7Years of WHO in the Region

For 70 years, the World Health Organization’s Regional Office for South-East Asia – which in 1948 was the first WHO region to be established – has been collaborating with its Member States to improve the health of all people in the Region. This collaboration has resulted in many remarkable achievements in improving people’s health. This book is an account of the journey of health development in countries of the South-East Asia Region. It describes the main achievements, challenges, and A Healthier South-East Asia: strategies to tackle public health problems specific to this Region in an historical A Healthier South-East Asia perspective.

Arranged chronologically around work carried out in each decade of collaboration, the various approaches in tackling health issues are outlined, including their successes in disease control, elimination and eradication, and in the improvement of health systems. The book also indicates the chosen path towards achieving the dream of health equity – universal health coverage. This historical document should be of compelling interest to all those who want to learn about health developments in the South-East Asia Region in the last 70 years. 70 Years of WHO in the Region

9 789290 226673 ii A Healthier South-East Asia A Healthier South-East Asia iii A Healthier South-East Asia: 70 years of WHO in the Region

ISBN 978-92-9022-667-3

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iv A Healthier South-East Asia A Healthier South-East Asia

Years of WHO in the Region

A Healthier South-East Asia v Conference hall at the Regional Office in Indraprastha Estate, New Delhi. The murals on the walls were painted by internationally renowned Indian artist Maqbool Fida Husain in 1963, entitled ‘History of Medicine’

vi A Healthier South-East Asia A Healthier South-East Asia vii Foreword by the Regional Director

The World Health Organization’s Regional Office for South-East Asia was the first regional office to be established. The year was 1948. Europe was in difficulty. The colonial world was collapsing. The world was being built anew. Naturally, though there must always be a first, it is possible that WHO South-East Asia’s ‘presence at the creation’, so to speak, reflected just how central our Region was – and still is – to global health and humanity’s shared future.

As we celebrate the WHO South-East Asia Region’s 70th anniversary, that point is worth contemplating. Our Region is home to more than a quarter of the world’s population. It has struggled more than many against disease and pestilence and against hunger, want and the many social determinants of health that people across the Region – and the world – encounter every day. And yet through it all we have made remarkable gains. Indeed, with the commitment and resolve of each of our 11 Member States we have achieved ground-breaking success, changed the course of history, and delivered the kind of results that provide a cogent riposte to those who deny humanity’s forward progress.

This is the story the following pages tell. A story of struggle, yes. But also a story of triumph. A story of how gradually and inexorably health systems have been strengthened. A story of how killer diseases have been vanquished and how innovative technologies backed by effective policy have made that possible. A story of ordinary people – their daily struggles and their life- changing experiences. A story of how their health has been transformed for the better. Indeed, a story that covers the breadth of the last seven decades and the effect our Organization has had on the health and well-being of a population that now equates to a staggering 1.8 billion people.

In telling this story, every attempt has been made to ensure both the public health fraternity as well as non-health audiences are provided key takeaways, both compelling and informative. Initial chapters, for instance, focus on our battle against a series of priority diseases, from tuberculosis to yaws, and viii A Healthier South-East Asia to the Organization’s attempt to eradicate malaria, even while enhancing the capacity of key training institutions.

Subsequent chapters describe the unyielding – and ultimately successful – quest to eradicate smallpox, as well as the introduction of oral rehydration solution as a standard means of combating diarrhoeal deaths. They also outline the global adoption of the Expanded Programme on Immunization, the Health for All movement, and the Organization’s revised strategies to tackle malaria and address HIV/AIDS alongside several noncommunicable diseases.

And in the final chapters, focus is increasingly given to implementing the DOTS strategy to combat TB, efforts to strengthen national immunization programmes and services for maternal, child and newborn health, to enhance tobacco control, and to fortify health security via the International Health Regulations. Notably, they also document how several diseases such as yaws, maternal and neo-natal tetanus, malaria, measles and trachoma among others have been eliminated either Regionwide or from several countries.

In recounting our many and varied achievements, it would of course be remiss of me not to mention our conquering of polio in 2014 – an achievement that is up there with our eradication of smallpox and which was also complemented the following year by being credited with halting and reversing the HIV, tuberculosis and malaria epidemics, all key Millennium Development Goals.

Indeed, while WHO South-East Asia may have been present at the creation, we are also defining the future. In an age where achieving universal health coverage is more than an ambitious slogan, our Region provides a critical test for humanity’s resolve to leave no one behind. Our ability to overcome challenges and achieve the dream of health equity is crucial to our collective vision: A vision that is – first and foremost – regional in scope, though unavoidably global in consequence.

Dr Poonam Khetrapal Singh Regional Director WHO South-East Asia Region

A Healthier South-East Asia ix Abbreviations

ASHAs Accredited Social Health Activists in EWARS Early Warning, Alert and Response India Systems AFP acute flaccid paralysis FAO Food and Agriculture Organization of AMR antimicrobial resistance the United Nations ARI acute respiratory infections FCHV female community health volunteer ART antiretroviral therapy FCTC WHO Framework Convention on Tobacco Control ASEAN Association of Southeast Asian Nations FINNIDA Finnish International Development AusAID Australian Agency for International Agency Development (until 2013) GDF Global Drug Facility BCG Bacillus Calmette–Guérin vaccine GFATM Global Fund to Fight AIDS, Tuberculosis and Malaria (or simply the Global BIRDEM Bangladesh Institute of Research and Fund) Rehabilitation for Diabetes, Endocrine and Metabolic Disorders GMP Good Manufacturing Practices GNM General Nursing & Midwifery CAPD continuous ambulatory peritoneal dialysis HeLLIS Health Literature, Library and Information Services CARE Cooperative for Assistance and Relief Everywhere (to 1993 Cooperative for HBV hepatitis B virus American Remittances to Europe) HCV hepatitis C virus CCS Country Cooperation Strategy HIV/AIDS Human immunodeficiency virus/ CDC Centers for Disease Control and acquired immune deficiency syndrome Prevention I2I innovation-to-implementation CDD control of diarrhoeal diseases ICRC International Committee of the Red CHWs community health workers Cross CIDA Canadian International Development IDD iodine-deficiency disorder Agency (until 2013) IDP Internally displaced person CRD chronic respiratory disease IDUs injecting drug users DDS diaminodiphenyl sulfone (dapsone) IHR International Health Regulations DFID Department for International (2005) (2005) Development IMCI Integrated Management of Childhood DHF dengue haemorrhagic fever Illness DPT diphtheria, pertussis (whooping IMNCI Integrated Management of Newborn cough), and tetanus. and Childhood Illness ESCAP Economic and Social Council for Asia IMPO International Medical Parliamentarians and the Pacific Organization

x A Healthier South-East Asia IPV inactivated polio vaccine SEA WHO South-East Asia Region JICA Japan International Cooperation REGION Agency SEARO WHO South-East Asia Regional Office MCH maternal and child health SIDA Swedish International Development MDA mass drug administration Cooperation Agency MDGs Millennium Development Goals STIs sexually transmitted infections MDR-TB multidrug-resistant tuberculosis TB Tuberculosis MDT multidrug therapy TBAs traditional birth attendants MMR maternal mortality ratio TDR United Nations Development Programme/World Bank/WHO Special MSF Médecins Sans Frontières Programme for Research and Training NCDs noncommunicable diseases in Tropical Diseases NGOs nongovernmental organizations TT tetanus toxoid NHSO National Health Security Office UCI universal child immunization (Thailand) UHC universal health coverage NID national immunization day UN United Nations NORAD Norwegian Agency for Development UNCAP UN Consolidated Appeals Cooperation UNDAF United Nations Development NTDs neglected tropical diseases Assistance Framework OIE World Organisation for Animal Health UNDP United Nations Development OPV oral polio vaccine Programme ORS oral rehydration therapy UNFPA United Nations Population Fund PAS para-aminosalicylic acid (to 1987: United Nations Fund for PEI Polio Eradication Initiative Population Activities) PHC primary health care UNICEF United Nations Children’s Fund (to 1953: United Nations International Polio Poliomyelitis Children's Emergency Fund) PSI Population Services International UNTAET United Nations Transitional SAARC South Asian Association for Regional Administration in East Timor Cooperation USAID United States Agency for International SARS Severe Acute Respiratory Syndrome Development SDGs Sustainable Development Goals VHWs Village Health Workers SEA- South-East Asia Advisory Committee VRC Virtual Resource Centre ACMR on Medical Research WHO World Health Organization SEAPHEIN South-East Asia Public Health Educational Institutes

A Healthier South-East Asia xi Contents

Foreword viii Abbreviations x Introduction 5

A healthier South-East Asia 5 The beginning of the global multilateral system 7 WHO in South-East Asia 9

1 THE FIRST DECADE: 1948–1957 Setting up health agendas and tackling priority diseases 16

Creating WHO’s regional organizations 21 The beginnings of WHO-SEARO 25 The “Big Six” and other regional priorities 25 WHO Area/Country Representatives: A pioneering idea 27 Demonstration projects and long-term assistance 28 Supporting medical and nursing education 29 Comprehensive rural health 29 Developing maternal and child health services 31 Addressing environmental health, sanitation and water supply 32 Developing a systematic nutrition programme 33 Adopting malaria eradication as a goal 35 Swift launch of tuberculosis programmes 36 Projects on venereal diseases 37 A systematic approach to leprosy control 37 Reducing yaws 38

2 THE SECOND DECADE: 1958–1967 Building the health workforce and launching eradication programmes 42

Basic health units and health workers 44 Embarking on malaria eradication programmes 47 Exploring drugs in TB treatment 49 Planning smallpox eradication 49 Controlling trachoma in the community 51 Responding to polio outbreaks 52 Responding to other major communicable diseases 52

1 A Healthier South-East Asia Establishing leprosy control programmes 53 Tackling lymphatic filariasis 54 A future free from kala-azar and yaws 55 Country health programming 57 The World Health Assembly is held in New Delhi 57

3 THE THIRD DECADE: 1968–1977 The eradication of smallpox 62

Implementing country health programming 64 New philosophy of health development 65 Regional training centres 66 Enlarging the concept of maternal and child health 66 Establishing model rural health centres 69 Systematizing traditional medicine 70 Environmental health 72 Launching the Expanded Programme on Immunization 72 Reacting to emerging public health issues 74 Smallpox eradication and innovative disease control initiatives 75 Strategizing TB control 79 Oral rehydration therapy in cholera treatment 79 Cancer control programmes 81 Promoting biomedical research 81

4 THE FOURTH DECADE: 1978–1987 Primary health care and Alma-Ata: Landmarks of the ‘New Vision’ 88

The Alma-Ata Declaration: Concept, principles and the role of the Region 90 Applying the new concept 92 Promoting district health systems and management 95 The first meeting of health ministers 96 Consultative Committee for Programme Development and Management 96 The Safe Motherhood Initiative 97 Progress in environmental health 99 Reaching the community with human resources for health 100 Reaching out with technical programmes 101

A Healthier South-East Asia 2 Contents

Disaster preparedness and response 102 Revisiting malaria control 103 Integrating the tuberculosis programme 104 Recognizing viral hepatitis as a public health issue 105 The resurgence of yaws 105 Dengue research 106 The new scourge of HIV/AIDS 106 The looming threat of NCDs 108

5 THE FIFTH DECADE: 1988–1997 Targeting disease elimination, strengthening partnerships 114

Emphasizing partnerships and All-for-Health policies 116 Leading health promotion into the 21st century 119 Implementing the DOTS strategy 120 A new concept of reproductive health 122 Responding systematically to ‘ageing and health’ 127 Reducing the major nutritional disorders 128 Universal access to essential drugs 130 New challenges in environmental health: Impact of urbanization 130 National immunization days 131 Declaring targets for disease elimination and control 133 Responding to new, emerging and re-emerging diseases 134 Dealing with the double burden of diseases 136 Fighting the tobacco pandemic 138

6 THE SIXTH DECADE: 1998–2007 Towards meeting the MDGs 142

The Calcutta Declaration on Public Health 144 Strengthening the health workforce 147 Progress towards universal health coverage 148 Recognizing traditional medicine systems 152 Towards reaching the MDGs in maternal and neonatal health 152 Challenges to adolescent health 154

3 A Healthier South-East Asia Strengthening emergency preparedness and response 155 Protecting health from climate change 163 Responding to the threat of NCDs 164 Progress in disease eradication 165 Tackling new threats 170 Universal access to AIDS treatment 171 Reducing the threat from malaria 173 Progress in health promotion 174 Introducing WHO’s country cooperation strategies 174

7 THE SEVENTH DECADE: 2008–2018 From MDGs to SDGs–the dream of health equity 178 UHC as a key public health principle 181 Completing the MDG agenda on maternal and child mortality 182 Freedom from polio and the ‘Endgame’ plan 185 Maternal and neonatal tetanus eliminated 189 Last push to eliminate measles 190 Accelerating efforts to end TB by 2030 191 Ending the HIV, malaria and viral hepatitis epidemics 192 Viral hepatitis as a public health threat 193 Eliminating neglected tropical diseases 194 Sustaining momentum to combat AMR 199 Innovating emergency risk management actions 199 Reducing premature deaths from NCDs 205 Rolling back the tobacco epidemic 206 Resilience to climate change 207

8 A HOUSE FOR wORLD HEALTH 214

World Health House 219

9 LOOKING AHEAD 228

UHC as a key instrument for change 233 Building coalitions for change 235

BIBLIOGRAPHY 237

A Healthier South-East Asia 4 Introduction

A healthier in a number of ancient cultures: the ayurvedic medicine practiced South-East Asia on the Indian subcontinent has its roots in the Bronze Age Indus Valley The story of human health goes back civilizations; while Greek medical to the birth of humankind. Since lore – referred to in the Region as time immemorial, human beings Unani or “Greek” medicine – with its faced the ever-present dangers links to Arab medicine also came to and emergencies from natural and Asia through Persia, bringing with it other causes and established some such concepts as medical diagnosis, standardized responses to them, prognosis, as well as medical ethics. often as a group or community. In the absence of science, they Civilizations came and went, the initially relied on prayer. They pre-scientific age generally yielded tried not to get hurt while out to the beginnings of evidence-based hunting or foraging. They learned medicine, and countries slowly about medicinal plants, and began began to improve their health care to build up a body of health mechanisms. Nevertheless, many knowledge. Medical systems and years later, around the time the curative remedies were developed World Health Organization came

5 A Healthier South-East Asia into existence, the public health common communicable diseases scenario in most countries in South- were ever-present menaces… yaws East Asia was still very bleak. As … afflicted millions and millions the then Regional Director, Dr VTH of people and was particularly Gunaratne, put it at the time of serious in Indonesia and Thailand. the World Health Organization’s In most of the newly independent 25th anniversary1: “It is sometimes countries, doctors and nurses difficult to recall what conditions were particularly scarce, and there were like in 1947. Malaria was were extremely limited facilities rampant. India alone had some 75 for training and preparing them. million cases of malaria, causing Finally, many countries were some 800 000 deaths a year. Some still attempting to deal with 2.5 million cases of tuberculosis led their health problems on a to half a million deaths annually. day-to-day basis, and there was The situation was equally grim in a dearth of overall planning, other countries. Smallpox reigned often an absence of rational goals, unchecked, scarring, blinding and and little attempt to improve killing thousands. Plague and other training techniques.”

1 25th Anniversary of the World Health Organization for South-East Asia: 1948–1973

A Healthier South-East Asia 6 Introduction

In the early years of WHO, directed towards the alleviation communicable diseases were widely of suffering due to sickness, and prevalent and contributed to the mostly catered to the needs of a high mortality and morbidity rates privileged group concentrated in in the countries of the Region. urban areas. Health facilities in rural Plague, cholera and diarrhoeal areas were extremely meagre and diseases ravaged populations and often inadequate. Some countries about 90% of the world’s cases experienced a large exodus of of smallpox were to be found in public health workers at the time this Region. In addition, endemic of their independence, and the diseases such as leprosy, filariasis, shortage of doctors and paramedical and guinea-worm and hookworm personnel became an acute problem. diseases, were responsible for There was an acute shortage of considerable morbidity and medical schools. mortality. Life expectancy was as low as 30 years in some countries, while crude death rates and infant The beginning mortality rates were very high. Common environmental problems of the global such as the lack of safe water and multilateral system poor sanitation also contributed to the high incidence of diseases. In the early years of the 20th century Environmental pollution arising most of Europe and many non- out of the rapid urbanization and European nations were plunged industrialization in the early years into chaos with the two World Wars. of the 20th century was becoming Soon after the Second World War a new menace. Overarching all was ended in 1945, the colonial system of the threat of a population explosion the previous century was gradually which outstripped the gains from dismantled. The birth of several progress and development impeded newly independent nations, the the success of endeavours to rapidly changing patterns of society control and combat various diseases and social order, and the beginnings through improved medical and of the inexorable rise of technology public health measures. all gave rise to new hopes and expectations. The nation state began At the time of the establishment to realize it could not go alone, and of the United Nations and the multilateralism was born. World Health Organization after the Second World War, many The first of the multilaterals was the of the countries in the Region League of Nations, a direct product were emerging from decades of of the Paris Peace Conference – the colonial rule. As a consequence meeting of the victorious Allied their health systems were primarily Powers following the end of World

7 A Healthier South-East Asia A photograph of World Health House, Indraprastha Estate New Delhi, from the 1960s

War I to set the peace terms for Franklin D. Roosevelt (in the the defeated Central Powers in Declaration of the United Nations), 1919. The desire of all nations to but it took until 24 October 1945 rebuild from the ashes and create for the world organization to be something new gave rise to the formally founded, replacing the idea that society is something that League of Nations. Specialized can be constructed: governments agencies were set up almost were actors in this construction simultaneously or soon thereafter: of a “makeable society”. The the Food and Agriculture International Labour Organization, Organization of the United Nations International Telegraph (later (FAO) actually started eight days Telecommunication) Union, and a earlier, on 16 October 1945, and number of other global bodies that the World Bank Group two months were precursors to many United later in December 1945. Others Nations Specialized Agencies began followed in quick succession: notably to function under the aegis of the the United Nations Educational, League of Nations. It took another Scientific and Cultural Organization world war before the notion was (UNESCO) in 1946, the International taken up decisively. Civil Aviation Organization (ICAO) in 1947, International Maritime The term “United Nations” was Consultative Organization (IMCO) coined in 1941 by US President in 1948 (called the International

A Healthier South-East Asia 8 Introduction

Maritime Organization, or IMO, economic development, but since 1982), and the World Health WHO also helps them in the Organization, which was established eradication, elimination and on 7 April 1948. control of communicable diseases and public health development, WHO in in reducing maternal and child mortality, reversing the epidemic South-East Asia of noncommunicable diseases, combating antimicrobial resistance, This commemorative volume covers improving emergency preparedness the history of seven decades of the and response, and in strengthening World Health Organization’s work the health systems on the road in South-East Asia. It is the story to the goal of universal health of WHO’s collaborative work in coverage (UHC). support of Member countries to help improve the health and well-being WHO’s work with its Member of the people in this Region. countries has been guided by the twin goals of health equity and The countries of the WHO South- social justice, both key principles of East Asia Region make up more than primary health care as set out in the a quarter of the world’s population, Alma-Ata Declaration2. The focus of and an even greater percentage of WHO’s collaboration with countries the global disease burden. This is a has been to strengthen public Region with a huge geographical health. This has included capacity- diversity. It has the world’s highest building for the formulation of mountains, deep oceans, long and evidence-based health policies broad rivers and impenetrable and strategies; strengthening forests. It is beset by heavy monsoon public health education; building rains, floods and tsunamis in some the health workforce; developing parts, and hit by frequent cyclones, public health infrastructure; volcanic eruptions, earthquakes, ensuring health system readiness for droughts and other natural disasters tackling the outbreaks of disease, in others. emergencies, disasters and In this Region, WHO’s collaborative radical climate changes; and the work with the countries to address generation of research and their challenges in health has evidence to build a knowledge base evolved: not only is it an integral for improving the effectiveness of component of their social and public health delivery.

2 The Declaration of Alma-Ata, adopted at the International Conference on Primary Health Care, Alma-Ata (now Almaty), former Kazakh Soviet Socialist Republic, 6–12 September 1978

9 A Healthier South-East Asia Till the turn of the 20th century, most doctors in countries of the Region were trained in indigenous schools of medicine such as Ayurveda, unani, Siddha and others that were prevalent in South-East Asia. There were very few Asian doctors with a Western medical education. Seen here are perhaps the first few doctors from Asian countries who had secured a Western medical degree: Anandibai Joshee (left) of India, who graduated from the Women’s Medical College of Pennsylvania, united States of America, with Kei Okami (centre) of Japan, and Tabat Islambooly of Syria. Each of the three was most likely the first woman in their respective countries to have secured a degree in medicine

However, the attainment of countries continues to advocate health for all cannot be achieved for and adopt a multisectoral in isolation by the health sector approach for addressing current working alone. Health outcomes and emerging health issues. The are affected by a complex interplay principle adopted is to strengthen of sociocultural, economic, “health in all policies”. political and environmental factors, and so progress in health The geographical entity of “South- requires dedicated, concerted and East Asia” has unparalleled cultural coordinated action by multiple variety, which is mirrored in the players from many sectors. WHO South East Asia (SEA) Region. Consequently, WHO’s work with The SEA Region was the first of the

A Healthier South-East Asia 10 Introduction

WHO Regions to be established, if the of the 20th, 25th, 40th, 50th and 60th WHO Region of the Americas (whose anniversaries of the Organization, along parent body, the Pan American Health with other publications on similar lines. Organization, was founded in 1902) is These served as excellent references excluded. for drafting this book. Compared with them, the focus of this publication is on Five countries originally joined the the major achievements of WHO in the South-East Asia Region in 1948: Region, their impact on people’s health, Afghanistan, Burma (later Myanmar), success stories, lessons learnt, as well as Ceylon (Sri Lanka), India, and Siam the persistent challenges that remain. (Thailand). These were later joined by Indonesia (in 1950), Nepal (1953), Data from various publications have Mongolia (1962), and Maldives been used to indicate the progress (1965). Afghanistan subsequently left in health status and health system the Region to join WHO’s Eastern development across different decades. Mediterranean Region in 1969. East However, it is to be acknowledged Pakistan acquired independence here that the data were obtained by as Bangladesh in December 1971, different methods during different and joined the Region in 1972. The periods and, as a result, comparisons Democratic People’s Republic of Korea between the countries should be joined the SEA Region in 1973, and made with caution, particularly in the Bhutan in 1982. Mongolia left to join early decades. The main publications the Western Pacific Region in 1995. referred to in drafting this volume have Timor-Leste was the last Member been listed separately. State to join the Region in 2002 and formally signed the WHO Constitution This commemorative publication is on 28 May 2003. designed to serve as a reference volume for those interested in the progress Thus WHO’s South-East Asia Region of health development in South-East now comprises 11 countries: Asia over the last 70 years. The many Bangladesh, Bhutan, the Democratic public health achievements in the People’s Republic of Korea, India, Member States since the founding of Indonesia, Maldives, Myanmar, Nepal, the Region in 1948 are described in Sri Lanka, Thailand and Timor-Leste. the book. These achievements are the For ease of comprehension, these and result of the ceaseless, untiring efforts other contemporary names for the of many players and stakeholders, led countries will be used throughout this by the national governments. WHO in book, irrespective of the name that the South-East Asia Region has been was in use in the given decade. collaborating with Member countries on the long haul to achieve the Commemorative books have been Sustainable Development Goals and published in the past on the occasions ensure universal health coverage for all.

11 A Healthier South-East Asia The 11 Member Country Became a party to States of the WHO Constitution WHO South-East Thailand 26 September 1947 Asia Region as (Siam until 1949)

of 2018 India 12 January 1948

Myanmar 1 July 1948 (Burma until 1989)

Sri Lanka 7 July 1948 (Ceylon until 1972)

Indonesia 23 May 1950

Nepal 2 September 1953

Maldives 5 November 1965

Bangladesh 19 May 1972 (East Pakistan until 1971)

Democratic People’s 19 May 1973 Republic of Korea

Bhutan 8 March 1982

Timor-Leste 28 May 2003

Afghanistan (1948–1969) and Mongolia (1962–1995) were also part of the Region in earlier years

A Healthier South-East Asia 12 Highlights of 70 years of WHO’s work in South-East Asia

13 A Healthier South-East Asia 1948-1957

ia control Malar ammes launched progr f malnutrition asse tude o ssed 1 agni 9 M fellowships ini g and tiated 5 ainin Tr de H 8 8 sease control be ve ea - eal di gins lop lt 1 ner C ed h 1 0 Ve ou w se cal and nursin n i rv 9 ar ee edi g m tr th i 2 az fr M es expande M et y b ce 6 - - olleg d al ho h a s - la t ia ild c ar d ea s s a e ar h B ia o l ic y 7 8 k rg l c paigns in e e lo th s s a a - s cam trod tte r g h t n t to li BCG uc r a y p e e i m - i ss ed tr d r a m 0 a n e r h a m a ic f o l t r e p M ogram e pri in a o t n io h y pr ori d i t r g h 0 i t a t s s R lth tie oc n i m r a a s , s ea for coun s t g o a u o e d P H up trie o n u m n e V n e D e set s D r in n 2 m i v m I n , t O s e l l i d n s a s f a m i d s H e e a e rol prog T n t f t t a m l e r h t L nt ram S it o e s i t f a t - co m d u e p l a o u r s st r d e e a p g o w e G n t t h l Ya plemented e l r i s M n n e n B a m ra o a u o N i r e m n i d b t b o r i r i a e r n d i p t n T e t c g s e m i t uth- a l e s n s y s a e So Ea t s y g i s d d rst st i m s – a l i c s m s l Fi i o s i e e n m a n n e n n y e t Region a m a m t a t i ia al E 1 t m n i r a s l l d e s a l t A p 9 l k s s n i a p u o g i n o a n o d mittee d 6 u n e e om u n i e o p r n r n s t u e t C n m 7 n a v r a e a a e i t n i x l a o t c m o n s i i r e c i a d o L h i d d i h t l l g s i i a m n l i c m e o e e a r n m A r i c h E e a h g d a 5 m l t t e S s t l s o i T M e c - r a m e , o a a f a l s s - a l a G u n E t t l s u - o e h e r i a D n l s R & e n h C r i e a t o F S t a e o t u p a a C n g M e K o s m i t i o c M S o u e s T i n S l r y r n 1 M y a m E s a c t O l Health t h o d P r a e e t y n 9 s i R e l m i r I S

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A Healthier South-East Asia 14 15 A Healthier South-East Asia THE FiRST DEcADE 1 1948–1957 Setting up health agendas and tackling priority diseases

A Healthier South-East Asia 16 The first decade: 1948–1957

MAJOR ACHIEVEMENTS IN THE FIRST DECADE: 1948–1957

1 2 3

A rural health strategy was Medical and nursing colleges Malaria control programmes were developed, including a focus were set up or expanded, and started in India, Indonesia, Myanmar, on community participation fellowships were awarded. A Sri Lanka and Thailand. In 1955, in health services, and model number of nurses, doctors and malaria eradication was adopted rural health centres. Countries auxiliaries were trained as a goal of all national malaria prioritized the development of control programmes in the Region community health services (in response to the development of resistance of the vector to DDT). The death rate from malaria was reduced 4 5 6

A mass BCG vaccination A yaws control programme The first WHO venereal disease campaign was introduced in the was implemented through control demonstration and training Region as a part of tuberculosis well-planned mass penicillin projects were established in India, control programmes. Domiciliary treatment Myanmar and Sri Lanka TB therapy trials were initiated and they proved to be successful 7 8

The magnitude of the malnutrition Training of national sanitary problem was assessed, and inspectors and sanitary engineers training programmes and was initiated fellowships supported

ccording to a UN Review in public health had lifted life of South-East Asia in the expectancy and a striking advance first post-War decade of in public education has made 1945–1955, the economic marked inroads upon illiteracy…”.3 and social situation was According to the review, the Aimproving rapidly: “Production improvement in the economic has doubled over the pre-War conditions of the countries of South- level. The evolution of social East Asia had also led to increased climate (is) favourable to economic allocations to the health sector development; (a) virtual revolution during that period.

3 World Health Organization, Regional Office for South-East Asia. Sixty Years of WHO in South-East Asia 1948–2008. World Health Organization 2008.

17 A Healthier South-East Asia The newly-independent countries in addressing the major health were all publicly committed to issues. Given the very high improving the general social morbidity and mortality resulting conditions and welfare of from malaria, particularly in their citizens. The charters and the South-East Asia Region, top Constitutions of the emerging priority was given to this disease countries spoke of social welfare in in the work of WHO. Then came all forms. In the 1950s and 1960s, tuberculosis. Despite the lack social development was accepted as of reliable regional data on its being synonymous with economic morbidity and mortality, it was development. Despite patchy well known that there was high health services infrastructure and prevalence of tuberculosis in India, a health workforce that was low Sri Lanka and Thailand. Leprosy was in numbers and poorly trained, all also highly prevalent in the Region countries included in their respective and action was taken at the global covenants the objective of serving level, led by the WHO Regional their own people to their best of Office for South-East Asia. The their abilities. WHO accordingly prevalence of venereal diseases was encouraged each Member State to also high and documented in some develop a good and efficient health countries of the Region. Plague system and to train an appropriate was a serious health problem and health workforce that was occurred as an endemic disease in a competent and skilled and evenly few countries. Nutritional deficiency distributed in the country, balancing diseases were considerably between urban and rural needs. aggravated by simultaneous public health problems such as hookworm However, the positive developments disease and chronic malaria, which had to confront the fact that the were also widespread. All this prevailing diseases in the Region contributed to the prevailing high were caused by poverty, illiteracy, morbidity and mortality in this unsanitary environments and lack Region at that time. of safe drinking water, and that the problems were particularly dominant Thus, the main focus of WHO’s in the rural areas where almost 80% work in the Region during the of the population lived at that time. first decade of its existence was the gradual establishment of a Accordingly, the World Health health agenda at the national and Assembly and the Regional international levels and building Committee for South-East Asia the capacities of Member States to began to support Member countries tackle the priority health problems.

A Healthier South-East Asia 18 THE FIRST DECADE: 1948–1957

Historical milestones:

Enforced isolation/ quarantine (the word literally means “40 days”) for ships in the Health Mediterranean Organization United and Adriatic of the Nations seaports of League of founded, Alexandria and Nations UN charter Ragusa formed adopted

14th-15th century 1920 1945

Mid-19th century to the 1943 1946 beginning of UN Relief and international the 20th century Rehabilitation Health Agency conference international established in New York: Sanitary First meeting conferences held in of the interim Europe commission for WHO; constitution of WHO signed

19 A Healthier South-East Asia Road to global public health before the SEA Region is founded

First meeting Article First World of the on health Health Regional incorporated Assembly committee into the UN held in for South-East charter of Geneva, Asia held in Human Rights Switzerland New Delhi June-July October 1947 1948 1948

April July November 1948 1948 1948 WHO World Health WHO constitution Assembly Regional comes into approves the Office for effect establishment South-East of the WHO Asia (SEARO) South-East established Asia Regional in New Delhi Office

A Healthier South-East Asia 20 The first decade: 1948–1957

Creating WHO’s regional organizations

The World Health Organization Organization”, which, in turn, is unique among international formed working parties to consider organizations and agencies of the the delimitation of geographical United Nations in that it has a very areas and to study the possible strong regional character. A major structures of regional organizations contributing factor to this was the of WHO for Europe, the Middle East prior existence of the Pan American and Near East, South-East Asia, the Sanitary Bureau, which was a strong Far East, and the rest of Africa. and functional regional organization for health in the Americas. When the formation of the World Health Organization was being There were many discussions discussed, the Interim Commission before and during the First World for WHO made preliminary inquiries Health Assembly in 1948 as to the among governments about their desirability of regionalization. views in the delineation of areas India and China pushed particularly for the regional organization of hard for regionalization from the WHO. After much debate, the Main beginning. They were supported by Committee set up to consider the the United States of America and the delimitation of the geographical Latin American countries, which did areas at the First World Health not wish to see the Pan American Assembly in 1948 recommended the Sanitary Bureau dissolved. following specific regions: Europe; Middle East, Near East and parts of Accordingly, the International Health North-East Africa; South-East Asia; Conference – held in New York from the Far East; and Africa. The area 19 June to 22 July 1946 to establish for the Americas was included later. the World Health Organization After much debate and considering and draft its Constitution – agreed all the options, the World Health to define geographical areas for Assembly resolved to define six the establishment of regional geographical areas for setting up organizations within WHO, with regional entities of WHO. These the approval of a majority of the six were: Eastern Mediterranean, Member States in each area, to meet Western Pacific, South-East Asia, their special needs. Europe, Africa (south of the Sahara), and the Americas. The First World Health Assembly set up a “Main Committee on The World Health Assembly in its Headquarters and Regional recommendations for regional

21 A Healthier South-East Asia Reduction of the present heavy morbidity due to communicable diseases will not be possible in South- East Asian countries until basic health services are strengthened and adequately supervised so as to be able to play their part. Let there be no mistake about this

Dr c. Mani, Regional Director, WHO South-East Asia, 1948–1968

groupings had considered several The States could also request to be factors and established specific transferred from one Region criteria for their designation. to another. However, in the end, all these criteria could not be, and were not, Key steps in defining the evolving applied consistently, and no uniform membership of the WHO South-East method was employed to delineate Asia Region were: the WHO Regions. The American and ĥ At the First World Health European Regions included whole Assembly in 1948, the original continents; the African Region was five members of the South-East based partly on political frontiers Asia Region had signified their and partly on geographical frontiers; consent to join the Region when for the Eastern Mediterranean, it was established. They were South-East Asia and the Western Afghanistan, India, Myanmar, Sri Pacific Regions, the states and Lanka and Thailand. territories that would be included in them were enumerated. Later, ĥ By a resolution of the Second countries that were not included in World Health Assembly, this enumeration and new Member representatives of Member States were assigned to the various States of WHO that did not Regions by the Health Assembly. have their seat of government

A Healthier South-East Asia 22 The first decade: 1948–1957

within a particular Region Pacific was established in 1951, but were responsible for these three countries opted to the conduct of international join that Region. relations for territories that were within that Region, were ĥĥ Nepal became a member of allowed to attend the Regional the World Health Organization Committee concerned. Thus, on 2 September 1953 and was in the South-East Asia Region, formally included in the South- France (representing French East Asia Region by a resolution possessions in India), Portugal of the World Health Assembly (representing the territory of that year. Goa, Daman and Diu in India) and the United Kingdom ĥĥ The next country to join the (representing Maldives) South-East Asia Region was attended the sessions of the Mongolia. It became a member Regional Committee for South- of WHO on 18 April 1962 East Asia in the early years. This and, although not belonging representation continued from geographically to South or the second to the sixteenth South-East Asia, it requested to sessions of the Regional be allowed to join this Region. Committee. French and This was formally approved Portuguese territories in India by the Fifteenth World Health became part of India in 1954 Assembly. However, from and 1961 respectively. Maldives 1 July 1995, Mongolia became an independent separated from the South-East country in 1965. Asia Region and joined the Western Pacific Region. ĥĥ The original World Health Assembly resolution in 1948 ĥĥ Maldives became independent had placed Indonesia in the on 26 July 1965. It became Western Pacific Region. But in a member of WHO on 5 1950, when Indonesia joined November 1965 and joined the WHO, it was transferred, at its South-East Asia Region. own request, to the South-East ĥ Asian Region. ĥ In 1969, Afghanistan, one of the original members of the ĥĥ Cambodia, the Lao People’s South-East Asia Region, was Democratic Republic and transferred at its request Viet Nam were also originally and the approval of the included in the South-East Asia Health Assembly to the Region by a resolution of the Eastern Mediterranean Region Third World Health Assembly, because of geographical but when the Regional contiguity as well as Office for the Western political reasons.

23 A Healthier South-East Asia ĥ Bangladesh was “East Pakistan” at the time of the independence of India and Pakistan in 1947. In December 1971, it gained independence. Bangladesh became a member of WHO on 19 May 1972 and joined the South-East Asia Region.

ĥ The Democratic People’s Republic of Korea became a member of WHO – the first UN agency that the country joined – on 19 May 1973. It opted to join the South-East Asia Region.

ĥ Bhutan joined WHO on 8 March 1982.

ĥ The most recent Member State to be included in the Region was Timor-Leste which joined WHO on 27 September 2002, and opted for joining the South-East Asia Region on 28 May 2003.

At the meeting of the working party for WHO South-East Asia on 2 July 1948, delegates from Australia, France, India, Myanmar, the Netherlands, New Zealand, Pakistan, Portugal, Sri Lanka, Thailand and the United Kingdom agreed unanimously that a regional organization should be set up “as a first priority”, with India as its headquarters. This decision was reported to the Main Committee which submitted it to the World Health Assembly. The First World Health Assembly approved this Cobra mask (above) and the disease devil-bird mask (below). Gifted by Sri Lanka recommendation at its eleventh plenary session on 10 July 1948.

A Healthier South-East Asia 24 The first decade: 1948–1957

The beginnings of WHO-SEARO

The stage was now set for holding Chapter 8 provides an account the first Regional Committee session of the long journey made by the and the establishment of the first Regional Office from a one-room regional office of the World Health set-up to finding its own permanent Organization, both in South- home in New Delhi. East Asia. The nomination by the Regional Committee for South-East In October 1948, the first session Asia of Dr Chandra Mani as the of the Regional Committee Regional Director was approved for WHO South-East Asia was by the WHO Executive Board at its inaugurated by H.E. Jawaharlal meeting in November 1948. The Nehru, Prime Minister of India. The South-East Asia Regional Office – or session was attended by the first SEARO – was now ready to start Director-General of WHO, Dr Brock functioning. The Regional Office Chisholm. It recommended that the began operations on 15 November Regional Office be located in New 1948 from one small room located Delhi. The Committee confirmed in the North Block of the Secretariat the appointment of Dr Chandra of the Government of India in Mani as the first Regional Director New Delhi. Those were humble for South-East Asia. The session was beginnings indeed: there were only attended by representatives from two staff members – the Regional Afghanistan, India, Myanmar, Sri Director and one messenger loaned Lanka and Thailand, with Nepal as from the Government of India. an Observer.

The ‘Big Six’ and other regional priorities

In the technical field, the “Big Six” South-East Asia, there was an priorities – malaria, tuberculosis, agreement that WHO’s initial venereal diseases, maternal and child programmes in the Region should be health, nutrition, environmental as follows: health and sanitation – were identified for international work ĥĥ India: tuberculosis, malaria, by the First World Health Assembly maternal and child health, in July 1948. At the first WHO venereal diseases, nutrition, Regional Committee for health education, fellowships

25 A Healthier South-East Asia ĥ Myanmar: tuberculosis, venereal organization staffed adequately diseases, maternal and child by trained public health officers. health, nutrition Areas such as Fellowships, assistance to technical institutions, medical ĥ Sri Lanka: malaria, tuberculosis, literature and teaching equipment, maternal and child health, and medical supplies were added to venereal diseases, filariasis the list of priorities for all countries.

ĥ Thailand: tuberculosis, malaria, The programme activities for the venereal diseases, maternal and South-East Asia Region in 1950 child health, nutrition. and 1951 ranged over a wider field than the priorities identified by the The countries were also encouraged Health Assembly and covered to have a national public health the following:

Other communicable diseases, including Venereal filariasis, cholera, diseases and plague, typhus, Malaria yaws Tuberculosis leprosy and smallpox 1 2 3 4

6 8 10 12 Nutrition Environmental Fellowships Medical sanitation and supplies 5 7 housing 9 11 Maternal and Public Assistance Medical child health health to institutes literature for technical and teaching education equipment

Over the next two decades, WHO’s assistance programme in the South-East Asia Region generally covered these fields

A Healthier South-East Asia 26 The first decade: 1948–1957

WHO Area/Country Representatives: A pioneering idea

Dr R. L. Tuli (to Sri Lanka) Dr T.C. Puri (to Myanmar) Dr N. K. Jungalwalla (to Indonesia) (file photo) (file photo) (file photo)

The first three WHO Area Representatives in the world

When the work of the WHO Regional subject of “Health Programmes and Office for South-East Asia started in 1948, their Coordination”. It was proposed to there was no plan or provision to appoint appoint and place in each country an WHO Representatives in Member countries. experienced public health officer to act The deployment of WHO Representatives in as “WHO Area Representative” on all the countries was pioneered by the South- matters, under the general supervision of East Asia Region. Starting in 1948 when the Regional Director. This was approved WHO appointed long-term programme by the Director-General. Five posts of staff in the countries, each project had “Area Representatives” were established a senior staff in charge. With several in 1952, and the posts in Sri Lanka (then individual projects at the country level, Ceylon), Myanmar (then Burma) and there were three or four senior advisers, Indonesia were filled immediately. each acting as WHO project leaders and exercising the function of liaison officers in The very first WHO Area Representative their particular field. However, it was found in a Member country was Dr Ram Lal that there was no cohesive force to keep all Tuli in Sri Lanka. He was followed by Dr these WHO advisers and their programmes T.C. Puri, who was assigned to Myanmar, together at the country level and to liaise and Dr N.K. Jungalwalla, who went with other United Nations agencies and to Indonesia. The posts for India and various bilateral and multilateral health Thailand were filled in September 1953 organizations. and May 1955 respectively. In Nepal, the WHO Public Health Adviser continued to On 24 December 1951, a proposal was carry out the function till January 1962, made by the Regional Office for South- when he was re-designated as the East Asia to the Director-General on the Area Representative.

27 A Healthier South-East Asia From time to time – in 1953, 1957, 1959 necessary, actually assisting the government and 1962 – the functions of the Area in planning and day-to-day coordination, Representatives were reviewed. While had been amply demonstrated. these developments were taking place in the South-East Asia Region, the principle of After further discussions, it was decided appointing country or area representatives at the meeting of the Regional Director was also being adopted in some of the with the Area Representatives in May 1962 other regions, and headquarters was that officers appointed to carry out such gradually assuming the role of coordinator functions should in future be designated with respect to their post descriptions and as “WHO Representatives”. On 1 February overall functions. By June 1961, it was 1963 WHO headquarters issued a Manual felt that the advantage of having a WHO Circular No. 75 on WHO Representatives Representative in developing countries containing the policies which were followed for the purpose of providing advice and, if for the next 15 years.

Demonstration projects and long-term assistance

The technical assistance of and approaches Regional Committee in 1951 was to expand adopted by the Regional Office for South- the programmes: the Regional Office East Asia in the initial years focused redirected its policies towards long-term on developing short-term (two-year) assistance, which included strengthening demonstration projects with the assistance public health administration and the of WHO experts. The aim was to train training of health personnel. national staff in the new approaches and techniques used in the control of malaria, venereal diseases, tuberculosis, yaws, and maternal and child health, and later to replicate these projects nationally. Early assistance to the countries was in the form of supporting mass campaigns using mobile health teams and mobile clinics to extend coverage to their most remote geographical areas.

Owing to a lack of resources, and in the absence of a strong health infrastructure, the improvements achieved by the small demonstration projects were not sustainable. The solution adopted by the Carrying supplies for a demonstration project on malaria

A Healthier South-East Asia 28 The first decade: 1948–1957

Supporting medical and nursing education

There was an acute shortage of health services. WHO assisted in skilled and experienced health setting up or expanding medical personnel in the Region in the 1940s. and nursing colleges and other The doctor-population ratio at that schools for auxiliaries, strengthening time ranged from 5700 people per teaching programmes, training of physician in India to 66 000 people teachers, and providing Fellowships per physician in Indonesia, and to for training abroad in special even 72 000 people per physician fields. The result of this work in Nepal. Furthermore, most of the was a significant improvement in doctors were concentrated in the human resources for health that urban areas, leaving the rural areas was gradually observed over the without adequate medical care. The following decades. situation with nursing personnel was similar. The Regional Office for South-East Asia launched a comprehensive These shortages were addressed by system of WHO Fellowships in medical and nursing education and 1948. These Fellowships focused the training of health auxiliaries. on health services, communicable The WHO programme on nursing diseases control, clinical and basic aimed at assisting and expanding medical sciences and medical and the process of training of nurses, nursing education. The Fellowships midwives and auxiliary nursing programme accounted for about personnel in large numbers and 20% of WHO’s regular Budget. the management of an expanding The number of Fellowships steadily nursing component within the increased during the decade.

Comprehensive rural health

Concentration of medical serve as models in the provision professionals and health services of comprehensive health services in the cities had left the rural to the rural community. The first populations deprived in the model rural health centres were countries of the Region. The established, with WHO’s assistance, Regional Committee stressed the in Kalutara in Sri Lanka, Singur near importance of setting up pilot Calcutta (now Kolkata) in India, and rural health centres. These would Najafgarh near New Delhi, India.

29 A Healthier South-East Asia The first Rural Health Conference in Following on from the 1957 Rural the region, held in Delhi in October Health Conference, WHO supported 1957, was sponsored by WHO. The developing rural health services major focus of the conference was through the training of auxiliary health on multipurpose village health workers in India, Indonesia, Myanmar, workers, community participation Sri Lanka and Thailand. The Regional in health services and village Office provided direct assistance to improvement, and intersectoral schools in Myanmar and Nepal to collaboration between health administer a two-year training course services and other social welfare for health assistants working at rural sectors. These issues were very similar health centres. The course focused on to those elaborated 20 years later at sanitation, smallpox vaccination, health the Alma-Ata Conference on Primary education, and the prevention and Health Care. control of diarrhoeal diseases.

A set of two gold coloured statues in a small glass case. Gifted by Thailand

A Healthier South-East Asia 30 The first decade: 1948–1957

Developing maternal and child health services

The mortality rate statistics available in of a network of MCH centres. It was usual some countries in the Region revealed the to combine MCH and nursing education magnitude of the problems in maternal in one project. These projects were and child health (MCH) services (Figure 1). carried out in India, Indonesia, Myanmar Apart from Sri Lanka, no other Member and Thailand. However, it was noted State had an administrative authority that these centres were not linked with for maternal and child health at the the general health facilities, and WHO governmental level. MCH work was limited recommended the integration of MCH to services in special centres, and to home services with general health services to and hospital child delivery services. Much enable more comprehensive and effective of the work was directed to the treatment care. The consensus was that to serve a of children’s illnesses. community best in the field of MCH – which includes antenatal care, deliveries, WHO assisted in developing MCH services postnatal care, and the health supervision in India, Indonesia, Myanmar, Sri Lanka and of infants, children and mothers – a Thailand, through pilot projects for the community health programme paying training of doctors in paediatric medicine, special attention to the vulnerable nurses in child care, as well as auxiliary sections of society (the mother and the midwives, and through the establishment child) was the need of the hour.

Figure 1: Infant mortality in selected countries of the SEA Region, data available for 1945–1952 and 1960 350 304 300 300 1945-1952 1960 262 251 250 195 195 200 165 158 158 150 150 109 103 87 IMR per 1000 LB 100 71 78 68 50

0 Bhutan Myanmar Sri Lanka DPR *East India Indonesia Mongolia Nepal Thailand Korea Pakistan Country

Reference: Collaboration in Health Development in South-East Asia, 1948–1988. WHO SEARO, December 1992

* Before 1971, East Pakistan (now Bangladesh) was part of the Republic of Pakistan, a member of the WHO Eastern Mediterranean Region

31 A Healthier South-East Asia Addressing environmental health, sanitation and water supply

WHO’s field programmes in the Although some good results were Region for the improvement achieved, progress was slow. The lack of environmental health and of efficient environmental health sanitation, including the provision of organizations and programmes, safe water supply, began initially as a the scarcity of trained personnel, part of other projects. For example, and the insufficiency of funds for WHO sanitary engineers and those major investments were the primary attached to malaria control and rural constraints. Most of the countries health demonstration teams began launched community water supply to train national sanitary inspectors programmes, but their development and sanitary workers in Afghanistan, could not keep pace with the needs India, Indonesia, Myanmar, Nepal, of the increasing populations. Sri Lanka and Thailand. This work evolved during the decade to take Many urban areas remained its place among the health priorities. underserved in respect of waste disposal. In rural areas, poor WHO’s environmental health sanitation continued to contribute programme was originally concerned to the indiscriminate pollution of mainly with the provision of water, food and soil, and all this was safe water and the training of responsible for the high incidence of environmental health personnel. water-related diseases.

WHO’s environmental health programme was initially concerned mainly with the provision of safe water supply

A Healthier South-East Asia 32 The first decade: 1948–1957

Developing a systematic nutrition programme

Malnutrition was widespread in To deal with the acute shortage the Region; this was clear from of health personnel trained in several one-off nutritional surveys nutrition at that time, one of conducted in India, Myanmar, Sri the major activities of WHO was Lanka and Thailand. What was to support training programmes badly needed was an accurate and provide Fellowships. Since baseline to assess the true extent most countries did not have the of the problem of malnutrition. As mechanism to coordinate nutritional a beginning towards this objective, health programmes, the Regional the Regional Office for South-East Office for South-East Asia assisted Asia assisted countries in carrying in setting up nutrition units within out a number of nutrition-related their ministries of health. Field work studies: on blood disorders and started to address protein-energy anaemia in India, on endemic malnutrition and endemic goitre, goitre in Sri Lanka, protein-energy particularly when compounded by malnutrition and vitamin deficiency improper infant-feeding practices. in Indonesia, and endemic goitre The Regional Office assisted in and beriberi in Thailand. conducting a survey on the incidence

The Regional Office assisted countries in conducting studies on the nutritional status of children

33 A Healthier South-East Asia of protein-energy malnutrition in First Regional Committee: Country Indonesia, and in national efforts to priorities and budgetary allocation control endemic goitre by iodizing crude, sun-dried salt in India. The (from the Regional Committee report) assistance included education in the proper feeding of infants and ‘The committee proceeded to discuss the programme they children, and in improving the roles wished to see carried out in the first year in South-East Asia as part of the over-all activities of WHO, keeping in mind of the public health nurses and the the six top priority programmes to which the First World functioning of the MCH programme. Health Assembly had decided that major attention should As the decade began, recently be devoted… The delegations from india and ceylon had acquired knowledge and brought with them detailed proposals for WHO assistance to their countries in respect of malaria, tuberculosis, venereal technologies provided new tools diseases and maternal and child health. in addition, india to combat and control priority asked for help with a nutrition programme and ceylon (for) communicable diseases. The bacille advice on filariasis control. Burma requested six Fellowships Calmette–Guérin (BCG) vaccine and a BcG team, and Thailand eight Fellowships and a against tuberculosis was first used malaria advisory team. Afghanistan did not at that time medically in the 1920s; DDT was make any specific request. After discussion, thec ommittee developed in the 1940s and was recommended to the Director-General and Executive Board used against vectors of malaria, the following allocation for field programmes for 1949: typhus and plague; and long-acting penicillin (discovered in 1928) began Afghanistan US$ 50 000 to be used for yaws and other Burma (Myanmar) US$ 94 000 infections in the 1940s. ceylon (Sri Lanka) US$ 78 000 The evolving regional nutrition india US$ 300 000 programme took up priorities Thailand US$ 56 000 proposed by the countries. For Total US$ 578 000 instance, India proposed including a “Health education and propaganda” For the financing of the Regional Office, the committee component, while Sri Lanka wanted recommended a budget of US$ 93 040, of which US$ 65 to include assistance for their 230 was to cover the salaries and allowances estimated for filariasis programme. the Secretariat, to consist of a Director, a Deputy Director, a category i officer and two category ii officers, with 24 On another note, the Second clerical and custodial staff members at local rates of pay. session of the Regional Committee in 1949 decided to retain the six The committee also decided that the Regional Director priority programme areas, beginning should be authorized to correspond directly with the with the intensification of malaria ministries of health of governments in the Region, control activities. There was major and the Director-General was requested to make the emphasis on WHO assistance in necessary arrangements with Member Governments to establishing or strengthening that effect...’ national training centres for the training of health personnel.

A Healthier South-East Asia 34 The first decade: 1948–1957

Adopting malaria eradication as a goal

Malaria was a major public health Thailand. In 1955, in response to the problem with high morbidity development of vector resistance and mortality in all countries of to DDT, malaria eradication was the Region. The success of the adopted as a goal of all national demonstration projects encouraged malaria control programmes in countries to consider largescale the Region. WHO assisted in the malaria control operations and development of national campaigns national campaigns. Accordingly, and creation of national malaria they created vertical structures to institutes. These would give combat the disease. By 1954, malaria technical directions to national control programmes started in India, programmes and become training Indonesia, Myanmar, Sri Lanka and centres for staff.

Some demonstration projects on malaria control Malaria was a major public health problem with helped stop transmission of the malarial parasite high morbidity and mortality in all countries of the Region, particularly among children

35 A Healthier South-East Asia Swift launch of tuberculosis programmes

Pulmonary tuberculosis was reported established in Madras (present- as one of the leading causes of day Chennai) in India. Controlled death in the Region. At its Second trials were initiated, with WHO’s session, the Regional Committee co-sponsorship, to find simple, recognized tuberculosis as a major effective and inexpensive methods public health problem. WHO’s of tuberculosis control through initial support focused on the domiciliary therapy. The results of development of standard methods the controlled trials showed that and techniques, including the domiciliary treatment was just as tuberculin test, direct sputum effective as sanatorium treatment. examination and mass radiography They also showed that such home of the general population. treatment did not expose close family contacts to any special risk The first “chest clinic” was of infection. Domiciliary treatment established at the Bir Hospital in was much cheaper, and could Kathmandu, Nepal, in 1951. By 1952, be done without any drastic tuberculosis campaigns had begun in dislocation of the family. It opened India, Indonesia, Myanmar, Sri Lanka the door to a new understanding and Thailand. Model tuberculosis of the national tuberculosis centres were established, and in control programme. these case-finding, diagnosis and treatment were demonstrated The focus on tackling malaria and national staff trained. Four and tuberculosis and also other tuberculosis demonstration projects communicable diseases revealed (two in India and one each in to the countries the benefits of Myanmar and Thailand) were enhancing their health services started. Biomedical technology was infrastructure and training their vital here as well, providing the health workforces. Accordingly, new anti-tuberculosis drugs WHO encouraged Member streptomycin (discovered in 1943) countries to develop efficient and isoniazid (first made in 1952). A health systems and train a health mass BCG vaccination campaign was workforce that was appropriate launched in the Region as part of to the needs, had the requisite the tuberculosis control programme. competence and skills, distributed evenly in the country, and In 1955, the Tuberculosis responding to both urban and Chemotherapy Centre was rural needs.

A Healthier South-East Asia 36 The first decade: 1948–1957

Projects on venereal diseases

Unstable social conditions during population. The first WHO venereal and after the Second World War disease control demonstration and associated with extreme population training projects were established movements led to a considerable in India in 1949, Sri Lanka in 1950 increase in the prevalence of and Myanmar in 1951. Thanks to venereal diseases. The incidence of the widespread use of penicillin syphilis, and infant mortality due to promoted by these projects, a syphilis, rose steeply. Some studies dramatic decline in the reported showed that, in some areas of India incidence of new syphilis infections and Sri Lanka, venereal diseases was observed between 1950 affected from 10% to 60% of the and 1957.

A systematic approach to leprosy control

Leprosy was highly prevalent surveys in the countries affected in the Region. Consequently an had found high prevalence rates, international effort for leprosy the Regional Office began to control was prepared, similar to provide support for national those mounted for malaria and leprosy control programmes, tuberculosis. The Regional Office particularly in Myanmar (1952), for South-East Asia took the lead Sri Lanka(1954), Thailand (1955) and initiated global actions – and Indonesia (1955). This support convening an expert committee, comprised long-term staff or sending experts to the countries, and consultants, some supplies and providing antileprosy drugs. equipment, and Fellowships and training for local staff. The The work began in Myanmar and compulsory isolation of patients Sri Lanka. Surveys showed that the was abolished and replaced by magnitude of leprosy in Myanmar effective control of foci through was enormous, with 50% of cases treatment of those affected and being infectious. After subsequent surveillance of their contacts.

37 A Healthier South-East Asia Regional Directors of the World Health Organization South-East Asia Region

Dr chandra Mani Dr VTH Gunaratne Dr U Ko Ko 1948–1968 1968–1981 1981–1994

Dr Uton Dr Samlee Dr Poonam Muchtar Rafei Plianbangchang Khetrapal Singh 1994–2004 2004–2014 2014–Present

A Healthier South-East Asia 38 The first decade: 1948–1957

Reducing yaws

Yaws had been endemic in a survey. Surveys were conducted number of countries in the Region annually or every two years for centuries. In 1949, WHO and depending on the incidence of yaws the then United Nations Children’s initially discovered. Thanks to the Emergency Fund (UNICEF) launched declining proportion of active yaws a global yaws control programme, cases, programme activities were with the objective of achieving a able to move into the consolidation significant reduction in prevalence phase during the decade. through a well-planned campaign of mass penicillin treatment, followed by case detection and treatment of new or missed cases.

This programme was first implemented in India, Indonesia and Thailand. In Indonesia, the treponematoses control project started in 1950. The strategy was of elimination of all sources of infection by systematic detection and proper treatment of cases with penicillin aluminium monostearate (PAM). In India, mass campaigns were undertaken by the governments of the states together with the Union Government, WHO and UNICEF during 1952–1964. Anti-yaws teams were set up in the endemic states. These teams conducted surveys and provided treatment with long-acting penicillin to all detected cases and their contacts. In Thailand, 46 provinces were targeted by the campaign, following an initial

A village health worker provides information on yaws

39 A Healthier South-East Asia WHO reaches out to Indonesian children he first assistance from WHO to Indonesia was in 1950 to eradicate yaws. At that time TIndonesia was one of the poorest countries in the world. We were suffering sorrowfully as a consequence of the fight for independence against colonial rule from 1945 to 1950. Famine was everywhere throughout this country. The total Indonesian population in 1950 was around 72 million, and one out of five children suffered from yaws. WHO introduced penicillin injection for the first time to eradicate yaws in Indonesia. Between 1950 and 1953, about 21 million children were examined and 3.5 million of them were injected with penicillin oil. Because of its efficacy, penicillin was often referred to as ‘the magical shot’.

To improve the medical services, WHO sent a team of specialist doctors in 1953. They included well-known European specialists in internal medicine, paediatric care, thoracic surgery, anaesthesia and radiology. These experts helped design the education curriculum for doctors and medical specialists and improved medical services. A number of infectious disease control programmes back in the 1950s also benefited from WHO assistance, such as BCG immunization and malaria eradication in Java and Bali.

Dr Broto Wasisto, one of the leading experts in public health in Indonesia

A traditional Maldivian tapestry. Gifted by Maldives

A Healthier South-East Asia 40

Page40_WHO 70 Years.indd 39 24-08-2018 15:12:04 41 A Healthier South-East Asia THE SEcOND DEcADE 2 1958–1967 Building the health workforce and launching eradication programmes

A Healthier South-East Asia 42 Te h SECOND decade: 1958–1967

MAJOR ACHIEVEMENTS IN THE SECOND DECADE: 1958–1967

1 2 3 4

A system of basic Training institutions Epidemiological Malaria eradication health services to produce the units were created programmes were with ‘basic much needed health in the health launched across health units’ was workforce were directorates of the the Region developed established/enhanced ministries of health

5 6 7

The basics of the Intensified global Country health tuberculosis control programme programming strategy were for eradication methodologies were prepared, and are of smallpox formulated and health still in use today commenced in 1967 planners trained

n 1961 the United Nations General In this decade, the urgent need Assembly launched the UN to develop and strengthen basic Development Decade, reflecting health services at country level was the international socioeconomic encouraged by the Regional Office climate of that time. This was aimed for South-East Asia and continued Iat sustaining growth and providing to be supported. Building the for social advancement. This, and health workforce and controlling the subsequent UN Development the main communicable diseases Decade, helped countries to recognize continued to be the principal the limitation of socioeconomic areas of WHO’s support. Another development per se in improving the important focus during the second health of the people. decade was the introduction of country health programming and In WHO’s work, two approaches health planning. started to become apparent: the “vertical approach”, with a focus on disease In 1961, the Fourteenth World control campaigns (with each disease Health Assembly was held in being treated as a single vertical New Delhi – the first time the programme), and the “horizontal Health Assembly was held in Asia. approach”, with a broader emphasis on India’s Prime Minister Jawaharlal basic health services. This split resulted Nehru inaugurated the in uneven resource mobilization. 18-day conference.

43 A Healthier South-East Asia Basic health units and health workers

WHO’s work in the Region towards supporting the development of basic health services achieved a milestone in 1958 when it was agreed at an intercountry meeting that health centres could be defined as the “basic health units” of the system. The associated health workforce needed to serve in these units was also defined. In 1964, a WHO study group considered the integration of mass campaigns against specific Bronze figure. diseases into the general health Gifted by united services and set up a framework for Kingdom of Great Britain further priority setting. and Northern Ireland (on In the field of health workforce behalf of Maldives) development, for two decades since the founding of the Regional Office Member States had been Edinburgh undertook six-month endeavouring to establish training assignments in India. Myanmar institutions to produce the needed increased the number of its medical health workforce of doctors, colleges from one to three. The nurses, paramedics and technicians. Faculty of Medicine in Yangon New medical colleges were being (then Rangoon) was reinforced by opened in the countries, as well a medical institute in Mandalay as schools for other categories of and the Institute of Medicine in health workers. In general, these Mingaladon. Sri Lanka opened a new institutions were advised and new medical college in Galle, in assisted by expatriate teachers. addition to its two existing medical institutes. WHO was closely involved By the end of the second decade, in the preparation and opening of a India had more than 150 medical new medical and nursing institute at colleges. Despite the growing output Songkla, Thailand. In collaboration of trained national practitioners, with UNFPA (then the United Nations there were still many foreign Fund for Population Activities), the teachers. There were “bridging” Regional Office for South-East Asia schools such as the Baroda– supported the establishment of Edinburgh Project in India, in which the Tribhuvan Medical College in professors of the University of Kathmandu, Nepal.

A Healthier South-East Asia 44 Te h SECOND decade: 1958–1967

The Regional Office also assisted supported the establishment of in opening and developing more the School for Radiographers in schools for nurses and paramedics Colombo, and the School for Medical as well in many countries of the Radiography at the Ramathibodi Region. Many study tours were Hospital in Bangkok. organized by WHO during the period 1957–1965 for medical The Third session of the Regional college teachers to be trained in Committee in 1950 tabled a policy pre-clinical and para-clinical subjects. to direct WHO’s assistance to create Deans and principals were supported a central unit in each country to discuss teaching and research around which future mental health issues with their counterparts in services could be built. WHO other countries of the Region. provided consultants and long-term Fellowships for specialized training WHO’s assistance to the nursing of doctors from Indonesia, programme in the Region focused Myanmar, Sri Lanka and Thailand. on improving basic nurse training, The All-India Institute of Mental with the emphasis on post-basic Health, Bangalore, was established nurse training, midwifery education, by the Government of India with training of auxiliary nursing WHO’s assistance. personnel and the advancement of nursing administration. There was Public health dental services were a growing realization throughout almost non-existent in countries the Region of the need for more of the Region. The Regional Office and better prepared nursing focused its efforts on stimulating an professionals. Most countries faced interest in public health dentistry the problem of recruiting sufficient and generally to strengthen national numbers with adequate educational efforts to promote training. WHO qualifications into the nursing also provided a large number of profession. At the same time, the Fellowships in dental health. demand for nurses in hospitals and rural and urban health centres was Since the systematic epidemiological growing rapidly. Nursing schools of investigation of communicable acceptable quality were needed if diseases, and the general collection young men and women capable of and analyses of health information, providing leadership and direction were rarely practised, the Regional in nursing care were to be attracted Office initiated its assistance to the profession. There was in the training of nationals in also the need to supplement the epidemiology. Assistance was work of the professional nurse by provided to create epidemiological employing trained auxiliary nurses. units in the health directorates Considerable progress was of Indonesia and Sri Lanka, and made in the training of auxiliary later in Afghanistan and Myanmar. nurses. The Regional Office also Long-term assistance to promote

45 A Healthier South-East Asia At a WHO-assisted vaccination project in the Region, circa 1962 the development of statistical Regional Office assisted health organizations in health directorates education projects in India, and to improve peripheral reporting Indonesia, Myanmar, Sri Lanka systems in both vital and health and Thailand. The emphasis in statistics was first provided to health education changed from Indonesia and later extended to publicity and propaganda to public Afghanistan, Myanmar, Sri Lanka education as an integral part of and Thailand. general health services, to be carried out by health workers as a Health education increasingly part of their regular duties. It was became an important part of control recognized that health education programmes for smallpox, trachoma, had to play a more prominent malaria and tuberculosis, and for role in the implementation of the improvement of nutrition. The health programmes.

A Healthier South-East Asia 46 Te h SECOND decade: 1958–1967

Embarking on malaria eradication programmes

Beginning in 1956, all countries of WHO, together with the United the Region gradually embarked States Agency for International upon their national malaria Development (USAID) and the eradication programmes. Over the United Nations Children’s Fund next three years, India, Indonesia, (UNICEF), played a prominent Myanmar, Nepal and Sri Lanka role in carrying out the malaria launched malaria eradication eradication strategy in the countries. programmes, while Bangladesh and WHO promoted intercountry Thailand did so in 1961 and Maldives arrangements by holding a series in 1966. of regional and interregional

In the years from 1956, all countries of the Region began their national malaria eradication programmes

47 A Healthier South-East Asia meetings, coordinated research America. Malaria was reduced to by arranging regional training its lowest ebb in 1966, after which courses, periodically organized the situation began to deteriorate. independent appraisals of the The programme was officially malaria eradication programme, closed in 1969. and facilitated re-programming and the implementation of A number of factors were recommendations. responsible for this ultimate failure, not least the spread of The early years of the malaria DDT resistance in the mosquito eradication campaign witnessed vectors, spread of drug resistance dramatic successes. The task was in the parasite, poor health truly daunting, given the limited system infrastructure, low levels of tools and difficult environment, but economic development, an increase during the decade optimism that in the price of insecticides, and the disease would be eradicated donor fatigue. was high. Based on indoor residual spraying with DDT as the major tool, Another factor was that the initial the malaria eradication campaign dramatic achievements in reduction reached its pinnacle in the mid- of malaria incidence (see Table 1960s, and successfully eliminated 1) lulled many decision-makers the risk of malaria infection for into a false sense of security, about 700 million people living and consequently sustaining the in parts of Asia, Europe and Latin eradication efforts lost priority.

Table 1: The reduction of malaria incidence in the first two decades after 1948 in the SEA Region Incidence of malaria per 100 000 population Country Incidence (Year) Incidence (Year) Bangladesh 4 400 (1956) 5 (1965)

india 23 000 (1947) 13 (1961)

indonesia (Java and Bali) 40 000 (1951) 3 (1961)

Maldives 40 000 (1964) 227 (1974)

Myanmar 2 500 (1954) 5 (1961)

Nepal 5 000 (1950) 44 (1968)

Sri Lanka 38 000 (1945) 0.2 (1963)

Thailand 2 600 (1950) 280 (1961)

Reference: World Health Organization. Collaboration in Health Development in South-East Asia, 1948–1988. WHO SEARO, December 1992

A Healthier South-East Asia 48 Te h SECOND decade: 1958–1967

Exploring drugs in TB treatment

Effective drugs for treating support from the Indian Council of tuberculosis started becoming Medical Research, the government available from the 1940s of the state of Tamil Nadu and (streptomycin in 1944, para- WHO indicated that tuberculosis aminosalicylic acid (PAS) in 1946, patients did not need to be in thioacetazone in 1950, isoniazid in hospitals or sanatoria, and could 1952, and rifampicin in 1966). With be treated just as effectively at the availability of these drugs, the home under supervision without British Medical Research Council endangering the health of their initiated several randomized families or community members. controlled clinical trials to assess the It was also shown in Bangalore effective dosage, combination of that technicians working at the drugs and duration of treatment. periphery could, with minimal The trials noted the emergence of training and regular supervision, resistance while treating patients carry out sputum smear microscopy with a single drug, and found that a for the diagnosis of tuberculosis. combination of drugs could prevent The results of these early studies this. This led to the development of evolved into the basis of today’s multidrug treatment. tools for TB control. Indeed, the DOTS (directly observed treatment, During this second decade, the short-course) treatment strategy is general view was that tuberculosis one of the most successful and was being brought under control, cost-effective interventions in and the situation was positive. health available today while Studies on tuberculosis conducted sputum smear microscopy is still the in India in the 1950s and 1960s with mainstay of diagnosis.

Planning smallpox eradication

When WHO started its work in the Assembly towards the eventual Region, the number of cases and eradication of smallpox. deaths due to smallpox in Member countries was considerable. In By 1960, India, Indonesia, Myanmar India, more than 100 000 deaths and Thailand had developed plans were reported annually. In 1958 the for the eradication of smallpox Regional Committee for South-East through mass vaccination campaigns. Asia agreed to support the activities WHO assisted in arranging for the recommended by the World Health supply of the vaccines for current

49 A Healthier South-East Asia use and at the same time helped national authorities to produce freeze-dried vaccine for use in the mass campaigns.

The smallpox situation in the Region was reviewed at the Sixteenth session of the Regional Committee in 1964. The review revealed that smallpox was no longer endemic in Mongolia and Sri Lanka, while in Thailand it had practically disappeared. In Myanmar, a downward trend had been observed. The situation in Nepal was not clear as reporting was not well established. The largest number of cases reported was from India, reaching 93 423 in This little girl, Rahima Banu, of Bangladesh, was the last recorded case of smallpox in Asia. Seen here with 1963. Indonesia reported 17 000 her mother in 1975. The eradication of smallpox from cases in the same year. the world was certified by the Global Commission in December 1979 at WHO headquarters in Geneva

Oil painting (0.94 x 0.64 m). Gifted by Myanmar

A Healthier South-East Asia 50 Te h SECOND decade: 1958–1967

During the preceding five years (1959–1963), 70% to 80% of the world’s total number of cases had been reported from Asia. In 1966, the World Health Assembly resolved to embark on an intensified global programme for the eradication of smallpox. This commenced in 1967, and the Health Assembly considered that eradication could be achieved within a decade. Member States requested WHO to initiate all the actions necessary to carry out the worldwide eradication of smallpox, including financing from the Organization’s regular Budget, and other bilateral and Perhaps the largest national smallpox vaccination campaign in the multilateral assistance. world was launched in India

Controlling trachoma in the community

WHO helped establish pilot studies to control trachoma in the community. These interventions were initiated in India and Indonesia. A new approach was instituted to encourage people to participate actively in their own treatment, and make antibiotic ophthalmic ointments available where trachoma was hyper- endemic. This single-purpose vertical trachoma programme Volunteers from a WHO-assisted succeeded in reducing endemicity pilot project and preventing blindness from inspecting the health of village trachoma, but was generally children not sustained.

51 A Healthier South-East Asia Responding to polio outbreaks

In most countries of the Region, inexpensive and (in the case of oral polio virus infection was common in polio vaccine) easy to administer. infancy. There had been reports of Since the only hosts of the virus recurrent epidemics with paralytic are humans, it was believed that results in children under 10 years eradication of the disease was of age, particularly from India, possible. Two polio vaccines were Indonesia and Sri Lanka. A large already available. The first was the number of cases of paralytic polio inactivated polio vaccine which in young children were reported came into use in 1955. The oral from Yangon, Myanmar, during polio vaccine (attenuated) came 1964–1965. In Sri Lanka, an outbreak into commercial use in 1961. Mass of polio occurred in 1962 with vaccination campaigns against polio about 1800 cases of paralytic polio were carried out in the latter half of reported. the 1960s. But by 1970 it was evident that as a result of incomplete Paralytic polio is not curable. coverage of all infants with three However, it is a preventable disease doses of oral vaccine, epidemic polio with vaccines that are effective, safe, was increasing in the Region.

Responding to other major communicable diseases

In 1958, a new haemorrhagic form The Regional Office dispatched of dengue was reported in the vaccines and its staff to work with Region. The first epidemic occurred national officials to contain the in Bangkok, and had a case fatality epidemics. In 1961, the El Tor strain of 10%. The disease affected mainly of the Vibrio cholerae bacterium children. WHO assigned experts to spread from Sulawesi, Indonesia, work with national staff in outbreak to adjoining countries. Within response activities. three years, this strain had made its appearance in Myanmar and Major outbreaks of cholera had Thailand and, in 1964, was also occurred almost every year in reported in Calcutta, India. Bangladesh and India. There were major epidemics in 1958 in India, Since zoonoses and foodborne Nepal and Thailand, which spread diseases were major public to Afghanistan and Myanmar. health problems in the Region,

A Healthier South-East Asia 52 Te h SECOND decade: 1958–1967

the Regional Office supported and echinococcosis) and for food the strengthening of veterinary hygiene. WHO also provided public health programmes, assistance in the control of canine particularly for the control of rabies and in the production of priority zoonoses (rabies, brucellosis antirabies vaccine.

Establishing leprosy control programmes

The value of the cheap sulfone DDS, that time. The estimated number or dapsone, for mass treatment for of cases in the 1950s were over leprosy had been recognized in the a million in India, 110 000 in 1950s, and its efficacy demonstrated. Myanmar, 100 000 in Thailand, Institutional treatment was 80 000 in Indonesia and 4000 in considered impractical, as the Sri Lanka. Most endemic countries treatment had to be regular and started national leprosy control carried out over a long period. campaigns or specialized vertical Leprosy became one of the principal disease control programmes, tropical diseases addressed by the with technical and financial Special Programme for Research support from WHO and other and Training in Tropical Diseases developmental partners including (TDR) jointly initiated by the United nongovernmental organizations. Nations Development Programme, Despite intensive efforts carried World Bank and WHO. Since the out in the countries, the prevalence 1960s, TDR has advocated and increased from 8.4 cases per 10 000 coordinated many research studies population in 1966 to 12 cases per on leprosy in the Region. 10 000 in 1985. Leprosy remained a major public health problem with The Region accounted for about millions of people suffering from 50% of the global leprosy burden at this disease.

53 A Healthier South-East Asia Tackling lymphatic filariasis

Lymphatic filariasis, or population migration to new towns elephantiasis, a human disease and rapid urbanization. caused by parasitic worms called filaria, was a common sight In an agreement with the in many parts of the Region Government of Myanmar, a WHO during the first two decades of Filariasis Research Unit, including WHO. It was mostly prevalent in a Research Unit for the Control of India, Maldives, Myanmar and Aedes aegypti mosquitoes, was Sri Lanka. In some countries, it established in Yangon in 1962. was known to affect 80% of the Experts in epidemiology, ecology, population. In Indonesia, Nepal entomology and parasitology and Thailand, filariasis existed but were assigned to the Unit, where did not seem to be a serious public they studied the bionomics of the health problem. Filariasis due vectors of filariasis, development to Wuchereria bancrofti worms of the parasite in the mosquito and spread by infected mosquitoes in carriers other than man, and the increased every year as a result of epidemiology of the disease.

Painted mural on a wall in the Reception area of the WHO Regional Office, titled ‘Transplantation of paddy plants, with Mandalay Hill in the background’. 4.8 x 6.33 m. 1963. Gifted by Myanmar

A Healthier South-East Asia 54 Te h SECOND decade: 1958–1967

A future free from kala-azar and yaws

Visceral leishmaniasis (kala-azar) In fact, the sandflies were even is a disease caused by Leishmania more susceptible to DDT than the parasites which attack the internal Anopheles mosquitoes. Thanks to organs, while yaws is an infection of the widespread use of DDT for the the skin, bones and joints caused by control of malaria in South-East the Treponema pallidum bacterium. Asia, transmission of kala-azar was limited and the disease virtually During this decade, both kala-azar wiped out. However, after the and yaws were on the decline. In malaria eradication campaign kala-azar, this decline was largely ceased at the end of this decade, a byproduct of malaria eradication there was a resurgence of kala- activities, as the DDT used in the azar in Bangladesh, Nepal and latter was also effective against the neighbouring parts of India. This sandflies that spread the disease. situation persisted for the next few decades.

More than 50 million people were suffering from yaws globally when, in 1949, WHO and UNICEF launched a massive global programme to eliminate it. Since yaws was susceptible to a single dose of long-lasting penicillin, and with humans as the only host, the causative agent was relatively simple and cost-effective to conquer. By 1964, yaws cases had been reduced by 95%, and it had virtually been eradicated. However, owing to unsustainable surveillance and poor integration of the vertical programme with the basic health services, the disease resurged in some countries, particularly in neglected communities in remote areas. It became a priority in the Region for the next decades to eradicate the disease. Families being examined for yaws

55 A Healthier South-East Asia Recalling the eradication of yaws in Indonesia ‘I was with a team that visited a remote hill station in central Java. The people were summoned to receive their penicillin shots by the beating of gongs made from hollowed tree trunks. It was a grim sight. Living skeletons were carried in palanquins. Many came crippled and crawling with the claw-foot which occurs when yaws enters the sole and makes the foot contract like the claw of a perching bird.

One little boy who came crawling was Tresno. I made friends with him and held him when he got his injection. Ten days later we reassembled for the check-up and that little boy – who in his life had never had a reason to smile – came running and smiling up the path to greet me.

A year later I heard from a friend in that region. He wrote: “You remember the day Tresno smiled? That was exactly 12 months ago. Today was a feast day to celebrate the disappearance of yaws. Since that day a year ago, children have been born into life without yaws. Youngsters had almost forgotten what it was like but grown-ups remembered and they had a feast. Everybody contributed. Tresno climbed palm trees to collect coconuts. Men brought fish and rice which they had been able to harvest without yaws. The women plucked the chicken. The headman beat the gong and the children came chattering and laughing, skipping and jumping. The band beat out the tunes and old and young joined in the dancing – the dancing they had almost forgotten. People boasted about the size of the ulcers they once had. The local ‘comic’ put on an act, imitating the walk of the claw-footed yaws’ victims and everybody roared with laughter. The men teamed up in a show in which they mimed the painful slow-motion harvesting of the rice when they had yaws and worked up the tempo of the band to the prodigies of speed with which they could now reap. And Tresno’s smile had turned to laugher.’

Lord Ritchie Calder

(Collaboration in Health Development in South-East Asia, 1948–1988. WHO SEARO, December 1992)

A Healthier South-East Asia 56 Te h SECOND decade: 1958–1967

Country health programming

Countries needed not only to organizations, and develop an have health policies, but also effective mechanism for health to strengthen the planning and planning as a part of national organization of composite health planning. The Regional Office programmes for which available helped to organize health planning resources were far from adequate. units and train national staff WHO rose to this challenge and a through Fellowships, workshops, systematic approach was formulated. seminars and short courses. In The methodology formulated collaboration with the Economic was known as “Country health and Social Council for Asia and programming”. the Pacific and with support from the United Nations Development The session of the Regional Programme, WHO organized Committee in 1961 urged Member regional training courses in health States to use their existing facilities planning for health workers. By the to teach health administrators time the training ended in the late the techniques of national 1970s, more than 50 health planners planning. The countries were also from countries of the Region had urged to strengthen their health completed the training course.

The World Health Assembly is held in New Delhi

In 1961, the Fourteenth World that the progress with smallpox, Health Assembly was held in New though slow, was apparent. In Delhi, India. This was the first the battle against yaws, WHO time a Health Assembly had been was about half way through the held in Asia. Delegates from 105 programme, with 100 million countries attended the opening sufferers examined and 40 million session on 7 February, inaugurated given treatment. But in some of by Indian Prime Minister Jawaharlal the Member States the infant Nehru. The President of the mortality rate was still about 200 in Health Assembly declared that the 1000 births, compared with a drop Organization’s war against major to 20 in industrialized countries. pestilences was continuing, and Achieving the higher standard all

57 A Healthier South-East Asia over the world would mean that that some solid gains were made each year some 16 million more during the first two decades, for children under the age of 1 year the Organization was to face would survive.4 some exacting challenges in the following decade. The first two decades of WHO in South-East Asia thus saw a promising start to the Organization’s support to the countries in public health, and constituted a productive period. Important programmes had been launched with Member States in a spirit of cooperation, resulting in some excellent accomplishments. There had been major advances in the control of malaria, tuberculosis and venereal diseases, a marked increase in the development of the health workforce, and the A ceramic ceremonial urn. Gifted by the Democratic People’s Republic of Korea near-eradication of yaws. Of course, by comparison, some of the programmes had not made the same headway – such as the training of auxiliaries and, to a lesser degree, leprosy control. Towards the end of the second decade, outcomes and developments that were quite unanticipated had begun to surface, including the recrudescence of yaws and the development Bronze statue mounted on a marble pedestal to of resistance by the Anopheles commemorate the 40th Anniversary of WHO in mosquito to DDT. It was just as well 1988. Gifted by Indonesia

4 Available at https://www.britishpathe.com/video/VLVABXFDK3LX25GQ021ZFI822X95P-INDIA-14TH-WORLD-HEALTH-ASSEMBLY-OPENS-IN-DELHI/query/ Delhi, accessed on 14 May 2018

A Healthier South-East Asia 58 Te h SECOND decade: 1958–1967

The medical system in Sri Lanka in the 1960s: achievements and challenges In conversation with Dr Palitha Abeykoon

r Palitha Abeykoon, one of Sri Lanka’s Dleading public health experts, remembers the 1960s as a time of great achievements and great challenges for the medical system in the country. Globally, the Sixties were a time of change and flux and the country was no different, leading the way with the appointment of the world’s first woman Prime Minister Sirimavo Bandaranaike.

By 1960, the groundwork for much of the country’s future achievement in health care Dr Palitha Abeykoon had already been laid. Of particular relevance was the impact of the country’s free education While still a schoolboy, young Palitha cut his system, and of the generation of doctors and foot playing rugby and contracted tetanus. For nurses that were beginning to emerge from 11 days he hovered between life and death in the national public schools as a result. Kandy Hospital. The care he was given there, supported by his classmates – and the airlift Malaria continued to take its toll on the of antitetanus serum from India – saved his population, but eradication campaigns life. As he points out, he was very lucky. And and more sophisticated surveillance were subsequently a life-long advocate beginning to have an effect. Coupled with for immunization. advances in maternal and infant health care, the health of Sri Lanka’s growing population It was only in 1961 that DPT – the triple continued to improve. vaccine against diphtheria, whooping cough and tetanus – was introduced. This was Asked why he decided to enter medicine, followed by OPV, introduced in 1962, and Palitha says that the choice was very much BCG vaccination of neonates in 1963. made for him. In those days a well-educated Ceylonese had one of three choices: law, For Palitha, the 1960s were characterized by engineering or medicine. He chose medicine the widespread immunization programme and, by virtue of the alphabetical order of his introduced by the Government and WHO, and surname, became the very first student to widely embraced by the population. A well- enrol in the newly opened Peradeniya Medical educated population served by well-trained Faculty, Kandy, in 1962. It was the beginning public health professionals gave Sri Lanka an of an illustrious medical career, but it was a enormous benefit in countering many of the career that nearly didn’t happen. endemic diseases the country faced.

59 A Healthier South-East Asia Immunization campaigns were key public health successes in Sri Lanka during the 1960s

Sri Lanka now has some of the highest The Sixties were also a period of transition rates of immunization in the world. His mentor in Sri Lanka. Rapid urbanization, population at Peradeniya was the eminent medical growth, successful immunization programmes visionary Professor Senaka Bibile. It was from as well as improvements in infant mortality him that Palitha learned the importance of rates characterized the decade. Population establishing a sound medical education system growth pressure led to family planning being if a country was to progress. And not just integrated into the maternal health-care education for doctors but for all tiers of the system in 1965. And the lessons learnt were public health system. successfully exported to other countries in the Region. Sri Lanka in the Sixties experienced many of the demographic and social changes that As Palitha points out, Ceylon’s success in the other countries in the Region were to see in Sixties was built on the twin pillars of a good subsequent years. The old scourge of malaria primary health care system and widespread still afflicted thousands, particularly since the access to free education. He feels this was parasite had started to develop resistance something that Sri Lanka can be rightly proud to DDT, but slow and steady progress was of, as it serves as a model for others not just in being made towards its eventual eradication. the Region but also the rest of the world.

A Healthier South-East Asia 60 61 A Healthier South-East Asia THE THiRD DEcADE 3 1968–1977 The eradication of smallpox

A Healthier South-East Asia 62 Te h THIRD decade: 1968–1977

MAJOR ACHIEVEMENTS IN THE THIRD DECADE: 1968–1977

1 2 3 4

Smallpox Country health Regional training Family health eradicated from programming centres were programmes were South-East Asia, started established set up in Member and the world countries

5 6 7

Traditional system The Expanded Oral rehydration of medicine was Programme on salts successfully recognized and Immunization introduced in the systematized in was adopted by Region countries Member countries

he third decade of WHO Programme of Immunization and in the Region saw many the establishment of the goal of achievements resulting “Health for All by the Year 2000”, from WHO’s collaboration were milestones influencing with Member States. An WHO’s work and priority settings in Timportant step was to transform the Region. WHO’s role and introduce a systematic approach to technical Considerable progress had cooperation with Member countries. been made in health services This decade also witnessed the development, as evidenced by the global eradication of smallpox – one significant increase in the number of the greatest achievements in the of hospital beds and health centres, history of public health. It was also subcentres and health posts. There a decade of further strengthening was a definite shift from hospital- of health planning in countries based services towards field-oriented as a component of the overall health care. socioeconomic development and strengthened health infrastructure. Despite this progress, the health situation in the countries was far The global initiatives from this from satisfactory. The burden of decade, such as the Expanded communicable diseases, the lack

63 A Healthier South-East Asia of mother-and-child services, and was yet to take off. In addition to problems such as malnutrition, all this, three problematic areas population growth, shortages related to globalization and trade of trained health personnel and in health showed up during this inadequate coverage of general and next decades: i) breast-milk health services, persisted. There substitutes and infant foods versus was the need for greater political breastfeeding; ii) the provision of commitment to the development essential drugs; and iii) the tobacco of health care, and community industry and increasing incidence of participation in health improvement tobacco-related diseases.

It is only through social development programmes that human society can drive peace, stability and harmony. It is for this fundamental reason that a significant breakthrough in the field of health has become not only an urgent need but an imperative necessity Dr VTH Gunaratne Regional Director, 1968–1981

Implementing country health programming

WHO originally adopted the project-based approach was not approach of “funding projects in the effective. Based on policy guidance country”. But “the projects” often in WHO’s Fifth General Programme did not fit into the country’s main of Work (1973–1977), the socioeconomic development scheme, Organization’s role in direct country nor were potential socioeconomic support would become increasingly capacities seriously considered. It cooperative in character. To enable became evident that the fragmented this transition, it was essential to

A Healthier South-East Asia 64 Te h THIRD decade: 1968–1977

strengthen the health planning and People’s Republic of Korea, India organization in the countries. The and Mongolia, as the national Country health programming (CHP) health planning processes practised methodology developed during in these countries were considered WHO’s second decade started being appropriate for their own national applied throughout the Region in administrative systems. The first the third decade. Long-Term Health Plan (1975–1990) was developed and implemented The first application of the in Nepal. methodology was in Bangladesh in 1973, conducted by a national Even when the entire UN system was team with technical support from operating with technical assistance the Regional Office. Country health as its main modus operandi, WHO programming was conducted and its Member countries recognized in Nepal and Thailand in 1974, the importance of resources Myanmar in 1975, Indonesia in 1976 available internationally, and and in Sri Lanka in 1978. It was not strived for broader coordination carried out in other countries of and closer collaboration among the Region, notably the Democratic donor agencies.

New philosophy of health development

The prevailing view of classical health was not primarily caused by economists was that there should the common diseases; rather, low be an economic proof of social health status was a product of the benefits. In the late 1970s, this prevailing socioeconomic conditions, began to be challenged. The political structures, nutrition and opposing view was that social the environment. Thus, health benefits could not and should not development had to be seen as an be expressed solely in economic integral part of social and economic terms, but rather, development development both contributing to has to be viewed in terms of and benefiting from it. Viewed in social equity and social justice in this light, it became obvious that addition to economic terms, since for the solution of the priority its principal aim is to improve the health problems mere technical quality of life. knowledge in isolation from social awareness was no longer sufficient. In line with these changing ideas New approaches were needed. In on development in general, a new 1977, the goal of “Health for All philosophy of health development by the Year 2000” was formulated. was debated in WHO. According The principles of this goal will be to this new philosophy, poor elaborated in the next chapter.

65 A Healthier South-East Asia Regional training centres

Countries had been aware of the national teachers’ training centres importance of training and the were established at the Jawaharlal preparation of teachers. WHO Institute of Postgraduate Medical formulated a new and radical Education and Research (JIMPER) approach to overcome the problem at Pondicherry and, by 1980, at the of developing an appropriately Postgraduate Institute of Medical trained health workforce to run Education and Research (PGI) at the health services. The concept Chandigarh and the Institute of of “health services manpower Medical Sciences in Varanasi. development” consisted of the complete process of health In consultation with educationists workforce development involving in countries of the Region, and as the three main interrelated prompted by them, WHO initiated components of planning, a change in the medical education production and management. The curricula to attune it to community whole process led to the overall needs, under the programme development of health services. name of “Reorientation of Medical Education (ROME)”. By The countries of the Region had the next decade this had become been encouraged to consider a movement in all countries in the importance of training and the Region. Finally, to systematize the preparation of teachers. Two dental health services in Member Regional Teacher Training Centres countries, the Regional Office were established in 1972 – one in supported the establishment of Peradeniya in Sri Lanka, and the schools for the training of dental other in Chulalongkorn University hygienists and dental auxiliaries, in Bangkok, Thailand. India which were absent in most of the already had the All India Institute countries. New dental colleges were of Medical Sciences for training also established in India, Indonesia, medical teachers, and in 1976 Myanmar, Sri Lanka and Thailand.

Enlarging the concept of maternal and child health

This concept of maternal and child the whole of family health. Family health was expanded by the World health included the care of mother Health Assembly in 1968 to embrace and child, nutrition, immunization,

A Healthier South-East Asia 66 Te h THIRD decade: 1968–1977

health education and family national family planning policy planning. Family planning became were funded by UNFPA. This an important component of general programme contributed to the health services. The maternal and acceptance of family planning as an child health (MCH) programmes effective measure to help reduce established demonstration and maternal and infant morbidity and training projects for professional mortality and in upgrading the and auxiliary workers. These quality of life. The family health projects were aimed at a more programme was a development of comprehensive coverage through family planning services integrated a wide network of MCH centres. into MCH services in the context Furthermore, the integration of of community health. WHO’s MCH services into general health assistance to MCH programmes services aimed at forming a basis for helped to improve the health of more elaborate and effective care. In mothers and children. By 1970, Bangladesh in 1976, 13 500 women the infant and maternal mortality were trained and deployed as family rates had fallen in most countries, welfare assistants. though they still remained unacceptably high compared with Family health programmes in the industrialized countries Member countries that had a (Figures 2 and 3).

Figure 2: Infant mortality in SEA Region countries 1970–1975 and 1980

250 1970–1975

200 195 1980 159 149 152 150 140 140 124 122 117 114 100 98 94 71 73 63 60 IMR per 1000 LB 48 50 34 23 26 11 13 0 Bangladesh Bhutan Myanmar DPR Korea India Indonesia Maldives Mongolia Nepal Sri Lanka Thailand Country

Reference: Bulletin of Regional Health Information, 1982–1983. WHO SEARO

67 A Healthier South-East Asia Figure 3: Maternal mortality in selected SEA Region countries with available data, 1970 and 1982

3500 3000 3000 2500 2500

2000 1970 1982

1500 1340

1000

500 IMR per 1000 live births 130 180 120 230 0 Bangladesh Myanmar india indonesia Maldives Mongolia Nepal Sri Lanka Thailand Country

Reference: Bulletin of Regional Health Information, 1982–1983. WHO SEARO

WHO’s assistance to MCH programmes helped improve the health of mothers and children regionwide

A Healthier South-East Asia 68 Te h THIRD decade: 1968–1977

A serious obstacle that has to be overcome in providing health services, including family health to the community, is the shortage of trained health manpower. Therefore, WHO is giving high priority to develop education and training programmes so that the Member States will be in a position to prepare professional and auxiliary personnel in adequate numbers. The long-term objective is to incorporate all aspects of family health activities into the basic training of every category of health personnel. Until this objective is reached, orientation and refresher courses are necessary

Dr VTH Gunaratne Challenges and Response, Health in the South-East Asia Region, 1977

Establishing model rural health centres

As described in the previous as a model for the provision of chapters, the countries of the comprehensive health services to Region recognized early the need rural communities. Model rural to build their health infrastructure health centres were established in by establishing a network of rural India, Indonesia, Myanmar, Sri Lanka health centres. The Regional and Thailand. By 1968, rural health Committee in 1951 recommended activities had become an integral the establishment of model rural part of community development health centres, with at least one in planning. By the end of the decade, each country. This was to provide encouraging results had been achieved demonstration and training of in expanding the coverage through a required personnel and serve network of rural health centres.

69 A Healthier South-East Asia The Comprehensive Rural Health Project, Jamkhed, India The Jamkhed Comprehensive Rural Health Project, launched in 1970, was designed to meet the basic health needs of a rural population of about 40 000, in the Indian state of Maharashtra, by mainly using local resources. The key objective of the project was to meet these needs by providing: maternal and child health services, health education in the community, detection, prevention and control of chronic illnesses such as tuberculosis and leprosy, and environmental health through the provision of safe drinking water. The project stressed agricultural support for proper nutrition, the deepening of wells for irrigation and safe drinking water, and the training and use of village health workers and broad-based community participation in the decision-making processes regarding health services.

To achieve basic health-care services at low cost, the project included a number of innovative approaches, such as the use of fees derived from curative services to support promotive and preventive health programmes, and the incorporation into the project of indigenous and Ayurvedic practitioners and dais (traditional midwives).

One of the most important findings of the project was that it was ‘based on the recognition particularly by the project leaders, of the priorities determined by the community. To the community, health is not a number one priority; agriculture, water supply, housing are more important… In effect, it appears that in such communities, which have a low economic status and per capita income, doctors and health services will need to identify themselves with the community’s priorities in order to fulfil health objectives.’

(Collaboration in Health Development in South-East Asia, 1948–1988. WHO SEARO) For more information: http://jamkhed.org/research/

Systematizing traditional medicine

Traditional medicine is practised in all countries of South-East Asia. The commonly practised systems in the Region are Ayurveda, Unani, Siddha, Yoga (India), Jamu (Indonesia), Koryo medicine (Democratic People’s Republic of Korea), and those originating from other regions such as Chinese medicine, acupuncture and homeopathy. These various Silk embroidered systems use herbal medicines, wall hanging (0.35 x 0.60 m). manual and spiritual therapies, Gifted by and physical exercises. Many are DPR Korea

A Healthier South-East Asia 70 THE THIRD DECADE: 1968–1977

formal systems (such as Ayurveda, During this decade, WHO Siddha, Unani-Tibbi, Chinese and recognized the traditional systems Anchi (Tibet) systems), and some of medicine, emphasizing the yoga practices, and there are also important role they were playing many non-formal traditional systems in providing health-care services (herbalists, bone-setters, healers in to very large numbers of people, the thaad (element system), nature particularly in rural areas. The cure and home medications). The Regional Committee in 1975 use of traditional medicine practices requested WHO to collaborate with continued to expand, particularly Member States to develop well- for diseases and conditions that recognized traditional systems of are not effectively managed by medicine and enhance research. modern medicine. In 1976 the Regional Committee requested WHO to promote training and research in traditional systems, and requested interested governments to provide facilities for the training of health workers in traditional medicine, and protocols for their role and use in the basic health-care programme.

WHO’s Regional Office for South- East Asia has already identified over 110 institutions of traditional medicine in different Member countries for regional networking. Member countries have been strengthening their traditional systems of medicine as part of their national health development. In India there are over 340 recognized training institutions offering degree-level training in the various Indian systems of medicine. A University of Traditional Medicine was established in 2001 in Myanmar. In Thailand, the integration of traditional medicine into the health system by co-location has extended to over 96% of the regional hospitals and A Bhutanese thang-ka, a wall-mounted portrait of the Buddha, 1.53 x 2.63 m. Gifted by Bhutan 88% of health centres.

71 A Healthier South-East Asia Environmental health

A WHO review in 1975 showed that appeared to be the least expensive there had been a tangible increase solution to the social problems. in the population supplied with piped water in urban areas – the During the first two decades WHO’s proportion served had risen from environmental health programme had 50% in 1970 to almost 70% in 1975. focused mainly on the provision of safe A similar increase during the same water supply and disposal of excreta period was observed in access to safe for the community, with training drinking water in the rural areas – of personnel and establishment of from 9% to 19%. demonstration and pilot projects. In the third decade WHO’s activities More than 30% of the urban expanded and covered studies on population in Bangladesh, India, environmental pollution control, waste Myanmar, Nepal and Sri Lanka were disposal, environmental planning and served by bucket privies. The social information systems. The rapid growth aspects of this system were of great of populations, industrialization concern to the countries. A study and increasing urbanization was a by the Regional Office indicated cause for growing concern of the the possibility of replacing bucket governments and led to the privies with water-seal toilets. These WHO response.

Launching the Expanded Programme on Immunization

At the beginning of this decade, epidemic proportions – called for a several vaccines were being used in public health programme to use the paediatric practice in industrialized already available vaccines to control countries. It was clear that there several childhood diseases in low- were opportunities to bring this income settings. up to scale in applications in the Region. In 1974, the World Health The Expanded Programme on Assembly – noting that diphtheria, Immunization (EPI) was launched in pertussis, tetanus and measles were 1974, drawing on the principles of still major causes of infant mortality strategic and equitable application in developing countries, and that in the community. This provided a polio was widespread and often in blueprint for operations, including

A Healthier South-East Asia 72 Te h THIRD decade: 1968–1977

training manuals for vaccinators, Between 1974 and 1979, the who were mostly women health Expanded Programme on workers recruited from the community Immunization was adopted by itself. The diseases targeted all countries of the South-East for control through EPI were Asia Region. The vaccination of tuberculosis, diphtheria, pertussis, pregnant women against tetanus tetanus, polio and measles. was included in EPI to prevent neonatal tetanus. The historical The EPI was a low-cost public health public health success of smallpox programme. In order to allow eradication had shown that capacities to develop, the goal was it was possible to achieve the set to vaccinate 80% of eligible interruption of transmission, and children (with a target of universal elimination, of causative agents child immunization, or UCI, by 1990). by immunization, and to reduce The infant vaccinations consisted of morbidity and mortality from BCG (for tuberculosis) as early after vaccine-preventable diseases. birth as possible, DPT (for diphtheria, This was what the Expanded pertussis/whooping cough and Programme of Immunization now tetanus) and OPV (oral polio vaccine) took forward in the battle against during early infancy, and measles the diseases of children and vaccine at or after 9 months of age. their mothers.

Intensive immunization programmes have led to many public health successes in Member States

73 A Healthier South-East Asia In the early 1970s, international Member States to review sales attention on the advantages of promotion activities related to baby breastfeeding and the harmful foods and introduce appropriate effects of bottle-feeding increased. remedial measures, including Awareness was growing on the links legislation where necessary. between infant malnutrition and the promotion of breast-milk substitutes The countries of the South-East in developing countries. The World Asia Region, with their high infant Health Assembly in 1974 noted mortality rates, had a special that a decline in breastfeeding was interest in this and overwhelmingly one of the factors contributing to supported the Health Assembly infant mortality and malnutrition. resolutions on the subject. However, It strongly recommended the progress was slow and, by 1988, only encouragement of breastfeeding five of the then 10 countries of the as the ideal feeding method to Region had developed some form promote the harmonious physical of regulation, code or ordinance and mental development of based on the International Code of children. The Health Assembly urged Marketing of Breast-milk Substitutes.

Reacting to emerging public health issues

The lack of a comprehensive the selection of essential drugs national drug policy, as a component corresponding to their national of national health planning, created health needs. In the Region, WHO a gap between the demand for collaborated with countries in drugs and the actual health need for establishing drug policies and their essential drugs. Moreover, the cost management. However, because of of imported drugs and technology economic constraints, there was still for pharmaceutical production was an inadequate supply of essential very high. Even though in many drugs of assured quality for the countries a high proportion of the communities in several countries. health-care budget was spent on pharmaceuticals, 60%–70% of the There was overwhelming evidence, population did not have ready based on independent publications access to the most essential drugs. and studies of all kinds (prospective, This was particularly true in rural retrospective, clinical, case-control, areas. The World Health Assembly epidemiological and experimental), in 1975 resolved that greater indicating the link between tobacco assistance should be made available consumption and various diseases, to Member States in the formulation including cancers. However, the of national drug policies and in consumption of cigarettes continued

A Healthier South-East Asia 74 Te h THIRD decade: 1968–1977

Figure 4: Prevalence of smoking in adults in some SEA Region countries, late 1970s/early 1980s 100 90 87 80 75 70 72 48 70 70 66 60 Male 50 Female

Percentage 40 30 26 20 20 10 10 2 4 0 Bangladesh India Indonesia Nepal Sri Lanka Thailand Country

Reference: World Health Organization. Collaboration in Health Development in South-East Asia, 1948–1988. WHO SEARO, December 1992

to increase (Figure 4). Aggressive persons attending all meetings advertising by the tobacco industry, sponsored by the Regional Office and reluctance of the governments to refrain from smoking in future to take a strong stand on the issue on WHO premises. There were (since tobacco was a source of many Health Assembly resolutions revenue and foreign exchange), and expert committee meetings in countered the impact of scientific the 1970s on tobacco as a major evidence. public health problem, but it took many more years to strengthen In 1970, the Regional Committee national strategies for the control passed a resolution requesting of tobacco use.

Smallpox eradication and innovative disease control initiatives

The magnitude of smallpox as Around 1967, about 15 million cases a public health problem was occurred throughout the world each enormous. It has been estimated year. The fatality rate was about that in the 20th century, smallpox 30%, with a higher rate among caused 200–500 million deaths. babies. Often those who survived

75 A Healthier South-East Asia had extensive scarring of their skin and some were left blinded.

The goal of smallpox eradication was first articulated by WHO in 1959– 1960. In tackling this disease, there were several intrinsic opportunities. For a start, the smallpox virus had no other carrier – transmission was exclusively human-to-human. This made it vulnerable to the interruption of its transmission locally (elimination) and even globally (eradication) by vaccine- induced immunity.

The strategic application of smallpox vaccination under the leadership of WHO through the South-East Asia Regional Office achieved the interruption and elimination of smallpox virus transmission on the Indian subcontinent. In India, the last case of smallpox was reported in Assam on 24 May 1975. No cases had been detected during the preceding 12 months by active surveillance. Eradication was declared in Bangladesh on 14 December 1977 by the International Commission on Eradication. The Millions of vaccinations were performed in the 1960s to stop transmission Commission had earlier (in 1977) of smallpox certified Bhutan, India, Myanmar and Nepal as free from smallpox. Indonesia had already been declared The global eradication of smallpox smallpox-free (the last two known showed that WHO’s visionary cases detected on 23 January 1972). leadership in public health was able The strategy used in Myanmar, to bring together, at the global Sri Lanka and Thailand was based level, both the industrialized and on mass vaccination. In India and the developing world for a health its neighbouring countries, the cause. This was a perfect example emphasis was on active detection of of the potential of international cases and containment of outbreaks, cooperation for a significant in addition to mass vaccination. health benefit.

A Healthier South-East Asia 76 THE THIRD DECADE: 1968–1977

Milestones in the eradication of smallpox

Regional committee World Health recommends Last case in Assembly calls Last case in action against Democratic People’s for intensified Maldives smallpox Republic of Korea action

1880 1949 1961 1966

1939 1958 1962

Last case in World Health Last case in Mongolia Assembly calls Thailand for worldwide eradication

77 A Healthier South-East Asia Milestones in the eradication of smallpox

Last two cases Global in indonesia Last cases certification and last case in in india and of smallpox Sri Lanka Nepal eradication

1972 1975 9 Dec 1975 1980 1969 1974 1975

Last case in Last three cases Last case in World Health Myanmar in Bhutan Bangladesh: the Assembly: ‘the last case in Asia world and all its people have won freedom from smallpox’

A Healthier South-East Asia 78 Te h THIRD decade: 1968–1977

Strategizing TB control

Tuberculosis is a curable and Sputum smear microscopy was controllable disease; it is not only a found to be the most cost-effective medical but also a social problem, tool for diagnosis. because it affects mainly the poor and makes them even poorer. As These studies in the Region led indicated in the previous chapter, to the specifics of the strategies the sanatorium treatment approach for national tuberculosis control did not give the desired results, programmes in the Member mainly because the cost of mass countries. They were developed case-finding and management was based on sputum microscopy for extremely high and well beyond diagnosis, passive case-finding the resources available in most and ambulatory chemotherapy. developing countries. However, tuberculosis programme reviews showed that the The National Tuberculosis Institute programmes suffered from in Bangalore, India, in collaboration managerial weakness, lack of with WHO, developed the concept funding and failure to ensure of passive case-finding (when accessible diagnosis and treatment patients with active tuberculosis services. During that period, the experience symptoms serious interest of the agencies – including enough to seek health care), rather WHO – in tuberculosis control than active case-finding (any method deteriorated and the programme for tuberculosis identification that lost its visibility to a large extent. does not rely on patients coming in Tuberculosis continued to be a of their own accord). Passive case- major public health problem with finding was more cost-effective than serious health consequences, but active case-finding (it should be the international attention and noted that current evidence suggests resources devoted to its control it is less effective in case detection). were not adequate.

Oral rehydration therapy in cholera treatment

Outbreaks of diarrhoeal diseases Bangladesh and India, but also including cholera occurred regularly in other countries in the Region. in the South-East Asia Region. During this decade, the Regional This was the case particularly in Office included cholera control as

79 A Healthier South-East Asia a priority area in the collaborative all cases, except with those who programmes with the countries. were severely dehydrated and This helped reduce mortality who needed intravenous therapy and morbidity due to cholera. instead. The oral rehydration The treatment of diarrhoeal solution (ORS) was developed by diseases including cholera had Dr Rafiqul Islam in Bangladesh. dramatically changed because of WHO supplied ORS to countries oral rehydration therapy, which that reported cholera outbreaks. At was used for the first time in the the end of this decade, UNICEF also Region successfully to prevent started distributing ORS packets to dehydration. It worked in almost countries in the Region.

WHO was supplying ORS to countries that reported cholera outbreaks

A Healthier South-East Asia 80 Te h THIRD decade: 1968–1977

Cancer control programmes

The first World Health Assembly optional method at the community in 1948 had placed cancer sixth level was promoted, and training was on the list of priority diseases in conducted in Bangladesh and India. international work, with a focus primarily on studies and statistics. Practical national cancer control Until 1970, short-term consultants programmes which were well were employed by WHO to study planned with defined strategies the magnitude of the problem and were supported and strengthened provide advice to the countries. A in India, Maldives and Sri Lanka, number of international agencies always bearing in mind to use the shared a common interest in existing infrastructure and health cancer control and, after 1970, workforce as far as possible. WHO’s they established a more systematic technical collaboration in this technical coordination between important development was extended them. to prepare national cancer control plans in Bangladesh, the Democratic The strengthening of hospital- People’s Republic of Korea, India, based and population-based Indonesia, Mongolia, Myanmar, cancer registries was supported. Sri Lanka and Thailand. Information from these helped in the realistic planning of cancer The important role that tobacco control programmes. Special played as a cause of common cancers attention was given to oral and in the Region (oral, laryngeal and cervical cancers, which were the pulmonary) was well known, and most common cancers in the Region. WHO conducted regional meetings on The use of clinical screening of controlling the use of tobacco in the cancer of the cervix as a feasible and late 1970s and early 1980s.

Promoting biomedical research

From 1959, a comprehensive immunology, cancer, communicable health research programme under diseases and nutrition. Initially, the Global Advisory Committee the involvement of the regions on Medical Research had been was minimal. developed. WHO headquarters took the sole responsibility in Following demands from Member the field of research, mainly in countries and intense discussions biology standards, microbiology, in the WHO governing bodies, the

81 A Healthier South-East Asia World Health Assembly in 1974 Department of Medical Research and 1975 emphasized the need in Myanmar in the production of for involving and encouraging the plasma-derived hepatitis B vaccine, regions to implement appropriate and collaborated with Mahidol research programmes. The Regional University on the development Committee for South-East Asia of safe and effective individual discussed the matter in 1973 and dengue vaccines. The Regional 1974, and in 1975 endorsed the Office also authorized research proposal for the establishment funds that were earmarked for of the South-East Asia Advisory countries on an annual basis. At its Committee on Medical Research peak in 1988–1989, the research (SEA-ACMR), authorizing at the budget for the Region was same time adequate funding for US$ 5.97 million. research programmes. The members of the SEA-ACMR met twice in 1976 Life expectancy at birth in all and subsequently met annually. The countries of the Region continued SEA-ACMR identified six priority to increase during the decade. Only areas for the health research: two countries – the Democratic i) communicable diseases (covering People’s Republic of Korea and six diseases), ii) nutrition, iii) Sri Lanka – had reached the control of human fertility, iv) level of life expectancy found environmental health, v) delivery in industrialized countries, i.e. of health services, and vi) others, more than 70 years (see Figure 5). based on national priorities. These gains in longevity could be attributed to a number of factors, In developing the work of the including improved education, SEA-ACMR, the Regional Office socioeconomic conditions and collaborated closely with the lifestyle, as well as progress in countries. The Regional Office health care. supported the Indian Council of Medical Research in the evaluation Table 2 provides an analysis of of traditional medication in the the achievements of WHO in the treatment and management of Region made in the first 25 years of rheumatoid arthritis, and the its existence.

A Healthier South-East Asia 82 Te h THIRD decade: 1968–1977

Figure 5: Life Expectancy at Birth in countries of SEA Region, 1970–1980

80 65 65 70 70 67 67 65 66 65 64 63 64 63 64 62 61 5959 60 57 58 56 55 55 54 53 49 50 50 47 48 46 4646 47 46 46 47 47 45 41 40 Years

0 Bangladesh Bhutan Myanmar DPR Korea India Indonesia Maldives Mongolia Nepal Sri Lanka Thailand

Country 1970 Male 1970 Female 1980 Male 1980 Female

Reference: World Health Organization. Collaboration in Health Development in South-East Asia, 1948–1988. WHO SEARO, December 1992

60th Anniversary embroidered wall hanging. Gifted by Myanmar

83 A Healthier South-East Asia Table 2: Public health achievements during 25 years of WHO’s existence in the Region

1947–1948 1973

Malaria was rampant. india alone had 75 million Malaria, although attempting to stage a comeback, was cases and perhaps 800 000 deaths a year. The considerably reduced. in fact, from a total of 75 million cases situation was equally grim in other countries. in india in 1947 the number dropped to slightly more than 1 million; also, thanks to new antimalarial drugs, the disease is no longer a critical public health problem. Plague and many other common communicable Plague no longer represented a health problem in the Region; diseases were an ever-present menace. One of though some foci still existed, only a few sporadic cases were WHO’s first activities was to help in the control of reported from time to time. an outbreak of plague in Mysore state of india. Smallpox reigned unchecked, scarring, blinding The disease had been routed from most countries of the and killing thousands. Region. Another problem was yaws, which afflicted Thanks to the vigorous action by governments and WHO, yaws millions and millions of people and was was no longer a public health problem in our Region. particularly serious in indonesia and Thailand. Maternal and child health programmes did not The Organization’s interest in the health of mothers and exist in a systematic way and were not integrated children was extended and reinforced through the family into general health services. health programme. Unsanitary environment and lack of safe drinking The importance of safe community water supply was water were persistent problems particularly recognized and continued to be an important activity of the dominant in rural areas. Regional Office. Many countries were still attempting to deal with WHO and the governments laid particular stress on the need their health problems on a day-to-day basis, and for evolving well-planned national health schemes, which will there was a dearth of overall planning, often an integrate and improve the delivery of health services. A series absence of rational goals, and little attempt at of training courses on national health planning had been improving training techniques. National health conducted, and there were national health planning units in planning was not coherent and not based on various stages of development in every country of the Region. health statistics. Doctors and nurses were particularly scarce, and The number of medical colleges and nursing schools in the there were extremely limited facilities for training Region had risen significantly. in 1972 there were 147 medical and preparing them. colleges as compared with 41 in 1948, and 250 schools and 16 colleges for nurses’ training against 175 schools and 2 colleges in 1948. Although the nursing situation remained difficult, great strides were made over the past years. For example, india, indonesia and Thailand have more than doubled the number of nurses and midwives since 1956, and increased efforts are being made to see that nurses play an important role in the health team.

Reference: World Health Organization. Collaboration in Health Development in South-East Asia, 1948–1988. WHO SEARO, December 1992

A Healthier South-East Asia 84 Te h THIRD decade: 1968–1977

25 years of WHO in the South-East Asia Region

The 25th anniversary of WHO in the South-East Asia Region was celebrated on 18 September 1973 at World Health House, the Regional Office in New Delhi. Messages received from Heads of States or Heads of Governments of Member countries were read out. Messages were also received from representatives of the United Nations, the specialized agencies and intergovernmental organizations. Extracts from some of the messages are given below:

‘I note with sincere appreciation that successfully its noble mission, the WHO has been rendering a great service World Health Organization should to our war-ravaged country ever since contribute actively to the protection and her liberation following catastrophic improvement of the health of the people.’ human sufferings. With its commendable (The Government Representative of assistance and cooperation we have been Democratic People’s Republic of Korea) able to combat and avert malnutrition, disease and death in epidemic ‘WHO is one of those international proportions.’ agencies which have rendered substantial (President of Bangladesh) help in the eradication of human suffering. It has scored successes in the field of global ‘The honourable but difficult task of the health in many countries, besides India. World Health Organization of promoting Committees like this enable countries (the) health (of) mankind has been which share similar problems to discuss achieved with remarkable success, and the ways and means for promoting common Regional Office’s share in this undertaking health programmes in the respective has been no small contribution.’ countries.’ (Prime Minister of Burma) (President of India)

‘Allow me to avail myself of this ‘We, the people of Indonesia, have enjoyed opportunity to extend my fervent the benefit of this world organization. greetings to the Regional Director and In the span of a quarter of century of its other staff members of the Regional existence the Organization has shown Committee who have dedicated remarkable signs of progress. It has grown themselves for many years to the into an organization covering almost advancement of the work of WHO and all countries in the world. 137 member especially the South-East Asia Regional countries reflect the true manifestation Office … and to the delegates of the of the principle of ‘universality of Member States present here. Health membership’. Another significant service, therefore, is a sacred undertaking progress … important and encouraging for everyone who strives for the happiness achievements in the field of health made of the people and for their betterment. possible under the coordination and We think that, by accomplishing guidance of this Organization.’ (President of the Republic of Indonesia)

85 A Healthier South-East Asia ‘The invaluable benefits gained by diseases of the Region. I hope WHO mankind under the worldwide health will continue its relentless fight against programmes of the World Health various diseases to help attain “the highest Organization are too obvious to us all. The possible level of health by all people”.’ Administrators of this Specialized Agency (Prime Minister of Nepal) of the United Nations, the consultants, experts and staff of this worthy ‘Communicable diseases like malaria, Organization deserve to be congratulated tuberculosis and bowel diseases continue individually and collectively for the to remain in the forefront but I am happy tremendous efforts they have made … in to note that countries of this region have order to impart knowledge and techniques not suffered major outbreaks of diseases to safeguard mankind from the scourge of like smallpox or cholera during the last disease.’ year. I can confidently presume that this (President of Maldives) situation is largely due to the valuable assistance and guidance given by the ‘I take this opportunity to express my South-East Asia Regional Office towards Government’s appreciation of the disease control and prevention.’ contribution being made by WHO … to (Prime Minister of Sri Lanka) the development of Mongolia’s public health services. I am confident that our ‘I recall with happy memory of the cooperation and common endeavour will remarkable achievements being attained further yield fruitful results in the years to by the WHO Regional Office for South- come.’ East Asia since its inception in this region. (Deputy Chairman of the Council of Through its dynamic actions and unfailing Ministers of the Mongolian People’s efforts, it has brought ease from suffering Republic) and brightened the peoples of South-East Asia with joy, of which I am hopeful that ‘WHO has been instrumental in it will continue to progress and achieve by strengthening the health services and raising the levels of health and standard of promoting the health of the people by living more and more all over the region.’ helping to control various communicable (Prime Minister of Thailand)

(Reference: 25th Anniversary of the WHO Regional Organization for South-East Asia, 1948–1973. A commemorative volume)

A Healthier South-East Asia 86 87 A Healthier South-East Asia THE FOURTH DEcADE 4 1978–1987 Primary health care and Alma-Ata: Landmarks of the ‘New Vision’

A Healthier South-East Asia 88 Te h fOURTH decade: 1978–1987

MAJOR ACHIEVEMENTS IN THE FOURTH DECADE: 1978–1987

1 2 3 4

Countries District Health Disaster Community health introduced specific Systems and preparedness and programmes were approaches to Management response was implemented ‘Health for All’ and established systematized primary health care 5 6 7

Strategy to tackle Strategic plans to Strategies and methods malaria was address HIV/AIDS to address threats of revised were introduced in noncommunicable the countries diseases were initiated

his decade was dominated and targets for all aspects of health by the rise of a new health development. It was the Alma-Ata philosophy and a new focus. International Conference on Primary The combination was called Health Care, held in September “Health for All by the Year 1978 in the former Soviet Union, T2000 through the primary health that broadened the concept of care approach”. The idea was based basic health services to encompass a on social relevance and social justice, philosophy which went beyond the and had been discussed, agreed provision of the first-contact health upon and put on the national services. It identified the principles of health tables. Health for All by the primary health care philosophy: the Year 2000 and the Alma-Ata equity, community involvement, Declaration on Primary Health Care appropriate technology and a were extraordinary milestones in multisectoral approach. world health, influencing thinking and development both in the health The emphasis of WHO’s work in and also non-health sectors. They the Region was also put on health heralded the start of a new era services management, e.g. planning, in health. systematic implementation, monitoring and evaluation. The “Health for All” provided the first gains in universal immunization, overarching framework of goals which brought the Region closer

89 A Healthier South-East Asia to the eradication of polio, were national disaster preparedness and consolidated. At the same time, response programmes had to be other new priorities began to loom systematized. In the area of disease large for WHO and the countries. control important events – such Noncommunicable diseases had as the appearance in the Region become an even bigger concern. The of a new scourge, HIV/AIDS, the Region had always been particularly resurgence of yaws, and the revision exposed to natural disasters, and of the malaria strategy – called for during this decade, the regional and increased attention.

The challenge of health development Today, we are in a very challenging phase of health development. The possibilities of change are open to all people but no standard method or prescription is applicable to them all. Human ingenuity knows no frontiers and thus, if the issues and problems can be analysed in relation to the strengths, it should be possible to assure equitable development within the bounds of a sound ecosystem Dr U Ko Ko, Regional Director, 1981–1994

The Alma-Ata Declaration: Concept, principles and the role of the Region

Despite the collaborative efforts in meeting the health needs of of countries and the cooperative the people. The United Nations leadership role that WHO played supported the concept of technical in the field of health and the cooperation among developing two United Nations Development countries, and Member States in the Decades, various limitations and WHO Regions developed Charters shortcomings had been observed for Health Development. These

A Healthier South-East Asia 90 Te h fOURTH decade: 1978–1987

Charters were conceived on the basic WHO with a conceptual basis for premise that there was an urgent need health development. for mobilizing additional resources in order to accelerate the rate of health The Report of the International development to achieve an acceptable Conference on Primary Health Care standard of health for all by the year in 1978 and the ensuing Alma-Ata 2000. The South-East Asia Charter for Declaration on Primary Health Care Health Development was endorsed by influenced the world, including the the Regional Committee in 1978. countries of South-East Asia, in their outlook on primary health care. This Concurrent with these international influence persisted well beyond 1980 developments, and recognizing the and continues to be felt right into unsatisfactory health situation in most the 21st century. Delegations from all countries, WHO and UNICEF jointly Member countries of the WHO South- conceived the idea of holding an East Asia Region participated at the International Conference on Primary Alma-Ata Conference. Health Care. For about a decade, a preparatory commission had been The concept of primary health care stimulating the countries and begun was at first essentially an expansion preparing for the International of the ideas contained in the concept Primary Health Care Conference. of basic health services. But it was In order to alert their populations the Alma-Ata Conference that and prepare contributions for the broadened this concept to encompass international conference, individual a philosophy which went beyond countries organized specific activities the provision of first-contact health related it. These included mass services. The principles of the PHC meetings, national seminars, study philosophy are: equity, community projects and surveys, all reported to involvement, appropriate technology the Regional Committee. The South- and a multisectoral approach. And East Asia Regional Primary Health the Alma-Ata Declaration had Conference was held in November eight components, which were: i) 1977 in New Delhi. education concerning the prevailing WHO and UNICEF sent joint health problems and the methods observation teams on primary health of preventing and controlling them; care (PHC) to South-East Asia, and ii) promotion of food supply and selected Chandigarh, Ludhiana and proper nutrition; iii) an adequate Varanasi in India and Dhaka and its supply of safe water and basic neighbourhoods in Bangladesh for sanitation; iv) maternal and child these visits. Another group visited health care, including family planning; Kerala and Tamil Nadu in South v) immunization against the major India to observe PHC activities in the infectious diseases; vi) prevention area. The reports of those missions and control of locally endemic were approved in 1975 by the World diseases; vii) appropriate treatment of Health Assembly and served as basic common diseases and injuries; and viii) preliminary documents providing provision of essential drugs.

91 A Healthier South-East Asia Primary health care as defined in Alma-Ata Declaration

Primary health care is essential health care part both of the country’s health system, based on practical, scientifically sound of which it is the central function and and socially acceptable methods and main focus, and of the overall social and technology made universally accessible to economic development of the community. individuals and families in the community It is the first level of contact of individuals, through their full participation and at a the family and community with the national cost that the community and country can health system bringing health care as afford to maintain at every stage of their close as possible to where people live and development in the spirit of self-reliance work, and constitutes the first element of a and self-determination. It forms an integral continuing health-care process.

Plenary session of the International Conference on Primary Health Care, 6–12 September 1978, at Alma-Ata (now Almaty) in the former Kazakh Soviet Socialist Republic (now Kazakhstan)

Applying the new concept

In 1981, the World Health Assembly socioeconomic development. For the adopted the Global Strategy for first time, an attempt was made to Achieving Health for All by the develop a comprehensive set of goals Year 2000, and later in the year, and targets for health – a precursor the UN General Assembly endorsed of the goals found in the Millennium the strategy. It was an ambitious Development Goals and later the strategy signifying a new model Sustainable Development Goals. of development, with progress Associated with the overarching goal in health promoting overall of Health for All (HFA) in the Region,

A Healthier South-East Asia 92 Te h fOURTH decade: 1978–1987

To observe the tenth anniversary of the Alma-Ata Conference, a global meeting – From Alma-Ata to the year 2000: A midpoint perspective – was convened at Riga, Latvia, in the former Soviet Union, on 22–25 March 1988. View of delegates at the meeting that was convened by WHO and UNICEF

and with a view to accelerate lowest cost. The main social target progress towards it, the Regional of governments and WHO in the Committee urged the countries to coming decades was the attainment initiate and pursue efforts for the by all citizens of the world, by the development of a new cadre of HFA year 2000, a level of health that will leadership. Such a group of leaders permit them to lead a socially and needed a clear understanding of economically productive life. All the value system implicit in the countries of the Region committed strategy and principles of Health for themselves at the highest levels to All. This included an emphasis on, the attainment of the goal of HFA and commitment to, social equity by 2000, with primary health care and justice; a comprehension of as the key approach. The countries the intersectoral nature of health also developed and implemented development; and the willingness national strategies and plans of and capability to convert these action for attaining the goal. Many factors into opportunities. Above of these activities were supported all, the leaders needed to develop by WHO, both technically and a capacity to motivate others to financially. The countries embrace the HFA philosophy. themselves also came up with many innovative approaches. The new concept of health development was firmly rooted in its Community participation as social context. Health is a universal a cornerstone of PHC has a and fundamental human right, and long history in countries of the its attainment is an essential social Region. Even before the Alma- goal. The guiding principle of the Ata Conference, the countries new philosophy was to provide provided a number of examples the greatest health benefit to the of this approach. These included greatest number of people at the a project in Central Java in 1960,

93 A Healthier South-East Asia which involved village committees, realistic solution for attaining total village insurance schemes, and the population coverage with essential training of volunteers; the Jamkhed health care is to employ community health project in India described in health workers who can be trained the previous chapter; the Sarvodaya in a short time to perform a specific Shramadana Movement, which task”. They instituted programmes started providing development and for the training of large numbers conflict resolution programmes to of community health workers villages in Sri Lanka in 1972; the selected from the community and Lampang health project to expand by the community. There were health coverage among the rural success stories, as well as failures. population, particularly to women However, the use of volunteers for of childbearing age and preschool strengthening community action children, in Thailand in 1974; and for health in countries of the South- a Ministry of Health scheme for East Asia Region is a reality. It also community participation in Sri Lanka forms one of the essential strategies in 1975. in the efforts towards providing primary health care in a number of Most countries in the Region these countries. Of course, not all took to heart the Alma-Ata countries of the Region were at the recommendation that “for many same level in the extent of their use developing countries, the most of volunteers.

Delivering maternal and child health services in Nepal

Most of the Nepalese population lived in rural and remote areas, far from any health service facility. Despite this, the Government succeeded in bringing maternal and child health services and information to every community in the country. Nepal has used its own resources to deliver services innovatively. The female community health volunteer (FCHV) programme covers all of the country’s 75 districts.

Initially, these 48 000 FCHVs selected from within the community provided health education to mothers, distributed family planning devices, and offered support during campaigns. Their role was then expanded to act as both service providers and health-care promoters. They diagnosed and treated pneumonia in children, diagnosed diarrhoea and provided ORS and zinc, supported immunization campaigns, created awareness about the importance of vitamin A in the community, and referred severe cases.

FCHVs are the key players in the expanded Community-Based Neonatal Care Programme. In addition, they also identified and registered pregnant women, promoted institutional delivery, attended home deliveries, provided services and counselling for immediate newborn care and essential newborn care, managed birth asphyxia, assessed and managed neonatal infections, managed hypothermia and low birth weight, made the four postnatal follow-up visits, and referred severe cases to health facilities. An increasing percentage of pneumonia cases have been treated since 1995. FCHVs were 98% accurate in their assessment of patients. Nationally, 88% of vitamin A and 82% of deworming services was provided by FCHVs.

A Healthier South-East Asia 94 Te h fOURTH decade: 1978–1987

Promoting district health systems and management

The 1986 evaluation of the national in Maldives, township in Myanmar, strategies for HFA in the WHO division in Sri Lanka, tambon in South-East Asia Region indicated Thailand, and district in Bhutan, that there had been impressive Democratic People’s Republic of progress in some countries and Korea and Nepal). in many there had also been an expansion of health infrastructure. The Regional Office worked to This resulted in the countries facing strengthen the district health systems formidable managerial and financial in the countries. In the late 1980s, the problems in trying to ensure the emphasis shifted to the training of essential elements of primary middle-level health managers. This health care. step was relevant as a component of the decentralization of responsibility The greatest obstacle to achieving and authority. It took a longer time HFA was considered to be the for policy changes and formalization weakness in the planning, of the roles and functions of middle- organization and management of level managers (District Health Officers) health systems, particularly at the in a decentralized district to happen. middle managerial level, which was identified as the district level. In In the late 1980s, responding to the 1987, the Regional Office initiated criticism that primary health care an intensification and targeting was “second-class health care” and of national action programmes mainly for the poor, the Regional for primary health care, focusing Office emphasized the development on establishing manageable units and organization of referral systems, in the countries. These units were and organized several regional geographical areas small enough meetings and funded research to be able to manage health needs projects on various aspects of these effectively and efficiently, yet large systems, in Bangladesh, Bhutan, enough to make it feasible to India, Mongolia and Sri Lanka. The include all the ingredients required results of the studies showed that for self-reliant health care. the implementation of the referral system faced many difficulties, and These organizational units were that bypassing it was common. From called “districts”, but they had the early 1980s, WHO supported various local names in the countries studies on service coverage for urban (e.g. thana in Bangladesh, block in dwellers and on reform in urban India, kabupaten in Indonesia, atoll health service delivery. The results

95 A Healthier South-East Asia of the studies conducted in India, primary health care programmes. Indonesia, Myanmar and Thailand Since the early 1990s, the Regional were used in facing the challenges Office had played an important of the health consequences of role in this through advocacy and rapid urbanization. by providing technical and financial support to help countries build The issue of quality of health care quality assurance activities into their had so far not been addressed by the health-care systems. The first meeting of health ministers

During a meeting of the health in Jakarta in September 1981. At ministers of the Member States that meeting, the Ministers agreed of the Region on the sidelines that steps should be taken to of the World Health Assembly establish technical cooperation and in 1980, it was suggested that a collaboration among the countries regular ministerial meeting of of the Region. This was for ministers be held in the Region to countries to help each other in their provide a forum for the exchange efforts for health development. of information, experiences and Since then, the Ministers of Health views on the social, political and have been meeting regularly economic dimensions of health almost every year till 2015. In 2015 in the development process. The the format of this meeting was first Meeting of the Ministers of changed to a roundtable discussion Health of the countries of the WHO of the ministers during the Regional South-East Asia Region was held Committee.

Consultative Committee for Programme Development and Management

Unlike many other multilateral with representation of all Member organizations, the health planning countries. This was an important and management programmes step, enabling all Member countries of WHO were prioritized and to study, analyse and evaluate WHO coordinated in collaboration with programmes. Member countries. To facilitate this, the Consultative Committee Six countries of the Region for Programme Development and had already adopted country Management was set up in 1981, health programming or a similar

A Healthier South-East Asia 96 Te h fOURTH decade: 1978–1987

methodology for health planning. evaluation system. Bangladesh This had led to the rationalization finalized a national health of national medium-term health manpower development plan. plans in conformity with the needs Maldives attempted to involve island of the people. In addition, Nepal leaders in its efforts to assess the felt and Indonesia developed long- needs as an input to PHC planning. term perspective plans for health. Thailand had already decentralized Myanmar developed not only a planning to the provincial and workable process for monitoring district levels. The Regional Office the People’s Health Programme continued to support these but also put in place a built-in national efforts.

The Safe Motherhood Initiative

The Safe Motherhood Initiative was of maternal deaths. A global goal formally launched in 1987 during had been agreed as a part of HFA the International Conference on to reduce maternal mortality and Better Health for Women and morbidity by at least 50% by 2000. Children through Family Planning. Following the Conference, Member The Conference was organized countries of the Region developed to effectively address concerns national action plans to promote about the continuing high level safe motherhood.

Cross-sector public policies for women and children in Sri Lanka Sri Lanka had achieved one of the lowest child mortality rates among lower- middle-income countries. The country had made continuous progress as a result of a combination of cross-sector public policies that ensured universal access to education for women, clean water and improved sanitation for the majority, and health system developments that guaranteed universal coverage of essential preventive and curative health interventions to all women and children. The coverage of deliveries by skilled personnel was 98%, and coverage with measles, diphtheria, pertussis and tetanus vaccines was 97%. The country had the highest rates for breastfeeding in the Region.

(A Decade of Public Health Achievements in WHO’s South-East Asia Region 2004–2013. World Health Organization Regional Office for South- East Asia 2013)

97 A Healthier South-East Asia Bridging the Straits. Depicts composite scenes from the Hindu epic Ramayana. Oil on canvas. 2.27 x 1.56 m. Gifted by Indonesia

The painting portrays the birth of the God Boma. Oil on canvas. 3.08 x 1.93 m. Gifted by Indonesia

Balinese cremation. Oil on canvas. Gifted by Indonesia

A Healthier South-East Asia 98 Te h fOURTH decade: 1978–1987

Progress in environmental health

At the Alma-Ata Conference on at the end of the Decade. WHO Primary Health Care, environmental identified six priority areas for health was recognized as an Decade strategies and accordingly essential element. Another landmark supported the activities of the in this area was the endorsement by countries in these areas: WHO of the recommendations made i) promotion of the Decade, by the UN Water Conference held ii) development of national in Mar del Plata, Argentina, in 1977. institutions, iii) development of This conference gave priority to the human resources, iv) information provision of safe water supply and exchange and technology sanitation for all by the year 1990 development, v) mobilization and designated the decade of financial resources, and vi) 1981–1990 as the International coordination with other agencies. Drinking Water Supply and Sanitation Decade. The main The mid-Decade review showed objective of the “Decade” was to that Maldives, Nepal and Thailand stimulate and accelerate national were likely to achieve the urban water supply and sanitation sanitation targets, while Bangladesh programmes so that unserved and India had a very favourable populations in rural and urban chance in rural water supply, as areas had access to these facilities. did Indonesia and Thailand in rural This was of special relevance to sanitation. Bhutan, Indonesia and the Region, where a significant Myanmar were not likely to reach proportion of illness was accounted the revised urban water supply for by waterborne and water- targets set for the Decade. The related diseases. constraints that affected urban and rural water supply and sanitation In 1981, the Regional Office for were limited funds, operation and South-East Asia conducted a survey maintenance difficulties, lack of to provide baseline information adequately trained personnel, poor on the water supply and sanitation logistic support and, above all, the sector of each country, which could tremendous and rapid increase in later be used to monitor progress the urban population.

99 A Healthier South-East Asia Reaching the community with human resources for health

To address the increasing shortages CHW scheme in the late 1970s had of trained health-care professionals collapsed in most States within a and in line with the new HFA few years (owing to the community philosophy based on social relevance health workers’ demand that they and social justice, WHO encouraged should be enrolled as government the countries to recruit community employees rather than be part-time health workers (CHWs). This part of volunteers supported by a small the health workforce was trained honorarium). Lessons learnt were by, and worked in, the community that the CHWs must be continuously from which the individuals came. supported with strategies suitable Consequently, they were able to for utilizing, sustaining and enabling respond to local societal and cultural them to work effectively to reduce norms and customs. the disease burden, bridge the gaps in the health workforce, and Many CHW programmes were promote health. carried out in the Region in the 1980s as a part of wider health A good example of focusing sector reform. The principal aim CHW work were the community was to improve the accessibility activities of the traditional birth and affordability of health services attendants (TBAs). In this decade, for rural and poor communities WHO (together with UNICEF and within the context of primary health UNFPA) promoted the training of care. For example, in Indonesia in TBAs because most births took place 1982, during the restructuring of outside health-care facilities. This the health system with a focus on was considered to be an important health development, village health problem, and a major cause of the volunteers (selected and paid for high infant mortality in the Region. by the communities) became a part When working under the supervision of the health posts in the districts. of and in conjunction with other The dramatic increase in a number levels of health care, TBAs were of health posts contributed to found to have an important role significant achievements – infant in improving birth services. In mortality decreased by 30% within reviewing the role of medical seven years, and immunization doctors in the context of HFA, the coverage increased manifold. Regional Committee in 1976 passed a resolution that doctors In India, while some CHW projects should be as close to the community have been successful, the national as possible.

A Healthier South-East Asia 100 Te h fOURTH decade: 1978–1987

In the 1980s there was a movement and community-based education, for the reorientation of medical problem-based learning, and education to make it more responsiveness of medical education responsive to social and community to societal needs. By the late needs. The movement was 1990s, all Member countries with promoted by WHO and was taken medical schools had either partially up by the countries in the Region. or completely reoriented their The Regional Office organized programmes. Nursing educators a series of consultations, with a were simultaneously reorienting focus on community orientation nursing education programmes. Reaching out with technical programmes

As mentioned in the previous was made to ensure that the chapter, between 1974 and 1979 programme was within the reach the Expanded Programme on of the community. The programme Immunization (EPI) was adopted was soon able to report a dramatic by all countries of the Region. EPI fall in mortality thanks to improved provided a blueprint of operations management strategies. including training manuals, and was implemented by the health Later, in 1984, the acute respiratory workers close to the communities. infections (ARI) programme was By implementing EPI, countries established. In 1990, this was took a step forward in the battle merged with CDD. Innovative against the diseases of children and approaches such as the Integrated their mothers, and brought other Management of Childhood Illness important technical programmes (IMCI) initiative were introduced (such as CDD and ARI) within the in 1998. The focus of IMCI was the reach of the communities, in an complex health needs of the child, integrated manner. including combined treatment for the major disorders such as A good example of WHO’s malaria, pneumonia, measles and technical programmes reaching the malnutrition as well as diarrhoeal community was the establishment diseases. In the 1980s, the of a new programme on the control Government of Bangladesh provided of diarrhoeal diseases (CDD) in 1979. a one-year basic curative training The programme focused on the course covering all these areas to reduction of mortality and morbidity some 16 000 village doctors. from diarrhoeal diseases and their effects, including malnutrition, in An important step was taken in infants and children. Every effort this decade to share scientific

101 A Healthier South-East Asia information between Member States formed in 1979. This helped to of the Region and also with those make better use of existing library from other Regions. The Health resources in the countries of the Literature, Library and Information Region, by sharing information and Services (HeLLIS) network was carrying out training activities. Disaster preparedness and response

The countries of the Region cover of the Region. Cyclones were a vast area with a wide variety of almost a yearly occurrence in geoclimatic characteristics. As such, Bangladesh, but unprecedented they are particularly susceptible to floods hit Bangladesh and parts of a wide range of different natural India in September 1988. A severe calamities. Cyclones, floods, earthquake occurred in August 1988 earthquakes, volcanic eruptions, in Northern India and Nepal. As for droughts and tidal waves are complex emergencies, Bangladesh, frequent occurrences in one country India, Myanmar and Sri Lanka had or another (Table 3). In addition, the been experiencing conflicts and civil countries faced complex emergencies strife in some areas for some years. that were entirely man-made. The Regional Office established During the decade, various types action programmes for disaster of disasters had hit the countries preparedness and response as a

Table 3: Disaster profile of selected countries of WHO South-East Asia Region, 1987

Type of Bangladesh Bhutan India Indonesia Myanmar Nepal Sri Lanka Thailand emergency Flood + +++ +++ + Tornado + + Cyclone + + +++ + Tidal wave + + + Earthquake + ++ + Landslide ++ + + + Volcanic + eruption Drought ++ + ++ Industrial ++ ++ + accidents Complex + ++ +++ + emergencies

World Health Organization. Collaboration in Health Development in South-East Asia, 1948–1988. WHO SEARO, December 1992

A Healthier South-East Asia 102 Te h fOURTH decade: 1978–1987

part of the global programme. The for disaster preparedness and overall objective of the programme response. A survey conducted in 1986 was to prevent health hazards, on national disaster preparedness and reduce the adverse effects of showed that there were formal disasters on health or health services structures or mechanisms in six by strengthening national capacities countries of the Region.

The Regional Office established action programmes for disaster preparedness and response

Revisiting malaria control

The World Health Assembly development of human resources (supported by the WHO Expert and helped the countries through Committee on Malaria) in 1985 consultancies in reprogramming. It recommended that malaria control introduced malaria stratification for should be an integral part of priority and selective interventions, the primary health care systems. and intensified the monitoring of Member countries in the Region resistance to insecticides and drugs. gradually aligned their health delivery policies along the lines of The spread of drug-resistant the primary health care concept, malaria from the Region started and converted vertical malaria threatening global health. In the control programmes to horizontal renewed attack on malaria in the programmes. WHO supported the 1980s, interventions were highly

103 A Healthier South-East Asia focused to reduce morbidity and prevent deaths, and protect the achievements gained during the eradication phase. The number of malaria cases annually was first reduced to 3 million. Cases stagnated around the 3 million mark between 1973 and 2001, and then further declined to about 2.5 million by 2005.

Surveillance during the post- resurgence period had either reduced or broken down entirely, leading to gross underreporting of cases. “Man-made malaria”, which has been called the “curse of the tropics”, was increasing in many places – in urban centres, industrial belts, development projects, irrigated tracts, and the like. Prevention required a health impact assessment as a part of environment WHO supported human resource training in malaria and TB control impact assessment, which was rather as an integral part of primary health care limited in the Region.

Integrating the tuberculosis programme

Although infants and children the Region. It was accepted by were given the BCG vaccine the countries that interrupting as part of EPI, and national tuberculosis transmission and tuberculosis control programmes achieving a substantial reduction devoted considerable efforts to of morbidity and mortality would case-finding and treatment, their require the integration of the health impact did not match the tuberculosis programmes into efforts. Tuberculosis continued comprehensive health systems to be a serious health issue in based on primary health care.

A Healthier South-East Asia 104 Te h fOURTH decade: 1978–1987

Recognizing viral hepatitis as a public health issue

Viral hepatitis infections have to note that horizontal transmission frequently been reported from occurs during close contact with the South-East Asia Region in an an infected person, particularly in epidemic proportion. The high early childhood, and this causes prevalence of hepatitis A is caused the highest rates of hepatitis by faecal contamination of drinking infection turning chronic. Besides water and food. The infection was producing a severe, and sometimes reported from Bangladesh, Bhutan, fatal, liver condition, hepatitis B India, Maldives, Myanmar and Nepal. infection is a major cause of liver cancer. The Democratic People’s Furthermore, an estimated 14–16 Republic of Korea, Indonesia million people in the Region were and Myanmar began producing infected with hepatitis B virus, hepatitis B plasma-derived vaccine, which is acquired from blood and and India and Thailand planned body fluids of an infected person, to produce a DNA recombinant usually through sex or sharing hepatitis B vaccine. The vaccines injection needles. It can also be against hepatitis were a powerful passed on from a mother to her prevention tool to address the huge baby during delivery. It is important disease burden. The resurgence of yaws

Yaws is caused by the spirochete WHO and UNICEF launched a global bacterium Treponema pallidum control programme in 1949. In the pertenue, and affects the skin, South-East Asia Region, programmes bones and joints. Before the Second were launched in India, Indonesia World War, mass campaigns were and Thailand. These were successful carried out in India, Indonesia and and yaws was brought under Sri Lanka for the control of syphilis control. In Indonesia, the prevalence and yaws, using arsenic and bismuth decreased in Java and Bali and, by compounds for treatment. While the 1976, large areas of the country results in India and Indonesia were reported a rate of 0.001% or less. disappointing, the campaign in Sri In India, by 1967, transmission of Lanka was successful and, by 1940, yaws had been almost interrupted in yaws had ceased to exist in the country. the four major endemic states. The programme was equally successful When penicillin was identified as a in Thailand. new, effective tool to control yaws,

105 A Healthier South-East Asia Unfortunately, with “victory” in yaws had begun. In 1982, Indonesia sight the campaigns lost their reported a rise in the prevalence rate momentum. In Thailand, yaws of 0.176% with more than 11 000 control activities were integrated infectious cases. In India, a few cases into general health services in 1967. were reported from the states of In Indonesia, with the success of Orissa, Andhra Pradesh and Madhya the programme, authorities began Pradesh. In Thailand, sporadic cases to consider yaws as a relatively low were reported in 1970. Some cases priority health problem, and there were also reported from Sri Lanka was a loss of interest in maintaining in 1983. While it was technically a sustained surveillance. feasible to interrupt the transmission of yaws, it was clear that an all-out The results were predictable: by effort for the eradication of the the early 1980s, the resurgence of disease would be necessary. Dengue research

Epidemiological studies on dengue mosquito, the main vector of dengue and research in dengue vaccine fever. Support was also given for development were initiated during studies on A. aegypti in Indonesia. the decade. In 1980, a WHO The WHO Collaborating Centre in Collaborating Centre for Research in Virology, in Pune in India, developed Dengue Vaccine Development was rapid diagnostic techniques. established at Mahidol University, Epidemiological studies on dengue Bangkok. WHO also supported the fever, dengue haemorrhagic fever establishment of Aedes Research and dengue shock syndrome were Unit in Thailand to study the supported in Indonesia, Myanmar, bionomics of the Aedes aegypti Sri Lanka and Thailand.

The new scourge of HIV/AIDS

In 1981 the first case of acquired was retroactively identified as the immune deficiency syndrome (AIDS) first case. in the world was reported by the Centers for Disease Control in the The causative agent, human United States of America. Although immunodeficiency virus (HIV), the disease had been circulating was detected in 1983, and the many years before, a man who had first commercially available test sex with men reported with Kaposi’s to detect HIV antibodies became sarcoma in San Francisco in 1980 and available in 1985. Other tests,

A Healthier South-East Asia 106 Te h fOURTH decade: 1978–1987

such as the viral antigen assay, workers, which subsequently spread polymerase chain reaction and to their contacts, and then to the viral load measurement, became spouses of contacts and finally to available later. It became evident their children. HIV prevalence among from epidemiological studies that sex workers in Chiang Rai province there were only three modes of increased from 1% to 37% in a short transmission: i) sexual (homosexual span of time. By 1993, 12% of young and heterosexual), ii) transmission military recruits based in northern through infected blood and blood Thailand were found to be HIV- products and infected injecting positive. By 1996, HIV prevalence was equipment, and iii) mother-to-child 7.1% among pregnant women in transmission. Chiang Rai.

HIV was first detected in the South- Similar patterns and trends were East Asia Region in Thailand in 1984. observed in India. The first cases were Early cases in this country were reported among female sex workers generally confined to men having in 1986 in Chennai. The infection sex with men until 1987 when an spread mostly through heterosexual explosive outbreak occurred in transmission in the country, the Bangkok among injecting drug users six northern states being the most (IDUs). HIV prevalence among IDUs affected. There were outbreaks of HIV dramatically increased from 1% to among IDUs as well in some areas. For 40% between November 1987 and example, HIV prevalence among IDUs August 1988. This was followed in Manipur increased from 1% in 1988 by an outbreak among female sex to 56% in 1995.

Raising awareness about HIV/AIDS has been an important part of the control programme

107 A Healthier South-East Asia There had been outbreaks of HIV of women and effective control in other SEA Region countries too, measures for sexually transmitted although on a smaller scale. In infections. Myanmar, HIV prevalence among IDUs increased from 17% in 1989 The Special Programme on to 59% in 1990. In Indonesia, HIV AIDS, later renamed the Global prevalence among IDUs was nearly Programme on AIDS, was officially 50% in 2001. In Nepal, the first case established in WHO in 1987. An of HIV was reported in 1988. Since HIV/AIDS unit was also established then, the infection spread gradually, in the Regional Office. Since HIV mainly among female sex workers is a cross-cutting public health and IDUs. HIV prevalence among problem, the Regional Office took female sex workers increased from an integrated approach. Even 0.7% in 1992 to 15.7% in 2001 and before the HIV infection reached it was as high as 68% among IDUs an epidemic level in the Region, in Kathmandu. In Sri Lanka, the first the Regional Office assisted all case was reported in a foreigner countries in a quick assessment in 1986 and the first indigenous of the epidemiological situation transmission was recorded in and in preparing short-term 1989. Despite the presence of plans covering one year. This was vulnerability factors, HIV prevalence followed by medium-term plans remained at a low level in Sri Lanka of three to five years and later mainly thanks to a strong health by strategic plans covering five infrastructure and better access years. WHO support in the Region to health services, high level of focused on interventions aimed at education, the high social status both prevention and care. The looming threat of NCDs

During this decade, the public health and to assess the extent of the importance of noncommunicable problem in their populations. diseases (NCDs) was on rise in most Community-based, comprehensive countries. WHO’s attention focused cardiovascular disease control on the control of cardiovascular programmes were initiated in diseases, diabetes mellitus, the Member countries, based on prevention of visual impairment and primordial prevention – avoiding blindness, and accident prevention. the development of lifestyle-related risk factors. WHO led educational The Regional Office encouraged campaigns on “smoking and the countries to develop improved health” and advocated physical methods and strategies for exercise, balanced nutrition and the preventing cardiovascular diseases, avoidance of stress.

A Healthier South-East Asia 108 Te h fOURTH decade: 1978–1987

There was a severe paucity of In the early 1970s, there occurred reliable statistical data related to a change in the approach to the occurrence of diabetes mellitus the problem of blindness. It was in most countries. The Regional recognized that most of the world’s Office supported an integrated blindness was preventable and much approach on the prevention of it was curable. In 1972, WHO and control of NCDs including intensified its technical assistance diabetes. The Bangladesh Institute to national programmes for the of Research and Rehabilitation for prevention of visual impairment and Diabetes, Endocrine and Metabolic blindness. It provided assistance in Disorders (BIRDEM) was appointed organizing manpower training and a WHO collaborating centre for establishing community-oriented the community control of diabetes ophthalmic services. The regional mellitus. BIRDEM engaged in strategies for the prevention research and in community-oriented of blindness included a crash diabetes control activities based on programme to deal with the large the primary health care approach, backlog of curable blindness cases and conducted appropriate through eye camps and mobile training courses. ophthalmic units, establishing

Member countries were encouraged to develop improved methods and strategies for preventing cardiovascular diseases

109 A Healthier South-East Asia or strengthening a permanent and inadequate enforcement of infrastructure for eye health care traffic rules led to an increased and its extension to rural areas rate of road accidents. Industrial through primary health care, and accidents also increased as a emergency measures to deal with consequence of the lack of proper xerophthalmia with massive doses safety in industrialization and of vitamin A. These strategies mechanization of labour. WHO’s were strengthened during the technical collaboration was directed fourth decade. to creating national awareness on the rising morbidity and mortality Road traffic accidents were on the resulting from road accidents. WHO rise. Rapid urbanization, industrial also promoted the formulation of expansion, and an unprecedented national policies and encouraged increase in the number of epidemiological and operational vehicles coupled with high traffic research for the prevention and congestion, poor road conditions control of accidents.

The Goa Room, gifted by the Government of Portugal, when it was an Associate Member of the Region (representing its holdings in Goa, Daman and Diu in India). Blue ceramic tiles panel two walls of the room. One wall shows the Torre de Belem (Tower of Belem), the first thing Portuguese mariners saw as their ships returned to the homeland from mercantile voyages across the globe. The tiles on the second wall depict Portuguese mariners and missionaries installing the sceptre of Christ at the mouth of the Zaire river as they found another new settlement on the African continent in the late 16th century

A Healthier South-East Asia 110 Te h fOURTH decade: 1978–1987

The health situation in the South-East Asia Region in 1988

Socioeconomic sector: South-East Asia personnel had not yet fully understood was the most diverse and populous primary health care; in some cases, region, with about a quarter of the this lack of understanding created world’s population. The States played a resistance to change. leading role in regulating development processes and were responsible Intercountry cooperation: All countries for supporting key development were committed to the principle and programmes, including health. practice of intercountry cooperation. The Association of Southeast Asian Urban-rural population: The urban Nations (ASEAN) and the South Asian population constituted 21.5% of the Association for Regional Cooperation total population. (SAARC) were important regional Development of the health system: mechanisms for such cooperation. All countries of the Region adopted Health status: Only four countries the goal of Health for All (HFA) by the reported infant mortality rates of Year 2000, using primary health care as below 50 per 1000 live births, which the key approach, and recognized that was stipulated as the target in the HFA health policy should be integrated into goal. Three countries reported rates the overall national development policy. between 50 and 100, and four had more Health workforce: Efforts were being than 100 per 1000 live births. Two made in all Member countries to countries reported life expectancy at reorient health workers to primary birth of between 40 and 50 years, four health care. However, the countries countries between 50 and 60 years, were not able to balance their and another five countries between 60 distribution, especially with regard and 70 years or more. Malnutrition and to professional health personnel. nutritional deficiency disorders, vector- The ineffective utilization and low borne diseases, waterborne parasitic productivity of health workers caused and diarrhoeal diseases, tuberculosis, persistent concern. Professional health pertussis, tetanus, diphtheria and

111 A Healthier South-East Asia leprosy were all major causes of of children under the age of 5 years, morbidity in the Region. Cancer, with case-fatality rates in hospitalized cardiovascular disease and other children ranging from 4.2% in Thailand noncommunicable diseases had more to 17.6% in Bangladesh. In two recently become major public health countries of the Region, all infants were problems, particularly in countries fully immunized against the six EPI with higher life expectancies. The target diseases. South-East Asia Region accounted for about half of the total world incidence In conclusion, with a life expectancy of positive malaria cases. Decreases in at birth just exceeding 70 in the incidence were noted in some areas of Democratic People’s Republic of Korea, Bangladesh, Indonesia and Maldives. the two major causes of deaths in the In India, the incidence did not record country were cardiovascular diseases any change, and increasing trends and cancer. In the remaining countries, were observed in Bhutan, Nepal, excessive mortality and morbidity still Myanmar, Sri Lanka and Thailand. prevailed among children and women. Leprosy was an important public The majority of the population was health problem in eight countries: still exposed to high risks of infectious of the 11 million leprosy patients and parasitic diseases, often related to in the world at the time, 5.3 million inadequate access to clean water and (48%) were from South-East Asia. environmental sanitation. In addition, The estimated prevalence rate in the they were subject to several nutritional Region was 5.12 per 1000 population. deficiency disorders. Indirect health The average incidence of tuberculosis indicators showed inadequate in the Region was estimated at utilization of health services and 100 per 1000 population. Acute poor access to safe water supply and respiratory infections were major sanitation, in particular among the rural factors contributing to the mortality populations.

(World Health Organization. Collaboration in Health Development in South-East Asia, 1948–1988. WHO SEARO, December 1992)

A Healthier South-East Asia 112 113 A Healthier South-East Asia THE FiFTH DEcADE 5 1988–1997 Targeting disease elimination, strengthening partnerships

A Healthier South-East Asia 114 Tefthh Fi Decade: 1988–1997

MAJOR ACHIEVEMENTS IN THE FIFTH DECADE: 1988–1997

1 2 3

WHO forged Declaration Health promotion partnerships on Health was prioritized in health Development in the development SEA Region in the 21st century 4 5 6

DOTS strategy in A concept of Major nutritional tuberculosis was reproductive disorders were implemented health introduced reduced 7 8

National Targets for disease immunization days elimination and initiated control were set up

uring the 1990s, a consequently a changing role for number of international WHO as the leading technical agency conferences were held in health. supporting the goal of Health for All. Many During this decade, there was a Dothers followed at the beginning recrudescence of certain diseases. of the 21st century. These These included malaria, tuberculosis, developments created a strong cholera and visceral leishmaniasis. interest, encouraged commitments The re-emergence of diseases such and broadened the number of as human plague, the genesis of a partners in health, both within and new HIV/AIDS epidemic, and the outside the United Nations system. rise as a public health problem of This led to a new and complex noncommunicable diseases with relationship among traditional and all their risk factors were causes of new players and national authorities concern and reasons to prioritize in international health, and action.

115 A Healthier South-East Asia The need for partnerships

If we are serious about meeting the health challenges of our Region, we cannot rely on our own efforts. We need to work together with others, we need to form alliances and partnerships – partnerships for health! Partnerships for health mean bringing together all those involved in improving the health and quality of life of people

Dr Uton Muchtar Rafei, Regional Director 1994–2004

Emphasizing partnerships and All-for-Health policies

Between 1990 and 1996, nine and Development (Rio de Janeiro, international conferences were held 1992, also known as the Rio supporting Health for All. These Earth Summit), the International conferences included the United Conference on Population and Nations World Summit for Children Development (Cairo, 1994), and (New York, 1990), the International the Fourth Conference on Women Conference on Nutrition (Rome, 1992), (Beijing, 1995). Other notable the UN Conference on Environment conferences followed, including

A Healthier South-East Asia 116 THE FIFTH DECADE: 1988–1997

the UN Millennium Summit (2000), In addition, there were many the UNGA Special Session on Children powerful, government-backed (2002) and the Second Earth Summit donor agencies such as the (2002). These developments created a Australian Agency for International stronger interest in and commitment Development (AusAID until 2013), the to health among the United Nations British Department for International and other agencies, government aid Development (DFID), the Canadian authorities, professional organizations, International Development Agency international nongovernmental (CIDA until 2013), the Finnish organizations and philanthropists. International Development Agency (FINNIDA), the Japan International WHO was, and remains, the Cooperation Agency (JICA), the lead technical organization with Norwegian Agency for Development responsibilities for health, but Cooperation (NORAD), the Swedish there were then altogether 13 UN International Development organizations that were involved Cooperation Agency (SIDA) and in health-related work. In addition, the United States Agency for many UN agencies including UNDP, International Development (USAID). the World Bank, and the Asian Development Bank were extending International nongovernmental their interest from socioeconomic organizations were also showing development to health sector. The UN a greater interest in the health established UNAIDS, replacing WHO’s sector. During this decade, many Global Programme on AIDS, which new partners in health appeared on was terminated in 1995. The UN also the horizon every year, in addition supported, with great ambition and to gigantic private philanthropic massive resource mobilization, the organizations such as the Bill and establishment of the Global Fund to Melinda Gates Foundation, the Carter Fight AIDS, Tuberculosis and Malaria Centre, the Clinton Foundation, and (GFATM) in 2002. the Hewlett Packard Foundation.

Today, more than 60 international NGOs exist in the health sector, some of the most prominent being Cooperative for Assistance and Relief Everywhere (CARE, before 1993 the Cooperative for American Remittances to Europe), Médecins Sans Frontières (MSF), Population Services International (PSI), Save the Children and World Vision.

The decade witnessed an acceleration in the process of forming partnerships Mask with five small skulls on the crown. targeting a single disease or groups Gifted by Bhutan of diseases such as polio, measles,

117 A Healthier South-East Asia tuberculosis and filariasis. Beginning of Southeast Asian Nations (ASEAN) in 1972 with the launch of the with the signing of a memorandum Special Programme of Research, of understanding between ASEAN Development and Research Training and the WHO Regional Offices for in Human Reproduction (HRP), by South-East Asia and the Western the end of the decade WHO was Pacific. A similar memorandum of engaged in more than 70 global understanding between WHO and the partnerships for health. As time South Asian Association for Regional went on, there was hardly an area Cooperation (SAARC) was also signed. of work in WHO where global partnerships did not feature, The first International Conference both as fund-raising devices and of Medical Parliamentarians was as mechanisms for the delivery held in 1994 in Bangkok. It was of health programmes. This rise organized by the Asian Forum of in global partnerships for health Parliamentarians on Population was driven by economic factors Development in collaboration with and the realization that health WHO and the International Medical development is a process based on Parliamentarians Organization (IMPO). interdependence among numerous It recommended advocacy to place actors. health development – particularly the health of women, the poor and These factors led to a new and the disadvantaged groups – very high complex relationship among the on the political and developmental traditional and new players and agendas of the nations of the Region. national authorities in international The Bangkok Declaration and Call for health. The planning, management Action marked a watershed in WHO’s and utilization of resources became efforts towards advocacy for health increasingly complex, and there was and in forging new partnerships a pressing need for delineation and for health development. In 1997, harmonization of responsibilities. In WHO and IMPO organized another a way, however, these developments Conference of Parliamentarians on were encouraging, as they came Women, Health and Environment. with greater expectations for The conference proposed a series of support and collaboration with actions, including strong advocacy to national authorities. However, create conditions where women could the Member countries were also be empowered to live and work in realizing that each of them was an environment of equity and social required to improve its planning justice. and managing capability in order to handle these new complex The historic Declaration on Health developments effectively and to Development in the South-East Asia meet their national needs. Region in the 21st Century, adopted by Health Ministers of the Region in A major initiative was undertaken 1997, affirmed, among others, the in 1997 to strengthen WHO’s countries’ commitment to ensure partnership with the Association access to health care for all.

A Healthier South-East Asia 118 Tefthh Fi Decade: 1988–1997

Preamble to the Declaration on Health Development, Bangkok, 1997 ‘We, the Member States of the South-East Asia Region of WHO, take note of the developments in our Region since the social goal of “Health for All”, with primary health care as the key approach, was first adopted by the Member States of WHO two decades ago. Envisaging the scenarios as we move into the next century, recognizing the challenges that lie ahead, as well as the aspirations of our people, we now state our deepest concerns and unstinting commitment in this Declaration on Health Development in our Region. We affirm our unwavering commitment to ensure access to health care to all. Guided by strong political will, we pledge to take action and responsibility to ensure Health for All by mobilizing All for Health. Through collective leadership, we resolve to strengthen the character of the health sector, and to enhance national capacity and regional solidarity to further this aim. We declare that we will make relentless efforts to realize our peoples’ aspirations.’

Leading health promotion into the 21st century

Another important event related to that must be adopted to address partnerships and the determinants the challenges of promoting health of health and their role for the 21st in the 21st century. The Conference century was the Fourth International adopted “the Jakarta Declaration Conference on Health Promotion: on Leading Health Promotion into New Players for a New Era – Leading the 21st century”. The Declaration Health Promotion into the 21st included the following priorities century. The Conference was held in for health promotion in the 21st Jakarta in July 1997. It was the first century: such conference held in a developing country, and the first to involve ĥĥ promote social responsibility for the private sector in supporting health, health promotion. It provided an opportunity to reflect on what ĥĥ increase investments for health has been learned about effective development, health promotion, to re-examine the determinants of health, and to ĥĥ consolidate and expand identify the directions and strategies partnerships for health,

119 A Healthier South-East Asia ĥ increase community capacity The participants also endorsed and empower the individual, the formation of a global health and promotion alliance to advance the priorities for action in health ĥ secure an infrastructure for promotion that were set out in health promotion. the Declaration.

The role of the government health sector in meeting the new situations arising out of enlightenment and conscientiousness will also become more relevant. Health structures as such may not change significantly but strategies and approaches will. This will help to bring health closer to the people through greater decentralization, viable district health system and, most importantly, a willingness and motivation to work with sectors in addition to health to create supportive conditions for health Dr Uton Muchtar Rafei Partnerships: A New Health Vision. WHO, New Delhi, 1997

Implementing the DOTS strategy

During this decade DOTS was and prevent tuberculosis deaths. adopted by all Member countries Achieving these objectives through in the Region for the management the DOTS strategy was simple. It of tuberculosis cases. This was an envisaged the following: important step forward, because tuberculosis is curable and DOTS was ĥ Identify tuberculosis cases in proven to be the most successful communities around the world, and cost-effective treatment particularly those in developing strategy. The objectives of the countries. DOTS strategy were to decrease the ĥ Treat tuberculosis cases risk of infection, reduce morbidity by directly observing their and transmission of infection, medication intake for six to

A Healthier South-East Asia 120 Tefthh Fi Decade: 1988–1997

eight months. This was to were infected with both tuberculosis ensure that medication was and HIV were at higher risk of taken in the right combination developing active tuberculosis. HIV and appropriate dosage compromised a person’s immune in an effort to prevent the system, and accelerated the time development of multidrug- between tuberculosis infection and resistant tuberculosis (MDR-TB). the onset of the illness. An increase of HIV-associated tuberculosis had The tuberculosis patient is almost been observed in some countries. always cured if the medicines are The HIV epidemic and the spread of taken regularly for the entire length MDR-TB were threatening to reverse of treatment. DOTS was accepted by the gains of TB control with DOTS. all countries of the Region, although The revised new Stop TB Strategy coverage in some countries needed addressed these new threats. to be urgently expanded. DOTS The need to act with functional required political commitment and integration between the tuberculosis adequate resources allocated to and HIV/AIDS programmes and to tuberculosis control programmes. address the issue of MDR-TB had It was observed that persons who been recognized.

DOTS was adopted by all Member countries in the Region during this decade for the management of tuberculosis

121 A Healthier South-East Asia Monitoring the coverage of tuberculosis control activities is an important part of successful TB control programmes

A new concept of reproductive health

A new concept of reproductive system and to its functions and health emerged from the maternal processes (1994)”. and child health and family planning programmes. This new Over the preceding decade there concept had been evolving during had been a marked improvement the decade, and essentially saw in child survival and a significant reproductive health holistically as a reduction in infant mortality in all continuum that starts before birth, countries but similar achievements and progresses through childhood had not been observed in maternal and adolescence to adulthood health. Maternal morbidity and and old age. WHO’s definition of mortality was still high in all reproductive health was “a state countries except in Sri Lanka. Since of complete physical, mental and 1994, Member countries started social well-being and mot merely the developing strategies and plans absence of disease or infirmity in all of action for promoting matters relating to the reproductive reproductive health.

A Healthier South-East Asia 122 Tefthh Fi Decade: 1988–1997

Myanmar’s experience with DOTS

yanmar adopted WHO’s DOTS preserved and the interviews were based Mstrategy in 1997 to cope with on what they could recall. Most of them the tuberculosis epidemic. Donation recalled the difficulties in travelling to of TB medicine by the Global Drug hospital every month for diagnosis and Facility began in 2001 and contributed treatment, and the importance of having to nationwide coverage of DOTS at a good rapport with their doctors. the township level in November 2003. DOTS strategy was further expanded Three retired doctors who had worked to the community level since then to for the NTP since 1980 and were involved increase access to TB treatment very in the introduction and expansion of rapidly. From 1998 to 2007, the number DOTS in the late 1990s shared their of TB cases notified increased from 14 experiences. They were Dr Win Maung, 756 to 133 547. Treatment success rate who joined the NTP in 1983 and retired improved gradually from 82% in the late as Director of Disease Control in 2013; 1990s to achieve the international target Dr Tin Mi Mi Khaing, who was posted in of 85% at that time in the 2007 cohort. Shan and Kayah states in 1998–2008 and retired as Director in 2017; and Dr Myo Intersectoral collaboration, both public Zaw, who retired as Regional TB Officer and private, has been piloted since for Yangon in 2008. 2004 but needed to be scaled up to make a significant impact on case More than half of all townships in detection and treatment success at the Myanmar began to provide DOTS in the national level. A few TB patients who introduction phase since 1997. Short received TB treatment by the National course chemotherapy (SCC) could be Tuberculosis Programme (NTP) around applied only in DOTS townships. TB 2005 were interviewed anonymously. treatment in other townships relied Their treatment records were not on the injection of streptomycin and

123 A Healthier South-East Asia isoniazid. Patients who lived in non- Some DOT providers were members DOTS townships needed to travel to of nongovernmental organizations DOTS townships when they sought such as the Myanmar Red Cross quality medicine and had to stay there Society and the Myanmar Maternal to finish the full course of treatment. and Child Welfare Association. There A patient from Mong Tong in a was greater community participation mountainous area of Eastern Shan state and mobilization. ‘DOT supervisors’ was airlifted to the Taunggyi DOTS were assigned to townships, and they centre to receive proper TB treatment helped ensure the smooth functioning since there were no means of safe road of DOT providers and regular supply transport in that area at that time. of medication. Competent volunteers This patient had to stay in Taunggyi helped in early case detection. With to complete the course, which was patients introduced to treatment in financially very difficult for him and the early stages the spread of infection his family. in the community was halted. An international technical mission assessed When DOTS was expanded to the the DOT activity in the field with great whole country, TB patients became appreciation. A DOT provider was asked treated at their own place of if he was afraid of getting infected in residence. This saved both direct and the course of his work. The DOT provider indirect costs. In addition, it improved replied: ‘I knew how TB spread and how adherence to TB medication, with it can be prevented … and I was not patients receiving continuous support afraid of TB.’ from their families. Monitoring the adverse effects of drugs became Several activities were rapidly easier, and this improved treatment implemented by the national outcomes and reduced the number of programme and partners till the those who stopped getting treatment middle of the first decade of the 21st midway. DOTS helped cut the chain century. However, sustainability of DOTS of TB transmission in the community became an issue when the Global Fund and prevented drug-resistant TB. announced termination of funding The single oral dose medication also in 2006. There was a decline in case facilitated adherence to treatment notification from 2008. The National TB regimens. The basic health worker was Prevalence Survey 2009–2010 identified trained and assigned as DOTS provider. a larger TB burden than had been They monitored the side-effects of estimated previously. Myanmar had anti-TB drugs and performed contact to wait till 2011–2012 to once again tracing that helped locate more cases. strengthen DOTS through community- Community and family awareness about based TB care, and disseminating TB was promoted through peer essential components of Stop TB strategy group education. that included MDR-TB and TB/HIV care.

A Healthier South-East Asia 124 Tefthh Fi Decade: 1988–1997

The story of the ‘Doctor Mother’: The work of Tulasi Sharma, female community health volunteer, Surkhet, Nepal Dr Kiran Banstola, Emergency Programme Field Officer, Nepal Health Emergency Operation Centre, Surkhet, speaks about the work of Tulasi Sharma Who is ‘Doctor Mother’? ovingly referred to as ‘Doctor Mother’ Her motivation was her desire to serve Lby her community, Tulasi Sharma found other people, and she appreciated being life rewarding as a female community acknowledged for her services health volunteer (FCHV). Tulasi was by her community. She speaks with a permanent resident of Gurvakot pride when she says that it was her municipality in Mehelkuna, and had example and her profession that engaged in volunteer service since 1991. encouraged her granddaughter to She had been formally serving as an pursue a medical degree. FCHV since 1997. During a period when her country Learning never stopped for Tulasi. suffered from civil strife, Tulasi was She took the 15-day FCHV training, at some point abducted by one of the training on acute respiratory infections/ warring parties. But her evident drive pneumonia, and even on mental health to help people, and her motivation to issues. An active participant of various support the marginalized women and health-related orientation programmes, children, convinced her captors to release workshops and review sessions, she also her after just one day of captivity. She trained herself on reproductive health and went straight back to helping those implemented her learning in her practice. most in need.

125 A Healthier South-East Asia The FCHV for better health Tulasi considers waterborne disease, Tulasi has noted a decrease in jaundice, and cholera as the main health immunization coverage in the community, problems in her locality. She remembers which she thinks is due to short-term the cholera epidemic in 2010 in which labour migration. She also finds that more 67 people in a single neighbourhood people are suffering nowadays from high caught the disease as a result of water blood pressure, asthma, and cancer. But contamination. Tulasi and her team overall, she credits the improvement in supported the local health authorities, the services provided by the FCHVs as and together they contained the spread being instrumental in bringing about the with zero mortality. Later, she imparted many positive changes. health education on the implications of drinking purified water, and raised awareness to ensure that cholera would not return.

She notes the tremendous improvement in health services and in the health status of people in her community in recent years. ‘These days, most women deliver in hospital. The result is that very few women lose their babies in childbirth,’ she says happily. In recent years people are also more aware and cautious about eating a balanced diet, adopting healthier feeding habits, going for health check- ups, getting their children vaccinated at the right time, delivering babies in hospital, and attending regular follow-up health checks, all of which have made dramatic improvements in the health status of the community.

On improving the FCHV workforce Improving FCHV mobilization is actually improving better health service delivery. FCHVs receive a very small allowance to cover their expenses, but as prices go up, she hopes that the FCHV allowance will soon be increased. Moreover, she asks all stakeholders to work closely together so that the gains that Nepal has made with the help of the FCHVs are not lost. It would help, she says, if the FCHVs are given more recognition, and some rewards, for their contribution to health throughout the country. Most FCHVs, like Tulasi, find their motivation in contributing to the betterment of the community, but suggest some formal recognition would help.

A Healthier South-East Asia 126 Tefthh Fi Decade: 1988–1997

Responding systematically to ‘ageing and health’

In 1995, WHO restructured its programme on “Health of the Elderly”, renaming it “Ageing and Health”. This area of health care is becoming a dominant concern for the near future owing to rapid demographic changes and increased life expectancies in the Member countries. There was a need to have a systematic and concerted response from society to the needs of ageing. The main perspectives that guide programme activities in this area were as follows:

ĥĥ approaching ageing as a part of the life-cycle rather than compartmentalizing the health care of the elderly;

ĥĥ promoting long-term health – increasing awareness of the need to focus on the process of healthy ageing;

ĥĥ observing cultural influences;

ĥĥ adopting community-oriented approaches;

ĥĥ recognizing gender differences; and

ĥĥ strengthening inter- generational links.

There was a need for a systematic and concerted response of society to rapid demographic changes

127 A Healthier South-East Asia Reducing the major nutritional disorders

After the Alma-Ata International abortions, congenital anomalies, Conference on Primary Health Care endemic cretinism characterised by the prevailing vertical approaches in mental deficiency, deaf mutism and nutrition programmes had changed. spastic diplegia. The integration of nutrition into community-oriented health services In 1989, the Regional Committee was emphasized. In particular, called for the intensification of national nutrition programmes were measures to control iodine-deficiency now aimed at vulnerable groups disorders, including goitre, in view such as children, and pregnant and of their high incidence. The World lactating mothers. Health Assembly, in 1990, declared a target of eliminating iodine WHO provided support to health deficiency disorders as a major public workforce training. The four major health problem in all countries by nutritional problems of public 2000. In addition to the universal health importance in the Region iodization of common salt, the were addressed, namely protein- iodization of drinking water and oral energy malnutrition, iron deficiency administration of iodized oil were the anaemia, vitamin A deficiency and measures adopted by the countries. iodine-deficiency disorders. There was evidence of a reduction in protein-energy malnutrition in India, Indonesia, Myanmar and Thailand, and there had been an impact on iodine- deficiency disorders with continuing improvement in most countries and Bhutan and Thailand in particular.

There was another positive impact throughout the Region regarding vitamin A-related childhood deficiency blindness. However, there was no documented improvement with iron deficiency. Owing to lack of awareness this had not received the necessary attention. There was also a high prevalence of iodine deficiency disorders in the Member countries.

These disorders included enlargement Measuring growth: the integration of nutrition into community of the thyroid glands, stillbirths, health services was emphasized

A Healthier South-East Asia 128 Tefthh Fi Decade: 1988–1997

Thus, the nutritional problems that affected millions of people in this Region were controlled and overcome by procedures that were within the economic reach of the countries. The successful control of these nutritional deficiency diseases by the early 1990s must indeed rank as a major achievement. Increased awareness of the nature of these nutritional problems, better health care, and more judicious use of local food resources helped in successfully overcoming these formidable malnutrition challenges. With the control of nutritional deficiency diseases in children, there was a significant reduction in mortality of children aged under 5 years (Figure 6).

Cases of vitamin A-related childhood deficiency blindness decreased in the Region

Figure 6: Life expectancy at birth in countries of SEA Region, 1970–1980

80 6565 70 70 67 67 65 66 65 64 636463 64 6261 5959 60 57 58 56 55 55 54 53 49 50 50 47 4747 47 48 46 4646 46 46 45 41 40 Years

0 Bangladesh Bhutan Myanmar DPR Korea India Indonesia Maldives Mongolia Nepal Sri Lanka Thailand

Country 1970 Male 1970 Female 1980 Male 1980 Female

Reference: World Health Organization. Collaboration in Health Development in South-East Asia, 1948–1988. WHO SEARO, December 1992

129 A Healthier South-East Asia Universal access to essential drugs

One of the eight elements of of essential drugs and introduced primary health care defined in the concept of good manufacturing the Alma-Ata Declaration was the practices (GMP). provision of essential drugs. WHO published a model list of essential In 1997, the accessibility of essential drugs in 1977, as guidance for drugs (of good quality, safety and countries to serve in developing efficacy), especially at the PHC level, their own lists based on local was still a challenge in all countries conditions (such as demographic of the Region. Essential drugs were factors, disease incidence and acquired either from mostly public prevalence, treatment facilities, funding or from private funding health personnel, and financial – different countries had varying resources). During this decade, proportions of the two systems countries of the Region established working in combination. Based on a their national essential drug lists newly formed WHO-SEARO Working and also developed mechanisms for Group on Drug Financing, universal updating them. This was to ensure access to essential drugs at prices an adequate supply of essential people could afford had become a drugs for PHC, and to strengthen the priority in the Region. The Working distribution systems in countries so Group also recommended that national that these drugs were available at and local drug financing schemes health posts and at the first referral should be strengthened to ensure level. Some countries had also set equity and access to essential drugs, up facilities for the production and the situation started to improve.

New challenges in environmental health: Impact of urbanization

The first International Water Supply greater emphasis. Hospital waste and Sanitation Decade was observed management practices in Member in 1981–1990. The achievements countries were strengthened. Action were reviewed and monitoring programmes addressing food safety of progress continued. The were identified. A framework for Regional Office supported resource controlling environmental health mobilization efforts towards hazards was developed and a accelerating coverage. Water quality regional strategy for health and surveillance and improvements environment drafted. in management were given

A Healthier South-East Asia 130 Tefthh Fi Decade: 1988–1997

A programme on the safety and 43% by 2020 when there will be control of toxic chemicals and 867 million urban citizens in the hazardous waste was implemented Region). This rapid urbanization has in India, Indonesia, Myanmar, been causing many health problems Sri Lanka and Thailand. Poison associated with overcrowding, control centres were established inadequate water and sanitation in Bangladesh, India, Indonesia, facilities, proliferation of slums, drug Sri Lanka and Thailand. “Healthy abuse and environmental pollution. City” projects were initiated in Since the early 1980s, the Regional Bangladesh, Nepal and Thailand. Office for South-East Asia has been addressing this issue by strengthening There had been a substantial collaboration within the health increase in urbanization in all sector and among other sectors, countries of the Region. While reorienting health services and health less than 19% of the population staff to meet a wide range of urban lived in urban areas in 1970, by health problems, and involving the 1995 this proportion had increased community in the solution of their to 27% (and is expected to reach own health problems.

National immunization days

One of the important milestones in developing and endemic of this decade was the initiation countries, and routine of the national immunization day immunization with OPV and/ (NID). The NID approach for polio or inactivated polio vaccine eradication was used for the first elsewhere; time in Brazil in the early 1980s, and it proved to be an effective ĥĥ organization of “national way to achieve the highest possible immunization days” to provide coverage in the shortest possible supplementary doses of oral time. polio vaccine to all children aged under 5 years; NIDs began to be organized for polio eradication in the Region. ĥĥ active surveillance for wild They were one of four strategies poliovirus through reporting on which the global initiative to and laboratory testing of acute eradicate polio, established in 1988, flaccid paralysis cases; and was based: ĥĥ targeted ‘’mop-up’’ vaccination ĥĥ high infant immunization campaigns once wild poliovirus coverage with four doses transmission is limited to a of oral polio vaccine (OPV) specific area.

131 A Healthier South-East Asia When NIDs for polio eradication Thus, in the decade since 1988, were initiated in the Region, the there was considerable progress idea arose of holding synchronous towards eradicating polio. The NIDs in several countries at the same conduct of NIDs and other polio time. Between December 1996 and eradication strategies were January 1997, six countries in the particularly impressive in India, Region conducted synchronous NIDs: where by 1998 the number of about 165 million children below the reported polio cases had decreased age of 5 years were immunized in a by 90% compared with 1988. single day. It should be mentioned here At the end of 1997, synchronous that NIDs were useful for other NIDs were conducted in Bangladesh, interventions, too. Vitamin A Bhutan, Myanmar, Nepal and supplementation was integrated Thailand, as well as in other WHO into NIDs, as well as assessment of Regions (Pakistan in the Eastern the nutritional status of children. Mediterranean Region and the In the South-East Asia Region, the People’s Republic of China in the reported number of polio cases Western Pacific Region). Over 245 declined from 25 711 in 1988 million children under 5 years of to 1117 in 1996, representing a age, or nearly 40% of the world’s reduction of 96%. This set up a children of this age group, were good base for polio eradication immunized with oral polio vaccine within the next within a very brief period of time. few decades.

Millions of children were given the polio vaccine on national immunization days

A Healthier South-East Asia 132 Tefthh Fi Decade: 1988–1997

Declaring targets for disease elimination and control

Given the progress in the control of are extremely high. The disease certain diseases, the World Health can be prevented by hygienic Assembly began to set target dates delivery and cord care practices, for eliminating these diseases or and by immunizing children for reducing their prevalence to and women through the life- levels where they no longer posed a course with tetanus-toxoid- public health problem. Accordingly containing vaccines, which are the countries of the South-East Asia inexpensive and very efficacious. Region committed to the following All the Member countries of targets: the Region committed to this global elimination target. The ĥĥ Polio: the global eradication countries had taken initiatives of polio by the year 2000. This to achieve the target through was endorsed by all countries of collaboration with the MCH and the Region. The regional polio PHC programmes, by tetanus incidence rate had shown a toxoid (TT) immunization of significant decrease. In Bhutan, pregnant women and, indeed, the Democratic People’s TT immunization of all women Republic of Korea, Maldives, Sri of childbearing age. Lanka and Thailand, with high sustained coverage, the trend ĥĥ Guinea-worm/dracunculiasis in incidence indicated that the infection: India was the only target of polio eradication could country in the South-East Asia be achieved before the year Region in which this infection 2000. At the time, polio-free was present. In 1991, the World zones were found in parts of Health Assembly declared its Indonesia, Maldives, Sri Lanka commitment to the goal of and Thailand. eradicating dracunculiasis by the end of 1995. Supported ĥĥ Neonatal tetanus: in 1989, by the Regional Office, the the World Health Assembly Government of India launched announced the global target the Guinea-worm Eradication of elimination of neonatal Programme in 1979. By 1996, tetanus by 1995. Neonatal the number of cases had fallen tetanus was the most common from 40 000 in 12 840 villages life-threatening consequence of spread across 89 districts of unclean deliveries and umbilical seven states to only nine cases cord care practices; when recorded in three villages in tetanus develops, mortality rates Jodhpur district in Rajasthan.

133 A Healthier South-East Asia Since 1996, no case has been months for severe types of reported, and India was certified leprosy, and to as short a time as free from guinea-worm in as six months for the milder March 2000, a major milestone types of the disease. Combined in the disease eradication with intensified surveillance of history in the Region. new cases, there was a dramatic decline in the number of leprosy ĥ Leprosy: In 1991, the World cases in the countries. Health Assembly adopted the target of global elimination ĥ Iodine-deficiency disorder: The of leprosy as a public health World Summit for Children held problem by the year 2000. in 1990 at the United Nations After years of WHO-supported headquarters in New York research, a new treatment adopted the goal of elimination regimen consisting of two to of iodine-deficiency disorders three powerful anti-leprosy as a public health problem by drugs had been introduced in 2000. The approach taken was the early 1980s. This multidrug to use low-cost and effective therapy was found to be very remedies based mainly on effective and reduced the iodinated salt and iodized oil. duration of treatment from five years or more to only 12 Responding to new, emerging and re-emerging diseases

Several factors can contribute to Member States to strengthen the emergence of new diseases and their surveillance for infectious the increase in old and previously diseases in order to properly controlled diseases. These include detect re-emerging conditions and the migration of people around identify new infectious diseases. the world, overcrowding in cities In 1996, a hospital-based sentinel resulting in poor sanitation, poor surveillance system, an Early public health infrastructure, Warning, Alert and Response incomplete and lack of timely System (EWARS), was established reporting of disease outbreaks in Nepal. Associated with this and the emergence of resistance detection and identification to antibiotics and other medicines requirement was an urgent need linked to their irrational use. by the end of the decade to revise the International Health In 1995, the World Health Assembly Regulations (IHR). adopted a resolution urging

A Healthier South-East Asia 134 Tefthh Fi Decade: 1988–1997

The following were some of the Africa. The disease also reached new, emerging and re-emerging the South-East Asia Region and infectious diseases that were a cause cholera cases were reported for concern in the Region: from Bhutan, India, Indonesia, Myanmar, Nepal and Sri Lanka. ĥĥ Plague: An outbreak of plague in India started in Beed district ĥĥ Dengue/dengue haemorrhagic of Maharashtra in the mid- fever (DHF): This was endemic 1990s. Following a massive in Bangladesh, India, Indonesia, rodent die-off or “rat fall” in Maldives, Myanmar, Sri Lanka August 1994, a total of about and Thailand. The disease had 600 presumptive bubonic cases become a major leading cause were reported from nearby of hospitalization and death villages and other districts of among children in the Region, Maharashtra. The outbreak after diarrhoeal diseases and spread to Surat in the state of acute respiratory infections. Gujarat. About 150 presumptive DHF incidence was showing an pneumonic plague cases were increasing trend and was also reported and over 50 deaths spreading to new areas. occurred between 19 September and 22 October 1994. An ĥĥ Kala-azar/visceral leishmaniasis: independent international team The prevalence of visceral sent by WHO concluded that leishmaniasis in the Region clinical, epidemiological and dropped dramatically as a serological findings pointed result of the mass indoor to Yersinia pestis as the likely residual spraying of DDT causative agent of the Surat under the malaria eradication outbreak. Since this outbreak programme. It became almost was of global concern, WHO a forgotten disease for about convened an International 20 years, before returning with Meeting on Prevention and a vengeance in the mid-1970s. Control of Plague in March By 1987, it had again become a 1995 to review the lessons serious public health problem, learned from the outbreak, and particularly in Bangladesh, recommendations were made India and Nepal. In 1987, over for the prevention and control 110 million people living in of infectious diseases with the affected areas in these epidemic potential. countries were at risk. WHO was supporting multicentric ĥĥ Cholera: In 1991, there was a chemotherapy studies and global resurgence of the El Tor control measures. cholera pandemic starting in South America and spreading ĥĥ HIV/AIDS: WHO estimated that, rapidly in the Americas and in as of October 1998, there were

135 A Healthier South-East Asia more than 92 000 AIDS cases on HIV/AIDS. The programme and more than 3.7 million also encompassed ensuring people with HIV infection in the the safety of blood and blood Region. It was projected that products, supporting research by the year 2000 the number into more effective ways of of cases of AIDS in the Region encouraging safer sexual would be close to 2 million and behaviour, and providing HIV infections would range care to people with HIV/AIDS. between 8 and 10 million. The WHO supported national Regional Office assisted all AIDS programmes, in Member countries to set up collaboration with UNAIDS, in national AIDS programmes. providing technical support in It focused on strengthening the health aspects of HIV/AIDS the countries’ capacity to slow not only to governmental HIV transmission and reduce bodies but also to NGOs the adverse effects of AIDS and the private sector. The on affected individuals and Global Programme for AIDS communities. The Regional was succeeded by UNAIDS, Office provided technical the first joint programme in guidance on strategies of the United Nations system of proven effectiveness, such as various UN agencies (WHO, condom promotion, treatment UNICEF, UNDP, UNESCO, of other sexually transmitted UNFPA and the World Bank), diseases, and school education in January 1996.

Dealing with the double burden of diseases

The process of epidemiological acute respiratory illness) were still transition brought about by an the leading causes of illness and increased life expectancy had death. These were Bangladesh, already been observed in Member Bhutan, most of the states in India, countries in the previous decades. Maldives, Myanmar and Nepal. In The pattern of morbidity and some other countries, however, mortality in the countries has demographic transition was taking changed, with noncommunicable place together with development. diseases gradually superseding the Cardiovascular diseases, cancer, infectious diseases. diabetes, congenital anomalies, endocrine disorders and accidents In some of the Region’s countries, started to be the leading causes of infectious diseases (diarrhoea, morbidity and mortality. This pattern

A Healthier South-East Asia 136 Tefthh Fi Decade: 1988–1997

was observed in the Democratic alcohol, were posing further public People’s Republic of Korea, Sri Lanka health problems. The Region was and Thailand and, to some extent, thus faced with the double burden in Indonesia and those parts of of infectious and noncommunicable India that had achieved high levels diseases. of life expectancy. Fast changing lifestyles contributed significantly Estimates suggested that about to this situation. In addition, mental 450 million people suffered from disorders and substance abuse, mental, neurological, behavioural including abuse of tobacco and and substance abuse disorders in

Noncommunicable diseases became the leading causes of morbidity and mortality in some countries during this decade

137 A Healthier South-East Asia the Region during this decade, Therefore, WHO had developed and their cost in human, social programmes to enhance the and economic terms was very capacity of community-based high. During this decade, WHO workers – both ordinary health launched an intensive effort to raise workers and physicians – to identify public and professional awareness and manage these conditions at of the burden of these diseases. the primary health care level. The Unfortunately, many patients Regional Office supported Member suffering from these diseases were countries in developing their not getting optimum treatment. mental health programmes.

Fighting the tobacco pandemic

The consumption of tobacco in all packets to be 90% – the largest countries was on the increase. The in the world – in one of the most rise in tobacco consumption was cost-effective ways to increase particularly observed among young public awareness on the health men and women. Non-smoking risk and reduce consumption. campaigns over the previous years Crop substitution for tobacco was had not been successful. This was being tried in India and Nepal and mainly because of the aggressive community-based tobacco control advertisements and counter-attacks programmes were operational in by the tobacco industry, and the Bangladesh, India, Indonesia, Sri fact that nicotine is addictive. In Lanka and Thailand in this decade. addition, most governments were reluctant to take a strong stand The important achievements in on this issue, because tobacco was this decade related to WHO’s a source of revenue and foreign growing role in the partnership exchange. for health, in prioritizing health promotion, in implementing The Regional Office for South-East the DOTS strategy in treating Asia supported Member countries tuberculosis, in initiating the to establish comprehensive, national immunization days multisectoral and long-term and introducing a concept of national strategies for tobacco reproductive health, and in control. All countries in the Region declaring targets for disease have now banned cigarette elimination and control paved smoking in designated places. Nepal the way to the next decade of has also mandated the size of the unprecedented global initiatives pictorial health warning on tobacco and interest in public health.

A Healthier South-East Asia 138 Tefthh Fi Decade: 1988–1997

139 A Healthier South-East Asia M.F. Husain: Mother Teresa, 2003

On 7 May 2003, during the World Health sung by A.R. Rahman, which was playing Day celebration at the WHO South-East in the background. Three aspects of the Asia Regional Office, internationally concept of “mother” were represented renowned Indian artist, Mr M.F. Husain during the event: 1) the mother and painted this canvas in the Conference Hall child, 2) Mother Teresa as represented in in front of an audience that included staff, the painting, and 3) “mother” as in one’s Indian dignitaries, and members of the motherland, or native country. Mr Husain UN and diplomatic community. Mr Husain generously offered his creative work on completed the work in just 12 minutes, behalf of the children of the world, and accompanied by the famous song Maa presented WHO with the canvas painted tujhe salaam (A salute to you, Mother) on the occasion.

A Healthier South-East Asia 140 THE SIxTH DECADE: 1998–2007

141 A Healthier South-East Asia THE SixTH DEcADE 6 1998–2007 Towards meeting the MDGs

A Healthier South-East Asia 142 Tehh Sixt Decade: 1998–2007

MAJOR ACHIEVEMENTS IN THE SIXTH DECADE: 1998–2007 1 2 3 4

The Calcutta The MDG target for Benchmarks Implementation of Declaration on maternal mortality for emergency Framework Convention Public Health was achieved in four preparedness and on Tobacco Control promulgated out of 11 Member response developed, began in Member countries SEARHEF set up countries

5 6 7 8

Preparedness Traditional New Delhi Regional Strategy on and response medicine systems Declaration on the Adolescent Health to pandemics were recognized Health Impact of was developed strengthened, IHR Climate Change (2005) initiated

n September 2000, building on a a new millennium, this decade was decade of major United Nations marked by unprecedented global conferences and summits, world interest and action in public health. leaders came together at the The Millennium Development Goals United Nations headquarters provided enormous momentum Iin New York to adopt the United around global health issues; the Nations Millennium Declaration. Commission on Social Determinants In adopting this Declaration, they of Health reminded the global committed their nations to a public health community about new global partnership to reduce taking multisectoral action on the extreme poverty and accepted social determinants of health for a series of time-bound targets health equity; the Commission – with a deadline of 2015 – that on Macroeconomics and Health became known as the Millennium emphasized the primacy of health Development Goals (MDGs). for national development and called for increased public spending This unprecedented global initiative on health; and the Framework had influenced the prioritization Convention on Tobacco Control and of public health in the countries, the International Health Regulations particularly developing countries. 2005 were also watershed events in It also influenced the style of the global public health history. Organization’s approaches to assisting the countries and forming From 1999 on, WHO’s work in and partnerships. As the first decade of with each Member country was

143 A Healthier South-East Asia based on a Country Cooperation Two new WHO country offices with Strategy that responded to the their first WHO Representatives were country’s specific priorities and the opened in this decade: in Timor- institutional resources needed to Leste and in the Democratic People’s achieve its national health policies. Republic of Korea.

The first decade of the New Millennium

The first decade of the new millennium was marked by unprecedented global interest and action in public health. These included the Millennium Development Goals, the Commission on Social Determinants of Health, the Framework Convention on Tobacco Control and the International Health Regulations 2005

Dr Samlee Plianbangchang, Regional Director 2004–2014

The Calcutta Declaration on Public Health

The changing epidemiological and The Regional Office for South-East demographic patterns, the effects Asia organized a Regional Conference of globalization, socioeconomic on Public Health in the 21st century changes and other factors posed in November 1999 in Calcutta (now unprecedented challenges to public Kolkata), India. The venue of the health. It was felt that the public conference – the All India Institute of health systems in the countries of Hygiene and Public Health – was one South-East Asia had not been able of the oldest public health institutions to adjust quickly and contribute in the Region. The general objective appropriately to maintain and improve of the conference was to advocate the health of their people. There was a the importance of public health in need to revisit and take a close look at national, socioeconomic and political the countries’ health systems. development, and to promote new

A Healthier South-East Asia 144 Tehh Sixt Decade: 1998–2007

strategies for developing sound public Public Health Initiative, an important health systems in the 21st century. The component of which was to provide Conference brought together leaders new opportunities for multi- or in public health education, research bilateral training, between and within and services from South-East Asian countries in the Region. It emphasized countries, international experts in the recommendations of the public health, representatives of UN Calcutta Declaration, which called on agencies and bilateral and multilateral governments to establish a cross-sector agencies. The discussions focused collaborative “Platform on on the quality of schools of public Public Health.” health, professional capacities, societal commitment, dwindling resources The Public Health Initiative established for health and the resultant need for a web-based Virtual Resource Centre greater efficiency of interventions, (VRC) to provide users with well- and the realization of national public designed distance learning materials, health goals. The Calcutta Declaration which were made available to faculty adopted at the conference provided and institutions engaged in capacity- crucial messages and guidance for building for public health. Initial future work in the field of public modules on field epidemiology were health in the Region and the world available. The Public Health Initiative (for full text of Declaration, see box). was linked to an earlier initiative in the area of health systems development. A strong emphasis was placed on This was the South-East Asia Public public health education and training Health Initiative, launched in 2005. in the Region. The Regional Office To support the development of this for South-East Asia launched the initiative, a network of South-East Asia

The Sri Lanka Room, gifted by Sri Lanka, with two murals on the wall: one depicting public health scenes and different modes of care from village traditionalists to primary health clinics, and another depicting a ceremonial procession with caparisoned elephants. A collection of Sri Lankan traditional masks was also presented, including a peacock mask, the god Ravana, and others, and a few ‘sesatha’ or Kandyan ceremonial ornamental fans which are used in Buddhist processions at the Temple of the Tooth in Kandy

145 A Healthier South-East Asia Public Health Educational Institutes the programme of enrolling talented (SEAPHEIN) was formed. The focus and carefully selected young public of this development was to support health professionals to get first-hand countries in strengthening public experience of working in WHO was health education programmes to initiated. These were the “Junior Public ensure the availability of a competent Health Professionals” who worked public health workforce. in the regional offices and WHO headquarters. The programme was Another programme initiated by WHO intended to emphasize the desirability contributed directly to building a of a career in public health and give cadre of young professionals in public good experience to deserving health to serve as role models. In 2006, young professionals.

The Calcutta Declaration on Public Health ‘We, the participants in this Regional Conference on Public Health in South-East Asia in the 21st century, appreciate the substantial achievements made in improving the health status of the people in the countries of the South-East Asia Region during the past decades. However, we enter the 21st century with an unfinished agenda of existing health concerns and new and complex challenges that demand innovative solutions. We uphold the centrality of meeting the health needs of the community and our responsibility to preserve, protect and promote the health of the people. We commit ourselves to the goals of poverty alleviation, equity and social justice, gender equality and universal primary education, which are all essential elements in the pursuit of health for all. We recognize that expertise in public health and capacity-building as well as experience are essential for sustaining partnership in designing, developing and providing health for the community. We emphasize the importance of public health as a multidisciplinary endeavour to meet the health needs of people. Having noted the progress in public health practice, education and training, and research in the countries of the South-East Asia Region, and having reviewed the lessons from public health-related policies and programmes, we endorse he following strategies and directions for enhancing health development in the South-East Asia Region in the 21st century: Promote public health as a discipline and as an essential requirement for health development in the Region. In addition to addressing the challenges posed by ill-health and promoting positive health, public health should also address issues related to poverty, equity, ethics, quality, social justice, environment, community development and globalization; Recognize the leadership role of public health in formulating and implementing evidence-based healthy public policies; creating supportive environments; enhancing social responsibility by involving communities, and increasing the allocation of human and financial resources; Strengthen public health by creating career structures at national, state, provincial and district levels, and by establishing policies to mandate competent background and relevant expertise for persons responsible for the health of populations, and strengthen and reform public health education and training, and research, as supported by the networking of institutions and the use of information technology, for improving human resources development.

We urge all Member countries as well as WHO to continue to provide leadership and technical cooperation in building partnerships between governments and UN and bilateral development agencies; academia; NGOs; the private sector; the media, and other organs of civil society, and to jointly advocate and actively follow upon all aspects of this Calcutta Declaration on Public Health.’

A Healthier South-East Asia 146 Tehh Sixt Decade: 1998–2007

Strengthening the health workforce

Most countries of the South-East workforce in countries of the South- Asia Region were challenged with East Asia Region”, in which they problems of health workforce reaffirmed their commitment to shortages, maldistribution, an effective and motivated health inappropriate skill mix, and limited workforce. The Regional Office capacity for the production, supported countries in developing management and deployment of and carrying out national health human resources for health. The workforce strategies and plans. It Regional Office had collaborated also gave high priority to balancing with Member countries to address the preventive and promotive their health workforce challenges aspects of health care with the and advocated for high-level curative and rehabilitative aspects, commitment to strengthen health and took several initiatives to workforce development. strengthen the public health component of the curricula of In 2006, the health ministers of medical and nursing courses to the Region adopted a declaration better equip medical doctors for on “Strengthening the health service needs.

The Regional Office collaborated with Member States to address their health workforce challenges

147 A Healthier South-East Asia Other areas in which countries were Strengthening categories of supported included programme community-based health workers development, institutional – such as the community health capacity-building, establishing or workers and volunteers who run the strengthening teaching-learning community clinics in Bangladesh, resources and libraries, and faculty the household doctors in the development. The Regional Office Democratic People’s Republic of also developed comprehensive Korea, the accredited social health strategies and plans to strengthen activists (ASHAs) in India, the female the community-based health community health volunteers in workforce in order to address Nepal, and the Health Volunteers in the changing epidemiological Thailand – are a few examples of the and demographic profile of initiatives taken to strengthen the Member countries in the Region. community-based health workforce.

Progress towards universal health coverage

Countries in the Region had made function as a lead area of reforms significant progress towards for universal health coverage. universal health coverage, both in Member countries strengthened their conceptual thinking as well as both the process and content of in practice. Some Member countries national health policies and plans, demonstrated that universal health so as to use the national health coverage can be achieved at a low policy strategy and plan better cost and in resource-constrained for universal health coverage. settings. They took a pragmatic, Countries needed to provide better phased approach to universal health financing for universal health coverage by starting with primary coverage for social protection and health care priorities to eliminate equity in health. They also needed avoidable systems inequities and to provide better service delivery inefficiencies. The next phase would by enforcing cost containment and be to provide more comprehensive changing the incentives structure coverage as requisite systems in health systems to improve public and institutional capacities are and private sector performance developed. and partnerships. The focus would be on strengthening capacity and The current focus in countries institutions for evidence-based was on equity and efficiency in advocacy, development of policies, health systems, with most countries strategies and plans, and monitoring reviewing the health financing and evaluation.

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WHO begins its work in Timor-Leste Recollections of Dr Alex Andjaparidze, first WHO Representative to Timor-Leste, 2003–2008

HO’s presence in Timor-Leste Regional Office in New Delhi through the Wbegan in 1999. Much of the health WHO Representative’s Office in Jakarta, infrastructure was destroyed at that Indonesia, and with full logistic support time and the health system was not able through the WHO Darwin Office. The to serve the people. Since 1999, the Darwin Office was closed on 7 January international community assisted Timor- 2000 and all logistic arrangements and Leste in re-establishing its health system other management issues were handled and developing new health policies for the directly by the WHO Dili Office with a country. Two public health professionals Head of Office appointed by the Regional were placed by the Regional Office for Office. The WHO Head of Office worked South-East Asia on standby in Darwin, closely with UNTAET, UNICEF, ICRC and Australia, with the possibility of transferring many international NGOs to coordinate them to Timor-Leste to manage the initial health activities until the establishment of emergency and humanitarian assistance in the Interim Health Authority, the precursor health. WHO had to move quickly to deal to the national Division of Health Services. with malnutrition and prevent an upsurge In September 2001, the Interim Health in communicable diseases. Dr Gro Harlem Authority was formally transformed into Brundtland, then Director-General of the Ministry of Health. WHO, made an appeal to the international In September 2002, Timor-Leste became community to support the efforts of WHO the 192nd Member State of WHO and in that country. in May 2003, at the Fifty-sixth World Up to January 2000, the WHO Dili Office Health Assembly, it was designated the was technically supervised by the WHO 11th Member State of the South-East Asia

Dr Alex Andjaparidze with the then Regional Director Dr Samlee Plianbangchang during a field visit in Timor- Leste

149 A Healthier South-East Asia Region. As such, it received a separate notably on infectious disease control country budget allocation. A WHO Country (malaria, tuberculosis and leprosy), and Office was established and a WHO improved health services for children and Representative was appointed. mothers, and assisted with clinical nursing care. The successful work of WHO in In the initial stages, the situation in the Timor-Leste was recognized by national country compelled WHO to expand its and international organizations. The first traditional role of providing technical Country Cooperation Strategy for Timor- advice, norms and standards, technology Leste was launched in December 2003. and skills. Instead, WHO has been directly involved in the implementation of key I had the privilege to serve in the country health programmes and the coordination of from January 2000 till March 2008. I recall national staff involved in health activities. fondly the dedicated work of national During the emergency period in the 1970s health staff and WHO personnel in the and 1980s, WHO had played a key role in country office during that time. I am the coordination of health services that grateful to the then Regional Directors were provided in the country by a large Dr Uton Muchtar Rafei and Dr Samlee number of donors and NGOs. When the Plianbangchang, and the current Regional Ministry of Health was established, WHO Director, Dr Poonam Khetrapal Singh, supported its initial development and and the then WHO Representative in training of its staff. At the same time, WHO Indonesia, Dr Georg Petersen, for their played an important role in implementing crucial support and advice. key programmes in the country, most

WHO Country Office opens in Pyongyang, Democratic People’s Republic of Korea Recollections of Dr Eigil Sorensen, first WHO Representative to the Democratic People’s Republic of Korea

n 19 November 2001, Dr Uton The delegation from WHO headquarters OMuchtar Rafei, then Regional Director, also included Dr J.W. Lee, who later became officially opened the Country Office in WHO’s Director-General. Pyongyang, in the presence of Dr Kim Su Dr Uton gave a memorable speech. ‘As a Hak, Minister for Public Health, Dr Choe response to the difficulties the country Chang Sik, Vice-Minister, Mr Choe Su Hon, had been facing from natural disasters Vice-Minister, Ministry of Foreign Affairs, and problems in the economy, WHO had and Dr Gro Harlem Brundtland, Director- established an office for Emergency and General of WHO. The opening ceremony Humanitarian Action in Pyongyang in was attended by senior officials from the 1997. This office has been supporting Government, the diplomatic corps, UN emergency programmes focusing on agencies and international organizations.

A Healthier South-East Asia 150 Tehh Sixt Decade: 1998–2007

Dr Gro Harlem Brundtland, the then Director- General of WHO, during the opening of the Country Office in Pyongyang in the Democratic People’s Republic of Korea

control and surveillance of communicable control and treatment of tuberculosis in the diseases, in particular tuberculosis and country till today. malaria, EPI and polio eradication, and on I served in the country until 2006, and strengthening health care at the community negotiated an office building for WHO level. This contributed to increased close to the other UN agencies. The involvement of WHO in the country, and I country office is still in the same premises see the opening of a full country office as a today. The Pyongyang office was one of natural development of the strengthened the first country offices globally where collaboration between the Democratic WHO installed VSAT communications. This People’s Republic of Korea and WHO in enabled global telephone connectivity and recent years,’ he said. provided broadband Internet that vastly The high-level WHO delegation spent improved the effectiveness of the office. three days in the country meeting with WHO successfully mobilized resources government officials, including Mr Kim Yong in the following years for essential health Nam, President of the Standing Committee programmes mainly through the annual UN of the Supreme People’s Assembly. During Consolidated Appeals (UNCAP), provided a field visit to Hwangju County, the standardized medical supply and essential delegation took part in the second round medicine kits to Ri-clinics and country of the National Immunization Day. Dr hospitals, scaled up support for malaria, Brundtland and Dr J.W. Lee, then Director tuberculosis and emerging diseases, and for Tuberculosis at WHO headquarters, provided training in communicable disease visited the Sariwon Provincial Tuberculosis control and public health. The first Country Hospital and handed over the first round Cooperation Strategy for the Democratic of tuberculosis medicines from the Global People’s Republic of Korea 2004–2008 was Drug Facility (GDF). WHO and GDF are launched in 2003. continuing to provide support for the

151 A Healthier South-East Asia Recognizing traditional medicine systems

As we have observed earlier, and multicountry collaboration countries of the South-East Asia for the development of herbal Region have a rich heritage of and traditional medicines and the systems of traditional medicine. exchange of information on the Recognizing the key role of subject in the Region. A later revised these systems in the provision of edition listed 153 institutions. health care since ancient times, Health Ministers of Member countries in 2003 agreed that the traditional systems of medicine should be included as part of the national health-care system, with patient safety as the overriding consideration for use. The Regional Committee for South-East Asia in 2003 provided strategic directions for the development of traditional medicine in the Region. In 2008, the Regional Office compiled a list of traditional medicine institutions in the Region. These were the Traditional medicine plays an important role in the provision of core institutions for intercountry health care in countries of the Region

Towards reaching the MDGs in maternal and neonatal health

The remarkable reduction of the of this target, as the reduction in maternal mortality ratio (MMR) MMR translates into a regional in the Region from 270 per annual reduction of 5.2%. The 100 000 live births in 2005 to 200 per Democratic People’s Republic of 100 000 live births in 2010 became Korea, Maldives, Sri Lanka and possible because of strong political Thailand achieved the target, will and commitment to maternal while Bangladesh, Bhutan, India, and newborn health in all countries. Indonesia and Nepal were on track. Millennium Development Goal 5 targeted a reduction in MMR of Nepal showed what could be done 5.5% from the 1990 levels. The even in a continuing climate of Region as a whole was just short political turmoil and inadequate

A Healthier South-East Asia 152 Tehh Sixt Decade: 1998–2007

resources. It received two awards based health workers are an for its efforts to contain maternal integral part of the health system. deaths: in 2010 from the Millennium The Government of India trained Development Goals Review Summit, auxiliary nurse midwives to become and the Resolve Award in 2012. The skilled birth attendants. Bangladesh fall in maternal mortality was largely initiated a six-month training course due to the increase in the number of in midwifery, and planned to launch deliveries by skilled birth attendants. a three-year midwifery course.

However, there were inequities in Sociocultural issues have a critical access to skilled birth attendants bearing on maternal and neonatal between and among the countries. health outcomes, and needed to Indonesia and Sri Lanka made be urgently addressed to reach the progress in narrowing the gaps, Millennium Development Goals. In while in Bangladesh and Nepal the 2009, the Regional Office for South- progress was slower over the years. East Asia in collaboration with the To address this inequity in access, Regional Office for the Western- several countries took the help Pacific organized a Consultation on of the community, as community- the “Application of Sociocultural Approaches to Accelerate the Achievement of Millennium Development Goals 4 and 5”. The outcome was a “Strategic Framework for Sociocultural Approaches to Accelerate the Reduction of Maternal and Neonatal Mortality”. The South-East Asia Regional Office provided support to countries to develop and implement action plans based on the Framework, including an agenda for research on the sociocultural aspects of maternal and neonatal health.

The Region made tremendous progress in reaching out to millions of children with life-saving vaccines. This received a further boost with the launch of the Global Alliance for Vaccines and Immunization (GAVI), now simply called the Gavi Alliance, in 2000. It was a public-

The remarkable reduction in maternal mortality was possible private partnership led by WHO because of strong political will and commitment and UNICEF, and supported by the

153 A Healthier South-East Asia World Bank, leaders of the vaccine were eligible. The Gavi Alliance industry, bilateral aid agencies and has made significant contribution major foundations. The objective of to this Region to not only increase the Alliance was to reach vaccines to routine immunization coverage but the children of the world’s poorest also to help countries introduce new countries. Globally 75 countries were vaccines so that today all countries listed as GAVI-eligible at the time of have more than eight vaccines the launch of GAVI; in the South-East in their routine immunization Asia Region, nine of the 11 countries schedules. Challenges to adolescent health

The 350 million adolescents in long-term economic implications. the Region comprised nearly one Undernutrition and anaemia are fifth of its total population. The other health conditions that were many health and psychological prevalent among adolescents in the needs of this population must be Region. taken care of for adolescents to reach healthy adulthood. Some The work of the Regional Office in cultural practices in the Region are improving adolescent health services harmful to adolescent health, such was guided by the “4S” framework. as early marriage and childbearing This focused on four strategic areas: among girls. Some local norms strategic information, supportive do not allow discussions between policies, strengthening services, and parents, teachers and adolescents strengthening collaboration with on the subject of sex. As a result, other sectors. adolescents do not have adequate knowledge on how to protect In the area of strategic information, themselves. Onset of sexual activity countries were supported to before they acquire adequate develop adolescent profiles and knowledge and skills for protection country factsheets on adolescent exposes adolescents to the risks health and adolescent pregnancy. of acquiring sexually transmitted The Regional Office developed a infections and HIV, which have tool to assess relevant laws and far-reaching consequences. policies to determine whether these Unintended pregnancy is another were conducive to the provision likely consequence of unprotected of health services to adolescents. sex, which may be followed by the The application of this tool was risks of an unsafe abortion and supported in Bangladesh, India social censure. Many may have and Sri Lanka. The Regional Office to leave school, which reduces developed a Regional Strategy for their employability and thus has Adolescent Health in consultation

A Healthier South-East Asia 154 Tehh Sixt Decade: 1998–2007

with Member countries and UNFPA, and folic acid supplementation and provided technical assistance to for the management of anaemia. countries to develop their national WHO assisted in tackling the adolescent health strategies. The other common public health Regional office also developed issues, such as early marriage and a situation report on adolescent early childbearing, through the nutrition for the Region, and an development of guidelines for the evidence base for weekly iron prevention of adolescent pregnancy.

Masks. Gifted by Indonesia

Strengthening emergency preparedness and response

This decade seemed to bring more to give technical assistance upon than its fair share of calamities to requests from governments, and to the Region, in the occurrence of support and enable international earthquakes, cyclones and floods. agencies working at the frontline The great tsunami of December 2004 of disasters and emergencies. In was one of the deadliest in history, this role of coordinating the health and caught the world unawares as response to disasters lies one of the it devastated communities along Organization’s greatest strengths. thousands of miles of the Region’s During the decade, the Regional coastlines. Of all the people killed in Office was called to lead the “health natural disasters in the decade 1996– cluster” response to disasters in 2005, 58% were from the South-East the Region. WHO and Member Asia Region. countries had been preparing for disasters prior to the tsunami and Health action in crises has always even in the previous decade. WHO been part of WHO’s activities. WHO had assisted Member countries is mandated by its Constitution in strengthening their national

155 A Healthier South-East Asia capacities for disaster preparedness and response, and had developed a Global Action Plan for emergency preparedness and response working in conjunction with other regions and organizations.

Nevertheless, the tsunami was a wake-up call to the threat posed by natural disasters, and drew attention to the crucial issues of preparedness and risk mitigation, to the need for capacity at country level, to the need for better and more resilient health systems and for reducing the vulnerability of communities Galle in Sri Lanka was one of the places worst affected by the tsunami of December 2004. Here workers repair a hospital damaged by the tsunami through better preparedness, response and strategic plans. WHO’s activities included developing As the countless human tragedies benchmarks for emergency played out following the tsunami, preparedness and response in WHO responded by coordinating conjunction with Member countries, health protection and disease strengthening of capacity within prevention (e.g. setting up WHO and, in response to the surveillance and response systems), suggestion of the Member States, ensuring access to essential health setting up the South-East Asia care (e.g. water and sanitation, Regional Health Emergency Fund immunization, psychosocial support, (SEARHEF). nursing and midwifery), providing medical and logistic support (e.g. The last of these was achieved by emergency health kits, rehabilitation the Regional Committee in 2007, of laboratories), and mobilizing when it was decided that, in order resources among partners (for to streamline the ability of WHO to formulating and implementing respond speedily to natural disasters, country workplans). a special fund would be established for emergency response. The fund The tsunami brought many partners was set up by allocating a 1% together and today we are more contribution from the WHO regular aware of mutual capacities and Budget in the Region. SEARHEF perhaps better coordinated as a got an acclaimed opportunity to result of the tsunami response. Many demonstrate its benefits when lessons drawn from the tsunami Cyclone Nargis hit Myanmar in May have been applied in containing 2008 – funds were released within subsequent disasters. Since then, hours of the disaster.

A Healthier South-East Asia 156 Tehh Sixt Decade: 1998–2007

Story of health in Aceh, before, during and after the tsunami Recollections of Dr Media Yulizar, then Head of Disease Control and Environmental Health, Aceh Provincial Health Office

When the tsunami struck to provide the health care people needed. Health-care workers had or a long time, Aceh was in a state to wear their white jackets or vests Fof emergency. Armed conflict had to be able to reach communities started as early as the 1970s, and safely. Night service was difficult. the intensity increased in the 1990s. The work of the health sector was In 1998, there were big waves of focused on the health of IDPs, internally displaced persons (IDPs) as and on preventing and managing conflict forced the Acehnese to leave outbreaks. Preventive services their homes and fields. The regular were insufficient as the scope for curfew that began around 2000 movement was very limited. made it difficult for health workers

The tsunami on 26 December 2004 devastated Banda Aceh (seen in this picture) and the west coast of Sumatra in Indonesia, along with coastal areas of several Indian Ocean countries. Tens of thousands were left homeless and many thousands were drowned or injured by the killer waves

157 A Healthier South-East Asia Millions of survivors were left to pick up the pieces after the devastating tsunami of December 2004

In the immediate aftermath Ministry of Health in Jakarta reached Aceh, and so did WHO staff. When the tsunami struck, Dr Media was busy managing a health service to be The next morning, Monday, an official provided to a patient who was to go for of the Ministry of Health was driven to the Hajj pilgrimage. Suddenly, everything Dr Media’s house on a motorcycle. They was cut off, there was no phone signal or combed through Banda Aceh, visiting electricity. The sound of sirens came from areas where the health offices and many directions. Dr Media’s husband had hospitals used to be. The main general been out practising watersports at the hospital was severely damaged. Health coast, and nowhere to be found. There services for the residents were taken was no means of getting clear information up by the army hospital which was not about friends and families affected. This affected by the disaster. was the situation in the capital, Banda In the first week, Dr Media felt alone, Aceh, where Dr Media lived. It was much as if she had been simply left behind. Of worse in other places in Aceh. On Sunday the 35 staff in her unit, 7 were killed. afternoon, officials and staff from the Those who survived the tsunami were

A Healthier South-East Asia 158 Tehh Sixt Decade: 1998–2007

looking for or taking care of their family technical and logistical. Dr Media recalled members. Many of those she knew had how WHO played its key roles with the lost family members in the catastrophe. Ministry of Health, leading the health Dr Media lost her husband. Like others cluster and working side-by-side in every in the affected areas, health officials and technical area. Cars and motorcycles health workers too lost their houses and were procured to help health workers their belongings. Mobilizing health-care collect reports and provide health workers was a huge challenge. services. UNICEF also gave extensive support. Dr Media still remembers the Even as she coped with her personal regular meetings that took place in the grief, and while her family wanted her to emergency office, with people sitting and come home to Jakarta, Dr Media started standing everywhere, crowding even the her disaster response work. Her house stairs of the building. became the emergency office and she provided meals to those who came to, Foreigners flooded to Aceh, creating stayed and worked in her house. what she calls ‘the second disaster’. They brought medicines and supplies. Some of WHO helped to rent a house to set up them suddenly sprayed the city of Banda an emergency provincial health office, Aceh with disinfectant, some carried out and another, around 200 meters away, fogging for malaria. One organization to be used as the local control office went directly to the community and for communicable diseases. One of the started carrying out immunizations, and first responses was to conduct outbreak then came to Dr Media with a report prevention. The first worry was that of a filled in only with numbers – without any cholera outbreak. WHO and the Ministry information about the names, ages and of Health supported local authorities to location of the immunized people – and conduct cholera immunization. ’Thank requested a certification. Aceh had to God we managed to avoid the outbreak,’ redo the entire immunization process. she recalls.

A surveillance system was an urgent After the disaster necessity. Dr Media developed a system The support effort left drums of to ensure that necessary reports came insecticides and piles of medicines in from the numerous posts. She had one everywhere, and the Government of mobile phone with her receiving reports Aceh had to manage them for a long in English while her staff had another time – even two years after the tsunami. mobile phone to receive reports in Bahasa ‘There were piles of medicines … it was Indonesia. The communication network a problem. It took years to manage had not completely recovered by then. them.’ There were plenty of logistics The Ministry of Health and WHO worked elements that Aceh could not use. From closely together to provide support, both her observation and communications, Dr

159 A Healthier South-East Asia Media learned that many of the foreign Learning from her experience, Dr organizations had very little, if any, Media went to a regional meeting in information about the situation in Aceh. Bangkok with a WHO staff member to Keeping in mind diplomatic courtesies, give a presentation on post-tsunami the help was accepted, even though the surveillance. She feels there should be piles of well-intentioned material could a venue for the continuous sharing of not be used. information on disaster management. WHO could review the positive and After the emergency response, WHO, negative experiences and aspects of the Ministry of Health and the Aceh disaster response, collecting the lessons Provincial Health Office developed from all tsunami affected areas and a small book as a manual for disaster countries that were supported by WHO. response and management, to guide Also, she feels, lessons learnt and best people to take necessary action when a practices, before and after the disaster, disaster strikes. must be shared and there should be more The people of Aceh now are not merely communication between countries so aware of disaster response, they actually that they could learn from each other. live it. To be accredited, a community Young leaders in the health sector health centre (Puskesmas) must have should be well-informed about disaster an emergency plan. They must be management. Lessons learned should able to explain what they need to do be shared with them. Capacity-building when there is an emergency. Aceh now should be a continuous process, she says. has an independent unit for disaster ‘There should be a place to access management in the provincial and documents/books on disaster response, district/city health offices. The Ministry mitigation and management, so that instructed districts/cities to have a ‘119’ young health leaders could study them. emergency response team. The structure It was good I went to that refugee health for disaster response is now far better. meeting so that I had a bit of information Many agencies and organizations already as to what we need to do during have a contingency plan. Dr Media emergencies. I could use the knowledge. certainly sees considerable improvement: I would like to see that heads of health ‘Our preparedness is much better’. offices understand, for example, that Dr Media remembered that as late when a disaster strikes, immunization as 2007, WHO was still helping with is the immediate response to it. Such surveillance and immunization. By 2010, documents may be available, but they almost all international organizations have to be well-disseminated, reaching had left Banda Aceh, the capital of the managers in provinces, districts and province, while a few of them continued cities,’ Dr Media explained. working in some areas of Aceh.

A Healthier South-East Asia 160 Tehh Sixt Decade: 1998–2007

Investing in risk management is investing in future development

The Region has learnt from past destruction. Hospitals in Banda experiences and continues to better Aceh evacuated their patients manage risks. On 11 April 2012, an in an orderly manner, which is a earthquake of the magnitude of 8.7 reflection of their preparedness on the Richter scale hit the coast plans and drills. In Sri Lanka, the of Aceh for over four minutes with tourism sector was well organized tremors being felt in neighbouring and moved guests to higher countries. It seemed like a repeat ground. of the 2004 earthquake and The 11 April event has proved tsunami. Thankfully, it was not. that in Indonesia, India, Maldives, But some of our actions on that Sri Lanka and Thailand, the major day clearly demonstrated that catastrophe in 2004 was taken we have moved on with better as a turning point to integrate preparedness and response. There lessons into action. This shows was more organized evacuation how disaster risk management of people to higher grounds by can be improved with proper all coastal communities, not investments, both technical and only in Indonesia but also in financial. Political will and a Sri Lanka, India (in Chennai), disaster prevention perspective Maldives and parts of Thailand. can bring changes to populations The clear link of communication to better live with risks. between tsunami warning systems With this concrete display of and the community was seen in commitment of countries, the many coastal areas. There were Region is well poised to provide only eight deaths, and all those inputs to, and adapt and adopt injured were promptly treated and the new global framework and accounted for. guidance for emergency risk Although some health posts were management for health that WHO damaged, the infrastructure in is developing. the cities did not suffer major

Dr Samlee Plianbangchang Regional Meeting on Disaster Risk Management in the Health Sector, Bangkok, 6–8 June 2012

161 A Healthier South-East Asia Pashupati Nath Temple. Gold leaf replica. 1.07 x 1.45 m. Oil painting (0.54 x 0.65 m) for 40th Anniversary. Gifted by Nepal

A Healthier South-East Asia 162 Tehh Sixt Decade: 1998–2007

Protecting health from climate change

Widespread deforestation, other intensity and seasonality of other land-use changes, migration, change diseases. in occupation and increased human crowding are likely to influence the The World Health Organization has patterns and magnitude of occurrence advocated for and supported action of infectious diseases. The risk of cross- to reduce human-induced changes in species infection has also increased, climate. As a result, in 2007, ministers as is evident from the spread, and high officials of the ministries of emergence and re-emergence of environment and health endorsed the malaria, dengue, scrub typhus, Nipah Bangkok Declaration on Environment virus and neoplastic diseases in the and Health. Further efforts by the Region. Indiscriminate use of chemicals Regional Office resulted in the in response to an increase in pests formulation of a Regional Framework and insects bring additional health for Action to Protect Human Health problems, such as congenital diseases, from the Effects of Climate Change, poisonings and diarrhoeal deaths. in 2008. A Regional Working Group on Protecting Health from Climate Climate change is a harbinger Change was formed. of poverty, death and injury through various direct and indirect In 2008, a meeting of the health manifestations. Climate change may in ministers in the Region resulted the years ahead cause a serious survival in the New Delhi Declaration on problem for about 1.5 billion South the Impacts of Climate Change Asians, as it could increase migration, on Human Health, at which they poverty, malnutrition, mental committed to a number of specific problems and other diseases. Climate actions. To garner political support change would increase the prevalent for taking up adaptation measures in endemic diseases, both spatially and Member States, in October 2010 the in magnitude. This situation would Regional Office organized a Regional be further complicated by a decline Parliamentarians’ Conference on in the quality of the environment and Protecting Human Health from eco-degradation as a result of climate Climate Change. The Regional Office change. also convened a high-level meeting for the health and environment Health threats include the advent ministries in October 2010 to prepare of new diseases (e.g. Nipah virus their focal points on climate change carried by fruit bats, and severe acute to take up health concerns from respiratory syndrome, or SARS) as well climate change strongly at the as the emergence of new strains of Sixteenth Conference of Parties viruses (e.g. avian influenza), besides of the United Nations Framework changes in the incidence, range, Convention on Climate Change.

163 A Healthier South-East Asia Responding to the threat of NCDs

Work in the area of noncommunicable practices. Five countries in the Region diseases (NCDs) was guided by the applied the Package of Essential NCD Regional Framework for Prevention (PEN) interventions, consisting of and Control of Noncommunicable sets of protocols designed for non- Diseases developed in 2006. The physicians and medical doctors, and Framework listed key strategies. These a packet of tools to facilitate their include raising awareness of NCDs, application. conducting surveillance to map the risk factors for NCDs, and promoting NCD units operated within the primary prevention through health ministries of health in nine countries, promotion and legislation. Other where funding of their programmes aspects were early detection and was through the government budget. treatment at the primary care level, All Member countries provided at least and conducting research to gather one NCD-related service at the primary evidence on how best to control NCDs. health care level in public facilities. There were some key achievements, with WHO’s technical leadership, Legislation was adopted as a strategy related to prevention and control of to limit tobacco and alcohol use in the NCDs in the Region in the decade. Region. The Framework Convention on Tobacco Control (2003), the first The South-East Asia Network for NCD international treaty negotiated by Prevention and Control, launched in WHO to reduce the enormous burden 2004, reviewed progress towards the of deaths and disease from the use of control of NCDs in Member countries, tobacco, started to be implemented in and provided a forum for sharing best the Region during this decade.

Physical fitness was a key strategy endorsed by the Regional Framework for NCD Prevention and Control

A Healthier South-East Asia 164 Tehh Sixt Decade: 1998–2007

Progress in disease eradication

As mentioned earlier, in May 1991, Central Health Education Bureau, the World Health Assembly adopted a UNICEF, and the Rajiv Gandhi National resolution declaring its commitment to Drinking Water Mission, contributed the goal of eradicating guinea-worm to formal and non-formal education disease (or dracunculiasis) by the end efforts. Community participation of 1995. Some endemic countries could was encouraged in the process of not achieve this target but, by the year eradication. Village leaders, school 2000, the South-East Asia Region was teachers and children, health workers finally free of this disease. and women were involved in specific activities. In 2000, WHO certified India was the only country in the that India was free of guinea-worm Region where this disease was disease. endemic. A number of factors contributed to its eradication. With the exception of some parts of First, diagnosis did not require any Asia and Africa, the world has been laboratory test. The characteristic free from polio since 2000. In the symptoms and signs of the disease South-East Asian Region, the disease were easily identified by the victim mostly affected the northern states or his/her relatives. Then, the of India. With the implementation of geographical spread of the disease was WHO-recommended strategies, polio limited to areas where people entered cases in the Region declined sharply water sources and collected drinking – by over 98%. The last case of type water. It followed that infected 2 wild poliovirus in the Region was persons and contaminated water isolated in Aligarh, in the state of sources could be easily identified and Uttar Pradesh, India, in October 1999. treated. The provision of safe drinking With this, the type 2 wild poliovirus water contributed significantly to has probably been eliminated in India. the decline of guinea-worm disease. Health education also played a crucial Seven of the 11 Member countries part in empowering rural communities successfully interrupted the in dealing with the scourge. transmission of wild poliovirus for at least four years, with India being The National Guinea-worm Eradication the only endemic country, and Programme in India, launched in 1983, Bangladesh, Indonesia and Nepal demonstrated the advantages of suffering belated importation of wild partnership and networking between poliovirus. Overall, the number of Central and state governments of the cases of polio in the Region declined country, WHO, UNICEF and NGOs at by more than 94%, from a reported the national, state and district levels. 25 253 cases (types 1, 2 and 3) in 1988 Various national and international to 134 laboratory confirmed cases agencies, such as the National Institute (types 1 and 3) in India in 2004. of Communicable Diseases (NICD),

165 A Healthier South-East Asia India detected only 66 polio cases in of leprosy. During this decade it made 2005, compared with 134 in 2004. a remarkable contribution towards However, in 2006, the number of cases reducing the global leprosy burden. Of increased to 676, the majority being the more than 15 million cases globally type 1 cases from the state of Bihar. cured with multidrug therapy (MDT), In 2007, there was a similar peak in about 12.8 million were from this type 3 cases, with much reduced type Region, and more than 11.8 million 1, and totalling around 850 cases. of them were from India. Nine of the In 2008 the indicators showed that 11 countries in the Region achieved the marked peak of type 3 cases in elimination at the national level (with 2007 in India had declined and was a prevalence of less than 1 case per expected to come down to near 10 000 population), leaving only Nepal baseline level. A number of initiatives and Timor-Leste to achieve this goal. were undertaken in India in an In March 2008, in Nepal, there intensification of efforts to interrupt were 3277 cases on MDT with a transmission of wild poliovirus. In prevalence of 1.2 per 10 000, and in April 2005, the surveillance network Timor-Leste, there were 185 cases on in Indonesia detected and reported MDT with a prevalence of 1.7 per a wild poliovirus type 1 case in 10 000. Member countries revised West Java. The WHO laboratory in and updated their national guidelines Mumbai confirmed its relation to in accordance with the WHO Global polio outbreaks in Yemen and Sudan, Strategy and the Operational and also to viruses detected in Saudi Guidelines, and were applying these Arabia in late 2004. The number accordingly. Collaboration with various of affected children in Indonesia partners was strengthened in the increased to 287 in October 2005. Region during the decade, and there was increased involvement of people Yaws was still a public health problem affected by leprosy in efforts towards in Indonesia and Timor-Leste. These its control. countries had accelerated their public health efforts to eliminate About 150 million people in the this neglected tropical disease Region were at risk of contracting before 2020. To do this, the Region visceral leishmaniasis (kala-azar). adopted the new global strategy of Bangladesh and India were among treatment with oral azithromycin. The the most severely affected countries in Regional Strategic Plan to Eliminate the world. The disease was endemic in Yaws 2012–2020 was revised. The 109 districts (45 in Bangladesh, 52 in Regional Office took the lead in India and 12 in Nepal) in the Region. educating the affected population During this decade, cases and deaths regarding personal hygiene measures, had been reduced in Bangladesh and and advocating with ministries of Nepal, and India had strengthened health and other sectors for resource its surveillance, case detection and mobilization and clean water supply. treatment. A new rapid diagnostic test, along with improved surveillance, This Region has traditionally enhanced case detection. accounted for the highest case load

A Healthier South-East Asia 166 Tehh Sixt Decade: 1998–2007

The replacement of injectable improving the child’s nutritional status drugs with an effective oral drug and physical and cognitive growth. (miltefosine) reduced the number of deaths to less than 100 per year. WHO continued to supply albendazole to Member countries. Among the plans As a result of sustained advocacy by developed were to provide technical the Regional Office at the highest assistance for countries to scale up level, in 2005 a memorandum of MDA where required, carry out understanding was signed between transmission assessment surveys to stop Bangladesh, India and Nepal to MDA, and develop disability alleviation eliminate kala-azar by 2015, with the services. aim of reducing the incidence to less than one in 10 000 population. The During the decade, dengue fever was Regional Office planned to introduce one of the most important public a new drug, liposomal amphotericin health threats in the Region. The B, for treatment, and further scale increasing incidence, severity and up elimination in the three endemic frequency of dengue epidemics were countries. linked to trends in human ecology, demography and globalization. The The Region accounted for 65% of disease had spread to areas where the global burden of lymphatic it was historically unknown, such as filariasis. The progress made during Bhutan and Nepal. The Democratic the decade in mitigating the impact People’s Republic of Korea was the of this disease is likely to culminate only country that had not reported in the elimination of this disease by any indigenous cases of dengue. 2020. This is largely a result of mass Factors responsible for the spread of drug administration (MDA) with dengue fever included the lack of diethyl carbamazine and albendazole. availability of antiviral drugs to treat Coverage increased from 56 million the disease, changing vector dynamics, in 2004 to 365 million in 2011. As a geographical expansion of the vector result, the microfilaria rate declined due to climate change, community to less than 1%. Maldives and Sri ignorance, and weak public health Lanka stopped MDA and focused on actions in response to outbreaks. While surveillance. Thailand soon joined several of these factors were beyond these two countries. Many health the control of the health sector, WHO units in Bangladesh and Thailand had strived to keep mortality caused by this also discontinued MDA. disease to less than 1%. With Regional Office support, countries were able The elimination of lymphatic filariasis to achieve this. The target was not has the added benefit of controlling breached even during the massive soil-transmitted helminthic infections, outbreaks that hit Indonesia, Maldives, such as those caused by roundworm, Sri Lanka, Thailand and Timor-Leste. hookworm and whipworm. This helps This reflects the increased capacity of in reducing morbidity, especially the health services to manage clinical among schoolage children, and in cases effectively.

167 A Healthier South-East Asia Defeating Kala-azar in Bangladesh

isceral leishmaniasis, also known were carrying the disease, with some Vas kala-azar, or the ‘dark fever’, 20 000 to 30 000 fatalities. More than has long been a neglected tropical 90% of the new cases occurred in disease. It claimed hundreds of the six countries mentioned above. thousands of victims in South Asia While every country fought its own before it was dramatically curbed war against the disease, this was not during the 2005-2015 decade. Endemic enough. in six countries – Bangladesh and India, but also in Brazil, Ethiopia, ‘The cross-border issue was a big South Sudan and Sudan – kala-azar is challenge, as the life patterns of a vector-borne disease transmitted to people living in endemic neighbouring humans through the bites of infected areas in Bangladesh, India and Nepal female sandflies. It usually affects required common and concomitant the poorest populations, particularly actions,’ says Dr Sanya Tahmina, those living in mud houses. Mud is a current director of Centre for construction material that harbours Communicable Diseases in Bangladesh, sandflies. As such, kala-azar causes and a long-time fighter against further pain and suffering those communicable diseases. already deprived. The disease is fatal if left untreated. And the unprecedented happened: in 2005, during the World Health By 2005, according to WHO’s Assembly in Geneva, Switzerland, estimations, an annual 300 000 people the Ministers of Health of

Dr Mannan Bangali Dr Sanya Tahmina

A Healthier South-East Asia 168 Tehh Sixt Decade: 1998–2007

Bangladesh, India and Nepal signed helped our efforts. In 1998, a new a memorandum of understanding to rapid diagnostic test was developed eliminate visceral leishmaniasis in the and introduced in the country and, in Indian subcontinent. The roadmap was 2007, the classic 30-day treatment by challenging and the goal very bold: painful intramuscular injections was decrease the incidence of the disease replaced by a revolutionary single to below 1 case per 10 000 inhabitants oral dose of miltefosine. Furthermore, per year in endemic areas at subdistrict WHO, working with the Bangladesh level by 2015. Ministry of Health, Family and Welfare and the International Centre ‘The memorandum was, for us, the for Diarrhoeal Disease Research, foundation stone of a National Bangladesh, tested the efficiency of Kala-azar Elimination Programme new treatments. As a result, the use in Bangladesh. It provided a clear of a single-dose amphotericin B drug strategy and a pathway ahead. was recommended by WHO in 2012 Starting 2006, we strengthened as a first-line treatment against kala- the vector control, while intensive azar, not only in Bangladesh but in all spraying has been conducted with endemic areas of South Asia.’ community support for years, both before and after the monsoon season. Bangladesh reached the goal of Tens of thousands of mosquito nets having less than one case of kala- impregnated with insecticide have azar per 10 000 population in 2016. been distributed. Extensive awareness This was a major victory against a campaigns have been conducted centuries-old disease that brought and hundreds of health staff and misery and further impoverished the volunteers have been involved in case poorest of the poor. searches. An “early diagnosis and prompt treatment” strategy has also ‘This was a great achievement that been put in place,’ Dr Tahmena recalls. made everyone proud. But we should keep in mind that the disease is not Dr Mannan Bangali, retired WHO staff eradicated and that continuous efforts and regional specialist on vector-borne need to made to maintain the high diseases, explains the role of medical level of monitoring, early diagnosis developments in fighting kala-azar. and treatment, as well as the measures ‘The memorandum of understanding for vector control,’ says Dr Bangali. gave an enormous boost to the ‘We know we still have important fight against kala-azar, but the later work ahead of us but the last 13 years discoveries of faster diagnosis and of results prove that kala-azar can better treatment methods greatly finally be defeated.’ adds Dr Tahmina.

169 A Healthier South-East Asia Tackling new threats

Newly emerging diseases such as in all countries. Vaccination of Chandipura virus, Nipah virus and poultry was also done extensively in Crimean-Congo haemorrhagic fever Indonesia. All countries established also posed public health threats to functional surveillance and response the Region during the decade. These mechanisms through intersectoral new threats also threw up serious collaboration. challenges to national public health service capacities. WHO declared the first influenza pandemic of the 21st century in The beginning of the millennium June 2009. All countries of the saw global outbreaks of diseases Region reported outbreaks at with pandemic potential. Severe different times and a total of acute respiratory syndrome was the 76 302 laboratory confirmed cases first caused by a hitherto unknown with 2054 deaths were recorded. pathogen. A second was a pandemic All countries were better able to of influenza, which was similar to respond to this pandemic as WHO the three pandemics experienced in support had helped them develop the previous century. institutional and technical capacity by supporting their national Another emerging threat was caused avian and pandemic influenza by outbreaks of highly pathogenic preparedness plans. avian influenza (A(H5N1)) among poultry in Thailand and Indonesia (in A revision of the International 2004), India and Myanmar (in 2006), Health Regulations (referred to Bangladesh (in 2007), Nepal (in 2009) as IHR (2005)) was unanimously and Bhutan (in 2010). The disease adopted on 23 May 2005 by the was deeply entrenched in poultry in Bangladesh and Indonesia, while occasional outbreaks were reported in the other countries. The South- East Asia Region reported a total of 226 human cases of influenza A (H5N1) with 178 deaths since 2004.

Although the number of reported human cases had been decreasing over the previous five years, the fatality rate was very high (>80%). A “stamping out” policy was adapted for containment of Severe acute respiratory syndrome, or SARS, is one of the emerging poultry avian influenza outbreaks public health threats in the new century

A Healthier South-East Asia 170 Tehh Sixt Decade: 1998–2007

Substantial progress was made in implementing these Regulations in the Region during 2007 and 2008. The IHR (2005) were responsible in large part for the swift and effective control of epidemics.

A multidisciplinary team was stationed at the Regional Office’s Disease Surveillance and Epidemiology unit to provide normative and technical support to countries to strengthen national Specific precaution is needed while taking care of newly emerging diseases “Core Capacities” for preparedness, surveillance, risk assessment and outbreak response, as envisaged by World Health Assembly. The the IHR (2005). Member States were broadened purpose and scope expected to develop minimum core of IHR (2005) were to prevent, capacities to enable them to carry protect against, control and provide out the IHR (2005) by June 2014. a public health response to the The Regional Office invested its international spread of disease and resources to initiate and develop avoid unnecessary interference programmes such as the Field with international traffic and Epidemiology Training Programme, trade. These regulations came and the Early Warning, Alert and into force on 15 June 2007. The Response Systems. In addition, Regional Office worked closely with Member States appointed district all Member countries to facilitate surveillance officers to improve implementation of IHR (2005). surveillance capacity.

Universal access to AIDS treatment

Up to quite recently, having an number of people living with HIV infection meant certain death. HIV in the Region decreased Now, with greater awareness, from 6.2 million in 2004 to 3.5 strong policies and increased million in 2011, reducing the access to drugs, it is fast becoming overall prevalence from 0.7% to a chronic, manageable disease. 0.3%. The number of new HIV During this decade, the HIV infections fell by 31% during the epidemic was halted and reversed decade. This achievement would in several countries, notably India, not have been possible without Myanmar, Nepal and Thailand. The commitment at the highest level.

171 A Healthier South-East Asia The number of people receiving HIV infection. The Region adopted antiretroviral therapy (ART) an ambitious target to eliminate increased substantially during the new paediatric infections by 2015. decade, from 55 000 to more than Thailand was also the only country 814 000 people. The availability in the Region to have achieved of generic, quality and affordable universal coverage of testing and antiretroviral drugs produced in the counselling for HIV for all pregnant Region (mainly in India) played a women. Over 90% of women critical role in saving thousands of who test HIV positive receive lives, not only in this Region antiretroviral prophylaxis. Almost but also in several other all babies born to HIV-positive developing countries. women receive ART. This resulted in a reduction of the perinatal HIV Thailand was the first country transmission rate. to integrate interventions for preventing mother-to-child The Regional Health Sector Strategy transmission of HIV into its existing for HIV/AIDS 2011–2015 was strong antenatal care programme endorsed by Member countries. in early 2000. With support from The Strategy calls for “zero new the Regional Office, strong political infections, zero AIDS-related deaths commitment and an affordable and zero discrimination in a world antiretroviral therapy regimen, where people living with HIV are Thailand successfully reduced able to live long, healthy lives”. ART mother-to-child transmission of scaling-up was accelerated by a new HIV, and prevented more than approach – the 3x5 Initiative, which 20 000 children from acquiring aimed at providing ART to

Greater awareness, strong policies and increased access to drugs helped halt and reverse the HIV epidemic

A Healthier South-East Asia 172 Tehh Sixt Decade: 1998–2007

3 million people living with AIDS in who started on treatment increased developing countries by the end of from 18 000 in 2003 to 320 880 in 2005. In the South-East Asia Region, 2007, an 18-fold increase over four although remarkable progress years. Further expansion of access was made in scaling up ART since to ART would have to address the launch of the 3x5 Initiative, weaknesses in health systems, the coverage still remained low including in their human resources, compared to requirements (peaking poor strategic information, and low at only 23%). The number of people health-care financing. Reducing the threat from malaria

During this decade the reported Member countries to reduce malaria (confirmed) number of malaria cases cases and deaths by 75% by 2015 per 1000 population at risk was (compared with the year 2000) and to reduced by more than 30% and the contain resistance to the antimalarial reported mortality rate was reduced drug artemisinin (mainly in Myanmar by 72%. Malaria, however, remained and Thailand), with the long-term a major threat to socioeconomic goal of eliminating the disease. development in South-East Asia. The absolute number of people Of the malaria-endemic countries reported to be receiving antimalarial in the South-East Asia Region, five treatment also dropped. This reported decrease in malaria cases could be attributed to a significant and incidence rates of over 75% reduction in incidence in Bhutan, between 2000 and 2011. Another Democratic People’s Republic of (Bangladesh) was on track to achieve Korea, Indonesia, Nepal, Sri Lanka a decrease in malaria case incidence and Thailand. of 75% by 2015. India, the country with the largest number of cases in Interventions to control malaria the Region, was projected to achieve were scaled up considerably. For a decrease of between 50% and 75% example, the number of rapid in malaria case incidence by 2015. diagnostic tests conducted to To achieve this ambitious target, the diagnose malaria went up from 1.2 Regional Office was promoting high- million in 2004 to 15.2 million in level political collaboration, finding 2011. The number of insecticide- mechanisms to bridge the financial treated nets distributed increased gap, expanding access to quality from 3.35 million in 2004 to 29 medicines and technologies, million in 2011, and the number of ensuring universal coverage of key treatment courses administered rose malaria interventions in priority from 4 000 in 2004 to 4 million in areas, and accelerating research 2011. The Regional Office supported and development.

173 A Healthier South-East Asia Progress in health promotion

Promoting people’s health is the most environmental and political cost-effective measure to reduce their determinants of health that disease burden and consequently lie outside the health sector. reduce costs to the nation. Health Strategic directions were laid out promotion is not the purview of the to promote healthy public policies health sector alone, and must be the across all sectors. Evidence- joint responsibility of all social sectors. based policy development for To facilitate multisectoral actions for health promotion was advocated health and development, a Regional and implemented in most Strategy for Health Promotion for the countries. Specific national health South-East Asia Region was developed promotion policies, plans or in 2006. The Regional Strategy was strategies were developed in at based on the actions and commitments least seven Member countries contained in the Bangkok Charter for (Bangladesh, Bhutan, India, Health Promotion 2005, which was Indonesia, Maldives, Sri Lanka and articulated at the Global Conference Thailand). Some countries, such as on Health Promotion in August 2005. Democratic People’s Republic of Korea, Myanmar and Timor-Leste, The strategy was designed to integrated health promotion plans tackle the broad social, economic, into their national health policies. Introducing WHO’s country cooperation strategies

From 1999 onwards WHO’s country The CCS is the strategic basis for the work was based on “country planning process, and identified a cooperation strategies”. A Country focused and coherent set of priorities Cooperation Strategy (CCS) is a that responded to country needs. medium-term strategic vision to The CCS informs and reinforces the guide the Organization’s work in health dimension of the United and with a country, responding Nations Development Assistance to that country’s specific priorities Framework (UNDAF) and acts as the and institutional resources needed main instrument for harmonizing to achieve its national policies, WHO’s cooperation in a country strategies and plans, as well as in collaboration with other United the actions to achieve its national Nations agencies and development targets within the Millennium partners towards achieving the MDGs Development Goals (MDGs). and later the SDGs.

A Healthier South-East Asia 174 THE SIxTH DECADE: 1998–2007

Health in Timor-Leste: Then and now An interview with Eurico da Costa de Jesus, Village Head (Chefe Suco), Comoro, Dili, Timor-Leste

A ‘tai’ featuring traditional motifs on cloth. Gifted by Timor-Leste

urico da Costa de Jesus, 64, has ‘To give you a broad idea of where we Ewitnessed the journey of over half a were during colonial times and where century of the youngest Asian nation. we are now, let me tell you about the Timor-Leste gained its independence immunization programme. As I recall, in 1975 after nearly four-and-a-half before 1975 there were only two vaccines centuries of colonial rule. ‘The country’s in the immunization programme: BCG for tumultuous journey to independence tuberculosis and measles. Today we have and the process of rebuilding itself in the nine vaccines in the national immunization wake of absolute destruction is a story of schedule and we have impressive coverage collective grit and determination, and a too,’ he says. quest to rebuild a country literally from Eurico trained as a health volunteer during the ashes,’ says Eurico. the colonial era and worked in different After growing up in the eastern districts areas, including immunization. This was of Baucau and Manatuto Euirico, Eurico also the time when there were hardly moved to the capital Dili in 1979 and any qualified doctors in the country. The began to work in the area of health in Portuguese ran training programmes under different roles and capacities. which they trained volunteers to provide

175 A Healthier South-East Asia basic treatment and dispense medicines would be to compare the number of accordingly. ‘I remember yaws being doctors we had in the last century to the widespread in those days, but there was numbers today. From practically no doctors little we could do other than provide basic to now having 1000+ doctors has been a care, like first aid.’ long but rewarding journey for everyone. People now have significantly better access Religious institutions played a crucial to health care,’ says Eurico. role in catering to the health needs of the people before 1975, although old-timers Recalling the years after 1999, Eurico concede that before the restoration of highlighted his experiences in working independence in 2002, health services alongside WHO. ‘Health development were thinly spread. ‘After 1975 there and WHO in this country have been was marginal improvement in the health intertwined since 1999. To give you services, but that wasn’t enough. There an example, we are now in the malaria was one notable change though: we at elimination phase. We hope to be certified least had some doctors compared with nil malaria-free in the next few years. WHO’s before 1975. But access to health care was role in this is widely known. I also recall one limited.’ This was also a time when several major contribution of WHO in the early disease prevention measures were put days: the Organization contributed in a big in place. Eurico recalls his opportunity to way to the rehabilitation of the Comoro work with the malaria programme where and Manleuana health facilities. This they distributed mosquito nets to the changed the lives of the local community communities in Dili and in nearby districts. for better.’

1999 marked the beginning of the World Timor-Leste’s journey of rebuilding, Health Organization in Timor-Leste, however, isn’t over yet. The country has when the country started rebuilding committed itself to attaining the dream of infrastructure. ‘The process of rebuilding universal health coverage leaving no one from zero was arduous, long and testing, behind, and has made impressive gains in but not without its rewards. Today, the area. But there are plenty of challenges. the country boasts of one of the best In Eurico’ words: ‘There always is room for doctor-to-population ratios in the world. improvement. We now must have doctors The government is now successfully who are better qualified and on a par with implementing the second round of its best in the world. We must also invest flagship primary health care programme, more in frontline health workers. We rose the Saude na Familia (Health in the Family). from the ashes, so I am sure we can achieve Another good measure of our journey whatever we set our mind to.’

A Healthier South-East Asia 176 177 A Healthier South-East Asia THE SEVENTH DEcADE 7 2008–2018 From MDGs to SDGs – the dream of health equity

A Healthier South-East Asia 178 Te h SEVENTH decade: 2008–2018

MAJOR ACHIEVEMENTS IN THE SEVENTH DECADE: 2008–2018

1 2 3 4 5

The Region was Maternal and SDG targets on Measles was Yaws elimination certified to be neonatal tetanus maternal and eliminated in was verified in polio-free was eliminated under-5 mortality Bhutan, DPR Korea, India were achieved in Maldives and some countries Timor-Leste 6 7 8 9

Thailand was certified to Maldives and Maldives, Sri Lanka and Trachoma was have eliminated mother- Sri Lanka were Thailand were validated eliminated from to-child transmission of certified as for the elimination of Nepal HIV and syphilis malaria-free lymphatic filariasis

10 11 12 13

Bangladesh, Bhutan, Member States Regional Action Malé Declaration Maldives, Nepal, strengthened Plan on NCD was promulgated Sri Lanka and their emergency Prevention and Timor-Leste preparedness and Control 2013–2020 controlled rubella response mechanisms was formulated

uring this last decade WHO wide-ranging strategic and human and its Member States impact. The Region was certified in the Region recorded polio-free. The Region was credited substantive and inclusive with halting and reversing the HIV, gains in health and well- tuberculosis and malaria epidemics Dbeing. In line with the Region’s – all key Millennium Development guiding framework for action – Goals. South-East Asia became the the eight Flagship Priority Areas5 second WHO Region to eliminate – path-breaking change has been maternal and neonatal tetanus. delivered on a series of issues, with Thailand became the first country

5 (1) Measles elimination and rubella control by 2020; (2) the prevention of noncommunicable diseases through multisectoral policies and plans, with focus on “best buys”; (3) the unfinished MDGs agenda: ending preventable maternal, newborn and child deaths, with a focus on neonatal deaths; (4) achieving universal health coverage, with a focus on human resources for health and essential medicines; (5) building national capacity for preventing and combating antimicrobial resistance; (6) scaling up capacity development in emergency risk management in countries; (7) completing the task of eliminating diseases on the verge of elimination (kala-azar, leprosy, lymphatic filariasis and yaws); and (8) accelerating efforts to end tuberculosis by 2030.

179 A Healthier South-East Asia WHO South-East Asia Region and its Member countries are driving substantive, inclusive gains in health and wellbeing, in line with the Region’s Flagship Priority Areas. Overcoming challenges and achieving the dream of health equity is crucial to our collective vision. It is a goal that defines our professional and moral duty. As we strive to attain our regional vision, the significance of the moment must be fully grasped: We have the opportunity to advance the health of billions and secure wellbeing for all. History can be ours. Dr Poonam Khetrapal Singh, Regional Director since 2014

in Asia to eliminate mother-to- the world’s leading infectious cause of child transmission of HIV/AIDS and blindness. syphilis. Sri Lanka followed Maldives in being certified malaria-free. Both The Region became the first to assess countries and Thailand eliminated health services coverage using an index lymphatic filariasis as a public tool developed by WHO and the World health problem. India, meanwhile, Bank. The South-East Asia Regulatory became the first country to gain Framework, aimed at helping the yaws-free status. Region’s 1.8 billion consumers to access safe, high-quality medical products In August 2018, two countries of and thereby enhance health coverage, WHO South-East Asia Region, DPR was launched. National action plans Korea and Timor-Leste, were verified for antimicrobial resistance (AMR) for eliminating measles, and six prepared by each country in the countries certified for controlling Region would help to stymie the rapid rubella and congenital rubella and alarming emergence of AMR, syndrome, two years ahead of the thereby fortifying regional and global target year 2020. In May 2018, health security. Efforts to stimulate WHO validated Nepal for having physical activity and promote healthy eliminated trachoma as a public eating, as per the regional NCD plan, health problem – a milestone, as the would also help slash the projected country becomes the first in WHO’s rise in noncommunicable diseases in South-East Asia Region to defeat the coming years.

A Healthier South-East Asia 180 Te h SEVENTH decade: 2008–2018

UHC as a key public health principle

Universal health coverage (UHC) A regional consultation on the envisages that all people should role of UHC within the Sustainable have access to the services they need, Development Goals was held in without facing financial hardship. 2016 in the Regional Office. At the These services should be of high consultation, Member countries quality and should be oriented shared best practices in enhancing to the needs of local populations. service coverage and financial They should also be within reach, protection for excluded groups, regardless of a community’s location. including ethnic minorities, migrants, UHC will be realized progressively, mobile populations, refugees and needs to be an ongoing concern. and the urban poor. Another important technical consultation At the Sixty-seventh session of the was held in 2017, in which country WHO South-East Asia Regional representatives discussed enhancing Committee in 2014, Member national capacity to monitor countries committed themselves progress on the health-related SDGs, to enhancing health workforce including UHC. education and training as a part of the Decade for Strengthening The Region carried out an Human Resources for Health, an assessment of health service initiative launched earlier that year. coverage in all Member countries Key activities included enhancing the using the service coverage index retention of rural staff, providing developed by WHO and the World transformative education, and Bank; it was the first region to developing information systems that do this. Following the Colombo can collect data for action. Aligning Declaration, endorsed by the education with service needs is Sixty-ninth session of the Regional another key activity. Committee in 2016, all countries are now working to extend their services for noncommunicable diseases to the primary level. This would help detect NCDs or risk factors on time and prevent possible complications later. It would also help to achieve the SDG target of a one third reduction in premature deaths caused by NCDs by 2030.

The South-East Asia Regulatory Network, launched in 2016, will Strengthening mother and child health care are among the key components to achieve UHC harmonize regional cooperation on

181 A Healthier South-East Asia medical products regulation, ensuring East Asia is dedicated to realizing the that all drugs and medical devices promise of universal health coverage, produced and sold in the Region do and to continue working with exactly what they are supposed to Member countries to identify needs, do. The Regional Office for South- implement policies and track progress. Completing the MDG agenda on maternal and child mortality

The health of mothers and mothers- to accelerate action towards the to-be, neonates, children and unfinished MDG targets, and prepares adolescents is crucial for the Region’s the technical and strategic ground to future. With WHO support, between achieve the broader SDG agenda. 1990 and 2015 countries of the Region reduced maternal mortality The Region eliminated maternal by 69%. Child mortality was reduced and neonatal tetanus in 2016. The by 64%, while neonatal mortality combined measles and rubella was reduced by 54%. Despite all this, vaccine is now providing life-saving MDGs 4 and 5 on maternal and child protection to vulnerable groups mortality were not achieved. This is a in 10 of the Region’s 11 countries. key regional concern. The Integrated Management of Newborn and Childhood Illness Special focus is being given to (IMNCI) is being implemented in ensuring that every newborn survives health facilities across the Region. the first 28 days of life, and that the Maldives, Sri Lanka and Thailand quality and reach of family planning have already achieved the SDG target services are enhanced. WHO’s work on maternal mortality as well as on in this important area focuses on neonatal mortality. The Democratic enhancing advocacy, strengthening People’s Republic of Korea, Maldives, partnership, and delivering sound Sri Lanka and Thailand have achieved and effective technical assistance to the SDG target on under-5 mortality. Member countries. Increasing access to family planning services – including contraception – is In 2015, the Regional Office created a key objective of the 2015 regional a regional Technical Advisory Group reproductive, maternal, neonatal, on Women’s and Children’s Health, child and adolescent health strategy. comprising top global and regional This would drive down maternal and experts in these areas. The Group child mortality, empower women guides national governments, to avoid unintended pregnancies, implementing partners and and advance women’s social and other stakeholders on how best economic autonomy.

A Healthier South-East Asia 182 Te h SEVENTH decade: 2008–2018

Implementing universal health coverage in Thailand

The Director-General, Dr Tedros Adhanom Ghebreyesus, and the Regional Director for South-East Asia, Dr Poonam Khetrapal Singh, on a field visit in Thailand.

HO has praised Thailand for Security Office’s CAPD service at the Wproviding continuous ambulatory Phra Jen community, Dr Tedros said: ‘I peritoneal dialysis (CAPD) to kidney am so inspired by what I have seen that I patients for free. This model could also want to pass the story of Thailand on to be adopted by other countries. Speaking other nations so that they can improve after observing the National Health the quality of life for kidney patients

183 A Healthier South-East Asia around the world. I asked a kidney family members will be taught to patient in the community, who pays perform CAPD safely by themselves. for his treatment? He replied that the Community health volunteers have government helped, and that, without been encouraged to participate in the support from the government, he may project as well. not have survived until this day. I’m very There are more than 20 000 happy to see that the government broke kidney disease patients nationwide the financial barrier for kidney patients, receiving CAPD treatment. Dr Tedros allowing them to access necessary said another important element that medicines and health-care services.’ was observed was the involvement CAPD is a machine-free treatment of family members and people in the for kidney failure that patients can community in taking care of patients. perform at home by placing cleansing ‘Members of a patient’s family and fluids in their abdomens for draining community have helped with parts of waste. Previously, all kidney patients the job, and do not just rely on doctors who needed to take dialysis had to and nurses. They are all well trained go to hospital. Since 2008, Thailand in primary health care. When you has included CAPD treatment in its see the involvement of families and universal coverage health care scheme communities, you know that the system to give patients more independence is very sustainable.’ and remove the burden of travelling Piyathida Jungsamarn, a nephrologist to hospital for treatment. The Thai at Ban Phaeo Pattanakan Hospital, National Health Security Office said normal kidney dialysis is often a (NHSO) now subsidizes 100% of CAPD physically and emotionally draining treatment, which costs about 15 000 process, as patients must go to hospital Thai baht (about US$ 450) per month, two to three times per week, with each across the nation via public hospitals. session taking up to five hours. ‘By the The CAPD project, in which doctors time kidney patients recover from each and nurses at hospitals and clinics form treatment, it is time for the next,’ she teams to visit patients with kidney said. ‘However, with CAPD, patients disease at home once a month, has can have a more flexible lifestyle and a also been created. Patients and their sense of self-reliance.’

(Bangkok Post, 2 February 2018)

A Healthier South-East Asia 184 Te h SEVENTH decade: 2008–2018

Freedom from polio and the ‘Endgame’ plan

In March 2014, the WHO South-East Since the polio-free certification, Asia Region was certified polio- surveillance has been reinforced free. Mass immunization campaigns and expanded. Immunization were successful in reaching the most systems have been strengthened. vulnerable groups in the remotest Where vaccine-derived strains of of places, and interrupting the the virus have been detected, rapid transmission of the polio virus. Robust immunization campaigns have been and sensitive surveillance systems carried out. The Polio Endgame Plan helped guide and refine strategies, is being implemented in the Region. facilitating the innovations needed The Endgame has four objectives: i) to overcome the last challenges. virus detection and interruption, ii) Since January 2011, not a single case routine immunization strengthening, of wild poliovirus has been reported iii) containment and certification, in the Region. All countries of the and iv) mainstream polio functions, Region are committed to maintaining infrastructure and learning. this polio-free status.

Group photograph of participants at the Seventh Meeting of the South-East Asia Regional Certification Commission for Polio Eradication held in New Delhi, India, on 26–27 March 2014. The Region was certified polio-free in 2014

185 A Healthier South-East Asia The Region has had a complete engagement and surveillance has polio vaccine switch, replacing the meanwhile been replicated by other traditionally used trivalent oral public health programmes. polio vaccine with the bivalent oral polio vaccine. The bivalent vaccine During the Seventy-first World Health protects against the two remaining Assembly in 2018, Member States wild poliovirus strains (since the wild adopted a landmark resolution on poliovirus type 2 has already been poliovirus containment, and endorsed eradicated globally), and reduces the the five-year Strategic Action Plan small risk of paralysis from vaccine- on polio transition. The action plan derived polioviruses. outlines how essential polio functions, such as surveillance, laboratory As a part of the Endgame Plan, networks and core infrastructure, injectable inactivated polio vaccine can support the implementation of is now a standard component of the Post-Certification Strategy to childhood immunization schedules sustain a polio-free world, and how regionwide. Consequently, polio they can be integrated into the programmes are having wider immunization or health emergencies impact. The polio programme’s programme, or mainstreamed into emphasis on innovation, community national health systems.

The Polio Endgame Plan is being implemented in the Region

A Healthier South-East Asia 186 Te h SEVENTH decade: 2008–2018

Last case of polio in India

he story of Abdul Shah, an unskilled, became more focused and incredibly Tilliterate, landless and poor villager, intense. By that time Abdul was a is of a spectacular journey from stark changed man. He worked hand in hopelessness after learning that his hand with social mobilizers engaged daughter was affected by polio to specifically in polio immunization basking in the reflected glory of the activities aimed at breaking the taboo intense spotlight that followed. It of ‘immunization avoidance’. He spanned the gamut of emotions from pleaded with his brethren to not shy sky-high and unrealistic expectations away from immunization and face the to bleak frustration on realizing the same fate as his: a child with polio. He futility of his dreams, and ultimately withstood mockery and often hostility. coming to terms with reality. And the journey lasted seven years. This transformation of Abdul from ‘resister’ to ‘influencer’ was neither One wintry afternoon news reached instantaneous nor easy. In the last the family that the unthinkable had phase of the war against polio in the happened. Their daughter Ruksar, only country, every fresh case was a new one-and-a-half years old then, had a frontier. As soon as Ruksar was declared confirmed polio infection. The family a ‘confirmed polio’ case, urgent action had never had her immunized. They was initiated by the government health were averse to immunization, and never authorities, strongly supported by expected this attitude could affect them WHO. so dearly. Polio was not new to their village of Shahpara, in Howrah district The community to which Ruksar of the state of West Bengal, and so did belonged was greatly resistant to not appear to be a major catastrophe to immunization, even the fact of polio the community. But Abdul was shaken. itself failed to soften their stand. They His subsequent interactions with health accepted the disease stoically. Relentless workers revealed to him the folly of not efforts and counselling yielded having immunized his child. results slowly but surely. All the Polio Eradication Initiative (PEI) partners, led Gradually, as no further polio cases by WHO, pursued their single-minded were detected, the spotlight on Ruksar approach to break this resistance.

187 A Healthier South-East Asia Religious leaders were roped in, and so Happily, Ruksar was never crippled, were political personalities. despite being infected by the polio virus. At first, she limped, but very Abdul, who wasn’t even ready to talk soon was back to normal and running to anyone in the beginning, began to about freely. She joined the local listen, and then understand, and finally village school. She was too small to communicate. To see what it was all harbour any particular expectations about, he was taken along by PEI social other than to be able to keep running mobilizers on their outreach efforts and skipping happily. This wasn’t the to other resistant families in his own case with the rest of the community, locality. Gradually he started to speak which hoped for some monetary about immunization passionately and compensation. When this was not positively. forthcoming, frustration grew and the villagers started chasing out visitors, The following years saw a great circus blaming them for ‘selling their misery’. unfolding with Abdul. Uninterrupted ‘You benefit from the story of our visits by a stream of guests coming to child and give nothing in return!’ was meet Ruksar and her family became the refrain. the norm. Every visit ended cordially with folded hands and nodding heads. But Abdul, a poor, religious man, now The community saw that they now had feels enlightened. Come what may, he a true ‘VIP’ in their midst. The whole will help to convince his community show culminated in the year 2014 when not to take the wrong path of Ruksar and her family were invited avoiding vaccines. ‘I will ask everybody by none other than the President of not to make the same mistake as I India to the capital to commemorate made. I am lucky my child is walking three years of polio-free India. Ruksar today, but everybody everywhere may had become a truly national icon, and not be as lucky Abdul was overwhelmingly proud of as me…’ her. Abdul continued to work as an opinion leader, going from door to door (WHO Country Office, India) to convince the reluctant to immunize their families.

A Healthier South-East Asia 188 Te h SEVENTH decade: 2008–2018

Maternal and neonatal tetanus eliminated

Maternal and neonatal tetanus group. Timor-Leste soon followed, has been a major public health leaving India and Indonesia to chart problem in 90 countries in the the final course towards regionwide world, including all 11 of the elimination. South-East Asia Region. In May 2016, the Region was declared India’s health authorities took to have eliminated maternal and a state-by-state approach and neonatal tetanus, becoming the combined approaches, including second among six WHO regions to the provision of cash incentives, the achieve the target. Elimination was training of skilled birth attendants, achieved by concerted efforts in the and intensive behavioural change countries and thanks to several key programmes. These interventions factors: the courage of the health- led to a strengthening of the health care workers, the commitment of system, particularly as regards policy-makers and donors, and a maternal and child health, and renewed emphasis on responsive routine immunization coverage. programming that was able to meet India was validated as having local needs and challenges. eliminated maternal and neonatal tetanus in each of the country’s By the turn of the millennium, districts in April 2015. Bhutan, the Democratic People’s Republic of Korea, Maldives, Sri Indonesia was also strategic in Lanka and Thailand had eliminated its approach. To drive progress in the problem. By 2010, Bangladesh, affected areas, health authorities Myanmar and Nepal had joined this targeted tetanus vaccines to all women of childbearing age and held monthly health clinics. They also counselled women on the need for clean delivery and hygienic cord care. This combination proved a success, and Indonesia achieved elimination in May 2016.

Over the years, WHO’s Regional Office for South-East Asia supported each country to overcome this major killer disease that affected mothers and neonates. The resurgence of the disease should be avoided by Maternal and neonatal health services are accorded due priority

189 A Healthier South-East Asia strengthening the measures that and increasing immunization facilitated elimination in the first coverage, and upholding robust place: sustaining and enhancing surveillance systems that can identify access to quality maternal and lapses and provide the information newborn health care, maintaining needed for rapid action.

Last push to eliminate measles

More than 90% of the people in both doses – the level needed to the Region are now benefiting from establish herd immunity – has been the life-saving aspect of vaccines. achieved in five countries. Rubella The Regional Office for South-East vaccine was part of the combination Asia has identified the elimination vaccine in the majority of countries. of measles and control of rubella With the goal being regional and congenital rubella syndrome measles elimination and rubella as priority outcomes by 2020. Both control, Bhutan and Maldives were diseases continue to affect the verified to have eliminated measles lives of vulnerable groups across in April 2017, and DPR Korea and the Region, making the efforts Timor-Leste in 2018. More countries of Member countries both bold are expected to follow. Through and necessary. Success demands technical assistance and planning, a combination of robust political data management, advocacy and commitment, strong partnership and resource mobilization, WHO is sound technical planning. committed to ensuring each country is freed of the burden of measles. In 2014, the Regional Office in consultation with Member countries developed the Strategic Plan for Measles Elimination and Rubella and Congenital Rubella Syndrome Control, 2014–2020. The Region’s victories over polio and maternal and neonatal tetanus, as well as the overall increase in routine immunization coverage, mean the foundations for success are already in place. It is now a matter of fine- tuning and using strategies already long familiar to countries. Two doses of measles-containing vaccine have now been introduced in every Member country. A level of 95% of Laboratory examination is an important part of public health

A Healthier South-East Asia 190 Te h SEVENTH decade: 2008–2018

Accelerating efforts to end TB by 2030

The WHO South-East Asia Region TB in the Region was held in March bears a disproportionately high 2016. At the same time, the SEA burden of tuberculosis: almost 50% Regional Strategic Plan to End TB of the global burden is to be found 2016–2020 was launched. During in this Region which is home to a 2016, the concept of “Bending the quarter of the world’s population. Curve” was launched; studies on Six of the top 30 high-tuberculosis- accelerating the end of TB, and an burden countries are in the Region. analysis of the associated resource It has been estimated that the needs were drafted. In March 2017, Region loses nearly US$ 4 billion as the Ministerial Meeting towards direct and indirect costs to patients ending TB in the Region was held in for accessing tuberculosis services New Delhi and all Member countries and in income lost every year. signed the “Delhi Call for Action”. In March 2018, another high-level End Many important events in the TB Conference was organized also in Region have been conducted New Delhi. since the World Health Assembly adopted the “End TB Strategy” in The Delhi Call for Action to End TB 2014, which was endorsed by the in the South-East Asia Region was Sixty-eighth session of the Regional signed by all Member countries. Committee in September 2015. A The Call offered six interlinked high-level meeting to discuss ending approaches: i) establish empowered

Tuberculosis is an important public health problem in the South-East Asia Region

191 A Healthier South-East Asia national initiatives, ii) ensure full funding, iii) ensure universal access to high-quality TB care in all sectors, iv) provide patient- centred socioeconomic support, v) establish a regional innovation- to-implementation fund, and vi) mobilize global resources. The Regional Office’s technical assistance and collaboration would focus on key strategic actions related to the establishment of an empowered national initiative; strengthening Medicine is available, but an accelerated effort is needed to end technical support for alignment of tuberculosis by 2030 national strategic plans with the Delhi Call for Action; supporting commitments; and providing support the countries in identifying in mobilizing the domestic and innovation needs; following up on international resources needed to implementation of the national end TB.

Ending the HIV, malaria and viral hepatitis epidemics

Epidemics of HIV and malaria have Progress on HIV and malaria has taken millions of lives over the been substantial. From 2001 to 2015 decades. After sustained progress the Region cut new HIV infections over the years – including meeting by almost a half. Between 2000 and the Millennium Development Goal 2015, it reduced reported malaria to halt and reverse each epidemic cases by almost 50% and reported in Member countries – countries are malaria deaths by nearly 90%. In now in a position to end the HIV 2016, Thailand was certified to and malaria epidemics altogether have eliminated mother-to-child by 2030. Before the SDGs embraced transmission of HIV and syphilis. This this target, WHO supported Member was the first time a country with a countries to make cost-effective, large HIV epidemic had done so. Sri high-impact investments, pursue Lanka became the first country in inclusive, community-based policies, the SGD era and the second in the and harness cutting-edge, life-saving Region to have eliminated malaria technologies – strategies that remain (Maldives was certified malaria-free central to the Region’s focus. in 2015). Both achievements will

A Healthier South-East Asia 192 Te h SEVENTH decade: 2008–2018

Countries are now in a position to end the malaria epidemic by 2030

have life-changing consequences HIV, TB and malaria, in March 2017, for once-affected populations. countries registered their desire to Strong commitments have been see associated disease programmes made with regard to HIV and brought under a single, empowered malaria by all Member countries. At national body that could also tackle a regional consultation on ending viral hepatitis.

Viral hepatitis as a public health threat

Viral hepatitis is the seventh leading The South-East Asia Region is home cause of mortality worldwide and to an estimated 39 million people is the only communicable disease with chronic hepatitis B virus (HBV) wherein mortality is increasing. infections and an estimated 10 Viral hepatitis causes at least as million people with hepatitis C many, if not more, deaths annually virus (HCV) infections. An estimated than tuberculosis, AIDS or malaria. 410 000 people in the Region Around 90% of these deaths are a die annually as a result of viral result of hepatitis B and C infections. hepatitis, with chronic complications

193 A Healthier South-East Asia associated with HBV and HCV community involvement, universal accounting for 78% of the total health coverage, partnership and deaths. evidence-led actions – with a goal to eliminate viral hepatitis as a major Viral hepatitis infections are, public health threat in the Region to a large extent, amenable to by the year 2030. It has adopted prevention and control. There five strategies: i) increase birth dose are effective vaccines to prevent coverage for hepatitis B; ii) ensure hepatitis A and B, an effective that only reuse prevention syringes treatment for hepatitis B, and now a are used; iii) assure safe blood cure for hepatitis C in most cases. supply; iv) improve water and food sanitation; and v) increase access to The Regional Office developed a diagnostic and treatment services for regional action plan for 2016–2021 those infected. Increasing awareness – an actionable framework governed among public and health-care by principles of human rights, equity, providers is also critical.

Eliminating neglected tropical diseases

Neglected tropical diseases (NTDs) endemic country in the world to share the same biosocial causes of become yaws-free. Maldives, Sri neglect, marginalization, poverty Lanka and Thailand eliminated and stigma. In 2014, finishing lymphatic filariasis as a public health off the task of eliminating key problem. Nepal had maintained neglected tropical diseases was the elimination target for visceral made a priority area for action in the leishmaniasis of having less than Region. Accelerated action is being 1 case per 10 000 people pursued to achieve the time-bound at the subnational level for three regional NTD targets set in the consecutive years. Every subdistrict previous decade – by 2020, lymphatic in Bangladesh and 90% of the filariasis, visceral leishmaniasis, administrative blocks in India have schistosomiasis, trachoma and achieved the same. In leprosy, leprosy should be eliminated as although it has been eliminated a public health problem and the as a public health problem at the Region should be free of yaws – and regional level, active case-finding to guarantee the health and well- in affected communities has been being of the Region’s poor and enhanced, contact tracing has marginalized. become routine, and a sentinel system for monitoring drug In 2015, WHO formally resistance is being expanded. In acknowledged India to be the first Nepal, trachoma has been eliminated

A Healthier South-East Asia 194 Te h SEVENTH decade: 2008–2018 Photo: BVBD, MoPH Thailand MoPH BVBD, Photo:

Children taking a mass drug prophylactic: three countries of the Region have already eliminated lymphatic filariasis as a public health problem

as a public health problem and high-level “Call for Action” on validated by WHO. accelerating progress towards the elimination of NTDs endemic At the Sixty-ninth session of the in the Region. Targeting Regional Committee for South- interventions where they are East Asia in 2016, a special session needed most – the grassroots – is was held on NTDs to help countries fundamental. The Regional Office overcome the last challenges that is working with Member countries persist. The health ministers of to make this happen, and to all 11 countries reaffirmed their ensure that the biosocial causes of commitments to reaching the NTD NTDs and other health issues are targets. A regional consultation identified and removed. on NTDs in April 2017 issued a

195 A Healthier South-East Asia Elimination of trachoma in Nepal The national trachoma programme (NTP) was launched in 2002 with the single aim of rolling out “SAFE” (surgery, antibiotics, facial cleanliness and environmental improvement) interventions to eliminate trachoma from as many as 20 high-risk districts of Nepal. The NTP and Nepal Netra Jyoti Sangh (NNJS) trained thousands of community health volunteers to tackle the disease at all levels and across all endemic districts. Mass drug administration, counselling, referral of patients and sensitization of the community towards healthier hygiene and sanitation practices ensured that the transmission of trachoma was interrupted in Nepal. In collaboration with WHO, Nepal made concerted efforts to meet the high standards of data collection and disease management that were necessary for this remarkable feat. The result was commendable: the trachoma elimination target in all endemic areas was more than amply met and validated by the World Health Organization. Today, Nepal can stand as tall and proud as its highest mountain, knowing that it has achieved the peak of health stewardship in wiping out trachoma from within its borders. As its people celebrate their bright dreams and visions, I extend my sincerest congratulations to the people and leadership of Nepal on this outstanding success.

Dr Poonam Khetrapal Singh, Regional Director World Health Organization. Wiping out Trachoma from Nepal, How Nepal eliminated trachoma as a public health problem. WHO SEARO, 2018

Targeting interventions where they are needed most – the grassroots – is fundamental to eliminating neglected tropical diseases

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‘Filariasis has not stopped me’ In conversation with Ms Aminath Warudha, Maldives

s Aminath Warudha was about 10 Lymphatic filariasis, commonly known Myears old when she was diagnosed as elephantiasis, is a painful and with lymphatic filariasis, and this was profoundly disfiguring disease. While about 70 years ago. She is a resident the infection may be acquired during of Gaafu Alifu Dhevvadhoo, an island childhood, its visible appearances may in Maldives with a population of 1000. occur later in life, causing temporary or ‘When I was growing up, there were permanent disability. many people in our island who lived For Ms Warudha, it started with very with filariasis. I am among the only high fever and a lump on her foot. Her three to four people who are still alive fever continued for a week or more, and and fit enough to recall our experience,’ would often come back every month. ‘In she said. the olden days, our island had big water

197 A Healthier South-East Asia wells in every home. The water in these don’t even have a scar to show on my wells was visibly unclean. Everyone feet anymore.’ used to bathe and wash themselves On 19 July 2016, Dr Poonam Khetrapal submerged in the same well water. I Singh, Regional Director for South- believe this is where I might have been East Asia, certified Maldives as having bitten by mosquitoes. Unfortunately, attained the elimination of lymphatic medicine was not readily available and filariasis. She highlighted the fact that health centres were not yet established this was the result of seven decades at the time.’ of partnership between WHO and Even when Ms Warudha grew up, got Maldives: the first collaboration married and had children, she recalls between WHO and Maldives had been having fever at least once a week. ‘The on lymphatic filariasis campaigns in biggest two burdens I faced in life were 1951. living with this continuous fever and ‘When I learned that Maldives had the thickening and swelling of my feet. eliminated lymphatic filariasis, I was This became very challenging during my elated. Eight of my children are alive 12 pregnancies, because my feet used today and all of them are, and have to swell even more during that time. been, safe from this disease. Future However, I didn’t let this disease weigh generations will also be protected me down, or diminish my abilities.’ from this burden. If a small country ‘Despite my condition, I raised 12 like Maldives can eliminate filariasis, I children and I went to the forest every have no doubt that other countries are day to gather and carry wood, and used capable of doing the same,’ Ms Warudha it to cook fish to feed my family. Since said. then, I’ve been treated and received Elimination of lymphatic filariasis the appropriate medication to beat is among a series of health sector the disease. I want to tell people that achievements in Maldives in recent treatment is available and access to years, including the attainment of treatment early will stop the suffering. measles-free status in 2017. Although At the age of 80, I am still working the elimination target has been hard and am in good shape. Filariasis reached, efforts will need to be made has NOT stopped me. Of course, the to sustain the achievement. The people condition of some people was worse of Maldives can now look forward to than mine. I followed the sanitary a future free from a devastating and practices that were recommended, and stigmatizing neglected tropical disease.

A Healthier South-East Asia 198 Te h SEVENTH decade: 2008–2018

Sustaining momentum to combat AMR

Combating antimicrobial resistance the Regional Committee in 2015, (AMR) is one of the priorities in the a resolution was passed which South-East Asia Region. The Region emphasized the need for political is vulnerable to the emergence commitment and effective and spread of resistant bacteria multisectoral coordination to fight thanks to its large, densely packed the problem. In 2016, a roadmap for populations, inadequate water, the creation of national action plans sanitation and hygiene, and often to combat AMR was developed, and suboptimal antibiotic regulation countries pledged to finalize the and stewardship across the medical, plans by May 2017. animal and agricultural sectors. AMR national action plans are The consensus is that a concerted aligned with the target timelines set approach should be developed by the World Health Assembly. In to fight AMR. Countries have July 2018 an intercountry meeting national multisectoral action plans was held in Bangkok to review in place to tackle AMR. The Jaipur implementation of NAPs and the Declaration issued by the Region’s way forward. health ministers in 2011 was the first acknowledgment of the destructive AMR requires action at all levels, potential of AMR. It recognized the and with all partners. Ongoing irrational use of antibiotics as the engagement and advocacy will key driver of AMR, and advocated be vital to maintain Regionwide a holistic and multidisciplinary momentum. The Regional Office approach for its control. is committed to support Member countries to counter the growing At the Sixty-eighth session of menace of AMR.

Innovating emergency risk management actions

Across the South-East Asia Region, and re-emerging diseases such acute events such as earthquakes, as SARS (severe acute respiratory floods and cyclones imperil the syndrome), MERS-CoV (Middle East health of millions. So do emerging respiratory syndrome coronavirus)

199 A Healthier South-East Asia and the Zika virus. Managing risk emergency preparedness. means building health systems that can detect and respond to such Joint assessments of country events effectively. It also means capacity have demonstrated how integrating them into the wider gaps can be found, and where systems of national preparedness systems can be strengthened. As of and response. now, 10 of the 11 countries have conducted periodic assessments During this decade, emergency risk on capacities for emergency risk management has been a regional management, applying 12 SEA priority. This includes efforts to regional preparedness benchmarks achieve compliance with the IHR – a framework devised by Member (2005) – a task vital to health across countries to monitor and evaluate the Region – as well as global health progress. Regional consultations security. Since 2008, a one-of-a- and a ministerial conference on kind system has helped countries advancing health security and in the Region to respond to several disaster risk reduction, and on emergencies, providing over US$ 5 scaling up capacities in emergency million in emergency funding. The risk management, have been South-East Asia Regional Health conducted in recent years to Emergency Fund (SEARHEF) has maintain momentum and national been expanded and now includes commitments.

Member countries are striving to provide health care at all levels

A Healthier South-East Asia 200 Te h SEVENTH decade: 2008–2018

The Thai Room, which contains traditional Thai upholstery, curtains, dolls of traditional Thai dancers, and a table and chairs with very oriental designs. Gifted by Thailand

The Indonesia Room, which displays traditional handcrafted furniture and a series of paintings. Gifted by Indonesia

201 A Healthier South-East Asia A special fund to manage humanitarian emergencies

The South-East Asia Regional Health measure of support of US$ 175 000 Emergency Fund (SEARHEF) is an is not huge, the speed of release and operational fund that allows for a more the flexibility in its use makes a big rapid response to disasters caused difference for the health sector. by natural and human-generated hazards. Countries can obtain financial Although funding for preparedness is support from the Fund through the a big challenge, as the health sector’s country offices within 24 hours of an response to the 2015 Nepal Earthquake emergency. demonstrates, preparedness and good planning is vital. The Sixty-ninth session The earthquake and tsunami of of the Regional Committee endorsed a December 2004 taught the Region resolution on “Expanding the scope of valuable lessons about the need to SEARHEF” to include a preparedness create a fund that could immediately stream that would strengthen key respond to such emergencies and aspects such as disease surveillance, provide instant support to relief health emergency workforce and operations. SEARHEF was established health emergency teams. in 2008 at the Sixty-first session of the Regional Committee, funded by pooling ‘Enhancing health security is a critical a budget of US$ 1 million for each component of our public health mission, biennium from assessed contributions. and a core part of WHO’s work. The new SEARHEF funding stream will Since then, SEARHEF has supported 36 allow Member countries to invest in emergency operations in the Region, infrastructure and human resources, with disbursements from the Fund thereby strengthening emergency totalling more than US$ 5.95 million. preparedness,’ said Dr Poonam The types of emergencies supported Khetrapal Singh. through the Fund range from Cyclone Nargis in 2008 to various floods and The SEARHEF mechanism has received earthquakes to a recent diphtheria wide acclaim across different regions outbreak in the Rohingya refugee and has been an inspiration to initiate camps in Cox’s Bazar, Bangladesh, in other similar funding mechanisms 2017–2018. Although the standard elsewhere.

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Earthquake in Nepal, April 2015 The rapid assessment of the health impact and other actions

The response to the 2015 Nepal earthquake demonstrated the Region’s progress in emergency preparedness and response

A rapid assessment of health-care care in the districts, were found to be facilities by WHO and Nepal’s Ministry of functional but urgently in need of medical Health and Population in the earthquake- supplies. Preliminary findings from the stricken areas found that hospitals in assessment showed that, while there four of the worst affected districts had was a shortage of supplies, sufficient been completely destroyed or too badly health personnel were available to treat damaged to function. Five other major patients arriving at the hospitals that hospitals, providing important health were functioning.

203 A Healthier South-East Asia ‘WHO staff have been working round- the-clock to gather a snapshot of the damage inflicted on Nepal’s hospitals and clinics by the earthquake. This information will be a vital tool in guiding the short- to medium-term response by national and international health-care providers, determining where to move health teams and supplies in the country,’ explained the WHO Representative to Nepal.

Teams visited 21 hospitals in 14 of the districts most severely impacted by After the 2015 earthquake in Nepal the earthquake to gather information. They found that 17 hospitals were still operational. However, many hospitals According to the head of WHO SEARO’s informed the assessment team that they emergency response team, ‘the fact that were experiencing shortages of supplies, hospitals do not need additional staff, and including essential medicines, surgery that thousands of patients are receiving kits, IV fluids, antibiotics and suturing treatment, shows that the preparedness materials, while tents and mattresses measures taken by Nepal for emergencies were also required. WHO had provided are making a difference – but we must essential medicines and supplies to treat continue replenishing medical supplies, 120 000 people for three months, as well ensuring patients are treated, and as trauma and surgical kits. that those who require rehabilitation receive it.’ WHO coordinated the deployment of foreign medical teams and humanitarian While the rapid assessment provided organizations to priority districts based a snapshot of pressing needs in the on the needs of affected populations. aftermath of the quake, additional and Field hospitals were set up on the site ongoing assessments established a better of the four non-functioning district picture to enable the government and hospitals, identified as Ramachhap, health sector to tailor the delivery of Nuwakot, Chautara and Rasuwa. The medical relief. According to official figures five hospitals found to be functional but received on 1 May 2015, 6200 deaths had needing urgent support included Gorkha been recorded, while approximately 14 District Hospital, Patan Academy of 000 people were injured. Health Sciences, Dhading District Hospital, Hetauda District Hospital and From a Regional Office press release dated Alka hospital in Lalitpur. 2 May 2015

A Healthier South-East Asia 204 Te h SEVENTH decade: 2008–2018

Reducing premature deaths from NCDs

Services that can prevent, control and manage NCDs at the primary health care level are being extended everywhere

The burden of noncommunicable for the first time undernutrition, diseases (NCDs) such as diabetes and overnutrition, as well as health cardiovascular diseases is rapidly issues related to micronutrients. increasing in the South-East Asia Region, and is projected to continue A target of the Sustainable to do so in the foreseeable future. Development Goals is to achieve a Clearly, this is a key priority in the one third reduction in premature Region. A Regional Action Plan on deaths caused by NCDs by 2030. NCD Prevention and Control, 2013– To achieve this target, it is 2020 – endorsed by the Sixty-sixth essential to ensure services that session of the Regional Committee can prevent, control and manage – indicates 10 regional targets for NCDs are available at the primary NCD prevention and control. This health care level. In fact, it means is the first comprehensive NCD nothing less than achieving action plan in the Region, capturing universal health coverage.

205 A Healthier South-East Asia In the Region, NCDs cause more than Declaration calls for exploring 60% of all deaths, killing around 8.5 innovative financial methods, million people every year. Almost including taxation of health- 50% from NCDs prematurely, before damaging commodities such as the age of 60. Member countries are tobacco, alcohol and unhealthy taking steps to address the problem. foods and beverages. Healthy The Regional Committee in lifestyle promotion is another area 2016 endorsed the Colombo which should be promoted, with Declaration, which calls for a focus physical activity as a “best buy” on strengthening health systems to intervention for reducing NCD accelerate delivery of NCD services at mortality. The Urban Health Equity the primary level. The WHO Package Assessment and Response Tool, of Essential Noncommunicable (PEN) developed by the SEA Region with Disease Interventions has provided a Member countries, promotes the valuable avenue to the expansion of creation of healthy public spaces in NCD care across the Region. Recently, the cities. WHO PEN has been implemented in Bhutan, Indonesia and Sri Lanka. It All Member countries have is now being piloted in Bangladesh, established national NCD targets the Democratic People’s Republic to be achieved by 2025. These of Korea and Myanmar, and further will help them to gauge progress pilot projects are in preparation in towards the SDG target in 2030. Nepal and Timor-Leste. Nine of 11 countries have now developed multisectoral action plans In addition to strengthening as a whole-of-society approach to the health system, the Colombo reversing NCDs.

Rolling back the tobacco epidemic

Every year, tobacco-related diseases implemented in many countries. kill 1.3 million people in the South-East Asia Region. However, Since 2014, some 85% of the there are evidence-based policies cigarette packs in Thailand are to reduce this alarming number. displaying the warnings, while in The Framework Convention on Nepal (as mentioned earlier) it is Tobacco Control was tabled in 2003, as much as 90%. In 2016, India and since then 10 countries have increased the size of warnings on passed and implemented tobacco tobacco packs from 40% on the control legislation in line with the front to 85% on both sides, while Convention provisions. Graphic Myanmar made it mandatory for health warnings have been gradually 75% of the package surface area.

A Healthier South-East Asia 206 Te h SEVENTH decade: 2008–2018

Various initiatives have also been efforts, Prime Minister Rui Maria implemented in other countries. In de Araújo received the World No Bangladesh, smokeless tobacco was Tobacco Day Award in 2016. In Sri for the first time included under the Lanka, the country is phasing out definition of tobacco products and tobacco cultivation altogether, brought under the same controls. while highlighting the benefits In Bhutan, anti-tobacco media that farmers can reap by shifting to campaigns accelerated, urging the alternate crops. This approach was public to “make every day a no- a key agenda item at the Seventh tobacco day”. In the Democratic Session of the Global Conference of People’s Republic of Korea, a the Parties (COP7) meeting in New comprehensive ban on tobacco Delhi in November 2016. Sri Lanka’s advertising was implemented. In leadership on the issue is an Maldives, tobacco import taxes inspiration to tobacco-producing were hiked as a means to diminish countries across the world. Effective demand for tobacco products. tobacco control measures are a Timor-Leste passed some of the most powerful means to accelerate progressive tobacco control laws in progress to curb premature deaths the world; and for his outstanding from NCDs by a third by 2030.

Resilience to climate change

There is increasing evidence of the conditions of climate change, the direct and indirect adverse impacts health sector needs to collaborate of climate change on human health with sectors that have a direct and health systems, which may pose influence on health, such as water, a serious burden to sustainable energy and agriculture. The health socioeconomic development. In sector must engage communities if 2017, the Regional Committee health systems are to protect health endorsed the Malé Declaration on and facilitate community resilience. Building Health System Resilience to The Malé Declaration and the Climate Change. Framework for Action in Building Health Systems Resilience to Climate The Malé Declaration suggests that Change in the WHO South-East the six building blocks of the health Asia Region, 2017–2022, provides system are important for building a roadmap for implementing the overall resilience to climate change Malé Declaration, with the specific and strengthen existing health objective of providing a conceptual system capacities. In order to protect structure to develop specific national the health of the population in action plans.

207 A Healthier South-East Asia Oil painting on canvas. 0.86 x 1.5 m. Gifted by Thailand

Mask on frame (0.66 x 0.85 m). Gifted by Thailand

A Healthier South-East Asia 208 Te h SEVENTH decade: 2008–2018

Public health education in Bhutan

he Bachelor of Public Health Sciences. Some of the graduates have TProgramme in Bhutan, launched also completed their Masters degrees with WHO support in 2010, has helped in Public Health. to produce a cadre of health workers with a higher level of knowledge WHO helped initiate the Bachelor of and skills in public health. Areas Public Health Programme in 2008, and particularly covered are leadership provided the technical and funding and management; critical thinking and support for: problem solving; planning, monitoring and evaluation of health programmes; ĥĥ A public health specialist to review engagement in operational research; and revise the curriculum and and evidence-based practice. teach in the programme for two years More than 80 health workers have ĥĥ Sending six faculty members to graduated since 2010. Most of them study for their Masters in Public are leading the District Health System Health as district health officers, managing programmes at the Ministry of Health, ĥĥ Sending faculty members for and supervising the community health training in pedagogy units in hospitals and basic health units. Some were also inducted at the ĥĥ Strengthening library and learning Faculty of Nursing and Public Health, materials Khesar Gyalpo University of Medical

209 A Healthier South-East Asia ĥ Building linkages with th eFaculty The institute’s library has been of Public Health, Mahidol designated as a WHO Depository and University, and the South-East receives WHO publications regularly. Asia Public Health Education WHO supported the Bachelor in Institutions Network (SEAPHEIN) Nursing conversion programme in collaboration with La Trobe University, WHO has been a vital partner Australia, in 2001. A total of 52 in Bhutan in providing technical General Nursing & Midwifery Nurses support and capacity-building in in three batches were awarded their the health sector. This has brought Bachelor’s degree in Nursing from La about significant improvements Trobe University between 2001 and in the health of the population of 2008. This paved the way not only Bhutan, as evidenced by the marked for improving the quality of nursing improvement in health indicators. services in the country but also enhancing the quality of the nursing Since the establishment of the faculty at the Institute. In 2012, WHO Health School in 1974, WHO had provided technical and financial provided stipends for trainees in support for the Faculty to launch the primary health care for a number two-year Bachelor’s degree course in of years. It supported institutional Nursing and Midwifery. development, faculty development, and strengthening of the library (WHO Country Office, Bhutan) and teaching-learning facilities.

A Healthier South-East Asia 210 Te h SEVENTH decade: 2008–2018

Vision to Results: Advancing health for billions in the WHO South-East Asia Region

211 A Healthier South-East Asia Vision to Results: Advancing health for billions in the WHO South-East Asia Region

A Healthier South-East Asia 212 213 A Healthier South-East Asia A HOUSE FOR 8 WORLD HEALTH

A Healthier South-East Asia 214 A HOuSE FOR WORLD HEALTH

he Regional Office for However, on 1 February 1949 the South-East Asia (SEARO) Regional Office moved into its had very humble beginnings second premises situated at 12, when it started operations Hardinge Avenue (now Tilak Marg) on 15 December 1948 in in Lutyens’ Delhi. TNew Delhi. Its first home was one small room located in the North By then, the Deputy Regional Block of the Secretariat of the Director, Dr S.F. Chellappah, who Government of India. At that time, was from Sri Lanka, had already the Regional Office housed only the reported for duty, and started Regional Director and a messenger working from the one room that (with a part-time clerical assistant was the first Regional Office. The on loan from the Government of new accommodation on Hardinge India). On 27 December 1948, one Avenue was on the ground floor more clerical staff joined the frugal of a residential bungalow. Within workforce. Those were the early six months, it was accommodating days of Independent India when 24 staff members: the Regional Delhi was coping with an acute Director, the Deputy Regional shortage of official premises and Director, a medical officer, an residential accommodation for assistant finance officer, an assistant government functionaries. administrative officer, 11 clerical assistants, four messengers, one The first offer of formal driver, one daftary (office staff), one accommodation received by the guard and a janitor. Regional Office was of 15 small rooms in a rather dilapidated The Regional Director made several wartime extension of the Old suggestions for a more commodious Secretariat Building in Old Delhi. office, but only one offer of a larger

First home of SEARO: North Block building of the Secretariat of the Government of India, New Delhi, 1948 (file photo)

215 A Healthier South-East Asia Second home of SEARO: 12, Hardinge Avenue, New Delhi, from 1949 (file photo) premises was received in 1949 but and the position now is so acute without any guaranteed date of that he requests the direction of the availability: in Pattani House on Regional Committee in 6 5, Man Singh Road. This situation this matter. was even reflected in the Regional The Regional Committee was due Director’s report to the Second to meet on 26 September 1949. session of the Regional Committee: By then, because of the severe Difficulty with regard to office and paucity of suitable accommodation residential accommodation has options, suggestions were even paralysed the work of the Region afloat in some quarters that the from the very start. The office Regional Office be moved to the accommodation is wholly inadequate. capital of some other Member State. The present accommodation is not Fortuitously, on 17 September 1949, enough for the present staff. On just before the Regional Committee, the other hand, additional staff a letter was received by SEARO from already approved cannot assume government authorities offering duty for want of accommodation. a larger accommodation on the The programme for 1950 is likely to western wing of the ground floor of be double that of 1949, but it is not possible to undertake this work unless Patiala House. This was a palace adequate accommodation for the built for the Maharaja of Patiala, Regional Office … can be provided who was at that time occupying a immediately. All efforts of the part of the building. Regional Director to secure suitable accommodation have met with failure, But the shift to Patiala House was

6 First Annual Report of the Regional Director, 1948, document SEA2/2, p.7

A Healthier South-East Asia 216 A house for world health

Third home of SEARO: Patiala House, New Delhi, late 1949 (file photo)

mired in uncertainty. To begin Director was able to report to WHO with, vacating the portion that was headquarters that the furnishing assigned to WHO, which measured and equipping of the space allotted about 6500 square feet of floor to the Regional Office in Patiala space, was delayed. On 31 October House had been completed. 1949 the Regional Director literally walked in with his staff and occupied Patiala House remained the home of the allotted rooms in Patiala House. the Regional Office for 13 years. It Any objection on the ground was originally built as a maharaja’s that the premises were still not palace with large and lofty rooms vacant would be overruled by the and high ceilings, and never ideally immunities and privileges enjoyed suited for office work. It had to be by an international organization. partitioned into cubicles, which His action was prompted by rumours officers had to share with their that the delay in allotting Patiala secretaries. There was no room for House to WHO could mean another privacy and quietude. imminent change of venue. The magnificent ballroom with its The last two of the rooms originally minstrel galleries accommodated promised by the government were the administrative, personnel and made available only on 31 January finance departments. Once every 1950. It was not until the end of the year, this office was moved into a following March that the Regional marquee in order to make room for

217 A Healthier South-East Asia the Regional Committee sessions. during the Second World War) Working under canvas was not on Raisina Road, a mile and a easy during the monsoons, and the half from Patiala House. The acoustic qualities of the ballroom staff of the administration and did not facilitate discussions finance department moved into during the Regional Committee. this temporary accommodation in Nevertheless, there were June 1958. But this split was found advantages that emanated from unworkable, and they returned to such compression of office space: Patiala House, crowded though it an esprit de corps was fostered, was, after a few weeks. and coordination of operations of technical advisers was facilitated by In January 1959, UNICEF moved to their enforced proximity. new quarters on Lodi Road, and WHO was able to expand into the From 1950 WHO shared the space vacated. Work continued accommodation in Patiala House efficiently until November 1962, with UNICEF. The rapid growth when the new and permanent office of the programmes of both on land provided generously by the organizations involved a steady Government of India – World Health augmentation of staff. In September House – was ready for occupation. that year, the Regional Committee was informed of the space crunch. As The issue of a permanent the years went by, the government accommodation for the Regional made available additional space in Office had been raised very instalments in consultation with the early on. In September 1955, the Maharaja of Patiala himself. Each Regional Committee adopted a such occasion involved protracted formal resolution requesting the negotiations. Corridors were Regional Director to enter into occupied, verandas boarded up and immediate negotiations with the every last corner was converted into Government of India regarding office space. accommodation. This resolution was duly forwarded to the Government, In 1958, the Regional Office and correspondence and reminders recruited more staff members to continued until September 1956, cope with the malaria programme, when the Regional Committee then the largest regional branch again adopted a strongly worded of the global malaria eradication resolution urging a speedy solution campaign. There were 108 staff to the problem. members for malaria (with another 230 in the field), and the budget In October 1956, the Government amounted to US$ 2.7 million. offered Kapurthala House on Man The Government of India then Singh Road, which was expected to offered five rooms in the “P” Block be vacated by the end of the year. Hutments (a legacy constructed Though the floor space available

A Healthier South-East Asia 218 A house for world health

was less than that provided in Regional Director was informed Patiala House, the Government that the proposal for permanent was prepared to make this venue accommodation at Kapurthala suitable for the Regional Office’s House was withdrawn. needs. During 1957, both the Executive Board and the World Talks continued for a suitable house Health Assembly expressed for world health, with the Executive considerable concern over the Board and the Director-General matter, and references were made participating, until May 1958. That to the new buildings offered to month, the decision was finally WHO for some of its other regional taken to allot some land to build offices – in Brazzaville, Copenhagen an entirely new office exclusively and Manila – by the governments for WHO. In August 1958, land concerned. Discussions on proposed for WHO’s Regional Office was alterations that needed to be made identified in Indraprastha Estate in to Kapurthala House continued central New Delhi. through 1957. In January 1958, the

World Health House

Mr H. Rahman, a senior architect As could be expected with the empanelled by the Government erection of a large, six-storey office of India’s Central Public Works block, with a separate conference Department, was chosen to design the block of two floors, construction did new building. WHO owes him, as well not proceed without the occasional as the Government of India, a great alarm and difficulty. A strike by debt of gratitude for a fine building. construction workers held up the work for three days in April 1961. On The Organization was able to 2 August 1962, the monsoon caused arrange for Mr Rahman to travel a breach in a nearby stormwater to Manila to see the new WHO drain and flooded the site. The Regional Office for the Western water stood three feet deep at the Pacific in that city. His drawings site and reached a height of eight and plans were approved by all inches on the ground floor for concerned. However, it was not easy several days. That same year, there to get quick approvals for large- was a serious shortage of electricity scale construction works, and it was in Delhi and the local authorities only after the personal intervention failed to sanction enough power to of the then Prime Minister, Pandit run the office and meet the needs Jawaharlal Nehru, that construction for air-conditioning and the lifts. actually started on 4 February 1960. The final shock came in October

219 A Healthier South-East Asia 1962, when a national emergency of India in the war emergency. Prior was proclaimed following hostilities to the Secretariat’s move it became between India and the People’s possible to arrange for the Regional Republic of China on India’s Committee to hold its Fifteenth north-eastern frontier. It was even session in the new Conference Hall suggested that the Government of block of World Health House. India use the newly built office for the war effort. The new permanent Regional Office was a culmination of the However, the WHO Secretariat promise made by cablegram by at very short notice moved into the Prime Minister of India to the World Health House before it President of the First World Health was completed. The transfer was Assembly in Geneva 14 years earlier. effected between 4 and 8 November Now, the World Health Assembly 1962, and Patiala House was expressed eloquent gratitude to released for use by the Government the Government of India that was

World Health House photographed in 2018

A Healthier South-East Asia 220 A house for world health

Kantha work panel. 2.08 x 0.90 m. Gifted by Bangladesh

echoed widely and sincerely by all Minister in making World Health associated with the work of the House a reality. “This office,” said World Health Organization. Dr Mani,“is, in fact, the office of the governments of the South-East Asia On 24 April 1963, Prime Minister Region, where their representatives Nehru graciously inaugurated meet to discuss common health World Health House. In his problems and to develop WHO- inaugural speech he referred, as assisted health programmes for the at the first session of the Regional benefit of their public services.” Committee in 1948, to WHO as an organization of the United Nations One realizes that the office is which need not be affected by truly regional when one views the political influences and which had many cultural gifts from Member continued its work over the past countries and others decorating decade unaffected by international and illuminating the rooms, halls, strife. He expressed hope that this walls and corridors. These include: work would continue and pave marble tables and carpets from the way for closer international Afghanistan; a large mural painting cooperation between nations in and framed artwork from Myanmar; health as well as other fields. furnishings of a meeting room provided by Sri Lanka; an intricate The WHO Regional Director, in his tapestry from France; several acceptance speech, referred to the paintings, masks, carvings and batik personal commitment of the Prime curtains gifted by Indonesia; a carpet

221 A Healthier South-East Asia from Mongolia; a model of the has always been a part of the Pashupati Nath Temple covered collaboration between WHO and in gold leaf from Nepal; two wall the governments of the Region. tableaux of ornamental titles from India contributed two outstanding Portugal; Thai silk curtains, tables murals painted on the walls of and chairs and dolls for a meeting the Conference Hall in the 1960s room; a bronze statue from the by the well-known artist Maqbool United Kingdom of Great Britain Fida Husain, which together tell and Northern Ireland; a tapestry the story of the history of medicine and model ships from Maldives; a and are described elsewhere in the framed “kantha” embroidery and book. other paintings from Bangladesh; a flower vase from the Democratic In January 1967, at the 39th People’s Republic of Korea; session of the Executive Board, and tapestries and thangkas the Director-General announced from Bhutan; and a traditional that an offer had been made framed “tai” from Timor-Leste, by the Government of India to among many others. All these WHO for the outright purchase of were tokens of the goodwill that the Regional Office building for

Oil painting (1.16 x 0.86 m). Gifted by Bangladesh

A Healthier South-East Asia 222 A house for world health

about US$ 350 000. As the value for its work in the Region bears of the land and building at the testimony to the diligent efforts time of its construction had been of staff of the Organization to estimated at about US$ 1 million, bring tangible change to the lives the Government’s offer was indeed of the people in this part of the very generous. It was warmly world. This was to be WHO’s home welcomed by the Board, which had for the next 55 years, till 2018. no hesitation in recommending its In 2018 it was decided to rebuild acceptance by the Twentieth World and reconstruct the office at the Health Assembly. This purchase same place. Staff of the Regional was duly approved by the Health Office shifted temporarily to a new Assembly in May 1967. location for the reconstruction to happen. This project to build The functionally excellent, and a new iconic Regional Office by the then standards extremely Building incorporating the latest modern, office and conference hall contemporary technology will run that was made available to WHO for five years till 2023.

Extract from business case report to the Seventieth Session of the Regional Committee on 16 August 2017 The World Health Organization Regional Office for South-East Asia is located at New Delhi, India on a land parcel admeasuring approximately 7203 sq. metres. The land was leased to WHO by the Government of India on a long- lease basis at a concessional rate. The Main Building and the Conference Hall at the campus was constructed by the Central Public Works Department (CPWD) of Government of India. Since the campus is more than 50 years old, WHO is facing a number of real estate challenges in terms of safety, health, environment, locally applicable regulations, operational costs and future expansion. Most importantly, recent structural surveys carried out by CPWD and other external agencies have revealed that the current buildings within the office campus are highly vulnerable to seismic events, which consequently is a high risk to business continuity and employee safety.

Thus, it was agreed among the key stakeholders, including the Government of India, the Regional Director and the Director-General, to relocate business operations temporarily till such time that the current office is reconstructed in order to avoid any unfortunate incident and mitigate risks that could result in institutional, personal or financial liability and reputational risk for the entire UN system. In this regard, SEARO has identified suitable temporary ‘swing space’ options in central Delhi, for relocation of its 362 staff members, with the help of an international real estate consultant.

223 A Healthier South-East Asia At the Seventieth session of the cost of the relocation of the staff Regional Committee in Maldives in to temporary premises for a period September 2017, the decision to shift of up to five years for about US$ staff to a temporary office space and 20.49 million. The Committee totally dismantle and reconstruct expressed “deep appreciation” to the Regional Office Building was the Government of India for its finally etched in stone through continued generosity in hosting the decision SEA/RC70(2). By this Regional Office for South-East Asia, covenant, the Regional Committee and for agreeing to finance and decided to redevelop the whole manage the construction of the new campus and construct a new, state- building to the tune of about US$ 35 of-the-art and environmentally- million within a time frame of five friendly building. The estimated years. Some Member countries also budget for this project is US$ 55.89 pledged upfront financial support million, with WHO covering the for the project.

Reception lobby of WHO-SEARO in Indraprastha Estate, New Delhi, with a set of cane furniture. Gifted by Indonesia

A Healthier South-East Asia 224 A house for world health

History of Medicine, by M.F. Husain, 2 murals. Dimensions: 18.76 x 2.77 m each. Gifted by India

The twin murals on the walls of the Conference Hall were painted by M.F. Husain, titled ‘History of Medicine’, and were gifted by India. The mural on the southern (left) side of the hall has five panels. They depict the Hindu god Hanuman and the Ramayana legend about the god lifting a mountain to fetch the healing herb ‘Sanjivani’; a woman giving birth to twins; an eye surgery in progress; modern laboratory equipment and a scholar engaged in research; and the model of an atom representing nuclear medicine.

225 A Healthier South-East Asia On the northern (right) side the mural has eight panels. These portray the sun and herbs that helped heal various diseases in antiquity; the use of fire for curative purposes during an epidemic; an ancient Egyptian scribe writing out a prescription; the pestle and mortar used in the preparation of medicine; the hand of the practitioner and caregiver that plays an important part in healing; the Greek goddess of health Hygeia; and the ancient practice of adjusting a dislocated bone with the help of a ladder.

In 2018, the 13 panels on which the murals had been painted were carefully removed from the walls and have been transferred to a safe storage site. They will be mounted in the new WHO building when construction is complete.

A Healthier South-East Asia 226 227 A Healthier South-East Asia 9 LOOKiNG AHEAD

A Healthier South-East Asia 228 Looking ahead

he opening paragraphs of and overall reduction of morbidity the UN General Assembly and mortality. While several of Declaration endorsed by these follow on from the MDGs, 193 Heads of States and the health agenda in the SDGs is Governments in September more ambitious, both in its scope as T20157 set the scene for defining the well as its level of ambition. Where 17 new Sustainable Development the MDGs saw health in isolation, Goals (SDGs) and 169 targets.8 the new agenda frames health as These will build on the Millennium both a contributor to, and outcome Development Goals (MDGs) and of, sustainable development. The complete the “unfinished agenda”, intrinsic relationship among the while addressing ongoing and new goals are as important as the goals challenges for a prosperous peaceful themselves. Hence, this new agenda world in an inclusive and holistic provides a great opportunity to manner to ensure that “no one is accelerate progress in health, to left behind”. make universal health coverage a reality, and to improve the lives Goal 3 is the main health goal of millions. among the Sustainable Development Goals. This is broadly framed as The most fundamental and being: to ensure healthy lives positive change in the SDGs is the and promote well-being for all shift from a limited number of ages. Goal 3 includes 13 specific discrete Millennium Development targets covering health systems Goals to the much wider range strengthening, prevention and of interdependent Sustainable control of diseases and risk factors, Development Goals.

UHC increases access to health care to the people and communities

7 United Nations General Assembly, 21 October 2015, Seventieth session, Agenda items 15 and 116. Resolution adopted by the General Assembly on 25 September 2015. 70/1. Transforming our world: the 2030 Agenda for Sustainable Development (https://sustainabledevelopment.un.org/post2015/summit) 8 https://sustainabledevelopment.un.org/sdgs

229 A Healthier South-East Asia ‘Transforming Our World’: The 2030 Agenda for Sustainable Development

‘We resolve, between now and 2030, to end poverty and hunger everywhere; to combat inequalities within and among countries, to build peaceful, just and inclusive societies; to protect human rights and promote gender equality and the empowerment of women and girls; and to ensure the lasting protection of the planet and its natural resources. We resolve also to create conditions for sustainable, inclusive and sustained economic growth, shared prosperity and decent work for all, taking into account different levels of development.

As we embark on this great collective journey, we pledge that no one will be left behind. Recognizing that the dignity of the human person is fundamental, we wish to see the Goals and targets met for all nations and peoples and for all segments of society. And we will endeavour to reach the furthest behind first.

Source: Transforming our world: the 2030 agenda for sustainable development. Finalized text adopted by the United Nations General Assembly , 25 September 2015, New York (NY): United Nations; 2015.

The United Nations has undertaken of the SDGs in each country. To a process of reform to enable it this end, all UN agencies, including to address the SDGs within the WHO, are required to ensure the framework of its four-year work best configuration of support on cycle. The resolution covering the ground. All UN development this reform process9 calls for a activities should have enhanced revitalized, strategic, flexible and coordination, transparency, results- and action-oriented UN efficiency and impact, in accordance Development Assistance Framework with national development policies, in support of the implementation plans, priorities and needs.

9 Repositioning of the United Nations development system in the context of the quadrennial comprehensive policy review of operational activities for development of the United Nations system. UN General Assembly Resolution A/72/L.52. Available from: https://undocs.org/A/72/L.52

A Healthier South-East Asia 230 Looking ahead

WHO’s Thirteenth General Founded on WHO’s mission (to Programme of Work 2019–2013, or promote health, keep the world safe, GPW13,10 unanimously endorsed by and serve the vulnerable), the GPW13 Member States during the Seventy- sets an ambitious agenda with three first World Health Assembly in May goals coined as the “triple billion 2018, provides the strategic direction targets”. These envisage: for the work of the Organization in the next five years. It is based on the ĥĥ One billion more people SDGs and is relevant to all countries. benefiting from universal health coverage, This General Programme of Work is structured around three ĥĥ One billion more people interconnected strategic priorities better protected from health to ensure healthy lives and well- emergencies, and being for all at all ages: i) achieving ĥ universal health coverage, ii) ĥ One billion more people addressing health emergencies, and enjoying better health and iii) promoting healthier populations. well-being.

WHO’s Thirteenth General Programme of Work

'The enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being without distinction of race, religion, political belief, economic or social condition.

Unequal development in different countries in the promotion of health and control of diseases, especially communicable disease, is a common danger.

Health is fundamental to the SDGs and, in an interconnected world, WHO’s role in providing global public goods that help to ensure health for all people within and across national boundaries has never been more relevant. WHO’s unique status as a science- and evidence- based organization that sets globally applicable norms and standards makes it vital in a rapidly changing world. The Organization’s powerful voice for health and human rights is indispensable to ensure that no one is left behind. Broad and sustained efforts are needed to build a community to work for the shared future of humankind, empowering all people to improve their health, address health determinants and respond to health challenges.’

Thirteenth General Programme of Work 2019–2023: Promote health, keep the world safe, serve the vulnerable.

10 Thirteenth General Programme of Work, 2019–2023: Promote health, keep the world safe, serve the vulnerable. Available from: http://apps.who.int/gb/ ebwha/pdf_files/WHA71/A71_4-en.pdf?ua=1

231 A Healthier South-East Asia The Thirteenth General Programme contributing to the global health of Work sets out three key and sustainable development strategic shifts to facilitate the agendas. achievement of the strategic priorities and targets: The face of public health in the South-East Asia Region is changing ĥ Stepping up WHO’s leadership in unprecedented ways. If we look in several key areas, including at some measurable indicators, the diplomacy and advocacy, gender Region with more than a quarter of equality, health equity and the world’s population carries 30% human rights, multisectoral of the global disease burden and action and finance; accommodates about 40% of the world’s poor. Of all the six regions ĥ Driving public health impact of WHO, South-East Asia is the one in every country, with a with the highest probability of a differentiated approach based citizen dying from cardiovascular on capacity and vulnerability; disease, cancer, diabetes or chronic and respiratory disease between the ages of 30 and 70. It has the ĥ Focusing global public goods on highest prevalence of stunting impact, including by providing and wasting in children under normative guidance, data and five, the highest reported number research and innovation. of people requiring interventions against NTDs, the second-highest The strategic priorities and goals of tuberculosis incidence per 100 000 GPW13 are aligned with the eight population, the second-lowest Flagship Priorities of the Region amount of general government that were promulgated by Dr health expenditure as a Poonam Khetrapal Singh, Regional proportion of general government Director. They are also in line with expenditure, the second highest national health priorities as set suicide mortality rate, and is the out in the national health plans second lowest in completeness of and strategies and WHO country cause-of-death data. About 25% cooperation strategies agreed with of the population of the Region Member States. Implementation of does not have access to essential GPW13 and UN reform provides an health protection.11 opportunity for WHO to continue building on the successes and best There are several public health practices jointly with Member problems of vital importance to States and partners to achieve the the health of the people and to national and regional targets, while the governments of our Region.

11 World Health Organization. World Health Statistics, 2017: Monitoring Health for SDGs. Available at www.who.int/gho/publications/world_health_ statistics/2017/en/, accessed on 13 April 2018

A Healthier South-East Asia 232 Looking ahead

These include the growing threat long, but all these health-related of non communicable diseases, issues find their place in the SDGs. the health impacts of climate change, environmental pollution The basic components of a new and unplanned urbanization, health agenda are taking shape. and the new demands that result There is a need to think about from changing societal norms, three elements. First, the role of public expectations and ageing the health sector: what can be populations. achieved through the most effective, equitable and efficient deployment But there is more: the mounting of resources for preventive, curative, toll of deaths and disability on our promotive and rehabilitative roads, the persistent challenge of health care? Second, what health hunger for some and over nutrition outcomes are dependent on policy for others, the scandalous neglect and action by other sectors and of mental health, the blight on actors, and what can be done to communities caused by the traffic in make them happen? Third, how to narcotic and other drugs of abuse, deal with the set of cross-cutting the plight of migrants, the victims of concerns that underpin both of the human traffickers and others forced other two components: respect for to leave their homes by conflict and human rights; a concern for equity adversity, and the market and system (no one to be left behind); the failures that underpin antimicrobial primacy of evidence as the basis resistance and the lack of access to for decision-making, evaluation safe and affordable medicines and and accountability; and the need technologies. Public health does not for investment in research and stand still. The list of challenges is development?

UHC as a key instrument for change

The importance of the health sector The future work in the health will remain the primary concern sector is not just more of the same of most ministries of health. There business-as-usual. There is a need to is much that remains to be done: reconfigure service delivery so that completing the elimination of NTDs, clinics and hospitals can deal with further reducing maternal, new born multiple pathologies and continuity and child mortality, and sustaining of care, particularly for those with the gains made in malaria and HIV/ chronic diseases and for the elderly. AIDS are just a few examples. We There is a need for mature and have somehow underestimated the carefully managed partnerships with threat posed by tuberculosis. the private sector, which can help

233 A Healthier South-East Asia deliver public health outcomes. organization of health programmes We need new staffing profiles for in governments and, indeed, in the prevention and care of NCDs WHO. For UHC to fulfil its potential, at the frontline. We need financial all programmes should be managed incentives that reward prevention, in ways that support overall wellness and, increasingly in some national health strategies, rather countries, cost containment. And – than pursuing a set of separate this is the most critical factor – the and disparate objectives. UHC is health sector has to be adequately about the health sector as a whole, financed. Governments should and all its programmes – not just make more effort, both to raise the building blocks of health revenues (currently only about system strengthening. 15% of GDP) and spend more of this income on promoting better While UHC by definition is health (only four countries spend concerned with equity, the way more than 10% of their public universality is interpreted in sector budget on health). Unless practice matters greatly. This we see sustainable change, people is particularly in countries will continue to face potentially with refugee or other migrant impoverishing out-of-pocket populations at risk of being expenditures when they excluded from health care, fall ill. especially if they are not afforded the same rights as full citizens. Universal health coverage is our key For health to be a human right, it instrument of change. Its primary must be accessible to all. This is the intent is to ensure service access true meaning of universality – a and financial protection, but it concept that lies at the heart of the has broader implications for the Sustainable Development Goals.

Embroidered wall hanging encased in wood and glass cover (1.32 x 1.04 m), for 50th Anniversary, received in 1998. Gifted by Myanmar

A Healthier South-East Asia 234 Looking ahead

Building coalitions for change

Many of the health targets included marketing, promotion of exercise as a part of the SDGs require action and many others. Similarly, an both within the health sector and ageing population will place new beyond. Resilience in the face of demands on health-care providers emergencies requires a strong and require better access to assistive health sector, but also strong technologies. Equally, a healthy and links with many other parts of productive old age will depend on government. Tackling NCDs requires pension, taxation and employment effective preventive and curative policies, urban planning, transport health services. But to reduce the and connectivity. When it comes most important risk factors needs to road traffic injuries, the role of action in other domains: taxation, the health sector, at best, is just to advertising, food and beverage repair and rehabilitate – literally to

Tobacco control among youth to reduce the risk of NCDs is a significant component of the vision of Regional Director Dr Poonam Khetrapal Singh, seen here at an event in Dili, Timor-Leste

235 A Healthier South-East Asia pick up the pieces. The real action understanding of the interests of to prevent the damage – reducing all those involved – in building drink–driving and excess speed, age-friendly societies, in preventing vehicle and road maintenance, the further spread of antimicrobial driver and passenger safety – takes resistance and, indeed, ensuring place elsewhere. that the health sector is adequately financed. Advocacy and good This element of the agenda intention alone are no longer builds on the familiar themes of enough; together, we have to “intersectoral action” and “health become more effective champions in all policies”, but if we are to for people’s health. take the SDGs seriously we need to go further. In many areas we The responsibility for policy will already have multisectoral action always rest with governments, but plans, but too often they are seen the changing face of public health as being the primary concern of the will require new ways of working ministries of health that organized in WHO: creating new forms of their preparation. Their impact on partnership and building effective the rest of government is limited. coalitions; at the regional level, carrying out and commissioning There is a need to build on the solid analysis and research that provides platform provided by the SDGs and policy-makers with the information develop a more practical agenda they need to make their case; – issue by issue. There are also and, at country level, a widening lessons to be learned from what network of relationships across we have achieved so far. Progress government, civil society and in the fight against tobacco has academia. required an intense focus on a few key outcomes (for example, in the The combination of a more areas of taxation, marketing and equitable and effective health packaging). Ministries of health sector, more practical and issue- have been powerful advocates based work across society to for change, but the key decisions promote health, and continuing are made at different levels of insistence on equity and rights, government. backed by good science, evidence and research, represents the way Good health is a product of good forward. We have a long road to political decisions. And good travel, but our agenda in this Region political decisions require a deeper has become increasingly clear.

A Healthier South-East Asia 236 B ibLIOGRAPHY

1. World Health Organization, Regional Office for South-East Asia. From Vision to Results. World Health Organization, 2017

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5. 25th Anniversary of the WHO Regional Organization for South-East Asia 1948- 1973. Text of the Speeches and messages from Heads of State or Heads of Governments of Member countries, as well as the addresses delivered by the Director-General of WHO and the WHO Regional Director for South-East Asia.

6. World Health Organization, Regional Office for South-East Asia. Collaboration in Health Development in South-East Asia, 1948–1988. World Health Organization, December 1992

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237 A Healthier South-East Asia 11. World Health Organization, Regional Office for South-East Asia. The Work of WHO in the South-East Asia Region. Report of the Regional Director, 1 January – 31 December 2014. World Health Organization 2015

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14. United Nations Information Centre for India and Bhutan: Seven Decades and Beyond. The UN-India Connect. UN Information Centre 2016

15. World Health Organization. NTD Neglecting to Defeating – Neglected Tropical Diseases in WHO South-East Asia Region. World Health Organization Regional Office for South-East Asia, 2017

16. World Health Organization. Stomping out Filariasis. How Thailand curbed the public health problem of lymphatic filariasis. World Health Organization, Regional Office for South-East Asia, 2017

17. World Health Organization. An insight into risks – Nepal Earthquake 2015: A Vision for Resilience. World Health Organization, Regional Office for South-East Asia, 2016

18. World Health Organization. Roots for Resilience – A Health Emergency Risk Profile of the South-East Asia Region. World Health Organization, Regional Office for South-East Asia, 2017

19. UNICEF. India’s story of Triumph Over Polio – Reaching every child with two drops of life. The United Nations Children’s Fund, India Country Office, 2014

20. World Health Organization. Situational Analysis on Antimicrobial Resistance in the South-East Asia Region. World Health Organization, Regional Office for South-East Asia, Report 2016

A Healthier South-East Asia 238 239 A Healthier South-East Asia A Healthier South-East Asia 240 241 A Healthier South-East Asia For 70 years, the World Health Organization’s Regional Office for South-East Asia – which in 1948 was the first WHO region to be established – has been collaborating with its Member States to improve the health of all people in the Region. This collaboration has resulted in many remarkable achievements in improving people’s health. This book is an account of the journey of health development in countries of the South-East Asia Region. It describes the main achievements, challenges, and A Healthier South-East Asia: strategies to tackle public health problems specific to this Region in an historical A Healthier South-East Asia perspective.

7Years of WHO in the Region

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