent years has resulted in the provision of water supplies or appropriate sanitation to about six million people. An assessment of the situation indicates, however, that there are still about I 20 million people in the Region inadequately supplied with water and 4 5o million served by unacceptable sanitation systems. I 5. 78 The project for European cooperation on the environmental health aspects of the control of chemicals is now more than two years old. It comprises the formulation of programmes, approaches, and guidelines for training the necessary manpower; the preparation of contingency plans for emergencies and accidents; the development of methods of assessing the environmental health aspects; and the promotion of international collaboration and exchange of information on toxic chemicals. The manpower development component of the project is intended to assist in alleviating the crippling shortage of trained personnel for evaluation and control work. The skills, training, and education necessary for toxicologists, chemists, laboratory technicians, and public health inspectors are being defined, as is the knowledge needed by decision-makers in government. Training
courses are being designed for use at various national institutes. Due attention is being given to accidents and emergencies involving toxic chemicals. A survey of existing emergency systems in a number of countries is being conducted to find out where the responsibilities lie and what equipment, manpower, and information are available. A model contingency plan for dealing quickly and effectively with emergencies involving toxic chemicals has been drawn up for use by governments.
Health manpower development I 5. 79 Cooperation continued with nongovernmental organizations such as the Association for Medical Education in Europe, the Association of Medical Deans in Europe, the Nordic Federation for Medical Education, the Association of Schools of Public Health in the European Region, and the European Association of Programmes in Health Services Studies. Their presidents are members of the Region's advisory committee on health manpower development. A representative of the Regional Office is among the seven members of the executive committee of the Association of Medical Deans in Europe.
I 5.8o On behalf of WHO, the Association for Medical Education in Europe is undertaking a study on medical school admission procedures in the Region and on ways of introducing medical students to the different approaches to primary health and community care. It is also carrying out a study on different curricula for training in health management with a view to standardizing such training in schools of public health in the Region. With the collaboration of the Regional Office, the Association is extending its membership to countries in the south and east of the Region.
244
REGIONAL TRENDS
Publications I 5.8 I The European Region continued to be the main market for WHO publications, providing nearly 5o% of revenue from sales in I98o. Nevertheless, one of the main problems in the regional publications programme remains the distribution of information, especially to those who do not use the working languages of the Region (English, French, German, and Russian). The problem is being tackled by using a computerized list of addresses for the distribution of publications, by progressive updating of publishing methods through modern text-processing and printing facilities, and by encouraging translation into as many European languages as possible.
of all Member States. These arrangements, and the collaboration of WHO staff at all levels, have ensured a high rate of delivery of programmes with the minimum of interruption. I 5.84 Collaborative programmes within countries have been carried out with very little disruption and, although certain intercountry activities have had to be cut back, a number of technical meetings have been held on a wide variety of subjects. The provision of advisory services, fellowships, and supplies within the intercountry projects has continued normally. On the other hand, it was not found possible for the Regional Committee to meet in regular session in either I98o or I981. I 5. 8 5 Three subregional meetings (Damascus, Mogadishu, and Kuwait, I98o) provided the necessary impetus for the formulation of national strategies for health for all. The number of countries including primary health care programmes as an inherent component of their national health plans increased, and all the various activities have been heavily influenced by the national strategies for health for all and the focus on primary health care. The diversity of the demographic, social, economic, and political situations in the countries of the Region calls for a broad and flexible regional strategy. It can be considered as a regional framework for international cooperation and national efforts in meeting people's basic health needs and carrying out priority programmes corresponding to the eight main components of primary health care. During the biennium, for example, there was particular emphasis on the immunization of children, water supply and sanitation, and maternal and child care--all key components of primary health care.
15.82 A new departure was the sponsorship of a health encyclopaedia published commercially in weekly parts; it is appearing in Spanish in six countries, in French in three, and in Portuguese in two. It provides an unprecedented opportunity for WHO to reach a large audience with its views on health care.
Eastern Mediterranean Region I 5.8 3 The work of WHO in the Eastern Mediterranean Region in I 98o--I 98 I, as on several occasions in the past, was carried out against a background of repeated change and frequent realignment of policies among the Member States of the Region. Immediately following the Thirty-third World Health Assembly in May I98o, and in the light of the decision of a number of countries (conveyed to the Director-General on I9 May I98o, and confirmed by similar communications in May I98I and September I98I) that they would not be in a position to deal with the Regional Office at its present location, arrangements were made to ensure that the programme could continue to be delivered in the interests
15.86 The challenging task ahead-to accelerate the process of building up health systems based on primary health care 245
THE WORK OF WHO, 198o-r98r
principles-calls for substantial administrative and managerial reforms, the active participation of the population, and a coordinated effort on the part not only of the health sector but also of all sectors concerned with socioeconomic development. Such an endeavour requires a reshaping of the infrastructure of countries' health systems so that traditional priorities can be reviewed and priority accorded to the most essential health programmes. It also calls for reorientation of training programmes towards meeting community needs, increasing managerial skills at all levels, and promoting research on health services and on the development of appropriate technologies. Progress can therefore be made only gradually, in accordance with specific country situations and needs, but many countries of the Region have already taken steps towards meeting the challenge. 15.87 It is only through such adaptation that WHO can really maintain and develop further its usefulness to the countries and people of the Region, fulfilling its functions as the coordinating authority on international health work and the technical adviser and close partner of all Member countries.
selected countries. Management training per se has been the focus of a substantial number of fellowships and of two national training activities (in Israel and Somalia), which are expected to be followed by others on similar lines. I 5.90 It has been gratifying to observe the keen interest in evaluation. Bahrain and Egypt, with WHO's technical cooperation, have already embarked on the initial stages of setting up national mechanisms for the continous evaluation of their health manpower development activities, and a number of other countries have shown interest in taking similar steps.
Health manpower development I 5. 88 The need to focus the programme more intensively on primary health care has resulted in emphasis on certain activities which had in any event been coming to greater prominence in recent years. They include manpower planning and management and a broad series of activities relating to evaluation. I 5.89 In manpower planning and management there has been renewed emphasis on planning and prediction, including the preparation of a set of guidelines adapted for regional use and shortly to be tested in
I 5.9I A series of studies to evaluate the quality of nursing services was developed during the biennium. Both in nursing and in medicine, the oldest of the health professions, there are signs of increasing discontent with traditional approaches and with the imposition of imported models. So far as medical education is concerned, WHO collaboration in the traditional approach has been steadily declining. Building on a decade of experience in teacher-training and the application of modern methods to the training of medical teachers, it has concentrated its efforts on a few selected faculties and departments within the faculties, orienting them towards the community's defined health needs and introducing a problem-based approach to learning.
Research promotion and development I 5.92 The regional programme in research can be said to have come of age in its fifth and sixth years, and has become central to WHO's work.
I 5. 9 3 Health services research continued to receive high priority as recommended by the regional ACMR in its early years. The
REGIONAL TRENDS
health services coverage study in Bahrain, Egypt, and Yemen was completed (see paragraph 4· 33) and a detailed report was submitted to the sixth session of the regional ACMR. On the basis of the results of the study certain strategies have been proposed in order to increase coverage. The study will also be used as a teaching tool in health services research and planning. I 5·94 The subject of research manpower and the provision of adequate career opportunities for research workers in developing countries has assumed considerable importance during the recent past on account of the efforts being made by WHO to develop and strengthen national capabilities for research. A preliminary analysis of the research manpower situation in some countries of the Region has revealed a paucity of full-time medical research workers, even in the presence of an adequate career structure, and a lack of comprehensive plans for developing such manpower. It would appear that there is no single solution to this problem, and a variety of innovative approaches will have to be tried out.
three years. Member countries gave their full support to the International Code of Marketing of Breast-milk Substitutes (see paragraphs 6.7-6.10).
Disease prevention and control I 5.96 The control of communicable diseases remains an important component of primary health care and, above all, the epidemiological surveillance mechanisms of all countries need continuing and close attention. Encouraging progress has been made in providing the necessary manpower at national level but high priority must continue to be given to training. The persistence of many communicable diseases in developing countries is an indicator of social standards that could be largely improved through increased self-reliance, better management, a higher level of community participation, and more effective health education. All of these aspects continued to receive WHO's attention in its collaboration with countries.
Fami!J health I 5·9 5 The countries of the Region have welcomed the increased attention given to breast-feeding in recent years. Without exaggerating its importance or taking it out of its context in infant care and nutrition as a whole, there is no doubt that breast-feeding plays a key role in protecting the child from communicable diseases, especially diarrhoea, in the first year of life. This view is shared by almost all paediatricians in the Region, a number of whom, with special experience in the subject, took part in a scientific working group on breast-feeding (Nicosia, January I98I). The group's report provides clear guidelines, both for WHO and for Member States, on activities in this field for the next
I5 ·97 It is natural to take pride in the recent achievement of global eradication of smallpox, but at the same time the Region is facing many other threats, some of them new. Although by no means of a magnitude comparable to the threat of smallpox, periodic outbreaks of "new" diseases, including the viral haemorrhagic fevers such as CongoCrimean, Ebola, and Rift Valley fevers, have been causing particular concern to some countries of the Region in the past few years. New mechanisms of collaboration with governments were developed to tackle each of these outbreaks as it occurred. I5 .98 Every effort is being made to integrate communicable disease control programmes into the general health services at primary health care and other levels. There is also a definite trend towards developing integrated programmes for the control of 247
THE WORK OF WHO, '98o-198I
groups of communicable diseases that share common features. It is being increasingly realized that such an approach, besides being more effective in solving the problems, makes better and more economic use of available resources. An example of such a comprehensive programme is the Blue Nile health project for the control of water-associated diseases in Sudan. I 5·99 Acute diarrhoeal disease is still the most important cause of childhood morbidity and mortality in the Region, and the diarrhoeal disease control programme continues to be one of the major communicable disease programmes. A number of activities have been successfully implemented during the period under review, especially with regard to the development of national control programmes, training and dissemination of information, and applied research. The programme is particularly oriented towards the reduction of mortality through oral rehydration. Collaboration with UNICEF and Member States in the production of oral rehydration packages has continued; Afghanistan, Egypt, Pakistan, and the Syrian Arab Republic are producing such packages, and other countries will soon begin to do so. Applied research on various aspects of diarrhoeal disease control is being supported, both technically and financially, in various countries of the Region, and a regional scientific working group on diarrhoeal diseases research has been established. I 5. I oo The Expanded Programme on Immunization is fulfilling the high hopes expressed for it two years ago. It forms an essential part of all primary health care efforts, and all countries in the Region are collaborating in it. At the beginning of the second five years of this I 5-year programme (I 976-I 990 ), the annual regional totals of completed immunization courses in children of the most appropriate age had increased more than fivefold-from less than 4% of the number of
births to over 22%. This achievement was the result of considerable activity both within countries and at regional level. The Expanded Programme involves large-scale and complex management activities-for even if the state of knowledge of immunization procedures is advanced it is extremely difficult to ensure that all children are actually immunized. Large-scale training activities are required, as well as constant technical improvements, particularly to develop an effective cold chain so that vaccines and other material can be delivered in a safe and effective form to the point of immunization. At the beginning of the second five-year period, the review of existing programmes is a major activity; such reviews have already taken place in Bahrain, Somalia, Sudan, and the United Arab Emirates and are planned for other countries also. The reports recount achievements, identify major constraints, and make recommendations for future action. One conclusion that emerges from these reviews and from the regular reports all countries provide is that progress in combating tetanus of the newborn is not commensurate with the progress achieved in other parts of the Expanded Programme.
Promotion of environmental health
health Environmental proI5.IOI grammes are assuming ever-increasing importance in the Region, which is witnessing unprecedented urbanization and industrialization, accompanied by high population increases. WHO has collaborated with a number of countries in activities connected with the International Drinking Water Supply and Sanitation Decade, and special emphasis has been given to the training of all categories of personnel for environmental health work, particularly regarding water supply and sanitation.
REGIONAL TRENDS
Maintenance and repair of medical equipment I5 .Ioz It is widely recognized that one of the most serious obstacles to the implementation of health programmes throughout the Region is the fact that between zo% and 40% of a country's medical equipment may be out of order at any given time. There is a severe shortage of trained manpower to maintain and repair such equipment, which is purchased from widely different sources and varies greatly in sophistication and complexity. WHO is therefore collaborating with countries in developing regional training facilities-for example, at a regional training centre in Cyprus and at centres in Bahrain, Egypt, and Iraq. In general there has been vast expenditure on the renewal of supplies and equipment, while little has been budgeted for maintenance and repair. It is clear, however, that the provision of specialized manpower for this purpose will not in itself solve this huge problem, and a special effort will be made during the coming biennium to promote effective national policies on equipment maintenance and repair.
editorial board and supported by WHO. Like The Learner, it promises to become an important link among the network of people and institutions in the Region working in its sphere. A third vehicle of information-with wider dissemination, including all Member governments and the information media throughout the Region-is the EMRO Newsletter, which now appears monthly. Its objective is to keep all concerned informed of WHO's ongoing activities within the Region.
Western Pacific Region 15 .I04 At its thirty-second session in I98I the Regional Committee updated the regional strategy for the attainment of health for all, which is based on the national strategies developed by the Region's Member States. WHO has provided support for the planning, implementation, and evaluation of national health development measures aimed at achieving health for all, based on sound managerial practices adapted to the specific needs of each country. Countries are being encouraged to establish national health development networks that will provide a framework for TCDC activities.
Health information I 5. I o 3 Effective communication between those responsible for the various components of health services development is essential in this fast-developing Region, and three regional publications are being increasingly recognized as worthwhile developmental tools. The Learner, a quarterly journal of prime interest to educators of all categories of health professionals, published in collaboration with the University of Shiraz, Iran, is now in its eighth year of publication. The Health Services Researcher, a similar quarterly journal but with its focus on health services research, has been published since I98o by the health services research group of the Institute of National Planning, Cairo, under the guidance of a multidisciplinary international
Research promotion and development J5.I05 Additional WHO collaborating centres for research and training have been established in various Member States. An increasing number of grants have been made under the Special Programme for Research and Training in Tropical Diseases and the Special Programme of Research, Development and Research Training in Human Reproduction. WHO has supported studies on diseases of particular importance in the Region, such as clonorchiasis, schistosomiasis, dengue, acute respiratory infections, and fish poisoning. Meetings of the Western Pacific ACMR and its various subsidiary
249
bodies have laid the foundation for a substantial regional research programme which supplements national efforts.
their essential equipment in service. The need exists for simple diagnostic equipment, to be used in support of primary health care programmes. 15. I IO There have been few requests for technical cooperation in national occupational health programmes, in spite of concern about the health of rural workers, who are being increasingly exposed to chemical hazards. The more developed countries are continuing, and in some cases intensifying, their occupational health and accident prevention activities and increased cooperation may be expected in that domain between them and the developing countries. I 5. I I I Following a regional working group on health care of the elderly (Manila, October I98I), a programme is being promoted to increase awareness of the problems of the elderly, to encourage research, training, and education in regard to those problems, and to promote the establishment of services for the care of the aged. I 5. I I 1. In connexion with the International Year of Disabled Persons, I 9 8I, many countries in the Region have increased their educational, social, and therapeutic activities on behalf of the disabled. A regional working group (December I98I) planned a medium-term programme to encourage preventive measures, particularly in childhood, and to promote ways of increasing the independence of disabled persons. I 5. I I 3 Cooperation with Member States in respect of laboratory services consisted mainly in standardizing simplified laboratory techniques to be used principally at peripheral level for the diagnosis of the most important communicable diseases, special emphasis being placed on antibiotic susceptibility testing in view of the serious and growing problem of resistance among pathogenic bacteria. Efforts to improve the organization
Health services development I 5. I o6 Efforts in the Region were concentrated on developing a system of health services based on primary health care and community involvement. Countries were supported in developing their health manpower for primary health care. Health care delivery systems were reoriented and strengthened, and direct support was given to research and development. Exchange of information and of experience in the development of primary health care was encouraged.
I 5. I 07 Support for traditional medicine, including the use of medicinal plants, was continued. The use of appropriate technology in the prevention, diagnosis, and management of disease and in the rehabilitation of the disabled was promoted.
I 5. 108 The trend in the organization of the health services is increasingly towards decentralization, balanced development, an integrated approach to the provision of care, and more reliance on middle-level and lowerlevel health workers. Nevertheless some intermediate and higher-level facilities may have to be strengthened, since there are limits to the services that can be provided by peripheral health units. Intersectoral collaboration has become an increasingly important element in regional policies. I 5. I09 There was a growing demand for collaboration in the design, management, and maintenance of health facilities. WHO supported university and regional programmes of training in hospital administration; and a WHO-sponsored course was organized by New Zealand for the teaching of repair and maintenance skills so that countries can keep
1.50
REGIONAL TRENDS
and management of health laboratory services and quality control continued and are based on the training of laboratory staff and adaptation to national conditions of the techniques used in essential laboratory work.
session of the Regional Committee (I98I) adopted a resolution urging Member States to give their full support to implementing the Health Assembly resolutions on infant and young child feeding.
Fami!J health I 5. I I4 Many countries are showing increased awareness of the health needs of ' adolescents and particular attention is being given to the biological, psychological, and social problems, which include teenage pregnancy and fertility management.
I 5. I I 5 In maternal and child health care, interest in the risk approach has been stimulated by workshops on the subject. Malaysia has already completed the collection and analysis of data in this area and will be formulating a strategy in I982. National training programmes for personnel concerned with maternal and child health/family planning have been gradually strengthened throughout the Region. During the biennium three interregional courses for senior teachers on fertility management and maternal and child health care were held in Singapore. Papua New Guinea and the Republic of Korea have continuous training programmes, and in China the construction of two training centres began in I98o. National maternal and child health/family planning programmes concentrated on improving the delivery of services through primary health care. Eighteen projects, financially supported by UNFP A and executed b~ WHO, are under way in I 3 countries or areas of the Region. Activities to promote breastfeeding, with adequate supplementation at a later stage, are being carried out in several countries or areas in the Region and a number of meetings were held. The thirty-second
I 5. I I 6 Emphasis in nutrition was placed on the need for appropriate measures to control the marketing of breast-milk substitutes, and on developing health programmes within the framework of national food and nutrition policies. In many countries priority is being given to the control of specific nutritional deficiencies, the development of systems to monitor nutritional status, and the integration of the health sector's nutrition-related activities in the primary health care system. The various.categories of nutrition worker required for the health sector can now be trained in the Region itself.
I 5. I I 7 Health education in the Region aimed at promoting a healthy way of life and developing community self-reliance in health. Great importance was attached to teaching peripheral health and allied workers how to establish contact with the community and promote community organization, how to work in a team, how to collaborate with other sectors, and how to carry out health education. Support was given to the training of health education specialists, particularly at intermediate level. Eight countries or areas in the Region received support in developing communication strategies and improving audiovisual facilities. Efforts to give health education a more solid footing in priority health programmes continued, particularly in regard to tuberculosis and leprosy control, family health, water supply, and sanitation. Interest in behavioural research as an aid to health education was also encouraged. Activities were however limited by the shortage of trained manpower and of audiovisual equipment.
THE WORK OF WHO, 198o-I981
Mental health I 5. I I 8 In line with the recommendations of the regional coordinating group on mental health in I979, efforts were made to develop and strengthen mental health services in the Region. The emphasis was on integrating mental health services into primary health care: in many countries of the Region effective innovative programmes in community-based mental health care were developed. Among the priority subjects were alcoholism and related problems, misuse of psychotropic drugs, improved teaching of mental health, and the psychosocial aspects of child development in the face of rapid social change. During the biennium four WHO collaborating centres in mental health and neurosciences were designated in China and one in Japan.
contain a research component. WHO's insistence on the value of a sound disease surveillance system has led to a growing awareness of the need to strengthen national communication networks for the reporting and exchange of information on communicable diseases. WHO intensified its efforts to improve the collection, analysis, and dissemination of regional data. Support was given to courses in epidemiology in an attempt to correct existing deficiencies. I 5. I 2 I There was little change in the overall malaria situation. Strains of Plasmodium falciparum resistant to antimalarial drugs have now been found in all the endemic malarious countries in the Region. Progress in malaria control' was made in parts of the Lao People's Democratic Republic, Malaysia, and Viet Nam. The favourable trend observed in China during recent years was affected in I98o by adverse weather conditions, and there was a slight deterioration in other malarious countries of the Region. One achievement was the certification in I98I of malaria eradication in Australia, another the establishment of an Asian malaria training centre in Kuala Lumpur.
Diagnostic} therapeutic} and rehabilitative technology I 5. I I 9 Intercountry act1v1t1es on drug policies and management and on pharmaceuticals are being expanded, collaboration continuing in particular with governments in the South Pacific area, where a joint pharmaceutical service is to be inaugurated. WHO continued to collaborate with ASEAN countries in developing technical cooperation in the field of pharmaceuticals. Evaluation of the therapeutic properties and efficacy of medicinal plants continued.
Disease prevention and control I 5. I 20 Action to prevent or control diarrhoeal diseases, acute respiratory infections, arbovirus infections, and malaria was intensified and leprosy, tuberculosis, filariasis, schistosomiasis, and sexually transmitted diseases continued to receive due attention. Many of the activities undertaken
15 . r 2 2 In the programmes on immunization and the control of diarrhoeal diseases there was a shift in emphasis from interregional and intercountry to national activities, the latter including staff training, the improvement of information and surveillance systems, and the strengthening of programme evaluation. In the immunization programme special efforts are being made to improve the cold chain, while the diarrhoeal diseases programme is becoming increasingly involved in research. The programme on acute respiratory infections, which began with the establishment of a prototype research and control scheme in Goroka (Papua New Guinea), is being expanded to cover other countries. National units are being set up, research projects have been launched, and field assess-
REGIONAL TRENDS
ments are being made. There is increasing interest in viral diseases in the Region: research on the epidemiology of hepatitis B and dengue haemorrhagic fever concentrated on determining which groups should be vaccinated when vaccines become available. The importance as a health problem of haemorrhagic fever with a renal syndrome is being recognized. The widespread occurrence of beta-lactamase-producing strains of Neisseria gonorrhoeae is one of the factors that is perpetuating the problem of sexually transmitted diseases. Efforts to strengthen national control programmes for those diseases were continued. I 5. I 2 3 Leprosy control programmes are being developed in collaboration ~ith WHO in the many developing countries in the Region where the disease is a problem. A combined drug regimen, comprising dapsone and rifampicin or clofazimine, is now being introduced for the treatment of lepromatous and borderline cases. In some countries tuberculosis is on the decline, as is shown by the fall in the tuberculin-positive rate among children. Four prevalence surveys in the Republic of Korea showed a significant reduction in the prevalence of bacteriologically positive cases. In some other countries, on the other hand, there has been little or no improvement. In four countries or areas short-term therapy with streptomycin, isoniazid, rifampicin, and pyrazinamide has already been introduced. I 5. I 24 The programme for the prevention of blindness was promoted in many countries or areas in the Region through visits of consultants and provision of equipment and supplies. A workshop (Manila, December I98I) assessed the magnitude of the problem and outlined a programme for the Region.
the liver and the oesophagus. A communitybased control programme is under way in the Philippines for rheumatic fever and rheumatic heart disease and a similar scheme is being introduced in Viet Nam. Several epidemiological studies are being made on hypertension, and control programmes are being carried out in China, Japan, Malaysia, and the Philippines. In Australia and New Zealand, where ischaemic heart disease is common, comprehensive community-based programmes are being developed for the control of cardiovascular diseases, with emphasis on the need for a healthy way of life and a rational diet. As a result of rapid changes in social and economic conditions, leading to a high calorie intake and less exercise, diabetes is becoming a serious health problem among Polynesian and Micronesian populations in the South Pacific. Epidemiological studies are being conducted and control measures introduced, but international cooperation is urgently needed. I 5. I 26 WHO continued to support courses in public health dentistry and other educational projects as an important element in enabling countries to improve the planning of their basic oral health services. Periodontal disease continued to be a major cause of loss of teeth and a number of studies began whose aim is to provide a basis for preventive measures. To help combat dental caries the topical application of fluoride is gradually being introduced into schools in a number of countries. The oral health project in China, involving as it does professional training within the country and overseas training for a number of Chinese specialists, is a particularly significant undertaking.
Promotion of environmental health 15. I 2 7 Activities in relation to the International Drinking Water Supply and Sanitation Decade moved from the prepara2
5. I 2 5 Considerable progress has been made in research on the etiology of cancer of I
53
THE WORK OF WHO, 198o-I98I
tory stage to implementation. A programme was drawn up to guide regional activities during the next few years. Discussions on field projects were held with UNDP resident representatives, and UNDP-supported water supply and sanitation projects are now under way in several countries or areas. Increasing emphasis is being laid on programmes in rural areas involving community participation and a multidisciplinary approach. I 5. I 28 There are important programmes on the control of environmental hazards in both developed and developing countries and areas of the Region. Support was given to Member States and to UNEP's Global Environment Monitoring System (GEMS) through the further supply of monitoring equipment and the holding of WHO-assisted seminars and workshops on monitoring techniques. The Regional Centre for the Promotion of Environmental Planning and Applied Studies in Kuala Lumpur, now firmly established, was of particular assistance in meeting the real and growing need for advisory, planning, and training services.
preparing health workers for the expansion in their duties and improving their managerial skills. I 5. I 30 Strong support and encouragement were given to planning, training, and utilizing middle-level practitioners. Most countries have already defined their requirements and taken the first step towards appropriate programmes. For instance, a comprehensive programme is being developed in Tonga, with the ultimate goal of decentralizing the health services and improving health in the rural areas. Elsewhere curricula are being revised in the light of the new tasks to be performed and the system of supervision and referral to be introduced.
I 5. I 3 I Advances were made in the training of primary health care workers, especially through the exchange of information among the countries interested. Health workers from other regions made extensive studies of the systems used in China and the Philippines. Numerous seminars and workshops were held and attempts were made to determine the most appropriate training methods.
Health manpower development I 5. I 29 An increasing number of Member States in the Region are taking a fresh look at their health manpower requirements in the light of their national strategies for health for all. WHO has consequently placed increased emphasis on manpower planning, strengthening of the capacity of countries to produce health manpower, continuing education, and the application of educational theory and techniques to training programmes. In a number of countries however health manpower studies have been limited to certain categories required by the primary health care approach, e.g., community-oriented nursing staff and environmental health personnel. In several countries continuing education is being developed as an essential means of
I 5. I 32 Teacher-training and the development of more effective educational techniques and processes continued, not only for traditional categories of health personnel but also, increasingly, for new categories such as community health workers. In addition to the regional teacher-training centre, two national centres are expanding and are sharing their resources and experience. A third centre is soon to be established. Countries are showing great interest in the production and use of appropriate educational material, and WHO has been active in promoting this trend. I 5. I 33 WHO collaborated in the revision of curricula in a large number of programmes for training such categories of health worker as dentists, occupational therapists, anaesthetists, nurses, and midwives;
254
REGIONAL TRENDS I 5. I 34 The fellowships programme continued to expand, in particular to meet the training requirements of China and to accommodate trainees from other regions. A follow-up study of former fellows showed that the vast majority had made good use of their training on their return home.
given to lay reporting as an effective procedure for gathering data on health and health-related problems and services. Greater stress is being placed on the development of rational systems of medical records as an essential element in information systems for health management. I 5. I 36 The dissemination to countries in the Region of information contained in health and biomedical literature is being supported. Steps are being taken to develop the capacity of individual countries to establish and manage biomedical and health literature services. Access to information is being improved through the establishment of a regional biomedical information centre and a network of subcentres and libraries.
Health information
15. I 35 WHO strove to broaden its cooperation with Member States in selecting appropriate ways of utilizing data-processing technology and in strengthening the capacity of national health statistical services to analyse the data they obtain. Encouragement was
255
Annex 1
Members and Associate Members of the World Health Organization at JI December 1981 At 31 December 1981 the World Health Organization had 157 Member States and one Associate Member. They are listed below with the date on which each became a party to the Constitution or the date of admission to associate membership.
Afghanistan Albania Algeria* Angola Argentina* Australia Austria* Bahamas* Bahrain Bangladesh Barbados* Belgium* Benin Bolivia Botswana Brazil* Bulgaria* Burma Burundi Byelorussian SSR Canada Cape Verde Central African Republic* Chad Chile* China* Colombia Comoros Congo Costa Rica Cuba* Cyprus* Czechoslovakia* Democratic Kampuchea* Democratic People's Republic of Korea
I9 April I948 26 May I947 8 November I962 I 5 May I976 22 October I948 2 February I 948 30 June I947 I April I974 2 November I97I I9 May I972 25 April I967 25 June I948 20 September I96o 23 December I949 26 February I975 2 June I948 9 June I948 I July I948 22 October I962 7 April I948 29 August I946 5 January I976 20 September I96o I January I96I I 5 October I 948 22 July I946 I4 May I959 9 December I975 26 October I 960 I 7 March I 949 9 May I950 I6 January I96I I March I948 I7 May I950 I9 May I973
Democratic Yemen Denmark* Djibouti Dominica Dominican Republic Ecuador* Egypt* El Salvador Equatorial Guinea Ethiopia Fiji* Finland* France Gabon Gambia* German Democratic Republic* Germany, Federal Republic of* Ghana* Greece* Grenada Guatemala* Guinea* Guinea-Bissau Guyana* Haiti* Honduras Hungary* Iceland India* Indonesia* Iran* Iraq* Ireland* Israel Italy Ivory Coast*
6 May I968 I9 April I948 Io March I978 13 August I98I 2I June I948 I March I949 I6 December I947 22 June I948 5 May I98o I I April I947 I January I972 7 October I947 I6 June I948 21 November I96o 26 April I97I 8 May I973 29 May I95 I 8 April I957 12 March I948 4 December I974 26 August I949 I9 May I959 29 July I974 27 September I966 I2 August I947 8 April I949 I7 June I948 17 June I948 12 January I948 23 May I95o 23 November I946 23 September I947 20 October I947 2I June I949 11 April I947 28 October I96o
* Member States that have acceded to the Convention on the Privileges and Immunities of the Specialized Agencies and its Annex VII. 257
Jamaica* Japan* Jordan* Kenya* Kuwait* Lao People's Democratic Republic* Lebanon Lesotho* Liberia Libyan Arab Jamahiriya* Luxembourg* Madagascar* Malawi* Malaysia* Maldives* Mali* Malta* Mauritania Mauritius* Mexico Monaco Mongolia* Morocco* Mozambique Nepal* Netherlands* New Zealand* Nicaragua* Niger* Nigeria* Norway* Oman Pakistan* Panama Papua New Guinea Paraguay Peru Philippines* Poland* Portugal Qatar Republic of Korea* Romania* Rwanda* Saint Lucia Samoa
2I March I963 I6 May I951 7 April I947 27 January I964 9 May I96o I7 May I950 I9 January I949 7 July I967 I4 March I947 I6 May I95Z 3 June I949 I6 January I96I 9 April I965 24 April I958 5 November I965 I7 October I96o I February I965 7 March I96I 9 December I968 7 April I948 8 July I948 I 8 April I962 I4 May I956 I I September I975 2 September I953 25 April I947 Io December I946 zo April I95o 5 October I96o 25 November I96o I8 August I947 28 May I97I 23 June I948 20 February I95 I 29 April I976 4 January I949 I I November I949 9 July I948 6 May I948 I3 February I948 II May I972 I 7 August I 949 8 June I948 7 November I962 I I November I98o I6 May I962
San Marino Sao Tome and Principe Saudi Arabia Senegal* Seychelles Sierra Leone* Singapore* Somalia South Africa Spain* Sri Lanka Sudan Suriname Swaziland Sweden* Switzerland Syrian Arab Republic Thailand* Togo* Tonga* Trinidad and Tobago* Tunisia* Turkey Uganda Ukrainian SSR Union of Soviet Socialist Republics* United Arab Emirates United Kingdom of Great Britain and Northern Ireland* United Republic of Cameroon United Republic of Tanzania* United States of America Upper Volta* Uruguay* Venezuela VietNam Yemen Yugoslavia* Zaire* Zambia* Zimbabwe
I2 May I98o 23 March I976 26 May I947 3 I October I 96o I I September I979 20 October I 96 I 2 5 February I 966 26 January I96I 7 August I947 28 May I95I 7 July I948 I4 May I956 25 March I976 I6 April I973 28 August I947 26 March I947 I 8 December I 946 26 September I947 13 May I96o I4 August I975 3 January I963 I4 May I956 2 January I948 7 March I963 3 April I948 24 March I 948 30 March I972 zz July I946 6 May I96o I 5 March I962 2I June I948 4 October I 960 22 April I 949 7 July I948 17 May I95o 20 November I95 3 I9 November I947 24 February I96I 2 February I965 I6 May I98o
Associate Member Namibia I6 May I974
*Member States that have acceded to the Convention on the Privileges and Immumues of the Specialized Agencies and its Annex VII.
Annex
2
Organizational and Related Meetings
x.
Meetings in 1980
Executive Board: Working Group to study the question of the transfer of the Regional Office for the Eastern Mediterranean Executive Board: Programme Committee Executive Board, sixty-fifth session Executive Board: Standing Committee on Nongovernmental Organizations Executive Board: Working Group on the organizational study on the role of WHO in training in public health and health programme management, including the use of country health programming Executive Board: Ad Hoc Committee on Drug Policies World Health Assembly: Special Committee of Experts to study the health conditions of the inhabitants of the occupied territories in the Middle East Executive Board: Committee to Consider Certain Financial Matters prior to the Thirty-third World Health Assembly Thirty-third World Health Assembly Regional Committee for the Eastern Mediterranean, Sub-Committee A, special session Regional Committee for the Eastern Mediterranean, Sub-Committee B, special session Executive Board, sixty-sixth session Executive Board: Programme Committee (preparatory meeting) Regional Committee for South-East Asia, thirty-third session Regional Committee for the Western Pacific, thirty-first session Regional Committee for Africa, thirtieth session Regional Committee for the Americas, thirty-second sessionfXXVII Meeting of the Directing Council of P AHO Regional Committee for Europe, thirtieth session Executive Board: Programme Committee Executive Board: Working Group to study the functions and activities carried out by the Secretariat
Geneva, 7, 8 and 14 January Geneva, 8 and 22 January Geneva, 9-zj January Geneva, 10 and 16 January Geneva, 17 January; Geneva, 14 May; Geneva, 1 j-17 September Geneva, z3 January Geneva, j and zz-z4 April; Geneva, z1 May Geneva, j -6 May Geneva, j-Z3 May Geneva, 9 May
Geneva, 14 May Geneva, z6-z7 May Geneva, z7 May Male (Maldives), 1-7 September Manila, 9-1 j September Brazzaville, 17-z4 September Washington, zz September3 October Fez (Morocco), 7-11 October Geneva, z4-z8 November Geneva, 1-3 December
2.
Meetings in 1981
Executive Board: Working Group on the assessment of previous organizational studies of the Executive Board and their impact on the policy and activities of WHO
Geneva, 1z January; Geneva, z7 May; Geneva, 9-10 November
2
59
THE WORK OF WHO, Executive Board: Ad Hoc Committee on Drug Policies Executive Board, sixty-seventh session
I98o-I98I
Executive Board: Standing Committee on Nongovernmental Organizations Executive Board: Working Group on the organizational study on the role of WHO in training in public health and health programme management, including the use of country health programming Executive Board: Working Group to study the functions and activities earned out by the Secretariat
Geneva, I 3 January Geneva, I4-30 January Geneva, 20 January Geneva, 23 January
World Health Assembly: Special Committee of Experts to study the health conditions of the inhabitants of the occupied territories in the Middle East Executive Board: Committee to Consider Certain Financial Matters prior to the Thirty-fourth World Health Assembly Thirty-fourth World Health Assembly Executive Board, sixty-eighth session Executive Board: Programme Committee (preparatory meeting) Regional Committee for South-East Asia, thirty-fourth session Regional Committee for Europe, thirty-first sessiOn Regional Committee for Africa, thirty-first session Regional Committee for the Americas, thirty-third sessionfXXVIII Meeting of the Directing Council of PAHO Regional Committee for the Western Pacific, thirty-second session Executive Board: Programme Committee
Geneva, 27 January; Geneva, 2I, 22 and 27 May; Geneva, 29-30 October Geneva, 2 5 March; Geneva, 2I-23 April Geneva, 4-5 May Geneva, 4-22 May Geneva, 25-26 May Geneva, 2 5 May Denpasar, Bali (Indonesia), Ij-2I September Berlin, I 5- I 9 September Accra, I 6-2 3 September Washington, 2I September2 October Seoul, 22-28 September Geneva, 2-6 November
Annex J
Intergovernmental Organizations that have entered into Formal Agreements with WHO approved fry the World Health Assemb!J, and Nongovernmental Organizations in Official Relations with WHO at JI December I98I
1.
Intergovernmental organizations Islamic Development Bank League of Arab States Organization of African Unity
African Development Bank International Committee of Military Medicine and Pharmacy International Office of Epizootics
2.
Nongovernmental organizations lnternanonal Federatton of Gynecology and Obstetncs International Federation of Health Records Organizations International Federation for Housing and Planning International Federation for Information Processing International Federation for Medical and Biological Engineering International Federation of Medical Student Associations International Federation of Multiple Sclerosis Socteties International Federation of Ophthalmological Societies International Federation of Pharmaceutical Manufacturers Associations International Federation of Physical Medicine and Rehabilitation International Federation of Sports Medicine International Federation of Surgical Colleges International Hospital Federation International League against Epilepsy International League against Rheumatism International Leprosy Association International Organization for Cooperation in Health Care (Medicus Mundi Internationalis) International Organization for Standardization International Organization against Trachoma International Paediatric Association International Pharmaceutical Federation International Planned Parenthood Federation International Radiation Protection Association International Society of Biometeorology International Society of Blood Transfusion International Society for Burn Injuries International Society and Federation of Cardiology International Society of Chemotherapy International Society of Endocrinology International Society of Hematology International Society for Human and Animal Mycology International Society of Orthopaedic Surgery and Traumatology International Society of Radiographers and Radiological Technicians International Society of Radiology International Soctological Association International Solid Wastes and Public Cleansing Association International Union of Architects International Union of Biological Sciences International Union against Cancer International Union for Child Welfare International Union for Conservation of Nature and Natural Resources International Union for Health Education International Union of Immunological Societies International Union of Local Authorltles International Union of J'v.ficrobiological Societies
African Medical and Research Foundation International Biometric Society Christian Medical Commission Commonwealth Medical Association Council for International Organizations of Medical Sciences European Society for Clinical Investigation Inter-American Association of Sanitary and Environmental Engineering International Academy of Pathology International Agency for the Prevention of Blindness International Air Transport Association International Association for Accident and Traffic Medicine International Association of Agricultural Medicine and Rural Health International Association of Cancer Registries International Association for Child and Adolescent Psychiatry and Allied Professions International Association of Environmental Mutagen Societies International Association of Hydatid Disease International Association for the Study of the Liver International Association of Logopedics and Phoniatrics International Association of Medical Laboratory Technologists International Association for Suicide Prevention International Association on Water Pollution Research International Astronautical Federation International Brain Research Organization International College of Surgeons International Commission on Radiation Units and Measurements International Commission on Radiological Protection International Committee of Catholic Nurses International Committee of the Red Cross International Confederation of Midwives International Council on Alcohol and Addictions International Council on Jewish Social and Welfare Services International Council for Laboratory Animal Science International Council of Nurses International Council of Scientific Unions International Council on Social Welfare International Council of Societies of Pathology International Council of Women International Cystic Fibrosis (Mucoviscidosis) Association International Dental Federation International Diabetes Federation International Electrotechnical Commission International Epidemiological Association International Ergonomics Association International Federation of Clinical Chemistry International Federation of Fertility Societies
'
International Union of Nutritional Sciences International Union of Pharmacology International Union of Pure and Applied Chemistry International Union of School and University Health and Medicine International Union against Tuberculosis International Union against the Venereal Diseases and the Treponematoses International Water Supply Association Joint Commission on International Aspects of Mental Retardation League of Red Cross Societies Medical Women's International Association Permanent Commission and International Association on Occupational Health Population Council Rehabilitation International World Association of Societies of (Anatomic and Clinical) Pathology World Confederation for Physical Therapy World Council for the Welfare of the Blind
World Federation of Associations of Clinical Toxicology Centers and Poison Control Centers World Federation of the Deaf World Federation of Hemophilia World Federation for Medical Education World Federation for Mental Health World Federation of Neurology World Federation of Neurosurgical Societies World Federation of Nuclear Medicine and Biology World Federation of Occupational Therapists World Federation of Parasitologists World Federation of Proprietary Medicine Manufacturers World Federation of Public Health Associations World Federation of Societies of Anaesthesiologists World Federation of United Nations Associations World Medical Association World Psychiatric Association World Veterans Federation World Veterinary Association
z6z
Annex 4
Structure
of the
World Health Organization at j i December I98I
WHO Secretariat as a whole
Hlltth end l1omldial
lnformltlon Prot~nunnw Oivilion of l'ublk: lnformlt10n Drvilion of H•hh Stlt•ics
Divillon of Coordin~tlon1 Office of R-rch llromotion and DMkJpment Office of thl Llgll Cou1111l lntwMIAudit EmlfJIDCV Relief Operatiolll
Ml...il Aci!OR "'ogt'lmml Pll'llitic D'--llrog11mmt
DMiion of
Drvillon of Vector l1ology lnd Control Expended f'rogr~mrM
D-
Communie~bll
on
lmmunilltion
Divillon of
Env~ronmtntll
Hoolth DMiion of Family H•hh DiVIIion of Hllfth MlnpoWir
OIVIkJpnwnt Divillon of Strlngthtning of Htokh SoiVieo& SpltiiiProtn~mme of ft-rch, Development tnd ft-n:h Tnumng in Hum~n
fttproductton
DMIIon of Noncommumcablt Divwon of Oilgnoetic, Thlrlpeutic 1nd ftthlbilltati¥1 Technology Drv111on of Mtntll H•lth
D-
Divil1on of Plnonneland Gtnefll Servicas Divilton of ludglt and Fmanct Div..on of lnforrMtiOn Spttm& Support Specill Prognmm1 for Pl_,ch and Tl'linmg ID
WHOProg11mmt
Tropil:.l a -
Coonhnttors
1Tht liliton Office with tt. Unrttd Nlt1on1 and the WHO mtdictl acfvi11rs to UNICEF (who art tllo wrth UNFPA) rtport to tht Dw••on of Coordmltton.
~WpGnlibll
for
rw.on
2ftfllliOIIII OffiCI for tht Anwnc:u/Pin Aarictn Slnby lur~~u. 3ft. ft~gio•l OffiCI for Europe il rt1p0fllible on bnlt of the D1reetor-Genlfll for thlglobll progr~mmec on
Mllth
Cll'l
of tM eged and on 1111d t111ffic accultnta.
WHO Headquarters Secretariat
HEALTH AND IIOMEDICAL INFORMATION PROGRAMME OffiCI of l'ubhcltions
MALARIA ACTION PROGRAMME Eputlmtologictl Methodology 1nd EVIIUitton
DIVISION OF ENVIRONMENTAL HEALTH Ermronnntll Hmrdt: 1nd Food ProtiCtkm EnvironPntll Haith Technology IPd Support Glob1l PromotiOn end Coopmion for Wltlf Supply end S.mt1t10n lnt•n~tiollll Progremm1 on ChlmiCII Slftty
Offia of LlngUIII Slfvice~ Office of Library 1nd Htltth llltl'ltUfl ServiCII
llrogftmming end Trlinmg R .....ch and TechmCII lnttlllg1na
DIVISION OF NONCOMMUNICABLE DISEASES Ctrdkwllcullr o-..
DIVISION OF PERSONNEL AND GENERAL SERVICES Adm1nictrlf:ivl M~n~g~ment Ptnonrwl Steff Developnnt end Tr11mng Conftr~nce 1nd OffiCI Sewic:. Supply SewiCII J01nt Methcal Serv11:1
Cancor
D111ribut10n 111d Sills
PARASITIC DISEASES PROGRAMME Flltllll lnt.etior11
Humin Gentties Ore! Hulth Occupltlollll H•lth Immunology
ScbiltOJDm•s 1nd other DIVISION OF PUBLIC INFORMATION Amhovilutl Communil:ltton News Mllht R.-.o.. World H•lth M~g~ziM
Htlmmthic lnftetions TryiJIROIDm...s and Llilhll'lln....
DIVISION OF COMMUNICAILE DISEASES EpidtmtologiCII SuMita.nct of CommumCible Oi-DIVISION OF HEALTH STATISTICS H•lth Stlt•••ttl Methodology 0-miMtton of StatiltiCII lnforn.tion Devttopn.nt of Hulth Statlll:u:.l Silvie.
DIVISION OF FAMILY HEALTH Mlttfllll 1nd Child H•lth H•hh Edut:1t1on NutritiOn
DIVISION OF DIAGNOSTIC, THERAPEUTIC AND REHAIILITATIVE TECHNOLOGY BiologiCIIs H•lth Llborlf:Ory Technology ,._11111Ciut1CIII Act1on llrogremme on
DIVISION OF IUOGET AND FINANCE Budget fi111nce end Accounts
lmlllpox EI'MI1Cition Tublrculo111 1nd fiiiPil'ltOry lnftctions
Loprosy lactentl end Vtntr11l InfectiOns Viruso . . .
Eaontill Drugs DIVISION OF HEALTH MANPOWER DEVELOPMENT llrogremme of &.nt•l Surgery ftadietion Mtd•cirw T!lldltiOIIII Med1cine ftehlbilitlt1on
DIVISION OF INFORMATION SYSTEMS SUI'I'ORT Information Sysums Methodology Deta end Text Pro~ng Serv11:u
lntlmlttO•I C'-ihl:ltton of o - -
D11rrholll 0 ' - Control Prognmmt Specill ProiJimmt on Slftty hiUm m Microbiology l'ropmll'll for the PrMntion of llmdMS Vettrilllry Public HMith
DIVISION OF STRENGTHENING OF HEALTH SERVICES DIVISION OF COORDINATION Coopnt:IVI Progdlmm11 for
DIVISION OF MENTAL HEALTH
DIVISION OF VECTOR IIOLOGY AND CONTROL Pllt1clllt Development tnd S.fe U• Ecology tnd Control of V1tt011 Equtpmlflf., l'llnning end Optl'ltiorw
SPECIAL PROGRAMME FOR RESEARCH AND TRAINING IN TROPICAL DISEASES
Development CoonhMtton with othlr 0rglnillf:IOM
Food Atd llrogrlmrnll
SPECIAL PROGRAMME OF RESEARCH, DEVELOPMENT AND RESEARCH TRAINING IN HUMAN REPRODUCTION
* Thl r11po1111bilrtia of th11 Asslstent On·mor-Gerwr~l include thl cheirll'llmhlp of the OFFICE OF RESEARCH PROMOTION AND DEVELOPMENT OFFICE OF THE LEGAL COUNSEL INTERNAL AUDIT EMERGENCY RELIEF OPERATIONS EXPANDED PROGRAMME ON IMMUNIZATION HlldqUirtl11 Progremll'll Commltttl
INDEX
Index References are f?y paragraph. Main references i?J subject are in bold type.
Abortion, 6.I7, 6.38, 6.8o, 6.99 ACC, see Administrative Committee on Co-ordination Accidents, 8.65, 8.86 laboratory, 9.I46-9.I49 occupational, 8.86, Io.86, I 5.IIO road traffic, 8.I, 8.84-8.91, I 5. 73 interregional conference (I98I), 8.84, 8.88, 8.9I role of alcohol and drugs, 4.29, 7·I9, 8.85, 8.86 toxic chemicals, I 5. 78 Acupuncture, 8.73, 8,76, I2.6o World Congress, Seventh (I98I), 8.79 Administration and finance information system, 2.43 Administrative Committee on Co-ordination (ACC), 3·I3, 3-14
African Regwn, 1.21, 1.32, 2.7-2.10, 3.41, 4.10-4.16, 1·5· 5.42, 5·43, 5. 50, 6.5, 6.4I, 6.44, 6.46, 6.6o, 6.63, 6.65, 6.Io8, 6.n4-6.II5, 7·4-7.8, 8.I7, 8.48, 8.66, 8.77, 8.86, 8.96, 9.2I, 9·42-9.43, 9.89-9·90, 9·I54, 9.I6o, 9.I68, Io.6, II.I2-II.I4, I1.34, II.46, 12.43-I2-44, I2.55, I2.74-I2.75, I2.84, 12.92-I2.94, 12.Ill, I2.II8, I2.I27·12.128, I2.I48-I2.I49, I2.173I2.I74, I3•7, I3.24, IS.I-IS.I9 Charter for Health Development, 1.26, 1.42, I5 .I, I5 .I5 Health 2ooo Resources Group, r.2I, I 5. I 2
Regional Advisory Committee on Health Development, 1.3, 1.35, I5.6 Regional Health Development Centre, 6.44, 6.65, I2.IOI, I2.I48
Consultative Committee on Administrative Questions (CCAQ), I4.I7 Consultative Committee on Substantive Questions (Programme Matters), 3.Io Sub-Committee on Nutrition, 6.49 Administrative matters, q.n-q.26 Adolescence, see Youth and adolescence Advertising, breast-milk substitutes, 6. 7 tobacco products, I0.47 Advisory Committee on Medical Research, global (ACMR), 4·3-4·7· 7-48 subcommittees, 4· 3, 4· 7 on cancer, I0.3 on health services research, 4.3, 5·57, 6.31 on mental health and neuropsychiatry, 7·47 Advisory committees on medical research, regional, I. 3 5, 4·4 Africa, 4.I6, I5.6, I5.I4 Amencas, 4.I8, 7·45 Eastern Mediterranean, 4. 3r. I 5·9 3 Europe, 4.26-4.30, 5·53, 7·49, I5.68 South-East Asia, 4.22-4.23 Western Pacific, 4.38, 5·55, I5.I05 Aedes aegypti, 1.42, 9.136, 9.202, 9.2Io, 9.223, 9.259 Afghanistan, 6.I7, 9.25, I3.I5, I5·99 Aflatoxin, IO.I8, II. 53 Africa, newly independent and emerging States, 1.45 African Development Bank, 3.8
Aga Khan Foundation, 3.8 Aging: a challenge to society, 8.94 Aging, World Assembly (I982), p 5o 8.92 see also Elderly Air pollution, I3.35, I5.jl monitoring and control, I1.27, II.28, IL34 Aircraft, disinsection, 9.22I Alcohol, society and the state, 7.42 Alcohol-related problems, 1.38, 7.5, 7.6, 7·36·7·43, 7.66, 8.86, IO.I5, I0.85, I2.I53, I5.II8
Algeria, 2.I8, 3·39, 3·44, 5.3, 5.8, 5.27, 6.25, 9.27, 9.122, II.I8, I3.I5, 14.23, I4.24, I5·77
All-Africa Conference on Health Education (I98I), I2. I49
Allergic diseases, Io.6o, I0.92 Alma-Ala I97S: primary health care, r.I2 Americas, Region of the, 1.22, r.p, 2.II-2.I3, 3.42, 4·174·2 I, 5.6, 5.2I, 5.28, 5.42, 5·44, 5. 5I, 6.30, 6.3 I, 6.44, 6.46, 6.6o, 6.62, 6.1I6, 7·9·7.IO, 7.4I, 7·45, 8.I88.I9, 8.6o, 8.67, 8.78, 8.87, 9.22, 9.46, 9.91, 9.113, 9.I42, 9· I j4, 9.I6o, 9.I66, 9.I67, 9· 170, 9· I73, 9· I 75, 9·179, 9.I84, 9.202, 9.223, Io.6, Io.6o, II.5-II.I6, I1.34, I1.47, I2.I5, I2.26, I2.37, 12.45-I2.47, I2.5 II2.52, I2.56, I2.76, I2.8o, I2.86, I2.95, I2.II2, I2.I29-I2.13I, I2.I53, I2.I6I, I2.I75, I2.I79, I4.I3, IS.:ZO•IS·31 Americas, Ten-Year Health Plan (I97I-I98o), 1.4, I5.20
THE WORK OF WHO, I98o--I98I Anaemias, hereditary, Io.62, Io.65 nutritional, 6.17, 6.ss-6·S7 Anaesthesia and anaesthesiology, 8.75, 8.82, 8.83, 12.99 Andean region, 5.28, II.I5, II.47 Angola, 3·4I, 8.77, 9.38, 9.2Io, I5.IO Animal health, 9· I 79
Bacterial diseases, 9•78-9.119, 9.I2o, 9·IP-9·I55 Bahamas, 2.I9 Bahrain, 2.46, 4.33, 8.24, 9.I10, 10.74, I2.I6, I2.77, I2.I37, I5.90, I5.93, I5.IOO
Bangladesh, 3·43, 5·7, 5.25, 5·34, 5·45, 5.52, 6.40, 8.20, 8.59, 8.95, 9.II, 9·92, 9.IIO, I0.76, II.I7, 12.12, 12.27, I2.87 Barbados, 7.Io, II.I5, 12.9, 12.I53 Basic safety standards for radiation protection, I I. 37 BCG, vaccination and vaccine, 9.Ioi, 9.Io2, 9· I03, 9.I059·Io6, 9.IIO, 9.III, 9·II4, 9.I66, I2.I67 Behavioural sciences, 1.8, 1. I4, 1.42, 4.3, 6.63, 6.66, 6.8I, 7.25, 7.27, 7·47, 7·49, 9.263-9.264, II.I7, I5.37, I5.50, I5.II7
see also Veterinary public health Animals for research, 4.7, 9.200 nonhuman primates, 4.7, 8.40, 10.30 Anopheline mosquitos, 9.202, 9.207, 9.259 Antibiotics, 8.32, 8.33, 8.35, 9.I2I, 9.I24, 9·I52 in food, I 1.4 I resistance, I 5. I 3 Apartheid, 1.4 5, I 5. I o Approaches to planning and design of health care facilities in developing areas, 5.27 Appropriate technology for health, 1.4, 1. II, 1.13, 3. 27, 4·I3, S·37-S·48, 5·5l, 8.69, I0.2, II.I8, I5.86, I5.I07 action group, 6.50 directory, 5.40 information systems, 2.49, 5·37-5·4o, 5·47 newsletter, 5.40 Arab Board for Medical Specialization, I 2.98 Arab countries of the Gulf area, Council of Ministers of Health, 8.9I, 13·45 Arab Fund for Economic and Social Development, 3·.8 Arab Organization for Standardization and Metrology, I 1.50 Arab populations in occupied territories, health conditions, 1.46 Argentina, 7.66, 9.Io5, 9·I Io, 9· I I2, 9· I I3, 9.I85, I2.I 53 Arrhythmias, classification, I0.44 ASEAN, see Association of South-East Asian Nations Asian Development Bank, 5.26, 8.2I, I5.63 Asian Foundation for the Prevention of Blindness, 9· I 59 Associate Members of WHO, I4. I Association of Medical Deans in Europe, I 5. 79 Association for Medical Education in Europe, I 5. 79, I5.80
see also, Psychosocial factors and health Bejel, 9· I 54 Belgium, 3.4, 3.32, 7.8, 8.89, 9.5, II.31, II.38, I2.72, 12.97, I 5.76
Benin, 2.7, 3.6, 5·5, 6.64, 8.85, 9·39, 9.52, 12.42, I2.I27 Bhutan, 9· uo Biologicals, 1.24, 8.31-8.43 standardization, 8.32, 8.35, 8.37 Biomedical information, I3.23-I3.52 Biomedical research, see Research Birth control, see Fertility regulation Birthweight, low, 6.2o-6.2I, 13·I4 Blackfly, see Simulium Blindness, prevention, 9·1S6-9.164, I 5.48, I 5. I24 national programmes, preparation, 9· I 58 advisory group, 9·I57, 9.I62 P AHOJWHO advisory committee, 9· I 56 research, 9.I62, 9.I63 training, 9.I6o, 9.I6I, 9.I62 Blood products and transfusion, 8.32, 8.39 Blue Nile health project, 9.44, 9.2I9, I5.98 Boletin de Ia Oficina Sanitaria Panamericana, 8.I9 Bolivia, 5.6, 5.24, 7·35, 8.67, II.I6, 12.47, I2.jl, I4·7 Botswana, 2.I9, 5·5, 5·I5, 6.64, 7.4, 8.64, 9·39, 9.42, 10.74, 10.76
Association of Schools of Public Health in Europe, 12.I4I, I5·79
Association of South-East Asian Nations (ASEAN), 1.24, 8.6, 8.I4, 8.22, 8.26, 8.76, I5.Il9
Bovine tuberculosis, 9· I 79 Bowel cancer, IO.I7 "Brain drain" see MigratiOn of health manpower Brazil, 5.24, 7.4I, 8.6o, 8.85, 9.38, 9·39, 9.40, 9.46, 9.63, 9·II2,9.122,9·136,9.I48,9.234,9·247, 10.74, II.I5, II.38, 12.47 Breast-feeding, 3.22, 6.7, 6.Io, 6.I6, 6.p-6.36, 9.69, II.32, I2.I78, 13•33, 13.56, I5.95, I5.II5
Audiovisual materials, I2.II9, 12.128, I2.I78, I3.56, I3.59-I3.60, I5.II7
see also Teaching/learning materials Australia, 6.4, 6.128, 7.65, 9.26, 9.I25, 9.I85, 10.33, I2.I23, 13.25, I3.60, I5.I2I, I5.I25
Austria, 9· I 84, I 2. 58 Auxiliary health personnel, 9.I6o, 12.p, I2.68, I2.8oI2.83, 12.93, I2.I04, I2.I29, 12.I62
brochure, 6. 3 5 Breast-milk substitutes, 6.7, 6.Io, I5.II6 International Code of Marketing, 1.39, 3.22, 6.7-6.9, 6.32, I3•33, I3·56, I5·95
see also Commumty health workers; Medical assistants and auxiliaries: Primary health care workers; and under the various categories of health personnel Ayurvedic medicine, 8.79
Brucellosis, 9.I79, 9·I9o, I2.I69 Bulgaria, 3.52, 5.I5, 7.6I, 9.I85, Io.64, 10.74 Bulletin of the World Health Organization, I 3-30 Burkitt's lymphoma, 4· I 2 Burma, 2. I 5, 3·43, 5.2, 5.3, 5. 7, 5. I 8, 5·52, 6.29, 7·3 5, 8.20, 8.2I, 8.49> 8.j4, 8.59, 8.69, 8.79> 8.95, 9·92, 9·93,
INDEX
Burma (contznued) 9·130,9.208,9.213, 10.74, 10.76, 12.12, 12.20, 12.24, 12.27, I2.42, 13.17, I4.23, lj.38, lj.42 Burundi, 3.41, j.j, 12.74
Cameroon, see United Republic of Cameroon Canada, 7.42, 7.56, 9.113, 9.1p, 11.27 Canadian International Development Agency (CIDA), 11.16, I2.jl Cancer, 10.2-10.32, I0.79, 15.48, lj.75, lj.l2j classification of tumours, I o. 1I in domestic animals, 9· 198 control and prevention, common strategy and national programmes, Io.2, 10.4, 10.5, 15.75 integration with general health care, IO.j training, 1o.j, 12.17I coordinating committee, 10.4 epidemiology, 10.16, 10.30, 10.31 directories, 1o. 12 registries, 10.12, 10.13, 15.75 standardization of reporting, 10.13 research, 4.3, 10.12-10.29 comparative studies, 9.18I, 9.198-9.199 training, 10.30-Io.p screening and early detection, 1o. j statistics, 10.8, 10.10, 13.14, 13.18 Cancer incidence in jive continents, 10.12 Carcinogens, environmental, 10.26, 10.31 see also Chemicals, carcinogenic Cardiomyopathies, classification, 10.44 Cardiovascular diseases, 10.33-10.46, I j .48, 1 j. 76 classification, 10.44 community control, 10.38-Io.4o, lj.12j epidemiology, 10.4 j -10.46 long-term programme of WHO, 1 j. 76 primordial prevention, 10.34, 10.37 research, 4.I2, 4.38, 10.33, 10.35, 10.36, 10.41-10.43 studies on physical activity, I0.43 training in prevention and epidemiology, 10.4j-Io.46 Caribbean area, 6.39, 6.64, 8.67, II.Ij, 11.47, 12.45 Caribbean Community, l·4 Caribbean Development Bank, I 1. 16 Caribbean Food and Nutrition Institute, 6.44 Caribbean Regional Drug Testing Laboratory, 8.19 Caribbean sea, pollution, 11. 3 j Caries, 1 j. 126 Cataract, 9· 161 Central African Republic, 3.41, 9.38 Central America and Panama, I 1.1 <> community health training programme, 12.47, 1 2.j 1, I2.80, I2.112, 12.129 Cerebrospinal meningitis, 9· 1I 8 Cerebrovascular diseases, 10.33, 12. I j j CERN see European Organization for Nuclear Research Chad, 3.41, 9·4, 9.38, I5.Io
Chagas' disease, 9.63 research, 9.63, 9.232, 9.246-9.248 Charters for health development, regional, 1.26-1.27, 1.42, lj.l, 15,15 Chemicals, in food and the environment, 10.74, 10.79, 11.21, 11.53, lj.48, 15.78, 15.110 carcinogenic, 10.24-10.29, Io.3o, 11.22 international programme on safety, 4.28, n.22-II.2S interregional research units, I 1. 22 monitoring of effects, 10.74, 10.79 Chemotherapy of malaria, 9.2.8, 13.33 Children, 6.15, 6.16, 15.28 accidents, 8.89 cardiovascular diseases, 1o. 36 communicable diseases, 9.2I, 9.48, 9.82, 9.98, 9.101, 9•10j, 9·II4, 9.120-9.121, 9.124, 9.1j4, lj.20 diarrhoeal diseases and gastroenteritis, 9.68, 1 5.43, 15·99 drug treatment, 8.12, 1 j. 70 growth and development, 6.I6, 6.18, 6.28, 6.37, 6.jo, 7·4l health education, 6.64 mental health, 4.29, 7.5, 7·44-7·46, lj.118 mortality 6.1 j, 6. I 6, 6.4 j, 6.108, I j .98 see also Immunization; Infant and young child feeding; Maternal and child health Chile, 5.21, j.24, 7.1o, 7.4I, 7.46, 9.I85 China, 2.2.4, 2.25, 2..46, 3.51, 3.52, 4·37, j.15, 6.4, 6.24, 6.121, 6.128, 7·14, 7.j6, 7·57, 7·64, 8.27, 8.49, 8.76, 9·1 IO, 9.122, 9.12 j, 9·13 7, 9.223, 10.16, 10.67, 10.76, 11.27, 11.34, ll.jl, 12.60, 12.122, 12.145, 12.1jj, 13.23, 13.44, 14.22, lj.llj, I5.121, lj.l2j, 15.126, I j .134 Cholera, 9·75 Chromosomal diseases, 10.63 CIDA, see Canadian International Development Agency CIOMS, see Council for International Organizations of Medical Sciences Circumcision, female, 6. I 3 Classification, international, of diseases, injuries and causes of death, 13.7-13.9 of impairments, disabilities and handicaps, I 3. 7, 15. 74 of procedures in medicine, 13. 7 of tumours, 10.11 in domestic animals, 9.198 Clonorchiasis, 4.38, I5.105 <:;oastal water pollution, 11.3 j Codex Alimentarius Commission, FAOJWHO, 9·I93, 9·I95, I1.43-I1.45 "Cold chain" development and management, 3.21, 9.I68, 9.171, 9·172., 15.45, I5.IOO, I5.122 Collaborating centres, 1.4I, 4.10, 4.20, 4.28, 9.179, Io.48, 12.70, 12.106, 15.14, lj.60, Ij.IOj accident prevention, 8.89, 8.90 biostatistics, I o. I o blindness prevention, 9.162 cancer, IO.IO, IO.II
THE WORK OF WHO, I98o-I98I
Collaborating centres (continued) chemical reference substances, 8.6 classification of diseases, I 3·9 comparative oncology, 9·I99 dengue haemorrhagic fever, 4.24, 9.I37, I5·44 diabetes, IO. 55 disability prevention, 8.66, 8.70 disasters, epidemiology, 3·32 drug dependence and alcohol-related problems, 7.42 drug monitoring, international, 8.Io environmental, health I 1. I 5, I 1. 29 family health, 6.2I family planning, 6.II8, 6.II9 food contamination monitoring (FAO/WHO), I1.53 food hygiene and zoonoses (FAO/WHO), 9.I88, 9·I9I, I2.I68 food virology, 9.I89 health services research, 5. 52 hospital infections, 9·I 5o human genetics, Io.64 human reproduction, 6.84, 6.Io7, 6.II6, 6.II8, 6.II9 immunology, I0.9o laboratory technology, 8.49, 8.50 malacology 9·43, 9.2I4 manpower development, I 2.I3 medical informatics, 2.47 mental health, 7·5, 7·I5, I5.II8 neurosciences, 7. I 5, I 5. II8 nutrition, 15.36 occupatiOnal health, 10.73 pesticides, 9.203 equipment testing, 9.2o6 plague, 9·II7 primary health care, 5. I I psychosocial factors, 7. I I radiation, I 1. 33 emergency assistance, II. 38 rehabilitation, 8.66, 8.70 rickettsial diseases, 9· I 39 smallpox, vaccine, 9· 5 traditional medicme, 8.73, 8.74, 8.77, 8.78, 8.79, 8.8o virus diseases, 9·7• 9.I27, 9.I3o, 9·I3J, 9.I35, 9,I4I water resources development, 9·4I Colomb1a, 5.3, 5.6, 5.16, 5.21, 5.24, 5.42, 6-46, 6.8I, 7.Io, 7·35, 7.64, 8.57, 8.6o, 8.67, 9.Io5, 9.IIO, 9.II2, 9·I36,9.203,9·2IO, I2.I8, I2.24, I2.36, I2.5I, I2.65, 12.71, I2.I53 Commission of the European Commumties, Io. 32, I 3.46, I4.24 Committee for International Coordmat!On of National Research in Demography, 13.18 Commumcable d1seases, 1.26, 6.16, 8.65, 9.1-9.269, I0.6I, I0.64, I2.J30, I5.20, I5.40-I5.47, I5.96I 5. I 00, I 5. I 20- I 5. I 2 3 epidemics, consultation on strategies, 9· 2
epidemiological surveillance, 4.26, 8.44, 9·7· 9.8, 9.69, 9-128-9.I29, 9·133, 9·I38, 9·I4I, 9·I78, 9-I88, I5.40, I5.96, I5.I20 immunology, 10.93 integration of services in public and pnmary health care, 5.8, 9.18, 9.22, 9·33· 9·34· 9·54, 9.69, 9·7I, 9·83, 9·89, 9·9I, 9·92, 9·95. 9-IOI, 9-II4, 9-I2I, 9-122, 9-I24, I5·17· I5-98 malnutrition and infection, 6.I6, 6.43, 9.68 resistance to infection, I o.64 see also Expanded Programme on lmmumzation; Tropical diseases Communicable eye diseases, see Blindness; Trachoma Community health workers, training, 5.7, 5.I5, 6.44, 9.I60, 12.18, 12.59, I2.I04, I5.34, I5.I32 interregional study, 5.I5, I 2. 79 Commumty participation in health and development programmes, 1.4, 1. 7, 1.I3, 1.42, 5. 5, 5.6, 5.8, 5. 14, 6.23, 6.30, 6.p, 6.46, 6.59, 6.6o, 6.73-6.75, 9.237, I0.6, II.7-11.8, 12.24, 12.28, 12.4I, I2.59, I2.J35, I5.15, I5.28, I5.37, I5.38, I5.45, 15.96, I5.106, I 5·I 27 Comoros, 3·4I, 5·5 Comparative medicine, 9·I98-9.I99· 9.248 Computing, medical, 2.47-2.50, q.2o, 13.22 training, 2.48 see also Electronic data processmg Congemtal anomalies, I0.23 Congo, 5.5, 6.46, 6.64, 9.8, 9·39, 9.42, 9.2I4 Congo virus, I 5·97 Conjunctivitis, haemorrhagic, 9·I3 5 Constitutional and legal matters, 14.1-14.10 amendments to the WHO Constitution, J4.2-I4-4 Contraceptives, injectable, 6.89-6.9I, 6.I02-6. I03 oral, for men, 6.I04, 6.I07 for women, 6.85-6.86 postcoital preparations, 6.105 vaccines, 6.106
see also Fertility regulation; Intrauterine dev1ces Contnbutions to WHO, voluntary, see Extrabudgetary sources of funds Convention on Narcotic Drugs, Single (I96I) 7.I6 Convention on Psychotropic Substances, 7.I6, 7.2I Cook Islands, 2.24, 6.6o, 12.73 Coordination, in international health work, WHO's role, I.p, 3·I wuh the United Nations system of organizations, 1.9, I.I9, 1.30, I.p, 3·9-3·16, 3·35. 3·38, 3·47. 5-13. 5.I6, 6.8, 6.66, 7.8, 8.30, 8.6I, II.5, II.9, I3.60, I4.J7, I5.63 see also under names of indtvtdual organizations Coronary heart d1sease, 10.33, 10.34, 10.36, 10.43, I5 .76 Costa Rica, 5·3· 5.6, 5.I8, 5.22, 5.24, 5.42, 7·44• II.I5, 12.9, 12.42, 12-47 Council for International Organizations of Medical Sciences (CIOMS), 10.44, I 3.42, 13.48
INDEX
Council of Ministers of Health of Arab countnes of the Gulf area, 8.9I, I3·45 Country health programming, 2. Io, I 5. I 5 training, 2.Io, 2.I9, I5.I5 Cretinism, 6. 52 Cuba, 5.27, 6.4, 6.29, 6.128, 9·I37, 9.2Io, I0.8o, I2.5I, I2.I44 Culicine mosquitos, 9.202, 9.209, 9.2I6, 9.259 Cyclops, control, 9.2 I 5 Cyprus, 1.46, 3·45, 8.54, 9.I85, I4.22 Cysticercosis, 9·I9o, I2.I69 see also Hydatidosis Czechoslovakia, 6.29, 10.74,12.58
Dams, see Water resources and river basin development, health aspects Danish International Development Agency (DANIDA), 8.46, 8.49, 8.77, 9·84, 9·III, 9·2II, 9·223, II.29, IZ.I67 Data banks, 9.I64, I3.IO Data processing, see Electronic data processing Deafness, Io.66 Declaration of Alma-Ata, LIZ, 5.38, 6.59, 6.68 Declaration of Monrovia, I 5. 3 Declaration on the Prevention of Disablement, Leeds Castle, 8.65 Declaration on the Rights of Mentally Retarded Persons, United Nations, 7.29 Democratic Kampuchea, 3.46, 9.27, 14.22 Democratic People's Republic of Korea, 8.59 Democratic Yemen, 2.I9, 2.22, 2.23, 5.2, 5.3, 5.23, 6.17, 6.46, 8.24, 12.24, I 2. I 33 Demographic studies, I 3. I 7, I 3. I 8 see also Population Dengue and dengue haemorrhagic fever, 9· I 37, I 5·44 research, 9.I37, I5.44, I5.I05, I5.Iz2 vaccine, 4.24, I0.9I, I5.44, I5.Izz vector biology and control, 9.202, 9.2 Io, I 5.46 Denmark, z.I8, 3·4, 6.4, 6.128, 7.8, 9.I68, 12.72 Dental health, see Oral health Depression, 7·5I Development, health as part of (United Nations General Assembly resolutions), I.I2, r.I8, r.z8, 3·9 International Strategy, r.28, 3.II see also Children, growth and development; Rural development; Socioeconomic development; United Nations Development Programme; Women in health and development Development forum (Umted Nations), I 3.63 Development of indicators for monitoring progress towards health for all ~ the year 2000, I. I 7 Diabetes, 4.38, 7.56, ro.53-ro.57, I5.48, I5.I25 national programmes, ro.53-I0.54 study of vascular diseases in diabetics, Io. 57 training of health workers, Io. 56
Diagnostic substances and technology, 4.27, 8.r-8.6o, 9·I72 see also Reagents Diarrhoeal diseases, 4.6, 6. I6, 6.3 5, 9.66, 9.68-9.77• 9.2I9, I5.43, I5.95, I5.99, I5.I20, I5.I22 control programme (WHO), 2.42, 3.20, 3.2I, 9.68 management and financing, 9· 77 national programmes, promotion and evaluation, 9·69-9· 70, 9· 7 3> I 5·99 primary health care approach, 9.69, 9·7I rehydration therapy, 9.69, 9.7o, 9.72, 9·75, 9.76, I 5·43, I5·99 research, 4.I8, 4.24, 4.38, 5·55, 9·74-9·76, I 5. 14, I 5·99, I 5.I22 training in control, 9·7I-9.72, I5.43, I5·99 Diphtheria, 9·I73 vaccination and vaccine, I 5. z 3 see also DPT vaccine Director-General's Development Programme, 9.29
Directory of on-going research in cancer epidemiology, Io. I 2 Disability prevention and rehabilitation, 1.40, 8.6r-8.72, 8.86, 8.89, I5.28, I5.48, Ij.73-I5.74, Ij.I07, I5.II2 integration, in primary health care, 8.6z, I 5. 74 national programmes, 8.7I, 8.72 research, 8.64, 8.69, 8.7I, 8.89, I5.74 statistics, I 3. I 4 training, 8.64, 8.67, 8.69, 12.I54, I5.48 see also Blindness prevention Disaster relief, see Emergency assistance; Natural disasters and catastrophes Djibouti, 3·45, I4·7 DNA, recombinant, 9·I49, 9.256 Documents (WHO), IH7 see also Health literature services Dominica, 5.2I, I4.I Dominican Republic, 5.24, 6.29, 7.10, I2.5I, IZ.I53 DPT vaccine, 9.I66 Dracunculiasis, 9.2I 5 Drinking-water, I.2I, 9.2I5, IL4, II.2I, I1.29, I5.20, I 5.23 standards, I 1.29 supply, international decade (I98I-I99o), r.4o, 3.2o, 6.66, 9.2I5, II.I-II.20, I2.66-I2.67, I2.174, I3.56, I3.60, I5.I8, I5.23, Ij.p, I5.49, I5.IOI, I 5. I 27 Drznking-water and sanitation, I98I-I990:
a wqy to health,
II.3 Drug information, 8.8-8.9, 8.I9, 8.28
Drug problems in the sociocultural context: a basis for policies and programme planning, 7·34 Drugs, 4.42, 8.2-8.30 dependence and abuse, 7·5, 7.I6-7.22, 7·30·7·35• 8.75, I2.Ij3, I5.38, I5.II8 epidemiology and surveillance, 7·34-7·3 5, 7.4I, 7.66 information systems, 7.66 training in surveillance, 7. 31, 7. 35, I 2. I 53
2 73
THE WORK OF WHO, I98o-I98I
Drugs (continued) effects, in increasing occupational hazards, 8085, Ioo85 on motor-vehicle drivers, 4o29, 70 I9, 8o8 5, 8o86 essential drugs, 3o2I, 3037, 802, 804, 805, 8o8, I5o39 action programme, 2°42, 8.15-8.30 lists, 8oi4, 8oi6, 8oq, I 5o39 monitoring system for adverse reactions, 8oi4 nonproprietary names, 807 policies and management, 5o24, 802, 8oi5, 8oi9, 8020, 8°24, 8o28, 8°30, I5o39> I5o69, I5o72, I5oii9 procurement, 1.24, 707, 8oi7, 8oi8, 8oi9, 8o20, 8023, 8o25, 9oi70 production, national and regional, 8oi6, 8017, 8o2o, 8o28 good manufacturing practices, 8o I4 quality control, 8o2-8o4, 8014, 8°17, 8°19, 8°21, I5o39, I5o69
Educational handbook for health personnel, I 2oll7 Educational technology, 12075, I2o8o, 12oii5, I2oli9I 2o 120, I 5o I 3Z centres, Cairo, 12oi 36 Latin America, 2ol2, I2ol5, 12047, I2oll2, I2oll9, l2oi3'
see also Teachingflearning materials and processes Egypt, 2o46, 4033, p8, 5o23, 6oq, 6046, 6o8I, 7o35, 7°44, 8o54, 9o38, 9o39, 9o40, 9oi05, 9oJ38, l0o74, IOo77, loo8o, ll.I9, 12018, 12°137, 13o23, 15°90, 15o93, I5o99
host agreement with, 1409 El Salvador, 3o42, 5°24, 5°42, 8o67, IZo47, I4o7 Elderly, care of, r.8, 1.40, 801, 8065, 8068, 8o 70, 8.9:o~-8.95, I2oJ3, I3o60, I5o28, I5o73> ljoiii
certification scheme, 8 3 training, 8o14, 8029 registration, 809, 8o24 safety and efficacy, evaluation and monitoring, 809, o
8ol9, I5o69
supplies to countries, 8027, I4o23, I4o26 utilization in treatment, 8oi2, 8023, 8094, I5o70 research, 5ojl, 8oq, 8018, 8024, IOo85, 15069, I5o7I see also Contraceptives, oral; Filarictdes; Malaria, drugs; Medicinal plants; Pharmacology, clinical; Psychotropic substances Dusts, industrial and vegetable, IOo82, IOo84
drug treatment, 8012,8094, I5o7o mental disorders, prevention, 7o26-7o27 nutrition, 8o93 research, 407, 8096 World Assembly on Aging (I982), p 5, 8092 Electronic data-processing, 2o39-2o50, J3o20, 13022 Emergency assistance, 3·30-3·47• 14o23-I4o24 Encephalitis, ] apanese, 5 046 Encyclopaedias, medical, I 50 82 Energy sources, health risks, I r. 3 I Entomologists, training, 90222, 9o223 Environmental health, 1.24, 11.1-11.53, I5oi8, I5o49I5o52, 15o77-15o78, 15oiOI, I5ol27-I5ol28
Eastern Mediterranean Region, I.Io, 2021-2023, 3045, 4o3'-4o35> 5o9> 5o29, 5o42, 5o47, 5o54, 6oi7, 6oi20, 7oi2-7ol3, 7o6I, 802,8024, 8o71, 8o8o, 8o9o, 9o25, 9095, 9oi40, 9oi66, 9oi9I, IOo6, II.I9, 11.26, II.27, 11.34, 11.50, 12o29, 12o3Z, 12049, I2o59, I2o65, 12o82, I2o86, 12o98, I2oll4, I2oi2I, 12oJ32-12oi35, 12oi36-I2oi40, 12oi68, l3o24, I3o40, 15.83-15.103
centres, regional, II.I5, II.26, II.3o, I5oiZ8 criteria, I1.25, II.29, Ir.36 national planning and establishment of agencies,
I I
0
3,
II.4, II.I2, II.I5, II.I6, II.I7, II.26, I5oi8 research, II.25, II.34 training, II.3, II.9, II.I5, II.I6, II.I7, II.20, II.27, II.35, I2o63, I2o66-I2o67, I2o73, I2oi73-I2oi74, I5oiOI, I5ol28, I5oi29
Regtonal Health Development Advisory Committee, !.3 5
see also Chemicals in food and the environment; Sanitary and public health engineering; Sanitation; Sewerage; Wastes disposal; Water supplies Environmental health criteria, I I 02 5, I I 036 Environmental monitoring, II.27, IL34, I5o78 global system, I 50128 Environmental pollution and hazards, II.27-IL35, I5ol28
Ebola virus, 9oi4I, I5o97 ECA, see Economic Commission for Africa Echinococcosis, 9067, 90179, 90 I8o, 9o182, 9.185-9·186, 9o190, l2o I69
ECLA, see Economic Commission for Latin America Economic Commission for Africa (ECA), 6o4I, II.I4 Economic Commission for Latin America (ECLA), I 5o2 I, 1j o26 Economic Commission for Western Asia (ECWA), 12o64 Economic instability, health aspects, 301, 5o35 Economic Order, New International, 1.7, 3011, I5oi Economic and Social Commission for Asia and the Pacific (ESCAP), 1 p 8 Ecuador, 506, 5022, 5o24, 5042, 7035, 7o4I, 8°67, 9°54, 9oll2, 9o211, 12ojl, I2oi)3
emergencies, I 50 78 see also Air pollution; Chemicals; Coastal pollution; Soil pollution; Water pollution Epidemiology and epidemiological surveillance, 4o26, 8o44, 9o7, 9°8, 9oi9, 9o3J, 9°69, 9oi 2 8-9o129, 9oi33, 9oJ38, 9oi4I, 9°178, 9oi88, I5o40, I5o96, I5oi20 programme of WHO, 903, 9oi3 research, 6op, 9oi4I, 9o26I, 90265, IOo30, IOo58 training, 5o3J, 9oi62, 90262, I2oi60-I2oi62, I5o40, I 5oi20 Epilepsy, 7 58 Equatorial Guinea, I 4o I, I 40 7, I 50 I o o
ECWA, see Economic Commission for Western Asia Education, see Health education; Medical education
274
INDEX
Equipment, medical, 8.47, 8.5I, 8.58, 8.82, 8.83, I4.22 repair and maintenance, 5.42, 5.5I, 8.5I, 9·I7I, I2.84, lj.I02 training, 5.42, 9·I7I, I2.84, I5.I02, I5.I09 see also Supplies and equipment ESCAP, see Economic and Social CommissiOn for Asia and the Pacific Escherichia coli, enterotoxigenic, 9· 7 5 Essential drugs, see Drugs, essential Ethiopia, 3.4I, 5.2, 5.3, 5·I5, 9.II, 9·54, 9.78, I2.9, 12.24, 12.I73 European Association of Programmes in Health Services Studies, I 5. 79 European Economic Community, 3.26, I4.8 European Organization for Nuclear Research (CERN), 9·87 European Region, 1.22, 2.I8-2.20, 3·44, 4.26-4.30, 5.8, 5·32, 5·35, 5.46, 6.6I, 6.II9, 7.I1, 7·4I, 7.6I, 8.23, 8.70, 8.89, 9·24, 9·94, 9·I6I, 9·173, 9·I88, 9·I92, Io.6, II.I8, II.24, II.34, I1.49, I2.I2, I2.23, 12.3012.3 I, 12.48, I2.5 3, I2.58, 12.72, I2.8I, I2.106, 12.I13, 12.I43, I2.I47, I2.I54, 13•17, I3.40, I4.13, 15.64-15.82 Advisory Committee on Primary Health Care, 5.8 Advisory Committee on Health Legislation, I 3.40 Advisory Committee on Health Manpower Development, I 5· 79 Health Development Advisory Council, I. 7, I. 3 5, 2. I 8 European Society of Human Genetics, Io.64 European standards for drinking-water, I 1.29 Evaluation of programmes, 2.2 7, 2. 36, 2.38, 9· I 74-9. I 76, 9· 2 31
guiding principles, 2.4 national9.I77, I5.I22 Excreta disposal, I 5.20 Executive Board, I.I8, 1.I9, 1.20, 1.29, 1.30, 1.3I, 1.37, 1.39, 1.40, I.4I, 1.42, 1.44 membership, 1.34, I4.2 organizational studies, L4I, 12.40-I2.4I Programme Committee, 2.3 I-2.p, 10.3 Exercise, see Physical activity Expanded Programme on Immunization, see Immunization
Expert Committee on Disability Prevention and Rehabilitation (I98I), 8.63 Expert Committee on Energy and Protein Requirements, Joint FAOfWHO (I97I), 6.48 Expert Committee on Food Additives, Joint FAOf WHO (I98o and I98I), I1.4o, II.4I Expert Committee on Health Effects of Combined Exposures in the Work Environment (I98o), I0.85 Expert Committee on Implementation of the Convention on Psychotropic Substances (I98o), 7.I8 Expert Committee on Leprosy (I976), 9.8o Expert Committee on Methodology of Nutritional Surveillance, Joint FAOfUNICEFfWHO (I975), 6.49 Expert Committee on the Prevention of Coronary Heart Disease (I98I), 10.34 Expert Committee on Problems related to Alcohol Consumption (I979) 7.42 Expert Committee on Rabies (I972), 9.I84 Expert Committee on the Selection of Essential Drugs (I977), 8.8 Expert Committee on Specifications for Pharmaceutical Preparations (I98I) 8.4 Expert Committee on Tuberculosis, 9· IOI Expert Committee on Vector Biology and Control (I979), 9·2I9 Expert Committee on the Wholesomeness of Irradiated Food, Joint FAOfiAEAfWHO (I98o), II.42 Extrabudgetary sources of funds, 1.I9-1.22, 3.2-3.8, 6.128, 8.63, 9·I68, 9·2I9, I0.70, I2.4I, 12.42, I4.22, I 5.8, I 5. I I-I 5. I 2 Eye health care, 9·54, 9.I56, 9·I57, 9.I6o, 9.I6I, I2.I30 studies on economic aspects, Europe, 4.29 see also Visual impairment
Facts about low-level radiation, I 1. 37 Falkland Islands (Malvinas), 9.I85 Family health, 6.1-6.128, I 5·3 5-I 5.37, I 5·95, I 5. II4I
5•Il7
Expert Advisory Panel on V1rus Diseases (Antivirals and Interferon), 9· I44 Expert Advisory Panel on the International Pharmacopoeia and Pharmaceutical Preparations, 8. 5 Expert Advisory Panel on Traditional Medicine, 8. 75 Expert advisory panels and committees, organizational study, 1.4I Expert Committee on Bacterial and Viral Zoonoses (I98I), 9·178 Expert Committee on the Biological Control of Vectors (I98I), 9.2I7 Expert Committee on Biological Standardization (I98o and I98I), 8.p, 8.35, 8.37 Expert Committee on Diabetes Mellitus (I979), I0.53
indicators, 6.2 integration with general and primary health care services, 6.2-6.3, 6.I9, 6.24-6.25, 6.30, I5.II5 programme financing, 6. 3 records, 6.30 training, I2.146, 15.35 see also Maternal and child health Family planning, 6.5, 6.6, 6.I8, 6.8o, 6.II9, I5.II5 integration in primary health care, 6.68, 6. 72, 6. 7 3, 6. 79 International Conference, Djakarta (I98I), 6.93 national programmes, support, 6.23-6.27 psychosocial aspects, 6.70, 6.72, 6.74-6.75, 6.8I, 6.82, 6.n8, 6.I25, 7.24 research, 6.40, 6.I2I, 6.I25 staff, medical and nonmedical, 6.72 role of nurses and midwives, 6.78, 6.79
275
Family planning (contmued) training, 6.24, 6.26-6.27, 6.76-6.78, 6. I 20, 6. I2 I, I 2.87, I2.88, I2.I44, I2.I45, I2.I46, I5.II5
see also Fertility regulation; Human reproduction F AO, see Food and Agriculture Organization of the United Nations Fellowships, 1.42, 7· I 5, 8.2, 9.30, 10.31, Io.88, 12.4I, 12.48, 12.54-12.61, I2.I23, I2.I31, I2.I54, I2.I57, I2.I63, I5.84, Ij.89, I5.I34
programmeregionalization, I2.55, I2.56, I2.57, I2.6I, I 5·58
studies on utilization, I 2.6o, I 2.62 Fertility, 6.5-6.6, 6.74, I3.I5 Fertility regulation, 2.42, 6.5, 6.I2I, 8.75, I2.I46, I5.II4, I 5. I I 5
microbiological aspects, 9· I 92, 9·193-9.197• I 2.170 training, 9· I 92, I 1.4 7, I 1.49, I 1. 5o see also Infant and young child feeding Food safety services, I I ·49 Food standards and criteria, 9.I96, I 1.43-I 1.45 Foodborne diseases and food poisoning, 9.I8I, 9.I82, 9.I87, 9.188, 9·I90, I1.49, II.jl, I5.I05 training, I2.I69 Foot-and-mouth disease, 9· I 79 Formulating strategiesfor health for all by theyear 2000 ,guiding principles and essential issues, I. I 2 France, 3·4, 7·44, 8.58, 8.89, 9.I84, IO.I5, 12.72 Front-line States, assistance to, 1.45, I5.I3
research 4· I 5, 6. I I7, 6.126 natural methods, 6. Ioo-6. IOI new methods, 6.93-6. Io7 safety and efficacy, 6.83-6.92 Fibre, dietary, Io. 17 Fibres, man-made, health hazards, I0.2I-I0.22 Fiji, 2.24, 2.25, 3·46, II.5I, I2.73, 12.78, I2.83, I2.I62 Filarial infections, 9·47-9·57• I 5. I 20 chemotherapy and chemoprophylaxis, 9· 5 I, 9· 55, 9· 569·57
diagnostic techniques, 9.242 research, 9· 55-9.5 7, 9·240-9.242 vector biology and control, 9·209, 9.242, I 5.46 see also Onchocerciasis Filaricides, 9·51, 9·5 5-9.57, 9.240-9.24I Films (WHO), I 3.6o Finland, 5. I 8, 6.4, 6. 128, 7.42, 8.89, 9· I68, I0.4, Io. 5, 10.33, I0.36, 12.72, I5.76
Gabon, 9·39, 9.2I4, 12.9 Gambia, 3·4I, 5·5· 9.I36, 12.43, 12.93, 14.23 Gammaglobultn, 10.93 General Programmes of Work of WHO, 2.27 Seventh, 1.29, 2.2, 2.31-2.33, 2.35-2.36, 7.I, I5.27 Sixth, 2.2, 2.34, 2.35, 7.I Genetic disorders, Io.6I-Io.65 Genetic engineering, 9·I49, 9.235, 9.256 Genetic markers, I0.64 Genetics, human, Io.6I-Io.65 research centres, Io.62, Io.64 Genital ulcers, 9· I 53 Geriatrics and gerontology, see Elderly, care of the German Democratic Republic, 3.52, 10.36, I0.74 Germany, Federal Republic of, 3.4, 6.4, 6. 128, 7.56, 8.I I, S.jj, 8.58, 9.I84, I0.12, I0.36, II.3I, I2.I41, I2.I58
Gesellschaft fur Technische Zusammenarbeit (GTZ), 9.2I4, II.3, II.I2, II.I6, II.I9, I5.I8
Fish, larvivorous, 9.2I7, 9.260 Fish and shellfish hygiene, 9·I97, I5.I05 Flea control, 9.2 I 3 Food additives, I1.23, II.40-II.4I Food and Agriculture Organization of the United Nations (FAO), I1.35, I1.38 joint activities, I 3.42 communicable diseases, 9.212, 9.2I8, 9.223, II.9 food safety and hygiene, 9·I93· 9·I95, 9.I96, 9·I97, IO.I8, I1.39, II.40-II.46, II.50, II.53, I2.I68
Ghana, 3·4I, 5·5, 6.64, 7.6I, 9.38, 9·39, 9.42, 9·43, 9.52, 9·57, 9.136, 9.238, I2.I27, 13.6o
human reproduction, 6.4 nutrition, 6.4I, 6.48, 6.49 rural development, 5. I 6, 6.66 zoonoses, 9· 178, 9· I 86, I 2. I 68 Food contamination and hazards, I 1.39 joint monitoring programmes (FAO/IARCJUNEP/ WHO), Io.I8, I1.46, IL53 see also Chemicals Food and foodstuffs, fortified, 6. 54-6.5 5 irradtated, I 1.42 weaning foods, 6.47 see also Breast-mtlk substitutes Food safety and hygiene, 4· I 2, 4· I 3, 9· I So, 9· I 8 5, 9· I 89, II.39-II•53• I5.52
Global strategy for health for all by the year 2000, 1. I 2 Glossartes, I3.35, I3.46, 13·47 Glossina, see Tsetse fly Goitre, endemic, 6. 52 Gonococcal infections, 9· I 52, 9· I 53 Governing bodies, see Executive Board; Regional committees; World Health Assembly Greece, 3·7, 7·44, 10.32, Io.76, Io.So Grenada, 5.2I, 7.Io GTZ, see Gesellschaft fiir Technische Zusammenarbeit Guam, 9.IIo, 12.33, I2.73 Guatemala, 5.21, 5.24, 5.28, 6.46, 6. 55, 9·54, 9.2 I I, I 1. I 5, 12.47, I2.jl
Guide to trachoma control, 9· I 64 Guidelines for evaluating a training programme for health personnel, I2.I38 Guidelines for training community health workers in nutrition, 6.44
Guides, technical, 9.85, 9.I64, 9.I97, Io.67, II.26, 12.I6, 12.76, I2.88, 12.I17, I2.I25, I2.176
see also Manuals, techntcal Guinea, 6,64, 9.2 I I
INDEX
Guinea-Bissau, 9· 2 I I Gulf Arab Development Foundation for the United Nations, 3.8 Guyana, 5.24, 5.28
Habitual phystcal activity and health, I0.43 Haemorrhagic fever, 9·140-9.142, I 5·97 vaccine, 9· I42 see also Dengue and dengue haemorrhagic fever Haiti, 5.24, 9·5 5, I I. I 5, I r.I6 Headquarters, accommodation, I4.I9 structures and functions, r. 30 Health, attainment by the year :woo of a level permitting a socially and economically productive life, 4.2, 4.30, 13.20, I3.53-I3.54, I3.58, Ij.I, Ij.20
global strategy, r. I, 1.9, r. IO, 1.12-1.18, 1.28, 1.29, 2. I2.3, 2.p, 3·I2, 6.67, 12.3j, 13·3· I3.IO
monitoring and evaluation, r.6, r. 7, r.8, r. I7, r. I 8, 6.20, I3.2, I3.I2, I5.5, I5.30, Ij.66
indicators, 1.7, r.I7, 13.2, 13.Io, I5.66 national and regional strategies, 1.2-1.29, 1.30, 2.3, 2.6, 2.7, 2.IO, 2.II, 2.I8, 2.22, 2.24, 2.33, 6.5, 6.30, 6.39, 7.2, I2.II6, I5.3-I5.4, I5.I5, I5.17, I5.23I5·3l, I5.32, I5.64-I5.66, I5.85, I5.I04 political support, 1.23-1.28 resources, mobilization, LI5, r.I9-1.22, 3.2, I5·32 "Health for All" Series, 13.3 I, I 3·4 7 Health care, delivery, 1.7, r.8, 1.24, 5.20, 13.21, I5.24I5.25, I5.64, I5.93, I5.I06 costs, 2.20, 5.34-5 .36, 12.46, I 3.6 facilities, development, 5.27, 5.30, I5.I09
Health laboratory services, see Laboratory technology and services Health legislation, 1.42, 6.9, 6.34, 6.8o, 8.I6, 8.28, 8.77, 9·4I, 10.47, I2.I06, 13•38·13•43> I3.57, 15.69,15.74 Health literature services, 13·23-13·28, I5.57, 15.I36 see also Guides; Manuals; Teaching/learning materials; Textbooks Health management, 1.24, 1.42, I2.I9, 12..90, I3.3, 15.96 information systems, 2.46, 12..43, I5.6I, 15.I35 training, 2.5, 2.8-2.9, 2.I2, 2.I3, 2.23, 5.25, 5.26,12.40U.49, 12..99, Ij.80, I5.89 organizational study, 1.41, 12..40, 12..4I Health manpower, see Manpower development, management and planning Health planning and programmes, national, development, 1.24, 2.1-2.2S, 3.1, 5.2I, I5.6I conference, interministerial, Dakar ( r 980 ), 2. 7 guiding principles, 2.2 training in management, 2.13, 2.17, 2.24, 12.46 see also Country health programming; Environmental health, national planning; General Programmes of Work; Health for all by the year 2000, national and regional strategies; Programme of WHO Health programme evaluation: guiding principles, 2.4 Health records, see Medical records Health sciences, training centres, meetings of deans and directors, Africa, I2.75, 12..92, 12..127 Health services, development, 1.3, 1.4, S·I·S·s8, I5.I5, I5.I6, I5.2I, 15.24-I5.25, I5.34, Ij.67, I5.I06I 5.II3 financing, 4.14, 5·3, 5.7, 5.24, S·33-S·36, 12.46 information, 5·3, 5.24
patient management, I 2. I 8 research, 4· 2 7, 5. 53 see also Primary health care Health conditions in the Americas, I97?-zg8o, 13.I6 Health economics, 4.29, 5·33, 5·35, 5.36, 5·53, 12.46 Health education, 1.7, r.8, 1.40, 1.42, 6.s9-6.66, 13.58, I3.64, I5.II7
institution strengthening, 5. 3, 5. 5 planning and management, 5.3, 5·5, s.18-s.36 study of coverage, Eastern Mediterranean, I 5·93 see also Health management; Health planning and programmes, national, development; Manpower development, management and planning Health services research, 1.14, 2.17, 4.2, 4.3, 4.6, 4.14, 4.16, 4.18, 4.23, 4.28, 4.32, 4·37, 4.38, S·49-s-s8, 6.28, 6.31, 6.40, 6.70, 6.78, 6.79, 6.82, 6.II8, 6.119, 6.125, 12..90, Ij.J4, 15.59, 15.74, 15.86, 15.93 newsletter (Eastern Mediterranean), 5·54, 15.103 training, 4·I4, 4.29, 4.32, 4·33· 5.50, 5·54, 5.56, 5.58, 6.28, 6.82, 6. II9
in acc1dent prevention, 8.85 in breast-feeding, 13.56 incommunicable disease control, 6.6o, 6.63, 9·5 5, 9.82, 9·96, 9.I24, I5.96, I5.II7
in in in in in in in
environmental health, 6.6o, II.8, II.I7, Ij.II7 family health, 6.35, 6.39, 6.62, Ij.II7 mental health, 7·47 noncommunicable disease control, Io.6, 10.36 nutrition and food safety and hygiene, I r. 52 occupational health, 8.85, Io.8I tobacco, alcohol and drug abuse control, 10.47, IH7
Health statistics, see Statistics Health teams, r2.p, 12.68, 12.75, 12.90, 12.1oo-12.102, I2.IIO, I2.120, 15.54
Helen Keller International (Foundation), 6.54 Helminthic and protozoal infections, intestinal, 9.66-9.67 Hepatitis, viral, 9•130, ro.r9-10.2o, 15.122 vaccmation and vaccine, 8.32, 15.I22 see also Liver cancer and other chronic liver diseases Herpes virus, 9.144 Hipolito Unanue Agreement, 5.28 Histological classification of tumours, ro. r I
integration in primary health care, 6.6o, 6.65, I2.150, IH7
Pan African Conference (I98I), I2.I4'9 research, 6.6o, 6.6I training of staff, 6.65, I2.q8, 12.I49-I2.I52, 15.II7 regional ceqtres, 6.65, I2.148
THE WORK OF WHO, I98o-I98I
Honduras, 5·I5, 5.2I, 7.4I, 12.47, I2.p Hong Kong, 6.40, 7.65, 9.Io6, I2.I22 Hormones, in food, I 1.4I Hospitals, planning, administration and maintenance, 5·29, 5·30, 5·53. I3.I7
Indicators of health status, 5·32· 6.2, 6.5, 6.I7, 6.20, 6.50 Indonesia, 3·43, 5.7, 5.23, 5·45, 6.55, 6.79, 8.20, 8.2I, 8.22, 8.54, 8.69, 8.95, 9.27, 9·55, 9·57, 9.92, 9·93, 9· I05' 9·I IO, 9· I 37> 9·203, 9·204, 9·205' 9·209, 9·213, 9-222, I0.62, I0.77. II.34. II.48, 12.9, I2.I2, 12.27, I2.63, 12.87, I2.120, 12.I6o, I5.42, I5·44 Industrialization, 8.84, I 5. IOI Infant and young child feeding, I. 39, 6.7-6.1o, 6.45-6.48, I2.J78, I3.42, I5.II5-I5.II6 joint FAO/WHO/UNU consultation (I98I), 6.48 Infant mortality, 6.I5, 6.I6, 6.45, 6.108, 13·I4, I3.I5, I 5.20, I 5.2 3, I 5·99 Infertility, 6.5, 8.75 research, 4· I 5, 6. 70, 6.1o8-6.11o Influenza, 9· I 28-9. I 29 Information of the public, see Public information InformatiOn systems, 1.24, 2.39, 2.4I-2.42, 2.46, 2.50, 5.24, 7.66, 9·I9, 9.85, 9·I45, 9·I76, II.I5, II.J7, 12.37, 12.43, I2.I77> 13.2, I3·4-I3·5• I5.6I, I5.66, I 5. I 3 5 global programme, 2.39-2.50, 9·J7o, 9·I74 regional offices, 13. I o-13. II Insecticides, application, evaluation and testmg, 9·499·50, 9·51, 9·63, 9-203, 9·204-9-205, 9-207, 9-209, 9.21I, 9.212, 9·2J3, 9.221, 9.246, 9.264 equipment, 9.6o, 9.206, 9.2Io training, 9.223 resistance of vectors, 9.23, 9·49, 9.50, 9.202, 9.203, 9.21I, 9.2I3, 9·237 see also Larvicides; Pesticides
statistics, 13.6 training, 5.30, I5.I09 see also Medical records; Nosocomial infections Hospitals in the Americas, 13.I6 Human experimentation, I 3.42 Human genetics, see Genetics, human Human reproduction, I 1.25 research, development and research training, special programme, 2.42, 4· I 5, 6.67-6.128 financing, 6.4, 6. I 28 information dissemination, 6. I 26-6. I 27 institution-strengthening, 6.4, 6.69, 6. 70, 6.82, 6.III-6.I2I
training, 6. I 2 3 grants, 6. I 2 I, 6.122, I5. I05 see also Family planning; Fertility; Infertility; Sterilization ' Hungary, 3·52, 6.40 Hydatidosis, 9.67, 9· 179, 9.I8o, 9· I82, 9.185-9·186, 9·I90, 12.I69
Hypertension, arterial, 6.I7, 6.I9, I0.42, I 5.I25 WHO community control project, I0.39
IAEA, see International Atomic Energy Agency IARC, see International Agency for Research on Cancer ICAO, see International C1vil Aviation Organization Iceland, 12.97 ILO, see Interational Labour Organisation IMCO, see Inter-Governmental Maritime Consultative Organization Immunization, 1.3, 6.25, 6.35, 9.Io6, I5.23, I5.85 Expanded Programme, I.2I, 1.42, 2.42, 3.20, 3.2I, 5·55,6.I6,9·7I,9.I33,9·16S-9·177• 12.I31, I5.45, I5.IOO, I5.I22 global advisory group, 9·I74 information systems, 9·I70, 9·I74, 9·I76 national programmes, 9.I65, 9·I77 research, 9.I72-9.273, Io.64 training, 9.I68, 9·I7I, 12.I3o, 12.I31, I5.Ioo Immunoglobulins, 8.38, 8.39 Immunology, 4.38, 9.Io6, 9.233, 9·235-9.236, 9.239,
Institute of Nutrition of Central America and Panama (INCAP), 6.44, 6.46, 6.49 Inter-American Development Bank, 1.22, 3·5, 5.2I, II.I6, I5.2I
Interferons, 9·I43, 9·I44 Inter-Governmental Maritime Consultative Organization (IMCO), 9·I47, Io.8I, "·35 Intergovernmental organization, (Annex 3) International Agency for the Prevention of Blindness, 9·I59
International Agency for Research on Cancer (IARC), I0.2, 10.4, IO. 5, 10.12-10.32, I 1.22, I 1.46, I 3.28 publications Io. I 2, I0.24-Io.2 5 International Air Transport Association, 9· I47 International Atomic Energy Agency (IAEA), 8. 56-8.57, 8.59, 8.6o, 10.42, Io.82, II.3I, "·37• I1.38, II.42, I2.Ij8, 12.I59 International Children's Centre, 6.4, 8.8 5, I2. I46 InternatiOnal Civil Aviation Organization (ICAO), 9· I4 7
10.88-10.94 centres for research and training, Io.88, Io.89, I2.172 Inde:x medicus, 4.I6, 4.20, 13.27 India, 2.I 5, 3.26, 5.7, 5.I 5, 5.I6, 5-45, 5·52, 6.4, 6.29, 6.40, 6.64, 6.66, 6.79, 6.IJ7, 6.128, 7.64, 8.59, 8.64, 8.69, 8.88, 8.95' 9· 5' 9-II, 9·27, 9· 55' 9· 57. 9·64, 9· 78, 9·92, 9·93• 9.Io6, 9.202, I0.64, II.27, I1.34, II.48, I2.I8, 12.42, I2.87, I2.89, I2.I20, I2.Ijl, 13·I7, I5.38, I5·4 2
International Classification of Diseases, I 3. 7- I 3·9 centres, I3·9 Ninth Reviswn, I3·7 Tenth Revision, 13.8 International Classification of Impairments, Disabilities and Handicaps, I3·7· I5·74 International Classification of Procedures in Medicine, I3·7
INDEX
International Code of Marketing of Breast-milk Substitutes, 1.39, 3.22, 6.7-6.9, 6.p, I3.33, 13.56, I 5·95 International College of Surgeons, 8.83, I2.IOo International Commission on Radiation Units, 8. 58 International Commission on Radiological Protection, 8.58, II.37 International Committee of the Red Cross, 3. 3 5 International Computer Centre, 2.45 International Conference on Apartheid and Health (I98I), 1.45, I5.IO International Conference on Family Planning in the I98os (Djakarta, I98I), 6.93 International Conference on Global Impacts of Applied Microbiology, Sixth (I98o), 9.90 International Conference on Islamic Medicine, Second (I982), 8.8o International Conference on Primary Health Care (I978), I.I2, 12-79 International Congress on Medical Librariansh1p, Fourth (I98o), I p8 International Congress of Radiology, Fifteenth (I98I), 8.5 3 International Council on Alcohol and Addictions, 7.40 International Council for Laboratory Animal Science, 9-200 International Council of Nurses, I2.I4, I2.69, I2.IIO International Council of Scientific Unions, 9-I49 International Council of Women, 3·49 International Court of Justice, I4-9 International Development Strategy, 1.28, 3. I I International Diabetes Federation, Io.56 International Digest of Health Legislation, I3-4I, q.8 International Drinking Water Supply and Sanitation Decade (I98I-I99o), 1.40, 3.20, 6.66, 9.2I5, u.xu.2o, I2.66-I2.67, I2.I74, 13.56, I3.6o, I5.I8, I5.23, I5.49, I5.IOI, I5.I27 International Economic Order, New, 1.7, 3-II, I5.I International Electro technical Commission, 8. 58 International Eye Foundation, 9.I6o International Federation of Anti-Leprosy Associations, 9·83 International Federation of Gynecology and Obstetrics, 6.4 International Federation of Health Records Organizations, 13.6 InternatiOnal Federation of Hygiene, Preventive Medicine and Social Medicine, I 2. I oo International Federation of Pharmaceutical Manufacturers Associations, 8.29 International Federation of Surgical Colleges, 8.83 International Health Regulations, 9·3 additional regulations, I4.6 International Histological Classification of Tumours, 10.1 I
International Institute for Soc1al Studies, 6.6 3 International Labour Organisation (ILO), 6.66, 7-40, 8.69, 8.86, 10. 77, IO. 78, IO. 79, I0.80, I0.8I, I0.82, I0.87, II.9, II.22, II.23, II.37, II.38, I2.63 International League against Rheumatism, I0.59 International Leprosy Association, 9.83 International medical guide for ships, Io.8I International Nomenclature of Diseases, I 3.48 International Organization of Islamic Medicine, 8.8o International Paediatric Association, 6.4, 6.I8 International Pharmacopoeia, 8.5-8.6 International Planned Parenthood Federation, 6.4, 6.40 International Programme on Chemical Safety, 4.28, II.22-II.2S
International Radiation Protection Association, I I. 38 International Society and Federation of Cardiology, 10-44, 10-45 International Society of Prosthetics and Orthotics, 8.8 3 International Society of Radiographers and Radiological Technicians, 8.53 International Society of Radiology, 8.53 International standards for drinking-water, I I .29 International Telecommunications Union, 3.I 5 International Union against Cancer, 9.I98, 10.4, I0.5 International Union of Health Education, 6.4, I2.I49 International Union of Immunological Societies, I0.93 International Union of Nutritional Sciences, 6-4 International Union against Tuberculosis, 9· I I 2, 9· I I 5, 9.II6, 9-I2I, I0.58 International Vitamin A Consultative Group, 6.54 International Year of Disabled Persons ( I98I), 1.40, 3-I5, 8.65, 8.68, 8.85, 8.89, 9.I6I, 13.60, I5.73, I5.II2 Intersectoral coordination in health and environmental management: an examination of national experience, I I. 2 5
Intrauterine devices, 6.86, 6.87-6.88, 6.96-6.97 Iran, 3·45, 5. I 5, 9.25 Iraq, 2.22, 8.7I, 9·38 Ireland, 7.42 Irrigation, see Water resources and river basin development projects Ischaemic heart disease, 10.3 5, 10.36, 10.4I, 10.44, I 5. I2 5 Islamic Development Bank, 3.5, 3.8 Israel, 2.23, 6.40, 8.7I, 9-IIo, 10.36, 12.7I, I5.89 Italy, 3·44, 7.56, IO.I6, Io.62, 12.97, I4.23 Ivory Coast, 9.8, 9·49, 9.58, 9.6I, 9.202, 9.204, 9.2I2, 9-2I6, II.34, I2.I6I
International Institute of Applied Systems Analysis, I3.22
Jamaica, 3.42, 5.3, 5-I5, 5.I6, 5.24, I2.65, 12.7I Japan, 7.56, 8.I4, 8.zi, 9-III, I2.I67, I5.I25 Japan Shipbuilding Industry Foundation (Sasakawa Memorial Health Foundation), 3-4, 9.84, 9·93, 9·I58, 9.I68 Joint Commission on International Aspects of Mental Retardation, 7.29 Joint Committee on Health Policy, UNICEF/WHO, 3.24, 5.I-5.2, 9.82
2
79
THE WORK OF WHO, I98o-I98I
Joint Committee on the Health of Seafarers, ILO/WHO (I98I), I0.8I
combined leprosy and tuberculosis activities, 6.6o, 9·89, 9·9I
Joint Committee on Occupational Health, ILO/WHO (I98I), Io.78, Io.87
Joint FAO/IAEA/WHO Expert Committee on the Wholesomeness of Irradiated Food (I 980), I 1.42 Joint FAO/WHO Expert Committee on Energy and Protein Requirements (I97I), 6.48 Joint F AO/WHO Expert Committee on Food Additives (I98o and I98I), I 1.40, I L4I Joint FAO/WHO Food Standards Programme, II.43 Joint FAO/WHO meetings on pesticide residues (I98o and I98I), IL39 Joint FAOfWHOfOAU Regional Food and Nutrition Commission (Africa), 6.4I Jordan 8.7I, Io.76
diagnostic techmques, 9· 2 54 immunology, 9.232 information system, 9.85 primary health care approach, 9.83, 9·9I, 9.92, 9·95 research, 9.88, 9.90, 9.92, 9·93, 9·97, 9.232, 9·2539·255• I 5.42
Kellogg Foundation, 2.12, 12.45 Kenya, 5·5, 6.40, 6.74, 6.79, 7.4, 9.40, 9.42, 9.58, 9.Io5, 9.I22, 9.2I2, I0.76, I2.I6, I2.I26, I2.I73
training in control, 9.82, 9.83, 9·9I, 9·93, 9·95, 9·96 vaccines 9.8I, 9.253 Leptospirosis, 9· I 79, 9· I 90, I 2. I 69 Lesotho, 5·5· 7.4, 9.2I, I2.I8 Liberation, national, health aspects, I .42 Liberation movements recognized by OAU, health cooperation, 1.45, 3·47, I5.I3 Liberia, 5.5, 9.42, I2.43, I2.93, I2.Ioo Libraries, see Health literature services; Medical libraries Libyan Arab Jamahiriya, 5.9, 9.IIo Life table and mortality analysis, 13. I 5 Life-styles, see Behavioural sciences Liver cancer and other chronic liver diseases, IO.I8I0.2o, I2.I7I, I5.I25
Kiribati, 2.24, 6.6o, 6.65, 8. 76, 9· rro, I4· 7 Kuwait, 2.I9, 2.46, 3.4, 6.I7, 7.22, 7.6I, 10.92, I1.34, I2.J40
Long-term planning, 2.33
Laboratory ammals, health, breeding and management, 4·7, 9-200
Macao, Io.76 Madagascar, 3·4I, 9.38, 9.42 Malaria, r.2I, 1.42, 6.6o, 6.86, 9·14-9·34• I5-4I, I5.I2o, I
Laboratory equipment, 8.47, 8.5I, I4.22 Laboratory services and technology, 6. I 24, 8.44-8.p, 9·I31, 9·I45, 9·I5I, I5.II3
5. I 2 I
training of personnel, 6.I2o, 8.45, 8.46, 8.49, 9·IH9·I34, I2.II8, I2.I32, I5.II3 see also Collaborating centres; Microbiological labora-
advisory committee (global), 9·I9 Asian Conference, Seventh (I98o), 9·34 certification of eradication, 9.2I, 9.26, I5.I2I chemotherapy and chemoprophylaxis, 6.63, 9.I8, 9.28, 9·233-9·234, 9·236, 9·237
tories; Drugs, quality control Language services of WHO, I3·44-I3·45 Lao People's Democratic Republic, 6.6o, 8.27, I2.78, I4.22, I5.I2I
coordination between countries, 9.20, 9.22, 9.23, 9.24, 9·26
Larvicides, 9·49, 9·54, 9.I86, 9.202, 9.2II, 9.2I6, 9.246, 9·258
conferences, Europe, 9.24 intercountry border meeting, I 5·4 I drugs, resistance of parasites, 9.23, 9·32· 9.232-9.234, 9.237, I2.I66, I5.I2I
Larvivorous fish, 9.2q, 9.26o Las sa virus, 9· I 4 I Latin American Association of Schools of Public Health, 12-95
Latin Amerrcan Centre for Educational Technology in Health, 2.12, I2.I5, 12.47, I2.II2, I2.II9, I2.J3I Latin American Centre for Perinatology and Human Development, 6.22 League of Arab States, 3.8 League of Red Cross Societies, 3·35, 6.66 Lebanon, 1.46, 3·45, 5.29, 6.6o, 8.7I, II.I9, q.23 Leishmaniasis, 9·64-9.65, I 5.46 research, 9.65, 9.232, 9.249-9.252 Leprosy, 5-4I, 9·78-9.97, I5.120, I5.I23 chemotherapy, 9.78-9.8o, 9·9I, 9·93, 9·97, I5.I23 drug resistance, 9· 78, 9· 79, 9.8o trials, 9.255, I5.42
trials, 9.228, 9.232-9.234 epidemiology, 9·I9, 9·31 (Fig. 9-I) immunology, 9.233, 9.23 5-9.236 information system, 9· I 9 medium-term programme (WHO), 9.I6 national programmes, 9.27 prevention of reintroduction, 9.2o, 9.26 primary health care approach, 5.8, 9.I8, 9.22, 9·34 demonstration area, 9· 33 programme financing, 9.I6, 9.22 research, 4.I2, 4.I8, 9·31, 9·32, 9·34, 9·233-9.237, 9.26I, 9.264, I2.I65, I5.4I
revised strategy and action programme, 9.16-9.20, 9·23, 9·30, 9·32
strategy, African Region, 1.42, 9· I 8 training, 9.22, 9·29-9·32, 9·34, 9.223, I2.I63-I2.I66 centre, I5.I2I
280
INDEX
Malaria (continued) vaccine, trials, 9.23 5 vector control, 9.26, 9.:107-9·:~o8, 9.237, I5.46 biological and environmental, 9.208, 9.2I9 insecticides, 9· 206, 9· 207 resistance of vectors, 9.23, 9.202, 9.237 Malawi, 5·5, 9.38, 9.42, 9·54, 9.2I4 Malaysia, 2.24, 2.25, 2.48,4.37, 5.3, 5.11, 5.I8, 5·55, 5.56, 6.29, 6.40, 6.6o, 6.62, 6.8o, 7.22, 9.26, 9.29, 9·57, 9·78, 9-IIO, 9.116, 9-I22, 9-I25, 9·2I3, I0.33, 10-77, I2.9, I2.7I, 12.78, I2.87, I2.I22, I2.I23, I2.I52, I2.I64, 13.64, I5.II5, I5.I2I, I5.I25 Maldives, 8.79, 9.27, I2.S7 Mali, 2.7, 3·4I, 9.40, 9.42, 9·57, 9.78, 9.116, 9.211, 9.2I4 Malnutrition, 1.3, 6.7, 6.I6, 6.17, 6.4I, 6.42, 6.43, 6.45, 6.46, 6.47, 6.48, 7·45, 9.68, I0,54, I0.85, I5.20, I5.34, I5.116 see also Nutritional deficiencies Malta, I0.54 Management, see Health management; Programme of WHO, general development and management
Managmal process for national health development: guiding principles, 2. 3 Manpower development, management and planning, I .4, 1.13, 1.24, 1.26, 5.5, 1:1.1-1:1.180, I5.I5, I5.I9, I5.2I, I5.53-I5.58, I5.79-I5.8o, I5.88-I5.9I, I5.96, I5.I29-I5.I34 assessment of performance, I2.I6, I2.I42-I2.I43 career structures, I 2.63, I 5·94 community-oriented educational programmes, I2.47, I2.jl, I2.77, I2.80, I2.82, I2.I09, I2.112, I2.I29 continuing education, I 2.4I, 12.42, 12.so-12.53, I 2. 70, 12.98, I2.IOO, lj.56, I5.I29 curricula, I2.I4, I2.I5, 12.7I, I2.82, I2.83, I2.9I, I2.100, I2.110, I2.113, I2.115, I5·35, I5.130, I5.I33 directories, I2.85-I2.86 evaluationofprogrammes, I2.I36-I2.I4I, I5.88, I5.90 indicators, I2.37, I2.I37 information service, I 2. 7 information systems, 12.37 integration with health services development, I2.2212.24 international migration, I2.1, I2.5o, 12.64-12.65 medium-term programme of WHO, 12.5-I2.6 primary health care approach, 12.Io, I2.15, I2.79, 12.82, I2.9I, I2.93, 12.99> 12.100, I2.109 projections, 12.35-12.36 regional centres, Africa, 6.6 5 research, 4·34, IZ.8-IZ.ZI, I2.29, I2.34, 12.38-I2.39, 12.42 review of policy (I948-I98o), 12.8-I2.10 selection of applicants, 12.17, I2.124 statistics, I2.31, I3.6, I3.I4 training in management, 2. I 5 see also Auxiliary health personnel; Educational technology; Health management, training; Medical
education; Public health training; Teacher training Manuals, technical, 3.36, 4·35, 5.26, 5·33, 6.44, 6.48, 6.65, 6.i09, 7·5, 7·9, 8.28, 8.52, 8.62, 8.85, 9·4I, 9·73, 9·148,9.I55,9-I88,9.262, I0.81, I0.84, 11.35, II.36, 12.i6, 12.I8, 12.88, 12.I42, 12.I80, I3.I5, I3.16, I 3·3 3 see also Guides, technical Marburg virus, 9·I41 Marine pollution, 11.34, 11.35, I4.8 Maternal and child health, 1.26, 6.1s-6.4o, 6.62, 9.18, 9.177, I2.20, I2.I47, 13·15, I5·34, 15.85 national programmes, support, 6.23-6.27 research, 4.6, 5·57, 6.I9, 6.20, 6.22, 6.24 risk approach, 6.28-6.p, I2.I44, I5.35, I5.I15 statistics, 1 3. I 5 training, 6.22, 6.24, 6.26-6.27, 6.3o, 6.3 I, I2.87, I2.88, I2.I45, I2.I46, I5.115 Maternal mortality, 6.17-6.18, 6.I9, 6.57, 13·14, I3.I5 Mauritania, 2.7 Mauritius, 3.4I, 5·5, 9.2I, 9.27, 9.42, 10.33, Io.76, I0.77, I 3· I 5 Measles, immunization and vaccme, 8.35, 9·I34, 9.I66, 9·I67, 9·I72, I5.23 Meat hygiene, 9.I85, 9·195-9·196 Medical assistants and auxiliaries, I2.83, I2.I33 Medical care, see Health care Medical education, 12.59, 12.74-12·78, 12.98, I2.115, I2.I22, 12.Ijl, I5.79-I5.80, I5.9I continuing education of physicians, 12.1 oo curricula, I2.77, I2.10o, I2.11o medical textbooks, provision of, I 2.179 primary health care approach, I 2. 100, 1 5. So Medical libraries, 4.20, I3.23-13.25 meetings of librarians, 4.I6, 13.24, 13.28 regional libraries, 2.12, 4.20, I2.175, I5.57, I5.136 traming of librarians, I2.175, 13.27, 13.28 Medical records, I 3.4, 13.6, I 5. I 35 Medical schools, 12.76, I2.77, I2.85, I5.8o meetings of deans and directors, I2.75, I2.76 see also Medical education Medicinal plants, 8.28, 8.73, 8.76, 8.78, 8.79, I5.I07, I 5.119 Mediterranean sea, pollution, II.34, I1.35, J4.8 Medium-term programming, 2.27, 2.34-2.36 gmdelines, 2.36 MEDLARS, 13.25 Membership of WHO, J4.I (Annex 1) Meningitis, see Cerebrospinal meningitis Meningococcal vaccines, 8. 32 Mental health, 1.24, 7.1-7.67, 8.86, I5.38, I5.118 action group, African Region, 7·4-7·8 community services, 7.11, 7.13, 7.50, I5.118 drug treatment, 7·54-7·55 global coordinating group, 7. I integration in primary health care, 7.2-7.3, 7·47, I2. I 8, I5.118
281
Mental health (continued) national coordination groups, 7.8 natiOnal programmes, development and support, 7.6I7.67
Nepal, 3·43, 5.2, 5-3, 5·7, 6.66, 8.20, 8.49, 8.54, 8.59, 8.69, 9·92, 9·93, 9.II0, 9.II2, 9·I58, II.17, 12.27, I2.126
Netherlands, 2.Io, 3.4, 3.7, 5.21, 5.38, 6.4, 6.I28, 7.22, 7.42, 9.62, 9·I32, 9·I58, 9.I68, 9.210, II.8, I2.IOO
research, 4·3· 4.29, 7.3, 7.6, 7.28, 7·44, 7·47-7·6o, 7.64, 7·67
self-help, 7.23, 7.25, I5.38 statistics, I 3. I 9 training, 7·5, 7.I2, 7·I4, 7·I5, 7·47, 7·51, 7·54, I2.95, U.153-I2.157• I5.38, I5.II8 Mental retardation, 7.5, 7.29 Mentally disabled, I 2. I 54, I 5. 38 Methods of assessment of avoidable blindness, 9.I64 Mexico, 5.42, 6.9I, 7·4I, 7.56, 7.66, 8.64, 8.67, 9·54, 9.I05, 9.IIO, 9·I22, 9.2II
Neurological disorders, 7.56-7.59 traimng, I2.I53, I2.Ij6, I2.I57 New Hebrides, see Vanuatu New International Economic Order, 1. 7, 3. I I, I 5. I New Zealand, 5.30, 9.I85, 10.33, I5.I09, I5.I25 Nicaragua, 3.42, 5. 3, 5.24, 6.29, 9.64, 9· uo, 9· I I2, 12.47, I 2.5 I
Niger, 6.63 Nigena, 5.I8, 6.4, 6.40, 6.8o, 6.Io8, 6.128, 7.22, 7·44, 7.56, 7.57, 7.64, 8.64, 9.38, 9·40, 9.203, 9.2II, I0.62, 12.43, 12.7I, I2.I27, I2.J73, I5·17 Nomenclature of Diseases, International, I 3.48 Non-aligned countries, 1.25 Noncommunicable diseases, 10.1-10.94• 1 5.48 commumty control, IO.I, 10.38
Microbiological laboratories, prevention of accidents and infections, 8.45, 9·146-9.149 training, 9· I48 Microbiology, 9.I8I Micronesian Islands, 4· 38, I 5. I 2 5 Midwifery, I2.72, I2.73, I2.8I, I2.106, I2.I07, I2.Io8 role of midwives in family planning, 6. 78, 6. 79 role of midwives in primary health care. I2.70, 12.93 see also Nursing: Traditional birth attendants Migrants, health of, 1.8 Migration of health manpower, I2.I, I2.50, u.64-u.65 multinational study, I 2.64 Milk hygiene, 9.I8I, 9·I93 Mineral water, 9·I93 Miners, health of, 10.74 Molluscicides, 9.42, 9.2I4, 9.238 Mongolia, 5.29, 6.64, 8.20, 8.59, 9.uo, I2.Ijl Monkeypox, 9.8, 9·9· 9·I4I Monrovia Declaration, I 5. 3 Morocco, 2.I8, 5.3, 6.25, 7.22, 8.23, 8.49, 9·39, II.I8, I2.126, I5·77
research, 4· 1 2 Nongovernmental organizations in official relations with WHO, 3-35, 3·49-3·5o, 5.13, 6.8, 6.14, 6.66, 8.61, 8.82, 9·37, 9·I59, II.5, II.IO, II.23, 12.38, I2.70, 13.22, I3.42, I3.54, I3.59, I5.79, (Annex 3) Nordic Council on Medicmes, 8. I 3, I 5. 7 I Nordic Federation for Medical Education, I 5. 79 Norway, 3.4, 5.I6, 6.I28, 7.8, 9·I58, ro.36, I5.76 Nosocomial infections, 8.45, 9.150 Nuclear conflict, prevention, 1.47 Nuclear energy and fuel, It.p, 11.37, I1.38 Nuclear medicine, 8.85, 8.57, 8.59, 8.6o, I2.158 Nursing, 8.82, I2.13, 12.3I, 12.33, I2.I40, I5.9I mental health, 7. 5, I 2. I 53 post-basic nursing education, programmes, I 2.91, 12·94· 12·95, 12.97 regional centres, 12.93 pnmary health care, I2.69-I2.73, 12.9I, I2.93 research, 12.7 2 role of nurses in care of the elderly, 8.93 role of nurses in family planning, 6.78 textbooks, and other educational materials, 7.5, I2.106, I2.I07, I2.108, 12.II9, I2.128 training, I2.I3, 12.31, I2.33, I2.8I, I2.106, I2.Io7, I2.I08, I2.IIO, I2.128, I2.1jl, I5.56, I5.I29 teacher training, 12.9I, 12.u5, I2.II9, I2.I23 Nutrition, 1.3, 1.24, 3.24, 3.26, 6.7, 6.I8, 6.41-6.58, 8.93, I0.37, 11.44, Ij.I6, I5.36, I5.II6 centres for research and training, 6.44 integration in primary health care, 6.42, 6.43-6.44, 6.46, I5.I6, I5.36, I5.II6 national food and nutntion policies, I 5. u6 research, 4·3· 4·I3, 4.I8, 6.46, 6.52-6.55, 9·75, 9.76, 10.42, I5.I4, I5.36 surveillance, 4.13, 6.49-6.5o, I5.36, I5.u6 training, 6.49, I 5. II 6 Nutritional deficiencies, 6.48, 6.p-6.57, I 5. u6
Motor vehicles, effects of drugs on dnvers, 4.29, 7· I9, 8.85, 8.86
emissions, I 1. 30 road accidents, 8. I, 8.84-8.91, I 5. 7 3 Mozambique, 3·4I, 9.38, 9·39, 9.42, 10.76, I2. I6, I2. I I I, I2.I27
Myocardial mfarction, 10.42
Nam1bia, 1.45 Narcotic drugs, 7· I6-7.22 National decision-making for primary health care, 5. I National health councils, establishment, 1.30, 12.24 National staff, involvement in WHO programmes, 1.30, 1.32, I5·9
Natural disasters and catastrophes, preparedness and management, 3.30, 3·31-3·37 training, 3-3 3-3.34
see also Malnutrition
282
1'\DEX
OAU, see Organization of African Unity Obstetric emergencies, I2.I 32 Occupational health, 1.24, 10.73-10.87, I5 .IIO early detection of impairment, I0.84 exposure limits, I0.83-I0.85 integration into general and primary health services, 10.75, Io.76, Io.n, 10.78
Palestine, health conditions, I .46 Pan African Association of Neurological Sciences, 7·59 Pan African Development Institute, 6.44 Pan American Centre for Sanitary Engtneertng and Environmental Sciences, I r. I 5, I 1.26 Pan American centres for research, 4.20 Pan American conference on research policy, planned, 4-I7
research, 4.38, 10.75, I0.85 training, 10.76, Io.n, 10.78-Io.79 see also Working populations, health of Occupational therapy, Io.86, I2.I22 OECD, see Organisation for Economic Co-operation and Development Oesophageal cancer, Io.I6, I0.28, Ij.I2j Oman, 5·9
Pan American Federation of Associations of Medical Schools, 12.76 Pan American Foot-and-Mouth Disease Control Centre, 9·I79
On being in charge, I2.I04 Onchocerciasis, 9·47-9·54 chemotherapy, 9·51, 9.56-9.57 research, 4.II, 9·49, 9·50, 9·5 I, 9·57, 9.232, 9.240, 9.242 vectors, biology and control, 9·49-9·5 I, 9·54, 9.211, 9.216, 9·242
Pan American Health Organization (PAHO), I4.7, 15.20-15·31 publications, I3.I6, I3·3 5, I3-44 synchronization of planning cycle, r. 35 Pan American Sanitary Bureau, see Regional Office for the Americas Pan American Zoonoses Centre, 9· I79 Panama, 5.24, 7.22, 7.6I Papua New Guinea, 2.24, 2.25, 4.37, 5.3, 5.Io, j.I5, 5.26, 5·55, 6.26, 6.46, 6.6o, 6.65, 7.6I, 8.76, 9.96, 9.no, 9.122, 9-I2j, 12.24, 12.73, I2.I07, I2.II6, I2.Ij2, Ij.IIj, I5.122
resistance, 9·49, 9.50, 9.202, 9.2II Volta River basin area, control programme, 9•47-9·53• I5·I7
extension, 9· 51, 9· 52, 9· 2 I I financing, 9·4 7 Oncology, see Cancer, research Operational research, 6.46, I3.20 see also Health services research Ophthalmology, 9.I62, 12.I30 see also Eye health care Oral health, 10.67-10.72, Ij.I26 manpower, 10.70, 10.72 research, 4.12, I0.67, 10.70 training, 12.95, I2. I 32, I 5.126 Organisation for Economic Co-operation and Development (Nuclear Energy Agency), I1.37 Organization of African Unity, 1.3, 1.23, 1.45, 6.4I, 9.212, 9.223, Ij.3, Ij.I3
Organization for Coordination and Cooperation tn the Control of Major Endemic Diseases in West Africa, Technical Conference (I98I), 9.90 Organization of the Islamic Conference, 3.8 Organization of Petroleum Exporting Countries, 3.8 Organizational and related meetings, (Annex 2) Organizational structure of WHO, (Annex 4) re-examination in the light of functions, I.I, 1.30-1.44 Organizational studies by the Executive Board, 1.4I, 12.40-I2-4I
Paragonimiasis, 4· 38 Paraguay, 5.21, 5.24, I I. I 5, I r.I6 Parasitic diseases, 6.I7, 9·14-9.67, Io.8j, I3.2I research, 4· 37 see also Tropical diseases Particulate matter, health hazards, Io.82, I0.84 Patent rights, I4.IO Peace, health and, 1.47, 3.Io Perinatal care and perinatology, 6.19-6.22, 6.24, Io.2o Perinatal mortality, I3-I7, Ij.20 Periodontal diseases, Io.68, I 5.I 26 Permanent Commission and International Association on Occupational Health, 10.74 Pertussis, vaccination and vaccines, 9· I 7 3, I 5. 2 3 see also DPT vaccine Peru, 5.2I, 5.22, 6. 79, 7· 3 5, 7.66, 8.67, 9· I IO, 9·II 2, 9· I8j, 12.47, IZ.I26
Orthopaedic and orthotic services, see Disability prevention and rehabilitation Orthopoxvirus, 9.8, 9·9· 9.Io
Pesticides, 9.202, 9.2 II health hazards, I0.23, 10.79, I1.23, I1.53, Ij.48 residues, I r. 39 safe use, 9.205, Io.82, Io.8 3 traimng, 9.205 see also Insecticides; Larvicides; Molluscicides; Rodent control and rodenticides Pharmaceuticals, see Drugs Pharmacology, clinical, 8.II-8.I2, 8.I4, 8.23, 9.265 see also Psychopharmacology Philippines, 2.24, 2.25, j.Io, j.II, j.Ij, 5.3o, 5.48, 5·55, 6.55, 6.6o, 6.62, 7.65, 8.I4, 8.76, 9.38, 9·39, 9.40, 9.78, 9-IIO, 9.122, 9-I2j, 9.I84, I0.20, IO.j9, I0.74, 12.36, 12.7I, I2.87, 12.99, I2.I07, I2.I22, I2.I23, I2.I26, I2.Ij2, Ij.I2j Physical activity, 10.43
P AHO, see Pan American Health Organization Pakistan, 2.I9, 3.5, 3·45, 5.3, 5·9· 5·47, 6.q, 6.46, 6.6o, 6.8I, 8.49, 8.7I, 9·27, II.I9, 12.98, I5·99
THE WORK OF WHO, I98o-I98I
Physicians, role in preservation and promotion of peace, 1.47
of mental health, 7.2-7.3, 7·47, I2.I8, I5.II8 of nutrition services, 6.43-6.44, 6.46, I 5. I6, I 5.36, I5.II6
Pinta, 9· I 54 Plague, 9·117, 9.2I3, I5-46 Planning, see Environmental health, national planning; General Programmes of Work; Health planning and programmes; Long-term planning; Manpower development, management and planning; Mediumterm planning; Programme of WHO Pneumonia, 9.I2o, Io.64 Poland, 7.42, 10.74, I2.I6, rz.23, 12.72, I2.I46 Poliomyelitis, 9·132-9·133, 9.I67, 9·I72 immunization and vaccines, 8.32, 8.35-8.37, 9·I32, 9·I33, 9.I66, I5.23
of radiological services, 8. 59 International Conference (Alma-Ata, USSR, I978), I. I 2, IZ. 79
Pollution, see Air pollution; Costal pollution; Environmental pollution; Soil pollution; Water pollution Polynesian Islands, 4· 38, I 5. I 2 5 Population and Development, Parliamentary Conference, Africa (I98I), 6.93 Population dynamics, I 5.20 Portugal, 2.I8, 6.25, 6.40, 7.56, I5·77 Postgraduate training, 4.8, 5·53, 9·I92, 12.90-12.99• I2.I73, I2.I76
joint studies (UNICEF/WHO), 3-24, 5. I-j.Z, j.I 5 management, 5.8, 5·53 programme financing, 1.20 Health Resources Group, 1.20, 3.6, I5·32 initiative fund, 3. 7 interregional study, 5·17 records and statistics, I3.I-I3.4, I3.7, I3.I4, J3.2I research, 4·3, 4· I6, 4.29, 4· 33, 5.8, 5. Io, 5. 53, 5·55, 6.63 roleofnursesandmidwives, I2.69-I2.70, 12.73,12.93 role of traditional health workers, I 2.20 support, health systems, 1.38, 5.I9-5.20 training, 5.6, 5.8, 5.II, 8.79, 9·I 55, I2.48, IZ.jZ, I2.5 3, I2.6o, I2.62, I2.63, I2.68, 12.ti9-1z.84, 12.99, 12.100, 12..102, 12.111, 12..116, 12.124,
15-43,
I5.54, I5.55, I5.8o, Ij.Io6, I5.I29 teaching/learning materials, I2.I8, I2.Ioo, IZ.I03IZ.Io8, IZ.128, I2.I29, I2.J30, I2.I34, I2.I35
Poverty, 6.I5, Ij.65 Poxviruses, research, 9.8, 9·9 Pregnancy, hypertension problems, 6.I7, 6.I9 in adolescence, 6.38, 6.39, I5.II4 nutritional aspects, 6. I 8, 6.4 5, 6.46, 6. 57 spacing, 6.8 I termination, abortion and wastage, 6.I7, 6.38, 6.8o, 6.99, 6.Io8
workshops, 5.4, 5. I 2, 5. I7 see also Drugs, essential Primary health care workers, 6.44, 7·9· 7·47, 7.jl, 8.85, I0.5, I0.6, 12.36, 12.37, IZ.50, IZ.IIO, 13.40
training, 5.6, 5.7, 5.8, 6.z6, 6.44, 6.65, 7.23, 7.30, 8.28, IZ.I8, I2.35, I2.85, I2.I03, I2.II6, I2.I29, I2.J30, I2.I77, I5.38, I5.J3I Primates, nonhuman, 4.7, 8.40, Io.3o Programme budgeting, 1.5, 1.35, 2.27, 2.35, 2.36-2.37, 2.43 national, I 5.62 Programme budgets (WHO), 2.38, I 5.6I for I982-I983, 1.42 for I984-I985, 1.38, 2.36, 2.37
testing, 8.32 Prevention of alcohol-related problems: an international review l!f preventive measures, policies and programmes, 7.42 Prevention in childhood of health problems in adult life, 6. 37 Primary health care, 1.3, 1.4, I. II, I.I3, 1.24, 1.26, 1.42, 2.20, 3.I, 3.IO, 3.2I, 3·23, S·S-S·I7, 5.I8, 5·I9, 5.2I, 5·45, 6.I2, 6.I3, 6.3I, 7.25, 8.76, I0.75, I0.77, I2.28, I2.8o, I3.56, I3.57, I3.6o, I5.I, I5.4, I5·5, I5.I5, I5.25, I5.29, I5·34, I5.85-I5.86, I5.93, I5.I04, I5.I06 drugs for, 8.5, 8.I5, 8.I8
policy and strategy, I 5. 5 Programme Committee, Global, 1.37 of the Executive Board, 2.3 I-2.32, 10.3 regional programme committees, 1. 3 5, I 5.6 Programme coordinators (WHO), 1.32, 1.33, 3.6, 3.p, I5.8, I5.6I
elements, listed in Declaration of Alma-Ata (Part VII, para. 3), 3.10, 3.2I, 5.37, 5.38, 6.25, 6.42, 6.43, 6.68, 9.I65, 9·177, II.2, Ij.85
in urban areas, consultation, 5. I 3 integration, of disability prevention and rehabilitation, 8.62, I5.74
of disease control, 5.8, 9.I8, 9.22, 9·33, 9·34, 9·54, 9.69, 9·7I, 9.83, 9·9I, 9.92, 9·95, 9·II4, 9·I2I, 9.122, 9.I24, 9.I65, I5.17, I5.98 of family health, I 5. I I 5 of family planning 6.68, 6. 72, 6. 73, 6. 79, I 5. I I 5 of health education, 6.6o, 6.65, I2.I50, I5·37 of maternal and child health services, 6.2-6.3, 6.I9, 6.24-6.25, 6.30
national, 1. 32, I 5·9 Programme of WHO, general development and management, 2.26-2.50 use of resources, studies, 2.37 see also Evaluation Prosthetics, 8.67, 8.69, 8.7I Protein-energy malnutrition, 6.48 Protocol for the Protection of the Mediterranean Sea against Pollution from Land-based Sources, I4.8 Protozoal infections, 9.66-9.67 Psychiatry, 7.52-7.54 training 7.jl, 7·54, I2.I53, IZ.I55, I2.179 Psychopharmacology and psychopharmacotherapy, 7·54-7·55, I2.I55
INDEX
Psychosocial factors and health, 1.42, 7· 5, 7·23-7.28, 8.89, Io.86, I5.II8 research, r.S, 1.14, 4.3, 6.63, 6.66, 6.70, 6.82, 6.1 18, 6.I25, 7.23, 7.24, 7.25, 7.26, 7·49 Psychotropic substances, 7·7, 7.16-7.22, 7·55, I5.II8 Public health services, see Health services Public health training, I2.95, 12.96, I2.I41, 12.I48, I5.8o African centres, I 2. II 8 organizational study, 1.4 I schools, meetings of directors (I98I), 12.90 Public information 9.n6, 13·53-13·64 Publications, WHO programme, I3.I2, I3.I3, I3.I4, 13.29-13·36, I3-4I, I3.62 distribution and sales, I 3·49- I 3. 52 regional publications, 13.I6, I3·34-I3·35, I3·44, I3.47, Ij.8I-I5.82, I5.I03 translation, I 3. 36, I 5.8 I Publications and Documentation Service, PAHOjWHO (Mexico), I 3·44 Puerto Rico, 9.46
Qatar, 10.76 Quality control, see Biologicals; Drugs; Drinking-water; Water, quality control
Rabies, 9-I79, 9.I8o, 9.183-9·184, 9·I9o, I2.I69, I5-47 vaccines, 8.32, 9.I84, I5·47 wildlife rabies, 9· I 84 Radiation health and protection, 8.58, 8.59, 8.6o, IL3I, II.36-u.38 environmental radiation, I r. 33 ionizing radiation, 8. 58 personnel monitoring, I I. 37 non-ionizing radiation, I r. 36 standards, I r. 37 traming, 8.6o Radiation medicine, 8.j2-8.6o diagnosis, I 2. I 58, I 2. I So integration in primary health care, 8.59 therapy, 8.52, 8.53, 8.56, 8.57, 8.59, 8.6o, I2.I59 training of radiographers and radiological technicians, 8.52, I2.I58-I2.I59, I2.I80 Radiological equipment, 8.54 standard dosimetry, 8.56, 8.59 Reagents and reference substances, 6.I24, 8.6, 8.I4, 8.3 I, 8.36, 8.50, 9.I23, 9·I3I, 9·I39, 9.247, 10.93 production 8.45, 8.48, 9· I 30, 10.90 Refugees and displaced persons, 1.45, 1.46, 3·33, 3.36, 3-38, 9·25, I3.60 RegionalCommitteeforAfrica, 1.3, 1.35, 1.36, 1.37, 1.38, 1.39, 1.40, 1.42, 1.45,Ij.5-I 5·7 technical discussiOns, 4· I 6 Regional Committee for the Americas, 1.4-r. 5, 1.22, 1.29, 1.33, 1.38, 1.40, 1.42, 6.I 3 technical discussions, 6.6o, I I ·4 7
timing of sessions, r. 35 Regional Committee for the Eastern Mediterranean, I.46, I5.84 RegionalCommitteeforEurope, 1.7-1.9, 1.34, 1.35, 1.39, 1.40, 1.42 technical discussiOns, 1.40, I 5. 74 Regional Committee for South-East Asia, 1.6, 1.29, 1. 33, 1.39· 1.40, 1.42 techmcal discussions, I 2.28 Regional Committee for the Western Pacific, r.I I, 1.34, 1.38, 1.39· 1.40, 1.42 technical discussions, 1.40 Regional committees, r.I8, 1.I9, 1.23, 1.29, 1.30, r.p, I. 35, 1.42 methods of work, r. 36- I. 39 Regional development banks, 8.30 Regional Office for Africa, 2.43 structure, I 5·9 Regional Office for the Americas, 2.44, 13.Io publications, 13. I 6, I 3. 35, I 3-44 Regional Office for the Eastern Mediterranean, 2.44 publications, I3.I6, I3.34, I3.44, I3.47, I5.I03 transfer, I4·9 Reg10nal Office for Europe, 2.43, 2.44, 8.I, 8.I3 publications, I3.I6, I3.35, I5.8I-I5.82 Regional Office for South-East Asia, 2.44 Regional Office for the Western Pacific, 2.44, 13.10, 13·17 accommodation, I 4· I 8 Regional offices, (Fig. I 5. I) mformauon systems, I 3. I o- I 3. I I structures and functiOns, r. 3o Regions of WHO, (Fig. Ij.I) Rehabilitation, see Disability prevention and rehabilitation Rehydration salts, oral, 9.69, 9.72, 9· 75, 9· 76, I 5·43, I 5·99 production, 3.2I, 9.70 Reporting system of WHO, 2.40 Repository of chromosomal variants and anomalies in man, I0.63 Republic of Korea, 2.24, 2.25, 3.27, 4.37, 5·3· 5.I8, 5.30, 5.36, 6.29, 6.40, 6.62, 6.63, 6. 79, 9· IIO, 9.205, 10. 74, II.34, II.jl, 12.33, 12.7I, I2.I44, I5.II5, I5.I23 Research, 1.4, r. 13, r. I4, 4.1-4.39 capability, strengthening, 4.2, 4.II, 4.17, 4.2I, 4·364·37, 5-5 I, 6.29, I5-94 career structures, 4· 5 directory of institutions, 13. I 6 ethical aspects, 4· 7, 4· 17 evaluation, 4.22 financing, 4.I, 4.4, 4.I6, 4.29 mformation systems, 4-I4, 4.I6, 4.28, 5.56 management, 4.28, 4·35, 4.36, 4·37, 4·39 national medical research councils, establishment of and links with, 4.6, 4.Io, 4.37, I5.6o meetings of directors, 4.25 policy and priority-setting, 4· I, 4· I 7, 4· 34
Research (continued) reg10nal programmes, Ij.J4, Il·l9-I5.6o, Ij.68, Ij.92-Ij.94, Ij.I05 scientific planntng groups, 4· 3 standardization of procedures, 4.27, 4.29 technical cooperation among research institutions, 4.9, 4·36 training, 4.2, 4.6, 4.8-4·9• 4.II, 4.29, 4·37, I2.I44, Ij. 14, I 5.6o centres, 9.268 grants and awards, 4.8-4-9, 4.2I, 4.28, 6.I2I, 6.r:u, 9.230, 9.266, I5.J4, Ij.I05 IARC programme, IO.I2-Io.p see also Health services research; Human experimentation, and under mdividual suijects of research Research coordination, 1.25, 1.39, 4.6, 4.36, 6. I 25, I 5. I4, I5.6o Respiratory diseases, acute, 1.42, 6.I6, 9.no-9.n6, Ij.I20 chemotherapy, 9.I2I, 9.I24 research, 4.37, 4.38, 9.I2I-9.I23, 9.126, 9·131, Ij.I05, I5.I22 training in control, 9· I 23 chronic I o. 58 Reunion, 9.2I Revolving Fund for Teaching and Laboratory Equipment, I4.25 Rheumatic diseases, IO.j9·10.60 Rheumatic fever, 10.40, I l· I 2 5 Rheumatic heart disease, 10.40, I l· I 25 Rickettsial diseases, 9. I 39 Rift Valley fever, 9·J38, 9· I 8o, I 5·97 vaccine, 8. 3l Rockefeller Foundation, 9.46, I 2. I 30 Rodent control and rodenticides, 9.2 I 3 Rodent Control Demonstration Unit (Rangoon), 9.2I3 Romania, I0.64, I2.I54 Rotav1rus, 9·75 Royal Commonwealth Society for the Blind, 9· I 59 Rural development, j.I6, 9·45, 9.I78, I5.2I, I5.63 water supply and sanitation, 1.40, 3.27, 6.66, I 1.3, II.I5, II.I8, I5.I27 Rural health, 5.26, I2.73, I2.82, Ij.I30 incorporation of nutritiOn activities, 6.46 Rwanda, 7·4, 9.42, 9.2I4, I2.I27
Sahel, Club du, 3.8 Saint Helena, 9.2I Saint Lucia, 3.42, 8.64, 9.46, I4. I Saint Vincent and the Grenadines, 7.Io Salmonellosis, 9· I 8 7 Salt, iodization, 6. j2 Samoa, 2.24, 6.6o, 9.IIo, I2.73
San Marino, I4.I Sandflies, 9.202, 9.250 Sandoz Foundation, I 2.64 Sanitarians, I 2.6 3 Sanitary and public health engineering, training, I 2. I 7 3 Pan American centre, I 1. I l, II. 26 Sanitation, 1.3, I.2I, 1.26, 1.40, 6.6o, 9·44, II.4, II.5, II.6, II.II, II.J3, II.I6, II.I8, I3.56, Ij.23, Ij.49, I5.50, I5.63, Ij.77, I5.85, I5.I27 information systems, I I. I l , I I. I 7 integration in pnmary health care, I I. 2 international decade (I98I-I99o), 1.40, 3.20, 6.66, 9.2I5, 11.1-11.20, 12.66-I2.67, I2.I74, I3.j6, q.6o, ~.I8, I5.23, Ij.3I, I5.49, I5.IOI, I5.I27 national programmes, support, I 1.2, II .3, I 1.4, I 1. I 2, II.I5, II.I6, II.J7, I5.I8 see also Environmental health; Sewerage; Wastes disposal; Water supplies Saudi Arabia, 2.I9, 7·I3, 8.7I, 9.64, 9.206, Io.76, I2.I38 Schistosomiasis, 6.86, 9·36-9.46, I 5. I 20 chemotherapy, 9.40, 9.42, 9.238 research, 9.42, 9.232, 9·238-9.239, 9.26I, I5.I05 diagnostic techniques, 9.239 snail control, 9.42, 9·43, 9.2I4, 9.2I9, 9.238 training, 9·43 Schizophrenia, 7.50, 7·53 Scientific Group on Prevention Strategies in Cancer (I98I), 10.3 Scientific Group on Treponema! Infections (I98o), 9· I 5l Seafarers, health of, I o. 8 I Seas, regional, coordinated programme (UNEP), I 1. 35 Self-care and self-reliance in health care, 1.8, I. II, 1.24, 1.27, I.3J, 4·29, 4·33· j.8, 6.6I, 6.62, 9.68, I5·93 Self-help, 7.23, 7.2j, Ij-38 Senegal, 2.7, 5.I8, 5.27, 7,56, 8.85, 9.38, 9.40, 9.2II, I2.I27 Sera, 8.48 Sewerage, I 1. I l, I 5.2o Sexually transmitted diseases, 9· I l I-9· I 55, I 5. I 20, I 5. I 22 chemotherapy and drug resistance, 9· I 52 research on diagnostic techniques, 9· I 5 I, 9· I l 3 Seychelles, 9.2 I SIDA, see Swedish InternatiOnal Development Authority S1erra Leone, 2.I9, 9.8, 9.2II, I2.20, I2.87, 12.93, q.I5 Simulium, 9·49, 9·lo, 9·54, 9.202, 9.2II, 9.2I6 Singapore, 5.36, 7·44, 7.65, 9.26, IO.I9, Io.n, I2.78, I2.I22 Single Convention on Narcotic Drugs (I 96 I), 7. I 6 Sixth report on the world health situation, I3.I2, I3·32 Smallpox, eradication, 13.5 l, I 3.6o, I 5·97 declaration of, L4I, 9·3 exclusion from International Health Regulations, I4.6 Global Commission, 9· 3 post-eradication activities, 9· 3-9. II vaccination, 9.4, 9·7 discontinuation, 9·4, 9· I 2 reserves of vaccine, 9· 5
286
INDEX
Smoking and health, 1.42, Io.6, IO.I5, I0.27, I0.37, 10.4I, 10.47·10.52, I0.85, I3.57, 13.6o Snake-bite, 4.24 Social sciences, 4· I 8 Social security, 2.20, 5.22, 5·35, I5.2I, I5.28 Socioeconomic development and health, interrelationship, r.8, 1.24, 1.47, 2.6, 3·9-3·"• 3.I6, 3.28, 6.5, 6. II, 6. I 5, 6.4I, 7.23, 9· I 8, 9· 53, 9· q8, 9.263, 9.264, 13·I4, I3.I8, I5.4, Ij.20, I5.24, I5.65, I5.86 studies, 3.Io, 5.I6 Soil pollution, I 1.28 Solomon Islands, 2.24, 6.6o, 6.65, I2.I23 Solvents, exposure limits, I0.83 Somalia, 2.22, 2.23, 3·5, 3.38, 3·45, 5·9· 6.25, 9·3· 9·"· 9-IIO, I0.76, II.I9, I2.I33, I5.89, I5.IOO South Africa, 9.2I South Pacific, University of the, 5. 30 South Pacific Commission, I I. 5I South Pacific pharmaceutical service, 8.25, I5·"9 South-East Asia Region, 1.33, 2. 14-2.17, 3·43, 4.22-4.21, 5•7, 5.25, 5·45, 5.52, 6.46, 6.49, 6.63, 6.65, 6.II76.II8, 8.20-8.22, 8.48, 8.59, 8.68-8.69, 8.79, 8.88, 9·23. 9·92-9·93· 9·"4· 9-I40, 9·I54, 9·I59· 9.I6l, 9.I66, 9.I68, 9·I9I, I0.6, I0.66, II.I7, II.27, II.48, I2.27-I2.29, 12-57, I2.67, I2.96, I2.I02, I2.I20, I2.I50-I2.Ijl, 12.I64, I2.I68, I2.qi, I3.7, I3.I7, 13.24, I 3.27, 13.40, 15·32·15.63 Charter for Health Development, 1.27 Meeting of Ministers of Health, First (I 98 I), I 5. 33 Southern Africa, 7-4-7.8, I5.I3 Spain 2.I8, 7.56, 12.7I Special Programme of Research, Development and Research Training tn Human Reproductton: ninth and tenth
Structures of WHO, (Annex 4) study, I.I, 1.30-1.44 Study Group on Mental Health Care 1n Developmg Countries (I98I), 7·3 Study Group on Neuronal Aging and its Implications for Neurological Pathology (I98o), 8.94 Study groups on occupational exposure limits (I98o and I98I), I0.83 Sudan, 2.I9, 2.22, 2.23, 3·5, 3.6, 3·45, 5.3, 5·9· 5-I5, 5.23, 5.27, 5.29, 5·47, 6.q, 6.26, 6.Io8, 8.24, 9.38, 9.40, 9·44, 9·57, 9·95, 9-202, 9-205, 9-2I9, 9·238, 10.4, I0.5, 10.74, I0.80, II.I9, I2.24, 12.77, 12.98, I2.II6, I2.126, I2.I35, I2.I40, 13·I5, I5.98, I5.IOO Supplies and equipment, 5.51. 12.4I, 12.78, I5.84, I5.I24 services of WHO, 14.20-I4.26 see also Emergency assistance; Equipment Surgery, e~ntial care, 8.82-8.83 Suriname, 9.46 Swaziland, 6.64, 7.4, Io.I8, II.46 Sweden, 3.4, 6.4, 6.128, 9·I58, 9.I68, I2.23 Swedish Agency for Research and Cooperation with Developing Countries, 6.4 Swedish International Development Authority (SIDA), 5•4, 9.84, I0.52, II.3, II.12, I5.I8 Switzerland, 3.4, 6.40, 7.42, 10.74, Io.88, I2.23, 12.7I, 12.72, I2.I73 Syphilis, 9· I 54 Syrian Arab Republic, 5.29, 6.8I, 8.7I, 9.27, Io.67, I5·99 S"tems analysis, 13.20 Taeniasis, 9.I9o, I2.I69 Tanzania, see United Republic of Tanzania Teacher traming, 6.27, 6.n8, 9.29, 9.262, I2.2o, I2.5 3, 12.59, I2.82, 12.93, 12.97, I2.1I4, 12.116-12.125, I2.132, I2.I34, I2.I39, I2.I46, 12.I64, I2.q6, I5.35, I5.55, Ij.9I, I5.II5, I5.I32 regional centres, 6.27, I2.II5, I2.12o, I2.I2I, I2.I22, I2.I23, I5.I32 Teaching/learning materials and processes, 3.2o, 6.26, 6.77, 8.6I, 12.34, 12.4I, I2.82, I2.88, I2.IOO, I2.II5, I2.126-I2.135, I2.I47, I2.I77, I2.I80, I5.I32 for primary health care, I2.I8, I2.10o, 12.103·12.1o8, I2.128, I2.I29, I2.130, I2.I34, I2.I35 participation of students, I2.I07, I2.I25 see also Textbooks Teams, see Health teams Technical cooperation, 1. 31 among developing countries, I.I6, 1.32, 1.35, 2.2, 2.47, 3·39, 8.14, 8.q, 8.22, 8.26, 9.230, 9.266, II.I3, I2.6I, I5.II-I5.13, I5.I9, I5.25, I5·33 standmg committee, Africa, I 5.6, I 5. I I-I 5. I 2 Technical discussions, at Health Assembly, 1.38, 3· n, P9 at regional committees, 1.40 Africa, 4· I 6 Americas, 6.6o, I 1.4 7 Europe, 1.40, I 5. 74
annual reports (I98o and I98I), 6.7I see also Human reproduction, research, development
and research training, special programme Special Programme for Research and Training in Tropical Diseases, see Tropical diseases, research and training, special programme Sri Lanka, 2.I3, 3.6, 5.3, 5.7, 5.I6, 5·45, 5·52, 6.25, 6.29, 6.40, 6.79, 7·44, 8.20, 8.2I, 8.79, 8.88, 9.27, 9.Io5, 9.209, 10.4, I0.5, I0.6, 10.75, II.I7, II.48, I2.I2, 12.I6, I2.29, 12.42, I2.Ijl, I5.44 StaffofWHO, 14-II-I4.I7 recruitment, 1. 30 training, 14· I 2- 14· I 7 Statistics, Io.8, I0.10, 10.47, q.I-13.22 development of services, I 3. 3- I 3.6, I 5. I 3 5 dissemination by WHO's central services, I3. Io-13. I9 establishment of natiOnal committees, I3·5 lay reporting, I3.7, I5.I35 methodology, 6.30, 13.I6, 13.20-13.22 training, I2.I76, 13.2, I3·9 see also Classification Sterility, see Infertility Sterilization, female, 6.92, 6.98, 7.24 Streptococcal infections, 9·119, 9· I 20
THE WORK OF WHO, I98o-I98I
Technical discussions (continued) South-East Asia, I 2. 28 Western Pacific, 1.40 Terminology, 4.27, 13·46-13.48 Tetanus, 9· 167 neonatal, 9·I72, I5.roo vaccination and vaccine, 15.23, 15.Ioo see also DPT vaccine Textbooks (medical), I2.129, I2.I79 see also Nursing, textbooks Thailand, 2.I6, 2.46, 3.38, 3·43, 5.3, 5.II, 5·I5, 5.I6, 5.34, 5·39, 5·45, 5-52, 6.4, 6.29, 6.55, 6.78, 6.9I, 6.128, 7.22, 7.6I, 8.20, 8.2I, 8.22, 8.88, 8.95, 9.92, 9·93, 9· I05, 9· I 12, 9· 122, 9· I 37, 9.204, 9.207, 9.2 IO, 9.222, 9.234, Io.67, ro.75, Io.8o, Io.92, 11.34, Ir.48, I2.I2, I2.20, I2.27, 12.42, I2.63, 12.7I, I2.87, I2.89, I2.I6o, I3.6o, 15.42, I5.44, I5.45, I5.6~ Thalassaemia, Io.62
financing, 9.225, 9.269 scientific working groups, 9.232 grants, 4.2I, 9·23o, 9.266, Ij.I05 see also Vector biology and control Trust Territory of the Pacific Islands, 5.30, 9· IIO Trypanosomiasis, 9· 58-9.63 chemotherapy, 9· 59 research, 9·59, 9.6I, 9.63, 9.223, 9.232, 9.243-9-248, 9·256
diagnostic techniques, 9.243 drug trials, 9.244 seminar, OAUJFAOJWHO, 9.223 vector control, genetic, 9·59, 9.212, 9.223 insecticides, 9.6o, 9.63, 9.212, 9.246 see also Chagas' disease Tsetse fly, 9·59, 9.6o, 9.202, 9.212, 9.223, 9.243 Tuberculosis, 9-98-9.116, 13 .Go, 15. I 20, I 5. I 2 3 BCG vaccination and vaccine, 9-IOI, 9.Io2, 9.I03, 9·I05-9·I06, 9.IIO, 9.III, 9·II4, 9.I66, I2.I67, I j .2 3 chemotherapy, 9-IOI, 9.I02, 9.I03, 9.I07-9-I09, Ij.I23 combmed leprosy and tuberculosis activities, 6.6o, 9·89, 9·9 1
The primary health care worker: working guide, guidelines for training, guidelines for adaptation, I 2. I03 The proviston of care for the elderly, 8.93 The treatment and management of severe protem-energy malnutrition, 6.48 Therapeutic substances and technology, 4.27, 8.2-8.60 Thrombosis, ro.4 I Tobacco, consumption and production, ro.47 Tobacco report, Io.5o Tobacco-chewmg, Io.6 Togo, 6.64, 9· 52 Tonga, 2.24, 9.IIo, I2.83, I5.I30 Tounsm, see Travel Toxicologists, training, I 1.2 3, I 5. 78 Toxicology, see Chemicals; Drugs, safety and efficacy; Food safety and hyg1ene; Pesticides, health hazards Trachoma, 9.I64 Traditional birth attendants, 5.7, 6.30, I2.20, I2.68, 12.87-12.89, I 5. 56 Traditional health workers, 4·33, 8.77, I2.I49 training, 8. 79 Traditional medicine, 1.24, 5.7, 5·43, 8.73-8.81, I2.I49, I5.I07
Integration of services in general and primary health care, 9.IOI, 9·II4 national programmes, strengthening, 9.ror, 9.IIo research, 9.Io5-9·Io9, 9·IJ3, 9.II4, 9.II5 training, 9· II I, I 2. I67 Tumours, classification, I o. I I in animals, 9· I98 Tunisia, 6.25, 9·39, 9.II6 Turkey, 3·44, 5.8, 5. I 5, 6.2 5, 6.29, 6.40, 6.78, 6.8o, 6. I I9, 8.85, 9·I5, 9·33, 9.202, 9.207, 9.2I9, I0.22, II.I8, I2.I44, I5·77 Tuvalu, 6.65 Typhoid fever, 9·75 Typhus, 9.2 I 3
handbook for health administrators, 8.8I national programmes, 8. 79 research, 8.74, 8.76, 8.79 study tours in China, 8.76 training, 8.73, 8.74, 8.76 Travel and tourism, 9.I2-9.I3, 9.28 Treponematoses, endemic, 9· I 54-9· I 55 Trinidad and Tobago, 5.28, I3·15 Tropical diseases, 8. 75 research, 4. 37 capability strengthening, 9·230, 9.237, 9.261, 9.2659.268 centre (Ndola), 9.265 special programme, 2.42, 3.2o, 4· II, 9·32, 9·43, 9·50, 9·56, 9·59, 9-2I2, 9·214, 9-2I6, 9-222, 9-2259-269, r2.I66, I3,28, I5.4I
Uganda, 3·5, 3·4I, 9.42, 9·58 UNCTAD, see United Nations Conference on Trade and Development UNDP, see United Nations Development Programme UNDRO, see United Nations Disaster Relief Coordinator Unemployment, r.8, 5·35, q.65 UNEP, see United Nations Environment Programme UNESCO, see United Nations Educational, Scientific an Cultural Organization UNFDAC, see United Nations Fund for Drug Abuse Control UNFPA, see United Nations Fund for Population Activities UNHCR, see Umted Nations High Commissioner for Refugees UNICEF, see United Nations Children's Fund
288
INDEX
UNIDO, see United Nations Industrial Development Organization Union of Soviet Socialist Republics, 3·4· 9·5. 9.I68, 9.I85, Io.62, Io.64, 10.74, ro.8o, I2.48, '3·44 United Arab Emirates, I 5. roo
traditional medicine, 8.76, 8.79 water supplies and sanitation, II. 3, I r. 5, II ·9· I r. 12, IJ.I6, II.J7, II.I8, I1.19, I!.20, I3.56, 15.I8, I5·77• 15.127
Umted Kingdom of Great Britain and Northern Ireland, 3•4, 6.4, 6. I 28, 8.6j, 8.89, 9· I p, 9· I68, 12. 72, I 2. I 54
United Nattons, 1.18, 1.28, 1.30, 3·9· 3.ro, 3.1I, 3.I2, 3.13, 3.Ij, IJ.I, II.9, 1!.10, 11.35, I3.18
resident coordinators, 3. r 8 United Nations Disaster Relief Coordmator, Office of the (UNDRO), 3-35, II.38 United Nations Educational, Scientific and Cultural Organization (UNESCO), 6.66, 1I.9, II.27, 1I.35, I2.89
Economic and Social Council, 3.I2, 6.93 General Assembly resolutions on health as an integral part of development, r. I2, r. r8, r.28, 3·9 regional economic commissions, relations with WHO regional committees and offices, I. 3 5 United Nations Centre for Human Settlements, I r .9, I 1.3 5
United Nations Environment Programme (UNEP), 3. 3 5, 9.!86, 9·2I8, 10.18, 10.77. I0.82, 10.87, II.9, II.22, 11.23, II.27, I1.30, 1I.3I, I!.p, II.35, II.46, II.53, I3·42, I4.8 global environmental monitoring system, 15. I 28
United Nations Children's Fund (UNICEF), 3·ZI-3.Z4, 3·35, 15.63
joint activities, communicable diseases, 5.8, 9·33· 9.82 diarrhoeal diseases, 9· 70, 9· 77, r 5·99 disability prevention and rehabilitation, 8.63, 8.69 essential drugs, 8.q, 8.30 family health, 3.22, 6-4, 6.66 manpower development, 12.79 mental health, 7.8 nutrition, 3.24, 3.26, 6.7, 6.8, 6.49, 6.52, 6.54, 6.58, '3·56
United Nations Fund for Drug Abuse Control (UNFDAC), 7.22, 7·35 United Nations Fund for Population Activities (UNFPA), 6.3, 6.4. 6.23, 6.66, 6.r2I, 6.128, I2.J7, I2.25, I2.38, 12.89, I2.I45, J3.I8, I5.1I5
primary health care, 3.2I, 3.23, 3.24, j.I, 5.2, 5·4, 5·9• j.12, j.I3, j.Ij, 5.17
vaccination and vaccines, 9.1Io, 9.I68, 9.170 water supply and sanitation, 11.3, 1I.9, 13.56 United Nations Commission on Narcotic Drugs, 7.16 United Nattons Conference on Trade and Development (UNCTAD), 8.3o United Nations Conference on Women (198o), 6.1I United Nations Decade for Women (1976-I985), 6.1I6.12
United Nations High Commtsswner for Refugees, Office of the (UNHCR), 3·33, 3-35, 3-36, 3-37, 3.38, 14.22 Umted Nations Industrial Development Orgamzatwn (UNIDO), 6.52, 8.3o, 10.87, 1I.35 United Nations Research Institute for Social Development, 6.49 United Nations system, see Coordination with the United Nations system United Natwns University, 6.4, 6.48 United Nations volunteers, 3.48 Umted Nations Water Conference (I977), I 1.4 United Nations World Assembly on Aging (I982), preparation, 3.15, 8.92 United Republic of Cameroon, 3·5· 3·4I, 5.5, 6.26, 6.63, 6.Io8, 9-40, 9.58, 9.210, I2.r6, I2.1I6, I2.127, 12.16I United Republic of Tanzania, 6.49, 6.63, 6.64, 7·4, 8.49, 9.27, 9·38, 9·39, 9·40, 9·42, 9·43, 9·57, 9.1IO, 9.21I, 10.74, I2.42, I5.I7
United Nations Declaration on the Rights of Mentally Retarded Persons, 7. 29 United Nations Development Decade, Third, (I981-I990), 1.28
United Nations Development Programme (UNDP), 3·17·3.ZO, 11.18, 13.23, I4.22 country programming, 3. I 8 joint activities, chemical safety, II.24 communicable diseases, 3.20, 9.18o, 9.269 diarrhoeal diseases, 9· 7 2, 9· 77 drugs and vaccines, 8.14, 8.21, 8.26, 8.30, 8.4I, 9· I42, 9·168
United States Agency for International Development (USAID), 6.53, 6.54, 6.64, 9·33 United States of America, 3.4, 6.4, 6.128, 7· Io, 7·I9, 7.42, 7.6I, 7.67, 8.9, 8.I4, 8.46, 8.85, 9·33· 9.78, 9·I32, 9.163, 9·I94. 9.234, Io.8, 10.33, 10.47, IO So, Io.8I, Io.86, 10.93, 12.64, I2.65, I2.Ij7, 12.162, 13.25, I 5·76 Universal Postal Union, 9.1I6, 9·I47 UNU, see United Nations University Upper Volta, 5·5, 6.46, 9·57· 9.I22, 9.212, 12-43, I2.I6I, I 2. I 73 Urbanization and industria!tzation, 5.13, 7·5· 8.84, r 5.20, I5.IOI Uruguay, 5.2I, 8.6o, 9.185 USAID, see United States Agency for International
food safety, I r. 51 health manpower development, I2.I26, 12.173 health services development, 5. 24, 5. 2 8 occupational health, 10. 77, ro.82 pollution control, 1 1. 34 primary health care, 5. I I regional programmes, 3. I 9 rehabilitatiOn, I 2. r 54
Development
THE WORK OF WHO, I98o-I98I
Vaccination, see Immunization, and under individual diseases Vaccination certificate requirements for international .travel, 9ol2-9ol3 Vaccination certificates, 9°4, 9oi2, I3o33, I4o6 Vaccines, production and quality control, 3020, 8o328o37• 8o42-8o43, 9oi33, 9oi34, 9oi36, 9oi68, 9oi69, 90176, I2oi67 projection of requirements, 90 I 70 training, 8o4I, 8o43 regional and local production, 8036, 8042 research, 8035, 9075, 9o8I, 9oi05-9oio6, 9oii4, 90I27, 9oi29, 9oi37, 9oi42, 9oi53, 9oi79, 9oi84, 9o235, 9o252, 9o253, I0o9I, I5o44 storage, 90 5 supplies, I4o23, I4o26 see also under individual diseases Vanuatu (formerly New Hebndes), 9oiio, I2o33, 12o73, I4o7 Variola virus, survey of laboratory stocks, 906, 909 Vector biology and control, 4038, 9o26, 9o42, 9°43, 9o499o 5I, 9054, 9o 59, 9o60, 9063, 9•201-9.224, 9°23 7, 9°238, 9o242, 9o246, 9o2\0, I5o46 biological control, 9o2o8, 9o2II, 9o2I4, 9o2I6-9o2I7, 9o229, 9·257"9•260 environmental control, 9o2o8, 9.218-9.220 joint WHOJFAO/UNEP panel of experts, 902I8 genetic control, 9o209, 9o2I2 research units, 9o203, 9o207, 9o2II training, 9o20I, 9o2I3, 9o2I4, 9o2I9, 9.222-9.224 Venereal diseases, see Sexually transmitted diseases Venezuela, 5o27, 5o42, 6o8o, 7046, 9°46, 9°63, 9oi22, 9o203, I0o92 Veterinary public health 8032, 9·178-9.200 training, 90 I90-9o I92, I2o95, 12.168-12.169 VietNam, 3046, 8o27, 8o49, 8o 76, 9° I Io, 9° I 37, l2o 78, I4o 7, I4o22, I5oi2I, Ijoi25 Village health workers, see Community health workers Virus diseases, 9o3-9oii, 9oi20, 9.127•9o145• 9oi8I, I 5o !20, I 5oI 22 chemotherapy 90144 research, 909, 9oi27, 9oi29, 9oi30, 9o13I, 9oi32, 9oi37, 9o140-9oi4I, 9oi42, 9oi43, 9oi44, 9o2IO vaccines, 8o43 WHO reporting system, 9oi45 Visual impairment, 9oi6I, I5o73 Vitamin A deficiency, 6°53-6°54 Volta River basin area, onchocerciasis control programe, see under Onchocerciasis Voluntary Fund for Health Promotion, 302, 9oi 58, 9oi63, 9oi68, Ioo69, I3o7, 14026
Wastes disposal, It.6, ILI9, I5o20, I5o77 management of solid wastes, I r. I 8, I r. 34, I 303 5 radioactive waste, I I o3 I Water pollution, It.2I, IIo28, I1.29, I1.34, I5o5I see also Coastal pollution; Manne pollution
Water quality control, I r.q, I 1.20, I 1.27, I 1.34 Water resources and river basin development projects, health aspects, 3028, 9036, 9o4I, 9°222 see also Onchocerciasis, Volta River basin area, control programme Water supplies, 1.3, 1.26, 1.40, 3o27, 6o6o, 6°66, 9°44, I r. 5, It.6, II.II, II.13, It.I6, II.I8, I3oi7, 13056, I5o20, I5o49, I5o63, I5o77, I5o85, I5oi27 information systems, I r. I 5, I r. I 7 information transfer, IIo8, I1.9, ILI5 integration in primary health care, I I 0 2 national programmes, support, I 1.2, I 1.3, I 1.4, I r. I 2, I I. I 5, II oI 6, I I. I 7, I 5o I 8 Water-associated diseases, 9033, 9-44, 9o2I9, I 1.9, I 5o98 Blue Nile health project, 9044, 9o2I9, I5o98 Weaning and weamng foods, 6oiO, 6045, 6047 Weekty Epidemiological Record, 9o28, 9°85, 9oi75 Western Pacific Region, 1.22, 1.34, 1.35, 2°24, 2°25, 3°46, 4o36-4o39, 5oiO-j.II, 5°26, j.30, 5o48, 5°55-5056,6°5, 6039, 6o6o, 6°62, 6°63, 6064, 6065, 6ol2I, 7o2I, 7o4I, 7065, 8o2, 8o25-8o27, 8o42-8o43, 8048, 8o72, 8o91, 8o95, 9o 26, 9o45, 9°93, 9°96-9°97, 9o I40, 9o I6I, 9o qo, 9°173, 9oi75, I0o55, 11.20, II.5I, I2o33, I2o6o, 12083, I2o86, l2o99, I2oi07-I2oi08, I2oii5, I2oi22-I2oi23, I2oi52, I2oi55, I2oi65, I2oi7I, I3oi6, I3o24, I3o6o, I3o64, 14oi3, 15.104-15.136 Regional Centre for Promotion of Environmental Planning and Applied Studies, I r.26, I 1.30, I 5o I28 WFP, see World Food Programme WHO Chronicle, I2o7, I3o30 WHO guidelines for drinkmg-water, I I 029 Women in health and development, I 042, 50 5, 60 Io, 6.n6.J4, 6oi8, 6023, 6036, 6o62, I2o38-I2o39, I5o28 five-year plan, Americas, 6o I 3 studies, 5° 5, I2o3 8-I 2o 39 Word-processing equipment, 2o44 Working populations, health of, 1.42, 7o40, 8o86, IOo2I, 10.73·10.87, I 5o28, I 5o48 agnculturalworkers, roo74, roo79, IOo8I, I5o48, I5oiio World Assembly on Aging (I982), preparation, 3oi\, 8o92 World Association ofVetennary Food Hygiemsts, 9oi87 \\orld Bank, 9077, 9oi57, 90269, IOo82, II.9, I5o77 cooperative programme with WHO, 3o2o, 8o30, II.3, Ilo8, II.9, II.I4, II.I6, Il.I9 World CommunicatiOns Year (I 98 3), preparations, 30I 5 World Congress on Acupuncture, Seventh (I98I), 8079 World Congress on Biological Psychiatry, Third (1981), 7o54 World Congress of Neurology, Twelfth (I98I), 7o59 World Congress of Women (I98I), 6oii World directory of medical schools, I2o85 World Federation for Medical Education, I2oi4, I2oiiO World Federation of Proprietary Medicine Manufacturers, 802 World Federation of Societies of Anaesthesiologists, 8o8 3
INDEX
World Fertility Survey, 6.6 World Food Council, 6.52 World Food Programme (WFP), 3.25-3.29 World Health, 9.116, I3.62 World Health Assembly, LIS, 1.I9, 1.30, 1.31, 1.37, 1.38, 1.39> 1.40, I.4I, 1.42, 1.43, 1.45, 1.46, 1.47
vaccme, 8.34, 9· 136 vector bwlogy and control, 9.202, 9.2Io Yemen, 2.22, 2.23, 3·45, 4.33, 6.6o, 8.54, 9.38, 9.IIo, I0.76, II.I9, I2.77, I2.I33, I2.I40, I5·93
duration and periodicity of sessions, 1.43-1.44, I4. 5 method of work, 1.43-1.44 technical discussions, 1.38, 3.I I, 5·I9 World Health Days (I98o and I98I), I0.5I, I3·57-13·58 World health forum, I3.29-13·3o World health situation, sixth report, I3.I2, I3.32 World Health Statistics Annual, 13· 13 World Health Statistics Quarterly, I 3· I4 World Medical Association, I2.Ioo
Youth and adolescence, I 5. I 14 drug abuse, 7. 32 maturation and reproductive health, 6. 38-6.40, I 3.I 5, I5.II4
noncommunicable diseases, 10.36 smoking, 10.49 Yugoslavia, 3·44, 3.52, II.27, I2.23, I5·77
Zaire, 3.4I, 9.8 Zambra, 2.Io, 5.5, 5.27, 6.64, 7·4, 8.86, 9.38, 9·39, 9.40, 9·43, 9·234, 9-243, 9·26I, I0.64, 10. 76, 12-43
Zimbabwe, 1.45, 3.4I, 5.3, 5·5, 9·39, 9·43, 10.76, I2.7I, X-ray equipment, 8.52, 8.54 training of X-ray technicians, 8.j2, I2.I8o Xerophthalmia, 6.53, 6.54 I4.I, I4.7, I5·13
Yaws, 9·I54 Yellow fever, 9·I36
Zoonoses, 9·178-9.186, I 5·4 7 centres, 9· I 79-9. I 8 I Mediterranean, 9· I So Pan American, 9·I79 research, 9· I 79, 9.I84 training, 9·I90, I2.I68, I2.I69, I5.47
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C•••c"
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THE WORI< OF WHO 1980-198 I
THE WORI< OF WHO 1980-1981 Biennial Report of the Director-General to the World Health Assemb!J and to the United Nations
WORLD HEALTH ORGANIZATION GENEVA
•
The texts of the World Health Assembly and Executive Board resolutions referred to in this report can be found in the Handbook of Resolutions and Decisions of the World Health Assemb!J and the Executive Board, Volume I, I94S-I972, and Volume II,fourth edition (I97}-I9So). Resolutions adopted in 1981 can be found in WHO documents EB67/1981jREcj1, WHA34/1981jRECj1, and EB68j1981jRECji. The abbreviations used m this report include the following: ACC ACMR A SEAN CIDA CIOMS DANIDA ECA ECDC ECE ECLA ECWA ESCAP FAO GTZ Administrative Committee on Coordination Advisory Committee onMedical Research Association of South-East Asian Nations Canadian International Development Agency Council for International Organizations of Medical Sciences Danish International Development Agency Economic Commission for Africa Economic cooperation among developing countries Economic Commission for Europe Economic Commission for Latin America Economic Commission for Western Asia Economic and Social Commission for Asia and the Pacific Food and Agriculture Organization of the United Nations Gesellschaft fur Technische Zusammenarbeit (Agency for Technical Cooperation, Federal Republic of Germany) International Atomic Energy Agency International Agency for Research on Cancer International Civil Aviation Organization International Labour Organisation (Office) Inter-Governmental Maritime Consultative Organization Organization of African Unity Organisation for Economic Co-operation and Development OPEC - Organization of Petroleum Exporting Countries PAHO Pan American Health Organization Swedish International Development SIDA Authority TCDC Technical cooperation among developing countries UNCTAD- United Nations Conference on Trade and Development UNDP United Nations Development Programme Office of the Disaster Relief Coordinator UNDRO UNEP United Nations Environment Programme UNESCO- United Nations Educational, SCientific and Cultural Organization UNFDAC- United Nations Fund for Drug Abuse Control UNFPA United Nations Fund for Population Activities Office of the United Nations High UNHCR Commissioner for Refugees UNICEF United Nations Children's Fund UNIDO United Nations Industrial Development Organization US AID United States Agency for International Development World Food Programme WFP World Health Organization WHO OECD -
IAEA IARC ICAO ILO IMCO OAU -
©
ISBN 92 4 1j6073 8 World Health Organization 1982
Publications of the World Health Organization enjoy copyright protection in accordance with the provisions of Protocol2 of the Universal Copynght Convention. For rights of reproduction or translation of WHO publications, in part or tn toto, application should be made to the Office of Publications, World Health Organization, Geneva, Switzerland. The World Health Organization welcomes such applications. The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the Secretariat of the World Health Organization concerning the legal status of any country, territory, ciry or area or of its authorities, or concerning the delimitation of its frontiers or boundanes. Where the designation "country or area" appears in the heading of tables, it covers countries, territories, cities or areas. The mention of specific companies or of certain manufacturers' products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters.
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IV
Contents page
Strategy for health for all by the year zooo: Resolutions of the Thirty-fourth World Health Assembly . Introduction . . . . . . 1.
rx XIII
Policy basis: World Health Assembly, Executive Board, and Strategy for health for all by the year zooo . . WHO's structures in the light of its functions Health and politics . . . . . . . . . . . . . . .
regi~nal
committees
2.
General programme development and management Managerial process for national health development Managerial process for WHO's programme. Information systems support.
16 r6
3. Coordination . . . . . . Extra budgetary sources of funds. . . United Nations system . . . . . . . . United Nations Development Programme (UNDP) United Nations Children's Fund (UNICEF). World Food Programme (WPF). Emergency relief operations . . . United Nations Volunteers . . . . Nongovernmental organizations . Cooperative programmes undertaken with Member States .
26 z6 27 29 29 30 3I 33 33 34
4· Research promotion and development Global developments. . . . . . . . . Regional developments . . . . . . . .
35 35 37
5. Health services development Primary health care. . . . . . . . . . Health services planning and management Appropriate technology for health. Health services research . .
42 43 45 48
49 5I 54
6. Family health . . . . . Maternal and child health Nutrition . . . . . . . . . Health education . . . . . Special Programme of Research, Development and Research Training in Human Reproduction .
59
6z 64
v
7· Mental health . . . . . . . . . . . . . . . . . Development of community health services. . . . . . . Safe use of narcotic and psychotropic substances . . . . Psychosocial aspects of health promotion (including drug dependence and alcohol-related problems) Promotion of biomedical and health practice research . . . . . . . . . . . . . Monitoring and other mechanisms for programme development and support. . . . . . . . . . . . .
75 75 77 78 82
84
8. Diagnostic, therapeutic, and rehabilitative technology Pharmaceuticals. . . . . . . . . . . . . Action programme on essential drugs . Biologicals . . . . . . . . . . Health laboratory technology Radiation medicine . . Rehabilitation. . . . . Traditional medicine . Essential surgical care Prevention of road traffic accidents Care of the aged . . . . . . . . . . .
86 86 88
90 92 93 95
97 98
99 roo
9· Communicable disease prevention and control . . . . . . . . . . . . . . . . . . . Post-eradication activities in smallpox and epidemiological surveillance of communicable diseases. Malaria . . . . . . . . . Other parasitic diseases. Diarrhoeal diseases . Leprosy. . . . . . . . . Tuberculosis . . . . . . Other acute bacterial diseases Acute respiratory infections . Virus, rickettsial, and related diseases . Safety measures in microbiology. Hospital infections . . . . . . Sexually transmitted diseases . . . Prevention of blindness . . . . . Expanded Programme on Immunization Veterinary public health . . . . . . . . . Vector biology and control . . . . . . . Special Programme for Research and Training in Tropical Diseases .
I02
ro2 I05 I I I I I
7
119 122 126 I 27
128
' 31 1 32 1 32 I 33 I 34 1 37 I41
146
IO.
Noncommunicable disease prevention and control . Cancer . . . . . . . . . . . . . . . . . . . . . International Agency for Research on Cancer. Cardiovascular diseases. . . . . . . . . . . Other chronic noncommunicable diseases . Oral health . . . Workers' health Immunology . .
I
55 Ijj
157 I6o I64
I66
167 170
II.
Promotion of environmental health . . . . . . . . . International Drinking Water Supply and Sanitation Decade. Control of environmental hazards . Promotion of food safety . . . . . . . . . . . . . . . . . . . VI
I 2.
Health manpower development . . . Programme planning and general activities . . Health manpower planning and management . Promotion of training . . . . . . . . . . . . . Educational development and support . . . . Examples of health manpower activities in other programmes .
I
3. Health information. . . . . . . . . . . . . . . . . . Health statistics. . . . . . . . . . . Health and biomedical information legislation) . . . . . . . . . . . . Health information of the public . . . . . . . (including . . . . . . . . . . . . . . . . . . . . . health literature . . . . . . . . . . . . . . . . . . . services, WHO publications, and health . . . . . . . . . .
2I3 2I
3 7
2I
222
I4.
Constitutional, legal, and administrative developments . . . Constitutional and legal matters . Administration . . .
225 22j 227
I
5. Regional trends . . . African Region . . . . . Region of the Americas South-East Asia . . . . European Region. . . . Eastern Mediterranean Region. Western Pacific Region . . . .
Annex Annex
I.
Members and Associate Members of the World Health Organization at 3 I December I981. . . . . . . . . . . . . . . . Organizational and related meetings, I980-I98I . Intergovernmental organizations that have entered into formal agreements with WHO approved by the World Health Assembly, and nongovernmental organizations in official relations at 3I December I98I . . . . . . . . Structure of the World Health Organization at 3I December I98I (charts).
257 2
2.
59
Annex 3·
26o
Annex 4· Index . . .
VII
Strategy for Health for All by the Year 2000 The two following resolutions were adopted by the Thirty-fourth World Health Assemb!J in Mt!J I98I.
Global Strategy for health for all by the year The Thirty-fourth World Health Assembly,
2ooo
Recalling WHO's constitutional objective of the attainment by all peoples of the highest possible level of health, the Declaration of Alma-Ata, and resolutions WHA30.43, WHA32.30, and WHA33.24 concerning health for all by the year 20oo and the formulation of strategies for attaining that goal, as well as resolution 34/5 8 of the United Nations General Assembly concerning health as an integral part of development; Having reviewed the Strategy submitted to it by the Executive Board in the document entitled "Global Strategy for health for all by the year 20oo" ; 1 Considering this Strategy to be an invaluable basis for attaining the goal of health for all by the year 2ooo through the solemnly agreed, combined efforts of governments, people and WHO; 1. ADOPTS
the Global Strategy for health for all by the year
2000;
2. PLEDGES WHO's total commitment to the fulfilment of its part in this solemn agreement for health; 3· DECIDES that the Health Assembly will monitor the progress and evaluate the effectiveness of the Strategy at regular intervals;
I Global Strategy for health for all lry the year 2000. Geneva, World Health Organization, 198 r ("Health for All" Series, No. 3).
IX
4·
Member States: (I) to enter into this solemn agreement for health of their own volition, to formulate or strengthen, and implement, their strategies for health for all accordingly, and to monitor their progress and evaluate their effectiveness, using appropriate indicators to this end; (2) to enlist the involvement of people in all walks oflife, including individuals, families, communities, all categories of health workers, nongovernmental organizations, and other associations of people concerned; INVITES REQUESTS the Executive Board: (I) to prepare without delay a plan of action for the immediate implementation, monitoring and evaluation of the Strategy, and submit it, in the light of the observations of the regional committees, to the Thirty-fifth World Health Assembly; (2) to monitor and evaluate the Strategy at regular intervals; (3) to formulate the Seventh and subsequent General Programmes of Work as WHO's support to the Strategy; REQUESTS the regional committees: (I) to review their regional strategies, update them as necessary in the light of the Global Strategy, and monitor and evaluate them at regular intervals; (2) to review the Executive Board's draft plan of action for implementing the Strategy and submit their comments to the Board in time for it to consider them at its sixty-ninth session in January I982;
5.
6.
7.
the Director-General: (I) to ensure that the Secretariat at all operational levels provides the necessary support to Member States for the implementation, monitoring and evaluation of the Strategy; (2) to follow up all aspects of the implementation of the Strategy on behalf of the Organization's governing bodies, and to report annually to the Executive Board on progress made and problems encountered; to present the Strategy to the United Nations Economic and Social Council (3) and General Assembly in I98I, and report to them subsequently at regular intervals on progress made in implementing it, as well as United Nations General Assembly resolution 34/5 8. REQUESTS
WHA34·37
Resources for strategies for health for all by the year 2ooo
The Thirty-fourth World Health Assembly, Recalling resolution WHA30.43, which defined the goal of health for all by the year zooo, resolutions WHAp.3o and WHA33.24, which endorsed the Declaration of Alma-Ata and urged Member States to formulate national strategies for attaining health for all through primary health care as part of a comprehensive national health system, and X
STRATEGY FOR HEALTH FOR ALL
resolution 34/5 8 of the United Nations General Assembly concerning health as an integral part of development; Also recalling resolutions WHA27.29, and WHA29.32, which requested the DirectorGeneral to strengthen WHO's mechanisms for attracting and coordinating an increased volume of bilateral and multilateral aid for health; Noting with satisfaction the decision taken by the Executive Board at its sixty-seventh session concerning the establishment of a Health Resources Group; A ware that some countries have encountered difficulties in developing and implementing their national strategies for health for all, and convinced that these countries urgently require special support to enable them to overcome their difficulties; 1. WELCOMES the efforts being made by Member States to prepare and implement national strategies for health for all through the development of health systems based on primary health care; 2. URGES all Member States to allocate adequate resources for health and, in particular, for primary health care and the supporting levels of the health system;
3· URGES Member States that are in a position to do so to increase substantially their voluntary contributions, whether to WHO or through all other appropriate channels, for activities in developing countries that form part of a well-defined strategy for health for all, and to cooperate with these countries and support them in overcoming the obstacles impeding the development of their strategies for health for all; 4· INVITES the relevant agencies, programmes and funds of the United Nations system, as well as other bodies concerned, to provide financial and other support to developing countries for the implementation of national strategies to achieve health for all by the year zooo;
5. URGES those Member States that, for the implementation of their strategies for health for all, require external sources of funds in addition to their own resources, to identify those needs and report thereon to their regional committees; 6. INVITES the regional committees to review regularly the needs of Member States in the region for external resources in support of well-defined strategies for health for all, and report thereon to the Executive Board; 7. REQUESTS the Executive Board to review regularly the international flow of resources in support of the strategy for health for all, to ensure that such resources are effectively and efficiently used for that purpose, and to report thereon to the Health Assembly; 8. DECIDES that the Health Assembly shall review from time to time the international flow of resources for health, and encourage those Member States that are in a position to do so to ensure an adequate level of transfer; XI
9·
the Director-General: to support developing countries as required in preparing proposals for external funding for health; (z) to take appropriate measures for identifying external resource requirements in support of well-defined strategies for health for all, for matching available resources to such needs, for rationalizing the use of such resources, and for mobilizing additional resources if necessary; (3) to report regularly to the Executive Board on the measures he has taken and the results he has obtained. REQUESTS
( 1)
XII
Introduction The way strategies for health for all ry theyear 2000 were developed ry WHO's Member States in I9So and I93I was, ry atry standards, remarkable. When the International Conference on Primary Health Care met in Alma-Ata in I9JS it did not content itself with a paper plan of action; instead it urged governments to develop strategies for attaining health for all through health systems based on primary health care. And the response in a large number of countries throughout the world has been phenomenal. On the basis of national strategies WHO's regions developed regional strategies, and from them a Global Strategy was prepared reflecting the national and regional strategies. It was adopted ry the Health Assemb!J in Mcry I93I. The Global Strategy provides practical guidance to governments on how to develop health systems based on primary health care so as to suit wide!J differing health, social, economic, cultural, and political situations. It shows how cooperation between countries can be improved. It defines the role of WHO-a necessary act, for it must be stressed that while WHO's role is important it is ry no means that of guarantor of the implementation of the Strategy. Implementation will depend first and foremost on the action of Member States themselves, individual& and joint!J. As the Health Assemb!J requested, the Executive Board has worked out a plan of action to implement the Strategy and this is beingfinalized as the present report goes to press. It spells out what is expected of every Member State, of the governing bodies of WHO, and of the Director-General and Regional Directors. The burning question now is how to make sure that Member States will have adequate resources to carry out the Strategy. True, the World Health Assemb!J passed a resolution in which it urged all Member States to allocate adequate resources in furtherance of the Strategy; and it called on the more fortunate countries and the bilateral, multilateral, and voluntary agencies to increase their support to the less affluent countries to help them carry out strategies for health for all if these are well defined. But we in WHO do not live within a political and economic vacuum. At a time when national and international political instability is spreading, when the world's leaders right!J or wrong!J feel that its economy is floundering and see no easy wcry of reversing the situation in the near future, and when the developing countries have to run harder in order to stand still, it is not easy for programmes of human development to gain acceptance and the financial support thry require. Yet those are the very circumstances in which such programmes are most needed. Recent international political and economic proposals have large!J been made in an atmosphere ofpessimism and inconsistency, and the forecasts have not shown even a glimmer of hope of emerging from the confusion before the end of the century. No clear policies that have atry chance of being universal& accepted have emerged, let alone atry world strategy that, startingfrom countries themselves, has been built up block ry block. Unique!J, that is what has taken place within WHO. Not on!J that, but the consistent health XIII
THE WORK OF WHO, 198o-198I
policies and mutuai!J reinforcing national and international strategies for their implementation reach far beyond the health sector; they show how the struggle for health can be used effective!J as a springboardfor human development in general. Admitted!J the cost is far from negligible, b~t it is much lower than present expenditure on what, to put it mild!J, are far less lofty ideals. The effort to mobilize world opinion in favour of the health-for-all movement has not been totai!J in vain. Thus, following the resolution adopted~ the United Nations General Assemb!J towards the end of 1979 declaring that health is an integral part of development, the Economic and Social Council proposed another resolution that was adopted ~ the General Assemb!J in December Ig8I. This resolution endorses the Global Strategy for health for all~ the year 2000 and recognizes it as a mqjor contribution to the fulfilment of the International Development Strategy for the Third United Nations Development Decade. But is this any more than lip-service--the ea!J adoption of a resolution ~ consensus because it does not seem to do anybotfy any harm? When it came to the real test-the inclusion in government plaiforms and in the NorthfSouth dialogue of the poliry of giving human development pride of place over mere economic growth as an alternative approach to solving the world's current dilemma-there was regrettab!J no one even reatfy to entertain the possibility. This was unfortunatelY true not on!J in the organizations of the United Nations !)'Stem but also at the last Summit Conference of Non-aligned Countries and at the International Meeting on Cooperation and Development held in Cancun. This should not and will not deter WHO from going on trying to get its message across,for it is precise!J when an apparent impasse is reached that daring!J innovative concepts are most required and have a chance of taking root in people's imagination. To make the Organization fitter than ever to carry out the new roles devolving upon it in relation to the Strategy for health for all, a managerial stutfy of unusual magnitude for any organization, national or international, took place during the biennium-a stutfy of WHO's structures in the light of its functions. These functions now include taking positive action for health in addition to mere!J indicating how such action should be carried out. Action for health can be effective on!J if it is pursued consistent!J-derived from countries' needs, based on policies and principles that have been agreed upon collective!J, and applied~ governments and~ WHO in accordance with that collective agreement. To achieve such unity of action, the democratic government of the Organization as envisaged in its Constitution has been !)'Stematicai!J strengthened. National representatives in regional committees and the World Health Assemb!J are taking a much greater part in the affairs of the Organization than ever before. The Executive Board has never been so active in guiding the Health Assemb!J and in carrying out its policies. The debates in all these organs during the biennium were refreshinglY frank. Relationships between Member States and their Organization began to change, the notion of technical assistance where~ WHO gave "assistance" to countries being replaced~ that of technical cooperation where~ the Organization cooperates with Member States in a genuine partnership. This evolution has not been to everybotfy' s liking. Many voices have been heard bemoaning the diminution in action in countries as the old technical assistance prqjects began to fade out and new forms of technical cooperation were slow to replace them. For, I regret to have to admit it, the change in poliry from passive acceptance of assistance to active cooperation to stimulate the growth of national selfreliance in health matters has not yet gained universal recognition where it matters most-within the countries themselves. This was evident, for example, in relation to the International Drinking Water Supp!J and Sanitation Decade, which started in Ig8I. There were too many instances where the XIV
INTRODUCTION
impression was given that countries were waiting for funds to come from outside before taking action rather than rising to the challenge ofworking out local solutions, plunging into the thick of things without waiting for external support, and thus demonstrating the will to reach the target of safe water and sanitation for all fry 1990. It is on!J fry such bold endeavour that self-reliance will rise above the level ofan empty political slogan. As for the International Drinking Water Supp!J and Sanitation Decade, so for technical cooperation among developing countries. TCDC for health remained embryonic. It was more talked about than acted upon. It was often confused with passive acceptance of WHO support in intercountry activities, not seen as a genuine getting together of countriesfor joint health action, using WHO to help if and as necessary. This is as true of the developed as of the developing countries, although the Organization took great pains to point out to the former that thry have much to gain fry working together in joint endeavours with their Organization. There are growing signs that these countries have come to realize that thry cannot continue to spend more and more on their health services for the little additional health benefit received. So thry too are turning to the Strategy thry helped to put together in WHO. In the Secretariat as well there were ma'!Y who could not understand the evolution that was taking place in the Organization. Some resented what thry felt to be a threat to the influence of the permanent staff But as time went on, and as thry became involved in preparing the Organization's next General Programme of Work, which the Executive Board decided should represent WHO's support to the Strategy for health for all, most of them came to realize that what was involved was not a diminution of their power but a challenge to their ability to app!J their vast accumulation of knowledge in a different wcry and to use it as a springboard for national health personnel to develop their capacities. The emphasis on action for health of a more fundamental nature than the execution of different prf!!ects frequent!J brought its own counteraction or, as I would dare to call it, reaction. One such example is the International Code of Marketing of Breast-milk Substitutes. This has to be seen in its proper context, that of ensuring an acceptable level of health for all in the foreseeable future. Instead, it was considered in isolation and, because of the controver{Y created around it and the impassioned interventions of the advocates of opposing opinions, it received undue publicity of too sensational a nature. A similar storm is being artificiai!J brewed over the marketing of medicinal drugs. I take this opportunity of making it clear that WHO has no machiavellian schemes against af!Ybotfy genuine!J concerned with medicine and health. Those who are honest in their practices have nothing to fear. But WHO will never aijure its constitutional obligation to provide the world, without fear or favour, with the best available information on all matters relating to health. That is the crux of its constitutional position as directing and coordinating authority on international health work. The Health Assemb!J called upon ministries of health, or equivalent bodies acting on behalf of the minister responsible for health, to become directing and coordinating authorities on national health work. This did not go unnoticed and uncriticized. The main criticism was that the intersectoral nature of primary health care makes it impossible for af!) one ministry to be able to develop and implement it, and the ministry of health is particular!J unsuitable since in maf!Y countries it is considered of secondary importance. It is true that m_inistries of health have rare!J been given much weight in the affairs of state and have often been too deep!J engrossed in the dcry-to-day tasks of administering the health sector, and sometimes on!J the governmental parts of it. However, the need to modify their role in ma'!Y countries stems not from af!Y desire for greater prestige for the health sector but from the needfor a single botfy to direct and coordinate--not necessari!J to administer-all the interrelated activities in all the sectors concerned. XV
I
To the criticism that most ministries of health are too weak for that role and that more powerful ministries should be appointed as focal point, I would retort that nobot!J can look after a bafry so well as its parents. By taking on challenges requiring direction and coordination, ministries of health will progressivelY become directing and coordinating authorities. Integrated planning and administration for the totaliry of sectors in complex societies have proved to be a task bryond human capabilities; selective intersectoral action is therefore mandatory. As far as health is concerned there is no alternative but for a ministry of health or equivalent bot!J to identify what needs to be done, fry whom, how, when, where, with what resources, and through what mechanisms-in short, to elaborate a strategy for health. If such a ministry then reciprocates fry being reat!J to accept coordination of those of its activities that influence other social and economic endeavours, we have a good recipe for the best kind of intersectoral action. At the international/eve/, too, there is more than enough room for others to be active in the field of health. It is a pleasure to record the contribution to health made during the period under review fry such organizations as-to mention on!J afew-UNICEF, UNDP, UNFPA, and the World Bank, as well as fry ma'!} bilateral and voluntary organizations. Differences of interest or emphasis can be turned to advantage rather than be made a matter of contention, suiject to one condition of overriding importance: that the policies and principles decided upon collective!J in WHO fry its Member States are adhered to. WHO's constitutional role makes it the guardian of those policies and principles. A comment frequent!J heard throughout this transitional period was that WHO, in its attempts to inspire action for health, was becoming too politicized, to the detriment of its technical programmes. I believe that this report, which abounds in accounts of technical activities over a very wide range of endeavours, belies this accusation sufficient!J. I98o and I93I were most excitingyet controversialyears. I think that the controver!J contributed to the excitement. The years of germination of ideas nurtured fry worldwide debate bore fruit in the conversion of policies into strategies and the beginnings of plans of action for implementing them. The democratization of WHO's structures moved steadi!J forward. All these are continuing processes and the essential is that thry have started-! believe in the right direction. In spite of those who cannot see the wood for the trees, I submit that thry are all developments that have given greater solidiry and sense of purpose to the work of WHO. If that is the case, half the battle for health for all fry theyear 2000 is won. To win the other half we shall have to continue with the same determination we started with, never allowing cold international political and economic winds to deflect us from our path.
Director-General
XVI
Chapter
I
Policy Basis: World Health Assembly) Executive Board) and Regional Committees DURING the biennium I98o-I98I the governing bodies of WHO paid particular attention to two major issues-the Global Strategy for health for all by the year 2000 and the structures of WHO in the light of its functions. The Strategy defined the long-term health objectives of Member States and of WHO as well as action to attain them on the basis of policies and principles agreed upon by the governing bodies in previous years. The study of WHO's structures was undertaken to ensure that the Organization is optimally geared to its role in support of the Strategy. I. I
of comprehensive health services; health science and technology; and promotion and support. An implementation schedule includes objectives for I 990 related to immunization, water supply and sanitation, and the fight against hunger and malnutrition. The Regional Committee for Africa, in adopting the regional strategy, invited Member States to formulate detailed national plans of action with emphasis on primary health care and to put their strategies into effect with the support of WHO, OAU, and other organizations or institutions. It requested the setting up of mechanisms to evaluate the progress of the work every two years and the effectiveness of the work every six years. I ·4 The Regional Committee for the Americas (the Directing Council of PAHO) considered the regional strategy together with developments in the health sector in the decade I97I-I98o (the period covered by the Ten-Year Health Plan for the Americas). It agreed that primary health care and its components constitute the basic strategies for attaining the goal and that they include: the extension of health service coverage and environmental improvement; community organization and participation; better mechanisms for intersectorallinkages; development of research and appropriate technologies; and the development of human resources. It then adopted a plan of action to implement the strategy. This includes technical and admin-
Strategy for health for all by the year 1.2
2ooo
More than half of WHO's Member States have formally prepared national strategies for health. Many others have reviewed and updated their national health policies without giving the outcome of their review the official title of a national strategy for health for all. I. 3 In the African Region a newly formed African Advisory Committee on Health Development reviewed the regional strategy for health for all, which is a synthesis of the national strategies and a practical manifestation of the regional health charter. Specific objectives were taken from national strategies and classified into three groups: development
THE WORK OF WHO, '98o-1981
istrative support measures, means for identifying and mobilizing resources, research promotion, development of appropriate technologies, and information exchange; and it provides for further intrasectoral and intersectoral coordination as well as an overall system for monitoring and evaluation. I. 5 The Regional Committee recognized the need for the regional plan of action to be linked with the PAHO and WHO programming/budgeting cycles and the monitoring and evaluation periods in a manner that would enable PAHO's resources to be fully committed to the plan of action by I984. Member governments were urged to introduce the necessary adjustments in their national plans, and in their monitoring, evaluation, and information systems. The Regional Director was requested to review and orient PAHO's technical cooperation programme to support national efforts towards health for all by the year 2ooo, and to strengthen the catalytic role of the Organization.
the implementation of national strategies, including the establishment of high-level national councils and committees for coordinated implementation of the strategies and the specific objectives and targets that had been included in countrywide health programmes. It felt that, although there was increasing evidence of intersectoral coordination within countries, the national plans of action to implement the strategies with internal and international support needed to be vigorously pursued. It adopted a resolution (sEA/RC34/R4) urging Member States to strengthen national mechanisms for monitoring and evaluating the implementation of the Global Strategy and requesting the Regional Director to collaborate in the revision and updating of national and regional strategies. I. 7 In the European Region a Regional Health Development Advisory Council, composed of members of the Consultative Group on Programme Development and experts in the fields of political science, economics, and sociology, proposed a comprehensive long-term strategy for the Region. In I98o the Regional Committee endorsed the proposed strategy, with minor changes. It agreed that the main programmes should include: promotion of lifestyles conducive to health; reduction of preventable conditions; and reorientation of the health care system to cover the whole population with comprehensive health care to the maximum degree possible for each country according to its stage of development. Attention was also drawn to the importance for all programme areas of reducing poverty, and to the significance in this respect of the establishment of the New International Economic Order. The Regional Committee recommended that regional as well as national targets be set, with an annual review of progress. The importance of accurate indicators-relating not only to disease but also to health care systems-for monitoring progress and achievements was
1.6 The regional strategy for South-East Asia incorporates the national strategies of the Member States in the Region and is an operational expression of the regional health charter. When it adopted the regional strategy in I98o the Regional Committee urged Member States to develop a plan of action and commit themselves fully to its implementation. It also urged them to take individual and collective steps to update the national and regional strategies annually and to set up mechanisms at national level to monitor and evaluate the implementation of the strategy. It further requested the Regional Director to work out a regional plan of action and to take the steps required to ensure that WHO's technical cooperation with Member States was in consonance with the national and regional strategies. The following year the Regional Committee noted with satisfaction the progress reported by Member countries in 2
POLICY BASIS
fully recognized. The Regional Committee felt that monitoring as a continuing process during the implementation of the regional strategy was essential and that the strategy would need constant updating, the health for all movement being a dynamic process. Community involvement, more humanized care, and health education were other issues the Regional Committee considered should be given attention. 1.8 In 1981 the Regional Committee reviewed the progress made since its adoption of the regional strategy and noted that, in collaboration with experts working in different disciplines, work was now well under way in setting targets at both national and regional level. It advocated that an evaluation system based on relevant indicators should be developed. It also stressed the need for studies on the cultural and social forces contributing to lifestyles hazardous to health; for the strengthening of regional activities in health education and health promotion; for increased attention to the role of the family and the socioeconomic environment; and for examination of the way the health system and other sectors could respond to both present and future trends with a bearing on health. In the area of prevention, identification of the most important diseases was required, and also recognition of the emergence of highrisk groups such as the elderly, migrants, and the unemployed. This should lead to a reanalysis of the various systems of health care, particularly at primary health care level, including the concept of self-help and "alternative" health care. A re-examination of the present system of hospital care and of material and human resources in Europe would benefit not only countries in the Region but also those in other regions at different stages of development. 1 ·9 The Regional Committee, in considering the plan of action for implementing the Global Strategy, agreed that clarification
was needed on a number of key elements, such as the support that WHO should give to Member States in developing their national strategies, the means of mobilizing human and financial resources for their implementation, and the commitment of the United Nations system as a whole to the support of the Global Strategy. More specific targets would have to be set and information provided on the resources necessary for implementation. I. IO In the Eastern Mediterranean Region a number of Member States are actively pursuing their national strategies for health for all by the year zooo. Following subregional meetings held in Kuwait, Somalia, and the Syrian Arab Republic, draft regional strategies were formulated. These were taken into account in preparing the Global Strategy.
I. I I The Regional Committee for the Western Pacific in 1980 unanimously adopted a regional strategy for health for all by the year zooo, confident that it would be strengthened as countries made progress towards the goal through the acquisition of new knowledge and the application of that already existing. The strategy calls for three basic courses of action: laying the foundation for health (providing adequate food, water, and shelter); developing individual and community self-reliance in health; and providing appropriate and affordable health technology for the sick, the disabled, the chronically ill, and the socially maladjusted. The strategy focuses on primary health care as one of the principal approaches. The Regional Committee urged Member States to implement, monitor, and evaluate their national strategies, reviewing and updating them as required. It considered that commitment at all levels was of utmost importance and that managerial expertise would have to be strengthened. At its session in I98I, the Regional Committee adopted a revised reg-
3
THE WORK OF WHO, 198o-1981
ional strategy as well as a plan of action for implementing it. Liz In May I98I the Thirty-fourth World Health Assembly adopted a Global Strategy for health for all by the year zooo (resolution WHA34·36).1 It was based on the report of the International Conference on Primary Health Care and the Declaration of Alma-Ata 2 and on guiding principles for formulating strategies that had been prepared by the Executive Board.3 The Global Strategy reflects the national and regional strategies as seen from a global perspective, and responds to United Nations General Assembly resolution 34/5 8 concerning health as an integral part of development. I. I 3 The main component of the Strategy is the development, starting with primary health care, of the health system infrastructure for the delivery of countrywide programmes reaching the whole population that include measures for health promotion, disease prevention, diagnosis, therapy, and rehabilitation. The Strategy entails the specifying of measures to be taken by individuals and families in their homes, by communities, by the health service at the primary and supporting levels, and by other sectors. It also involves the selection of technology that is appropriate for the country concerned in being scientifically sound, adaptable to local circumstances, acceptable to those for whom it is used and to those who use it, and maintainable with resources the country can afford. It is crucial to the Strategy that social control of the health infrastructure and 1 Global strategy for health for all by theyear 2000. Geneva, World Health Organization, 1981 ("Health for All" Series, No. 3). 2 Alma-Ata I9J9: primary health care. Geneva, World Health Organization, 1978, reprinted 1981 ("Health for All" Series, No. r). 3 Formulating strategies for health for all by the year 2000 : guidingprincrples and essentialrssues. Geneva, World Health Organization, 1979, reprinted 198r ("Health for All" Series, No. z).
technology should be ensured by a high degree of community involvement. The Strategy also presupposes international action to support national action through the exchange of information, the promotion of research and development, technical support, training, coordination within the health sector and between the health and other sectors, and the fostering and support of the essential elements of primary health care in countries. I.I4 An inseparable part of the Strategy is the action required to promote and support it. This includes strengthening the ministry of health, or whatever authority represents the whole health sector, as the focal point for the national strategy. It is necessary to ensure political commitment at the highest level nationally and internationally, as well as the support of economic development planners. Professional groups inside and outside the health sector have to be enlisted. An appropriate managerial process for national health development has to be developed and applied, 4 and biomedical, behavioural, and health systems research oriented to support the Strategy. Policy, technical, and popular information to ensure acceptance of and involvement in the Strategy has to be widely disseminated. I. I 5 Another inseparable part of the Strategy is action to generate and mobilize all the resources possible. Not only health personnel but all human resources have to be mobilized, and all types of health personnel must be motivated. The best use has to be made of the human and fmancial resources available, and investments in health have to be increased if necessary. The international transfer of resources from developed to
4 Managerial process for national health development: guiding principles for use in support of strategies for health for all by the year 2000. Geneva, World Health Organization, 1981 ("Health for All" Series, No. 5).
4
POLICY BASIS
developing countries has to be rationalized and, if necessary, increased. I. I 6 Cooperation between countries is an essential feature of the Strategy, because few countries will be able to formulate and implement their strategies independently. This involves both technical and economic cooperation among countries (TCDC and ECDC) and the use of WHO's regional arrangements to facilitate such cooperation. I. I 7 To monitor progress in implementing the Strategy and to evaluate its effectiveness, suitable monitoring and evaluation processes 1 will be set up by countries as part of national health development management. At the international level WHO mechanisms will be used to report progress and assess the impact of the Strategy. Indicators will be used at the global level that are useful first of all at the national level; a list of such indicators has been prepared, based on national and regional strategies.z
the involvement of people in all walks of life, including individuals, families, communities, all categories of health workers, nongovernmental organizations, and other associations of people concerned. It requested the Executive Board to prepare without delay a plan of action for the immediate implementation, monitoring, and evaluation of the Strategy, for review by the regional committees before being finalized. It requested the DirectorGeneral, inter alia, to present the Strategy to the United Nations Economic and Social Council and General Assembly in I98I, and report to them subsequently at regular intervals on progress made in implementing it as well as United Nations General Assembly resolution 34/5 8. (See also paragraphs 3. I 2 and 1.28.) I. I 9 The governing bodies devoted much attention to the mobilization of resources for implementing the Strategy. Thus, in resolution WHA34·37 the Health Assembly urged all Member States to allocate adequate resources for health and, in particular, for primary health care and the supporting levels of the health system. It urged Member States that are in a position to do so to increase substantially their voluntary contributions, whether to WHO or through all other appropriate channels, for activities in developing countries that form part of a welldefined strategy for health for all, and to cooperate with those countries and support them in overcoming the obstacles impeding the development of their strategies for health for all. It invited the relevant agencies, programmes and funds of the United Nations system, as well as other bodies concerned, to provide financial and other support to developing countries for the implementation of national strategies to achieve health for all by the year 2000. It urged Member States that, for the implementation of their strategies for health for all, require external sources of funds in addition to their own resources, to identify those needs and report thereon to
I. I 8 When the Health Assembly adopted this Strategy it considered it to be an invaluable basis for attaining the goal of health for all by the year 2ooo through the solemnly agreed combined efforts of governments, people, and WHO. It pledged WHO's total commitment to the fulfilment of its part in the agreement. It invited Member States to enter into this solemn agreement for health of their own volition; to formulate or strengthen--and implement-their strategies for health for all accordingly; and to monitor the progress and evaluate the effectiveness of those strategies using appropriate indicators for the purpose. It also invited them to enlist
1 Health programme evaluation: gu1dmg principles for its application in the managerial process for national health development. Geneva, World Health Organization, 1981
("Health for All" Series, No. 6). 2 Development of indicators for monitoring progress towards health for all by the year 2000. Geneva, World Health
Organization, 1981 ("Health for All" Series, No. 4).
THE WORK OF WHO, r98o--r98r
their regional committees. It then invited the regional committees to review regularly the needs of Member States in their regions for external resources in support of well-defined strategies for health for all, and to report on them to the Executive Board. It requested the Executive Board to review regularly the international flow of resources in support of the strategy for health for all, to ensure that such resources are effectively and efficiently used for that purpose, and to report on those matters to the Health Assembly. It decided that the Health Assembly would review from time to time the international flow of resources for health and encourage Member States in a position to do so to ensure an adequate level of transfer. Finally, it requested the Director-General to support developing countries as required in preparing proposals for external funding for health; and to take appropriate measures for identifying external resource requirements in support of well-defined strategies for health for all, for matching available resources to such needs, for rationalizing the use of such resources, and for mobilizing additional resources if necessary.
1.21 It has been estimated that an additional $z 5oo million per year 1 will be required to implement the regional strategy for Africa, a sum that includes $zooo million for drinking-water and sanitation, $55 million for the Expanded Programme on Immunization, and $2 5 million for malaria control. This sum amounts to $7-$1o per inhabitant per year. External funding will be necessary, and an African Regional Health 2ooo Resources Group was therefore set up. It includes representatives of Member countries, of organizations of the United Nations system, and of intergovernmental, governmental, and nongovernmental organizations. Its terms of reference include advising on how best to secure extrabudgetary support, stimulating the mobilization of resources for health development, and promoting the exchange of information on health needs and resources. 1. 22 The Regional Committee for the Americas advocated the establishment of national systems for fmancing the health strategies and reorientation of international cooperation. A mechanism has been established not only to identify needs and possible sources of external funds for countries but also to help countries draw up suitable proposals for the programmes that have a high likelihood of being financed. Discussions have been held in particular with the Inter-American Development Bank. In the European Region the feasibility of setting up a regional health resources group is under discussion. In the Western Pacific Region a resource mobilization committee composed of staff members reviews the regional programme to identify needs for extrabudgetary resources and initiate approaches to funding agencies.
1.20 One of the measures taken by the Director-General was to invite representatives of bilateral, multilateral, and nongovernmental agencies as well as of developing countries to meet in a Health Resources Group for Primary Health Care. The aim of this Group is to promote the rationalization of the flow of resources required for primary health care activities in developing countries, and to stimulate the mobilization of new resources (see also paragraph 3.6). This conforms to the directive given by the Executive Board that the Health Resources Group should function under the aegis of WHO and in accordance with its constitutional mandate--a directive that was noted with satisfaction by the Thirty-fourth World Health Assembly.
I Throughout this volume the $ stgn denotes US dollars.
6
POLICY BASIS I. 2 3 Political support is essential for implementing the Strategy for health for all. Such support needs to be sought and promoted, and the regional committees have been active in doing so. Among the sources of political support are the geopolitical groupings of countries, an example being OAU. WHO is inviting OAU to include health for all by the year 2000 as an agenda item at one of its forthcoming summit meetings. I .24 Another example is ASEAN. The cooperative spirit characteristic of ASEAN has permeated the health sector and reinforced international health cooperation, particularly with WHO. A meeting of ASEAN health ministers (from Indonesia, Malaysia, the Philippines, Singapore, and Thailand), held in Manila, accepted among its regional priorities WHO's goal of health for all by the year 2ooo through primary health care. The ministers signed a declaration of collaboration in health affirming "their agreement to strengthen and coordinate regional collaboration in health among ASEAN countries". They adopted guidelines to ensure that collaboration should contribute directly or indirectly towards regional selfreliance and self-determination; to emphasize health as an integral part of overall socioeconomic development; to aim at making health care accessible to the whole population, priority being given to the underserved and depressed areas; to promote health manpower development consistent with the needs of the ASEAN member countries; to continue with international collaboration in health while striving to be self-reliant in the delivery of health services; and to emphasize primary health care in the overall development strategy. The ministers also agreed to develop a formal mechanism within ASEAN to facilitate effective collaboration in the areas of: primary health care; disease control; health planning, management, and information systems; nutrition; health manpower development; environmental and occupa-
tional health; pharmaceuticals, biologicals, and traditional medicine; and mental health. 1.25 A third example is the movement of non-aligned countries. The Fourth Meeting of Ministers of Health of the Non-aligned and Other Developing Countries (Geneva, I98o) adopted a resolution supporting the goal of health for all by the year 20oo and calling on all countries in the movement to develop an appropriate programme of action. The ministers agreed to use WHO mechanisms for bilateral and multilateral exchanges of the experience obtained in this direction; to exchange information; to request or send consultants and advisers, in line with each country's possibilities; to coordinate research in biomedical and health matters; and to request or offer material, technical, human, and financial support for implementing the priorities of the programme of action adopted at the Sixth Summit Conference of Nonaligned Countries (Havana, I979) in line with possibilities and needs. 1.26 The adoption of regional charters for health development is a welcome event, indicative of widespread political support for WHO's policies and acceptance of the concept of technical cooperation. The official signing by certain countries of the Charter for the Health Development of the African Region was of major importance, marking a decisive step in reaffirmation of the individual and collective determination of Member States to attain a reasonable level of health. The objectives of the Charter include improvement in primary health care, manpower development and training, provision of safe water and sanitation, promotion of maternal and child health, and control of communicable diseases. The Charter affirms the commitment of Member States in areas they jointly consider important for health development. By collectively binding governments to ideals they already hold individually, the Charter can be an effective instrument for peace, progress, and cooperation.
7
1.27 The countries of the South-East Asia Region have signed the Asian Charter for Health Development. The Charter is a means for the countries of the Region to cooperate in building up individual selfreliance and collective self-sufficiency. Its aim is to promote intercountry consultation and collaboration, foster close international cooperation, and provide a common basis for formulating health plans, programmes, and projects in the best way possible, within the framework of national, regional, and global development policies. I. 2 8 Political support was also forthcoming at the global level. Following the adoption by the United Nations General Assembly of resolution 34/5 8 on health as an integral part of development, the Economic and Social Council recommended to the General Assembly the adoption of a resolution on the Global Strategy for health for all by the year 2000. The General Assembly subsequently adopted resolution 36/43, in which it recognized that the implementation of the Global Strategy would constitute a valuable contribution to the improvement of overall socioeconomic conditions and thus to the fulfilment of the International Development Strategy for the Third United Nations Development Decade. The General Assembly endorsed the Strategy and urged all Member States to ensure its implementation as part of their multisectoral efforts to implement the provisions contained in the International Development Strategy, and to cooperate with one another and with WHO to that end. It requested all appropriate organizations and institutions of the United Nations to collaborate fully with WHO in carrying out the Strategy, and asked the Director-General of WHO to ensure that measures to implement the Strategy are taken into account in the review and appraisal of the implementation of the International Development Strategy for the Third United Nations Development Decade.
1.29 In compliance with its constitutional functions the Executive Board embarked on the preparation of the Seventh General Programme of Work covering the period I984-I989 inclusive. It decided that this Programme of Work should constitute WHO's support to the Global Strategy for health for all, being the first of three such general programmes of work up to the target date 2000. Draft material for the Programme was considered and commented on by the regional committees at their I98I sessions. For example, the Regional Committee for the Americas decided to consider its plan of action for the implementation of the regional strategy as the Region's contribution to the preparation of the Seventh General Programme of Work. The Regional Committee for South-East Asia stressed that the Programme should be relevant to the particular needs of the countries of the Region. These, as well as the comments and recommendations of the other regional committees, were brought to the attention of the Programme Committee of the Executive Board, which took them into account when it prepared a draft of the Programme for the consideration of the Executive Board in January I982. (See also paragraphs 2.3I2·3 3·)
WHO's structures in the light of its functions 1.30 A managerial study of unprecedented magnitude on WHO's structures in the light of its functions took place under the direction of the Executive Board during I 98o and I 98 I. Following wide consultation throughout the Organization, the matter was reviewed extensively and intensively by the regional committees and the Executive Board. The high point of the study was the adoption by the Health Assembly in May I98o of resolution WHA33·I7, in which it decided that WHO should concentrate its 8
POLICY BASIS
activities on support to strategies for attaining health for all, and that its role in promoting action for health, in addition to indicating how such action might be carried out, should be strengthened. The Health Assembly felt that the functions of the regional offices and WHO headquarters should be redefined and organizational structures and staffing adapted so as to ensure the provision of adequate and consistent support to Member States. The engagement of national staff and of international WHO field staff should be reviewed to ensure the full involvement of both kinds of staff in collaborative national programmes. The Health Assembly considered that the Executive Board should strengthen its role in giving effect to the decisions and policies of the Health Assembly and in advising it; become increasingly active in presenting major issues to the Assembly; and correlate its own work with that of the Assembly and the regional committees, monitoring the way in which the regional committees reflect the Assembly's policies in their work. The regional committees, in the view of the Health Assembly, should intensify their efforts to develop regional health policies and programmes in support of health for all, support technical cooperation among all Member States, support the establishment or strengthening of multisectoral national health councils, and increase their own monitoring, control, and evaluation activities. The Health Assembly also urged Member States themselves to take action. They should review the role of their ministries of health, establish multisectoral national health councils, and mobilize all possible resources that could contribute to health development. In addition, they should improve their coordinating mechanisms in support of their health development strategy and technical cooperation, and coordinate their representation within WHO and in the United Nations and the specialized agencies concerned with development. The Health Assembly requested the Director-General to 9
take all the measures within his constitutional prerogatives that he considered nec,essary to ensure the provision of timely, adequate, and consistent support to Member States. I. 3 I In this context the regional committees, the Executive Board, and the Health Assembly reconsidered the nature of WHO's international health work as mentioned in the Constitution. The Thirty-fourth World Health Assembly (resolution WHA34.24) welcomed the changed climate in WHO and among its Member States that has given rise to the rejection of the concept of "technical assistance", whereby aid was provided by socalled "donors" to "recipients", and its replacement by the concept of "technical cooperation" founded on the common and mutual interest of all, whereby Member States cooperate with their Organization, as equal partners, to define and achieve their health . goals through programmes that are determined by their needs and priorities and that ptomote their self-reliance in health development. The Health Assembly reiterated that WHO's unique constitutional role in international health work comprises in essence the inseparable and mutually supportive functions of acting as the directing and coordinating authority on international health work and ensuring technical cooperation between WHO and its Member States, essential for the attainment of health for all by the year zooo, making no distinction between these integral functions carried out at country, regional, and global levels, whether financed from the WHO regular budget or from other sources. It affirmed that coordination in international health work is the facilitation of the collective action of Member States and WHO to identify health problems throughout the world, to formulate policies fqr solving them, and to define principles and develop strategies for giving effect to these policies; and that technical cooperation in international health work is the joint action of Member States cooperating among themselves and
THE WORK OF WHO, r98o-r98r
with WHO, as well as with' other relevant agencies. to achieve their common goal of the attainment by all people of the highest possible level of health by implementing the policies and strategies they have defined collectively. It urged Member States to act collectively in order to ensure the most effective fulfilment by WHO of its constitutional functions and the formulation by the Organization of appropriate international health policies, principles, and programmes to implement them; to formulate their requests for technical cooperation with WHO in the spirit of the policies, principles, and programmes they have adopted collectively in WHO; and to take full account of the experience of technical cooperation between WHO and its Member States when deciding collectively on policies, principles, and programmes in WHO. The Health Assembly also requested the Director-General to emphasize WHO's unique constitutional role in inter-. national health work in all appropriate forums, and particularly in the United Nations system and in other international or bilateral organizations. 1.32 In the course of 1981 the regional committees, the Executive Board, and the Health Assembly reviewed a plan of action that had been prepared by the Director-General for implementing resolution WHA33.17. In this plan of action particular emphasis is given to the proper fulfilment by WHO of its role in supporting Member States at country level, including the role of the WHO programme coordinators. In the African Region more than 30% of all WHO programme coordinators are nationals of the country concerned, and the proportion is increasing yearly. A global strategy to strengthen WHO's role of facilitating technical cooperation among developing countries (TCDC) has been prepared, and all regions are developing plans of action to implement this strategy in a manner appropriate to their own circumstances. IO
Particular attention was paid to TCDC in Africa and the Americas. In the African Region, for example, work has been organized through three subregional groupings of countries with the aim of supporting TCDC within each of them. 1. 3 3 The Regional Committee for the Americas recommended that Member governments should play a more active individual and collective role in the work of WHO and enhance the continuity, preparation, and coordination of their delegations to the governing bodies ofPAHO and WHO. It subsequently requested that the regional structures should take into account the requirements of the plan of action for the regional strategy for health for all. The Regional Committee for South-East Asia endorsed the plan of action prepared by the Director-General for implementing resolution WHA33.17. It urged Member States to initiate action as recommended in this resolution, especially in regard to the strengthening of the role of ministries of health ; and also to ensure the highest level of representation at its sessions in order to strengthen the role of the Regional Committee. It again emphasized the overriding importance of strengthening operations at country level, including the work of the WHO programme coordinators. 1. 34 The Regional Committee for Europe revised its methods of work to ensure more effective conduct of the proceedings. Thus in even-numbered years, when there will be shorter Health Assemblies and when the regional programme budget proposals for the forthcoming biennium are considered, the Regional Committee will be held in Copenhagen and the working sessions will be somewhat extended to make it possible to complete the agenda without undue haste. The Regional Committee for the Western Pacific felt that WHO had been particularly successful in that Region in implementing many of the measures identified as themes of
POLICY BASIS
the study. Despite this, the Regional Committee wished to achieve an even deeper relationship with the Health Assembly and the Executive Board and decided to include a review of mechanisms for improving this relationship on the agenda of a future session. It invited representatives who are also members of the Executive Board to comment during sessions of the Regional Committee on issues of special interest for regional activities. The Regional Committee adopted a resolution recommending that consideration should be given to devising a means of increasing the number of members from the Western Pacific Region serving on the Executive Board. I. 3 5 Regional committees have undoubtedly responded to the challenge to take a more active part in the work of the Organization. The following are some of the ways that have been adopted to facilitate this: - The letter inviting Member States to attend the Regional Committee requests them (i) to coordinate their representation at regional committees and the Health Assembly and to designate representatives to the regional committees and delegates to the Health Assembly who will later be in a position to influence national health policy so as to make it consistent with collective health policy adopted in WHO; and (ii) to take into account as far as possible the multidisciplinary nature of health activities when forming their delegations to the Health Assembly and the Regional Committee (African Region). - An advisory group of members of the Regional Committee who have attended the Health Assembly prepares material for the Regional Committee on the Health Assembly's resolutions (European Region). - Regional committees have established various advisory bodies: programme committees (African and Western Pacific Regions); consultative groups on programme development and on budgetary
questions (European and Eastern Mediterranean Regions); a standing committee or subregional committee on TCDC (African and Western Pacific Regions); a regional advisory committee on medical research (all regions); and a regional health development advisory council (African, European, and Eastern Mediterranean Regions). - Consultations with Member States on given subjects take place through groups of experts who report to the Regional Committee (European Region). - Biennial seminars of representatives of Member States are being organized to discuss the letter of consultation on preparing the programme budget proposals (European Region). - Relations between the regional committees/regional offices and the United Nations regional economic commissions, as well as with subregional geopolitical groupings of Member States, are being strengthened (all regions). - A regional plan of action has been formulated for implementing resolution WHA33.I7 (Western Pacific Region). - The synchronization of PAHO's and WHO's planning cycles is under consideration, as well as of the sessions of the Regiqnal Committee (i.e., the Executive Committee or the Directing Council of P AHO) with those of the Executive Board and the Health Assembly, in order to strengthen PAHO's contribution to these organs (Region of the Americas). 1.36 Much attention was also paid to improving methods of work in regional committees. For example, in the African Region the work of the Regional Committee has been greatly facilitated not only by the establishment of consultative mechanisms of the type indicated above but also by a new presentation of the material for the Committee's consideration, in which fundamental questions are posed at the end of the documents. I I
THE WORK OF WHO, r98o--r98r I. 37 There has been greater correlation of the work of the regional committees, the Executive Board and the Health Assembly. Agendas are better coordinated, and to facilitate this move appropriate action is taken at every session of the Global Programme Committee of the Secretariat, which consists of the Director-General, the Deputy Director-General, the Regional Directors, and the Assistant Directors-General. The following are further examples of the ways in which the work of the governing bodies is being better correlated: - Resolutions of the preceding Health Assembly and sessions of the Executive Board are reviewed, particularly with respect to their regional implications (all regions). - A document submitted to the Regional Committee containing a summary of the resolutions of the Health Assembly and Executive Board permits that Committee to expand and deepen its analysis of the regional and national implications of those resolutions (African Region). - The provisional agenda for the session of the Regional Committee is examined at the preceding session, taking into account the regional implications of decisions of the governing bodies at other levels (African Region). - A regional plan of action for implementing the resolutions is adopted by the Regional Committee (African Region).
sembly in May I981. The Regional Committee for the Americas decided that the programme budget framework of PAHO for I984-I98 5 should conform not only to the regional plan of action for the strategy for health for all, but also to the classified list of programmes to be established by WHO under the Seventh General Programme of Work. Moreover, in order to improve the correlation between the health programmes of individual countries and those of WHO, the Regional Committee decided to develop a new set of criteria for the allocation of resources among country programmes. These criteria should reflect the relative health needs of the countries and their relative capacities to implement global and regional priority programmes within their national health systems. 1.39 The issues that were discussed by the regional committees, the Executive Board, and the Health Assembly during I98o and I 98 I illustrate further how the work of the governing bodies was correlated and indicate the specific matters that were considered by one or other of these bodies in the light of their particular interests. Reference has already been made to the interaction between the regional committees, the Board, and the Assembly for the development of the strategies for health for all, the Seventh General Programme of Work, and the study of WHO's structures in the light of its functions. The consideration by the Health Assembly in I98o of the development and coordination of health research, which led to resolution WHA3 3.2 5, was followed by discussions on this matter in the Regional Committee for Africa in I98o (resolution AFR/RC3o/R5) and I98I (resolution AFR/ RC 3 I /R 5) and in the Regional Committee for the Western Pacific in I98I (resolution WPR/ RC32/RI4). Intense debate on infant and young child feeding in the Health Assembly in I98o (resolution WHA33·32), the Board in 198I (resolution EB67.RI2), and again in the 12
I. 38 Certain issues to be discussed at the Health Assembly are first reviewed in the regional committees. For example, in I 98 I the Regional Committee for Africa reviewed the subject of alcohol consumption and alcohol-related problems in preparation for the Technical Discussions during the Thirtyfifth World Health Assembly in May I982. Again, the Regional Committee for the Western Pacific discussed health systems support for primary health care, which was the subject of the Technical Discussions during the Thirty-fourth World Health As-
POLICY BASIS
Assembly in I98I (resolution WHA34.23), led to the adoption of the International Code of Marketing of Breast-milk Substitutes (resolution WHA34.22). This was subsequently considered by the Regional Committees for South-East Asia (resolution SEA/RC34/R8), Europe (resolution EUR/RC3 I/R5), and the Western Pacific (resolution wPRjRcpjRII).
I .40 Disability prevention and rehabilitation were considered by the Regional Committee for the Western Pacific in I98o (resolution WPR/RC3I/R2o). In I98I the Executive Board considered the International Year of Disabled Persons (decision EB67 (I 2)) as did the Health Assembly (resolution WHA34·3o). This was followed in the same year by discussions on the subject in the Regional Committee for the Americas (resolution XLIII). The Technical Discussions at the Regional Committee for Europe in I98I were devoted to the medical and social problems of disabled persons (resolution EUR/RC 3I /R I 3). The International Drinking Water Supply and Sanitation Decade was considered by the Regional Committees for South-East Asia and the Western Pacific in I98o (resolutions SEA/RC33/R9 and WPR/ RC3J/R2I respectively), by the Health Assembly in I98I (resolution WHA34.25), and following this by the Regional Committee for Europe (resolution EUR/RC3 I/R9) as well as by the Regional Committee for Africa as part of its review of programmes with I 990 as deadline (resolution AFR/RC3I/RI4). The Technical Discussions at the I98I session of the Regional Committee for the Western Pacific had as their subject "Health education and rural water supply and sanitation". A decision of the Executive Board in I 98 I concerning health care of the elderly (decision EB67 (13)) was followed by consideration of the matter in the Regional Committees for the Americas (resolution XLI) and the Western Pacific (resolution WPR/Rcp/RI5)·
L4I The organizational studies of the Executive Board dealt with (i) the role of WHO expert advisory panels and committees and collaborating centres in meeting the needs of WHO regarding expert advice and in carrying out technical activities in WHO, and (ii) the role of WHO in training in public health and health programme management. Both were prepared by working groups of the Board, considered by the Board itself (resolutions EB65 .RI4 and EB67.RI4 respectively), and subsequently reviewed by the Health Assembly (resolutions WHA33.20 and WHA34.I4). The Executive Board carefully reviewed the evidence concerning the global eradication of smallpox (resolution EB65 .RI7) and its review was followed by the resolutions of the Health Assembly (wHA33·3 and WHA 33.4) solemnly declaring the eradication of the disease and indicating the measures to be taken to ensure that it did not reappear. I .42 As for matters of particular interest to one or other of the governing bodies, the Thirty-third World Health Assembly reviewed the programme on workers' health, the programme on smoking and health, and the strengthening of the health legislation programme, adopting resolutions WHA 33. 3I, WHA33·35, and WHA33.28 respectively. Of specific interest to the Regional Committee for Africa, for example, were the Charter for the Health Development of the African Region, national liberation and health (resolution AFR/RC3o/RI4), and the regional antimalaria strategy (resolutions AFR/RC 30/R 17 and AFR/RC3 I /R I I). The Regional Committee for the Americas reviewed malaria control in I98o (resolution XIII) and the problem of Aedes aegypti in I98I (resolution xxi). It gave particular attention to the question of women in development both in I98o and I98I (resolutions xvn and xv respectively). It also reviewed alternatives for the full capitalization of the Revolving Fund of the regional Expanded Program on Immunization (resolution xx, I 98 I). The Regional Committee for
South-East Asia reviewed the Expanded Programme on Immunization itself (resolution SEA/RC34/R2) as did the Regional Committee for Africa as part of its review of programmes with I99o as deadline (resolution AFR/RC3 I/RI4)· The Regional Committee for South-East Asia paid particular attention to health manpower and community participation in primary health care and also to the managerial process for national health development (resolution SEA/RC34/R5)· The Regional Committee for Europe studied the assessment of medical technology, health education, and the promotion of health and prevention of disease through the adoption of appropriate lifestyles (resolution EUR/ RC3 I/R6). The Regional Committee for the Western Pacific took a particular interest in the programme of acute respiratory infections (resolution WPR/RC3 IjR23). It carried out an evaluation in the Region of the fellowships programme (resolution WPR/RC32/Rq), a subject to be reviewed by the Executive Board in January I982. Finally, all regional committees, followed by the Board and the Health Assembly, gave great attention to reviewing the programme budget proposals for I982-I983, which were described by the Director-General as "progressive programming and conservative budgeting". 1.43 The World Health Assembly did not leave its own structures untouched: it launched an Organization-wide debate on the periodicity, duration, and method of work of Health Assemblies. Following wide discussions by Member States in the regional committees and a thorough review in the Executive Board, the Thirty-fourth World Health Assembly finally resolved to maintain the practice of annual Assemblies for the time being (resolution WHA34.28). It also decided that, commencing in I982, the duration of the Health Assembly would be limited to not more than two weeks in even-numbered years, when there is not a proposed programme budget to consider. It requested the 14
Executive Board to work out the necessary methods of work for implementing this decision on a trial basis at the Thirty-fifth World Health Assembly in May I982 and asked the Director-General and the Executive Board to submit a report on the results of the trial, in respect of both the methods of work and the duration of the Health Assembly, for the consideration of the Thirty-sixth World Health Assembly in May I98 3 (resolution WHA34.29).
The above developments and what I ·44 led to them have been carefully considered within the Secretariat by the regional, headquarters, and global programme committees, as well as by an independent review group that was set up by the Director-General and that consists of a currently serving and an emeritus regional director. In addition, a working group of the Executive Board has been reviewing the work of the Secretariat and will report to the Executive Board in January I982.
Health and politics 1.45 Even if the attainment of health is the least controversial of social aspirations, its pursuit is fraught with political hurdles. These were not lost on the governing bodies during the biennium I980-I981. For example, the Regional Committee for Africa, considering that the political and economic liberation of the totality of African countries is indispensable for social and health progress in the Region, requested the Regional Director to organize a conference on apartheid and health (resolution AFR/Rqo/R4)· This took place in Brazzaville in November I 98 I in collaboration with the African liberation movements, the front-line countries, and the OAU Committee for the Liberation of Africa. Both in I 980 and in I 98 I the Health Assembly adopted a number of resolutions aimed at intensifying cooperation with newly
POLICY BASIS
independent and emerging States in Africa as part of their struggle for liberation, in particular by providing health assistance to front-line States, to Zimbabwe, to Namibia, and to refugees in Africa (resolutions WHA33·33, WHA33.34, WHA34.3J, WHA34.34,
including Palestine (resolutions WHA 3 3. 1 8 and WHA34·I9)· 1.47 The Health Assembly also considered general issues for maintaining world peace. In a resolution on "The role of physicians and other health workers in the preservation and promotion of peace as the most significant factor for the attainment of health for all" (resolution WHA34.38), the Health Assembly appealed to Member States to multiply their efforts to consolidate peace in the world. It gave instructions for the creation of an international committee composed of eminent experts in medical science and public health to study the contribution that WHO could make to economic and social development and to facilitate the implementation of the United Nations resolutions on strengthening peace and in particular preventing thermonuclear conflict.
and WHA34·35)·
I .46 The two subcommittees of the Regional Committee for the Eastern Mediterranean did not hold sessions during the biennium. In each of these years, the Health Assembly called for intensified health assistance to refugees and displaced persons in Cyprus (resolutions WHA33.22 and WHA34.2o), health and medical assistance to Lebanon (resolutions WHA33.23 and WHA34.21), and continued efforts to improve the health conditions of the Arab populations in the occupied Arab territories,
Chapter
2
General Programme Development and Management Managerial process for national health development DURING 198o-I981 WHO continued to improve the methodology of an integrated managerial process for national health development and to collaborate with countries in its application. This was in response to the real need of countries for a managerial process that would strengthen their capacity to formulate and implement their strategies and plans of action for achieving health for all by the year zooo. The strategy developed by WHO to this end comprises the following elements: promotion of the concept, technical cooperation, training, material support, further development of the methodology, and strengthening of WHO's support capacity. 2.1 2. 2 The plan of action that was developed in 198o-I981 to implement the strategy covers all these elements and concentrates primarily on providing the relevant support to countries in the remaining years of the Sixth General Programme of Work (1982-1983), bearing in mind the need for an extension into the Seventh General Programme of Work (1984-1989). It is being carried out by the entire WHO Secretariat (i.e., staff at country level, in the regional offices, and at headquarters) and entails close working relations and mutual support
between the various levels. In its support to health authorities it applies the principles of technical cooperation among developing countries (TCDC). 2.3 During the biennium WHO published guiding principles for the tlMlnagerial process for national health development, in support of the strategies for achieving health for all.l They set out the concepts and principles that can serve as a basis for more specific national guidelines. The managerial process, with all its components, is shown schematically in Figure 2. 1. 2-4 Guiding principles for health programme evaluation as part of this managerial process were also published,z to assist countries in developing evaluation activities that will permit the monitoring of progress towards health for all. , 2. 5. Problem-based learning material to illustrate the main issues arising in the application of the managerial process is in preparation. Such material constitutes a conceptual framework for the training process and provides an opportunity to learn the 1 World Health Organization. Managerial process for national health development: gutding principles. Geneva, I 98 I ("Health for All" Senes, No. 5). 2 \X' orld Health Orgamzauon. Health programme evaluatzon: gutding pnnciples. Geneva, I 98 I ("Health for All" Series, No. 6).
GENERAL PROGRAMME DEVELOPMENT AND MANAGEMENT
strategies of bringing about change; the techniques of planning, programming, programme implementation, and monitoring; and the skills required for teaching others. 2.6 In 198o-r98r most countries were engaged in formulating their national strategies and plans of action for achieving health for all by the year 2000 and in so doing used some form of the managerial process that was relevant to their political, social, economic,
and administrative situations. Most of them determined their long-term plans of action during this period and are now implementing countrywide priority programmes, using the managerial process for this purpose. A common characteristic of such plans is that they aim at a comprehensive national health system encompassing the entire population and include components both from the health sector and from other sectors whose interrelated action contributes to health develop-
Figure 2.1
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THE WORK OF WHO, I98o-I98I
ment. Many countries specifically foresee the development and application of an integrated managerial process and the establishment of a well-coordinated infrastructure for the delivery of countrywide programmes using appropriate technology and providing complete coverage. 2. 7 In the African Region all countries formulated national strategies for health for all during I98o--I98I, again with the help of the managerial process for national health development. An interministerial conference on the planning and management of health services was held in Dakar (I98o) with the participation of the ministers of health and economic planning of Benin, Mali, Mauritania, and Senegal.
2. Io Several intercountry workshops on country health programming were organized. National training workshops were held in most countries of the Region, with WHO support. In Zambia, for example, a national strategy and plan of action for health for all and primary health care was elaborated, material support being given by the Government of the Netherlands for its implementation.
2. I I In the Region of the Americas, all countries have formulated national strategies and plans of action for health for all, using appropriate managerial processes.
2.8 The first consultation in that Region on the development of health management training was held in Arusha (United Republic of Tanzania) in I98o, its object being to promote and strengthen such training in the African Region by establishing national networks of institutions. Participants came from health and management training institutions and from ministries of health and social welfare. Prior to the meeting, questionnaires had been sent out to ascertain what management procedures were being followed in certain institutions in Africa so that they could be reviewed at the meeting along with those used by ministries and by WHO. The relevance of existing courses to the goal of health for all by the year 2ooo was discussed, together with ways in which existing training programmes could be strengthened at all levels. 2.9 Following the recommendations of an interregional consultation, an African network of health management training and development programmes was set up in I981. This network is open to all national institutions.
2. I 2 To supplement the existing 49 regular courses in health care administration, a new phase of the PAHOJWHO programme in health administration was initiated with the support of the W. K. Kellogg Foundation. Literature was prepared and workshops organized as part of a strategy to improve the educational process and the content of courses in three areas : (i) economics and finance, (ii) organizational methods, and (iii) health assessment and planning. The participating institutions were the Regional Library of Medicine and Health Sciences (BIREME), the Latin American Center for Educational Technology in Health, the Case Western Reserve University (USA), and the London School of Hygiene and Tropical Medicine. 2. I 3 Two further important activities were an advanced programme in health administration training for the Central American countries and an international course on planning for the development of health service systems at the School of Public Health, Mexico City. 2. I4 In South-East Asia a regional plan of action for support to the managerial process was drawn up, based on national medium-term programmes developed in I 979 and updated in both I98o and I981. These
GENERAL PROGRAMME DEVELOPMENT AND MANAGEMENT
programmes clearly spell out the needs of countries and the type of cooperation required for implementing national priority programmes. 2. I 5 Burma, India, and Sri Lanka took part in a study of training programmes to improve manpower management in primary health care. Burma carried out a systems analysis of its management problems and, on the basis of that analysis, began work on a training programme for managers of primary health care services at all levels. India and Sri Lanka initiated similar action. In Thailand the National Economic 2.16 and Social Development Board established a macrosocial development subcommittee, with task forces concerned with (i) health, (ii) education and culture, and (iii) social welfare and security. Five ministries were involved. At the request of the subcommittee the Development Board formulated long-range objectives and strategies and indicated the mechanisms for achieving them through a 2o-year development plan, the first five years of which (I982-I986) coincide with the national social development project. The three task forces will devise medium-term plans for those five years. The objectives, initially established on the basis of past trends, will be refined with experience; indicators will be selected and expressed in terms of targets agreed by all the agencies concerned. Progress will be monitored throughout the period and evaluated before the next five-year planning cycle begins. Fundamental and supportive strategies in the main sectors will be defined, future resources will be estimated, and delivery of services will be planned accordingly. This broad approach is well in line with WHO's recommendations, and progress in Thailand will be watched with great interest by many Member countries. 2. I 7 Training material and modules have been prepared by training institutions in the
various countries of the Region in support of national planning and management activities, particularly in the evaluation of health services research. 2. I 8 In Europe, the Regional Health Development Advisory Council at its first meeting (March I 98o) discussed the development of regional strategies for the preparation of national and regional targets-strategies that were reviewed by the Council in I 98 I and circulated to all countries. Several projects in health planning and management were supported-in Algeria, Denmark, Morocco, Portugal, and Spain. 2.I9 Two international workshops on country health programming and related managerial processes were held in the United Kingdom in I98o and I98I-at the Usher Institute (Edinburgh) and the Nuffield Centre for Health Services Studies (University of Leeds). Participants came from several European countries and from countries of other regions, namely the Bahamas, Botswana, Democratic Yemen, Kuwait, Pakistan, Saudi Arabia, Sierra Leone, and Sudan. Country health programming was introduced into the workshops held in Amsterdam and Antwerp, in I98o and I98I, for participants from developing countries in Africa, South-East Asia, and the Eastern Mediterranean. 2.20 A regional workshop on the control of health care costs in social security systems (Vienna, I98I) laid stress on the need to coordinate primary health care and strengthen health care measures both within and outside the health sector. Another workshop (Munich, I98I), on the cost-effectiveness of standard patterns of long-term health care, focused on the quality of that care. 2.2I In the Eastern Mediterranean Region, a document to guide national authorities in introducing or strengthening the
THE WORK OF WHO, I98o-I98I
managerial process for national health development was issued in 198I and has been distributed to all countries of the Region. 2.22 The managerial process for national health development was used in preparing the five-year plans in Iraq, Somalia, Sudan, and Yemen. In Democratic Yemen, Sudan, and Yemen, the process was used in elaborating the national health policies, strategies, and plans of action for health for all. 2.23 The first workshop on the strengthening of health management in the Eastern Mediterranean Region (Mogadishu, 1980) was attended by participants from Democratic Yemen, Somalia, Sudan, and Yemen. The emphasis was on training needs, and use was made of local case material adapted to the requirements of the participants and the country concerned. A national workshop on health management was held in Israel in I 98 I for 24 key nationals from health and social security agencies. 2.24 In the Western Pacific Region, countries made use of the managerial process for national health development in updating their policies and strategies for primary health care and the achievement of health for all. The process was, for example, used in preparing five-year plans in the Cook Islands, Fiji, Papua New Guinea, Samoa, the Solomon Islands, and Tonga. In Kiribati, using a broad programming methodology, the plan for the country was updated and translated into priority programmes. In Malaysia, the preparation of the five-year plan was facilitated by a national workshop for senior health administrators. In the Republic of Korea the economic and financial aspects of the next five-year plan were worked out. In Malaysia, Papua New Guinea, the Philippines, and the South Pacific countries national strategies and plans of action for achieving health for all were elaborated, with the technical support of staff of the Regional Office. In China, a
course on management in national health development was held (1981), in which 50 senior public health administrators from throughout the country took part. 2.25 The establishment of national centres for health development was promoted in China, Fiji (for the South Pacific), Malaysia, Papua New Guinea, the Philippines, and the Republic of Korea. A regional network of centres is being established, to ensure technical cooperation among countries in the application of the managerial process for national health development.
Managerial process for WHO's programme 2.26 During 198o-198I WHO's own process of programme development focused on continuing the impetus given by the Thirty-first World Health Assembly (I978), which in resolution WHA3 1.43 requested that "managerial methods for health development [should be] devised and applied by WHO in an integrated manner", and by the Executive Board in elaborating the Seventh General Programme of Work (I984-I989 inclusive). 2.27 In recent years WHO has sought to promote an approach to health programme development and management that is relevant, practical, economical, and comprehensive. However, the components of this process have tended to develop at different speeds, and during the period 198o-I98I efforts were made to harmonize them more closely. There is now a systematic, unified managerial process in operation at all levels of WHO, whereby its general programmes of work are formulated on the basis of the Organization's policies and strategies and are then converted into medium-term programmes, which in turn form the basis of the biennial programme budgets. A process of monitoring and evaluation tracks the course 20
GENERAL PROGRAMME DEVELOPMENT AND MANAGEMENT
of the programmes as they are implemented and assesses their efficiency and effectiveness with a view to improvement where necessary. Ensuring that information both for and from the above-mentioned components is readily available is an integral part of this managerial process (see paragraph 2.39 to end of chapter). 2.28 A summary describing this integrated process has been issued. 1 It gives a short account of WHO's methods of programme development and is used for providing information both within and outside the Organization. 2.29 Whereas the preceding biennium was characterized by the development of methods for the management of WHO's programmes, the period now under review has seen a shift from the developmental phase to a phase in which the process is utilized to improve the content of programmes and their implementation. 2. 30 The regional committees, the Programme Committee of the Executive Board, the Executive Board itself, and the Health Assembly were all actively concerned with the periodic review and consequent reorientation of the process. 2. 3 I
The Board therefore classified individual programmes into (I) those that are required for the direction, coordination, and management of the Organization's act1v1ttes; (2) those that are required for the establishment of a sound health system infrastructure based on primary health care; (3) programmes of science and technology to ensure the appropriateness of the technology used by that health system; and (4) programmes designed for the practical and administrative support required by these three groups. 2. 32. At the same time, the Board requested the Programme Committee to prepare a draft of the Seventh General Programme of Work for its sixty-ninth session. Preparatory work was carried out in all regions and at headquarters, on the basis of the guidance given by the Board and its Programme Committee, and the material prepared was presented to the regional committees, whose comments were then taken into consideration by the Programme Committee (November I98I) in preparing its draft. 2. 33 The Seventh General Programme of Work is the first of the three such programmes that will be required up to the year 2ooo; its targets, for the period I984-I989, are therefore intermediate. It represents the Organization's response to the individual and collective needs of its Member States in implementing the strategies for health for all. It is moreover the first general programme of work to have been prepared on the basis of information on long-term strategies emanating directly from Member States and from the regions, thus enabling firm long-term trends to be established.
At its sixty-seventh session (January
I98I) the Executive Board considered the
report of its Programme Committee on the preparation of the Seventh General Programme of Work covering a Specific Period ( 1984-1989 inclusive) and confirmed that the latter should constitute support to the Global Strategy for health for all by the year zooo. The Strategy's emphasis is on developing health systems based on primary health care for the integrated delivery of health services to the entire population, using appropriate technology. 1 The managerial process for WHO's programme development (WHO document MPWPD/8I.I), 1981.
2.34 In I98o the medium-term programmes pertaining to the Sixth General Programme of Work were completed, all of them based on information and requests from Member States. Although their objectives, ap2I
proaches, and actlvttles originally derived from the Sixth General Programme of Work, the programmes formulated were greatly influenced by the new policy directives enunciated by the governing bodies of WHO in the context of health for all; medium-term programmes developed earlier were revised in the light of those directives. Moreover, now that these medium-term programmes have entered the implementation phase, they are providing further evidence of the usefulness of the process. 2.. 3 5 The experience gained during the Sixth General Programme of Work is being used in developing medium-term programmes pertaining to the Seventh General Programme. Because of the need for testing methodology, the medium-term programmes relating to the earlier General Programme were developed at different times, thus making it more difficult to ensure the necessary correlation. The medium-term programmes for the Seventh General Programme will all be worked out at the same time with a view to proper linkage. They will then form the basis of the biennial programme budgets.
2.. 37
With the programme budget for
I98o-I98I WHO adopted a new and more
2..36 Guidelines for joint medium-term programming and programme budgeting were issued in I 98 I to ensure the homogeneous development of the Seventh General Programme of Work into medium-term programmes, and the progressive translation of the latter into the three programme budgets that will cover I984-I989. To ensure that the activities described in the programme budget are consistent with the medium-term programmes, individual summaries of the latter will be included in the global programme statements in the budget document presented to the Executive Board and the Health Assembly in 1983. The guidelines also emphasize evaluation as an integral component of this medium-term programming/programme budget sequence (see paragraph 2..38). 2.2.
flexible approach to programme budgeting and the management of WHO's resources at country level, intended to strengthen the relevance and impact of WHO's support to governments and facilitate the Organization's role as the international partner of every Member State in developing and implementing the health policies and strategies that countries have adopted for the attainment of health for all by the year zooo. In many countries however this new approach has not yet come up to expectation. In some cases the potential for collaboration between WHO and the country concerned has not been fully utilized; in others the continuation of traditional practices and procedures has proved a constraint on the new approach. Accordingly in I98I studies were initiated in countries in two regions to determine- how WHO can give better support to Member States, including more effective programme budgeting and better use of WHO resources at country level. The conclusions drawn from these studies should help in establishing the programme budget for I984-I985 and in strengthening the relevance and effectiveness of WHO support to Member States. 2.. 38 Programme evaluation is an integral part of the managerial process for WHO's programme development and the Organization's internal mechanisms (including the regional and headquarters programme committees) continued their periodic reviews of WHO-supported projects and programmes. Although progress has been made in applying the evaluation process, significant lacunae still remain. For example, the proper dissemination to the various levels of the Organization of the results of evaluation, and the consequent utilization of its findings in order to achieve change, has not been fully realized; in other words, the synthesis and interpretation of evaluation results-and the feedback of the conclusions drawn-need to
GENERAL PROGRAMME DEVELOPMENT AND MANAGEMENT
be improved. One way of achieving such improvement is to relate evaluation results more closely to medium-term programmes and to programme budgets, e.g., by including a short assessment of previous activities under the various headings of the proposed programme budget.
services; and-most important of allsupport to Member States in the development and operation of their information services. 2.42 Direct services in support of the planning, programming, implementation, monitoring, evaluation, and coordination of WHO's collaborative programmes with Member States differ, depending on the nature of the technical programme, its mode of operation, and its management. For example, in 1980-1981 support to the Special Programme of Research, Development and Research Training in Human Reproduction included (i) a management information system providing financial and administrative data on projects, grants, and collaborating institutions or scientists, and (ii) dataprocessing services for multicentre studies on various fertility regulation methods. Another example is the assistance given to the Special Programme for Research and Training in Tropical Diseases in basic management studies, development of an information service on collaborating institutions or scientists, and provision of computer support. In addition, a text analysis system was developed for documents produced by the Expanded Programme on Immunization to ensure that the terminology used would be familiar to readers. Experience such as the above is providing a basis--and in part the tools-for information systems support to the relatively new diarrhoeal diseases control programme and to the action programme on essential drugs. 2.43 Direct services were also continued to the administrative and financial side of WHO's activities. The computerized administration and finance information system was of assistance inter alia in preparing, consolidating, and finalizing the operations required in establishing the biennial programme budget. This system was improved during 1980-1981. Moreover its main components (related to budget control, expendi-
Information systems support 2.39 Information systems support to the managerial process falls into two main areas: (1) operation and development of WHO's own information system in relation both to management of WHO programmes and to international exchange of health information and experience ; and ( 2) direct and indirect support to Member States in developing certain aspects of their national health information systems, particularly as regards methodology and technology. 2.40 During 1980-1981, the main activities carried out and the systems developed were reviewed by an interregional advisory group. As a result of this review, the Director-General decided that responsibility for the internal reporting system at headquarters should be transferred to the programme managers. This system has been in operation since January 1978 and incorporates such useful features as an organizationwide compatible format for the recording, reporting, storage, and retrieval of information on programmes and projects; sixmonthly and annual reporting-by-exception; and an information flow geared to the Organization's managerial process for programme development. 2.41 As from January 1981 therefore the information systems programme concentrated on methodological and technological support for information systems throughout the Organization; the provision of compatible data-processing and text-processing
ture accounting, general ledger entries, and payment of claims) were adapted for use in regional offices on a minicomputer. The system is running to the satisfaction of the Regional Office for Europe, which agreed to be the pilot regional office in this respect and to train staff from other regions. Plans were developed for introducing the system in 1982-1983 in the Regional Office for Africa (which already uses a minicomputer for training purposes) and a start was made with relatively simple applications related to personnel, supplies, fellowships, budget, and country health information. 2.44 The use of the fully compatible word-processing equipment installed at headquarters and in the Regional Offices for the Americas, South-East Asia, Europe, and the Western Pacific was strengthened in 1980-1981 by training new operators, developing new applications, and making the equipment available to a larger number of programmes. A feasibility study was carried out in the Regional Office for the Eastern Mediterranean with a view to the acquisition of similar equipment early in 1982. 2.45 Computer services at headquarters continued to be provided by the Genevabased International Computer Centre. But throughout 1980-1981 the policy was to decentralize electronic data-processing and word-processing services to the regional offices. This is reflected in the fact that the relevant expenditure has been more or less stabilized at headquarters, whereas it has increased in the regional offices, all of which now have electronic data-processing or wordprocessing installations, and in some cases both. 2.46 The following are examples of methodological and technological support to national health information systems during the biennium, and there were many others:
- A review of Bahrain's health information system and a proposed strategy for its improvement. The first phase of the latter aimed at establishing users' requirements for both manual and computerized components of the system. It is expected that the experience, and in part the tools, developed for Bahrain will be shared by other Member States in the Gulf area. - Support to China in developing a strategy for a computerized information network to strengthen the biomedical information centre of the Academy of Medical Sciences, Beijing. The first phase aimed at familiarizing key staff with the support that can be given to routine library operations by simple microcomputers, and training them to develop the software applications needed. - Support to Egypt in revising its datacollection forms and in establishing key health indicators and the outline for subsequent reports. Six types of microcomputer were selected and, after development of the software, were field-tested in six provinces of the country. - Support to Kuwait in establishing a strategy for a largely computerized health information system as part of an integrated health care system, but starting initially with five relatively new hospitals. - Support to Thailand in a health management information system for central, provincial, and district level. During the first phase, users' requirements were established; studies were carried out on the information flow from the district level and on storage and processing facilities at that level; and additional computer support for the Ministry of Public Health from other government institutions was negotiated. 2.47 Experience acquired from the type of project described above can be drawn upon in the context of technical cooperation among developing countries. To help to meet increasing demands, WHO also called upon
GENERAL PROGRAMME DEVELOPMENT AND MANAGEMENT
its collaborating centres in medical (health) informatics, of which there are at present two, in Paris and Uppsala (Sweden). 2.48 There was a considerable training element in most of the activities. Where appropriate, it covered the utilization of upto-date systems and computer-supported techniques. For example, to follow up the support given to the Malaysian health information system in I978-I979 a workshop was held (Malaysia, I98o) which benefited from a demonstration and evaluation of the improvements introduced. 2.49 Since microcomputers, if properly selected and utilized, often constitute the "appropriate technology" required, WHO maintains comparative data on some of the more suitable models available, and on their applications in health work. Two studies were initiated in I 98o-I 98 I (both involving
the WHO collaborating centres) to develop such applications and test their practical and economic implications; the first study related to processing of tabular material, the second to retrieval of health ·literature. 2.50 The years I98o-I981 saw a major evolution in the methodology and technology of information systems that will have an impact in the health sector. It was accompanied by a significant increase in Member States' requests to WHO for assistance with their health information systems. To enable the Direcor-General to take full advantage of the opportunities opened up by informatics, an international consultationon informatics applications in health-was convened (November 1981) to advise on priorities for 1984-1989 and on ways and means of meeting them in consonance with the strategies for health for all by the year 2000.
Chapter J
Coordination
COORDINATION activities in 1980-1981 moved into higher gear in response to certain factors: (i) the nature of primary health care, which requires multisectoral support and has thus brought to the fore the need to engage the interest of other agencies and disciplines; (ii) the growing production by countries of national health plans, calling inevitably for more external resources of all kinds; (iii) the translation into practical terms of WHO's constitutional role as the coordinating body for international health activities by way of a completely new approach, that of rationalizing the flow of international health resources in accordance with WHO's priorities and with nationally perceived requirements; and (iv) the atmosphere of deepening financial crisis, which has made it more difficult to mobilize those resources at the very time when the need for them is increasing. 3.1
198o-1981, the sum of $75 789 67o was contributed to WHO's Voluntary Fund for Health Promotion. By the end of 1981 a further $29 697 695 had been pledged but not yet received.
3. 3 This channelling of funds through WHO was accompanied by a similar increase in direct bilateral support to the health sector and in loans and grants from development banks and funds. A noteworthy development has been the express wish of donors to increase their mutual collaboration under the aegis of WHO, in order to avoid wastage or duplication and to ensure that every dollar for development is used to the best effect. WHO is increasingly consulted for guidance as regards bilateral health programmes. This trend has given rise to a more formalized collaboration with the main traditional donors that includes annual review meetings in addition to the routine daily contacts. 3·4 During the biennium substantial contributions were received by the Organization from the traditional donors, notably Belgium, Denmark, France, the Federal Republic of Germany, Kuwait, the Netherlands, Norway, Sweden, Switzerland, the United Kingdom, the United States of America, and the USSR. The Japan Shipbuilding Industry Foundation (Sasakawa Memorial Health Foundation) maintained a substantial contribution to selected programmes. 26
Extrabudgetary sources of funds 3. 2 The period under review was characterized by continued recognition on the part of donor countries, foundations, nongovernmental organizations, and others concerned with health development that an acceptable level of health for all by the year 2ooo can be achieved only by channelling substantial resources-human, financial, and materialinto the health sector. During the biennium
COORDINATION
3. 5 The development banks increased the proportion of their grants and loans to the health sector. In I98o the Inter-American Development Bank provided $244 million in loans related to public health or environmental health. The agreement between WHO and the Islamic Development Bank led to the funding by the latter of important health projects in different countries, including a health network in southern Sudan, a primary health care network for refugees from Ogaden (Somalia), equipment for a hospital and wells for drinking-water in Pakistan, a primary health care network in the United Republic of Cameroon, and hospital equipment for Uganda. The funding of these projects to date has totalled $4 million, and further projects are under study. 3.6 The Director-General established the Health Resources Group for Primary Health Care as a forum where all those interested in supporting the global health effort could discuss the international transfer of resources for health work. The Group met in December I 98o and decided upon an initial approach that includes in particular a review of resource utilization in those countries whose primary health care programme is at a stage where external support can be absorbed and effectively used. The aim is to provide an authenticated document that can form the basis on which external support is provided by a group of donors acting in unison with the country concerned. At a meeting in December I981 the results of the first reviews-in Benin, Ecuador, Gambia, Sri Lanka, and Sudan-were presented by the representatives of the ministries of planning and health of those countries to a wide group of governments and organizations interested in supporting health development. This approach is proposed as an appropriate mechanism for achieving more effective use of existing resources for health and encouraging the allocation of a larger proportion to the health sector. The planning authorities of 27
each of the countries where reviews were made will convene a meeting of interested external partners in health development during I982. In addition, the exchange of information is being intensified. WHO programme coordinators and other staff are being made more aware of the possibilities for obtaining a due proportion of external resources for health work at country level. 3. 7 A trust fund-the Primary Health Care Initiative Fund-has been set up to provide a ready source of financing for "seed" and catalytic activities connected with primary health care, particularly in the developing countries. Contributions have been received, notably from Greece and the Netherlands, and a number of pledges have been made. 3.8 A particularly intensive effort was made during the period to enhance collaboration with the Arab banks or funds assisting socioeconomic development. Contacts were made with the OPEC Fund for International Development, the Arab Fund for Economic and Social Development, the African Development Bank, the Islamic Development Bank, the Club du Sahel, the Gulf Arab Development Foundation for the United Nations, the Aga Khan Foundation, the Organization of the Islamic Conference, and the Health Department of the League of Arab States.
United Nations system 3·9 Coordination within the United Nations system continued to be an important concern, particularly in view of the resolution adopted by the United Nations General Assembly in I979 entitled "Health as an integral part of development" (resolution 34/5 8). 3. I o In response to that resolution, and as part of the follow-up required by the Inter-
THE WORK OF WHO, 198o-I981
national Conference on Primary Health Care (Alma-Ata, I978), the Director-General undertook a study of the various components of primary health care in relation to the work programmes of the United Nations itself and of the specialized agencies in its system. The report was presented to the March I 98o session of the Consultative Committee on Substantive Questions (Programme Matters) of the Administrative Committee on Coordination. It helped to create a greater awareness of the extent to which sectors other than health were concerned in the implementation of primary health care. The discussion in the Consultative Committee served as a basis for a study submitted to the Thirty-fourth World Health Assembly when it considered the contribution of health to socioeconomic development and peace. This study was subsequently brought to the attention of other organizations and institutions of the United Nations system.
3. I 2 This promotion of concerted action within the United Nations system was complemented in I 98 I by the submission to the Economic and Social Council (at its second regular session in I 98 I) of the Global Strategy for health for all by the year 2ooo. The Director-General presented the Global Strategy in plenary meeting and it was subsequently discussed in committee. On the recommendation of the Council, the United Nations General Assembly at its thirty-sixth session endorsed the Strategy as "a major contribution to attaining the worldwide social goal of health for all by the year zooo", and requested all appropriate organizations and institutions of the United Nations system to collaborate fully with WHO in carrying it out (General Assembly resolution 36/43). 3. I 3 WH 0 took part in three crossorganizational programme analyses undertaken by the United Nations Secretariat at the request of the Committee for Programme and Coordination. The studies focused on science and technology, activities related to young people, and public administration and finance. A number of other contributions were made to United Nations reports dealing with such subjects as: exchange of information on banned hazardous chemicals and unsafe pharmaceutical products; protection of consumers; human rights; and disarmament and its relationship to socioeconomic development and to operational activities for such development. Much of the collaboration took place within the framework of the Administrative Committee on Coordination (ACC) but certain matters were coordinated through ad hoc interagency meetings in which WHO continued to ensure that health concerns and WHO programmes are thoroughly related to the broader work of the United Nations system. 3. I 4 The Director-General ensured WHO's full participation in the work cif ACC and its subsidiary bodies. As in earlier years, a 28
3. I I In connexion with the Technical Discussions held during the Thirty-third World Health Assembly on "The contribution of health to the New International Economic Order", publications and other written material were solicited from the United Nations system and served as a basis for the documentation for the debate. No less than I4 organizations contributed. Several organizations were also represented at the Technical Discussions and this helped to bring into better focus the health sector's contribution to a more equitable social and economic order. The results of the Technical Discussions were brought to the attention of the United Nations in the Director-General's report to the eleventh special session of the General Assembly (September I98o), which met to consider a new International Development Strategy and to assess the progress made in implementing the Programme of Action on the Establishment of a New International Economic Order.
COORDINATION
very wide range of subjects came under review by ACC, including rural development, information systems, science and technology, water resources, disarmament questions, and the role of women in socioeconomic development. 3. I 5 Specific attention was given by WHO to the International Year of Disabled Persons (I98I), the Organization hosting an interagency meeting in this connexion in August I98o. There was also close cooperation with the United Nations in preparations for the World Assembly on Aging (I982). Work was instituted with the International Telecommunication Union in preparation for World Communications Year in I983. 3.I6 WHO took an active part in the preparations for and the proceedings of the United Nations Conference on the Least Developed Countries (Paris, September I 9 8 I), the Director-General emphasizing in his address the total interdependence and indivisibility of health and economic development.
mentioned sessions emphasized the need for the specialized agencies to be involved in the development of activities for this third programming cycle. They particularly stressed the use of UNDP country programming as a flexible frame of reference for the operational activities to be carried out by governments through their planning, programming, and coordinating processes. The designation of resident coordinators serving the United Nations system at country level is now well advanced. 3. I 9 An innovative step was the joint programming of WHO activities under the UNDP regional programme for Asia and the Pacific, involving three WHO regions; similar steps were taken for Africa and Europe. 3.20 Continued support was given under UNDP's global and interregional programmes to the UNDPfWorld Bank/WHO Special Programme for Research and Training in Tropical Diseases; negotiations were undertaken for the third phase of this support, in an amount of $8.6 million. Increased financial support was also assured for the Expanded Programme on Immunization, the quality control of vaccines, the control of diarrhoeal diseases, and work in connexion with the International Drinking Water Supply and Sanitation Decade. Preliminary assistance was given to the new programme on health learning materials.
United Nations Development gramme (UNDP)
Pro-
3.17 The key issue of the I 98o and I 98 I sessions of the UNDP Governing Council was the third cycle of programming and planning, I982-I986. The preliminary pledges so far made by donor governments for that period-some $5 Ioo million-fell short by 24% of the target of $6 700 million required for implementing the programme planned, and efforts are being made to bridge the gap. The Council decided that So% of the total allocations available for countries should be allotted to those with a per capita gross national product of less than $ 5oo.
United Nations Children's Fund (UNICEF) 3.2I The biennium I98o-I98I saw encouraging and fruitful developments in the cooperation between WHO and UNICEF. Primary health care was the main area of collaboration. This took the form of development of methodology, organizing of regional and national workshops, and collaboration
3. I 8 Various interagency meetings and the UNDP Governing Council at its above-
with governments in the implementation of primary health care at country level. Certain of the main components of primary health care were developed, at least in their services aspect, as joint UNICEF /WHO programmes. The most important of these relate to the Expanded Programme on Immunization and include development of the cold chain; control of diarrhoeal diseases and national production of oral rehydration solutions; and work on essential drugs. 3.22 A significant achievement-with which UNICEF was closely associated as part of the promotion of proper infant and young child feeding-was the International Code of Marketing of Breast-milk Substitutes, approved by the Health Assembly in May I98I (paragraphs 6.7-610). 3.23 In November I98o the DirectorGeneral of WHO and the Executive Director of UNICEF met to explore ways of achieving even closer collaboration, particularly between field offices. It was agreed that WHO and UNICEF should make a special effort to accelerate the development of primary health care in those countries that were ready for such an undertaking. 3.24 The UNICEF/WHO Joint Committee on Health Policy met in February I 98 I. It considered a study carried out by the two organizations on country decision-making for the achievement of the objectives of primary health care (see paragraph p) and recommended it to the UNICEF Executive Board for approval. The Joint Committee also agreed to a proposed new study, provisionally entitled "Implementation of primary health care, with emphasis on the most effective support that WHO and UNICEF could give jointly to governments" (paragraph 5.2). Other subjects considered were the Expanded Programme on Immunization, essential drugs, leprosy control, schistosomiasis, the joint UNICEFJWHO programme
on childhood disabilities, control of diarrhoeal diseases, and infant and young child feeding. UNICEF and WHO are also collaborating in a joint plan of action on nutrition covering the years I98I-I985. The activities of the Joint Committee were warmly commended by the UNICEF Executive Board.
World Food Programme (WFP) 3.25 Since the ever-increasing demands for emergency food aid are now being met in part by special donor financing, the World Food Programme (WFP) was again able to devote most of its regularly pledged resources to food aid for socioeconomic development, particularly for rural development projects in the least developed countries. WHO, as health adviser to WFP, 3.26 contributed directly to enhancing the nutritional value of some of the commodities supplied by the latter. An example of this was vitamin-A-enriched dried skim milk, where WHO's recommendations were generally accepted by WFP and also by governments providing food aid bilaterally. Likewise the European Economic Community, which makes a substantial contribution of dried skim milk, acted on these recommendations when taking over WFP's support to India's "Operation Flood", a remarkably successful dairy development project. One WHOdeveloped technique was widely used in the field by nongovernmental and voluntary organizations to check the presence of vitamin A in batches of dried skim milk. WHO's guideline for the measurement of the nutritional impact of supplementary feeding programmes aimed at vulnerable groups was re-issued, t the English version being supplemented by UNICEF-financed translations in French and Spanish. 1
WHO document FAP/79.1 (1979).
COORDINATION
3.27 To increase the impact of rural development projects funded by WFP commodity grants, WHO worked to develop appropriate technology, e.g., control circuits for rural water tanks and solar-powered electric water pumps. This stimulated WFP to grant$ I 5. 5 million in food aid to the Republic of Korea to help in extending the rural selfhelp water supply system to the entire country, an exemplary enterprise that should be of benefit to many other developing countries. 3.28 Finally, WHO advised on the development projects being considered for funding by WFP with a view to minimizing any adverse effects on health or, in extreme cases, recommending postponement or cancellation of a project. This advice is crucial in the case of large-scale projects such as dams and irrigation systems that may have profound ecological and health effects but whose economic or prestige value renders them irresistibly attractive. In one such instance, WHO's analysis of the adverse impact on health was sufficiently convincing to persuade the project's sponsors to defer their
support until the necessary precautions were taken. 3.29 The allotment ofWFP resources to projects most directly related to health promotion is summarized in Table 3. I.
Emergency relief operations 3.30 The I98o-I98I biennium saw a considerable expansion of WHO's action in emergencies. The Organization continued its traditional response to emergency situations caused by natural or other disasters, consisting mainly of immediate aid in the form of urgently needed medical equipment, drugs, vaccines, and other services. Steps were taken concurrently to strengthen disaster preparedness and disaster management within WHO and in Member States.
Disaster preparedness 3. 3I Technical cooperation with disasterprone countries was increasingly aimed at
Table 3.1
World Food Programme: commitments to projects, 1980-1981
Nature of project
Projects approved from 1 July 1979 to 30 June 1980 Number Amount US$
Projects approved from 1 July 1980 to 30 June 1981 Number Amount US$
All projects Development aid . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Emergency aid . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49 67 410000000 148600000 558600000 59 91 502000000 192 600 000 694600000
-----------------------------------116 150
Health-related projects Health promotion . . . . . . . . . . . . . . . . . . . . . Institutional feeding . . . . . . . . . . . . . . . . . . . . Teaching institutions . . . . . . . . . . . . . . . . . . . . . . . . . . . . Community housing and development . . . . . . . . . . . . . . . . . .
8 4 2
3 ------------------------------17 179 900 000 26 282500000
42500000 94000000 14000000 29400000
4 10 3 9
129 000 000 106400000 14100 000 33000000
THE WORK OF WHO, 1980-1981
improving national capacity both to take preventive measures and to remain effective in emergency situations. This involved WHO in activities related to the public health management of emergencies, research on the epidemiology of disasters, study of populations at risk, assessment of needs and priorities in the event of there being mass casualties, case studies of catastrophes, investigation of patterns of disease following disasters, and study of the disease control measures required. Two resolutions (EB67.RII and WHA34.26) were adopted by WHO's governing bodies in 1981 underlining the importance of the matter. 3. 32 A collaborating centre was established at the Centre for Research on the Epidemiology of Disasters, University of Louvain, Belgium. This was made possible by a generous grant from the Government of Belgium. 3·33 The first major WHO course on health management in natural disasters (October 198o) brought together senior officials from 2 3 developing countries; in view of the interest shown, similar courses will be held regularly in disaster-prone developing countries. In collaboration with UNHCR and the London School of Hygiene and Tropical Medicine, a multidisciplinary seminar on health problems in refugee communities was conducted in 1980 and 1981 and will be repeated annually in different regions. 3·34 Under WHO's impetus several universities have established undergraduate and postgraduate programmes on health management in disasters. This has already resulted in better-trained personnel becoming available for field work in emergencies. 3. 3 5 Several organizations of the United Nations system are establishing disaster units at senior level and the system's capacity to deal with disasters is being seriously studied.
WHO's considerable experience in these matters has enabled it to make a valuable contribution. It has maintained close relations with UNDRO, UNHCR, UNICEF, UNEP, and other organizations of the United Nations system, taking part in all the major multi-agency missions on disaster situations; and with the International Committee of the Red Cross, the League of Red Cross Societies, and other nongovernmental organizations. WHO was increasingly involved in 3.36 the health problems of refugees and in other disasters of a sociopolitical nature. In collaboration with UNHCR and the University of London, a manual on health in refugee camps was prepared and is being tested in the field. 3. 37 Lists of essential drugs for mass emergencies are being formulated. Specifications for a standard UNHCRJWHO kit of emergency drugs and supplies have been established.
Emergenry relief 3-38 WHO participated fully in the provision of emergency assistance by the United Nations system, the regional offices in particular increasing their contribution. The joint appointment of UNHCRJWHO senior coordinators for the health of refugees, as in Somalia and Thailand, set a new pattern of cooperation. 3·39 Technical cooperation among developing countries found concrete expression in the case of emergencies, with WHO in the position of coordinator of such cooperation. The experience of the Algerian earthquake disaster is but one example. 3.40 made Particularly high demands were on WHO's resources during I 98o-1 981. Some $zo million were mobil-
COORDINATION
ized, mostly from extrabudgetary sources. It is significant that emergencies requiring international assistance are increasing in both frequency and seriousness: during the biennium WHO conducted more than Ioo emergency operations, some of which are listed below. 3·4 I African Region. Angola (health aspects of liberation activities of the SouthWest Africa People's Organization); Burundi (influx of refugees); Central African Republic (national reconstruction); Chad (strife, reconstruction work); Comoros (supply of drugs); Ethiopia (drought, rehabilitation work); Gambia (disturbances, emergency surgery); Ghana (yaws); Madagascar (cyclones); Mali (cerebrospinal meningitis); Mauritius (cyclone); Mozambique (cholera); Uganda (drought, sleeping-sickness); United Republic of Cameroon (influx of refugees); Zaire (influx of refugees, diarrhoeal diseases); Zimbabwe (general humanitarian assistance, national reconstruction). Region of the Americas. El Salvador 3.42 (population movement); Jamaica (floods); Nicaragua (rehabilitation work); Saint Lucia (hurricane). 3·43 South-East Asia Region. Bangladesh (floods); Burma (devastating fires); Indonesia (influx of refugees, earthquake); Nepal (earthquakes); Thailand (influx of refugees). 3·44 European Region. Algeria (earthquake); Italy (earthquake); Turkey (malaria); Yugoslavia (rehabilitation work). 3·45 Eastern Mediterranean Region. Cyprus (reconstruction work, thalassaemia); Djibouti (drought); Iran (floods); Lebanon (strife); Pakistan (influx of refugees); Somalia (influx of refugees); Sudan (influx of refugees, drought, cholera); Yemen (floods). 33
3.46 Western Pacific Region. Democratic Kampuchea (national reconstruction); Fiji (cyclone); VietNam (typhoon). 3·4 7 N ationa/ liberation movements. In collaboration with other agencies in the United Nations system, WHO provided urgently needed health assistance to the national liberation movements recognized by the Organization of African Unity.
United Nations Volunteers 3.48 Close cooperation with the United Nations Volunteers programme has made possible the greater use of qualified professionals for middle- and upper-level operational services in WHO-executed projects. Between July I98o and July I98I the average monthly number of United Nations volunteers working in the health field was 200. Since 75% of the volunteers currently in service are nationals of developing countries and are working in other developing countries, they are a good example of technical cooperation among developing countries in action.
Nongovernmental organizations 3·49 Collaboration has continued with the I 24 nongovernmental organizations in official relations with WHO, the latest of which-the International Council of Women-was admitted during the biennium. A complete list of these nongovernmental organizations will be found in Annex 3 to this report. Working relations, or more informal contacts of an ad hoc nature, were maintained with a considerable number of them. 3. 5o A more integrated approach to such collaboration has been sought, wherever possible specific activities being undertaken within a jointly agreed framework. Efforts
were made to ensure WHO's full participation in the various international congresses and technical meetings organized by the nongovernmental organizations, and the Organization agreed to sponsor or cosponsor a number of those that were of direct interest to its programmes. Possibilities were explored for strengthening collaboration at national level, where it can be particuarly effective.
tinued to expand and its joint coordinating committee, meeting annually, reviewed or programmed the support being provided by WHO (at both regional and headquarters level), UNDP, UNICEF, UNFPA, and various multilateral or bilateral sources. The appointment in 1981 of a WHO programme coordinator in Beijing has been of significant help in planning and monitoring this complex programme. 3. 52 Meetings were held with the authonues in Bulgaria, China, the German Democratic Republic, Hungary, and Yugoslavia for the continuation of cooperative efforts in training, collaborative research, and exchange of experience, particularly for workers from developing countries.
Cooperative programmes undertaken with Member States 3·5 1 The cooperative programme launched in 1978 by WHO and China con-
34
Chapter 4
~esearch JDro~otion
and 4.1
Develop~ent
poLICIES and programmes in the field of health-whether for the control of disease, the development of community health services, or the promotion of environmental health--are constantly evolving. This is both the result of and the rationale for the continual development of biomedical research in its widest sense. But a proper balance must be reached between research and services, between the acquisition of new knowledge and the utilization of what already exists. To attain this balance, the social function of biomedical research, i.e., its practical application, must always be kept to the fore. Only thus can the allocation of resources to biomedical research and its various components be rationalized. 4.2 In May 1980 the Health Assembly restated the contribution to be made by biomedical, health services, and health promotion research towards attaining health for all by the year 2000 (resolution WHA33.25). It urged Member States to intensify their cooperation in health research and to give high priority to research training and institution-strengthening.
viewed the progress made in WHO's current research efforts, including the special programmes on research and training; it also discussed the action taken on the recommendations made at its previous session, especially in relation to nutrition, control of diarrhoeal diseases, and ethical review procedures for research involving human subjects. ACMR reviewed the work of its subcommittees on information, health services research, research on mental health and human behaviour in primary health care, research administration, and research career structures. It recommended that the subcommittees on information and on research administration should continue their work; that a subcommittee should be established to study the research component of WHO's cancer programme; that the subcommittee on health services research should, after its November 198o session, be transformed into a scientific planning group; and that scientific planning groups should also be established for the programmes in (i) nutrition and (ii) mental health and human behaviour in primary health care. When reviewing the work of the regional ACMRs, the global ACMR noted that one of the main constraints on effective action by certain of them was lack offunds. It proposed that all regional offices should earmark a minimum of 5% of their regional budgets for research. It also noted that the 4·4 35
Global developments 4· 3 The global Advisory Committee on Medical Research (ACMR) at its twentysecond session (Geneva, October 198o) re-
THE WORK OF WHO, I980-198I
disparity between the capabilities of the various regions, and also between countries in those regions, prevented some regional ACMRs from instituting relevant countrybased studies. Since the practical implementation of research programmes at country level depends not only on the availability of resources but also on effective communication, ACMR suggested that efforts should be made to achieve better interdigitation between national research priorities and those of WHO at regional and global level. Certain projects might be funded partly by WHO and partly by Member States; others might benefit from experience acquired at interregional level. 4· 5 ACMR also discussed research career structures, including a recommendation that, rather than promote research career structures per se, WHO should support research as a basic component of health plans and programmes. It was stressed in the discussion that research opportunities and career structures were essentially a national matter and that careers in research could not be viewed separately from those in other government services or institutions. The general view was that appropriate systems of peer approval and opportunities for interaction between young scientists and their colleagues constituted a stimulus to research workers. At its twenty-third session (Geneva, 4.6 October 1981) the global ACMR noted with appreciation the considerable progress made at regional level in coordinating and developing health research. It considered the advances in health services research (particularly in maternal and child health), in diarrhoeal disease research, and in general promotional activities (e.g., training in research management and research methodology) to be of particular importance. Regional offices had gone a long way in strengthening the links between medical research councils in their regions. The global
ACMR encouraged the further creation of focal points for coordinating research in those countries where formal bodies did not exist. 4· 7 The final report on ethical review procedures for research involving human subjects was examined; progress reports were received from the subcommittees on cancer, information, research administration, health services research, and mental health; and specially commissioned papers-on the formulation of research activities in gerontology and on the utilization and protection of nonhuman primates and other animals required for research-were discussed.
Research training 4.8 By enabling individual scientists to obtain additional training, WHO research trammg grants complement institutionstrengthening. The emphasis is on postgraduate education, although grants are also awarded for training other health, laboratory, and support personnel from developing countries and, in some cases, for training in research management. A wards are also made to promote the exchange of scientific knowledge by enabling investigators working on subjects of relevance to WHO programmes to visit scientists in other countries working in similar or related fields. 4·9 These two types of grants are funded by the special programmes for research and training as well as by the regular budget. Nearly 200 grants for research training, and some 5o grants to enable scientists to visit other institutions, were funded by those programmes during the biennium. In general, grants are increasing in number as well as in duration of the period of training. Particular attention is given to ensuring the relevance of the training to regional and national health research priorities and to providing it within the context of technical cooperation among developing countries.
RESEARCH PROMOTION AND DEVELOPMENT
Regional developments African Region
4· Io Member States of the Region are increasingly aware of the contribution that research can make to health development and 22 of them have medical research councils. Thirty-one of WHO's collaborating centres are in the African Region and there are also 4 5 national centres recognized by WHO. 4· I I The Special Programme for Research and Training in Tropical Diseases continued to expand in the Region, reaching a total of 206 projects since its inception; 7 I of these were in research and development, I I9 in research training, and I6 in institutionstrengthening. Onchocerciasis research, carried out mainly in the Volta River basin area, focused on: vector biology and control; environmental studies; clinical, epidemiological and parasitological investigations; and chemotherapy.
4· I 5 In relation to the Special Programme of Research, Development and Research Training in Human Reproduction, an African study group was set up and met in Antananarivo (June I98I). The four priorities of the Special Programme in the Region relate to pregnancy and delivery, male and female infertility, fertility regulation, and gynaecological disorders. 4· I6 The regional ACMR at its fifth session (Nairobi, April I98I) dealt with three broad areas. One was evaluation of the regional research programme since I 976: it was felt that health policy-makers, including those from countries that have not established medical research councils, should be brought together at regular intervals; and it was recommended that at least 5% of the regular budget for the Region should be allocated to research. The second was strengthening of research information systems: following the meeting of medical librarians from the African Region (Belgrade, September I98o), the establishment of an African Index Medicus and the intensification of bibliographical services in the Region were approved. The third area was the integration of applied research in primary health care: it was considered that ministries of health and faculties of medicine should collaborate in the development and management of health services research and that technical discussions should be organized to this effect during the Regional Committee.
4· I 2
Research diseases covered food safety, oral between Burkitt's
in the noncommunicable cardiovascular diseases, health, and the relation lymphoma and malaria.
4· I 3 In nutrition, investigations were continued to determine simple indicators of nutritional status, surveillance methods, postweaning dietary regimes, and appropriate technology for the storage of foodstuffs. In health services research, a training course on methodology was held in Ouagadougou (August-September I98o); a workshop on financing of health services was organized in Botswana (October I98o); and a multidisciplinary group on health services research met (February I98I) to study problems of evaluation, information systems, and financing. 4· I4 37
Region of the Americas
4· I 7 Research in this Region has two main objectives: (i) to develop and strengthen national capabilities for bringing research to bear on the country's health problems, and (ii) to give a lead in developing those areas of research that are critical for the achievement of health of all by the year 2000. Meetings were held in all five subregions with a view to
THE WORK OF WHO, 198o-I98I
a Pan American conference on research policy that will assist countries in setting research priorities, focusing research more sharply on the problems encountered, establishing reference systems, and formulating ethical codes for research involving human subjects. 4.I8 The PAHO Advisory Committee on Medical Research continued to promote research in nutrition, diarrhoeal diseases, health services, and the social sciences as related to health. A bibliography of social science research was completed, and specific attention is being given to the social factors that are critical in the control of malaria. Six scientific meetings on health services research were held.
South- East Asia Region
At its sixth and seventh sessions (New Delhi, April I98o and April I98I) the South-East Asia Advisory Committee on Medical Research considered several issues. At its seventh session it evolved a format for reporting progress in WHO-supported research in the Region, essentially by evaluating the catalytic role of the research programme in generating national activities and by assessing its impact on health care systems in Member States. 4.22
4· I 9 An extensive study of the impact of research on health development was in its final stage. It includes an analysis of the human and material resources directed to research in the Region, which indicates that the majority of projects are for applied research, mainly in public health, social medicine, microbiology, and parasitology. There are Io Pan American centres carrying out research in nutrition, perinatology, epidemiology, the zoonoses, environmental health and sanitary engineering, ecology, and educational technology. PAHOfWHO also coordinates the work of the I63 WHO collaborating centres in the Region. The Regional Library of Medicine (BIREME) continues to perform an important task, its 2 35I journal titles constituting the major reference source in Latin America. The Index Medicus Latino-Americano which it publishes complements the Index Medicus of the National Library of Medicine, United States of America. 4.2o
A subcommittee of the regional ACMR developed a conceptual basis for orienting research towards the objectives of health for all and enabling the Regional Office to screen the research activities that would contribute to national strategies. Similarly, a subcommittee on health services research provided a conceptual description of such research and a regional plan for promoting it in relation to national priorities. 4.23
Planning proceeded for a unique research programme on snake-bite, which is of particular interest to this Region. Efforts are also being made, at the WHO collaborating centre in Thailand, to develop a dengue vaccine. Under the global programme for diarrhoeal diseases control, a scientific working group was set up for implementing operational studies. 4· 24
4· 2 I The Special Programme for Research and Training in Tropical Diseases has supported over 300 projects in the Americas through grants to individual scientists or to strengthen institutions.
Since the meeting of directors of medical research councils or analogous bodies in I979, Member countries have been active in developing a coordinated managerial process for research on priority problems, using all the available national potential. A second such meeting (I98I) discussed progress and identified the specific issues to which the Regional Office should address itself during the Seventh General Programme of Work (I984-I989). 4.25
RESEARCH PROMOTION AND DEVELOPMENT
European Region The Regional Committee for Europe at its thirtieth session reviewed the work of the European ACMR and recommended that meetings dealing with research in the different countries of the Region should bring research workers into closer touch with the problems of individual countries; and that the programme, even though adapted to the requirements of a region predominantly composed of industrialized countries, should not neglect the continuous surveillance of communicable diseases. 4.26
4· 2 7 Planning groups of the European ACMR reviewed in depth problems of health care delivery; standardization of methods, measurements, and terminology; and evaluation of therapeutic and diagnostic substances. At its sixth session (Copenhagen, September I98o), the European ACMR itself discussed the latest recommendations of its planning groups in five priority areas: (I) health services research programmes (mental health, hypertension as related to health care, and health economics); (2) national organization and management of health research, and development of information systems; (3) participation of the Regional Office in the international programme on chemical safety; (4) the role of WHO collaborating centres; and (5) the need to develop research manpower by way of a training grants scheme. In general, the European ACMR approved the recommendations of its planning groups, but it emphasized that in the areas studied by all these groups research should be oriented towards services, as a prerequisite for achieving health for all. 4.28 4.29 The European ACMR stressed the importance of drug-related problems in studies on self-care, and the need for more specific recommendations on research into
the effect of drugs on the behaviour of drivers. It recommended priority for a study of the economic aspects of recent developments in primary health care, and the continuation of studies on the economic aspects of health care of the eyes, which could also be used as a model for the interdisciplinary approach. In mental health, it underlined the need for continuing research on etiology in addition to health services research, and for further studies in child psychology and early prevention of disorders. It also stressed the need for expanding the activities of the planning group on standardization into various biomedical areas and for collaborating closely with national centres working on standardization. Recognizing the great need for research training, it urged that funds be used primarily for training the research workers involved in large regional studies and for stimulating training in health services research. Lastly, it advocated additional voluntary funding to permit a further expansion of the Regional Office's work on research. 4.30
In I98I eight new Member States were represented on the European ACMR, bringing the total to I 7. Among the main concerns at its session in that year were the research implications, in the European context, of the strategy for health for all by the year zooo, particular emphasis being given to the sociological aspects.
Eastern Mediterranean Region The research activities sponsored by the Regional Office, under the guidance of the Eastern Mediterranean Advisory Committee on Biomedical Research, are now increasingly aimed at supplementing national research activities in the Member States of the Region. The regional ACMR met twice during the biennium. It reviewed ongoing activities, including those in nutrition, malaria, mental health, cancer, maternal 4,3 I
39
THE WORK OF WHO, 198o-I98'
health, and diarrhoeal diseases. It also advised on the research needs of the various technical programmes. 4· 32 Health services research continued to receive special attention. A training course in the methodology of such research was organized at the Department of Community l::lealth, University of Nottingham, United Kingdom (July I98o), and was attended by I8 nationals from five countries of the Region. The learning material used in the course is being adapted for use by the participants in organizing national workshops and courses. 4· 33 A health coverage study was initiated and completed during I98o-I98I in Bahrain, Egypt, andY emen, aimed at providing the three countries with information necessary to develop alternative strategies for achieving health for all through effective primary health care coverage of the population. The findings indicate that the three countries are committed to a policy of total coverage but that their present strategies emphasize physical rather than functional aspects. Self-care support by the informal health system, including traditional healers, is still the main source of primary health care. Community involvement in the provision and management of the health services is generally lacking. Through taking part in this study, a large number of health personnel in the three countries were trained in the concepts, methods, and management of health services research. Guidelines were developed on the basis of the experience gained and will be of use to other countries undertaking similar coverage studies. 4· 34 In order to refine the regional research priorities in health services manpower development, a consultation was held (September I98I). It resulted in research proposals that will be further developed into projects to be carried out by selected institutions in the Region.
4· 3 5 To build up national expertise in managing research programmes and research centres, a workshop (Islamabad, April I98I) was devoted to: organization of research at national and institutional level; research planning; evaluation of research proposals and scientific activities; staff promotion and development; research information; and management techniques applicable to medical research. A manual was in preparation as an aid to conducting similar workshops at national level, some of them in the form of research programme exercises at which ongoing activities are evaluated and future plans established.
Western Pacific Region
4.36 The general objective of the regional programme is to achieve selfsufficiency in health research (biomedical, health services, and health behaviour research) with particular relation to the major health problems of Member States. The specific objectives during the biennium were (I) to strengthen national research capability; (2) to increase technical cooperation among research institutions in the Region; and (3) to promote research management and coordination mechanisms at national level. 4· 37 To advance objective (I), resources were used to strengthen institutes in Malaysia for research on tropical diseases; in Papua New Guinea for research on acute respiratory infections; and in the Republic of Korea for research on parasitic diseases and health services. A working group was convened (Manila, February I98o) to encourage Member States to establish health research councils or national focal points with a view to better research management. Training in research methodology received increased attention, and a WHO-supported national workshop on the subject was conducted in China (May I98I).
RESEARCH PROMOTION AND DEVELOPMENT
4· 38 In relation to objective ( z) a number of themes were promoted as part of WHO's programmes of technical cooperation, the following being considered priority areas by the regional ACMR: health services research; diarrhoeal disease control; acute respiratory infections; application of modern immunological techniques; vector control methods; occupational health; cardiovascular diseases (including diabetes in the Polynesian and
Micronesian islands); and clonorchiasis and paragonimiasis. 4·39 As for objective (3), a redistribution of resources has taken place since 1979, increasing the responsibility of regional programme managers for programming the research component as an integral part of health development activities and thus relating it more closely to the solution of regional and national health problems.
41
Chapter J
Health Services Development
RESULTS of the study on national decision-making for primary health care carried out by the UNICEF/WHO Joint Committee on Health Policy were published in I981. 1 Seven countries politically committed to the goal of health for all by the year zooo had studied how the principles of primary health care were being put into practice, tracing the factors determining the initial political decision, the steps followed in the implementation of policies, the progress made, and the problems or constraints encountered. The study is intended to contribute to the formulation of policies for international cooperation through UNICEF and WHO and to clarify for participating and other countries the main issues involved and different ways of moving forward. Participating countries were requested to designate a national multidisciplinary team and a national coordinator, and these were supported by UNICEF and WHO staff and consultants. The fact that the studies were carried out by national teams not only improved the countries' understanding of the issues investigated but also provided an opportunity for nationals to acquire valuable experience in the development and implementation of primary health care, including reasses&ment of policies and planning mechanisms. 5-I I World Health Organization. National decision-making for primary health care. Geneva, 1981.
THE
5.2 Following the promising outcome of the study, the Joint Committee recommended at its February I 98 I session that the I98I-I982 UNICEF/WHO study should be on the implementation of primary health care. The two main aims of the study, which will be a longitudinal process rather than a retrospective analysis, are to further the development of primary health care in countries where a serious commitment is evident and there is reasonable chance of success, and to ascertain how UNICEF and WHO can best support such development. It will be a multinational endeavour with responsibility taken by countries as part of their efforts towards achieving health for all by the year 2ooo. A plan of action was formulated with UNICEF in I98I; four countries were selected for the study initially (Burma, Democratic Yemen, Ethiopia, and Nepal) and others will be included later. UNICEF and WHO held joint briefing sessions for those at headquarters, regional, and country level engaged in reviewing strategies and drawing up plans of action in support of primary health care.
5. 3 Activities carried out during the biennium to strengthen national health development networks were of four categories: (I) promotion of the concept by making relevant information available and creating the opportunity for exchange of experience and ideas; (2) participation in the formulation and implementation of national plans of
HEALTH SERVICES DEVELOPMENT
action and in the development of a framework for monitoring and enlisting the contribution of the networks to the health development process; (3) promotion of the orientation and training of national staff in the management of institutions and of the health development process; and (4) collaboration with countries in the mobilization of the resources necessary for the proper functioning of networks and centres, ensuring that financial and other support for projects and the strengthening of institutions are available for sufficiently long periods to produce an impact. These activities were carried out, in collaboration with other agencies of the United Nations system, in Algeria, Burma, Colombia, Costa Rica, Democratic Yemen, Ethiopia, Jamaica, Malaysia, Morocco, Nepal, Nicaragua, Pakistan, Papua New Guinea, Republic of Korea, Sri Lanka, Sudan, Thailand, and Zimbabwe. 5·4 Workshops on primary health care in the Caribbean area were sponsored by the Caribbean Community (CARICOM), UNICEF, and WHO in support of the national health development networks programme. SIDA has provided financial aid for WHO activities in this field.
inherited an economic infrastructure severely weakened by years of armed struggle, a massive refugee problem with thousands of displaced people, an economy ill adapted to the needs of the whole population, a health care system characterized by a grossly inequitable distribution of resources as between the urban and rural areas, and a type of health care providing predominantly curative medicine, with expensive and sophisticated facilities available only to a minority. In short, the distribution of the resources available for health improvement bore little relation to the health needs of the majority. Following a WHO-supported symposium (Salisbury, December I98o), a primary health care programme was developed with emphasis on community participation and the village health worker, and on legislation to ensure more equitable hospital services. Support is being provided to strengthen national capabilities, particularly in the planning and programming of health services and manpower development. Studies on the role of women in health development, particularly in relation to primary health care, were begun in I 98o, covering nine countries of the Region. 5.6 In the Region of the Americas special emphasis was placed on ascertaining the needs of underserved groups, promoting intersectoral cooperation and community participation, developing appropriate technology for administering and delivering services, and updating the training of health personnel. Efforts were made-e.g., in Bolivia, Colombia, Costa Rica, and Ecuador-to organize health care so that the requirements of primary care are met and the quantity, quality, and accessibility of secondary and tertiary levels of care are improved. 5. 7 In countries of the South-East Asia Region activities were focused on the training and utilization of community health workers and supporting staff, and manuals for this purpose were prepared 1n Bangladesh, 43
Primary health care 5. 5 In the African Region interministerial coordination committees, or similar mechanisms to promote intersectoral activities within the primary health care programme, have been set up in Botswana, Gambia, Ghana, Kenya, Lesotho, Liberia, Malawi, Mauritius, and Zambia, and national action programmes for primary health care were formulated during I98o and I98 I in Benin, Burundi, Comoros, Congo, Gambia, Upper Volta, United Republic of Cameroon, and Zambia. Priority attention has been given to newly independent nations. Zimbabwe's newly elected Government, for example,
THE WORK OF WHO, 1980-1981
Indonesia, and Nepal. Mechanisms for intersectoral coordination at all levels were developed-as reflected in the establishment of village health committees in Bangladesh and of a "basic minimum needs" steering committee in Nepal, and in the plans of other ministries as well as the health ministry in India. The increase in the health budget in India, the reorganization of the health care delivery system in Sri Lanka, the review of the national health system in Indonesia (where an assessment was made of activities carried out by traditional birth attendants), and the improvement of the indigenous system of medicine in Burma, all reflected increased attention to primary health care. 5.8 The main emphasis in the European Region was on self-care, community partici' pation, the integration of primary, secondary, and tertiary care, and particular attention to underserved and vulnerable groups. The Regional Advisory Committee on Primary Health Care, which met for the first time in Copenhagen in August I98o to review proposed activities, accorded highest priority to action to combat social inequalities in health, clarification of the concept of primary health care in industrialized countries, analysis of the relative contributions to primary health care of various health care sectors and groups of personnel, and research and training. The completion in I 98o of the first phase of a regional study resulted in an inventory of primary health care management problems. The Government of Algeria, which is firmly committed to the development of primary health care, decided to implement a demonstration project in one province; and in Turkey a plan of action was prepared, with the collaboration of UNICEF, to demonstrate how the solution of a major problem-malaria-can benefit from an integrated primary health care approach. 5·9 In the Eastern Mediterranean Region further countries incorporated primary health 44
care programmes as an integral component of their health development plans, or are in the process of doing so. Many of them (the Libyan Arab Jamahiriya, Oman, Pakistan, Somalia, Sudan, and Yemen) have requested WHO cooperation in the formulation, implementation, or evaluation of primary health care programmes. In January I 98 I Bahrain, Democratic Yemen, Lebanon, Saudi Arabia, the Syrian Arab Republic, and Yemen were represented at a meeting of a working group, organized by UNICEF with WHO collaboration, to review the current status of primary health care programmes and pinpoint the essential elements for converting the AlmaAta commitment into action. 5. I o In the Western Pacific Region attention was focused on the promotion of national commitment to primary health care and its translation into action plans. Studies were carried out in Papua New Guinea and the Philippines to determine the most appropriate way of organizing community health development. 5. I I Interregional trammg courses on primary health care were organized in China in I98o, with visits to three centres which were later designated as WHO collaborating centres. UNDP-supported courses for administrators were held at these centres (three in I98o, one in I98I). Staff of the centres visited Malaysia, the Philippines, and Thailand to observe primary health care activities, with a view to introducing improvements in the courses. The aim has been to encourage 5. I 2 countries to exchange views and work together on common issues in health development. Two UNICEF /WHO workshops on primary health care--in Mozambique (English-language, February/March I98o) and in Senegal (French-language, February I98I)-dealt with a number of political, managerial, and technical issues. Following a
HEALTH SERVICES DEVELOPMENT
two-year interval during which the countries represented at the workshops will seek to introduce any necessary modifications in their primary health care programmes, representatives of the same countries will meet and compare experience. 5. I 3 If present trends continue, by the end of the century 5o% of the world's population will be living in cities, at very high density and in appalling squalor. Cities in general receive the lion's share of health resources but many of them have large and rapidly growing slum areas whose population rarely benefits from health care programmes. A WHO consultation was held on primary health care in urban areas, with emphasis on the urban poor (Geneva, January I98I), and similar action was initiated in the Region of the Americas and in the South-East Asia and Western Pacific Regions; a number of cities have expressed interest in participating in this programme, in which UNICEF and various other United Nations and nongovernmental organizations are collaborating. 5.14 Community involvement is one of the prerequisites for successful implementation of primary health care, and social control of the health infrastructure and technology through such involvement is essential for achieving the goal of health for all. Moreover, community self-reliance requires that people participate in the planning and implementation of their health care. Technical collaboration with countries to increase community involvement in primary health care was therefore intensified, and in I98I preparations were made for a comprehensive review of approaches and experience in different national settings. p 5 A UNICEF /WHO interregional study on the training and utilization of community health workers, begun in I979, was completed, and a workshop held in Jamaica in February I98o was attended by 45
representatives of the participating countries (Botswana, Bulgaria, China, Ethiopia, Honduras, India, Iran, Jamaica, Papua New Guinea, the Philippines, Sudan, Thailand, and Turkey). A set of recommendations was drawn up on the training of community health workers as an integral part of the public health programme, and on their selection, functions, and support. Follow-up activities, relating especially to training and support, are under way. 5. I 6 With regard to intersectoral action, WHO is collaborating in an intercountry study (being carried out initially in Colombia, India, Jamaica, Norway, Sri Lanka, and Thailand) to review concepts and experience regarding the contribution of other sectors to health development. It is also cooperating with F AO and other organizations in the United Nations system in connexion with regional integrated rural development programmes, with a view to practical action in this area. 5. I 7 The problem of financing primary health care at the local level has caused concern in many countries. An interregional study on the subject was carried out in I I countries, and the findings were discussed at a UNICEF/WHO workshop (Geneva, December I98o).
Health services planning and management 5. I 8 Most countries directed their main efforts to extending coverage of their populations with essential health care by reorienting their health services in line with the primary health care approach. A study on the measurement of coverage, effectiveness, and efficiency of various patterns of health care was carried out in Burma, Costa Rica, Egypt, Finland, Malaysia, Nigeria, the Republic of Korea, and Senegal, and the results were
consolidated in preparation for publication. Some of these countries proceeded, with WHO collaboration, to develop monitoring schemes to be tested at national and local level. 5. I 9 "Health system support for primary health care" was the subject of the Technical Discussions held during the Thirty-fourth World Health Assembly and an informal consultation was organized on the concepts, processes, and implications of health systems reorientation (Geneva, June I98I). The related documentation was circulated for use by countries in analysing and reorienting their health systems. 5. 2.0 An interregional course (the third in English) on the planning, organization, and management of health care delivery in support of primary health care was held in Sofia (October I98o). 5. 2. I In the Region of the Americas national health plans were formulated in Dominica, Grenada, Honduras, and Peru. The Organization cooperated in implementing the health plan and project for extended service coverage in Guatemala and provided technical advice on the extension of coverage in Paraguay (with the financial support of the Inter-American Development Bank in both countries). An agreement was concluded with the Colombian Government on a programme, to be funded by the Netherlands, to develop the primary health care aspects of the national integration plan. Projects on health system design were supported in Chile, Peru, and Uruguay. Previously vertical programmes are being integrated into comprehensive services in several countries. Social security is playing an increas5.2.2. ingly important role in health care, and the Organization collaborated with the social security institutes of Ecuador, Peru, and Costa Rica in the development of activities in the health field.
In South-East Asia assistance was 5.2.3 given to Indonesia in finding alternative patterns for reorganization of the national health system; and in the Eastern Mediterranean WHO gave support to Democratic Yemen, Egypt, and Sudan in their efforts to increase the equity of their health systems through social and economic reforms and administrative decentralization. 5. 2.4 As regards the organization of health services, in the Region of the Americas assistance was provided to improve regionalization and management (budget, personnel, and supplies) in Bolivia, Costa Rica, the Dominican Republic, Ecuador, El Salvador, Guatemala, Guyana, Haiti, Nicaragua, and Paraguay. Studies on drug supply management in health units were carried out in Ecuador and Panama; analyses of financing, accounting, cost control, and budgets were intensified in Guyana and Jamaica; a broad project for administrative development was started with UNDP financial support in Colombia; and organizational behaviour studies were initiated in Brazil and Chile. In addition, assistance was provided to many countries for training in the collection of health information and for the development of improved health information systems. 5. 2. 5 The organization of health services was reviewed in several countries of the South-East Asia Region, and a workshop on health management was held in Bangladesh for senior government officials. 5.2.6 In the Western Pacific Region WHO-supported national workshops for managers of health services were held in six countries, the role of front-line health staff was studied in three, and manuals for rural health units were revised or adapted with WHO collaboration in two. The Asian Development Bank and WHO cooperated with Papua New Guinea in a study on the strengthening of the rural health services.
HEALTH SERVICES DEVELOPMENT
5. 2 7 As part of a WH 0-supported interregional study being carried out with a view to increasing the relevance of health care facilities to local needs and possibilities, national case studies on the planning, construction, and operation of such facilities within the context of national health systems were completed in Algeria, Cuba, Senegal, Sudan, Venezuela, and Zambia. The reports included analyses of the health care systems and management in those countries, and the process led to national recommendations on how to improve the situation. A WHOsponsored meeting on health care facilities in developing countries was held in Geneva in November I98o. Volume 4 of Approaches to planning and design of health care facilities in developing areas was prepared in I98I for
ing hospital facilities suited to local conditions. 5. 30 Health service planning and management projects, with emphasis on primary health care, were supported in nine countries in the Western Pacific Region. Under an intercountry project on hospital management, design and maintenance, support was given to courses in New Zealand, the Philippines, and at the University of the South Pacific, and for strengthening hospital services in the Republic of Korea and the Trust Territory of the Pacific Islands. 5. 3I To promote the use of epidemiology as a tool in implementing the preventive and community aspects of primary health care, an interregional workshop was held in Malaysia (March I98o), attended by senior health managers and epidemiologists from Botswana, Burma, Ecuador, Indonesia, Malaysia, Morocco, the Philippines, Sudan, the United Republic of Tanzania, Thailand, and Zambia. 5. 32 In the European Region the need for improved communication between producers and users of health information was stressed in the recommendations of a workshop on the use of health indicators (Brussels, November I98o), and a consultation on indicators for health for all by the year zooo was held in April I981. 5. 33 Following an interregional seminar on the economic aspects of health services (Mexico, 1979) and on the basis of experience gained during an intercountry training course in the African Region (Botswana, 198o), a manual providing guidance for surveys of health financing was finalized.
publication.t 5.28 In the Americas a subregional seminar on the planning and maintenance of health facilities (Venezuela, April I 980 ), organized in collaboration with UNDP and the secretariat of the Hipolito Unanue Agreement, was attended by 7 2 health officers from I4 countries. Assistance with project preparation was provided to the Andean countries and to Guatemala, Guyana, and Trinidad and Tobago. Cooperation in teaching and research was initiated with the Health Facilities Research Center of the University of Buenos Aires.
5. 29 In the Eastern Mediterranean Region technical support was given to Lebanon, Sudan, and the Syrian Arab Republic in the design and management of health facilities, and a survey was made of national capabilities for health facility development in the Region. In South-East Asia assistance was given to Mongolia in designt Kleczkowski, B.M. & Pibouleau, R., ed. Approaches to planning and design of heath care faciltties in developtng areas, Volume 4 (in preparation). Geneva, World Health Organization. Volumes r, 2, and 3 were published as Offset Publications Nos 29, 37, and 45 in 1976, 1977, and 1979 respectively.
5. 34 In the South-East Asia Region a study of the financial aspects of health care delivery in Bangladesh was completed. In Thailand alternative strategies for health development were analysed and compared. 47
THE WORK OF WHO, r98o-r98r
5. 3 5 In the European Region the reports of two meetings on health economics (the economic aspects of health care, and those of eye health care) were issued. Guidelines for national health accounting were simplified and tested in six countries during I 980. A multinational study on the influence on health of economic factors such as unemployment and economic instability was initiated by a planning meeting (Copenhagen, November I 98o ). At a workshop on the control of health care costs in social security systems (Vienna, May I98I) stress was laid on the need for cost containment to extend beyond the health care system, encompassing, for instance, environmental pollution and self-imposed risks. 5. 36 In the Western Pacific Region WHO cooperated with the Republic of Korea in a review of new systems for financing health care, and with Singapore in the development of modules for teaching health econom1cs.
elements of primary health care listed in the Declaration of Alma-Ata.l The scope of this long-term activity is to be extended through participation in the SATIS network (Socially Appropriate Technology Information System) based in the Netherlands, which publishes thematic bibliographies having a bearing on health. The Regional Offices for the Americas, South-East Asia, and the Eastern Mediterranean have already identified national institutions interested in collaborating in this programme. 5·39 Following the recommendations made at a consultation in Manila at the end of I979 regarding the establishment of an information system for appropriate technology, efforts were made in some countries, notably Thailand, to set up an integrated information service. 5.40 The ATH Newsletter-a means of disseminating information to health workers at the periphery-was widely distributed and well received. A new edition of the directoryz of organizations, institutions, groups, and individuals concerned with appropriate technology was issued in I98o, after careful assessment of their activities.
Appropriate technology for health 5. 37 The emphasis in this area was on promoting the concept of appropriate technology and developing integrated information services. On the basis of country studies, two interregional workshops were held (French-language, Washington, December I98o; and English-language, New Delhi, March I98I) to review the experience of the participating countries and progress in the development of appropriate technology for the different elements of primary health care, and to identify areas for WHO collaboration. These workshops served to sensitize participants to options suitable for their specific national situations. 5. 38 An inventory of the in-house documentation related to appropriate technology for health is being made with a view to issuing annotated bibliographies on the eight
5.4I To overcome certain specific problems in developing countries, support was provided for research to develop prototypes of a solar heater, a "Sahelian" cooker, a vapour-sterilizer, a dry-heat sterilizer, a water distiller, and a portable tester for thermal sensation in the clinical examination of leprosy. 5.42 The maintenance and repair of equipment are considered of vital importance
1 Alma-Ata 1978: primary health care. Geneva, World Health Organization, 1978, reprinted r98r ("Health for All" Series, No. r), p. 4· 2 WHO document ATH/8o.z (August 198o).
HEALTH SERVICES DEVELOPMENT
in this programme. In the Americas special stress was placed on the establishment or expansion of services for the maintenance of health facilities and equipment in Colombia, Costa Rica, Ecuador, El Salvador, Mexico, and Venezuela. The Eastern Mediterranean and African Regions have also been active in this subject, particularly as regards training. Work in the African Region centred 5·43 on the exchange of information with many countries throughout the world, particularly with regard to traditional medicine. 5-44 In the Americas a regional symposium on appropriate technology for health and three area seminars-for countries of Central America, the Andean region, and the Caribbean-were held during the biennium. 5·45 In the South-East Asia Region, Bangladesh, India, Indonesia, and Thailand gave increased emphasis to research on appropriate technology as support for primary health care, and several seminars and workshops on the subject were organized, both at interregional level (New Delhi, October I98o) and at country level (India, Sri Lanka, and Thailand, I 9 8 I). 5.46 A meeting at the European Regional Office (May I98I) reviewed possible systems of technology assessment. Its recommendations covered: establishment of the national organizational base; identification of needs; involvement of decision-makers, the information media, and the general public; the multidisciplinary approach; and the need for international cooperation. In the Eastern Mediterranean 5·4 7 Region, Pakistan and Sudan are playing a leading role in the establishment of a regional information service on appropriate tech-' nology for health. Both countries are also implementing national projects f6r the provision of low-cost spectacles. 49
5.48 Technical and financial support was given to a number of countries in the South Pacific for the construction of ferro-cement water tanks, and to the Philippines for the development of pilot biogas digesters in small communities.
Health services research 5·49 Health services research, with emphasis on support for national strategies for achieving health for all based on primary health care, was carried out as part of WHO's various programmes at both regional and global level. 5. 5o In the African Region there was increased emphasis ·on training in health services research. Workshops held in Gambia, Mali, and Upper Volta were attended by participants from Benin, Congo, Guinea, Mali, Mauritania, Niger, Senegal, and the United Republic of Cameroon. A study group on health services research was established; its tasks included the formulation of a regional programme for I98I-I983. 5. 5I Countries of the Americas have made specific recommendations for promoting and using health services research. Despite the constraints-lack of competent investigators, unsatisfactory communication between health workers and researchers, inadequate definition of research needs, and scarcity of funds-progress was made in implementing the recommendations, and the Organization initiated a health services research programme with emphasis on the strengthening of local capabilities. It collaborated in various surveys and studies on drug administration in hospitals, development of supply administration, infection control centres in hospitals, and appropriate technology for maintenance of health facilities. A regional workshop (Washington, January I98I) was attended by specialists in
epidemiology, sociology, systems engineering, economics, health administration, teaching, and research. 5·52 In South-East Asia WHO-supported health services research was carried out in Bangladesh, Burma, India, and Thailand. Seminars on methodology for such research were organized at the Centre for Research Development in Health Services, Surabaya, Indonesia (a WHO collaborating centre), as well as in Sri Lanka and Thailand. 5. 53 The European ACMR approved the proposals of its planning groups on the problems of health care delivery and on the economic aspects of health care, emphasizing the importance of orientation towards services. WHO supported studies on health service accounts, management of primary health care, and hospital administration. An international course on research in primary health care was organized for postgraduate research workers (Kuopio, Finland, May 198o).
5. 55 Increased emphasis was placed on health services research in the Western Pacific Region, where the task force on the subject was designated as a subcommittee of the regional ACMR and a draft plan for 1981-1983 was formulated. WHO supported studies related to primary health care (in Malaysia, Papua New Guinea, and the Philippines) and to the immunization and diarrhoeal disease control programmes. 5. 56 A workshop on health services research was held at the Korea Development Institute, Seoul (October 198o), and the Public Health Institute in Kuala Lumpur was designated as a lead agency for health services research in Malaysia. A regional information system on health services research is being established. 5. 57 At global level, two meetings of the ACMR subcommittee on health services research were held-one in Manila, when it focused attention on the strengthening of national capabilities, and the other in Addis Ababa, when it considered the potential contribution of health services research to the strategy for health for all, taking maternal and child health care as a concrete example. 5. 58 With a view to ascertaining training requirements, a review is being made of the initiatives undertaken by countries and WHO to orient and train people in the principles and practice of health services research.
5. 54 In the Eastern Mediterranean Region, where a quarterly newsletter- The health services researcher-is published, a health services coverage study was completed in Bahrain, Egypt, and Yemen. Research proposals were prepared during a course in health services research held in the United Kingdom (see paragraphs 4·32 and 4.33).
Chapter 6
Fami!J Health
THE FAMILY is the basic unit of health care, and the emphasis given to it in primary health care is a recognition of that fact. Its role is vital to health promotion and to the prevention, early' diagnosis, and treatment of disease since the bulk of health action is carried out in the home before any contact with health workers. It is the family-in general the mother-that rears the children, cares for the sick and the elderly, determines the diet, maintains the immediate environment, transmits attitudes and lifestyles, and decides when to have recourse to the health services. 6. 2 The indicators of the health of the family in Table 6. I show the wide disparity Table 6.1
6. I
that exists between developed and developing countries, and suggest the extent to which the health of members of the family depends on a whole range of social and economic factors and requires for its improvement the intersectoral and integrated approach embodied in primary health care. 6.3 WHO's programme in I98o-I98I focused on managerial, technical, and research support to family health programmes in over 90 countries. The trend throughout all regions was towards an integrated approach, combining maternal and child health, family planning, immunization, diarrhoeal disease control, and many other components. These national family health programmes
Indicators of family health
Developing countries Typical value Infant mortality rate' Percentage of newborn weighing less than 2500 g• .. Fertility rate' . . . . . . . . . . . . . . . . . . . . . . . . Percentage of pregnant women who are anaemic• .. Maternal mortality per 100 000 live births' . . . . . . . • Without China this figure would be 120. Range of values
Developed countries Typical value Range of values
109. 18
5.3 60 about 400
13-217 6-50 1.8-7.4 15-77 13-600
20 7 2.0 20 21
7-39 4-12 1.4-4.2 5-22 1.5-37.3
Sources 'Population Reference Bureau Inc., Washington, 1981 data sheet. • See footnote to paragraph 6.20. • United Nations Demographic Yearbook, 1918, for developed countries; data for developing countries are WHO estimates.
THE WORK OF WHO, I98o-I98I
came closer to making family and community involvement, and the intersectoral approach,. a reality. One important aspect was community-oriented training for health workers, community development workers, schoolteachers, traditional health practitioners, and women's groups. Information tools such as family health records and children's growth charts were developed in parallel. UNFP A's financial support, channelled through WHO, contributed significantly to these developments. 6.4 Activities relating to research on human reproduction, and institution-strengthening for such research, received financial support from the Governments of Australia, China, Cuba, Denmark, Finland, the Federal Republic of Germany, India, the Netherlands, Nigeria, Norway, Sweden, Thailand, the United Kingdom, and the United States of America, as well as from UNFP A. Joint activities were carried out with UNICEF, F AO, the International Children's Centre, and the United Nations University; with the International Federation of Gynecology and Obstetrics, the International Paediatric Association, the International Planned Parenthood Federation, the International Union of Health Education, and the International Union of Nutritional Sciences; and with the Swedish Agency for Research and Cooperation with Developing Countries.
and education. In Africa concern was also expressed at the proportion of infertility in certain population groups. Fertility was viewed as a main indicator not only of health but also of the interrelationship of health and socioeconomic development. The analyses in the World Fertility 6.6 Survey and the reviews of WHO's own programmes pointed to the large unmet need for family planning and to the demands for greater emphasis on the "users' perspective" and on community-based services. On the basis of experience over the past I o years in providing services, training, and research in family planning, WHO reinforced its activities in I 980-I 98 I (see paragraph 6.67 to end of chapter).
Infant and young child feeding 6. 7 WHO made headlines in the world's press in I 98o-I 98 I with its work on infant and young child feeding. Joint work with UNICEF had highlighted the severity of malnutrition in this age group and the negative impact on feeding practices of certain social and economic forces, in particular as related to the declining trend in breastfeeding in some parts of the world. The subsequent drafting of an International Code of Marketing of Breast-milk Substitutes 1 and its adoption by the Thirty-fourth World Health Assembly (I98I) were historic events, since it was the first code of its kind. Its aim is "to contribute to the provision of safe and adequate nutrition for infants, by the protection and promotion of breast-feeding, and by ensuring the proper use of breast-milk substitutes, when these are necessary, on the basis of adequate information and through ap-
Fertility 6. 5 The importance given to fertility trends in national and regional strategies for achieving health for all by the year zooo reflects the more open recognition by Member States of the health aspects of fertility and of population issues. In the Western Pacific, for example, fertility reduction is among the objectives of the regional strategy, and all regions gave a clear priority to expanding family planning care, research,
1 World Health Organization. International code of marketing of breast-milk substitutes. Geneva, 1981.
FAMILY HEALTH
propriate marketing and distribution". The Code covers: the information to be provided on infant and young child feeding; the advertising or other forms of promotion of breast-milk substitutes; the presentation and quality of such substitutes; and the responsibilities of health authorities and of health workers. 6.8. The process leading to the adoption of the Code was in itself an innovation: extensive consultations were held with all interested parties, including the governments of more than 8o countries, organizations in the United Nations system, the scientific community, nongovernmental organizations, consumer advocate groups, and industry. The WHO/UNICEF Meeting on Infant and Young Child Feeding (Geneva, October I979) was followed in I98o by six meetings to discuss its recommendations and to review the draft of the Code. 6.9 The Thirty-third World Health Assembly (resolution WHA 33. 32) endorsed the recommendations of the WHO/UNICEF Meeting that a final Code should be developed; the Executive Board (January I98I) unanimously resolved that it should be adopted as a recommendation; and it was so adopted by the Thirty-fourth World Health Assembly. In resolution WHA34.22 the Health Assembly urged all Member States: (I) to give full and unanimous support to the provisions of the International Code in its entirety as an expression of the collective will of the membership of the World Health Organization; (z) to translate the International Code into national legislation, regulations or other suitable measures; (3) to involve all concerned social and economic sectors and all other concerned parties in the implementation of the International Code and in the observance of the provisions thereof; 53
(4) to monitor the compliance with the Code. 6. I o Meetings were held in each region to examine in detail how infant and young child feeding practices could be improved. Regional and global plans of action were established that cover the full recommendations of the WHO/UNICEF Meeting, namely: (i) encouragement and support of breast-feeding; (ii) promotion and support of appropriate weaning practices; (iii) strengthening of education, training and information; (iv) improvement of the health and social status of women; and (v) appropriate practices for marketing breast-milk substitutes. Guiding principles to help Member States in monitoring progress and determining the kind of cooperation they require were discussed by the regional committees at their I 9 8 I sessions.
Women in relation to health and development1 6. I I The midway point in the United Nations Decade for Women was marked by the United Nations Conference on Women (Copenhagen, I98o) and the World Congress of Women (Prague, I 98 I). Despite pessimism as to progress, there was agreement that at least it was now recognized that socioeconomic development, including health development, cannot be achieved without significant changes in the condition of women, whose unequal status inhibits or distorts development. 6.I2 WHO's whole programme can be considered as contributing to the aims of the Decade, in the sense that all the programme areas relate in some way to women. The Organization has however specifically at-
1 For study on women as providers of health care, see paras 12.38-rz.39·
THE WORK OF WHO, 198o-I981
tempted to define the interrelationship between the status of women and health development, in order to create awareness of the health priorities of women and their roles in health care, by asking how the social, educational, employment, and political factors influencing the status of women affect, or are affected by, health; how women's involvement in health care can be made more equitable and more effective; how women's organizations can be mobilized to promote primary health care; and what kinds of societal, community, and family action are needed to ensure equity for woman as mothers and a better balance of men's and women's responsibilities. 6. I 3 In the African Region support was given to increase the effectiveness of villagebased women's organizations for health care; in the European Region, the importance of women's self-help movements was stressed; in the Western Pacific, women's participation in primary health care was analysed; in the Eastern Mediterranean a plan of action was formulated to discourage negative traditional practices such as female circumcision; in South-East Asia national focal points for information exchange were designated; and in the Americas a five-year plan of action on women in health and development was adopted at the Regional Committee's I98I session. 6. I4 WHO cooperated with nongovernmental organizations in strengthening the health components of their intersectoral programmes for improving women's status. An international meeting in Geneva (I 98 I) brought together women representing nongovernmental organizations and women's groups at community level; they radically questioned the "male-dominated health establishment", urging that more serious account should be taken of women's views when health programmes are being developed. 54
Maternal and child health Infant mortality and health
6. I 5 Progress in lowering the mortality and morbidity rates for infants and young children was unsatisfactory in most countries. Infant mortality rates have traditionally been linked to inadequate socioeconomic development but the complex conditions of today's world require a more precise analysis of these links if intersectoral action is to be effective. WHO initiated several studies in I 98 I on the social correlates of infant mortality. Joint activities were undertaken with various organizations and institutes to explain the vulnerability of children to certain situations of poverty, e.g., those related to the abuse of child labour, abandoned children, urban squatters, or the "fourth world"-the pockets of destitution that exist even in affluent societies. 6.I6 WHO's work in child health cannot be seen in isolation from other activities described in this report. The major causes of infant and child mortality and morbidity are infectious diseases-including diarrhoeal diseases and acute respiratory infectionscombined with malnutrition. During I98oI98I joint work with programmes in those fields was intensified. The children's growth chart is used by the Expanded Programme on Immunization; material on breast-feeding is utilized both by that programme and by the diarrhoeal diseases control programme; activities were undertaken in common with the programme on acute respiratory infections.
Maternal mortality
6. I 7 There has been a tendency to underestimate the relative magnitude of preventable maternal mortality. However, a global review in I 98o-I 98 I showed that in many developing countries the figures for maternal
FAMILY HEALTH
deaths are from 5o to 200 times higher than in developed countries. Maternal mortality is thus a key health indicator that highlights disparities. Numerous interrelated biological and social factors contribute to that mortality. The immediate causes are induced abortion, hypertensive disorders of pregnancy, infections, multiparity, malnutrition (especially anaemia), and parasitic diseases; they are closely linked to lack of care in pregnancy and childbirth, and to the heavy burden of women's work. In the Eastern Mediterranean Region, a scientific working group on maternal health (November I98o) proposed new initiatives, including a system of confidential inquiries into maternal deaths. Studies on such a system are under way in Afghanistan, Democratic Yemen, Egypt, Kuwait, Pakistan, and Sudan. 6. I 8 An increase of knowledge on the direct or indirect causes of maternal deaths (including predisposing factors) has significance for programmes in family planning, maternal nutrition, and health care of women, as well as for those in the broader perspective of the status of women. The perinatal and intergenerational aspects of women's health are crucial for the survival and the healthy growth and development of children. This interaction was further analysed at a joint International Paediatric Association/WHO workshop on the effects on the offspring of nutrition during pregnancy (September I98o).
conditions in rural or urban peripheral areas. This requires not only better_ tools but also new knowledge, based on epidemiological studies. In I 98 I a collaborative research project on hypertensive disorders of pregnancy-a main cause of maternal deathswas instituted in I I countries, involving some 40 ooo women. Its outcome is expected to be the development of intervention techniques for the prevention and management of such disorders as part of primary health care. 6.20 Birth weight was selected as an indicator for monitoring progress towards health for all by the year 2000; it is valuable in that it reflects the mother's reproductive capability (and thus her health and nutritional status) and predicts the chances of the infant's survival and subsequent growth and development. The estimates made in I98o of the incidence of low birth weight 1 show how little is known about the problems related to birth in developing countries. WHO is attempting to define those problems, to investigate the determinants of low birth weight, and to examine the effects of intervention strategies, especially at home and village level. In I980-I98I reviews were made of methods of neonatal heat regulation (e.g., simple types of incubator or techniques suitable for home use) and of the possible utilization of the gravidogram and the partogram outside hospital settings. 6.2I Data on the distribution of birth weight, collected as part of the collaborative study on hypertensive disorders of pregnancy (paragraph 6. I9), laid the groundwork for a system of surveillance of perinatal problems, to be coordinated through WHO's collaborating centres, of which the latest (in Athens) was designated in I981.
Perinatal health and health care
6. I 9 Many technologies are available in affluent countries for such aspects of maternal health as safe childbirth, some of them sophisticated in the extreme. But there are fewer of them for the care of the mother and her baby during the perinatal period, especially technologies that are suitable for the home level and can be adapted to local 55
1 The incidence oflow birth weight: a critical review of available information. World Health Statistics Quarterly, 33: 197-224 (r98o). Also available as offprint.
THE WORK OF WHO, 198o-198I
6.22 PAHO's Latin American Center for Perinatalogy and Human Development continued its research and training in this field, work being directed towards simplifying perinatal care.
Support to national maternal and child liealthj jami!J planning programmes
community groups were involved in the programmes. In the Eastern Mediterranean Region many of the pilot projects were reformulated and expanded into nationwide programmes. In the Americas links were strengthened with other sectors of socioeconomic development, e.g., education, agriculture, and labour. 6.24 Technical cooperation with China was expanded during I 98o-I 98 I ; it covered research in perinatology, work in relation to family planning services, and training. Several study tours were organized to enable health workers from China to go abroad and. those from other countries to study various aspects of China's maternal and child health/ family planning programmes. An interregional meeting (Shanghai, I98o), with participants from all WHO regions, reviewed policies for maternal and child health care and ways of improving it in the context of primary health care. . 6. 2 5 In all regions the emphasis was on integrating the priority components of primary health care and strengthening the managerial aspect. A method of rapid programme assessment for the maternal and child health and immunization components was developed in I 98 I ; it was used in Somalia and Sri Lanka at village, health centre, and central government level. Country case studies on the integration of family planning at different levels of care were organized in Algeria, Morocco, Portugal, Tunisia, and Turkey. A workshop, complemented by field visits, for the exchange of experience between the United Republic of Tanzania and Zimbabwe (November-December I98I) made recommendations on maternal and child health policy and on practice within the context of primary health care. 6.26 Training received high priority in WHO's support to national programmes, and there was a marked shift towards community-
6.23 Technical and managerial back-up was provided to some 8o family health programmes in different countries, funded mainly by UNFPA (see Table 6.2). Services coverage, training, and health services research were increased, and progress was also made in promoting community participation and the intersectoral approach. In several African, European, and Western Pacific countries, for example, women's bureaux and
Table 6.2 Maternal and child health/family planning country projects receiving UNFPA support as at December 1981 African Region Benin, Botswana, Central African Republic, Congo, Gambia, Guinea-Bissau, Lesotho, Liberia, Malawi, Mali, Mauritania, Mauritius, Mozambique, Nigeria, Sierra Leone, Swaziland, Zambia Region of the Americas Antigua and Barbuda, Bolivia, British Virgin Islands, Cayman Islands, Chile, Colombia, Cuba, Dominica, Ecuador, El Salvador, Guatemala, Haiti, Honduras, Jamaica, Mexico, Nicaragua, Panama, Peru, Saint Lucia, Saint Vincent and the Grenadines, St Kitts, Uruguay South-East Asia Region Bhutan, Mongolia, Nepal, Sri Lanka, Thailand European Region Bulgaria, Czechoslovakia, Hungary, Malta, Portugal, Turkey Eastern Mediterranean Region Afghanistan, Bahrain, Democratic Yemen, Jordan, Pakistan, Somalia, Sudan, Syrian Arab Republic, Yemen Western Pacific Region China, Cook Islands, Fiji, Kiribati, Malaysia, Papua New Guinea, Samoa, Solomon Islands, Tonga, Tuvalu, Vanuatu, Viet Nam
FAMILY HEALTH
oriented training of a wide range of health and other workers. Practical methods of problem definition and task analysis at local level enabled primary health care workers in maternal and child health/family planning to acquire their knowledge in real situations; training centres were situated in the rural communities with which they were directly involved. This approach was followed in Papua New Guinea, Sudan, and the United Republic of Cameroon, and was reviewed at a meeting of teachers from African and Arab countries (Barakat, Sudan, I98I). The emphasis was on improving the pre-service and in-service training of health workers with a view to transferring responsibilities to the appropriate level and promoting the use of such resources as traditional birth attendants and community development workers. Support was given to developing curricula suitable for community-oriented programmes and to producing teaching/learning material. International and regional training of teachers ensured a more rap~d build-up of capabilities. Support was given! to a regional training centre in Singapore; preparations were made for a regional centre in Mauritius; and numerous study tours and courses were organized (see paragraphs I2.144-I2.I47). 6.27
the point of view both of the community and of the family or individual, and the subsequent design oflocal strategies to ensure the best allocation of human, material, and financial resources according to the level of risk. 6.29 The risk factors are not only biological: they can be socioeconomic, environmental, or cultural and they thus call for intersectoral and community action in addition to individual treatment. Studies and training in this approach were carried out in all regions during I98o-I98I (see paragraph I 2. I44), reinforced by methodology prepared at global level. Studies in Burma, Cuba, Czechoslovakia, the Dominican Republic, India, Malaysia, Nicaragua, the Republic of Korea, Sri Lanka, Thailand, and Turkey strengthened national capabilities for research and development. An annotated bibliography was issued.l 6.30 The preliminary results of many of the studies indicate the changes in programmes and~policy that the risk approach requires at both local and national level: redistribution of tasks; training of traditional birth attendants and their incorporation into the health care structure; improved data collection; introduction of family health records; and community involvement. The risk approach is being used in one country as a basis for nationwide primary health care, and in the Americas as a basis for the regional strategy for achieving health for all by the year 2ooo.
Risk approach 6.28 All mothers and all children require some form of care throughout the cycle of growth, development, and reproduction, but the traditional model for such care prescribes methods and tasks that are often inappropriate to local problems or resources and never come anywhere near adequate coverage. In response to Health Assembly resolution WHA32.42 health services research, including research training in the field, was carried out on the development and utilization of the "risk approach", i.e., the identification and quantification of risk factors from
6. 3I A meeting of the global ACMR subcommittee on health services research (Addis Ababa, November I98o) reviewed experience in maternal and child health care in Burma, China, Congo, Cuba, Ethiopia,
1 Rtsk approach for maternal and child health: a selected annotated bibliography (WHO document MCHfRAj8LI), 1981.
57
THE WORK OF WHO, 198o--198r
Sweden, and Upper Volta as well as in the Gaza Strip. In the Americas, demonstration areas were set up that combined primary care, training, and epidemiological and health services research; various national studies were supported to improve the research design of existing programmes. An approach was devised for assessing community processes and encouraging community participation.
6. 34 Guidelines were prepared to facilitate changes in hospital and maternity clinic practices, and a review of legislation was initiated with reference to provision for maternity leave, breaks during working hours, day nurseries, or other arrangements at places of employment to allow women the time and a place for breast-feeding. To facilitate the monitoring of patterns and trends, a document on surveillance techniques z was prepared and was given a preliminary testing in two countries. 6. 3 5 Educational material was produced-e.g., an audiovisual presentation; a handbook on how to organize workshops and evaluate follow-up action; and a series of clinic posters and calendars on the themes of breast-feeding, immunization, and diarrhoeal diseases. The WHO brochure on breastfeeding3 is now available in seven languages.
Breast-feeding 6. 3 2 That the natural biological process of breast-feeding, whose importance for infant health is universally recognized, should require scientific, promotional, and educational action by WHO may be thought paradoxical. But there are a number of constraints associated with breast-feeding, and the practice is declining in many countries.l One of the efforts to prevent this decline was the adoption of the International Code of Marketing of Breast-milk Substitutes (see paragraphs 6.7-6.10). 6. 3 3 The promotion of breast-feeding was intensified during the biennium by the organizing of workshops, scientific groups and symposia (in 1980 in Antigua, Chile, Colombia, Fiji, Ghana, Grenada, Hong Kong, Indonesia, Papua New Guinea, Saint Lucia, Samoa, and Thailand; in 1981 in the Caribbean area, Congo, Ethiopia, Guyana, Nigeria, Peru, Saudi Arabia, Sri Lanka, Tunisia, and Zaire). These meetings contributed to increased awareness of the importance of breast-feeding and to the introduction of measures for its support. (See also paragraph 15.95.)
6.36 A WHO report on the status of women and breast-feeding,4 distributed to women's organizations and to policy-makers, outlines the factors that affect women's circumstances and their options as regards breast-feeding, and indicates areas for future action, both at political and at grass-roots level.
Growth and development of children 6. 37 One of the main concerns in maternal and child health is, through preventive, promotive and rehabilitative care, to ensure the healthy physical growth and psychosocial development of children. The aim of WHO's programme is that families should be able to contribute to the monitoring of their own 2 Methodology for determination of breast-feeding patterns (WHO document MCHJBFJSURJ8r.r), 1981. 3 World Health Organization. Breastjeeding. Geneva, 1979· 4 WHO document FHEj81.1 (r98r).
I
World Health Organization. Contemporary patterns of
breast feeding: report on the WHO collaborative stutfy on breastjeeding, Geneva, 1981; Infant andyoung child feeding: current issues, Geneva 1981.
FAMILY HEALTH
children's health and thus prevent problems from arising or ensure their early diagnosis. A publication on the consequences for adulthood of health problems during the period of growth and development 1 shows how the foundations for healthy maturity are laid in the earliest stages of human life, the growth and development of girls being especially crucial for future generations.
Adolescence 6. 38 Adolescence is a critical period in growth and development; the importance of preparing adolescents for their role as parents is recognized, and the risks of teenage pregnancies or abortions are viewed with particular concern. During 198o-198I meetings were held in the European, South-East Asia and Western Pacific Regions, with a global meeting in Mexico City (April-May I 98o) at which health authorities from numerous developing countries described the health and social problems of adolescents, their demographic potential, and the contribution they could make to primary health care. 6. 39 The regional strategy for attaining health for all in the Western Pacific Region includes a specific objective for reducing the number of adolescent pregnancies, and a regional plan of action was prepared covering services and educational research. In the Caribbean area, the Organization gave support to activities to reduce the incidence of teenage pregnancies. 6.40 At global and regional level studies were carried out on growth and sexual development during puberty (Hong Kong,
Hungary, Israel, Kenya, Nigeria, Sri Lanka, and Switzerland). These indicate inter alia that age at menarche may be a useful indicator of health in the female population. Studies on the use of prenatal and family planning services by adolescents are under way, or being developed, in Bangladesh, India, Malaysia, Nigeria, Portugal, the Republic of Korea, Sri Lanka, and Turkey. A series of family life education programmes, both in school and elsewhere, was developed in several Caribbean, European, and South-East Asia countries. Much of this work was carried out in collaboration with the International Planned Parenthood Federation (IPPF). On the basis of these programmes, guidelines for health services research on adolescent reproductive health are being prepared.
Nutrition Malnutrition is recognized as one of the most serious problems in the world today, and the situation in Africa in particular has deteriorated. A sustained improvement in the nutritional status of populations will not be achieved in isolation from socioeconomic development, including a more equitable distribution of products. Thus the health sector alone cannot be expected to correct the basic causes of malnutrition. However, in addition to the impact that nutritional work can have at primary health care level, the health sector can provide information on the extent and nature of malnutrition as a spur to multisectoral action. During 198o-198I WHO deployed its efforts in this direction. In Africa, for example, it participated in the joint F AOJWHOJOAU Regional Food and Nutrition Commission, which, with ECA, is testing new approaches. Other regions also collaborated in multisectoral efforts to develop and implement adequate food and nutrition policies. 6.41
1 Falkner, F., ed. Prevention in childhood of health problems in adHit life. Geneva, World Health Organization, 1980.
59
THE WORK OF WHO, 198o-I981
6.42 An Expert Committee on the Role of the Health Sector in Food and Nutrition met in I 980 1 to reassess the contribution of the health sector to the fight against malnutrition, both through its direct work and in collaboration with other sectors. Following extensive analysis of the situation in a number of countries, a meeting (Dacca, December 198o) defined the structure and functions of central-level nutrition units within ministries of health. In several regions, e.g., South-East Asia, analyses of the nutrition component of primary health care were carried out. 6.43 Without political will and a new approach to the production, storage, and distribution of food, the health machinery cannot go beyond certain limits. Yet sound nutrition is paramount for health, and the synergistic effects of malnutrition and infections are particularly serious for infants and young children. WHO's main concern in I98o-1981 was therefore to ensure the proper integration of nutrition within primary health care, which offers unique opportunities for improving nutritional status, and to develop the related components of primary health care-maternal and child health/family planning, water supply and sanitation, immunization, and disease control, particularly In relation to diarrhoeal diseases. 6.44 The role of community-level or primary health care workers as a crucial element in nutrition work makes their training and supervision particularly important. A manual for the training of such workers was published 2 after four years of preparation involving nutrition specialists and teachers from institutions in all regions and including field testing. It contains a methodology for
tratning that can be adapted to local situations and covers the basic content of nutrition work as part of primary health care. Training in nutrition was supported through educational programmes, e.g., in the Americas, as part of the programmes of the Caribbean Food and Nutrition Institute and the Institute of Nutrition of Central America and Panama (IN CAP); and in Africa at the Regional Health Development Centre (Cotonou) and the Pan African Development Institute (Douala, United Republic of Cameroon). In the latter Region, a network of national centres for research and training in nutrition was established.
Child nutrition 6.45 Attention focused on the nutritional status of pregnant and lactating women, and on feeding patterns in young children. As epidemiological evidence clearly shows, it is the under-threes who suffer most acutely from malnutrition, especially during the weaning period; this is not only the critical period in terms of morbidity, mortality, and long-term consequences but the stage at which proper dietary and feeding practices must be established if lasting improvements are to be made. 6.46 A consultation on child nutrition in primary health care (New Delhi, February I 98 I) reviewed activities and identified needs for operational resarch. In Africa, the Americas, and South-East Asia assessments of regional needs in research were made and plans developed. Studies were conducted in Congo on the incorporation of child nutrition into rural health programmes, and in Upper V alta on nutritional status and diet in young children. In Colombia, determinants of feeding practices for infants and young children were studied, including opportunities for and
1 2
WHO Techmcal Report Series, No. 667, 1981.
World Health Orgamzatlon. Gmdelmes jur tratnii(R commumty health workers m nu!rttion. Geneva, 198 I (WH() Offset Publication No. 59).
Go
FAMILY HEALTH
constraints on improvement. INCAP, in collaboration with the child nutrition agency of Guatemala, instituted a system for the early diagnosis, prevention, and correction of malnutrition in children or pregnant women in poor urban areas; it includes community participation and coordination with local primary health care services. In the Eastern Mediterranean similar studies were s_upported in Democratic Yemen, Egypt, and Pakistan. In the Western Pacific a study was carried out in Papua New Guinea on beliefs and attitudes of mothers regarding the feeding of infants and young children. In the South-East Asia Region studies on child nutrition were initiated in all countries. 6.4 7 One of the questions to be answered by certain of the above studies was how available resources, including local foods, can best be used for combating malnutrition, particularly as concerns weaning, one of the key areas in the WHO programme on infant and young child nutrition. In I 98 I the Health Assembly (resolution WHA34.2.3) asked for a report on the nutritional value and safety of products specifically intended for infant and young child feeding, and this was prepared after a meeting on the subject (October I 98 I). 6.48 Since the work in I 97 I of a Joint FAOfWHO Expert Committee on Energy and Protein Requirements 1 new information has become available on the specific requirements of infants and young children, and a joint FAO/WHO/United Nations University consultation met in I98I to evaluate it. In the same year WHO published a manual2 on treatment and rehabilitation in cases of severe protein-energy malnutrition, for use by workers in health centres.
Surveillance of nutritional status 6.49 Methodological aspects of nutritional surveillance were further developed. Collaboration continued with the Tanzanian Food and Nutrition Centre in setting up a trial community-based surveillance system in the Iringa district, and with INCAP in the retrospective identification of indicators of nutritional status and their field testing. There was collaboration with the United Nations Research Institute for Social Development on the inclusion of indicators of nutritional status in its project for measurement of social change at local level in southern India. To review experience since the F AO/ UNICEF/WHO Joint Expert Committee on Methodology of Nutritional Surveillance met in I 97 5, 3 an international workshop was organized.(Cali, Colombia, I98I) on behalf of the ACC Subcommittee on Nutrition and was attended by more than 6o participants from five WHO regions. Another workshop--on nutrition monitoring and evaluation-was organized in the South-East Asia Region. 6. 5o The collection of published data on anthropometric indicators of health and nutritional status was started. A simple infant-length measuring board that could be constructed at village level was developed in collaboration with the Appropriate Health Resources and Technologies Action Group.
Specific nutritional deficiencies 6. 5I Technologies exist for the control of certain specific nutritional deficiencies and WHO endeavoured to ensure that they were used effectively. 6. 52. Together with UNICEF and the World Food Council, control programmes
WHO Technical Report Series, No. 522, I973· World Health Organization. The treatment and management of severe protein-energy malnutrition. Geneva, I 98 I. I 2
3
WHO Technical Report Series, No. 593, 1976.
6I
THE WORK OF WHO, r98o-r98r
for endemic goitre were promoted in countries where, together with endemic cretinism, it is a major public health problem (several countries of Africa and Asia). Work was carried out with UNIDO in a number of African countries to determine the feasibility of salt iodization as a control measure. 6. 53 Work on xerophthalmia included identification of the countries where the disease is prevalent. Very little information is available for the Eastern Mediterranean and African Regions. Reports established in collaboration with USAID indicate that in some countries the prevalence has hitherto been underestimated, and control programmes were planned. Research needs were identified and priorities for WHO studies were recommended by a consultation (Manila, 1980). 6. 54 Cooperation continued with the International Vitamin A Consultative Group, (IV ACG) of which WHO is a member, to develop and coordinate control activities. In addition to a meeting held in Cebu (Philippines), a joint WHO/UNICEF/USAID/ Helen Keller International/IV ACG meeting reviewed progress in the institution of measures to control vitamin A deficiency and xerophthalmia (Jakarta, October 198o).l Programmes for fortification of sugar with vitamin A were evaluated in several Central American countries. Ampoules containing o.o 55 g of water-miscible retinol palmitate for intramuscular injection were provided free of charge to all countries that requested them. 6. 55 Applied research on nutritional anaemia centred on practical control measures. A simple methodology for screening and models for the fortification of food with iron were developed. Studies on the feasibility and
the effectiveness of fortification schemes were carried out on sugar (Guatemala) and fish sauce (Thailand). Experience in several countries shows that the iron preparations at present distributed have a number of sideeffects that jeopardize the success of control programmes; field trials were therefore conducted, in Indonesia and the Philippines, to test new preparations. 6. 56 Two meetings of the International Nutritional Anaemia Consultative Group were held, in Bangkok and Santiago (Chile), to ensure coordinated activities. 6. 57 WHO is emphasizing the importance of controlling nutritional anaemia, which contributes significantly to maternal morbidity and mortality and is estimated to affect nearly two-thirds of pregnant and onehalf of non-pregnant women in developing countries. 6. 58 In reappralSlng its nutrition programmes during 198o-1981 WHO clearly recognized that their impact would remain inadequate, given present resources. While there has been a promising reorientation in approach, much more is required in the way of large-scale action at country level. A fiveyear plan was developed with UNICEF, in close collaboration with several other agencies, as a step towards meeting these needs.
***
Health education 6.59 The Declaration of Alma-Ata (1978), by emphasizing the need for individual and community participation, gave a new meaning and direction to the practice of health education. The dynamic definition of health education would now be: a process to promote a situation in which people want to be healthy, know how to achieve that wish, do what they can individually or collectively,
1
WHO Technical Report Series, No. 672, 1982.
FAMILY HEALTH
and seek help when needed. As distinct from the paternalistic approach of the past, the new slant requires people's active, voluntary, and sustained involvement in their own health care, in partnership with the providers of health services. It also presupposes a symbiosis of health education and information, with links between the mass communications media, political opinion-makers, health educators, community development workers, and the various community-oriented organizations at all levels. Communication has to be intensified, evolving between the different levels rather than filtering down from the top.
Self-care Jself-help 6.6I Health education has traditionally been associated with disease prevention but two emerging themes are self-care and health promotion. The European Region embarked on a radically new programme based on activities in health promotion, prevention, and care that can be carried out by the layman. Studies are under way to explore health promotion through sport and creative leisure activities. 6.6z All regions concerned themselves with health education in family health. In the Americas it was included in I 8 national maternal and child health programmes. In the Western Pacific a special effort was made in relation to intersectoral community development, including the involvement of women's groups (Malaysia, the Philippines, the Republic of Korea, and seven countries in the South Pacific).
6.6o In I98o-I98I WHO's programmes were geared to reorienting health education in this way, within primary health care. In the African Region, work in I 7 countries emphasized inter alia the organization of community awareness campaigns and the creation of village health committees; a regional meeting was held on this subject (Dakar, February I98I). In the Americas, community health education was the topic of the Technical Discussions held during the Regional Committee in I98o; studies were made in 23 countries to determine the present status of health education and indicate new strategies and techniques. In the Eastern Mediterranean Region, new approaches to health education were made in Lebanon, Pakistan, and Yemen. Community participation was the object of several activities in the Western Pacific Region-in relation for example to leprosy/ tuberculosis control (throughout the Region), development of water supply and sanitation activities (Kiribati), and malaria control (Papua New Guinea). Communication strategies, including use of media facilities, were strengthened in the Cook Islands, the Lao People's Democratic Republic, Malaysia, the Philippines, Samoa, and the Solomon Islands. Radio broadcasts were used as a medium for health education in many African countries.
Sociocultural research 6.63 Increased attention was given to the sociocultural determinants of health and health behaviour. Intercountry meetings on research needs in this area were held in the South-East Asia and Western Pacific Regions; in the African Region cooperation was established with the International Institute for Social Studies. Studies in the United Republic of Tanzania focused on improving the distribution and use of antimalaria tablets. Applied social research in primary health care was carried out in Niger and the United Republic of Cameroon. In the Republic of Korea, research was directed towards determining patterns of communication and adoption of health practices.
Health education for children 6.64 In collaboration with USAID and the University of the West Indies, school
THE WORK OF WHO, 198o--198I
health curricula were reshaped in a number of Caribbean countries. Similar work was carried out in Africa (Benin, Botswana, Congo, Ghana, Guinea, Swaziland, Togo, the United Republic of Tanzania, and Zambia), in SouthEast Asia (India and Mongolia); and in the Western Pacific.
carried out in Bihar and Uttar Pradesh. Other activities took place in the context of the International Drinking Water Supply and Sanitation Decade. Collaboration continued with ILO, FAO, and UNESCO, especially in relation to family well-being in the context of rural development. UNFP A collaborated with WHO in providing support for more intensive family life education.
Training 6.65 Training in the health education aspects of primary health care was intensified in all regions by way of institutional support, workshops, seminars, etc. In South-East Asia an intercountry workshop was held with participants from Bangladesh, India, Indonesia, and Thailand; in the Western Pacific the focus was on training peripheral health and allied workers, e.g., in Kiribati, Papua New Guinea, the Solomon Islands, and Tuvalu. In Africa, the regional centres for health education (University oflbadan, Nigeria), health development (Cotonou), and training of health workers (Lome and Lagos) were also active in this direction. A practical manual for teaching the essentials of health education to primary health workers, prepared with WHO support by the Department of Preventive and Social Medicine, University of lbadan, was issued. (See also paragraphs I 2. 148-I 2. I 52.)
Special Programme of Research, Development and Research Training in Human Reproduction 6.67 The Special Programme is WHO's major resource for research in family planning, including infertility. In the Global Strategy for health for all by the year zooo, the special research programmes are seen as the "main instruments for promoting and coordinating the international research and development required for the successful implementation of the Strategy" and thus for supporting countries "in strengthening their capacities for organizing and conducting biomedical, behavioural and health systems research related to the implementation of their strategies" .1 6.68 Family planning was recognized in the Declaration of Alma-Ata as a basic component of primary health care, and the Special Programme's research activities are oriented to "the provision of guiding principles and training material for its delivery in the most efficient way through health infrastructures". 2
Involvement of other organizations 6.66 A number of United Nations agencies and nongovernmental organizations stepped up their work in health education and collaborated to increase the impact of programmes. Notable among the latter were the International Union for Health Education and the League of Red Cross Societies, which devised an interesting programme for primary health care. UNICEF and WHO worked together in several countries, e.g., in Nepal and India; an investigation of behavioural attitudes to rural water supply was
1 Global strategy for health for all by the year 2000. Geneva, World Health Organization, 1981 ("Health for All" Series, No. 3), part VIII, para. 12. 2 Op. cit. part VIII, para. 20.
FAMILY HEALTH
6.69 Through the Special Programme governments and scientists are able to collaborate in both research and institutionstrengthening; they jointly identify priorities, plan strategy, conduct activities, assure quality, and disseminate results. In 1981, So countries were involved, 54 of them developing countries. 6. 70 World efforts on service and psychosocial research in family planning, studies on the safety and efficacy of current methods of birth control, development of new methods, and research on infertility-all these are at present very limited. Apart from the WHO programme, they are concentrated in the United States of America and one or two other developed countries. As to institutionstrengthening in developing countries for service and biomedical research in family planning, it is virtually confined at international level to the Special Programme. 6. 71 A full report on the Special Programme's activities is published each year and widely disseminated. 1 The main trends in 198o-I981 are illustrated below.
6. 73 Community partiCipation. Research under the Special Programme is exploring how to involve the community in family planning in the primary health care contextas a whole and also through its particular elements, e.g., schoolteachers, housewives, local religious leaders, or practitioners of traditional medicine.
Health services research and psychosocial research 6. 7 z Research is increasingly used by governments to improve the availability and utilization of family planning services. This was reflected in the large number of requests for collaboration in the past two years. They related mainly to manpower for family planning in primary health care, integration of family planning with other activities, impact of services and of psychosocial factors on family planning practices, field trials of contraceptives, and definition in different communities of the need for services. 1 World Health Organization. Special Programme of Research, Development and Research Training in Human Reproduction: ninth annual report, Geneva, I 980; tenth annual report, Geneva, 198 I.
6. 74 The first phase of a study in two rural areas of Kenya, designed to enable the community to define its family planning needs and the type of services it desires, and to secure its participation in the provision of such care, showed clearly the conflict between (i) the high esteem in which fertility is held and (ii) the realization of the economic constraints that large families impose and of the health hazards of grand multiparity. Family planning to space pregnancies or avoid the dangers of grand multiparity was acceptable, whereas current slogans such as "two [or even four] children are enough" met with general laughter or incomprehension. The communities had been left in a state of confusion by the introduction of the concept of planning their families without any attention being given to other aspects of their lives. This had confirmed them in the opinion that family limitation was in the interest of "other people" with ulterior motives, not in their own interest.
6.75 Another factor which emerged was the acceptance within the family circle of extramarital children and of the children of other relatives, brought in to "fill out" the smaller families. These practices weaken the economic rationale for limiting family size, since the family that has adopted birth control merely spends more of its resources on other children. The need for group acceptance and group practice of family planning emerged very clearly from the studies and also the fact that the community, rather than the in-
THE WORK OF WHO, 198o-I981
dividual or the family, should be the target for information and education. 6. 76 Manpower training. To respond to the growing interest of governments in experimenting with the training, reorientation, and deployment of various members of the community and different categories of health personnel for family planning care, support was given to developing protocols for studies, preparing training manuals, elaborating post-training evaluation criteria, and evolving mechanisms for surveillance and supervision, in addition to the financial and technical support common to many parts of the programme. 6. 77 Educational material for tratntng nonmedical personnel in any culture to teach natural family planning methods was developed in the course of a three-year project and evaluated in six countries. This "learning package" deals with the two methods at present most widely practised-the ovulation method and the symptothermal. The package includes simple visual aids that can be used without any equipment and are suitable for teaching couples, groups, or individuals. 6. 78 One of the criticisms of health services research is that it is difficult to replicate at national level the findings of pilot studies. The national extension of two pilot studies (Thailand and Turkey) for training midwives or nurses to provide the clinical family planning services hitherto provided only by physicians is showing this criticism to be unfounded. In Thailand the pilot project showed that operating-room nurses could be trained to perform post-partum tubal ligations as competently as surgeons, and with equally low morbidity rates. In the national extension, in 3000 procedures the immediate complication rate (o. 2% ), the percentage of women satisfied with the result (99· 2% ), and the rates and types of complication detected at the six-week follow-up visit were highly 66
satisfactory and in line with the data reported · during the pilot project. 6.79 Integrated care. Resolution WHA3 1.37, which urged the Director-General to intensify health services research under the Special Programme, focused particularly on the role of such research in facilitating "the complete integration of services for fertility regulation into the primary health care systems of the countries concerned". Projects of this type were developed in India, Indonesia, Kenya, Peru, the Republic of Korea, and Sri Lanka. The most advanced of these--that in Sri Lanka-is testing two such integrated approaches in different regions of the country and comparing them with control areas that have normal government services. In one area midwives who normally provide maternal and child health services are involved in a streamlined management and referral system that enables them to provide family planning services as well. In the second area, midwives and district medical officers of health concerned with prevention are brought in to the same management process but are in addition provided with certain drugs for curative purposes. The setbacks encountered in this project exemplify the difficulties of conducting large-scale field research projects: an epidemic of cholera in one area, a typhoon in another, transfer of field staff and their replacement by inexperienced personnel, and power cuts affecting data processing. Nevertheless, the results of introducing the curative care package have already been so positive that a national conference on the restructuring of the health services (August 1981) recommended its inclusion on a national scale. 6.8o Health rationale for jami(y planning. Many countries have changed their legislation on family planning as a result of local studies showing the effect on mortality and morbidity, and the ensuing cost to health services, of lack of access to family planning
FAMILY HEALTH
services or failure to use them. Studies on illegal abortion were completed in Ankara, Ibadan (Nigeria), Kuala Lumpur, Caracas and Valencia (Venezuela). The cost of illegally induced abortion was found to be considerable both in human and in health services terms: of the hospitalized cases in Ibadan nearly one woman in twenty died, while in Ankara and Kuala Lumpur there was one death for every 2 5o such admissions. The cost of providing hospital beds, drugs, blood transfusions, and other scarce services for cases of illegally induced abortion was enormous, amounting to over one million dollars a year for the two cities in Venezuela alone. 6.81 Studies were carried out in Colombia, Egypt, Pakistan, and the Syrian Arab Republic 1 on the effects on maternal and child health of the timing, spacing and number of pregnancies, and of environmental and behavioural variables. As was the case with earlier WHO studies (in India, Iran, Lebanon, the Philippines, and Turkey) they showed the risk of poor pregnancy outcome to be lower for low parity groups at maternal ages 20-29 and for pregnancy intervals of 3-5 years. It is interesting to note that, although completed fertility ranged from 5.6live births in Colombia to 9· 1 in Egypt, the ideal family size as seen by the same women ranged from 3.2 to 6.5. 6.82 Institution-strengthening for health services and p!]chosocial research. The greatest single constraint on the development of services and psychosocial research in family planning continues to be the shortage of trained manpower, and governments are acutely aware of this. Research training courses held during the biennium are listed in Table 6-3-
Table 6.3 Courses in health services and psychosocial research in family planning, 1980-1981
Title of course and country from which trainees came Health services research in family planning (1980) India, Bangladesh, Egypt, Indonesia, Nepal, Republic of Korea, Thailand, Turkey Application of epidemiology to research in fertility regulation (1980) India, Kenya, Nepal, Sudan, Thailand, Turkey WHOIESCAP workshop on psychosocial research (1980) Bangladesh, China, India, Indonesia, Japan, Malaysia, Nepal, Pakistan, Papua New Guinea, Philippines, Republic of Korea, Singapore, Sri Lanka, Thailand Health services research in family planning (1980) Turkey Health services research in family planning (1981) Bangladesh, Bra2il, Egypt, India, Indonesia, Kenya, Nigeria, Sri Lanka, Tunisia, United Republic of Cameroon Application of epidemiology to research in fertility regulation (1981) Bangladesh, China, Colombia, Mexico, Thailand, Yugoslavia
Duration
3 weeks
6 months
2 weeks
2 months
3 weeks
6 months
Safety and efficacy of current methods of fertility regulation 6.83 Investigations on the safety and efficacy in developing countries of current methods of fertility regulation were conducted at the request of national authorities concerned at having to use, in their own population, birth control methods that had been tested only in developed countries. For some methods, e.g., pills and intrauterine devices, guidance was requested as to which preparation or device was best suited to the particular population. In other instances controversy in developed countries on the safety of certain products, e.g., the injectable depot-medroxyprogesterone acetate
I Omran, A.R. & Stllndley, C.C. Further studies on fami!J formation patterns and health. Geneva, World Health Organization, 1981.
THE WORK OF WHO, 198o-r98r
(DMPA), spilled over into the developing countries, which turned to the Special Programme for analysis of the situation and for further research. Some problems, particularly those relating to possible long-term effects such as cancer, are still of concern to developed as well as to developing countries. The Special Programme's research 6.84 in this direction represents the largest world effort to answer such questions as they relate to the population of the developing countries. It is conducted mainly through the network of WHO collaborating centres, using common protocols so that not only are data of immediate local relevance obtained but interpopulation comparisons can also be made and sufficiently large numbers of subjects can be accumulated to find an answer to the questions rapidly. Some examples of recent findings are given below. 6. 8 5 Oral contraceptives. A bewildering number of oral contraceptives are available: as many as 68 different ones were being marketed in I978, under 228 trade names. A comparative study was therefore conducted in I 2 countries to cover the commonly used range of dosages and combinations of progestogens and estrogens. Over 34 ooo cycles were observed in about 3000 women. Preparations containing 30 to 3 5 Jlg ethinylestradiol were found to be as effective as those containing the higher dose of 5o Jlg, but those containing 20 !lg could not be recommended. Discontinuation because of bleeding was more common with preparations containing norethisterone, and discontinuation because of nausea and vomiting with those containing norgestrel. The local "acceptability" of these two side-effects will have a bearing on the choice of preparations for national programmes. 6.86 For conditions such as malaria or other parasitic diseases that barely exist in developed countries, few data are available as 68
to possible interaction with contraceptive methods. Studies are continuing in areas where malaria and schistosomiasis are endemic, and studies on liver fluke infection have been completed. Clonorchis sinensis, for which there is no safe effective therapy, affects the biliary system and is widespread in Asia. Liver function was compared in infected and non-infected women using oral contraceptives or intrauterine devices; no significant differences were found after one year of pill use.
6.87 Intrauterine devices ( IU Ds ). There is also a wide variety of IUDs available-plain plastic, copper, or hormone-releasing-but little in the way of comparative clinical data, particularly from developing countries, to help in choosing the most appropriate type. National authorities sought guidance on the effectiveness of IUDs inserted immediately after delivery, and on their safety when inserted after an induced or a spontaneous abortion. More than I 3 ooo women participated in the studies on these questions, and by October I98I more than 2I7 ooo womanmonths of data had been collected in 22 countries.
6.88 In all the studies, the Copper T 22oC intrauterine device was found to be better than either the Lippes Loop or the Copper 7, pregnancy and medical removal rates being lower and continuation rates higher. IUD insertion following first-trimester induced or spontaneous abortion carried no greater risk of perforation or infection than if the device had been inserted during or immediately after the menses. IUD insertion following second-trimester abortion is not recommended however, in view of the high expulsion rates revealed by the studies. Insertion immediately after delivery was associated with even higher expulsion rates.
FAMILY HEALTH
6.89 I'!}ectable contraceptives. Two longacting progestogen preparations, depotmedroxyprogesterone acetate (DMP A) and norethisterone enantate (NET-EN), are used widely throughout the world. Clinical and epidemiological studies on their safety and effectiveness were conducted and also field trials on their provision by health services. DMP A has for a number of years been the subject of controversy and on two occasions the Special Programme has issued guidelines for national authorities on its use. 6.90 The controversy was further fuelled in the latter part of 1980 by an article in a United States consumer magazine which gave a somewhat one-sided account of adverse effects of DMP A. This led to renewed demands for guidance from various governments, UNFP A, and other technical cooperation agencies. Guidelines were therefore prepared at a meeting (October 1981) bringing together members of the programme's Toxicology Review Panel, representatives of the drug regulatory agencies of India, Mexico, Sweden, Thailand, the United Kingdom, and the United States of America, representatives of the manufacturers of these products, and scientists working in this field.l The meeting found no reason to recommend discontinuing the provision of either DMP A or NET-EN. The guidelines are being widely distributed. z 6.91 One finding from WHO studies in Mexico and Thailand that has considerable health, cost, and acceptability implications is that the three-monthly dose of DMP A at present administered- I 5o mg-may be larger than is required to achieve protection against pregnancy in the smalier women of 1 Facts about injectable contraceptives: memorandum from a WHO meeting. B11/letin of the World Health Organization, 6o (2), 1982. 2 Injectable contraceptives: technical and safety aspects. Geneva, World Health Organization, 1982 (WHO Offset Publication No. 65).
these developing countries. The larger dose may moreover account for some of DMPA's undesirable side-effects in these women. Studies on a xoo mg dosage will now be conducted.
Female sterilization. Some of the 6.92 many procedures for female sterilization require only the most basic general surgical and anaesthetic skills and facilities; others demand special skills and relatively complex equipment. In a study of the various procedures in xo countries, minilaparotomy was found to be the best suited to primary health care since it requires only minimal surgical skills and basic facilities.
New methods of fertility regulation 6.93 The need for improved and new methods of fertility regulation was repeatedly stressed during the biennium by national authorities and in international meetingsfor example, by the Parliamentary Conference on Population and Development in Africa (July 1981), the International Conference on Family Planning in the 198os (Jakarta, April 1981), and the United Nations Economic and Social Council (May 1981), which in resolution 1981/28 urged "international organizations, including the United Nations Fund for Population Activities and the World Health Organization, and national Governments to give high priority to research on human reproduction and the development of more acceptable, safer, and more effective means of fertility regulation". 6.94 The development of better methods of fertility control has always received high priority within the Special Programme, which has shown its ability to marshal from both developed and developing countries the resources required for the many types of research involved-from basic reproductive biology through chemistry and bioengineer-
ing to animal toxicology, clinical studies and product development. Such research and development are however very costly, and owing to funding constraints fewer of the promising leads are being pursued than merit it. 6.95 Some of the products under development are nearing the stage at which they will be available to family planning programmes, some are at an earlier stage of clinical assessment, while others are still at the stage of studies in animals. 6.96 Intrauterine devices. The steroidreleasing IUD developed by WHO has been shown to reduce the bleeding associated with currently used IUDs, which is a main reason for women discontinuing their use and which is demonstrated by WHO studies to be a health hazard for anaemic women in developing countries. The WHO device has an intended life-span of 10 or more years, and during the biennium it successfully completed the clinical trials in small numbers of women that precede large-scale clinical testing. 6.97 Vaginal rings. At a similar stage of development is the WHO steroid-releasing vaginal ring. Its advantage over the IUD is that a woman can insert and remove the ring herself; and over barrier methods, that it can be left in place for periods of up to three months. WHO studies have shown it to be acceptable in different cultural groups. Machinery for mass production is being developed by the Special Programme. 6.98 Female sterilization. A method that has reached an advanced state of clinical testing is a non-surgical method of female sterilization-chemical occlusion of the fallopian tubes-that can be performed by either physicians or non-physicians on an outpatient basis. If its final testing proves successful it will represent an important logistic and
economic advance for family planning programmes in those developing countries that provide sterilization services. 6.99 Prostaglandins. Similarly, drugs for the termination of pregnancy have reached the final stage of testing. During the biennium, a number of clinical trials were completed on prostaglandin analogues, which have a high degree of effectiveness and relatively minor side-effects. 6.100 Determination of the fertile period. Technical difficulties were encountered in the development of simple methods to enable women themselves to predict the fertile phase of the menstrual cycle. Such methods should permit a reduction of the period of abstinence required by present methods. The two main lines pursued were: (i) chemical tests in the form of simple kits for home use, and (ii) automated devices for taking, recording, and interpreting basal body temperature. From the start of work on do-it-yourself kits, it was understood that alternative laboratory methods, too sophisticated for home use but easier, quicker, safer, and less expensive than radioimmunoassays, would be an intermediate step in their development; this is well on its way to being accomplished. The methods developed are a significant improvement on existing methods for measuring plasma hormones, especially in places or conditions where blood sampling is not acceptable or where long-term monitoring is desired. They have already been adopted by more than half the collaborating centres working with the programme, but methodological constraints make it unlikely that onestep methods suitable for home use can be developed within the next few years. 6.101 However, an automated electronic device for detecting ovulation and the postovulatory infertile phase of the menstrual cycle is at the prototype stage. There is great public interest in it: in 1981 reports appeared
FAMILY HEALTH
in the press all over the world, the terms "sexometer" and "intelligent thermometer" being used to describe the device. 6. I02. ltljectable contraceptives. The demand remains great from developing countries for injectable or implantable contraceptives that would have significantly fewer side-effects than the two injectable compounds at present available and would provide greater choice in terms of duration of action. Efforts were concentrated in three areas: development of biodegradable implants with a one-year lifespan, synthesis of new long-acting compounds, and improvement of monthly injectable preparations. 6. I03 The biodegradable implant, a way of delivering a drug at a constant rate for a long period of time, involves highly innovative polymer chemistry. Local irritation problems were, however, encountered in the first human trials and further animal studies are required. Synthesis and biological screening were completed of more than 2.00 new injectable compounds produced by university laboratories in I 2. countries, of which seven were developing countries. Patents have been applied for in the case of the two most promising compounds; for the more promising of these, pre-clinical toxicological studies are beginning. 6. I04 Plants for fertility regulation. A systematic study of plants used for fertility regulation aims at exploring their merits scientifically in order both to discover new compounds or extracts and to discourage ineffective or harmful practices. At present the emphasis is on identifying agents that could be taken if a period is missed or immediately after coitus. Some work has started on orally active agents for men that ~ould inhibit spermatogenesis or sperm maturation. A computerized data base has been established for selection of the plants to be tested. Over Ioo plants have been pro7I
cured, I46 different extracts prepared, and 175 bioassays performed. In addition, about I4 extracts have been fractionated and significant progress has been made in elucidating the structure of two promising pure compounds. 6. I05 Newer approaches. A number of other leads are being followed that have not yet reached the stage of clinical testing. The aim in each case is simplicity of use in the primary health care setting. They include drugs that could be taken immediately after intercourse; when a woman notices that her period is late; or regularly once a month. All three approaches are intended to limit bodyexposure to drugs and obviate the need for daily pill-taking. 6. I o6 Birth control vaccines would also make an important contribution to family planning programmes. They would provide long-term protection, could be administered by paramedical personnel at low cost and, in view of the acceptance of vaccination in general in developing countries, might be a popular method, particularly since they are not likely to disrupt the menstrual cycle or cause the metabolic disturbances associated with most currently used drugs. Work on a vaccine is well advanced and should reach clinical testing in I982..
6. I07 Research on methods of male fertility control has been conducted mainly through the collaborating centres in China. A major part of it was concerned with chemical work and animal studies on gossypol, a substance derived from cotton-seed oil.
Research on infertility 6. I o8 Research on infertility is of particular interest to countries in the African Region. A simplified questionnaire has been prepared, the answers to which will give a
reasonable estimate of the prevalence of primary and secondary infertility, pregnancy wastage, and infant and child mortality. It consists of about 25 to 30 questions, to be answered by community samples of 300 to 5oo couples, and is designed to be processed by hand under field conditions. The original prototypes were developed, pre-tested, and modified after field testing in rural areas of Nigeria, Sudan, and the United Republic of Cameroon. In the surveys of primary and secondary infertility conducted, some very high rates of infertility were found, e.g., 40% of women aged 30 to 44 in a Sudanese population showed primary infertility. Wide variation was also found in different population groups in the same country. 6. I09 The techniques used for the investigation of the infertile couple vary widely from one centre to another. In some cases the male partner is never examined at all, and in many centres urologists have little interest in male infertility. This has resulted in incorrect diagnoses, inappropriate treatment, and erroneous comparisons of the frequencies of various forms of infertility and of results of treatment. The WHO manual for the investigation and diagnosis of the infertile couple is now being used in the 34 centres taking part in research on infertility. A total of 2 53 7 couples have to date entered the standardized study. Other studies are evaluating com6. I I o monly used diagnostic and therapeutic procedures, several of which appear of questionable value, and are developing less expensive and more appropriate methods. Others are determining the etiology in the large proportion of infertile cases previously classified as of unknown cause. Institution-strengthening
research institutions was reflected in the greater emphasis placed during the biennium on this part of the programme. There was an increase in the number of requests by Member States for institution-strengthening, and a concomitant rise in the related expenditure. 6. I I 2 The distinction frequently made between institution-strengthening and research is in fact a false dichotomy as regards the Special Programme, whose fundamental principle and practice it has been to strengthen institutions through research. Collaboration involves, from the very outset, developing a research plan, assisting in the elaboration of research projects, introducing the required research training and purchase of equipment, and helping to establish methods and implement projects by regular visits to the institution. At the same time scientists from the institutions take part in the collaborative research of task forces and in the planning and reviewing activities of steering committees. 6. I I 3 Although on the one hand institution-strengthening activities are localized and aim at achieving national self-reliance in research, on the other hand they mobilize the capabilities of many countries for both research training and consultant expertise and are thus interregional. This dual character is also evident in the outcome of institutionstrengthening: in the immediate it provides resources for the solution of research problems of local importance, yet at the same time it promotes collaboration among scientists of different countries, interests the developed countries in the problems of the developing countries, and increases the world's pool of knowledge and technology. The following paragraphs give only a few examples of activities in the past two years. 6.1t4 African Region. Activities have hitherto been limited, since for most of the countries in the Region research in human
6. I I I The priority given by all WHO policy-making bodies to the strengthening of
FAMILY HEALTH
reproduction was not a high priority. However, attitudes are changing rapidly. A study group on human reproduction met (Madagascar, June I 9 8 I) to develop research activities in conjunction with the Special Programme and to link research to training and service activities.
psychosocial research both in Bangkok and in rural areas; it also acts as a base for a national scheme for standardizing clinical chemistry methods and provides courses on advances in family planning and methodology of clinical research for teachers in medical schools and public health workers. 6. I I9 European Region. The collaborating centres of this Region played an important role in strengthening the institutions of developing countries by providing training and consultants. In the USSR the Moscow research and training centre in human reproduction has begun to strengthen research institutes in Tashkent and Erevan. The collaborating centre for research and research training on service aspects of family planning, Ankara, has served to expand significantly health services research on family planning in Turkey and to train health scientists in this area.
6. I I 5 The major project in Africa under the Special Programme is the Nairobi centre for research in reproduction, which is conducting research on clinical problems of pregnancy, infertility, and family planning and, in local animal species, on models for research in human reproduction. 6. u6 Region of the Americas. A new collaborating centre for clinical research in human reproduction was designated in Colombia. The collaborating centres in Cuba and Mexico are developing other centres in their own countries. One of the hoped-for outcomes of institution-strengthening is the multiplier effect by which centres, once strengthened, take on similar responsibilities for other institutions. 6.II7 South-East Asia Region. In India, institution-strengthening focused mainly on three key national institutions-in Bombay, Chandigarh, and New Delhi-which were expected to have a multiplier effect at national level. The Special Programme's activities have now been extended to the network of centres of the Indian Council of Medical Research, which has restructured its administrative mechanisms relating to research in fertility regulation, using the Special Programme as a model.
6. I 20 Eastern Mediterranean Region. A research centre for the national family planning programme was established in Tunis. The Special Programme collaborated in building up its laboratories and in training personnel in laboratory and epidemiological methods. 6. I 2 I Western Pacific Region. During the biennium there was collaboration with China in the development of two large institutes for research in family planning, one in Shanghai and the other (UNFP A-funded) in Beijing. In I98I, and on a smaller scale, support was given to institutes in Nanjing and Wuhan. Research training, although concentrating mainly on the Beijing and Shanghai institutes, also included scientists from other parts of China. Some 58 research training or "visiting scientist" grants 1 were awarded, usually coupled with intensive language tuition. Three national courses were held in China on radioimmunoassay techniques and on male 1
6. I I 8 The two collaborating centres in Bangkok are a good illustration of how academic institutions can work closely with national authorities by giving advice and conducting research on problems encountered in the family planning programme. One of them is active in health services and 73
See paras 4.8-4.9·
THE WORK OF WHO, 198o-198I
reproduction, as well as a major symposium on advances in fertility regulation, the proceedings of which appeared in Chinese and English. 6. I 22 Research training grants. Some 2 5o research training and "visiting scientist" grants were awarded during I98o-I98I, nearly twice the number awarded in the previous biennium; they went mainly to staff of the institutions that are being built up in collaboration with the Special Programme, in order to achieve research groups of a viable size rather than disperse available resources. 6. I 2 3 The 20 research training courses organized (nearly three times as many as in the previous biennium) covered health services and psychosocial research, epidemiology, pharmacology, andrology, and laboratory techniques. Eight of them were held in the collaborating centres of developing countries. 6. I 24 Standardization and quality control. To ensure comparability of results in multicentre trials and other collaborative studies, a major effort was made in the standardization and quality control of laboratory procedures. This has also had a significant institutionstrengthening impact, since the provision of well-validated methodologies, reagents, and the means for assessing assay performance enabled many investigators to pursue research projects that would otherwise have been difficult to undertake. There are now I42 laboratories, in 48 countries, participating in these schemes.
exchange of information on agencies' activities and plans, identification of possible areas of overlap or neglect, and discussion of obstacles to progress.
Dissemination of information 6. I 26 In addition to providing guidelines, responding to numerous requests for information, and issuing manuals, as mentioned above, the Special Programme undertook a variety of activities to disseminate information to policy-makers, programme administrators, providers of services, scientists, and the general public. Twelve symposia or seminars were organized (in China, Colombia, India, Israel, Malaysia, the Republic of Korea, and Thailand) to present an overview of recent advances in research on fertility regulation or to focus on the results of studies in specific areas, e.g., female sterilization, regulation of male fertility, plantderived products, prostaglandins, immunological approaches to fertility regulation, termination of pregnancy, synthesis of new compounds, psychosocial aspects of family planning, and infertility.
6.127 The main channel for dissemination to the scientific community of the results of studies supported by the Special Programme is through articles in professional journals, of which over 700 appeared in the biennium. Access to the scientific literature is still a problem in many countries, and journal subscriptions were provided to 8 5 institutions in developing countries.
Coordination 6. I 2 5 In its coordinating capacity the Special Programme brought together on three occasions the main international, national, and nongovernmental agencies conducting or directly supporting research in family planning. The meetings focused on biomedical, health services and psychosocial research. They provided the opportunity for 74
Funding 6.128 The Special Programme is largely financed by voluntary contributions. For I98o-I98I the donors were Australia, China, Cuba, Denmark, Finland, the Federal Republic of Germany, India, the Netherlands, Nigeria, Norway, Sweden, Thailand, the United Kingdom, the United States of America, and UNFP A.
Chapter 7
Mental Health
GLOBAL Coordinating Group for Mental Health at its fourth session (New Delhi, October 1981) gave particular attention to evaluating the progress achieved and the problems encountered during the period covered by the Sixth General Programme of Work (1978-1983) and agreed on the adjustments necessary to ensure a smooth transition into the Seventh General Programme. The scope of the mental health programme 1 was considered and specific recommendations for action were made with reference to the prevention and treatment of mental and neurological disorders; alcohol and drugrelated problems; better use of mental health knowledge in improving general health care; and prevention of the untoward psychological consequences of socioeconomic change. Two regional advisory groups on mental health also met in 1981, those for the South-East Asia and European Regions. 7.1
THE
(Brazil, Colombia, Egypt, India, the Philippines, Senegal, and Sudan) continued a collaborative study on ways and means of incorporating mental health components into primary health care. Representatives from the countries met twice during 198o-1981 to consider the results of repeat observations demonstrating that it is possible for staff with only simple training to recognize and deal efficiently at primary health care level with serious mental disorders, and that attitudes of staff and the community can be positively influenced through well-defined intervention.
Development of community health services 7.z At national level, mental health was included by a number of countries in their national strategies for achieving health for all by the year zooo. Teams from seven countries I
World Health Organization. Social dimensions for
mental health. Geneva, 1 98 r.
7. 3 The report of the study was presented to the Study Group on Mental Health Care in Developing Countries (Geneva, 1981), which concluded that recent evaluative research had produced evidence of the feasibility of introducing mental health care into primary health care settings. The Study Group recommended ways of doing so, and identified the following as priority subjects for research: psychosocial factors affecting health care; management of common disorders; protection and promotion of mental life; and evaluation of the general health services' contribution to mental health care. The Study Group also made recommendations on the role that WHO can play in facilitating developments at country level. The information gained in the study was widely 75
THE WORK OF WHO, 198o-r98r
disseminated through publications, national seminars, and professional contacts. 7·4 In the African Region, a project of technical cooperation in mental health in southern African countries, initiated in I977 at the request of the five countries forming the African Mental Health Action Group (Botswana, Rwanda, Swaziland, the United Republic of Tanzania, and Zambia) made considerable progress during I98o-I981. The Action Group, which meets annually in Geneva during the Health Assembly, was joined by two more countries, Kenya and Lesotho; its meetings during the biennium were attended by representatives from neighbouring countries and from developed countries supporting this action. 7. 5 The problems pinpointed by these countries include the psychosocial effects of population uprooting and movement; disrupted family life; adverse effects of urbanization; delinquency; alcohol and drug abuse; and mental retardation in children. Since the main constraint in dealing with these problems is the lack of trained personnel at all levels, activities in I98o-I98I concentrated on postbasic training. Workshops were organized in the United Republic of Tanzania (I98o) and in Lesotho (I98I); an analytical report was prepared on selection criteria for the intake of nurse trainees and on the status of training institutes; and recommendations were made for strengthening the postbasic training of nurses in mental health. Manuals were prepared and translated into Swahili, and other material was tried out in several countries. For example, flow-charts (paragraph I 2. I 8) for the diagnosis and management of common mental disorders were prepared and field-tested in Lesotho mainly for their use by general nurses, and some modifications were made for this specific setting. The training capability of the WHO collaborating centre for research and training in mental health, in Aro (Abeokuta,
Nigeria), was strengthened with a view to using this centre inter alia for the postbasic training of nurses from other parts of Africa. The countries of the Action Group 7.6 sent participants to the meeting in Zambia which considered the first phase of a research project on community response to alcoholrelated problems (see paragraph 7·37)· This provided an opportunity for a detailed discussion of ways and means of carrying out similar work in their own countries. 7· 7 A review of the supply, distribution, monitoring and control of psychotropic drugs in Botswana, Lesotho, Swaziland, and Zambia led to recommendations on measures to overcome the difficulties encountered in obtaining drugs, e.g., bulk purchasing to reduce costs. 7.8 National coordinating groups were established or strengthened in the countries of the Action Group, involving all sectors concerned with the implementation of national plans (for example, health, labour, education, justice, and internal affairs). Other organizations in the United Nations system, e.g., UNICEF, were approached with a view to including a mental health component in their projects in the countries of the Group. The financial and technical support of countries such as Belgium, Denmark, and Norway is an important element in this project, for which further financial support is being sought. 7·9 In the Region of the Americas, a working group (Washington, March I98o), with participants from Bolivia, Brazil, Colombia, Guatemala, Honduras, Panama, Peru, the United States, and Venezuela, discussed the functions of the primary health worker as a mental health agent and made recommendations on training material. A simple manual on mental health for the primary health worker was drafted in I 98 I
MENTAL HEALTH
and will be field-tested in a rural sector adjacent to the city of Cali (Colombia). 7· IO The Organization cooperated in planning and organizing community services for the care and rehabilitation of chronic mental patients in Barbados, Colombia, the Dominican Republic, Grenada, Saint Vincent and the Grenadines, and the United States of America. A seminar on mental health at the primary level of health care was held in Chile and its recommendations served as a basis for the planning of a national programme. (For training programmes in the Americas, see paragraph I2.I53·) 7· I I In the European Region, a workshop on mental health planning for the city of Rotterdam (August I98o) provided an opportunity for introducing in a practical setting the principles and objectives of community mental health care developed by the Region over the past decade. A similar activity was the consultation on architecture and mental health organized at the WHO collaborating centre for psychosocial factors and health, Brussels. (For training programmes in the European Region, see paragraph I2.154.) 7. I 2 In the Eastern Mediterranean Region, the results of studies in Egypt and Sudan on the extension of mental health care, and in Kuwait on the monitoring of needs, were appraised; they were considered as making an important contribution to the provision of wider coverage and the improvement of the quality of care. The Region has made sustained efforts to develop training programmes in this field to equip general health workers with the necessary knowledge and skills for providing optimal mental health care at the primary health care level. 7. I 3 Current collaborative work to promote training in psychological medicine has enabled some countries of the Region, par77
ticularly Saudi Arabia, to establish a countrywide network of psychiatric services and to move from isolated, insitution-based care towards community-oriented services. 7· I4 In the Western Pacific, collaborative activities with China were developed in I98o-I981. They concentrated on training (see paragraph I 2. I 55) and on preparations for a major epidemiological investigation of mental health problems in the country. 7·15 Study missions enabled Chinese psychiatrists to visit WHO collaborating centres in Europe (the Netherlands, Switzerland, the United Kingdom, and Yugoslavia). Fellowships were awarded. Four institutes, in Beijing and Shanghai, were designated as WHO collaborating centres for research and training in mental health and the neurosciences. Plans were made for the designation of other centres.
Safe use of narcotic and psychotropic substances 7. I 6 In the context of the Convention on Psychotropic Substances, I97I, and the Single Convention on Narcotic Drugs, I96I, the evaluation of the benefit/risk ratio of narcotic and psychotropic drugs continued. The United Nations Commission on Narcotic Drugs (February I98I) reviewed WHO's recommendations on the control of anorectic drugs and agreed to include benzphetamine, mazindol, phendimetrazine, and phentermine in the schedules of the I97I Convention. The Commission also approved the termination of the exemption of certain preparations containing a controlled psychotropic substance, submitted in notifications by the Governments of Bulgaria and Mexico. 7. I 7 Two groups of psychotmpic substances-benzodiazepines, and opiate agonists and antagonists-were reviewed in
THE WORK OF WHO, 198o-198I I 98 I, resulting in specific recommendations concerning the level of control of these groups.
7.I8 WHO continued to develop the methodology for the scheduling of psychotropic substances. The Expert Committee on Implementation of the Convention on Psychotropic Substances 1 reviewed the methodology for assessing the public health and social problems associated with the use of psychotropic drugs.
plant origin, and to support such programmes by the development of appropriate guidelines". A project was initiated in six countries (Kuwait, Malaysia, Morocco, Nigeria, Panama, and Thailand) to gather the information required for formulating such guidelines, which should enable countries to derive maximum benefit from psychoactive drugs with minimum harm. The Government of the Netherlands, together with UNFDAC, has given financial support to this programme.
7· I9 The role of drugs in modifying the behaviour of drivers was reviewed in collaboration with the National Institute for Drug Abuse (USA). 7.20 Four seminars (one national, two regional, and one interregional) were held on the subject of safe use of narcotic and psychotropic substances, involving participants from about 40 developing countries.
Psychosocial aspects of health promotion Work in this area focused on: (I) the mental health sequelae of social and economic processes ; ( 2) the psychosocial aspects of public health programmes; (3) social support systems relevant to health, e.g., self-help and mutual aid schemes; (4) modification of lifestyles and the prevention of disease; and (5) training material for the primary health care worker. 7.2 3
7. 2 I In the Western Pacific Region, a workshop on psychotropic drugs was convened (Manila, August I98o). It concluded that, although certain countries of the Region already applied controls in keeping with the I97I Convention on Psychotropic Substances and provided information on an informal basis, all countries should work towards proper ratification of the Convention; and, further, that all countries should review combination drugs in the spirit of that Convention. 7.22
The Thirty-third World Health Assembly (resolution WHA33.27) asked WHO "to promote the initiation and strengthening of national and international programmes for the assessment, scheduling, control and appropriate use of narcotic and psychotropic substances, including those of
One example of collaborative research to assess the psychosocial implications of public health action was the multicentre study on the p!]chosomatic sequelae of female sterilization carried out under family planning programmes. Some 2000 women in five different countries were followed up for a year after tubal ligation. The aim was to identify those at risk of developing psychosomatic symptoms, assess the need for specific pre-operation psychological counselling, and evaluate the psychosocial effects of this form of family planning on the woman and on the family unit. 7.24 7.25 The effect that modification of community attitudes or behaviour may have on the
t
WHO Technical Report Series, No. 656, 1981.
prevention of various diseases or disorders was examined by a working group, which formulated strategies for community-based trials on the relationship between mental
MENTAL HEALTH
health action and the control of physical disease. Another working group focused on the potentialities of self-help and mutual aid as an important resource of primary health care.
7.26 As part of WHO's programme of health care for the elderly (see paragraphs 8.92.-8.96) new emphasis was laid on psychogeriatrics. A project was launched to evaluate different models of health care for the elderly and to assess the relation between place of care, psychological factors, and efficacy of treatment. The study compares two groups of patients, one admitted to the general hospital and the other to the geriatric hospital. Standardized data are being gathered on the quantity and quality of hospital care, and on the attitudes and vocational adjustment of health personnel towards the elderly sick. The effect of care and of the treatment environment on the physical and mental health of the patient and on his or her social functioning is also being evaluated.
7.2.9 A booklet on care of the mentai!J retardedl was prepared under contract by the Joint Commission on International Aspects of Mental Retardation, a nongovernmental organization in official relations with WHO, and was widely circulated. On the basis of the comments received, one of the constituent bodies of the Commission-the International League of Societies for the Mentally Handicapped-issued a brochure2 discussing the implementation of the major recommendations of the United Nations Declaration on the Rights of Mentally Retarded Persons (I97I).
Drug dependence 7.30 Projects atmmg to strengthen the capacity of national authorities for the treatment and prevention of drug dependence and to develop models for the training of primary health care workers are under way in nine countries. One such model, developed in the hill tribes area of Thailand, has recently been expanded to cover a larger area of population.
7. 2 7 A task force on neuroendocrinology' and behaviour was constituted in I 98 I and a research protocol was drafted for a series of neurobehavioural tests and neurohormone titratio,ns in aging persons. Field research centres in Canada, Italy, and Nigeria were selected for participation in the study. Meetings were held to agree on the protocol for a multicentre study of the epidemiology of senile and presenile dementia. 7.2.8 The collaborative study on the assessment of "dangerousness" of individuals by use of mental health expertise was completed in mid- I 98 I, when representatives of the six participating countries (Brazil, Denmark, Egypt, Swaziland, Switzerland, and Thailand) met to discuss the results. A report on the study is in preparation. 79
7. 3I A centre was established in Bangkok for training physicians, social workers and nurses to work as a team in the management of drug dependence. Similar models will be developed in other countries, e.g., Burma and Pakistan.
7. 32 A number of potentially useful technologies became available during the biennium, e.g., on the methodology of student
t Mental retardation: prevention, amelioration and service delivery. Brussels, Joint Commission on International Aspects of Mental Retardation, 1980. 2 Step fry step: implementation of the rights of mentally retarded persons. Brussels, League of Societies for the Mentally Handicapped, 1980.
THE WORK OF WHO, 198o-r981
drug-use surveys, 1 drug-abuse reporting systems, 2 general population surveys of drug abuse,3 drug use among non-student youth,4 and evaluation of treatment for drug dependence. 7· 33 One project nearing completion was an assessment of treatment methods for drug dependence in developing countries, in which investigators in 10 countries took part. 7·34 A study on the sociocultural aspects of drug problems,s by investigators in 15 countries, analysed the epidemiology of the drug problem, patterns of drug abuse, health care approaches, treatment, and prevention. It was based on 40 case studies of different forms of drug dependence in widely differing settings. The study emphasizes the importance of sociocultural considerations in selecting the approach to be adopted and demonstrates the practical implications of that approach for policy and programme formulation.
strengthening both national and international programmes. It was facilitated by financial support from the Nordic countries. Activities have focused on methods of investigating the nature and extent of alcohol problems and on technologies for their prevention and management at both commmunity and national level. 7. 37 Reports on the first phase of a project on community and national response to alcohol problems were presented at meetings in the collaborating countries-Mexico, the United Kingdom, and Zambia. These meetings were also attended by several neighbouring countries in each region that were considering the possibility of similar activities. A second phase of the project involved the three collaborating countries in monitoring the implementation of the proposed policies and programmes. The Thirty-second World Health Assembly (resolution WHA32.4o) requested WHO to encourage collaboration in "reviewing existing trade practices and agreements relating to alcohol". A project on the public health aspects of the international production, marketing, and distribution of alcoholic beverages was subsequently launched. 7.38 7·39 The consequences of excessive alcohol consumption are damaging not only for the heavy drinker but also for the family. During 1981 work started on a project concerned with the prevention and management of alcohol problems in the family setting. 7.40 Moreover, the consequences of drinking among the work force at all levels, both in industry and in other forms of employment, are extremely costly. Studies on alcohol problems in the employment setting were started during 1981 in cooperation with ILO and the International Council on Alcohol and Addictions.
7· 3 5 The Organization collaborated with Bolivia, Burma, Colombia, Ecuador, Egypt, and Peru in other UNFDAC-financed projects for control of drug dependence, which included clinical, epidemiological, and operational research, and training of personnel.
Alcohol-related problems 7.36 The expanded programme on alcohol-related problems derives from resolution WHA32.40, which stressed the need for
WHO Offset Publication No. jO, Geneva, 198o. WHO Offset Publication No. 55, Geneva, 1980. 3 WHO Offset Publication No. j 2, Geneva, r 980. 4 WHO Offset Publication No. Go, Geneva, 1981. 'Edwards, G. & Arif, A., ed. Drug problems in the sociocultural context: a basis for poltcies and programme plannmg. Geneva, World Health Organization, 1980 (Pubhc Health Papers, No. 73). 2
1
So
MENTAL HEALTH
7-4I In the European Region a workshop on the epidemiology and prevention of alcohol- and drug-related problems was held in Dublin (I98o). In the Western Pacific a working group on prevention and control of alcohol-related problems met in Tokyo (I 98 I). In the Americas, surveys on the prevalence of alcohol-related problems were carried out in Ecuador, Honduras, and Mexico. The Organization cooperated with the Governments of Brazil, Chile, and Ecuador in running courses for health professionals. 7.42 The report of the Expert Committee on Problems related to Alcohol Consumption was published in I98o.l A review of preventive measures, policies and programmes, compiled with the help of contributors from more than 8o countries in all six WHO regions, was published on behalf of the Organization by the Alcoholism and Drug Addiction Research Foundation, Toronto, Canada, a WHO collaborating centre for research and training on alcohol and drug dependence problems. 2 Another report published by this Foundation records the outcome of an international study, in collaboration with WHO, of alcohol control experience in seven countries (Canada, Finland, Ireland, the Netherlands, Poland, Switzerland, and the United States of America).3 7·43 A study was completed on the social factors that have a bearing on alcohol-related problems in a number of countries. It pro-
vides basic information on the role of such factors in increasing alcohol consumption, identifies the high-risk groups in the population, and suggests practical preventive measures.
Mental health of children 7·44 More than half the population of the developing world are children, and epidemiological investigations show that at least one child in 20 is liable to suffer from a mental disorder. Available resources for mental health care are not always used to the full advantage of children and their families. In I 9 8 I seven countries-Costa Rica, Egypt, France, Greece, Nigeria, Singapore, and Sri Lanka-completed national studies on the nature of these disorders and on the possibility of programmes for their control. Once analysed, this information will form the basis of specific recommendations for action at national and international level. 7-4 5 In the Americas, the findings of various regional studies on the influence of malnutrition and certain environmental factors on child development were discussed by a study group (Washington, I98o) attended by specialists from Chile, Colombia, Guatemala, Jamaica, Mexico, the United States of America, and Uruguay. The subject was also discussed at the I 98o meeting of the regional Advisory Committee on Medical Research (Costa Rica). The documentation and recommendations of those meetings were w.idely distributed. 7.46 The Organization also cooperated with the Governments of Chile and Venezuela in the provision of services for the psychologically impaired child. 8I
1 2
WHO Technical Report Series, No. 65o, 198o. Moser, J. Prevention of alcohol-related problems: an
international review of preventive measures, policies and programmes. Toronto, Alcoholism and Drug Addiction Research Foundation, 1980. 3 Makela, K. eta!. Alcohol, society and the State. Toronto,
Alcoholism and Drug Addiction Research Foundation, 1981.
THE WORK OF WHO, 198o-t981
Promotion of biomedical and health practice research 7·47 The Subcommittee on Mental Health and Neuropsychiatry of the global Advisory Committee on Medical Research, in its report to the Committee in I 98o, gave high priority to (i) research on the detection and treatment of mental disorders by primary health care workers and the use of behavioural science principles in improving the effectiveness of primary care; (ii) institutionstrengthening for the purpose of ensuring long-term commitment and continuity in mental health research, development, and training; and (iii) research on related health education. There was agreement that WHO's research in mental health in developing countries should primarily be addressed to those aspects on which practical measures could be taken at primary health care level. In relation to the report of its 7.48 Scientific Planning Group, the global ACMR considered detailed options for mental health research in the I98os and I99os, produced in consultation with WHO's collaborating centres and leading scientists. Similar developments took place at 7·49 regional level. In the Eastern Mediterranean the regional ACMR at its fifth session (September I98o) reviewed the regional research programme in mental health, discussed options and priorities, and accepted in principle the proposals submitted for future research, which were later scrutinized and redefined by a scientific working group (Karachi, Pakistan, June I98 I). The Western Pacific ACMR (April I98o) recommended that a subcommittee on mental health should be established or that a representative of this discipline should be co-opted on to the Committee. The European ACMR (June I98I) particularly emphasized research on lifestyles and on the psychosocial factors influencing health and health behaviour.
7.50 WHO continued to coordinate cross-cultural multicentre studies aiming to provide a data base for planning mental health services, evaluating care, and developing new technologies for prevention and management. One of these studies ascertained for the first time the incidence of schizophrenia and other severe mental disorders in Io countries representing five of the WHO regions. A longitudinal study on the impairments and social disabilities consequent on an episode of mental disorder was carried out in seven countries. The preliminary results of the above-mentioned studies give reason for cautious optimism as to the possibility of providing effective care for these conditions and preventing their severer sequelae by means of community-based services, without recourse to costly technology or the custodial type of care that is now regarded as completely obsolete. 7. 5I Depression--one of the most common mental disorders, and frequently undiagnosed or misdiagnosed-was studied in several countries by examining a series of persons consulting the health services for other reasons. The study confirmed that a large number of mental disorders (including depression) are encountered in general health care, and it raised such important questions as the psychiatric training of general physicians and the capacity of primary health care workers to detect and handle mental health problems.
Biological p{Jchiatry and p{Jchopharmacology 7·52 WHO's work in biological psychiatry took three principal directions: collaborative research, training, and exchange of information. A network of 3 I centres in various countries collaborate in this programme and can be said to constitute an "international institute" of biological psychiatry. Activities were concentrated on the
MENTAL HEALTH
search for biological approaches to the prevention and control of mental disorders, on new methods of treatment, and on improving the classification of psychiatric illnesses. 7. 53 The last two years have produced new findings on the biological markers of functional psychoses that can be used to identify groups at high risk of mental disorder. Studies continued on other possible types of biological marker (ABO blood groups in affective disorders, dexamethasone suppression test in depressive illness). Important results (e.g., the effect of naloxone on verbal hallucinations) were obtained in collaborative research on the involvement of internal opioid systems in the pathogenesis of schizophrenia. 7. 54 Several meetings were held. At the Third World Congress of Biological Psychiatry (Stockholm, June-July 1981), which WHO co-sponsored, symposia were organized by WHO with participants from 14 countries. The methodology of multicentre trials in psychopharmacology was discussed at a WHO symposium held in connexion with the congress of the Collegium internationale Neuro-psychopharmacologicum (Goteborg, Sweden, June 198o). A training course and travelling seminar on biological psychiatry and psychopharmacology was also organized, for both English- and French-speaking countries. 7· 55 A project on the effects of psychotropic drugs in different populations (involving 1 2 countries) aims at determining the optimal dosage of drugs taking into account cultural, climatic, nutritional, and other considerations.
pathies was implemented. Baseline data were collected in the participating countries (Canada, China, Federal Republic of Germany, Italy, Japan, Mexico, Nigeria, Portugal, Senegal, and Spain) and the results are being prepared for publication. The second phase--devoted to pharmacological control of diabetic neuropathies-was also initiated. 7. 57 Data on the incidence and prevalence of neurological disorders are urgently needed by Member States : a protocol for international studies was prepared and a pilot study was carried out in China and Nigeria. Field research centres were selected in several countries of Africa, and in China, Italy, Mexico, and Spain. (For training in neurology, see paragraphs 12.156 and 12.157·)
7. 58 The need for better control of epilep[J in all parts of the world, especially in the developing countries, is generally recognized. A protocol was prepared for an international collaborative study to find safe and efficacious pharmacological means for such control. This project will also introduce health authorities in different countries to new views on the prevention and management of epilepsy. 7· 59 Several international symposia were organized in collaboration with nongovernmental organizations, the subjects including peripheral neuropathies, biological membranes in growth and development, phagocytosis, immunogenetics, neuronal aging, and cerebrovascular disorders. Two round-table discussions on peripheral neuropathies were organized by WHO: the first on the occasion of the Fifth Biennial General Meeting and Conference of the Pan African Association of Neurological Sciences (Nairobi, April 1981), the second related to the Twelfth World Congress of Neurology (Kyoto, Japan, September 1981).
Neurological disorders 7· 56 The first phase of an international collaborative study on peripheral neuro-
***
THE WORK OF WHO, '98o--198I
7.6o It is hoped that the survey of prospective longitudinal research with mental health implications 1 published in I 98 I will focus interest on the potential value and the limitations of long-term research for primary prevention of chronic psychological disorders.
Monitoring and other mechanisms for programme development and support 7.6I Work continued on the evaluation of the psychopathological, psychological, and social components of health programmes and health services. Seven countries (Bulgaria, Ghana, Kuwait, Panama, Papua New Guinea, Thailand, and the United States of America) completed work on a method to monitor mental health needs and assess the burden on general and specialized health services attributable to patients with psychopathological problems. These countries then went on to use the method in various parts of their own services. Other countries plan to use similar models for monitoring the psychiatric component of their health services, and the WHO regional offices are developing resource centres to facilitate collaboration and exchange of experience, e.g., in Kuwait, for countries of the Eastern Mediterranean Region. In the European Region such methods have been tested and utilized in 2 I pilot areas in I 6 countries. 7.62 Social and psychological problems are frequently the reason, or at least one of the reasons, for patients contacting the primary health care services. However, data registration and problem classification schemes are at present almost exclusively somatic.
During the biennium seven countries began collaboration in a project to develop and field-test methods for a triaxial (physical, psychological, and social) classification and registration of primary health care contacts. A further aim of this work-which is being carried out in centres in Brazil, Canada, Colombia, Malaysia, Thailand, the United States of America, and Zambia (and is envisaged in Cuba)-is to assess the extent to which such information can be used in planning health and social services and allocating multisectoral resources. 7. 6 3 A review of the indicators of mental health service utilization as reported in official national publications demonstrated the utility of such indicators for medium and long-term projections. Work has now started on establishing indicators to assess the psychological implications of primary health care programmes and the determinants of their effectiveness. In parallel, indicators are being compiled and tested that will permit the evaluation of social development programmes and their impact on health. 7.64 The systematic assessment of people's behaviour is a frequent prerequisite for neuropsychiatric (in particular clinical and epidemiological) research. Developing countries have hitherto been severely hampered in the evaluation of findings by the lack of facilities for analysing data. Microcomputers may provide the answer, and a feasibility study was launched on the use of microcomputer methodology and technology in mental health surveys. Four countries are participating or plan to participate: China, Colombia, India, and Nigeria. 7.65 In the Western Pacific Region, systems of reporting cases of drug abuse were reviewed in Australia, Hong Kong, the Philippines, and Singapore. The need was assessed for a network of centres to facilitate the exchange of information in this field.
1 Mednick, S. A. & Baert, A. E. Prospective longitudinal research: an empirical basis for the primary prevention of p.rychological disorders. Oxford University Press (published on behalf of the WHO Regional Office for Europe),
1981.
MENTAL HEALTH
7.66 In the Americas, the feasibility study on the establishment of a drug abuse monitoring system in Argentina, Mexico, and Peru was continued. One of its main aspects is the feeding of data on drug and alcohol abuse into existing national health information systems.
7. 67 The general increase in research in to the causes of mental disorders has necessitated a re-examination of the approach to their diagnosis and classification. WHO, in cooperation with the Alcohol, Drug Abuse and Mental Health Administration, Institute of Mental Health (USA), launched a new programme in which scientists from some 4 5 countries review scientific knowledge with a view to translating the advances made in a number of disciplines into a coherent "common language" for use in diagnosing
and classifying mental health problems. In the first phase of this programme, nine working groups were convened. They identified the need for further work in such areas as child mental health; psychosocial aspects of aging; stress-related conditions; neurotic and personality disorders; alcohol- and drug-related problems; functional psychoses; organic psychosyndromes, including those associated with tropical and parasitic diseases; and mental health problems in primary health care. Task forces were set up for the development of assessment instruments, the standardization of terminology and nomenclature, and the measurement of personality variables in different cultures. The conference in which the programme will culminate (April 1982) should result in a global plan of activities and the development of improved diagnostic methods, evaluation technologies, and classification tools for mental health care.
Chapter 3
Diagnostic) Therapeutic) and Rehabilitative Technology THIS chapter brings together important aspects of clinical and technological support for the delivery of health care both at the level of first contact between the community and the health professional and at that of referral services. It includes such newcomers to WHO programmes as traditional medicine and essential surgical care, which are destined to play an increasingly important role in the future. It also includes the two programmes for which the· Regional Office for Europe has world-wide responsibility, namely: prevention of road traffic accidents, and care of the aged. 8.1
the Twenty-eighth World Health Assembly (resolution WHA28.65), provides that the health authorities of exporting countries should supply a certificate for each product stating that it is authorized for sale in the exporting country and that the manufacturer is subject to regular inspection. By the end of 1981, 71 Member countries had agreed to participate in the scheme and had designated responsible national authorities.t 8.4 Basic tests for over 2 5o essential pharmaceutical substances were endorsed by the WHO Expert Committee on Specifications for Pharmaceutical Preparations (December 1981). They are simplified laboratory procedures designed primarily to confirm the identity of pharmaceutical substances and to ensure that gross degradation has not occurred. 8. 5 Volume 2 of the third edition of the International Pharmacopoeia 2 was published on the basis of advice offered by the WHO Expert Advisory Panel on the International Pharmacopoeia and Pharmaceutical Preparations. It contains revised monographs for substances essential to primary health care. Monographs are in preparation for other
Pharmaceuticals 8.2 WHO continued its efforts to increase the availability of essential drugs of adequate quality, particularly in developing countries, where technical facilities for the assessment of pharmaceutical products are limited. To strengthen national capability for quality control, the Eastern Mediterranean Region provided specialist advice to countries and awarded fellowships. A subregional workshop sponsored by the Western Pacific Region in Kuala Lumpur in 1980 considered drug quality control and management.
8.3 A revised certification scheme on the quality of pharmaceutical products moving in international commerce, adopted in 1975 by 86
1 See WHO Chronicle, 34: 427-432 (1980). World Health Organization. The International Pharmacopoeia, Third Edition, Vol. 2,Q~~ality specifications. Geneva, 1981. 2
DIAGNOSTIC, THERAPEUTIC, AND REHABILITATIVE TECHNOLOGY
essential drugs and will be included in Volume 3· 8.6 The WHO collaborating centre for chemical reference substances in Sweden distributed more than z6oo samples of international reference materials required for analytical methods described in the International Pharmacopoeia to laboratories in some 5o Member States. Nine new reference substances were established, bringing the total number maintained at the centre to 98. Secondary reference standards are now being developed on a subregional ba'sis within the A SEAN group of countries, an initiative that is likely to be followed elsewhere. 8. 7 New international nonproprietary names for pharmaceutical substances were selected on the basis of requests by national nomenclature authorities and by pharmaceutical manufacturers. During the biennium new names were proposed for 340 substances, bringing to 5I 2 I the total number of nonproprietary names so far established by WHO. A sixth cumulative list containing all names published up to May I98I will be published in I982. 8.8 Information sheets on essential drugs intended for prescribers at various levels of the health care system in developing countries are in preparation, in accordance with the recommendations of the Expert Committee on the Selection of Essential Drugs.t Consultations on the content and format of these sheets were held in January and November I98I, and the material will subsequently be field-tested to ascertain its relevance to national needs. 8.9 Information on the safety and efficacy of widely used drugs, evaluated in the light of recent decisions by national drug registration authorities, was provided in the quarterly 1 WHO
bulletin Drug Information. An international conference of drug registration authorities, co-sponsored by WHO and the Food and Drug Administration of the United States of America, convened in I 979, had stressed the need for international exchange of information on regulatory decisions and harmonization of national registration procedures. 8.Io The WHO collaborating centre on international drug monitoring, Uppsala (Sweden), became fully operational during the biennium, and 22 countries continued actively to contribute data.
8. I I The series of 'annual symposia on clinical pharmacological evaluation in drug control, organized by the Regional Office for Europe in collaboration with the Government of the Federal Republic of Germany, continued in I98o and I981. 8. I 2 A symposium on clinical pharmacology held in the Federal Republic of Germany (I98o) dealt with drug treatment of the elderly. It was designed to complement an ad hoc technical group on the use of medicaments by the elderly in relation both to clinical management and to regulation. Another symposium, in I 98 I, was on problems associated with drug treatment for infants and children (see also paragraphs I 5.69 and 15·70). 8. I 3 The work of the WHO drug utilization research group continued to be organized by the Regional Office for Europe. 2 A working relationship was established with the Nordic Council on Medicines working group, which has devised a classification of drugs and designed a system of defined daily
Technical Report Series, No. 6Ij, 1977.
2Bergman, U. eta!., ed. Studies in drug utilization: methods and applications. Copenhagen, World Health Organization, 1979 (WHO Regional Publications, European Series, No. 8).
THE WORK OF WHO, r98o-r98r
doses as units of measurement that are considered suitable for measuring drug use and conducting international comparative studies. It has been widely agreed to present drug utilization data in terms of the number of defined daily doses per Iooo inhabitants per day; for hospital utilization the number of defined daily doses will be per Ioo bed days. International collaborative studies on antihypertensives, antidiabetics, and antimicrobials will be studied within the group.
Action programme on essential drugs 8. I 5 In conformity with resolutions
EB6I.RI7, EB63.R20, WHA31.32, and WHA32.4I, WHO established an action programme on essential drugs in February I981.
8. I4 The second meeting on technical cooperation among ASEAN countr1es on pharmaceuticals (Manila, August I98o) developed a plan of action for exchange of information; training and exchange of expertise; reference substances; an essential drug list; practical guidelines for implementing good manufacturing practice; drug evaluation; and control and quality assurance. An initial meeting on the establishment of secondary reference materials was held in Bangkok in November I98o and a further meeting in Malaysia in December I981. A training programme for the preparation of standard substances began in Sweden in September I981. A subregional workshop on quality assurance was held in Kuala Lumpur in February and March I98o. In September I98o the UNDP project for a national drug standardization centre in China was implemented; it strengthens national drug assurance capability by providing laboratory equipment and arranging study missions and fellowships. In August and September I 98 I, under the programme agreed by the China/ WHO joint coordination committee, a study tour on clinical pharmacology and the evaluation and authorization of new drugs was made to Japan and the United States, and a seminar on methodological approaches in clinical pharmacology was arranged. WHO monitored adverse drug reactions so as to strengthen national drug assurance systems in the Philippines.
Its major objective is to support governments in increasing the availability and utilization of drugs at the lowest possible cost for primary health care, particularly through the formulation and implementation of national drug policies. Some of the major deficiencies in developing countries can be remedied by using drugs rationally, by maximizing the use of limited manpower and financial resources, and by ensuring the availability of the least expensive and most effective drugs. 8.I6 The WHO model list of essential drugs 1 was the basis for cooperation with Member States; more than 40 countries have developed a national list. Cooperation took place with many Member States, for example in the selection of essential drugs, the quantification of drug needs, the development of national distribution systems (including storage facilities and logistic support), quality assurance, drug legislation and regulatory control, early feasibility studies for the establishment of a formulation plant, and manpower development. Fact-finding missions were undertaken in more than 20 countries-jointly with the pharmaceutical industry in four-for an exchange of views and analysis of the problems experienced by developing countries. As a result, valuable experience has been gained which could be applied in a more general way to other countries. 8. I 7 In the African Region the paucity of drugs is a major problem. However, the situation has been analysed in at least I 2
t
See WHO Techmcal Report Series, No. 64r, I979·
88
DIAGNOSTIC, THERAPEUTIC, AND REHABILITATIVE TECHNOLOGY
countries and a list of some 40 essential drugs has, in principle, been accepted by 33 Member States of the Region. This list is intended to form a basis on which these countries can pool procurement facilities, in collaboration with UNICEF. TCDC activities in local production and quality control are only in the initial process of development in this Region. 8. I 8 In the Americas, resolution XXIII of the thirty-second session of the Regional Committee (I98o) requires study of mechanisms for, among other things, the collective purchase of drugs. An interdisciplinary operational research project was undertaken to assess the management and use of drugs in selected health centres, hospitals, and health posts; in five countries deficiencies were apparent at various levels of the pharmaceutical supply system. The need to strengthen health infrastructures to provide patients with drugs at primary health care level is also to be studied. 8.19 A m<.:<.:ting on drug policies and management was convened in late 1981 with the participation of countries in the Region. Regular information in Spanish on the safety and efficacy of drugs has been provided in a special quarterly section of the Boletfn de Ia Oficina Sanitaria Panamericana. A revolving fund for the procurement and distribution of essential drugs among Member States has just started to function. Professional staff were recruited for the Caribbean regional drug testing laboratory in Jamaica to ensure the quality of essential drugs.
8.2I In the field of quality control and distribution, Burma, Indonesia, Sri Lanka, and Thailand obtained technical support from WHO and financing from the Government of Japan, the Asian Development Bank, and UNDP. 8.22 As an example of interregional collaboration, Indonesia and Thailand have joined the TCDC programme among A SEAN countries (paragraph 8. 26).
8.23 The main areas of interest in the European Region are clinical pharmacology, drug evaluation, and drug utilization (see paragraphs 15 .69-I 5. 72). A survey of the pharmaceutical supply system was carried out in Morocco. 8.24 In the Eastern Mediterranean Region utilization studies for more rational prescribing and use of drugs were carried out in Democratic Yemen and Sudan. The formulation of national drug policies was initiated in Sudan. A drug licensing scheme was introduced in Bahrain. 8.25 In the Western Pacific Region emphasis was placed on the development of a joint purchasing system for the South Pacific countries. 8.26 The second meeting on technical cooperation among ASEAN countries on pharmaceuticals was hosted by the Regional Office for the Western Pacific in August I98o and a third meeting took place in Kuala Lumpur in December I98I to discuss how such cooperation could be achieved. The implementation phase of this programme is funded by UNDP.
8.20 In the South-East Asia Region the various components of a pharmaceutical supply system were assessed, in collaboration with Member States. In the field of production, Bangladesh, Burma, Indonesia, Mongolia, Nepal, and Sri Lanka received WHO support. Progress was made in the development of national drug policies in Indonesia and Thailand.
8.27 Negotiations are under way with China for the supply of some essential drugs for developing countries. Collaboration with the Lao People's Democratic Republic and VietNam consisted mainly in the provision of drugs.
8.28 At global level, action was begun to prepare manuals for important areas of drug policies and management. A consultation was arranged with a view to preparing different kinds of information sheets on essential drugs, some aimed at professional workers at various levels of education and skill, others at nonprofessional primary health care workers. This consultation obtained the reaction of potential users of the information sheets and assessed the relevance of the sheets to the various levels of expertise available in Member States. Guidelines and recommendations for the establishment of a low-cost pharmaceutical formulation plant in developing countries were produced. 1 The basic elements of drug legislation and of regulatory control for developing countries were defined with the help of a consultative group meeting in June I981. Guidelines are under preparation on the formulation of national drug policies and drug distribution and management, as well as on the proper use of the most widely used medicinal plants. 8.29 The International Federation of Pharmaceutical Manufacturers Associations and the World Federation of Proprietary Medicine Manufacturers have offered, on behalf of member companies, to provide training for government-sponsored technicians in various aspects of drug quality control. To date six individuals from developing countries have been trained, and six more are being trained. 8.30 An interregional working group (New Delhi, December I98o) formulated a global strategy for the action programme on essential drugs. This strategy includes the development of appropriate national drug policies linked with country health programmes for the achievement of the goal of
health for all by the year 2ooo through health systems based on primary health care. It also. envisages technical cooperation among Member States and greater coope-ration with the pharmaceutical industry, without whose help drugs cannot be provided. Further cooperation is also proposed with a number of organizations in the United Nations system, including UNICEF, UNCTAD, UNIDO, UNDP, the World Bank, and with the regional development banks.
Biologicals 8. 3 I The need for biological reference materials continues to increase. In the past two years 2 5 new or replacement reference materials were established, bringing the total to I 8 5 for international reference materials and I8o for reference reagents. About 12 500 reference materials are distributed every year, more than half of them to developing countries. As the distribution is accompanied by the transfer of technical information on their correct use, the service continues to assist primary health care. 8. 32 The new requirements for biological substances approved at the 1980 meeting of the Expert Committee on Biological Standardization 2 include: rabies vaccine for veterinary use; hepatitis B vaccine; thromboplastins and plasmas used to control oral anticoagulant therapy; and immunoassay kits used on a wide scale in the standardization of pregnancy test kits. The requirements that have been revised in order to take modern technology into consideration are: rabies vaccine prepared in cell cultures and intended for human use; poliomyelitis vaccine (oral); meningococcal polysaccharide vaccine; and antibiotic susceptibility tests.
1WHO
document DPMf8o.z (r98o).
2WHO Technical Report Series, No. 658, 1981.
DIAGNOSTIC, THERAPEUTIC, AND REHABILITATIVE TECHNOLOGY
8. 33 In addition to these requirements, guidance on the national control of vaccines and sera was published.l This will be of particular assistance to Member States contemplating the establishment of quality control. Guidelines for the quality assessment of antitumour antibiotics were also published.z The original procedure for the 8.34 approval by WHO of yellow fever vaccines was established some 30 years ago, since when the technology of production has advanced and new manufacturers are now requesting recognition. In reviewing the procedures the opportunity was taken to record the history of all the yellow fever virus strains derived from the Rockefeller Foundation strain qD and used throughout the world. 8.35 At its 1981 meeting the Expert Committee on Biological Standardization 3 approved the requirements for Rift Valley fever vaccine and completely revised the requirements for antibiotic susceptibility tests to take into consideration antimicrobial agents other than antibiotics. The Committee noted that the research programme (supported from extra budgetary sources) to improve the stability of measles vaccines has now been completed. As a result of the findings WHO has been able to devise a stability test to be applied to each batch of vaccine in order to ensure that only the most stable vaccines are distributed in countries with high ambient temperatures. Similar action is now being taken to improve the stability of oral poliomyelitis vaccine. 8.36 Surveillance of the production and control of oral poliomyelitis vaccine has continued, with particular reference to the test for neurovirulence. A single test has been
accepted by all the countries involved and variations in results between countries, which presented problems in the past, have now decreased. International reference materials for inclusion in the test were approved at a meeting of the manufacturing and national control laboratories. Two countries continue to be assisted by WHO in establishing consistency in the production of this vaccine. Developments in the technology of 8.37 production of inactivated poliomyelitis vaccine have led to culture of the virus in a nontumorigenic cell line grown in large tanks. These techniques give a greater virus yield and so a greater yield of the purified antigens. The requirements for the production and testing of the vaccine were revised to take account of the new technology and the revised requirements 4 were approved by the Expert Committee on Biological Standardization. 8.38 Problems that have occurred in the expression of biological activity of some classes of immunoglobulins were discussed at a meeting of a small group of experts particularly involved in such work. 8. 39 Within the activities of the blood programme, four groups of scientists considered plasmapheresis practices and the uses and misuses of blood coagulation factors, albumin, and immunoglobulins. Their views will be of assistance to countries either importing these biologicals or contemplating their production with national resources. 5
8.40 It has been suggested for some years that WHO should play a role in ensuring future supplies of nonhuman primates, which are vital for biomedical research and drugOp. cit. (Annex z). World Health Organization. The collection, fractronation, quality control, and uses of blood and blood products. Geneva, 1981. 4 5
tOp. cit. (Annex II). z Op. cit. (Annex 9). 3
WHO Technical Report Series, No. 673, 1982.
THE WORK OF WHO, 198o-I981
testing programmes. An international primate resources programme has accordingly been formulated and appropriate action was discussed at an international meeting. 8.41 Individual and group training programmes in the quality control of vaccines continue, with financial assistance from UNDP. Although the number of candidates for individual training is increasing, there are still fewer than were originally anticipated. During the biennium 10 candidates from seven countries in three regions were trained, and two training courses were arranged in another region. 8.42 In the Western Pacific Region largescale modern vaccine production started in Alabang Serum and Vaccine Laboratories (Philippines), and other vaccine production centres in the Region are contemplated. The establishment of quality control laboratories in the Region and quality control programmes linked with other international laboratories is also being considered. 8.43 A course on quality control of viral vaccines was held in May 1980 at the Commonwealth Serum Laboratories, Parkville, Australia.
8.45 The need. to improve the reliability of health laboratory results was clearly demonstrated by a worldwide laboratory proficiency testing programme organized by WHO. The Organization accordingly intensified its training programme in laboratory techniques and its cooperation with countries in the development of national quality control schemes. It organized seminars and workshops, inter alia on: laboratory safety, particularly in the field of microbiology, since infections continue to be frequently reported; local production and control of biological reagents with the objective of establishing self-reliance; and hospital cross-infection. 8.46 WHO collaborated with eight countries in seeking the best way to organize peripheral laboratories, the aim being to improve the quality of health care and to integrate all laboratory services at the peripheral level to achieve the control of all major diseases. With the aid of DANIDA and the Centers for Disease Control, Atlanta (USA) WHO organized a laboratory management course to strengthen the managerial capabilities of central and intermediate-level laboratory directors. In this course great importance is attached to low-cost supervision and the organization of supplies to prevent demoralizing shortages. A training course for laboratory tutor technicians was arranged in Nepal. At this course the students individually prepare a curriculum structure for teaching laboratory tests used at the peripheral level. Emphasis is also given to stimulating enthusiasm and strengthening the responsibilities of the peripheral laboratory worker. 8.47 To make simple, sturdy, low-cost laboratory equipment available to developing countries is a matter not merely of designing and producing a prototype in research centres in industrialized countries but also of finding a country where the equipment can be produced at low cost. This can only be a
Health laboratory technology 8.44 WHO collaborated with countries in the different regions in developing their health laboratory infrastructure through the strengthening of central reference laboratories and the expansion of the national network to meet the needs of primary health care. Emphasis was given to the public health aspects of laboratory activities and support to the communicable diseases surveillance programme. Particular attention was also given to increasing the efficiency of the national laboratory system and improving logistic support and supervision.
DIAGNOSTIC, THERAPEUTIC, AND REHABILITATIVE TECHNOLOGY
developing country where both the technology for production and the market are present. The patent on the robust and simple MONA colorimeter designed at the Clinical Research Centre, Harrow (United Kingdom) does not cover any of the countries where WHO is likely to be interested in producing it. This will make it easier to promote local production or assembly in developing countries. With the aid of the laboratory equipment research sections of the Clinical Research Centre and the Centers for Disease Control, WHO cooperated with developing countries in the evaluation of locally produced equipment. Technical information was provided to local industry for the improvement of its equipment. WHO is also cooperating with 8.48 countries in the African and South-East Asia Regions in the local production of bloodgrouping reagents, and with countries in North Africa and the Western Pacific Region in the production of quality control sera. 8.49 In an effort to improve the quality of the services given by the health laboratories, nine training courses were organized-in Burma, China, Morocco, Nepal, Pakistan, the United Republic of Tanzania, and Viet Nam. They were mainly financed by DANIDA. With the same objective WHO intensified its international proficiency testing programme in clinical chemistry, haematology, and bacteriology, with the technical support of collaborating centres in Belgium and the United Kingdom. It is estimated that only 40% of the laboratory results in clinical chemistry and 1 5% of those in bacteriology are of an acceptable quality in developing countries.
Kingdom and the United States of America and was widely distributed. This should assist national central laboratories in the preparation of national reference material and in the assessment of local methods and equipment. A protocol for the evaluation of reagent kits has also been tested in the field. 8. 51 It has been estimated that there is $6ooo-$8ooo million worth of biomedical equipment in developing countries. However, most of this equipment is not adapted to withstand the prevailing environmental conditions. In some countries up to 6o% of the equipment lies idle because of the lack of suitable facilities for maintenance and repair. With a group of experts, a programme for improving the utilization of laboratory equipment has been set up, and guidelines for the establishment of a national laboratory equipment maintenance and repair service have been prepared.
Radiation medicine 8. 52 The concept of basic radiological services continues to be promoted, and in the course of four consultations a WHO advisory group prepared technical specifications for a basic X-ray machine and a manual for the training of machine operators. Substantial progress was also made in the preparation of a manual on film interpretation for general practitioners. Two WHO consultations, one on radiology in Africa (Nairobi, November 198o), the other on radiology in Europe (Copenhagen, December 198o) discussed basic radiological services, problems related to radiotherapy, and the comprehensive development of radiological services at country level. 8. 53 An exhibition on basic radiological services was held during the Thirtyfourth World Health Assembly and at the XV International Congress of Radiology 93
8. 5o One of the rna jor reasons for this is the poor quality of the reagents. Reference material with assigned values for some of the essential components was prepared with the aid of collaborating centres in the United
(Brussels, June-July I98I), where the problems of radiology in developing countries were discussed with the International Society of Radiology and the International Society of Radiographers and Radiological Technicians. A round-table discussion on radiology in the developing world held during that Congress was attended by participants from developing and developed countries. It reviewed the present situation of radiotherapeutic and radiodiagnostic services and the problems and possible solutions. 8. 54 Four prototypes of basic radiological machines have been produced, two of which have been tested under clinical conditions in Copenhagen and Lund (Sweden), the results serving to improve the design of the tube cassette holder. The quality of the radiographs produced with mediumfrequency X-ray generators powered by lead acid batteries compared favourably with that obtained by high-powered three-phase generators. The Regional Offices for South-East Asia and the Eastern Mediterranean have made progress towards the implementation of basic radiological services projects in Cyprus, Egypt, and Yemen, and more recently in Burma, Indonesia, and Nepal. 8. 55 With the support of the Federal Republic of Germany,WHO organized two workshops on quality assurance in diagnostic radiology and in nuclear medicine in October and November I98o. The reports give practical guidance on the planning and implementation of quality assurance programmes. Again with the support of the Federal Republic of Germany, a meeting on the efficacy and efficiency of radiological and nuclear medicine procedures was held in Munich-Neuherberg (November I98I). It reviewed studies on this subject and prepared rational referral criteria.
nescent dosimetry intercomparison, aimed at improving the dose delivery to patients in radiotherapy, was continued: a total of 2 3 5 dosimeter sets were processed in I98o-I981. Some of the results were analysed at a joint symposium on dosimetry in biology and medicine (Paris, October I98o). Action was taken to expand the intercomparison to orthovoltage machines and to high-energy photons used in radiotherapy. 8. 57 Other joint IAEA/WHO activities were: two courses and study tours on nuclear medicine (USSR, I98o and I98I); an international symposium on medical radionuclide imaging (Heidelberg, Federal Republic of Germany, September I98o), at which a panel on quality assurance was held; an international seminar on quality assurance in nuclear medicine (Bogota, May I 98 I), with the collaboration of the Government of Colombia; and a seminar on prospective methods of radiotherapy in developing countries (Kyoto, Japan, September I98I). The outcome of the meetings on quality assurance in nuclear medicine was an internationally coordinated study to evaluate the performance of nuclear medicine imaging devices, which began in September I98I in collaboration with the College of American Pathologists and the Physics Department, Westminster Hospital, London. Another study brought out the need for an internationally coordinated quality assurance programme to improve radiotherapy.
There was close collaboration be8.56 tween IAEA and WHO. The thermolumi-
8. 58 Radiation protection activities continued in relation to the medical use of ionizing radiation. Film badge services were provided to I4 Member States in four regions. These services are provided free of charge by the Service central de Protection contre les Rayonnements ionisants, France, and the Gesellschaft fiir Strahlen- und Umweltforschung, Federal Republic of Germany. In addition, WHO participated in the redrafting of publications of the Inter-
94
DIAGNOSTIC, THERAPEUTIC, AND REHABILITATIVE TECHNOLOGY
national Commission on Radiological Protection dealing with the medical use of ionizing radiations. It also participated in the work of the International Commission on Radiation Units and Measurements and the International Electrotechnical Commission on standards for electromedical equipment. 8.59 In South-East Asia pilot projects were set up in selected countries to study basic radiological services as an integral part of primary health care. Radiation health protection was promoted through a regular supply of films to Bangladesh, Burma, Mongolia, and Nepal for personal dosimetric measurement. Standardization of radiotherapy was furthered through the increasing participation of radiotherapy departments in the IAEAfWHO dosimetry intercomparison programme (see paragraph 8.56). The development of nuclear medicine was promoted through advisory services to the Democratic People's Republic of Korea and India. In the Region of the Americas 8.6o efforts were made to develop a basic X-ray system for health centres and front-line hospitals. Clinical field trials of the basic radiology system are being carried out. Quality assurance in radiotherapy was promoted through intercomparison studies for cobalt-Go teletherapy units, carried out in collaboration with IAEA. In nuclear medicine quality assurance was furthered through cooperation with regional and national nuclear medicine soc1et1es in Brazil, Colombia, and Uruguay. Radiation protection services have been established within the ministries of health in 1 3 countries, with the assistance of the Regional Office. They cover instrumentation and methods for radiation measurement, calculation of radiation shielding, personal dosimetry services for workers, radiation control regulations and inspections, training of personnel, and prevention of radiation accidents. 95
Rehabilitation 8.61 In response to resolutions WHA29.68 and WHA34·3o, WHO embarked on a programme (i) to design and evaluate schemes aimed at minimizing disability through prevention and rehabilitation, (ii) to develop and test training packages and learning material, (iii) to promote innovative approaches to rehabilitation and support the planning, implementation, and evaluation of projects, and (iv) to cooperate with other organizations in the United Nations system, nongovernmental organizations, and other interested parties in the development and implementation of the new policies and programmes in rehabilitation. 8.62 Emphasis was placed on refining and further developing the concept of disability prevention and rehabilitation within the context of primary health care. Guidelines were prepared on community-based disability prevention and rehabilitation as a part of health and development systems at all levels. A manual on training the disabled in the community was prepared and distributed for trial, evaluation, and adaptation to local settings. Field testing of the manual was carried out in Botswana, Burma, India, Indonesia, Mexico, Nepal, Nigeria, the Philippines, Saint Lucia, and Sri Lanka. The programme was endorsed by 8.63 the WHO Expert Committee on Disability Prevention and Rehabilitation (February 1981). 1 UNICEF actively supported the programme and substantial extrabudgetary resources were obtained for it. 8.64 National and intercountry workshops on community-based rehabilitation were organized in Botswana, India, Nigeria, and Saint Lucia, to foster implementation of the programme and assist in the development t
WHO Technical Report Series, No. 668, r98r.
THE WORK OF WHO, •98o--I981
of the necessary manpower. Development projects for training, research, and service delivery were started in Botswana, India, Mexico, Nigeria, and Saint Lucia. Support was given to disability studies in five countries. 8.65 WHO hosted an interagency meeting in Geneva and actively collaborated at meetings in Paris and Vienna as well as in regional technical meetings on the International Year of Disabled Persons, I 98 I. It played an active role in a meeting on the prevention of disablement organized by the Government of the United Kingdom (November I 98 I) and attended by a large number of international experts, including representatives of many intergovernmental and nongovernmental organizations. The meeting particularly emphasized the prevention of disability due to age, to accidents, and to communicable diseases against which immunization is effective. Its outcome was the Leeds Castle Declaration on the Prevention of Disablement, which clearly defines the areas where impairment is preventable and sets out an action programme as part of the follow-up to the International Year of Disabled Persons. 8.66 In the African Region the National Orthopaedic Hospital, Lagos, was designated as a WHO collaborating centre for training and research in orthopaedics and rehabilitation. Its activities in community-based programmes were supported. 8.67 In the Americas a programme of simplified rehabilitation at community level was introduced in Mexico and the Caribbean area and was promoted by a training workshop held in Saint Lucia in May-June I981. Support in prosthetics and orthotics was given to Bolivia, Colombia, Ecuador, El Salvador, and Peru.
8.68 In South-East Asia aid was provided to countries, in connexion with the International Year of Disabled Persons, to assess the social and health status of the elderly in the community. Participants from Bangladesh, India, Nepal, and Thailand attended regional and global preparatory meetings organized in Melbourne, Australia, in December I98o. 8.69 Pilot demonstration projects were established in collaboration with the Medical College, Trivandrum (India) to train health and allied personnel in disability prevention and rehabilitative services through primary health centres affiliated to the College. In collaboration with UNICEF, national meetings were sponsored for planning and implementing rehabilitation programmes for the different categories of disabled in the community. Community-oriented disability prevention and rehabilitation training centres were set up in Burma, with ILO and WHO as the executing agencies. A national sample survey of the disabled was sponsored in Nepal and technical assistance was provided to India and Indonesia for the analysis of WHO-aided disability surveys. Research and development were promoted to meet the national demand for orthotic and prosthetic appliances by utilizing appropriate technology and local resources.
8. 70 In the European Region the Institute of Physical Medicine and Rehabilitation, Hercegnovi, Yugoslavia, was designated as a collaborating centre. A working group on disability in the elderly (Cologne, Federal Republic of Germany, November I 9 8 I) established guidelines and priorities for disability prevention programmes. 8. 7 I In the Eastern Mediterranean Region support was given to national actlvltles in Iraq, Israel, Jordan, Lebanon, Pakistan, Saudi Arabia, and the Syrian Arab Republic, with the aim of assisting in the development of national programmes of
DIAGNOSTIC, THERAPEUTIC, AND REHABILITATIVE TECHNOLOGY
disability prevention and rehabilitation, including prosthetic and orthotic services. A research project on community-based rehabilitation was started in Pakistan. 8. 7 2 In the Western Pacific Region a working group on rehabilitation and disability prevention (Manila, December I98I) formulated recommendations and guidelines on WHO's collaborative role in the development of regional and national programmes on disability prevention and rehabilitation and outlined practical ways for the implementation of such programmes.
8. 7 5 The WH 0 expert advisory panel on traditional medicine now has over 40 members from a wide variety of health and allied health disciplines with geographical representation of all six WHO regions. The wide range of disciplines is necessary in view of the role of traditional medicine in such fields as fertility regulation, treatment of infertility, control of tropical endemic diseases, drug dependence, anaesthesia, and analgesia. 8. 76 Some African and Asian countries have already created departments for traditional medicine in ministries of health and universities. In the Western Pacific Region training courses in acupuncture and study tours on traditional medicine were organized in China, with participants from four WHO regions. In Kiribati, Papua New Guinea, and the Philippines medicinal plants and traditional medicine were studied. An interregional meeting on the standardization and use of medicinal plants was held in Tianjin (China) in I98o. With UNDP support, WHO collaborated with China in the development and establishment of a research centre in traditional medicine. It cooperated with Viet Nam in relation to the cultivation, preparation, distribution, and use of medicinal plants as well as in the preparation of a pharmacopoeia of traditional medicine. A meeting of ASEAN ministers of health (Philippines, I 9 So) to promote technical cooperation called for collaboration in primary health care and traditional medicine. Advisory services were provided by WHO at the request of the Government of China for a cooperative programme on the nomenclature of standard acupuncture points.
Traditional medicine 8. 73 During the period under review increasing interest in traditional medicine was shown by several countries and recognition was given by some governments to traditional and indigenous health care systems.l Collaborating centres for traditional medicine were established in Africa, the Americas, Asia, and Europe to carry out research in the evaluation of medicinal plants and herbal remedies, in the mechanisms of acupuncture, in the training of potential scientists from developing countries, and in the collection and analysis on a global basis of information relating to traditional medicine. 8.74 A coordinating meeting of directors of WHO collaborating centres for traditional and indigenous systems of medicine was held in Geneva (November I 98 I). It indicated the need for additional collaborating centres, particularly in the developing countries, reviewed and compared the research carried out, and established future strategies for research and training.
1 See paragraphs birth attendants.
12.20
and
12.87-12.89
for traditional
8.77 In August I98o the Regional Office for Africa, with support from DANIDA, organized a meeting at Accra at which 2 5 participants from Ethiopia, Kenya, Lesotho, Nigeria, Sierra Leone, Uganda, the United Republic of Tanzania, and Zambia considered collaboration between practitioners
97
of traditional and of allopathic medicine, collaboration that should ultimately lead to improved health coverage of the population. The first meeting organized by Angola on traditional medicine with the participation of healers and doctors was supported by WHO. Some countries in the African Region have already drawn up legislation and regulations governing traditional medicine and its allied activities. Four WHO collaborating centres for traditional medicine were established, in Ghana, Mali, and Nigeria; and there are plans for further centres in the Region in the near future. 8. 78 Three collaborating centres for traditional medicine were established in the Americas in I98I, two in the United States of America (Chicago and New York) and one in Mexico. WHO participated in a meeting on medicinal plants and traditional herbal remedies held in Mexico in I981. 8. 79 In South-East Asia two collaborating centres for traditional medicine are now in operation in India, one in Jamnagar and the second in V aranasi. Centres will be established in other countries as soon as the formalities have been concluded. An intercountry meeting on the development of research protocols on priority areas in traditional medicine was held in V aranasi in I98o. Advisory services were provided to a number of countries in the Region: to Burma and Sri Lanka, for example, which are developing national programmes on traditional medicine. A national workshop on the promotion and development of traditional medicine was held in Dacca in I98o and on the basis of its recommendations advisory services are being provided by WHO to assist in the development of a systematic programme. The Government of Burma, with the support of WHO and UNDP, plans to strengthen the Institute of Indigenous Medicine in Mandalay as well as existing traditional medicine hospitals and
dispensaries by establishing another 30 dispensaries. WHO also provided assistance in the development of medicinal herbs and ayurvedic drugs. The Government of Maldives is planning to train practitioners of traditional medicine for primary health care. In Sri Lanka a Ministry of Indigenous Medicine has now been established. WHO co-sponsored the Seventh World Congress on Acupuncture held in Colombo in I 98 I. 8.8o In the Eastern Mediterranean Region formalities are under way for the establishment of two WHO collaborating centres and other centres are under review. WHO collaborated with the International Organization of Islamic Medicine in connexion with the Second International Conference on Islamic Medicine, to be held in Kuwait in I982. 8.8I A handbook for health administrators and practitioners on traditional medicine and health care coverage is in preparation. It will be of use to health administrators and practitioners in understanding the variety of health care facilities available to and used by local populations. It will contain information on the present state of the law in relation to traditional medicine and its practitioners and there will be a chapter on the role of WHO.
Essential surgical care 8.82 The programme of essential surgical care was established on I February I981. Its aim is to assess the basic surgical facilities at primary health care level and to draw up a list of the essential minimum equipment for use at first referral hospital level. For that purpose liaison is being established with nongovernmental organizations in the field of surgery, surgical specialties, anaesthesia, nursing, and first-aid care.
DIAGNOSTIC, THERAPEUTIC, AND REHABILITATIVE TECHNOLOGY
8. 83 Contact has been made with surgical societies in Member States through the International Federation of Surgical Colleges and the International College of Surgeons. Comments have been received about the programme itself and about a list of surgical equipment circulated to them that was the product of an earlier consultation between WHO and the International Federation. Informal consultations were held with the World Federation of Societies of Anaesthesiologists and steps are being taken for a joint review of anaesthetic literature, equipment, and drugs. Consideration is being given to the quality control of surgical instruments, implants, and other bioengineering equipment extensively used in surgery at present. Preliminary discussions were held with a group of bioengineers belonging to the International Society for Prosthetics and Orthotics.
On the basis of its recommendations, proposals were made on ways in which WHO could support national and regional strategies. The Conference was the first worldwide review of accident prevention policies. 8.85 WHO participated with the International Children's Centre (Paris) in community surveys of accidents in Benin, Brazil, Senegal, and Turkey with the aim of preparing a manual on injury prevention and treatment for use by primary health workers. In cooperation with the United States National Institute for Drug Abuse, guidelines were drawn up on international cooperation and research on the role of drugs in accidents. Guidelines were also prepared in the framework of the International Year of Disabled Persons and presented to national committees for the International Year; they emphasize the need for education on pedestrian and driver safety in schools and industrial undertakings. The national programmes for the International Year attracted attention in several Member States to road accident prevention. In Africa various projects in mental 8.86 health, workers' health, disability prevention, and rehabilitation have highlighted the toll of disability and death exacted by road traffic accidents. The role of alcohol consumption in road traffic accidents was studied in Zambia as part of a WHO-supported project on the community response to alcohol problems (paragraphs 7.6 and 7·37)· In collaboration with ILO, meetings were held on problems of workers' health and safety in three Member States. At these meetings control of the work environment, improved knowledge on safety, and reduction of drug and alcohol consumption were emphasized as essential steps in the prevention of accidents at work, on the roads, and in the home. 8.87 In the Americas, where road accident cases occupy up to 30% of hospital 99
Prevention of road traffic accidents 8.84 In many developing countries industrialization and urbanization are rapidly changing lifestyles and creating environmental hazards, among which road traffic accidents rate as one of the most harmful to health, especially among the young. The initial, and main, focus of the programme has been to assess the extent of this problem in developing countries, to draw the attention of governments to its health and socioeconomic consequences, and to promote intersectoral cooperation in dealing with it. A survey in 4 I developing countries provided epidemiological information and highlighted some of the main human and environmental features of transport accidents in those countries. The findings were presented at an Interregional Conference on Road Traffic Accidents in Developing Countries (Mexico City, November 1981) at which 50 countries, including the 41 mentioned above, met to formulate national strategies for prevention.
THE WORK OF WHO, r98o-r98r
surgical beds, a regional plan of action is being developed to support national prevention programmes. 8. 8 8 In South-East Asia a regional profile of the accident problem was prepared for the Interregional Conference on Road Traffic Accidents (paragraph 8.84). WHO cooperated with India, Sri Lanka, and Thailand in relation to the implementation of national plans for accident prevention. 8.89 The European Region continued to promote intersectoral cooperation on road accidents at national level and guidelines on the role of health services were drawn up. In cooperation with the Government of Belgium, a document was issued on psychosocial factors relating to accidents in children that provides guidelines for health service intervention and for further research. In the framework of the International Year of Disabled Persons, a symposium on the epidemiology of accident injuries and resulting disabilities identified priorities for intervention and research (see also paragraphs I 5. 73 and I 5. 74). A review of major national road safety policy issues was also begun, in cooperation with Finland, France, and the United Kingdom. The first WHO collaborating centre for the accident prevention programme was designated in the United Kingdom, at the Transport and Road Research Laboratory, London. 8.90 In the Eastern Mediterranean an assessment, completed by I 6 countries and analysed by the above-mentioned collaborating centre, demonstrated the urgent need for appropriate measures to prevent road accidents. It called for intersectoral cooperation between ministries and departments at national level. 8.9I A multidisciplinary meeting on road traffic accidents was organized in Kuwait in March I98I, with WHO support, by the IOO
Secretariat-General of the Council of Ministers of Health of the Arab Countries of the Gulf Area. The meeting set the frame for coordinated action and highlighted the main national issues to be considered. The conclusions of this meeting were thoroughly discussed at the Interregional Conference described in paragraph 8.84. The Western Pacific Region used its programme to make a contribution to that Conference.
Care of the aged 8.92 WHO participated in the preparations for the United Nations World Assembly on Aging, to be held in I982. It was represented at an interagency meeting on the elderly and the aged (Vienna, SeptemberOctober I98o) to coordinate the contributions of the various agencies. A preparatory conference for the World Assembly was convened by WHO in December I98o in Mexico City. 8.93 The orientation of the programme on care of the aged towards health service development was manifest in the work of a meeting on services and systems of care for the elderly (Helsinki, October I98o) and of another on appropriate levels of continuing care (Berlin (West), November I98o). A book was published on the provision of services for care of the aged.l There was also a trend towards closer consultation with national policy-makers and directors of national gerontological institutes. WHO reports appeared on nutrition, the education of physicians, and the role of nursing in relation to care of the aged. (For work in psychogeriatrics, see paragraphs 7.26 and 7.27.)
1 Kinnaird, J. et al., ed. The provision of care for the elder!y. Edinburgh and London, Churchill Livingstone, r98r.
DIAGNOSTIC, THERAPEUTIC, AND REHABILITATIVE TECHNOLOGY
8.94 The technology component of the programme was not overlooked. A meeting was held on the use of medicaments by the elderly (paragraph 8. 12); a three-volume book on scientific and social aspects of aging was published on behalf of WHO ;1 and a WHO study group reported on neuronal aging and its implications in human neurological pathology in December 198o.2
WHO co-sponsored a symposium in Hamburg, Federal Republic of Germany, on aging in developing countries. In the Western Pacific a working group on health care of the elderly met in Manila (August 1981). Advisory services were provided to Bangladesh, Burma, India, Indonesia, and Thailand. 8.96 In the African Region WHO endeavoured to promote the use of epidemiological data and knowledge of lifestyles and general environmental conditions to identify factors harmful to the health of the elderly. Preliminary studies began in that Region to assess mortality and morbidity and the environmental conditions of the aged. Traditionally the aged were cared for within the family, but the migration of young workers is now leaving them in social isolation and without economic support. The aim of the studies is not only to obtain precise data but also to make governments aware of the growing problem.
The geographical coverage of the programme was greatly expanded during the biennium. An interregional working group on the care of the elderly in the developing countries of Asia and the Pacific met in Melbourne, Australia (December 198o). 8.95
1 These three volumes were published under the general title Aging: a challenge to science and society. Vol. 1 : Biology, ed. Danon, D. & Shock, N.W. Vol. 2: Medicine and social science, ed. Gilmore, A.J.J. et a!. Vol. 3: Behavioural sciences and conclusions, ed. Birren, J .E. et a!. London, Oxford University Press, 1981. 2 \1\'HO Techntcal Report Senes, No. 665, 1981.
101
Chapter 9
Communicable Disease Prevention and Control cOMMUNICABLE diseases, complicated by malnutrition and other adverse socioeconomic factors, continued to contribute to the inordinately high levels of mortality, morbidity, and disability in all developing countries, particularly in the under-five age group. Member States and WHO intensified their activities against major killers such as malaria and other parasitic diseases, acute diarrhoeal and respiratory infections, tuberculosis, and early childhood infections. Significant developments also took place in science and technology, in several cases promoted by an impressive expansion in global and regional collaborative research. 9· I her I98I to develop guidelines for contingency planning and establish requirements for national emergency services and criteria for regional and global collaboration.
Post-eradication activities in smallpox and epidemiological surveillance of communicable diseases 1 The case recorded in October I977 in Somalia remains the last known case of endemic smallpox in the world and, in May I98o, the Thirty-third World Health Assembly solemnly decl~red that smallpox eradication had been achieved throughout the world (resolution WHA33·3) and that there was no evidence that it would return as an endemic disease. The Health Assembly endorsed the recommendations on posteradication policy made by the Global Commission for the Certification of Smallpox Eradication (resolution WHA33.4), activities in I98o and I98 I being the implementation of those recommendations. In May I98I the Thirty-fourth World Health Assembly excluded smallpox from the list of diseases subject to the International Health Regulations (I969). 9·3 For training in epidemiology, see paras
9.2 Epidemics and pandemics of viral, bacterial, parasitic, and toxic origin occurred and will continue to present a threat because epidemiological surveillance is inadequate, preventive measures are deficient, and man continues to disturb his environment. Acquired resistance and natural insensitivity to chemotherapeutic agents, hospital infections, and vector resistance to chemical pesticides impede progress against disease and increase the costs of control. To review emergency situations in the light of WHO's past experience of epidemics, an informal consultation on strategies for the control of emergencies caused by epidemics of communicable disease was organized in NovemIOZ
1
I2.I6o--
I2.I62.
COMMUNICABLE DISEASE PREVENTION AND CONTROL
Vaccination poliry 9·4 The Health Assembly recommended that routine smallpox vaccination should be discontinued in every country except for investigators at special risk. At the end of I 979 routine smallpox vaccination was still continuing in 5I countries; however, by December I98I it had been officially discontinued in I44 Member States. In six countries it remains obligatory and in another six countries information about the situation is being sought. WHO is making every effort to discourage the continuation of vaccination and, except in Chad, a smallpox vaccination certificate is no longer required from international travellers.
laboratories have transferred or destroyed their stocks of virus and, in October I98I, only the five laboratories listed in Table 9· I retain stocks. These laboratories have been inspected periodically by a WHO team of experts to ensure that the variola virus stocks are being kept under strict control.
Table 9.1 Laboratories retaining variola virus as at 1 October 1981
Laboratory Centers for Disease Control * National Institute of Virology Research Institute of Viral Preparations* Rijksinstituut voor de Volksgezondheid * Centre for Applied Microbiology and Research*
City/country Atlanta, Georgia, USA Sandringham, South Africa Moscow, USSR Bilthoven, Netherlands Parton Down, United Kingdom
Reserve stocks of smallpox vaccine 9· 5 WHO has established two refrigerated depots for vaccine storage in Geneva and New Delhi. In I98o and I98I, 5ooooooo doses of smallpox vaccine were donated by the USSR, 6 030 ooo doses by India, and 2 ooo ooo doses by Belgium for the emergency reserve. WHO stocks are now sufficient to vaccinate more than 200 million people using the bifurcated needle. A timetable has been prepared for vaccine sampling at the WHO collaborating centre in the Netherlands during the next Io-year period to monitor the potency of the vaccine. Seed lots of vaccinia virus suitable for the preparation of smallpox vaccine and reference vaccine for potency testing are being maintained in designated WHO collaborating centres. In addition, many national producers retain their own batches of seed virus.
* Laboratories acting as WHO collaborating centres.
Investigation of suspected cases of smallpox 9· 7 The Organization has maintained surveillance of suspected cases of smallpox in collaboration with countries where the cases have been reported. Since January I98o, 55 rumours from 29 countries have been reported to WHO and found to be false alarms consisting of misdiagnosed cases of chickenpox, measles or other diseases, or errors in recording. A document1 has been prepared and widely distributed to facilitate appropriate investigation of any rumour of smallpox reported to national health authorities. It is important to note, as stressed in the
Variola virus stocks in laboratories 9.6 At the end of I979 seven laboratories retained variola virus. WHO has continued to discourage its retention. Since then, two 1 Management of suspected cases of smallpox in the post-eradication era (WHO document SE/So. I 57 Rev. I), I980.
document, that vaccination should not be done unless the presumptive diagnosis of smallpox is confirmed through examination by a physician with extensive experience in the clinical diagnosis of smallpox and demonstration of poxvirus particles by electron microscopy. WHO collaborating centres in Atlanta (USA) and Moscow have participated in the laboratory diagnosis of suspected cases of smallpox as required during the surveillance activities.
Laboratory investigation and research
Human monkrypox
9.8 The Thirty-third World Health Assembly specifically recommended special surveillance of human monkeypox. In I98o and I98I six cases of the disease were reported from Zaire and one from the Ivory Coast. Since human monkeypox was first identified in Zaire in I 970, 57 cases of the disease have been detected. In April I98o a seminar with participants from I 3 countries in Africa was held at the Regional Office for Africa, Brazzaville, to coordinate surveillance activities in countries where human monkeypox had occurred or its presence was suspected. Detailed guidelines were developed to establish a monkeypox surveillance system. Accordingly, in I98o and I98I WHO organized and assisted special surveillance programmes on human monkeypox in Congo, the Ivory Coast, Sierra Leone, and Zaire. Medical personnel from hospitals and health units in tropical rainforest areas of those countries were trained to recognize and report the disease. In addition, serological surveys to determine the prevalence of orthopoxvirus antibodies in unvaccinated children were conducted in those areas. A total of I 2 ooo serum specimens were collected and will be screened for poxvirus antibodies, then tested for antibodies specific to monkeypox, so as to estimate the prevalence of the disease and its public health importance in the posteradication era. I04
9·9 WHO continues to encourage and coordinate research on orthopoxviruses, which is essential to promote post-eradication surveillance activities. It includes the development of simple and reliable screening tests for orthopoxvirus antibodies and tests for the detection of antibodies specific to monkeypox virus or other species of orthopoxvirus. Further development of these methods involves the production of monoclonal antibodies specific to different species of poxvirus. These studies will enable WHO to estimate the effectiveness of the special human monkeypox surveillance programme. Increasingly detailed studies of DNA from monkeypox and variola viruses and of the persistence of monkeypox virus in various animals are needed. In I98o and I98r virologists from WHO collaborating centres met to discuss the technical aspects of research related to WHO smallpox post-eradication strategies and agreed on the direction orthopoxvirus research should take for the next five-year period.
Committee on orthopoxvirus infections
9· Io A committee on orthopoxvirus infections has been established to review regularly the Organization's activities and ensure that they meet the recommendations made by the Thirty-third World Health Assembly for smallpox post-eradication policy.
Documentation
9· I I Publications supported by WHO include books on the eradication programmes in Bangladesh, Ethiopia, India, and Somalia. All relevant scientific, operational, and administrative data of the smallpox eradication programme are now being catalogued with a
COMMUNICABLE DISEASE PREVENTION AND CONTROL
view to their retention for archival purposes. Preparations were begun for the publication of a monograph on smallpox and its eradication.
malaria. In IO countries the risk of malaria is minimal, while in large parts of the remaining 9 3 the risk is moderate to high. 9· I 5 Approximately I 8oo million people living in I03 countries or areas are exposed in varying degrees to the risk of malaria (see Figure 9· I and Table 9.2). In I98o more than 2 I o million people were chronically infected or suffered from acute malaria. In Europe malaria transmission is recorded only in Turkey, where 35 ooo cases were detected in I98o, mostly from the Asian part of the country. In Europe malaria contracted abroad (3 500 cases per year) is a cause of significant mortality because of inadequate prophylaxis and, often, late diagnosis. In Africa north of the Sahara the incidence is less than I ooo cases a year.
Vaccination requirements for international travel
9· I 2 Because no traveller now needs to be vaccinated against smallpox, the opportunity was taken in the I98I edition to change the format and increase the scope of the booklet on vaccination certificate requirements for international travel so as to provide more general health advice.! The booklet is addressed to national health administrations, which have the responsibility (coopting as necessary the aid of the medical profession, tourist agencies, shipping companies, airline operators, and other bodies) for advising travellers on the risks they might encounter when visiting other countries. 9· I 3 In addition to providing information on malaria, which is being increasingly reported among travellers, the booklet covers a number of health hazards and indicates where they most frequently occur. It also mentions the precautions that should be taken against certain diseases.
Strategy of malaria control
Malaria During I98o-I98I malaria in individual countries or areas generally followed the trend observed in the period I978-I979· Although in some countries a noticeable reduction in the number of cases was observed, in most no such progress was reported. Out of I43 countries or areas wholly or partly malarious, 40 have been freed and continue to be free from autochthonous 9·I4 1 World Health Organization. Vaccination certificate requirements for international travel, and health advice to travellers: situation as on I January I98I. Geneva, 198 r.
The period I98o-I98I marked the finalization and implementation of the global medium-term programme for malaria, its objectives being to prevent and control malaria epidemics, prepare long-term malaria control programmes, train personnel to meet present and future manpower requirements, and promote research primarily to develop better instruments and methods for malaria control. The main approach is through a worldwide strategy requiring the development of realistic national plans based on malaria endemo-epidemicity levels and available manpower and financial resources. 9.I6
pursuance of resolution the Director-General submitted a progress report on malaria control strategy to the Executive Board at its sixty-fifth session and to the Thirty-third World Health Assembly. The Executive Board decided to undertake a more detailed study of the implementation of the malaria action programme. This was carried out in I98o by the WHA 31.4 5,
9· I 7
In
Figure 9.1
Epidemiological assessment of
CAPE VERDE
D
AREAS IN WHICH MALARIA HAS DISAPPEARED,
D
AREAS WITH LIMITED RISK
•
AREAS
106
COMMUNICABLE DISEASE PREVENTION AND CONTROL status of malaria, December 1 980
MAC40
/Q 60 !\ ·~.r·
I
HONGKONG
J MALDIVES
~~ • •'111 "4'~
~
0
...
_____.
COMOROS
,P
MAURITIUS
VANUATU
... \
BEEN ERADICATED, OR NEVER EXISTED
WHERE MALARIA TRANSMISSION OCCURS
WHO li11Ul7
THE WORK OF WHO, 198o-198I
Table 9.2
Global malaria situation in 1980
Zone
Number of countries or areas affected
Population at risk (millions)
Estimated number of infections
Africa south of the Sahara Asia and Oceania Central America South America Africa north of the Sahara, and Europe* • Including the Asian part of Turkey.
45 31 10 11 6
313 1400 21 22 40
160000000 50000000 1 300000 1 300000 36000
Board's Programme Committee, whose report to the sixty-seventh session of the Board endorsed the line of action proposed by the Director-General for the implementation of the malaria control strategy in endemic countries showing a clear commitment. 9· I 8 A strategy for malaria control within primary health care for Africa is being developed with the aim of reducing mortality and incapacity by making antimalarial drugs available and of protecting the populations in urban and rural communities so as to improve productivity and reduce maternal, fetal, and neonatal mortality. The programme design is guided by the social target of health for all by the year 2ooo and, as it is based on the primary health care approach, is in keeping with the reorientation of the malaria strategy ap~roved by the Thirty-first World Health Assembly. It has been formulated to meet ecological, epidemiological, and socioeconomic criteria, and Member States have been invited to give priority to their national malaria control strategies, which when combined are expected to lead to the adoption of a regional strategy. Malaria control must be intensified to save human lives and enable the population to benefit from the socioeconomic advantages control brings. 9· 19 The global Malaria Advisory Committee met in I98o and again in 1981. In 1980
the Committee felt that most countries with active malaria control or eradication programmes were preoccupied with controlling epidemics and preventing the further spread of the disease, little attention being paid to an epidemiological approach. It was also noted that an acute shortage of trained and experienced personnel was hampering the reorientation of control. In I 98 I the Committee emphasized the need to maintain a nucleus of specialized persons to plan, supervise, and evaluate antimalaria activities, through horizontal services wherever these proved to be effective enough to secure the necessary coverage of the population at risk. The Committee also stressed the need for a better information system to provide the malaria action programme with reliable data, which would greatly facilitate planning of the global programme and assessment of its progress.
9.20 A second Indian Ocean inter-island seminar on malaria and other communicable diseases was convened in Reunion under the auspices of the health authorities of Reunion and WHO. It stressed the need to develop regional programmes based technically and financially on intercountry and multilateral cooperation and to develop appropriate antimalaria strategies based on the local situation or take effective steps to prevent the reintroduction of malaria.
108
COMMUNICABLE DISEASE PREVENTION AND CONTROL
Position in the regions 9.21 In the African Region there were 42 malarious countries or areas and approximately 300 million persons live in areas at risk of malaria. In addition to causing high mortality among infants and young children, the disease also affects the output of workers and inhibits socioeconomic development. Malaria is one of the five leading causes of mortality and morbidity in tropical Africa and accounts for 15-20% of all hospital admissions. Lesotho, Seychelles, St Helena, the western Sahara, and the major part of South Africa are naturally free of malaria. Reunion was officially registered as having eradicated malaria. In Mauritius, however, cyclones have contributed to the recent reestablishment of malaria transmission.
9.23
In the South-East Asia Region malaria continues to be a problem in eight of the 10 Member countries. The problems of vector resistance to insecticides and of parasite resistance to drugs have yet to be solved. Nevertheless, the shift in strategy from eradication to control has shown encouraging results in some areas. There is however an urgent need to strengthen some of the programmes. During the period under review the resistance of Plasmodium falciparum to sulfonamide and pyrimethamine combinations emerged and is threatening progress in control. Efforts are being made to prevent the spread of resistance through intersectoral coordination and cooperation in border areas and a drug resistance monitoring programme. 9· 24 In the European Region a conference on the coordination of antimalaria activities in south-east Europe (Brice, Sicily, October 1979) emphasized the need for additional efforts to adjust the nature and intensity of vigilance to the risk of transmission, and for periodic review of activities in the light of environmental and social change. In countries where malaria transmission exists a special effort is needed to strengthen cooperation with neighbouring countries by exchanging technical information and conducting appropriate antimalaria activities in border areas. The role and participation of European countries in the fight against malaria in the world were discussed at another conference held in the Region (Cagliari, Sardinia, October 198o). 9.25 In the Eastern Mediterranean Region, as far as can be ascertained from the available information, the malaria situation and malaria control in Afghanistan and Iran have considerably deteriorated. In parts of other countries conflicts have hampered normal antimalaria acttvttles and surveillance. Refugees in several countries of the Region pose a special problem and efforts have been
9.22 In the Region of the Americas, the countries of which differ widely in the relative intensity and distribution of malaria and in resources and general development policies, a continental plan was formulated for the promotion and support of malaria programmes. To date, 12 countries of the Region have reformulated their plans of action and five more have requested programme review teams in 1981. As a general principle programmes aim at preserving effective operational capacity based on precise timing and coverage, and at mobilizing community and government resources for all activities. Most programmes need funds for new human and material resources and for the structural changes required for the implementation of new strategies. As an essential part of the continental plan, it is proposed that experience in countries should be analysed and collated with a view to guidelines of regional or global applicability. A special effort is being accorded to the development of primary health care systems in interaction with the malaria programmes. The plan includes a continental training programme to be carried out through a coordinated network of institutions.
THE WORK OF WHO, 198o-1981
made to prevent or contain serious malaria outbreaks among them. 9.2.6 In the Western Pacific Region Australia was officially certified malaria-free by WHO, thus bringing the number of countries or areas registered to 2.4. Singapore's certification is still under consideration. The Regional Committee urged Member States to prevent the establishment of imported malaria vectors, to provide adequate diagnostic and treatment facilities, to coordinate antimalaria operations along common borders, and to disseminate and exchange information. A comprehensive review was made of antimalaria programmes in countries with endemic malaria. Considerable progress has been achieved in some countries, especially Malaysia, but in others there have been setbacks owing to adverse climatic conditions, budgetary constraints, and other factors. 9.2.7 WHO cooperation was obtained by 10 Member countries for the assessment and planning of antimalaria activities (Algeria, Democratic Kampuchea, India, Indonesia, Maldives, Mauritius, Pakistan, Sri Lanka, the Syrian Arab Republic, and the United Republic of Tanzania).
therapy of malaria was published in I981. 1 It reflects the therapeutic progress made during the past three decades and provides practical guidance in this increasingly difficult field.
Training and research 9.2.9 Once countries have defined their priorities and approaches, estimated their resources, and determined their training requirements, it is of paramount importance that they should develop and maintain national training facilities to provide the necessary expertise for the planning, implementation, and evaluation of malaria control programmes. For this purpose, a permanent secretariat for coordinating the malaria training programme in Asia is being developed as a cooperative effort of national training centres and WHO, with possible bilateral contributions. Its task is to cooperate with national centres in the development of curricula, the provision of teaching aids and consultant teachers as necessary, and the organization of courses for the training of teachers. Funds were provided from the Director-General's Development Programme for the establishment of the permanent secretariat and the Government of Malaysia has agreed to house it. 9· 30 The malaria action programme is accelerating the development of the skills necessary for malaria control and promoting greater national expertise through specially arranged fellowships tailored to the needs of individuals and countries. This programme was slow in starting because of difficulty in finding suitable candidates, but it has now gained impetus.
Dissemination 9.2.8
of information
WHAI0.32., WHAI
application of resolutions 3·5 5, and WHA2.2..48, yearly reviews of malaria were published in the Week!J Epidemiological Record, and information regarding risks and advice on prophylaxis for travellers were made available to national health administrations, the medical profession, institutions, and bodies dealing with international travel (see paragraphs 9· I z-9. I 3). A second, entirely revised edition of the WHO monograph on the chemoIIO
In
I Bruce-Chwatt, L.J ., ed., et al. Chemotherapy of malaria, second edition. Geneva, World Health Organization, 1981 (WHO Monograph Series, No. 27).
COMMUNICABLE DISEASE PREVENTION AND CONTROL
9· 3I A seminar on the planning and execution of applied malaria research was conducted in Shanghai in I98o with the participation of staff from malaria control services and scientific institutions. It was followed by a workshop on malaria epidemiology and mathematical modelling. An international course on continuous in vitro cultivation and its application in malaria research was held in Moscow in I98o. 9· 32 In view of the increasing problem of drug-resistant P. falciparum in large parts of eastern Asia and South America and the serious threat it poses to other malarious areas of the world, further efforts were made to train national personnel in the standard techniques of drug sensitivity testing. Four regional workshops were held-in Cotonou, Geneva, Kuala Lumpur, and Sennar (Sudan) -and several subregional or country courses were held in the American, European, SouthEast Asia, and Western Pacific Regions. Most were supported by the Special Programme for Research and Training in Tropical Diseases, which also supported most of malaria research. This research, which is reviewed in paragraphs 9·233-9.237, is a coordinated activity of the Special Programme and the malaria action programme.
in cooperation with the Government of Turkey, is developing a pilot project and demonstration area in the south of Turkey, where a primary health care system will be developed simultaneously with antimalaria activities and the control of waterborne diseases. 9·34 After an II-year gap the Seventh Asian Malaria Conference was convened in Manila in November I 980. Participants from 25 Member countries in four WHO regions discussed the current malaria situation, emphasizing the need for planning, supervision, evaluation, and specialized training. The Conference examined the link between malaria control strategies and primary health care. It recommended the inclusion of specific malaria control targets within national strategies for health for all by the year 2000 and the clear defmition within the health plans of each country of the functions and responsibilities of the persons to be involved in the delivery of primary health care services. Cooperation between countries for the optimum utilization of available training resources, and continuing and increasing support for basic and applied field research in malaria were considered to be essential.
Malaria control and primary health care 9· 33 Representatives from UNICEF, USAID, the United States Public Health Service, and WHO at a malaria coordination meeting concluded that long-term malaria control should be an integral part of primary health care, since it requires a high degree of coverage in space and time, which could be provided through this approach. Experience from the implementation of antimalaria programmes should be taken into consideration when planning appropriate systems. In this regard the malaria action programme, through the Regional Office for Europe and II I
Other parasitic diseases 9· 3 5 Parasitic diseases remain among the most ubiquitous and serious public health problems in developing countries, with a depressingly high prevalence of the major protozoan and helminthic infections.
Schistosomiasis 9· 36 In many countries agricultural reliance on irrigation techniques has led to increases in the incidence, prevalence, and intensity of schistosomiasis. The construction
THE WORK OF WHO, r98o-r98r
of various types of dam, from small village ponds to large manmade lakes, has aggravated and will aggravate the situation in endemic areas. Schistosomiasis is a social and economic scourge and, paradoxically, one that is frequently created by man in his development efforts. 9· 37 In collaboration with national and nongovernmental organizations, WHO continued to promote awareness of the importance of schistosomiasis and of the need for appropriate control measures. In I98o-I98I emphasis was on the further collection, evaluation, and dissemination of data on the medical, social, and economic importance of schistosomiasis. The collection of statistical data on the geographical distribution and prevalence of schistosomiasis in 7 3 Member States for the period I970-I98o was completed. These data provide a basis for the preparation of an atlas on the geographical distribution of schistosomiasis in the world. 9.38 In response to resolution WHA28. 53, a survey of the schistosomiasis problem in the world was made using information on schistosomiasis control programmes provided by I03 Member States in reply to a questionnaire circulated by WHO. This was published in the Bulletin of the World Health Organization. 1 According to the estimated prevalence and the size of the endemic areas, the most severely affected countries were: in Africa: Angola, Central African Republic, Chad, Egypt, Ghana, Madagascar, Malawi, Mozambique, Nigeria, Senegal, Sudan, United Republic of Tanzania, Zambia in South America: Brazil in South-East Asia: Philippines in South-West Asia: Iraq, Yemen.
9· 39 WHO collaborated in the evaluation and planning of schistosomiasis control in Benin, Brazil, Egypt, Ghana, Mozambique, the Philippines, Tunisia, the United Republic of Tanzania, and Zambia. Technical cooperation in the development of control programmes was established with Botswana, Congo, Gabon, Morocco, and Zimbabwe.
9.40 Of the different control techniques, effective chemotherapeutic treatment of infected persons remains the cornerstone. WHO continued to collaborate with the pharmaceutical industry in the development and evaluation of the effectiveness in the field of a new drug, praziquantel (see paragraphs 9.238-9.239). This compound was used in extensive field trials in Brazil, Egypt, Kenya, Mali, Nigeria, the Philippines, Senegal, Sudan, the United Republic of Cameroon, the United Republic of Tanzania, and Zambia. The data on praziquantel show that it can now be used effectively within the primary health systems of endemic countries.
1 Bulletin of the World Health Organization, 59: (r98r).
IIj-127
9·4 I A consultant team reported on disease prevention and control in water resources development schemes. An informal consultation on health protection in such schemes was held in Geneva in I 98 I with the aim of emphasizing the need (i) to establish a network of WHO collaborating centres for monitoring data on epidemiological situations in large water resources development schemes causing serious public health problems, (ii) to increase the manpower in developing countries by providing training for planners, engineers, and technicians dealing with implementation of such schemes, and (iii) to prepare a manual on health protection in water resources development schemes. In I 98 I a consultant team reported on regulations on health protection in water development schemes, based on a review of national legislation and world literature on the subject. II2
COMMUNICABLE DISEASE PREVENTION AND CONTROL
clature of influenza viruses, now based on I 2 haemagglutinin and nine neuraminidase subtypes; assessment of the role of the newer molecular and biochemical methods for virus strain characterization; studies on influenza ecology; and support for the development of both inactivated and live attenuated vaccines. 9· I 30 Hepatitis. Serological tests are now available to detect infections with viral hepatitis A and B, and hence, by exclusion, nonA/non-B. However, much information is lacking on their incidence and trend in developing countries and, particularly, the mode of transmission of hepatitis B and nonAjnon-B hepatitis. The role of mother-toinfant transmission of hepatitis B is the subject of collaborative research in Burma, the aim being to show whether vaccine or early administration of immunoglobulin halts transmission. In view of the high cost of laboratory reagents and the need for standardizing reference material and techniques, WHO has set up a network of 35 national centres, mainly in developing countries, which will be supported through workshops and a coordinated scheme for the regional production of reagents with the cooperation of the four designated collaborating centres. 9· I 3 I Acute respiratory infections. In support of the WHO programme on acute respiratory infections, a simple rapid technique based on the detection of viral antigens by immunofluorescence was established and reagents of high quality were obtained. Two collaborating centres provide reference services to maintain the quality of tests carried out in countries participating in the programme. 9· I 32 Poliomyelitis. Recent studies on the virus have led to the use of highly strainspecific absorbed sera and biochemical procedures and shown that the outbreaks caused by poliovirus type I in Canada, the Netherlands, and the United States had a
common origin and that all recent poliovirus type 3 isolates in the United Kingdom were related to the same vaccine strain (Sabin). The ability to characterize strains serologically and biochemically is of considerable epidemiological significance and has called for a better system of nomenclature, which was published in late I981.1 9· I 33 With the implementation of the Expanded Programme on Immunization, laboratories are called upon for surveillance, evaluation of the effectiveness of immunization, estimation of the impact of immunization programmes, studies of individual cases or outbreaks, and quality control of vaccines. To bring up to date the technical knowledge of laboratories in their regions, the Regional Offices for the Western Pacific and the Eastern Mediterranean conducted workshops on the laboratory diagnosis of poliomyelitis. 9· I 34 Measles. As the control of measles vaccine presents the same problems as that of poliomyelitis, both being live vaccines, techniques for the quality control of measles vaccines were included in the abovementioned workshops on poliomyelitis diagnosis. 9· I 35 Haemorrhagic cotljunctttlltts. Extensive outbreaks of acute haemorrhagic conjunctivitis occurred in I98I in Africa, Asia, and, for the first time, the Americas. WHO virus collaborating centres were involved in the identification of the causative agent. Enterovirus type 70 was confirmed in one outbreak. Other possible agents known to cause this kind of outbreak, adenovirus type I I and coxsackievirus A type 24, were not identified.
1 Bulletin of the World Health Organization, 59: 8 53-8 54 (1981).
THE WORK OF WHO, 198o-198I
9· I 36 Yellow fever. A large number of cases occurred in I98o, mainly in Africa, where Ghana, affected for two years consecutively, set up an intensive vaccination programme with WHO support. Ecological studies in West Africa showed that epizootics can develop in monkey populations and move along riverine forests in waves lasting three to four years. This may result in periodic epidemics among local human populations, as in Gambia in I978-I979· In the Americas the upward trend of jungle yellow fever since I972 was arrested in I98o, but a gradual spread to previously unaffected areas occurred; the vector Aedes aegypti is widespread and there is an increased risk of urban transmission. The I 7D yellow fever vaccine in use is still remarkably effective, but its mode of preparation does not allow for production on a scale to meet the demand. New techniques for vaccine production are being studied in the Americas and production facilities in Brazil and Colombia improved. 9· I 37 Dengue haemorrhagic fever. All four serotypes of dengue virus are now prevalent in the dengue endemic areas of Asia and America. Serotype 4, which was introduced in many islands of the South Pacific in I979-I98o, was for the first time isolated in the Americas in I 98 I and caused several outbreaks in the Caribbean. Haemorrhagic and fatal cases were also recorded for the first time in the Americas in I 98 I, in a violent outbreak in Cuba. In the endemic areas of Asia, Thailand had the highest number of cases ever in I98o and Indonesia remains highly endemic, while in China and VietNam the disease seems to be increasing. In other areas where the virus is known to be prevalent the disease is either silent or present mainly as the milder classical dengue fever. The pathogenesis of the severe forms is still largely unknown and further clinical, immunological, epidemiological, and virological studies are required. Vaccine development has high priority; strains for a quadrivalent qo
vaccine have been selected by the WHO collaborating centre in Bangkok and are being cultured by serial passage to achieve attenuation. Research and vaccine development were reviewed at interregional meetings held in Delhi in March I98o and March I981. 9· I 38 Rift Valley fever. Following its dramatic appearance in Egypt in I977, Rift Valley fever continues to arouse concern in the Mediterranean and Middle East. An informal consultation in Geneva in I98I stressed the general lack of preparedness for dealing with any extension of this hitherto purely African disease. It listed the effective epidemiological surveillance mechanisms available, reviewed control measures, indicated areas where the vaccine could be used in humans and livestock, and outlined national contingency plans applicable both in countries that had experienced the disease and in countrie_s potentially receptive to its introduction.l 9· I 39 Rickettsial diseases. The present status of rickettsial diseases was reviewed and guidelines for the development of national control programmes were prepared by a working group convened in Geneva in I 98 I. An additional WHO collaborating centre for rickettsial reference and research was established at the Gamaleya Institute of Epidemiology and Microbiology, Moscow, in order to increase the availability of reagents for diagnosis and control. Specific antigens and antisera were distributed to national laboratories.
Diseases restricted to circumscribed geographical areas
9· I40 Viral haemorrhagicfevers. The spread ofhaemorrhagic fevers seems to be limited to 1 World Health Organization. Rift Va/lry fever: an emerging human and animal problem. Geneva, 1982 (WHO
Offset Publication No. 63).
COMMUNICABLE DISEASE PREVENTION AND CONTROL
endemic zones, but they carry the threat of infection in any part of the world. A meeting was convened in New Delhi in March I98o to consider research in viral haemorrhagic fevers in the Eastern Mediterranean, SouthEast Asia, and Western Pacific Regions. It outlined measures and research that could be undertaken if the diseases appeared in a new country. 9·I4I Although no epidemic occurred in I98o-I98I, epidemiological research by the
9· I44 With the advent of selective antiherpes drugs, the prospects for effective chemotherapy of viral diseases look promising. To play an active part in this rapidly developing area of research, WHO has established an expert advisory panel on virus diseases (antivirals and interferon). 9·I45 Exchange of information. WHO has maintained a virus reporting system since I963, the total number of reports now exceeding Ioo ooo per year and the number of reports from the participating laboratories in developing countries being almost one and a half times as many in I98o-I98I as in I 978-I 979· The reporting system, by keeping laboratories in developing countries in contact with the network of virus laboratories throughout the world, has been of value to those countries in assessing the progress they have achieved in laboratory diagnosis.
WHO collaborating centres in Africa has continued on Lassa, Marburg, and Ebola viruses, in coordination with monkeypox surveillance. These viruses were found to be present in larger areas of Africa south of the Sahara than was suspected. 9· I42 The Regional Office for the Americas and UNDP supported a project to develop a vaccine against the Junin virus, the causative agent of Argentine haemorrhagic fever. In I98I a possible seed virus was developed as a vaccine candidate.
Safety measures in microbiology 9· 146 Various collaborating centres and national authorities were assisted in relation to the biosafety requirements of diagnostic and research laboratories working with dangerous pathogens. Biosafety guidelines in microbiology have been developed by an international working group for use, as they are, by individual laboratories or national governments, or for adaptation to local or national conditions. A number of other guidelines have been prepared or are under preparation, and those for the management of accidents involving microorganisms have been published.l 9·I47 WHO participated with the Universal Postal Union and the International Air Transport Association in the revision of their regulations for the safe and expeditious 1 Bulletin of the World Health Organization, 58: 24 5-2 56 (198o).
Research and information
9· I43 Research on antiviral agents. A WHO/National Institute of Allergy and Infectious Diseases workshop on DNA recombinant interferon cloning held in Washington in I98o devised a system for the orderly nomenclature of interferons. DNA recombinant techniques are expected to provide large quantities of relatively cheap highly purified interferons. To determine the significance of different types and subtypes in the treatment of certain diseases and to prevent duplication and wastage of interferon, international cooperation is necessary. A WHO informal meeting in Rotterdam, Netherlands, in I 98 I discussed approaches to such international collaboration in relation to the clinical use of interferon. I3J
THE WORK OF WHO, 198o--198I
shipment of diagnostic specimens and agents. It is currently involved with ICAO and IMCO in the revision of their requirements
for the transport of the same agents. 9· I48 An international consultation on training programmes in biosafety was held and model training programmes and trainers' manuals were developed for use at regional, national, and local level. The first training course was held in Brazil. 9· I49 Active liaison has been maintained with the Committee on Genetic Experimentation of the International Council of Scientific Unions and with several national programmes regarding assessment of the risk of laboratory procedures associated with R-DNA research. Recommendations were made in relation to laboratory facilities.
particularly in developing countries; there 8o-8 5% of the inhabitants do not have even minimum health care for sexually transmitted diseases, which are frequently present in 5-I 5% of the adult population. To diagnose and treat the diseases as early as possible before the appearance of complications, cooperative research was carried out to develop simplified and rapid diagnostic techniques for use by non-specialized personnel; this would obviate the need for cumbersome, expensive, and sophisticated laboratory methods. Research was carried out at the same time on the development of simplified rapid diagnostic techniques for bacterial infections. 9· I 5z The emergence of gonococcal strains that are highly or totally resistant to penicillin or to a range of drugs is a serious problem. WHO organized a worldwide resistance surveillance programme, in line with the recommandations of resolution WHA 3I. 57 and of various scientific groups. This problem is compounded by the indiscriminate use of antimicrobial agents in man and animals and by their wide use in food preservation. A scientific working group in I 98 I proposed methods of dealing with the problem, which particularly affects countries that find it difficult to meet the cost of the new antibiotics required to deal with resistance. 9· I 53 In many regions of the world genital ulcers of diverse bacterial and viral origin are responsible for a great many sexually transmitted diseases. A multinational research project on methods of diagnosis, treatment, and '·control has been coordinated by WHO. Research was also carried out to identify the antigens responsible for the attachment to and penetration of gonococci into cells and tissues and to elucidate the mechanism of antibody production. The findings have helped in the identification of vaccine candidates and opened the way to promising diagnostic technology.
Hospital infections 9· I 5o Larger hospitals, particularly in the developing countries, increased specialization, modern diagnostic and curative techniques, and various newly developed drugs that affect immunoresistance contributed to higher morbidity and mortality rates from hospital infections. To define the magnitude and nature of such infections, WHO initiated a prevalence study in selected countries. Surveillance will be carried out by a collaborating centre for reference and research on hospital infections that has now been established at the Public Health Laboratory, Colindale, London.
Sexually transmitted diseases 9· I 5I WHO's objective, in close cooperation with countries, research centres, and nongovernmental organizations, is to make effective control services available to an increasing percentage of the population,
COMMUNICABLE DISEASE PREVENTION AND CONTROL
9· I 54 Endemic treponematoses. A review 1 of the epidemiological situation shows that yaws and endemic syphilis still constitute a considerable health hazard to the child population in medically underserved areas, particularly in West and Central Africa and, to a lesser extent, in South-East Asia and the Americas. The incidence of endemic syphilis (bejel) in the sub-Saharan region approaches that of yaws in the savanna and rain forest region of West Africa. Recent WHO surveys in the Sahel found that approximately 2.8 million of the region's 30 million inhabitants were at risk of endemic syphilis. Reports suggest, however, that pinta has virtually disappeared from countries of Latin America. WHO cooperated with national health administrations and bilateral agencies in assessment of the problem in a number of countries of West and Central Africa and in the implementation and evaluation of control. 9· I 55 A WHO Scientific Group on Treponema! Infections (October I98o) updated and simplified the treatment schedules recommended for use in treponematoses control programmes. 2 A field manual on the clinical and control aspects of endemic treponematoses for health workers in primary health care areas is in preparation.
9·I 57
The WHO Advisory Group on the Prevention of Blindness met in Ouagadougou in I98o at the headquarters of the Onchocerciasis Control Programme, and in I98I in New Delhi. The latter meeting was attended by representatives from all the regional offices with a view to achieving coordination of the programme. The economic implications of the prevention of blindness were reviewed by a small expert group in I98o in which the World Bank participated. Useful guidelines for eye care within the framework of primary health care were elaborated by another working group in Geneva in I 980.
9· I 58 Contributions through the Voluntary Fund for Health Promotion, in particular from the Netherlands, Norway, Sweden, and the Japan Shipbuilding Industry Foundation, have considerably strengthened activities in several countries, e.g., the prevention of blindness programme in Nepal, operational since I98o. Advisory services for the formulation of national programmes were provided by WHO to more than 30 countries during I98o-I98I.
Prevention of blindness 9· 15 6 Work proceeded in several countries on the assessment of blindness and its causes and on the planning of preventive measures and provision of essential eye care at peripheral level. A resolution on the prevention of blindness was adopted by the Regional Committee for Africa in I98o. The first meeting of the PAHOJWHO advisory committee on prevention of blindness took place in Brazil in I98o. Week!J Epidemiological Record, 56: 241-244 (1981). Report to be published in the WHO Technical Report Series, 1982. t 2
9· I 59 Close collaboration was mamtained with several nongovernmental organizations, in particular the International Agency for the Prevention of Blindness. Funds provided by the Royal Commonwealth Society for the Blind and the Asian Foundation for the Prevention of Blindness permitted the employment of a full-time WHO programme coordinator for the prevention of blindness in South-East Asia for a two-year period. 9· I6o Several seminars and workshops on the prevention of blindness were held at the intercountry and national levels. The training of auxiliary health personnel, particularly community health workers, in eye care was the subject of two meetings in I98o in the African Region, sponsored jointly by I33
THE WORK OF WHO, 198o-1981
WHO and the International Eye Foundation. Following those meetings, the possibility of strengthening the training of health personnel in eye care within the framework of TCDC was investigated in six neighbouring countries in Africa. Intercountry cooperation in the surveillance and prevention of blindness was discussed in a seminar in Uruguay in I 98 I at which five Latin American countries were represented. 9.I6I Support was given to training in eye care at the national level for various categories of health personnel. A regional workshop on the prevention of blindness in the Western Pacific Region focused on training and its interrelation with the establishment of blindness surveillance systems. The organization of cataract relief services was considered by a workshop in South-East Asia, as well as by several seminars at the national level. The use of residual vision by visually disabled persons was reviewed in a multidisciplinary meeting in the European Region in I98I, convened within the context of the International Year of Disabled Persons.
collection of data on blindness and applied field research. Additional technical staff have been recruited for this work, which has so far been carried out in two African countries. 9· I64 Two publications have appeared, one on applied survey techniques,! the other on the prevention and control of trachoma.z A standard eye examination record, which was developed and field-tested for surveys on blindness, is adapted to computer data analysis and will be available in several languages. A blindness data bank has been established, with periodic updating of available information on blindness throughout the world. A pamphlet giving general information about the programme has been prepared.
Expanded Programme on Immunization 9· I65 At the time of the Alma-Ata Declaration in I978, which included immunization against the major infectious diseases of childhood among the eight elements necessary to provide primary health care to all the world by the end of the century, no training programmes for the management of immunization programmes had been developed; no consensus was to be found on the type of information needed to monitor and evaluate progress; no routine reporting existed of immunization coverage and vaccine quality, particularly in the developing countries; and few efforts were being made to provide immunization within the framework of comprehensive health services. Now all developing countries or areas in the six WHO regions are in the process of implementing immunization programmes in accordance with WHO recommendations that include 1 World Health Organization. Methods of assessment of avoidable blindness. Geneva, 1980 (WHO Offset Publication No. 54). 2 Dawson, C.R., Jones, B.R. & Tarizzo, M.L. G11ide to trachoma control in programmes for the preventton of blindness. Geneva, World Health Organization, 1981.
9· I 62 The network of WHO collaborating centres for the prevention of blindness has been strengthened and at present comprises Io institutions. The training and research programmes of these centres were reviewed at the annual meetings of the Advisory Group on the Prevention of Blindness in I98o and I98I and priorities for applied research were established. Training courses for medical personnel in the epidemiology and public health aspects of ophthalmology are being arranged by some collaborating centres. 9· I63 The lack of reliable data on disorders causing blindness and their effect is in certain areas an obstacle to systematic prevention or treatment. A grant in I98o from the National Eye Institute, National Institutes of Health (USA) through the Voluntary Fund for Health Promotion is being used for the
COMMUNICABLE DISEASE PREVENTION AND CONTROL
specific targets for both immunization coverage of the infant population and disease reduction. 9· I 66 Programme management. The target for DPT, poliomyelitis, and measles immunization in I983 is to cover 50% of the newborn, and for BCG 7 5%. However at present coverage can be stated regionally only by three of the WHO regions: for exemple, for DPT, the most frequently given antigen, coverage is 37% in the Americas, 2.2% in the Eastern Mediterranean, and I 5% in SouthEast Asia. Specific coverage surveys in geographical areas where phased development of the immunization programme is starting are more encouraging. In the period I979-I98I such surveys were carried out in 49 countries and showed more than 50% coverage in 3 5% of the surveys for DPT, 3o% of those for polio vaccine, and 54% of those for measles vaccine. 9.I67 Following the pattern of developed countries in the past two decades, a reduction in poliomyelitis, measles, and tetanus has already been recorded in limited areas of the developing world, particularly in the Americas, where immunization and recording systems are more advanced. At global level it is too early to discern any meaningful trends. 9.I68 External resources. Of the multilateral funding bodies UNICEF continued to be the major supporter of the programme, primarily with vaccines and cold chain equipment. UNDP continued to provide funds for the improvement of vaccine quality control and intercountry activities in the African and South-East Asia Regions. Considerable extrabudgetary funds were channelled through the Voluntary Fund for Health Promotion. All activities relating to cold chain development were funded through contributions received from Denmark, Finland, the United Kingdom, and the Japan Shipbuilding I
Industry Foundation, and the extended training activities during this period would not have been possible without significant contributions from the Netherlands and Sweden. Contributions of vaccine were made by Finland, the Netherlands, and the USSR. 9· I69 Vaccines. Figure 9.2 summarizes the information available on countries that use vaccines conforming to WHO requirements. A system of certification of laboratories qualified to test individual vaccines for their conformity with WHO requirements is now being initiated. 9· I 70 The Regional Office for the Americas established a successful rotating fund for the purchase of vaccines and other selected materials. The Regional Office for the Western Pacific is considering establishing a regional procurement system for vaccines and drugs, and WHO and UNICEF have been collaborating closely to satisfy national vaccine requirements. The global information system continues to suffer from weaknesses in forecasting vaccine needs, but is improving as national planning capacity improves.
Training
9· I7I The emphasis has been on management at all levels; senior health officials from I 20 countries were trained in immunization planning, and staff from 7 3 countries participated in national and intercountry courses for mid-level supervisory personnel. Courses in cold chain management and cold chain equipment repair were held for technicians from 52 countries.
Research
9· I 7 2 Work was completed or is progressing in ~4 target research areas, notably: the 35
Figure 9.2 Quality of Expanded Programme vaccines being used (Percentage of countries/areas, by WHO region)
AFRICA (46)
.................... ....... . .... . ... . .. .... . .. .. .......... .. . .... ...... .... ... .................... ... ...... . .... .. . . . . ...... .. ... .. ..... .. . .... ..... ... .. . . . . .. .. ... .... . . . . . . . . .. .. . . .... ..... ... .... .. . ....................... ..... . .. . .. . ....... .... . .. ..... .. ... . . .... .. .. ..................... ....................... . . . .. .. .. . .. ..... .. .. . . .. . .. .. ... .... ... ... . . .. . . . . ............ .. . .
AMERICAS (47)
... . ..... ......... .... . .. ......... ... . . .. ... . . . . .... . . ... ... .. . . .. ..... SOUTH-EAST ASIA :·: ·: ·: ·: ·: ·: ·: ·: ·: ·: ·: ·: ·: ·: ·: ·: ·: ·: ·: ·: ·: ·: ·: ·: ·: ·: ·: ·: ·: ·: ·: ·: ·: ·: ·: · (11) :::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: ..................................... . . . . . ..... . . .... . . . . .. .. . . . . . . . . . EUROPE (37)
..... ... . . ...... .. ..... ... .. ............ .. .. .. .. .. .. .. . .. ............................... ....................... . .. .... .. . . .. ... . . . .. . .... . . ... . . .... .. . .. .......... .. .. ... . . . . . . . . . . . . .... .. ..... .... .. ........ . ..... . . . ............ . . . . . . . . . . .. . ................................ ..... . . . . . . . .. . .. .. .. .. .. .. .. .. .. .. . .. . .. . . .. .. .. . . . . . . . . . .. . . . . . . . ... . . . . .. . . . .. . . . .. .. .. . . . ... . ... . ... .. .... .. . .. . . . . . . . . . . . . . . . . . . . . . . . ..... . ... . .. .. .. .. .. . .... .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. . .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. . .. .... . . .... . . ... .. .. .. .. .. .. .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..
EASTERN MEDITERRANEAN (24)
WESTERN PACIFIC:::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: (32)
.... ...
:::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: ~~~~~~~~~~~~~~~~~~~~~
.... .... co
0
0
10
20
30
70 40 50 60 Percentage of countries
80
90
100
~ ~
Countries/areas in which vaccines conform to WHO requirements Countries/areas in which one or more vaccines do not conform to WHO requirements Countries/areas using vaccines of quality unknown to WHO
(00)
Number of countries/areas in the region
COMMUNICABLE DISEASE PREVENTION AND CONTROL
epidemiology of neonatal tetanus, measles, and poliomyelitis; the development of costing guidelines; the preparation of diagnostic materials; the development of more stable measles vaccines; and the development and commercial production of a wide range of cold boxes, refrigerators, freezers, and temperature indicators. 9· I 7 3 Satisfactory progress has not been achieved with respect to pertussis, for which an improved vaccine and improved diagnostic methods are needed. Basic research in this field is being pursued, particularly in the American, European, and Western Pacific Regions. Little progress has been made in better defining the geographical distribution of diphtheria but, although this is technically feasible, it is not at present considered to be a matter of priority.
9· q6 Despite the considerable improvement in information systems in recent years, much remains to be done. Reports on the incidence of all the target diseases were received from only 83 countries or areas for the year ending December I98o, and the quality of vaccines being used was not known for 75 countries or areas. 9· I77
An increasing number of countries are conducting national programme reviews, 17 having been completed in I979 and I98o and seven in I 9 8 1. The methods used are adapted to the needs of the country concerned. The current emphasis is on broadening the review process to include other elements of primary health care than immunization, with particular emphasis on maternal and child health care.
Veterinary public health Evaluation 9·I74 Using data obtained from the global information system and regional and global narrative reports, the programme's advisory group conducts an annual review and issues a report. The group met in Geneva in I98o and in Washington in I981. 9·I78 The WHO Expert Committee on Bacterial and Viral Zoonoses that met in Geneva in I98I 1 with the participation of F AO reviewed the socioeconomic aspects and the factors influencing the prevalence of zoonoses and recommended measures for surveillance, prevention, control, and possible elimination. It dealt particularly with the need for intersectoral and interdisciplinary collaboration and for comprehensive national programmes to ensure the mobilization of resources in the different sectors concerned with health-the environment, food, safety of animal products, and wastes. It placed special emphasis on surveillance and control of emerging zoonoses and immediate improvement of rural economic development services.
9· I 7 5 The Regional Office for the Americas started a newsletter in May I979 which has received wide circulation inside and outside the Region. The Western Pacific Region includes information on the incidence of the programme's target diseases in its monthly epidemiological bulletin. One or more countries in each region either have special newsletters or periodic reports concerning the programme or include information on immunizable diseases in their epidemiological records or bulletins. Wider circulation of this information is given by the Weekry Epidemiological Record.
1 Report to be published in the WHO Technical Report Series, 1982.
THE WORK OF WHO, 198o-1981
Zoonoses centres 9· I 79 The veterinary public health programme and the zoonoses control centres are supported in their activities by WHO collaborating centres. The Pan American Foot-andMouth Disease Center in Rio de Janeiro and the Pan American Zoonoses Center ,in Buenos Aires continued to cooperate with the national authorities and institutions of several countries in the Americas in planning new control and prevention programmes for zoonoses and exotic diseases. They conducted applied research on vaccines and diagnostic procedures and trained staff in various fields of veterinary public health and animal health. Several countries, with close technical cooperation from the Zoonoses Center, carried out control programmes for brucellosis, bovine tuberculosis, echinococcosis/hydatidosis, leptospirosis, and rabies. 9· I So The Mediterranean Zoonoses Centre (UNDPfWHO) extended its services to almost all the Mediterranean countries, particularly for rabies, echinococcosis/hydatidosis, and improvement of the hygiene of food products of animal origin. It organized or took part in meetings that provided practical guidelines on echinococcosis/hydatidosis control (Morocco, I 98o), intersectoral and interprofessional cooperation (Portugal, . I98I), and Rift Valley fever (Geneva, I98I) (see also paragraph 9·138). 9.I8I The various WHO collaborating centres also hosted a world congress on foodborne infections and intoxication in Berlin (West) (I98o), a seminar .on milk hygiene (Hanover, Federal Republic of Germany, I98o), a seminar on environmental hygiene dealing with the hygienic aspects of animals in urban areas (Hanover, I98I), a symposium on the comparative aspects of leukaemias, lymphomas, and papillomas (Munich, I98o), and a symposium on the microbiology of prospective biological products for viral diseases (Munich, I98I).
Control of zoonoses and Joodborne diseases 9· I 82 In line with resolution WHA3 1.48, emphasis continued to be placed on the development of national, regional, and global strategies and methods for the surveillance, prevention, and control of zoonoses and foodborne diseases attributable to animal products. Guidelines on echinococcosis/ hydatidosis control were issued t and other guidelines were in preparation. 9· I 8 3 Rabies. WHO developed regional and global strategies specifically for the control of rabies in dogs in developing countries since, with the improvement of vaccines and immunoglobulins for the treatment in man, the elimination of the disease in its animal reservoirs is being neglected. Information was collected from all regions on successful dog rabies control projects and a model comprehensive national programme was developed and used in collaboration with Member States. WHO has become directly involved in national programme planning and execution, since rabies calls for the coordination of activities in adjacent countries. 9· I 84 Research was carried out on dog ecology in selected areas of the Americas, North Africa, and the Philippines. The recommendations of the WHO Expert Committee on Rabiesz were reviewed and amendments proposed at informal meetings in I98o in Lyon, France (co-sponsored by the Pasteur Institute) and in I98I in Nancy, France (organized jointly with the French National Rabies Research Centre). An international research programme on natural barriers to wildlife rabies was given guidance at a WHO
I 2
WHO document VPH/81.28 (1981). WHO Technical Report Series, No. j23, '973·
q8
COMMUNICABLE DISEASE PREVENTION AND CONTROL
meeting in I 98 I in Vienna (co-sponsored by the Austrian Government). Specific aspects of modern cell culture vaccines for humans were discussed and vaccine schedules defined at a meeting held in I98o in Essen, Federal Republic of Germany (co-sponsored by the University of Essen). 9· I 8 5 Echinococcosisff?ydatidosis. Following a remarkable expansion of interest in this subject, programmes were launched successfully in Cyprus, the Falkland Islands (Malvinas), New Zealand, and Tasmania, representing island models, and in Argentina, Bulgaria, Chile, Peru, Uruguay, and parts of the USSR, representing continental models. Experience gained from these programmes highlighted the important steps in control and their sequence and clearly showed that a reduction in echinococcosis in all age groups of the human population as well as in food animals can be rapidly achieved by relatively simple control measures. However, traditions, habits, inadequate meat inspection, access of dogs and other animals to infected offal, inadequate intersectoral cooperation, and the absence of suitable programmes remain obstacles to successful control in many Member States.
9· I 87 Salmonellosis. The WHO/World Association of Veterinary Food Hygienists Round Table Conference on the Present Status of the Salmonella Problem (Prevention and Control), held in the Netherlands in I 980, noted that salmonellosis from food of animal origin is the most common food borne disease in the world and causes great morbidity and economic loss. Guidelines were prepared to assist public health and veterinary authorities and food and feed industries in taking practical measures to prevent and control salmonellosis. 9.I88 Surveillance of joodborne diseases. An international surveillance programme to aid national programmes for control of foodborne diseases was established in the European Region, mainly by the FAOJ WHO collaborating centre for research and training in food hygiene and zoonoses, Berlin (West). Fifteen European countries agreed to participate and in nine a contact point was designated to provide relevant information. A manual on surveillance of foodborne diseases is being prepared to advise countries on how to organize programmes at national level. 9· I 89 More than 2 5o requests for information on food virology were received from 40 Member countries. Two centres, one in the United States of America (Madison, Wisconsin), the other in Czechoslovakia (Brno ), actively collaborated in the food virology programme. 9· I90 Training. Two international courses on zoonoses management in which WHO closely collaborated were convened in I98o and I98I in the USSR. Rabies, brucellosis, leptospirosis, echinococcosis/hydatidosis, taeniasis/cysticercosis, and food borne disease control were subjects in the courses, in which 45 students from five WHO regions participated.
9· I 86 In cooperation with F AO and UNEP, WHO in I98I formulated research requirements for future decades and collaborated with an increasing number of Member States in planning, executing, and evaluating national programmes. Fresh knowledge has accrued on host-parasite relationships, sociocultural factors modifying them, strain differences, and the dynamics of transmission. Serological diagnosis in man can now be applied with a high degree of sensitivity in some areas and highly effective drugs are available for the large-scale treatment of dogs. Some drugs were identified as having larvicidal activity in animals and are being evaluated in man. I39
THE WORK OF WHO, 198o-t981
9·I9I A WHO workshop on veterinary public health was conducted by the FAO/WHO collaborating centre for research and training in food hygiene and zoonoses. The participants were senior public health and veterinary public health officers from the Eastern Mediterranean and SouthEast Asia. 9· I 92 Four international training centres in Europe coordinated international postgraduate courses in food microbiology for students from developing countries.
ment of programmes for monitoring critical control points. 9· I95 Meat hygiene. Work was carried out jointly with F AO on an international code of principles for ante-mortem and post-mortem judgement of slaughter animals and meat, and a code of hygienic practice for game. They were discussed by the Codex Committee on Meat Hygiene (London, I98I) and the Codex Alimentarius Commission itself (Geneva, I98I). 9· I96 In developing countries slaughterhouses and meat-handling practices contribute greatly to poor health and the spread of animal diseases. Two guidelines-on the design and construction of simple slabs where modern facilities are lacking and on slaughter and meat-handling where there are few slaughter facilities-were the subject of an informal consultation with F AO in Geneva in April I981. 9·I97 Fish and shelfish hygiene. Work on fish hygiene was carried out jointly with F AO within the framework of the Codex Committee on Fish and Fishery Products. Several codes of hygienic practice for fish products were discussed at the meeting of the Committee in Bergen, Norway, in I98o, including microbiological specifications for frozen, cooked, and ready-to-eat shrimps and prawns, which are widely available in international trade. In view of the public health importance of intoxications caused by shellfish, particularly in tropical areas of the world, a guide on paralytic shellfish poisoning was begun.
Microbiological criteria for food 9· I 9 3 An FA 0 /WH 0 working group on microbiological criteria for dried milk products and natural mineral water met in Washington (November I98o) and inter alia finalized general principles for the establishment and application of microbiological criteria for food. These were adopted at the fourteenth session of the FAOfWHO Codex Alimentarius Commission (Geneva, I98I). 9· I 94 Effective control over pathogenic microorganisms and their toxins in food must be exercised not only during the processing of the food but also during its distribution, wholesale and retail storage, and final consumption either in food service establishments or at home. The hazard analysis and critical control point system is an approach to these problems. This system, originally developed for use in food processing establishments in the United States of America, has the full support of WHO. The first meeting of experts in this field was convened in Geneva in I 980 to discuss further development of the system, including: assessment of the health and spoilage risks associated with processing and marketing a given food product; determination of critical control points in the manufacturing process; and the establish140
Comparative medicine 9· I 98 Emphasis was laid on studies in cancer therapy from which results can be extrapolated to man. The classification of tumours in domestic animals by extent,
COMMUNICABLE DISEASE PREVENTION AND CONTROL
condition of lymph nodes, and presence or absence of distant metastases (TNM) was issued. 1 It is as close an adaptation as possible to the TNM classification of malignant tumours in man, published by the International Union against Cancer and in international use. The purpose of the animal tumour classification is to provide an unambiguous method of reporting clinical observations and a guide to prognosis and therapy. 9· 199 In international clinical trials carried out in conjunction with the WHO collaborating centre for comparative oncology, the Department of Clinical Veterinary Medicine, University of Cambridge (United Kingdom), the TNM classification was already being used. The trials covered the use of radiotherapy in spontaneous osteosarcoma in dogs, with and without a hypoxic cell sensitizer, and the immunotherapy of spontaneous canine mammary tumours. The results will be directly relevant to human cancer.
Vector biology and control 9.201 Greater efforts were made to develop training facilities, particularly at the advanced level, and to collaborate with national professional staff in improving control of insect vectors, rodent reservoirs, and snail intermediate hosts of disease.
Vector resistance 9.202 Insecticide resistance in important vectors of disease continued to spread, appearing in additional species and in additional geographical areas. With the appearance of resistance to DDT in the sandfly Phlebotomus papatasi in Bihar State, India, the tsetse remains the only important vector group in which resistance has not been reported. The most serious challenge to a large-scale programme has been the development in the Ivory Coast of resistance to temephos in two species of the Simulium damnosum complex, S. soubrense and S. sanctipauli. First noted in the south in May 198o, resistance to this organophosphorus insecticide has since spread, so that the Onchocerciasis Control Programme has had to shift to alternative insecticides; in October 1981, cross-resistance was detected to one of these alternatives, chlorphoxim. The further spread of resistance to organophosphorus insecticides among important vectors of malaria has greatly increased the technical and financial problems these programmes face. Multiple resistance has been reported in nine additional species of anophelines, including Anopheles sacharovi in Turkey, A. culicifacies and A. stephensi in India, and A. arabiensis in Sudan. The appearance of resistance in populations of Aedes aegypti in the Americas may increase operational problems in the intensified programmes against this vector of yellow fever, dengue, and dengue haemorrhagic fever. Cross-resistance to synthetic pyrethroids in DDT-resistant A. aegypti is of great concern, 141
Laboratory animal health 9.200 Cooperation with Member States in laboratory animal health was expanded and WHO, together with the International Council for Laboratory Animal Science, drafted a medium-term programme covering: guidelines on husbandry, breeding methods and quality, rational use, experimental techniques, and transportation; education and training; and research. The programme was adopted at a meeting of the Council's Governing Board (Dusseldorf, Federal Republic of Germany, 1981).
1
WHO document VPH/CMO/So.zo (198o).
THE WORK OF WHO, 198o-198I
since this is the newest group of insecticides available for use against resistant vectors. All in all, by 1980, 54 different species of anopheline and 42 species of culicine mosquitos had developed resistance to one or more insecticide compounds used in vector control programmes. This increases the urgency of the need to develop alternative pesticides and alternative methods of vector control that can be integrated with, or at least in part substituted for, the use of chemical pesticides and so reduce the selection pressure.
Pesticide production and safe use 9.204 WHO carried out trials of new formulations of existing insecticides in Indonesia, the I vary Coast, and Thailand and the information provided on them to manufacturers has resulted in marked improvements in the performance, stability, and packaging of formulations. 9.205 Some of the alternative compounds under trial are less safe for spraymen and inhabitants of treated houses than the insecticides they must replace. Safety protocols were developed in collaboration with national authorities, the manufacturer being invited to participate in field trials by providing the insecticide, analysis equipment, and technical staff, particularly toxicologists, to carry out safety assessment of the compound. Such a trial was carried out in Indonesia. Continued concern about the possible enhanced toxicity of malathion waterdispersible powders as a result of defective or prolonged storage led to frequent requests for assessment of the toxicity of suspect batches. A course on the safe use of pesticides adaptable to national needs was started in the Republic of Korea and Sudan, and Spanish and Portuguese texts for it are being prepared.
Testing and evaluation of new insecticides 9.203 To overcome vector resistance to insecticides, especially where alternative methods are difficult to implement or are not available, it is necessary to shift to insecticide compounds that involve no cross-resistance to existing groups. The industry was encouraged to provide such candidate compounds for field tests, and WHO organized or participated in collaborative trials in Colombia, Indonesia, Nigeria, and Venezuela of compounds against several different vector species, including mosquitos and triatomid bugs. Unfortunately, the number of new compounds submitted to WHO for testing remains low. Testing has been intensified to expedite the screening of the new compounds made available and to ensure that they reach the essential large-scale field trial stage with the least delay. The industry also increased its collaboration by requesting WHO to comment on the protocols of its own trials. Representatives of the industry visited the WHO collaborating centres in the Ivory Coast, United Kingdom, and United States of America as well as the WHO field testing unit in Indonesia. The results of field trials have been rapidly disseminated to the Member States through unpublished documents issued by WHO.
Testing and evaluation of insecticide application equipment 9.206 Laboratory and field tests were carried out with a new type of sprayer and it was then tried out in a national malaria programme in Saudi Arabia. The results of the tests were communicated to the manufacturer and weak points in the construction have been remedied. Draft specifications for mist blowers and aerosol generators were drawn up and are being tested at the WHO collaborating centre for equipment testing, Silwood Park, United Kingdom. Tests were
COMMUNICABLE DISEASE PREVENTION AND CONTROL
also carried out wtth an electrostatic sprayer at this centre and the initial results were encouraging, though the dispersal patterns must be improved.
Biology and control of specific vectors 9.207 Malaria vectors. Studies on the ecology of Anopheles balabacensis in Thailand and A. sundaicus, A. aconitus, and A. sacharovi in Turkey were carried out in collaboration with national malaria programmes. A seminar on the biology and control of A. sinensis was held in China in I 9 8 1. Field trials of new insecticides, new insecticide formulations, and new approaches were carried out by the WHO research unit, Semarang, Java. Large field tests of an organophosphate, a carbamate, and a pyrethroid were undertaken in a number of villages. Selective spraying of fenitrothion (OMS-43) on the lower portion of walls where most A. aconitus rest provided acceptable and much more economical control than total house coverage. 9.208 An interregional seminar in Adana (Turkey) reviewed environmental management methods and their application to malaria vector control. WHO collaborated with the Government of Burma in its vectorborne disease control programme, which was aimed primarily at control of malaria and its vectors. 9.209 Vectors of filariasis. Longitudinal studies on the biology, ecology, and distribution of vectors of Brugian and Bancroftian filariasis in Java and Sumatra (Indonesia) were completed and the vectorial capacity of the mosquito vectors was determined. Entomological, parasitological, and control studies were carried out in Sulawesi in collaboration with the Ministry of Health. Studies on the control ofBancroftian filariasis in Sri Lanka were carried out in collaboration with the Government. The efficacy of insect growth inhibitors and biological control I43
agents against the main urban vector of filariasis, Culex quinquefasciatus, was examined by several different collaborating laboratories. The South-East Asia and the Western Pacific Regional Offices provided expertise, material for susceptibility tests, and insecticides for field trials against vectors of filariasis. 9.2Io Vectors of yellow fever and dengue. With funds from the Government of the Netherlands, an intensive study was initiated on the biology and distribution of Aedes aegypti in Colombia. There are already indications that it has spread to parts of the country in which it was never found before. Because of a major outbreak of dengue and the first appearance of dengue haemorrhagic fever in Cuba, WHO collaborated with the Government in emergency vector control measures. Trials of vehicle-mounted insecticide application equipment against A. aegypti were carried out by a reference laboratory in Thailand. Following a yellow fever outbreak in Angola, a collaborative study was made of the distribution and population density of A. aegypti in Lunda; another was carried out in the United Republic of Cameroon. A grant was provided to a laboratory in Dakar for research on the vectors of yellow fever in Central and West Africa; these studies are providing more data on the transovarial transmission of yellow fever virus.
9· 2 I I Vectors of onchocerciasis. Following the appearance of insecticide resistance in two Simulium species in the areas of the Onchocerciasis Control Programme in West Africa, efforts to develop and field-test chemical and biological pesticides as alternatives to temephos were intensified. WHO cooperated with Guinea, Guinea-Bissau, Mali, Senegal, and Sierra Leone in a feasibility study on onchocerciasis control. Through its research unit in Kaduna it cooperated with Nigeria in the preparation of a national
THE WORK OF WHO, 198o-I981
onchocerciasis control campaign. DANIDA funded an onchocerciasis pilot scheme in the United Republic of Tanzania with which WHO cooperated. WHO also participated in missions to evaluate onchocerciasis and its vectors in Guatemala and Mexico, and in planning in Ecuador in relation to the newly discovered onchocerciasis vectors there.
for control. In Malaysia WHO assessed potential rodent reservoirs of plague and advised on control. A two-week interregional training course on rodent control was held in Rangoon. 9.2I4 Snail intermediate hosts and schistosomiasis control. In collaboration with GTZ, missions were undertaken to Congo, Malawi, and Mali to prepare collaborative support for schistosomiasis control programmes. A similar mission was carried out in Rwanda, and another, combined with a teaching course, in Gabon. In view of the worldwide shortage of persons trained in medical malacology, support was given to the development of regional centres for applied malacology. In association with the Special Programme for Research and Training in Tropical Diseases, assistance was given to many research projects in the prevention and control of major trematode diseases. Reviews, manuals, and practical field guides on such subjects as plant molluscicides, biological control, and snail host taxonomy by regions were prepared. The prospects for biological control of snail hosts at virtually no cost in integrated control schemes are now promising. A programme for the development of biocontrol agents, mainly competitor andfor predator snails, was begun in I98I, involving WHO collaborating centres in several Member States.
Vectors of trypanosomiasis. With the Special Programme for Research and Training in Tropical Diseases, research programmes were carried out on tsetse vectors of sleeping sickness (see paragraphs 9·2439.248). Studies in the Ivory Coast and Kenya on the biology, ecology, and population dynamics of tsetse provided a basis for control activities. Improved trapping methods for sampling and controlling tsetse have been developed and give hope that simple traps and insecticide-impregnated screens can be used by villagers for their own protection in sleeping sickness endemic areas. WHO participated in meetings organized by F AO and OAU on the planning of tsetse control programmes. A long-term feasibility study on the genetic control of tsetse vectors of sleeping sickness in Upper Volta has been completed and the results are being assessed. 9.212
9· 2 I 3 Rodent andflea control. Studies at the WHO rodent control demonstration unit in Rangoon were completed. A large-scale trial carried out by the Burmese Government and WHO staff using new rodenticides and application and evaluation systems demonstrated the practicality of a high level of cost-effective control of rodent populations. The establishment of laboratory facilities for work on agents of rodent-borne diseases will enable studies on plague and murine typhus to continue. Susceptibility tests on flea vectors of plague and murine typhus in Burma and Java showed high levels of DDT resistance, and field trials of insecticide compounds formulated as dusts demonstrated the availability of effective alternative chemicals I44
9· 2 I 5 Cyclops and dracunculiasis control. In connexion with the International Drinking Water Supply and Sanitation Decade, WHO collaborated with the agencies involved in the reduction or elimination of guinea-worm infection, especially in West Africa, through the provision of safe drinking-water supplies.
Biological control 9· 2 I 6 Research on the biological control of vectors, supported largely by the Special Programme for Research and Training in
COMMUNICABLE DISEASE PREVENTION AND CONTROL
clature of influenza viruses, now based on I 2 haemagglutinin and nine neuraminidase subtypes; assessment of the role of the newer molecular and biochemical methods for virus strain characterization; studies on influenza ecology; and support for the development of both inactivated and live attenuated vaccines. 9· I 30 Hepatitis. Serological tests are now available to detect infections with viral hepatitis A and B, and hence, by exclusion, nonA/non-B. However, much information is lacking on their incidence and trend in developing countries and, particularly, the mode of transmission of hepatitis B and nonAfnon-B hepatitis. The role of mother-toinfant transmission of hepatitis B is the subject of collaborative research in Burma, the aim being to show whether vaccine or early administration of immunoglobulin halts transmission. In view of the high cost of laboratory reagents and the need for standardizing reference material and techniques, WHO has set up a network of 35 national centres, mainly in developing countries, which will be supported through workshops and a coordinated scheme for the regional production of reagents with the cooperation of the four designated collaborating centres. 9· I 3 I Acute respiratory infections. In support of the WHO programme on acute respiratory infections, a simple rapid technique based on the detection of viral antigens by immunofluorescence was established and reagents of high quality were obtained. Two collaborating centres provide reference services to maintain the quality of tests carried out in countries participating in the programme. 9· I 32 Poliomyelitis. Recent studies on the virus have led to the use of highly strainspecific absorbed sera and biochemical procedures and shown that the outbreaks caused by poliovirus type I in Canada, the Netherlands, and the United States had a
common origin and that all recent poliovirus type 3 isolates in the United Kingdom were related to the same vaccine strain (Sabin). The ability to characterize strains serologically and biochemically is of considerable epidemiological significance and has called for a better system of nomenclature, which was published in late I98I.I 9· I 33 With the implementation of the Expanded Programme on Immunization, laboratories are called upon for surveillance, evaluation of the effectiveness of immunization, estimation of the impact of immunization programmes, studies of individual cases or outbreaks, and quality control of vaccines. To bring up to date the technical knowledge of laboratories in their regions, the Regional Offices for the Western Pacific and the Eastern Mediterranean conducted workshops on the laboratory diagnosis of poliomyelitis. 9· I 34 Measles. As the control of measles vaccine presents the same problems as that of poliomyelitis, both being live vaccines, techniques for the quality control of measles vaccines were included in the abovementioned workshops on poliomyelitis diagnosis. 9· I 3 5 Haemorrhagic corijuncttvttts. Extensive outbreaks of acute haemorrhagic conjunctivitis occurred in 198I in Africa, Asia, and, for the first time, the Americas. WHO virus collaborating centres were involved in the identification of the causative agent. Enterovirus type 70 was confirmed in one outbreak. Other possible agents known to cause this kind of outbreak, adenovirus type I I and coxsackievirus A type 24, were not identified.
1
Bulletin of the World Health Organization, 59: 85 3-854
(1981).
THE WORK OF WHO, r98o--r98r
9.136 Yellow fever. A large number of cases occurred in I98o, mainly in Africa, where Ghana, affected for two years consecutively, set up an intensive vaccination programme with WHO support. Ecological studies in West Africa showed that epizootics can develop in monkey populations and move along riverine forests in waves lasting three to four years. This may result in periodic epidemics among local human populations, as in Gambia in I978-I979· In the Americas the upward trend of jungle yellow fever since I972 was arrested in I98o, but a gradual spread to previously unaffected areas occurred; the vector Aedes aegypti is widespread and there is an increased risk of urban transmission. The I 7D yellow fever vaccine in use is still remarkably effective, but its mode of preparation does not allow for production on a scale to meet the demand. New techniques for vaccine production are being studied in the Americas and production facilities in Brazil and Colombia improved. 9· I 37 Dengue haemorrhagic fever. All four serotypes of dengue virus are now prevalent in the dengue endemic areas of Asia and America. Serotype 4, which was introduced in many islands of the South Pacific in I979-I98o, was for the first time isolated in the Americas in I 98 I and caused several outbreaks in the Caribbean. Haemorrhagic and fatal cases were also recorded for the first time in the Americas in I98I, in a violent outbreak in Cuba. In the endemic areas of Asia, Thailand had the highest number of cases ever in I98o and Indonesia remains highly endemic, while in China and VietNam the disease seems to be increasing. In other areas where the virus is known to be prevalent the disease is either silent or present mainly as the milder classical dengue fever. The pathogenesis of the severe forms is still largely unknown and further clinical, immunological, epidemiological, and virological studies are required. Vaccine development has high priority; strains for a quadrivalent qo
vaccine have been selected by the WHO collaborating centre in Bangkok and are being cultured by serial passage to achieve attenuation. Research and vaccine development were reviewed at interregional meetings held in Delhi in March I98o and March I98 1. 9·13 8 Rift Valley fever. Following its dramatic appearance in Egypt in I977, Rift Valley fever continues to arouse concern in the Mediterranean and Middle East. An informal consultation in Geneva in I 98 I stressed the general lack of preparedness for dealing with any extension of this hitherto purely African disease. It listed the effective epidemiological surveillance mechanisms available, reviewed control measures, indicated areas where the vaccine could be used in humans and livestock, and outlined national contingency plans applicable both in countries that had experienced the disease and in countries potentially receptive to its introduction. 1 9· I 39 Rickettsial diseases. The present status of rickettsial diseases was reviewed and guidelines for the development of national control programmes were prepared by a working group convened in Geneva in I981. An additional WHO collaborating centre for rickettsial reference and research was established at the Gamaleya Institute of Epidemiology and Microbiology, Moscow, in order to increase the availability of reagents for diagnosis and control. Specific antigens and antisera were distributed to national laboratories.
Diseases restricted to circumscribed geographical areas
9· I40 Viral haemorrhagicfevers. The spread of haemorrhagic fevers seems to be limited to 1 World Health Organization. Rift Valley fever: an emerging human and animal problem. Geneva, 1982 (WHO Offset Publication No. 63).
COMMUNICABLE DISEASE PREVENTION AND CONTROL
endemic zones, but they carry the threat of infection in any part of the world. A meeting was convened in New Delhi in March 1980 to consider research in viral haemorrhagic fevers in the Eastern Mediterranean, SouthEast Asia, and Western Pacific Regions. It outlined measures and research that could be undertaken if the diseases appeared in a new country. 9· 141 Although no epidemic occurred in 198o-1981, epidemiological research by the
9· 144 With the advent of selective antiherpes drugs, the prospects for effective chemotherapy of viral diseases look promising. To play an active part in this rapidly developing area of research, WHO has established an expert advisory panel on virus diseases (antivirals and interferon). 9· 145
WHO collaborating centres in Africa has continued on Lassa, Marburg, and Ebola viruses, in coordination with monkeypox surveillance. These viruses were found to be present in larger areas of Africa south of the Sahara than was suspected. 9· 142 The Regional Office for the Americas and UNDP supported a project to develop a vaccine against the Junin virus, the causative agent of Argentine haemorrhagic fever. In 1981 a possible seed virus was developed as a vaccine candidate.
Exchange of information. WHO has maintained a virus reporting system since 1 96 3, the total number of reports now exceeding 100 ooo per year and the number of reports from the participating laboratories in developing countries being almost one and a half times as many in I98o-1981 as in 1978-1979· The reporting system, by keeping laboratories in developing countries in contact with the network of virus laboratories throughout the world, has been of value to those countries in assessing the progress they have achieved in laboratory diagnosis.
Safety measures in microbiology 9· 146 Various collaborating centres and national authorities were assisted in relation to the biosafety requirements of diagnostic and research laboratories working with dangerous pathogens. Biosafety guidelines in microbiology have been developed by an international working group for use, as they are, by individual laboratories or national governments, or for adaptation to local or national conditions. A number of other guidelines have been prepared or are under preparation, and those for the management of accidents involving microorganisms have been published.! WHO participated with the Universal Postal Union and the International Air Transport Association in the revision of their regulations for the safe and expeditious 9· 147 1 Bulletzn of the World Health Organization, 58: 245-256 (198o).
Research and information
9· 143 Research on antiviral agents. A WHO/National Institute of Allergy and Infectious Diseases workshop on DNA recombinant interferon cloning held in Washington in 1980 devised a system for the orderly nomenclature of interferons. DNA recombinant techniques are expected to provide large quantities of relatively cheap highly purified interferons. To determine the significance of different types and subtypes in the treatment of certain diseases and to prevent duplication and wastage of interferon, international cooperation is necessary. A WHO informal meeting in Rotterdam, Netherlands, in 1981 discussed approaches to such international collaboration in relation to the clinical use of interferon.
THE WORK OF WHO, 198o-I981
shipment of diagnostic specimens and agents. It is currently involved with ICAO and IMCO in the revision of their requirements for the transport of the same agents. 9· I48 An international consultation on training programmes in biosafety was held and model training programmes and trainers' manuals were developed for use at regional, national, and local level. The first training course was held in Brazil. 9· I49 Active liaison has been maintained with the Committee on Genetic Experimentation of the International Council of Scientific Unions and with several national programmes regarding assessment of the risk of laboratory procedures associated with R-DNA research. Recommendations were made in relation to laboratory facilities.
particularly in developing countries; there 8o-8 5% of the inhabitants do not have even minimum health care for sexually transmitted diseases, which are frequently present in 5-15% of the adult population. To diagnose and treat the diseases as early as possible before the appearance of complications, cooperative research was carried out to develop simplified and rapid diagnostic techniques for use by non-specialized personnel; this would obviate the need for cumbersome, expensive, and sophisticated laboratory methods. Research was carried out at the same time on the development of simplified rapid diagnostic techniques for bacterial infections. 9· I 52 The emergence of gonococcal strains that are highly or totally resistant to penicillin or to a range of drugs is a serious problem. WHO organized a worldwide resistance surveillance programme, in line with the recommandations of resolution WHA 3 I. 57 and of various scientific groups. This problem is compounded by the indiscriminate use of antimicrobial agents in man and animals and by their wide use in food preservation. A scientific working group in I 98 I proposed methods of dealing with the problem, which particularly affects countries that find it difficult to meet the cost of the new antibiotics required to deal with resistance. 9· I 53 In many regions of the world genital ulcers of diverse bacterial and viral origin are responsible for a great many sexually transmitted diseases. A multinational research project on methods of diagnosis, treatment, and control has been coordinated by WHO. Research was also carried out to identify the antigens responsible for the attachment to and penetration of gonococci into cells and tissues and to elucidate the mechanism of antibody production. The findings have helped in the identification of vaccine candidates and opened the way to promising diagnostic technology.
Hospital infections 9· I 5o Larger hospitals, particularly in the developing countries, increased specialization, modern diagnostic and curative techniques, and various newly developed drugs that affect immunoresistance contributed to higher morbidity and mortality rates from hospital infections. To define the magnitude and nature of such infections, WHO initiated a prevalence study in selected countries. Surveillance will be carried out by a collaborating centre for reference and research on hospital infections that has now been established at the Public Health Laboratory, Colindale, London.
Sexually transmitted diseases 9· I 5I WHO's objective, in close cooperation with countries, research centres, and nongovernmental organizations, is to make effective control services available to an increasing percentage of the population,
COMMUNICABLE DISEASE PREVENTION AND CONTROL
9· I 54 Endemic treponematoses. A review 1 of the epidemiological situation shows that yaws and endemic syphilis still constitute a considerable health hazard to the child population in medically underserved areas, particularly in West and Central Africa and, to a lesser extent, in South-East Asia and the Americas. The incidence of endemic syphilis (bejel) in the sub-Saharan :egion approaches that of yaws in the savanna and rain forest region of West Africa. Recent WHO surveys in the Sahel found that approximately 2.8 million of the region's 30 million inhabitants were at risk of endemic syphilis. Reports suggest, however, that pinta has virtually disappeared from countries of Latin America. WHO cooperated with national health administrations and bilateral agencies in assessment of the problem in a number of countries of West and Central Africa and in the implementation and evaluation of control. 9· I 55 A WHO Scientific Group on Treponema! Infections (October I98o) updated and simplified the treatment schedules recommended for use in treponematoses control programmes.2 A field manual on the clinical and control aspects of endemic treponematoses for health workers in primary health care areas is in preparation.
9· I 57 The WHO Advisory Group on the Prevention of Blindness met in Ouagadougou in I98o at the headquarters of the Onchocerciasis Control Programme, and in I98I in New Delhi. The latter meeting was attended by representatives from all the regional offices with a view to achieving coordination of the programme. The economic implications of the prevention of blindness were reviewed by a small expert group in I98o in which the World Bank participated. Useful guidelines for eye care within the framework of primary health care were elaborated by another working group in Geneva in I98o. 9· I 58 Contributions through the Voluntary Fund for Health Promotion, in particular from the Netherlands, Norway, Sweden, and the Japan Shipbuilding Industry Foundation, have considerably strengthened activities in several countries, e.g., the prevention of blindness programme in Nepal, operational since I98o. Advisory services for the formulation of national programmes were provided by WHO to more than 30 countries during I980-I98I.
Prevention of blindness 9· I 56 Work proceeded in several countries on the assessment of blindness and its causes and on the planning of preventive measures and provision of essential eye care at peripheral level. A resolution on the prevention of blindness was adopted by the Regional Committee for Africa in I98o. The first meeting of the PAHOJWHO advisory committee on prevention of blindness took place in Brazil in I98o. t Week!J Epidemiological Record, 56: 241-244 (1981). z Report to be published in the WHO Techmcal Report Senes, 1982.
9· I 59 Close collaboration was mamtained with several nongovernmental organizations, in particular the International Agency for the Prevention of Blindness. Funds provided by the Royal Commonwealth Society for the Blind and the Asian Foundation for the Prevention of Blindness permitted the employment of a full-time WHO programme coordinator for the prevention of blindness in South-East Asia for a two-year period. 9· I6o Several seminars and workshops on the prevention of blindness were held at the intercountry and national levels. The training of auxiliary health personnel, particularly community health workers, in eye care was the subject of two meetings in I98o in the African Region, sponsored jointly by
THE WORK OF WHO, I98o-I98I
WHO and the International Eye Foundation. Following those meetings, the possibility of strengthening the training of health personnel in eye care within the framework of TCDC was investigated in six neighbouring countries in Africa. Intercountry cooperation in the surveillance and prevention of blindness was discussed in a seminar in Uruguay in I98I at which five Latin American countries were represented. 9· I 6 I Support was given to trammg in eye care at the national level for various categories of health personnel. A regional workshop on the prevention of blindness in the Western Pacific Region focused on training and its interrelation with the establishment of blindness surveillance systems. The organization of cataract relief services was considered by a workshop in South-East Asia, as well as by several seminars at the national level. The use of residual vision by visually disabled persons was reviewed in a multidisciplinary meeting in the European Region in I98I, convened within the context of the International Year of Disabled Persons. 9· I 62 The network of WHO collaborating centres for the prevention of blindness has been strengthened and at present comprises Io institutions. The training and research programmes of these centres were reviewed at the annual meetings of the Advisory Group on the Prevention of Blindness in I98o and I98I and priorities for applied research were established. Training courses for medical personnel in the epidemiology and public health aspects of ophthalmology are being arranged by some collaborating centres. 9· I63 The lack of reliable data on disorders causing blindness and their effect is in certain areas an obstacle to systematic prevention or treatment. A grant in I98o from the National Eye Institute, National Institutes of Health (USA) through the Voluntary Fund for Health Promotion is being used for the I34
collection of data on blindness and applied field research. Additional technical staff have been recruited for this work, which has so far been carried out in two African countries. 9· I64 Two publications have appeared, one on applied survey techniques, 1 the other on the prevention and control of trachoma.z A standard eye examination record, which was developed and field-tested for surveys on blindness, is adapted to computer data analysis and will be available in several languages. A blindness data bank has been established, with periodic updating of available information on blindness throughout the world. A pamphlet giving general information about the programme has been prepared.
Expanded Programme on Immunization 9.I65 At the time of the Alma-Ata Declaration in I978, which included immunization against the major infectious diseases of childhood among the eight elements necessary to provide primary health care to all the world by the end of the century, no training programmes for the management of immunization programmes had been developed; no consensus was to be found on the type of information needed to monitor and evaluate progress; no routine reporting existed of immunization coverage and vaccine quality, particularly in the developing countries; and few efforts were being made to provide immunization within the framework of comprehensive health services. Now all developing countries or areas in the six WHO regions are in the process of implementing immunization programmes in accordance with WHO recommendations that include 1 World Health Organization. Methods of assessment of avoidable blindness. Geneva, I98o (WHO Offset Publication No. 54). 2 Dawson, C.R., Jones, B.R. & Tarizzo, M.L. Gutde to trachoma control in programmes for the prevention of blmdness. Geneva, World Health Organization, I 98 I.
COMMUNICABLE DISEASE PREVENTION AND CONTROL
specific targets for both immunization coverage of the infant population and disease reduction. 9· I66 Programme management. The target for DPT, poliomyelitis, and measles immunization in I983 is to cover 50% of the newborn, and for BCG 7 5%. However at present coverage can be stated regionally only by three of the WHO regions: for exemple, for DPT, the most frequently given antigen, coverage is 37% in the Americas, 22% in the Eastern Mediterranean, and I 5% in SouthEast Asia. Specific coverage surveys in geographical areas where phased development of the immunization programme is starting are more encouraging. In the period I 979-I 98 I such surveys were carried out in 49 countries and showed more than 50% coverage in 3 5% of the surveys for DPT, 3o% of those for polio vaccine, and 54% of those for measles vaccine.
Industry Foundation, and the extended training activities during this period would not have been possible without significant contributions from the Netherlands and Sweden. Contributions of vaccine were made by Finland, the Netherlands, and the USSR. 9· I69 Vaccines. Figure 9.2 summarizes the information available on countries that use vaccines conforming to WHO requirements. A system of certification of laboratories qualified to test individual vaccines for their conformity with WHO requirements is now being initiated.
9· I 67 Following the pattern of developed countries in the past two decades, a reduction in poliomyelitis, measles, and tetanus has already been recorded in limited areas of the developing world, particularly in the Americas, where immunization and recording systems are more advanced. At global level it is too early to discern any meaningful trends. 9· I 68 External resources. Of the multilateral funding bodies UNICEF continued to be the major supporter of the programme, primarily with vaccines and cold chain equipment. UNDP continued to provide funds for the improvement of vaccine quality control and intercountry activities in the African and South-East Asia Regions. Considerable extrabudgetary funds were channelled through the Voluntary Fund for Health Promotion. All activities relating to cold chain development were funded through contributions received from Denmark, Finland, the United Kingdom, and the Japan Shipbuilding
9· I 70 The Regional Office for the Americas established a successful rotating fund for the purchase of vaccines and other selected materials. The Regional Office for the Western Pacific is considering establishing a regional procurement system for vaccines and drugs, and WHO and UNICEF have been collaborating closely to satisfy national vaccine requirements. The global information system continues to suffer from weaknesses in forecasting vaccine needs, but is improving as national planning capacity improves.
Training
9· I 7 I The emphasis has been on management at all levels; senior health officials from I 20 countries were trained in immunization planning, and staff from 7 3 countries participated in national and intercountry courses for mid-level supervisory personnel. Courses in cold chain management and cold chain equipment repair were held for technicians from 52 countries.
Research
9· I 7 2 sing in
i4 target research areas, notably:
Work was completed or is progresthe
THE WORK OF WHO, 198o-198I
Figure 902 Quality of Expanded Programme vaccines being used (Percentage of countries/areas, by WHO region)
AFRICA (46)
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AMERICAS (47)
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SOUTH-EAST ASIA ::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: ::.~:::::::::::::::: ::::::::::::::::::::::::::::::::::::::::: (11) ........... . ... . .. .. .. .. .. . . .. .. .. ..................................... 0 :::::::::: 0
EUROPE (37)
..................... .. . . . . . . . . . . . . . . . . . .. .. .. . .. .. .... .... .. .... . . .. . . .. .. . . . . . . .... . .. .. . . .................................. . . . .. ...... .. . . . .. . ... . . . . . .. . .. ..... ..... . . .. • 0 • • • • • • • • 0 0 • • • • • • • • • • • • • • • 0 • • • • • • • • • • • • • •
EASTERN ................................. MEDITERRANEAN • • • • • • • 0 • • • • • • • • • • • • • • • • • • • • • • • • • 0 0. 0 • • • • • • • • • • • • • • • 0 ••• 0. 0 0. 0
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WESTERN PACIFIC :::::::::::::::::::::::::::::::::::::::::::. ·::::::::::: ·::::::::::: (32) : 0: ·: 0:·:·:o:• : 0:.:.: 0: 0:· :·:. :·: ·:· :· :·:.:. :·:·: .·.:.:.: 0: :. :. : o:•
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10
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Percentage of countries Countries/areas in which vaccines conform ~ to WHO requirements ~
Countries/areas in which one or more vaccines do not conform to WHO requirements Countries/areas using vaccines of quality unknown to WHO
(00)
Number of countries/areas in the region
COMMUNICABLE DISEASE PREVENTION AND CONTROL
epidemiology of neonatal tetanus, measles, and poliomyelitis; the development of costing guidelines; the preparation of diagnostic materials; the development of more stable measles vaccines; and the development and commercial production of a wide range of cold boxes, refrigerators, freezers, and temperature indicators. 9· I 7 3 Satisfactory progress has not been achieved with respect to pertussis, for which an improved vaccine and improved diagnostic methods are needed. Basic research in this field is being pursued, particularly in the American, European, and Western Pacific Regions. Little progress has been made in better defining the geographical distribution of diphtheria but, although this is technically feasible, it is not at present considered to be a matter of priority.
9· q6 Despite the considerable improvement in information systems in recent years, much remains to be done. Reports on the incidence of all the target diseases were received from only 8 3 countries or areas for the year ending December I98o, and the quality of vaccines being used was not known for 75 countries or areas. 9· I 77 An increasing number of countries are conducting national programme reviews, 17 having been completed in I979 and I98o and seven in I981. The methods used are adapted to the needs of the country concerned. The current emphasis is on broadening the review process to include other elements of primary health care than immunization, with particular emphasis on maternal and child health care.
Veterinary public health
Evaluation 9·I74 Using data obtained from the global information system and regional and global narrative reports, the programme's advisory group conducts an annual review and issues a report. The group met in Geneva in I98o and in Washington in I981.
9· 175 The Regional Office for the Americas started a newsletter in May I979 which has received wide circulation inside and outside the Region. The Western Pacific Region includes information on the incidence of the programme's target diseases in its monthly epidemiological bulletin. One or more countries in each region either have special newsletters or periodic reports concerning the programme or include information on immunizable diseases in their epidemiological records or bulletins. Wider circulation of this information is given by the Week!J Epidemiological Record.
9· q8 The WHO Expert Committee on Bacterial and Viral Zoonoses that met in Geneva in I 98 I 1 with the participation of F AO reviewed the socioeconomic aspects and the factors influencing the prevalence of zoonoses and recommended measures for surveillance, prevention, control, and possible elimination. It dealt particularly with the need for intersectoral and interdisciplinary collaboration and for comprehensive national programmes to ensure the mobilization of resources in the different sectors concerned with health-the environment, food, safety of animal products, and wastes. It placed special emphasis on surveillance and control of emerging zoonoses and immediate improvement of rural economic development services.
1 Report to be published in the WHO Technical Report Series, 1982.
THE WORK OF WHO, I98o-I98I
Zoonoses centres 9· I 79 The veterinary public health programme and the zoonoses control centres are supported in their activities by WHO collaborating centres. The Pan American Foot-andMouth Disease Center in Rio de Janeiro and the Pan American Zoonoses Center ,in Buenos Aires continued to cooperate with the national authorities and institutions of several countries in the Americas in planning new control and prevention programmes for zoonoses and exotic diseases. They conducted applied research on vaccines and diagnostic procedures and trained staff in various fields of veterinary public health and animal health. Several countries, with close technical cooperation from the Zoonoses Center, carried out control programmes for brucellosis, bovine tuberculosis, echinococcosis/hydatidosis, leptospirosis, and rabies. 9· I So The Mediterranean Zoonoses Centre (UNDP(WHO) extended its services to almost all the Mediterranean countries, particularly for rabies, echinococcosis/hydatidosis, and improvement of the hygiene of food products of animal origin. It organized or took part in rpeetings that provided practical guidelines on echinococcosis/hydatidosis control (Morocco, I 980), intersectoral and interprofessional cooperation (Portugal, I98I), and Rift Valley fever (Geneva, I98I) (see also paragraph 9· 13 8). 9· I 8 I The various WHO collaborating centres also hosted a world congress on foodborne infections and intoxication in Berlin (West) (I98o), a seminar .on milk hygiene (Hanover, Federal Republic of Germany, I98o), a seminar on environmental hygiene dealing with the hygienic aspects of animals in urban areas (Hanover, I98I), a symposium on the comparative aspects of leukaemias, lymphomas, and papillomas (Munich, I98o), and a symposium on the microbiology of prospective biological products for viral diseases (Munich, I 98 I).
Control of zoonoses and Joodborne diseases 9· I 82 In line with resolution WHA3 1.48, emphasis continued to be placed on the development of national, regional, and global strategies and methods for the surveillance, prevention, and control of zoonoses and foodborne diseases attributable to animal products. Guidelines on echinococcosis/ hydatidosis control were issued t and other guidelines were in preparation. 9.I83 Rabies. WHO developed regional and global strategies specifically for the control of rabies in dogs in developing countries since, with the improvement of vaccines and immunoglobulins for the treatment in man, the elimination of the disease in its animal reservoirs is being neglected. Information was collected from all regions on successful dog rabies control projects and a model comprehensive national programme was developed and used in collaboration with Member States. WHO has become directly involved in national programme planning and execution, since rabies calls for the coordination of activities in adjacent countries.
9· I 84 Research was carried out on dog ecology in selected areas of the Americas, North Africa, and the Philippines. The recommendations of the WHO Expert Committee on Rabies2 were reviewed and amendments proposed at informal meetings in I98o in Lyon, France (co-sponsored by the Pasteur Institute) and in I98 I in Nancy, France (organized jointly with the French National Rabies Research Centre). An international research programme on natural barriers to wildlife rabies was given guidance at a WHO
1
WHO document VPH/8L28 (1981). z WHO Techmcal Report Series, No. 523, 1973·
q8
COMMUNICABLE DISEASE PREVENTION AND CONTROL
meeting in I 98 I in Vienna (co-sponsored by the Austrian Government). Specific aspects of modern cell culture vaccines for humans were discussed and vaccine schedules defined at a meeting held in I98o in Essen, Federal Republic of Germany (co-sponsored by the University of Essen). 9· I 8 5 Echinococcosisfrydatidosis. Following a remarkable expansion of interest in this subject, programmes were launched successfully in Cyprus, the Falkland Islands (Malvinas), New Zealand, and Tasmania, representing island models, and in Argentina, Bulgaria, Chile, Peru, Uruguay, and parts of the USSR, representing continental models. Experience gained from these programmes highlighted the important steps in control and their sequence and clearly showed that a reduction in echinococcosis in all age groups of the human population as well as in food animals can be rapidly achieved by relatively simple control measures. However, traditions, habits, inadequate meat inspection, access of dogs and other animals to infected offal, inadequate intersectoral cooperation, and the absence of suitable programmes remain obstacles to successful control in many Member States. In cooperation with F AO and UNEP, WHO in I981 formulated research requirements for future decades and collaborated with an increasing number of Member States in planning, executing, and evaluating national programmes. Fresh knowledge has accrued on host-parasite relationships, sociocultural factors modifying them, strain differences, and the dynamics of transmission. Serological diagnosis in man can now be applied with a high degree of sensitivity in some areas and highly effective drugs are available for the large-scale treatment of dogs. Some drugs were identified as having larvicidal activity in animals and are being evaluated in man. 9.186 1 39
Salmonellosis. The WHO/World Association of Veterinary Food Hygienists Round Table Conference on the Present Status of the Salmonella Problem (Prevention and Control), held in the Netherlands in 198o, noted that salmonellosis from food of animal origin is the most common food borne disease in the world and causes great morbidity and economic loss. Guidelines were prepared to assist public health and veterinary authorities and food and feed industries in taking practical measures to prevent and control salmonellosis. 9.I87
Surveillance of foodborne diseases. An international surveili:lpce programme to aid national programmes for control of foodborne diseases was established in the European Region, mainly by the F AO/ WHO collaborating centre for research and training in food hygiene and zoonoses, Berlin (West). Fifteen European countries agreed to participate and in nine a contact point was designated to provide relevant information. A manual on surveillance of foodborne diseases is being prepared to advise countries on how to organize programmes at national level. 9. I 8 8 9· I 89 More than 2 5o requests for information on food virology were received from 40 Member countries. Two centres, one in the United States of America (Madison, Wisconsin), the other in Czechoslovakia (Brno ), actively collaborated in the food virology programme. 9· I9o Training. Two international courses on zoonoses management in which WHO closely collaborated were convened in 1980 and I98 I in the USSR. Rabies, brucellosis, leptospirosis, echinococcosis/hydatidosis, taeniasis/cysticercosis, and foodborne disease control were subjects in the courses, in which 45 students from five WHO regions participated.
THE WORK OF WHO, 1980-1981
9· I9I A WHO workshop on veterinary public health was conducted by the F AOJWHO collaborating centre for research and training in food hygiene and zoonoses. The participants were senior public health and veterinary public health officers from the Eastern Mediterranean and SouthEast Asia.
ment of programmes for monitoring critical control points.
Four international training centres in Europe coordinated international postgraduate courses in food microbiology for students from developing countries. 9· I92
Meat hygiene. Work was carried out jointly with F AO on an international code of principles for ante-mortem and post-mortem judgement of slaughter animals and meat, and a code of hygienic practice for game. They were discussed by the Codex Committee on Meat Hygiene (London, I 98 I) and the Codex Alimentarius Commission itself (Geneva, I98I). 9· I95
Microbiological criteria for food 9· I93 An FAOJWHO working group on microbiological criteria for dried milk products and natural mineral water met in Washington (November I98o) and inter alia finalized general principles for the establishment and application of microbiological criteria for food. These were adopted at the fourteenth session of the FA 0 JWH 0 Codex Alimentarius Commission (Geneva, I98I).
9· I 96 In developing countries slaughterhouses and meat-handling practices contribute greatly to poor health and the spread of animal diseases. Two guidelines-on the design and construction of simple slabs where modern facilities are lacking and on slaughter and meat-handling where there are few slaughter facilities-were the subject of an informal consultation with F AO in Geneva in April I98I. 9· I 97 Fish and shelfish hygiene. Work on fish hygiene was carried out jointly with F AO within the framework of the Codex Committee on Fish and Fishery Products. Several codes of hygienic practice for fish products were discussed at the meeting of the Committee in Bergen, Norway, in I98o, including microbiological specifications for frozen, cooked, and ready-to-eat shrimps and prawns,- which are widely available in international trade. In view of the public health importance of intoxications caused by shellfish, particularly in tropical areas of the world, a guide on paralytic shellfish poisoning was begun.
9· I 94 Effective control over pathogenic microorganisms and their toxins in food must be exercised not only during the processing of the food but also during its distribution, wholesale and retail storage, and final consumption either in food service establishments or at home. The hazard analysis and critical control point system is an approach to these problems. This system, originally developed for use in food processing establishments in the United States of America, has the full support of WHO. The first meeting of experts in this field was convened in Geneva in I 980 to discuss further development of the system, including: assessment of the health and spoilage risks associated with processing and marketing a given food product; determination of critical control points in the manufacturing process; and the establish140
Comparative medicine 9· I98 Emphasis was laid on studies in cancer therapy from which results can be extrapolated to man. The classification of tumours in domestic animals by extent,
COMMUNICABLE DISEASE PREVENTION AND CONTROL
condition of lymph nodes, and presence or absence of distant metastases (TNM) was issued. 1 It is as close an adaptation as possible to the TNM classification of malignant tumours in man, published by the International Union against Cancer and in international use. The purpose of the animal tumour classification is to provide an unambiguous method of reporting clinical observations and a guide to prognosis and therapy. In international clinical trials carried out in conjunction with the WHO collaborating centre for comparative oncology, the Department of Clinical Veterinary Medicine, University of Cambridge (United Kingdom), the TNM classification was already being used. The trials covered the use of radiotherapy in spontaneous osteosarcoma in dogs, with and without a hypoxic cell sensitizer, and the immunotherapy of spontaneous canine mammary tumours. The results will be directly relevant to human cancer. 9· r 99
Vector biology and control 9.201 Greater efforts were made to develop training facilities, particularly at the advanced level, and to collaborate with national professional staff in improving control of insect vectors, rodent reservoirs, and snail intermediate hosts of disease.
Vector resistance 9.202 Insecticide resistance in important vectors of disease continued to spread, appearing in additional species and in additional geographical areas. With the appearance of resistance to DDT in the sandfly Phlebotomus papatasi in Bihar State, India, the tsetse remains the only important vector group in which resistance has not been reported. The most serious challenge to a large-scale programme has been the development in the Ivory Coast of resistance to temephos in two species of the Simulium damnosum complex, S. soubrense and S. sanctipauli. First noted in the south in May 1980, resistance to this organophosphorus insecticide has since spread, so that the Onchocerciasis Control Programme has had to shift to alternative insecticides; in October 1981, cross-resistance was detected to one of these alternatives, chlorphoxim. The further spread of resistance to organophosphorus insecticides among important vectors of malaria has greatly increased the technical and financial problems these programmes face. Multiple resistance has been reported in nine additional species of anophelines, including Anopheles sacharovi in Turkey, A. culicifacies and A. stephensi in India, and A. arabiensis in Sudan. The appearance of resistance in populations of Aedes aegypti in the Americas may increase operational problems in the intensified programmes against this vector of yellow fever, dengue, and dengue haemorrhagic fever. Cross-resistance to synthetic pyrethroids in DDT-resistant A. aegypti is of great concern,
Laboratory animal health 9.200 Cooperation with Member States in laboratory animal health was expanded and WHO, together with the International Council for Laboratory Animal Science, drafted a medium-term programme covering: on husbandry, breeding guidelines methods and quality, rational use, experimental techniques, and transportation; education and training; and research. The programme was adopted at a meeting of the Council's Governing Board (Dusseldorf, Federal Republic of Germany, 1981).
1
WHO document VPH/CMOJSo.zo (198o).
THE WORK OF WHO, 1980-I98I
since this is the newest group of insecticides available for use against resistant vectors. All in all, by 1980, 54 different species of anopheline and 42 species of culicine mosquitos had developed resistance to one or more insecticide compounds used in vector control programmes. This increases the urgency of the need to develop alternative pesticides and alternative methods of vector control that can be integrated with, or at least in part substituted for, the use of chemical pesticides and so reduce the selection pressure.
Pesticide production and safe use 9.204 WHO carried out trials of new formulations of existing insecticides in Indonesia, the Ivory Coast, and Thailand and the information provided on them to manufacturers has resulted in marked improvements in the performance, stability, and packaging of formulations. 9.205 Some of the alternative compounds under trial are less safe for spraymen and inhabitants of treated houses than the insecticides they must replace. Safety protocols were developed in collaboration with national authorities, the manufacturer being invited to participate in field trials by providing the insecticide, analysis equipment, and technical staff, particularly toxicologists, to carry out safety assessment of the compound. Such a trial was carried out in Indonesia. Continued concern about the possible enhanced tox1c1ty of malathion waterdispersible powders as a result of defective or prolonged storage led to frequent requests for assessment of the toxicity of suspect batches. A course on the safe use of pesticides adaptable to national needs was started in the Republic of Korea and Sudan, and Spanish and Portuguese texts for it are being prepared.
Testing and evaluation of new insecticides 9.203 To overcome vector resistance to insecticides, especially where alternative methods are difficult to implement or are not available, it is necessary to shift to insecticide compounds that involve no cross-resistance to existing groups. The industry was encouraged to provide such candidate compounds for field tests, and WHO organized or participated in collaborative trials in Colombia, Indonesia, Nigeria, and Venezuela of compounds against several different vector species, including mosquitos and triatomid bugs. Unfortunately, the number of new compounds submitted to WHO for testing remains low. Testing has been intensified to expedite the screening of the new compounds made available and to ensure that they reach the essential large-scale field trial stage with the least delay. The industry also increased its collaboration by requesting WHO to comment on the protocols of its own trials. Representatives of the industry visited the WHO collaborating centres in the Ivory Coast, United Kingdom, and United States of America as well as the WHO field testing unit in Indonesia. The results of field trials have been rapidly disseminated to the Member States through unpublished documents issued by WHO.
Testing and evaluation of insecticide application equipment 9.206 Laboratory and field tests were carried out with a new type of sprayer and it was then tried out in a national malaria programme in Saudi Arabia. The results of the tests were communicated to the manufacturer and weak points in the construction have been remedied. Draft specifications for mist blowers and aerosol generators were drawn up and are being tested at the WHO collaborating centre for equipment testing, Silwood Park, United Kingdom. Tests were
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also carried out with an electrostatic sprayer at this centre and the initial results were encouraging, though the dispersal patterns must be improved.
Biology and control of specific vectors 9.207 Malaria vectors. Studies on the ecology of A11opheles balabacensis in Thailand and A. sundaicus, A. aconitus, and A. sacharovi in Turkey were carried out in collaboration with national malaria programmes. A seminar on the biology and control of A. sinensis was held in China in I 98 1. Field trials of new insecticides, new insecticide formulations, and new approaches were carried out by the WHO research unit, Semarang, Java. Large field tests of an organophosphate, a carbamate, and a pyrethroid were undertaken in a number of villages. Selective spraying of fenitrothion (OMS-43) on the lower portion of walls where most A. aconitus rest provided acceptable and much more economical control than total house coverage. 9.208 An interregional seminar in Adana (Turkey) reviewed environmental management methods and their application to malaria vector control. WHO collaborated with the Government of Burma in its vectorborne disease control programme, which was aimed primarily at control of malaria and its vectors. 9.209 Vectors of filariasis. Longitudinal studies on the biology, ecology, and distribution of vectors of Brugian and Bancroftian filariasis in Java and Sumatra (Indonesia) were completed and the vectorial capacity of the mosquito vectors was determined. Entomological, parasitological, and control studies were carried out in Sulawesi in collaboration with the Ministry of Health. Studies on the control ofBancroftian filariasis in Sri Lanka were carried out in collaboration with the Government. The efficacy of insect growth inhibitors and bielogical control I43
agents against the main urban vector of filariasis, Culex quinquejasciatus, was examined by several different collaborating laboratories. The South-East Asia and the Western Pacific Regional Offices provided expertise, material for susceptibility tests, and insecticides for field trials against vectors of filariasis. 9.2Io Vectors of yellow fever and dengue. With funds from the Government of the Netherlands, an intensive study was initiated' on the biology and distribution of Aedes aegypti in Colombia. There are already indications that it has spread to parts of the country in which it was never found before. Because of a major outbreak of dengue and the first appearance of dengue haemorrhagic fever in Cuba, WHO collaborated with the Government in emergency vector control measures. Trials of vehicle-mounted insecticide application equipment against A. aegypti were carried out by a reference laboratory in Thailand. Following a yellow fever outbreak in Angola, a collaborative study was made of the distribution and population density of A. aegypti in Lunda; another was carried out in the United Republic of Cameroon. A grant was provided to a laboratory in Dakar for research on the vectors of yellow fever in Central and West Africa; these studies are providing more data on the transovarial transmission of yellow fever virus. I Vectors of onchocerciasis. Following the appearance of insecticide resistance in two Simulium species in the areas of the Onchocerciasis Control Programme in West Africa, efforts to develop and field-test chemical and biological pesticides as alternatives to temephos were intensified. WHO cooperated with Guinea, Guinea-Bissau, Mali, Senegal, and Sierra Leone in a feasibility study on onchocerciasis control. Through its research unit in Kaduna it cooperated with Nigeria in the preparation of a national
9.2 I
THE WORK OF WHO, 198o-I981
onchocerciasis control campaign. DANIDA funded an onchocerciasis pilot scheme in the United Republic of Tanzania with which WHO cooperated. WHO also participated in missions to evaluate onchocerciasis and its vectors in Guatemala and Mexico, and in planning in Ecuador in relation to the newly discovered onchocerciasis vectors there.
for control. In Malaysia WHO assessed potential rodent reservoirs of plague and advised on control. A two-week interregional training course on rodent control was held in Rangoon. 9.2I4 Snail intermediate hosts and schistosomiasis control. In collaboration with GTZ, missions were undertaken to Congo, Malawi, and Mali to prepare collaborative support for schistosomiasis control programmes. A similar mission was carried out in Rwanda, and another, combined with a teaching course, in Gabon. In view of the worldwide shortage of persons trained in medical malacology, support was given to the development of regional centres for applied malacology. In association with the Special Programme for Research and Training in Tropical Diseases, assistance was given to many research projects in the prevention and control of major trematode diseases. Reviews, manuals, and practical field guides on such subjects as plant molluscicides, biological control, and snail host taxonomy by regions were prepared. The prospects for biological control of snail hosts at virtually no cost in integrated control schemes are now promising. A programme for the development of biocontrol agents, mainly competitor andfor predator snails, was begun in I98I, involving WHO collaborating centres in several Member States. 9.2I 5 Cyclops and dracunculiasis control. In connexion with the International Drinking Water Supply and Sanitation Decade, WHO collaborated with the agencies involved in the reduction or elimination of guinea-worm infection, especially in West Africa, through the provision of safe drinking-water supplies.
Vectors of trypanosomiasis. With the Special Programme for Research and Training in Tropical Diseases, research programmes were carried out on tsetse vectors of sleeping sickness (see paragraphs 9.2439.248). Studies in the Ivory Coast and Kenya on the biology, ecology, and population dynamics of tsetse provided a basis for control activities. Improved trapping methods for sampling and controlling tsetse have been developed and give hope that simple traps and insecticide-impregnated screens can be used by villagers for their own protection in sleeping sickness endemic areas. WHO participated in meetings organized by F AO and OAU on the planning of tsetse control programmes. A long-term feasibility study on the genetic control of tsetse vectors of sleeping sickness in Upper Volta has been completed and the results are being assessed. 9.2 I 2
9· 2 I 3 Rodent andflea control. Studies at the WHO rodent control demonstration unit in Rangoon were completed. A large-scale trial carried out by the Burmese Government and WHO staff using new rodenticides and application and evaluation systems demonstrated the practicality of a high level of cost-effective control of rodent populations. The establishment of laboratory facilities for work on agents of rodent-borne diseases will enable studies on plague and murine typhus to continue. Susceptibility tests on flea vectors of plague and murine typhus in Burma and Java showed high levels of DDT resistance, and field trials of insecticide compounds formulated as dusts demonstrated the availability of effective alternative chemicals I44
Biological control 9· 2 I 6 Research on the biological control of vectors, supported largely by the Special Programme for Research and Training in
COMMUNICABLE DISEASE PREVENTION AND CONTROL
Tropical Diseases, has reached the stage at which some agents, in particular some entomopathogenic spore-forming bacteria, can be put into operational use in the near future. This is shown by the successful field trial of Bacillus thuringiensis H-I4 against blackfly in the Ivory Coast. Research is now under way to determine the optimum particle size spectrum and suspensibility characteristics of B. thuringiensis H-I4 formulations for blackfly and mosquito control. All trials confirm that B. thuringiensis H-I4 is a highly specific larvicide with virtually no effect on nontarget fauna. Links were established with industry and several United Nations agencies to ensure the practical application of research information so as to strengthen vector control in tropical countries. Field trials against mosquito larvae have been carried out with strain I 59 3 of B. sphaericus, isolated from Indonesia. This organism sometimes persists and recycles, particularly in polluted water, a characteristic that makes it a promising agent for the control of Culex quinquefasciatus. Mammalian toxicity tests show no hazard to man, but considerable development work has still to be carried out. 9· 217 To facilitate the evaluation of candidate biological agents in field trials in Member States, data sheets detailing all laboratory and field background on the most prom1smg agents were prepared and disseminated. A WHO Expert Committee on Biological Control of Vectors of Disease (December I 9 8 I) 1 reviewed available and potentially available agents and made recommendations to expedite their use in vector control programmes. An informal consultation on fish for mosquito control (October I98I) considered the potential of different larvivorous fish species for mosquito control and made recommendations for field trials and operational use of the fish alone or in combination with other methods. 1 Report to be published in the WHO Technical Report Series, 1982.
Environmental control
9.2I8 A joint WHO/FAOfUNEP panel of experts on environmental management for vector control was established and a meeting was held in Geneva in September 1981. The aim is to facilitate interagency collaboration, promote integrated development strategies with due consideration for the protection of human health, provide technical guidance, and recommend priorities for financial support to projects and activities within this field. 9.219 As a follow-up to the recommendations on the subject of the WHO Expert Committee on Vector Biology and Control,2 steps were taken to integrate appropriate, simple, inexpensive environmental management methodologies for vector control into large-scale vectorborne disease control programmes as well as into primary health care systems. In several programmes, including those in Sudan and Turkey, operational trials and staff training were started. The Blue Nile health project in Sudan, an example of integrated control strategy, utilizes environmental management as appropriate in the control of a group of water-related diseases, notably malaria, schistosomiasis, and diarrhoeal diseases. The project has made good progress and outside funding is forthcoming on an increased scale. 9.220 A seminar on integrated control of mosquito vectors (Adana, Turkey, November 198I) provided information on new methods and approaches. Participants from several professional disciplines had an opportunity for intersectoral exchanges of views.
Vector control in international health
9.221 The risk of exotic vector species crossing international boundaries continues z WHO Technical Report Series, No. 649, 198o.
145
THE WORK OF WHO, 198o-I98I
to increase. Freon-based aerosols were recommended for use in disinsecting aircraft following experiments indicating that propane-based and isobutane-based aerosol formulations pose a greater potential fire hazard in aircraft. New and more effective methods of disinsecting, including residual contact insecticides, continue to be sought.
Training and dissemination of information 9.222 A special effort was made to organize and support a series of M. Sc. courses in medical entomology and vector control, in close collaboration with national authorities and the Special Programme for Research and Training in Tropical Diseases. Courses were established in Africa-in Nairobi, Jos (Nigeria), and Bouake (Ivory Coast)-and support was given to universities in Bogor (Indonesia) and Bangkok. The Regional Office for South-East Asia collaborated in a national intersectoral seminar held in Burma on integrated vectorborne disease control in connexion with dam construction. 9.223 A short training course in vector biology and control funded by DANIDA was held in Ciloto, Indonesia, and a joint OAUJFAOJWHO seminar on trypanosomiasis and Glossina research and control was held in Arusha, United Republic of Tanzania. The Regional Office for the Western Pacific, in collaboration with the Government of China, organized a course on low-toxicity insecticides in Shanghai as well as several general national training courses. The Regional Office for South-East Asia held a workshop in September I98I in Sri Lanka on manpower requirements in entomological aspects of malaria control programmes. Several courses were held in the Americas on the maintenance and use of insecticide application equipment and on emergency measures for the control of Aedes aegypti.
9.224 Detailed information on vector biology and control is lacking in many parts of the world. A number of issues in the WHOJVBC series of documents summarized new developments in control, the subjects covered including the vectors, reservoirs, and control of leishmaniasis; urban filariasis vectors in Africa; and the biology and control of human lice. In all 77 documents were issued in this series, among them a special report on the use of pesticides in public health, I 978-I 979, and a forecast of the demand for I98o-I984 that includes data from I03 developing countries.
Special Programme for Research and Training in Tropical Diseases 9.225 From its inception in I975 until 3 I December I 98 I the Special Programme supported I368 projects; over 2300 scientists
from I I 8 Member States participated in its planning, implementation, and evaluation; and more than $7o million were spent on direct support to national scientists and institutions. The percentage of funds for project support going to developing countries affected by the tropical diseases rose from 29% in I977 to 63% in I981. 9.226 Progress was made in: the drug treatment of malaria, schistosomiasis, and filariasis; biological control of the disease vectors of malaria and onchocerciasis; the development and testing of a possible vaccine against leprosy; the fundamental knowledge required to develop a vaccine against malaria; and simple and accurate diagnostic field test kits for malaria, leprosy, and African trypanosomiasis. Most of the results obtained in research and development were intermediate, in the sense that it will take time before the new information, valuable though it is, can be applied in the control of disease. Many years of systematic work are required for the development of a new agent, whether it is a
COMMUNICABLE DISEASE PREVENTION AND CONTROL
drug or a vaccine, and the need for longsustained effort is recognized. 9.227 Up to mid-1981 over 11oo scientific papers had been published describing the results of work supported by the Special Programme. 9.228 To achieve optimal effectiveness, the Special Programme remained in close touch with research sponsored by other agencies, including the pharmaceutical industry, and whenever appropriate it undertook a catalytic or coordinating role. Some promising activities initiated by other agencies before the Special Programme was established were also supported. For example, in collaboration with the Walter Reed Army Institute of Research, Washington, and the pharmaceutical industry, the Special Programme supported research on the potential antimalarial agent mefloquine, including studies on the bioavailability of different formulations and its clinical evaluation 1n endemic areas in three continents. 9.229 By funding work on standardization, safety testing, and field trials, the Special Programme contributed to the rapid development of Bacillus thuringiensis H-14 as a biological agent for the control of vectors. Although this agent was discovered before the start of the Special Programme, its potential usefulness was recognized and its development and evaluation were accelcrated. The agent will be ready shortly for application 1n national disease control programmes. 9.230 The other objective of the Special Programme, the strengthening of the research capability of the developing countries, was also pursued vigorously, especially through the promotion of technical cooperation among those countries. For example, through institutional and research training grants and other forms of support, insti147
tutions in developing countries are now increasing their capability for research and for the training of scientists from their own and neighbouring countries. Over 2 5o individual training grants have been awarded and 26 institutions are being strengthened through long-term support, while 26 others have received shorter-term support. 9· 2 31 The Special Programme continues to lay great emphasis on evaluation, from the level of individual projects up to the Special Programme as a whole. As recommended by its Scientific and Technical Advisory Committee, each component undergoes in-depth review and evaluation by a scientific and technical review committee at least once every four years.
Research and development 9.232 The planning, implementation, and evaluation of the Special Programme are carried out by collaborating national scientists. Thus research and development are carried out by scientists working in their own institutions, whose activities are coordinated by the steering committees of the Special Programme's scientific working groups. This network approach is proving productive and cost-effective and has overcome some of the constraints that in the past have limited research on tropical diseases. Basic scientists have been able to contribute their specialized skills in disciplines such as immunology, molecular biology, and biochemistry, and the scarce biological materials they require are provided by the networks of scientific working groups. For example, the Scientific Working Group on Immunology of Leprosy provided scientists throughout the world with leprosy bacilli, and other groups provided freeze-dried worms for schistosomiasis research and sera from patients and controls for research on Chagas' disease. The network has made it possible to tackle problems affect-
'
ing many countries, using standard protocols (e.g., for the epidemiology of leishmaniasis) and standard diagnostic kits (e.g., for in vitro testing of the sensitivity of malarial parasites to drugs) to conduct experiments and trials wherever the local ecological situation is most suitable. Thus natural onchocercal infection in cattle in Australia was discovered to be an excellent tertiary and definitive model for the human disease, which occurs only in tropical Africa and Central America. Malaria. Up to 31 December 1981, 87 projects had been supported on chemotherapy and drug development, 68 on immunology, and 57 on field research. Work continued on the development of kits to perform the microtest for the sensitivity of malaria parasites to drugs, and prototype kits were evaluated in endemic countries. Research priorities for the development of tissue schizonticidal drugs were established and work continued on metabolic pathways in malaria parasites, with comparisons among strains that differ in their response to drugs. 9.233
sensitivity to pyrimethamine was developed in collaboration with the Centers for Disease Control, Atlanta, USA. 9.23 5 Immunological research received a major stimulus through the introduction of the cell fusion (hybridoma) technique for the production of monoclonal antibodies. Several of these antibodies proved to have parasiteinactivating or growth-inhibiting properties. A particularly promising monoclonal antibody inactivating sporozoites of P. berghei was found to interact with a sporozoite surface antigen and to confer complete resistance in mice to infection with P. berghei. The system is now being applied to P. falciparum in order to obtain inhibitory monoclonal antibodies and use them for isolating the relevant pure antigen, with a view eventually to reproducing and mass producing the protective antigen through modern methods of genetic engineering. As a result of these developments the concept of malaria vaccination has shifted from the use of crude whole-parasite vaccines to that of specific protective antigens, which are more acceptable from the aspect of vaccine safety. A solid-phase radioimmunoassay for the detection of low numbers of malaria parasites has been adapted from a rodent model to P. Jalciparum; it detects malaria infection at a level of 8 parasites per 106 erythrocytes. Current work is aimed at adapting the test to an enzyme-linked immunosorbent assay (ELISA) system. 9.236 In basic biology, support of chemotherapeutic and immunological research continued. Progress was made with continuous in vitro cultivation of various primate plasmodia and with mass production techniques for P. Jalciparum. The availability of viable gametocytes of P.Jalciparum from in vitro culture now permits the production of great numbers of sporozoites, which are much needed in chemotherapeutic and immunological research. Other current studies
Chemotherapeutic research and development received substantial support through the Special Programme. Phase I clinical trials of mefloquine, a highly active blood schizonticide, were completed in Brazil and Zambia, Phase II trials in Brazil and Thailand, and Phase III trials in Brazil, Thailand, and Zambia. Progress was made with the preclinical development ofQinghaosu (artemisinine) and its derivatives. Another blood schizonticidal candidate compound was selected for further development. Certain aminoacid derivatives of primaquine proved to be more active and better tolerated than the parent compound. The microtest system for in vitro assessment of the drug sensitivity of Plasmodium Jalciparum (to chloroquine, amodiaquine, quinine, and mefloquine) was further developed and large-scale validation studies were implemented in countries of all regions. A microtest for the assessment of 9.234
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concern the structure and function of parasite and erythrocyte membranes in relation to parasite invasion, material and energy transport, and antigenic components. 9.237 In applied field research high priority was given to the implementation or further development of studies on drug resistance of malaria parasites, especially P. jalciparum. These studies are carried out with the close cooperation of the malaria services of the countries concerned. Besides the establishment of baselines and the monitoring of drug sensitivity levels, which are essential prerequisites to the use of drugs in control measures, major efforts are being made to develop and strengthen methods for the containment of drug-resistant malaria. Other essential research is on the operational use of antimalarial drugs 1 community participation in antimalaria measures, vector control in areas with exophilic or insecticide-resistant anophelines, and the epidemiological basis for rational planning and evaluation of malaria control. Special efforts are being made in research training and in the improvement of the field research capabilities of national antimalaria services and scientific institutions in tropical malarious countries. 9.238 Schistosomiasis. One hundred and five projects were funded in applied field research, including vector biology and control, chemotherapy, and immunology. Integrated approaches to the control of schistosomiasis in manmade bodies of water were studied at Lake V alta, Ghana, and the findings will shortly be published. Studies were carried out on focal mollusciciding based on ecological conditions in Sudan and on the dynamics of snail transmission in different irrigation systems. Eleven physicians participated in a worskhop on the population epidemiology of Schistosoma japonicum in the Philippines. Research was sponsored on the intermediate snail hosts of schistosomiasis, and a slow-release formu149
lation of a molluscicide is being tested. Projects complementing the work of the pharmaceutical industry were supported on the chemotherapy of schistosomiasis, and basic biochemical studies were designed to elucidate the mode of action of schistosomicidal drugs as well as their pharmacological effects on man. Clinical trials on praziquantel, a drug developed by the pharmaceutical industry in collaboration with WHO, were supported. 9.239 A collaborative study of immunodiagnosis involving eight laboratories was recently completed. Immunology research was also promoted by the provision of parasite material to investigators, e.g., lyophilized adult worms and S. mansoni eggs. The immunological responses of the mammalian host to infection are being studied, including work on the mechanism of resistance to infection.
9· 240 Filariasis. Priority continued to be given to onchocerciasis, and work on lymphatic filariasis was expanded. The aim is to improve the use of existing filaricides, find new ones, and seek means of reducing the inflammatory reactions that occur in the human host in response to the presence and death of filarial worms. Over 6ooo compounds have been tested; those showing activity in primary screening were subjected to further evaluation and the promising ones were tested in Australian cattle infected with Onchocerca gibsoni and 0. gutturosa. So far three compounds have shown high macrofilaricidal activity, and they are being developed further for eventual testing in man. New chemical compounds are also being screened for antifilarial activity. 9.241 Microfilarial density was reduced by 88% in patients treated with mebendazole in combination with levamisole. Mebendazole alone or in combination with levamisole has a chemosterilizant effect, as shown
THE WORK OF WHO, 198o-1981
by nodules examined after treatment. Studies using radiolabelled diethylcarbamazine have provided new information on the metabolism of this drug in the human body. Work continued on the identification and characterization of antigens for serodiagnosis. In addition, models were designed for the study of the pathogenesis of ocular lesions in onchocerciasis; progress was made with regard to the vectors of both lymphatic ftlariasis and onchocerciasis; and some epidemiological studies were funded. An onchocerciasis mathematical model for predictive simulations of control strategies was developed. 9.243 African trypanosomiasis. Recent results led to a greater understanding of the epidemiology of this disease. Several game animals were shown to harbour trypanosomes, some of which appear to be identical with the human stock of Trypanosoma b. gambiense. This complements the earlier finding of similar infection in pigs and dogs. Further confirmation was obtained of the finding that tsetse flies travel over much longer distances than had been assumed in the past. A second field trial of the ion-exchange minicolumns for parasitological diagnosis was carried out, this time in a T.b. rhodesiense endemic area. The direct card agglutination test for trypanosomiasis was improved to achieve better fixation of the antigen to the card, and comparison with three other tests is planned. A longitudinal study of trypanosomiasis was started in Zambia. 9.244 In drug development, work was carried out on compounds that can disrupt threonine metabolism and those which affect the parasite enzyme ornithine decarboxylase. Screening of potential trypanocides continues at two centres, one in Kenya, the other in the Federal Republic of Germany. Pharmacological studies continued on the drugs in current use, antrypol and organic arsenicals. 150
9· 24 5 Although immune complexes are found in the sera of patients with and without cerebral complications, they were found in the cerebrospinal fluid only in the meningoencephalitic stage. Work continued on antigenic variation in the parasites. American trypanosomiasis. Field research on the prevalence and distribution of Chagas' disease began in several endemic countries with standard protocols and diagnostic methods. A field evaluation of paint containing a slow-release insecticide showed promising results, with effective control of the insect vector for nine months. Work continued on the study of the mode of action of organophosphates on Triatoma itifestans larvae. 9.246 9.247 A comparative serological study started in July 1980 with the collaboration of reference laboratories in three countries. In a project based in Brazil, reference sera from patients and uninfected controls were collected and are being made available to scientists for standardization of their tests. The mechanisms of pathogenesis of the lesions of Chagas' disease are being elucidated; of particular interest are the correlation of parasite strains with clinical manifestations and the role of antibodies in endocardial, vascular, muscular, and peripheral nerve lesions. 9.248 Work on antigenic analysis and purification is making good progress ; specific antigenic components are being identified by the use of monoclonal antibodies. A successful animal model for chronic lesions of the disease has been developed in inbred rabbits.
Leishmaniases. To increase knowledge of the geographical distribution and varieties of this group of diseases the existing literature was reviewed and is being summarized on a country-by-country basis. 9.249
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Epidemiological surveys are in progress in 17 countries and the preliminary data are being analysed. The animal reservoirs of both the cutaneous and mucocutaneous and the visceral forms are being identified in different geographical locations. 9· 2 5o Type collections of sandflies from many different parts of the world are being catalogued for taxonomic purposes and for the training of scientists. Blood meal identification is being widely used to pinpoint the local vectors and efforts continue to obtain a more exact typing of leishmania! strains. In addition to the standard serological, biochemical (enzymological), and biological characteristics, a new technique using radiorespirometry could prove valuable in the classification of reference material. 9.251 Clinical evaluation of promising drugs again confirmed that nifurtimox has some effect in mucocutaneous leishmaniasis but, when used alone, does not achieve a high cure rate. In combination with meglumine antimonate, it improved the results obtained by treatment with either drug alone. Allopurinol, which had shown in vitro activity, has so far proved disappointing in visceral leishmaniasis in clinical trials. The observation in experimental animals that entrapment in liposomes enhances the therapeutic activity of some antileishmanial drugs is being pursued in the hope of applying the finding in human disease, and biological screens for cutaneous and visceral disease are being evaluated. Standardized protocols for drug trials-including the selection of patients, identification of the parasites, treatment schedules, follow-up, and criteria of cure--were developed. 9· 2 52 Work was supported on diagnosis with modern techniques of antigenic analysis and specific monoclonal antibodies. Mechanisms of immunity are being studied, the demonstration of cross-reacting antigens
between Leishmania enriettii and L. tropica having opened up the possibility of using the former, a non-pathogenic species, as a potential vaccine. 9· 2 53 Leprory. Work on the development of a vaccine continued to make progress. Experiments in mice confirmed the protective effect of four different preparations of killed Mycobacterium leprae; the preferred procedure produces a high yield, with minimal damage to bacteria and minimal contamination. It is proposed to test the immunogenic potential of this preparation in human beings with and without BCG, as the first step in trials of the vaccine. 9.254 Immunodiagnostic tests were further developed. An ELISA test of sensitivity comparable with that of the radioimmunoassay test to M. leprae and a method for the early detection of systemic infection in armadillos were established. Monoclonal antibodies are being evaluated for their specificity for M. leprae.
9· 2 55 Clinical trials of drug combinations continued. Detailed protocols for field trials of chemotherapy of lepromatous leprosy were drafted and two trials will start soon. In drug development, analogues of thalidomide and of rifampicin failed to yield promising leads but preliminary trials with analogues of ethionamide and prothionamide continued. Prolonged-release preparations of dapsone are under development and surveys are being carried out on the frequency of primary dapsone resistance in endemic countries. 9.256 Biomedical sciences. The Special Programme continued actively to stimulate the further application of basic biomedical sciences to the study of tropical parasitic and infectious diseases, with particular emphasis on innovative approaches. It supported projects on the use of recombinant DNA technology for the study of kinetoplast DNA in
THE WORK OF WHO, r98o-r98r
Trypanosoma lewisi and of the variant antigen sequences of trypanosomatids. Work is progressing on the gene organization and function of parasitic protozoa. The role of factors under genetic control in relation to susceptibility to infection is being investigated with regard to G-6-PD deficiency and P.Jalciparum infection in man. Two studies in animal models are investigating genetic factors in relation to leishmania! infections. The metabolic pathways of parasites were studied, including purine metabolism in trypanosomes and the role of oxygen reduction products in the killing of parasites. The exchange of scientific information was encouraged through co-sponsorship of courses and workshops with national institutions. Biological control of vectors. Collabor9.2 57 ation continued with national scientists and industrial firms in the testing and development of biological agents for vector control. The tests for efficacy and safety of the agents followed the scheme developed by WHO expert committees.
pathogenic for larvae of Culex and certain species of Anopheles, but much less effective against certain species of Aedes, in particular A. aegypti. 9.260 Of the non-microbial agents, high priority was assigned to the fish Gambusia affinis. The use of this and other larvivorous fish was reviewed at a special consultation in October I 981. A variety of other agents are being systematically examined according to the standard scheme for investigating potential biological agents. 9· 261 Epidemiology. A multidisciplinary longitudinal epidemiological study in Zambia is providing useful information about the health status of the population in rural areas. Analysis of the data has shown correlations suggesting interaction between malaria and schistosomiasis infection. A field study was started and about IOoo persons were examined during the initial survey. Collaboration continued in the strengthening of training courses at key institutions in developing countries. In collaboration with the Regional 9.262 Office for the Western Pacific, a regional workshop was held for teachers of epidemiology. The activities of the 26 participants will be followed up in 1982. Other activities in support of training in epidemiology include the preparation of a field manual. Social and economic research. The 9.263 Special Programme aims at increasing the effectiveness of disease control programmes through the incorporation of human behavioural factors into the design and management of programmes, behaviour being defined so as to include social, cultural, and economic factors. Most of the projects funded related to the intermediate objective of defining the relationship between those factors and the transmission and control of diseases and, as far as possible, they were developed in 152
9· 2 58 Of the microbial agents, the highest priority has been assigned to Bacillus thuringiensis, serotype H-14, which has now reached the stage of large-scale testing for the control of mosquito and blackfly larvae. Tests have shown that it is a potent non-residual larvicide of these larvae, with a large safety margin in relation to man and other nontarget organisms. The activity of the agent is not affected by salinity, a pH within reasonable limits, or water temperature, but it is less effective in polluted than in clear water. The delta endotoxin is stable under tropical conditions. 9· 2 59 Work continued with another bacterial agent, B. sphaericus. Safety tests showed that this agent is innocuous for mammals under normal conditions of exposure, and environmental studies show no harmful effects on non-target organisms. The agent is
COMMUNICABLE DISEASE PREVENTION AND CONTROL
assoc1at10n with ongoing epidemiological research or disease control programmes. 9.264 A preliminary report was made on knowledge, attitudes, and behaviour with regard to malaria, where the reasons were sought for the decline in the collaboration of the population in the indoor spraying of DDT in a programme of control. In another study the role of the school in the control of locally endemic diseases was examined through a questionnaire administered to primary school children.
or most of their training in developing countries other than their own. The host countries were Brazil, Ethiopia, the I vary Coast, Kenya, Malaysia, Singapore, Thailand, Venezuela, and Zambia. 9.267 Interaction between scientists from developing countries also occurs through short-term workshops and seminars and long-term courses. All such group learning activities took place in developing countries and were planned and carried out by local scientists; and all included participants from other developing countries. Seven of the institutions receiving long-term support are engaged in group training activities involving nationals from other developing countries. 9.268 Activities were expanded to provide for collaboration among the institutions supported so as to build up a network of research and research training institutions in countries where tropical diseases are endemic. Accordingly, training workshops in research management were developed for scientists with a managerial role in institutional development programmes; the first was held at global level, but plans have been made to hold others at regional level. Plans were made for technical meetings of scientists working in developing countries, so that they can exchange information that has not yet been formally published and also exchange experiences in institutional development. Other ~ promotional action includes the development of training programmes in endemic countries and the development of research manpower in institutions on the basis of nationally approved explicit long-term plans.
Strengthening of research capability 9.265 The strategic plan for this area of the Special Programme, which was formulated and implemented in 1979, was reviewed in depth by a scientific and technical review committee. The development of a durable network of institutions in endemic countries, an objective of the plan, involves the shifting of resources to less developed institutions when those which initially received support no longer require it. In this context, the Government of Zambia assumed responsibility for the management of the Ndola Tropical Disease Research Centre, formerly a Special Programme activity, and a Zambian physician/scientist was appointed as the first director. The Centre continues to collaborate with the Special Programme on research in epidemiology and clinical pharmacology and is also playing an important role in the training of scientists from other developing countries. 9.266 Most promotion of technical cooperation among developing countries took place through training activities, which can lead to the forging of links among institutions in developing countries. Of the 53 scientists supported by research training grants and visiting scientist grants between 1 July 198o and 30 June 1981, 21 received all
Financing of the Special Programme 9.269 By 31 December 1981, 25 governments (including those of ro developing countries) and six other organizations,
THE WORK OF WHO, r98o-r98r
together with UNDP, the World Bank, and WHO, had contributed over $95 million to the Special Programme. The Joint Coordinating Board (the Special Programme's top management body) approved a maximum budget of $61.64 million for the 1982/1983 biennium, an amount that would permit
the Special Programme to maintain its momentum but a decrease of 5.2% in real terms over the previous biennium. The Joint Coordinating Board urged governments and agencies to contribute to the Special Programme so that the very real opportunities which it presented could be realized.
/
I
54
Chapter ro
Noncommunicable Disease Prevention and Control 10.1 DURING the biennium the concept
of a comprehensive integrated programme for the prevention and control of chronic noncommunicable diseases was further developed, as opposed to the traditional specialty-oriented approach. As an outcome of a number of consultations and meetings (Geneva, June 198o; Zurich, October 198o; Kaunas (USSR), November 1981), an experimental programme was designed and a few target centres and countries, both developed and developing, were selected for the testing and implementation of the proposed programme.
spare incurable cancer patients unnecessary pain as widely as possible. Priority is given to those cancers that can be prevented. 10.3 The outlines of this programme were drawn up by the first meeting of the Subcommittee on Cancer of the global ACMR (September 1981), the Scientific Group on Prevention Strategies in Cancer (October 1981), and the Programme Committee of the Executive Board (November 1981) when it discussed a progress report by the Director-General on long-term planning of international cooperation in the field of cancer. 10.4 The Director-General's Coordinating Committee on Cancer, which includes representatives of WHO, IARC, and the International Union against Cancer (UICC), has held regular yearly meetings to discuss policy matters and coordination. One result has been a clearer division of work between WHO and IARC: WHO concentrates on cancer control, including prevention, early diagnosis, therapy, rehabilitation, and operational research, IARC on carcinogenesis, epidemiology, and laboratory and field research. During the biennium the Coordinating Committee promoted cooperation with countries in the formulation of national cancer policies and programmes as part of their health programming process. Three countries, Finland, Sri Lanka, and Sudan,
Cancer 10.2 WHO's activities in the field of cancer were given a more pragmatic orientation in 198o-I981 so as to ensure: effective cooperation with Member countries in designing and implementing national cancer control programmes, in line with the Global Strategy for health for all by the year zooo; efficient coordination of cancer activities between headquarters, the regional offices, and IARC; and research on appropriate technologies for cancer prevention and control. The main targets of the programme are, by way of existing knowledge and parallel goal-directed research, (i) to prevent up to one-third of the cancers at present encountered, (ii) to cure up to one-third, and (iii) to
THE WORK OF WHO, 198o-I981
were selected for that purpose to provide experience for future policies. 10.5 The programme in Sri Lanka was based on a situation analysis by a team including representatives of WHO, IARC, and UICC. It was followed by a pilot study to determine whether primary health workers could be effectively used in a cancer control programme integrated with the general health care system. Oral cancer-one of the most frequent neoplasms in the countrywas selected for the early detection study that started in I 98 I. In Sudan, where cancer is among the most important health problems, the formulation of priorities was begun with WHO cooperation: a national cancer control policy and programme was formulated at a meeting in December I981. In view of the crucial lack of qualified specialists in all areas of cancer control and the paucity of economic resources, an approach emphasizing professional education was chosen as a first step. The situation is very different in Finland, which has well developed cancer control facilities. A report on the organization of the national cancer control programme in this country is available for the planning of national programmes in countries with a similar level of development.
countries (Region of the Americas); for the detection of oral cancer using primary health care workers (South-East Asia Region); and for a project on self-examination for breast cancer detection (European and Eastern Mediterranean Regions). Experts from both developed and developing countries met in Geneva in October I98I to formulate proper strategies for cancer prevention. They reviewed existing knowledge and analysed the approaches that might be adopted in individual countries. 10.7 A reappraisal of the present situation in the prevention and control of lung cancer, one of the most common tumours in many countries, was made at a "state of the art" meeting in November I981. The participants were directors of medical services, whom the reappraisal will help in their policymaking, and generalists. Io.8 At a meeting held in I98I in Japan to discuss prevention and cancer statistics for developing countries, the data from different countries were analysed. The United States National Institutes of Health generously agreed to provide, for selective distribution by WHO, the 50 ooo-6o ooo abstracts of cancer literature appearing each year.
Prevention, treatment, and after-care Io.6 The prevention component of the cancer programme includes an energetic antismoking programme in the Eastern Mediterranean Region, a campaign against tobaccochewing in South-East Asia in collaboration with the Government of Sri Lanka, and a health education programme for the prevention of skin cancer in the African Region. The early detection aspect of the programme stresses community involvement and the use of primary health care workers. Realistic guidelines are being prepared for the early detection of cervical cancer in developing
10.9 One goal of the programme is to develop simple, safe, inexpensive methods of therapy for common cancers that can be used in developing as well as in developed countries. For this purpose WHO collaborating groups for the assessment of the essential minimum of treatment for breast and lung cancer are being formed. A project has been started to identify and disseminate information on the relief of pain. Io. Io The work of the collaborating centres is being aligned with the aims of the newly oriented cancer programme. Accordingly, they are preparing succinct practical manuals on specific forms of cancer,
q6
NONCOMMUNICABLE DISEASE PREVENTION AND CONTROL
for use at the district hospital level. A WHO collaborating centre for biostatistics was established to provide quantitative expertise for WHO field projects in Member countries and develop methods of teaching cancer control suitable for developing countries.
Histological classification of tumours Io. I I The work on the International Histological Classification of Tumours, which had been coordinated by WHO for over 20 years, came to a close. The last two publications of the 25-volume series went to press during the biennium. In the future such highly technical standardizations of methodologies will be contracted out to the WHO collaborating centres.
Io.q In collaboration with WHO an analysis was carried out of differences in coding practices relating to some 5o diagnostic terms, which could affect the comparability of cancer registry data. A critical review of observed time-trends in cancer incidence was begun, taking into account the effect of changes in population age structure and other competing causes of death. IO.I4 Following the observation that the incidence of malignant melanoma is increasing by about 5% per annum in many populations, an international collaborative study was started into all forms of malignant melanoma; 33 cancer registries will contribute to a retrospective study and 29 to a prospective study.
Alcohol consumption and cancer International Agency for Research on Cancert IO.I2 The I98o and I98I editions of the Directory of on-going research in cancer epidemiology were published, continuing the annual volumes that have been prepared jointly with the Cancer Research Centre, Heidelberg (Federal Republic of Germany), since I976. The latest volume 2 contains I 3 I 3 projects reported from So countries and includes an index of chemicals for which human exposure has been recorded and studied. In the preparation of Volume IV of Cancer incidence in five continents, cancer registry data for the quinquennium I973-I977 were collected from 9 I registries covering I I 6 ethnic groups. 1 For a more detailed description ofiARC's activities, see: International Agency for Research on Cancer, Annual report, r98o, Lyon, 198o; Annual report, r98r, Lyon, 1981. 2 Muir, C.S. & Wagner, G., ed. Dmctory of on-going research in cancer epidemiology, r98r. Lyon, International Agency for Research on Cancer, 1981 (!ARC Scientific Publications, No. 38).
Io. I 5 The association between the consumption of alcohol and cancers of the digestive and upper respiratory tract has now been demonstrated in a number of studies. Oesophageal cancer, in particular, is strongly associated with both drinking and tobacco consumption, and a detailed case-control study is being completed in Calvados and Orne (France), where the mortality rates exceed 30 per Ioo ooo inhabitants in both males and females. Concurrent experimental studies in which Wistar rats were given samples of apple brandy in their drinkingwater failed to show any excess of tumours or precancerous lesions in the animals.
Oesophageal cancer Io. I6 The prevalence of oesophagitis has been studied in a population at high risk of oesophageal cancer in Lin Xian, China, and for comparison in a low-risk population in Jiao Xian. Oesophagitis, identified by endoscopy, was seen approximately twice as I
57
THE WORK OF WHO, I98o-1981
often in the high-risk population of Lin Xian, both male and female, as in Jiao Xian. These findings support the hypothesis that this lesion is a precursor of oesophageal cancer, a finding that should prove of considerable importance in epidemiological studies of the causation of the cancer. The study was carried out with the collaboration of the Beijing Cancer Institute, the Honan Medical College and Honan Cancer Institute, China, and the Regina Elena Institute, Rome.
confirmed by a-fetoprotem determmatwn, since no histopathological confirmation is available. IO.I9 A cohort study to determine the risk of developing primary liver cancer among carriers of hepatitis B surface antigen is being carried out in the Chinese population of Singapore, in collaboration with the University and the Blood Bank. Of a total of 929 people in the cohort, 65 (7%) were positive for the surface antigen. Io.2o A study is in progress in the Philippines, in collaboration with the Department oflnternal Medicine, Philippines General Hospital, to determine the rate of perinatal transmission of hepatitis B virus and subsequent development of a carrier state among children born to "carrier" mothers as compared with "non-carrier" mothers. Blood was taken from the children after the first month of life and they will be followed up until the age of one year.
Cancer of the large bowel I o. I 7 The international study of cancer of the large bowel has largely confirmed the hypothesis regarding the protective role of dietary fibre. The results so far suggest that the risk is determined by a complex interaction of dietary factors and it is postulated that dietary fat and protein promote cancer by increasing the output of bile acid. The action of dietary fibre appears to be to increase the faecal bulk and thus reduce the concentration of any carcinogen or cocarcinogen that may be present in the stool and in contact with the bowel mucosa. In a study of the distribution of various lesions of the colon and rectum in populations in Europe, it was shown that the prevalence of polypoid lesions was higher in areas of high incidence of cancer of the large bowel, and that the polyps also tended to be larger.
Hazards of man-made mineral fibres I0.2 I The follow-up study of the health risks associated with mineral fibre production has reached its final phase. The collection of data from I 3 factories in seven countries is now complete, and the results of the environmental survey carried out by the Institute of Occupational Medicine, Edinburgh (United Kingdom), at each of the factories have been sent to the Agency, so that estimations of exposure to airborne fibres can be made for individual work stations. Cancer morbidity and mortality will be compared among groups of workers with differing degrees and lengths of exposure. I0.22 In the study of a localized high incidence of mesothelioma in central Turkey, zeolite fibres were found in higher concentration in some of the samples of air from the
Cancer of the liver Io.I8 In collaboration with FAO and UNEP, the Agency is assessing the effect of measures to decrease aflatoxin contamination of foodstuffs on the prevalence of liver cancer in Swaziland. At the Agency's laboratory in Swaziland, more than 1000 specimens have so far been analysed for mycotoxins. In order to strengthen the data collected from the cancer registries, cases of liver cancer are being
q8
NONCOMMUNICABLE DISEASE PREVENTION AND CONTROL
village affected, but the overall fibre concentrations were too low for a definite assessment. A case-control approach is now being made to ascertain the frequency of zeolite deposits in the houses of cases as compared with those of controls. Rock samples are being analysed at the Medical Research Council Pneumoconiosis Unit, Penarth, United Kingdom.
of which occupational exposures are typical examples, was a new departure in the series. I o. 2 5 The ninth information bulletin in the survey of chemicals being tested for carcinogenicity included reports on 970 chemicals in 99 institutes in I 8 countries. 2
Long-term effects of pesticides on human health I0.23 A cohort of 9ooo workers in Colombia engaged in floriculture is being followed to determine the health hazards arising from long-term exposure to pesticides. In the first phase a prevalence survey was carried out of congenital malformations among children born to women engaged in floriculture or to women whose husbands were so engaged. A case-control study will follow in an effort to establish reproductive histories and details of occupational exposure.
Io.26 Laboratory studies were devoted to methods of monitoring human exposure to environmental carcinogens and identifying individuals at higher risk. The preparation of monoclonal antibodies against carcinogenDNA adducts has provided a method that may make it possible to determine an individual's exposure to a given carcinogen. Pilot studies were carried out on oesophageal tissues collected in Lin Xian, China, to identify adducts indicating exposure to carcinogenic nitrosamines. I0.27 The differences between individuals in levels of carcinogen-metabolizing enzymes may indicate differences in susceptibility to given carcinogens. For example, the differences in susceptibility to cigarettesmoking between individuals might be attributable to differences in the activity of the enzymes responsible for metabolizing benzo(a)pyrene, one of the carcinogens present in cigarette smoke. Benzo(a)pyrene metabolism was therefore studied in lung tissue and mucosal specimens from lung cancer patients, and compared with the metabolic levels observed in cancer-free individuals. Io.28 Methods have been developed in experimental animals to permit quantitative estimation of the in vivo formation of nitrosamine. The safety of the methods having been confirmed, they have been used
Chemical carcinogens I o. 24 During the biennium five international working groups met in Lyon to evaluate the published literature relating to 53 chemicals and 8 industrial processes. Their proceedings were included in the IARC monographs on the evaluation of the carcinogenic risk of chemicals to humans, of which the first four were published. 1 The evaluation of risks associated with complex exposures,
1 International Agency for Research on Cancer. !ARC monographs on the eval~~t~tton of the carcinogenic risk of chemicals to humans: Volume 24, Miscellaneous pharmaceutical drugs, Lyon, 198o; Volume 2J, Wood, leather and some associated industries, Lyon, 1981; Volume 26, Some antineoplastic and immunosuppressive agents, Lyon, 1981; Volume 27, Some aromatic amines, anthraquinones and nitroso compounds, and inorganic fluorides used in drinking-water and dental preparations, Lyon, 198 r.
2 Ghess, M.J ., Wilbourn, J.D., Bartsch, H. & Tomatis, L. Information bulletm on the survry of chemicals being tested for carcinogenicity, volume !I· Lyon, International Agency for Research on Cancer, 1981.
THE WORK OF WHO, 198o-I981
to determine the levels of in vivo nitrosamine formation in humans. Techniques of chemical analysis of nitrosamines have also been applied to the measurement of these P~!tative carcinogens in urine samples collected in areas of high and low risk of oesophageal cancer. I0.29 The development continued of short-term tests based on methods of measuring mutagenic activity and capable of indicating possible carcinogenic substances. Tests employing bacterial colonies, and others in which mammalian cell lines were used, were applied to screening for active substances and to the study of mechanisms of carcinogenic activity by the identification of active metabolites.
Cardiovascular diseases I0.33 Changes appear to be occurring in the incidence of cardiovascular diseases that may require the strengthening of WHO activities in developing countries. For instance, the figures from Malaysia show that, while cardiovascular diseases rated fourth among all causes of mortality in I965 and third in I97o, they were first in I975 and accounted for I 3% of all deaths. There was a similar development in Mauritius, where in I979, if cerebrovascular diseases are included, more than 30% of all deaths were attributable to cardiovascular diseases. On the other hand, several countries that previously had rising death rates have shown a levelling off or even a decrease in the rates (e.g., Australia, Finland, New Zealand, and the United States of America). Planning for an international study to monitor the trends and determinants in cardiovascular diseases was therefore started in I98o. A protocol was prepared in I 98I and tested in a feasibility study in three centres in Europe-North Karelia (Finland), Kaunas (USSR), and Copenhagen. The first meeting of investigators in the multicentre study was held in October I98r. The study will start in 1982 and, over a Io-year period, will measure trends in cardiovascular disease mortality and coronary heart and cerebrovascular disease morbidity and assess the extent to which the trends in defined communities are related to changes in known risk factors, health care, or major socioeconomic features. This project might serve as a model for monitoring morbidity trends in other diseases and should lead to the development of a permanent system for the collection of data on morbidity from chronic disease.
Training 10.30 Seven short courses were held. Two in the Agency were devoted to epidemiological aspects of occupational cancer and one to chemical carcinogenesis. A course on the utilization of primates in cancer research was held in Sukhumi (USSR), and three on epidemiology were organized in Bogota, Limassol (Cyprus), and Ndola (Zambia). There were approximately 40 participants in each course. I0.3I Twenty-five fellowships were awarded during the biennium to postdoctoral scientists studying epidemiology or aspects of environmental carcinogenesis. Of these, seven were tenable at the Agency. 10.32 An international symposium on host factors in human carcinogenesis was organized with the support of the Commission of the European Communities and the Greek Government. A training component was included that enabled I2 promising young postdoctoral scientists to participate. I6o
Primary prevention 10.34 An Expert Committee on the Prevention of Coronary Heart Disease held in Geneva in November-December I98I
NONCOMMUNICABLE DISEASE PREVENTION AND CONTROL
reviewed the available data, discussed alternative approaches to prevention, and made practical recommendations on strategies for population-based approaches to prevention in countries with a high as well as a low incidence of coronary heart disease. In the former the most effective approach is the mass approach aimed at reducing the levels of different risks; in the latter it is primordial prevention of the development of unfavourable lifestyles and risk factors. Io. 3 5 The results of the follow-up study on primary prevention of ischaemic heart disease were published in the Lancet.l In this trial a lipid-lowering substance, clofibrate, was administered in a double-blind trial to middle-aged male volunteers whose serum cholesterol levels were within the upper third of the distribution in their respective populations (Budapest, Edinburgh, Prague). After an average of 5. 3 years of observation, the initial serum cholesterol level having been reduced by about 9%, the incidence of ischaemic heart disease had fallen by 20% in the intervention group as compared with the placebo group (which received olive oil), thus demonstrating the preventive value of lowering this plasma lipid. However, there was a significant increase in total mortality and in non-cardiovascular mortality in the group that received clofibrate, a trend that seems to be continuing, as evidenced by follow-up studies. The explanation for this trend is not clear, but several possible mechanisms are being considered, including the long-term toxic effect of clofibrate, the possible consequences of reducing body cholesterol pools in middle-aged men, and even chance. Close monitoring of all the volunteers in the centres that took part in the trial is being carried out and will continue for several years.
10.36 To stimulate research in the prevention of ischaemic heart disease in early life, WHO is coordinating pilot programmes on the study of risk factors in childhood and youth. After descriptive epidemiological investigations in Geneva and northern Italy had ended, intervention programmes in schoolchildren started in Finland, the German Democratic Republic, the Federal Republic of Germany, Israel, and Norway to assess the most appropriate health education methods for healthy low-risk ways oflife. To study the origins of coronary heart disease, preparations were made for a morphological study to assess structure and structural changes in the coronary arteries of children. I o. 37 Within the context of prevention, a new concept, primordial prevention, is receiving special attention. This is primary prevention in its purest sense-prevention of the development of risk factors in populations still free from most of the cardiovascular diseases. A project was started to see if, in selected developing countries, cardiovascular diseases can be prevented from reaching the epidemic proportions experienced in industrialized countries by removing risk factors. The design was further elaborated by a group of consultants in February I98r. Initially the main emphasis will be on the control of tobacco smoking and the development of healthy nutritional habits.
Community control Io.38 The WHO-coordinated study on comprehensive cardiovascular community control programmes, which started in I974 and is carried out by centres in all parts of the world, was the subject of two meetings during the biennium, one in Prague in September I98o, the other in Nairobi in October I981. Experience from this study is being used in developing the programme on integrated noncommunicable disease prevention and control (paragraph I o. I).
10.39 A WHO-coordinated 1o-year study on the community control of hypertension ended in 1980. The preliminary results were discussed at the final meeting of investigators in December 1980 in Geneva. One of the most important outcomes of this cooperative project is the experience gained in organizing and operating hypertension control programmes in different social and health care settings. The preliminary report covered the setting up, management, and evaluation of a hypertension project; cooperation with and motivation of the health services; and the need to make hypertension control an integral part of basic health care. The conclusion was that pilot programmes for the community control of hypertension are feasible and effective and a useful tool for acquiring new knowledge of hypertension control methods in populations. However, when formulating plans for hypertension control in total populations, the sociopolitical environment in its widest sense should be taken fully into consideration. A report on the whole study will be prepared after analysis of the outstanding data. 10.40 Following a meeting of investigators held in New Delhi in November 1979, which marked the end of a long-term study on the community control of rheumatic fever and rheumatic heart disease, a report was issued emphasizing the feasibility and practicality of early prevention measures. Experience from the multicentre cooperative project showed that control projects as outlined in the WHO protocol 1 are feasible in developing countries. Regular surveillance can be difficult, but the gains are considerable even with a followup rate of 5o% and only half of those followed up on regular prophylaxis. Although it was not possible to measure the direct health benefits quantitatively, the benefits in terms 1 WHO Chronicle, 34: 336-345 and 389-395 (r98o); Bulletin of the World Health Organization, 59: 285-294 (I 98 I).
of health care expenditure were such that the direct health benefits can be assumed to be great indeed. An essential requirement for success is for the programme to be part of the national health policy. Rheumatic fever control should be at national and local community level, with full cooperation between the cardiological, paediatric, and school health ser':ices within the framework of primary health care. The elaboration, publication, and dissemination of strategies for the community control of rheumatic fever and rheumatic heart disease are under way, with special reference to developing countries.
Research and information 10.41 A research project on the standardization of tests to assess abnormal tendencies to thrombosis began in centres in London, Prague, and Krakow (Poland). It will form the basis for prospective studies in which an assessment will be made of their predictive value in ischaemic heart disease events. As a first step a feasibility study was started (i) to demonstrate the feasibility of collecting large numbers of samples for haemostatic function tests in a fairly short time, and (ii) to see whether within each centre there are similar relationships with age, smoking, and other risk factors in the population samples studied. 10.42 The role of nutritionai!J induced trace element imbalance in the occurrence of myocardial infarction and hypertension has been studied for the past ten years in collaboration with IAEA and a network of collaborating pathology institutes and analytical laboratories. The project has now ended and the results are being evaluated. 10.43 Physical activity to prevent coronary heart disease is continuing to attract worldwide interest. After the publication of a
NONCOMMUNICABLE DISEASE PREVENTION AND CONTROL
monograph in 1978, 1 another on physical activity in disease prevention and treatment is in preparation.
Nomenclature and classification 10.44 WHO and the International Society and Federation of Cardiology (ISFC) continued to collaborate closely. Joint WHOJISFC task forces prepare recommendations for the standardization of classification, nomenclature, and diagnostic criteria for different cardiovascular diseases. Task forces on nomenclature and classification of arrhythmias and on nomenclature of ischaemic heart diseases have published reports in previous years.2 The task force on definition and classification of cardiomyopathies published its report in 1980.3 A task force on haemodynamics is finalizing its recommendations. A task force on nomenclature in echocardiography has been organized. It is planned that WHO, ISFC, and CIOMS will eventually publish a compendium of all the recommendations of these task forces.
10.46 A course in cardiovascular diseases epidemiology was held in Singapore in September 1980. It was organized by the Regional Office for the Western Pacific and was a follow-up of the course held in 1978 in Wellington.
Smoking and health 10.47 An international clearing-house for information on smoking and health became operational in May 1981. Its purpose is to collect (i) statistics on national tobacco and cigarette production, per capita consumption, smoking prevalence by age, sex and race, etc.; and (ii) information on smoking control activities, including legislation, public information, educational approaches, health warning labels, statements of tar, nicotine, and carbon monoxide yield, advertising restrictions, and other action or voluntary agreements for the purpose of reducing smoking. These data are widely scattered in the literature and in reports, many of which are not easily available; they will be collated and issued by WHO in special reports. The dearing-house is partly funded by the United States Department of Health and Human Services. 10.48 A project on the analysis of tar, nicotine, and carbon monoxide yields of cigarettes collected in selected developing countries has begun. The analyses are being carried out at WHO collaborating centres. 10.49 An international conference on tobacco and youth was held in Venice in November 1981 with WHO co-sponsorship. 10.50 Tobacco report, a WHO newsletter, appeared twice in 1981 and is expected to be issued quarterly in 1982. Five thousand copies in English and three thousand in French of each issue were distributed worldwide and have been well received.
Training 10.45 Annual ISFC 1o-day international teaching seminars on cardiovascular epidemiology and prevention, held in collaboration with WHO, were organized in Kaunas (USSR) in August 1980 and in Heidelberg (Federal Republic of Germany) in August 1981.
1 Lange Andersen, K. et a!. Habitual pf!ysical activity and health. Copenhagen, World Health Organization,
1978 (WHO Regional Publications, European Series, No.6). 2 American Heart Journal, 95: 796-8o6 ( 1978) and 98: 263-267 (1979); Circulation, 59: 607-609 (1979). 3 British Heart Journal, 44: 672-673 (198o).
THE WORK OF WHO, 198o-1981
Io.p The theme of World Health Day I98o, "Smoking or health-the choice is
yours", aroused a great deal of interest and resulted in intensified anti-smoking campaigns in many countries. Io. 52 The first of two workshops on smoking and health issues in developing countries, organized in collaboration with SIDA and national authorities, was held in Colombo in November I98I; a second will be held in I982 in Swaziland.
Io. 55 During the biennium two national research centres were designated as WHO collaborating centres: the Institute for Diabetes, Endocrinology and Metabolic Diseases, Zagreb (Yugoslavia), as WHO collaborating centre for the development of appropriate technology in the control of diabetes mellitus; and The Royal Southern Memorial Hospital, Caulfield, Victoria (Australia) as WHO collaborating centre for the epidemiology of diabetes mellitus, to assist WHO in training and the organization of epidemiological studies on diabetes in the Western Pacific.
Other chronic noncommunicable diseases Diabetes mellitus 10. 53 The WHO Expert Committee on Diabetes Mellitus, the second report of which was published in I98o,1 drew particular attention to the need to involve the community as well as the patient. The main health services for diabetics, it considered, should be at community level; preventive, promotive, curative, educational, and research activities should all have their basis in primary health care; and national diabetes programmes should be developed. 10.54 Following those recommendations, planning for a national diabetes programme in Malta was begun in I98o; it covered an epidemiological study, an educational programme for health personnel, patients, and the public at large, and the development of health services. A collaborative epidemiological study on diabetes as related to malnutrition was started in which a number of developing countries are participating.
10. 56 Cooperation with nongovernmental organizations such as the International Diabetes Federation was further developed. The training of health personnel and the dissemination of information to front-line health workers were promoted. WHO, along with the Federation and the national authorities, organized the first international seminar on clinical epidemiology and public health aspects of diabetes in Cambridge (United Kingdom) in July I981. I0.57 The follow-up stage of the WHO multinational study of vascular disease in diabetics was continued. In this study I4 research centres from I 3 countries are collaborating.
Chronic respiratory diseases 10. 58 Stronger emphasis was placed on the involvement of the community in chronic respiratory disease prevention and control, and closer cooperation was developed with the scientific committee on respiratory diseases of the International Union Against Tuberculosis. A joint meeting (Geneva, February I 98 I) identified priorities for epidemiological and operational research within the framework of an overall WHO programme on respiratory diseases.
1 WHO Technical Report Series, No. 646, 1980.
NONCOMMUNICABLE DISEASE PREVENTION AND CONTROL
Chronic rheumatic diseases I o. 59 Guidelines for the further development of a rheumatic diseases programme were drawn up at a joint meeting in Geneva (January I98I) with the International League against Rheumatism. 1 The Philippines was selected as the target country for a community-oriented rheumatic diseases prevention and control programme, jointly coordinated by the national authorities, the International League, and WHO.
Io.6o In the Americas collaborative studies are being carried out on the profile of patients with chronic rheumatic diseases who seek care in rheumatology and allergy clinics. Particular emphasis is placed on the degree of disability and dependency caused by these diseases, including their effect on functional and working capacity and, in allergic diseases, their relation with risk factors in the environment. The use of medical facilities for both groups of diseases is also being investigated.
incidence of hereditary anaemias and related conditions were collected in Bali (Indonesia), Nigeria, and the USSR, and the molecular base of their heterogeneity was investigated. With WHO assistance a programme on community control of thalassaemias was carried out by the University of Ferrara, Italy, in which a sharp downward trend in the birth rate of affected children was observed. To review experience in other countries, assess recent advances, and gauge the possibilities of support for a worldwide attempt to control hereditary anaemias, an ad hoc WHO meeting was held in Cagliari (Italy) in June I 9 8 I in association with an international symposium on thalassaemias. It considered that the preventive approach to hereditary anaemias could be integrated into the health care programmes of the communities where the diseases are common, and that WHO could be of assistance to the Member States concerned by providing guidance and establishing standards. To explore the subject further a working group on the community control of hereditary anaemias was held in Geneva (November I98I). Io.63 The Organization continued to support the development of international repositories for genetic disorders. The seventh and eighth listings in the Repository of chromosomal variants and anomalies in man have been produced.z Io.64 Two international meetings were given support: the annual meeting of the European Society of Human Genetics held in Dubrovnik (Yugoslavia) in I98o and the VII International Workshop on Human Gene Mapping held in Oslo in I981. Eight WHOassisted research centres concentrated their activities on the genetic approach in the
Hereditary diseases and those where there is genetic predisposition Io.6I In human genetics the programme concentrated mainly on international collaboration in the management of some common genetic disorders and the application of genetic knowledge and further development of the genetic risk approach in the prevention and control of certain communicable and noncommunicable diseases. Io.6z Five research centres in four regions collaborated on the management of certain genetic disorders (hereditary anaemias and thalassaemias in particular, highly prevalent in the areas where malaria was formerly common). New data on the distribution and
1
WHO document NCDJOND/ RHEUM/8I.I (1981).
2 Repository of chromosomal variants and anomalies in man. Seventh listing, June 1980, Denton, North Texas State University. Eighth listing, August 1981, Wilmington Medical Center, Delaware (USA).
prevention and control of noncommunicable and infectious diseases. Genetically determined differences in susceptibility to infectious diseases were further studied in India, the USSR, and Zambia with a view to developing methods for the utilization of genetic markers in the prevention and treatment of communicable and parasitic diseases. In addition to the markers previously studied, a complex of genetic, anthropometric, and clinical characters were found to be correlated with non-specific lowered resistance to disease such as childhood pneumonia. A new project was also initiated on the genetic nature of differences in response to vaccination, and a WHO-assisted feasibility study is under way in Bulgaria. New data were collected on the distribution of HLA-DR antigens in normal populations of the USSR and on the association of some HLA antigens with diseases in Romania (ankylosing spondylitis, Behc;et's. syndrome, and lupus erythematosus). Research on the genetic component of common chronic diseases and on genetic epidemiology was coordinated with the assistance of the WHO collaborating centre for the processing of human genetic data (University of Hawaii, USA). 10.65 A review of the programme on human genetics took place during the biennium and a WHO task group met in November 1981 to consider the action required. The working group on the community control of hereditary anaemias (paragraph 1 o.62.) inter alia assessed their suitability as model genetic disorders in the development of WHO's human genetics programme.
visited the countries of the Region, assessed the facilities for treatment available, and prepared a draft medium-term programme for the prevention and control of deafness.
Oral health 10.67 Emphasis was given to the development of standard methods for analysing the oral health situation and coordinating planning, and WHO published a guide for both developed and developing countries.! The major activity in all regions continued to be technical cooperation in the integrated planning of oral health services. The concept of demonstration, training, and research centres for oral health is now well accepted. The first such centre was officially opened in Thailand and agreement has been reached with the Syrian Arab Republic for the development of a similar centre. Further centres are under consideration in China and in Africa. These centres will develop and strengthen technical cooperation between countries at different levels of development and provide a focus for the dissemination of standard methodology on integrated planning and for the improvement of teaching and of technology. They will help in international collaborative research on, for example, the intake and metabolism of fluoride in different cultural and nutritional settings or the evaluation of alternative health care delivery systems. They will also provide field demonstrations of preventive measures and delivery systems. 1o.68 To assist countries in the monitoring of their oral disease trends, WHO collaborated in studies of the epidemiology of oral diseases and continued to monitor the global oral health programme. A new standard methodology, the community peri1 Planning oral health services. Geneva, World Health Organization, 1980 (WHO Offset Publication No. 53).
Preventable deafness 1o.66 In the South-East Asia Region it was concluded, on the basis of preliminary data from rural areas, that preventable deafness attributable to otitis media was a health problem requiring attention. A consultant 166
NONCOMMUNICABLE DISEASE PREVENTION AND CONTROL
odontal treatment needs index, was developed for assessment of the periodontal status and treatment needs of populations and was tested in an international collaborative study involving I 3 countries. This index, which will now be used as an international standard, provides a reliable method for the planning, monitoring, and evaluation of periodontal disease prevention and control programmes. Io.69 The first of a series of field demonstrations of preventive programmes and measures was completed in one country, and similar programmes are in progress in three other countries. These field demonstrations are supported by the Voluntary Fund for Health Promotion. 10.70 Annual coordination meetings continued, with the help of extrabudgetary funds, to coordinate essential research. In the international collaborative study on dental manpower systems, I 3 sets of data from I I countries are now being prepared for analysis.
Workers' health 10.7 3 Resolution WHA 33. 31, endorsing the programme of action on workers' health for the years I979-I984, urged Member States to pay special attention to the provision of health care to working populations, particularly "underserved" workers, and requested the Director-General to "support the developing countries in ensuring safe working .conditions and effective protective measures for workers' health in agriculture, mining and industrial enterprises by using experience available in this field". This resolution was followed by intensified efforts (i) to identify the major occupational health problems of underserved working populations in developing countries, (ii) to initiate country projects in occupational health services and training, and (iii) to develop occupational health knowledge and technology in cooperation with WHO collaborating centres in various parts of the world.
Following reports of the development of new and more efficient preventive procedures, a system of review and assessment of preventive materials was instituted. The detailed information obtained will be used to advise administrators on the choice of such materials. Io. 7I 10.72. The trend towards decreased oral disease in highly industrialized countries, accompanied by a continuing high level of production of oral health personnel, has reached the stage at which dental manpower surpluses of considerable proportions are imminent in a number of countries. Consideration is being given by WHO to the possibility of deploying the surpluses to ease the worsening manpower situation in developing countries until their own oral health manpower training facilities are sufficiently developed to provide adequate numbers of trained personnel.
Identification of problems
10.74 WHO collaborated with 15 Member States in field surveys to identify occupational health problems and develop practical methods for the detection, evaluation, and control of various occupational health risks. Cross-sectional studies of workers' health problems in agriculture and small industries were made in Burma, Egypt, the Philippines, Sudan, the United Republic of Tanzania, and several other countries. Miners' health problems, particularly pneumoconiosis, were investigated in Bahrain, Botswana, and the Republic of Korea. A research programme on the monitoring of occupational exposure and the effects on health of chemical and physical hazards was carried out in Brazil, Bulgaria, Czechoslovakia, Poland, Switzerland, and the USSR. An epidemiological study correlating various working conditions, workload, and health of
THE WORK OF WHO, '980-198'
workers was undertaken in the German Democratic Republic. A review of the findings of investigators of occupational health problems in developing countries was made by the Permanent Commission and International Association on Occupational Health at a meeting in Colombo (April I98I)-cosponsored by WHO. I o. 7 5 In Thailand, a new feasibility study was initiated in June I98I to introduce primary health care in workplaces, particularly in small-scale industries where no other health systems are available. One of the aims of the study is to produce guidelines on primary health care in workplaces for examination in regional workshops. A similar study started in Sri Lanka in November I981.
the ILOJWHOJUNDP project on central and regional occupational health laboratories in Indonesia included the development of primary health care for workers in rural areas and the introduction of modern control technology in large industrial establishments. WHO assisted the Ministry of Health in Malaysia in the development of an occupational health unit, which will become the national reference centre on occupational health matters. The aim of a WHOJUNDP project in Mauritius is to develop a unit for the training of occupational health and safety personnel, and of one in Singapore to set up a national institute of occupational health and safety. 10.78 Occupational health manpower is in short supply in most countries. The Joint ILOJWHO Committee on Occupational Health at its meeting in March I98I developed guidelines on training and education in occupational health, safety, and ergonomics.! WHO also organized or coordinated several regional or interregional courses and seminars on various occupational health subjects. The third interregional workshop on the organization of occupational health services took place in Sofia in June I98I and was attended by I 5 participants from I 5 different countries. It emphasized the multidisciplinary approach to the control of occupational health hazards and recommended methods for their assessment and control and for the integration or coordination of occupational health with national health services. 10.79 In May I98I WHO assisted the fourth international course in occupational and environmental toxicology in Belgrade, which was attended by I 7 participants from developing countries----chemists, physicians, and other health personnel--and provided
Technical cooperation 10.76 The number of countries involved in technical cooperation with WH 0 increased to some 30, in all regions. Preliminary surveys to assess health problems and develop occupational health units and laboratories were assisted by WHO consultants in Bangladesh, Botswana, Burma, China, Greece, Jordan, Kenya, Macao, Mauritius, Mozambique, Qatar, Saudi Arabia, Somalia, Yemen, Zambia, and Zimbabwe. A main purpose was to assist the health authorities in developing workers' health programmes that are integrated or fully coordinated with the national health services. Some projects also included the training of personnel and the preparation of plans for the development of occupational health institutes. WHO assisted in the development of an industrial health service centre with occupational hygiene laboratories in a newly industrialized district in Burma. In collaboration with UNEP, Io. 77 WHO assisted in the development of the national centre for occupational and environmental health near Cairo. The second phase of I68
1
WHO Technical Report Series, No. 663, 1981.
NONCOMMUNICABLE DISEASE PREVENTION AND CONTROL
instruction in basic knowledge and practical methods. It organized an international seminar on the risk assessment of chemicals, with 27 participants from Europe, in Lodz (Poland) in September I98o, and an international course on occupational health in agriculture, particularly emphasizing pesticide intoxications, in September and October I98o at the same institute. The latter course was attended by I o participants from different countries. An advanced course on biological monitoring of exposure to industrial chemicals was coordinated by the Regional Office for Europe at the Institute of Occupational Health, Helsinki, in August I98o. WHO and ILO co-sponsored an international symposium on occupational cancer in Helsinki in April I98I and an international symposium on education and training policies in occupational safety and health and ergonomics in Sandefjord (Norway) in August I981. Io.8o WHO initiated a study on the organization of occupational health services in Cuba, Egypt, Greece, Sudan, Thailand, the United States of America, and the USSR, and prepared a working document for a joint ILOfWHO project on institutional arrangements for occupational health at national level. The responsibilities of different government agencies and mechanisms will be identified to ensure coordination and cooperation among them.
agriculture, as a first step towards guidelines for the detection and control of occupational hazards in agricultural work and for the health education of workers in agriculture. A meeting of the Joint ILO/WHO Committee on the Health of Seafarers took place in September I98I to revise and update the International medical guide for ships, a joint WHO/ILO/IMCO guide for the diagnosis and treatment of emergencies and diseases affecting seafarers, published in I 967. Io.82 In the field of occupational hygiene, guidelines were produced on the evaluation of airborne particulates in the work environment. Two consultations helped with their preparation, the second meeting during the biennium (Alexandria, September I98I). These guidelines will provide occupational hygienists with simplified methods for the evaluation of the different airborne dusts. WHO also organized an interagency consultation on guidelines in occupational health for the establishment and operation of specific industries (June I98I), bringing together participants from UNDP, UNEP, ILO, the World Bank, IAEA, and WHO. Two main industries were selected as a priority: (i) iron and steel, and (ii) pesticides (manufacture, formulation, and use). I0.83 Two study groups were convened to recommend occupational exposure limits, one in June I98o for the commonly used solvents carbon disulfide, toluene, trichloroethylene, and xylene,l the other in June I98I for the pesticides malathion, carbaryl, lindane, and dinitro-o-cresol.2 Io.84 Guidelines on the early detection of health impairment in occupational exposure to vegetable dusts were finalized in I98o. In the same year a consultation was held 1 WHO Technical Report Series, No. 664, 1981.
Occupational health technology I0.8I In relation to occupational health technology, WHO organized a meeting in Copenhagen to prepare a manual on occupational health epidemiology that will become self-instruction reference material and also be used in training courses. This project is supported by the National Institute for Occupational Safety and Health (USA). A consultation was also held in April and May I98o on a manual on occupational health in
To be published in the WHO Technical Report Series in 1982. 2
THE WORK OF WHO, 198o-I981
on the preparation of a manual whose aim will be to help occupational physicians with the early diagnosis of occupational diseases in periodic health examinations of workers. I0.85 In view of the importance of synergism in the health hazards of the work environment, WHO convened an expert committee on the subject in December I 98o 1 to review research on combined exposure to multiple factors, physical, chemical, and biological, and their effects on health. It also reviewed existing knowledge on the influence of smoking, alcohol and drug consumption, malnutrition, and parasitic diseases on the health effects of occupational hazards. It identified gaps in knowledge and made recommendations on further research and the application of occupational hygiene standards in combined exposure.
programming and harmonization. An interagency meeting took place with ILO, UNEP, and other bodies in Rome (September I98o) for the preparation of a medium-term plan for occupational health and safety identifying the main areas of concern for each agency or body in the improvement of the working environment.
Immunology Io.88 During the biennium the network of WHO immunology research and training centres was expanded by the addition of a new centre in Beijing at the Institute of Basic Medical Sciences, Chinese Academy of Medical Sciences. The centre organized a four-week course on immunology in I981. The training programme of the centre at Lausanne/Geneva, supported largely by the Swiss Government, was enlarged by the granting of six-month fellowships to enable two students to stay on for further studies after the annual course in English. The number of students accepted for the course in French was increased from five to seven. A complementary programme was also established to help ex-students to set up their own research and training programme on their return to their home institutions. These extensions of the programme were made possible by an increased donation from Switzerland. The PAHO/WHO immunology research and training centre organized a course in I 98o in Sao Paulo, Brazil. Io.89 The WHO immunology research and training centre for advanced studies in Rehovot (Israel) organized a course on molecular and cellular aspects of antigenicity. The centre in Singapore organized a symposium on hybridoma technology. Assistance was provided for a symposium on clinical inimunology in Caracas.
New areas of concern Io.86 Consultations took place in the second half of I 98 I to prepare a detailed programme of work on psychosocial factors and ergonomics. A new programme on injury prevention, assisted financially and technically by the National Institute for Occupational Safety and Health, USA, was initiated by a consultation in November I98I dealing with human aspects in the control of occupational injuries.
Coordination with other organizations Io.87 Coordination with UNEP, UNIDO, ILO, and other agencies continued during the biennium. The Joint ILOfWHO Committee on Occupational Health (paragraph 10. 78) also reviewed ILO and WHO work in occupational health with a view to joint
t
WHO Technical Report Series, No. 662, 1981.
NONCOMMUNICABLE DISEASE PREVENTION AND CONTROL
10.90 Under the programme for the production of immunological reagents, a course was organized in Bangkok and a collaborating centre was established in Birmingham (United Kingdom). The centre will provide the standard reagents needed for the production of good-quality immunological reagents in different countries, train technical personnel, and control the quality of the material produced. A regional centre for the production of immunological reagents was established in Islamabad and a request for the establishment of a similar centre in Bangkok is being considered. 10.91 Interregional collaboration for the development of a vaccine against dengue haemorrhagic fever is progressing according to schedule. Attenuated strains of all four serotypes were obtained.
Union of Immunological Societies, WHO conducted a critical review of some of the most frequently used tests in clinical immunology with the aim of reducing the cost of patient care. The results of the meeting were published 1 and steps are being taken to bring this source of economy to the attention of ministries of health. With the same committee, WHO reviewed the effectiveness of gammaglobulin in preventing some infectious diseases and treating immunological disorders. In collaboration with the standardization committee of the International Union, a standard anti-human IgG labelled with horseradish peroxidase was produced and is being considered for acceptance as an international reference reagent. The work was made possible by a grant from the United States National Institutes of Health. 10.94 A meeting on the immunity of the mucous membrane reviewed the present state of knowledge and made recommendations for further research.
A programme to assess the socioeconomic importance of allergic diseases in developing countries started in Kuwait, Thailand, and Venezuela. 10.92 10.93 Together with the clinical immunology committee of the International
1
Bulletin of the World Health Organization, 59: 717-728
( 1981 ).
Chapter
II
Promotion of Environmental Health International Drinking Water Supply and Sanitation Decade II.I THE INTERNATIONAL Drink-
ing Water Supply and Sanitation Decade, I98I-I990, was launched by the United Nations General Assembly in November I98o, the aim being to provide all people with adequate supplies of safe water and sanitation by I99o, if possible. For the launching of the Decade, the Secretary-General of the United Nations prepared a comprehensive report t on the drinking-water supply and sanitation situation. WHO had a principal role in the analysis, collation, and interpretation of the data and in the preparation of the report. II.2 In May I98I the Thirty-fourth World Health Assembly, in resolution WHA 34· 2 5, emphasized safe drinking-water and adequate sanitation as basic elements of primary health care and listed the principles through which the Decade will contribute to the improvement of health as part of the Global Strategy for health for all by the year 2ooo. The Health Assembly recommended that Member States propose relevant water supply and sanitation programmes and projects for external support with the objective 1 Development and international economic co-operation, International Drinking Water Supp!J and Sanitation Decade: present sit11ation and prospects. Report of the Secretary-General (United Nations document A/35/367).
of reaching underserved populations, fostering coordinating mechanisms, focusing on national health priority problems, associating the community with all stages of the programmes and projects, and strengthening national agencies. Multilateral and bilateral agencies were invited to support national plans. I I. 3 The launching of the Decade stimulated wide interest in national planning to extend and improve water supply and sanitation services. Some 6o countries have formed national action committees, and national Decade plans are being prepared in a number of countries. Increasing attention is being given to projects that will benefit underserved rural and urban fringe populations. WHO helped more than 30 countries in four regions in Decade planning, using its own resources as well as resources from UNDP, GTZ, and SIDA. The World Bank/ WHO cooperative programme played an important part in this work. WHO organized I 5 national planning workshops, in the course of which national officials clarified the issues, agreed on urgent measures, and formulated a policy for Decade planning. In addition, a number of specialized workshops were held on the economic and financial, technology transfer, and data management aspects of Decade planning. The results of WHO's experience were summed up in the document referred to in paragraph I 1. 1. WHO also
PROMOTION OF ENVIRONMENTAL HEALTH
published guidelines for the application of the principles of the Decade in the preparation of national plans. 1 WHO strategy is to cooperate with the governments that have the will to give effect to the principles of the Decade and to help in the mobilization of resources; to cooperate in national efforts with other internatiomil organizations, particularly UNDP, UNICEF, and the World Bank; to advocate forcefully and consistently the orientation of the Decade towards the priority health problems of Member States; and to give precedence to technical cooperation at country level. I I ·4 A review of the progress achieved in the provision of drinking-water supply and sanitation during the I 97os showed that the targets set for the I o years prior to the Decade were not fully met. Only about two out of five persons had access to safe drinking-water and only one out of four had some kind of sanitary facility. A rough comparison between the situation in I970 and in I98o showed a modest improvement in water supply but practically no progress in sanitation. Since the United Nations Water Conference at Mar del Plata (Argentina) in I977, however, changes have occurred; Member States are increasingly aware of the potential of the Decade as a means of improving people's health and the quality oflife, and new programmes are being initiated. Big differences nevertheless occur from country to country in political commitment, in government planning mechanisms, and in the experience of government planners. Whereas in some countries the governments have clear ideas about the Decade and are taking strides towards the establishment of national plans, others have needed WHO help in planning and preparing projects. WHO's present concern is to ensure that the momentum created at the start of the Decade should not be lost and that WHO support for 1 World Health Organization. Drinkzng-water and sanitation, I98I-I990: a wery to health. Geneva, 198 r.
efforts in countries should be appropriate and consistent. I 1. 5 It is recognized that many of the water supply and sanitation systems built by governments at considerable expense have not achieved any lasting improvement of health. This is the result partly of inadequate planning but more often of neglect in the operation and maintenance of the systems. To help remedy this situation, WHO has given greater attention to the development of infrastructures and the strengthening of manpower at the community level. Throughout the biennium it supported national sector agencies, national action committees, and UNDP in identifying and formulating projects, solving institutional problems, and designing appropriate equipment. It devoted increasing resources to (i) the development, in cooperation with other organizations in the United Nations system and nongovernmental organizations, of methods and models for strengthening national, institutional, financial, and human resources; (ii) the creation of systems for the exchange of information on Decade technology, financial and technical resources, and projects in need of external support; and (iii) the devising of global and national evaluation mechanisms for assessing the impact of Decade efforts, especially on human health. I 1.6 In its work with governments and with sister agencies, WHO has always recommended sanitary collection and disposal of household and community wastes as a necessary complement to the provision of clean water. The bulk of current investment projects only give better service to communities already served by public systems. WHO seeks to persuade governments and lending agencies that rational and comprehensive projects to ensure safe water supply and sanitation for underserved communities must be implemented on a very large scale during the next IO years. I73
I I. 7 Contiguous communities or districts seldom recognize the economies of scale they might enjoy by cooperative water systems; hence they may resist centrally planned regional schemes. WHO has shown that such schemes can be made self-reliant and selfsustaining through careful on-site planning and implementation of projects calling for the maximum participation of the communities concerned, and has promoted this approach in all its field activities. I I .8 The choice of plant and equipment, at the production and especially at the consumer end of the system, and of institutional mechanisms for getting them properly installed and used is very large. Through the programme for the exchange and transfer of information on water supply and sanitation (POETRI) initiated by the Netherlands Government, WHO is bringing the choice to the attention of experts and decisionmakers in national water supply and health agencies; in consulting firms, in international agencies, and in nongovernmental organizations. WHO also emphasizes health education and community action, activities that were included in a number of investment projects prepared through the World Bank/ WHO cooperative programme. I I ·9 During the biennium WHO considerably developed its collaborative work with the organizations in the United Nations system: with ILO and UNESCO in human resources development methodology; with FAO in the prevention of water-related diseases; and with the World Bank in the formulation of development projects with positive health benefits. The cooperative programme with the World Bank was continued, with increased emphasis on infrastructure development; in addition to activities at headquarters, 36 missions to countries were carried out during the biennium. The steering committee for cooperative action for the Decade, consisting of the United Nations
agencies concerned with the Decade (the United Nations itself, UNDP, UNEP, the United Nations Centre for Human Settlements, UNICEF, ILO, F AO, WHO, UNESCO, and the World Bank) met five times in the period I98o-I981. The committee, which is chaired by the Deputy Administrator of UNDP (WHO providing secretariat services), promotes a coordinated approach to implementation of the Decade. Task forces have been set up to deal with public information, information exchange, project formulation, and human resources development. (For training activities, see also paragraphs I2.66 and 12.67.) I I. IO Under the sponsorship of the steering committee, a second consultative meeting involving donor governments, the United Nations and other international organizations, nongovernmental organizations, and representatives from countries was held at WHO headquarters in June I98o. It reviewed progress during the preparatory phase of the Decade, issues related to its launching and implementation, and ways of furthering cooperation with a view to increasing the flow of resources to the sector.
Progress in Member States I I. I I The information available indicates that, since the start of the Decade, most Member States have intensified their efforts to increase the provision of safe water supplies and sanitation facilitaties. WHO is helping them to overcome weaknesses in current practices. Coordination mechanisms have been established at national and international level, communication between supporting agencies and countries has been improved, allocations for water supply and sanitation have been increased at national and international level, arid a public information campaign covering developed and developing countries is being implemented to promote the Decade and its objectives.
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PROMOTION OF ENVIRONMENTAL HEALTH I I. I 2 In the African Region substantial progress has been made in organizing Decade activities. Of the 4 5 countries in the Region, 22 have established some form of national action committee for intersectoral coordination in relation to water supply and sanitation. In 29 countries a technical support team has been organized, including staff from WHO and other international agencies. WHO is executing interregional cooperative projects supported by UNDP, GTZ, and SIDA in I 7 countries, projects that are all concerned with national planning and programming for the Decade. WHO also participated in technical cooperation in three other countries for the development of a national plan, and in seven national workshops concerned with the development of intersectoral planning and programming for the Decade. I I. I 3 An intercountry TCDC project in basic sanitary measures has been implemented. Sanitary engineering posts have been established in each of the three subregions to ensure more direct support to countries in respect of the water supply and sanitation aspects of TCDC.
age authority in Barbados; the setting up of administrative, operation, and maintenance systems for water service in Haiti; the development of rural water supply programmes in Guatemala and Paraguay; and institutional development in Costa Rica. Institutional development was also supported by the inclusion of human resources development as a component in technical cooperation with countries, examples of which were the Caribbean area water management project to develop a self-sustaining training system, and projects for the development of drinkingwater and sanitation institutions in the Andean subregion and in Central American countries. The Pan American network of national focal points for information and documentation on sanitary engineering and environmental sciences was further developed and a start was made in coordinating it with the international collaborating centre information programme. The Pan American Center for Sanitary Engineering and Environmental Sciences, Lima, carried out studies on waste-water stabilization ponds, biogas, and the development of a new type of chlorinator. The regional programme providing help with analysis to water and wastewater laboratories was continued.
I 1. I4 WHO helped in the Economic Commission for Africa meeting (Addis Ababa, August I98o) concerning national water supply and sanitation action related to the Decade. The World Bank/WHO cooperative programme also gave support to water supply and sanitation activities in a number of countries. I I. I 5 Institutional development was an important feature of programme activities in the Region of the Americas. The Organization collaborated with some I 2 countries in organizing information systems for national and local institutions. The projects assisted included: the strengthening and development of water and sewerage agencies in Brazil; the establishment of a national water and sewer-
I I. I 6 The Organization collaborated with countries in support of their strategies for the Decade. This included work under the cooperative programme with the World Bank, and with the Inter-American Development Bank and GTZ. The work with GTZ focused on national planning and infrastructure development in Bolivia, Haiti, and Paraguay, and the establishment of a centre for training in the operation and maintenance of water and sanitation services for Central America and Panama. Cooperation also continued with several countries to assure water quality and continuity, UNDP, CIDA, and the Caribbean Development Bank providing support.
175
I I. I 7 Most of the countries in the SouthEast Asia Region have given high priority to water and sanitation and have established mechanisms to coordinate policy and action for the Decade with UNDP resident representatives. Several activities in the countries of the Region are now mainly concerned with the preparation of a national plan and the implementation of projects during the Decade. WHO held two intercountry workshops on Decade planning and Decade support programmes, including information systems, health education, behavioural studies, operation and maintenance, manpower development, and water quality surveillance. National plans were completed for Bangladesh, Nepal, and Sri Lanka and will shortly be prepared for other countries in the Region. I I. I 8 In the European Region particular effort was directed towards accelerating activities in water supply and sanitation in Algeria, Morocco, and Turkey (paragraph I 5. 77), where WHO sanitary engineers have been stationed to provide technical support to the UNDP resident representative. While the programme under WHO's regular budget focused on rural sanitation, large-scale action took place within the framework of the UNDP country programmes. In Algeria a large-scale project related to solid wastes collection and disposal for 6o medium-sized cities was begun. In Morocco a seminar on appropriate technology for rural sanitation was held in Rabat in December I98o as a preparatory activity for a pilot project. I I. I 9 In the Eastern Mediterranean Region consultations or workshops bringing together representatives from departments and organizations concerned were conducted with WHO assistance in Egypt and Sudan (through a UNDP-funded interregional cooperation project), in Somalia (through a similar GTZ-funded project), and in Pakistan (with UNDP support). These meetings
focused on technical cooperation with countries in their preparation of national sector plans for the Decade. A sector study in Yemen executed through the World Bank/ WHO cooperative programme identified a number of projects requiring external resources. In Lebanon a WHO/UNDP national waste management project prepared a draft master plan and, despite some problems, is proceeding with the preliminary engineering and feasibility studies for four priority areas. I I. 20 Training and human resources development were important aspects of water supply and sanitation activities in the Western Pacific Region. Two workshops considered the financial and economic aspects, another was held on regional strategies for the Decade, and a number of courses dealt with technical subjects such as surveillance of drinking-water quality. The Region administers more than 30 projects concerned with basic sanitary measures, largely supported from UNDP funds. A new UNDP/WHO project began in I 98o for the training of water supply and sewerage personnel for countries of the South Pacific area. Summary reports were completed by July I98 I for all countries and areas except Brunei, Democratic Kampuchea, and Macao. An assessment was prepared of the situation in the Region and of the strategies and approaches to be followed.
Control of environmental hazards I I. 2 I While the International Drinking Water Supply and Sanitation Decade is generally seen as directed mainly towards developing countries, many related problems remain unresolved in developed countries, such as the contamination of drinking-water by chemicals and the widespread pollution of rivers, lakes, and groundwater. In the past, too, serious toxic wastes were often disposed
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PROMOTION OF ENVIRONMENTAL HEALTH
of in an uncontrolled manner and have become a serious public health problem in a number of countries. In four WHO regions there are programmes on ways and means of dealing with those problems.
International programme on chemical safety I I. 22 The international programme on chemical safety was put on a broader footing during the biennium. At the international level, ILO and UNEP have joined the programme as cooperating agencies. At the national level, I 2 Member States have formally adhered to the programme by a memorandum of understanding. Twelve national institutions have been designated as lead institutions for specific programme areas. IARC is the lead institution for carcinogenesis. UNEP has established an international register for the collection, retrieval, and dissemination of information on potentially toxic chemicals. An interregional research unit was established at the National Institute of Environmental Health Sciences, North Carolina, USA. Another is being set up in the Environmental Protection Agency, Washington. I 1.23 A programme advisory committee was set up to advise the Director-General and the executive heads ofiLO and UNEP on the overall aspects of the international programme. The committee met twice during the biennium and established four priorities: evaluation of the effects of pesticides, food additives, household chemicals, and selected industrial chemicals; dissemination of information; training of toxicologists; and development of methodologies, especially for monitoring exposure from various sources and for validating tests for the detection of mutagenicity, carcinogenicity, and teratogenicity. It developed guidelines for designating lead institutions and for ensuring that the work they perform corresponds to the
international character of the programme. It also dealt with the question of unpublished proprietary data and the participation of nongovernmental organizations in the programme. It reviewed the special needs of developing countries and made recommendations on the training of manpower, the dissemination of information, and the drafting of basic guidelines on the safe use of chemicals. I 1.24 The Regional Office for Europe was active in the field of chemical safety (paragraph I 5. 78). It has developed plans for dealing with emergencies and accidents involving the release of toxic chemicals, plans that could be adapted for global application. It is also implementing a UNDP-supported project on European cooperation on environmental health aspects of the control of chemicals that aims at the strengthening of national capabilities in this area.
I 1.25 The preparation of environmental health criteria documents on chemicals constitutes an important part of the programme. Three documents were published in the biennium and a fourth is in press.t Under the new arrangements in the programme the lead institutions take the responsibility for the preparation of the criteria documents under the guidance of the central unit. The drafts go to countries for review and comments and the revised draft is finally reviewed by a group of international experts. Twelve lead institutions have begun the preparation of I 8 additional documents on I 8 chemicals or groups of chemicals. In all, 3 I criteria documents on chemicals are at various stages of preparation and I6 are already in print. Guidelines on the preparation of the criteria 1 World Health Organization. Tin and organotin compounds: a preliminary review, Geneva, 1980 (Environmental Health Criteria, 15); Manganese, Geneva, 1981 (Environmental Health Criteria, 17); Arsenic, Geneva, in press (Environmental Health Criteria, 1 8); Hydrogen sulfide, Geneva, 1981 (Environmental Health Criteria,
19)·
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documents have been prepared. Work has begun in relation to methodology on: principles and methods for evaluating the toxicity of chemicals; general principles in epidemiological methods for environmental health studies; assessment of the effects of chemicals on reproductive function; short-term tests to predict the mutagenic and carcinogenic potential of chemicals; integrated evaluation of acute and chronic prenatal toxicity of chemicals; and evaluation of neurobehavioural toxicity. Environmental health planning I 1.26 A guide on environmental health planning was finalized and distributed to a wide range of users at country level. An analysis was also published 1 of a study conducted in 2 I countries at various stages of development. It makes comparative information available for the first time on the different approaches adopted to deal with the complex issue of intersectoral coordination and health in environmental management. The Western Pacific Regional Centre for Promotion of Environmental Planning and Applied Studies and the Pan American Center for Sanitary Engineering and Environmental Sciences continued to give the highest priority to this subject. In the Eastern Mediterranean Region studies continued on the establishment of a similar regional centre for environmental health activities. The Regional Office for Africa organized a consultation on the establishment of a regional network of national environmental sciences institutes (Dakar, June-July I98I), attended by participants from I I countries in the Region. The meeting agreed that, as a first step, a feasibility study should be begun on the establishment of a regional environmental health centre. 1 Schaefer, M. lntersectoral coordznation and health in environmental management: an examination rif national experience. Geneva, World Health Organization, 1981 (Public Health Papers, No. 74).
Monitoring and control of pollution I 1.27 During the biennium WHO continued its UNEP-supported air and water quality monitoring projects, which aim at initiating or strengthening national monitoring programmes and at obtaining information on pollution levels on a regional and global scale. Some So countries now participate in the air quality monitoring programme. New approaches are being developed and tested so as to improve the information base for assessment of the impact of air pollution on human health. Pilot studies were initiated in Toronto (Canada) and Zagreb (Yugoslavia) in I98o, and arrangements were made to initiate similar studies in China and India. By the end of I98I data under the water quality monitoring project were being collected and analysed routinely from more than 30 countries. The last two regional training courses in the initial series on water quality monitoring were held in Dakar and Nairobi in collaboration with UNESCO. A training course on the quality assurance aspects of water quality monitoring was organized in Nagpur, India, for participating countries in the South-East Asia and Eastern Mediterranean Regions. I 1.28 A relatively simple method2 has been developed and tested over the past few years for the identification and assessment of air, water, and land pollution sources in a given city, region, or even country. Its application will yield an industrial waste profile and indicate the most urgent control problems and the problems that may be emerging. I I .29 The revision and merging of International standards for drinking-water and European standards for drinking-water proceeded well in I98I, with a view to their 2 World Health Organization. Rapid assessment of sources ofair, water, and land poJJution. Geneva, 198 2 (WHO Offset Publication No. 6z).
PROMOTION OF ENVIRONMENTAL HEALTH
publication as WHO guidelines for drinkingwater quality. During the biennium a number of working groups were convened by WHO to prepare sections of the guidelines dealing with the contamination of drinking-water by biological organisms and chemical and physical constituents and to set forth recommended limits. This project is supported financially by DANIDA and by a number of WHO collaborating centres and focal points for the environmental health criteria programme. I 1.30 For the UNEP industry and environment programme, WHO participated in a review of the environmental aspects of nonferrous metal industries by providing information on the known health effects. Also, as a follow-up to UNEP's review of the environmental problems caused by motor vehicles, WHO together with UNEP sponsored two workshops on motor vehicle emissions, the first at the Western Pacific Regional Centre for Promotion of Environmental Planning and Applied Studies in I98o with the participation of representatives from countries in the Western Pacific and South-East Asia Regions, the second in Moscow in I 98 I with the participation of representatives from countries in the African, European, and Eastern Mediterranean Regions. The Regional Office for Europe initiated a project on the assessment of toxicological problems associated with specific industries, and a planning meeting was held in I981.
held in Nashville, USA, in I 981. The symposium placed special emphasis on methods of quantification, comparison, and analysis of health risks; the development of epidemiological parameters for the evaluation of the health impact; and cost/benefit analysis. The health impact of various components of nuclear fuel cycles and the environmental health implications of the disposal of highlevel radioactive waste were reviewed by a working group organized by the Regional Office for Europe in cooperation with the Belgian Government. I I. 32 During the biennium a pilot project on the assessment of human exposure to pollutants through biological monitoring for selected metals and for organochlorine compounds was carried out with the participation of some I 5 countries and the support of UNEP. The measurement of concentrations in human tissues and fluids is an excellent means of estimating the uptake and deposit of these substances in the body. This type of monitoring is technically difficult, and most of I98o-I98I was devoted to strengthening the analytical capabilities of participating laboratories and instituting a vigorous analytical quality assurance programme. By the end of I98I most of the participating laboratories had either begun or made plans to begin monitoring selected populations. Under this pilot study, lead and cadmium are being measured in the blood, cadmium in the kidney cortex, and organochlorine compounds such as DDT, DDE, and polychlorinated biphenyls in breast milk. I I. 33 Monitoring of environmental radiation was continued through the WHO collaborating centre at the Service central de Protection contre les Rayonnements ionisants, Le Vesinet, France. Under this programme some 30 national laboratories in 2 I Member States and four WHO collaborating centres participate by providing information on radiation levels in air, water, milk, and bone.
Ever-increasing demands for I I. 3 I energy have made it necessary to evaluate and compare the health risks of different sources of energy (wood, coal, oil, nuclear power, etc.). Approaches to a comparative assessment of detriment to health from energy production were considered at a WHO meeting organized jointly with the Federal Republic of Germany. The problem was further discussed at a WHO/UNEP/IAEA symposium on health impacts of different sources of energy 179
THE WORK OF WHO, 1980-1981 1 1. 34 Technical cooperation activities were undertaken through the regional offices. Countries in the Eastern Mediterranean actively participated with the Regional Office in the planning and implementation of marine pollution control programmes as part of both the Mediterranean and the Kuwait action plans. In the South-East Asia Region technical cooperation activities in air and for water quality management were carried out in India, Indonesia, and Thailand. The Regional Office for the Americas supported a series of projects in countries concerned with the development of environmental control programmes, research, and the collection and exchange of information. The European Region was involved in the promotion of assessments of environmental impact, the improvement of systems for the collection and disposal of solid wastes, and the development of environmental pollution control programmes. In the Western Pacific Region cooperation continued with the Republic of Korea in the development of air and water pollution control measures. In China UNDPsupported projects were initiated on the monitoring and control of pollution. In the African Region a pilot project on the development of a control programme for air and water pollution was carried out in Abidjan. The results of this study will serve as a model for use in conjunction with the guidelines on environmental pollution assessment (paragraph 1 1.28). 1 I. 3 5 WH 0 continued to participate in the work of UNEP's coordinated regional seas programme by providing specific information on the human health aspects. Work was continued in the Mediterranean, Caribbean, and other regional seas. In addition, WHO coordinated the development of training material for a projected series of workshops on assessment of the environmental impact of coastal area development. This work was carried out with the participation of the United Nations, the United Nations Centre
for Human Settlements, FAO, UNESCO, IMCO, and UNIDO, and resulted in 1981 in an instructor manual, a student manual, and an illustrative case studies manual.
Protection against radiation and other pl!Jsical factors 1 I. 36 The health risks associated with exposure to non-ionizing radiation and other physical factors are undergoing evaluation; during the biennium environmental health criteria documents were issued on noise and on radiofrequency and microwaves. 1 Additional criteria documents are in preparation on lasers, ultrasound and extremely low frequency, and power line electromagnetic fields. The Regional Office for Europe is completing preparation of a manual on protection from non-ionizing radiation.
1 1. 37 A number of guidelines on various aspects of radiation protection have been developed or updated to assist Member States in the management of national services. Among these, mention should be made of Basic safety standards for radiation protection, which was revised jointly by IAEA, ILO, WHO, and the OECD Nuclear Energy Agency on the basis of the recommendations of the International Commission on Radiological Protection (ICRP), 2 and the IAEA/ WHO code of practice on basic requirements for personnel monitoring.3 The application of radiation protection standards was the
1 World Health Organization. Noise, Geneva, 1980 (Environmental Health Criteria, I2); Radiojrequency and microwaves, Geneva, I 981 (Environmental Health Criteria, I 6). 2 Basic safety standards for rad1at10n protectiOn: report of an advisory group ;ointly sponsored by IAEAJWHOJ ILOJNEA. Vienna, International Atomic Energy Agency, I98r. 3 Basic requirements for personnel monitoring: a code of practice sponsored by the International Atomic Energy Agency and the World Health Organization. Vienna, International Atomic Energy Agency, I98o (Safety Series, No. I4).
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subject of a joint WHOfiAEAfOECDNEAfiCRP symposium held in Madrid on the application of the dose limitation system in nuclear fuel cycle facilities and other radiation practices. A joint IAEA/WHO booklet on low-level radiation was issued 1 to provide information to the general public. I r. 38 To improve the preparedness of public health authorities for possible radiation accidents, in addition to the system for mutual assistance in radiation accidents devised by IAEA, WHO, FAO, ILO, UNDRO, and the International Radiation Protection Association,2 two WHO collaborating centres for radiation emergency medical assistance were designated in Paris and Oak Ridge (USA) to assist all the regions in the handling of radiation accidents and the treatment of radiation injuries. The rationale for public health action in case of possible radiation accidents was considered at a WHO meeting organized in cooperation with the Belgian authorities. Regional training seminars on general procedures for the management of persons receiving whole-body or part-body radiation were jointly organized by the Regional Office for the Americas and the Brazilian Atomic Energy Commission.
acceptable daily intakes and maximum residue limits in foods, of pesticides used extensively in agriculture and public health. At its I98o meeting 4 it included items of a general nature such as general principles for establishing acceptable daily intakes, the quality and validation of toxicological data, and proposals for maximum residue limits for food groups. Among the specific problems discussed were delayed neurotoxicity as a hazard posed by some organophosphorus insecticides, impurities in technical pesticides, and pesticide residues in stored products. I I .40 Two meetings of the Joint F AOJWHO Expert Committee on Food Additives were held in I98o 5 and I98r. 6 The report of the I98o meeting dealt with the approach followed by the Expert Committee in evaluating food additives claimed to be free from cariogenic activity; the need, under certain circumstances, for impurities or transformation products of food additives to be tested separately; the special problems posed by toxicological evaluation of modified food ingredients; and the nutritional significance of reactions between additives and normal food components. Particular attention was given to the implications of temporary acceptance of food additives: the time limits proposed for the completion of further investigations on some food additives would, in the Committee's view, create no public health hazards. I 1.4 I The I 98 I meeting examined a number of colouring agents, carrier and extraction solvents, flavouring agents, enzyme preparations, sweeteners, and miscellaneous food additives. Special attention was given to: the use of hormones in stockraising and the problems posed by their 4
Promotion of food safety 3 Food additives and contaminants IL39 In I98oand I98I the Joint Meeting of the F AO Panel of Experts on Pesticide Residues and the Environment and the WHO Expert Group on Pesticide Residues provided toxicological evaluations, in terms of 1 Facts about low-level radiation. Vienna, International Atomic Energy Agency, 1981. 2 Mutual emergency assistance for radiation accidents. Vienna, International Atomic Energy Agency, 1980 (IAEA-TECDOC- 2 37). 3 For food safety in relation to veterinary publtc health, see paras 9.182-9.197·
F AO Plant Production and Protection Paper No. 26,
1981.
s WHO Technical Report Senes, No. 65 3, 1980. 6WHO Technical Report Series, No. 669, 1981.
I8I
THE WORK OF WHO, r98o-r98r
residues in food; the safety aspects of plastic materials in food packaging; antibiotics as direct food additives; and enzymes used in food processing. The Committee also examined its current approach to the evaluation of natural and nature-identical food additives. It reviewed the work it had carried out for 2 5 years and the benefits developing countries could derive from it. I 1.42 A Joint FAOfiAEAfWHO Expert Committee on the Wholesomeness of Irradiated Food was convened in I98o.l It considered that the irradiation of food commodities up to an overall average dose of Io kGy presents no toxicological hazard, that toxicological testing of foods so treated is no longer required, and that such irradiation introduces no special nutritional or microbiological problems; but it emphasized that attention should be given to the significance of any changes in relation to each particular irradiated food and to its role in the diet.
reviewed and assessed the results of its work. One of the important issues dealt with was that of nutrition. Many draft and existing Codex standards either contain specific nutrition provisions or help to protect the nutritional quality of the food supply by controlling the composition and distribution of foods passing into trade. The Commission concluded that nutritional considerations had not been neglected in its work, either past or present, which had considerable nutritional impact. I 1.45 Following recommendations of its committee on general principles, the Commission adopted revised procedures for the elaboration of worldwide and regional Codex standards aimed at simplifying and speeding up the mechanism for acceptance by Member States.
Technical cooperation with Member States I I .46 Technical cooperation in market and food sanitation was provided in the African Region as part of the general sanitation programme. Preparatory work began in connexion with a proposed regional expert committee on the development of food safety policy. The FAOfWHOfiARCfUNEP project on control of fungal contamination of food and human health, initiated in Swaziland, has been extended until the end of
Food standards programme I 1.43 The primary objective of the joint FAOfWHO food standards programme under the aegis of the Codex Alimentarius Commission, which now has a membership of I 2 I countries, is to protect consumers from the health hazards related to food and from fraudulent practices. It attempts to do so by establishing international or regional standards and drawing up codes of practice for the safe handling of food. During the biennium I 7 commodity and general subject committees were convened, and meetings were held of the coordinating committees for Africa, Europe, and Latin America. I I ·44 The fourteenth session of the Codex Alimentarius Commission took place in Geneva in I 98 I, when the Commission
I982. I I ·4 7 In the Americas technical cooperation was undertaken with a number of countries. In I98o the ministers responsible for health in the Caribbean countries began planning and developing strategies for a subregional food protection (food safety) programme. The Andean countries have also voiced interest in the development of a subregional food safety programme. Training continued under the regional education programmes for food protection based in
I
WHO Technical Report Series, No. 659, r98r.
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Colombia. At the thirty-third session of the Regional Committee (September I98I) the subject of the Technical Discussions-the sanitary control of food-resulted in an action plan that will guide future regional activities. I 1.48 In South-East Asia country projects on a range of food safety topics were undertaken in India, Indonesia, Sri Lanka, and Thailand. The need for the systematic development of national food safety programmes in the Region is being increasingly recognized. I I.49 The Regional Office for Europe published Food safety services, 1 the result of a survey of national food safety services in the countries of the Region; it is intended to be used as background material for working groups, e.g., on food inspection principles, sampling programmes, the training of food inspectors, and selected coordination problems. Preparatory work relating to food safety in mass catering continued, with the collection of material for proposed studies and working groups. A working group on health examination of food-handling personnel met in I98o. A surveillance programme for foodborne infections and intoxications in Europe became operational. II. 5o Basic sanitary measures, with special emphasis on the improvement of food safety and hygiene, are recognized as vital in the socioeconomic and climatic conditions of the Eastern Mediterranean Region. Collaboration continued with governments and with international organizations such as F AO, as well as with the Arab Organization for Standardization and Metrology, on improving food control and hygiene activities. A sixweek programme for training food inspectors was organized in Amman in October I981. 1 Johnson, R., ed. Food safety services. Copenhagen, World Health Organization, 1981 (Public Health in Europe, No. 14).
II. 5I In the Western Pacific Region country projects included the initiation of a project on food safety in China, with UNDP support. National seminars were held in Fiji and the Republic of Korea to develop national food control systems. A working group on the public health aspects of marine food poisoning was convened in cooperation with the South Pacific Commission.
Information and monitoring I 1. 52 WHO is further emphasizing its food safety activities by providing information and health education programmes for schoolchildren, food-handling personnel, and the general public. I 1.5 3 The UNEP-supported joint F AO/ WHO food contamination monitoring programme aims at providing information on environmental pollutants in food (organochlorine pesticides, polychlorinated biphenyls, cadmium, lead, and aflatoxins) in order to assess the health risks to man from exposure to such pollutants and to determine priorities for developing pollution control strategies at the national, regional, or global level. Under this programme F AO/WHO collaborating centres in 2I countries contribute monitoring data on contaminants in foods and in total diet. These data are being evaluated to determine trends and potential health hazards and a summary of data received up to July I98o was prepared. In almost all cases the estimated dietary intakes of the organochlorine pesticides are low and reflect the decreased utilization of these pesticides in certain countries. Cadmium dietary intakes indicate that this contaminant should be monitored closely. An analytical quality control programme was implemented. The second session of the technical advisory committee of the joint F AO/ WHO programme was convened in April I98I to review progress and problems and to advise on the future operational phase of the programme.
Chapter
I2
Health Manpower Development
REVIEW of present health manpower systems reveals a number of problems arising from the absence or inadequacy of national health manpower policies. The neglect of coordinated training and utilization of health personnel results, among other things, in a shortage of such personnel; an uneconomic utilization of the health team; an imbalance between different categories of staff; inequities in geographical distribution, aggravated by the migration of qualified personnel; and in many cases the absence of a clear definition both of functions and of required competencies for the various categories of health worker. There is often no wellconceived manpower system operating as an integral part of the health system. The most frequent problem is the lack of coordination of the three main elements of the health manpower development process-planning, production (i.e., training), and management. A related problem is the lack of coordination between the health manpower development process and other sectors, e.g., general education, social security, labour, and agriculture. I 2. I I2.2 The first element in the health manpower development process is planning. In many countries there are no health manpower plans at all, or if they do exist they are often exclusively quantitative in character. Where there is no proper planning of health
A
teams, the result is an undue emphasis on the training of certain conventional categories of health personnel-particularly physicians and nurses--at the expense of other categories. 12.3 In health manpower production the main problem is the shortage of facilities for training the required type and number of health personnel needed by the national health services. This includes a shortage of teachers of health sciences, especially of teachers competent to plan, implement, and evaluate the teaching/learning process, using a systems approach and ensuring that what students learn is relevant to the demands that will be made upon them on completion of their training. Only too frequently there are wide divergencies between academic training goals and the requirements of the health services. Curricula, methods, and systems of evaluation are often unsuitable for training health workers to meet the real health needs of the community and to work in teams. Moreover the absence of collaboration between those responsible for training staff and those responsible for health care delivery is liable to result in educational programmes that develop in isolation from the changing needs of health care. 12.4 Problems in health manpower management include unattractive working conditions, e.g., insecurity of tenure, limited
HEALTH MANPOWER DEVELOPMENT
promotion prospects, and inadequate financial or other incentives. Very often there is no provision for continuing education and this in itself is a severe limitation on maintaining and improving the level of competence and performance of health workers.
Medium-term pro,f!,ramme I 2. 5 During the biennium, the basis of work was the medium-term programme for I978-I983, endorsed by the Thirtyfirst World Health Assembly (resolution WHA3 1.36). A partial revision of this programme was undertaken to ensure that it remained relevant to the changing health priorities of Member States and was in line with the principles adopted at the Alma-Ata Conference and the Global Strategy for health for all.
"Health Manpower News", that provided information on health manpower plans, programmes, and processes; teaching/learning materials; processes and tools for programme evaluation; and training institutions and other learning facilities. Nine newsletters in all appeared up to January I981. Since that date, owing to the reduction in periodicity of the Chronicle (paragraph I 3.30), the newsletter has been discontinued although information on health manpower development is still carried by the Chronicle.
Research I 2. 8 During the biennium, an analysis was made of health manpower development policy in WHO from its inception (I948) up to I98o. 1 The intention was to document the relationship between expressed policy, implementation by way of programme, and final outcome. The study set out to identify the main policies and objectives of the programme and the factors (political, social, economic, cultural, health, etc.) that shaped them; to determine to what extent policy was implemented; to find out which factors influenced the successes or failures of the programme; and to ascertain what changes, if any, in WHO's Member States could be attributed to the influence of WHO's health manpower development programme. I 2.9 The methods used to carry out the study included an analysis of United Nations and WHO official documents; a statistical analysis ;2 the canvassing of expert opinion; case studies in six countries (Barbados, Costa Rica, Ethiopia, Gabon, Indonesia, and
I2.6 In I98o-I98I an attempt was made to assess progress after three years' experience of implementing the medium-term programme. It was found that many of the problems inherent in a first effort had been solved in the course of implementation; but, as with any programme extending over a long period, it was necessary to revise, add, or discontinue activities because national health priorities had changed. In general however the targets set in I977 remain essentially the same. A final assessment will be made in I 98 3 to determine to what extent targets have been met by the end of the six-year period. The progress made can be seen from the following pages.
Programme planning and general activities Information service 12.7 The WHO Chronicle was hitherto the vehicle for publishing a newsletter,
1 Fiilop, T. & Roemer, M.I. International development of health manpower. Geneva, World Health Organization, 1981 (WHO Offset Publication No. 61). 2 Fiilop, T. & Reinke, W.A. Statistical analysis of interdependence of country health resource variables, with special regard to manpower-related ones. Bulletin of the World Health Organization, 59: 129-141 (1981).
THE WORK OF WHO, r98o-r98r
Malaysia) to assess the relationship between WHO's programme and the status of health manpower development in the country; and an analysis of the literature on WHO's work in health manpower development. I2.IO In the conclusions of the study, guidelines for the future are discernible. 1 It is clear that further progress in health manpower development depends on the political will at national level to seek and apply proper solutions to manpower problems that have been properly diagnosed in relation to the need for health services based on the primary health care approach. Moreover it emerges clearly from the study that it is WHO's role to act as an agent of change, to stimulate the right political response without which even the best technical solution may end in failure, and to promote the political will that alone can ensure an effective development process. I 2. I I To produce "effective" health manpower, i.e., appropriately trained manpower that is able and willing to care for the entire population of a country, requires active research on all aspects of the manpower development process: policy formulatwn, planning, production, and management. During the biennium WHO launched several activities to promote research of this kind.
I 2. I 3 Eight WHO collaborating centres in seven countries are collecting epidemiological information on the nursing care needs of elderly and elective surgical patients, data being drawn from 30 health care institutions in I 3 countries. Participating nursing personnel attend in-service training programmes on the process required (assessment of health needs, planning and implementation of nursing care, and evaluation of its effectiveness). A meeting (Switzerland, I98o) discussed the importance of records in carrying out this process.
I 2. I4 In collaboration with the International Council of Nurses and the World Federation for Medical Education, a study was made on the concept and practice of a competency-based curriculum that could be used to promote a shift from the subjectcentred or discipline-oriented curriculum to a problem-solving approach. Part of this study consists in examining the experience of educational programmes that have defined and used learning objectives. I 2. I 5 In the Region of the Americas, the Latin American Center for Educational Technology in Health (Rio de Janeiro) is developing research projects on a curriculum and didactic planning model based on the health needs of primary health care programmes, including communication with the supervisory level.
I 2. I 2 In the South-East Asia, European, and Eastern Mediterranean Regions, several meetings were held on research in manpower development. In the South-East Asia Region, a consultant visited five countries (Bangladesh, Burma, Indonesia, Sri Lanka, and Thailand) to determine research needs. A consultative group on the organization and scope of research in education for the health professions (Prague, I 98 I) met to decide what action should be taken to promote research in the European Region that would enable Member States to develop plans and activities to attain health for all. 1
I 2. I 6 Procedures for assessing the performance of health workers and students were worked out by investigators in six countries: Bahrain, Kenya, Mozambique, Poland, Sri Lanka, and the United Republic of Cameroon. The theoretical basis for this research and its practical aspects were published in the form of guidelines. 2 2 Katz, F.M. & Snow, R. Assessing health workers' performance: a manual for training and supervision. Geneva,
WHO Chronicle, 36: 3-6 (r98z).
World Health Organization, 1980 (Public Health Papers, No. 72).
I86
HEALTH MANPOWER DEVELOPMENT I 2.17 The important matter of how to select suitable applicants for training as health workers was studied with the support of UNFP A. A working group met in Geneva (I98o) and in Maputo (I98I) to provide alternatives to the most commonly used practices, such as the almost universal reliance on scholastic achievement as a criterion for selection. The procedures recommended by the working group will be disseminated in the form of guidelines.
coincided with the results of epidemiological surveys. Such an approach could prove even more useful in the national managerial process, of which manpower planning is an element. I 2.20 Although there is still some opposition to the utilization of traditional birth attendants in the health services, those countries that do use them commend their contribution to the extension of coverage and are continually seeking ways to increase it. Research has begun in Thailand to determine what additional role the traditional birth attendant can play in primary health care. A study has also begun in Burma to determine the ability of the traditional birth attendant to function as a first-level health worker in maternal and child health care and to detect women and newborn infants at special risk; its outcome will serve as a basis for guidelines on the training of teachers of traditional birth attendants in such screening. In Sierra Leone, where 70% of deliveries are attended by traditional birth attendants, a training programme was initiated as early as I974 to improve their skills and practices. A countrywide study began in I98I to assess the impact of their work on health care services. It includes the development and testing of evaluation tools and of a methodology for assessing the effectiveness of training programmes. I 2.2 I Research is an integral part of all health manpower development activities and futher examples will be found throughout this chapter.
I 2. I 8 A flowchart for decision-making in patient management, for use especially in primary health care but also as a training device, was tested in a number of countries. The flowchart project was extended to other areas of health care, e.g., mental health, where a problem-oriented method was developed to determine the appropriate management of mental illness in cross-cultural primary care settings. The method is designed for use by intermediate-level health workers in developing countries and was tested by psychiatric field workers in Colombia, India, and Lesotho. In preliminary reports from Lesotho the diagnosis made on the basis of the flowchart showed a 76% agreement with the consultant psychiatrist's diagnosis in 6o cases. Reports from India showed agreement in 28 out of 30 cases. The method is currently being evaluated in Colombia and Egypt. WHO also sponsored the preparation and field testing of a manual to teach instructors and learners how to adapt and use the flowchart method. It outlines the basic clinical skills that must be acquired before the method can be used. The manual is being adapted for use by village health workers. I 2. I 9 The failure to assess health manpower requirements in terms of health needs is an obstacle to realistic planning. An approach was devised for eliciting information from health workers, health administrators, and the community (see paragraph I 2. 36). It was found that what they perceived to be the main health problems usually
Health manpower planning and management
Coordination between health services and manpower development institutions I 2.22 To improve the planning of health manpower, the proper deployment of health
workers, and the relevance of training programmes to community health needs, WHO continued to promote the integrated development of health services and of manpower. Virtually all regions promoted discussion and organized meetings on the subject, and the concept was adopted by an increasing number of Member States. I2.23 In the European Region, a working group on communication and collaboration between and· within the health and educational systems reviewed the promotional work of WHO and Member States in that connexion. Case studies were presented from different systems of health care-in Poland, Sweden, and Switzerland. At the request of the health authorities of Montenegro, Yugoslavia, a visit was made to the area in I 98 I to discuss the organization of health services and health manpower training. I 2.24 The recognition that health development requires both an intersectoral approach and community participation has led to the establishment of national health councils and health development networks that include a health manpower component. This is occurring in Burma, Colombia, Democratic Yemen, Ethiopia, Papua New Guinea, and Sudan.
lines can be used as a basis for one-week workshops; they indicate the steps to be followed in formulating manpower plans, as should routinely be done after the workshop to reinforce learning by doing. 12.26 In the Americas, regional courses to train personnel in project planning were conducted in Colombia and Peru. An intercountry workshop was held (Lima, November I98I) to promote manpower planning in the countries represented, test the procedural steps outlined in the guidelines, and adapt them for a Spanish version. I2.27 In the South-East Asia Region, Bangladesh, Burma, Nepal, and Thailand held national workshops on the guidelines, followed by the formulation of manpower plans. In I98o Bangladesh formed a steering committee and a working group for a health manpower study that was undertaken in 1981. Indonesia is carrying out health manpower planning as part of its national health planning. 12.28 In recent years the countries of the South-East Asia Region have shown increasing interest in health manpower planning, an interest stimulated in great part by the Regional Office. The Technical Discussions at the thirty-third session of the Regional Committee (Maldives, 198o) were on the subject of health manpower planning and community participation for primary health care. An intercountry workshop on the I2.29 methodology of health manpower planning (Colombo, December 198o/]anuary I98I) brought together senior administrators and educators from the South-East Asia and Eastern Mediterranean Regions with a view to their guiding health manpower planning in their countries and training other health workers. Sri Lanka's approach to manpower planning was more specific in that limited 188
Planning of health manpower I 2.2 5 Cooperative activities to strengthen the health manpower planning capability of Member States as part of the managerial process for national health development continued. Guidelines for health manpower planning were field-tested in country and intercountry workshops and were published with the financial aid of UNFP A.t These guide1 Hornby, P. et a!. Guidelines for health manpower planning: a course book. Geneva, World Health Organization, r98o.
HEALTH MANPOWER DEVELOPMENT
studies directly related to the expressed needs of the decision-makers were conducted, e.g., a study on norms and standards for the staffing of health institutions. 12.30 In the European Region an intercountry workshop on health manpower planning (Copenhagen, October 1981) was faced with a situation peculiar to that Region-the oversupply and overspecialization of physicians. The workshop did not provide readymade solutions but attempted to show possible alternatives based on the exchange of information and experience. 12.31 A study on nursing services and education was made in nine countries of the Region. The resulting information, compiled at the end of 1981, will be of use to all European countries in developing policies and plans. It will also be a useful contribution to international statistics on nursing personnel. 12.32 Member States in the Eastern Mediterranean Region gave particular attention to the forecasting of health manpower requirements. The guidelines for health manpower planning (paragraph 12.2 5) were adapted to the conditions of countries in the Region and will be translated into local languages. A workshop on their use was held in Democratic Yemen (December 1981) and will be followed by the formulation of a national manpower plan.
in planning the development of the health services. 12.34 WHO has produced a number of learning modules-for example, on setting of health priorities-which are currently being field-tested. 12.35 In keeping with the recommendations of the Global Strategy for health for all, t work began on an interregional project to stimulate the establishing of national manpower projections for the year 2000, especially for the categories of health worker that will be directly involved in primary health care. A preparatory meeting was organized to decide on national plans of action; participants came from Bangladesh, Democratic Yemen, Dominica, Gambia, Hungary, the Philippines, the United Kingdom, Vanuatu, and Zimbabwe. In addition, Burma and Indonesia are participating in the project. 12.36 A simple way of obtaining information for such manpower projections is to ask selected health workers, administrators, and community representatives what they consider to be the health needs of the community and its manpower requirements. This approach, which has been field-tested in Colombia, obviates the need for large-scale surveys over a long period of time. The results are promising but need to be tried out in other countries; further testing is being undertaken in the Philippines in relation to the role and functions of primary health workers. 12.37 The need for updated inventories of health workers, particularly primary health care workers, and for the development of country-specific indicators of health man1 Global strategy for health for all by the year 2000. Geneva, World Health Organization, 1981 ("Health for All" series, No. 3), part III, paragraph r6.
12.3 3 Most countries in the Western Pacific Region have national health plans and a number of them carried out initial studies of health manpower, using the guidelines. In the Republic of Korea a review was made of requirements in the categories of health manpower trained in junior health colleges, and of their utilization. In Guam, a review was made of nursing manpower and nursing education. In Vanuatu an analysis of the health manpower situation was made to help
THE WORK OF WHO, 198o--198I
power development is gradually gaining acceptance in Member States. In the Region of the Americas, the Organization cooperated with several countries on information systems to determine the availability of personnel and the training needed to meet future demands.
World Health Assembly (May I98I). The Assembly adopted resolution WHA34. I4, which recognized the importance of management training in reorienting health systems towards the attainment of health for all, and endorsed the recommendations of the study. I 2.4 I The study concluded that management training should form part of national strategies for health for all. It should be clearly oriented towards the managerial process for health development and be capable of responding to the evolving health needs of the community. It should form an integral part of basic, postbasic, and continuing education programmes; be available to personnel at all levels; be team-oriented and promote community participation; and rely on the learning-by-doing approach, with particular emphasis on problem-solving and the use of locally available resources. WHO's role in helping to develop coordinating mechanisms in the form of national health development networks that include management training resources was underlined. The establishment of such networks-whose aim is self-reliance in management trainingwould require WHO to collaborate in mobilizing extrabudgetary resources, provide fellowships and equipment, and cooperate on request in the formation of the national group that would assume overall responsibility for management training. The strategy recommended in the study includes the promotion of career mobility and of incentives to those prepared to invest in continuing education and management development. I 2.42 Member States showed a growing interest in management training of national staff responsible for the health services. A consultation on health management training and work studies in June I98I brought together representatives from a number of national projects currently under way (Benin, Burma, Costa Rica, India, Sri Lanka, Thailand, and the United Republic of Tanzania).
Women as providers of health care 12.38 WHO has initiated a multinational study on women as providers of health care, funded by UNFPA. Its purpose is to stimulate action on the part of all individuals and groups who are (or should be) concerned to facilitate and enhance the work of women in health development; it aims at providing information and guidance for the formulation of policies and the implementation of practical action within the next few years. The outcome of the study will have implications for governments, international agencies (governmental and nongovernmental), women's organizations, and organizations of health professionals. 12.39 More specifically the project will describe in statistical terms the situation of women as providers of health care; analyse statistical and other information to show how that situation is related to economic, political, social, or cultural variables; and propose intervention strategies to improve it. The study, to be completed in I982, will include contributions from Brazil, Colombia, Egypt, Ethiopia, France, Hungary, India, Indonesia, Jamaica, Mali, Nigeria, the Philippines, Poland, and Thailand.
Training in health mancW'llli'lll I 2.40 The Executive Board's organizational study on the role of WHO in training in public health and health programme management! was submitted to the Thirty-fourth 1
WHO document EB67/I98I/RECfi, Annex
j.
HEALTH MANPOWER DEVELOPMENT
These projects promote the basic training and the continuing education needed for managing health services, especially in primary health care. The meeting assessed the progress made, noted the constraints, and agreed on ways of expanding the projects in line with the recommendations of resolution WHA34. I4. It also discussed the basic elements for an interregional network of health management training projects; the role of work studies in health manp0wer management, training for management, and educational and manpower planning; methods of carrying out such studies; and ways of obtaining extrabudgetary support. I 2.43 A growing number of countries in the African Region have asked WHO to collaborate in health planning and in developing health information systems for management. Workshops were held in five countries (Gambia, Liberia, Nigeria, Upper Volta, and Zambia). I 2.44 A meeting in Arusha, United Republic of Tanzania (July I98o), with participants from I 5 countries, discussed the functions of a training network, teaching methods, and the role of health development centres. On its recommendation, I 3 selected teaching establishments will each organize a workshop on how to integrate management training into the curriculum. 12.45 In the Region of the Americas, a programme for advanced training in health administration for Latin America and the Caribbean area has been under way since I 979 with the support of the W.K. Kellogg Foundation. The network of training programmes is being continuously expanded and at present numbers 49· I 2.46 During the biennium regional workshops were held on (i) education in organizational behaviour, (ii) education in health economics, finance, and costs control,
and (iii) health planning. Their reports are being prepared for issue, in addition to two bibliographies on health administration. 12.47 A programme of training for supervision and consultation in local health service units is being supported by the Organization in Bolivia, Brazil, Costa Rica, El Salvador, Guatemala, Honduras, Nicaragua, Panama, and Peru. A meeting coordinated by the Latin American Center for Educational Technology in Health (Rio de Janeiro) was held in Lima to organize the work in Bolivia, Brazil, and Peru. Similarly, a community health training programme coordinated the work of the countries of Central America and Panama in implementing a process for training in supervision at country level. An evaluation of programme activities was carried out in the countries that had been participating for two years (Costa Rica, El Salvador, Guatemala, Honduras, and Nicaragua) and was presented to a meeting in Guatemala City, which agreed that WHO's continued support was essential to the future of the programme. I 2.48 In the European Region, collaboration fontinued with several teaching institutions, including the Central Institute for Advanced Medical Studies, Moscow; the latter runs annual international courses for public health administrators for which WHO provides lecturers and fellowships. At the fifth scientific session of the I98o course (Budapest, June I98o) the theme was primary health care and the role of outpatient departments in increasing the effectiveness of such care. A third meeting of the joint committee to evaluate the courses was also held.
12.49 The Regional Office for the Eastern Mediterranean sponsored a series of workshops on training in management (Somalia, I 980, and Israel, I 98 I) and is continuing its efforts to promote similar meetings in other countries of the Region.
THE WORK OF WHO, r98o-r98r
Continuing education 12.50 Continuing education is an essential element in good health manpower management. It is of particular importance in retaining primary health personnel where their services are most needed and in reducing the migration of trained personnel. I 2. 5I A programme on continuing education in the Region of the Americas has been jointly supported since I978 by PAHOJ WHO and CIDA in seven countries-Bolivia, Colombia, Cuba, the Dominican Republic, Ecuador, Guatemala, and Hondurasjoined in 1980 by Nicaragua. The community health training programme for Central America and Panama has been designated as reference centre for the programme. An evaluation carried out in April I981 (San Jose, Costa Rica) showed that each country had adapted the programme to its own needs. The programme's main aim is the continuing education of auxiliary and middle-level technical health personnel but it would be desirable for it to cover the entire health team; a proposal for its expansion has therefore been made to CIDA. I 2. 52 A set of standards for primary health care services, which can also be used in the continuing education of health service administrators, is being developed in the Region.
health services and professional associations can promote a systematic programme of continuing education that will reorient and reinforce primary health care services in line with the regional strategy, and (ii) what are the best methods and mechanisms to implement that strategy at country level, particularly as regards the promotion of lifestyles conducive to health, the provision of adequate and accessible health care services, the contribution of the various levels of management, and the relationship of those levels in a system of continuing education.
Fellowships 12.54 Fellowships continue to play an important part in WHO's manpower development programme. The emphasis is on training fellows in an environment and with a study programme similar to that of their home country. During the biennium WHO awarded 702 I fellowships (see Table I 2. I). It also provided travel and subsistence allowances to enable some 7570 participants to attend educational meetings or national courses organized by WHO. 12.5 5 In the African Region, the exchange of instructors between countries of the Region continued. In I98o four students from Liberia and the United Republic of Tanzania studied in Nigeria and Kenya, and in I98I two Tanzanian students took courses in Nigeria. I 2. 56 The administration of fellowships is being decentralized in the Region of the Americas, the process beginning with Colombia and countries of the Caribbean area . Seminars were held in Brasilia, Lima, and Mexico City, to plan further decentralization. To facilitate this planning, a new administrative manual and a directory of training programmes were prepared.
12.5 3 In the European Region a consultative meeting to review recent developments in continuing education (Copenhagen, May I98o) stressed the importance of teacher training. It prepared the programme outline for a seminar on the continuing education of . health workers in primary health care (San Remo, Italy, I98I), which brought together administrators responsible for planning such programmes and representatives of national health services and health training institutions. The discussion centred on (i) how
HEALTH MANPOWER DEVELOPMENT Table 12.1 Distribution of fellowships, by subject of study and by region, 1980-1981 SouthEast As1a Reg10n Eastern Med1terranean Reg1on
SubJect of study
Afncan Reg1on
Reg1on of the Amen cas
European Region
Western Pac1fic Reg1on
Total
Public health admm1slrat10n Hosp1tal and med1cal care ad minas!ratiOn . . . . . . . ConstructiOn of health mstllullons Medical libranansh1p Subtotal Environmental san,tal10n Food control Subtotal Nursmg and m1dw1fery Public health nursmg Med1cal soc1al work Subtotal Maternal and child health. Paed1atncs and obsletncs Subtotal Mental health Health education . Occupational health Nutnt1on. Health stat1st1cs Oral health . Rehabilitation . . . . Control of pharmaceutical and biOlog1cal preparat1ons Subtotal Total
513 11 3 527 101 4 105 79 55 134 31 27 58 13 82 3 20 6 18 21 6 169
141 27 4 9 181 54 22 76 57 25 1 83 120 26 146 53 14 9 14 60 30 15 20 215
265 32 4 301 204 20 224 42 16 58 97 26 123 39 115 37 31 58 34 14 31 359
26 6 1 33 162 8 170 12
67 28
117 16 4 137
1129 120 8 24 1 281 647 78 725 274 121 6 401 494 134 628 181 246 103 91 179 130 94 122 1146
102 49 10 59 31 6 1 38 62 31 93 24 11 22 10 18 19 30 22 156
77 14 91 53 19 4 76 78 14 92 17 21 15 14 16 24 7 27 141
12 106 10 116 35 3 17 2 21 5 7 16 106
-
HEALTH ORGANIZATION AND SERVICES
993
701
1 065
437
448
537
4181
Percentage
71% 26 9 11 87 41
62Y. 38 9 17 103 72 2 241
56% 85 8 41 115 171 3 423
72% 3 8 3 8 23 20 65
44% 61 8 22 61 76 4 232
56% 77 7 18 41 55 1 199
60% 290 49 112 415 438 30 1 334
. . . Malana . . Sexually transmitted d1seases Tuberculosis Other commumcable d1seases Laboratory serv1ces. Chemotherapy, ant1b10t1cs Total - COMMUNICABLE DISEASES Percentage Surgery and medicine Anaesthes1ology . Rad1ology Haematology Other med1cal and surg1cal specialties Subtotal Bas1c med1cal sc1ences Med1cal and allied educa11on Undergraduate medical stud1es . Subtotal Total - CLINICAL MEDICINE, BASIC MEDICAL SCIENCES, AND MEDICAL AND ALLIED EDUCATION
174
13% 11 4 85 5 27 132 43 6 43 92
21%
22% 37 3 28 8 89 165 57 203 3 263
11% 28 2 5 8 35 78 13 13 26
23% 34 27 91 12 59 223 47 51 7 105
20Y. 6 11 27 4 40 88 53 62 26 141
19% 120 47 245 43 286 741 232 454 79 765
9 6 36 55 19 119 138
224
193
428
104
328
229
1 506
Percentage GRAND TOTAL
16% 1 391
17% 1135
22Y. 1 916
17% 606
33% 1 008
24% 965
21% 7 021*
• Of wh1ch 3 504 dunng 1980 and 3 517 dunng 1981
1 93
THE WORK OF WHO, r98o-r98r
12.57 Fellowships in the South-East Asia Region accounted for more than 22% of the regional budget for I98o-I981. The trend towards placing fellows in their own region has continued: of the I005 fellowships awarded in I98o, 57% were for study within the Region as compared with 27% of the I 546 fellowships in the previous biennium. Procedures for evaluating the knowledge and experience gained by fellows are being improved. In the European Region the subI 2. 58 jects studied by WHO fellows reflect the health problems of their countries of origin and the emphasis placed by WHO on certain of those problems. The third meeting of European national fellowships officers (Bratislava, Czechoslovakia, August 198o) discussed the purpose of WHO fellowships, the use made of them by Member States, the way in which fellows were utilized on their return, and how administrative procedures could be improved. The meeting was partly financed by voluntary contributions from Austria and Czechoslovakia. The Regional Office continues to promote the organization of international courses for the benefit of fellows. There were four such courses in I98o, three concerned with health services and one with teacher training. 12.5 9 In the Eastern Mediterranean Region the trend towards a reduction in the total number of fellowships continued-497 were awarded in I98o as against 5 IO in I979 and 562 in I978. One reason for this is the tendency to support training in other ways: for example, during the biennium all the WHO-sponsored training of community health workers for primary health care, and that of their teachers, took place within the countries concerned. At other levels-even that of teacher training for medical schoolsincreasing use is being made of workshops, courses, seminars, etc., at country level,
where WHO's contribution is indirect and does not require the granting of fellowships. I2.6o A selective study on the utilization of ex-fellows was presented to the Regional Committee for the Western Pacific in September I 98 I. Almost all countries and areas of the Region benefit from the fellowships programme, China now being one of the major beneficiaries. Study tours to that country are also being increasingly organized; in addition to the established courses in acupuncture, China provides short courses and workshops in primary health care. I 2.6 I Increasing cooperation at regional level and greater recourse to TCDC is particularly evident in the case of fellowships. The policy of placing fellows either within their own region or in countries with comparable socioeconomic conditions has been made even more imperative by the recent sharp increase in the costs of training in certain European and other industrialized countries. I 2.62 In response to requests made at the Thirty-third World Health Assembly, a report was prepared for the Executive Board, t which at its sixty-ninth session (January I982) was to review the use of WHO fellowships. The report describes the objectives of the fellowships scheme as set by the Health Assembly and traces its operation from I947 up to the present day. It examines the administration of fellowships in the different regions, the responsibility of Member States for nominating fellows, and the contribution of the host country and its institutions. The evidence gathered confirms that fellowships have made an important contribution to WHO's work. More than 70 ooo fellowships were awarded from I947 to I98o, almost all the fellows were able to utilize the new skills acquired, and Member States expressed their 1
WHO document EB69jz6 (r98r).
HEALTH MANPOWER DEVELOPMENT
satisfaction at the contribution made by fellowships to the development of health manpower. Among a number of suggestions for action by Member States and WHO, one recommendation stresses the need for countries to have a manpower plan, in line with the national policy for health development, which would inter alia be the principal point of reference for the nomination, selection, and evaluation of fellows. To carry out national strategies for achieving health for all, more fellowships should be awarded to those who will be directly involved in primary health care programmes.
tries, organized by ECWA (Beirut, 1980). 2 A study of the case of the United States of America, sponsored by the Sandoz Foundation, was prepared by WHO on the basis of the overall study.3 Details of the case of Latin America, also prepared by WHO, were included in a study supported by the Fogarty International Center (USA). 4 Several Member States have shown interest in adopting measures to control undesirable migration of health manpower in line with the conclusions of the report. Colombia, Jamaica, the United States of America, and several countries in the Eastern Mediterranean Region have begun to study the problem on a national basis and to take the necessary steps.
Development of career structures I 2.6 3 The absence of appropriate career structures for health workers is frequently a cause of lack of motivation. But career structure policy often spans the whole civil service and is thus difficult to change in the health sector alone. In the South-East Asia Region, studies on the conditions of employment of sanitarians and auxiliary sanitarians were carried out in both Indonesia and Thailand. The reports prepared by the national investigators are being discussed with ILO before recommendations are made to Member States on the training and management 'f environmental health staff at primary health care level.
International Drinking Water Supp!J and Sanitation Decade I 2.66 · The development of human resources is a prominent component of the activities related to the International Drinking Water Supply and Sanitation Decade (I98I-I99o). WHO proposed a two-phase strategy for international action. During the first three years the international agencies would support the efforts of some 5o countries to assess and meet their most pressing needs for manpower in the water and sanitation sector; they would then support I 2 of those countries in testing and utilizing various methods of planning, producing, and 2 Zahlan, A. B., ed. The Arab hrain drain :proceedings of a seminar organized hy the Natural Resources, Sciences and Technology Division of the United Nations Economic Commission for Western Asia, Beirut, 4-8 February rg8o. London, Ithaca Press, 1981. 3 Mejia, A., Pizurki, H. & Royston, E. Foreign medical graduates: the case of the United States. Lexington, MA, D. C. Heath, 1980 (Sandoz Institute of Health and SocioEconomic Studies). 4 Mejia, A. Health manpower migration in the Americas. In: Kidd, C. V., ed. Biomedical research in Latin America: background studies. Washington, National Institutes of Health, 1980 (NIH Publication 8o-zo5 1).
Migration of health manpower 2.64 The findings of the WHO multinational study on physician and nurse migration 1 were widely circulated and aroused considerable interest. They were presented at a seminar on the brain drain in Arab counI 1 Mejia, A., Pizurki, H. & Royston, E. Physician and nurse migration: analysis and poliry implications. Geneva, World Health Organization, 1979.
THE WORK OF WHO, 198o-r98r
managing the human resources required for the Decade. In the second phase the approaches that had proved most fruitful would be applied on a broader scale within those I 2 countries and also extended to others. I 2.67 Several WHO regions are devising strategies and action for developing human resources for the Decade, and the South-East Asia Region is at an advanced stage in its plans.
was to evolve strategies that would increase the contribution of nursing/midwifery personnel to national plans of action and emphasize the reorientation towards primary health care of nursing education, nursing services, and continuing education. It outlined the technical support that would be required at national, regional, and global level and from WHO collaborating centres and nongovernmental organizations. I2.7I WHO also collaborated with countries in revising basic nursing education programmes in order to produce graduates who could work effectively in primary care. Guidelines were developed and field-tested in I98I showing how curricula should be revised so that the focus of nursing education became care of health rather than care of sickness. The guidelines were initially tried out at the School of Nursing of Chulalongkorn University, Bangkok, and proved helpful to teachers in all aspects of curriculum development. The trial was repeated in other countries: Colombia, Israel, Jamaica, Malaysia, Nigeria, the Philippines, the Republic of Korea, Spain, Switzerland, Thailand, and Zimbabwe. National and regional workshops were organized to facilitate the reorientation of basic nursing education programmes towards primary health care.
Promotion of training I2.68 During I98o-I98I activities were geared to developing and promoting a variety of training strategies for all categories of health staff. Close collaboration was maintained with Member States in their efforts to train the health teams required for primary health care (in particular auxiliary and intermediate-level personnel working at the periphery) and traditional birth attendants.
Educational programmes for primary health care I2.69 Work was carried out with the International Council of Nurses (ICN) to implement the recommendations made at the I979 ICN/WHO workshop on the role of nursing in primary health care. Information was gathered on how national nursing associations are supporting primary health care and how they will collaborate in developing and implementing their countries' strategies for achieving health for all. The ICN congress in I 98 I, attended by 6ooo nurses, promoted awareness of this concept. Its theme was "Health care for all-Challenge for nursing". 12.70 An informal working group, representing national personnel, WHO collaborating centres, and nongovernmental organizations, was sponsored by WHO. Its aim
1 In the European Region, Member States showed increasing interest in the nursing/midwifery programme (see also paragraph I2.8I), which is designed to ensure the participation of nationals through a network of collaborating and participating centres in I 8 countries. Eight nursing research centres are now collaborating directly with the WHO nursing programme, in Belgium, Denmark, Finland, France, Poland, Switzerland, and the United Kingdom (England and Scotland). The centres take part in multinational studies using standardized research instruments and report the results achieved by following the I 2. 72
HEALTH MANPOWER DEVELOPMENT
methodology outlined in WHO's mediumterm programme. 12.73 In the Western Pacific Region several countries and territories-the Cook Islands, Fiji, Guam, Papua New Guinea, and Vanuatu-have with WHO collaboration undertaken the revision of their basic nursing education programmes to bring them into line with the primary health care approach. WHO is collaborating with Samoa and Vanuatu in preparing nurses to assume greater responsibilities in the primary health care services of rural areas ; the training will cover community assessment, diagnosis and treatment of disease, midwifery, health promotion and disease prevention, environmental health, and management of rural health facilities. I 2. 74 Training ofphysicians in the African Region was carried out in 48 institutions in I 98o; several of them have been organized as university centres of health sciences and their first physicians are now graduating. In Burundi, the Faculty of Medicine of Bujumbura introduced the second phase of its medical curriculum-clinical studies. During the biennium 32 country and I 3 intercountry projects were supported in the Region, the training whenever possible being carried out by nationals.
the Americas in recent years prompted the Organization's collaboration with the Pan American Federation of Medical School Associations in setting minimum requirements for the establishment of new schools. Regional meetings were held in Brazil and Venezuela to define basic principles for such requirements and in I98o work was carried out with national medical school associations. A guide to the assessment of existing schools was prepared for use at a first national meeting, in Lima. Meetings were subsequently held in Colombia and Mexico. In the Eastern Mediterranean Region, continued support was given to the medical schools in Bahrain and Yemen, still in their planning stage, and to those in Gezira and Juba (Sudan), only recently established, to ensure that training programmes are relevant to the health needs of the communities where graduates will serve and that the methods used are educationally sound. 12.78 In the Western Pacific Region, WHO cooperated with Fiji in training medical graduates and with faculties of medicine in the Lao People's Democratic Republic, Malaysia, and Singapore. Viet Nam, whose health system was totally disrupted, is now regularly receiving supplies and equipment for its faculties of medicine. I 2. 79 The International Conference on Primary Health Care (I978) drew attention to the need to review the training and clarify the functions of community health workers, emphasizing the importance of exchange of experience on their training, utilization, and deployment. In response, WHO and UNICEF undertook an interregional study to collect information on such experience and to define the critical issues, e.g., selection, functions, tasks, and remuneration. Workshops for the analysis of experience were held in Kingston (February I98o) and in Dakar (February I98I). The reports on the findings
12.75 A regional seminar on the teaching and delivery of health care in Africa (December I98o) brought together 4I deans and directors of medical schools or university centres of health sciences from 26 countries. The seminar reiterated the need for training the health team, promoting the teaching of management and educational methodology, and establishing coordination between the health and education sectors and other development sectors. 12.76 The explosive growth in the number of medical schools in the Region of I97
THE WORK OF WHO, 198o-I981
should help decision-makers and health workers to improve the training and use of community health workers as part of the primary health care approach. Follow-up activities are being carried out at country level and will be reviewed at an interregional workshop. 12.8o In the Region of the Americas the advisory commitee to the community health training programme for Central America and Panama, at its meeting in 1980, approved a plan of action covering nine subprogrammes. It included the production of new models for extension of primary health care coverage and for in-service training, and the development of educational technology. The main emphasis in the Region has been on intermediatelevel and auxiliary personnel, in line with the priorities of primary health care. 12.81 Support continued to be given to Member States of the European Region in developing a nursing/midwifery subsystem of the overall health staffing system that will enable them to plan for, train, and efficiently utilize this type of personnel. Two workshops for nurse managers at national, regional, and local level were followed by a working group (1980) to study the training and use of auxiliary nursing/midwifery personnel. The group considered that the proliferation of categories of auxiliary personnel would inhibit the development of efficient and costeffective nursing services. It recommended that all categories of nursing staff should receive appropriate training before entering the health services; that the content of programmes for the training of nursing auxiliaries should be better defined; that the minimum level of general education required before nursing education could be undertaken should be raised to correspond to any rise in a country's general level of education; and that the definition of different categories of auxiliary nursing personnel throughout the Region should be standardized.
12.82 A considerable effort has been made in the Eastern Mediterranean Region to reorient the education of health personnel towards the primary health care concept, with particular emphasis on the training of middlelevel and rural health workers. WHO support focused on teacher training, the development of task-based, community-oriented curricula, and the preparation of learning materials. There has been growing cooperation between countries of the Region and an increasing number of institutions are now able to provide training for nationals of other countries. The regional directory of education and training programmes for health personnel (paragraph 12.86) facilitates such cooperation. 12.83 In the Western Pacific Region WHO has worked with countries to establish their requirements in various types of middlelevel health worker. The training of medical assistants is being promoted in a number of countries. Tonga, where a training programme is being implemented, has developed an infrastructure that facilitates inter alia the training and use of such staff. WHO has collaborated with Fiji in revising training curricula. 12.84 An important member of the health team is the medical technician, whose responsibilities include the maintenance and repair of medical equipment. In the African Region, the training centre at Freetown has been operating at full capacity since April 1980 for students from English-speaking countries, while the centre in Lome receives students from French-speaking countries. (See also paragraph q.102.)
Information on training institutions 12.85 WHO regularly publishes directories of medical schools and schools of public health. A French version of the fifth
HEALTH MANPOWER DEVELOPMENT
edition of the World directory of medical schools 1 was published in 1980. Information on the training of primary health workers is being collected at the request of Member States in order to maintain a source of up-to-date basic data for the promotion of training programmes and the planning of facilities. 12.86 In the Region of the Americas a directory of training programmes in Latin America and the Caribbean area was prepared in 1980. In the Eastern Mediterranean Region the next issue is being prepared of the biennial directory of education and training programmes for health personnel, which contains information on programmes for all levels of health worker. The fifth edition of the registry of training courses available for health personnel in the Western Pacific Region was completed.
traditions, customs, and resources and in keeping with the background of the trainees, who for the most part are illiterate or semiliterate. A manual has therefore been prepared for instructors of traditional birth attendants; it consists of a practical description of training strategies, an indication of simplified technologies that can be used in maternal and child health care and family planning, and a guide to the production of low-cost teaching/learning materials.z After wider field testing, these manuals will be distributed to all countries that ask for them. 12.89 A joint effort is being made w1th UNESCO to integrate literacy skills into the training of traditional birth attendants. Both India and Thailand have expressed interest in this activity which, if it is successful, should make the traditional birth attendant a more effective member of the community as well as a better health worker and educator. Work in the training of traditional birth attendants was supported by UNFP A.
Traditional birth attendants 12.87 A number of countries in the South-East Asia and Western Pacific Regions (Bangladesh, India, Indonesia, Malaysia, Maldives, the Philippines, and Thailand) are developing strategies to train traditional birth attendants and utilize them in their maternal and child health carejfamily planning services. There are programmes in 52 countries to train such staff but few to ensure their supervision and evaluate their work. A study has begun in Sierra Leone to develop and test methods for assessing the extent to which trained traditional birth attendants contribute to an improvement in community health. I 2.88 The atmosphere in which traditional birth attendants are able to work has improved, but there are still impediments to their training-chiefly the absence of methods and teaching material based on local
Postgraduate and postbasic education 12.90 In 1981, the ninth interregional meeting of directors and representatives of schools and departments of public health was held in Cotonou, attended by participants from 33 countries in the African, South-East Asia, Eastern Mediterranean, and Western Pacific Regions. The meeting defined the role of schools of public health and of centres or national networks for health development in carrying out priority programmes for achieving health for all by the year 2ooo. Emphasis was given to the integrated training of the health team, collaboration among all levels of the health delivery system, self-sufficiency in health development, and teaching methods and research in health development and health management. 2 World Health Organization. A TBA trainer's kit . London, British Life Assurance Trust Centre, 1982.
1 World Health Organization. World directory of medical .rrhool.r. fifth edition. Geneva, 1979.
1 99
THE WORK OF WHO, 198o-1981
12.9I For over a decade surveys of postbasic nursing education programmes have pointed to the shortage of qualified nurse educators and nurse administratorsthe key personnel not only in training nurses and other health personnel but also in reorienting basic nursing education. In preparation for an expert committee in I 98 3, a global survey was made of post basic nursing education programmes; its purpose was to clarify the nature, characteristics, and progress of changes in training programmes, determine the extent to which those changes are oriented towards primary health care, and examine the factors impeding their realization. Questionnaires were sent to I 8 2 schools (in all regions) offering postbasic programmes for the preparation of nurse teachers and managers. Analysis of the data began in late I981. This type of curriculum reform is part of the response to Health Assembly resolution WHA30.48, which calls for nursing/midwifery staff to be given the opportunity to develop the skills required for effective participation in the planning, management, and execution of primary health care programmes. 12.92 In the African Region a working group on postgraduate education discussed the training of specialists and recommended the establishment of a regional network of specialized training centres. The sixth meeting of deans and directors of health sciences faculties, schools, and university centres (Brazzaville, I 980) reviewed the recommendation and approved the establishment of I 3 sub-networks, each specializing in the teaching of one priority discipline. 12.93 The regional postbasic nursing education centre at Dakar introduced the teaching of primary health care in I 98 I, and the centre at Yaounde is to follow suit. The centre in Luanda has based its programme on the principles of primary health care. At a workshop on teaching methodology for 200
nurse educators from French-speaking countries (Lome) discussion centred on the teaching of primary health care and the tasks to be carried out by nurses and midwives, indicating the duties that could be performed by auxiliaries. A similar workshop was held at Banjul for nurses working in the hospitals and health centres of three English-speaking countries (Gambia, Liberia, and Sierra Leone). 12.94 As part of technical cooperation among developing countries, Cuttington University College, Liberia, introduced a postbasic nursing education course attended by students from Gambia and Sierra Leone as well as from Liberia. 12.95 In the Region of the Americas the emphasis in collaboration with schools of public health was on the decentralization of programmes by means of regional basic courses that include in-service training. The Latin American Association of Public Health Schools, which is responsible for graduate programmes in public health and social medicine, continued to receive support from WHO; at the eleventh regional meeting of the Association, in I 98 I, the main topic discussed was public health training on a regional basis. Postbasic training courses were organized at national and regional level in nursing, dentistry, mental health, and veterinary medicine. I 2.96 A group of experts in the SouthEast Asia Region (October I98o) examined the possibility of a network of national public health training institutes that would share their facilities and expertise. A regional meeting at the All India Institute of Hygiene and Public Health, Calcutta (I98I) discussed what activities such a network could undertake.
12.97 In the European Region, WHO continued to support four university pro-
HEALTH MANPOWER DEVELOPMENT
grammes in nursing education-in Belgium, Iceland, Italy, and Berlin (West). The projects in Belgium and Italy came to an end and were evaluated; the others are continuing, visiting professors being provided to teach in those areas of clinical medicine for which national teachers are being trained abroad. I 2.98 In the Eastern Mediterranean Region, the resources of the WHO-supported medical education projects in Pakistan and Sudan were mainly used for postgraduate and continuing education. Over the past two years WHO has been closely associated with the development and activities of the Arab Board for Medical Specialization. I 2.99 Support was given to a regional course in anaesthesiology to serve the need of developing countries in the Western Pacific Region. In the Philippines, WHO collaborated with the Institute of Public Health, Manila, to upgrade the training of the managers and administrators required for health care systems based on primary health care.
team leader at project level, one related to Liberia and the other to the Netherlands. Methodologies will be proposed for the design of curricula and learning materials to prepare physicians and other health personnel for a leadership and supervisory role in primary health care. Further case studies will be published to guide Member States in developing training programmes suited to local conditions. Continuing education programmes intended for physicians already in practice will also be examined. I 2. IOI The regional health development centre in Cotonou, which since June I98o has had a national director, has trained 8 5 students from French-speaking countries of the African and other regions. During the biennium 40 of the students came from I 7 countries of the African Region, including for the first time two Portuguese-speaking countries. The training covered most members of the health team-physicians, nurses, midwives, social assistants, health, medical, and sanitary technicians, sanitary engineers, dental surgeons, pharmacists, nutritionists, administrators, and sociologists. The centre offers a diploma, a master's degree, and a doctorate in public health.
Development of the health team 12. I oo Work continued on promotion of the health team approach, with special emphasis on the team leader. A study begun in I98o on the role and tasks of leaders of primary health care teams will be used as a basis for a review of training, beginning with training programmes for physicians. Three nongovernmental organizations were associated with the study-the International College of Surgeons, the International Federation for Hygiene, Preventive Medicine and Social Medicine, and the World Medical Association--and their national chapters undertook surveys at country level. The findings were analysed, reviewed, and used in preparing two case studies on the role of
I2.I02 In the South-East Asia Region, a group of experts met in I98o to clarify the concept of teamwork as it applies to the Region, define its essential components, and develop guidelines for training. A subsequent consultative meeting, with participants from Bangladesh, India, Indonesia, Maldives, Mongolia, Nepal, Sri Lanka, and Thailand, was in general agreement with the recommendations made; it also agreed on the design of case studies in those countries to determine what primary health care teams are already in action and what are the factors facilitating or impeding their functioning. A training programme for health teams will be based on the findings of the study.
20I
Teaching/ learning materialsfor primary health care I2.I03 The preparation of teaching/ learning materials for primary health care workers continued to receive high priority. A revised edition of The primary health worker, with new chapters on record-keeping, reporting, and participating in community development, together with new illustrations, was published during the biennium. 1 This publication has been in constant demand and has also been translated into the local language, after adaptation where necessary to local conditions, in about 20 countries. I 2. I04 Experience shows that the success of health auxiliaries and village health workers depends on the support and supervision they receive. To meet the need for teaching/learning materials for middle-level managers in primary health care--public health nurses, midwives, sanitarians, and in some instances physicians--a guide has been published entitled On being in charge. 2 It is intended to help health workers who have to organize, supervise, administer, and provide technical or administrative support to primary health care programmes at intermediate level. The publication is being widely promoted. I2.I05 The scarcity of educational resources in both printed and non-printed form, especially those designed to permit selfinstruction, is a serious constraint on the preparation of personnel for primary health care.
training nursing staff in the WHO network of collaborating and participating centres; so far one module, on the nursing process, has been prepared. Studies were carried out on (i) communication and collaboration between health professionals, (ii) legislation on nursing services and training, and (iii) legislation on midwifery services and training. Nine basic documents and workbooks were completed and distributed throughout the network, some of them prepared on the basis of these three studies, others as part of various activities in the nursing/midwifery programme. 12. I07 In the Western Pacific a regional module bank went into operation in I98I to meet the need of nursing/midwifery schools for learning modules that have already been tested. Modules are also being developed on primary health care, both for instructors and for health workers. Reports on the use of the modular approach to learning in Papua New Guinea and the Philippines indicate that it is successful in fostering the student's own responsibility for learning and his or her active participation in the learning process. I 2. 108 Books and other teaching materials to promote self-instruction are being supplied to schools of nursing/midwifery in the South Pacific.
Educational development and support
Educational planning In the European Region, a teaching/learning package, to consist of seven interrelated modules, is being developed for I 2.106 1 The primary health worker: working guide, guidelines for training, guidelines for adaptation, revised edition. Geneva, World Health Organization, 1980. 2 McMahon, R., Barton, E. & Piot, M. On being in charge: a guide for middle-level management in primary health care. Geneva, World Health Organization, 1980.
I 2. I 09 Among the acttvtttes to ensure that training programmes adopt the primary health care approach is the promotion of a network of community-oriented educational institutions for health sciences. This network is now two years old and operates as an independent entity, WHO continuing to lend support on request. It provides participating
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institutions with an opportunity for mutual assistance in developing problem-based training programmes. One of the task groups established by the network has examined the organizational requirements for a community-oriented educational programme. Among the reasons for the success of the network are a capable secretariat (University of Limburg, the Netherlands) and the enthusiasm of its member institutions. I 2. I IO WHO is collaborating with several Member States in producing detailed job specifications for different categories of staff, especially primary health care workers. Methods are being worked out for determining easily and economically the tasks to be carried out by the members of the health team. A world survey of task-centred (competency-based) curricula is being jointly undertaken in nursing and medical schools by WHO, the International Council of Nurses, and the World Federation for Medical Education. Data collected so far indicate that, in spite of their proven qualities, methodologies for the preparation of task-centred curricula are not widely accepted by teaching staff. It is hoped that the information produced by the survey will encourage the planning of more effective educational programmes, based on actual professional tasks and responding to the real needs of the community. I 2. I I I In the African Region, the planning of training programmes for all categories of health personnel, particularly those directly concerned with primary health care, is an important part of WHO's work with Member States. In Mozambique, for example, the Organization helped to develop an overall plan for training the manpower needed in that country. I 2. I I 2 In the Region of the Americas, collaboration was channelled through the Latin American Center for Educational Technology in Health, Rio de Janeiro, which
provides a wide range of courses and advisory services, e.g., in Central America and Panama, where it has collaborated with the community health training programme. It is expected that in the future this programme will be able to coordinate all educational activities in the subregion. I 2. I I 3 In the European Region, a workshop on educational planning was organized (Copenhagen, I98o) to develop skills in formulating objectives, identifying determinants of planning, and evaluating competence. Participants stated the goals they wished to achieve during the I 2 months following the workshop and prepared plans of action as a basis for self-evaluation at the end of that period. The Regional Office took part in a seminar on curriculum development for health professionals (I98o) held at the Institute for Research in Education and Evaluation, Berne. I 2. I I 4 In the Eastern Mediterranean Region, the 26 participants in the tenth regional workshop on educational planning (Amman, I98o) came from Jordan, Somalia, and Sudan. All were professional educators in key posts, for whom this was the first experience of modern techniques of planning and evaluation. A workshop on educational planning and evaluation at the High Institute of Public Health, Alexandria (I98o) brought together I 8 faculty members, also without previous experience of such work, and prepared them to carry out the overall evaluation of an institutional programme. 12. I I 5 In the Western Pacific Region a workshop on medical education was conducted in I98o for deans and senior faculty members of the institutions participating in the regional teacher-training centre, Sydney, Australia. Senior nurse educators from the South Pacific attended a workshop on learner-centred curricula (Suva, I 9 So) and discussed current trends in educational meth-
THE WORK OF WHO, 1980-1981
odology. Schools are being encouraged to introduce learner-centred activities and to develop teaching materials appropriate to the health needs of the South Pacific.
~eacher
training
I 2. II 6 During the biennium acuvrtles focused on preparing teachers of primary health care workers and others to plan curricula relevant to national strategies for achieving health for all. In Papua New Guinea, Sudan, and the United Republic of Cameroon, courses on primary health care in rural areas for supervisors and teachers were carried out in those rural areas where primary health care was being organized. I 2. I I 7 To help teachers to recognize their own strengths and weaknesses, a guide was prepared and widely circulated for comment, with a view to its revision for publication. In the same context, the widely distributed educational handbook for health personnel was thoroughly revised after continuous field testing and use at teachertraining workshops.t The revision is available in English, French, Italian, and Spanish.
I 2. I I 9 The Latin American Center for Educational Technology in Health offered several courses in teacher training during the biennium. They covered the use of audiovisual aids in nursing education; group dynamics in education; didactics as applied to health sciences; and use of computer programming techniques in education. The Center continued to take part in the master's degree programme in educational technology offered by the Federal University, Rio de Janeiro.
I 2. I 20 The two regional teacher-training centres in South-East Asia, at Peradeniya (Sri Lanka) and Bangkok, continued to support improvements in educational planning and methodology. The centres have organized a wide range of short courses on such subjects as design of self-learning packages, professional attitudes and their measurement, clinical evaluation techniques, and the concept of the health team. India established a second national teacher-training centre at the postgraduate Institute of Medical Education and Research, Chandigarh, and Indonesia now has a network of five such centres.
I 2. I I 8 In the African Region, the regional training centres at Lagos and Lome continued to strengthen health systems in the countries of western and central Africa. The courses offered by the centres are planned in cooperation with the countries and are especially geared to the training or retraining of teachers who will go on to organize education and training programmes in their own countries. The Lagos centre has trained 24 5 students from I 8 countries, and the Lome centre 58 I (including I 76 laboratory technicians).
I 2. I 2 I In the Eastern Mediterranean Region teacher-training activities are entirely carried out by nationals, mainly trained at the regional centre, Shiraz (Iran).
1 Guilbert,].-]. Educational handbook for health personnel. Geneva, World Health Organization, 1977, revised 1981 (WHO Offset Publication No. 35).
I2.I22 In the Western Pacific a number of activities were carried out with the support of the WHO regional teacher-training centre, Sydney (Australia). In Hong Kong, a curriculum was developed for occupational therapists; medical education workshops were organized in China; faculty development was undertaken at the Institute of Health Sciences, Tacloban (Philippines); an integrated curriculum was developed at the universities in Kuala Lumpur and Penang
HEALTH MANPOWER DEVELOPMENT
(Malaysia); a review was made of the multiple-choice questions used in instruction; and a medical education unit was established at the University of Singapore. I 2. I 2 3 In Malaysia a national teachertraining centre has been set up at the Public Health Institute, Kuala Lumpur, the faculty being given WHO fellowships for their training, most of it at the regional teachertraining centre, Sydney. In the Philippines WHO helped to establish a programme for a master's degree in education of health personnel at the national teacher-training centre in Manila. In the Solomon Islands a project is under way to develop a cadre of nurse teachers by contract with Armidale College, Australia: faculty members from the College visit Honiara periodically and assignments are set for students to complete before the next visit; the students also spend some time in Armidale for training and teaching practice.
Learning materials I 2.126 The aim of WHO's interregional programme in this area, which is complemented by two regional programmes, is to promote national self-reliance in the production of teaching and learning materials that are relevant to health services and community needs. Such materials are urgently required for all categories of health personnel at all stages of their careers-as students, practitioners, or teachers-and for their continuing education. This UNDP-supported programme provides an excellent opportunity for technical cooperation among countries by the sharing of their expertise in the production, adaptation, and distribution of learning materials. Six countries are participating: Kenya, Morocco, Nepal, Peru, the Philippines, and Sudan. A meeting to determine strategies and define the role of the interregional network (Geneva, I 98 I) was attended by representatives of organizations that have practical experience of producing learning materials in or for countries of the Third W odd. I2.I27 In the African Region, attempts are being made to establish a network of national centres for the production and distribution of learning materials. A preliminary survey was carried out in five countries (Ghana, Mozambique, Nigeria, Senegal, and the United Republic of Cameroon) and was followed up at the sixth meeting of deans and directors of health sciences faculties, schools, and university centres (Brazzaville, I98o). A regional programme to complement the interregional work is based on a network of country projects linking the health science centres in Benin, Mozambique, Nigeria, and Rwanda. I2.128 A workshop on the production and use of audiovisual material (I 98 I) brought together teachers from the centres for higher education in nursing (Dakar,
I2.I24 Work began during the biennium on guidelines to assist administrators of training programmes in selecting trainees. These guidelines are being tested in a number of countries to ensure that the procedures really meet the requirements, namely the selection of the candidates most likely to benefit from training for primary health care.
I 2. I 2 5 As a guide to teachers on how to make students more effective members of the instructional team, two documents were prepared. The first, Students learning from students,l is currently being tested in a number of training institutions in developing countries. The other, Students helping in the teaching/ learning process,2 is a review of peer-learning experience and includes a bibliography.
t WHO document HMD/8o.3 (198o). ZWHO document WHOfEDUCf8I.I81 (1981).
THE WORK OF WHO, 198o-I98'
Luanda, and Yaounde) and from national schools of nursing and midwifery. Its aim was that participants should be able to produce their own material for use in teaching primary health care. I 2. I29 In the Region of the Americas, the textbooks and instructional materials programme was expanded to provide highquality material for health personnel at all levels, with emphasis on primary health care workers. A meeting of the community health training programme for Central America and Panama, with the participation of ministries of health, defined priorities and requested WHO support for the preparation of instructional manuals for auxiliary personnel. One such manual prepared ' as a result of this meeting deals with maternal and child health.
I 2. I 32 The preparation, production, and distribution of learning materials have received full support in the Eastern Mediterranean Region. A number of training manuals were translated into Arabic, relating inter alia to management of obstetric emergencies in health centres, basic techniques for health laboratories, prevention and emergency care of common oral diseases, and a guide for teachers of health staff. I 2. I 33 Following a meeting in Alexandria (April I98o) it was decided to develop a library for the medical assistant (or equivalent) during training and service. Production of learning materials at country level was further accelerated by a regional programme (complementary, as in the African Region, to the interregional programme) involving projects in Democratic Yemen, Somalia, the Syrian Arab Republic, and Yemen.
I 2.130 With the support of the Rockefeller Foundation, instructional material on epidemiological principles was prepared for the use of professional personnel in the health services and in other training programmes. Manuals on clinical laboratory work and on the training of primary health workers in eye care are under way. WHO has sponsored the preparation of a set of instructional modules for training health workers in communicable disease and immunization strategies and procedures.
I 2. I 34 WHO continued to collaborate with training institutions of the Region in field-testing various teaching/learning materials for relevance and suitability. Primary health care manuals were prepared and reproduced for local adaptation (even more than most learning materials, such manuals need to be country-specific). Plans are under way to collaborate with Member States in training nationals to prepare educationally sound and relevant teaching/learning materials, with particular emphasis on teacher-training material. I 2. I 3 5 The educational communication project that has been in operation in Sudan since I978 was terminated at the end of I981. It developed a methodology by which health workers can enlist the participation of the community in solving its own health problems, making use of available resources and local methods of communication. The methods and learning materials developed in the course of the project are now being utilized in Sudan's primary health care programme.
I 2. I 3 I The Latin American Center for Educational Technology in Health cooperated with the Expanded Programme on Immunization in producing educational material for regional and national training programmes. The Center offers two types of programme: faculty development workshops, and special courses in education. More than 500 professors of health sciences have participated in these programmes through fellowships offered by PAHOfWHO and the Center.
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Evaluation processes I 2.13 6 Programme evaluation as a means of improving the quality of health manpower programmes has received increasing attention from Member States, for example in the Eastern Mediterranean Region. The approaches used range from evaluation of national programmes to assessment of programmes of key institutions, such as was carried out at the Centre for Educational Technology in the Health Sciences, Cairo, in I981. The Centre had for many years received WHO support and the assessment was intended to determine the extent to which it had attained its objectives and suggest possible modifications in its work. I2.I37 WHO collaborated with Bahrain and Egypt in setting up a unit in the ministry of health to evaluate health manpower development on a continuing basis and to plan, implement, and monitor programmes in relation to the health services. The staff charged with this task in the two countries were given initial training in Geneva and will continue to receive support in carrying out the evaluation, which includes a review of organization, structure, and mechanisms. To reinforce this work, health manpower development indicators are being formulated and will be tested in different Member States. I2.138 Evaluation of the efficiency, ef. fectiveness, .and impact of educational programmes· by those responsible for them continues to be promoted. WHO's guidelines 1 are now being utilized in a number of institutions. Two workshops on programme evaluation were organized by the King Faisal University Faculty of Medicine, Dammam, Saudi Arabia-one at the Health Training Institute in Mogadishu, for sanitarians and 1 Katz, F.M. Guidelinesfor evaluating a trainingprogramme for health personnel. Geneva, World Health Organization, 1978 (WHO Offset Publication No. 38).
laboratory technicians, the other for the staff of the Faculty of Medicine and Surgery, Somali National University, Mogadishu. I 2. I 39 These activities are a continuation and extension of the regional teacher-training programme. Over the last I o years training institutions for health personnel have been established in a number of countries, and they are now in a position to examine their educational programmes critically and revise their curricula to make them more relevant to the needs of the population.
I 2. I40 During the biennium an evaluation was made of the quality of nursing care in hospitals, using methodology and criteria field-tested in Kuwait, Sudan, and Yemen. The results were examined at a working group organized with WHO support in Khartoum (I 98 I). Similar evaluation exercises but on a larger scale will be carried out elsewhere in the Region. 12. I4I With the support of WHO and the Association of Schools of Public Health in the European Region, the Academy of Public Health, Dusseldorf (Federal Republic of Germany), organized a workshop on the evaluation of educational programmes for public health personnel. This was in relation to the establishment of a network of collaborating institutions for training in modern aspects of public health.
I 2. I42 Assessment of performance. In view of the importance of assessment in guiding the work of students and supervising the performance of health workers, WHO has published a manual on the subject.2 A catalogue has been widely distributed listing the methodologies for performance assessment compiled at headquarters) 2 Katz, F.M. & Snow, R. Assessing health workers' performance: a manual for training and supervision. Geneva, World Health Organization, 1980 (Public Health Papers, No. 72). 3 WHO document HMD/8r.6 (1981).
207
THE WORK OF WHO, 198o-I98I
I 2. I43 A working group in the European Region (Varna, Bulgaria, I98o) considered trends in the assessment of the competence of students of the health professions, discussed the issues arising at all stages of training, and established principles for the selection and implementation of assessment procedures.
for instructors in nursing and midwifery given in collaboration with the National Research Institute for Mother and Child, Warsaw; and (iii) a postgraduate course for instructors from developing countries. Interregional courses on fertility management and maternal and child health were also organized. I2.I47 In the European Region, modern methods of learning requiring the active participation of students and group work were the main features of a seminar on the planning and organi-zation of maternal and child health (Bulgaria, I 98 I). In the African Region, the reI 2.148 gional health education centre at the University of Ibadan, Nigeria, continued to provide training in health education for three categories of health worker: (i) an advanced course, leading to a diploma, for people already engaged in health education work in departments of health; (ii) a course leading to a degree of master of public health with specialization in health education; and (iii) a new programme for a doctor's degree in public health with specialization in health education. In I98I there were 40 students from I 6 countries following these courses. Health education was also part of the training of health workers at the regional health development and training centre, Cotonou. I 2. I 49 The first All Africa Conference on Health Education was organized in I98I by the Federal Ministry of Health, Nigeria, with the collaboration of WHO and the International Union for Health Education. In addition to the health educationalists a number of other health professionals participated, including practitioners of traditional medicine. The Conference constituted inservice training in health education for a number of the participants. I 2.15 o In the South-East Asia Region, an intercountry workshop on health education 208
Examples of health manpower activities in other programmes Training of manpower for specific tasks
I 2. I44 Regional workshops or meetings of national task forces were used during the biennium to train researchers and health administrators in the concept, methodology, and application of the risk approach in maternal and child care and fami!J planning (see paragraph 6.28). Interregional workshops to prepare the participants for research or intervention strategies were held in Bogota, Geneva, Manila, Nairobi, and Nottingham (United Kingdom); they contributed to the production of a workbook on the risk approach that can be used as a training tool. National task forces in Cuba, the Republic of Korea, and Turkey further advanced training in the risk approach. WHO collaborated with the I2.I45 Ministry of Public Health, China, in organizing interregional study tours on maternal and child health and family planning. These study tours, financially supported by UNFP A, included training programmes in French and English for health personnel and other community workers. I 2. I46 Three interregional courses on family health and family planning took place in I 980: (i) a course for health and social workers organized jointly with the International Children's Centre, Paris; (ii) a course
HEALTH MANPOWER DEVELOPMENT
was organized in I98o as part of the strategy for achieving health for all. Members of the faculties of six institutions attended: the Central Health Education Bureau, New Delhi; the All India Institute of Hygiene and Public Health, Calcutta; the Gandhigram Institute of Rural Health and Family Welfare, Madurai (India); the National Institute of Preventive and Social Medicine, Dacca; the Faculty of Public Health, University of Indonesia, Jakarta; and the F acuity of Public Health, Mahidol University, Bangkok. The discussions centred on the changes, modifications, and improvements that are required to meet the new challenges of primary health care. I 2. I 5 I India and Sri Lanka have introduced health education into the basic training of their medical, nursing, and midwifery students. In Mongolia, health education has become part of the curriculum in secondary schools and teachers' colleges; a manual on sex and family life education was prepared as part of the instructional material. I 2. I 52 The training of health education specialists was strengthened in the Western Pacific Region, where WHO collaborated with Malaysia in reviewing the curriculum of postgraduate courses in health education at the Public Health Institute, Kuala Lumpur. Special attention was given to developing health education models for use in hospitals and for education of patients. In Papua New Guinea, the diploma course in health education at the College of Allied Health Sciences was improved by linking up classroom teaching with field practice. In the Philippines, an intensive three-month course was organized for the in-service training of provincial health educators who have had little formal training in health education.
Dominican Republic; the Organization subsequently collaborated in running the courses. In IO countries of the Americas short courses for general practitioners were conducted in psychiatry, behaviour therapy, child psychiatry, management of alcoholism and drug dependence, and neurology. In the Dominican Republic and Ecuador, the Organization took part in the introduction of new programmes for resident training in psychiatry. I2.154 In the European Region, an evaluation was carried out of the seven courses in mental health organized by the Regional Office from I97I to I978, the results of which were highly positive. A UNDPsupported project on rehabilitation of the handicapped in Romania began during the biennium with a training course in Bucharest and Ia§i. Fellowships were given for participation in the continuing programme of education and training in rehabilitation in the United Kingdom. I 2. I 5 5 In the Western Pacific, collaborative activities with China included training in mental health. WHO took part in workshops on the epidemiology of mental disorders and on recent advances in the teaching of psychiatry in medical schools. Training courses covered psychopharmacology, control of nervous diseases, and control and management of cerebrovascular disorders.
I 2. I 56 As part of the training programme in neurology, a series of courses on clinical and basic neurology was organized in Beijing, Durango (Mexico), Marseilles (France), and San Miniato (Italy).
I 2. I 53 Work in mental health included the revision of curricula in psychiatric nursing in Argentina, Barbados, Colombia, and the
I2.I57 WHO and the National Institute of Neurological and Communicative Disorders and Stroke (USA) both continued to award fellowships. Candidates from China, Nigeria, and the Philippines received training in neurology.
I 2. I 58 As part of the training work in radiology, WHO and IAEA jointly organized a workshop and training seminar on quality assurance in nuclear medicine (for Latin American countries) and an interregional training course and study tour on the application of nuclear methods in medicine. In collaboration with the Federal Republic of Germany, workshops on quality assurance in diagnostic radiology and nuclear medicine were held whose reports will serve as guidelines for programme implementation. I 2. I 59 The programme for medical physicists from developing countries continues to provide training on a biennial basis. A course on the dosimetry of radiotherapy, jointly organized with IAEA, was held in I981. WHO is currently indicating medical facilities that can provide practical training for radiotherapists and medical physicists from developing countries.
I 2. I62 Where not enough physicians are available for training in epidemiology, auxiliary staff require adequate instruction and experience. The Government of Fiji, in collaboration with WHO and the Centers for Disease Control (USA), has conducted courses in epidemiological surveillance for such health personnel in the South Pacific.
I 2. I 6 3 The malaria action programme is accelerating the development of manpower for malaria control work and increasing national expertise by acquainting health workers with different ecological situations or specific techniques by way of fellowships tailored, to the needs of the individual or to local requirements. This programme was slow to begin owing to difficulties in finding suitable candidates, but it is now progressing satisfactorily.
Go Training in epidemiology is most effective when carried out in the framework of a career development scheme and this type of training, utilizing an in-service, learningby-doing approach, was emphasized at both regional and national level. The approach has been adopted in Thailand and is being developed in Indonesia. I 2. I I 2. I6I The interregional epidemiology courses have continued to the extent that they are needed to reinforce regional activities. They were given in English in Prague, Moscow, and the United Republic of Cameroon; and in French in Paris, Abidjan, and Bobo Dioulasso (Upper Volta). In Ivory Coast, the United Republic of Cameroon, and Upper Volta, field training is linked to communicable disease control programmes. In the Americas, in addition to the regional course in Venezuela, assistance was given to the strengthening of epidemiological courses in national schools of medicine and public health throughout the Region.
I 2. I 64 In the South-East Asia and Western Pacific Regions, WHO is setting up a secretariat to coordinate training programmes in malaria control as part of a cooperative effort involving WHO, national trammg centres, and possibly bilateral agencies. WHO's responsibility will relate to design of curricula, provision of consultant teachers, supply of teaching aids, and organization of teacher-training courses. The Government of Malaysia has agreed to provide accommodation for the coordinating secretariat.
I2.I65 A seminar on the planning and execution of field-applied malaria research (Shanghai, I98o), with participants from malaria control services and scientific institutions, was followed by a workshop on malaria epidemiology and mathematical modelling. An international course on continuous in vitro cultivation and its application in malaria research was held in Moscow (I98o).
2IO
HEALTH MANPOWER DEVELOPMENT I 2. I66 In view of the increasing problem of drug-resistant Plasmodium Jalciparum in large parts of eastern Asia and South America, and the serious threat it poses to other malarious areas of the world, training in standard techniques for testing drug sensitivity was continued. Four regional workshops were held-in Cotonou, Geneva, Kuala Lumpur, and Sennar (Sudan)-and also several subregional or national courses in the Americas, Europe, South-East Asia, and the Western Pacific. Most of these activities were supported by the Special Programme for Research and Training in Tropical Diseases. I 2. I 67 Training in the epidemiology and control of tuberculosis was given to health personnel from different regions at an annual course in Tokyo, sponsored by WHO and the Government of Japan. A subregional course for South Pacific countries was organized in the Solomon Islands. International courses on the management of tuberculosis programmes were sponsored in Argentina, Brazil, Chile, Cuba, and Mexico; a course in bacteriology is held annually in Argentina. With support from DANIDA, training in the production and quality control of BCG vaccine was given at the State Serum Institute, Copenhagen. I 2. I 68 A workshop on veterinary public health was organized by the FAOfWHO collaborating centre for research and training in food hygiene and zoonoses, Berlin (West), for senior public health and veterinary public health officers from the South-East Asia and Eastern Mediterranean Regions.
12. qo Four training centres-two in France, one in the Netherlands, and one in the United Kingdom-are running postgraduate courses in food microbiology for students from developing countries. I 2.17 I The cancer programme in the South-East Asia Region included training sessions on the recognition of cancerous and precancerous lesions of the oral cavity in adults and a workshop on the standardization of histological criteria for diagnosis of liver disease (Karachi). A seminar on the histopathological diagnosis of tumours took place in the Western Pacific.
12. I 72 Courses in immunology continued at the WHO immunology research and training centres in Brazil, China, Egypt, and Switzerland. A course on hybridoma technology was given in Singapore and a course on molecular and cellular aspects of antigenicity in Israel. 12.17 3 The teaching of environmental health to sanitary engineers and other health workers was continued in the African Region through five national and three intercountry projects. An agreement between the Federal Polytechnic School, Lausanne (Switzerland), and the Ecole inter-Etats d'Ingenieurs de l'Equipement rural, Ouagadougou, made it possible to offer a one-year programme in sanitary engineering. WHO cooperated with UNDP in establishing a training programme in sanitary engineering at the Faculty of Technology, University of Addis Ababa. Postgraduate programmes in environmental health were established at the University of Ife (Nigeria) and at the University of Nairobi; and the objectives of a training programme in sanitary engineering were defined for the Higher Institute of Technical Training and Research, Nairobi. I2.I74 As part of work in relation to the International Drinking Water Supply and
I2.I69 WHO collaborated closely in organizing two international courses on zoonoses management in the USSR. Twentytwo students from five WHO regions took part in the courses, which covered rabies, brucellosis, leptospirosis, echinococcosis/ hydatidosis, taeniasis/cysticercosis, and foodborne diseases.
211
THE WORK OF WHO, I98D-I98I
Sanitation Decade, an investigation has been in progress since I 978 of institutions offering training in the water and sanitation sector in countries of western Africa-Gambia, Ghana, Ivory Coast, Liberia, Mali, Niger, Nigeria, Senegal, Sierra Leone, Togo, the United Republic of Cameroon, and Upper Volta. This investigation should assist the planned development of health manpower at national and regional level. I 2. I 7 5 In the Americas, the Regional Library of Medicine (BIREME) ran courses for the training of librarians to enable them to provide the information needed for health care.
Teaching/learning materials I 2. I 77 To strengthen national information .rystems and provide guidance for health workers, particularly at primary health care level, WHO has prepared a series of booklets on the practical aspects of community surveys: how to gather, process, and present information, and how to use it in routine work as well as in the management of health care.
Teacher training I 2.176 Training in health statistics and related subjects continued with a series of workshops in various regions for teachers of health statistics, epidemiology, and health records systems. Several handbooks were prepared, e.g., a guide for teachers 1 that provides a systematic approach to the teaching of health statistics to medical undergraduates. As recommended by the interregional conference on teaching of statistics to medical undergraduates (Karachi, I978), a standard teaching programme was worked out covering the essential minimum of subjects. A similar programme for the teaching of statistics to postgraduate medical students was initiated. 1 Lowe, C.R., ed. Health statistics and medical students: a gutde for teachers. Karachi, 1981 (A handbook sponsored
I 2. 17 8 Different types of instructional material on infant and young child feeding were prepared, including a handbook on the organization of workshops, an audiovisual presentation for training health administrators, and a brochure on breast-feeding for middle-level health workers and educators.
I 2. I 79 In the Region of the Americas, an informal working group discussed the current status of teaching materials in Latin America and designed a textbook on p.rychiatry on the basis of material prepared by Latin American specialists.
by the World Health Organization and the Government of Pakistan).
I 2. I So Further teaching/learning materials in diagnostic radiology were produced for the basic radiological services programme (see paragraphs 8. 52-8. 54). The operator's manual on patient positioning was revised, a chapter being added on patient care, first aid, and hygiene. A general practitioner's manual on the interpretation of radiographs was drafted and should be ready for field testing in early I982.
2I2
Chapter
I}
Health Information
Health statistics 13.I NATIONAL authorities in the de-
cation between those who provide the information and those who use it.
veloping countries realize that, if the goal of health for all is to be attained by the year zooo, their health programmes must be based on statistical information that faithfully reflects the country's health problems and the needs of its population. In particular, the new strategy has highlighted the serious lack of statistical support at the primary health care level. Even in developed countries the statistical services may not be flexible enough to cope with evolving requirements, and health planners and administrators may lack the skill to exploit fully those statistics that are available. 13.2 I98o-I98I was the period in which a conceptual frame was evolved for information support in monitoring progress towards health for all. Preparatory work was undertaken in collaboration with national experts, in particular with a view to establishing indicators suitable for regional and global monitoring (see paragraph 1. q). Technical cooperation with Member States to strengthen their health information systems and services was reoriented in the light of the new developments. Priority was given to training of staff; data generation at the periphery; data processing, flow, and analysis; and utilization of the information produced. Emphasis was on better communi213
Development of health statistical services I 3. 3 As work on the Global Strategy for health for all progressed, the information support that it required was clarified. Intercountry and interregional workshops or consultations were held to define concepts and principles and to develop action programmes. They included a working group on the counting of births and deaths and a consultation on potential uses of statistics in health management (both held in Rijeka, Yugoslavia, September I98I), and a workshop on health records and health statistics practice at family, community, ~nd primary health care level (Papua New Gu~nea and the Philippines, October-November I 98 I), followed by a consultation in Sri Lanka to prepare guiding principles on the same subject. All these meetings centred on the generation of a least a minimum of essential statistical data and their utilization at community and primary health care level.
I 3·4 Work in relation to national health information systems focused on improving national capabilities for monitoring and utilizing vital and health statistics and health records. WHO cooperated with a number of countries in this respect. Several workshops
THE WORK OF WHO, 1980-I981
were held to exchange experience and to identify the technical problems encountered in devising information systems to support the planning, management, and evaluation of health development programmes. Most of them were concerned with primary health care programmes. I 3. 5 Since any improvement in national systems for health information depends on better communication between the producers of information and its users, WHO continued to promote broadly-based national committees on vital and health statistics as forums for such communication. A document was issued reviewing the activities of national committees over the last 30 years and emphasizing the importance of their role, whatever the stage of development of the country.!
cation of Diseases, Injuries, and Causes of Death (ICD),2 the International Classification of Procedures in Medicine,3 and the International Classification of Impairments, Disabilities, and Handicaps. 4 Developmental work was carried out on classifications that have hitherto been neglected, priority being given to health problems in primary health care and lay reporting. The above work was financed in part by contributions to the Voluntary Fund for Health Promotion. Meetings were organized for countries of the South-East Asia Region (New Delhi, October I98o) and of the African Region (Nairobi, September I98I), with the aim of initiating or promoting the use of lay reporting systems in obtaining information for the planning, monitoring and evaluation of community and primary health care services. 13.8. Work started on the next (tenth) revision ofiCD, which, as recommended by a meeting of experts, will be based upon a thorough evaluation of the Ninth Revision as utilized in Member States. To permit that evaluation, the Director-General sought the opinion of Member States as to the desirability of postponing the Tenth Revision for five years, i.e., submitting it to the Health Assembly in I 990 instead of in I 98 5 as a decennial revision would require. Almost all Member States were in favour of deferment. The preparatory work is being organized accordingly. I 3·9 Valuable technical contributions were made by the six WHO collaborating centres for classification of diseases (Caracas,
13.6 The preparation of several methodological guidelines was undertaken-on health situation analysis, health surveys, health expenditure statistics, measurement of outcome of health action, health manpower statistics, hospital statistics, and vital statistics. Guidelines were also completed on the keeping of medical records-a subject on which a joint programme was instituted with the International Federation of Health Records Organizations. (For training of teachers in health statistics, see paragraph I2.176).
International Classification of Diseases and related classifications I 3. 7 Among the basic tools for the recording, processing and analysing of health information are the internationally adopted classifications of health problems. Member States were given support in introducing the Ninth Revision of the International Classifi-
t WHO (198o).
document
WHO/HSjNAT.COM/8o.369
2 World Health Organization. Man11al rif the international statistzcal classification of dzseasts, in;uries, and causes of death, IfJ7 f revision, Volume I, Geneva, 1977; Volume 2 (Alphabetical mdex), Geneva, 1978. 3 World Health Organization. International classification rif procedures in medicine, Volumes I and 2. Geneva, 1978. 4 World Health Organization. International classification of impairments, disabilities, and handicaps: a manual of classification relating to the consequences of diseases. Geneva,
1980.
2I4
HEALTH INFORMATION
London, Moscow, Paris, Sao Paulo, and Washington) in training staff to use the Ninth Revision of ICD, assisting Member States with coding problems, updating computer software, and adapting ICD and the related classifications into national languages. A new centre was established in I98I in Beijing.
use in the assessment of progress towards health for all by the year 2000. The World Health Statistics Annual, r 3. I 3 the main WHO statistical publication, was for many years published in three volumes; for reasons of economy it was reduced during the biennium to two. The volume dealing with vital statistics and causes of death will continue to appear annually, but the second volume will in one year contain statistics on cases of infectious diseases and in the alternate year statistics on health personnel and hospital establishments. To improve the appearance of the Annual, it was decided to go over to photocomposition for its production. 13. I4 The World Health Statistics Quarter(y continued to emphasize analytical studies on special subjects of public health interest. During I 9 So- I 9 8 I it carried articles on cancer mortality (projections and socioeconomic implications); health manpower; primary health care; prevalence of low birth weight; infant, child, and maternal mortality in relation to fertility patterns; and physical and mental disabilities. Five ad hoc surveys on infant and I 3. I 5 early childhood mortality in relation to fertility patterns were made in the I97os, the report on Afghanistan being published in I978. Detailed tabulations for the latter were issued during the biennium, as were the reports on the surveys in Algeria, Sierra Leone, and Sudan in cooperation with the respective governments (the report on Trinidad and Tobago should be issued in 1982). Data collected in a special cohort study of infant mortality in Mauritius were analysed with a view to publication. Three volumes on maternal and child health statistics were in preparation: a study of maternal mortality, a symposium on adolescent reproductive health, and a study of infant mortality in the socialist countries of Eastern Europe. The English editions of the manual of mortality 2I5
Dissemination of statistical information 13. IO Following adoption of the Global Strategy for health for all in I 98 I, the Secretariat began assembling data on global indicators for the monitoring of health progress from available national reports. Plans were made for updating the information in the headquarters data bank. The regional offices initiated similar action with respect to regional and national indicators. At the Regional Office for the Americas a new computerized data base was designed and new methods of data collection were devised. The Regional Office for the Western Pacific plans to establish a data bank on indicators for all countries in the Region.
I 3. I I Studies were undertaken to improve the general information base and to generate new data. A number of projects for improving the data base at national level were planned as a complement to the projects of the regional offices. 13.I2 The Sixth report on the world health situation, 1 covering the years I973-I977• was published in I98o in two parts. The first describes global health problems and the measures taken to solve them, indicating the success or failure of such measures at national, regional, and international level. The second part reviews the situation country by country. This report was the first attempt to provide Member States with baseline information for 1 World Health Organization. Sixth report on the world health situation, I97J-I977· Part 1, Global anafysis; Part 2, Review by country and area. Geneva, 1980.
THE WORK OF WHO, r98o-r98r
analysis 1 and the life table and its application 2 were revised and were adapted for translation into French. A manual of fertility analysis was also in preparation. I 3. I 6 The Regional Office for the Western Pacific completed country health information profiles, based on I979-I98o data, for all but two countries of the Region. The Regional Office for the Eastern Mediterranean issued a directory of selected institutions actively engaged in biomedical research. The European Regional Office published a manual on standard definitions and methods of measurement for use in health statistics. Among the P AHO publications were Hospitals in the Americas and Health conditions in the Americas, I!J77-If)3o. I 3. I 7 In addition, the regional offices carried out or were associated with a number of new studies. In South-East Asia these covered perinatal mortality in five countries, the impact of improved water supply in India, and hospital distribution and utilization in Burma. The Regional Office for the Western Pacific introduced a statistical type of reporting that can form the basis for projections of health trends when planning future requirements. In the European Region I 3 Member States are taking part in establishing similar projections; I 5 Member States are collaborating in a study of demographic trends in Europe and their implications for health.
Committee for International Coordination of National Research in Demography (CICRED)-dealt with socioeconomic differential mortality in industrial societies. The meeting in Manila-sponsored by WHO and ESCAP-focused on mortality in Asia. Meetings on data bases (Bangkok, I98I) and on sex differentials in mortality (Canberra, I98I) were sponsored by the United Nations and WHO as part of joint United Nations/ WHO mortality studies. There were also meetings on family life cycles (Wiesbaden, Federal Republic of Germany, July I98I) and on cancer statistics in developing countries (Nagoya, Japan, August I98I), the latter the fourth of its kind. I3.I9 A project for monitoring the requirements of countries as regards mental health statistics was completed during the biennium.
Health statistical methodology I 3. 20 The work of the health statistics programme in providing statistical support for other WHO programmes was reoriented to ensure integration with the Seventh General Programme of Work, I984-I989, and to serve the particular needs of the strategies for attaining health for all by the year 2000. Such support covers the statistical or methodological basis for the planning and execution of projects; the analysis and evaluation of field data; operational research and systems analysis as applied to epidemiological investigations or the improvement of health delivery systems; and the use of computer facilities or other aspects of medical informatics.
13 . I 8 A special health demo graph y programme financed by UNFP A was expanded with interragency collaboration. Two meetings were convened (Geneva and Manila, I98o). The Geneva meeting-sponsored by WHO, the United Nations, and the 1 Mortality analysis: a manual on methods of analysis of national mortality statisticsfor public health purposes. Geneva,
World Health Organization, 1977 (reprinted 198o). 2 Chin Long Chiang. Life table and mortality analysis. Geneva, World Health Organization, 1978 (out of print; revision in preparation). 2I6
I 3. 2 I Much of the basic statistical processing was transferred to country level. WHO was however increasingly involved in general planning, coordination, and promotion of statistical operations in countries that have
HEALTH INFORMATION
the necessary professionally qualified staff. The consequent increase in interpretative and evaluative work was particularly evident in multicountry projects, where countries often felt the need for independent planning, review, and appraisal of comparative findings - a role to which WHO is particularly suited. In addition, statistical support was provided for specific programmes (health delivery systems, parasitic disease control, projection of health trends, etc.), emphasis being given to innovative methods of data collection and methodologies for primary health care. 13.22 Close contact was maintained with several intergovernmental and nongovernmental organizations working in the general field of medical informatics and medical computing. General systems methodology was also promoted through continued and close liaison with the International Institute of Applied Systems Analysis, Vienna.
consolidated list of the periodicals held by health sciences libraries in Africa that should develop into a major resource-sharing tool. The Regional Office for South-East Asia sponsored regional and national meetings for the establishment of national focal points, cooperative national health library networks, and a regional network of health literature, library, and information services. In the Eastern Mediterranean the Regional Office carried out a second survey of health libraries and issued a revision of the "List of sources for a basic medical faculty library". In the Western Pacific a survey was made of the health literature situation and plans were drawn up for a regional library network. I 3. 2 5 The agreement between WH 0 and the United States National Library of Medicine for the provision of MEDLARS searches and related photocopy services was renewed up to the end of I981. The Regional Office for the Western Pacific entered into an agreement with the Government of Australia for the supply of MEDLARS material to developing countries in that Region; this service operates through a system of national focal points.
Health and biomedical information Health literature services 13.23 During the biennium WHO took vanous initiatives in the health literature programme, providing advice at regional and country level and placing increased emphasis on the strengthening of health libraries, information services, and documentation centres. Direct technical cooperation focused on the establishment of a national health literature project in Egypt and a biomedical information centre and network in China; strategies were formulated and UNDPfinanced activities began.
I3.26 During I98I WHObeganissuinga monthly list of its technical documents with a view to improving access to the information it produces. Two new studies were under way to determine how best to collect, process, and disseminate the health-related literature emanating from the developing countries. Much of this "fugitive", often unconventional, literature could be of considerable interest to other countries with similar health problems. I 3. 2 7 Three regions drew up initial plans for indexing the health and biomedical periodicals of developing countries. A planned African Index Medicus was discussed and casted. The Regional Office for SouthEast Asia held a two-week workshop to train
The Regional Office for Africa sponsored a first meeting of African medical librarians, which prepared the ground for a consortium of health libraries in Africa. WHO cooperated in the production of a 13.24 2I7
THE WORK OF WHO, 1980-1981
librarians of the Region in indexing (using the medical subject headings of the United States National Library of Medicine) and issued a first experimental index to South-East Asian health literature. 13.28 A number of training plans were made. For their implementation assistance was obtained from certain other WHO programmes, notably the Special Programme for Research and Training in Tropical Diseases, which is prepared to finance the training of librarians in institutions receiving long-term support from the Special Programme. WHO promoted the part1c1pation of medical librarians from developing countries in the Fourth International Congress on Medical Librarianship (Belgrade, September I98o), a meeting that provided an occasion for them to follow continuing education courses. A subsequent meeting in Geneva of WHO librarians from headquarters, five regional offices, and IARC laid the basis for improved intra-organizational cooperation in the health literature field.
I 3. 30 The Forum was financed without any overall increase in the publications budget. This meant some reduction in other publications: notably the issues of the WHO Chronicle, which is published in the same six languages, were reduced from 12 in I98o (Volume 34) to six in I98I (Volume 35). Within those limitations the Chronicle continued to perform its task of keeping the health professions informed about WHO's activities and publications. There was no change in the frequency of publication of WHO's scientific journal, the Bulletin of the World Health Organization, which is published in a bilingual English/French edition and in a Russian edition; six issues (Volume 58) and a supplement appeared in I98o, and six issues (Volume 59) in I981. I 3. 3 I An important development was the initiation of a new series of non-periodical publications-the "Health for All" S crieswhich is published in Arabic, Chinese, English, French, Russian, and Spanish. This series is a medium for the publication of fundamental texts on policies, strategies, and processes that will assist countries in planning, implementing, and evaluating their own programmes for attaining health for all by the year 2ooo. The report of the Alma-Ata Conference (I978) and the document prepared by the Executive Board on formulating strategies for health for all (I979) were included, retroactively, as Nos I and 2 in this series. The other volumes issued up to the end of I 98 I were: Global strategy for health for alll!J the year 2000 (No. 3), Development of indicators
WHO publication.r 13.29 In 1980 an experimental issue of World Health Forum: an international journal of health development (Volume I, Nos I and 2
combined) was produced in English and French versions. This issue was widely circulated and the replies to the questionnaire that accompanied it revealed almost universal approval of the proposed new journal. In January I98I the Executive Board discussed the Forum and was in favour of its regular production in Arabic, Chinese, English, French, Russian, and Spanish. During I98I four issues (Volume 2, Nos I-4) appeared and were given an encouraging reception. The journal is directed principally at those responsible for health policy, at health planners and administrators, and at teaching staff in schools of public health and similar institutions. 2I8
for monitoring progress toward.r health for alll!J the year 2000 (No. 4), Managerial process for national health development (No. ;), and Health programme evaluation: guiding principles (No. 6). I3·32 The two volumes of the Sixth report on the world health situation, I97J-I9J7,
prepared in accordance with resolution WHA29.22, appeared in a new format in I98o (see paragraph J3.12).
HEALTH INFORMATION
I 3. 33 Among the numerous other books published during the biennium, the following give some indication of the wide range of topics covered by WHO's publishing programme: the second edition of Chemotherapy of malaria (WH 0 Monograph Series, No. 2 7), which has been completely revised to present the latest information at a critical time for malaria control; the report on the first phase of the WHO collaborative study on breastfeeding (Contemporary patterns of breastfeeding) and the text of the International Code of Marketing of Breast-milk Substitutes adopted by the Thirty-fourth World Health Assembly (see paragraphs 6. 7-6.10); the Manual of basic techniques for a health laboratory, which describes in detail but in simple terms (each step being illustrated) all the techniques that a health laboratory will need to perform in support of primary health care; and a completely new version of the annual Vaccination certificate requirements for international travel that endeavours to increase security against the international spread of diseases by incorporating health advice to travellers (see also paragraphs 9.I2-9.I3).
The health aspects offood and nutrition: a manual for developing countries in the Western Pacific Region of WHO. Regional publishing programmes also covered some topics of global interest, as witness the P AHO publication Emergenry health management after natural disaster and the European Regional Office glossaries on air pollution and on solid waste. 13.36 An indicator of the success of WHO publications is provided by the growing number of requests from national bodies (governmental or other) to reprint them for distribution among professional associations or to issue translations into languages in which WHO does not regularly publish. While the greatest number of requests concerned German, Japanese, and Portuguese, permission was granted for translations into numerous other languages-among them Bengali, Indonesian, Italian, Korean, Turkish, and Vietnamese.
WHO technical documentation I 3. 37 An ad hoc working group met in Geneva (October I98o) to discuss methods for improving the relevance and quality of documents prepared by WHO for use by countries. It made a number of recommendations concerning documentation for meetings, handbooks and manuals, bibliographies, and other types of technical documentation. These recommendations were implemented in 1981.
3. 34 The strengthening of the regional publications programmes, noted in the previous biennial report, was particularly marked during the period under review in the Eastern Mediterranean Region, where a large number of texts were issued as part of the regional Arabic programme. Some of these originated in the Region, while others were translations of WHO publications issued in other languages; all were selected for their particular relevance to regional needs and conditions. I
Health legislation 13.38 Work continued during the biennium to implement resolution WHA30.44, concerning the reorientation of the health legislation programme in accordance with the overall strategies of WHO and Member States. The sixty-fifth session of the Executive Board in January I98o fully en2I9
I 3. 35 Publications suited to regional concerns elsewhere may be illustrated by the following, which were issued by the appropriate regional offices: two volumes of Health development in Africa; The eradication of smallpox from Bangladesh; The planning of health services: studies in eij!,h! huroperm 1 o1mtries; and
THE WORK OF WHO, r98o--r98r
dorsed the Director-General's report on measures taken to strengthen the programme (resolution EB65.RI3), and in May I98o the Thirty-third World Health Assembly strongly supported the proposed strategies for technical cooperation and information transfer in this sector; in resolution WHA 33. 28 it requested the Director-General to proceed with the formulation of a detailed programme based on these strategies. I3·39 The groundwork was laid for the preparation of such a programme, and many components are already operative; an informal global network of sources of expertise was further developed during the biennium. There was enhanced technical cooperation between WHO and Member States in the preparation of new legislation in key areas of both personal and environmental health services. An unprecedented number of requests for information, sometimes on policy issues and sometimes on highly detailed matters, was received from Member States. WHO was able to respond to these requests with the generous assistance of many national and international institutions and experts. The Regional Office for SouthI 3.40 East Asia promoted the holding of national seminars on health legislation issues; a seminar on law and health for development (Chonburi, Thailand, August I98o) was one outcome of this endeavour. A firm basis for programmes in the European Region was ·established by a regional advisory committee on health legislation, which held its first meeting in Dresden, German Democratic Republic (June I98I). The Regional Office for the Eastern Mediterranean carried out an in-depth study of the legal status of primary health care workers that will undoubtedly also be of interest to health administrators in other parts of the world. Technical cooperation activities in I 3·4 I health legislation, as in many other fields, 220
must be based on up-to-date and reliable information. WHO provides such information in its quarterly journal, the International Digest of Health Legislation. In resolution EB65 .Rq the Executive Board reaffirmed the criteria established for the selection of material for publication in the Digest and emphasized "the need for priority to be given to legislation in support of Member States' strategies for attaining health for all their people". Accordingly a reoriented Digest, with legislative texts arranged by subject rather than by country and with more analytical, comparative, and bibliographical material than hitherto, was introduced in I 98 I and was favourably received. During the biennium the Digest reported on new legislation in Member States on such topics as breast-milk substitutes and breast-feeding, disabled persons and the elderly, workers' health, food and drug safety, and environmental health. The proportion of international as opposed to national texts was increased, and for the first time bilateral treaties between developed and developing countries for cooperation in the health sector were covered.
I 3.42 In line with the provisions of resolution WHA30.44, collaboration with other specialized agencies concerned with health legislation was strengthened. Thus WHO cooperated with FAO in systematically compiling national legislation governing foods for infants and young children. It played an active role in the preparations for, and was represented at, the Ad Hoc Meeting of Senior Government Officials Expert in Environmental Law, held under the auspices of UNEP (Montevideo, November I98I).Cooperation with nongovernmental organizations was intensified; for example, there was particularly close cooperation with the Council for International Organizations of Medical Sciences (CIOMS) in regard to legislation on human experimentation.
HEALTH INFORMATION I 3·4 3 By its very nature health legislation is intersectoral, and an increasing number of WHO technical programmes (concerned with such matters as traditional medicine, essential drugs, control of smoking, drug dependence, control of alcohol abuse and alcoholism, care of the elderly, and chemical safety) undertook activities that have a health legislation component but are dealt with in other sections of this report.
House, Beijing, under an agreement with the Ministry of Health, China (for Chinese); with the Medicina Publishing House, Moscow, under an agreement with the Ministry of Health, USSR (for Russian); and at the PAHO/WHO Publications and Documentation Service in Mexico (for Spanish). I 3·4 5 In I 98 I the Council of Arab Ministers of Health decided to establish a centre for Arabic health documentation and publications in Kuwait and requested the cooperation of WHO. The Organization gave its full support to this centre as exemplifying the principles of technical cooperation among developing countries. It is expected that in due course it will contribute significantly to the WHO Arabic language programme.
Language services I 3·44 The new policies and approaches of WHO had their impact on the language services during the period under review. The reduction in the number of permanent staff in response to resolution WHA29.48 was completed. There was however a steady increase in translated material in all languages. In order to cope with this situation several approaches were used, including:
Technical terminology I 3.46 As in the previous biennium, the need for clear and unambiguous terminology continued. A study indicated that the establishment of a central computer terminology bank would be unjustifiably costly. Accordingly terminology work was reorganized so as to make maximum use of electronic text-processing equipment. Thanks to the use of special text-processing programmes for the preparation of multilingual glossaries and lists of terms, this has led to an increase in efficiency that is conservatively estimated at zoo%. A further development was an agreement with the Terminology Bureau of the Commission of the European Communities, in Luxembourg, under which it enters and maintains all WHO-developed terminology in its large, multilingual computer term bank, all of which is made available ro WHO free of charge.
- contracting out, under supervision, a significant proportion of the required translation work; and promoting a policy of selfrevision among the permanent language staff while maintaining only for certain documents, of a legal, political, or regulatory nature, the more elaborate process of revision by a senior translator. - exchanging translators/revisers between headquarters and regional offices during peak periods, in the interest of quality of translation and uniformity of terminology. The number of such exchanges increased substantially during the biennium. - strengthening collaboration and coordination between central, regional, and country level, with increasing decentralization and delegation of functions. Examples were the activities carried out as part of the Arabic language programme of publications of the Regional Office for the Eastern Mediterranean; with the People's Medical Publishing 22I
13·47 Numerous glossaries and other terminological documents were prepared, primarily to ease the increasing termin-
THE WORK OF WHO, 198o-I981
ological problems faced by technical and linguistic staff. They covered such subjects as food hygiene, nutrition, health statistics, and nomenclature of pathogenic microorganisms. Of particular interest is a multilingual glossary of managerial terms, prepared in separate Arabic, Chinese, English, French, Russian, and Spanish versions with a view to publication as a volume in the "Health for All" Series. The Regional Office for Europe completed preliminary work on a thorough revision of its glossary of health care terminology. The Regional Office for the Eastern Mediterranean continued to support the preparation of English/ Arabic and French/Arabic medical dictionaries by the Special Working Committee on Medical Arabic Terminology, these dictionaries being scheduled for publication in 19!!2. 13.48 WHO continued its part in the joint CIOMSJWHO project on the International Nomenclature of Diseases, for which CIOMS is the executing agency. However, owing to lack of funds, progress on this project was slower than had been foreseen, although one volume (on mycoses) was readied for publication 1 and another (on viral diseases) was prepared in draft form.
of flexibility--and eventually of feedback from recipients-should be completed by April I982. 1 3. 5 I The policy was continued of actively seeking facilities in various countries, particularly developing countries, where WHO's publications could be printed on more advantageous terms. The consequent reduction in printing costs was reflected in the sale price of publications. As a result of this and other factors, revenue from sales decreased from $5 07 I I 6 3 in the biennium I 978-I 979 to $4 670 9 I 3 in I 980-I 98 I.
I 3. 52 The bulk of sales continued to be made in western Europe (46%) and North America (3 I%).
Health information of the public I3·53 The Thirty-fourth World Health Assembly, in adopting the Global Strategy for health for all by the year 2ooo, called upon Member States to "enlist the involvement of people in all walks of life" in this historic movement. The challenge to the health information programmes during the biennium was therefore to create an understanding of the issues underpinning the Global Strategy and a willingness to become involved in and support the primary health care process. I 3· 54 As the Director-General acknowledged in an article in World Health magazine,3 the concept of health for all had aroused scepticism. "How do you define health?" "What do you mean by all?" These were the questions asked. By means of the printed word, audiovisual methods, and common efforts with the mass communication media,
Distribution and sales I 3·49 Promotional efforts were continued to make WHO publications more widely known; they were exhibited at technical and medical congresses and also at bookfairs. A new catalogue was issued in English and French,2 and a Spanish edition is in preparation.
I 3. 5o The computerization of mailing lists that has been undertaken in the interests CIOMSJWHO. Internatronal nomenclature of diseases. 2: Mycoses. Geneva, CIOMS, 1982. 2 World Health Organization. W flO publications: catalogue 1947-1979, Geneva, 198o; Supplement 19S0-19SI, Geneva, 1981. Vol. II, Part 1
3 What is health for all? World Health, November 1979, pp. 3-j.
222
HEALTH INFORMATION
the nongovernmental organizations, and the information departments of Member States, WHO set out to answer these questions and to demonstrate by numerous examples and case histories that the principles adopted in the Declaration of Alma-Ata were more than abstract theories. As a counterpoint to this global effort to form public opinion on complex and often controversial issues, the Organization sought to create a greater awareness of the advantages of living a healthy life by providing material for local campaigns to promote attitudes and behaviour conducive to health. I 3. 55 Among a number of events utilized to direct world attention to the work of Member States and WHO was the ceremony at the Thirty-third World Health Assembly (May I98o) that marked the eradication of smallpox. This was the occasion for radio broadcasts and television coverage, a transatlantic news conference, the production of a film, and the dissemination of information kits. Newspapers often critical of the United Nations system commented on the eradication of smallpox as demonstrating the value of international institutions. I 3. 56 Two central themes of the primary health care approach-maternal and child health, and provision of clean water and adequate sanitation-provided an opportunity to demonstrate the role of WHO as the directing and coordinating authority on international health work. Cooperating with UNDP and UNICEF, WHO undertook a global public information campaign to build up support for the International Drinking Water Supply and Sanitation Decade. Similarly, an intensive two-year campaign of information and education of the public, jointly conducted with UNICEF, preceded the adoption by the Thirty-fourth World Health Assembly (May I98I) of the International Code of Marketing of Breast-milk Substitutes. The campaign included national
and international seminars for the mass media and nongovernmental organizations, and wide dissemination of printed and audiovisual material. The groundwork was laid for support to Member States in their health education campaigns to protect and promote breast-feeding. 13·57 World Health Day, 7 April I98o, took as its subject "Smoking or health: the choice is yours". The theme was used to illustrate the roles of personal behaviour and community action in the primary health care process. Almost all Member States mounted health information and education campaigns and many found it opportune to introduce legislative or administrative curbs on the tobacco habit. I 3. 58 The information campaign to promote the new health doctrines reached a peak with World Health Day I98I, which was devoted to the theme "Health for all by the year zooo". Declarations of support were issued by many heads of state or ministers of health and WHO material was used as the basis for national information campaigns in most Member States.
1 3. 59 In the Global Strategy for health for all, information is seen as the "permanent operational arm of national and international strategies to mobilize political, financial, managerial, technical, and popular support" .1 Member States, nongovernmental organizations, and the mass media look to WHO to popularize the aims and benefits of the Strategy and to bring the process alive by reporting on the progress made and the problems encountered. This requirement guided the work of WHO's information officers in responding to day-to-day inquiries and in producing publications and audiovisual material. 1 Global strategy for health for all by theyear 2000. Geneva, World Health Organization, 1981 ("Health for All" Series, No. 3), part IV, para. 26.
223
THE WORK OF WHO, 198o-1981
13.60 During the biennium two new documentary films were produced, bringing to six the number in the series entitled "Health for all-Aspects of primary health care". They dealt with the primary health approach in Ghana and in Thailand. Other documentaries had as their subjects smoking, eradication of smallpox, health of the aged, and the continuing fight against tuberculosis-the latter to commemorate the discovery by Koch of the tuberculosis bacillus. WHO also joined with other organizations in the United Nations system in producing films on the International Drinking Water Supply and Sanitation Decade, the International Year of Disabled Persons, and the plight of African refugees. Work began on a film describing primary health care in the Western Pacific, to be financed by a contribution from the Australian Government. Some 950 copies of WHO films were sold.
With a monthly circulation of some I 5o ooo in English, French, Portuguese, Russian, and Spanish, and with quarterly issues in Arabic and Persian, not only is World Health widely read but its articles are frequently reprinted in the daily press. 13.63 In addition to collaborating with the United Nations system on specific issues, WHO continued to furnish material for the monthly newspaper, Development Forum.
q.61 The WHO radio service provided some 240 radio stations or networks with regular monthly programmes in English, French, and Spanish. q.62 The 20 issues of World Health magazine published in 198o-I981 reflect the broad spectrum of WHO's activities.
q.64 Measures were taken to increase the relevance of reports on health by the mass media and to ensure that health information was popularized with accuracy. In Geneva, 40 scientific journalists were briefed on the latest developments in tropical disease research. The Regional Office for the Western Pacific cooperated with the Malaysian Ministry of Health in running a workshop on health reporting for journalists. A regional workshop on information, education, and communication for health was held in Manila (1981). A working group on information and health (Luxembourg, November 198o) recommended that WHO and Member States should foster greater access by journalists to health information and should seek their advice in formulating health education and information campaigns.
224
Chapter I4
Constitutional) Legal) and Administrative developments Constitutional and legal matters five new Members joined the World Health Organization: Dominica, Equatorial Guinea, Saint Lucia, San Marino, and Zimbabwe (formerly an Associate Member under the name of "Southern Rhodesia"). The Organization thus maintained its virtually universal character, which is vital to the fulfilment of its objectives. A list of Members (at present I 57) and Associate Members (at present one) is given in Annex I. I98o-I98I, I4.2 The amendments to Articles 24 and 2 5 of the Constitution, adopted in I 976 by the J4.I DURING
of acceptances thus reached 53 at the end of I98I. I4·4 The amendment to Article 74, providing for the inclusion of an Arabic version of the Constitution among the authentic texts, which had been adopted in I978 by the Thirty-first World Health Assembly, had received a total of I 6 acceptances by the end of I981. I4·5 The Thirty-fourth World Health Assembly (May I98I) considered proposals for a transition from annual to biennial Health Assemblies but felt that this change in periodicity should take place only in association with other structural reforms, such as changes in the composition and size of the Executive Board and in the role and functions of all bodies of the Organization. It therefore resolved to maintain the practice of annual Health Assemblies for the time being. However, it decided that, beginning in I982, the duration of the Health Assembly should be limited to not more than two weeks in even-numbered years, when there is no proposed programme budget to consider (see paragraph 1.43). I4.6 The Thirty-fourth World Health Assembly also adopted Additional Regulations amending the International Health Regulations (I969) in order to exclude smallpox, in view of its global eradication, from the 225
Twenty-ninth World Health Assembly and providing for an increase in the membership of the Executive Board from 30 to 3 I, were accepted by I 3 Member States during the biennium, bringing the total number of instruments of acceptance so far deposited to 58 ; a further 4 7 acceptances were still required for the entry into force of the amendments, which under Article 7 3 of the Constitution must be accepted by two-thirds of the Members. I4·3 One instrument of acceptance was deposited for the amendment to Article 7 of the Constitution, adopted by the Eighteenth World Health Assembly in I965 ;1 the number 1
See resolution
WHAI8.48.
THE WORK OF WHO, 198o-I981
diseases subject to the International Health Regulations. The Additional Regulations came into force on I January I982, and States bound by them may now no longer require smallpox vaccination certificates from international travellers (see also paragraph 9·4). I4·7 Basic agreements on technical advisory cooperation were concluded during the biennium by WHO with Djibouti, Equatorial Guinea, Kiribati, Vanuatu, Viet Nam, and Zimbabwe; and by PAHO with Bolivia and El Salvador.
14· 8 The Protocol for the Protection of the Mediterranean Sea against Pollution from Land-based Sources, which had as a startingpoint the studies and first drafts prepared by WHO at the request ofUNEP, was signed on I7 May I98o in Athens by I2 Mediterranean coastal States and by the European Economic Community. It was published in the International Digest of Health Legislation. 1 I4·9 On 20 May I98o the Thirty-third World Health Assembly, having regard to proposals to remove the Organization's Regional Office for the Eastern Mediterranean from Alexandria, requested an Advisory Opinion of the International Court of Justice on the question whether the negotiation and notice provisions of the Agreement concluded with Egypt on 2 5 March I 9 5I were applicable in the event of such transfer. In paragraph 5I of its Opinion of 20 December I 98o, the Court advised that the Organization and Egypt have a duty: (a) to consult together in good faith as to the question under what conditions and in accordance with what modalities a transfer rna y be effected;
(b) in the event of a transfer being finally decided, to consult together and to negotiate regarding the arrangements needed to effect the transfer in an orderly manner and with a minimum of prejudice to the work of the Organization and the interests of Egypt; (c) to give a reasonable period of notice taking account of all the practical arrangements needed to effect an orderly and equitable transfer. On I8 May I98I the Thirty-fourth World Health Assembly accepted the Advisory Opinion of the Court and recommended to all parties concerned to be guided by it. The Assembly further requested the DirectorGeneral: (I) to initiate action as contained in paragraph 5I of the Advisory Opinion and report the results to the sixty-ninth session of the Executive Board in January I982 for consideration and recommendation to the Thirty-fifth World Health Assembly in May I982; (2) to continue to take whatever action he considered necessary to ensure the smooth operations of the technical, administrative, and managerial programmes of the Regional Office for the Eastern Mediterranean during the period of consultation. As a result of the action initiated by the Director-General with regard to the Advisory Opinion, a meeting was held (Cairo, November I98I) between the representatives of the Government of Egypt and of the Director-General. I4. Io Questions of patent rights and the protection of the public sector with regard to inventions resulting from cooperation of the Organization with research institutions or industry raised increasingly complex issues. A study of these issues was initiated in I 98 I and a document was prepared for consideration by the Executive Board in January I982 and by the Health Assembly in the following May.
I International Digest of Health Legislation, 31: 950-95 8 (198o).
226
CONSTITUTIONAL, LEGAL, AND ADMINISTRATIVE DEVELOPMENTS
Administration t Establishment
I4.II On 30 November I98I the total staff (excluding staff of the Pan American Health Organization) was 43 77 as compared with 4378 on 30 November I979 and 432I on 30 November I98o. The number of professional or higher graded staff fell from I 6 3o in November I979 to I57I in November I 98 I, whereas that of general service staff rose slightly-from 2748 to 28o6-in the same period, this being mainly due to an increase in general service project staff.
and communication skills of field staff were developed. In all, close on 5o programmes were conducted or sponsored in managerial and related skills alone. A number of them focused on priority issues in health development, e.g., strategies for the International Drinking Water Supply and Sanitation Decade. 14. I4 To maintain their technical proficiency, a total of 42 staff members were granted individual study leave for varying periods of time. 14·15 Secretarial development was expanded, some 450 staff members taking part in programmes for this purpose at headquarters or in regional offices. 14· I 6 Language training continued to absorb greater resources owing to demands for proficiency in German and Portuguese, as well as in the traditional official languages (Arabic, Chinese, English, French, Russian, and Spanish). 14· 17 WHO played a major role in fostering interagency cooperation in staff training within the United Nations common system. Documentation in relation to career development, management training, and evaluation of staff training was prepared for consideration by a subcommittee of the ACC Consultative Committee on Administrative Questions. Other agencies were invited to participate in WHO training programmes.
Staff development and training
I 4· I 2 Development and training of staff were intensified, the main expansion taking place in the three regional offices that have staff and established training programmes for this purpose (the Americas, Europe, and the Western Pacific). I 4· I 3 Particular emphasis was given to training both WHO and national staff in the implementation of strategies and plans of action for national health development, and to introducing new technical and managerial approaches in the various programme areas. This is well demonstrated by the European Region, where four training programmes were conducted, two in advanced health services management and two in country health programming and managerial processes for national health development. Twenty-eight WHO staff members and many more nationals took part in these programmes. Similarly, in the Western Pacific, over So staff members took part in management workshops. In the Americas programmes for strengthening the management 1 Budgetary and financial data are presented separately in the annual financial reports.
Office accommodation
14· I 8 At the Regional Office for the Western Pacific, two additional floors were added to the annex building in I981. Improvements to the main building were undertaken, including warehouse and covered parking space. 227
THE WORK OF WHO, r98o-r98r
14· I 9 At headquarters, part of the V Annex building (I 8 offices) was demolished to make way for a road that has been constructed by the authorities of the Canton of Geneva (the building stands on land owned by the Canton).
laboratory instruments to several collaborating centres and national institutes for research in various fields (regular budget and UNDP, $5o869I5)· I 4· 2 3 Emergency assistance following natural or other disasters was provided to Algeria, Burma, Gambia, Italy, and Lebanon in the form of drugs, vaccines and other medical supplies ($214 215 ).
Supp!J services Supply operations during I98o9 8 I showed a certain stabilization of centralized procurement and a steady increase in procurement at regional and country level, in the spirit of technical cooperation among developing countries. Inflation in the major industrialized countries was reflected in commodity prices and in freight transport costs, both by sea and by air. I4.20 I
I4.2 I The cost of supplies and equipment purchased by the Organization reached a record figure of $8I 898 3 I4, not including the $12 284 747 required to cover freight and insurance charges. Line items ran to 126 797, necessitating some 22 86o purchase orders. 14.22 Approximately two-thirds of all purchases were financed by extrabudgetary funds. Operations during the period included the provision of medical supplies and equipment to Democratic Kampuchea, the Lao People's Democratic Republic, and Viet Nam (extrabudgetary resources and regular budget, $5 213 465); and continuation of the long-term programme of United Nations humanitarian assistance to Cyprus (funded by UNHCR, $I 400 52I). Under an expanded programme of technical cooperation with China, WHO provided capital equipment and
14.24 The Regional Office for Europe gave technical advice on the purchase and erection of prefabricated buildings for one hospital and five health centres in the earthquake-stricken area of El Asnam, Algeria. Funds came from a grant of one million European units of account by the Commission of the European Communities. The Regional Office also arranged for the purchase and dispatch to El Asnam of emergency supplies and equipment in the amount of $100 500. I 4· 2 5 In contrast to a decline in the previous biennium, there was an increase in purchase of supplies against reimbursement during I98o-I98I, mainly in the Eastern Mediterranean Region. The total amount of such purchases, including those made under the Revolving Fund for Teaching and Laboratory Equipment, was $6 I23 6q.
I4.26 Large quantities of vaccines and drugs donated by various countries to the Voluntary Fund for Health Promotion were received in Geneva and redistributed later to developing countries for their immunization programmes. The estimated value of these donations in I980-I98I was $z4I8 352·
228
Chapter
If
Regional Trends
Mrican Region 15. I MEMBER STATES of the Region 1 have shown their determination to ensure that, through primary health care, individuals, families, and communities achieve a level of health that will permit them to lead a socially and economically productive life by the year 2000. In the years I98o and I98I virtually all those Member States signed the Charter for the Health Development of the African Region (paragraph 1.26) and made efforts to attain national self-reliance with a view to achieving the social objective of health for all by the year 2ooo. This objective is neither a pious hope nor a publicity slogan; rather it is the expression of a general political will to combat social injustice, which is incompatible with the establishment of a new international economic order. 15.2 Health is an inalienable and fundamental right. States have a duty to ensure, with the full participation of their people, that the essential needs of those people are met and that the quality of their life is improved. To this end they must exercise over the national health system, and the technology it adopts, the social control that is essential for rational
implementation of national and regional health development strategies. I 5. 3 Far from being utopian, the strategy of the African Region, which is an integral part of the Global Strategy, is a reality to which the health revolution has only to give shape. The Lagos Plan of Action, adopted by OAU in April I98o, provides for implementation of the strategy contained in the Monrovia Declaration (I979) on the basis of the relevant guiding principles and the practical measures required for attainment of national and collective self-reliance in the social and economic fields.
1 Figure I j. I delineates the six WHO regions and shows the location of regional offices.
15 ·4 In I 980 the Regional Committee devoted its attention to the subject of health for all by the year 2ooo. It concluded that the objective was both justified and relevant, as it offered a means of combating social injustice and cultural alienation, the principal causes of political instability and economic underdevelopment. The social liberation of the African peoples is dependent on integrated, multidisciplinary, multisectoral social and health development. A simplistic approach to the problem of health must be avoided, for the problem is essentially multidimensional and complex, and there should be no slavish copying of health systems that do not fit national requirements. The search for alternative paths to health development should be based on critical reflexion and open the way
Figure 1 5.1
Regional offices and the areas they serve
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~ Regional Offace for ~ the Western Pacific WHO 71012
REGIONAL TRENDS
to other acqulSltlons in the field of social practice; for health practice cannot exist in isolation from the social setting. The implementation of measures arising from a proper approach must lead to the social and health liberation of communities and contribute to their physical, mental, and social well-being. That is the meaning of the objective of health for all by the year zooo, which has now been translated into a regional strategy. The main concern of this strategy is development of the health infrastructure on the basis of primary health care, with the object of ensuring that social and health measures reach the entire population.
I 5. 7 A plan of action for implementation of the resolutions adopted is drawn up after each session of the Regional Committee. This plan is given wide distribution in order to facilitate supervision and monitoring of the implementation of the regional programme in accordance with the guidelines laid down by the governing bodies. I 5. 8 Governments receive, through the WHO programme coordinators, periodic situation reports on the use of WHO regular budget funds allocated to them. They are also informed of the situation with regard to extrabudgetary funds. Free and frank use of the supervision and monitoring machinery has created a climate of mutual confidence and established close contacts between the Regional Office and Member States.
Supervision and monitoring I 5. 5 The supervision and monitoring mechanisms are instruments of collaboration between Member States and the Regional Office. The Regional Committee is responsible for monitoring regional programme budget policy and strategy. The periodic reports of the Regional Director on the work of WHO in the African Region are mainly concerned with reviewing the implementation of national and regional development strategies, with particular emphasis on primary health care.
Regional structures I 5·9 In order to increase efficiency, the Regional Office structures have been reorganized in accordance with resolution WHA33.I7. The experiment of having national coordinators for WHO's programme at country level is continuing and they report directly to the Regional Director. Programme coordinators are participating increasingly in the international cooperation activities of ministries of health. In this capacity, they are often included in national delegations to meetings and sessions of WHO's governing bodies.
1 5.6 The co-management mechanisms, such as the Programme Subcommittee, the Standing Committee on TCDC, and the regional ACMR, have been strengthened. Other mechanisms have been introduced, in particular: (i) participation of members of the Programme Subcommittee in other meetings concerned with programming; (ii) study visits by representatives of health services to other countries of the Region, in accordance with the Regional Committee's decision at its thirtieth session; (iii) the establishment of an advisory committee on health development; and (iv) increased use of regional experts.
Special cooperation programmes I 5. I o The International Conference on Apartheid and Health (Brazzaville, November I98I) provided an opportunity for discussion on action to put an end to an inadmissible injustice. The particularly disturbing health situation in Chad and in Equatorial Guinea led to the establishment of
THE WORK OF WHO, 198o-198I
special programmes of technical cooperation. A mission headed by the Chairman of the thirty-first session of the Regional Committee studied the social and health situation created by armed aggression in Angola and proposed an emergency programme of technical cooperation.
Technical cooperation among developing countries (TCDC) I 5. I I Subregional working groups concerned with TCDC met in I98o and in I98I, and their reports were considered by the Standing Committee on TCDC and then by the Regional Committee. In I 9 8 I, for the first time, the countries of each subregion studied topics chosen by themselves. The priority projects recommended were included in the list drawn up by WHO with a view to seeking extrabudgetary funds. I 5. I 2 The African Health/ 2ooo Resources Group, composed of I 2 countries that are members of the Standing Committee on TCDC and a number of technical cooperation agencies, met in June I98o and reviewed all the projects in the list. It made recommendations and issued an urgent appeal to the international community for funds. I 5. I 3 The accession of Zimbabwe to independence has made possible a concentration of the efforts to increase support to the national liberation movements recognized by OAU and to the front-line States, whose social and health situation remains precarious because of South African aggression.
nation of information, and trammg of research workers. Material facilities have been improved by grants, and collaborating centres have been designated. Project formulation and coordination have been strengthened through meetings of subcommittees on nutrition, diarrhoeal diseases, and health services research. The regional ACMR has played a decisive role in promoting and coordinating research.
Health services development 15 . 15 The African Health Charter I 97 52ooo gave priority to activities aimed at improving peripheral services and the Charter for the Health Development of the African Region (resolution AFR/RC29/RI I) confirmed that priority. The regional development strategy, which is a consolidation of the national strategies, places special stress on primary health care and calls for continuing creative effort, improvement of the management process, and community participation. The strategy has two main components: (i) the training of health personnel, with particular emphasis on country health programming, and (ii) technical cooperation at country level for the implementation of country health programming. I 5. I6 The food and nutrition situation in the Region continues to be disturbing, particularly in the arid zones, and conflicts, migration, and inflation are aggravating factors. During the biennium emphasis was placed on nutrition as an element of primary health care.
Research promotion and development I 5. I 4 Regional research has been reoriented in the light of the objective of health for all by the year zooo. The main thrusts are promotion of research activities, dissemi-
Disease prevention and control I 5. I 7 Disease prevention and control form part of the strategy for attainment of the social objective of health for all. The Regional Committee at its thirty-first session (Sep-
REGIONAL TRENDS
tember I98I) adopted a plan of action for implementation of the regional strategy. National control strategies are emphasizing the role of primary health care in the treatment of disease and the protection of vulnerable groups, the training of health personnel, public information and education, and the participation of the international community. The Onchocerciasis Control Programme in the Volta River Basin Area is continuing satisfactorily. Control programmes have been planned for the new zones of infection in Nigeria and the United Republic of Tanzania.
Region of the Americas I 5. 20 The major developments in I98o-I98I were the decisions and action taken to achieve health for all by the year 2ooo. At Punta del Este, Uruguay, in I96I the decision had been taken to improve health as an integral part of socioeconomic development. In I972 the results of the preceding IO years' efforts formed the basis of the Ten-Year Health Plan for the Americas (I97I-I98o), which was adopted at the Third Special Meeting of Ministers of Health. At the end of that period a regional evaluation of the Plan was carried out, based on reviews by 2 5 governments of the progress made toward the goals and objectives set in I972. It showed that life expectancy at birth in the Region has risen to 67 years-63.6 for Latin America, 69.9 for the Caribbean, and 71. I for Canada and the United States. Infant mortality in Latin America dropped from more than I05 deaths per 1000 live births in I970 to less than 65 per 1000 in I98o. Mortality among children I -4 years old declined from 8. 5 to 4· 3 per 1000 during the decade. Yet perinatal deaths still account for about 5% of all deaths, an indication of the vulnerability of the neonate. In communicable disease control, which had high priority during the decade, several countries showed progress; in others mortality from preventable diseases, especially among children under 5, is still a source of concern. Communicable diseases and diseases associated with hostile environments and overcrowding are still problems in all countries, reflecting deficient social and economic conditions and extreme poverty. Levels of health are decisively influenced by two phenomena: population growth and increasing urbanization. Undernutrition remains a serious problem, but some governments have started to take intersectoral measures to solve it. A determined effort was made to provide water supply and waste disposal services covering So% of the urban and 50% of the rural population. By the end of the decade 7I% of
Promotion of environmental health I 5. I 8 The countries of the Region have begun the planning of water supply and sanitation programmes and, with the cooperation of GTZ, SIDA, UNDP, and WHO, have mobilized resources for part of the planned action. Nevertheless, the success or failure of the International Drinking Water Supply and Sanitation Decade in Africa depends essentially on the extent of participation in national efforts by the international community as a whole.
Health manpower development I 5. I 9 The training of health manpower at all levels, an essential element of the regional strategy for attainment of health for all, has been given fresh urgency by new programming approaches and the increase in health and social services, which have led to a growing need for personnel with management capability. Training is provided by a network of national centres supported by regional centres to which they can refer. The TCDC approach has played a major role in this activity.
the urban population and 34% of the rural population had access to sanitary drinking water supplies ; 42% of the urban and 3% of the rural population benefited from adequate sewerage and excreta disposal facilities.
National and regional strategies for health for ail I 5.2 3 In I 98o Member governments reaffirmed or revised their national strategies for attaining health for all, and the regional strategies based on them were adopted by P AHO's Directing Council at its XXVII Meeting (the thirty-second session of the Regional Committee) in September I 980. The regional strategies reflect the situation and experience of the countries in the Region and provide a common reference point for reorienting national policies and plans. In adopting the regional strategies in terms of level of health and coverage by health services, the governments set minimum goals for health structures and levels and undertook to pool their resources and energies so that no country would fall short of them two decades hence. Among the minimum goals the governments proposed that in no country should life expectancy at birth be less than 70 years, infant mortality be more than 30 deaths per 1000 live births, or mortality among children under 5 years of age be more than 2.4 deaths per 10oo. Other goals are: immunization services against diphtheria, tetanus, whooping cough, tuberculosis, measles, and poliomyelitis; the provision of drinkingwater supplies and sanitation facilities to 100% of the population by I99o, in accordance with the aims of the International Drinking Water Supply and Sanitation Decade, overall coverage being sustained through to the year 2ooo; and access to health services for the entire population. I 5.24 The regional objectives set were: reorganization and expansion of health systems to make them more efficient, equitable, and effective; intersectoral linkages; and promotion and improvement of regional and interregional cooperation. Certain important features in the regional strategies were stressed. The first is the need to adopt innovative solutions to health problems, inasmuch as the essential determinants of
15.2 I The main objective in the Region was to extend health service coverage to the entire population. The few valid indicators available for gauging the extent to which the coverage increased show that about half of the countries have made substantial gains. Nevertheless, the organization of the health sector and the development of human resources did not keep pace with the growth of facilities. Some countries made substantial efforts to promote intrasectoral coordination, particularly between the public health sector and the social security agencies. Several attempts were made to create intersectoral linkages in local projects within integrated rural development programmes and major economic and regional development. Regionally also, a close link was forged between the Regional Office and ECLA. Despite considerable investment in the health infrastructure, to which the Inter-American Development Bank contributed substantially, the growth of public expenditure for health care appears to have been slow and often to have lagged behind the general economic growth.
I 5.zz In short, while the countries in the Region made real gains, the gains in some cases fell short of expectations, because national economic development was unequal, economic structures and development measures were not always conducive to attaining the goals, or the time allowed for reaching them was too short. In addition, countries encountered difficulties in translating their goals into targets, and the will to attain the goals was not always as strong or sustained as it should have been.
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health status largely lie outside the health sector's traditional sphere of action. This means changes in the environment, in styles of socioeconomic development, and in living conditions. Just what changes are to be made depends on what is done in the various sectors to contribute to comprehensive community development and improved wellbeing. The second feature stressed is the urgency of revising traditional practices and methods so that health services are accessible to all the population and especially to the groups at greatest risk. Promotion and prevention programmes should be developed in combination with programmes for health restoration and rehabilitation and in close coordination with improvement of the physical and social environment. I 5. 2 5 It should be emphasized that the strategies also call for the reorientation of health systems so that services are extended to as much of the population as possible through the primary health care approach. This reorientation is to be accomplished by basic measures for enhancing the efficiency of the systems and increasing the public's use of the services. Their operating capacity must be improved, resources must be made more productive, and budgetary programming, control, and evaluation must be tightened up so as to guarantee that the system will be efficient. The strategies emphasize the redirection of resources to the established goals and full mobilization of all national resources. International cooperation must be intensified, particularly in relation to TCDC.
mittee's Subcommittee on Long-term Planning and Programming. The proposed regional plan, which was approved by the Directing Council of P AHO at its XXVIII Meeting (the thirty-third session of the Regional Committee) in September I98I, outlines the responsibilities and tasks assigned to governments and to the Organization. 15.2 7 This regional plan of action is the intermediate stage between the statement of regional objectives, goals, and strategies, and their translation into concrete programmes. For governments it serves as a guide and frame of reference for adjusting national health plans so they make their contribution to the regionwide effort by solving priority national problems. For the Organization it is the basic source of guidance for adjusting its cooperation policies, procedures, and programmes. At the world level it represents the input of the Americas to the global plan of action and to WHO's Seventh General Programme of Work. I 5.28 The aim of the regional plan is to satisfy the health needs of the entire population, and especially of those groups development has bypassed; priority is given to rural and marginal urban groups and, within them, to special population groups, namely women, children, workers, the elderly, and the disabled. The plan calls for the organization of services to maximize their equity and efficiency. New technologies, procedures, and methods will have to be devised to improve productivity and strengthen planning and administration. The plan makes restructuring of the health sector an essential requirement and involves the incorporation of social security systems, the refocusing of financing mechanisms, and the participation of the community in improving its health.
Regional plan of action 15.26 The regional strategies later became the basis for the health component of the new regional development strategy adopted by ECLA in Uruguay in May I981. A plan of action was drawn up with the participation of the PAHO Executive Com-
I 5.29 The plan clearly establishes that primary care entails much more than the extension of basic health servi<;:es: it is an
integral constituent of social development, and as such will lead countries to strengthen their social policies and harmonize their intersectoral plans and measures. I 5. 30 One of the plan's most notable and innovative features is its establishment of a regional monitoring and evaluation system closely coordinated with those of countries. The regional system is called on to supply to Member governments and PAHO(WHO the information necessary for gauging progress and making decisions about new methods and adjustments of policies, strategies, goals, and objectives at national, regional, and global level.
being established to follow up the implementation of the strategies in all their aspects and reports will be made to the Regional Committee--annually in the initial years. I 5. 33 Political commitment to health development was reinforced at the first meeting of ministers of health of Member States of the Region (] akarta, September I 98 I). The ministers affirmed that the action to follow on their commitment would be not only at political but also at executive and technical level. Recognizing the importance of technical cooperation among developing countries, they decided that time-limited plans of action for cooperation and collaboration should be prepared by meetings of government representatives, WHO fulfilling its coordinating and supporting role. The health ministers agreed to meet again immediately after the Regional Committee in
15.3 I To implement the plan of action, the Directing Council has asked governments to assess, in the light of the national situation, the compatibility of their priorities and strategies with regional goals and priorities and make the adjustments found to be necessary. Governments will also have to devise mechanisms for improving international and intercountry programming and coordination.
I982.
Health services development I 5. 34 A deeper appreciation of the need for equity in the allocation of health resources is evident and its result is a greater emphasis on the primary health care approach. Besides extending the network of primary health centres and subcentres, and retraining present single-purpose health workers as multipurpose workers, Member countries are also training and deploying a large number of community health volunteers, particularly in rural areas. A number of promotional activities have been planned that give increased attention to urban primary health care. In all countries multisectoral action is being taken to combat malnutrition, improve maternal and child health, and cover a number of other fields. Current initiatives, which span the entire health system and reach all levels, will improve the system's capacity to deliver a variety of services through skilled manpower; they also give reason for con-
South-East Asia Region I 5. 32 Regional and national strategies for attaining health for all by the year zooo were formulated after intensive consultation and were endorsed by the Regional Committee at its thirty-fourth session, in I981. High-level national councils or committees with responsibility for directing and coordinating their implementation were set up in almost all countries of the Region. Steps are being taken for the mobilization of resources for health development; for example, a study of resource utilization (in collaboration with the Health Resources Group for Primary Health Care) has been completed in one country. Mechanisms are
REGIONAL TRENDS
tinued optimism as to a rapid improvement in health throughout the Region.
ating centres were established, in Bogor (Indonesia) and Dacca. I 5. 37 With the rapid extension of primary health care services, especially in rural communities, health education is being reoriented to meet the educational and community participation needs of those services. In consequence, health behaviour studies, health education programmes, and appropriate educational methods and materials are being developed while at the same time mass communication is being utilized as an integral component of health education. WHO action supports national efforts and emphasizes health education as a process for influencing health behaviour, attitudes, and values.
Fami(y health I 5. 35 In the family health programme the main emphasis continues to be on extension of coverage to underserved populations, particularly those groups at greatest risk. In line with this, support has been given to several countries for studies on the risk approach in the delivery of maternal and child health care; the guiding principles developed by WHO for monitoring and evaluating such programmes were tested in this Region. As regards manpower, training curricula for all levels of health workers are being remodelled to meet changing health needs; and national self-reliance in education and training is being fostered by means of regional teachertraining programmes and institution-strengthening. WHO continues to advocate the small family as the norm. I 5. 36 The integration of nutrition work into primary health care and the development of a coordinated approach with other disciplines in planning, programming, and research are the main elements of the comprehensive nutrition programme. Surveillance of nutritional status and research-cumaction projects in priority areas were successfully introduced in several countries of the Region. Evaluation of ongoing nutrition work in primary health care programmes was undertaken under the research priorities, and the preliminary results were discussed at a meeting of principal investigators; the results of this evaluation are being utilized for improvement of programmes. The regional food and nutrition strategies were discussed in a consultative meeting and clear indications for future activities were given. As part of the network being developed to provide training and research facilities as supportive mechanisms for government activities, two collabor-
Mental health I 5. 38 The programme in mental health focused on extending population coverage by the appropriate training of primary health care workers. Community involvement and self-help were promoted, with successful results in some countries, e.g., community participation in the drug-abuse control programme in Burma, and the self-help groups for the mentally handicapped in some parts of India.
Diagnostic, therapeutic and rehabilitative technology I 5. 39 Countries of the Region are at different stages of developing pharmaceutical supply systems. Lists of essential drugs for primary health care have been prepared but systems of procurement, distribution, and utilization need further strengthening. The trend at present seems to be towards improving the separate components of the pharmaceutical system; WHO has, however, assisted countries in developing a coordinated approach as well as in tackling specific
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THE WORK OF WHO, 198o-I981
aspects. There is greater emphasis on achieving self-reliance in the production of essential drugs and on improving quality assurance. In the coming years WHO will cooperate with Member countries in further strengthening the technical, managerial, and administrative aspects of their drug policies and management.
treatment regimens. Multidrug regimen trials were started in India, Indonesia, and Thailand. The results of the rifampicin trial in Burma are expected to be available at the end of I982. I5 ·43 In diarrhoeal diseases the essential is to decrease, through oral rehydration, the high mortality from acute diarrhoea in children under 5 years of age. Regional training centres were established in Bangladesh and India, and preparations were completed for establishing a third centre in Indonesia, to train programme managers who will transmit their knowledge and skills to those working in primary health care. I 5·44 In the control of dengue haemorrhagic fever, early diagnosis and treatment was emphasized. Research on production of a vaccine is progressing satisfactorily at the WHO collaborating centre in Bangkok. Research studies on the pathogenesis and the epidemiological and entomological aspects of dengue haemorrhagic feverfdengue shock syndrome were conducted in Indonesia, Sri Lanka, and Thailand, with the support of the Regional Office.
Disease prevention and control I 5.40 Epidemiological surveillance services are being improved in order to make them an effective tool in controlling prevalent communicable diseases. The emphasis is on training programmes in field epidemiology.
Antimalaria work continues to receive priority owing to the persistence of the disease and its explosive potential. Despite the expansion of operations, which absorb a major part of the public health funds of most countries, there was a levelling out of the sharp decline in incidence recorded during the past five years. In particular, the incidence of Plasmodium falciparum infection showed an overall regional increase of I4% between I979 and I98o. In the face of these discouraging indications national control programmes are being revised; applied field research to overcome technical and operational constraints is being carried out with the help of the Special Programme for Research and Training in Tropical Diseases; national malaria coordinating committees are being strengthened by the participation of sectors other than health; and countries with common borders and similar problems are coordinating their approach by holding joint meetings. I5 .42 In leprosy, field studies to improve case-finding and treatment are in progress in several institutions. Research priorities have been identified and protocols developed, particularly in regard to drug resistance and
I 5.4I
I 5·4 5 The Expanded Programme on Immunization is being rapidly developed. Surveys have been carried out in most countries to measure baseline incidence rates in the target diseases, evaluate immunization coverage in the target age groups, and assess community participation. Thailand was selected as a demonstration and training area for the global programme. Newly developed cold-chain equipment (including solarpowered refrigerators and freezers) are being field-tested, and several countries have begun the local manufacture of cold boxes and vaccine carriers. The expansion of the programme is however hampered by two factors: the inadequacy of the cold chain, and the less than optimal community participation as reflected in the high drop-out rate.
REGIONAL TRENDS I 5.46 The principal trend in vector biology and control is the emphasis on comprehensive integrated programmes, increasingly employing bioenvironmental methods. Intersectoral collaboration is being promoted in order to reduce the prevalence--particularly in agricultural and industrial development areas--of malaria, filariasis, dengue haemorrhagic fever, Japanese encephalitis, leishmaniasis, and plague. The introduction of a health component at the planning stage of major development projects in most Member countries is a welcome step forward.
Promotion of environmental health I 5·49 The launching of the International Drinking Water Supply and Sanitation Decade greatly influenced the nature and type of environmental health work. WHO gave its support to coordinated policies and action to meet the requirements of a vastly increased programme in water and sanitation that includes the implementation of specific projects and various support programmes (appropriate technology, manpower development, and community education based on sociobehavioural studies). The very size of the Decade programme has aroused an interest in managerial aspects, information systems, and programme monitoring and evaluation.
I 5·47 Most countries are developing programmes for the control of zoonotic diseases of public health significance, particularly rabies. WHO is helping to strengthen facilities for the production of rabies vaccine and to train national personnel in production technology and in modern methods of zoonosis control.
I 5. 5o Greater emphasis is being given to low-cost sanitation for the small towns and urban fringe areas that have hitherto been neglected. Sociobehavioural studies, using the multidisciplinary approach, are providing new insights into people's attitudes. I 5. 5I In spite of their low per capita income, a few countries of the Region have undertaken considerable work in control of air and water pollution. WHO has cooperated in assessing the environmental impact.
5.48 As regards noncommunicable diseases, there has been greater emphasis on training peripheral workers to identify high-risk groups and on providing facilities for early diagnosis and treatment (including rehabilitation) in the case of cancer, cardiovascular diseases, diabetes, blindness, and deafness, and for treatment and rehabilitation in the case of injuries resulting from accidents. Community-oriented activities in disability prevention and rehabilitation have been promoted through national surveys and through training programmes for the disabled, for members of their families, and for health workers. Health services for the working population have improved with the provision of better laboratory facilities and the availability of trained manpower; the hazards to agricultural workers as a result of the increasing use of pesticides and chemical fertilizers will receive continued attention. I
I 5. 52 Food safety programmes are at present mainly confined to urban centres with central laboratories. WHO's role is now seen as that of promoting comprehensive food safety programmes in which veterinary and public health aspects are integrated with sanitation.
Health manpower development I 5. 53 Cooperation between WHO Member States was directed towards planning of health manpower and more effective coordination of planning, training, and utilization of personnel.
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THE WORK OF WHO, 198o-I98I I 5. 54 Progress was made in clarifying the nature and dimensions of teamwork as related to primary health care. This work will form the basis for a series of descriptive case studies of the health team in countries of the Region that will later be used to improve training programmes. I 5. 55 Teacher-training programmes for health personnel also made progress. Many countries now have formal structures for providing such programmes and these are being used to reorient the training towards community needs and primary health care.
all. A group of scientists from Member countries worked out a framework for actionoriented health services research, and projects in this context have already begun in several countries. 15 .6o In view of the need for a multisectoral approach to research, the Regional Office has taken action to associate medical research councils, analogous bodies, and research foci in ministries other than the health ministry with its promotion and development of research. At national level also, coordination and management of research will be enhanced by greater contact with medical research councils. Training in research management and methods is being developed. Centres of excellence in the Region are being identified and networks of collaborating centres are being established to permit greater participation by national scientists and institutions in WHO programmes.
I 5. 56 Intensive efforts were made to redesign or reorient programmes of basic nursing education and to incorporate on a large scale the training of traditional birth attendants and similar workers. WHO cooperated in evolving a systematic approach to continuing education that should make it more relevant and accessible for a maximum number of health personnel, particularly at primary health care level. I 5. 57 Progress was made in organizing a regional health literature, library, and information system. It is being used for the training of staff and for research programmes, and is expected to contribute to the Region's capacity for technical cooperation.
Programme planning and development · q.6I The planning, development, and delivery of programmes have been facilitated by the streamlining of internal management information systems, frequent government and WHO reviews of programme implementation (in two countries by joint governmental/WHO bodies), and the increased financial responsibility delegated to WHO programme coordinators. WHO's programme budget as it relates to the country concerned is being used by ministries of health to coordinate and make better use of external resources. I 5.62 A programme budgeting exercise carried out in Thailand has led to a better understanding of national and WHO procedures and should ensure that the programme budget for that country is closely related both to national objectives and strategies and to WHO's General Programme of
I 5. 58 The trend towards awarding fellowships for study within the Region continued; 57% of fellowships were of this type in I98o as compared with 47% in I979· The monitoring and evaluation process to ensure that fellowships meet the requirements of Member countries has been improved.
Research promotion and development I 5. 59 The research programme was reoriented towards support of national and regional strategies for achieving health for
REGIONAL TRENDS
Work. A mechanism for the Thai Government's management of the WHO country programme is being designed, to be set up in early I982. 15 .6 3 There has been close collaboration with several organizations in the United Nations system, particularly UNICEF, m consultative programme formulation at country level. An increasing number of missions relating to health, water, and sanitation in the Region are being jointly supported by WHO and the Asian Development Bank. This augurs well for further collaboration in defining the health component of Bank-assisted rural development programmes.
in education and public information, changes in social and economic conditions, and even regulatory controls to ensure food safety and halt illegal imports. The deteriorating economic climate, however, is likely to take its toll on the health of the less fortunate socioeconomic groups. Preliminary studies have shown that unemployment has particularly deleterious and long-term effects on health; those caused by poverty are better known. The failure to recognize the extent to which health policy is dependent on that of other sectors-in particular the economic-has in the past militated against the optimum use of resources. The new strategy attempts to correct that tendency. I 5.66 The new strategy is designed to encourage policy-makers to lead rather than to follow; it is therefore vitally important to develop regional targets to promote its implementation. Work in this sense has begun and takes into account both technological and economic possibilities and constraints. To monitor achievements, indicators are now being developed, due regard being paid to the different levels of development of health information systems in countries of the Region and to the WHO list of I2 indicators for monitoring progress at globallevel. 1 The regional indicators fall into four categories: health status; factors affecting health; health care provision; and policy measures. These were in the course of I98I subjected to analysis by national administrations and various international bodies with a view to finalizing a document on regional targets in I982. Several Member States of the Region have held seminars and meetings on the subject to stimulate interest among their health professionals.
European Region I 5.64 The biennium saw the steady development of a European strategy for health for all by the year zooo. One of the elements of the strategy is prevention, another the improvement of health care systems. The former covers a wide spectrum, from genetic counselling and immunization through food control and the provision of adequate drinking-water supplies and sanitation to the reduction of accidents, including road traffic accidents, and their consequences. Improvement of health care systems in accordance with the principles of the Declaration of Alma-Ata will, in many countries of the Region, entail major changes in professional practice and in the organization and financing of health care. I 5.6 5 Other elements of the strategy, of immediate concern to the European Region, are the promotion of healthy lifestyles and minimization of the detrimental effects on health of poverty and unemployment. Healthy lifestyles are both an individual and a community responsibility, requiring efforts
1 Global strategy for health for a/1/ry theyear 2000. Geneva, World Health Organization, 1981 ("Health for All" Series, No. 3), part VII, para. 6.
THE WORK OF WHO, 1980-1981
Technology and quality assurance of health services
I 5.67 The Regional Office developed a new medium-term programme in I98o, on model health care programmes and quality assurance of services. Many current quality assurance programmes aim at obtaining maximum instead of optimum quality because they over-emphasize the scientific and technical aspects. In the attempt to provide the best possible care for everybody the costs become prohibitive. The new programme, with the aim of making the most efficient use of available resources, suggests solutions to the problem such as routine quality assurance mechanisms and standard patterns of care.
and administrative practices; others have influenced the clinical study and utilization of drugs. I 5. 70 The I 98o symposium concentrated on drugs for the elderly. The I98I symposium, the tenth in the series, was on the use of drugs in infants and children. It considered the factors to be taken into account both in the choice of drugs and in the establishment of precautions to be taken by investigators and regulatory agencies to ensure the safe and efficacious use of drugs in the young, especially the very young. Since the beginning of the I 97os, a I 5. 7 I drug utilization research group has dealt with methodological problems in the measurement and comparison of drug utilization, working closely with the Nordic Council on Medicines (paragraph 8.13). Marked differences in drug utilization in different countries have been found and the group is now studying the extent to which these differences are attributable to disease patterns or traditions of treatment, or both. I 5. 72 To improve the efficiency of pharmaceutical supply systems, the Regional Office has provided Member States with information on the role therein of regulatory agencies, health professions, universities, social security schemes, regional economic groupings, industry, and the consumer. The aim is to enable Member States to formulate the drug policies most appropriate to their own traditions and needs. I 5. 7 3 International Year of Disabled Persons. According to population surveys and
Research promotion and development
I 5.68 The work of the European ACMR at its sessions in I 980 and I 98 I is described in paragraphs 4.26-4.30.
Diagnostic, therapeutic, and rehabilitative technology
15 .69 I 980 was the first full year of operation of the new regional programme on prophylactic, diagnostic, and therapeutic substances, which at present deals mainly with chemical and pharmacological evaluation in drug control, research on drug utilization, and the development of national drug policies. Symposia held every year since I972 in the Federal Republic of Germany have made recommendations on the investigation and regulation of drugs-on their efficacy, safety, quality, indications, and use. The broader themes discussed have included national drug policies and the utilization of specific groups of pharmaceuticals. Many of the recommendations of the symposia have been accepted by the European governments concerned and incorporated into their national legislation
other data, the number of disabled people is alarmingly high in many countries of the European Region, amounting to at least 10% of the population. The Regional Office contributed to the WHO programme on disability prevention and rehabilitation by convening meetings on the use of residual
REGIONAL TRENDS
vision by visually impaired persons 1 and on ways of preventing disability in the elderly. In addition, over the last five years, the European programme for the prevention of road traffic accidents has reviewed all the related public health issues, with emphasis on the action required on the part of the authorities not only in the health sector but also in the other public sectors concerned. In March I98I a symposium reviewed the characteristics of accident injuries, analysed disability patterns and their consequences for the health services, and considered the problem of indicators of the level of severity of injuries. I5·74 At the thirty-first session of the Regional Committee (Berlin, September I98I) the Technical Discussions had as their theme the medical and social problems of disabled persons. These were discussed in the light of the International Classification of Impairments, Disabilities, and Handicaps (paragraph I3.7). The aim was to provide guidance to Member States in formulating health and social policies to integrate the disabled into society. It was concluded that the severely disabled have special needs that should be carefully assessed and appropriately met by the rehabilitation services; that social problems are often the major determinants of handicap resulting from an impairment or a disability; and that, because structural and other physical barriers still prevent many disabled from becoming socially integrated, more attention should be given to the encouragement of barrier-free design. Appropriate preventive measures should be taken by way of legislation, and rehabilitation should whenever possible be carried out using the primary health care approach. Services should be community-based, with
appropriate systems for supervtston and referral, and should provide total coverage of the population. The administration and organization of disability prevention and rehabilitation services should be restructured to reflect the new approaches; and there should be concerted action by the authorities concerned with health, social affairs, and labour. Research, particularly health services research, should be encouraged and measures should be taken for the full participation of the disabled in community activities.
Cancer I 5. 7 5 A working group (Luxembourg, October I98I) reviewed the extent of development of cancer centres in Europe; the structure and functions of community-based cancer control programmes within the general health care system; and cancer registration and its role in cancer control. Proposals were made for a further expansion of the Regional Office's programme in this field to include the systematic development of national cancer control programmes.
Cardiovascular diseases I 5. 76 In I 967, when the Region embarked on its long-term programme in this field, cardiovascular diseases were already the cause of some 5o% of the deaths in Europe2 5% of them due to coronary heart disease alone. The sharp decline in mortality from cardiovascular diseases in the USA since the mid-sixties has recently attracted interest. In Europe, however-except for Belgium, Finland, and Norway--coronary heart disease mortality, according to available data, is static or is continuing to rise, in the latter case particularly in the younger age groups. During the biennium work proceeded on a publication to evaluate the results of the longterm programme.
1 The use of residual vision by visual(y disabled persons. Copenhagen, World Health Organization, 1981 (EURO Reports and Studies, No. 41).
243
THE WORK OF WHO, 1980-1981
Promotion of environmental health I 5. 77 Continuous support has been given to Member States in water supply and waste disposal programmes, a major component of the support being the work undertaken by WHO as executing agency for UNDP. In Algeria, Morocco, Portugal, Turkey, and Yugoslavia pre-investment projects have been completed, the results of which have been used by the governments in successful applications for loans to the World Bank. The cost of the studies undertaken by the Regional Office in these projects has been about $5 . 5 million, amounting to some 2% of the loans generated. These figures do not include national investments based on project recommendations, which are considerable. The work of the Regional Office in recent years has resulted in the provision of water supplies or appropriate sanitation to about six million people. An assessment of the situation indicates, however, that there are still about I 20 million people in the Region inadequately supplied with water and 4 5o million served by unacceptable sanitation systems. I 5. 78 The project for European cooperation on the environmental health aspects of the control of chemicals is now more than two years old. It comprises the formulation of programmes, approaches, and guidelines for training the necessary manpower; the preparation of contingency plans for emergencies and accidents; the development of methods of assessing the environmental health aspects; and the promotion of international collaboration and exchange of information on toxic chemicals. The manpower development component of the project is intended to assist in alleviating the crippling shortage of trained personnel for evaluation and control work. The skills, training, and education necessary for toxicologists, chemists, laboratory technicians, and public health inspectors are being defined, as is the knowledge needed by decision-makers in government. Training
courses are being designed for use at various national institutes. Due attention is being given to accidents and emergencies involving toxic chemicals. A survey of existing emergency systems in a number of countries is being conducted to find out where the responsibilities lie and what equipment, manpower, and information are available. A model contingency plan for dealing quickly and effectively with emergencies involving toxic chemicals has been drawn up for use by governments.
Health manpower development I 5. 79 Cooperation continued with nongovernmental organizations such as the Association for Medical Education in Europe, the Association of Medical Deans in Europe, the Nordic Federation for Medical Education, the Association of Schools of Public Health in the European Region, and the European Association of Programmes in Health Services Studies. Their presidents are members of the Region's advisory committee on health manpower development. A representative of the Regional Office is among the seven members of the executive committee of the Association of Medical Deans in Europe.
I 5.8o On behalf of WHO, the Association for Medical Education in Europe is undertaking a study on medical school admission procedures in the Region and on ways of introducing medical students to the different approaches to primary health and community care. It is also carrying out a study on different curricula for training in health management with a view to standardizing such training in schools of public health in the Region. With the collaboration of the Regional Office, the Association is extending its membership to countries in the south and east of the Region.
244
REGIONAL TRENDS
Publications I 5.8 I The European Region continued to be the main market for WHO publications, providing nearly 5o% of revenue from sales in I98o. Nevertheless, one of the main problems in the regional publications programme remains the distribution of information, especially to those who do not use the working languages of the Region (English, French, German, and Russian). The problem is being tackled by using a computerized list of addresses for the distribution of publications, by progressive updating of publishing methods through modern text-processing and printing facilities, and by encouraging translation into as many European languages as possible.
of all Member States. These arrangements, and the collaboration of WHO staff at all levels, have ensured a high rate of delivery of programmes with the minimum of interruption. I 5.84 Collaborative programmes within countries have been carried out with very little disruption and, although certain intercountry activities have had to be cut back, a number of technical meetings have been held on a wide variety of subjects. The provision of advisory services, fellowships, and supplies within the intercountry projects has continued normally. On the other hand, it was not found possible for the Regional Committee to meet in regular session in either I98o or I981. I 5. 8 5 Three subregional meetings (Damascus, Mogadishu, and Kuwait, I98o) provided the necessary impetus for the formulation of national strategies for health for all. The number of countries including primary health care programmes as an inherent component of their national health plans increased, and all the various activities have been heavily influenced by the national strategies for health for all and the focus on primary health care. The diversity of the demographic, social, economic, and political situations in the countries of the Region calls for a broad and flexible regional strategy. It can be considered as a regional framework for international cooperation and national efforts in meeting people's basic health needs and carrying out priority programmes corresponding to the eight main components of primary health care. During the biennium, for example, there was particular emphasis on the immunization of children, water supply and sanitation, and maternal and child care--all key components of primary health care.
15.82 A new departure was the sponsorship of a health encyclopaedia published commercially in weekly parts; it is appearing in Spanish in six countries, in French in three, and in Portuguese in two. It provides an unprecedented opportunity for WHO to reach a large audience with its views on health care.
Eastern Mediterranean Region I 5.8 3 The work of WHO in the Eastern Mediterranean Region in I 98o--I 98 I, as on several occasions in the past, was carried out against a background of repeated change and frequent realignment of policies among the Member States of the Region. Immediately following the Thirty-third World Health Assembly in May I98o, and in the light of the decision of a number of countries (conveyed to the Director-General on I9 May I98o, and confirmed by similar communications in May I98I and September I98I) that they would not be in a position to deal with the Regional Office at its present location, arrangements were made to ensure that the programme could continue to be delivered in the interests
15.86 The challenging task ahead-to accelerate the process of building up health systems based on primary health care 245
THE WORK OF WHO, 198o-r98r
principles-calls for substantial administrative and managerial reforms, the active participation of the population, and a coordinated effort on the part not only of the health sector but also of all sectors concerned with socioeconomic development. Such an endeavour requires a reshaping of the infrastructure of countries' health systems so that traditional priorities can be reviewed and priority accorded to the most essential health programmes. It also calls for reorientation of training programmes towards meeting community needs, increasing managerial skills at all levels, and promoting research on health services and on the development of appropriate technologies. Progress can therefore be made only gradually, in accordance with specific country situations and needs, but many countries of the Region have already taken steps towards meeting the challenge. 15.87 It is only through such adaptation that WHO can really maintain and develop further its usefulness to the countries and people of the Region, fulfilling its functions as the coordinating authority on international health work and the technical adviser and close partner of all Member countries.
selected countries. Management training per se has been the focus of a substantial number of fellowships and of two national training activities (in Israel and Somalia), which are expected to be followed by others on similar lines. I 5.90 It has been gratifying to observe the keen interest in evaluation. Bahrain and Egypt, with WHO's technical cooperation, have already embarked on the initial stages of setting up national mechanisms for the continous evaluation of their health manpower development activities, and a number of other countries have shown interest in taking similar steps.
Health manpower development I 5. 88 The need to focus the programme more intensively on primary health care has resulted in emphasis on certain activities which had in any event been coming to greater prominence in recent years. They include manpower planning and management and a broad series of activities relating to evaluation. I 5.89 In manpower planning and management there has been renewed emphasis on planning and prediction, including the preparation of a set of guidelines adapted for regional use and shortly to be tested in
I 5.9I A series of studies to evaluate the quality of nursing services was developed during the biennium. Both in nursing and in medicine, the oldest of the health professions, there are signs of increasing discontent with traditional approaches and with the imposition of imported models. So far as medical education is concerned, WHO collaboration in the traditional approach has been steadily declining. Building on a decade of experience in teacher-training and the application of modern methods to the training of medical teachers, it has concentrated its efforts on a few selected faculties and departments within the faculties, orienting them towards the community's defined health needs and introducing a problem-based approach to learning.
Research promotion and development I 5.92 The regional programme in research can be said to have come of age in its fifth and sixth years, and has become central to WHO's work.
I 5. 9 3 Health services research continued to receive high priority as recommended by the regional ACMR in its early years. The
REGIONAL TRENDS
health services coverage study in Bahrain, Egypt, and Yemen was completed (see paragraph 4· 33) and a detailed report was submitted to the sixth session of the regional ACMR. On the basis of the results of the study certain strategies have been proposed in order to increase coverage. The study will also be used as a teaching tool in health services research and planning. I 5·94 The subject of research manpower and the provision of adequate career opportunities for research workers in developing countries has assumed considerable importance during the recent past on account of the efforts being made by WHO to develop and strengthen national capabilities for research. A preliminary analysis of the research manpower situation in some countries of the Region has revealed a paucity of full-time medical research workers, even in the presence of an adequate career structure, and a lack of comprehensive plans for developing such manpower. It would appear that there is no single solution to this problem, and a variety of innovative approaches will have to be tried out.
three years. Member countries gave their full support to the International Code of Marketing of Breast-milk Substitutes (see paragraphs 6.7-6.10).
Disease prevention and control I 5.96 The control of communicable diseases remains an important component of primary health care and, above all, the epidemiological surveillance mechanisms of all countries need continuing and close attention. Encouraging progress has been made in providing the necessary manpower at national level but high priority must continue to be given to training. The persistence of many communicable diseases in developing countries is an indicator of social standards that could be largely improved through increased self-reliance, better management, a higher level of community participation, and more effective health education. All of these aspects continued to receive WHO's attention in its collaboration with countries.
Fami!J health I 5·9 5 The countries of the Region have welcomed the increased attention given to breast-feeding in recent years. Without exaggerating its importance or taking it out of its context in infant care and nutrition as a whole, there is no doubt that breast-feeding plays a key role in protecting the child from communicable diseases, especially diarrhoea, in the first year of life. This view is shared by almost all paediatricians in the Region, a number of whom, with special experience in the subject, took part in a scientific working group on breast-feeding (Nicosia, January I98I). The group's report provides clear guidelines, both for WHO and for Member States, on activities in this field for the next
I5 ·97 It is natural to take pride in the recent achievement of global eradication of smallpox, but at the same time the Region is facing many other threats, some of them new. Although by no means of a magnitude comparable to the threat of smallpox, periodic outbreaks of "new" diseases, including the viral haemorrhagic fevers such as CongoCrimean, Ebola, and Rift Valley fevers, have been causing particular concern to some countries of the Region in the past few years. New mechanisms of collaboration with governments were developed to tackle each of these outbreaks as it occurred. I5 .98 Every effort is being made to integrate communicable disease control programmes into the general health services at primary health care and other levels. There is also a definite trend towards developing integrated programmes for the control of 247
THE WORK OF WHO, '98o-198I
groups of communicable diseases that share common features. It is being increasingly realized that such an approach, besides being more effective in solving the problems, makes better and more economic use of available resources. An example of such a comprehensive programme is the Blue Nile health project for the control of water-associated diseases in Sudan. I 5·99 Acute diarrhoeal disease is still the most important cause of childhood morbidity and mortality in the Region, and the diarrhoeal disease control programme continues to be one of the major communicable disease programmes. A number of activities have been successfully implemented during the period under review, especially with regard to the development of national control programmes, training and dissemination of information, and applied research. The programme is particularly oriented towards the reduction of mortality through oral rehydration. Collaboration with UNICEF and Member States in the production of oral rehydration packages has continued; Afghanistan, Egypt, Pakistan, and the Syrian Arab Republic are producing such packages, and other countries will soon begin to do so. Applied research on various aspects of diarrhoeal disease control is being supported, both technically and financially, in various countries of the Region, and a regional scientific working group on diarrhoeal diseases research has been established. I 5. I oo The Expanded Programme on Immunization is fulfilling the high hopes expressed for it two years ago. It forms an essential part of all primary health care efforts, and all countries in the Region are collaborating in it. At the beginning of the second five years of this I 5-year programme (I 976-I 990 ), the annual regional totals of completed immunization courses in children of the most appropriate age had increased more than fivefold-from less than 4% of the number of
births to over 22%. This achievement was the result of considerable activity both within countries and at regional level. The Expanded Programme involves large-scale and complex management activities-for even if the state of knowledge of immunization procedures is advanced it is extremely difficult to ensure that all children are actually immunized. Large-scale training activities are required, as well as constant technical improvements, particularly to develop an effective cold chain so that vaccines and other material can be delivered in a safe and effective form to the point of immunization. At the beginning of the second five-year period, the review of existing programmes is a major activity; such reviews have already taken place in Bahrain, Somalia, Sudan, and the United Arab Emirates and are planned for other countries also. The reports recount achievements, identify major constraints, and make recommendations for future action. One conclusion that emerges from these reviews and from the regular reports all countries provide is that progress in combating tetanus of the newborn is not commensurate with the progress achieved in other parts of the Expanded Programme.
Promotion of environmental health
health Environmental proI5.IOI grammes are assuming ever-increasing importance in the Region, which is witnessing unprecedented urbanization and industrialization, accompanied by high population increases. WHO has collaborated with a number of countries in activities connected with the International Drinking Water Supply and Sanitation Decade, and special emphasis has been given to the training of all categories of personnel for environmental health work, particularly regarding water supply and sanitation.
REGIONAL TRENDS
Maintenance and repair of medical equipment I5 .Ioz It is widely recognized that one of the most serious obstacles to the implementation of health programmes throughout the Region is the fact that between zo% and 40% of a country's medical equipment may be out of order at any given time. There is a severe shortage of trained manpower to maintain and repair such equipment, which is purchased from widely different sources and varies greatly in sophistication and complexity. WHO is therefore collaborating with countries in developing regional training facilities-for example, at a regional training centre in Cyprus and at centres in Bahrain, Egypt, and Iraq. In general there has been vast expenditure on the renewal of supplies and equipment, while little has been budgeted for maintenance and repair. It is clear, however, that the provision of specialized manpower for this purpose will not in itself solve this huge problem, and a special effort will be made during the coming biennium to promote effective national policies on equipment maintenance and repair.
editorial board and supported by WHO. Like The Learner, it promises to become an important link among the network of people and institutions in the Region working in its sphere. A third vehicle of information-with wider dissemination, including all Member governments and the information media throughout the Region-is the EMRO Newsletter, which now appears monthly. Its objective is to keep all concerned informed of WHO's ongoing activities within the Region.
Western Pacific Region 15 .I04 At its thirty-second session in I98I the Regional Committee updated the regional strategy for the attainment of health for all, which is based on the national strategies developed by the Region's Member States. WHO has provided support for the planning, implementation, and evaluation of national health development measures aimed at achieving health for all, based on sound managerial practices adapted to the specific needs of each country. Countries are being encouraged to establish national health development networks that will provide a framework for TCDC activities.
Health information I 5. I o 3 Effective communication between those responsible for the various components of health services development is essential in this fast-developing Region, and three regional publications are being increasingly recognized as worthwhile developmental tools. The Learner, a quarterly journal of prime interest to educators of all categories of health professionals, published in collaboration with the University of Shiraz, Iran, is now in its eighth year of publication. The Health Services Researcher, a similar quarterly journal but with its focus on health services research, has been published since I98o by the health services research group of the Institute of National Planning, Cairo, under the guidance of a multidisciplinary international
Research promotion and development J5.I05 Additional WHO collaborating centres for research and training have been established in various Member States. An increasing number of grants have been made under the Special Programme for Research and Training in Tropical Diseases and the Special Programme of Research, Development and Research Training in Human Reproduction. WHO has supported studies on diseases of particular importance in the Region, such as clonorchiasis, schistosomiasis, dengue, acute respiratory infections, and fish poisoning. Meetings of the Western Pacific ACMR and its various subsidiary
249
bodies have laid the foundation for a substantial regional research programme which supplements national efforts.
their essential equipment in service. The need exists for simple diagnostic equipment, to be used in support of primary health care programmes. 15. I IO There have been few requests for technical cooperation in national occupational health programmes, in spite of concern about the health of rural workers, who are being increasingly exposed to chemical hazards. The more developed countries are continuing, and in some cases intensifying, their occupational health and accident prevention activities and increased cooperation may be expected in that domain between them and the developing countries. I 5. I I I Following a regional working group on health care of the elderly (Manila, October I98I), a programme is being promoted to increase awareness of the problems of the elderly, to encourage research, training, and education in regard to those problems, and to promote the establishment of services for the care of the aged. I 5. I I 1. In connexion with the International Year of Disabled Persons, I 9 8I, many countries in the Region have increased their educational, social, and therapeutic activities on behalf of the disabled. A regional working group (December I98I) planned a medium-term programme to encourage preventive measures, particularly in childhood, and to promote ways of increasing the independence of disabled persons. I 5. I I 3 Cooperation with Member States in respect of laboratory services consisted mainly in standardizing simplified laboratory techniques to be used principally at peripheral level for the diagnosis of the most important communicable diseases, special emphasis being placed on antibiotic susceptibility testing in view of the serious and growing problem of resistance among pathogenic bacteria. Efforts to improve the organization
Health services development I 5. I o6 Efforts in the Region were concentrated on developing a system of health services based on primary health care and community involvement. Countries were supported in developing their health manpower for primary health care. Health care delivery systems were reoriented and strengthened, and direct support was given to research and development. Exchange of information and of experience in the development of primary health care was encouraged.
I 5. I 07 Support for traditional medicine, including the use of medicinal plants, was continued. The use of appropriate technology in the prevention, diagnosis, and management of disease and in the rehabilitation of the disabled was promoted.
I 5. 108 The trend in the organization of the health services is increasingly towards decentralization, balanced development, an integrated approach to the provision of care, and more reliance on middle-level and lowerlevel health workers. Nevertheless some intermediate and higher-level facilities may have to be strengthened, since there are limits to the services that can be provided by peripheral health units. Intersectoral collaboration has become an increasingly important element in regional policies. I 5. I09 There was a growing demand for collaboration in the design, management, and maintenance of health facilities. WHO supported university and regional programmes of training in hospital administration; and a WHO-sponsored course was organized by New Zealand for the teaching of repair and maintenance skills so that countries can keep
1.50
REGIONAL TRENDS
and management of health laboratory services and quality control continued and are based on the training of laboratory staff and adaptation to national conditions of the techniques used in essential laboratory work.
session of the Regional Committee (I98I) adopted a resolution urging Member States to give their full support to implementing the Health Assembly resolutions on infant and young child feeding.
Fami!J health I 5. I I4 Many countries are showing increased awareness of the health needs of ' adolescents and particular attention is being given to the biological, psychological, and social problems, which include teenage pregnancy and fertility management.
I 5. I I 5 In maternal and child health care, interest in the risk approach has been stimulated by workshops on the subject. Malaysia has already completed the collection and analysis of data in this area and will be formulating a strategy in I982. National training programmes for personnel concerned with maternal and child health/family planning have been gradually strengthened throughout the Region. During the biennium three interregional courses for senior teachers on fertility management and maternal and child health care were held in Singapore. Papua New Guinea and the Republic of Korea have continuous training programmes, and in China the construction of two training centres began in I98o. National maternal and child health/family planning programmes concentrated on improving the delivery of services through primary health care. Eighteen projects, financially supported by UNFP A and executed b~ WHO, are under way in I 3 countries or areas of the Region. Activities to promote breastfeeding, with adequate supplementation at a later stage, are being carried out in several countries or areas in the Region and a number of meetings were held. The thirty-second
I 5. I I 6 Emphasis in nutrition was placed on the need for appropriate measures to control the marketing of breast-milk substitutes, and on developing health programmes within the framework of national food and nutrition policies. In many countries priority is being given to the control of specific nutritional deficiencies, the development of systems to monitor nutritional status, and the integration of the health sector's nutrition-related activities in the primary health care system. The various.categories of nutrition worker required for the health sector can now be trained in the Region itself.
I 5. I I 7 Health education in the Region aimed at promoting a healthy way of life and developing community self-reliance in health. Great importance was attached to teaching peripheral health and allied workers how to establish contact with the community and promote community organization, how to work in a team, how to collaborate with other sectors, and how to carry out health education. Support was given to the training of health education specialists, particularly at intermediate level. Eight countries or areas in the Region received support in developing communication strategies and improving audiovisual facilities. Efforts to give health education a more solid footing in priority health programmes continued, particularly in regard to tuberculosis and leprosy control, family health, water supply, and sanitation. Interest in behavioural research as an aid to health education was also encouraged. Activities were however limited by the shortage of trained manpower and of audiovisual equipment.
THE WORK OF WHO, 198o-I981
Mental health I 5. I I 8 In line with the recommendations of the regional coordinating group on mental health in I979, efforts were made to develop and strengthen mental health services in the Region. The emphasis was on integrating mental health services into primary health care: in many countries of the Region effective innovative programmes in community-based mental health care were developed. Among the priority subjects were alcoholism and related problems, misuse of psychotropic drugs, improved teaching of mental health, and the psychosocial aspects of child development in the face of rapid social change. During the biennium four WHO collaborating centres in mental health and neurosciences were designated in China and one in Japan.
contain a research component. WHO's insistence on the value of a sound disease surveillance system has led to a growing awareness of the need to strengthen national communication networks for the reporting and exchange of information on communicable diseases. WHO intensified its efforts to improve the collection, analysis, and dissemination of regional data. Support was given to courses in epidemiology in an attempt to correct existing deficiencies. I 5. I 2 I There was little change in the overall malaria situation. Strains of Plasmodium falciparum resistant to antimalarial drugs have now been found in all the endemic malarious countries in the Region. Progress in malaria control' was made in parts of the Lao People's Democratic Republic, Malaysia, and Viet Nam. The favourable trend observed in China during recent years was affected in I98o by adverse weather conditions, and there was a slight deterioration in other malarious countries of the Region. One achievement was the certification in I98I of malaria eradication in Australia, another the establishment of an Asian malaria training centre in Kuala Lumpur.
Diagnostic} therapeutic} and rehabilitative technology I 5. I I 9 Intercountry act1v1t1es on drug policies and management and on pharmaceuticals are being expanded, collaboration continuing in particular with governments in the South Pacific area, where a joint pharmaceutical service is to be inaugurated. WHO continued to collaborate with ASEAN countries in developing technical cooperation in the field of pharmaceuticals. Evaluation of the therapeutic properties and efficacy of medicinal plants continued.
Disease prevention and control I 5. I 20 Action to prevent or control diarrhoeal diseases, acute respiratory infections, arbovirus infections, and malaria was intensified and leprosy, tuberculosis, filariasis, schistosomiasis, and sexually transmitted diseases continued to receive due attention. Many of the activities undertaken
15 . r 2 2 In the programmes on immunization and the control of diarrhoeal diseases there was a shift in emphasis from interregional and intercountry to national activities, the latter including staff training, the improvement of information and surveillance systems, and the strengthening of programme evaluation. In the immunization programme special efforts are being made to improve the cold chain, while the diarrhoeal diseases programme is becoming increasingly involved in research. The programme on acute respiratory infections, which began with the establishment of a prototype research and control scheme in Goroka (Papua New Guinea), is being expanded to cover other countries. National units are being set up, research projects have been launched, and field assess-
REGIONAL TRENDS
ments are being made. There is increasing interest in viral diseases in the Region: research on the epidemiology of hepatitis B and dengue haemorrhagic fever concentrated on determining which groups should be vaccinated when vaccines become available. The importance as a health problem of haemorrhagic fever with a renal syndrome is being recognized. The widespread occurrence of beta-lactamase-producing strains of Neisseria gonorrhoeae is one of the factors that is perpetuating the problem of sexually transmitted diseases. Efforts to strengthen national control programmes for those diseases were continued. I 5. I 2 3 Leprosy control programmes are being developed in collaboration ~ith WHO in the many developing countries in the Region where the disease is a problem. A combined drug regimen, comprising dapsone and rifampicin or clofazimine, is now being introduced for the treatment of lepromatous and borderline cases. In some countries tuberculosis is on the decline, as is shown by the fall in the tuberculin-positive rate among children. Four prevalence surveys in the Republic of Korea showed a significant reduction in the prevalence of bacteriologically positive cases. In some other countries, on the other hand, there has been little or no improvement. In four countries or areas short-term therapy with streptomycin, isoniazid, rifampicin, and pyrazinamide has already been introduced. I 5. I 24 The programme for the prevention of blindness was promoted in many countries or areas in the Region through visits of consultants and provision of equipment and supplies. A workshop (Manila, December I98I) assessed the magnitude of the problem and outlined a programme for the Region.
the liver and the oesophagus. A communitybased control programme is under way in the Philippines for rheumatic fever and rheumatic heart disease and a similar scheme is being introduced in Viet Nam. Several epidemiological studies are being made on hypertension, and control programmes are being carried out in China, Japan, Malaysia, and the Philippines. In Australia and New Zealand, where ischaemic heart disease is common, comprehensive community-based programmes are being developed for the control of cardiovascular diseases, with emphasis on the need for a healthy way of life and a rational diet. As a result of rapid changes in social and economic conditions, leading to a high calorie intake and less exercise, diabetes is becoming a serious health problem among Polynesian and Micronesian populations in the South Pacific. Epidemiological studies are being conducted and control measures introduced, but international cooperation is urgently needed. I 5. I 26 WHO continued to support courses in public health dentistry and other educational projects as an important element in enabling countries to improve the planning of their basic oral health services. Periodontal disease continued to be a major cause of loss of teeth and a number of studies began whose aim is to provide a basis for preventive measures. To help combat dental caries the topical application of fluoride is gradually being introduced into schools in a number of countries. The oral health project in China, involving as it does professional training within the country and overseas training for a number of Chinese specialists, is a particularly significant undertaking.
Promotion of environmental health 15. I 2 7 Activities in relation to the International Drinking Water Supply and Sanitation Decade moved from the prepara2
5. I 2 5 Considerable progress has been made in research on the etiology of cancer of I
53
THE WORK OF WHO, 198o-I98I
tory stage to implementation. A programme was drawn up to guide regional activities during the next few years. Discussions on field projects were held with UNDP resident representatives, and UNDP-supported water supply and sanitation projects are now under way in several countries or areas. Increasing emphasis is being laid on programmes in rural areas involving community participation and a multidisciplinary approach. I 5. I 28 There are important programmes on the control of environmental hazards in both developed and developing countries and areas of the Region. Support was given to Member States and to UNEP's Global Environment Monitoring System (GEMS) through the further supply of monitoring equipment and the holding of WHO-assisted seminars and workshops on monitoring techniques. The Regional Centre for the Promotion of Environmental Planning and Applied Studies in Kuala Lumpur, now firmly established, was of particular assistance in meeting the real and growing need for advisory, planning, and training services.
preparing health workers for the expansion in their duties and improving their managerial skills. I 5. I 30 Strong support and encouragement were given to planning, training, and utilizing middle-level practitioners. Most countries have already defined their requirements and taken the first step towards appropriate programmes. For instance, a comprehensive programme is being developed in Tonga, with the ultimate goal of decentralizing the health services and improving health in the rural areas. Elsewhere curricula are being revised in the light of the new tasks to be performed and the system of supervision and referral to be introduced.
I 5. I 3 I Advances were made in the training of primary health care workers, especially through the exchange of information among the countries interested. Health workers from other regions made extensive studies of the systems used in China and the Philippines. Numerous seminars and workshops were held and attempts were made to determine the most appropriate training methods.
Health manpower development I 5. I 29 An increasing number of Member States in the Region are taking a fresh look at their health manpower requirements in the light of their national strategies for health for all. WHO has consequently placed increased emphasis on manpower planning, strengthening of the capacity of countries to produce health manpower, continuing education, and the application of educational theory and techniques to training programmes. In a number of countries however health manpower studies have been limited to certain categories required by the primary health care approach, e.g., community-oriented nursing staff and environmental health personnel. In several countries continuing education is being developed as an essential means of
I 5. I 32 Teacher-training and the development of more effective educational techniques and processes continued, not only for traditional categories of health personnel but also, increasingly, for new categories such as community health workers. In addition to the regional teacher-training centre, two national centres are expanding and are sharing their resources and experience. A third centre is soon to be established. Countries are showing great interest in the production and use of appropriate educational material, and WHO has been active in promoting this trend. I 5. I 33 WHO collaborated in the revision of curricula in a large number of programmes for training such categories of health worker as dentists, occupational therapists, anaesthetists, nurses, and midwives;
254
REGIONAL TRENDS I 5. I 34 The fellowships programme continued to expand, in particular to meet the training requirements of China and to accommodate trainees from other regions. A follow-up study of former fellows showed that the vast majority had made good use of their training on their return home.
given to lay reporting as an effective procedure for gathering data on health and health-related problems and services. Greater stress is being placed on the development of rational systems of medical records as an essential element in information systems for health management. I 5. I 36 The dissemination to countries in the Region of information contained in health and biomedical literature is being supported. Steps are being taken to develop the capacity of individual countries to establish and manage biomedical and health literature services. Access to information is being improved through the establishment of a regional biomedical information centre and a network of subcentres and libraries.
Health information
15. I 35 WHO strove to broaden its cooperation with Member States in selecting appropriate ways of utilizing data-processing technology and in strengthening the capacity of national health statistical services to analyse the data they obtain. Encouragement was
255
Annex 1
Members and Associate Members of the World Health Organization at JI December 1981 At 31 December 1981 the World Health Organization had 157 Member States and one Associate Member. They are listed below with the date on which each became a party to the Constitution or the date of admission to associate membership.
Afghanistan Albania Algeria* Angola Argentina* Australia Austria* Bahamas* Bahrain Bangladesh Barbados* Belgium* Benin Bolivia Botswana Brazil* Bulgaria* Burma Burundi Byelorussian SSR Canada Cape Verde Central African Republic* Chad Chile* China* Colombia Comoros Congo Costa Rica Cuba* Cyprus* Czechoslovakia* Democratic Kampuchea* Democratic People's Republic of Korea
I9 April I948 26 May I947 8 November I962 I 5 May I976 22 October I948 2 February I 948 30 June I947 I April I974 2 November I97I I9 May I972 25 April I967 25 June I948 20 September I96o 23 December I949 26 February I975 2 June I948 9 June I948 I July I948 22 October I962 7 April I948 29 August I946 5 January I976 20 September I96o I January I96I I 5 October I 948 22 July I946 I4 May I959 9 December I975 26 October I 960 I 7 March I 949 9 May I950 I6 January I96I I March I948 I7 May I950 I9 May I973
Democratic Yemen Denmark* Djibouti Dominica Dominican Republic Ecuador* Egypt* El Salvador Equatorial Guinea Ethiopia Fiji* Finland* France Gabon Gambia* German Democratic Republic* Germany, Federal Republic of* Ghana* Greece* Grenada Guatemala* Guinea* Guinea-Bissau Guyana* Haiti* Honduras Hungary* Iceland India* Indonesia* Iran* Iraq* Ireland* Israel Italy Ivory Coast*
6 May I968 I9 April I948 Io March I978 13 August I98I 2I June I948 I March I949 I6 December I947 22 June I948 5 May I98o I I April I947 I January I972 7 October I947 I6 June I948 21 November I96o 26 April I97I 8 May I973 29 May I95 I 8 April I957 12 March I948 4 December I974 26 August I949 I9 May I959 29 July I974 27 September I966 I2 August I947 8 April I949 I7 June I948 17 June I948 12 January I948 23 May I95o 23 November I946 23 September I947 20 October I947 2I June I949 11 April I947 28 October I96o
* Member States that have acceded to the Convention on the Privileges and Immunities of the Specialized Agencies and its Annex VII. 257
Jamaica* Japan* Jordan* Kenya* Kuwait* Lao People's Democratic Republic* Lebanon Lesotho* Liberia Libyan Arab Jamahiriya* Luxembourg* Madagascar* Malawi* Malaysia* Maldives* Mali* Malta* Mauritania Mauritius* Mexico Monaco Mongolia* Morocco* Mozambique Nepal* Netherlands* New Zealand* Nicaragua* Niger* Nigeria* Norway* Oman Pakistan* Panama Papua New Guinea Paraguay Peru Philippines* Poland* Portugal Qatar Republic of Korea* Romania* Rwanda* Saint Lucia Samoa
2I March I963 I6 May I951 7 April I947 27 January I964 9 May I96o I7 May I950 I9 January I949 7 July I967 I4 March I947 I6 May I95Z 3 June I949 I6 January I96I 9 April I965 24 April I958 5 November I965 I7 October I96o I February I965 7 March I96I 9 December I968 7 April I948 8 July I948 I 8 April I962 I4 May I956 I I September I975 2 September I953 25 April I947 Io December I946 zo April I95o 5 October I96o 25 November I96o I8 August I947 28 May I97I 23 June I948 20 February I95 I 29 April I976 4 January I949 I I November I949 9 July I948 6 May I948 I3 February I948 II May I972 I 7 August I 949 8 June I948 7 November I962 I I November I98o I6 May I962
San Marino Sao Tome and Principe Saudi Arabia Senegal* Seychelles Sierra Leone* Singapore* Somalia South Africa Spain* Sri Lanka Sudan Suriname Swaziland Sweden* Switzerland Syrian Arab Republic Thailand* Togo* Tonga* Trinidad and Tobago* Tunisia* Turkey Uganda Ukrainian SSR Union of Soviet Socialist Republics* United Arab Emirates United Kingdom of Great Britain and Northern Ireland* United Republic of Cameroon United Republic of Tanzania* United States of America Upper Volta* Uruguay* Venezuela VietNam Yemen Yugoslavia* Zaire* Zambia* Zimbabwe
I2 May I98o 23 March I976 26 May I947 3 I October I 96o I I September I979 20 October I 96 I 2 5 February I 966 26 January I96I 7 August I947 28 May I95I 7 July I948 I4 May I956 25 March I976 I6 April I973 28 August I947 26 March I947 I 8 December I 946 26 September I947 13 May I96o I4 August I975 3 January I963 I4 May I956 2 January I948 7 March I963 3 April I948 24 March I 948 30 March I972 zz July I946 6 May I96o I 5 March I962 2I June I948 4 October I 960 22 April I 949 7 July I948 17 May I95o 20 November I95 3 I9 November I947 24 February I96I 2 February I965 I6 May I98o
Associate Member Namibia I6 May I974
*Member States that have acceded to the Convention on the Privileges and Immumues of the Specialized Agencies and its Annex VII.
Annex
2
Organizational and Related Meetings
x.
Meetings in 1980
Executive Board: Working Group to study the question of the transfer of the Regional Office for the Eastern Mediterranean Executive Board: Programme Committee Executive Board, sixty-fifth session Executive Board: Standing Committee on Nongovernmental Organizations Executive Board: Working Group on the organizational study on the role of WHO in training in public health and health programme management, including the use of country health programming Executive Board: Ad Hoc Committee on Drug Policies World Health Assembly: Special Committee of Experts to study the health conditions of the inhabitants of the occupied territories in the Middle East Executive Board: Committee to Consider Certain Financial Matters prior to the Thirty-third World Health Assembly Thirty-third World Health Assembly Regional Committee for the Eastern Mediterranean, Sub-Committee A, special session Regional Committee for the Eastern Mediterranean, Sub-Committee B, special session Executive Board, sixty-sixth session Executive Board: Programme Committee (preparatory meeting) Regional Committee for South-East Asia, thirty-third session Regional Committee for the Western Pacific, thirty-first session Regional Committee for Africa, thirtieth session Regional Committee for the Americas, thirty-second sessionfXXVII Meeting of the Directing Council of P AHO Regional Committee for Europe, thirtieth session Executive Board: Programme Committee Executive Board: Working Group to study the functions and activities carried out by the Secretariat
Geneva, 7, 8 and 14 January Geneva, 8 and 22 January Geneva, 9-zj January Geneva, 10 and 16 January Geneva, 17 January; Geneva, 14 May; Geneva, 1 j-17 September Geneva, z3 January Geneva, j and zz-z4 April; Geneva, z1 May Geneva, j -6 May Geneva, j-Z3 May Geneva, 9 May
Geneva, 14 May Geneva, z6-z7 May Geneva, z7 May Male (Maldives), 1-7 September Manila, 9-1 j September Brazzaville, 17-z4 September Washington, zz September3 October Fez (Morocco), 7-11 October Geneva, z4-z8 November Geneva, 1-3 December
2.
Meetings in 1981
Executive Board: Working Group on the assessment of previous organizational studies of the Executive Board and their impact on the policy and activities of WHO
Geneva, 1z January; Geneva, z7 May; Geneva, 9-10 November
2
59
THE WORK OF WHO, Executive Board: Ad Hoc Committee on Drug Policies Executive Board, sixty-seventh session
I98o-I98I
Executive Board: Standing Committee on Nongovernmental Organizations Executive Board: Working Group on the organizational study on the role of WHO in training in public health and health programme management, including the use of country health programming Executive Board: Working Group to study the functions and activities earned out by the Secretariat
Geneva, I 3 January Geneva, I4-30 January Geneva, 20 January Geneva, 23 January
World Health Assembly: Special Committee of Experts to study the health conditions of the inhabitants of the occupied territories in the Middle East Executive Board: Committee to Consider Certain Financial Matters prior to the Thirty-fourth World Health Assembly Thirty-fourth World Health Assembly Executive Board, sixty-eighth session Executive Board: Programme Committee (preparatory meeting) Regional Committee for South-East Asia, thirty-fourth session Regional Committee for Europe, thirty-first sessiOn Regional Committee for Africa, thirty-first session Regional Committee for the Americas, thirty-third sessionfXXVIII Meeting of the Directing Council of PAHO Regional Committee for the Western Pacific, thirty-second session Executive Board: Programme Committee
Geneva, 27 January; Geneva, 2I, 22 and 27 May; Geneva, 29-30 October Geneva, 2 5 March; Geneva, 2I-23 April Geneva, 4-5 May Geneva, 4-22 May Geneva, 25-26 May Geneva, 2 5 May Denpasar, Bali (Indonesia), Ij-2I September Berlin, I 5- I 9 September Accra, I 6-2 3 September Washington, 2I September2 October Seoul, 22-28 September Geneva, 2-6 November
Annex J
Intergovernmental Organizations that have entered into Formal Agreements with WHO approved fry the World Health Assemb!J, and Nongovernmental Organizations in Official Relations with WHO at JI December I98I
1.
Intergovernmental organizations Islamic Development Bank League of Arab States Organization of African Unity
African Development Bank International Committee of Military Medicine and Pharmacy International Office of Epizootics
2.
Nongovernmental organizations lnternanonal Federatton of Gynecology and Obstetncs International Federation of Health Records Organizations International Federation for Housing and Planning International Federation for Information Processing International Federation for Medical and Biological Engineering International Federation of Medical Student Associations International Federation of Multiple Sclerosis Socteties International Federation of Ophthalmological Societies International Federation of Pharmaceutical Manufacturers Associations International Federation of Physical Medicine and Rehabilitation International Federation of Sports Medicine International Federation of Surgical Colleges International Hospital Federation International League against Epilepsy International League against Rheumatism International Leprosy Association International Organization for Cooperation in Health Care (Medicus Mundi Internationalis) International Organization for Standardization International Organization against Trachoma International Paediatric Association International Pharmaceutical Federation International Planned Parenthood Federation International Radiation Protection Association International Society of Biometeorology International Society of Blood Transfusion International Society for Burn Injuries International Society and Federation of Cardiology International Society of Chemotherapy International Society of Endocrinology International Society of Hematology International Society for Human and Animal Mycology International Society of Orthopaedic Surgery and Traumatology International Society of Radiographers and Radiological Technicians International Society of Radiology International Soctological Association International Solid Wastes and Public Cleansing Association International Union of Architects International Union of Biological Sciences International Union against Cancer International Union for Child Welfare International Union for Conservation of Nature and Natural Resources International Union for Health Education International Union of Immunological Societies International Union of Local Authorltles International Union of J'v.ficrobiological Societies
African Medical and Research Foundation International Biometric Society Christian Medical Commission Commonwealth Medical Association Council for International Organizations of Medical Sciences European Society for Clinical Investigation Inter-American Association of Sanitary and Environmental Engineering International Academy of Pathology International Agency for the Prevention of Blindness International Air Transport Association International Association for Accident and Traffic Medicine International Association of Agricultural Medicine and Rural Health International Association of Cancer Registries International Association for Child and Adolescent Psychiatry and Allied Professions International Association of Environmental Mutagen Societies International Association of Hydatid Disease International Association for the Study of the Liver International Association of Logopedics and Phoniatrics International Association of Medical Laboratory Technologists International Association for Suicide Prevention International Association on Water Pollution Research International Astronautical Federation International Brain Research Organization International College of Surgeons International Commission on Radiation Units and Measurements International Commission on Radiological Protection International Committee of Catholic Nurses International Committee of the Red Cross International Confederation of Midwives International Council on Alcohol and Addictions International Council on Jewish Social and Welfare Services International Council for Laboratory Animal Science International Council of Nurses International Council of Scientific Unions International Council on Social Welfare International Council of Societies of Pathology International Council of Women International Cystic Fibrosis (Mucoviscidosis) Association International Dental Federation International Diabetes Federation International Electrotechnical Commission International Epidemiological Association International Ergonomics Association International Federation of Clinical Chemistry International Federation of Fertility Societies
'
International Union of Nutritional Sciences International Union of Pharmacology International Union of Pure and Applied Chemistry International Union of School and University Health and Medicine International Union against Tuberculosis International Union against the Venereal Diseases and the Treponematoses International Water Supply Association Joint Commission on International Aspects of Mental Retardation League of Red Cross Societies Medical Women's International Association Permanent Commission and International Association on Occupational Health Population Council Rehabilitation International World Association of Societies of (Anatomic and Clinical) Pathology World Confederation for Physical Therapy World Council for the Welfare of the Blind
World Federation of Associations of Clinical Toxicology Centers and Poison Control Centers World Federation of the Deaf World Federation of Hemophilia World Federation for Medical Education World Federation for Mental Health World Federation of Neurology World Federation of Neurosurgical Societies World Federation of Nuclear Medicine and Biology World Federation of Occupational Therapists World Federation of Parasitologists World Federation of Proprietary Medicine Manufacturers World Federation of Public Health Associations World Federation of Societies of Anaesthesiologists World Federation of United Nations Associations World Medical Association World Psychiatric Association World Veterans Federation World Veterinary Association
z6z
Annex 4
Structure
of the
World Health Organization at j i December I98I
WHO Secretariat as a whole
Hlltth end l1omldial
lnformltlon Prot~nunnw Oivilion of l'ublk: lnformlt10n Drvilion of H•hh Stlt•ics
Divillon of Coordin~tlon1 Office of R-rch llromotion and DMkJpment Office of thl Llgll Cou1111l lntwMIAudit EmlfJIDCV Relief Operatiolll
Ml...il Aci!OR "'ogt'lmml Pll'llitic D'--llrog11mmt
DMiion of
Drvillon of Vector l1ology lnd Control Expended f'rogr~mrM
D-
Communie~bll
on
lmmunilltion
Divillon of
Env~ronmtntll
Hoolth DMiion of Family H•hh DiVIIion of Hllfth MlnpoWir
OIVIkJpnwnt Divillon of Strlngthtning of Htokh SoiVieo& SpltiiiProtn~mme of ft-rch, Development tnd ft-n:h Tnumng in Hum~n
fttproductton
DMIIon of Noncommumcablt Divwon of Oilgnoetic, Thlrlpeutic 1nd ftthlbilltati¥1 Technology Drv111on of Mtntll H•lth
D-
Divil1on of Plnonneland Gtnefll Servicas Divilton of ludglt and Fmanct Div..on of lnforrMtiOn Spttm& Support Specill Prognmm1 for Pl_,ch and Tl'linmg ID
WHOProg11mmt
Tropil:.l a -
Coonhnttors
1Tht liliton Office with tt. Unrttd Nlt1on1 and the WHO mtdictl acfvi11rs to UNICEF (who art tllo wrth UNFPA) rtport to tht Dw••on of Coordmltton.
~WpGnlibll
for
rw.on
2ftfllliOIIII OffiCI for tht Anwnc:u/Pin Aarictn Slnby lur~~u. 3ft. ft~gio•l OffiCI for Europe il rt1p0fllible on bnlt of the D1reetor-Genlfll for thlglobll progr~mmec on
Mllth
Cll'l
of tM eged and on 1111d t111ffic accultnta.
WHO Headquarters Secretariat
HEALTH AND IIOMEDICAL INFORMATION PROGRAMME OffiCI of l'ubhcltions
MALARIA ACTION PROGRAMME Eputlmtologictl Methodology 1nd EVIIUitton
DIVISION OF ENVIRONMENTAL HEALTH Ermronnntll Hmrdt: 1nd Food ProtiCtkm EnvironPntll Haith Technology IPd Support Glob1l PromotiOn end Coopmion for Wltlf Supply end S.mt1t10n lnt•n~tiollll Progremm1 on ChlmiCII Slftty
Offia of LlngUIII Slfvice~ Office of Library 1nd Htltth llltl'ltUfl ServiCII
llrogftmming end Trlinmg R .....ch and TechmCII lnttlllg1na
DIVISION OF NONCOMMUNICABLE DISEASES Ctrdkwllcullr o-..
DIVISION OF PERSONNEL AND GENERAL SERVICES Adm1nictrlf:ivl M~n~g~ment Ptnonrwl Steff Developnnt end Tr11mng Conftr~nce 1nd OffiCI Sewic:. Supply SewiCII J01nt Methcal Serv11:1
Cancor
D111ribut10n 111d Sills
PARASITIC DISEASES PROGRAMME Flltllll lnt.etior11
Humin Gentties Ore! Hulth Occupltlollll H•lth Immunology
ScbiltOJDm•s 1nd other DIVISION OF PUBLIC INFORMATION Amhovilutl Communil:ltton News Mllht R.-.o.. World H•lth M~g~ziM
Htlmmthic lnftetions TryiJIROIDm...s and Llilhll'lln....
DIVISION OF COMMUNICAILE DISEASES EpidtmtologiCII SuMita.nct of CommumCible Oi-DIVISION OF HEALTH STATISTICS H•lth Stlt•••ttl Methodology 0-miMtton of StatiltiCII lnforn.tion Devttopn.nt of Hulth Statlll:u:.l Silvie.
DIVISION OF FAMILY HEALTH Mlttfllll 1nd Child H•lth H•hh Edut:1t1on NutritiOn
DIVISION OF DIAGNOSTIC, THERAPEUTIC AND REHAIILITATIVE TECHNOLOGY BiologiCIIs H•lth Llborlf:Ory Technology ,._11111Ciut1CIII Act1on llrogremme on
DIVISION OF IUOGET AND FINANCE Budget fi111nce end Accounts
lmlllpox EI'MI1Cition Tublrculo111 1nd fiiiPil'ltOry lnftctions
Loprosy lactentl end Vtntr11l InfectiOns Viruso . . .
Eaontill Drugs DIVISION OF HEALTH MANPOWER DEVELOPMENT llrogremme of &.nt•l Surgery ftadietion Mtd•cirw T!lldltiOIIII Med1cine ftehlbilitlt1on
DIVISION OF INFORMATION SYSTEMS SUI'I'ORT Information Sysums Methodology Deta end Text Pro~ng Serv11:u
lntlmlttO•I C'-ihl:ltton of o - -
D11rrholll 0 ' - Control Prognmmt Specill ProiJimmt on Slftty hiUm m Microbiology l'ropmll'll for the PrMntion of llmdMS Vettrilllry Public HMith
DIVISION OF STRENGTHENING OF HEALTH SERVICES DIVISION OF COORDINATION Coopnt:IVI Progdlmm11 for
DIVISION OF MENTAL HEALTH
DIVISION OF VECTOR IIOLOGY AND CONTROL Pllt1clllt Development tnd S.fe U• Ecology tnd Control of V1tt011 Equtpmlflf., l'llnning end Optl'ltiorw
SPECIAL PROGRAMME FOR RESEARCH AND TRAINING IN TROPICAL DISEASES
Development CoonhMtton with othlr 0rglnillf:IOM
Food Atd llrogrlmrnll
SPECIAL PROGRAMME OF RESEARCH, DEVELOPMENT AND RESEARCH TRAINING IN HUMAN REPRODUCTION
* Thl r11po1111bilrtia of th11 Asslstent On·mor-Gerwr~l include thl cheirll'llmhlp of the OFFICE OF RESEARCH PROMOTION AND DEVELOPMENT OFFICE OF THE LEGAL COUNSEL INTERNAL AUDIT EMERGENCY RELIEF OPERATIONS EXPANDED PROGRAMME ON IMMUNIZATION HlldqUirtl11 Progremll'll Commltttl
INDEX
Index References are f?y paragraph. Main references i?J subject are in bold type.
Abortion, 6.I7, 6.38, 6.8o, 6.99 ACC, see Administrative Committee on Co-ordination Accidents, 8.65, 8.86 laboratory, 9.I46-9.I49 occupational, 8.86, Io.86, I 5.IIO road traffic, 8.I, 8.84-8.91, I 5. 73 interregional conference (I98I), 8.84, 8.88, 8.9I role of alcohol and drugs, 4.29, 7·I9, 8.85, 8.86 toxic chemicals, I 5. 78 Acupuncture, 8.73, 8,76, I2.6o World Congress, Seventh (I98I), 8.79 Administration and finance information system, 2.43 Administrative Committee on Co-ordination (ACC), 3·I3, 3-14
African Regwn, 1.21, 1.32, 2.7-2.10, 3.41, 4.10-4.16, 1·5· 5.42, 5·43, 5. 50, 6.5, 6.4I, 6.44, 6.46, 6.6o, 6.63, 6.65, 6.Io8, 6.n4-6.II5, 7·4-7.8, 8.I7, 8.48, 8.66, 8.77, 8.86, 8.96, 9.2I, 9·42-9.43, 9.89-9·90, 9·I54, 9.I6o, 9.I68, Io.6, II.I2-II.I4, I1.34, II.46, 12.43-I2-44, I2.55, I2.74-I2.75, I2.84, 12.92-I2.94, 12.Ill, I2.II8, I2.I27·12.128, I2.I48-I2.I49, I2.173I2.I74, I3•7, I3.24, IS.I-IS.I9 Charter for Health Development, 1.26, 1.42, I5 .I, I5 .I5 Health 2ooo Resources Group, r.2I, I 5. I 2
Regional Advisory Committee on Health Development, 1.3, 1.35, I5.6 Regional Health Development Centre, 6.44, 6.65, I2.IOI, I2.I48
Consultative Committee on Administrative Questions (CCAQ), I4.I7 Consultative Committee on Substantive Questions (Programme Matters), 3.Io Sub-Committee on Nutrition, 6.49 Administrative matters, q.n-q.26 Adolescence, see Youth and adolescence Advertising, breast-milk substitutes, 6. 7 tobacco products, I0.47 Advisory Committee on Medical Research, global (ACMR), 4·3-4·7· 7-48 subcommittees, 4· 3, 4· 7 on cancer, I0.3 on health services research, 4.3, 5·57, 6.31 on mental health and neuropsychiatry, 7·47 Advisory committees on medical research, regional, I. 3 5, 4·4 Africa, 4.I6, I5.6, I5.I4 Amencas, 4.I8, 7·45 Eastern Mediterranean, 4. 3r. I 5·9 3 Europe, 4.26-4.30, 5·53, 7·49, I5.68 South-East Asia, 4.22-4.23 Western Pacific, 4.38, 5·55, I5.I05 Aedes aegypti, 1.42, 9.136, 9.202, 9.2Io, 9.223, 9.259 Afghanistan, 6.I7, 9.25, I3.I5, I5·99 Aflatoxin, IO.I8, II. 53 Africa, newly independent and emerging States, 1.45 African Development Bank, 3.8
Aga Khan Foundation, 3.8 Aging: a challenge to society, 8.94 Aging, World Assembly (I982), p 5o 8.92 see also Elderly Air pollution, I3.35, I5.jl monitoring and control, I1.27, II.28, IL34 Aircraft, disinsection, 9.22I Alcohol, society and the state, 7.42 Alcohol-related problems, 1.38, 7.5, 7.6, 7·36·7·43, 7.66, 8.86, IO.I5, I0.85, I2.I53, I5.II8
Algeria, 2.I8, 3·39, 3·44, 5.3, 5.8, 5.27, 6.25, 9.27, 9.122, II.I8, I3.I5, 14.23, I4.24, I5·77
All-Africa Conference on Health Education (I98I), I2. I49
Allergic diseases, Io.6o, I0.92 Alma-Ala I97S: primary health care, r.I2 Americas, Region of the, 1.22, r.p, 2.II-2.I3, 3.42, 4·174·2 I, 5.6, 5.2I, 5.28, 5.42, 5·44, 5. 5I, 6.30, 6.3 I, 6.44, 6.46, 6.6o, 6.62, 6.1I6, 7·9·7.IO, 7.4I, 7·45, 8.I88.I9, 8.6o, 8.67, 8.78, 8.87, 9.22, 9.46, 9.91, 9.113, 9.I42, 9· I j4, 9.I6o, 9.I66, 9.I67, 9· 170, 9· I73, 9· I 75, 9·179, 9.I84, 9.202, 9.223, Io.6, Io.6o, II.5-II.I6, I1.34, I1.47, I2.I5, I2.26, I2.37, 12.45-I2.47, I2.5 II2.52, I2.56, I2.76, I2.8o, I2.86, I2.95, I2.II2, I2.I29-I2.13I, I2.I53, I2.I6I, I2.I75, I2.I79, I4.I3, IS.:ZO•IS·31 Americas, Ten-Year Health Plan (I97I-I98o), 1.4, I5.20
THE WORK OF WHO, I98o--I98I Anaemias, hereditary, Io.62, Io.65 nutritional, 6.17, 6.ss-6·S7 Anaesthesia and anaesthesiology, 8.75, 8.82, 8.83, 12.99 Andean region, 5.28, II.I5, II.47 Angola, 3·4I, 8.77, 9.38, 9.2Io, I5.IO Animal health, 9· I 79
Bacterial diseases, 9•78-9.119, 9.I2o, 9·IP-9·I55 Bahamas, 2.I9 Bahrain, 2.46, 4.33, 8.24, 9.I10, 10.74, I2.I6, I2.77, I2.I37, I5.90, I5.93, I5.IOO
Bangladesh, 3·43, 5·7, 5.25, 5·34, 5·45, 5.52, 6.40, 8.20, 8.59, 8.95, 9.II, 9·92, 9.IIO, I0.76, II.I7, 12.12, 12.27, I2.87 Barbados, 7.Io, II.I5, 12.9, 12.I53 Basic safety standards for radiation protection, I I. 37 BCG, vaccination and vaccine, 9.Ioi, 9.Io2, 9· I03, 9.I059·Io6, 9.IIO, 9.III, 9·II4, 9.I66, I2.I67 Behavioural sciences, 1.8, 1. I4, 1.42, 4.3, 6.63, 6.66, 6.8I, 7.25, 7.27, 7·47, 7·49, 9.263-9.264, II.I7, I5.37, I5.50, I5.II7
see also Veterinary public health Animals for research, 4.7, 9.200 nonhuman primates, 4.7, 8.40, 10.30 Anopheline mosquitos, 9.202, 9.207, 9.259 Antibiotics, 8.32, 8.33, 8.35, 9.I2I, 9.I24, 9·I52 in food, I 1.4 I resistance, I 5. I 3 Apartheid, 1.4 5, I 5. I o Approaches to planning and design of health care facilities in developing areas, 5.27 Appropriate technology for health, 1.4, 1. II, 1.13, 3. 27, 4·I3, S·37-S·48, 5·5l, 8.69, I0.2, II.I8, I5.86, I5.I07 action group, 6.50 directory, 5.40 information systems, 2.49, 5·37-5·4o, 5·47 newsletter, 5.40 Arab Board for Medical Specialization, I 2.98 Arab countries of the Gulf area, Council of Ministers of Health, 8.9I, 13·45 Arab Fund for Economic and Social Development, 3·.8 Arab Organization for Standardization and Metrology, I 1.50 Arab populations in occupied territories, health conditions, 1.46 Argentina, 7.66, 9.Io5, 9·I Io, 9· I I2, 9· I I3, 9.I85, I2.I 53 Arrhythmias, classification, I0.44 ASEAN, see Association of South-East Asian Nations Asian Development Bank, 5.26, 8.2I, I5.63 Asian Foundation for the Prevention of Blindness, 9· I 59 Associate Members of WHO, I4. I Association of Medical Deans in Europe, I 5. 79 Association for Medical Education in Europe, I 5. 79, I5.80
see also, Psychosocial factors and health Bejel, 9· I 54 Belgium, 3.4, 3.32, 7.8, 8.89, 9.5, II.31, II.38, I2.72, 12.97, I 5.76
Benin, 2.7, 3.6, 5·5, 6.64, 8.85, 9·39, 9.52, 12.42, I2.I27 Bhutan, 9· uo Biologicals, 1.24, 8.31-8.43 standardization, 8.32, 8.35, 8.37 Biomedical information, I3.23-I3.52 Biomedical research, see Research Birth control, see Fertility regulation Birthweight, low, 6.2o-6.2I, 13·I4 Blackfly, see Simulium Blindness, prevention, 9·1S6-9.164, I 5.48, I 5. I24 national programmes, preparation, 9· I 58 advisory group, 9·I57, 9.I62 P AHOJWHO advisory committee, 9· I 56 research, 9.I62, 9.I63 training, 9.I6o, 9.I6I, 9.I62 Blood products and transfusion, 8.32, 8.39 Blue Nile health project, 9.44, 9.2I9, I5.98 Boletin de Ia Oficina Sanitaria Panamericana, 8.I9 Bolivia, 5.6, 5.24, 7·35, 8.67, II.I6, 12.47, I2.jl, I4·7 Botswana, 2.I9, 5·5, 5·I5, 6.64, 7.4, 8.64, 9·39, 9.42, 10.74, 10.76
Association of Schools of Public Health in Europe, 12.I4I, I5·79
Association of South-East Asian Nations (ASEAN), 1.24, 8.6, 8.I4, 8.22, 8.26, 8.76, I5.Il9
Bovine tuberculosis, 9· I 79 Bowel cancer, IO.I7 "Brain drain" see MigratiOn of health manpower Brazil, 5.24, 7.4I, 8.6o, 8.85, 9.38, 9·39, 9.40, 9.46, 9.63, 9·II2,9.122,9·136,9.I48,9.234,9·247, 10.74, II.I5, II.38, 12.47 Breast-feeding, 3.22, 6.7, 6.Io, 6.I6, 6.p-6.36, 9.69, II.32, I2.I78, 13•33, 13.56, I5.95, I5.II5
Audiovisual materials, I2.II9, 12.128, I2.I78, I3.56, I3.59-I3.60, I5.II7
see also Teaching/learning materials Australia, 6.4, 6.128, 7.65, 9.26, 9.I25, 9.I85, 10.33, I2.I23, 13.25, I3.60, I5.I2I, I5.I25
Austria, 9· I 84, I 2. 58 Auxiliary health personnel, 9.I6o, 12.p, I2.68, I2.8oI2.83, 12.93, I2.I04, I2.I29, 12.I62
brochure, 6. 3 5 Breast-milk substitutes, 6.7, 6.Io, I5.II6 International Code of Marketing, 1.39, 3.22, 6.7-6.9, 6.32, I3•33, I3·56, I5·95
see also Commumty health workers; Medical assistants and auxiliaries: Primary health care workers; and under the various categories of health personnel Ayurvedic medicine, 8.79
Brucellosis, 9.I79, 9·I9o, I2.I69 Bulgaria, 3.52, 5.I5, 7.6I, 9.I85, Io.64, 10.74 Bulletin of the World Health Organization, I 3-30 Burkitt's lymphoma, 4· I 2 Burma, 2. I 5, 3·43, 5.2, 5.3, 5. 7, 5. I 8, 5·52, 6.29, 7·3 5, 8.20, 8.2I, 8.49> 8.j4, 8.59, 8.69, 8.79> 8.95, 9·92, 9·93,
INDEX
Burma (contznued) 9·130,9.208,9.213, 10.74, 10.76, 12.12, 12.20, 12.24, 12.27, I2.42, 13.17, I4.23, lj.38, lj.42 Burundi, 3.41, j.j, 12.74
Cameroon, see United Republic of Cameroon Canada, 7.42, 7.56, 9.113, 9.1p, 11.27 Canadian International Development Agency (CIDA), 11.16, I2.jl Cancer, 10.2-10.32, I0.79, 15.48, lj.75, lj.l2j classification of tumours, I o. 1I in domestic animals, 9· 198 control and prevention, common strategy and national programmes, Io.2, 10.4, 10.5, 15.75 integration with general health care, IO.j training, 1o.j, 12.17I coordinating committee, 10.4 epidemiology, 10.16, 10.30, 10.31 directories, 1o. 12 registries, 10.12, 10.13, 15.75 standardization of reporting, 10.13 research, 4.3, 10.12-10.29 comparative studies, 9.18I, 9.198-9.199 training, 10.30-Io.p screening and early detection, 1o. j statistics, 10.8, 10.10, 13.14, 13.18 Cancer incidence in jive continents, 10.12 Carcinogens, environmental, 10.26, 10.31 see also Chemicals, carcinogenic Cardiomyopathies, classification, 10.44 Cardiovascular diseases, 10.33-10.46, I j .48, 1 j. 76 classification, 10.44 community control, 10.38-Io.4o, lj.12j epidemiology, 10.4 j -10.46 long-term programme of WHO, 1 j. 76 primordial prevention, 10.34, 10.37 research, 4.I2, 4.38, 10.33, 10.35, 10.36, 10.41-10.43 studies on physical activity, I0.43 training in prevention and epidemiology, 10.4j-Io.46 Caribbean area, 6.39, 6.64, 8.67, II.Ij, 11.47, 12.45 Caribbean Community, l·4 Caribbean Development Bank, I 1. 16 Caribbean Food and Nutrition Institute, 6.44 Caribbean Regional Drug Testing Laboratory, 8.19 Caribbean sea, pollution, 11. 3 j Caries, 1 j. 126 Cataract, 9· 161 Central African Republic, 3.41, 9.38 Central America and Panama, I 1.1 <> community health training programme, 12.47, 1 2.j 1, I2.80, I2.112, 12.129 Cerebrospinal meningitis, 9· 1I 8 Cerebrovascular diseases, 10.33, 12. I j j CERN see European Organization for Nuclear Research Chad, 3.41, 9·4, 9.38, I5.Io
Chagas' disease, 9.63 research, 9.63, 9.232, 9.246-9.248 Charters for health development, regional, 1.26-1.27, 1.42, lj.l, 15,15 Chemicals, in food and the environment, 10.74, 10.79, 11.21, 11.53, lj.48, 15.78, 15.110 carcinogenic, 10.24-10.29, Io.3o, 11.22 international programme on safety, 4.28, n.22-II.2S interregional research units, I 1. 22 monitoring of effects, 10.74, 10.79 Chemotherapy of malaria, 9.2.8, 13.33 Children, 6.15, 6.16, 15.28 accidents, 8.89 cardiovascular diseases, 1o. 36 communicable diseases, 9.2I, 9.48, 9.82, 9.98, 9.101, 9•10j, 9·II4, 9.120-9.121, 9.124, 9.1j4, lj.20 diarrhoeal diseases and gastroenteritis, 9.68, 1 5.43, 15·99 drug treatment, 8.12, 1 j. 70 growth and development, 6.I6, 6.18, 6.28, 6.37, 6.jo, 7·4l health education, 6.64 mental health, 4.29, 7.5, 7·44-7·46, lj.118 mortality 6.1 j, 6. I 6, 6.4 j, 6.108, I j .98 see also Immunization; Infant and young child feeding; Maternal and child health Chile, 5.21, j.24, 7.1o, 7.4I, 7.46, 9.I85 China, 2.2.4, 2.25, 2..46, 3.51, 3.52, 4·37, j.15, 6.4, 6.24, 6.121, 6.128, 7·14, 7.j6, 7·57, 7·64, 8.27, 8.49, 8.76, 9·1 IO, 9.122, 9.12 j, 9·13 7, 9.223, 10.16, 10.67, 10.76, 11.27, 11.34, ll.jl, 12.60, 12.122, 12.145, 12.1jj, 13.23, 13.44, 14.22, lj.llj, I5.121, lj.l2j, 15.126, I j .134 Cholera, 9·75 Chromosomal diseases, 10.63 CIDA, see Canadian International Development Agency CIOMS, see Council for International Organizations of Medical Sciences Circumcision, female, 6. I 3 Classification, international, of diseases, injuries and causes of death, 13.7-13.9 of impairments, disabilities and handicaps, I 3. 7, 15. 74 of procedures in medicine, 13. 7 of tumours, 10.11 in domestic animals, 9.198 Clonorchiasis, 4.38, I5.105 <:;oastal water pollution, 11.3 j Codex Alimentarius Commission, FAOJWHO, 9·I93, 9·I95, I1.43-I1.45 "Cold chain" development and management, 3.21, 9.I68, 9.171, 9·172., 15.45, I5.IOO, I5.122 Collaborating centres, 1.4I, 4.10, 4.20, 4.28, 9.179, Io.48, 12.70, 12.106, 15.14, lj.60, Ij.IOj accident prevention, 8.89, 8.90 biostatistics, I o. I o blindness prevention, 9.162 cancer, IO.IO, IO.II
THE WORK OF WHO, I98o-I98I
Collaborating centres (continued) chemical reference substances, 8.6 classification of diseases, I 3·9 comparative oncology, 9·I99 dengue haemorrhagic fever, 4.24, 9.I37, I5·44 diabetes, IO. 55 disability prevention, 8.66, 8.70 disasters, epidemiology, 3·32 drug dependence and alcohol-related problems, 7.42 drug monitoring, international, 8.Io environmental, health I 1. I 5, I 1. 29 family health, 6.2I family planning, 6.II8, 6.II9 food contamination monitoring (FAO/WHO), I1.53 food hygiene and zoonoses (FAO/WHO), 9.I88, 9·I9I, I2.I68 food virology, 9.I89 health services research, 5. 52 hospital infections, 9·I 5o human genetics, Io.64 human reproduction, 6.84, 6.Io7, 6.II6, 6.II8, 6.II9 immunology, I0.9o laboratory technology, 8.49, 8.50 malacology 9·43, 9.2I4 manpower development, I 2.I3 medical informatics, 2.47 mental health, 7·5, 7·I5, I5.II8 neurosciences, 7. I 5, I 5. II8 nutrition, 15.36 occupatiOnal health, 10.73 pesticides, 9.203 equipment testing, 9.2o6 plague, 9·II7 primary health care, 5. I I psychosocial factors, 7. I I radiation, I 1. 33 emergency assistance, II. 38 rehabilitation, 8.66, 8.70 rickettsial diseases, 9· I 39 smallpox, vaccine, 9· 5 traditional medicme, 8.73, 8.74, 8.77, 8.78, 8.79, 8.8o virus diseases, 9·7• 9.I27, 9.I3o, 9·I3J, 9.I35, 9,I4I water resources development, 9·4I Colomb1a, 5.3, 5.6, 5.16, 5.21, 5.24, 5.42, 6-46, 6.8I, 7.Io, 7·35, 7.64, 8.57, 8.6o, 8.67, 9.Io5, 9.IIO, 9.II2, 9·I36,9.203,9·2IO, I2.I8, I2.24, I2.36, I2.5I, I2.65, 12.71, I2.I53 Commission of the European Commumties, Io. 32, I 3.46, I4.24 Committee for International Coordmat!On of National Research in Demography, 13.18 Commumcable d1seases, 1.26, 6.16, 8.65, 9.1-9.269, I0.6I, I0.64, I2.J30, I5.20, I5.40-I5.47, I5.96I 5. I 00, I 5. I 20- I 5. I 2 3 epidemics, consultation on strategies, 9· 2
epidemiological surveillance, 4.26, 8.44, 9·7· 9.8, 9.69, 9-128-9.I29, 9·133, 9·I38, 9·I4I, 9·I78, 9-I88, I5.40, I5.96, I5.I20 immunology, 10.93 integration of services in public and pnmary health care, 5.8, 9.18, 9.22, 9·33· 9·34· 9·54, 9.69, 9·7I, 9·83, 9·89, 9·9I, 9·92, 9·95. 9-IOI, 9-II4, 9-I2I, 9-122, 9-I24, I5·17· I5-98 malnutrition and infection, 6.I6, 6.43, 9.68 resistance to infection, I o.64 see also Expanded Programme on lmmumzation; Tropical diseases Communicable eye diseases, see Blindness; Trachoma Community health workers, training, 5.7, 5.I5, 6.44, 9.I60, 12.18, 12.59, I2.I04, I5.34, I5.I32 interregional study, 5.I5, I 2. 79 Commumty participation in health and development programmes, 1.4, 1. 7, 1.I3, 1.42, 5. 5, 5.6, 5.8, 5. 14, 6.23, 6.30, 6.p, 6.46, 6.59, 6.6o, 6.73-6.75, 9.237, I0.6, II.7-11.8, 12.24, 12.28, 12.4I, I2.59, I2.J35, I5.15, I5.28, I5.37, I5.38, I5.45, 15.96, I5.106, I 5·I 27 Comoros, 3·4I, 5·5 Comparative medicine, 9·I98-9.I99· 9.248 Computing, medical, 2.47-2.50, q.2o, 13.22 training, 2.48 see also Electronic data processmg Congemtal anomalies, I0.23 Congo, 5.5, 6.46, 6.64, 9.8, 9·39, 9.42, 9.2I4 Congo virus, I 5·97 Conjunctivitis, haemorrhagic, 9·I3 5 Constitutional and legal matters, 14.1-14.10 amendments to the WHO Constitution, J4.2-I4-4 Contraceptives, injectable, 6.89-6.9I, 6.I02-6. I03 oral, for men, 6.I04, 6.I07 for women, 6.85-6.86 postcoital preparations, 6.105 vaccines, 6.106
see also Fertility regulation; Intrauterine dev1ces Contnbutions to WHO, voluntary, see Extrabudgetary sources of funds Convention on Narcotic Drugs, Single (I96I) 7.I6 Convention on Psychotropic Substances, 7.I6, 7.2I Cook Islands, 2.24, 6.6o, 12.73 Coordination, in international health work, WHO's role, I.p, 3·I wuh the United Nations system of organizations, 1.9, I.I9, 1.30, I.p, 3·9-3·16, 3·35. 3·38, 3·47. 5-13. 5.I6, 6.8, 6.66, 7.8, 8.30, 8.6I, II.5, II.9, I3.60, I4.J7, I5.63 see also under names of indtvtdual organizations Coronary heart d1sease, 10.33, 10.34, 10.36, 10.43, I5 .76 Costa Rica, 5·3· 5.6, 5.I8, 5.22, 5.24, 5.42, 7·44• II.I5, 12.9, 12.42, 12-47 Council for International Organizations of Medical Sciences (CIOMS), 10.44, I 3.42, 13.48
INDEX
Council of Ministers of Health of Arab countnes of the Gulf area, 8.9I, I3·45 Country health programming, 2. Io, I 5. I 5 training, 2.Io, 2.I9, I5.I5 Cretinism, 6. 52 Cuba, 5.27, 6.4, 6.29, 6.128, 9·I37, 9.2Io, I0.8o, I2.5I, I2.I44 Culicine mosquitos, 9.202, 9.209, 9.2I6, 9.259 Cyclops, control, 9.2 I 5 Cyprus, 1.46, 3·45, 8.54, 9.I85, I4.22 Cysticercosis, 9·I9o, I2.I69 see also Hydatidosis Czechoslovakia, 6.29, 10.74,12.58
Dams, see Water resources and river basin development, health aspects Danish International Development Agency (DANIDA), 8.46, 8.49, 8.77, 9·84, 9·III, 9·2II, 9·223, II.29, IZ.I67 Data banks, 9.I64, I3.IO Data processing, see Electronic data processing Deafness, Io.66 Declaration of Alma-Ata, LIZ, 5.38, 6.59, 6.68 Declaration of Monrovia, I 5. 3 Declaration on the Prevention of Disablement, Leeds Castle, 8.65 Declaration on the Rights of Mentally Retarded Persons, United Nations, 7.29 Democratic Kampuchea, 3.46, 9.27, 14.22 Democratic People's Republic of Korea, 8.59 Democratic Yemen, 2.I9, 2.22, 2.23, 5.2, 5.3, 5.23, 6.17, 6.46, 8.24, 12.24, I 2. I 33 Demographic studies, I 3. I 7, I 3. I 8 see also Population Dengue and dengue haemorrhagic fever, 9· I 37, I 5·44 research, 9.I37, I5.44, I5.I05, I5.Iz2 vaccine, 4.24, I0.9I, I5.44, I5.Izz vector biology and control, 9.202, 9.2 Io, I 5.46 Denmark, z.I8, 3·4, 6.4, 6.128, 7.8, 9.I68, 12.72 Dental health, see Oral health Depression, 7·5I Development, health as part of (United Nations General Assembly resolutions), I.I2, r.I8, r.z8, 3·9 International Strategy, r.28, 3.II see also Children, growth and development; Rural development; Socioeconomic development; United Nations Development Programme; Women in health and development Development forum (Umted Nations), I 3.63 Development of indicators for monitoring progress towards health for all ~ the year 2000, I. I 7 Diabetes, 4.38, 7.56, ro.53-ro.57, I5.48, I5.I25 national programmes, ro.53-I0.54 study of vascular diseases in diabetics, Io. 57 training of health workers, Io. 56
Diagnostic substances and technology, 4.27, 8.r-8.6o, 9·I72 see also Reagents Diarrhoeal diseases, 4.6, 6. I6, 6.3 5, 9.66, 9.68-9.77• 9.2I9, I5.43, I5.95, I5.99, I5.I20, I5.I22 control programme (WHO), 2.42, 3.20, 3.2I, 9.68 management and financing, 9· 77 national programmes, promotion and evaluation, 9·69-9· 70, 9· 7 3> I 5·99 primary health care approach, 9.69, 9·7I rehydration therapy, 9.69, 9.7o, 9.72, 9·75, 9.76, I 5·43, I5·99 research, 4.I8, 4.24, 4.38, 5·55, 9·74-9·76, I 5. 14, I 5·99, I 5.I22 training in control, 9·7I-9.72, I5.43, I5·99 Diphtheria, 9·I73 vaccination and vaccine, I 5. z 3 see also DPT vaccine Director-General's Development Programme, 9.29
Directory of on-going research in cancer epidemiology, Io. I 2 Disability prevention and rehabilitation, 1.40, 8.6r-8.72, 8.86, 8.89, I5.28, I5.48, Ij.73-I5.74, Ij.I07, I5.II2 integration, in primary health care, 8.6z, I 5. 74 national programmes, 8.7I, 8.72 research, 8.64, 8.69, 8.7I, 8.89, I5.74 statistics, I 3. I 4 training, 8.64, 8.67, 8.69, 12.I54, I5.48 see also Blindness prevention Disaster relief, see Emergency assistance; Natural disasters and catastrophes Djibouti, 3·45, I4·7 DNA, recombinant, 9·I49, 9.256 Documents (WHO), IH7 see also Health literature services Dominica, 5.2I, I4.I Dominican Republic, 5.24, 6.29, 7.10, I2.5I, IZ.I53 DPT vaccine, 9.I66 Dracunculiasis, 9.2I 5 Drinking-water, I.2I, 9.2I5, IL4, II.2I, I1.29, I5.20, I 5.23 standards, I 1.29 supply, international decade (I98I-I99o), r.4o, 3.2o, 6.66, 9.2I5, II.I-II.20, I2.66-I2.67, I2.174, I3.56, I3.60, I5.I8, I5.23, Ij.p, I5.49, I5.IOI, I 5. I 27 Drznking-water and sanitation, I98I-I990:
a wqy to health,
II.3 Drug information, 8.8-8.9, 8.I9, 8.28
Drug problems in the sociocultural context: a basis for policies and programme planning, 7·34 Drugs, 4.42, 8.2-8.30 dependence and abuse, 7·5, 7.I6-7.22, 7·30·7·35• 8.75, I2.Ij3, I5.38, I5.II8 epidemiology and surveillance, 7·34-7·3 5, 7.4I, 7.66 information systems, 7.66 training in surveillance, 7. 31, 7. 35, I 2. I 53
2 73
THE WORK OF WHO, I98o-I98I
Drugs (continued) effects, in increasing occupational hazards, 8085, Ioo85 on motor-vehicle drivers, 4o29, 70 I9, 8o8 5, 8o86 essential drugs, 3o2I, 3037, 802, 804, 805, 8o8, I5o39 action programme, 2°42, 8.15-8.30 lists, 8oi4, 8oi6, 8oq, I 5o39 monitoring system for adverse reactions, 8oi4 nonproprietary names, 807 policies and management, 5o24, 802, 8oi5, 8oi9, 8020, 8°24, 8o28, 8°30, I5o39> I5o69, I5o72, I5oii9 procurement, 1.24, 707, 8oi7, 8oi8, 8oi9, 8o20, 8023, 8o25, 9oi70 production, national and regional, 8oi6, 8017, 8o2o, 8o28 good manufacturing practices, 8o I4 quality control, 8o2-8o4, 8014, 8°17, 8°19, 8°21, I5o39, I5o69
Educational handbook for health personnel, I 2oll7 Educational technology, 12075, I2o8o, 12oii5, I2oli9I 2o 120, I 5o I 3Z centres, Cairo, 12oi 36 Latin America, 2ol2, I2ol5, 12047, I2oll2, I2oll9, l2oi3'
see also Teachingflearning materials and processes Egypt, 2o46, 4033, p8, 5o23, 6oq, 6046, 6o8I, 7o35, 7°44, 8o54, 9o38, 9o39, 9o40, 9oi05, 9oJ38, l0o74, IOo77, loo8o, ll.I9, 12018, 12°137, 13o23, 15°90, 15o93, I5o99
host agreement with, 1409 El Salvador, 3o42, 5°24, 5°42, 8o67, IZo47, I4o7 Elderly, care of, r.8, 1.40, 801, 8065, 8068, 8o 70, 8.9:o~-8.95, I2oJ3, I3o60, I5o28, I5o73> ljoiii
certification scheme, 8 3 training, 8o14, 8029 registration, 809, 8o24 safety and efficacy, evaluation and monitoring, 809, o
8ol9, I5o69
supplies to countries, 8027, I4o23, I4o26 utilization in treatment, 8oi2, 8023, 8094, I5o70 research, 5ojl, 8oq, 8018, 8024, IOo85, 15069, I5o7I see also Contraceptives, oral; Filarictdes; Malaria, drugs; Medicinal plants; Pharmacology, clinical; Psychotropic substances Dusts, industrial and vegetable, IOo82, IOo84
drug treatment, 8012,8094, I5o7o mental disorders, prevention, 7o26-7o27 nutrition, 8o93 research, 407, 8096 World Assembly on Aging (I982), p 5, 8092 Electronic data-processing, 2o39-2o50, J3o20, 13022 Emergency assistance, 3·30-3·47• 14o23-I4o24 Encephalitis, ] apanese, 5 046 Encyclopaedias, medical, I 50 82 Energy sources, health risks, I r. 3 I Entomologists, training, 90222, 9o223 Environmental health, 1.24, 11.1-11.53, I5oi8, I5o49I5o52, 15o77-15o78, 15oiOI, I5ol27-I5ol28
Eastern Mediterranean Region, I.Io, 2021-2023, 3045, 4o3'-4o35> 5o9> 5o29, 5o42, 5o47, 5o54, 6oi7, 6oi20, 7oi2-7ol3, 7o6I, 802,8024, 8o71, 8o8o, 8o9o, 9o25, 9095, 9oi40, 9oi66, 9oi9I, IOo6, II.I9, 11.26, II.27, 11.34, 11.50, 12o29, 12o3Z, 12049, I2o59, I2o65, 12o82, I2o86, 12o98, I2oll4, I2oi2I, 12oJ32-12oi35, 12oi36-I2oi40, 12oi68, l3o24, I3o40, 15.83-15.103
centres, regional, II.I5, II.26, II.3o, I5oiZ8 criteria, I1.25, II.29, Ir.36 national planning and establishment of agencies,
I I
0
3,
II.4, II.I2, II.I5, II.I6, II.I7, II.26, I5oi8 research, II.25, II.34 training, II.3, II.9, II.I5, II.I6, II.I7, II.20, II.27, II.35, I2o63, I2o66-I2o67, I2o73, I2oi73-I2oi74, I5oiOI, I5ol28, I5oi29
Regtonal Health Development Advisory Committee, !.3 5
see also Chemicals in food and the environment; Sanitary and public health engineering; Sanitation; Sewerage; Wastes disposal; Water supplies Environmental health criteria, I I 02 5, I I 036 Environmental monitoring, II.27, IL34, I5o78 global system, I 50128 Environmental pollution and hazards, II.27-IL35, I5ol28
Ebola virus, 9oi4I, I5o97 ECA, see Economic Commission for Africa Echinococcosis, 9067, 90179, 90 I8o, 9o182, 9.185-9·186, 9o190, l2o I69
ECLA, see Economic Commission for Latin America Economic Commission for Africa (ECA), 6o4I, II.I4 Economic Commission for Latin America (ECLA), I 5o2 I, 1j o26 Economic Commission for Western Asia (ECWA), 12o64 Economic instability, health aspects, 301, 5o35 Economic Order, New International, 1.7, 3011, I5oi Economic and Social Commission for Asia and the Pacific (ESCAP), 1 p 8 Ecuador, 506, 5022, 5o24, 5042, 7035, 7o4I, 8°67, 9°54, 9oll2, 9o211, 12ojl, I2oi)3
emergencies, I 50 78 see also Air pollution; Chemicals; Coastal pollution; Soil pollution; Water pollution Epidemiology and epidemiological surveillance, 4o26, 8o44, 9o7, 9°8, 9oi9, 9o3J, 9°69, 9oi 2 8-9o129, 9oi33, 9oJ38, 9oi4I, 9°178, 9oi88, I5o40, I5o96, I5oi20 programme of WHO, 903, 9oi3 research, 6op, 9oi4I, 9o26I, 90265, IOo30, IOo58 training, 5o3J, 9oi62, 90262, I2oi60-I2oi62, I5o40, I 5oi20 Epilepsy, 7 58 Equatorial Guinea, I 4o I, I 40 7, I 50 I o o
ECWA, see Economic Commission for Western Asia Education, see Health education; Medical education
274
INDEX
Equipment, medical, 8.47, 8.5I, 8.58, 8.82, 8.83, I4.22 repair and maintenance, 5.42, 5.5I, 8.5I, 9·I7I, I2.84, lj.I02 training, 5.42, 9·I7I, I2.84, I5.I02, I5.I09 see also Supplies and equipment ESCAP, see Economic and Social CommissiOn for Asia and the Pacific Escherichia coli, enterotoxigenic, 9· 7 5 Essential drugs, see Drugs, essential Ethiopia, 3.4I, 5.2, 5.3, 5·I5, 9.II, 9·54, 9.78, I2.9, 12.24, 12.I73 European Association of Programmes in Health Services Studies, I 5. 79 European Economic Community, 3.26, I4.8 European Organization for Nuclear Research (CERN), 9·87 European Region, 1.22, 2.I8-2.20, 3·44, 4.26-4.30, 5.8, 5·32, 5·35, 5.46, 6.6I, 6.II9, 7.I1, 7·4I, 7.6I, 8.23, 8.70, 8.89, 9·24, 9·94, 9·I6I, 9·173, 9·I88, 9·I92, Io.6, II.I8, II.24, II.34, I1.49, I2.I2, I2.23, 12.3012.3 I, 12.48, I2.5 3, I2.58, 12.72, I2.8I, I2.106, 12.I13, 12.I43, I2.I47, I2.I54, 13•17, I3.40, I4.13, 15.64-15.82 Advisory Committee on Primary Health Care, 5.8 Advisory Committee on Health Legislation, I 3.40 Advisory Committee on Health Manpower Development, I 5· 79 Health Development Advisory Council, I. 7, I. 3 5, 2. I 8 European Society of Human Genetics, Io.64 European standards for drinking-water, I 1.29 Evaluation of programmes, 2.2 7, 2. 36, 2.38, 9· I 74-9. I 76, 9· 2 31
guiding principles, 2.4 national9.I77, I5.I22 Excreta disposal, I 5.20 Executive Board, I.I8, 1.I9, 1.20, 1.29, 1.30, 1.3I, 1.37, 1.39, 1.40, I.4I, 1.42, 1.44 membership, 1.34, I4.2 organizational studies, L4I, 12.40-I2.4I Programme Committee, 2.3 I-2.p, 10.3 Exercise, see Physical activity Expanded Programme on Immunization, see Immunization
Expert Committee on Disability Prevention and Rehabilitation (I98I), 8.63 Expert Committee on Energy and Protein Requirements, Joint FAOfWHO (I97I), 6.48 Expert Committee on Food Additives, Joint FAOf WHO (I98o and I98I), I1.4o, II.4I Expert Committee on Health Effects of Combined Exposures in the Work Environment (I98o), I0.85 Expert Committee on Implementation of the Convention on Psychotropic Substances (I98o), 7.I8 Expert Committee on Leprosy (I976), 9.8o Expert Committee on Methodology of Nutritional Surveillance, Joint FAOfUNICEFfWHO (I975), 6.49 Expert Committee on the Prevention of Coronary Heart Disease (I98I), 10.34 Expert Committee on Problems related to Alcohol Consumption (I979) 7.42 Expert Committee on Rabies (I972), 9.I84 Expert Committee on the Selection of Essential Drugs (I977), 8.8 Expert Committee on Specifications for Pharmaceutical Preparations (I98I) 8.4 Expert Committee on Tuberculosis, 9· IOI Expert Committee on Vector Biology and Control (I979), 9·2I9 Expert Committee on the Wholesomeness of Irradiated Food, Joint FAOfiAEAfWHO (I98o), II.42 Extrabudgetary sources of funds, 1.I9-1.22, 3.2-3.8, 6.128, 8.63, 9·I68, 9·2I9, I0.70, I2.4I, 12.42, I4.22, I 5.8, I 5. I I-I 5. I 2 Eye health care, 9·54, 9.I56, 9·I57, 9.I6o, 9.I6I, I2.I30 studies on economic aspects, Europe, 4.29 see also Visual impairment
Facts about low-level radiation, I 1. 37 Falkland Islands (Malvinas), 9.I85 Family health, 6.1-6.128, I 5·3 5-I 5.37, I 5·95, I 5. II4I
5•Il7
Expert Advisory Panel on V1rus Diseases (Antivirals and Interferon), 9· I44 Expert Advisory Panel on the International Pharmacopoeia and Pharmaceutical Preparations, 8. 5 Expert Advisory Panel on Traditional Medicine, 8. 75 Expert advisory panels and committees, organizational study, 1.4I Expert Committee on Bacterial and Viral Zoonoses (I98I), 9·178 Expert Committee on the Biological Control of Vectors (I98I), 9.2I7 Expert Committee on Biological Standardization (I98o and I98I), 8.p, 8.35, 8.37 Expert Committee on Diabetes Mellitus (I979), I0.53
indicators, 6.2 integration with general and primary health care services, 6.2-6.3, 6.I9, 6.24-6.25, 6.30, I5.II5 programme financing, 6. 3 records, 6.30 training, I2.146, 15.35 see also Maternal and child health Family planning, 6.5, 6.6, 6.I8, 6.8o, 6.II9, I5.II5 integration in primary health care, 6.68, 6. 72, 6. 7 3, 6. 79 International Conference, Djakarta (I98I), 6.93 national programmes, support, 6.23-6.27 psychosocial aspects, 6.70, 6.72, 6.74-6.75, 6.8I, 6.82, 6.n8, 6.I25, 7.24 research, 6.40, 6.I2I, 6.I25 staff, medical and nonmedical, 6.72 role of nurses and midwives, 6.78, 6.79
275
Family planning (contmued) training, 6.24, 6.26-6.27, 6.76-6.78, 6. I 20, 6. I2 I, I 2.87, I2.88, I2.I44, I2.I45, I2.I46, I5.II5
see also Fertility regulation; Human reproduction F AO, see Food and Agriculture Organization of the United Nations Fellowships, 1.42, 7· I 5, 8.2, 9.30, 10.31, Io.88, 12.4I, 12.48, 12.54-12.61, I2.I23, I2.I31, I2.I54, I2.I57, I2.I63, I5.84, Ij.89, I5.I34
programmeregionalization, I2.55, I2.56, I2.57, I2.6I, I 5·58
studies on utilization, I 2.6o, I 2.62 Fertility, 6.5-6.6, 6.74, I3.I5 Fertility regulation, 2.42, 6.5, 6.I2I, 8.75, I2.I46, I5.II4, I 5. I I 5
microbiological aspects, 9· I 92, 9·193-9.197• I 2.170 training, 9· I 92, I 1.4 7, I 1.49, I 1. 5o see also Infant and young child feeding Food safety services, I I ·49 Food standards and criteria, 9.I96, I 1.43-I 1.45 Foodborne diseases and food poisoning, 9.I8I, 9.I82, 9.I87, 9.188, 9·I90, I1.49, II.jl, I5.I05 training, I2.I69 Foot-and-mouth disease, 9· I 79 Formulating strategiesfor health for all by theyear 2000 ,guiding principles and essential issues, I. I 2 France, 3·4, 7·44, 8.58, 8.89, 9.I84, IO.I5, 12.72 Front-line States, assistance to, 1.45, I5.I3
research 4· I 5, 6. I I7, 6.126 natural methods, 6. Ioo-6. IOI new methods, 6.93-6. Io7 safety and efficacy, 6.83-6.92 Fibre, dietary, Io. 17 Fibres, man-made, health hazards, I0.2I-I0.22 Fiji, 2.24, 2.25, 3·46, II.5I, I2.73, 12.78, I2.83, I2.I62 Filarial infections, 9·47-9·57• I 5. I 20 chemotherapy and chemoprophylaxis, 9· 5 I, 9· 55, 9· 569·57
diagnostic techniques, 9.242 research, 9· 55-9.5 7, 9·240-9.242 vector biology and control, 9·209, 9.242, I 5.46 see also Onchocerciasis Filaricides, 9·51, 9·5 5-9.57, 9.240-9.24I Films (WHO), I 3.6o Finland, 5. I 8, 6.4, 6. 128, 7.42, 8.89, 9· I68, I0.4, Io. 5, 10.33, I0.36, 12.72, I5.76
Gabon, 9·39, 9.2I4, 12.9 Gambia, 3·4I, 5·5· 9.I36, 12.43, 12.93, 14.23 Gammaglobultn, 10.93 General Programmes of Work of WHO, 2.27 Seventh, 1.29, 2.2, 2.31-2.33, 2.35-2.36, 7.I, I5.27 Sixth, 2.2, 2.34, 2.35, 7.I Genetic disorders, Io.6I-Io.65 Genetic engineering, 9·I49, 9.235, 9.256 Genetic markers, I0.64 Genetics, human, Io.6I-Io.65 research centres, Io.62, Io.64 Genital ulcers, 9· I 53 Geriatrics and gerontology, see Elderly, care of the German Democratic Republic, 3.52, 10.36, I0.74 Germany, Federal Republic of, 3.4, 6.4, 6. 128, 7.56, 8.I I, S.jj, 8.58, 9.I84, I0.12, I0.36, II.3I, I2.I41, I2.I58
Gesellschaft fur Technische Zusammenarbeit (GTZ), 9.2I4, II.3, II.I2, II.I6, II.I9, I5.I8
Fish, larvivorous, 9.2I7, 9.260 Fish and shellfish hygiene, 9·I97, I5.I05 Flea control, 9.2 I 3 Food additives, I1.23, II.40-II.4I Food and Agriculture Organization of the United Nations (FAO), I1.35, I1.38 joint activities, I 3.42 communicable diseases, 9.212, 9.2I8, 9.223, II.9 food safety and hygiene, 9·I93· 9·I95, 9.I96, 9·I97, IO.I8, I1.39, II.40-II.46, II.50, II.53, I2.I68
Ghana, 3·4I, 5·5, 6.64, 7.6I, 9.38, 9·39, 9.42, 9·43, 9.52, 9·57, 9.136, 9.238, I2.I27, 13.6o
human reproduction, 6.4 nutrition, 6.4I, 6.48, 6.49 rural development, 5. I 6, 6.66 zoonoses, 9· 178, 9· I 86, I 2. I 68 Food contamination and hazards, I 1.39 joint monitoring programmes (FAO/IARCJUNEP/ WHO), Io.I8, I1.46, IL53 see also Chemicals Food and foodstuffs, fortified, 6. 54-6.5 5 irradtated, I 1.42 weaning foods, 6.47 see also Breast-mtlk substitutes Food safety and hygiene, 4· I 2, 4· I 3, 9· I So, 9· I 8 5, 9· I 89, II.39-II•53• I5.52
Global strategy for health for all by the year 2000, 1. I 2 Glossartes, I3.35, I3.46, 13·47 Glossina, see Tsetse fly Goitre, endemic, 6. 52 Gonococcal infections, 9· I 52, 9· I 53 Governing bodies, see Executive Board; Regional committees; World Health Assembly Greece, 3·7, 7·44, 10.32, Io.76, Io.So Grenada, 5.2I, 7.Io GTZ, see Gesellschaft fiir Technische Zusammenarbeit Guam, 9.IIo, 12.33, I2.73 Guatemala, 5.21, 5.24, 5.28, 6.46, 6. 55, 9·54, 9.2 I I, I 1. I 5, 12.47, I2.jl
Guide to trachoma control, 9· I 64 Guidelines for evaluating a training programme for health personnel, I2.I38 Guidelines for training community health workers in nutrition, 6.44
Guides, technical, 9.85, 9.I64, 9.I97, Io.67, II.26, 12.I6, 12.76, I2.88, 12.I17, I2.I25, I2.176
see also Manuals, techntcal Guinea, 6,64, 9.2 I I
INDEX
Guinea-Bissau, 9· 2 I I Gulf Arab Development Foundation for the United Nations, 3.8 Guyana, 5.24, 5.28
Habitual phystcal activity and health, I0.43 Haemorrhagic fever, 9·140-9.142, I 5·97 vaccine, 9· I42 see also Dengue and dengue haemorrhagic fever Haiti, 5.24, 9·5 5, I I. I 5, I r.I6 Headquarters, accommodation, I4.I9 structures and functions, r. 30 Health, attainment by the year :woo of a level permitting a socially and economically productive life, 4.2, 4.30, 13.20, I3.53-I3.54, I3.58, Ij.I, Ij.20
global strategy, r. I, 1.9, r. IO, 1.12-1.18, 1.28, 1.29, 2. I2.3, 2.p, 3·I2, 6.67, 12.3j, 13·3· I3.IO
monitoring and evaluation, r.6, r. 7, r.8, r. I7, r. I 8, 6.20, I3.2, I3.I2, I5.5, I5.30, Ij.66
indicators, 1.7, r.I7, 13.2, 13.Io, I5.66 national and regional strategies, 1.2-1.29, 1.30, 2.3, 2.6, 2.7, 2.IO, 2.II, 2.I8, 2.22, 2.24, 2.33, 6.5, 6.30, 6.39, 7.2, I2.II6, I5.3-I5.4, I5.I5, I5.17, I5.23I5·3l, I5.32, I5.64-I5.66, I5.85, I5.I04 political support, 1.23-1.28 resources, mobilization, LI5, r.I9-1.22, 3.2, I5·32 "Health for All" Series, 13.3 I, I 3·4 7 Health care, delivery, 1.7, r.8, 1.24, 5.20, 13.21, I5.24I5.25, I5.64, I5.93, I5.I06 costs, 2.20, 5.34-5 .36, 12.46, I 3.6 facilities, development, 5.27, 5.30, I5.I09
Health laboratory services, see Laboratory technology and services Health legislation, 1.42, 6.9, 6.34, 6.8o, 8.I6, 8.28, 8.77, 9·4I, 10.47, I2.I06, 13•38·13•43> I3.57, 15.69,15.74 Health literature services, 13·23-13·28, I5.57, 15.I36 see also Guides; Manuals; Teaching/learning materials; Textbooks Health management, 1.24, 1.42, I2.I9, 12..90, I3.3, 15.96 information systems, 2.46, 12..43, I5.6I, 15.I35 training, 2.5, 2.8-2.9, 2.I2, 2.I3, 2.23, 5.25, 5.26,12.40U.49, 12..99, Ij.80, I5.89 organizational study, 1.41, 12..40, 12..4I Health manpower, see Manpower development, management and planning Health planning and programmes, national, development, 1.24, 2.1-2.2S, 3.1, 5.2I, I5.6I conference, interministerial, Dakar ( r 980 ), 2. 7 guiding principles, 2.2 training in management, 2.13, 2.17, 2.24, 12.46 see also Country health programming; Environmental health, national planning; General Programmes of Work; Health for all by the year 2000, national and regional strategies; Programme of WHO Health programme evaluation: guiding principles, 2.4 Health records, see Medical records Health sciences, training centres, meetings of deans and directors, Africa, I2.75, 12..92, 12..127 Health services, development, 1.3, 1.4, S·I·S·s8, I5.I5, I5.I6, I5.2I, 15.24-I5.25, I5.34, Ij.67, I5.I06I 5.II3 financing, 4.14, 5·3, 5.7, 5.24, S·33-S·36, 12.46 information, 5·3, 5.24
patient management, I 2. I 8 research, 4· 2 7, 5. 53 see also Primary health care Health conditions in the Americas, I97?-zg8o, 13.I6 Health economics, 4.29, 5·33, 5·35, 5.36, 5·53, 12.46 Health education, 1.7, r.8, 1.40, 1.42, 6.s9-6.66, 13.58, I3.64, I5.II7
institution strengthening, 5. 3, 5. 5 planning and management, 5.3, 5·5, s.18-s.36 study of coverage, Eastern Mediterranean, I 5·93 see also Health management; Health planning and programmes, national, development; Manpower development, management and planning Health services research, 1.14, 2.17, 4.2, 4.3, 4.6, 4.14, 4.16, 4.18, 4.23, 4.28, 4.32, 4·37, 4.38, S·49-s-s8, 6.28, 6.31, 6.40, 6.70, 6.78, 6.79, 6.82, 6.II8, 6.119, 6.125, 12..90, Ij.J4, 15.59, 15.74, 15.86, 15.93 newsletter (Eastern Mediterranean), 5·54, 15.103 training, 4·I4, 4.29, 4.32, 4·33· 5.50, 5·54, 5.56, 5.58, 6.28, 6.82, 6. II9
in acc1dent prevention, 8.85 in breast-feeding, 13.56 incommunicable disease control, 6.6o, 6.63, 9·5 5, 9.82, 9·96, 9.I24, I5.96, I5.II7
in in in in in in in
environmental health, 6.6o, II.8, II.I7, Ij.II7 family health, 6.35, 6.39, 6.62, Ij.II7 mental health, 7·47 noncommunicable disease control, Io.6, 10.36 nutrition and food safety and hygiene, I r. 52 occupational health, 8.85, Io.8I tobacco, alcohol and drug abuse control, 10.47, IH7
Health statistics, see Statistics Health teams, r2.p, 12.68, 12.75, 12.90, 12.1oo-12.102, I2.IIO, I2.120, 15.54
Helen Keller International (Foundation), 6.54 Helminthic and protozoal infections, intestinal, 9.66-9.67 Hepatitis, viral, 9•130, ro.r9-10.2o, 15.122 vaccmation and vaccine, 8.32, 15.I22 see also Liver cancer and other chronic liver diseases Herpes virus, 9.144 Hipolito Unanue Agreement, 5.28 Histological classification of tumours, ro. r I
integration in primary health care, 6.6o, 6.65, I2.150, IH7
Pan African Conference (I98I), I2.I4'9 research, 6.6o, 6.6I training of staff, 6.65, I2.q8, 12.I49-I2.I52, 15.II7 regional ceqtres, 6.65, I2.148
THE WORK OF WHO, I98o-I98I
Honduras, 5·I5, 5.2I, 7.4I, 12.47, I2.p Hong Kong, 6.40, 7.65, 9.Io6, I2.I22 Hormones, in food, I 1.4I Hospitals, planning, administration and maintenance, 5·29, 5·30, 5·53. I3.I7
Indicators of health status, 5·32· 6.2, 6.5, 6.I7, 6.20, 6.50 Indonesia, 3·43, 5.7, 5.23, 5·45, 6.55, 6.79, 8.20, 8.2I, 8.22, 8.54, 8.69, 8.95, 9.27, 9·55, 9·57, 9.92, 9·93, 9· I05' 9·I IO, 9· I 37> 9·203, 9·204, 9·205' 9·209, 9·213, 9-222, I0.62, I0.77. II.34. II.48, 12.9, I2.I2, 12.27, I2.63, 12.87, I2.120, 12.I6o, I5.42, I5·44 Industrialization, 8.84, I 5. IOI Infant and young child feeding, I. 39, 6.7-6.1o, 6.45-6.48, I2.J78, I3.42, I5.II5-I5.II6 joint FAO/WHO/UNU consultation (I98I), 6.48 Infant mortality, 6.I5, 6.I6, 6.45, 6.108, 13·I4, I3.I5, I 5.20, I 5.2 3, I 5·99 Infertility, 6.5, 8.75 research, 4· I 5, 6. 70, 6.1o8-6.11o Influenza, 9· I 28-9. I 29 Information of the public, see Public information InformatiOn systems, 1.24, 2.39, 2.4I-2.42, 2.46, 2.50, 5.24, 7.66, 9·I9, 9.85, 9·I45, 9·I76, II.I5, II.J7, 12.37, 12.43, I2.I77> 13.2, I3·4-I3·5• I5.6I, I5.66, I 5. I 3 5 global programme, 2.39-2.50, 9·J7o, 9·I74 regional offices, 13. I o-13. II Insecticides, application, evaluation and testmg, 9·499·50, 9·51, 9·63, 9-203, 9·204-9-205, 9-207, 9-209, 9.21I, 9.212, 9·2J3, 9.221, 9.246, 9.264 equipment, 9.6o, 9.206, 9.2Io training, 9.223 resistance of vectors, 9.23, 9·49, 9.50, 9.202, 9.203, 9.21I, 9.2I3, 9·237 see also Larvicides; Pesticides
statistics, 13.6 training, 5.30, I5.I09 see also Medical records; Nosocomial infections Hospitals in the Americas, 13.I6 Human experimentation, I 3.42 Human genetics, see Genetics, human Human reproduction, I 1.25 research, development and research training, special programme, 2.42, 4· I 5, 6.67-6.128 financing, 6.4, 6. I 28 information dissemination, 6. I 26-6. I 27 institution-strengthening, 6.4, 6.69, 6. 70, 6.82, 6.III-6.I2I
training, 6. I 2 3 grants, 6. I 2 I, 6.122, I5. I05 see also Family planning; Fertility; Infertility; Sterilization ' Hungary, 3·52, 6.40 Hydatidosis, 9.67, 9· 179, 9.I8o, 9· I82, 9.185-9·186, 9·I90, 12.I69
Hypertension, arterial, 6.I7, 6.I9, I0.42, I 5.I25 WHO community control project, I0.39
IAEA, see International Atomic Energy Agency IARC, see International Agency for Research on Cancer ICAO, see International C1vil Aviation Organization Iceland, 12.97 ILO, see Interational Labour Organisation IMCO, see Inter-Governmental Maritime Consultative Organization Immunization, 1.3, 6.25, 6.35, 9.Io6, I5.23, I5.85 Expanded Programme, I.2I, 1.42, 2.42, 3.20, 3.2I, 5·55,6.I6,9·7I,9.I33,9·16S-9·177• 12.I31, I5.45, I5.IOO, I5.I22 global advisory group, 9·I74 information systems, 9·I70, 9·I74, 9·I76 national programmes, 9.I65, 9·I77 research, 9.I72-9.273, Io.64 training, 9.I68, 9·I7I, 12.I3o, 12.I31, I5.Ioo Immunoglobulins, 8.38, 8.39 Immunology, 4.38, 9.Io6, 9.233, 9·235-9.236, 9.239,
Institute of Nutrition of Central America and Panama (INCAP), 6.44, 6.46, 6.49 Inter-American Development Bank, 1.22, 3·5, 5.2I, II.I6, I5.2I
Interferons, 9·I43, 9·I44 Inter-Governmental Maritime Consultative Organization (IMCO), 9·I47, Io.8I, "·35 Intergovernmental organization, (Annex 3) International Agency for the Prevention of Blindness, 9·I59
International Agency for Research on Cancer (IARC), I0.2, 10.4, IO. 5, 10.12-10.32, I 1.22, I 1.46, I 3.28 publications Io. I 2, I0.24-Io.2 5 International Air Transport Association, 9· I47 International Atomic Energy Agency (IAEA), 8. 56-8.57, 8.59, 8.6o, 10.42, Io.82, II.3I, "·37• I1.38, II.42, I2.Ij8, 12.I59 International Children's Centre, 6.4, 8.8 5, I2. I46 InternatiOnal Civil Aviation Organization (ICAO), 9· I4 7
10.88-10.94 centres for research and training, Io.88, Io.89, I2.172 Inde:x medicus, 4.I6, 4.20, 13.27 India, 2.I 5, 3.26, 5.7, 5.I 5, 5.I6, 5-45, 5·52, 6.4, 6.29, 6.40, 6.64, 6.66, 6.79, 6.IJ7, 6.128, 7.64, 8.59, 8.64, 8.69, 8.88, 8.95' 9· 5' 9-II, 9·27, 9· 55' 9· 57. 9·64, 9· 78, 9·92, 9·93• 9.Io6, 9.202, I0.64, II.27, I1.34, II.48, I2.I8, 12.42, I2.87, I2.89, I2.I20, I2.Ijl, 13·I7, I5.38, I5·4 2
International Classification of Diseases, I 3. 7- I 3·9 centres, I3·9 Ninth Reviswn, I3·7 Tenth Revision, 13.8 International Classification of Impairments, Disabilities and Handicaps, I3·7· I5·74 International Classification of Procedures in Medicine, I3·7
INDEX
International Code of Marketing of Breast-milk Substitutes, 1.39, 3.22, 6.7-6.9, 6.p, I3.33, 13.56, I 5·95 International College of Surgeons, 8.83, I2.IOo International Commission on Radiation Units, 8. 58 International Commission on Radiological Protection, 8.58, II.37 International Committee of the Red Cross, 3. 3 5 International Computer Centre, 2.45 International Conference on Apartheid and Health (I98I), 1.45, I5.IO International Conference on Family Planning in the I98os (Djakarta, I98I), 6.93 International Conference on Global Impacts of Applied Microbiology, Sixth (I98o), 9.90 International Conference on Islamic Medicine, Second (I982), 8.8o International Conference on Primary Health Care (I978), I.I2, 12-79 International Congress on Medical Librariansh1p, Fourth (I98o), I p8 International Congress of Radiology, Fifteenth (I98I), 8.5 3 International Council on Alcohol and Addictions, 7.40 International Council for Laboratory Animal Science, 9-200 International Council of Nurses, I2.I4, I2.69, I2.IIO International Council of Scientific Unions, 9-I49 International Council of Women, 3·49 International Court of Justice, I4-9 International Development Strategy, 1.28, 3. I I International Diabetes Federation, Io.56 International Digest of Health Legislation, I3-4I, q.8 International Drinking Water Supply and Sanitation Decade (I98I-I99o), 1.40, 3.20, 6.66, 9.2I5, u.xu.2o, I2.66-I2.67, I2.I74, 13.56, I3.6o, I5.I8, I5.23, I5.49, I5.IOI, I5.I27 International Economic Order, New, 1.7, 3-II, I5.I International Electro technical Commission, 8. 58 International Eye Foundation, 9.I6o International Federation of Anti-Leprosy Associations, 9·83 International Federation of Gynecology and Obstetrics, 6.4 International Federation of Health Records Organizations, 13.6 InternatiOnal Federation of Hygiene, Preventive Medicine and Social Medicine, I 2. I oo International Federation of Pharmaceutical Manufacturers Associations, 8.29 International Federation of Surgical Colleges, 8.83 International Health Regulations, 9·3 additional regulations, I4.6 International Histological Classification of Tumours, 10.1 I
International Institute for Soc1al Studies, 6.6 3 International Labour Organisation (ILO), 6.66, 7-40, 8.69, 8.86, 10. 77, IO. 78, IO. 79, I0.80, I0.8I, I0.82, I0.87, II.9, II.22, II.23, II.37, II.38, I2.63 International League against Rheumatism, I0.59 International Leprosy Association, 9.83 International medical guide for ships, Io.8I International Nomenclature of Diseases, I 3.48 International Organization of Islamic Medicine, 8.8o International Paediatric Association, 6.4, 6.I8 International Pharmacopoeia, 8.5-8.6 International Planned Parenthood Federation, 6.4, 6.40 International Programme on Chemical Safety, 4.28, II.22-II.2S
International Radiation Protection Association, I I. 38 International Society and Federation of Cardiology, 10-44, 10-45 International Society of Prosthetics and Orthotics, 8.8 3 International Society of Radiographers and Radiological Technicians, 8.53 International Society of Radiology, 8.53 International standards for drinking-water, I I .29 International Telecommunications Union, 3.I 5 International Union against Cancer, 9.I98, 10.4, I0.5 International Union of Health Education, 6.4, I2.I49 International Union of Immunological Societies, I0.93 International Union of Nutritional Sciences, 6-4 International Union against Tuberculosis, 9· I I 2, 9· I I 5, 9.II6, 9-I2I, I0.58 International Vitamin A Consultative Group, 6.54 International Year of Disabled Persons ( I98I), 1.40, 3-I5, 8.65, 8.68, 8.85, 8.89, 9.I6I, 13.60, I5.73, I5.II2 Intersectoral coordination in health and environmental management: an examination of national experience, I I. 2 5
Intrauterine devices, 6.86, 6.87-6.88, 6.96-6.97 Iran, 3·45, 5. I 5, 9.25 Iraq, 2.22, 8.7I, 9·38 Ireland, 7.42 Irrigation, see Water resources and river basin development projects Ischaemic heart disease, 10.3 5, 10.36, 10.4I, 10.44, I 5. I2 5 Islamic Development Bank, 3.5, 3.8 Israel, 2.23, 6.40, 8.7I, 9-IIo, 10.36, 12.7I, I5.89 Italy, 3·44, 7.56, IO.I6, Io.62, 12.97, I4.23 Ivory Coast, 9.8, 9·49, 9.58, 9.6I, 9.202, 9.204, 9.2I2, 9-2I6, II.34, I2.I6I
International Institute of Applied Systems Analysis, I3.22
Jamaica, 3.42, 5.3, 5-I5, 5.I6, 5.24, I2.65, 12.7I Japan, 7.56, 8.I4, 8.zi, 9-III, I2.I67, I5.I25 Japan Shipbuilding Industry Foundation (Sasakawa Memorial Health Foundation), 3-4, 9.84, 9·93, 9·I58, 9.I68 Joint Commission on International Aspects of Mental Retardation, 7.29 Joint Committee on Health Policy, UNICEF/WHO, 3.24, 5.I-5.2, 9.82
2
79
THE WORK OF WHO, I98o-I98I
Joint Committee on the Health of Seafarers, ILO/WHO (I98I), I0.8I
combined leprosy and tuberculosis activities, 6.6o, 9·89, 9·9I
Joint Committee on Occupational Health, ILO/WHO (I98I), Io.78, Io.87
Joint FAO/IAEA/WHO Expert Committee on the Wholesomeness of Irradiated Food (I 980), I 1.42 Joint FAO/WHO Expert Committee on Energy and Protein Requirements (I97I), 6.48 Joint F AO/WHO Expert Committee on Food Additives (I98o and I98I), I 1.40, I L4I Joint FAO/WHO Food Standards Programme, II.43 Joint FAO/WHO meetings on pesticide residues (I98o and I98I), IL39 Joint FAOfWHOfOAU Regional Food and Nutrition Commission (Africa), 6.4I Jordan 8.7I, Io.76
diagnostic techmques, 9· 2 54 immunology, 9.232 information system, 9.85 primary health care approach, 9.83, 9·9I, 9.92, 9·95 research, 9.88, 9.90, 9.92, 9·93, 9·97, 9.232, 9·2539·255• I 5.42
Kellogg Foundation, 2.12, 12.45 Kenya, 5·5, 6.40, 6.74, 6.79, 7.4, 9.40, 9.42, 9.58, 9.Io5, 9.I22, 9.2I2, I0.76, I2.I6, I2.I26, I2.I73
training in control, 9.82, 9.83, 9·9I, 9·93, 9·95, 9·96 vaccines 9.8I, 9.253 Leptospirosis, 9· I 79, 9· I 90, I 2. I 69 Lesotho, 5·5· 7.4, 9.2I, I2.I8 Liberation, national, health aspects, I .42 Liberation movements recognized by OAU, health cooperation, 1.45, 3·47, I5.I3 Liberia, 5.5, 9.42, I2.43, I2.93, I2.Ioo Libraries, see Health literature services; Medical libraries Libyan Arab Jamahiriya, 5.9, 9.IIo Life table and mortality analysis, 13. I 5 Life-styles, see Behavioural sciences Liver cancer and other chronic liver diseases, IO.I8I0.2o, I2.I7I, I5.I25
Kiribati, 2.24, 6.6o, 6.65, 8. 76, 9· rro, I4· 7 Kuwait, 2.I9, 2.46, 3.4, 6.I7, 7.22, 7.6I, 10.92, I1.34, I2.J40
Long-term planning, 2.33
Laboratory ammals, health, breeding and management, 4·7, 9-200
Macao, Io.76 Madagascar, 3·4I, 9.38, 9.42 Malaria, r.2I, 1.42, 6.6o, 6.86, 9·14-9·34• I5-4I, I5.I2o, I
Laboratory equipment, 8.47, 8.5I, I4.22 Laboratory services and technology, 6. I 24, 8.44-8.p, 9·I31, 9·I45, 9·I5I, I5.II3
5. I 2 I
training of personnel, 6.I2o, 8.45, 8.46, 8.49, 9·IH9·I34, I2.II8, I2.I32, I5.II3 see also Collaborating centres; Microbiological labora-
advisory committee (global), 9·I9 Asian Conference, Seventh (I98o), 9·34 certification of eradication, 9.2I, 9.26, I5.I2I chemotherapy and chemoprophylaxis, 6.63, 9.I8, 9.28, 9·233-9·234, 9·236, 9·237
tories; Drugs, quality control Language services of WHO, I3·44-I3·45 Lao People's Democratic Republic, 6.6o, 8.27, I2.78, I4.22, I5.I2I
coordination between countries, 9.20, 9.22, 9.23, 9.24, 9·26
Larvicides, 9·49, 9·54, 9.I86, 9.202, 9.2II, 9.2I6, 9.246, 9·258
conferences, Europe, 9.24 intercountry border meeting, I 5·4 I drugs, resistance of parasites, 9.23, 9·32· 9.232-9.234, 9.237, I2.I66, I5.I2I
Larvivorous fish, 9.2q, 9.26o Las sa virus, 9· I 4 I Latin American Association of Schools of Public Health, 12-95
Latin Amerrcan Centre for Educational Technology in Health, 2.12, I2.I5, 12.47, I2.II2, I2.II9, I2.J3I Latin American Centre for Perinatology and Human Development, 6.22 League of Arab States, 3.8 League of Red Cross Societies, 3·35, 6.66 Lebanon, 1.46, 3·45, 5.29, 6.6o, 8.7I, II.I9, q.23 Leishmaniasis, 9·64-9.65, I 5.46 research, 9.65, 9.232, 9.249-9.252 Leprosy, 5-4I, 9·78-9.97, I5.120, I5.I23 chemotherapy, 9.78-9.8o, 9·9I, 9·93, 9·97, I5.I23 drug resistance, 9· 78, 9· 79, 9.8o trials, 9.255, I5.42
trials, 9.228, 9.232-9.234 epidemiology, 9·I9, 9·31 (Fig. 9-I) immunology, 9.233, 9.23 5-9.236 information system, 9· I 9 medium-term programme (WHO), 9.I6 national programmes, 9.27 prevention of reintroduction, 9.2o, 9.26 primary health care approach, 5.8, 9.I8, 9.22, 9·34 demonstration area, 9· 33 programme financing, 9.I6, 9.22 research, 4.I2, 4.I8, 9·31, 9·32, 9·34, 9·233-9.237, 9.26I, 9.264, I2.I65, I5.4I
revised strategy and action programme, 9.16-9.20, 9·23, 9·30, 9·32
strategy, African Region, 1.42, 9· I 8 training, 9.22, 9·29-9·32, 9·34, 9.223, I2.I63-I2.I66 centre, I5.I2I
280
INDEX
Malaria (continued) vaccine, trials, 9.23 5 vector control, 9.26, 9.:107-9·:~o8, 9.237, I5.46 biological and environmental, 9.208, 9.2I9 insecticides, 9· 206, 9· 207 resistance of vectors, 9.23, 9.202, 9.237 Malawi, 5·5, 9.38, 9.42, 9·54, 9.2I4 Malaysia, 2.24, 2.25, 2.48,4.37, 5.3, 5.11, 5.I8, 5·55, 5.56, 6.29, 6.40, 6.6o, 6.62, 6.8o, 7.22, 9.26, 9.29, 9·57, 9·78, 9-IIO, 9.116, 9-I22, 9-I25, 9·2I3, I0.33, 10-77, I2.9, I2.7I, 12.78, I2.87, I2.I22, I2.I23, I2.I52, I2.I64, 13.64, I5.II5, I5.I2I, I5.I25 Maldives, 8.79, 9.27, I2.S7 Mali, 2.7, 3·4I, 9.40, 9.42, 9·57, 9.78, 9.116, 9.211, 9.2I4 Malnutrition, 1.3, 6.7, 6.I6, 6.17, 6.4I, 6.42, 6.43, 6.45, 6.46, 6.47, 6.48, 7·45, 9.68, I0,54, I0.85, I5.20, I5.34, I5.116 see also Nutritional deficiencies Malta, I0.54 Management, see Health management; Programme of WHO, general development and management
Managmal process for national health development: guiding principles, 2. 3 Manpower development, management and planning, I .4, 1.13, 1.24, 1.26, 5.5, 1:1.1-1:1.180, I5.I5, I5.I9, I5.2I, I5.53-I5.58, I5.79-I5.8o, I5.88-I5.9I, I5.96, I5.I29-I5.I34 assessment of performance, I2.I6, I2.I42-I2.I43 career structures, I 2.63, I 5·94 community-oriented educational programmes, I2.47, I2.jl, I2.77, I2.80, I2.82, I2.I09, I2.112, I2.I29 continuing education, I 2.4I, 12.42, 12.so-12.53, I 2. 70, 12.98, I2.IOO, lj.56, I5.I29 curricula, I2.I4, I2.I5, 12.7I, I2.82, I2.83, I2.9I, I2.100, I2.110, I2.113, I2.115, I5·35, I5.130, I5.I33 directories, I2.85-I2.86 evaluationofprogrammes, I2.I36-I2.I4I, I5.88, I5.90 indicators, I2.37, I2.I37 information service, I 2. 7 information systems, 12.37 integration with health services development, I2.2212.24 international migration, I2.1, I2.5o, 12.64-12.65 medium-term programme of WHO, 12.5-I2.6 primary health care approach, 12.Io, I2.15, I2.79, 12.82, I2.9I, I2.93, 12.99> 12.100, I2.109 projections, 12.35-12.36 regional centres, Africa, 6.6 5 research, 4·34, IZ.8-IZ.ZI, I2.29, I2.34, 12.38-I2.39, 12.42 review of policy (I948-I98o), 12.8-I2.10 selection of applicants, 12.17, I2.124 statistics, I2.31, I3.6, I3.I4 training in management, 2. I 5 see also Auxiliary health personnel; Educational technology; Health management, training; Medical
education; Public health training; Teacher training Manuals, technical, 3.36, 4·35, 5.26, 5·33, 6.44, 6.48, 6.65, 6.i09, 7·5, 7·9, 8.28, 8.52, 8.62, 8.85, 9·4I, 9·73, 9·148,9.I55,9-I88,9.262, I0.81, I0.84, 11.35, II.36, 12.i6, 12.I8, 12.88, 12.I42, 12.I80, I3.I5, I3.16, I 3·3 3 see also Guides, technical Marburg virus, 9·I41 Marine pollution, 11.34, 11.35, I4.8 Maternal and child health, 1.26, 6.1s-6.4o, 6.62, 9.18, 9.177, I2.20, I2.I47, 13·15, I5·34, 15.85 national programmes, support, 6.23-6.27 research, 4.6, 5·57, 6.I9, 6.20, 6.22, 6.24 risk approach, 6.28-6.p, I2.I44, I5.35, I5.I15 statistics, 1 3. I 5 training, 6.22, 6.24, 6.26-6.27, 6.3o, 6.3 I, I2.87, I2.88, I2.I45, I2.I46, I5.115 Maternal mortality, 6.17-6.18, 6.I9, 6.57, 13·14, I3.I5 Mauritania, 2.7 Mauritius, 3.4I, 5·5, 9.2I, 9.27, 9.42, 10.33, Io.76, I0.77, I 3· I 5 Measles, immunization and vaccme, 8.35, 9·I34, 9.I66, 9·I67, 9·I72, I5.23 Meat hygiene, 9.I85, 9·195-9·196 Medical assistants and auxiliaries, I2.83, I2.I33 Medical care, see Health care Medical education, 12.59, 12.74-12·78, 12.98, I2.115, I2.I22, 12.Ijl, I5.79-I5.80, I5.9I continuing education of physicians, 12.1 oo curricula, I2.77, I2.10o, I2.11o medical textbooks, provision of, I 2.179 primary health care approach, I 2. 100, 1 5. So Medical libraries, 4.20, I3.23-13.25 meetings of librarians, 4.I6, 13.24, 13.28 regional libraries, 2.12, 4.20, I2.175, I5.57, I5.136 traming of librarians, I2.175, 13.27, 13.28 Medical records, I 3.4, 13.6, I 5. I 35 Medical schools, 12.76, I2.77, I2.85, I5.8o meetings of deans and directors, I2.75, I2.76 see also Medical education Medicinal plants, 8.28, 8.73, 8.76, 8.78, 8.79, I5.I07, I 5.119 Mediterranean sea, pollution, II.34, I1.35, J4.8 Medium-term programming, 2.27, 2.34-2.36 gmdelines, 2.36 MEDLARS, 13.25 Membership of WHO, J4.I (Annex 1) Meningitis, see Cerebrospinal meningitis Meningococcal vaccines, 8. 32 Mental health, 1.24, 7.1-7.67, 8.86, I5.38, I5.118 action group, African Region, 7·4-7·8 community services, 7.11, 7.13, 7.50, I5.118 drug treatment, 7·54-7·55 global coordinating group, 7. I integration in primary health care, 7.2-7.3, 7·47, I2. I 8, I5.118
281
Mental health (continued) national coordination groups, 7.8 natiOnal programmes, development and support, 7.6I7.67
Nepal, 3·43, 5.2, 5-3, 5·7, 6.66, 8.20, 8.49, 8.54, 8.59, 8.69, 9·92, 9·93, 9.II0, 9.II2, 9·I58, II.17, 12.27, I2.126
Netherlands, 2.Io, 3.4, 3.7, 5.21, 5.38, 6.4, 6.I28, 7.22, 7.42, 9.62, 9·I32, 9·I58, 9.I68, 9.210, II.8, I2.IOO
research, 4·3· 4.29, 7.3, 7.6, 7.28, 7·44, 7·47-7·6o, 7.64, 7·67
self-help, 7.23, 7.25, I5.38 statistics, I 3. I 9 training, 7·5, 7.I2, 7·I4, 7·I5, 7·47, 7·51, 7·54, I2.95, U.153-I2.157• I5.38, I5.II8 Mental retardation, 7.5, 7.29 Mentally disabled, I 2. I 54, I 5. 38 Methods of assessment of avoidable blindness, 9.I64 Mexico, 5.42, 6.9I, 7·4I, 7.56, 7.66, 8.64, 8.67, 9·54, 9.I05, 9.IIO, 9·I22, 9.2II
Neurological disorders, 7.56-7.59 traimng, I2.I53, I2.Ij6, I2.I57 New Hebrides, see Vanuatu New International Economic Order, 1. 7, 3. I I, I 5. I New Zealand, 5.30, 9.I85, 10.33, I5.I09, I5.I25 Nicaragua, 3.42, 5. 3, 5.24, 6.29, 9.64, 9· uo, 9· I I2, 12.47, I 2.5 I
Niger, 6.63 Nigena, 5.I8, 6.4, 6.40, 6.8o, 6.Io8, 6.128, 7.22, 7·44, 7.56, 7.57, 7.64, 8.64, 9.38, 9·40, 9.203, 9.2II, I0.62, 12.43, 12.7I, I2.I27, I2.J73, I5·17 Nomenclature of Diseases, International, I 3.48 Non-aligned countries, 1.25 Noncommunicable diseases, 10.1-10.94• 1 5.48 commumty control, IO.I, 10.38
Microbiological laboratories, prevention of accidents and infections, 8.45, 9·146-9.149 training, 9· I48 Microbiology, 9.I8I Micronesian Islands, 4· 38, I 5. I 2 5 Midwifery, I2.72, I2.73, I2.8I, I2.106, I2.I07, I2.Io8 role of midwives in family planning, 6. 78, 6. 79 role of midwives in primary health care. I2.70, 12.93 see also Nursing: Traditional birth attendants Migrants, health of, 1.8 Migration of health manpower, I2.I, I2.50, u.64-u.65 multinational study, I 2.64 Milk hygiene, 9.I8I, 9·I93 Mineral water, 9·I93 Miners, health of, 10.74 Molluscicides, 9.42, 9.2I4, 9.238 Mongolia, 5.29, 6.64, 8.20, 8.59, 9.uo, I2.Ijl Monkeypox, 9.8, 9·9· 9·I4I Monrovia Declaration, I 5. 3 Morocco, 2.I8, 5.3, 6.25, 7.22, 8.23, 8.49, 9·39, II.I8, I2.126, I5·77
research, 4· 1 2 Nongovernmental organizations in official relations with WHO, 3-35, 3·49-3·5o, 5.13, 6.8, 6.14, 6.66, 8.61, 8.82, 9·37, 9·I59, II.5, II.IO, II.23, 12.38, I2.70, 13.22, I3.42, I3.54, I3.59, I5.79, (Annex 3) Nordic Council on Medicmes, 8. I 3, I 5. 7 I Nordic Federation for Medical Education, I 5. 79 Norway, 3.4, 5.I6, 6.I28, 7.8, 9·I58, ro.36, I5.76 Nosocomial infections, 8.45, 9.150 Nuclear conflict, prevention, 1.47 Nuclear energy and fuel, It.p, 11.37, I1.38 Nuclear medicine, 8.85, 8.57, 8.59, 8.6o, I2.158 Nursing, 8.82, I2.13, 12.3I, 12.33, I2.I40, I5.9I mental health, 7. 5, I 2. I 53 post-basic nursing education, programmes, I 2.91, 12·94· 12·95, 12.97 regional centres, 12.93 pnmary health care, I2.69-I2.73, 12.9I, I2.93 research, 12.7 2 role of nurses in care of the elderly, 8.93 role of nurses in family planning, 6.78 textbooks, and other educational materials, 7.5, I2.106, I2.I07, I2.108, 12.II9, I2.128 training, I2.I3, 12.31, I2.33, I2.8I, I2.106, I2.Io7, I2.I08, I2.IIO, I2.128, I2.1jl, I5.56, I5.I29 teacher training, 12.9I, 12.u5, I2.II9, I2.I23 Nutrition, 1.3, 1.24, 3.24, 3.26, 6.7, 6.I8, 6.41-6.58, 8.93, I0.37, 11.44, Ij.I6, I5.36, I5.II6 centres for research and training, 6.44 integration in primary health care, 6.42, 6.43-6.44, 6.46, I5.I6, I5.36, I5.II6 national food and nutntion policies, I 5. u6 research, 4·3· 4·I3, 4.I8, 6.46, 6.52-6.55, 9·75, 9.76, 10.42, I5.I4, I5.36 surveillance, 4.13, 6.49-6.5o, I5.36, I5.u6 training, 6.49, I 5. II 6 Nutritional deficiencies, 6.48, 6.p-6.57, I 5. u6
Motor vehicles, effects of drugs on dnvers, 4.29, 7· I9, 8.85, 8.86
emissions, I 1. 30 road accidents, 8. I, 8.84-8.91, I 5. 7 3 Mozambique, 3·4I, 9.38, 9·39, 9.42, 10.76, I2. I6, I2. I I I, I2.I27
Myocardial mfarction, 10.42
Nam1bia, 1.45 Narcotic drugs, 7· I6-7.22 National decision-making for primary health care, 5. I National health councils, establishment, 1.30, 12.24 National staff, involvement in WHO programmes, 1.30, 1.32, I5·9
Natural disasters and catastrophes, preparedness and management, 3.30, 3·31-3·37 training, 3-3 3-3.34
see also Malnutrition
282
1'\DEX
OAU, see Organization of African Unity Obstetric emergencies, I2.I 32 Occupational health, 1.24, 10.73-10.87, I5 .IIO early detection of impairment, I0.84 exposure limits, I0.83-I0.85 integration into general and primary health services, 10.75, Io.76, Io.n, 10.78
Palestine, health conditions, I .46 Pan African Association of Neurological Sciences, 7·59 Pan African Development Institute, 6.44 Pan American Centre for Sanitary Engtneertng and Environmental Sciences, I r. I 5, I 1.26 Pan American centres for research, 4.20 Pan American conference on research policy, planned, 4-I7
research, 4.38, 10.75, I0.85 training, 10.76, Io.n, 10.78-Io.79 see also Working populations, health of Occupational therapy, Io.86, I2.I22 OECD, see Organisation for Economic Co-operation and Development Oesophageal cancer, Io.I6, I0.28, Ij.I2j Oman, 5·9
Pan American Federation of Associations of Medical Schools, 12.76 Pan American Foot-and-Mouth Disease Control Centre, 9·I79
On being in charge, I2.I04 Onchocerciasis, 9·47-9·54 chemotherapy, 9·51, 9.56-9.57 research, 4.II, 9·49, 9·50, 9·5 I, 9·57, 9.232, 9.240, 9.242 vectors, biology and control, 9·49-9·5 I, 9·54, 9.211, 9.216, 9·242
Pan American Health Organization (PAHO), I4.7, 15.20-15·31 publications, I3.I6, I3·3 5, I3-44 synchronization of planning cycle, r. 35 Pan American Sanitary Bureau, see Regional Office for the Americas Pan American Zoonoses Centre, 9· I79 Panama, 5.24, 7.22, 7.6I Papua New Guinea, 2.24, 2.25, 4.37, 5.3, 5.Io, j.I5, 5.26, 5·55, 6.26, 6.46, 6.6o, 6.65, 7.6I, 8.76, 9.96, 9.no, 9.122, 9-I2j, 12.24, 12.73, I2.I07, I2.II6, I2.Ij2, Ij.IIj, I5.122
resistance, 9·49, 9.50, 9.202, 9.2II Volta River basin area, control programme, 9•47-9·53• I5·I7
extension, 9· 51, 9· 52, 9· 2 I I financing, 9·4 7 Oncology, see Cancer, research Operational research, 6.46, I3.20 see also Health services research Ophthalmology, 9.I62, 12.I30 see also Eye health care Oral health, 10.67-10.72, Ij.I26 manpower, 10.70, 10.72 research, 4.12, I0.67, 10.70 training, 12.95, I2. I 32, I 5.126 Organisation for Economic Co-operation and Development (Nuclear Energy Agency), I1.37 Organization of African Unity, 1.3, 1.23, 1.45, 6.4I, 9.212, 9.223, Ij.3, Ij.I3
Organization for Coordination and Cooperation tn the Control of Major Endemic Diseases in West Africa, Technical Conference (I98I), 9.90 Organization of the Islamic Conference, 3.8 Organization of Petroleum Exporting Countries, 3.8 Organizational and related meetings, (Annex 2) Organizational structure of WHO, (Annex 4) re-examination in the light of functions, I.I, 1.30-1.44 Organizational studies by the Executive Board, 1.4I, 12.40-I2-4I
Paragonimiasis, 4· 38 Paraguay, 5.21, 5.24, I I. I 5, I r.I6 Parasitic diseases, 6.I7, 9·14-9.67, Io.8j, I3.2I research, 4· 37 see also Tropical diseases Particulate matter, health hazards, Io.82, I0.84 Patent rights, I4.IO Peace, health and, 1.47, 3.Io Perinatal care and perinatology, 6.19-6.22, 6.24, Io.2o Perinatal mortality, I3-I7, Ij.20 Periodontal diseases, Io.68, I 5.I 26 Permanent Commission and International Association on Occupational Health, 10.74 Pertussis, vaccination and vaccines, 9· I 7 3, I 5. 2 3 see also DPT vaccine Peru, 5.2I, 5.22, 6. 79, 7· 3 5, 7.66, 8.67, 9· I IO, 9·II 2, 9· I8j, 12.47, IZ.I26
Orthopaedic and orthotic services, see Disability prevention and rehabilitation Orthopoxvirus, 9.8, 9·9· 9.Io
Pesticides, 9.202, 9.2 II health hazards, I0.23, 10.79, I1.23, I1.53, Ij.48 residues, I r. 39 safe use, 9.205, Io.82, Io.8 3 traimng, 9.205 see also Insecticides; Larvicides; Molluscicides; Rodent control and rodenticides Pharmaceuticals, see Drugs Pharmacology, clinical, 8.II-8.I2, 8.I4, 8.23, 9.265 see also Psychopharmacology Philippines, 2.24, 2.25, j.Io, j.II, j.Ij, 5.3o, 5.48, 5·55, 6.55, 6.6o, 6.62, 7.65, 8.I4, 8.76, 9.38, 9·39, 9.40, 9.78, 9-IIO, 9.122, 9-I2j, 9.I84, I0.20, IO.j9, I0.74, 12.36, 12.7I, I2.87, 12.99, I2.I07, I2.I22, I2.I23, I2.I26, I2.Ij2, Ij.I2j Physical activity, 10.43
P AHO, see Pan American Health Organization Pakistan, 2.I9, 3.5, 3·45, 5.3, 5·9· 5·47, 6.q, 6.46, 6.6o, 6.8I, 8.49, 8.7I, 9·27, II.I9, 12.98, I5·99
THE WORK OF WHO, I98o-I98I
Physicians, role in preservation and promotion of peace, 1.47
of mental health, 7.2-7.3, 7·47, I2.I8, I5.II8 of nutrition services, 6.43-6.44, 6.46, I 5. I6, I 5.36, I5.II6
Pinta, 9· I 54 Plague, 9·117, 9.2I3, I5-46 Planning, see Environmental health, national planning; General Programmes of Work; Health planning and programmes; Long-term planning; Manpower development, management and planning; Mediumterm planning; Programme of WHO Pneumonia, 9.I2o, Io.64 Poland, 7.42, 10.74, I2.I6, rz.23, 12.72, I2.I46 Poliomyelitis, 9·132-9·133, 9.I67, 9·I72 immunization and vaccines, 8.32, 8.35-8.37, 9·I32, 9·I33, 9.I66, I5.23
of radiological services, 8. 59 International Conference (Alma-Ata, USSR, I978), I. I 2, IZ. 79
Pollution, see Air pollution; Costal pollution; Environmental pollution; Soil pollution; Water pollution Polynesian Islands, 4· 38, I 5. I 2 5 Population and Development, Parliamentary Conference, Africa (I98I), 6.93 Population dynamics, I 5.20 Portugal, 2.I8, 6.25, 6.40, 7.56, I5·77 Postgraduate training, 4.8, 5·53, 9·I92, 12.90-12.99• I2.I73, I2.I76
joint studies (UNICEF/WHO), 3-24, 5. I-j.Z, j.I 5 management, 5.8, 5·53 programme financing, 1.20 Health Resources Group, 1.20, 3.6, I5·32 initiative fund, 3. 7 interregional study, 5·17 records and statistics, I3.I-I3.4, I3.7, I3.I4, J3.2I research, 4·3, 4· I6, 4.29, 4· 33, 5.8, 5. Io, 5. 53, 5·55, 6.63 roleofnursesandmidwives, I2.69-I2.70, 12.73,12.93 role of traditional health workers, I 2.20 support, health systems, 1.38, 5.I9-5.20 training, 5.6, 5.8, 5.II, 8.79, 9·I 55, I2.48, IZ.jZ, I2.5 3, I2.6o, I2.62, I2.63, I2.68, 12.ti9-1z.84, 12.99, 12.100, 12..102, 12.111, 12..116, 12.124,
15-43,
I5.54, I5.55, I5.8o, Ij.Io6, I5.I29 teaching/learning materials, I2.I8, I2.Ioo, IZ.I03IZ.Io8, IZ.128, I2.I29, I2.J30, I2.I34, I2.I35
Poverty, 6.I5, Ij.65 Poxviruses, research, 9.8, 9·9 Pregnancy, hypertension problems, 6.I7, 6.I9 in adolescence, 6.38, 6.39, I5.II4 nutritional aspects, 6. I 8, 6.4 5, 6.46, 6. 57 spacing, 6.8 I termination, abortion and wastage, 6.I7, 6.38, 6.8o, 6.99, 6.Io8
workshops, 5.4, 5. I 2, 5. I7 see also Drugs, essential Primary health care workers, 6.44, 7·9· 7·47, 7.jl, 8.85, I0.5, I0.6, 12.36, 12.37, IZ.50, IZ.IIO, 13.40
training, 5.6, 5.7, 5.8, 6.z6, 6.44, 6.65, 7.23, 7.30, 8.28, IZ.I8, I2.35, I2.85, I2.I03, I2.II6, I2.I29, I2.J30, I2.I77, I5.38, I5.J3I Primates, nonhuman, 4.7, 8.40, Io.3o Programme budgeting, 1.5, 1.35, 2.27, 2.35, 2.36-2.37, 2.43 national, I 5.62 Programme budgets (WHO), 2.38, I 5.6I for I982-I983, 1.42 for I984-I985, 1.38, 2.36, 2.37
testing, 8.32 Prevention of alcohol-related problems: an international review l!f preventive measures, policies and programmes, 7.42 Prevention in childhood of health problems in adult life, 6. 37 Primary health care, 1.3, 1.4, I. II, I.I3, 1.24, 1.26, 1.42, 2.20, 3.I, 3.IO, 3.2I, 3·23, S·S-S·I7, 5.I8, 5·I9, 5.2I, 5·45, 6.I2, 6.I3, 6.3I, 7.25, 8.76, I0.75, I0.77, I2.28, I2.8o, I3.56, I3.57, I3.6o, I5.I, I5.4, I5·5, I5.I5, I5.25, I5.29, I5·34, I5.85-I5.86, I5.93, I5.I04, I5.I06 drugs for, 8.5, 8.I5, 8.I8
policy and strategy, I 5. 5 Programme Committee, Global, 1.37 of the Executive Board, 2.3 I-2.32, 10.3 regional programme committees, 1. 3 5, I 5.6 Programme coordinators (WHO), 1.32, 1.33, 3.6, 3.p, I5.8, I5.6I
elements, listed in Declaration of Alma-Ata (Part VII, para. 3), 3.10, 3.2I, 5.37, 5.38, 6.25, 6.42, 6.43, 6.68, 9.I65, 9·177, II.2, Ij.85
in urban areas, consultation, 5. I 3 integration, of disability prevention and rehabilitation, 8.62, I5.74
of disease control, 5.8, 9.I8, 9.22, 9·33, 9·34, 9·54, 9.69, 9·7I, 9.83, 9·9I, 9.92, 9·95, 9·II4, 9·I2I, 9.122, 9.I24, 9.I65, I5.17, I5.98 of family health, I 5. I I 5 of family planning 6.68, 6. 72, 6. 73, 6. 79, I 5. I I 5 of health education, 6.6o, 6.65, I2.I50, I5·37 of maternal and child health services, 6.2-6.3, 6.I9, 6.24-6.25, 6.30
national, 1. 32, I 5·9 Programme of WHO, general development and management, 2.26-2.50 use of resources, studies, 2.37 see also Evaluation Prosthetics, 8.67, 8.69, 8.7I Protein-energy malnutrition, 6.48 Protocol for the Protection of the Mediterranean Sea against Pollution from Land-based Sources, I4.8 Protozoal infections, 9.66-9.67 Psychiatry, 7.52-7.54 training 7.jl, 7·54, I2.I53, IZ.I55, I2.179 Psychopharmacology and psychopharmacotherapy, 7·54-7·55, I2.I55
INDEX
Psychosocial factors and health, 1.42, 7· 5, 7·23-7.28, 8.89, Io.86, I5.II8 research, r.S, 1.14, 4.3, 6.63, 6.66, 6.70, 6.82, 6.1 18, 6.I25, 7.23, 7.24, 7.25, 7.26, 7·49 Psychotropic substances, 7·7, 7.16-7.22, 7·55, I5.II8 Public health services, see Health services Public health training, I2.95, 12.96, I2.I41, 12.I48, I5.8o African centres, I 2. II 8 organizational study, 1.4 I schools, meetings of directors (I98I), 12.90 Public information 9.n6, 13·53-13·64 Publications, WHO programme, I3.I2, I3.I3, I3.I4, 13.29-13·36, I3-4I, I3.62 distribution and sales, I 3·49- I 3. 52 regional publications, 13.I6, I3·34-I3·35, I3·44, I3.47, Ij.8I-I5.82, I5.I03 translation, I 3. 36, I 5.8 I Publications and Documentation Service, PAHOjWHO (Mexico), I 3·44 Puerto Rico, 9.46
Qatar, 10.76 Quality control, see Biologicals; Drugs; Drinking-water; Water, quality control
Rabies, 9-I79, 9.I8o, 9.183-9·184, 9·I9o, I2.I69, I5-47 vaccines, 8.32, 9.I84, I5·47 wildlife rabies, 9· I 84 Radiation health and protection, 8.58, 8.59, 8.6o, IL3I, II.36-u.38 environmental radiation, I r. 33 ionizing radiation, 8. 58 personnel monitoring, I I. 37 non-ionizing radiation, I r. 36 standards, I r. 37 traming, 8.6o Radiation medicine, 8.j2-8.6o diagnosis, I 2. I 58, I 2. I So integration in primary health care, 8.59 therapy, 8.52, 8.53, 8.56, 8.57, 8.59, 8.6o, I2.I59 training of radiographers and radiological technicians, 8.52, I2.I58-I2.I59, I2.I80 Radiological equipment, 8.54 standard dosimetry, 8.56, 8.59 Reagents and reference substances, 6.I24, 8.6, 8.I4, 8.3 I, 8.36, 8.50, 9.I23, 9·I3I, 9·I39, 9.247, 10.93 production 8.45, 8.48, 9· I 30, 10.90 Refugees and displaced persons, 1.45, 1.46, 3·33, 3.36, 3-38, 9·25, I3.60 RegionalCommitteeforAfrica, 1.3, 1.35, 1.36, 1.37, 1.38, 1.39, 1.40, 1.42, 1.45,Ij.5-I 5·7 technical discussiOns, 4· I 6 Regional Committee for the Americas, 1.4-r. 5, 1.22, 1.29, 1.33, 1.38, 1.40, 1.42, 6.I 3 technical discussions, 6.6o, I I ·4 7
timing of sessions, r. 35 Regional Committee for the Eastern Mediterranean, I.46, I5.84 RegionalCommitteeforEurope, 1.7-1.9, 1.34, 1.35, 1.39, 1.40, 1.42 technical discussiOns, 1.40, I 5. 74 Regional Committee for South-East Asia, 1.6, 1.29, 1. 33, 1.39· 1.40, 1.42 techmcal discussions, I 2.28 Regional Committee for the Western Pacific, r.I I, 1.34, 1.38, 1.39· 1.40, 1.42 technical discussions, 1.40 Regional committees, r.I8, 1.I9, 1.23, 1.29, 1.30, r.p, I. 35, 1.42 methods of work, r. 36- I. 39 Regional development banks, 8.30 Regional Office for Africa, 2.43 structure, I 5·9 Regional Office for the Americas, 2.44, 13.Io publications, 13. I 6, I 3. 35, I 3-44 Regional Office for the Eastern Mediterranean, 2.44 publications, I3.I6, I3.34, I3.44, I3.47, I5.I03 transfer, I4·9 Reg10nal Office for Europe, 2.43, 2.44, 8.I, 8.I3 publications, I3.I6, I3.35, I5.8I-I5.82 Regional Office for South-East Asia, 2.44 Regional Office for the Western Pacific, 2.44, 13.10, 13·17 accommodation, I 4· I 8 Regional offices, (Fig. I 5. I) mformauon systems, I 3. I o- I 3. I I structures and functiOns, r. 3o Regions of WHO, (Fig. Ij.I) Rehabilitation, see Disability prevention and rehabilitation Rehydration salts, oral, 9.69, 9.72, 9· 75, 9· 76, I 5·43, I 5·99 production, 3.2I, 9.70 Reporting system of WHO, 2.40 Repository of chromosomal variants and anomalies in man, I0.63 Republic of Korea, 2.24, 2.25, 3.27, 4.37, 5·3· 5.I8, 5.30, 5.36, 6.29, 6.40, 6.62, 6.63, 6. 79, 9· IIO, 9.205, 10. 74, II.34, II.jl, 12.33, 12.7I, I2.I44, I5.II5, I5.I23 Research, 1.4, r. 13, r. I4, 4.1-4.39 capability, strengthening, 4.2, 4.II, 4.17, 4.2I, 4·364·37, 5-5 I, 6.29, I5-94 career structures, 4· 5 directory of institutions, 13. I 6 ethical aspects, 4· 7, 4· 17 evaluation, 4.22 financing, 4.I, 4.4, 4.I6, 4.29 mformation systems, 4-I4, 4.I6, 4.28, 5.56 management, 4.28, 4·35, 4.36, 4·37, 4·39 national medical research councils, establishment of and links with, 4.6, 4.Io, 4.37, I5.6o meetings of directors, 4.25 policy and priority-setting, 4· I, 4· I 7, 4· 34
Research (continued) reg10nal programmes, Ij.J4, Il·l9-I5.6o, Ij.68, Ij.92-Ij.94, Ij.I05 scientific planntng groups, 4· 3 standardization of procedures, 4.27, 4.29 technical cooperation among research institutions, 4.9, 4·36 training, 4.2, 4.6, 4.8-4·9• 4.II, 4.29, 4·37, I2.I44, Ij. 14, I 5.6o centres, 9.268 grants and awards, 4.8-4-9, 4.2I, 4.28, 6.I2I, 6.r:u, 9.230, 9.266, I5.J4, Ij.I05 IARC programme, IO.I2-Io.p see also Health services research; Human experimentation, and under mdividual suijects of research Research coordination, 1.25, 1.39, 4.6, 4.36, 6. I 25, I 5. I4, I5.6o Respiratory diseases, acute, 1.42, 6.I6, 9.no-9.n6, Ij.I20 chemotherapy, 9.I2I, 9.I24 research, 4.37, 4.38, 9.I2I-9.I23, 9.126, 9·131, Ij.I05, I5.I22 training in control, 9· I 23 chronic I o. 58 Reunion, 9.2I Revolving Fund for Teaching and Laboratory Equipment, I4.25 Rheumatic diseases, IO.j9·10.60 Rheumatic fever, 10.40, I l· I 2 5 Rheumatic heart disease, 10.40, I l· I 25 Rickettsial diseases, 9. I 39 Rift Valley fever, 9·J38, 9· I 8o, I 5·97 vaccine, 8. 3l Rockefeller Foundation, 9.46, I 2. I 30 Rodent control and rodenticides, 9.2 I 3 Rodent Control Demonstration Unit (Rangoon), 9.2I3 Romania, I0.64, I2.I54 Rotav1rus, 9·75 Royal Commonwealth Society for the Blind, 9· I 59 Rural development, j.I6, 9·45, 9.I78, I5.2I, I5.63 water supply and sanitation, 1.40, 3.27, 6.66, I 1.3, II.I5, II.I8, I5.I27 Rural health, 5.26, I2.73, I2.82, Ij.I30 incorporation of nutritiOn activities, 6.46 Rwanda, 7·4, 9.42, 9.2I4, I2.I27
Sahel, Club du, 3.8 Saint Helena, 9.2I Saint Lucia, 3.42, 8.64, 9.46, I4. I Saint Vincent and the Grenadines, 7.Io Salmonellosis, 9· I 8 7 Salt, iodization, 6. j2 Samoa, 2.24, 6.6o, 9.IIo, I2.73
San Marino, I4.I Sandflies, 9.202, 9.250 Sandoz Foundation, I 2.64 Sanitarians, I 2.6 3 Sanitary and public health engineering, training, I 2. I 7 3 Pan American centre, I 1. I l, II. 26 Sanitation, 1.3, I.2I, 1.26, 1.40, 6.6o, 9·44, II.4, II.5, II.6, II.II, II.J3, II.I6, II.I8, I3.56, Ij.23, Ij.49, I5.50, I5.63, Ij.77, I5.85, I5.I27 information systems, I I. I l , I I. I 7 integration in pnmary health care, I I. 2 international decade (I98I-I99o), 1.40, 3.20, 6.66, 9.2I5, 11.1-11.20, 12.66-I2.67, I2.I74, I3.j6, q.6o, ~.I8, I5.23, Ij.3I, I5.49, I5.IOI, I5.I27 national programmes, support, I 1.2, II .3, I 1.4, I 1. I 2, II.I5, II.I6, II.J7, I5.I8 see also Environmental health; Sewerage; Wastes disposal; Water supplies Saudi Arabia, 2.I9, 7·I3, 8.7I, 9.64, 9.206, Io.76, I2.I38 Schistosomiasis, 6.86, 9·36-9.46, I 5. I 20 chemotherapy, 9.40, 9.42, 9.238 research, 9.42, 9.232, 9·238-9.239, 9.26I, I5.I05 diagnostic techniques, 9.239 snail control, 9.42, 9·43, 9.2I4, 9.2I9, 9.238 training, 9·43 Schizophrenia, 7.50, 7·53 Scientific Group on Prevention Strategies in Cancer (I98I), 10.3 Scientific Group on Treponema! Infections (I98o), 9· I 5l Seafarers, health of, I o. 8 I Seas, regional, coordinated programme (UNEP), I 1. 35 Self-care and self-reliance in health care, 1.8, I. II, 1.24, 1.27, I.3J, 4·29, 4·33· j.8, 6.6I, 6.62, 9.68, I5·93 Self-help, 7.23, 7.2j, Ij-38 Senegal, 2.7, 5.I8, 5.27, 7,56, 8.85, 9.38, 9.40, 9.2II, I2.I27 Sera, 8.48 Sewerage, I 1. I l, I 5.2o Sexually transmitted diseases, 9· I l I-9· I 55, I 5. I 20, I 5. I 22 chemotherapy and drug resistance, 9· I 52 research on diagnostic techniques, 9· I 5 I, 9· I l 3 Seychelles, 9.2 I SIDA, see Swedish InternatiOnal Development Authority S1erra Leone, 2.I9, 9.8, 9.2II, I2.20, I2.87, 12.93, q.I5 Simulium, 9·49, 9·lo, 9·54, 9.202, 9.2II, 9.2I6 Singapore, 5.36, 7·44, 7.65, 9.26, IO.I9, Io.n, I2.78, I2.I22 Single Convention on Narcotic Drugs (I 96 I), 7. I 6 Sixth report on the world health situation, I3.I2, I3·32 Smallpox, eradication, 13.5 l, I 3.6o, I 5·97 declaration of, L4I, 9·3 exclusion from International Health Regulations, I4.6 Global Commission, 9· 3 post-eradication activities, 9· 3-9. II vaccination, 9.4, 9·7 discontinuation, 9·4, 9· I 2 reserves of vaccine, 9· 5
286
INDEX
Smoking and health, 1.42, Io.6, IO.I5, I0.27, I0.37, 10.4I, 10.47·10.52, I0.85, I3.57, 13.6o Snake-bite, 4.24 Social sciences, 4· I 8 Social security, 2.20, 5.22, 5·35, I5.2I, I5.28 Socioeconomic development and health, interrelationship, r.8, 1.24, 1.47, 2.6, 3·9-3·"• 3.I6, 3.28, 6.5, 6. II, 6. I 5, 6.4I, 7.23, 9· I 8, 9· 53, 9· q8, 9.263, 9.264, 13·I4, I3.I8, I5.4, Ij.20, I5.24, I5.65, I5.86 studies, 3.Io, 5.I6 Soil pollution, I 1.28 Solomon Islands, 2.24, 6.6o, 6.65, I2.I23 Solvents, exposure limits, I0.83 Somalia, 2.22, 2.23, 3·5, 3.38, 3·45, 5·9· 6.25, 9·3· 9·"· 9-IIO, I0.76, II.I9, I2.I33, I5.89, I5.IOO South Africa, 9.2I South Pacific, University of the, 5. 30 South Pacific Commission, I I. 5I South Pacific pharmaceutical service, 8.25, I5·"9 South-East Asia Region, 1.33, 2. 14-2.17, 3·43, 4.22-4.21, 5•7, 5.25, 5·45, 5.52, 6.46, 6.49, 6.63, 6.65, 6.II76.II8, 8.20-8.22, 8.48, 8.59, 8.68-8.69, 8.79, 8.88, 9·23. 9·92-9·93· 9·"4· 9-I40, 9·I54, 9·I59· 9.I6l, 9.I66, 9.I68, 9·I9I, I0.6, I0.66, II.I7, II.27, II.48, I2.27-I2.29, 12-57, I2.67, I2.96, I2.I02, I2.I20, I2.I50-I2.Ijl, 12.I64, I2.I68, I2.qi, I3.7, I3.I7, 13.24, I 3.27, 13.40, 15·32·15.63 Charter for Health Development, 1.27 Meeting of Ministers of Health, First (I 98 I), I 5. 33 Southern Africa, 7-4-7.8, I5.I3 Spain 2.I8, 7.56, 12.7I Special Programme of Research, Development and Research Training tn Human Reproductton: ninth and tenth
Structures of WHO, (Annex 4) study, I.I, 1.30-1.44 Study Group on Mental Health Care 1n Developmg Countries (I98I), 7·3 Study Group on Neuronal Aging and its Implications for Neurological Pathology (I98o), 8.94 Study groups on occupational exposure limits (I98o and I98I), I0.83 Sudan, 2.I9, 2.22, 2.23, 3·5, 3.6, 3·45, 5.3, 5·9· 5-I5, 5.23, 5.27, 5.29, 5·47, 6.q, 6.26, 6.Io8, 8.24, 9.38, 9.40, 9·44, 9·57, 9·95, 9-202, 9-205, 9-2I9, 9·238, 10.4, I0.5, 10.74, I0.80, II.I9, I2.24, 12.77, 12.98, I2.II6, I2.126, I2.I35, I2.I40, 13·I5, I5.98, I5.IOO Supplies and equipment, 5.51. 12.4I, 12.78, I5.84, I5.I24 services of WHO, 14.20-I4.26 see also Emergency assistance; Equipment Surgery, e~ntial care, 8.82-8.83 Suriname, 9.46 Swaziland, 6.64, 7.4, Io.I8, II.46 Sweden, 3.4, 6.4, 6.128, 9·I58, 9.I68, I2.23 Swedish Agency for Research and Cooperation with Developing Countries, 6.4 Swedish International Development Authority (SIDA), 5•4, 9.84, I0.52, II.3, II.12, I5.I8 Switzerland, 3.4, 6.40, 7.42, 10.74, Io.88, I2.23, 12.7I, 12.72, I2.I73 Syphilis, 9· I 54 Syrian Arab Republic, 5.29, 6.8I, 8.7I, 9.27, Io.67, I5·99 S"tems analysis, 13.20 Taeniasis, 9.I9o, I2.I69 Tanzania, see United Republic of Tanzania Teacher traming, 6.27, 6.n8, 9.29, 9.262, I2.2o, I2.5 3, 12.59, I2.82, 12.93, 12.97, I2.1I4, 12.116-12.125, I2.132, I2.I34, I2.I39, I2.I46, 12.I64, I2.q6, I5.35, I5.55, Ij.9I, I5.II5, I5.I32 regional centres, 6.27, I2.II5, I2.12o, I2.I2I, I2.I22, I2.I23, I5.I32 Teaching/learning materials and processes, 3.2o, 6.26, 6.77, 8.6I, 12.34, 12.4I, I2.82, I2.88, I2.IOO, I2.II5, I2.126-I2.135, I2.I47, I2.I77, I2.I80, I5.I32 for primary health care, I2.I8, I2.10o, 12.103·12.1o8, I2.128, I2.I29, I2.130, I2.I34, I2.I35 participation of students, I2.I07, I2.I25 see also Textbooks Teams, see Health teams Technical cooperation, 1. 31 among developing countries, I.I6, 1.32, 1.35, 2.2, 2.47, 3·39, 8.14, 8.q, 8.22, 8.26, 9.230, 9.266, II.I3, I2.6I, I5.II-I5.13, I5.I9, I5.25, I5·33 standmg committee, Africa, I 5.6, I 5. I I-I 5. I 2 Technical discussions, at Health Assembly, 1.38, 3· n, P9 at regional committees, 1.40 Africa, 4· I 6 Americas, 6.6o, I 1.4 7 Europe, 1.40, I 5. 74
annual reports (I98o and I98I), 6.7I see also Human reproduction, research, development
and research training, special programme Special Programme for Research and Training in Tropical Diseases, see Tropical diseases, research and training, special programme Sri Lanka, 2.I3, 3.6, 5.3, 5.7, 5.I6, 5·45, 5·52, 6.25, 6.29, 6.40, 6.79, 7·44, 8.20, 8.2I, 8.79, 8.88, 9.27, 9.Io5, 9.209, 10.4, I0.5, I0.6, 10.75, II.I7, II.48, I2.I2, 12.I6, I2.29, 12.42, I2.Ijl, I5.44 StaffofWHO, 14-II-I4.I7 recruitment, 1. 30 training, 14· I 2- 14· I 7 Statistics, Io.8, I0.10, 10.47, q.I-13.22 development of services, I 3. 3- I 3.6, I 5. I 3 5 dissemination by WHO's central services, I3. Io-13. I9 establishment of natiOnal committees, I3·5 lay reporting, I3.7, I5.I35 methodology, 6.30, 13.I6, 13.20-13.22 training, I2.I76, 13.2, I3·9 see also Classification Sterility, see Infertility Sterilization, female, 6.92, 6.98, 7.24 Streptococcal infections, 9·119, 9· I 20
THE WORK OF WHO, I98o-I98I
Technical discussions (continued) South-East Asia, I 2. 28 Western Pacific, 1.40 Terminology, 4.27, 13·46-13.48 Tetanus, 9· 167 neonatal, 9·I72, I5.roo vaccination and vaccine, 15.23, 15.Ioo see also DPT vaccine Textbooks (medical), I2.129, I2.I79 see also Nursing, textbooks Thailand, 2.I6, 2.46, 3.38, 3·43, 5.3, 5.II, 5·I5, 5.I6, 5.34, 5·39, 5·45, 5-52, 6.4, 6.29, 6.55, 6.78, 6.9I, 6.128, 7.22, 7.6I, 8.20, 8.2I, 8.22, 8.88, 8.95, 9.92, 9·93, 9· I05, 9· I 12, 9· 122, 9· I 37, 9.204, 9.207, 9.2 IO, 9.222, 9.234, Io.67, ro.75, Io.8o, Io.92, 11.34, Ir.48, I2.I2, I2.20, I2.27, 12.42, I2.63, 12.7I, I2.87, I2.89, I2.I6o, I3.6o, 15.42, I5.44, I5.45, I5.6~ Thalassaemia, Io.62
financing, 9.225, 9.269 scientific working groups, 9.232 grants, 4.2I, 9·23o, 9.266, Ij.I05 see also Vector biology and control Trust Territory of the Pacific Islands, 5.30, 9· IIO Trypanosomiasis, 9· 58-9.63 chemotherapy, 9· 59 research, 9·59, 9.6I, 9.63, 9.223, 9.232, 9.243-9-248, 9·256
diagnostic techniques, 9.243 drug trials, 9.244 seminar, OAUJFAOJWHO, 9.223 vector control, genetic, 9·59, 9.212, 9.223 insecticides, 9.6o, 9.63, 9.212, 9.246 see also Chagas' disease Tsetse fly, 9·59, 9.6o, 9.202, 9.212, 9.223, 9.243 Tuberculosis, 9-98-9.116, 13 .Go, 15. I 20, I 5. I 2 3 BCG vaccination and vaccine, 9-IOI, 9.Io2, 9.I03, 9·I05-9·I06, 9.IIO, 9.III, 9·II4, 9.I66, I2.I67, I j .2 3 chemotherapy, 9-IOI, 9.I02, 9.I03, 9.I07-9-I09, Ij.I23 combmed leprosy and tuberculosis activities, 6.6o, 9·89, 9·9 1
The primary health care worker: working guide, guidelines for training, guidelines for adaptation, I 2. I03 The proviston of care for the elderly, 8.93 The treatment and management of severe protem-energy malnutrition, 6.48 Therapeutic substances and technology, 4.27, 8.2-8.60 Thrombosis, ro.4 I Tobacco, consumption and production, ro.47 Tobacco report, Io.5o Tobacco-chewmg, Io.6 Togo, 6.64, 9· 52 Tonga, 2.24, 9.IIo, I2.83, I5.I30 Tounsm, see Travel Toxicologists, training, I 1.2 3, I 5. 78 Toxicology, see Chemicals; Drugs, safety and efficacy; Food safety and hyg1ene; Pesticides, health hazards Trachoma, 9.I64 Traditional birth attendants, 5.7, 6.30, I2.20, I2.68, 12.87-12.89, I 5. 56 Traditional health workers, 4·33, 8.77, I2.I49 training, 8. 79 Traditional medicine, 1.24, 5.7, 5·43, 8.73-8.81, I2.I49, I5.I07
Integration of services in general and primary health care, 9.IOI, 9·II4 national programmes, strengthening, 9.ror, 9.IIo research, 9.Io5-9·Io9, 9·IJ3, 9.II4, 9.II5 training, 9· II I, I 2. I67 Tumours, classification, I o. I I in animals, 9· I98 Tunisia, 6.25, 9·39, 9.II6 Turkey, 3·44, 5.8, 5. I 5, 6.2 5, 6.29, 6.40, 6.78, 6.8o, 6. I I9, 8.85, 9·I5, 9·33, 9.202, 9.207, 9.2I9, I0.22, II.I8, I2.I44, I5·77 Tuvalu, 6.65 Typhoid fever, 9·75 Typhus, 9.2 I 3
handbook for health administrators, 8.8I national programmes, 8. 79 research, 8.74, 8.76, 8.79 study tours in China, 8.76 training, 8.73, 8.74, 8.76 Travel and tourism, 9.I2-9.I3, 9.28 Treponematoses, endemic, 9· I 54-9· I 55 Trinidad and Tobago, 5.28, I3·15 Tropical diseases, 8. 75 research, 4. 37 capability strengthening, 9·230, 9.237, 9.261, 9.2659.268 centre (Ndola), 9.265 special programme, 2.42, 3.2o, 4· II, 9·32, 9·43, 9·50, 9·56, 9·59, 9-2I2, 9·214, 9-2I6, 9-222, 9-2259-269, r2.I66, I3,28, I5.4I
Uganda, 3·5, 3·4I, 9.42, 9·58 UNCTAD, see United Nations Conference on Trade and Development UNDP, see United Nations Development Programme UNDRO, see United Nations Disaster Relief Coordinator Unemployment, r.8, 5·35, q.65 UNEP, see United Nations Environment Programme UNESCO, see United Nations Educational, Scientific an Cultural Organization UNFDAC, see United Nations Fund for Drug Abuse Control UNFPA, see United Nations Fund for Population Activities UNHCR, see Umted Nations High Commissioner for Refugees UNICEF, see United Nations Children's Fund
288
INDEX
UNIDO, see United Nations Industrial Development Organization Union of Soviet Socialist Republics, 3·4· 9·5. 9.I68, 9.I85, Io.62, Io.64, 10.74, ro.8o, I2.48, '3·44 United Arab Emirates, I 5. roo
traditional medicine, 8.76, 8.79 water supplies and sanitation, II. 3, I r. 5, II ·9· I r. 12, IJ.I6, II.J7, II.I8, I1.19, I!.20, I3.56, 15.I8, I5·77• 15.127
Umted Kingdom of Great Britain and Northern Ireland, 3•4, 6.4, 6. I 28, 8.6j, 8.89, 9· I p, 9· I68, 12. 72, I 2. I 54
United Nattons, 1.18, 1.28, 1.30, 3·9· 3.ro, 3.1I, 3.I2, 3.13, 3.Ij, IJ.I, II.9, 1!.10, 11.35, I3.18
resident coordinators, 3. r 8 United Nations Disaster Relief Coordmator, Office of the (UNDRO), 3-35, II.38 United Nations Educational, Scientific and Cultural Organization (UNESCO), 6.66, 1I.9, II.27, 1I.35, I2.89
Economic and Social Council, 3.I2, 6.93 General Assembly resolutions on health as an integral part of development, r. I2, r. r8, r.28, 3·9 regional economic commissions, relations with WHO regional committees and offices, I. 3 5 United Nations Centre for Human Settlements, I r .9, I 1.3 5
United Nations Environment Programme (UNEP), 3. 3 5, 9.!86, 9·2I8, 10.18, 10.77. I0.82, 10.87, II.9, II.22, 11.23, II.27, I1.30, 1I.3I, I!.p, II.35, II.46, II.53, I3·42, I4.8 global environmental monitoring system, 15. I 28
United Nations Children's Fund (UNICEF), 3·ZI-3.Z4, 3·35, 15.63
joint activities, communicable diseases, 5.8, 9·33· 9.82 diarrhoeal diseases, 9· 70, 9· 77, r 5·99 disability prevention and rehabilitation, 8.63, 8.69 essential drugs, 8.q, 8.30 family health, 3.22, 6-4, 6.66 manpower development, 12.79 mental health, 7.8 nutrition, 3.24, 3.26, 6.7, 6.8, 6.49, 6.52, 6.54, 6.58, '3·56
United Nations Fund for Drug Abuse Control (UNFDAC), 7.22, 7·35 United Nations Fund for Population Activities (UNFPA), 6.3, 6.4. 6.23, 6.66, 6.r2I, 6.128, I2.J7, I2.25, I2.38, 12.89, I2.I45, J3.I8, I5.1I5
primary health care, 3.2I, 3.23, 3.24, j.I, 5.2, 5·4, 5·9• j.12, j.I3, j.Ij, 5.17
vaccination and vaccines, 9.1Io, 9.I68, 9.170 water supply and sanitation, 11.3, 1I.9, 13.56 United Nations Commission on Narcotic Drugs, 7.16 United Nattons Conference on Trade and Development (UNCTAD), 8.3o United Nations Conference on Women (198o), 6.1I United Nations Decade for Women (1976-I985), 6.1I6.12
United Nations High Commtsswner for Refugees, Office of the (UNHCR), 3·33, 3-35, 3-36, 3-37, 3.38, 14.22 Umted Nations Industrial Development Orgamzatwn (UNIDO), 6.52, 8.3o, 10.87, 1I.35 United Nations Research Institute for Social Development, 6.49 United Nations system, see Coordination with the United Nations system United Natwns University, 6.4, 6.48 United Nations volunteers, 3.48 Umted Nations Water Conference (I977), I 1.4 United Nations World Assembly on Aging (I982), preparation, 3.15, 8.92 United Republic of Cameroon, 3·5· 3·4I, 5.5, 6.26, 6.63, 6.Io8, 9-40, 9.58, 9.210, I2.r6, I2.1I6, I2.127, 12.16I United Republic of Tanzania, 6.49, 6.63, 6.64, 7·4, 8.49, 9.27, 9·38, 9·39, 9·40, 9·42, 9·43, 9·57, 9.1IO, 9.21I, 10.74, I2.42, I5.I7
United Nations Declaration on the Rights of Mentally Retarded Persons, 7. 29 United Nations Development Decade, Third, (I981-I990), 1.28
United Nations Development Programme (UNDP), 3·17·3.ZO, 11.18, 13.23, I4.22 country programming, 3. I 8 joint activities, chemical safety, II.24 communicable diseases, 3.20, 9.18o, 9.269 diarrhoeal diseases, 9· 7 2, 9· 77 drugs and vaccines, 8.14, 8.21, 8.26, 8.30, 8.4I, 9· I42, 9·168
United States Agency for International Development (USAID), 6.53, 6.54, 6.64, 9·33 United States of America, 3.4, 6.4, 6.128, 7· Io, 7·I9, 7.42, 7.6I, 7.67, 8.9, 8.I4, 8.46, 8.85, 9·33· 9.78, 9·I32, 9.163, 9·I94. 9.234, Io.8, 10.33, 10.47, IO So, Io.8I, Io.86, 10.93, 12.64, I2.65, I2.Ij7, 12.162, 13.25, I 5·76 Universal Postal Union, 9.1I6, 9·I47 UNU, see United Nations University Upper Volta, 5·5, 6.46, 9·57· 9.I22, 9.212, 12-43, I2.I6I, I 2. I 73 Urbanization and industria!tzation, 5.13, 7·5· 8.84, r 5.20, I5.IOI Uruguay, 5.2I, 8.6o, 9.185 USAID, see United States Agency for International
food safety, I r. 51 health manpower development, I2.I26, 12.173 health services development, 5. 24, 5. 2 8 occupational health, 10. 77, ro.82 pollution control, 1 1. 34 primary health care, 5. I I regional programmes, 3. I 9 rehabilitatiOn, I 2. r 54
Development
THE WORK OF WHO, I98o-I98I
Vaccination, see Immunization, and under individual diseases Vaccination certificate requirements for international .travel, 9ol2-9ol3 Vaccination certificates, 9°4, 9oi2, I3o33, I4o6 Vaccines, production and quality control, 3020, 8o328o37• 8o42-8o43, 9oi33, 9oi34, 9oi36, 9oi68, 9oi69, 90176, I2oi67 projection of requirements, 90 I 70 training, 8o4I, 8o43 regional and local production, 8036, 8042 research, 8035, 9075, 9o8I, 9oi05-9oio6, 9oii4, 90I27, 9oi29, 9oi37, 9oi42, 9oi53, 9oi79, 9oi84, 9o235, 9o252, 9o253, I0o9I, I5o44 storage, 90 5 supplies, I4o23, I4o26 see also under individual diseases Vanuatu (formerly New Hebndes), 9oiio, I2o33, 12o73, I4o7 Variola virus, survey of laboratory stocks, 906, 909 Vector biology and control, 4038, 9o26, 9o42, 9°43, 9o499o 5I, 9054, 9o 59, 9o60, 9063, 9•201-9.224, 9°23 7, 9°238, 9o242, 9o246, 9o2\0, I5o46 biological control, 9o2o8, 9o2II, 9o2I4, 9o2I6-9o2I7, 9o229, 9·257"9•260 environmental control, 9o2o8, 9.218-9.220 joint WHOJFAO/UNEP panel of experts, 902I8 genetic control, 9o209, 9o2I2 research units, 9o203, 9o207, 9o2II training, 9o20I, 9o2I3, 9o2I4, 9o2I9, 9.222-9.224 Venereal diseases, see Sexually transmitted diseases Venezuela, 5o27, 5o42, 6o8o, 7046, 9°46, 9°63, 9oi22, 9o203, I0o92 Veterinary public health 8032, 9·178-9.200 training, 90 I90-9o I92, I2o95, 12.168-12.169 VietNam, 3046, 8o27, 8o49, 8o 76, 9° I Io, 9° I 37, l2o 78, I4o 7, I4o22, I5oi2I, Ijoi25 Village health workers, see Community health workers Virus diseases, 9o3-9oii, 9oi20, 9.127•9o145• 9oi8I, I 5o !20, I 5oI 22 chemotherapy 90144 research, 909, 9oi27, 9oi29, 9oi30, 9o13I, 9oi32, 9oi37, 9o140-9oi4I, 9oi42, 9oi43, 9oi44, 9o2IO vaccines, 8o43 WHO reporting system, 9oi45 Visual impairment, 9oi6I, I5o73 Vitamin A deficiency, 6°53-6°54 Volta River basin area, onchocerciasis control programe, see under Onchocerciasis Voluntary Fund for Health Promotion, 302, 9oi 58, 9oi63, 9oi68, Ioo69, I3o7, 14026
Wastes disposal, It.6, ILI9, I5o20, I5o77 management of solid wastes, I r. I 8, I r. 34, I 303 5 radioactive waste, I I o3 I Water pollution, It.2I, IIo28, I1.29, I1.34, I5o5I see also Coastal pollution; Manne pollution
Water quality control, I r.q, I 1.20, I 1.27, I 1.34 Water resources and river basin development projects, health aspects, 3028, 9036, 9o4I, 9°222 see also Onchocerciasis, Volta River basin area, control programme Water supplies, 1.3, 1.26, 1.40, 3o27, 6o6o, 6°66, 9°44, I r. 5, It.6, II.II, II.13, It.I6, II.I8, I3oi7, 13056, I5o20, I5o49, I5o63, I5o77, I5o85, I5oi27 information systems, I r. I 5, I r. I 7 information transfer, IIo8, I1.9, ILI5 integration in primary health care, I I 0 2 national programmes, support, I 1.2, I 1.3, I 1.4, I r. I 2, I I. I 5, II oI 6, I I. I 7, I 5o I 8 Water-associated diseases, 9033, 9-44, 9o2I9, I 1.9, I 5o98 Blue Nile health project, 9044, 9o2I9, I5o98 Weaning and weamng foods, 6oiO, 6045, 6047 Weekty Epidemiological Record, 9o28, 9°85, 9oi75 Western Pacific Region, 1.22, 1.34, 1.35, 2°24, 2°25, 3°46, 4o36-4o39, 5oiO-j.II, 5°26, j.30, 5o48, 5°55-5056,6°5, 6039, 6o6o, 6°62, 6°63, 6064, 6065, 6ol2I, 7o2I, 7o4I, 7065, 8o2, 8o25-8o27, 8o42-8o43, 8048, 8o72, 8o91, 8o95, 9o 26, 9o45, 9°93, 9°96-9°97, 9o I40, 9o I6I, 9o qo, 9°173, 9oi75, I0o55, 11.20, II.5I, I2o33, I2o6o, 12083, I2o86, l2o99, I2oi07-I2oi08, I2oii5, I2oi22-I2oi23, I2oi52, I2oi55, I2oi65, I2oi7I, I3oi6, I3o24, I3o6o, I3o64, 14oi3, 15.104-15.136 Regional Centre for Promotion of Environmental Planning and Applied Studies, I r.26, I 1.30, I 5o I28 WFP, see World Food Programme WHO Chronicle, I2o7, I3o30 WHO guidelines for drinkmg-water, I I 029 Women in health and development, I 042, 50 5, 60 Io, 6.n6.J4, 6oi8, 6023, 6036, 6o62, I2o38-I2o39, I5o28 five-year plan, Americas, 6o I 3 studies, 5° 5, I2o3 8-I 2o 39 Word-processing equipment, 2o44 Working populations, health of, 1.42, 7o40, 8o86, IOo2I, 10.73·10.87, I 5o28, I 5o48 agnculturalworkers, roo74, roo79, IOo8I, I5o48, I5oiio World Assembly on Aging (I982), preparation, 3oi\, 8o92 World Association ofVetennary Food Hygiemsts, 9oi87 \\orld Bank, 9077, 9oi57, 90269, IOo82, II.9, I5o77 cooperative programme with WHO, 3o2o, 8o30, II.3, Ilo8, II.9, II.I4, II.I6, Il.I9 World CommunicatiOns Year (I 98 3), preparations, 30I 5 World Congress on Acupuncture, Seventh (I98I), 8079 World Congress on Biological Psychiatry, Third (1981), 7o54 World Congress of Neurology, Twelfth (I98I), 7o59 World Congress of Women (I98I), 6oii World directory of medical schools, I2o85 World Federation for Medical Education, I2oi4, I2oiiO World Federation of Proprietary Medicine Manufacturers, 802 World Federation of Societies of Anaesthesiologists, 8o8 3
INDEX
World Fertility Survey, 6.6 World Food Council, 6.52 World Food Programme (WFP), 3.25-3.29 World Health, 9.116, I3.62 World Health Assembly, LIS, 1.I9, 1.30, 1.31, 1.37, 1.38, 1.39> 1.40, I.4I, 1.42, 1.43, 1.45, 1.46, 1.47
vaccme, 8.34, 9· 136 vector bwlogy and control, 9.202, 9.2Io Yemen, 2.22, 2.23, 3·45, 4.33, 6.6o, 8.54, 9.38, 9.IIo, I0.76, II.I9, I2.77, I2.I33, I2.I40, I5·93
duration and periodicity of sessions, 1.43-1.44, I4. 5 method of work, 1.43-1.44 technical discussions, 1.38, 3.I I, 5·I9 World Health Days (I98o and I98I), I0.5I, I3·57-13·58 World health forum, I3.29-13·3o World health situation, sixth report, I3.I2, I3.32 World Health Statistics Annual, 13· 13 World Health Statistics Quarterly, I 3· I4 World Medical Association, I2.Ioo
Youth and adolescence, I 5. I 14 drug abuse, 7. 32 maturation and reproductive health, 6. 38-6.40, I 3.I 5, I5.II4
noncommunicable diseases, 10.36 smoking, 10.49 Yugoslavia, 3·44, 3.52, II.27, I2.23, I5·77
Zaire, 3.4I, 9.8 Zambra, 2.Io, 5.5, 5.27, 6.64, 7·4, 8.86, 9.38, 9·39, 9.40, 9·43, 9·234, 9-243, 9·26I, I0.64, 10. 76, 12-43
Zimbabwe, 1.45, 3.4I, 5.3, 5·5, 9·39, 9·43, 10.76, I2.7I, X-ray equipment, 8.52, 8.54 training of X-ray technicians, 8.j2, I2.I8o Xerophthalmia, 6.53, 6.54 I4.I, I4.7, I5·13
Yaws, 9·I54 Yellow fever, 9·I36
Zoonoses, 9·178-9.186, I 5·4 7 centres, 9· I 79-9. I 8 I Mediterranean, 9· I So Pan American, 9·I79 research, 9· I 79, 9.I84 training, 9·I90, I2.I68, I2.I69, I5.47
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BRAZIL: B1bhoteca Reg1onal de Med1cma OMSJOPS, Umdade de Venda de Pubhca¢es, Catxa Postal 20381. V1la Clementmo, 04023 SAo PAULO, S P BURMA: see lnd1a, WHO Reg10nal Off1ce CANADA: Smgle and bulk coptes of mdn·tdual pubhcallons (not subscnptwns) Canad1an Pubhc Health AssocJatJon, 1335 Carhng Avenue, SUite 210, 0rrAWA, Ont KlZ 8N8 Subscnptwns Subscnptwn orders, accompam~d h) cheque made out to the Royal Bank or Canada, OnAWA, Account World Health Orgamzation, should b~ s~nt to th~ World Health Orgamzauon, P 0 Box 1800, Postal Station 8, OnAWA, Ont KIP SRS Co"~spond~nce concermng subscnptwns should be addressed to th~ World Health Orgamzat10n, D1stnbut10n and Sales, 1211 GENEVA 27, Switzerland CHINA: Ch1na National Publications Import Corporation, P 0 Box 88, BEUING (PEKING) COWMBIA: D1stnhbros Ud, Pio Alfonso Garc1a, Carrera 4a, Nos 36119, CARTAGENA CYPRUS: Publishers' D1stnbutors Cyprus, 30 Democratlas Ave Ay1os DhometJous, P 0. Box 4165, NICOSIA CZECHOSWVAKIA: Art1a, Ve Smeckach 30, 11127 P"'GUE I DENMARK: Munksgaard Export and Subscnpt1on Serv1ce, Nerre S0gade 35, 1370 COPENH•GEN K ECUADOR: L1breria Ctentif1ca SA, P 0 Box 362, Luque 223, GUAYAQUil. EGYPT: Os!TIS orr.ce for Books and Rev Jews, 50 Kasr El Nil Street, CAIRO EL SALVADOR: L1breria Estud1ant1l, EdJfiCIO Comerc1al 8 No 3, Avemda L1bertad, SAN SALVADOR FIJI: The WHO Programme Coordmator, P 0 Box 113, SuvA FINLAND: Akateem1nen Kujakauppa, Keskuskatu 2. 00101 HELSINKI 10 FRANCE: L1brame Arnette, 2 rue CasJmlr-DelavJgne, 75006 PARIS GERMAN DEMOCRATIC REPUBLIC< Buchhaus Le1pz1g, Postfach 140, 701 LEIPZIG GERMANY, FEDERAL REPUBLIC OF: Gov1-Verlag GmbH, GtnnheJmerstrasse 20, Postfach 5360, 6236 EscHBORN - W E Saarbach, Postfach 101610, Follerstrasse 2, 5000 KOLN I - Alex Horn, Splegelgasse 9, Postfach 3340, 6200 WIES&ADEN GHANA: F1de; Enterpnses, P 0 Box 1628, Ace•• GREECE: G C Eleftheroudakl~ SA, L1bra1ne Jnternat1onale, rue N1k15 4, ATHENS (T 126) HAm: Max Bouchereau, L1brame ''A Ia Caravelle", Boite postale IllB. PoiH-AU-PRINCE HONG KONG: Hong Kong Government Information Serv1ces, Beaconsfield Hou~. 6th Floor, Queen's Road. Central, VICTORIA HUNGARY: Kultura, P 0 B 149, BuD•PEST 62- Akadem1a1 Konyvesbolt, Volc1 utca 22, BUDAPEST V ICELAND: SnaebJern Jonsson & Co, PO Box 1131, Hafnarstraet1 9, REYKJAVIK INDIA: WHO Regional Office for South-East A"•· World Health House, lndraprastha Estate. Rmg Road, NEw DELHI 110002 Oxford Book & Stauonery Co. Scmdta House, NEW DELHI 110001, 17 Park Street, C•u:urr• 700016 (Sub-agent) INDONESIA: M/s Kalman Book Serv1ce Ltd. Kw1tang Ray• No II. PO Box 3105/Jkt, !•KARIA IRAN: I raman Amalgamated D1stnbuuon Agency, 151 Khtaban Soraya, TEHERAN IRAQ: Mm1stry or Information, National House for Pubhshmg, 0Jstnbutmg and Ad\-ertlsmg, BAGHDAD IRELAND: The Stationery Off1ce, DUBLIN 4 , ISRAEL: Hethger & Co, 3 Nathan Straw,,<, Street. JERUSALEM ITALY: Edtz1om Minerva Med1ca, CorMJ Bramante 83-85, 10126 TURIN; V1a Lamarmora 3, 20100 MILAN JAPAN: Maruzen Co Ltd, P 0 Box 5050. ToKYO International, 100-31 KOREA, REPUBLIC OF: The WHO Programme Coordmator, Central P 0 Box 540, SEOUL KUWAIT: The Kuwa1t Book>hops Co Ltd, Thunayan AI-Ghanem Bldg, P 0 Box 2942, Kuw"T
LAO PEOPLE'S DEMOCRATIC REPUBLIC: The WHO Programme Coordmator, P 0 Box 343, VIENTIANE LEBANON: The Levant D"tnbutors Co S A R L, Box 1181, Makd"'" Street, Hanna Bldg, BEIRUT LUXEMBOURG: L1brame du Centre, 49 bd Royal, LUXEMBOURG MALA WI: Molaw1 Book Servtce, P 0 Box 30044, Ch1ch1t1, Bc.NT¥Rr 3 MALAYSIA: The WHO ProgrJmme Coordmator, Room 1004, FltzpJtnck Bu1ldmg, Jalan RaJa Chulan, KUALA LuMPUR 05--02 - Jubilee (Book) Store Ltd, 97 !alan Tuanku Abdul Rahman, P 0 Box 629. Ku•c. LuMPUR 01--{)8 - Parry's Book Center, K L H1lton Hotel. JJn Treacher, P 0 Box 960, KUALA LUMPUR MEXICO: La Prensa Med1ca Mex1cana, Ed!cJones CJentif1cas, Paseo de las Facultade. 26, Apt Po•tal 20-413, MExt<o CIT¥ 20, D F MONGOLIA: see lnd1a, WHO Reg1onal Off1ce MOROCCO: Ed1t10ns La Porte, 281 avenue Mohammed V, RABAT MOZAMBIQUE: INLD, Catxa Postal 4030, M•Puro NEPAL: see lnd1a, WHO Reg1onal Office NETHERLANDS: Med1cal Books Europe BV, Noorderwal 38, 7241 BL Loc'HEM NEW ZEALAND: Government Prmtmg Office, Pubhcat1ons Section. Mulgrave Street, Pnvate Bag, WELLINGTON 1 , Walter Street, WELLINGTON, World Trade Butldmg, CubaCc:tde, Cuba Street, WELLINGTON Govemm~nt BooAshops at Hannaford Burton Bu1ldmg. Rutland Street, Pnvate Bag, AucKLAND. 159 Hereford Street. Pnvate Bag, CHRISTCHURCH, Alexandra Street, PO Box 857, HAMILTON, T & G Butldmg, Pnnces Street, P 0 Box 1104, DUNEDIN - R H11l & Son. Ud. Ideal House, Cnr G1lhes Avenue & Eden St. Newmarket, AucKLAND I NIGERIA: Umvers1ty Bookshop N1gena Ltd, Umven.1ty of lbadan, IIADAN NORWAY: J G Tanum AjS, P 0 Box 1177 Sent rum, OsLO I PAKISfAN: M1rza Book Agency, 65 Shahrah-E-Qua1d-E-Azam, P 0 Box 729, lAHORE 3 PAPUA NEW GUINEA: The WHO Programme Coord~nator, PO Box 5896, 8oROKO PHILIPPINES: World Health Orgamzatton, Reg1onal Off1ce for the Western Pacific, P 0 Box 2932, MANILA - The Modern Book Company Inc, P 0 Box 632, 922 R1zal Avenue, M•NIL• 2800 POLAND: Skfadmca Ks1~garska. ul Mazow1ecka 9, 00052 WARSAW (except penodu·a/~)- BKWZ Ruch, ul Wroma 23, 00840 WARSA\\
(penodtcals onh) PORTIJGAL: L1vrana Rodngues, 186 Rua do Ouro, LISIION 2 SIERRA LEONE: NJala Untverstty College Bookshop (Umverstty of S1erra Leone), Pnvate Mall Bag. FREETOWN SINGAPORE: The WHO Programme Coordmator, 144 Moulmem Road, G P 0 Box 3457, SING•PDRE I -Select Books (Pte) Ltd. 215 Tanghn Shopping Centre, 2/F. 19 Tanghn Road, SING,PORE 10 SOUTH AFRICA: Van Scha1k's Book>tore (Pty) Ltd, PO Box 724. 26H Church Street, PRETORIA 0001 SPAIN: Comerc1al AtheneumS A. ConseJo de C1ento 130-136, BAR(ELONA 15, General Moscard6 29, MADRID 20 - L1brena D1az de Santos, Lagasca 95 y Maldonado 6, M•DRIO 6, Balmes 417 y 419. BARCELONA 22 SRI LANKA: see lnd1a, WHO Reg1onal Off1ce SWEDEN: Akuebolaget C E Fntzes Kung! Hovbokhandel, Regermg'>gatan 12, 10327 STOCKifOLM SWITZERLAND: MediZIOISCher Verlag Han~ Huber, Langgass Stras~oe 76, 3012 BERN 9 SYRIAN ARAB REPUBLIC: M Farras Kekh1a, PO Box No 5221. ALEPPO THAILAND: see lnd1a, WHO Reg1onal Off1ce TIJNISIA: Soc1ete Tums1enne de D1ffus1on, 5 avenue de Carthage, TUNIS TURKEY: Haset K1tapev1, 469 l>ttklal Cadde,., Beyoglu, lsr.NIUL UNITED KINGDOM: H.M Stationery Off1ce 49 H1gh Holborn. LoNDON WCIV 6HB, 13a Castle Street, EDINBURGH EH2 3AR, 41 The Hayes, CARDIFF CFI IJW. 80 Chichester Street, BELFAST BTl 4JY, Brazennose Street, MANCHESTER M60 8AS, 258 Broad Street. BIRMINGHAM Bl 2HE, Southey House, W1ne Street, BRISTOL BSI 2BQ All mat/ orders should b• s.nt to P 0 Box 569, LoNDON SEI 9NH UNITED SfATES OF AMERICA: Smgle and bulk coptes of tnthwdual publtcatwns (not subscnptwns) WHO Pubhcat1ons Centre USA, 49 Shendan Avenue, ALBANY, NY 12210 Suhscnptwns Suhscnptwn orders, a(compamed hl che£1... mad~ out to the ChemJc.il Bank, New York, Account World Health Orgamzat1on, should be snu to the World Health Orgamzat1on, P 0 Box 5284, Church Street Station, NEw YORK, NY. 10249 Co"espondence comemmg subscnptwm 'ihould be addressed to the World Health Orgamz.at1on. D1stnbut1on and Sales, 1211 GENEVA 27, Switzerland PubliCattotls are also amllahle from the Umted Nations Bookshop, NEw YoRK, NY 10017
(retatl onh) USSR: For readers m the USSR requmng Russtan edawns Komo,omolskiJ prospekt 18, Me<hcmskaJa Kmga, Moscow - For "adn \ outstde the USSR requmng Russtan ed11wns KuzneckiJ most 18. MeZdunarodnaJa Kn1ga. Moscow G-200 VENEZUELA: Ed1tonal lnteramencana de Venezuela C A, Apartado 50 785. C•••c.s 105- L1breria del Este, Apartado 60 337, 106- L1breria Medtca Pans, Apartado 60 681, CARACAS 106 YUGOSLAVIA: Jugoslovenska Kn31ga, Teraz13e 27/11. 11000 BELGRADE ZAIRE: L1brame umver~1ta1re, avenue de Ia Pa1x No 167. B P 1682. KINSHASA I
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Special ter~s fo~ developing countries are obtainable on application to the WHO Programme Coordtnators or WHO Regtonal Offtces ltsted above or to the World Health Organizatton, Distribution and Sales Service, 1211 Geneva 27, Switzerland. Order~ from countnes whe~e sales agents have not vet been appotnted may also be sent to the Geneva address. but must be patd for tn pounds sterltng. US dollars, or Swiss francs. Prtce Sw.fr. 18.Pnces are subject to change without notice. C/1/81