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MINUTES OF THE SIXTH MEETING 95 MINUTES OF THE SIXTH MEETING Regional Office for Europe, Copenhagen Thursday, 27 September 1984, at 9 a.m. CHAIRMAN; Professor D. JAKOVLJEVIC (Yugoslavia) CONTENTS 1. Review of the report of the Regional Director on the work of WHO in the European Region in 1983 and the interim report for the period January - June 1984 ......................................................................... 96 2. Report of the Consultative Groups on Programme Development and on Budgetary Questions ......................................................................... 96 3. Detailed review of the proposed programme budget 1986-1987 ........................... 99 9 6 REGIONAL COMMUTEE; THIRTY-FOURTH SESSION 1. REVIEW OF THE REPORT OF THE REGIONAL DIRECTOR ON THE WORK OF WHO IN THE EUROPEAN REGION IN 1983 AND THE INTERIM REPORT FOR THE PERIOD JANUARY - JUNE 1984; Item 11.1 of the Agenda (EUR/RC34/2 and /Conf.Doc./2) The REGIONAL DIRECTOR introduced his report for 1983 and the interim report for the period January - June 1984. The work in the Region was a continuum of policy-making, planning and programme implementation, and the reports provided some background to the work being planned for 1986-1987; the annual report for 1983 also provided an evaluation of the Sixth General Progranme of Work in the Region. He mentioned the continued involvement of international bodies and collaborating centres, and stressed that with the prospect of zero economic growth the Regional Office would need to collaborate even more with centres in the Region to implement its programmes. In particular, agreement on overall health policies would need continual collaboration. Financial support from the Member States over and above their regular budget contributions would also enable the work of the Office to be implemented more thoroughly. 2. REPORT OF THE CONSULTATIVE GROUPS ON PROGRAMME DEVELOPMENT AND ON BUDGETARY QUESTIONS; Item 11.2 of the Agenda (EUR/RC34/8) Dr GRECH (Malta) introduced the joint report of the Consultative Group on Programme Development (CGPD) and the Consultative Group on Budgetary Questions (CGBQ) in the absence of the Chairman of the CGPD, Professor Maleev. The CGPD had considered two items; the common framework and format for evaluating the strategies for health for all, and the proposed programme budget for 1986-1987. The programme budget document was similar in presentation to that drawn up two years before, for the 1983-1984 programme. The only alterations were those requested at the thirty-second session of the Regional Committee in resolution EUR/RC32/R5. In the current document, the former part II had been amalgamated into part I to avoid unnecessary repetition, and the budget estimates were now to be found at the beginning of each objective in the different programmes. As requested, more information had been included on the Regional Office's cooperation with individual Member States. The CGPD wished to express its satisfaction with the improved layout of the document, the level at which programmes had been maintained, the continuation of activities despite financial constraints, and the way in which the different elements of the programme had been brought into line with the regional targets. The shift towards country programmes, together with the reorientation taking place in the context of the strategy for health for all, seemed completely justified. The Group felt that special attention should be paid, and appropriate resources allocated, to activities in the fields of alcoholism, smoking and rehabilitation. The Group endorsed increased cooperation with collaborating centres, due consideration being given to their ability to operate in the official languages of the Regional Office. A reasonable balance should also be maintained between national and international funding for the work to be performed by such centres. The Group therefore advised the Regional Office to find out by what time requests for voluntary donations had to reach Member States in order for them to be taken into account in their own budgetary plans. Ms LUND (Chairman, Consultative Group on Budgetary Questions), introducing the second part of the joint report, drew the Committee's attention to section 3.4 of that report. She mentioned the explanation given by the Regional Director concerning the traditional composition of the group and expressed her thanks to the members for their contribution. The World Health Organization was currently pursuing a zero growth policy, reflecting the economic climate throughout the world and among the European countries in particular. The nominal growth in the 1986-1987 budget proposals, as adjusted after the transfer of Algeria to the African Region, was estimated at 3.74% over the previous biennium, and real growth was now practically nil. The only sector in which growth was envisaged was that of the country programmes. The CGBQ welcomed the awareness of the need to reallocate resources, as reflected in the fact that no increase was foreseen in duty travel. The Group fully supported the view that the most important elements of the programme should be financed from the regular budget. The proposed increase in the Regional Director's development fund, from US $120 000 in 1984-1985 to US $425 000 in the following biennium, had been endorsed after the Group had studied the size of the development fund in other regions and taken note of the explanation given in the global programme budget. That endorsement had been given on the understanding that those funds should be used in accordance with the Regional Director's outline of priority areas and with reference to the directions and explanations given in the global budget and the financial report. MINUTES OF THE SIXTH MEETING 97 The Group had considered how inflation rates had been calculated in the proposed budget. The increase in costs over the biennium had been based on expected rates of inflation both in Denmark and in other European countries, as well as on the 2-3% allowance for statutory cost increases provided for by the Staff Rules. She informed the Committee about the current forecast for Denmark, which indicated a 4% inflation rate in 1985. The rate of exchange between the US dollar and the Danish krone had been set at US $1 • DKr 8.1 in the proposed programme budget. The Group had noted that the actual rate at the time of its meeting was considerably more favourable to the dollar, but it accepted the prudent estimate in view of what it considered to be an overvalued dollar. Since April 1984, the US dollar had been constantly rising and the exchange rate was now fluctuating around DKr 11 ” US $1. A marked decrease had recently occurred. Exchange rates were dependent on many uncertain factors. Therefore, there could be no safe and justified estimate of the exchange rate against the dollar in 1986-1987. She reminded the Committee, however, that the bulk of any savings made by the Regional Office due to a favourable exchange rate would have to be returned to WHO headquarters. Concerning staffing, there was to be no increase in the number of staff under the regular budget, although it was proposed to increase by six the number funded from other sources. The Group had asked the Regional Director to consider whether a redistribution of staff might be possible, so as to improve efficiency and to ensure that as far as possible the most important programmes were the responsibility of staff paid from regular funds. The Group had taken notice of the fact that it was becoming increasingly difficult to obtain extrabudgetary funds, and had made proposals for the possible co-financing of meetings arranged by the Regional Office. It had been noted that the funds available for country programmes had been shown in the proposed programme budget as "programme support". Arrangements for the disbursement of those funds should be coordinated with the overall WHO budget procedures. The Group had noted that the Regional Director would seek a solution to that problem before the thirty-fourth session of the Regional Committee. Professor ISAKOV (Union of Soviet Socialist Republics) gave a generally favourable assessment of the activities carried out in the Region under the Sixth General Programme of Work, and especially of those in the fields of disease prevention and health promotion. There were a few specific comments that he would like to make, however. One cause for concern, for example, was the marked reduction in the number of WHO fellows .sent to study in various countries of the Region: there were 300 fewer fellows than in 1982. Urgent measures were needed to correct the situation that had arisen. He stressed the need for greater efforts to foster and coordinate research and to prevent and control the most widespread and dangerous diseases. Work on the medical and health aspects of environmental protection was also of particular significance. In future, resources should be focused on developing activities to protect family health, and in particular to prevent chronic childhood diseases and to organize child health protection within the framework of primary health care. He went on to say that WHO's Regional Office for Europe was paying more attention to alternative methods of care than they deserved. In conclusion, he emphasized that the comments contained in document EUR/RC34/3 should lay greater stress, for example, on resolution WHA37.17 entitled "Monitoring progress in implementing strategies for health for all by the year 2000"; among other things, that resolution contained an extremely important statement affirming that attainment of health for all was "intimately related to socioeconomic development and commitment to and the preservation of world peace". Professor MERDJANOV (Bulgaria) said that his country's delegation had read the Regional Director's annual report with great interest. The fact that countries were paying more attention to the development of health services based on primary health care was proof of the indisputable contribution made by WHO's Regional Office for Europe. The conference on primary health care in the industrialized countries, held in Bordeaux in the previous year, had reviewed the work done to date and pointed out ways of solving existing problems. He went on to express support for the Regional Office's activities to control the most widespread noncommunicable diseases. Multisectoral efforts were essential for identification, containment and elimination of the factors that led to the rise in such diseases. Campaigns against harmful behaviour patterns and activities to encourage healthly lifestyles were also of particular importance. Individuals, families and society as a whole all had to be extensively involved in the control of environmental hazards, in order to solve the fundamental problems which stood in the way of attaining the overall goal of health for all by the year 2000. 98 REGIONAL COMMITTEE: THIRTY-FOURTH SESSION He also focused attention on the cardiovascular disease control programme. There was still not enough information on the extent of hypertension in communities, and work on solving that problem should clearly proceed in parallel with studies on genetic markers, salt consumption, etc. Nor had much yet been done to identify, develop and assess approaches to controlling ischaemic heart diseases. With regard to the cancer control programme, he was in agreement with WHO's viewpoint which advocated prevention and early detection of oncological conditions. In conclusion, he gave a favourable assessment of the work carried out in the European Region during the period under review. Under the present conditions of an escalating arms race and the real threat of nuclear conflict, more energetic steps had to be taken to implement the provisions of the UN resolution on peace, disarmament and prevention of nuclear war, as well as of resolution WHA36.22. Dr MÜLLER (German Democratic Republic) thanked the Regional Director and his staff for their considerable efforts in producing the report on the work of WHO in the European Region in 1983 and the interim report on work from January to June 1984, both of which the delegation of the German Democratic Republic had carefully reviewed. Among the multitude of activities, tasks and problems described in those reports, his delegation wished to draw attention to the following questions; in the introduction to his annual report, the Regional Director had rightly pointed out that it had become apparent during the period under review "that the scientific community and national health authorities must regard the health of the population in much broader perspectives, taking into account not only social and economic developments but also the environmental and behavioural patterns of people in given societies". His delegation found that unfortunately those very significant statements of principle were not adequately reflected in the following sections of the annual report. A major shortcoming of the report was that the real sociopolitical situation in the Member States of the Region had been considered in too undifferentiated a fashion, leading to unjustifiable and nonscientific generalizations being made. That was apparent from the following example: the introduction to Chapter 6 of the report mentioned the increasing problem of unemployment among physicians and, in that connection, the importance of communication and cooperation between educational and health systems. It went without saying that in the German Democratic Republic, as in other European member countries of the CMEA, not only was there no increase in unemployment among physicians, but there was no unemployment at all. Despite a complex external trade situation, the social antagonisms in production relations that were necessarily responsible for unemployment, poverty, homelessness, drug addiction and other social afflictions had been done away with forever in his country by means of a socialist planned economy. It would be obvious to any objective reader that the annual report reflected activities which did not do justice to all the countries in the European Region. The delegation of the German Democratic Republic was very pleased that the annual report had a special feature on women and health. Women and mothers had always enjoyed special welfare facilities in the German Democratic Republic. One of the first laws adopted by the State which had been founded 35 years ago was that of September 1950 on the protection of mothers and children and the rights of women. The efficient socialist health care system was another significant social achievement. It was also a source of pride that the German Democratic Republic was among the countries with the lowest maternal and infant mortality rates. It was certainly possible to imagine the health services in the German Democratic Republic without men but not without women, since the latter accounted for 88% of the 580 000 staff in the health system. His delegation noted with great pleasure that cooperation with the Regional Office had fundamentally improved in recent years. A visible expression of that trend was the outline plan of work for joint activities in 1984-1985; it was an eloquent example of how constructive the cooperation of an individual state with WHO could be, as both the Director-General and the Regional Director had stressed in their statements. Despite that positive development, the German Democratic Republic's cooperation and involvement in the activities of the Regional Office for Europe were still far below the average and in no way even came close to exhausting the potential capabilities of both sides. In that connection, his country welcomed the statement in the annual report that more extensive recourse should be had to the proven network of collaborating centres and that joint activities should be stepped up. The delegation of the German Democratic Republic endorsed the Regional Director's statement in the introduction to his annual report that in a region such as Europe it was not easy "to create basic policies" and that it had been worth serving "as a bridge between groups of countries having health systems with different socioeconomic backgrounds and with quite a variation in the resources available for health activities". In the European Region, as in no other, a multitude of states with different socioeconomic structures had found in WHO a way of working with each other; that was not only a great opportunity but also an obligation for all the Member States, the Regional Committee and the Regional Office. Positive multilateral cooperation in the fields of health and MINUTES OF THE SIXTH MEETING 99 medical science could be seen as a contribution to implementation of the final act of the Helsinki Conference, as the Director-General and the Regional Director had emphasized in their statements on the universality of WHO. By still more active cooperation, the Regional Committee for Europe could make a considerable contribution to moving towards a policy of détente and understanding in Europe and throughout the world. His delegation felt that the Regional Director was giving a binding explanation and making a personal plea when he wrote at the end of the introduction to his annual report that "a peaceful, constructive relationship between the Member States is essential if our goal is to be reached". Since the annual report already referred to packages such as "health and energy", "women and health" or "social justice and health", it was time that a complex answer was also given to the fundamental question of "peace and health". Hopefully that would be the case as from the beginning of the United Nations International Year of Peace in 1985. In that connection, the document on European targets contained encouraging statements on the tasks and responsibility of the European Region of WHO. The delegation of the German Democratic Republic had already expressed its position on that subject on the previous day. 3. DETAILED REVIEW OF THE PROPOSED PROGRAMME BUDGET 1986-1987: Item 11.3 of the Agenda (EUR/RC34/9) Dr ASVALL (Director, Programme Management) said that there would be six separate presentations for the budget. After each presentation, the delegations would be given the opportunity to comment on and discuss the proposals laid before them. Chapter I dealt with health and health-related problems, Chapter II set out the relationship between the 1986-1987 programme budget proposals, the HFA2000 policy and the Seventh General Programme of Work, while Chapter III contained a budgetary analysis. Document EUR/RC34/Conf.Doc./4 established the links between the programme budget, the Regional Director's report, and World Health Assembly resolutions. The three main issues he would address would be the structure and format of the programme budget document, the direction of the progranme, and the budgetary implications. Taking the structure and format first, he said that the aim had been to translate the policies of HFA2000 and the Seventh General Programme of Work into an operational programme. The basis had been a rolling plan concept, i.e., a four-year projection beyond the biennium period. The main difference in style arising from the 1982 Regional Committee decisions was that the budget was now presented as a unified whole, i.e., the previous narrative information was now integrated with the budget provisions for each progranme. In the context of narrative, he moved on to Chapter IV, Intercountry programmes, where changes made in already approved targets had been indicated, as had any cancellations, merges or moves. Targets with a deadline in the present biennium had been kept in the budget but marked "completed" as it was expected that that would be the case. He proposed that the next session of the CGPD might look into the matter of how that record should be kept in future bienniums. In addition, the links with intergovernmental and nongovernmental organizations and WHO headquarters had been indicated for each target, as had links between EURO programmes. In Chapter V, Country programmes, a more extensive introduction had been given. It should also be noted that Algeria had left the European Region, and had accordingly been deleted from the tables in that chapter. The Annex to the budget provided a comparison between the global classificaton for the Seventh General Programme of Work and the corresponding programmes for the European Region. The consultation process for preparation of the present programme budget had begun in the autumn of 1982, with a systematic in-house evaluatory review of all programmes which had led to a number of changes being proposed. The first draft of the new proposals had then been prepared in the spring of 1983, and subsequently edited and translated in time for the consultation briefing seminar in October 1983. The proposals had then been transmitted to the Member States, and their comments and priorities had resulted in an in-house rewrite of the document. The revised document had then been presented to the CGPD and CGBQ in April 1984 and finalized in May 1984. It was now being presented to the Regional Committee and would eventually form part of the Director-General's overall proposal to next year's Executive Board and World Health Assembly. 100 REGIONAL COMMITTEE: THIRTY-FOURTH SESSION The regional strategy for HFA had already provided the basis for the 1984-1985 programme budget, so the changes were not extensive. However, in future, important modifications might have to be made in the light of the HFA targets. Under the Seventh General Programme of Work, WHO had four roles: making existing knowledge available to Member States; promoting research; promoting national HFA policies; and fostering international cooperation. Those roles were an important part of the "background" to preparation of the budget, as was the necessity to maintain zero real growth. There had been a shift towards country programmes of approximately 15-20%, in line with WHO's overall roles as set out in the Seventh General Programme of Work. Working groups had been cut by approximately one third, while more regional courses were planned and studies remained the same. No programmes had been dropped and none had been added. One programme formerly called "Unemployment and health" had been renamed "Social equity and health". It was hoped to have more networking and collaborating centres, with the general aim of achieving more flexibility. At the end of the previous biennium it had been possible, from savings, to help certain countries in the promotion of HFA. To continue that, a provision had been made in the budget for "Promotion of HFA issues in country programmes" in 1986-1987. Of the targets for 1986-1987 proposed in the 1984-1985 programme budget, 90% remained and only 10% had been dropped, but of the remaining ones, some would either be reached in 1984-1985 or were being postponed beyond 1987. There was an emphasis on health promotion and preventive activities. Noncommunicable diseases had also been given prominence, as had primary health care and appropriate technology. In the environmental field, chemical safety and the International Drinking Water Supply and Sanitation Decade had been especially noted. Tables on staffing and budget for each intercountry programme, comparing 1984-1985 with 1986-1987, had been included. A separate summary table gave the same data, but arranged according to the global classification: that would be the presentation used in the Official Records published by WHO headquarters. There would be a provision of US $36 503 100 for the regular budget. Funds from other sources (UNDP, voluntary contributions, etc.) had been budgeted at US $8 084 400. However, he was sure the Committee appreciated how difficult it had been to make an accurate forecast of the latter. The increase in the projected budget had been due to three factors: anticipated changes in exchange rates, cost increases, and real increases. The relationship between the Danish krone and the US dollar had been the main factor taken into consideration, and after consultation with the CGBQ an exchange rate of 8’. 1 Danish kroner to the US dollar had been taken. Although regular budget funds for country programmes were given as increasing by 17.5%, in fact cost increases accounted for 13.5%, leaving only a 4% real increase. As a result, the funds allotted to country programmes amounted to US $70 000. As compared to 1984-1985, the major heads of expenditure had been increased as follows: 13.5% for the Regional Committee and its advisory bodies; 2% for salaries and allowances - while keeping staffing levels constant; 17.5% for country programmes. There would be a 12% increase for intercountry projects and a 2% decrease for common services. Duty travel would remain unchanged. Among the intercountry programmes, there would be an increase in general programme development, health education and health information and research, and a decrease in health systems. The programmes on mental health, environmental health, diagnostic and therapeutic substances and disease prevention would remain approximately the same. Ideally, the Office should expand to follow up the regional HFA targets, but he was well aware of the economic constraints Europe was facing. The desired results would therefore have to be obtained by internal reorganization. In terms of voluntary support he would be looking not so much for direct funding but for Member States to take networking into account when planning their budgets. Alternative forms of financing would be discussed at the next meeting of the CGPD, and a study group had been established to prepare recommendations for that meeting. In conclusion he said that the programme budget was not just a legal document for the Regional Committee's approval; more and more, it was becoming an important tool for implementation and monitoring of practical measures, and a useful reference document when planning cooperation through country programmes. Dr ACHESON (United Kingdom) said that his delegation was generally satisfied with the overall balance between programmes. In particular, they welcomed the emphasis on programmes on health promotion, health education, and environmental health. MINUTES OF THE SIXTH MEETING 101 His delegation also welcomed the fact that taking account of provision for inflation and statutory increases, the programme budget for 1986-1987 was based on projected zero real growth. They were glad that, within that overall standstill, the Regional Director had been able to freeze heads of expenditure and to find savings in certain areas so that country programmes, in particular, could be increased. His delegation particularly welcomed the practical approach reflected in the concentration on studies rather than meetings, as mentioned in paragraph 4 of Chapter II, and the change in balance between areas of expenditure, as shown in Table 1 of Chapter III. That approach reflected the secretariat's desire to obtain value for money in extremely difficult times. With the Chairman’s permission, he wished to comment on one particular aspect, namely the section on drug policies and management. One of the activities for attaining target 1.1.4 of that programme was the institution of the "Summary basis of drug decisions" scheme. As that concerned information about the registration of medicinal products licensed by Member States, his delegation questioned whether it was an area in which WHO should become involved. The United Kingdom delegation also had doubts about the Drug bulletins review mentioned in connection with target 2.1.3 since to some extent it might be a duplication of the Drug information bulletin produced by headquarters. A further area of concern related to the guidelines on specific groups of drugs. The United Kingdom issued detailed guidelines on the data requirements for clinical trial certificates and product licences. Guidelines on the clinical investigation of drugs were not issued, although he recognized that such guidelines might be helpful to some countries. Nevertheless, he would point out that similar work was already being done, for example, by the working party set up by the EEC Committee for Proprietary Medicinal Products, which among other things was preparing clinical guidelines. Those could presumably be made available to countries outside the EEC and the United Kingdom delegation was concerned that the WHO guidelines might duplicate or be at variance with the EEC guidelines. For those reasons his delegation asked for the item to be reconsidered carefully before any final decision was taken. He was sure that he did not need to remind the Committee of the realities of zero real growth. It was necessary, therefore, to be certain that particular programmes had the required high priority before allowing them to proceed. In that context, he would like to point out that the programme budget stated that funding of the cardiovascular programme was to be reduced by 4.36%, in spite of the very high priority assigned to it by the Regional Committee. Professor KRYST (Poland) supported the programme budget for the years' 1986-1987 and expressed his great satisfaction with the report of the Regional Director, which gave a comprehensive presentation of the activities of the Regional Office. Special mention should be made of activities aimed at developing and implementing the regional strategy for HFA2000, together with health education of the public and information on the health status of populations. Both the management and use of health care resources and the promotion of women's health had also been emphasized. He also wished to stress that the period since 1967, during which Dr Kaprio had been in charge of the Regional Office, had been one of great success for the European Region. On behalf of the Polish delegation, he wanted to pay tribute to Dr Kaprio and his staff for their efficient work. He wished to emphasize once again the fundamental importance of preserving peace as a vital prerequisite for both human existence and health. That was rightly considered in the target document as the most important condition for achieving HFA2000. The threat and fear of war could be eliminated by strengthening cooperation, promoting mutual respect among nations, and disseminating information on the consequences of nuclear war. In Poland, implementation of the HFA2000 strategy and the promotion of primary health care were continuing, and the effectiveness of methods of preventing afflictions such as cardiovascular diseases, cancer and accidents was being intensively studied. Great attention was also being paid to women's health, as shown by the construction of a facility to be called the Memorial Hospital - Mother's Health Centre. His Government had great pleasure in continuing to support the Regional Office and was ready to strengthen and extend both regional and bilateral cooperation in relation to the European strategy for HFA2000. Dr WESTERHOLM (Sweden) said that the Committee had before it a very clear and well written programme budget. A kind of consensus on the targets had been reached on the previous day. Ideally, the programme budget should follow the main lines of the target document. Her delegation understood the difficulties involved in reorganizing the programme budget both with regard to the global programme structure and the need for continuity in the programme budget process. The aim, however, had to be to follow the target document more closely in the future. 102 REGIONAL COMMITTEE: THIRTY-FOURTH SESSION Her delegation was pleased to note that, in line with the regional targets, priority was given to health promotion and they also endorsed the priority given to health promotion and to programme management and development. In contrast, however, there was not sufficient emphasis on the equity aspect, and she would return to that matter later. Her delegation also welcomed the increased flexibility and the redistribution of resources since it was vital, in view of the economic situation, that flexibility should be preserved and that the Regional Office should concentrate on a smaller number of programmes. In particular, certain programmes of marginal interest to Europe might be transferred to the global level. Mrs DE LA BATUT (France) congratulated Dr Asvall on his nomination and joined with other delegations in expressing thanks to Dr Kaprio. The French delegation welcomed the new presentation of the budget, by which the information previously contained in Part II had now been incorporated into the main part of the document. That arrangement made it simpler to read, but she hoped it would be improved still further since there were still some instances of repetition, e.g. Tables 1 and 2 in Chapter V. The layout of the budget by programme was in accordance with United Nations guidelines, but it should have included a more comprehensive summary table by head of expenditure (staff salaries, travel, meetings, payment of experts and consultants, fellowships, grants to collaborating centres) than that given in Table 1 of Chapter III. Such a breakdown would give a better view of the costs involved and was already made by the Regional Office since the document stated, for example, that 80% of expenditure was affected by increases in the cost of living in Denmark and gave percentages for increased expenditure on salaries and travel. A summary table of that kind could therefore be included without entailing additional work for the secretariat. In the "programme perspective" section, the description of activities listed in pellmell fashion those activities that were planned for the 1986-1987 biennium (the only ones on which the Committee had to express its views at the present session), those scheduled for following years, those which had already been carried out and those which had been discontinued. That might provide the secretariat with a useful working tool, but it did not make the delegations' task in considering the document any easier. No distinction was made between activities carried out by the Regional Office, those which required additional staff to be recruited and those funded from sources other than the regular budget, over which the Committee had no decision-making powers. Lastly, each of those activities (cost of a consultant, a meeting, etc.) should be quantified. Comparison of cost/benefit ratios would enable activities to be ranked by priority. The proposed overall total budget for the period 1986-1987 showed an increase of 3.74%. It was not clear precisely what the rate of real growth was: 0% according to the budget document, or 0.25% according to document EUR/RC34/8. That might appear to be a small increase, but the figure on which it was calculated should be clearly stated. It was also stated in a footnote to Chapter III that the allocation of US $396 000 for Algeria had been removed from the original budget. For purposes of comparison, therefore, reference should be made to the budget of the previous period less those sums allocated to Algeria for projects and support expenditure. Algeria's allocations should be included in the budget of the African Region and would be found in the Organization's global budget, which was to be met by the Member States as a whole. In addition, as a result of the appreciation of the United States dollar, the preceding financial periods had shown an excess of resources over estimated expenditure. The percentage increase of the budget should therefore be calculated in terms of figures revised to take account of that surplus. It would have been useful to have a document giving the balance sheet for 1983. In that connection, the French delegation emphasized that the "savings" made as a result of fluctuations in exchange rates should be regarded not as casual income but rather (and that was in line with the United Nations ruling) as additional funds which, unless the World Health Assembly decided otherwise, would be paid back to Member States against their contributions. That was the procedure which had been used in another organization. Of course, it was difficult to forecast exchange and inflation rates, but the exchange rate used when calculating the budget seemed somewhat arbitrary to the French delegation, and they would welcome with interest any suggestion on that subject. The European Region's budget would be added to those of the other regions to form WHO's overall budget. Some of those other regional budgets would probably be showing an increase of more than 3.84%. Maintenance of zero growth in real terms for the Organization's overall budget, as advocated by France and other countries, accordingly implied a redeployment which would take the form of a reduction, in terms of real growth, in the European Region's budget. Such a MINUTES OF THE SIXTH MEETING 103 redistribution would be in line with France's - and WHO's - policy of giving preferential treatment, in budgetary options, to those developing countries that were in greatest need of support from the international community. To prepare for that eventuality, degrees of priority should be assigned to the proposed activities when the programmes were being reviewed. The French delegation asked for some clarifications with regard to document EUR/RC34/8. They wished to know the reasons for the 13% increase in expenditure on the Regional Committee and what repercussions the promotion of secretaries (section 4) would have on staff costs, and they would like information on the solution to the problem raised in paragraph 3.4.6 of that document and on the subject of the creation of six additional posts (paragraph 3.4.4); was there a relationship between that move, which was contrary to the general policy of a freeze in numbers of staff, and the promotions mentioned in section 4? The French delegation saw no grounds for increasing the Regional Director's Development Fund from US $120 000 to US $425 000, since Europe was a region with few developing countries and any emergencies which might occur could be tackled in other ways, for example by carrying funds forward. Her delegation was in favour neither of the creation of a health development fund or a health research fund, nor of the financing of preliminary studies. Generally speaking, the French Government did not view favourably the seeking of so-called extrabudgetary funds to supplement the financing of activities covered by the Organization's regular budget. That comment was obviously directed neither towards specific projects carried out by WHO with funds allocated by other United Nations agencies, nor towards contributions to special programmes with clearly defined goals, nor to the support that States might provide to the Organization for courses or collaborating centres. The REGIONAL DIRECTOR said that he would deal with all the comments at the end of the discussion, but would like to clarify the issue of casual income and savings raised by the delegate of France. The World Health Assembly had decided many years ago that nearly all casual income would be returned to Member States. Such income could not be used by WHO except for certain special purposes, such as the buffer fund established at headquarters for dealing with a decline in the US dollar in terms of the Swiss franc. It had also been decided that the same system should apply to the regions. On the other hand, owing to the recent rise in the value of the US dollar, the European regional budget had already been cut by US $5 million in 19S4. The Regional Office did not yet have a reserve of the type existing at headquarters to safeguard it against a fall in the US dollar, and it was for that reason that the dollar rate selected had been somewhat on the low side. Some casual income had of course been derived from increases in interest rates, but that did not help the Regional Office. Dr RAKCEEV (Union of Soviet Socialist Republics) noted with satisfaction the great amount of work done by the secretariat at the Regional Office on drawing up the proposed programme budget and their prior inquiries as to the opinions of the Member States on the perspectives for development of planned activities in Europe. At the same time, the Soviet delegation had some comments of a general nature to make on the question under consideration. Firstly, the new form in which the budget document was presented did not correspond fully with the provisions of resolution EUR/RC32/R5, which suggested that the two parts of the budget should be combined and the overall length of the descriptions of intercountry projects should be limited, thereby making it easier for countries to receive as much information on those projects as in the past. It was not at all intended to cut down information on the titles of projects and the sums allocated to them. In their view, therefore, the provisions of resolution EUR/RC32/R5 could not be regarded as having been fulfilled. The resolution had had the purpose of making it simpler and easier to use the proposed programme budget document and of excluding the possibility of duplication of material, and not of making it less informative. The 1986-1987 proposed programme budget (document EUR/RC34/9) was manifestly less informative than that for the period 1984-1985. In that connection, he also wished to comment on the first operative paragraph of the draft resolution. Secondly, the regular budget of the European Region was continuing to grow, even in real terms (by 0.21%), despite the fact that the Thirty-sixth World Health Assembly and the thirty-second session of the Regional Committee for Europe had adopted resolutions on zero budgetary growth. Thirdly, the resources allocated to intercountry activities were continuing to fall (by 16% compared with the previous biennium). However, they included precisely those types of measure that were the subject for discussion at the Regional Committee for Europe and which successfully yielded to long-term planning (as had been pointed out, incidentally, in Chapter V of the budget document), besides being relatively easily evaluated and monitored. Conversely, there were increased allocations to country programmes which could not be precisely planned even two years in advance, and again as stated in Chapter V, those allocations were in practice neither discussed nor monitored by the Regional Committee. 104 REGIONAL COMMITTEE; THIRTY-FOURTH SESSION In conclusion he emphasized Chat, like Che French delegation, the SovieC delegation considered that the arguments put forward in the proposed programme budget for 1986-1987 in favour of an increase of approximately 254% in the allocations to Che Regional Director's Development Programme were not sufficiently convincing. It might be that there were some other grounds for such an abrupt increase in allocations, in which case he would be glad to learn of them. The Soviet delegation also supported France's view concerning the suitability of including allocations to two voluntary funds in the proposed programme budget. Such a step would appear to be premature. Mr APAKAN (Turkey) said that his delegation welcomed the format and content of the budget document and also endorsed its basic orientation. With regard to the country programmes, his delegation was pleased to note the increased flexibility with regard to the use of budget resources in supporting them. He also noted with satisfaction Che real increase in the budget allocation to country programmes, which was to be commended. Three points deserved further consideracion in relaCion Co the country programmes. The first concerned the improvement of health sCrucCures in countries benefiting from those programmes', that was the real issue which should continue to be addressed. The second related to human resources development, where his delegation took the view that wider use could be made of fellowships. Finally, ways should be sought, through the country programmes, to recruit national consultants whenever feasible. Dr MÜLLER (German Democratic Republic) said he wished to make several comments on the proposed programme budget. Firstly, his country was on principle against a continuous increase in the regular budget, especially when those resources were being used not exclusively for programme and project activities but also for greater expenditure on administration and staff. Secondly, there was on the whole an unfavourable relationship in the budget between expenditure for projects and programmes and that for administrative purposes. He noted, of course, that the proportion for the former had risen from 19.6% (1984-1985) to 21.5% (1986-1987), while allocations for administration had fallen from 79.6% to 77.7%, but the latter nonetheless showed an overall rise in absolute terms. Thirdly, progress in the right direction still appeared to be too slow, and the overall relationship in the allocation of resources between programme activities and administrative costs, which at present stood aC approximacely 20% to 80%, was still too unfavourable. Lastly, in connection with Europe's specific role in the work of WHO, it had to be urgently pointed out that certain specific areas of disease control that were of particular relevance to the European Region had not been sufficiently reflected in the proposed programme budget before the Committee. He referred in particular to the reduction in resources allocated not only to the control of acute respiratory infections, cancer and cardiovascular diseases (major programme 4), but also to research promotion and development, accident prevention and workers' health in major programme 3, Professor STEINBACH (Federal Republic of Germany) said that the citizens of his country enjoyed considerable liberties which the Government set great store by. It was sometimes difficult, therefore, to take regulatory measures, but those difficulties were accepted in order to preserve and extend the freedoms of his country's citizens. Despite the large number of priorities and the financial constraints being faced, he described the programme as a balanced one and congratulated the Regional Office on drawing it up. There were a few comments that he wished to make, however. Firstly, the Federal Republic of Germany had its own programmes, especially those on cancer and circulatory diseases, which laid great emphasis on prevention. WHO documents, on the other hand, frequently gave the impression that the curative sector was of secondary importance. Efforts had to be made to dispel that impression. Confrontation between the curative and preventive sectors occurred above all when unbalanced arguments were put forward in WHO documents. It also had to be remembered that the present generations would not be able to enjoy the benefits of prevention, and even if by the year 2000 people would be healthier and living longer lives thanks to prevention, there would still be cardiovascular diseases and cancers that required treatment. On the subject of drugs he shared the opinion of the United Kingdom delegation. There were so many tasks to be carried out in that field that one could not afford duplication of effort. In his view, the supranational evaluation of product licences was not WHO's job and would be strongly objected to. With regard to the financial aspects of the programme budget, he expressed the same reservations concerning repercussions on the adoption of the global budget in Geneva as the delegations of the Soviet Union and France. Although zero growth was apparent at first sight, the appropriations contained imbalances which jeopardized zero growth. He felt the proposed rate of exchange was unrealistic, and the basis of comparison for computation of the budget increase also needed correcting. MINUTES OF THE SIXTH MEETING 105 Mr ZANDVLIET (Netherlands) proposed that the question of exchange rates be further examined and suggested that a possible increase in the US dollar/Danish krone rate from 8.1 to 8.55 be considered. That modification would prevent an overall increase in the budget from 1984-1985 to 1986-1987. Or SIÀGAEV (Council for Mutual Economic Assistance) commented on certain aspects related to the proposed programme budget, the Regional Director's interim report and the document on regional targets in support of the regional strategy for health for all. More specifically, he said that particular attention should be directed towards the question of broad involvement of various international organizations, including the CMEA, in implementing the proposed programmes. However, as a result of the Regional Office secretariat being inadequately informed, the Council had been included as a participant in the plan of cooperation on certain subjects that were of no interest to it. He recalled that he had forwarded the document in question to the secretariat, together with the necessary clarifications and additional comments concerning CMEA participation in various programmes of cooperation and joint projects. He hoped that the comments contained in that document would be taken into account when the final draft of the proposed programme budget was drawn up. The budget document was in all respects a difficult one, and on the whole he was most appreciative of its quality. Turning to the regional target document, he recalled the fundamental directions laid down for activities in the public health field at various levels and drew the delegates' attention to the importance of a method that was broadly applied in the socialist countries, namely ensuring coverage of the whole population by means of dispensaries. That method helped to ensure early detection of target diseases by means of screening, continuous observation of patients identified and compulsory preventive treatment. The member countries of the CMEA had developed a coordinated view of the principles of "dispensarization" and were planning ways of effecting a phased changeover to generalized dispensary-based care for their populations. Referring to the Regional Director's interim report for the first six months of 1984, he singled out for mention the Gabrovo model of health care and mass screening of the population, using teams made up of various groups of specialist medical personnel. That model had been favourably reviewed in the above-mentioned report and was of interest to the Member States of WHO. The report further stated that the Gabrovo model could also be seen as a field for the application of the European strategy for health for all by the year 2000. Returning to the regional target document, and in particular to Section 6 on research, he drew attention to the fact that the overall tasks had been correctly formulated but that approaches had not been worked out for applied research in the fields of cardiology and oncology. Targets 9 and 10 in Section 2 of the target document made provision for a marked reduction in fatality from those diseases, but that was hardly conceivable without new and specifically scientific achievements. The strategy for tackling those tasks clearly consisted in scientists in the countries of the Region joining forces, so far as possible, in the search for effective methods to prevent and treat those diseases, and also in improving the coordination of the corresponding scientific research. The REGIONAL DIRECTOR said that the secretariat could understand the Committee's difficulty in accepting the exchange rate proposed in the budget document, but in that case the Committee should propose a new one. The matter could of course be referred to the Director-General, who could make a final correction when setting the global programme budget. So far as the reduction in programme areas was concerned, that reflected the policies accepted by the Member States themselves, namely to place more emphasis on etiology and prevention. Lastly, the Regional Director's development fund had been increased in order to allow for flexibility in answering the urgent needs of countries. Mr WESTENBERGER (Director, Support Programme), referring to the statutory increases in staff costs, recalled that those had been studied by the CGBQ which had agreed that 2-3% was required for the biennium, to cover reclassification of posts, within-grade salary increments, an increase in contributions to the UN Joint Staff Pension Fund, etc. The increases were therefore not due to inflation but were to be absorbed in the overall 13.5% cost increase accepted by the CGBQ for the biennium. Replying to France's question about the increase in Regional Committee costs, Mr Westenberger explained that the figure given in the document included expenditure on the advisory bodies (CGPD, CGBQ and RHDAC), mainly for language staff and experts recruited as temporary advisers. The figure of US $301 000 estimated in the 1986-1987 programme budget was 13.5% higher than the 1984-1985 allocation of US $265 300; however, the amount actually used for that purpose in 1982-1983 had been US $262 000. 106 REGIONAL COMMITTEE; THIRTY-FOURTH SESSION With regard to the exchange rate used, there was a growing consensus among economists that the US dollar was overvalued by 25-30%, and there were fears tht it might fall sharply at some time in the future. There could therefore be nothing but extreme uncertainty on that point. Dr ASVALL (Director, Programme Management), referring to the proposal of the delegate of Sweden that the programme budget should follow the layout of the regional HFA target document, recalled that the Regional Committee had also discussed that point at Fez when the regional strategy had been accepted. However, in view of the global programme classification, it had then been decided to maintain the present layout but, if the Committee agreed, the secretariat could raise that question again at the April 1985 meeting of the CGPD so that it could be referred back to the Regional Committee at its next session. With reference to the comment by the delegate of France concerning a breakdown of costing elements, Dr Asvall confirmed that cost estimates for each activity were available with the secretariat but that the documentation would be voluminous if they were to be included. Specific items could, however, be studied on request. With regard to the additional posts mentioned in paragraph 5 of Chapter III of the budget document, the Director-General had allocated resources in 1984 for extra staff in the field of appropriate technology, but it was not certain that that measure could be continued in the 1986-1987 biennium and it had therefore been included in the regional proposals for funding from voluntary contributions. Secondly, attempts had already been made, without success, to obtain voluntary contributions for extra staff on psychoactive drugs and drug policies and management, and their posts would probably have to be covered from other regional resources. Thirdly, the requirement for a junior programmer post reflected the increased computer services the Regional Office was now making available to Member States; and lastly, the need for a country programme coordinator was due to the considerable increase in work involved in the preparation of country programmes. In answer to the request of the USSR delegate for more information on individual programmes, he suggested that that matter could be taken up by the CGPD at its meeting in April 1985. It was true that the ratio of expenditure on staff to programmes of 80% to 20% might appear unbalanced, but it should be borne in mind that the staff of the European Region also covered country programmes and therefore had to have a close network of contacts with national counterparts, IGOs and NGOs throughout the Region. As regarded the increase in the Regional Director's development fund, it was in fact very much lower in Europe than in other Regions, but it was essential to have sufficient operational flexibility to face sudden problems in health developments in the Region. The use of that fund was reported back to the advisory bodies, so that Member States were kept informed of the situation. He was sorry if it had been understood that WHO did not support prevention with regard to cancer; that had certainly not been the intention, as could be seen by the emphasis placed on cervical screening, as well as the establishment of the new programmes on smoking and alcoholism. Finally, he apologized to the CMEA representative for the omission of information on cooperation with that organization and explained that meetings were held every two years to discuss cooperation with IGOs and NGOs, the next of which was planned for the spring of 1985. Professor MARZIALE (Council of Europe), referring to Dr Siagaev's statement on certain intergovernmental organizations' cooperation with the Regional Office, recalled that for 25 years he had been listening to the representatives of governments complaining about duplication and advocating the need for those organizations to ensure that their activities were complementary, with results which were often far from satisfactory. A step forward was perhaps about to be made in the field of the control of drug abuse, since a number of pilot projects could soon be launched jointly by WHO, the Council of Europe and the European Communities. A consensus of principle had been reached by the experts consulted, and it was to be hoped that those experiments could begin next year. To do so, however, each member state of those various organizations would now have to make its position clear and allocate the funds required to ensure that that joint work could begin under the proper conditions. The credibility of those organizations and of the governments which made them up was at stake, and the latter had to be fully aware of their responsibilities and of the need to rationalize their activities. The bodies involved would be judged, both by governments and by pwblic opinion, on their efforts to implement that new activity next year.