The Work of WHO 1992-1993

Biennial Report of the Director-General

CORRIGENDUM

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The Work of WHO 1992·1993

Biennial Report of the Director-General to the World Health Assembly and to the United Nations

~ . 'I .. ~ ~-~ ~ ~ ~""?~ World Health Organization Geneva 1994 The texts of the World Health Assembly and Executive Board resolutions referred to in this report can be found in the Handbook ofResolutions and Decisions of the World Health Assembly and the Executive Board, Volume I, 1948-1972, Volume II, 1973-1984 and Volume Ill, third edttion (1985-1992). Throughout this volume the $ sign denotes US dollars. The abbreviations used in this report include the following:

ACC -Administrative Committee on Coordination OAU -Organization of African Unity ACHR -Advisory Committee on Health Research OECD - Organisation for Economic Co-operation AGFUND -Arab Gulf Programme for United Nations and Development Development Organizations PAHO - Pan American Health Organization ASEAN -Association of South-East Asian Nations SAREC - Swedish Agency for Research Cooperation CIDA -Canadian International Development with Developing Countries Agency SIDA - Swedish International Development CIOMS -Council for International Organizations of Authority Medical Sciences UNCTAD -United Nations Conference on Trade and DANIDA -Danish International Development Agency Development ECA -Economic Commission for Africa UNDCP -United Nations International Drug Control ECE -Economic Commission for Europe Programme ECLAC -Economic Commission for Latin America UNDP -United Nations Development Programme and the Caribbean ESCAP - Economic and Social Commission for Asia UNDRO -Office of the United Nations Disaster Relief and the Pacific Coordinator ESCWA - Economic and Social Commission for UNEP -United Nations Environment Programme Western Asia UNESCO -United Nations Educational, Scientific and FAO -Food and Agriculture Organization of the Cultural Organization United Nations UNFPA -United Nations Population Fund FINNIDA -Finnish International Development Agency UNHCR -Office of the United Nations High Com­ GTZ -German Technical Cooperation Agency missioner for Refugees IAEA - International Atomic Energy Agency UNICEF -United Nations Children's Fund IARC -International Agency for Research on UNIDO -United Nations Industrial Development Cancer Organization ICAO -International Civil Aviation Organization UNRWA -United Nations Relief and Works Agency for IFAD -International Fund for Agricultural Devel- Palestine Refugees in the Near East opment USAID -United States Agency for International ILO - International Labour Organisation Development (Office) WFP -World Food Programme IMO - International Maritime Organization WHO -World Health Organization ITU -International Telecommunication Union WIPO - World Intellectual Property Organization NORAD -Norwegian Agency for International Development WMO -World Meteorological Organization

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iv Contents

Introduction IX

1. Governing bodies 1

2. WHO's general programme development and management 3 Constitutional and legal matters 3 WHO's programme development 3 Informatics management 4 External coordination for health and social development 4 Emergency relief operations 7

3. Strategy for health for all 11 Monitoring and evaluation 11 Regional and national activities and policies 11 Health for all and economic development 12

4. Health system development 13 Assessment of global health situation and future trends 13 Intensified cooperation with countries and peoples in greatest need 15 Technical cooperation among developing countries 16 Health systems research and development 17 Health legislation 18

5. Organization of health systems based on primary health care 21 National health systems and policies 21 District health systems 23

6. Development of human resources for health 27 Policy analysis, planning and management 27 Nursing 29 Educational development 30 Staff development 33

V THE WORK OF WHO 1992-1993

7. Public information and education for health 35 Public information 35 Education for health 35

8. Research promotion and development 39

9. General health protection and promotion 43 Women, health and development 43 Food and nutrition 44 Oral health 47 Injury prevention 49 Tobacco or health 50

10. Protection and promotion of the health of specific population groups 53 Maternal and child health and family planning 53 Health of adolescents 56 Human reproduction research 58 Occupational health 62 Health of the elderly 63

11. Protection and promotion of mental health 65 Mental health policy, and support to national programmes 65 Psychosocial and behavioural problems and relevant interventions 66 Prevention and control of alcohol and drug abuse 66 Mental and neurological services and treatment 68

12. Promotion of environmental health 71 Community water supply and sanitation 71 Environmental health in rural and urban development and housing 72 International Programme on Chemical Safety 74 Control of environmental health hazards 75

13. Diagnostic, therapeutic and rehabilitative technology 77 Clinical technology 77 Health laboratory technology and blood safety 77 Radiation medicine 78 Technology development, assessment and transfer 78 Drug management and policies 78 Pharmaceuticals 79 Biologicals 80 Traditional medicine 80 Action Programme on Essential Drugs 80 Rehabilitation 82

vi CONTENTS

14. Disease prevention and control 85 Immunization 85 Control of tropical diseases 88 Disease vector control 96 Leprosy 97 Tropical disease research 99 Diarrhoeal diseases 101 Acute respiratory infections 103 Tuberculosis 105 Zoonoses 106 AIDS and other sexually transmitted diseases 108 Other communicable diseases 113 Research and development in the field of vaccines 116 Blindness and deafness 117 Cancer 118 International Agency for Research on Cancer 120 Cardiovascular diseases 121 Other noncommunicable diseases 123

15. Health information support 125 Health literature services 125 WHO publications 126 Technical terminology 128 Distribution and sales 128

16. Support services 129 Personnel 129 Office accommodation 129 Budget and finance 130 Equipment and supplies for Member States 131

Map showing regional offices and the areas they serve 132

17. African Region 133

18. Region of the Americas 137

19. South-East Asia Region 141

20. European Region 145

21. Eastern Mediterranean Region 149

vii THE WORK OF WHO 1992-1993

22. Western Pacific Region 153

Annex 1. Members and Associate Members of the World Health Organization 159

Annex 2. Regional distribution of Members and Associate Members of the World Health Organization 161

Annex 3. Organizational and related meetings, 1992-1993 163

Annex 4. Intergovernmental organizations that have entered into formal agreements with WHO approved by the World Health Assembly, and nongovernmental organizations in official relations with WHO at 31 December 1993 164

Annex 5. Structure of the World Health Organization at 31 December 1993 (charts) 167

Index 171

viii Introduction

The period 1992-1993 was marked by deep economic and social tensions as well as ethnic, religious and territorial conflicts, on a scale unprecedented since the second world war. In these difficult circumstances WHO continued to deliver its programme of work, to help countries sustain their health achievements, strengthen their human resource capabilities, and enhance their disease prevention and control activities. At the same time WHO initiated a review of its policies, management and structures in order to adapt to the challenges, constraints and opportunities of the changing global envi­ ronment. In 1993, within the overall reform process undertaken with the Executive Board and its working group on the WHO response to global change, I introduced a number of mechanisms to enhance coordination throughout WHO's worldwide network. The Global Policy Council, whose membership includes the Regional Directors, and the Management Development Committee will ensure joint participation of headquarters and the regions in all stages of decision-making, from the formulation of strategies and updating ofpolicies to the coordination and tightening ofprogramme budget manage­ ment procedures, in particular through the development and harmonization of infor­ mation systems. During this biennium WHO upheld its commitment to health for all through primary health care, increasing its direct technical support to countries, and coordinat­ ing international health work with a view to reducing inequities in access to health care, both between and within countries. WHO's proposed Ninth General Programme of Work (1996-2001) takes the same approach and, to foster cross-sectoral collabora­ tion, suggests a new "clustering" ofprogrammes and activities around four interrelat­ ed policy orientations: integration of health and human development in all public policies; equity in access to health services; promotion and protection of health; preven­ tion and control of specific health problems. In 1992-1993 WHO put much effort into providing countries with workable guidelines and indicators and helping them set measurable goals and targets to achieve cogency in the planning, implementation and evaluation of their health policies and activities nationwide. The establishment and maintenance of a good database have proved essential for identifying health issues, priorities and critical strategies for health development, and for monitoring resources and impact. WHO made a major contribu­ tion to the World Bank's World development report 1993: investing in health and seized this opportunity to re-emphasize the close interaction between health, social and economic development.

ix THE WORK OF WHO 1992-1993

Decentralization to district level was a major thrust of WHO's cooperation with countries. The Organization's support to national health system and health informa­ tion development focused on strengthening district capacities to identify and solve problems and carry out epidemiological surveillance. Training for primary health care also emphasized quality assurance of care and facilities at district level. In health education, particular efforts were made to teach communities and especially families simple techniques of case management and risk assessment in the home, as a means of reducing mortality from diarrhoea! diseases and acute respiratory infections. Likewise, communities were encouraged to take greater responsibility for rehabilitative care and, as part of integrated management of the environment, includ­ ing water supply and sanitation, for the prevention and containment ofpublic health problems such as cholera, dengue and dracunculiasis. Health and the environment, malaria and nutrition were at the core of WHO's agenda during the biennium. Integrated approaches were defined and global strategies revised, with emphasis on research and community participation. Such approaches were also promoted against noncommunicable diseases, in which lifestyles can be an important risk factor as well as a tool for prevention and control. Under WHO leadership, intersectoral coordination in the fight against AIDS was stressed, both at national level and within the United Nations system. In May 1992 the Health Assembly endorsed an expanded global AIDS strategy with a strong­ er focus on patient care, sexually transmitted diseases, social vulnerability of women, a more supportive environment for AIDS prevention, socioeconomic impact of the pandemic, and the public health rationale for overcoming discrimination. WHO having sounded the alarm on the upsurge of tuberculosis worldwide, and on its further threat as an opportunistic infection of AIDS, additional national and external resources were being mobilized by the end of the biennium to strengthen national programmes and intensify research. In spite of severe economic constraints on immunization programmes, WHO continued to give high priority to children's health. Achieving synergy through joint action with other United Nations bodies and organizations, WHO was able to rally support from industry within the framework of the Children's Vaccine Initiative. Great strides were made towards poliomyelitis eradication, particularly in the Ameri­ cas, and a major effort is now required to reach those populations that have not yet been protected, while preserving past achievements. The same applies to leprosy elimi­ nation and dracunculiasis eradication, two goals towards which considerable progress was recorded in the past two years. As an essential part of all these programmes, the Organization produced and disseminated a stream of validated scientific and technical information targeted to users at different levels. Emphasis was placed on providing the widest possible access to this information in countries. The quest for peace through solidarity and equity in health development inspires all WHO's programmes and activities, including humanitarian assistance in which WHO became increasingly involved during the biennium in many parts of the world, particularly Afghanistan, Cambodia, Mozambique, Rwanda, the Middle East and former Yugoslavia.

X INTRODUCTION

Based on a better appreciation of global interdependence and a reassessment of health within our societies, the "new health partnership" advocated by WHO stresses the need for all countries, sectors, communities and private citizens to share resources and responsibilities, thus making solidarity a deliberate and reasoned policy, at nation­ al as well as international level. The reform process which WHO has embarked on will facilitate partnerships with Member States, building both on the diversity of WHO's regions and on their common purpose to achieve health for all in a spirit ofjustice and mutual respect.

Vf. •

Director-General

xi

CHAPTER 1 Governing bodies

1.1 With profound changes sweeping the commissiOn on women's health (resolution world, the Organization has undertaken a careful WHA45.25), which is to hold its first meeting re-examination of its mission and strategies. An shortly. In 1993 the Health Assembly called for important step in this process was the establish­ budgetary reform (resolution WHA46.35), and ment in January 1992 of a working group on the decided to shorten the duration of the Health WHO response to global change (decision Assembly in even-numbered years when pro­ EB89(19)) with responsibility for drawing up gramme budgets are not discussed (resolution recommendations concerning the Organiza­ WHA46.11). Dr Hiroshi Nakajima was reap­ tion's mission, leadership role, preparedness pointed Director-General of the World Health for changes in priorities, and structure; strength­ Organization (resolution WHA46.2); he called ening of WHO's coordinating role within the for a "new partnership in health" to meet the United Nations system; orientation and prepara­ challenge of increasing worldwide change. tion of the Ninth General Programme of Work; and enhancement of the technical quality of the 1 4 In 1992 the regional committees reviewed Organization's programmes. The group con­ the proposed activities to be carried out in each cluded its work during the biennium and submit­ WHO Region1 during the 1994-1995 biennium ted detailed recommendations on those points. A in the same way that the Executive Board, number dealt with the Executive Board's own through its Programme Committee and in ac­ method of work, and one in particular proposed cordance with resolution EB79.R9, reviewed the that subgroups or committees of the Board proposed global and interregional activities. should meet during the Executive Board sessions These proposals provided the basis for prepara­ to review specific programmes. The Programme tion of the Organization's 1994-1995 pro­ Committee of the Executive Board met in No­ gramme budget, approved by the Health Assem­ vember 1993 to review planning for the imple­ bly in May 1993. At the same time the regional mentation of the Working Group's recommen­ committees in 1993, at the request of the Execu­ dations prior to their consideration by the Board. tive Board, studied the implications of recom­ mendations made by the Board's working 1.2 The interrelation of environment, health group on the WHO response to global change, as and development was highlighted by addresses applicable to regional and country activities, to the Health Assembly in May 1992. Mr Mario with a view to reporting to the Board in January Soares, President of Portugal, spoke of the need, 1994. following the ending of the cold war, for re­ newed efforts to achieve "a new world order 1.5 The Forty-sixth World Health Assembly founded on law and greater equality of opportu­ approved for 1994-1995 an effective working nity for all human beings". Dr J aime Paz Zamora, budget level of$ 822 101 000. 2 This represents a President of Bolivia, referred to the earth as one decrease of 3.5% in real terms when compared large ecosystem and life as a phenomenon of with the approved programme budget for 1992- global interdependence. Technical Discussions were held on the related theme of "Women, health and development". 1 See Annex 2 for d1stnbut1on of Member States and Associate Members 1n the SIX WHO regions: Africa, Americas, South-East Asia, Europe, Eastern 1.3 Health Assembly resolutions in 1992 in­ Mediterranean, Western Pac1fic. cluded a request for the establishment of a global 2 Throughout this book the s1gn $ denotes United States dollars. THE WORK OF WHO 1992-1993

1993. The increase of$ 105 523 000 or 14.46% in years. The Health Assembly agreed to reduce 1994-1995, compared with 1992-1993, is attrib­ assessments on individual Members by their utable to estimated inflationary cost increases of share of the amount of interest earned and availa­ almost 11% as well as statutory salary and other ble for appropriation($ 12 741 000), credited to unavoidable cost increases for which adequate them in accordance with the incentive scheme budgetary provision has not been made in recent established by resolution WHA41.12.

2 CHAPTER 2 WHO's general programme development and management

Constitutional and legal WHO's programme matters development

2.1 Several changes occurred in the membership of the Organization during the biennium (see An­ Ninth General Programme of Work nex 1), with the result that there were 187 Members and two Associate Members as at 31 December 2.4 Preparation of WHO's Ninth General 1993. Ukraine notified WHO that it wished to Programme of Work covering a specific period reactivate its membership in the Organization. (1996-2001), initiated by the Executive Board at its January 1992 session, was pursued by the 2 2 During the biennium 34 instruments of Board's Programme Committee, the regional acceptance were deposited for the amendment of committees and staff at all levels of the Organiza­ Articles 24 and 25 of the Constitution to provide tion throughout the biennium; a final draft will for an increase in the membership of the Execu­ be submitted to the Board for review in January tive Board from 31 to 32 (resolution WHA39.6); 1994. It emphasizes WHO's role in supporting this brought the number of acceptances to 118, countries and the international health communi­ the requirement for adoption being two-thirds of ty, and in reducing inequities in the health sector. the Organization's membership. No instru­ It provides a global framework for health policy ment of acceptance was deposited for the amend­ by defining goals and targets. The targets include ment of Article 7 on suspension of rights and specific improvements in health, access to care privileges of Members (resolution WHA18.48), and services of good quality, and policy design so the number of acceptances remained 53. Simi­ and implementation, and are presented as the larly, no instrument of acceptance was deposited minimum of what should be achieved by the year for the amendment of Article 74 to include an 2001. Four related orientations are proposed to Arabic version among the authentic texts of the reach the goals. Constitution (resolution WHA31.18), and the number of acceptances remained 34. Programme development and 2.3 Cameroon and Bahrain acceded to the Convention on the Privileges and Immunities of management the Specialized Agencies with respect to WHO on 30 April and 17 September 1992 respectively. 2 5 To strengthen WHO's policy-making Ukraine and Belarus, which had previously ac­ capacity and to ensure effective implementation ceded to the Convention with respect to other of programmes and application of the recom­ agencies, submitted notifications of application mendations of the Executive Board's working of the Convention with respect to WHO. Instru­ group on the WHO response to global change ments of succession to the Convention were sub­ (see paragraph 1.1), the Director-General has es­ mitted by Bosnia and Herzegovina, Czech tablished a Global Policy Council. The members Republic, Croatia, Slovakia and Slovenia. As a are the Director-General, the Regional Direc­ result, 102 Member States had accepted the Con­ tors, the Assistant Directors-General and the Di­ vention with respect to WHO by the end of the rector of IARC. The Council's mandate is to biennium. restate the mission of WHO in the light of world

3 THE WORK OF WHO 1992-1993 changes; to review the global and regional strate­ PAHO/WHO started to assess the effects of gies for health for all; to ensure the monitoring of "strategic orientations and programme priori­ the attainment of health-for-all targets and their ties" on policy-making and health development periodic updating; to ensure that, through the in Member States and on technical cooperation. necessary coordination, programme implemen­ In the Eastern Mediterranean visits were ar­ tation at headquarters, regional and country lev­ ranged to enable senior health officials to study els conforms to the global policy, while giving WHO's policies and strategies and to exchange due respect to national priorities; and to adjust views on ways to ensure optimal allocation of WHO's managerial structure to reforms stem­ resources to priorities. ming from WHO's response to global change. The Council held its first meeting in November 1993. It will be supported in its work by a Man­ agement Development Committee, particularly lnformatics management in matters of management coordination through­ out the Organization. 2 9 More WHO staff throughout the world were assured of access to a microcomputer con­ nected to a local area network. A new network was commissioned for the Regional Office for Programme budgeting South-East Asia in September 1992. WH 0 head­ quarters became a node of the Internet "net­ 2 6 Zero budget growth for six consecutive work of communications networks" as a first bienniums has led to a real reduction in the Or­ stage in establishing economical and effective ganization's regular budget and a greater de­ communications within and outside the Organi­ pendence on extrabudgetary resources; this has zation. Central management for both adminis­ accentuated the need to be selective in develop­ trative and health databases was updated using ing WHO's programmes. The Director-Gen­ new software. PAHO/WHO began replacing its eral has continued to transfer some resources computerized administrative system, and the from existing activities to areas of high priority system in the Regional Office for Europe was determined in previous bienniums. also updated. In general, regional offices and cer­ tain country offices continued to make more ef­ 2.7 Resolution WHA46.35 called for pro­ fective use of their administrative and pro­ found changes in the way the Organization's gramme management systems. Steps were taken programme budget is prepared, starting with the to foster closer interregional cooperation in the 1996-1997 biennium. It stressed the importance use of these systems. WHO supported several of setting realistic targets and describing "meas­ Member States in developing their health infor­ urable outcomes", and of ensuring the highest mation systems and improving their reporting standards of accountability and transparency. It systems, including Mexico, Oman, Seychelles, expressed concern about the complexity and lack Syrian Arab Republic, United Arab Emirates of clarity of the existing budget documents, par­ and six countries in the Western Pacific. The ticularly about the failure to relate financial allo­ Organization also played an active part in inter­ cations and staff costs to specific priorities. As a national conferences on health cards (Marseille, result, the programme budget for the financial France, September 1993) and on health period 1996-1997 will be prepared in a simplified informatics in Africa (Ile-Ife, Nigeria, April form. It will show how strategic and financial 1993). priorities are determined within agreed global objectives; how realistic and measurable targets are established in accordance with each health priority; and how a process of regular evaluation External coordination for tracks progress towards the agreed targets. There health and social development will be fewer budgetary tables and more infor­ mation about sources of financing, both regular 2.10 The biennium was marked by the contin­ and extrabudgetary. uing concern of all organizations of the United Nations system to streamline structures and inte­ 2.8 At regional level several measures were grate development cooperation programmes taken to strengthen WHO's programme devel­ with those for humanitarian assistance and opment and management. In the Americas peace-keeping. The financial resources of the

4 WHO'S GENERAL PROGRAMME DEVELOPMENT AND MANAGEMENT system were stretched as never before, with a vast endorsed the WHO policy on non-sponsorship discrepancy between the tasks assigned and of international conferences on AIDS in coun­ funds available. tries with HIVI AIDS-specific travel restrictions (resolution WHA45.35) and recommended that 2 11 Restructuring of the social and economic all organizations of the United Nations system sectors of the United Nations system moved adopt this policy. ahead. To be able to respond more effectively to the new international situation, the Administra­ 2.14 The Council gave greater prominence to tive Committee on Coordination (A CC) carried health and social development in its deliberations out a review of its role and functioning. WHO during 1992 and 1993. WHO, in collaboration was fully involved in this review process, which with 11 other organizations of the United Na­ began with a meeting in April 1992 at WHO tions system, prepared the Secretary-General's headquarters in Geneva, and was completed at a report to the 1993 Council's substantive session meeting in April 1993 at FAO headquarters in on preventive action and intensification of the Rome. WHO is a member of the two consulta­ struggle against malaria and diarrhoea! diseases, tive bodies reporting to ACC - the Consultative especially cholera; in 1994 the Secretary-General Committee on Administrative Questions of the United Nations will submit a report on (CCAQ) and the Consultative Committee on improved coordination to the Council, specify­ Programme and Operational Questions ing goals, workplans, schedules and the resources (CCPOQ). WHO is one of the nine core mem­ required to combat these scourges. The Council bers of the ACC Inter-Agency Committee on also adopted a resolution on the subject of tobac­ Sustainable Development which was set up to co or health (see paragraph 9.53). consider policy relating to follow-up of the 1992 United Nations Conference on Environment 2.15 WHO participated in Council discussions and Development and to monitor implementa­ on enhancing international cooperation for de­ tion of Agenda 21 (see paragraph 12.1). velopment, covering the role of the United Na­ tions system, assistance in the eradication of pov­ 212 The Commission on Sustainable Devel­ erty and support to vulnerable groups, the coor­ opment was established as a 53-member inter­ dination of humanitarian assistance, emergency governmental body by the Economic and Social relief and the "continuum" from relief to reha­ Council (resolution 1993/207) at the request of bilitation and development. WHO was also in­ the United Nations General Assembly (resolu­ volved in Council deliberations on the Interna­ tion 471191). At its first meeting in June 1993 this tional Year of the Family (1994 ), control of nar­ body agreed on a programme of work for the cotic drugs and psychotropic substances, and period 1993-1996. WH 0 has been assigned the strengthening of international cooperation and responsibility for implementation of the health coordination of efforts to minimize the conse­ chapter of Agenda 21. quences of the Chernobyl disaster.

213 WHO provided documentation, technical 216 Together with other agencies, WHO re­ information and guidance for the discussions ported to the Council on the implementation of with the Economic and Social Council and other United Nations General Assembly resolution organizations of the United Nations system on 471199 concerning operational activities of the the prevention and control of HIVIAIDS, lead­ United Nations system, which called for a sub­ ing to a better understanding at political level of stantial increase in multilateral resources for de­ the magnitude of the problem and the responsi­ velopment. WHO emphasized, particularly bility of governments. The Council recognized through CCPOQ, the importance of making ac­ the urgent need to invest in preventive measures tion of the United Nations system more respon­ and to avoid discrimination against those infect­ sive to national objectives and more efficient. For ed with HIV or suffering from AIDS, approved instance, WHO supported the establishment of the activities of the Commission on Human United Nations country offices and confirmed Rights in this respect, endorsed the updated glo­ its interest in sharing premises that are being bal AIDS strategy and gave its full support to established in Moscow. resolution WHA46.37 concerning the feasibility and practicability of establishing a joint, 217 WHO held discussions and exchanged in­ cosponsored United Nations programme on formation with the five United Nations regional HIVI AIDS. In addition, ACC in October 1993 commissions: the Economic Commissions for Af-

s THE WORK OF WHO 1992-1993 rica, for Europe, and for Latin America and the meetings convened by UNFPA to prepare for Caribbean, and the Economic and Social Commis­ the 1994 international conference on population sions for Asia and the Pacific, and for Western Asia. and development.

218 The UNICEF/WHO Joint Committee 2 22 WHO expanded collaboration with the on Health Policy met at WHO headquarters in Organization of African Unity (OAU) through 1992 and 1993 to discuss, in particular, ways and the WHO Office for OAU and ECA on several means to achieve the goals set by the 1990 World subjects including malaria, AIDS, nutrition, hu­ Summit for Children, and improved manage­ manitarian action and emergency assistance, and ment of district health systems as an essential on the formulation of a health protocol for the element of infrastructure. Treaty Establishing the African Economic Com­ munity. 2.19 From early 1992 WHO joined the World Bank in preparing and launching the Bank's 2 23 Following the signature of a letter of in­ 1993 report, 1 which examines the interplay be­ tent between WHO and the Commission of the tween health, health policy and economic devel­ European Communities early in 1992, a repre­ opment. In addition to attending the meeting of sentative of the Director-General was appointed the boards of governors of the World Bank and to facilitate cooperation with the European insti­ the International Monetary Fund, WHO partici­ tutions, concentrating on providing technical ex­ pated in the annual meetings of the boards of pertise for the Commission's regulatory activi­ governors of the African Development Bank, the ties and on promoting the health aspects of the Asian Development Bank, the European Bank European Community's development work. In for Reconstruction and Development, and the May 1993 the Council of Ministers invited the Inter-American Development Bank, all of which Commission to ensure closer cooperation with are increasingly active in the social sector. In WHO. Collaboration was also intensified with accordance with Executive Board resolution OECD and other intergovernmental organiza­ EB92.R4, a draft cooperation agreement is being tions outside the United Nations system. used as a framework for relations between WHO and the African Development Bank and the Afri­ 2 24 During the biennium WHO undertook can Development Fund prior to submission of policy and technical reviews with various govern­ this document to the World Health Assembly in ments to strengthen existing collaboration, devise May 1994. Opportunities to enhance the collab­ new forms of cooperation, and solicit extra­ orative framework and pursue existing and new budgetary support for the Organization's health areas of cooperation were discussed with these programmes at global, regional and country lev­ multilateral financial institutions on several occa­ els. The government officials participating in the sions in 1992 and 1993. reviews represented multilateral and bilateral co­ operation departments in the appropriate minis­ 2 20 Joint UNDP/WHO activities were con­ tries, thus ensuring a comprehensive approach to solidated, and new areas for collaboration deter­ meeting health needs. Representatives from sever­ mined, particularly at country level. al countries2 were particularly active in securing support for health programmes coordinated by 2 21 WHO coordinated act1v1t1es with WHO. Despite the global economic recession af­ UNFPA through that body's technical support fecting official development assistance levels, services, which include multidisciplinary, inter­ extrabudgetary support for the Organization's agency country support teams in eight locations work was maintained. Additional policy consulta­ throughout the world. The administrative arm of tions organized in 1993 resulted in long-term the technical support services is the UNFPA agreements on financial and other support being interagency task force, which meets once or offered to WHO so that it can accomplish the twice a year, bringing together organizations work approved by the Member States. within the United Nations system, including WHO. WHO was represented at expert group 2 25 The work of WHO continued to benefit meetings on population and development and at from the resources made available by the

1 World Bank. World development report 1993 mvestmg tn health New 2 Austrra, Canada, France, Germany, Ireland, Italy, Japan, Netherlands, Nor­ York, Oxford Unrversity Press, 1993. way, Sweden, Swrtzerland, United Krngdom, Unrted States of America.

6 WHO'S GENERAL PROGRAMME DEVELOPMENT AND MANAGEMENT nongovernmental community, especially those formation on health needs in the republics, and of the 177 nongovernmental organizations in of­ drawing them to the attention of the internation­ ficial relations, a further twelve of which were al community; setting up databases; monitoring admitted during the biennium. Examples of this the health situation in each republic; and main­ wide-ranging collaboration are humanitarian as­ taining country information profiles. So far ex­ sistance with the International Federation of Red isting WHO information sources have been used Cross and Red Crescent Societies and the Inter­ to prepare an operational database on the repub­ national Committee of the Red Cross; training of lics, and a health news bulletin issued in English, medical personnel with the International Society French and Russian for exchange of information for Prosthetics and Orthotics and La Leche on the health situation, on assistance received League International; community mobilization and on cooperation established. for vaccination programmes with Rotary Inter­ national; and advocacy in relation to the special needs of women and female children with the International Alliance of Women and Sorop­ Emergency relief operations timist International. 2 28 In addition to communicable diseases 2 26 In addition to its work related to the strat­ and other long-standing problems affecting egy of intensified cooperation with countries and health in many Member States, ecological peoples in greatest need, the Organization pro­ change, rural-urban migration and severe natu­ moted partnership between governments and co­ ral or man-made disasters have posed threats to operating agencies (United Nations, multilateral, the very existence of health services in some bilateral and nongovernmental organizations) so countries in recent years. WHO has therefore that external resources could be provided for strengthened its mechanisms for emergency maximum effect in support of overall health de­ preparedness, humanitarian assistance, and re­ velopment. WHO participated in reviews of bi­ lief and rehabilitation in situations of armed lateral support to certain countries, for instance, conflict. A number of Health Assembly resolu­ support from the Netherlands and Sweden to tions have endorsed increased involvement by Zambia. Another example of cooperative work WHO in this field. 1 was the fourth population and health project ( 1992-1996) in Bangladesh, costing $ 600 million 2.29 Some 20 African countries have benefited and managed by the World Bank through a mul­ from enhanced relief activities. In Eritrea WHO ti-donor consortium in which WHO has an in­ is cooperating in UNHCR efforts to resettle fluential voice as well as being executing agency some half a million refugees. In the next phase it for 21 of the 65 project components. Further is planned to strengthen provincial health ser­ examples were a review in Chad carried out in vices to meet the needs of returning refugees and coordination with the African Development displaced persons, thus ensuring a continuum of Bank, and cooperation in Mozambique in pre­ support from relief to rehabilitation. One of sev­ paring a 12-year development programme for eral emergency health programmes in Ethiopia implementation with FINNIDA support. provides for the rehabilitation of about 40 pro­ vincial hospitals, health centres and health posts. 2.27 The international community's concern In Mozambique WHO is helping to implement a about deteriorating health in the former Soviet programme of primary health care for some Union found expression in the convening of a 100 000 demobilized soldiers, including on-the­ ministerial-level coordinating conference on as­ spot treatment of ailments, health education, col­ sistance to the new republics (Washington, Janu­ lection of epidemiological data, and provision of ary 1992). During the conference a medical supplies and equipment. working group was set up to meet regularly and conduct missions to assess health needs in the republics. This group agreed on terms of refer­ ence for a clearing-house for information on 1 Emergency and humamtarian relief operations (WHA46.6) Health condr­ health assistance to the republics; and responsi­ trons of the Arab population rn the occupied Arab terrrtorres, rncluding bility for administering it was entrusted to Polestrne (WHA46 26) Collaboration withrn the United Notrons system WHO at a second coordinating conference (Lis­ health assistance to specrfrc countries - Cuba (WHA46 28) Colloboro­ tron withrn the Unrted Notrons system health assistance to specrfrc coun­ bon, May 1992). The clearing-house's tasks in­ trres (WHA46.29). Health and medrcol servrces in trmes of armed conflict clude collating, analysing and disseminating in- (WHA46.39)

1 THE WORK OF WHO 1992-1993

2.30 WHO participated in the work of the stan; considerable quantities of medicines and UNHCR-coordinated interagency task force set medical supplies were distributed in Iraq to alle­ up to determine the requirements of republics of viate extreme shortages resulting from the Gulf the former Soviet Union for humanitarian assist­ conflict; and support was given in setting up a ance (see paragraph 2.27), and drew up a health central pharmacy and a reference laboratory and sector plan of action for the consolidated appeal in providing urgent medical assistance in Soma­ launched for Armenia, Azerbaijan, Georgia and lia. WHO is also working closely with local Tajikistan. Activities in the war-afflicted areas of health institutions and experts, as well as Pales­ former Yugoslavia included the establishment of tinians from the occupied Arab territories, in programmes for health monitoring, nutritional preparing a master plan for transfer of authority surveillance, rehabilitation of war victims, provi­ and responsibility for health services and the sion of medical supplies and additional support promotion of broader regional cooperation in in winter. health matters. In Egypt a national emergency plan was prepared and a conference organized 2.31 WHO is contributing to United Nations (Cairo, November 1993) in conjunction with the programmes for humanitarian assistance to a annual promotion day for the International Dec­ number of countries in the Eastern Mediterrane­ ade for Natural Disaster Reduction. Other inter­ an; emergency medical supplies and equipment ventions included support to the Islamic Repub­ were provided to war-torn regions of Afghani- lic of Iran and to Yemen.

WHO emergency health kits ready for shipment to disaster-stricken areas of the world.

WHO emergency health ki ts me a reliable, standardized, inexpensive, appropriate and quick ly availa ble source of the essen tial drugs (none of them injec ta ble), renewable medical supplies (co tton wool, gloves, etc.) ond health equipment (including o complete steril ization kit) urgently needed in o disaster situation. They ore designed to be used by o primary hea lth core worker with li mited traini ng who treats symptoms rathe r thon diagnosing diseases. Eoch kit is sufficient for about I0 000 outpatient consultations ond con serve o popu lation of I 0 000 peopl e for o period of ap proxima tely three months.

8 WHO'S GENERAL PROGRAMME DEVELOPMENT AND MANAGEMENT

2.32 WHO provided medical kits and other (Bangkok, February 1993) and Africa (Tangiers, emergency supplies to several countries affected Morocco, May 1993). Training in emergency re­ by natural disasters.1 Tuberculosis drugs and lief and humanitarian assistance was organized technical services were supplied to Cambodia, for WHO Representatives and staff in the East­ where WHO is cooperating with UNHCR in ern Mediterranean. WHO and the International the ·repatriation of refugees. Committee of the Red Cross cosponsored two emergency preparedness training courses in Ge­ 2.33 Workshops were held for training emer­ neva and Manila. A consultation convened in gency health managers from Asia and the Pacific October 1992 to discuss a programme on health and development for displaced persons (Hedip) was attended by experts from 16 countries as well as staff of the United Nations and other agencies. A quarterly magazine, Hedip forum, 1 Albama, Bangladesh, Egypt, Eritrea, Kyrgyzstan, Lebanon, Lesotho, Mada­ gascar, Malawr, Namibia, Pakistan, Phrlrpprnes, Rwanda, Srerra Leone, was launched in April 1993, and pilot pro­ Swaziland, Unrted Republrc of Tanzania, Yemen, Zambia. grammes are under way in several countries.

9

CHAPTER 3 Strategy for health for all

of the World Summit goals. At a meeting in Monitoring and evaluation October 1993 it was agreed that a joint UNICEF/WHO statement should be issued ex­ 3 1 In May 1992 the Health Assembly ap­ pressing commitment to the monitoring process proved the report on the second evaluation of the agreed to at the Summit, including assessment of implementation of the Global Strategy for mid-decade achievements. It was also agreed to Health for All by theYear 2000, which is also the expedite the preparation of comprehensive eighth report on the world health situation and is guidelines on health indicators. based on national and regional evaluation re­ ports. A total of 151 Member States with a popu­ lation of 5200 million reported their findings concerning advances made and constraints en­ Regional and national activities countered in improving health throughout the and policies world and in providing services on a basis of equity. The global review and reports from the 3 4 In the Americas the Second Ibero-Ameri­ six WHO regions have been published.1 can Conference of Heads of State and Govern­ ment and the XXXVI meeting of the Directing 3.2 A common framework was developed for Council of PAHO/forty-fourth session of the use by Member States in carrying out a third Regional Committee for the Americas in Sep­ exercise in monitoring progress in the implemen­ tember 1992 adopted, in pursuance of the region­ tation of the health-for-all strategy, from late al strategy for health for all, a regional plan for 1993 to early 1994. It will enable Member States investment in the environment and health. The to review achievements in the application of their plan, which specifies investments that will need national health-for-all strategies and report the to be made in Latin America and the Caribbean findings to WHO, using common criteria. Par­ over the next 12 years, will be useful for guiding ticular importance is attached to the collection countries, institutions financing development, and presentation of data broken down according and cooperation agencies in remedying deficien­ to geographical area, sex, age and priority popu­ cies in drinking-water supply, wastewater treat­ lation groups. ment, basic sanitation services and other envi­ ronmental health measures. 3.3 WHO and UNICEF have agreed on a set of indicators for monitoring progress towards 3 5 WHO supported activities to improve the health goals set by the 1990 World Summit the health of the underprivileged in Bangladesh, for Children. Joint activities by WHO and India, Mongolia, Nepal and Thailand, following UNICEF should prove helpful to both organi­ a 1991 consultation on this subject which had zations in their efforts to monitor implementa­ recommended the adoption of a strategy linking tion of the health-for-all strategy and attainment measures for economic and social development that draw upon the energy, inventiveness and capability of the local population. Health ministers from South-East Asia also discussed ways to promote the health of the underprivi­ 1 Implemental/On of the Global Strategy for Health for All by the Year 2000, second evaluatron. Erghth report on the world health srtuotron, Vols 1-7. leged at their ninth meeting (Male, March-April Geneva, World Health Organization, 1993 1993).

11 THE WORK OF WHO 1992-1993

3 6 Implementation of the health-for-all poli­ and it has therefore become even more necessary cy in Europe progressed steadily despite major than ever for decision-makers to design health changes and the diversity of conditions in the policies that take this fact into account. Deter­ Member States, many of which now have nation­ mining and assessing economically feasible op­ al policies based on the European regional poli­ tions for the financing, delivery and administra­ cy, an updated version of which was published in tion of health services is an important compo­ 1993\ or have explicitly incorporated elements nent of WHO's initiative for intensified coop­ of it into their legislation and policy documents. eration with countries and peoples in greatest Meetings and other activities took place during need, which tackles urgent problems but is also the biennium in preparation for a 1994 European concerned with priorities among human needs conference on health policy, at which partici­ (see paragraph 4.11). pants will take stock of developments, explore new avenues for participation with organizations 3 9 In June 1992 an international conference such as the Council of Europe, the Commission considered the link in countries in greatest need of the European Communities and OECD, and between the macroeconomic environment and consider ways to ensure that health for all is the health, examining in detail such issues as health goal pursued by European Member States for the and economic growth, policies for macroeco­ remainder of the century and beyond. nomic adjustment and for the elimination of pov­ erty, and macroeconomic aspects of health financ­ 3.7 In Europe a "regions for health" network ing. Case studies were presented on Bolivia, Chad, was established in 1992, with an initial grouping of Guinea, Guinea-Bissau, Malawi, Mali and Nepal 11 regions: 10 in Belgium, France, Germany, as well as Latin America and the Caribbean as a Spain, Sweden, Switzerland and the United King­ whole; they showed how the macroeconomic en­ dom, and a Baltic region comprising Estonia, vironment affects health conditions and how it Latvia and Lithuania. In order to accelerate the influences the establishment or adjustment of implementation of national health policies, it was health policies and health financing schemes. felt that regions should work together to promote the health-for-all policy according to a strategy 310 WHO contributed to the preparation of that emphasizes dynamic alliances, cooperation to the World Bank's 1993 report,2 which examines improve health at regional and local levels, trans­ the interplay between human health, health policy fer of knowledge, the organization of high-quali­ and economic development. This report was used ty, effective services without waste or unnecessary as a point of departure by more than 150 repre­ duplication, and intersectoral action that makes sentatives of bilateral and multilateral aid agencies, health for all a common responsibility. A first foundations, international organizations and de­ annual meeting (Barcelona, Spain, October 1993) veloping countries at a major conference support­ examined practical examples of ways to orient ed by WHO and the World Bank and hosted by health professionals towards health promotion. the International Development Research Centre (Ottawa, October 1993 ); this conference provided an opportunity to establish a framework for pro­ moting partnerships so that external aid can be Health for all and economic used more effectively for improving health in the development developing world. One of the main aims of WHO's contribution will be to reinforce the 3 8 In many of the poorest countries, public capacity of countries to formulate and implement resources for health have been seriously reduced effective health policies, thereby facilitating their owing to recent macroeconomic developments, access to external support.

1 Health for all targets the health polrcy for Europe Copenhagen, World 2 World Bank. World development report 1993 rnvestmg in health. New Health Organization, 1993 (Health for All Senes, No 4). York, Oxford Unrversity Press, 1993

12 CHAPTER 4 Health system development

posed to set up an enhanced network for sharing Assessment of global health methods, expertise and training opportunities, situation and future trends and WHO will apply some of these techniques in its analysis and formulation of health policy and 4.1 Data collected during the second evalua­ strategy. A regional consultation (Prague, July tion of the Global Strategy for Health for All by 1992) discussed the present environment and fu­ the Year 2000 have been entered into WHO's ture trends of health in Europe, and considered health-for-all database. Two documents in­ the implications for health action. tended as an aid to ensuring consistency of data disseminated by WHO programmes were updat­ ed: one, on global health situation and projec­ tions1, provides agreed estimates for many dis­ Country health information development eases and causes of death, and the other, on de­ mographic data for health assessment and projec­ 4 3 Missions were organized to Cambodia, tions2, presents United Nations data in a conven­ Guinea-Bissau and Maldives under WHO's in­ ient tabular format. The World health statistics tensified cooperation initiative and also to annual provided analyses of the health situation Bangladesh where WHO is responsible for de­ and trends in addition to the latest statistics on veloping the management information system causes of death. The World health statistics quar­ for health and for strengthening the Institute of terly dealt with such themes as demographic Epidemiology, Disease Control and Research in trends, aging and noncommunicable diseases, di­ Dhaka as part of the World Bank's fourth pop­ abetes, violence and health, and mortality from ulation and health project. Support, including cardiovascular diseases in developing countries. the organization of workshops, was given for A regional bulletin provided information on the strengthening national health information sys­ health situation, health programmes, demogra­ tems including the improvement of medical phy and socioeconomic conditions in South-East records systems in Cambodia, Fiji, Marshall Is­ Asia during the period 1988-1990.3 lands, Micronesia (Federated States of), Samoa and T onga; surveillance of childhood diseases in 4.2 A network of over 300 experts on health Cameroon; phased implementation of a health monitoring, evaluation and "futures studies" has information system in India; strengthening of proved useful for sharing findings with a view to national epidemiological capacity in Pakistan; better management of health systems. In July health information support at district level in 1993, a consultation on "health futures"4 looked Togo; and cholera surveillance in Zambia. WHO at ways to apply futures studies to support health also advised on the establishment of an emergen­ policy formulation and health system reform; cy monitoring system for former Yugoslavia. many methods, including some from developing countries, were considered promising. It is pro- 4.4 As shown by the dramatic changes in Eu­ rope, there is now an unprecedented demand for health information within national information 1 Document WHO/HST/92 1. systems. At the same time it is important to make 2 Document WHO/HST/GSP /93.2. health managers more "information-sensitive". 3 Document SEA/HS/186 For this purpose projects for training epidemiol­ 4 Document WHO/HST/93 4. ogists in decision-making and management have

13 THE WORK OF WHO 1992-1993

been undertaken in the Americas and WHO is 4.8 Epidemiological and statistical support was providing support for a special course on health given to various WHO technical programmes data management in the Western Pacific. In the such as those on cardiovascular and tropical dis­ Eastern Mediterranean intercountry activities in­ eases. Advice was given on database management volving senior national staff were organized to for national control programmes, including geo­ promote the use of epidemiology for disease pre­ graphical information systems; development of vention and control; a regional advisory panel on new health and service indicators; and evaluation health information systems was established; and a of health care systems. Work is also being done on plan of action for the creation or improvement of a developing methods for the analysis of data from health statistics information system was prepared. multiple sources as well as new epidemiological methods, including non-conventional procedures 4 5 Progress has been made in developing and multiple-cause analysis. Countries in Europe methods for rapid evaluation and problem-solv­ are being asked to study and describe the measures ing procedures for district teams. These have they use and report their findings in order to iden­ proved effective both for staff training and for tify cultural differences that may affect measure­ planning and improvement of services, and have ments of the quality of life. already been applied in programmes such as that on safe motherhood. Taking into account the 4 9 The WHO statistical information system new emphasis on public health action at district (WHOSIS) was upgraded to make it more func­ level, the type of information system required tional and accessible, and a limited version is now and the means for generating information to sup­ available internationally over Internet, the port work at this level were discussed by an ex­ worldwide computer network. WHO also col­ pert committee in November 1993. laborates within the Consortium for Interna­ tional Earth Science Information Network (CIESIN) to ensure international access to its databases. The Regional Office for the Eastern Epidemiological surveillance and Mediterranean now has its own health statistics statistical services database on its local area network system, thus facilitating the use of health information by pro­ 4 6 WHO continued to support Member grammes and countries. WHO cooperated with States in the implementation of the International the United Nations Statistical Commission, no­ health regulations and to disseminate informa­ tably by presenting a review of statistical activi­ tion through the Weekly epidemiological record ties related to health at the twenty-sixth session and an annual update of the International travel of the ACC Subcommittee on Statistical Activi­ and health booklet. A project on epidemiological ties in April 1992. WHO contributed to the surveillance systems was developed for the Cen­ World Bank's 1993 report/ especially in the tral American countries. The risk of introduction assessment of the global burden of disease. of cholera in this subregion was assessed and PAHO/WHO continued to collaborate with the disease outbreaks in Belize and Guyana were Organization of American States on strategies to investigated by the Caribbean Epidemiology improve the coverage and quality of vital statis­ Centre (CAREC). tics in the Americas.

4.7 An informal WHO/UNICEF consulta­ tion in December 19921 made operational recom­ mendations for measuring cause-specific and International classification of diseases overall mortality in children, especially in the and other health-related classifications absence of civil registration systems, in the con­ text of monitoring the health goals set by the 4.10 Volume 1 (tabular list)3 of the tenth revi­ 1990 World Summit for Children. A subsequent sion of the International Classification of Dis- meeting of experts drafted questionnaires to be used during verbal autopsies as well as a protocol for their evaluation.

2 World Bank. World development report 1993. mvesting in health New York, Oxford Umversrty Press, 1993

l International stat1st1cal classificatiOn of d1seases and related health prob· 1 Document WHO/ESM/UNICEF /CONS/92 5 /ems. Vol. 1 Geneva, World Health Organizatron, 1992

14 HEALTH SYSTEM DEVELOPMENT eases (ICD-10) was published in English in 1992 and French in 1993; volume 2 (instruction manu­ Intensified WHO cooperation al)1 was published in English in 1993, and the French version is in preparation; volume 3 (al­ • The chronic global economic recession phabetical index) is in press in English and in of the past decade has made it even more preparation in French. PAHOIWHO is prepar­ difficult for very poor countries to meet ing the Spanish versions. National versions and the health needs of their populations, and other health-related classifications are being pro­ consequently the gap in health service duced in collaboration with WHO technical pro­ coverage between these countries and the grammes, scientific associations and nongovern­ rest of the world has widened. It was mental organizations. A three-character version against this background that WHO, in of I CD-1 0, containing the rules, definitions, 1989, launched the initiative that has come standards and its own index, is being prepared in to be known as intensified cooperation English and French to meet the needs of develop­ with countries and peoples in greatest ing countries. The mechanism for updating ICD need. It seeks to coordinate resources and between revisions has been tested and proved to programmes and mobilize international be feasible. A first international computer-based commitment to meet health and develop­ course for reorientation of trained coders in the ment needs on a country-by-country ba­ use of ICD-10 (Southampton, United Kingdom, SIS. April 1992) brought together participants from The initiative is country-specific since it is five regions, who will now be able to train other recognized that there are considerable varia­ national coders. Regional training courses for tions not only in the health problems of early implementation of ICD-10 have been un­ countries but also in their human and finan­ dertaken. A meeting was held to prepare the cial resources and the effectiveness of their revision of the International Classification of health systems. The aim is therefore not Impairments, Disabilities and Handicaps2 merely to provide expert advice, but to en­ (Zoetermeer, Netherlands, March 1992), and a sure that staff of both governmental and reprint incorporating a foreword and a number other agencies are equipped to fulfil their of corrections to the original version was issued responsibilities. This is a particularly impor­ in January 1993. On the occasion of the twenty­ tant requirement for ensuring sustainability seventh session of the ACC Subcommittee on of health development in very poor coun­ Statistical Activities held in Geneva, the cente­ tries. nary of the ICD was commemorated on 7 Sep­ Agreement to launch activities under the tember 1993 in collaboration with the Interna­ WHO initiative in a given country is fol­ tional Statistical Institute, the Swiss Federal Of­ lowed by a joint analysis by WHO and fice of Statistics and the United Nations Statisti­ national staff of the different aspects of cal Division. health development, including the eco­ nomic and institutional environment for the provision of health care, and an assess­ ment of the form and volume of contribu­ Intensified cooperation with tions by donor agencies and the role of countries and peoples private and nongovernmental organiza­ in greatest need tions. The aim is to identify critical strate­ gic issues in health development, areas 4.11 Health policy and strategy development is where resources are most urgently needed, a crucial issue for countries undergoing political and options for action. and economic reforms and/or transition from emergency to recovery and rehabilitation. It is therefore a major thrust of the WHO initiative for intensified cooperation with countries and peoples in greatest need (see box).3 Activities in

1 International statistical classdlcat/On of d1seases and related health prob· 'The 1n1t1at1ve 1s currently being Implemented in 25 countr1es. Bangladesh, /ems. Vol 2 Geneva, World Health OrganiZatiOn, 1993 Ben1n, Bol1v1a, Cambod1a, Cape Verde, Central Afr1can Republic, Chad, 1 InternatiOnal classification of lmpalfments, d1sabiilt1es and hand1caps A Dpbouti, Eth1op1a, Guatemala, Guinea, Gu1nea·B1ssau, Ha1t1, Loo People's manual relatmg to the consequences of disease. Geneva, World Health Democratic Republ1c, Mald1ves, Mongol1a, Mozambique, Myanmar, Nepal, Organization, 1980. Sao Tome and Pr1ncipe, Uganda, V1et Nom, Yemen, Za1re, Zamb1a

IS THE WORK OF WHO 1992-1993 this area during the biennium included support to WHO initiative, as in the Bangladesh project. In the ministries of health in Mongolia, Mozambique, Guatemala a training programme on acute com­ Yemen and Zambia in reviewing their health policy municable diseases control and sanitation sur­ and implementing health systems reform. veillance on farms with migrant workers was set up, and has significantly reduced cholera out­ 4 12 National policy-making is not the only breaks. Similarly, an intersectoral approach to entry-point for WHO intervention; attention is cholera control was developed in Zambia. also given to decentralization and reorganization of health systems. Provincial and district man­ 4.17 Demand for support through the WHO agement was in fact the immediate priority in initiative is expected to increase in the future and Guinea-Bissau and the Lao People's Demo­ experience indicates a need to concentrate on the cratic Republic. However, strengthening of following areas: integration of health into overall health management at this level was not an end in socioeconomic development, and poverty allevi­ itself, and the management teams were subse­ ation; better use of economic analysis in identify­ quently able to play a more active role in national ing policy options and guiding health sector re­ policy development, with a clearer idea of how form; improved management of external aid; bet­ the other levels should be supported from the ter coordination of support by different United centre. Nations bodies at country level; and establish­ ment of a stronger link between activities of the 4 13 Developing capacity for economic analy­ WHO initiative and the Organization's overall SIS 1s another important element of the WHO resource allocation to the countries concerned, initiative. In Nepal WHO helped to establish an so as to focus WHO country budgets on key interministerial task force on health economics, strategic issues. which is now in a position to analyse the health development implications of different scenarios in relation to economic growth and the availabil­ ity of external financing. Technical cooperation among developing countries (TCDC) 4.14 Partnership with other development agen­ cies (see paragraph 2.26) ensures conformity with 4.18 An interregional consultation on pro­ national policy, joint project preparation and co­ gramming of technical cooperation among devel­ ordination of funding and is likewise an important oping countries in health Qakarta, February feature of the WHO initiative. In Bangladesh do­ 1993) examined country experiences and made nor coordination for the country's fourth popu­ recommendations for strengthening this initia­ lation and health project is managed by theWorld tive. It considered strategies for promotion and Bank through a donor consortium. WHO is the advocacy, recommended the establishment of executing agency for 21 of the 65 project compo­ national focal points for TCDC in health and nents, making it possible to coordinate all the dis­ considered the monitoring, evaluation and fi­ ease control components and giving the Organi­ nancing of activities. The report of the consulta­ zation an influential voice in the consortium. tion was discussed by the seventeenth meeting of Ministers of Health of Non-Aligned and Other 415 The WHO initiative is also concerned Developing Countries (Geneva, May 1993), who with supporting governments on aid manage­ adopted a resolution on this subject. ment. The new national health policy in Mozam­ bique, for instance, forms the basis of a long­ 419 Examples of global and regional activities term health development plan, which the Gov­ undertaken during the biennium include support ernment will be able to use to coordinate external to the Caribbean Cooperation in Health initia­ cooperation and ensure that it focuses on the tive; technical cooperation in pharmaceuticals country's priority needs. For this purpose, among ASEAN countries; and TCDC in re­ WHO staff introduced Ministry of Health offi­ search, development and research training in hu­ cials to computer software programmes that can man reproduction, including family planning be used to keep track of the volume, purpose and (see paragraphs 10.36-10.41). In the latter activity disbursement of donor funds. encouragement is given to efforts such as prepa­ ration of research protocols whereby advanced 4.16 Finally, strengthening and integration of institutions in developing countries support in­ disease control is an important thrust of the stitutions in other developing countries. It is

16 HEALTH SYSTEM DEVELOPMENT planned to invest some $ 1 million in these coop­ 4.22 Through the Network of Community­ erative activities during the next biennium, with oriented Educational Institutions for Health Sci­ the Rockefeller Foundation providing one-half ences, WHO has promoted health systems re­ of this sum. WHO actively participates in search in some 15 medical schools in different interagency work in TCDC, including that of the regions. University task forces to strengthen re­ United Nations High-Level Committee on the search capacity were established in the United Review of Technical Cooperation Among De­ Republic of Tanzania, Zambia and Zimbabwe. veloping Countries and the UNDP Special An anthology of health services research was Unit for TCDC. published by PAHO/WH0.1 A separate budg­ etary allocation for institutional strengthening grants was established in South-East Asia, and response to this scheme has been generally fa­ Health systems research and vourable. A workshop was held in collaboration development with the European Medical Research Council to support countries of eastern and central Europe 4 20 Many countries have initiated activities in in reorganizing their health research administra­ health systems research, which is now generally tions and to promote information exchange recognized as an effective method for acquiring among European countries. A meeting was con­ information needed for rational decision-making vened to devise strategies to improve coopera­ in health management. WHO has sought to en­ tion between ministries of health and universities courage such work, to strengthen national capaci­ in the Eastern Mediterranean (Cairo, June 1992). ties and to ensure sustainability in these efforts. A To increase inputs from social sciences into global working group (Lilongwe, November health systems research, collaborative activities 1993), bringing together international experts and have been pursued with the International Forum representatives of nongovernmental organiza­ for Social Sciences in Health and its regional net­ tions, international health research programmes works. A third interregional training work­ and donor agencies, endorsed this strategy and set shop for senior research managers (Cuernavaca, long-term priorities for the strengthening of re­ Mexico, July 1992) was held to promote net­ search institutions, cooperation with other insti­ working in this field between lead institutions; tutions and individuals, and consolidation of this was followed in 1993 by regional training knowledge in areas of concern to many countries. courses in Malawi and Thailand.

4.21 Bridge, the international newsletter on 4.23 WHO, PAHO and the International De­ health systems research supported by the Interna­ velopment Research Centre (Canada) have pro­ tional Development Research Centre (Canada), duced a five-volume set of training guides2 pro­ continued to appear three times a year in English viding instruction for all levels of health profes­ and-in collaboration with WHO regional offices­ sionals, researchers and managers in the concepts Arabic and Spanish. It currently covers some ten and practice of health systems research; volume 2 international health research networks informally contains the core course, volume 1 is intended for organized into a consortium known as the Puebla decision-makers, volume 3 for researchers and Group which facilitates cooperation among health academics, volume 4 for research managers and researchers in Africa, Latin America and Asia. A volume 5 for those who plan to teach. first directory of training programmes in health services research, providing practical information 4.24 The project on health systems research for on some 150 training programmes, was produced southern Africa, administered jointly by WHO in collaboration with the Foundation for Health and the Ministry for Development Cooperation Services Research (USA). WHO supported re­ and the Royal Tropical Institute of the Nether­ gional meetings in Africa (Kampala, April 1992; lands, has been extended for a second phase of Mbabane, May 1993; Lilongwe, November 1993) four years (1992-1995) during which infrastruc- and theWestern Pacific (Malaysia, 1993) as well as country meetings (Madagascar, Morocco, Namibia, Nigeria, Philippines, Thailand), bring­ ing together decision-makers in governments, 1 White KL et al., eds Health se!VIces research an anthology. Washrngton, Pan American Health Organizatron, 1992 (Screntrfrc Publication, nongovernmental organizations, the academic No. 534). world and research, in order to reinforce commit­ 2 Available from. Communications Drvisron, IDRC, PO Box 8500, Ottawa, ment to health systems research. Ontarro, Canada KIG 3H9.

17 THE WORK OF WHO 1992-1993 ture and institutional arrangements in the 13 par­ databases; so far these are available in priority ticipating countries will be further strengthened fields of legislation including HIVI AIDS, tobac­ and the experience applied to other countries co or health, and organ transplantation. The (Cameroon, Ghana, Kenya, Nigeria, Uganda) LEYES database, containing an index to Latin and other regions. The fourth intercountry American and Caribbean health legislation, con­ workshop on this project (Lilongwe, November tinues to be produced by PAHOIWHO, and is 1993) reviewed achievements, identified areas re­ now available on compact disc. A computerized quiring additional efforts, and recommended listing of health legislation enacted or issued in strategies for consolidating this work. Innovative Europe in 1990-1991 was produced in 1992. approaches for further institutionalizing health systems research have been developed through 4.27 Technical support took diverse forms in regional task forces and meetings (Teheran, Janu­ the different regions. The Regional Office for ary, 1992; Cuernavaca, Mexico, August 1992; Africa has received an unprecedented number of Copenhagen, October, 1993; Y angon, October, requests for cooperation, and has undertaken an 1993). A number of countries (India, Indonesia evaluation to measure the impact of legislation at and Myanmar) have made specific provision for national, district and community levels. A high health systems research in their national budgets. level of interest in patients' rights in Europe led Effective partnerships for the application of re­ to a study on this subject, the results of which search in solving priority problems have been have been published.1 WHO is working closely established both within the Organization, for in­ with Member States in the Eastern Mediterra­ stance with the leprosy, human reproduction, nean to establish, on the basis of precise legal tuberculosis, nursing and AIDS programmes, standards, an appropriate health legislation and with other bodies such as the nongovern­ framework which is perceived as a prerequisite mental Council on Health Research for Devel­ for effective utilization of health resources. In the opment, UNICEF in respect of the Bamako Ini­ Western Pacific WH 0 is cooperating with coun­ tiative, and the Washington-based International tries in the formulation or revision of legislation, Health Policy Programme. so as to provide a sound foundation for the pro­ motion and implementation of national health policies and strategies. Indeed, in most parts of that Region, health legislation is now seen as a Health legislation means of promoting beneficial change rather than merely curbing abuses. In China coopera­ 4.25 Major developments in health and envi­ tive activities focus on the development of new ronmental legislation occurred in many Member forms of legislation to deal with priority issues States during the biennium, for example in sup­ such as health care financing and the registration port of the health reforms in countries of central of health professionals. Throughout theWestern and eastern Europe. WHO seeks to facilitate Pacific particular emphasis is placed on using such reforms, notably by supplying reliable in­ legislation to support action on health priorities formation but also through direct technical co­ such as the effective deployment of human re­ operation. Thus consultant services were provid­ sources, financial viability and quality of care. ed to some 20 countries, and national workshops were organized in several countries, including 4.28 WHO monitors and reports on all signifi­ China, India and Pakistan. WHO also cooperat­ cant international, national and subnationallegal ed extensively with the Russian Federation. In an instruments dealing with HIVI AIDS, and was innovative project PAHO/WHO worked di­ closely involved in meetings at which legal, hu­ rectly with legislatures in the Americas, drawing man rights and ethical aspects were discussed. It up model health legislation in priority areas and also monitors laws and other measures for imple­ preparing comparative analyses. mentation of the International Code of Market­ ing of Breast-milk Substitutes. Workshops were 4 26 The cornerstone of WHO's work in in­ convened to discuss policy issues relating to ap­ formation transfer at global level remains the plication of the Code at national level, and direct quarterly International digest of health legisla­ tion, which serves as a clearing-house to give Member States necessary information in user­ friendly form. Documentation available to 1 See Leenen HJJ, Gevers JKM, Prnet G. The nghts of patients m Europe· a WHO is also communicated in forms such as comparative study. Deventer, Kluwer Law and Taxation Publrshers, 1993

18 HEALTH SYSTEM DEVELOPMENT support was given to countries in the preparation port on human rights in relation to women's of implementing legislation. health (see paragraph 9.3). The Organization was also represented at United Nations meet­ 4 29 An intercountry meeting on health legis­ ings on human rights issues and cooperates lation (Cairo, December 1993) provided an closely with the United Nations Centre for Hu­ opportunity to exchange information and expe­ man Rights. Similarly, close working relations rience and to promote the concept of health are maintained with other agencies and bodies legislation as a tool for strengthening health pol­ with an interest in health legislation, within and icies and strategies. WHO was involved in prepa­ outside the United Nations system. In the field rations for the World Conference on Human of bioethics, close links were maintained, in par­ Rights (Vienna, June 1993), for which it drew up ticular with UNESCO, the Council of Europe position papers and commissioned a major re- and CIOMS.

19

CHAPTER 5 Organization of health systems based on primary health care

to look at ways of coping with the increasing National health systems and demand for health services with limited resourc­ policies es (Kiel, Germany, November 1992). Health leaders from 12 countries met (Madrid, June 1992) to discuss such issues as contracting of Health economics and financing health services, and public and private responsi­ bility for health care. An intercountry consulta­ 5.1 A guidebook on health insurance for poli­ tion of ministers of health (Windhoek, October cy-makers was prepared jointly with ILO and 1993) reviewed experience of user fees, social in­ used as a basis for appraising insurance options in surance innovations, management of private in­ Ghana. It proved useful in reaching agreement surance and of the non-profit nongovernmental among interest groups concerning the benefit sector, and identified needs for technical cooper­ package provided as part of a new social insur­ ation. ance scheme, and showed that partial population coverage would be necessary at first. A Russian 53 In June 1993 a 12-month international version was used as a background document for master's programme in health economics began an intercountry consultation on health financing, at Chulalongkorn University in Bangkok, attended by m1msters from Kazakhstan, cosponsored by WHO and the World Bank; Kyrgyzstan and Uzbekistan (Almaty, December some fellowships were reserved for participants 1993). Further studies on cost recovery mecha­ from countries such as VietNam that are receiv­ nisms were supported in several countries. Of ing intensified WHO cooperation. Intercountry particular interest are the effects of charges on seminars and workshops on health economics service utilization by women and children, and were organized with WHO and World Bank the reactions of communities. Studies in Ghana support at the National Institute of Public and Kenya led to reviews of exemptions practice Health in Algiers, which now has a health eco­ and of banking arrangements for the protection nomics unit and resource centre. of revenues. Studies of alternative financing op­ tions were undertaken in several countries. Organizational change 5.2 In its report' a WHO study group re­ viewed recent changes in the methods used in different countries to finance health services. A 5.4 Many countries have expressed the inten­ network was established to provide expert advice tion to pursue decentralization policies, but have on the financing and economics of health services not made significant progress; and in some in­ in central and eastern Europe. Similarly, a perma­ stances decentralization has led to neglect of so­ nent forum for the exchange of views and experi­ cial services in favour of directly productive sec­ ence was established to support European Mem­ tors. A series of studies was therefore undertaken ber States undergoing reforms in health care with support from NORAD to examine the management and financing. A meeting was held question of decentralization and health develop­ ment in the light of experience in countries, par­ ticularly Botswana, Kenya and Uganda. Prelimi­ nary findings indicate that inadequate capacity at 1 WHO Techn1cal Report Series, No. 829, 1993. the periphery to take on enlarged responsibilities

21 THE WORK OF WHO 1992-1993 and to demonstrate results are obstacles to the dation, and the British Columbia Institute of implementation of sometimes ambitious decen­ Technology (Canada). A paper was prepared on tralization policies. the planning and financing of medical equip­ ment. 5 5 In Africa the accent was on reorienting health systems towards clear implementation of 5.8 Close cooperation continued with train­ primary and community health care. Thus the ing institutions in London, Lyon, Mbabane and Regional Committee examined the question of Nicosia. Following the closure of WHO restructuring provincial and local hospital net­ projects in Sierra Leone and Togo, agreement works in 1992, and related activities are in was reached for GTZ-supported centres in progress. Infrastructure development was the Mombasa (Kenya) and Diourbel (Senegal) to subject of the 1993 Technical Discussions, with serve as regional training centres. Training emphasis on the formulation of national plans of courses for republics of the former Soviet Un­ action. ion and countries of central and eastern Europe and Latin America were organized in Boston 5.6 Bangladesh, with WHO support, under­ (USA) jointly with the American College of took a review of the functions and structure of Clinical Engineering, the American Interna­ the Ministry of Health and prepared several pro­ tional Health Alliance, the International Feder­ grammes for financing by the World Bank and ation for Medical and Biological Engineering, donor agencies. Bhutan reviewed its health de­ UNICEF and UNIDO. Support was given to velopment programme in the context of its na­ workshops on maintenance and repair of health tional plan. A radically revised organizational care equipment in Afghanistan, Cyprus, Egypt, structure for the Ministry of Health in Ghana Jordan, Syrian Arab Republic, Tunisia and was established with WHO support. One inno­ Yemen. The WHO collaborating centre in Cy­ vation was the replacement of vertical pro­ prus continued to offer training for staff from grammes by a central coordination and research Africa, South-East Asia and the Eastern Medi­ division with an advisory and standard-setting terranean. A centre for the maintenance and role; new procedures for resource allocation and repair of medical equipment was opened in financial management were also introduced. Sim­ Damascus in 1992. ilarly, Mongolia reviewed the structure and func­ tions of its Ministry of Health. A WHO team 5.9 In the area of physical infrastructure and helped to assess obstacles to integrated service maintenance, PAHO/WHO cooperated directly delivery in Namibia, and proposed a restructur­ with 14 engineering and maintenance pro­ ing of the Ministry of Health and Social Services grammes at health establishments in the Ameri­ on a functional basis rather than according to cas, and disseminated technical information, bib­ professional allegiances and interests. The liographic material, and information on profes­ Organization also worked with the Ministry sional and technical training facilities to all such of Health of Zambia in planning sweeping establishments. policy reforms in respect of decentraliza­ tion, public participation, financing and relations 5.10 The role of health facilities planning for with the nongovernmental sector. Joint pro­ quality improvement was discussed at an inter­ gramme reviews were carried out by WHO and national public health seminar (Buenos Aires, national staff in most Eastern Mediterranean May 1992) organized by the International Hos­ countries. pital Federation, the public health group of the International Union of Architects and WHO. Guidelines for health facilities planning were dis­ cussed at a follow-up meeting. Problems of Management of physical resources for physical infrastructure faced by countries of cen­ health tral and eastern Europe were examined during the conference of the International Hospital Fed­ 57 Studies on health care equipment manage­ eration (London, October 1992); and questions ment were carried out in Botswana in coopera­ of cost-conscious planning, design and mainte­ tion with GTZ, NORAD, the British Overseas nance of health care facilities were subsequently Development Administration and the University explored at a joint conference of WHO and the of Sussex (United Kingdom), and in Cameroon International Union of Architects (Chicago, with support from GTZ, the Rockefeller Foun- USA, June 1993).

22 ORGANIZATION OF HEALTH SYSTEMS BASED ON PRIMARY HEALTH CARE

District health systems The Ain Shams proiect

Improved service delivery • Vulnerable groups exist in all societies: women and children are especially likely to lack access to food, water, shelter and 5.11 A community-based development strategy sanitation and consequently to be in poor in which components for health, functional litera­ health. Such was the case in the Ain Shams cy and income generation are integrated was test­ district of Cairo, which gave its name to a ed in an urban slum district of Cairo (see box). A project involving five countries (Egypt, national agency for primary health care promo­ Ghana, Nigeria, Zambia and Zimbabwe) tion was established in Nigeria with WHO sup­ aimed at improving the health of the poor­ port following a review in 1992. The Ministry of est women. In five districts - one in each Health of Zimbabwe tried out different strategies country-there was emphasis on function­ for linking community health development with alliteracy for women, viable economic ac­ the district health system, whereby people in com­ tivities and community-based health serv­ munities have, for instance, been trained by health ices as the key components in improving centre staff to carry out basic preventive and cura­ women's health and that of their families tive procedures. Participants in an interregional and the community as a whole. The Ain consultation (Bandung, Indonesia, 1993) noted Shams project, now completed, provided that the main lesson to be learned from experience lessons in the empowerment of vulnerable in countries is that a district health system cannot groups. It resulted in improved literacy work without simultaneous changes in central ad­ among women with little or no education, ministration and regulation. and the setting up of community-based health services including a health centre 5.12 As part of efforts to strengthen local health and clinics, 24-hour emergency services, systems, meetings were organized in seven Latin outreach services for maternal and child American countries and for the English-speaking health, and a referral system. In addition, Caribbean countries, to analyse local management profit-making economic activities were processes and to introduce managerial and leader­ established and community-managed de­ ship mechanisms. The organization and financing velopment projects were organized, such of health services, administration in local health as creating a park, building sanitary facili­ systems, leadership, management information ties and improving roads and lighting. systems, project management and strengthening of training institutions received particular atten­ tion in the Americas. Strategies to strengthen local health systems are now being expanded to include work at district (county) level and in urban areas. A study on the implementation of health care models examined local health systems in Bolivia, Dominican Republic and Haiti; the aim is to dis­ gerial capacity of health teams at local and dis­ seminate a methodology for comprehensive eval­ trict levels, using such materials, combined with uation, with a view to promoting greater efficien­ supportive supervision and performance moni­ cy, effectiveness and equity. An intercountry con­ toring, to enable better integration of health serv­ sultation (Lome, September 1992) brought to­ ices. The importance of improved management gether 14 national experts from five African coun­ at district level for overall programme coordina­ tries to discuss information support for district tion was demonstrated in Malaysia and the Phil­ management. ippines in the course of a 1992 review of projects in the Western Pacific. 5 13 In response to repeated complaints by ministries of health about lack of coordination and wasted time and effort when several training Health development structures programmes are arranged for the same staff, in 1992 WHO embarked on a project to produce learning materials that concentrate on problem­ 5.14 A study of the effectiveness of the health solving, and to build up the technical and mana- committees and boards and other health devel-

23 THE WORK OF WHO 1992-1993

opment structures that have been established at able urban development. The World Bank and various levels of district health systems in many other agencies support these initiatives, in which countries began after a global framework had WHO plays an important technical role, includ­ been agreed upon at a planning meeting attended ing the publication of materials. by investigators from Colombia, Indonesia, Jamaica, Nigeria, Philippines, Senegal, Sudan and 5.17 One aspect of urban health development Yemen in February-March 1993. An inter­ is the correct role to be played by each level of country workshop on primary health care devel­ health facility. Self-referral to hospital, by-pass­ opment (Cairo, April 1993) devised approaches ing the health centre, is a common phenomenon for strengthening local and district planning so as in urban areas where hospitals are the sole pro­ to ensure that each health facility, public and viders of complex care. In addition, health servic­ nongovernmental, has clearly defined responsi­ es in urban areas are frequently organized in a bilities for health care within its specified catch­ way that is not conducive to community involve­ ment area. ment. However, recent advances in technology have made it possible for specialist health centres with added capacity to carry out fairly complex procedures, such as eye cataract operations, pre­ Urban health viously requiring hospital admission. Known as "reference health centres" to distinguish them 5.15 Following a WHO workshop in March from traditional first-contact health centres, 1993 hosted by the urban health group of these facilities have been shown to bring appro­ Nijmegen Catholic University (Netherlands) priate care closer to the population at only 25% with the collaboration of the Swiss Tropical In­ of the cost of hospital interventions.2 Following stitute and the London School of Hygiene and pioneering work in Cali (Colombia) and cities in Tropical Medicine, proposals on research and de­ the United States of America, Europe and Asia, velopment were prepared for the cities of WHO is supporting the establishment of refer­ Dar es Salaam, Jakarta, Kingston, Managua and ence health centres in Bangkok, Cairo, Harare, Mirzapur (India) and presented to the Nether­ Jakarta and Manila as well as Bombay, Calcutta, lands Government for financing. In Africa a first Delhi and Madras in India. Healthy Cities meeting was organized (Dakar, July 1992) as part of collaboration with the Healthy Cities network of Quebec (Canada) and the commune of Dakar, and attended by repre­ Community involvement in health sentatives of 14 cities and five nongovernmental organizations from eight countries. A network 518 The use of volunteer health workers was of African Healthy Cities is being set up, for reviewed in several countries. The experience of which preparatory activities were initiated in Thailand's self-care programme was shared Accra and Ibadan (Nigeria). with other South-East Asian countries. An intercountry study on self-medication was be­ 5.16 Approaches to urban health development gun in that region. Following a global study were discussed at a regional meeting (Harare, showing that traditional healers can be efficient November-December 1993) jointly sponsored community health workers, investigations were by WHO and GTZ. Preparations were made for started in Africa, Asia and Latin America to de­ studies of the effects of environmental and hous­ termine the conditions necessary for success. ing factors on urban public health, to be carried Case studies of community involvement in out in Ibadan (Nigeria) in 1994. Most cities in health in Bolivia, Nepal and Senegal were repeat­ South-East Asia have launched extensive urban ed in 1993; the findings underlined the impor­ development programmes for slum-dwellers. tance of national political leadership for the suc­ The European Healthy Cities project expanded cess of programmes, although a surprising degree to involve over 500 cities. Guidelines for project of sustainability was found even without clear development were issued. 1 Policies for improv­ ing the health of the urban poor were discussed at an interregional meeting (Manila, August 1993 ). The topics covered included ways of extending 1 Twenty steps for developmg a Healthy City pro1ect. Copenhagen, World coverage through health care reform, and ap­ Heolth Orgomzotion, 1992. proaches for achieving environmentally sustain- 2 WHO Technrcol Report Serres, No. 827, 1992.

24 ORGANIZATION OF HEALTH SYSTEMS BASED ON PRIMARY HEALTH CARE

Rgure 5.1 WHO core library THE WHO CORE LIBRARY FOR DOCTORS WORKING IN SMALL HOSPITALS

ANAESTHESIA GENERAL SURGERY SURGERY IT AT THE AT THE THE DISTRICT HOSPITAL: DISTRICT DISTRICT OBstETRICS, HOSPITAL HOSPITAL GYNAECOLOGY,

Moellatl B. Oobsoo ORTHOPAEDICS, IMD TRAUMATOLOGY

John Cook Batu S•nkate" Ambfose e o. w .,.unna

WHO Basic Radiological System Manual of Radiographic Interpretation for General Practitioners

Towards the end of the biennium WHO began promoting a core library for physicians working in small hospitals. This small library consists of seven clinical manuals that are considered indispensable to hospitals at first referral level and could form the nucleus of a hospital library. The three surgery manuals describe life-saving procedures, as does the malaria publication. The book on respiratory infections in children is directly relevant to a major problem in hospitals, and the radiography manual provides a complete set of radio­ graphic images for clinical use. Finally, the book on the relief of cancer pain is included because many cancer patients in developing countries are admitted to hospital on account of intractable pain, and the disease is often so advanced that pain relief is the sole treat­ ment option.

To encourage the widest possible dissemination of these manuals, WHO has made the core library available at a nominal price.

25 THE WORK OF WHO 1992-1993

political support. In conjunction with social se­ 5 20 During the biennium WHO issued the re­ curity agencies, PAHOIWHO participated in port of a study group on the hospital in rural and work undertaken at the Inter-American Center urban districts/ documents on the hospital of to­ for Social Security Studies (Mexico) relating to morrow2 and on hospital economics and financ­ community participation and setting up manage­ ing,3 and guidelines for the development of district ment information systems. Globally, the move­ hospitals.4 A limited number of reference works ment towards participatory health development were selected to form a "core library for doctors continues to grow slowly but surely, especially at working in small hospitals" and this package was local level. used in many countries (see Figure 5.1).

5.21 An interregional meeting (Pyongyang, October 1992) stressed the need to incorporate Hospital performance and quality of core quality assurance in all aspects of a health sys­ tem.5 WHO encouraged collaboration between 5 19 Studies indicate that too little attention is institutions active in this field in developing paid to the performance of hospitals, a disturbing countries, such as DANIDA, USAID, the situation in view of the amount spent on them. An Netherlands Government and the International international workshop (Yaounde, November Society on Quality Assurance. A joint consulta­ 1992), sponsored by WHO, GTZ and the Prince tion on quality assurance in developing countries Leopold Tropical Institute (Belgium), drew atten­ (Maastricht, Netherlands, June 1993) was organ­ tion to the crisis affecting small hospitals that pro­ ized with WHO support through the collaborat­ vide services for large rural and urban populations ing centre for hospitals and other health institu­ while receiving little support from governments tions in Utrecht. WHO issued a document on and donors. A seminar on hospital cooperation in the use of standards, and cooperated with Saudi Europe was convened jointly with the European Arabia in producing a manual.6 A national work­ Community (Strasbourg, France, November shop on quality assurance was held in Zambia 1992). WHO gave support to Indonesia in testing jointly with USAID and DANIDA. a medical audit system; to the Islamic Republic of Iran in conducting a national workshop on the role of the hospital in primary health care; to 1 WHO Techn1cal Report Series, No 819, 1992. Mongolia in upgrading facilities such as peripheral 2 Document WHO/SHS/CC/92.1 hospitals; and to Myanmar in producing hospital 3 Document WHO/SHS/NHP /92.2 procedure manuals. PAHO/WHO continued to 4 D1stnct hosp1tals: gu1delmes for development. Manila, World Health Organ­ provide technical support for the strengthening of Ization, 1992 (Western Pac1f1c Ser1es, No 4). hospitals in the Americas. Workshops and semi­ 5 Document SEA/HSD/180. nars were held in 10 countries for the purpose of 6 Guideline manual on quality of pnmary health care. R1yodh, M1n1stry of revising hospital accreditation arrangements. Health of Saud1 Arab1a, 1993

26 CHAPTER 6 Development of human resources for health

6.1 Optimal performance by health personnel health, focusing on maldistribution and imbal­ depends on effective training and management as ance of staff, and the appropriateness of training well as proper planning. Rapid socioeconomic, to work requirements. Policy analysis was seen political and technological changes have made as vital to the solution of specific problems. planning difficult, yet the demand for cost-effec­ tiveness, efficiency and accountability has ren­ 6.4 World Bank health sector loans to such dered it more necessary than ever. countries as Bangladesh, China, Indonesia and Nepal have required the preparation of master 6 2 Against this background, budgetary con­ plans for health personnel which pay particular straints have obliged WHO to explore new attention to numbers, types and distribution. modalities of cooperation in the development of WHO has been involved in this process either human resources for health. In particular more directly (Bangladesh, Nepal) or in conjunction emphasis has been given to the involvement of with World Bank consultants (China). Existing collaborating centres, nongovernmental organi­ planning methods were reviewed by an zations, institutions and individuals in the Or­ interregional consultation (Bangkok, March ganization's work. This experience has mostly 1992) which stressed the importance of decen­ been positive and has enabled WHO to maintain tralizing planning to the implementation level the scope of its activities despite the resource and of involving interest groups. A regional constraints. workshop (New Delhi, February 1993) dis­ cussed planning and policy development for countries concerned by the WHO intensified support 1mt1at1ve; participants recommended Policy analysis, planning and that Member States carry out national reviews of management their human resources for health, and draw up guidelines for this purpose. In China WHO 6 3 Policy analysis for human resources de­ organized a workshop (Shanxi, June-July 1992) velopment was given high priority during the to identify problems in planning for decentral­ biennium, with financial support from Japan. ized health management. Several other national WHO prepared a draft manual on the subject, workshops on different aspects of health person­ which was reviewed by an intercountry group nel planning and management were conducted. (Cairo, June 1993). The group recommended that a revised version of the document should serve as background information for a future meeting of ministers of health in the Eastern Planning tools Mediterranean. Central American countries and the Dominican Republic have been involved in 6.5 Computerized planning tools were tested the development of methods to ensure better in­ and improved with support from Japan. A com­ tegration of health teams and enhance their capa­ pendium on planning is now available on dis­ bility to analyse local health conditions. The kette, with an operational manual. 1 Computer­ Technical Discussions held during the 1992 ses­ ized supply and requirement projection models sion of the Regional Committee for South-East Asia (Kathmandu, September) dealt with the bal­ ance and relevance of human resources for 1 Document HRH/93 5.

27 THE WORK OF WHO 1992-1993 were field-tested in the Caribbean (Barbados, right balance between them to ensure that the Saint Kitts and Nevis, and Saint Lucia), China and necessary knowledge and skills are available. A Hong Kong. The work in China included the year-long experience in Thailand with the development of an information system in connec­ RADICAL~ method for optimizing human re­ tion with a World Bank health sector loan, and use sources for health provided some information on of the projection models to determine whether the its strengths and weaknesses, which were re­ existing data were adequate for planning and viewed at three meetings (Ayutthaya, Thailand, whether the existing infrastructure would be re­ July 1992 and July 1993; Jakarta/Bandung, Indo­ ceptive to change; this approach highlighted the nesia, July 1993). There are indications that the multisectoral nature of health workforce plan­ method might be appropriate for countries with­ ning. In the light of the positive experience, it is out a strong planning tradition, although it clear­ expected that these projection models will prove ly needs further refinement. useful in a variety of ways ranging from the crea­ tion of scenarios to the monitoring of staffing 6.9 The public/private mix of human resour­ plans. A revised version of the models, based on ces for health was the subject of a meeting (Bang­ the field-test results, will be available in 1994 to­ kok, June-July 1992) which examined ways of gether with an operating manual. Health work­ harmonizing the two sectors, and in particular force planning manuals were also prepared in col­ recommended strengthening the capacity of laboration with the Western Pacific Regional ministries of health to formulate national policies Training Centre in Sydney, Australia. and plans covering both sectors. A consultation with leading medical practitioners in March 1993 6.6 As a basis for planning, it is important for examined political and practical aspects of pri­ countries to develop their own health workforce vate practice and public responsibility; it stressed norms in accordance with their policies and situa­ the need to use both public and private services tion. In this respect WHO is examining two to provide improved access to affordable and methods: workload indicators of staffing need high-quality health care. • (WISN) and functional job analysis (FJA). WISN has been tried out in several countries in Africa, 6 10 In Seychelles WHO supported a 1992 South-East Asia and theWestern Pacific, and FJA study on staff requirements and supply projec­ is seen as having the potential for overcoming tions, as well as management and training issues, traditional professional divisions of labour and and this was expanded in 1993 to cover capacity­ thus allowing more efficient deployment of staff. building for planning and management within the Ministry of Health and strengthening of 6.7 An interregional consultation Qakarta, training programmes. The study gave high prior­ June 1993) reviewed country experiences and ity to review of the responsibilities of nurses. identified areas for further study with regard to This step-by-step approach may serve as a refer­ methodology for multiprofessional policy and ence for other countries with similar problems. planning. It noted that although many models exist for workforce planning and projection, they tend to be complex and try to cover as many events as possible in the planning process. They Management also tend to concern tertiary care settings in de­ veloped countries. The WHO choice therefore 6 11 Efforts are being made to create a health reflects a compromise: methods that are relative­ workforce information system that will capture ly simple to use, but capture only significant data from both public and private sectors. A events. One of the strategies being pursued is to specific system for nursing/midwifery personnel form a core of people to help countries in their is also being developed as an integral part of own region or outside it to use the methods. country and global data banks. This professional category poses a particular problem as the desig­ nation "nurse" includes a wide range of educa­ tional levels and responsibilities. The only corn- Optimizing human resources for health

6 8 In many countries the problem is no longer one of shortage of health professionals 1 RADICAL rs on acronym for Rapid DiagnoSIS, lmmedrote Concern, Action for but rather of establishing or maintaining the Lasting Change.

28 DEVELOPMENT OF HUMAN RESOURCES FOR HEALTH

mon factor is educational level, which it is hoped project implementation has not been very success­ will be translatable into comparable competencies. ful owing to lack of country support. N everthe­ less, a first regional meeting (Tunis, June 1992) 6.12 Participants from Lesotho, Namibia, issued a statement underlining the need for each Swaziland and Zambia attended an intercountry country to have a continuing education pro­ workshop on leadership and management for gramme for all categories of health personnel as an nurses (Mbabane, April1992) with financial sup­ integral part of its national health system. It rec­ port from the Kellogg Foundation. National ommended the creation of a structure within the meetings were subsequently held on this subject ministry of health that would be responsible for in the United Republic of Tanzania (Morogoro, the planning, implementation and evaluation of October 1993) with NORAD support, and in the programmes. A manual on continuing educa­ Namibia (Windhoek, November 1993) with sup­ tion for health personnel has also been proposed. port from the Kellogg Foundation. Requests for In Europe WHO is cooperating with the World further support in management and leadership Federation for Medical Education in a study on training have been received. To become truly how continuing medical education could be im­ self-sustaining, these activities have to be inte­ plemented and supported. The possibility is being grated into national action plans. explored of establishing a forum to promote con­ tinuing medical education to support health sector 6.13 National workshops were organized on reforms in eastern and central Europe. use of the WHO manual on human resources management (Colombo, May 1992; Kathmandu, September 1992). Based on the participants' evaluation, the manual was subsequently revised, Nursing particularly to make it less culture-specific, and the new version was used in a further workshop 6.15 A global advisory group on nursing and (Khartoum, October-November 1993 ). An midwifery was established in response to Health intercountry workshop (Beirut, June 1993) pro­ Assembly resolution WHA45.5, and a first meet­ vided an opportunity for health managers to ana­ ing held in November-December 1992; it rec­ lyse tasks and work out clear job descriptions, ommended that nursing/midwifery be declared a which should help to avoid duplication and priority area for WHO action, that strategies be strengthen management. developed to ensure its optimal contribution to health care, and that the necessary resources be made available.' Modest additional funds have since been provided to support research in prior­ Continuing education ity areas identified by the group, and attempts are being made to fill information gaps so as to 6 14 If there is one area where much has been facilitate monitoring and evaluation as well as talked about and consensus reached on its impor­ planning and deployment. A headquarters coor­ tance, but without this being reflected in action, it dinating committee streamlines the work of the is continuing education. Where difficulties exist to different technical programmes in strengthening provide even basic training, this is not surprising. nursing/midwifery services and reviews WHO At the same time not everyone is convinced that vacancies to ensure that whenever possible pro­ continuing education should be an integral part of fessionals other than physicians can also apply. basic education. Fortunately there are some ex­ A WHO study group on nursing beyond the ceptions. In the Americas work continued on the year 2000, convened in July 1993, recognized conceptual and methodological development of that a multisectoral and multiprofessional ap­ continuing education as an alternative approach to proach would be needed to prepare health care training in such fields as management, epidemiol­ providers to work in a rapidly changing environ­ ogy, public health and nursing. Continuing edu­ ment. A European regional publication2 provid- cation is being used to support decentralization and strengthening of care at local level. In the Eastern Mediterranean a workshop was held to promote planning of continuing education 1 Document WHO/HRH/NUR/93 1. projects with priority to district health personnel 2 Salvage J ed Nursing m actton strengthenmg nursmg and mtdwtfery to (Rabat, May 1992); it was hoped to extend this support health for all World Health OrganiZation, Copenhagen, 1993 approach to other countries, but paradoxically (European Ser1es, No 48).

29 THE WORK OF WHO 1992-1993

ed useful background information for the study ing made to identify those elements which define group, whose conclusions in turn were used as the quality of educational experience.2 Similarly, input for the meeting of the global advisory efforts are being made to understand the factors group in November 1993. which facilitate change, and to establish common criteria so that monitoring of improvements in 6 16 In South-East Asia nursing education has medical education and practice can be carried out tended to make greater progress than nursing globally. Four issues of a new bulletin, Changing services. An intercountry consultation on medical education and medical practice, were dis­ reorientation of nursing services in support of tributed during the biennium as well as a revised health for all (Kathmandu, December 1992) edition of the WHO guide for teachers of prima­ identified and promoted new approaches to col­ ry health care staff.3 laboration between nursing education and serv­ ices in order to achieve the goal of providing 6.19 To build on the work of the 1988 World high-quality nursing care. Both basic and further Conference on Medical Education, the World training of nursing personnel are a priority in all Federation for Medical Education, with support countries in the Eastern Mediterranean. In Egypt from WHO, UNICEF, UNESCO, UNDP and teaching modules and training packages have the World Bank, organized a further major con­ been developed and teacher training promoted. ference in Edinburgh (August 1993) on the theme Pakistan has approved a new curriculum with of societal changes and their implications formed­ emphasis on community orientation, and Yemen ical education. The conference considered such now offers a bachelor of science degree in nurs­ issues as the new skills being demanded of physi­ ing in addition to a community-oriented pro­ cians, the economic impact of medical decisions, gramme. In the Western Pacific WHO cooper­ the importance of better communication with the ates with Member States in planning for nursing community and individuals, and the growing con­ development. Ministries of health have estab­ sensus that radical reform is required to ensure lished nursing units or strengthened nursing ex­ that the skills of graduates who will practise in the pertise at central level. Computerized nursing 21st century will be relevant to the needs. management information systems have been cre­ ated to support national planning units in Aus­ 6.20 In Africa support was given in strengthen­ tralia, Papua New Guinea and VietNam. ing the College of Medicine in Blantyre (Malawi) and the Faculty of Health Sciences in N'Djamena. Workshops were organized with the aim of adapt­ ing medical education to community needs. Educational development 6 21 Participants in a regional consultation 6.17 Although a great deal of innovation has (New Delhi, February 1993) underlined the need occurred in the education and training of health for holistic strategies to achieve meaningful personnel, there seems as yet little consensus that reorientation of medical education, as many ac­ it should be generally applied. As stressed by a tivities at country level are still confined to the study group on this subject in October 1992, 1 arena of institutional reform. To accelerate ac­ problem-based learning must extend beyond lim­ tion, it was agreed that more attention must be ited clinical confines into social and community paid to such issues as organizational develop­ issues if it is to realize its full potential. Although ment, programme evaluation, the use of health educational experience can undoubtedly be en­ systems research and team approaches. A con­ hanced if teaching institutions assume new re­ sortium of medical schools in India continued sponsibilities in health care organization and serv­ the second phase of the innovative project on ice, this is beyond their traditional mandate and "Inquiry-driven strategies for changing medical they will therefore need to build up new alliances education". In Myanmar a twinning initiative and partnerships with professional associations, was launched with the University of New service organizations and the community. Mexico in Albuquerque (USA) to test a strategy to reorient medical education using continuing edu- 618 Although WHO has moved away from the concept of global curricula, attempts are be- 2 Document WHO/HRH/92.7 3 Abbatt FR. Teachmg for better learnmg. a guide for teachers of p(lmary 1 WHO Techn1cal Report Series, No 838, 1993 health care staff, 2nd ed. Geneva, World Health Organization, 1992.

30 DEVELOPMENT OF HUMAN RESOURCES FOR HEALTH cation and the medical association as entry-points. ry and practice of public health has become an Activities related to training of allied health work­ important area of work, and two publications were ers focused on improving staff capacity and curric­ issued.1 2 The seventh and eighth groups taking ulum reform. WHO supported Sri Lanka's Na­ part in the regional residency programme in inter­ tional Institute of Health Sciences in making a national health graduated during the biennium. comprehensive evaluation of different programmes Learning modules produced in 1991 for a Euro­ for training allied health workers, and the Institute pean master of public health course are being re­ of Health Personnel in Maldives in upgrading the vised. Educational policies, basic competencies country's training programmes. and learning environments were discussed at a first meeting of the European Dialogue on Training in 6.22 An intercountry workshop on training of Public Health (Rome, June 1992) with a view to trainers of health personnel in Eastern Mediter­ development of the course. A further meeting was ranean countries (Damascus, November 1992) held to review a strategy for training and research discussed existing programmes in this region, the in public health (Copenhagen, November-Decem­ role of educational development centres in teach­ ber 1993 ). Following discussion of aspects of pub­ er training and ways to increase trainer capabili­ lic health training by the Regional Committee for ty. Activities to promote the use of national lan­ the Western Pacific (Manila, September 1993 ), a guages in medical education also progressed. database was established to promote cooperation WHO sponsored briefing visits of medical pro­ between institutions and sharing of resources; this fessors from Egypt, Sudan, Tunisia and Yemen activity is a collaborative undertaking by WHO, to faculties in the Syrian Arab Republic for this the Asia-Pacific Academic Consortium for Public purpose. Packages containing selected medical Health and the Regional Training Centre in Syd­ texts and reference works in Arabic have been ney (Australia). An intercountry workshop at distributed to all medical faculties. which ten countries were represented (Sydney, July 1993) considered three aspects of public health 6.23 In the South Pacific a three-point plan was training: availability and organization of resources, introduced to revitalize the Fiji School of Medi­ scope and approaches, and required developments. cine. A new category of health workers known as Participants prepared plans of action for their own primary care practitioners graduated at the end countries. of 1993 and will undergo one year's internship in their countries under the supervision of senior medical officers, for whom a workshop was or­ ganized with WHO support (Suva, July 1993). Health learning materials Young health officers were recruited as faculty for the new programme. 6.26 Technical support to networks of more than 30 developing countries was increased un­ 6 24 Fellowships still remain an important part der the interregional health learning materials of the Organization's work, although there has programme, which is financed largely from been a falling trend in recent years and the figure extrabudgetary sources. Meetings were held to for the 1992-1993 biennium (see Table 6.1) repre­ plan future strategies and collaboration between sents a reduction of 875 over 1990-1991. To help projects (Harare, April1992), to examine project ensure relevance of training to country priorities, evaluation and planning in South-East Asian the application form was revised to provide more countries (Colombo, August 1992) and to ex­ details of applicants. A total of 207 new research change experience of projects in nine English­ training grants were processed in the areas of speaking African countries (Nairobi, December tropical diseases and human reproduction. 1993). An intercountry workshop (Damascus, November 1992) provided an opportunity for country coordinators to initiate research on the Public health training and research development of distance learning. Other work-

6.25 A meeting of directors of schools of pub­ lic health (Douala, Cameroon, December 1992), 1 The msis of public health: reflections for the debate Washington, Pan American Health OrganiZation, 1992 (Scientific Publication, No. 540). decided to establish a network of African institu­ 2 International health a north south debate. Washmgton, Pan American tions in order to strengthen training and research in Health Organization, 1992 (Human Resources Development Series, this field. In the Americas analysis of current theo- No. 95).

31 THE WORK OF WHO 1992-1993

Table 6.1 Distribution of fellowships, by subject of study and by region, 1992-1993

South- Eastern Reg1on East Med1ter- Western Afncan of the As1a European ranean Pac1f1c Subject of study Reg1on Amen cas Reg1on Reg1on Reg1on Reg1on Total

Publ1c health adm1nistrat1on 51 160 362 51 138 560 1 322 Hosp1tal and med1cal care adm1n1strat1on 8 50 6 65 Construction of health InstitUtions 1 2 3 20 26 Med1call1branansh1p 15 15 Subtotal 60 161 429 54 164 560 1 428

Enwonmental sanitation 17 14 149 7 36 45 268 Hous1ng and town plann1ng 19 19 Food control 6 3 20 29 Subtotal 17 20 149 10 75 45 316

Nurs1ng and midwifery 2 30 49 21 25 28 155 Public health nurs1ng 5 18 2 25 Med1cal soc1al work 2 3 5 Subtotal 2 37 67 21 30 28 185

Maternal and ch1ld health 25 17 108 45 49 244 Paed1atncs and obstetncs 10 21 11 1 75 118 Subtotal 35 38 119 46 124 362

Mental health 17 12 78 14 92 10 223 Health education 1 9 35 17 62 Occupational health 2 2 5 1 38 6 54 Nutrition 6 19 41 1 63 19 149 Health stat1st1cs 8 32 2 27 69 Dental health 6 1 16 30 18 71 Rehabil1tat1on 2 11 21 26 7 68 Control of pharmaceutical and b1olog1cal preparations 5 7 102 4 34 51 203

Subtotal 47 61 330 23 327 111 899

Total Health organ1zat1on and serv1ces 161 317 1 094 154 720 744 3 190 Percentage 45 82 67 83 65 84 70

Mal ana 17 3 60 3 33 116 Sexually transmitted d1seases 2 48 57 107 TuberculoSIS 13 30 1 16 19 79 Vetennary publ1c health 67 11 95 14 99 68 354 Laboratory serv1ces 18 22 23 1 33 97 Chemotherapy, antibiotics, 1nsect1c1des 1 1

Total Communicable d1seases 115 38 256 16 209 120 754 Percentage 32 10 16 09 19 14 16 Surgery and med1c1ne 13 1 12 2 58 10 96 Anaesthes1ology 3 4 96 11 114 Rad1ology 23 3 11 3 40 Haematology 14 2 23 9 48 Other med1cal sc1ences 19 3 58 12 31 12 135 Subtotal 72 13 200 14 112 22 433 Bas1c med1cal sc1ences 5 9 44 26 85 Med1cal and all1ed education 1 8 49 33 91 Undergraduate stud1es 6 13 19 Subtotal 12 17 93 72 195

Total Clin1cal med1c1ne, bas1c med1cal sc1ences and med1cal and allied educat1on 84 30 293 15 184 22 628 Percentage 23 08 18 08 17 02 14 GRAND TOTAL 360 385 1 643 185 1 113 886 4 572*

Of wh1ch 2135 dunng 1992 and 2422 dunng 1993

32 DEVELOPMENT OF HUMAN RESOURCES FOR HEALTH shops, both intercountry and national, were or­ were organized for them during the biennium. A ganized on key issues such as project manage­ series of workshops on macroeconomics was or­ ment, writing and editing, distance learning and ganized for WHO Representatives and senior educational methods, and also on field-testing and staff in Africa. These workshops have enabled evaluation, which was the subject of a meeting WHO Representatives to interact more effec­ (Kigali, September 1993) with participants from tively with members of country support teams nine French-speaking countries. Unfortunately responsible for economics. The 1993 seminar for there has been a significant fall in extrabudgetary WHO Representatives took into account rele­ support in spite of the stated needs. vant recommendations of the Executive Board's working group on the WHO response to global change. While training in languages other than English and French has had to be Staff development curtailed owing to budget cuts, workshops con­ tinued to be held on such topics as report writ­ 6.27 High priority was again given to the train­ ing, teamwork, time management and cross­ ing of WHO Representatives, and three seminars cultural effectiveness.

33

CHAPTER 7 Public information and education for health

focus world attention on particular health issues: Public information World Health Day (7 April) on the theme "Heartbeat: the rhythm of health" in 1992 and 7.1 WHO's public information programme "Handle life with care: prevent violence and enhances awareness of the Organization's negligence" in 1993; World No-Tobacco Day work among the general public and transmits (31 May) on the theme "Tobacco-free important public health messages. Growing gen­ workplaces: safer and healthier" in 1992 and eral interest in health issues is reflected in the "Health services: our window to a tobacco-free increased time and space now being devoted to world" in 1993; and World AIDS Day (1 Decem­ health matters in the media. This situation offers ber) on the theme "AIDS: a community com­ more opportunities for WHO to publicize its mitment" in 1992 and "AIDS: time to act" m work and to disseminate authoritative informa­ 1993. tion on health questions. WHO continued to strengthen its contacts with all branches of the 7 4 WHO continued to provide public infor­ news media-wire services, newspapers and mag­ mation services for a broad range of users azines, television and radio. Radio programmes through visits and publications and by respond­ were produced and distributed to over 200 radio ing to enquiries. The brochure, Facts about stations. WHO also worked with international WHO, and the video, The battle for health- a television news and features syndicators of audi­ global challenge, produced during the previous ovisual material as well as national broadcasters biennium, were used for briefing purposes. A to ensure appropriate distribution through their large number of enquiries were dealt with and networks. A large number of briefings, press 300 group visits to WHO headquarters were conferences and interviews were arranged. conducted in six languages; by 30 September 1993 there had been about 10 000 visitors from 7.2 Materials produced to meet requests from over 60 countries during the biennium. the media around the world included some 200 press releases and a range of features, fact sheets and press kits. Efforts were made to improve the technical content of press releases, to simplify Education for health their language, and to time their distribution so as to attract maximum attention. Topics dealt with 7.5 WHO's three main health education included WHO's global drug policy, immuniza­ strategies are: advocacy of healthy public poli­ tion of children, tropical diseases, AIDS, cholera, cies, "empowerment" of people by increasing tuberculosis and emergency relief. Press kits in their knowledge and skills in health matters, and different languages were prepared for the United building social support for health. Within this Nations Conference on Environment and Devel­ framework WHO and UNEP cooperated in or­ opment (Rio de Janeiro, Brazil, June 1992), the ganizing meetings on supportive environments International Conference on Nutrition (Rome, for health (Nairobi, June 1993; Bangkok, No­ December 1992) and the Ministerial Conference vember 1993) for countries in Africa, South-East on Malaria (Amsterdam, October 1992). Asia and theWestern Pacific. Both meetings pro­ duced statements that identified important chal­ 7.3 A variety of materials were distributed in lenges and strategies for action. An outcome of connection with the special days designated to the 1991 conference in Sundsvall (Sweden) has

35 THE WORK OF WHO 1992-1993 been the preparation of a handbook on promo­ prepared as an aid to youth leaders in promoting tion of health-supportive environments, to be action among young people in support of health. published in 1994. A joint WHO/World Bank In 1993 an informal consultation with workers' mission assisted in reviewing and strengthening organizations proposed ways in which trade un­ Zambia's national health education infrastruc­ ions could be involved in promoting health edu­ ture, with emphasis on health education in cation at the worksite. A four-year project on schools and on environmental health; a WHO health promotion among industrial workers was team then visited the country to advise on curric­ launched in China. ulum development and programme planning. 7 9 During the biennium at least 25 WHO 7 6 Intercountry meetings in Sri Lanka and programmes were supported in the production Costa Rica (Colombo, October 1992; SanJose, and dissemination of educational materials, ex­ November 1993) produced guidelines for intro­ change of materials and audiovisual coverage of ducing comprehensive approaches to school educational events. Sixteen educational video health education for countries in South-East Asia films were produced as were 22 newsreels, which and the Americas. Two national workshops were were distributed through television networks organized in Argentina and Namibia on the same worldwide. Similarly, video footage from subject. A health education curriculum for pri­ WHO's image library was made available to mary schools in Cameroon was designed and external production companies and television reviewed. During two international AIDS con­ networks. An interagency database for the ex­ ferences (Amsterdam, July 1993; Berlin, June change of video materials was established in 1993), working groups were organized on 1993. strengthening the role of schools in preventing HIV infection. In November 1993 an informal 7.10 Radio programmes on priority health is­ meeting on school-based surveillance of health­ sues continued to be provided regularly to over risk behaviour among secondary school students 200 radio stations. On average 13 000 print drafted a protocol for such surveillance in devel­ photographs are distributed each year to the oping countries. press, publishers, nongovernmental organiza­ tions and training institutions. In 1992-1993, 7 7 By the end of the biennium 28 countries 48 exhibitions and displays were prepared for had formally joined the European Network of technical meetings, conferences and international Health Promoting Schools, established in 1991. health events such as World Health Days, World A strategy for action in 1992-1993 was formulat­ Health Assemblies, the Ministerial Conference ed during a first international consultation with on Malaria (Amsterdam, October 1992), the In­ national coordinators of the network (Stras­ ternational Conference on Nutrition (Rome, bourg, France, May 1992). Two workshops were December 1992), the two international confer­ organized for teachers from eastern European ences on AIDS mentioned above, and the United countries (Budapest, September 1992; Prague, Nations Conference on Human Rights (Vienna, April 1993). Prototype action-oriented school June 1993). In South-East Asia information kits health education programmes were introduced on various health issues were prepared and dis­ in 12 Eastern Mediterranean countries in collab­ seminated and a regional newsletter, HFA 2000, oration with UNICEF and UNESCO. In 1992 a is distributed quarterly. national training course on rural school health education and a national symposium on school 7.11 In November 1992 an interagency meet­ health education were held in China with WHO ing on strategies for health advocacy was organ­ support. Teacher training workshops took place ized to continue the work of the 1991 third in a number of African countries. interagency round-table on communication for development. It was concerned particularly with 7.8 A WHO intercountry workshop on strategies to enlist decision-makers' support youth involvement in health promotion was held for health. The fourth round-table (Lima, Febru­ in Barbados (Bridgetown, November 1992); it ary 1993) considered ways to strengthen training formulated a regional youth statement on action in communication for development. for health and helped to initiate a Caribbean youth network. A national workshop on youth 7.12 Health education staff were trained in and health development took place in India. A Botswana, Chad, Congo, Kenya and Namibia brochure entitled "Health facts for youth" was with the help of WHO fellowships. In 1993 a

36 PUBLIC INFORMATION AND EDUCATION FOR HEALTH manual for training community health workers their decentralization to intermediate and dis­ in human relations, communications and leader­ trict levels. An international conference on ship skills was successfully tested during a train­ community health, with emphasis on commu­ ing session for supervisors and community nity participation and exchange of educational health workers in Kenya. An intercountry work­ experience, was held in cooperation with the shop was organized for radio and television Congolese Government (Brazzaville, Septem­ health communicators from Cameroon, Central ber 1992). Following reviews, proposals were African Republic and Congo (Y aounde, April made for strengthening national health educa­ 1993). A training guide on HIV/AIDS was pro­ tion programmes in Benin, Guinea and Uganda. duced for use by health workers in the Eastern Five intercountry working groups were formed Mediterranean. Four teaching centres in that re­ and three intercountry workshops organized to gion are providing training for national health strengthen health education programmes and education staff. WHO supported the authorities enhance community participation in health in in Oman in designing a programme to train the Americas. Intercountry workshops were women health educators for work in health cen­ conducted in the Eastern Mediterranean to pro­ tres. An intercountry workshop was held to dis­ mote the planning of health education pro­ cuss ways of integrating health education and grammes (Manama, July 1992) and the produc­ promotion into the training of health personnel tion of health education materials for urban (Sydney, Australia, July 1992). Technical sup­ health development (Sanaa, July 1993 ). A work­ port for this purpose was provided to Papua ing group reviewing the health education pro­ New Guinea. A video on the health aspects of gramme for the Western Pacific (Singapore, household energy use was produced in VietNam March 1993) called for greater emphasis on both with WHO support. community and government action. An inter­ national symposium on health education was 7.13 Support was given to several African organized in collaboration with the All China countries in strengthening the management of Health Education Association (Shanghai, Octo­ health education programmes and organizing ber 1992).

37

CHAPTER 8 Research promotion and development

8.1 In a wide-ranging discussion of the role of sources for research; international cooperation in health research, the Health Assembly in May health research; ethical aspects of health research; 1992 provided policy guidance on this subject, and recommendations on priorities. The strategy stressing a number of points: the multidisci­ document will provide a set of guiding principles plinary nature of health research, and the need to for health research priorities at global, regional concentrate on particular themes (health policy and country levels so as to deal with emerging research, research on methods to support deci­ health problems and a changing health situation. sion-making, health systems research, and re­ It will apply not only to WHO but also to the search on nursing); constant updating and refine­ scientific community in the health field, deci­ ment of coherent research strategies; strengthen­ sion-makers, donor agencies and concerned ing research capability; the role of scientific and nongovernmental organizations. technological infrastructure in facilitating appli­ cation of findings of health research; the evalua­ 8 4 During the biennium WHO's Council tion of technology, using both qualitative and for Science and Technology, composed of staff quantitative indicators for measuring progress; concerned with research, met several times to financing of health research at all levels; and discuss ways of improving communication and WHO's role in bioethics. cooperation among the various WHO pro­ grammes that have a research component. Priori­ 8 2 At its thirty-first session in September­ ty-setting and extrabudgetary support of re­ October 1992 the Advisory Committee on search were found to be matters requiring de­ Health Research (ACHR) directed its attention tailed investigation. In July 1993 the Council to improving coordination between global and held a joint meeting with the Standing Commit­ regional research activities; appraising the work tee of ACHR, providing an opportunity to ex­ of ACHR's task forces and subcommittees and change views and information about ACHR's planning their future tasks; providing guidance work. Collaboration also continued with the for updating WHO's health research strategy; United Nations Research Institute for Social De­ reviewing the work of several WHO pro­ velopment on the subject of qualitative indica­ grammes that have substantial research compo­ tors of development. nents; and considering ethical aspects of health research, particularly the productive cooperation 8 5 WHO's collaborating centres perform between WHO and CIOMS. an invaluable service in promoting health re­ search throughout the world. In 1992-1993 the 8 3 One outcome of the 1992 session was a network of centres continued to expand, reach­ meeting of an ACHR working group (Salisbury, ing a total of 1221 centres (see Figure 8.1). A United Kingdom, April1993) called to prepare a global review and evaluation of the centres was framework for updating WHO's research begun. strategy. The outline proposed was as follows: objectives of health research; restatement of cur­ 8.6 Expert advisory panels constitute another rent strategy and new dimensions of research (in major source of expertise. The 54 panels, com­ view of scientific advances); emerging problems prising more than 2000 experts, provide impor­ and forecasting (especially related to science and tant scientific advice to the Organization. During technology, biotechnology and health care); the biennium 16 expert committee meetings were strengthening research capabilities, including re- held.

39 THE WORK OF WHO 1992-1993

Figure 8.1 WHO collaborating centres, by region and by year.

600 . - .. -.... - .. African Region 500 ------Region of the Americas --- South-East Asia Region 400 European Region 300 ------Eastern Mediterranean Region

200 Western Pacific Region

100

0 1948 1953 1958 1963 1968 1973 1978 1983 1988 1993

Figure 8.1

8.7 WHO provided scientific and technical projects were funded in priority areas. The re­ support to the French Ministry of Cooperation gional system for vaccine development in Latin and Development in organizing an international America and the Caribbean (SIREVA) was fur­ symposium on "technology, health and devel­ ther developed. There were several meetings of opment" (Paris, December 1992). Cooperation "Convergencia", an interagency initiative to with the Council on Health Research for Devel­ promote cooperation in health science and tech­ opment was initiated following the creation of nology. The PAHO/WHO Advisory Commit­ that nongovernmental organization in March tee on Health Research held its twenty-ninth 1993. Formal mechanisms for strengthening this meeting in August 1993. cooperation are being explored. 8.10 In South-East Asia current research strat­ 8.8 In Africa a fund was created for the pro­ egies were reviewed and updated. The eighth motion of health systems research and develop­ meeting of directors of medical research councils ment. Prizes were awarded to eight research and analogous bodies (Bangkok, November workers in African medical schools in acknowl­ 1992) stressed the essential role of WHO in pro­ edgement of their publications and theses. moting the establishment or strengthening of "Public health research" was the subject of the such bodies. Further funding was provided for Technical Discussions held during the 1992 ses­ training in research, provision of grants for visit­ sion of the Regional Committee. ing scientists, and other activities directed to­ wards strengthening research capacity. Meetings 8 9 In the Americas an analysis was made of of the South-East Asia Advisory Committee on health research in Argentina, Brazil, Cuba, Health Research continued to be held on a yearly Mexico and Venezuela', with the aim of improv­ basis. ing health research policies. A total of 39 research 8.11 In Europe a joint workshop was organ­ ized with the European Medical Research Council (Prague, January 1993) to help the

1 Pellegrim Filho A. Health research 10 Latm America. Bulletin of the Pan countries of central and eastern Europe to reor­ Ameffcan Health Organization, 1993. 27(2): 168-182. ganize their national health research administra-

40 RESEARCH PROMOTION AND DEVELOPMENT ------tions and to increase the effectiveness of con­ methods, and the publication of a manual.1 A joint tacts between western and eastern Europe. It meeting in August 1992 of the regional ACHR was recommended that those countries should and directors of health research councils or analo­ consider establishing independent national gous bodies stressed the value of networking ar­ health research institutions as part of a national rangements between experts and research insti­ science research council. tutes, and the importance of adequate infrastruc­ ture, information exchange and quality control in 8.12 In the Eastern Mediterranean support health research. was given to several research projects in priority areas such as nutrition, primary health care, 8.14 Details of research on particular subjects health systems research and assessment of ma­ (for instance, human reproduction, immuniza­ ternal and child health services. Research infor­ tion and tropical diseases) may be found in the mation was disseminated through a Health chapters and sections of this report dealing with services journal. the WHO programmes concerned.

8.13 In the Western Pacific human resources for health research were promoted by means of train­ 1 Health research methodology. a guide for training m research methods. ing grants, short courses on research design and Manila, World Health OrganizatiOn, 1992.

41

CHAPTER 9 General health protection and promot1on•

AIDS, taking into account the work of a consul­ Women, health and tation on women and drugs in August 1993. Par­ development ticipants stressed that problems of substance abuse occur among women in all countries, re­ 9.1 WHO is concerned with the way in which gardless of their cultural, social and economic the health of women affects and is affected by circumstances, and that priority must therefore their social, political, cultural and economic sta­ be given to public education, treatment and reha­ tus, and with their contribution to health and bilitation specific to women's needs, and to overall development. An interdivisional steering devising measures and policies that take those committee on women, health and development needs fully into account. A report on human has been set up with the task of ensuring that rights in relation to women's health, which ex­ WHO's technical programmes and the Ninth amines the implicit and explicit threats to wom­ General Programme of Work give proper atten­ en's health, was commissioned for the confer­ tion to matters affecting women's health in all ence on the health of women in central and east­ areas. The committee has prepared a checklist of ern Europe, to be held in Vienna in 1994. WHO indicators for programme managers, including maintains databases on women's health, in­ indicators relating to differences between the cluding bibliographies and lists of indicators. sexes in health and access to and use of health services; the impact of activities on the health of 9 4 The network of multisectoral teams on women; and the participation of women and women's leadership and participation was fur­ women's organizations in health promotion ther strengthened following a fourth UNFPA­ and disease prevention. It has also indicated areas supported interregional workshop on leadership where research is needed on matters of concern and participation of women in maternal and to women. It will work with the Director-Gen­ child health and family planning (Washington, eral's adviser on health and development policies November 1992); it now encompasses 42 coun­ in preparations for the fourth world conference tries. on women, to be held in Beijing in 1995, and ensure that due importance is given to women's 9.5 In the context of the 1993 World Health health in the proposed "platform for action". Day on the theme of accident and injury preven­ tion, particular attention was drawn to violence 9.2 The Director-General has appointed an affecting girls and women, including not only adviser on the employment and participation of physical and mental abuse but also the hidden women to help achieve WHO's objective of violence of discrimination or denial of the basic increasing the number of women in professional human rights where food, medical care, educa­ and higher-graded posts and ensuring their par­ tion and a safe environment are concerned. Reso­ ticipation in the Organization's activities. Simi­ lution WHA46.18 highlighted the importance of larly, a multidisciplinary coordination group has eliminating such harmful practices as female gen­ been set up to ensure that nurses have access to ital mutilation and other social and behavioural certain kinds of WHO assignment in which there obstacles affecting the health of women and chil­ has been a strong bias towards physicians. dren. Technical and financial support was pro­ vided for national surveys on such practices and 9.3 The United Nations is preparing a report for measures to combat them, including training on the subject of women, drug abuse and HIVI of traditional birth attendants and midwives.

43 THE WORK OF WHO 1992-1993

9 6 Work continued in the Americas to options available to them for promoting and strengthen national capability for using a method protecting their health. that takes proper account of women's needs in the analysis and evaluation of health policies and programmes. Technical support was provided for subregional training workshops in Costa Food and nutrition Rica, Ecuador, Guatemala, Jamaica, Panama, and Trinidad and Tobago. Research focused on vio­ 9.9 In response to the recommendations in lence against women, quality of care in service the world declaration and plan of action adopted delivery for women, and women and tropical by the International Conference on Nutrition diseases; the findings on violence were taken into (Rome, December 1992) the Director-General, account in formulating policy proposals and re­ reaffirming WHO's continuing commitment to viewed by a Central American seminar on its proper food and nutrition for a healthy life, de­ public health aspects (Managua, March 1992). A cided in May 1993 to establish a new division to publication on gender, women and health1 was be responsible for all WHO's activities con­ prepared by a multidisciplinary group. cerned with food aid, food safety and nutrition. It will strengthen the Organization's capacity for 9.7 As part of a European initiative, "Invest­ action in those areas and support Member States ing in women's health", supported by Austria, in implementing national plans of action for nu­ Norway and Sweden, a preparatory meeting tritional improvement, giving priority to the (Copenhagen, March 1993) drew up a plan for a countries that are least developed, have low in­ European women's health forum, to be offi­ come or are affected by disasters. cially inaugurated at the conclusion of the Vien­ na meeting in 1994. Within the context of the Healthy Cities action plan on women's health, an information network is being established that Food aid programmes will link all parts of Europe and provide a specif­ ically urban input for the forum. 9.10 WHO continued to advise on the health aspects of food-assisted development projects 9 8 Concerted efforts have been made supported by the World Food Programme, and is through intercountry activities in the Eastern cooperating with WFP to assess the effectiveness Mediterranean to improve quality of life for of such projects in improving health and to deter­ women and utilize their potential for health mine whether they should be continued, phased promotion and development. For this purpose out or modified. The Organization also continued contributions are being made in several coun­ to participate in WFP-financed interagency mis­ tries to activities outside the health field, such as sions for the design and evaluation of the health functional literacy training and income genera­ aspects of development projects, and to a lesser tion. A regional commission for Arab women is degree for the design of health-related compo­ being set up, with the participation of interested nents of school feeding projects aimed at improv­ agencies and influential nongovernmental or­ ing attendance and performance. In such projects ganizations. The Regional Committee for the particular importance is attached to providing reg­ Eastern Mediterranean held technical discus­ ular treatment for intestinal helminths in areas of sions in 1993 on the theme "The role of wom­ high prevalence, and to ensuring a healthy school en in support of health for all". Participants environment with emphasis on safe water supply stressed that there should be greater acknowl­ and sanitation. Unfortunately, the attention paid edgement of women's contribution to the health to the health aspects of rural development projects of families and communities, and noted that supported by food aid is not commensurate with their involvement in health can be enhanced by the gravity of the problems encountered and does using women's networks and community not suffice to offset the adverse effects associated groups to disseminate information on the health with some interventions, such as the transmission risks they face, their right to health care and the of malaria and schistosomiasis in rural irrigation schemes. WHO continued its involvement with health and nutrition aspects of emergency opera­ tions, particularly in long-term projects for refu­ 1 Gender, women and health. Washington, Pan American Health Orgamza­ gees and displaced persons (see paragraphs 2.28 tiOn, 1993 (Scientrfrc Publicatron, No. 541) to 2.33).

44 GENERAL HEALTH PROTECTION AND PROMOTION

Food safety Nutrition

9.11 Work on the development of internation­ 914 The International Conference on Nutri­ ally agreed food standards continued through tion (Rome, December 1992) was the culmination WHO's contribution to the Codex Alimentarius of more than two years' joint effort by WHO Commission. Codex provisions offer adequate and FAO to promote awareness of the extent and health protection and are recognized under the seriousness of nutritional and diet-related prob­ General Agreement on Tariffs and Trade lems and to achieve consensus on how to deal with (GATT) as providing sufficient justification for them. It was attended by more than 1300 people import restrictions. In accordance with the Final representing 159 governments and some 160 inter­ Act of the "Uruguay Round" of multilateral national and nongovernmental organizations. Ini­ trade negotiations launched by GATT, countries tial preparatory work for the conference focused could be required to furnish justification for any on stimulating effective intersectoral cooperation restrictions based on national regulations that are in countries so as to improve nutritional well­ stricter than the Codex provisions. being. Regional and subregional meetings were then organized to assess common food and nutri­ 9 12 A review article1 and fact-sheet were is­ tion problems. Information on the resulting coun­ sued on unsafe food - a common cause of infant try and regional consensus provided background diarrhoea. Since cholera and other food-borne material for a preparatory committee that met in diseases may be transmitted by street-vended August 1992 to review the main findings and draft foods, a document was issued setting out essen­ a world declaration and plan of action which were tial safety requirements for such foods. 2 This subsequently adopted by the conference.6 As they subject was discussed at an Asian conference on represent a global consensus on the nature and street foods (Beijing, October 1993 ), convened in causes of nutritional problems, the declaration collaboration with the International Life Scienc­ and plan now provide a basis for WHO support to es Institute. WHO worked with the Industry national plans of action. In response to requests Council for Development in conducting training from governments, WHO has so far provided courses in Asia and Africa and preparing training technical support and funds to 14 least developed materials and a document3 on the use of the sys­ countries in Africa, to one each in the Americas, tem of hazard analysis critical control point eval­ South-East Asia and the Eastern Mediterranean uations, which should be of value to national and three in the Western Pacific. authorities and the food industry in improving food safety. 9.15 Accurate assessment of body mass and growth, which is indispensable to interventions 913 WHO cooperated with FAO and UNEP aimed at improving physical welfare, remains a in the food contamination monitoring compo­ much debated topic. In November 1993 WHO nent of the Global Environmental Monitoring convened an expert committee to consider con­ System (GEMS), and with FAO and IAEAin the flicting ideas on this subject and more particular­ work of the International Consultative Group ly reference data and guidelines for their use and on Food Irradiation. In addition, food process­ interpretation at all stages of life. 7 ing technologies were assessed, workshops were held, and texts were prepared on food irradia­ 916 WHO, UNICEF, Wellstart International tion4 and biotechnology.5 (a WHO collaborating centre in San Diego, USA), and the World Alliance for Breastfeeding Action jointly sponsored three lactation man­ agement training workshops for 65 Russian­ speaking health workers (Saint Petersburg, Rus­ sian Federation, August 1993 ). This provided an 1 Motaqem1 Y et al Contaminated weaning food: a major risk factor for d1arrhoea and associated malnutrition Bulletm of the World Health Organ· ization, 71 (l): 79·92 (1993) 2 Document WHO/HPP /FOS/92 3. 6 World declaratiOn and plan af act10n for nutnt10n. Rome, FAO/WHO, 3 Document WHO/FNU/FOS/93.3. 1992. 4 Safety and nutritional adequacy of 11radwted food. Geneva, World Health 7 Physical status· the use and interpretation of anthropometry. Report of a Organization (In press). WHO Expert Committee. Geneva, World Health Organization (in prepara· 5 Document WHO/FNU/FOS/93.6. lion).

4S THE WORK OF WHO 1992-1993 opportunity to prepare Russian-language edi­ tions of two of WHO's most popular publica­ The Baby-friendly Hospital Initiative tions: the WHO/UNICEF statement on breast­ feeding and the role of maternity services 1 and a • The Baby-friendly Hospital Initiative is summary of the latest scientific findings on the a global movement, spearheaded by WHO physiological basis for infant feeding. 2 and UNICEF, that aims to give every baby the best start in life by creating a health care 9 17 In support of countries implementing the environment where breast-feeding is a WHO/UNICEF Baby-friendly Hospital Initia­ norm. To become truly baby-friendly, tive (see box), WHO provided training for health hospitals and maternity wards around the professionals to serve as hospital assessors in world will want to give practical effect to China, Egypt, Jordan, Lebanon, Philippines and the principles set out in the joint WHO/ Russian Federation; prepared guidelines for baby­ UNICEF statement on breast-feeeding friendly training workshops; and helped establish and maternity services. 1 WHO and lactation management training centres in Manila UNICEF are supporting national authori­ and in Sao Paulo (Brazil). With financial assistance ties responsible for designating maternity from USAID, the WHO data bank on breast­ wards and hospitals as baby-friendly in a feeding was expanded, using a revised set of inter­ variety of ways, including the issue of nationally agreed indicators; it now contains in­ guidelines and support for training. The formation from more than 2000 surveys or studies initiative is based on the principles de­ carried out in over 170 countries or territories. scribed in the joint statement, which are synthesized in "Ten steps to successful 9.18 Financial contributions from the Govern­ breast-feeding": ment of the Netherlands and SIDA enabled WHO to provide technical support in translating Every facility providing maternity services the International Code of Marketing of Breast­ and care for newborn infants should: milk Substitutes into appropriate national meas­ ures in Guatemala, Iraq, Morocco, Syrian Arab • have a written breast-feeding policy Republic, United Republic of Tanzania, and Viet that is routinely communicated to all Nam; to organize a workshop (Cairo, September health care staff; 1993) on the implementation of the Code for par­ • train all health care staff in skills neces­ ticipants from 15 Eastern Mediterranean coun­ sary to implement this policy; tries; and to brief 12 consultants (Geneva, Septem­ • inform all pregnant women about the ber 1993) who can be called upon to help the benefits and management of breast­ Organization respond to requests from Member feeding; States for technical support on this subject. • help mothers initiate breast-feeding within a half-hour of birth; 9 19 New evidence of the importance of • show mothers how to breast-feed, and vitamin A nutriture in the broader realm of child how to maintain lactation even if they health and survival and renewed commitment by should be separated from their infants; national health authorities and international or­ • give newborn infants no food or drink ganizations and bodies alike provided the impe­ other than breast milk, unless medical­ tus for producing a third revised and expanded ly indicated; edition of WHO's 1978 best-selling field man­ • practise rooming-in - allow mothers ual for assessing vitamin A deficiency.3 Technical and infants to remain together - 24 hours a day; • encourage breast-feeding on demand; 1 Protectmg, promotmg and supportmg breast-feedmg the speoal role of • give no artificial teats or pacifiers (also matern1ty sefVIces. Atomt WHO/UNICEF statement Geneva, World Health called dummies or soothers) to breast­ Orgamzat1on, 1989 Available or in preparation 1n more than 40 language ed1t1ons feeding infants; • foster the establishment of breast­ 2 Akre J ed. Infant feedmg the physiOlogical baSIS (Supplement to Vol 67 of the Bulletm of the World Health Orgamzat1on), Geneva, 1990 Availa­ feeding support groups and refer ble or 1n preparation 1n 13 language editions mothers to them on discharge from the 3 Sommer A V1tamin A defiCiency and 1ts consequences: a f1eld gu1de to hospital or clinic. thelf detection and control, 3rd ed. Geneva, World Health OrganiZation (in press)

46 GENERAL HEALTH PROTECTION AND PROMOTION consultations were held to revise the criteria for scriptive tables used in its oral epidemiological assessing iodine deficiency disorders (November studies.2 The booklet on dental caries levels was 1992), vitamin A deficiency (November 1992), updated.3 and iron deficiency anaemia (December 1993). The updated criteria represent a major advance in 9 22 The 1993 figures on caries collected by the unifying international efforts to prevent, control global oral data bank (see Figure 9.1) show a or eliminate these serious health problems and small further improvement for both developing are essential for monitoring progress towards the and industrialized countries. However, the trend goals adopted by the World Health Assembly in is consistent only for the latter. It is now quite 1990 (resolution WHA43.2) and 1992 (resolu­ clear that in countries which have espoused the tion WHA45.33) and by the World Summit for "prevention first" strategy, oral health will con­ Children in 1990. They have also contributed to tinue to improve in the immediate future. Mean­ the development of WHO's global micro­ while, in view of reiterated reports of growing nutrient deficiency information system, in which caries prevalence in the most populous develop­ three linked databases covering prevalence, sta­ ing countries, comprehensive preventive pro­ tus of control programmes and reference data are grammes must be launched or at least formulated being compiled for iodine, vitamin A and iron for rapid implementation when the need arises. deficiencies. The first report1 produced on this basis provides the most comprehensive estimates so far on the global prevalence of iodine deficien­ cy, suggesting that there are 655 million people Figure 9.1 Mean numbers of decoyed, missing or filled with goitre in 118 countries in all WHO regions. teeth (DMFT) ot12 years, 1980-1993 (weighted averages by size of population) 9 20 WHO and FAO jointly organized a con­ sultation (Rome, October 1993) on the role of DMFT fats and oils in human nutrition, particularly in 5-.------. relation to chronic noncommunicable diseases. So much new evidence had accumulated since 1977, when the subject was last reviewed, that it 4 was considered imperative to reassess the ques­ tion and the dietary implications for coronary heart disease in developed and developing coun­ 3 tries alike. The consultation made recommenda­ tions of direct relevance to Member States' nu­ 2 trition policies and to the development of nation­ al dietary guidelines.

Oral health 1981 1983 1985 1987 1989 1991 1993 9 21 As comparable oral health data have accu­ mulated from about 160 countries, global trends are becoming sufficiently clear for WHO to for­ Figure 9.1 mulate a coherent oral health strategy for Mem­ ber States. Surveys using WHO-recommended 9.23 The "community periodontal index of methods and standard recording forms contin­ treatment need" was developed in recognition of ued to supply data for the WHO global oral data the serious lack of epidemiological data on perio­ bank. In order to promote common strategies or dontal diseases. It rapidly became the standard methods for oral health surveys, WHO also pro­ index for oral health surveys and for several duced a document containing the standard de- years has provided a robust database covering

1 1 WHO/UNICEF /InternatiOnal Council for Control of lod1ne Def1c1ency Disor­ Document WHO/ORH/EIS/ICS-11/91. ders_ Global prevalence of 10dme defiCiency disorders Geneva, World 3 Dental caries levels at 12 years Geneva, World Health OrganiZation, Health Orgamzat1on, 1993 1993

47 THE WORK OF WHO 1992-1993

113 countries; a compilation of data for age­ pregnated with prophylactic agents are being used groups 15-19 years and 35-44 years, issued in to widen the choice of preventive methods and to 1992,1 has significantly changed global and na­ convince communities of the prime importance of tional estimations of the need for prevention and prevention within the framework of primary treatment of periodontal diseases, and thus pro­ health care. vides a basis for goal-setting. 9 28 Intercountry centres for oral health in Ni­ 9 24 Eight sites in six countries have reported geria, Syrian Arab Republic and Thailand, to­ results from the second international collabora­ gether with the WHO collaborating centre for tive study of oral health outcomes, in which clin­ oral health in Europe, recently designated in ical and sociological data are collected in stand­ Minsk, continued to support WHO's strate­ ard form together with data from care providers gies. More than 30 WHO collaborating centres and administrators. The information obtained is in 19 countries have made effective contributions of value for the preparation of guidelines for to country activities, for instance by updating improved oral health. situation analyses, formulating national plans of action, and providing training in the planning 9 25 A new "atraumatic restorative treat­ and management of oral health programmes. ment", in which dental cavities are cleaned with hand instruments only and then filled with glass 9 29 Considerable work was done in updating ionomer cement, is being tested in several villages existing methods and devising new ones. The in the province of Khon Kaen in Thailand. Pre­ fourth edition of Oral health surveys: basic liminary results indicate that it may prove the methods is in final draft form as is the third edi­ most appropriate technology for rural and disad­ tion of Application of the International Classifi­ vantaged communities that at present have no cation of Diseases to dentistry and stomatology. access to oral care. Short courses on the tech­ Guidelines on hygiene and infection control in nique were given for dental nurses in Cambodia oral care settings, mouth care for severely ill pa­ and the Lao People's Democratic Republic. tients, training of examiners for oral health sur­ veys, and hand instruments for community and 9.26 Extrabudgetary funds were obtained for a restricted referral level oral care were completed project to provide special curative and preventive for distribution. Extensive information material services to populations living in zones contami­ was prepared for World Health Day 1994 on the nated as a result of the Chernobyl accident. An theme "Oral health for a healthy life". international action network on oro-facial muti­ lations and noma (gangrenous stomatitis) in Af­ 9.30 Training of oral health personnel remains rica has been set up; its aim is to combine primary a major priority for most countries, and in some prevention with the availability of moderately cases there is a strong focus on situating oral complex treatment and with a referral system for health within the overall context of the health very complex care. sciences. Methods for training undergraduates and auxiliary personnel using performance simu­ 9 27 A number of projects have been undertak­ lation have been developed jointly with several en as part of the continuing effort to demonstrate collaborating centres, and a manual has been the effectiveness of oral disease prevention. With completed. Following a detailed review of cur­ support from the Borrow Dental Milk Founda­ rent dental education in countries belonging to tion (United Kingdom), WHO launched an inter­ the Commonwealth of Independent States, pro­ national milk fluoridation programme; it includes posals were made for radical changes, particular­ community projects and laboratory and feasibility ly in orienting the curriculum towards the studies, and is being implemented in nine coun­ "health sciences" approach and gearing it to so­ tries. A five-year community project successfully ciety's health priorities and needs. completed in Bulgaria confirmed that milk can be used like water or salt as a vehicle for fluoride to 9 31 Different aspects of the work were em­ combat dental caries in children. In other projects, phasized in the various regions: planning of ser­ fluoride-containing toothpastes and sealants im- vices and development of human resources and technology (Africa; Americas); application of primary health care principles to the develop­ ment of services (South-East Asia); quality assur­ 1 Document WHO/ORH/EIS/CPITN/92. ance through information systems, situation

48 GENERAL HEALTH PROTECTION AND PROMOTION

analysis and implementation of planned services 9.36 A second world conference on injury con­ (Eastern Mediterranean; Europe); and surveil­ trol (Atlanta, USA, May 1993), organized by the lance of populations at risk and promotion of United States National Center for Injury Pre­ preventive measures through the adoption of vention and Control, a WHO collaborating cen­ measurable targets for oral health improvement tre, with support from other WHO collaborat­ (Western Pacific). ing centres, was the occasion for a thorough eval­ uation of injury control programmes throughout the world. The conference succeeded in its three objectives: to strengthen technical cooperation lniury prevention between research institutes, including WHO col­ laborating centres; to further the adoption of 9.32 Under the technical coordination of the commonly agreed standards for developing ana­ WHO collaborating centre for community safe­ lytical methodology for injury control, including ty promotion at the Karolinska Institute in control of violence; and to arouse broad interest Stockholm, the network of demonstration in the WHO programme for community safety. projects on community safety expanded to in­ volve ten countries.1 9.37 Using research protocols prepared by WHO in cooperation with nongovernmental or­ 9.33 A WHO-sponsored second international ganizations and collaborating centres, two epide­ conference on safe communities (Glasgow, United miological studies are under way, one (in Tou­ Kingdom, September 1992) included violence pre­ louse, France; and Albuquerque, USA) dealing vention in its agenda. The results of case studies with falls in the elderly, and the other with burns, were used in an analysis of the concept of safety on the basis of a,n epidemiological analysis being that took into account the community's views on carried out in India and several European coun­ how it should be protected from a variety of haz­ tries. The International Society for Burn Injuries ards, including natural disasters and willful vio­ and WHO are jointly preparing a manual on the lence. The conference also examined the inadequa­ epidemiology, prevention and care of burns. cy of political or administrative mechanisms in the area of safety promotion. 9.38 In connection with the safety helmet initi­ ative carried out under the leadership of the 9.34 Programme leaders who met on the occa­ United States National Center for Injury Pre­ sion of a WHO interregional seminar on methods vention and Control, WHO convened a sympo­ for planning community safety programmes sium on neurotrauma prevention and manage­ (Toulouse, France, November 1993) decided to ment (Brussels, December 1993 ). Participants produce reference material for health planners and were reminded that brain injuries represent workers in response to the increasing demand for about half of all severe injuries from road acci­ guidance on methodology and information on ex­ dents and a large proportion of injuries from perience. The group also produced a document on other causes; they are frequently associated with community action for safety in preparation for the spinal cord trauma. The symposium initiated an 1994 Technical Discussions on the subject of epidemiological analysis based on common "Community action for health". protocols, set up a network of research centres to develop protective techniques, formulated strat­ 9.35 World Health Day 1993 provided an op­ egies to promote the use of such techniques, and portunity to present the theme of violence from a established an international forum for improving public health viewpoint. It was followed by inten­ the medical management of brain-injured per­ sive consultation both in the Organization and sons and for enhancing rehabilitation techniques between WHO and institutes in France and the and services. These activities will be coordinated United States of America with a view to building by WHO collaborating centres. up a pool of technical expertise and establishing a network of public health experts concerned with 9.39 WHO collaborated with seven Member the prevention of intentional injury. States in the Eastern Mediterranean in strength­ ening measures to promote safety and prevent accidental injury. In 1993 a course on the man­ agement of burn injuries was held for nurses, 1 Argentma, Australia, Denmark, France, lnd10, lndonesta, Sweden, That­ dealing with nursing care, treatment of cases and land, Untied Ktngdom, United States of Amertca prevention of sequelae.

49 THE WORK OF WHO 1992-1993

9 46 In the Western Pacific WHO participated Tobacco or health in a variety of activities undertaken by Member States and supported the work of non­ governmental organizations concerned with to­ Strengthening notional programmes bacco control, including regional and national conferences, meetings and workshops. By the 9.40 WHO's direct support to Member end of the biennium nine countries and areas had States included involvement in establishing and established tobacco control policies backed by at strengthening comprehensive national tobacco least some legislative measures, and most Mem­ control programmes in all regions. ber States had designated national focal points. The majority of countries and areas had taken 9 41 WHO cosponsored an all-Africa confer­ steps towards implementing the Western Pacific ence on tobacco control (Harare, November regional action plan on tobacco or health for 1993 ). Tobacco-producing countries in Africa 1990-1994 but, as the Regional Committee noted took initial steps towards harmonizing their na­ in 1992, more vigorous action is needed. tional tobacco control programmes and consid­ ered possible ways of reducing their economic dependence on this product. There was general realization of the need for greater efforts in all Health promotion, advocacy and public countries to counter the growing presence of to­ information bacco advertising, mainly by transnational to­ bacco companies; in Senegal, for example, ex­ 9 47 The 1992 and 1993 World No-Tobacco penditure on tobacco advertising exceeds Days were widely observed throughout the 1000 million CFA francs annually. world and were well reported in the news media. WHO issued information and recommendations 942 In the Americas PAHO/WHO partici­ on tobacco-free workplaces and on the role of pated actively in a meeting of the Latin American health services and health personnel in attaining a Committee against Tobacco Use (San Jose, June tobacco-free society, and awarded medals to 1993) and collaborated with the United States anti-tobacco campaigners from all regions. National Institutes of Health in setting up tobac­ Worldwide distribution of the quarterly news­ co control projects in Chile and Mexico. letter Tobacco alert continued.

9 43 In South-East Asia WHO cooperated 9.48 WHO promoted tobacco control meas­ with Bangladesh, India, Mongolia, Nepal and ures at several international conferences includ­ Thailand in strengthening national action plans ing a world conference on tobacco or health to combat tobacco use. (Buenos Aires, March-April 1992). The agree­ ments reached to hold smoke-free Olympic 9 44 Missions were sent to eight countries of Games in 1992 at Albertville (France) and Barce­ central and eastern Europe to assist in imple­ lona (Spain) and in 1994 at Lillehammer (Nor­ menting national tobacco control programmes. way) were of great publicity value. Throughout Among other regional and national meetings in the world action was stepped up to encourage Europe, the Organization supported the second Member States to adopt comprehensive tobacco and third European seminars on tobacco or control policies. health for national policy advisers and pro­ gramme managers (Budapest, January 1992; Vi­ enna, March 1993 ), which brought together par­ Data collection and research ticipants from 35 countries.

9 45 In the Eastern Mediterranean a consulta­ 9 49 Research findings were published in the tion (Alexandria, May 1992) reviewed national form of monographs on women and tobacco1 tobacco control policies and programmes and and on tobacco controllegislation2 and a techni- formulated guidelines. A joint consultation be­ tween WHO and the International Union against Cancer (Cairo, February 1993) discussed 1 Women and tobacco Geneva, World Health Orgamat1on, 1992 the political manipulation of tobacco control and 1 Roemer R Legtsfative actton to combat the world tobacco epidemtc, 2nd the role of physicians in antismoking activities. ed1t1on. Geneva, World Health Orgamzation, 1993.

50 GENERAL HEALTH PROTEUION AND PROMOTION cal document on the interaction of smoking and workplace hazards.1 lnteragency collaboration

9 50 In conjunction with the University of Ox­ 9.52 WHO worked closely with ICAO and ford (United Kingdom), WHO initiated and sup­ participated in the twenty-ninth session of its ported a series of prospective epidemiological stud­ Assembly (Montreal, September 1992), which ies to monitor the health effects of tobacco use in decided to urge all contracting States to take several countries.2 measures to restrict smoking progressively on all international passenger flights, with the objective 9 51 PAHO/WHO published a report on to­ of completely banning smoking by July 1996. bacco use, tobacco-related diseases and preven­ tion and control measures in the Americas.3 The 9.53 In response to Health Assembly resolu­ Organization also collaborated with the Office tion WHA45.20, the Director-General submit­ of the Surgeon General of the United States of ted a report on tobacco or health to the Eco­ America in preparing a wide-ranging report on nomic and Social Council of the United Nations, the problems posed by tobacco consumption in which in July 1993 adopted a resolution request­ the Americas4 and stressing the need for regional ing the Secretary-General of the United Nations coordination and cooperation to create a smoke­ to set up a focal point for multisectoral collabo­ free society. ration on the economic and social aspects of to­ bacco production and consumption, taking into account the serious health consequences of to­ bacco use.

1 Document WHO/OCH/TOH/92 1 9.54 In pursuance of the further Health As­ 2 Argentrna, Chrna, Cuba, Egypt, India, Mexrco, Poland, Unrted Kingdom, sembly resolution WHA46.8, the Director­ Unrted States of America General has urged the Secretary-General of the 3 Tobacco or health. status 1n the Amencas. Washrngton, Pan Amerrcon United Nations to ban the sale and use of Health Orgonrzotron, 1992 (Scientific Publrcot10n, No 536). tobacco products in all workplaces and public 4 Unrted States Deportment of Health and Human Servrces Smoking and areas in buildings owned, operated or con­ health 1n the Amencas· a 1992 report of the Surgeon General, in collabora· t10n with the Pan Amencan Health Organization. Atlanta, 1992 (OHHS trolled by organizations of the United Nations Publrcotion, No. (CD() 92-8420) system.

SI

CHAPTER 10 Protection and promotion of the health of specific population groups

minology to reflect the wider nature of the pro­ Maternal and child health, and gramme. family planning

10.1 During the biennium WHO gave priori­ Family planning and population ty to the integration of family planning in pri­ mary health care, and the achievement of high quality, sustainable care and management in 103 WHO worked with FAO, UNESCO, maternal and child health and family planning ILO and UNFPA in providing multidisciplinary services. The health of women and children technical cooperation and support to national continued to improve in many countries. How­ family planning and population programmes ever, in the least developed countries the various through eight regionally based teams, composed indicators (maternal mortality, anaemia during of staff from WHO and the other four organiza­ pregnancy, low birth weight) have remained tions. At an interregional meeting (Bangkok, unchanged or have deteriorated and in other May 1993) national programme managers, policy countries certain subgroups of women and chil­ makers, and representatives of nongovernmental dren show little progress. In yet other countries organizations and bodies in the United Nations the level of improvement falls short of what system agreed on strategies for increasing the might be expected, considering the coverage of choice of contraceptive methods and ensuring a services. Among the problems encountered are: high quality of care in family planning pro­ -insufficient resources allocated to services, lack grammes. A good service was defined as one of integration, and failure of services to take whose clients can decide on the basis of full and proper account of women's needs. Two fea­ accurate information about a particular contra­ tures mark countries that have made the greatest ceptive method, can expect to receive good fol­ advances in improving the health of women and low-up care and can consult well-trained staff children: the essential elements of maternal and who communicate clearly and honestly with child health and family planning services have them. Various related concepts were reformulat­ been fully implemented and are equitably pro­ ed: safety (to reflect concern about the side­ vided, managed and financed; and family plan­ effects of contraceptives); effectiveness (reflect­ ning services with a wide range of methods are ing not merely the prevention of unwanted preg­ readily accessible to all. nancies but also the effects that a method has on sexual relationships, the sense of control over the 10.2 In December 1993 a WHO expert method, freedom to use it when the person wish­ committee considered the situation of maternal es and its efficacy in preventing infection); ac­ and child health and family planning in the ceptability (reflecting satisfaction and dissatisfac­ 1990s, reviewed recent trends and technical tion with p~rticular methods, rather than looking advances and their applicability to national only at the numbers of people starting a method programmes, and stressed the need for support­ and contining to use it); and availability (reflect­ ing action by various other sectors. It drew at­ ing not only accessibility but also affordability). tention to required changes and recommended Countries are being encouraged to increase fami­ that policies, services and care should be ly planning services for adolescents and for mi­ reoriented to meet the real needs of the popula­ grants, refugees and other minorities lacking tion. It also proposed the adoption of new ter- them.

53 THE WORK OF WHO 1992-1993

Acommunity health worker explains details of birth·spacing to a mother, using a home·based materna l record .

1 10.4 Guidelines have been drawn up to assist Maternal health and safe motherhood programme managers and staff in dealing with questions of contraceptive choice and to ensure that the user's perspective is taken into ac­ 10.5 The Organization contributed to the prep­ count in programme formulation, implementa­ aration of national safe motherhood plans in 28 tion and evaluation. In addition, updated tech­ countries by cooperating in research, devising nical and managerial guidelines are being pre­ training plans and collecting and applying data. pared on services for intrauterine devices, and Decentralization of care and reinforcement of the others have been issued on use of the rapid health infrastructure at district level were advocat­ evaluation method2 and district team problem­ ed. A framework for national action plans to re­ solving in maternal and child health and family duce maternal and neonatal mortality was pre­ planning services.3 pared: known as the "mother-baby package", it describes effective measures that can be used at different levels of the health care system and be adapted by countries according to their needs.

1 (ontwceptive method mix: guidelines for policy and service delivery. 10.6 In 1992 WHO, UNFPA and UNICEF Geneva, World Heollh Organization (in press). issued a joint statement on traditional birth at­ 1 Document WHO/MCH·FPP /MEP / 931 . tendants, outlining their value and limitations; 3 Document WHO/ MCH·FPP / MEP / 93.2. WHO also produced a training package for these

54 PROTECTION AND PROMOTION OF THE HEALTH OF SPECIFIC POPULATION GROUPS practitioners. In 1993 WHO and UNDP initiat­ quality of care and reducing maternal and ed a project to strengthen national capacity to neonatal mortality and morbidity. Following a reduce maternal mortality and disabilities. In regional consultation on prevention of maternal collaboration with the International Confedera­ mortality and on infertility in sub-Saharan Africa tion of Midwives and UNICEF, the Organiza­ (Kigali, January 1992), a regional task force was tion convened an international workshop (V an­ created to plan a centre for training and research couver, Canada, May 1993) to examine ways of on safe motherhood and the status of women. improving the quality of maternal health care. Workshops on problem-solving for district teams were organized in Senegal and United Re­ public of Tanzania and a regional support project, "Accelerated action for safe mother­ Child health and development hood in the African Region", was launched. WHO assisted in the design of a national mater­ 10 7 The Organization concentrated its efforts nal health and safe motherhood programme in in this area on the promotion of perinatal and Lesotho and participated in programme evalua­ neonatal health; breast-feeding; growth, develop­ tion in Gambia. As part of efforts to strengthen ment and care of children in difficult social cir­ national capacity, an intercountry workshop cumstances; application of the Convention on the (Brazzaville, February 1993) was held to brief Rights of the Child; and action following the 1990 representatives from 37 countries, UNICEF and World Summit for Children. Health Assembly the International Children's Centre on a resolution WHA45.22 served as a basis for adapt­ number of topics including data collection for ing and applying an integrated strategy for mater­ the regional family health data bank, which was nal care and care of the newborn in district-based started during the biennium. Collaboration with programmes. Findings of earlier studies on locally­ UNICEF was strengthened through the merging produced kits were applied in national pro­ of existing interagency task forces into a single grammes to promote clean delivery practices (for joint UNICEF/WHO technical advisory group. instance, in China, Philippines and VietNam) as a complement to administration of tetanus toxoid 10 9 Activities in the Americas focused on to eliminate neonatal tetanus and reduce maternal perinatal conditions and low birth weight as and neonatal sepsis. Guidelines and training mate­ leading causes of neonatal deaths. Development rials for the management of hypothermia, an im­ of specific perinatal care was supported and portant and often unrecognized underlying cause training in aspects of maternal and child health of neonatal mortality and morbidity, were field­ services and research was strengthened. Mem­ tested. Methods and materials were devised for the ber States made particular efforts to integrate successful management of birth asphyxia, another maternal and child health programmes. The Or­ major cause of early neonatal mortality, and ganization undertook joint activities with na­ protocols and training materials were tested for tional and nongovernmental organizations in­ the management of sick newborn infants. A sim­ cluding Family Health International, Interna­ ple method for assessment of gestational age was tional Project Assistance Services (USA), Family developed to identify newborns requiring special Care International, the Population Council and care or possible referral. On the basis of earlier the United States Centers for Disease Control. research, the home-based growth and develop­ Financial support was received from Italy, Neth­ ment record was widely used in China in primary erlands, the Kellogg Foundation, UNICEF and health care and day-care centres in collaboration UNFPA. Work continued on perinatal health with UNESCO and UNICEF; this type of record projects in Bolivia, Honduras, Nicaragua and was also used in Kiribati, Papua New Guinea, Peru, together with the promotion of maternal Philippines and Viet N am, and enables both preg­ and child health education in nursing schools in nant women and health workers to recognize eight countries. risks and take appropriate action. 1010 Further progress was made in South-East Asia in developing well-integrated maternal and child health and family planning services as part Regional activities of primary health care. The safe motherhood ini­ tiative was successfully promoted at country lev­ 10 8 In Africa particular attention was paid to el: for example, the Ministry of Health of Indo­ extending the coverage of services, improving the nesia drew up a strategy and plan of action for

ss THE WORK OF WHO 1992-1993

1992-1996 in close cooperation with WHO and Guinea and VietNam as a guide to improving UNDP, a multisectoral task force in Nepal draft­ the services. An integrated management informa­ ed a national plan of action for 1993-1997, and tion system for maternal and child health and Bangladesh adopted the long-term objective of family planning services was used experimentally building up an effective, realistic and compre­ in some areas of China after training of all health hensive programme of care to reduce maternal workers involved. In most Member States family and neonatal mortality and morbidity. The Or­ planning has become an integral part of family ganization took an active part in a ministerial health services, including the introduction of conference on children organized by the South new contraceptive methods such as subdermal Asian Association for Regional Cooperation implants and long-acting injectable contracep­ (Colombo, September 1992), which outlined tive hormones. The family planning acceptance challenges, opportunities and future tasks and rate is generally low, varying between 2% (Papua drew up strategies for achieving the goals of the New Guinea) and 35% (Tuvalu) of women of 1990 World Summit for Children as part of over­ reproductive age; the low rate is attributable to all development strategy. such factors as religious beliefs, lack of aware­ ness, misconceptions, poor logistics, insufficient 10.11 In countries of central and eastern Europe managerial skills, and financial problems. emphasis was given to assisting specific groups such as teenagers and socially deprived women in overcoming barriers to family planning. Reduc­ ing the high rate of abortion in those countries, Health of adolescents accounting for a sizeable proportion of maternal deaths, is a key goal of the programme "From 1014 WHO, with support from UNFPA and abortion to contraception", resulting from the UNICEF, launched a new initiative to promote 1990 Tbilisi conference on this subject. WHO the healthy development of young people, in­ cooperated with Estonia, Romania and Russian cluding strengthening of the information base, a Federation in improving maternal and child review of the current health status of young health care and family planning, and with Alba­ people in developing countries, and technical nia in upgrading family planning and gynaeco­ support to countries. This initiative has also logical services. strengthened WHO's collaboration with non­ governmental organizations at country level. In 1012 In the Eastern Mediterranean activities fo­ the Americas activities accelerated following the cused on strengthening national capacity for approval in 1991 of a regional plan of action to planning and implementing effective maternal promote the health of adolescents; and a network and child health and family planning pro­ of institutions in this field in 10 countries was set grammes. Support was provided to countries in up with support from the Kellogg Foundation. setting up safe motherhood programmes and in reducing maternal and infant mortality rates. In a 10.15 Materials issued during the biennium in­ number of countries the prevalence of low birth cluded a publication on the health of young 1 weight remains high, even though maternal and people ; two documents prepared jointly with child health programmes have been in operation the International Youth Foundation, one on for decades. An intercountry consultation on principles of success in programming for young ways to reduce the frequency of low birth weight people2 and the other containing summaries of (Rabat, June 1992) reviewed past efforts, identi­ more than 400 exemplary programmes or 3 fied reasons for failures, and drew up an im­ projects ; and a module for training in counsel­ proved strategy for combating this problem. ling skills in adolescent sexuality and reproduc­ tive health.4 In the Americas documentation cen­ 1013 Activities in the Western Pacific were tres were established in Brazil and Colombia, largely devoted to strengthening the manage­ ment of national maternal and child health pro­ grammes. WHO's "rapid evaluation method", which combines various epidemiological and 1 The health of young people a challenge and a promrse. Geneva, World service research procedures, was used for collect­ Health OrganiZatiOn, 1993. ing information on the performance, strengths 2 Document WHO/ADH/92 3. and weaknesses of maternal and child health and 3 Document WHO/ADH/92.4. family planning services in China, Papua New 4 Document WHO/ADH/93.3

S6 PROTEaiON AND PROMOTION OF THE HEALTH OF SPECIFIC POPULATION GROUPS

~~~~------~~--~------~----~-~---~~- and PAHOIWHO developed instruments for service evaluation, care of adolescents, and clini­ The narrative research method cal history-taking. A manual on health in adoles­ cence was widely disseminated, and an informa­ • Today the health of young people is of tion system to provide data on adolescents was growing concern in most parts of tli.e world designed in Brazil in cooperation with UNFPA as changing behaviour patterns confront and the Kellogg Foundation. them with new health hazards. This is espe­ cially true of sexual and reproductive health. 10.16 Research on the interaction of adolescents, WHO together with UNFPA, the World adults and health providers was expanded. The Assembly of Youth and the World Organi­ zation of the Scout Movement and their af­ "narrative research method" 1 (see box) was filiates undertook a study of the sexual be­ used in Africa, and a meeting was held (Dakar, haviour of young people in 11 countries of April 1993) to bring young people together with sub-Saharan Africa, with over 12 000 re­ representatives of ministries of health to decide on spondents. It was carried out using a tech­ future action. The method was also used in Brazil, nique known as the "narrative research Chile, Switzerland and Thailand. A survey in In­ method", which was designed for this pur­ donesia, Nigeria and Philippines explored the ex­ pose but can be used for any research that tent to which services for maternal and child lends itself to a storyline. In the present health, for family planning and for the control of study selected young people from the youth sexually transmitted diseases are meeting the organizations used role play to develop a story which they regarded as most typical of needs of young people. In Nigeria a review of law the way in which a relationship between and policy on adolescent health was completed. two young people in their communities The research instruments from these studies are leads to an unwanted pregnancy. This story being elaborated for wider use. was then presented to representative sam­ ples of young people in each of their coun­ 10.17 A number of countries formulated national tries for modification. The resulting aggre­ policies for adolescent health, including Brazil, gated story, as well as differences among Chile, Colombia, Costa Rica and Indonesia. An adolescents of different sex, age and resi­ intercountry consultation involving representa­ dence, were reviewed by the youth organi­ tives of governments and nongovernmental or­ zations to plan future action. The intention of the study was to capitalize on those who ganizations in the Eastern Mediterranean (Beirut, know most about young people's behav­ June 1993) prepared a social profile of adolescent iour-young people themselves. girls, including adverse lifestyle factors that may It emerged from the study that there was impair their reproductive health, and suggested substantial agreement on the choice of story action at country level to provide special services in all the countries, suggesting the existence for this group. An intersectoral meeting on the of a common adolescent culture that crosses health of young people was held in Morocco national and cultural boundaries. Moreover, (Rabat, June 1992), and a school sentinel service the predominant story tended to be shared for adolescent health was set up in Tunisia. A joint by respondents of both sexes. It was also project with the Council of Europe and the Com­ clear that there is a great need to prepare young people for dealing with relationships mission of the European Communities was un­ and sexual encounters, and also to prepare dertaken on health promotion for children and families and responsible adults such as teach­ adolescents in schools. Health education courses ers, so that they can give the necessary sup­ and workshops on adolescent health were held in port. Health services too must be adapted so countries of the Western Pacific. that young people are able and willing to use them for prevention, care and treatment. 10.18 Training in counselling on adolescent sex­ This method will be of value in designing uality and reproductive health was carried out programmes for adolescents throughout the with national affiliates of the International world, spearheaded by youth leaders who, Planned Parenthood Federation in 10 countries because of their age, motivation and experi­ ence, are in the best position to learn about in South-East Asia, the Eastern Mediterranean the realities of young people's lives and provide that information to those who make policy and implement programmes for ado­ lescent health and development, including youth organizations. 1 Document WHO/ADH/93.4.

57 THE WORK OF WHO 11JIJ2-11JIJ3 and the Western Pacific, using the WHO mod­ States Food and Drug Administration approved ule. PAHO/WHO supported 11 regional meet­ its use as a contraceptive. ings for training and sensitization on adolescent health for multidisciplinary teams. A core curric­ ulum for professional training in adolescent New monthly injectable contraceptive health and development is being prepared. preparations

10.21 In 1992 major phase Ill clinical trials were Human reproduction research completed on two once-a-month injectable preparations, Mesigyna (50 mg of norethisterone 1019 1992 marked the twentieth anniversary of enantate plus 5 mg of estradiol valerate) and the Special Programme of Research, Develop­ Cyclofem (25 mg of medroxyprogesterone ace­ ment and Research Training in Human Repro­ tate and 5 mg of estradiol cypionate), developed duction, which is funded almost exclusively from by WHO. One of the trials, conducted in extra budgetary contributions and is cosponsored 12 centres in Egypt, evaluated the two prepara­ by UNDP, UNFPA, WHO and the World tions and the results will be taken into account in Bank. To mark this occasion, a special report on deciding whether to approve them for the na­ the global status of reproductive health was is­ tional family planning programme. The second sued as part of the Programme's 1990-1991 bi­ trial, in China, compared the same preparations ennial report.1 and Chinese Injectable No. 1. Preliminary analy­ ses confirmed the high efficacy and superior clin­ ical efficacy of Mesigyna and Cyclofem; and this may lead to a shift to use of these preparations in Contraceptive safety China. In June 1993 a consultation of experts reviewed the available data on the new prepara­ 10.20 In May 1993 a group of experts met to tions and confirmed that they were safe and ef­ review available data on the use of depot­ fective in preventing pregnancy. They also offer medroxyprogesterone acetate (DMPA) and the significant advances over progestogen-only risk of cancers of the breast, cervix, endometrium injectables owing to the relatively high frequency and ovary, including data from the large WHO of predictable menstrual patterns. Preliminary collaborative study of neoplasia and steroidal data suggest that return to ovulation occurs contraceptives. The experts concluded that there within a reasonable time, but further work is was no evidence for an overall increase in the risk required to confirm return to fertility. The ex­ of cancer at any of the four sites reviewed, associ­ perts recommended these methods for routine ated with the use of DMPA, and therefore did use in family planning clinics, bearing in mind not recommend restricting its use as a contracep­ that they have contraindications similar to those tive on the grounds of risk of neoplasia. Al­ applicable to oral contraceptives. though an increased risk of breast cancer was observed in certain subgroups of women using DMPA, the findings were difficult to interpret. It was considered unlikely that the growths ob­ Intrauterine devices served represented new tumours caused by DMPA. On the other hand there was good evi­ 10 22 Until recently many of the copper-bear­ dence of protection against endometrial cancer. ing intrauterine devices (IUDs) were approved It was also recommended that further studies by national drug regulatory authorities for up to should be conducted to collect data on long-term only four years of continuous use as there was DMPA use by young women and the effect of its little information on their efficacy beyond that use in combination with estrogen. In 1992, fol­ period. Long-term studies by WHO on two cop­ lowing the publication of results of the WHO per-bearing IUDs- the TCu220C and TCu380A study of DMPA and breast cancer, the United - have now provided data on up to nine years of continuous use. The pregnancy rates for the de­ vices at nine years of use represented an annual risk of accidental pregnancy of less than 1% with 1 Khanna J, Van look PFA, Gr1ff1n PO, eds Reproducttve health· a key to a one device and less than 0.5% with the other. bnghter future Geneva, World Health Organ1zat1on, 1992. Comparative trials of these devices are continu-

ss PROTEatON AND PROMOTION OF THE HEALTH OF SPECIFIC POPULATION GROUPS ing and will provide information on their safety duct a multicentre trial to determine the lowest and efficacy up to and beyond ten years of use. In effective dose of mifepristone for emergency the light of these studies, the United States Food contraception. and Drug Administration decided in August 1991 to extend the approved duration of use of the TCu380A from six to eight years. Methods for the regulation of male 10.23 An important issue in recent years has fertility been whether use of the IUD is related to pelvic inflammatory disease (PID) and whether long­ 10.25 Work continued in evaluating hormonal term use is associated with severe forms of the contraceptive options for men and assessing the disease. A study of the large database on IUDs safety and efficacy of various methods for occlu­ maintained by WHO has shown that in a total of sion of the vas deferens. A five-centre study in 22 908 insertions in 12 trials, the overall rate of Indonesia on sperm suppression induced by PID was 1.6 cases per 1000 woman-years of use, combined androgen-progestogen administration i.e. only three cases of PID could be expected in was completed in 1992, and the results submitted two thousand women using an IUD for one year. for publication. It was found that testosterone The study also showed that the risk of PID was enantate or 19-nortestosterone ester plus DMPA seven times higher than the above rate in the 20 resulted in much higher rates of azoospermia in days following insertion of the device, but there­ Indonesian men (97%) than previously observed after was low and remained constant for at least with such drug combinations in Caucasian men. eight years of use. There was no evidence of an The multicentre study on the contraceptive relia­ increase in the severity of PID with increasing bility of testosterone-induced severe oligozoo­ duration of use. Because of the greater risk of spermia continued in 15 centres in nine coun­ PID associated with insertion, IUDs should be tries. Previous studies had revealed variations in left in place up to their maximum lifespan and the responsiveness of men of different ethnic ori­ not be routinely replaced earlier, if there are no gins to contraceptive steroids, and the underly­ contraindications to continued use and the wom­ ing mechanisms are being explored further in an wishes to continue with the method. investigations supported by WHO and collabo­ rating agencies.

10.26 A study is under way in China on the Mifepristone for emergency contraception safety and efficacy of three different methods of vas occlusion, the "no-scalpel method", percu­ 10.24 Antiprogestogens have been shown to taneous injection of a sclerosing agent, and injec­ have potential for use in emergency contracep­ tion of a polyurethane plug into the lumen of the tion. These compounds neutralize the action of vas deferens. A consultation was held in Septem­ the hormone progesterone and can block ovula­ ber 1992 to review progress in research on tion or retard the preparation of the uterus for Tripterygium wilfordii, which is used in tradi­ implantation, depending on whether they are ad­ tional Chinese medicine for the treatment of pso­ ministered before or after ovulation. WHO riasis; it recommended setting up a programme funded two randomized trials to compare the of limited duration to determine whether an efficacy and side-effects of a single dose of antifertility drug could be developed from the 600 mg of mifepristone with those of the stand­ active compounds identified in extracts of this ard Yuzpe regimen ("morning-after" pill), plant. which is the currently used method in emergency contraception. In these trials none of the 597 women given mifepristone became pregnant as compared to nine pregnancies among the 589 Vaccines for fertility regulation treated with the Yuzpe regimen. The women treated with mifepristone reported less nausea 10.27 It is proposed to develop a birth-spacing and vomiting, as well as lower rates of other side­ vaccine that will be effective for a period of up to effects, than the women treated with the Yuzpe 18 months, since this is perceived to be a useful regimen; but the onset of their next menstrual interval for users at practically all stages in their period was more likely to be delayed. In view of reproductive lives. A prototype anti-hCG vac­ the encouraging results, it is now planned to con- cine was developed solely to demonstrate the

59 THE WORK OF WHO 1992-1993 safety and feasibility of the approach and not as a vice was tested in a multicentre trial, as was the final product. It had therefore been envisaged measurement of guaiacol peroxidase, an enzyme that this vaccine would not be used beyond the with a concentration in cervical mucus that is phase I clinical trial stage, and that an improved inversely related to blood estrogen levels during anti-hCG vaccine would be prepared for further the follicular phase of the cycle. WHO also pro­ clinical testing and product development. How­ vided support for the development of assays of ever, the results of the phase I trial were consid­ urinary steroid glucuronides that require only ered sufficiently encouraging to proceed with a the collection of urine on to filter paper, thus phase II trial to determine whether the level of avoiding the problems of storage and transport anti-hCG antibodies produced in response to the of liquid urine. vaccine does in fact provide protection against pregnancy in fertile women. Prevention and management of infertility 10.28 Studies to develop an anti-trophoblast vaccine continued. This research concentrated on the use of monoclonal antibodies and molecular 10.31 Research has focused on the prevention of genetics techniques in order to identify and char­ infertility caused by sexually transmitted diseas­ acterize tissue-specific antigens, with particular es and the management of infertility, especially in emphasis on antigens that may be suitable for the developing countries. This work includes stand­ development of a vaccine which will have an ardizing the investigation of infertile couples, effect prior to the completion of implantation. evaluating certain treatments of infertility in the male and the female, developing and evaluating kits for simplified diagnosis of sexually transmit­ ted diseases, and estimating their prevalence Methods for the natural regulation of through seroprevalence studies in developing fertility countries. Also under way are the development of a vaccine against genital infection with 10.29 The highest research priority for WHO in Chlamydia trachomatis and the evaluation of this area continued to be lactation and its role in barrier methods for the prevention of sexually the suppression of ovulation. In addition, re­ transmitted diseases. In 1992 WHO was instru­ search was conducted on indicators of the fertile mental in introducing polymerase chain reaction period, including new possibilities for the meas­ (PCR) methodology for chlamydial antigen de­ urement of urinary steroid glucuronides, and on tection in tertiary health care centres in six de~el­ natural family planning. The prospective oping countries. multicentre study of the relation of breast-feed­ ing practices to the duration of lactational amenorrhoea continued. The purpose of this study, which involves 3850 mother-infant pairs, Introduction and transfer of technology is to elucidate the factors that determine lactational infertility. Other current research in­ 10 32 A strategy for the introduction of new and cluded studies on the effects of supplementary underutilized methods of fertility regulation was nutrition to nursing mothers on the return of drawn up during the biennium. The strategy shifts ovulation, studies on the immunoactivity and the emphasis in the introduction of methods from bioactivity of luteinizing hormone and prolactin, the product itself to users' needs and programme and studies on the interface between breast-feed­ capabilities, and also provides background infor­ ing and the adoption of other methods of contra­ mation for decisions by national family planning ception. programmes concerning additional methods. It takes into account not only the potential demand 10 30 Accurate estimation of the fertile interval for a method but also the capability of services to in women is vital to the efficacy of family plan­ cope with the demand and to back up the method ning methods based on periodic abstinence. Re­ with the appropriate care. The strategy will be search concentrated on inexpensive and simple implemented initially in selected countries in Lat­ methods or devices that can be used in the home in America and sub-Saharan Africa. to measure biochemical or biophysical markers of the fertile period. The measurement of 10 33 Studies on the introduction of the once-a­ cervico-vaginal fluid volume using a simple de- month injectable contraceptive, Cyclofem, into

60 ------PROTECTION AND PROMOTION OF THE HEALTH OF SPECIFIC POPULATION GROUPS national family planning programmes in Indone­ of these, 50 (in 30 countries) were designated as sia, Jamaica, Mexico, Thailand and Tunisia have WHO collaborating centres for research in hu­ been completed or are being assessed. They exam­ man reproduction, while the remainder were in­ ine such factors as use-effectiveness, reasons for volved in research capability strengthening. Ef­ discontinuation of methods and service delivery forts were made to encourage and support tech­ constraints in each of these countries, based on the nical cooperation among developing countries. A experience of 7700 women, and the findings are special fund has been set aside for this purpose, now being written up. After completion of the to which the Rockefeller Foundation contrib­ pilot phase, the study in Chile was extended to utes. additional clinics at the end of 1992. New studies were begun in Brazil, Colombia and Peru in 1993. 10.38 In Africa emphasis continued to be given to the least developed countries and to the pro­ 10_34 Following a 1991 meeting on women's motion of "South-South" collaboration for re­ perspectives in the selection and introduction of search capability strengthening. A task force on fertility regulation methods, representatives of the prevention of maternal mortality and infertil­ women's health groups, researchers and policy­ ity was established following a regional consulta­ makers from Bangladesh, India, Indonesia and tion on this subject (Kigali, January 1992). A Philippines met for further discussion of this research management workshop (Harare, March topic (Manila, October 1992). 1992) brought together scientists from eight countries.

10.39 Assessments of research needs in reproduc­ Social science research tive health were supported in Chile, Panama, Peru and English-speaking countries of the Caribbean. 10J5 Work continued in the major research ini­ These were followed by interagency coordination tiative on the determinants of induced abortion, and fund-raising to meet the research challenges launched in 1991. Of 27 projects supported by identified. Promotion of training capabilities in WHO, about half were completed by the end of the Americas included support for a master's 1993. In the area of male fertility and contracep­ degree course in reproductive epidemiology and a tion, studies supported thus far under the con­ one-year course in the organization of clinical tri­ dom acceptability initiative were completed by als. Much of the responsibility for the award of the end of 1992, and new studies continue to be short-term training grants has been delegated to accepted. Research was begun on the role of men regional research and training organizations. This in determining family size and in making deci­ policy improves coordination, reduces costs and sions about contraceptives. Acceptability studies administrative time spent, and encourages in­ of contraceptive methods including vasectomy, volvement of researchers themselves in decision­ female sterilization, the diaphragm, IUDs and making. A regional network for epidemiological monthly injectable preparations are under way. research is now fully operational and a regional Several studies concerned with gender roles are programme on social science research is under proceeding. Factors affecting contraceptive use way. Reproductive health research will benefit continue to be of major interest to researchers in from strengthening of non-human primate facili­ the developing world, and remain a priority sub­ ties in Chile, research on molecular biology in ject for research supported by WHO. Mexico, and reproductive immunology research in Cuba and Peru. Technical cooperation among developing countries is an important part of the strategy, as is the encouragement of links with Resources for research leading research institutions in developed coun­ tries. Workshops on scientific writing were con­ 10.36 WHO seeks to strengthen the capabilities ducted in Argentina, Brazil, Chile and Venezuela. of developing countries to plan and carry out pri­ ority research in reproductive health. It also main­ 10.40 Two intercountry meetings organized in tains contacts with a network of research centres Cairo to assess research needs, one dealing with that participate in global research activities. maternal and child health (November 1991) and the other with reproductive health (December 10_37 A total of 105 institutions in 56 countries 1992), provided a basis for formulating an East­ were working with WHO during the biennium; ern Mediterranean regional strategy to promote

61 THE WORK OF WHO 1992-1993 research and strengthen national research capaci­ guide for ships; and harmonization of medical ty in these fields. examination requirements for seafarers. The Committee appealed to all the parties concerned 10 41 A shift of emphasis in support in South­ to collect comparable statistics concerning acci­ East Asia and the Western Pacific led to a sub­ dents and other health problems of seafarers. stantial increase in collaboration with least devel­ oped countries, which now receive about 50% of 10.45 Work continued on reference methods the available funds. Following the signature of a and quality assurance in the evaluation of expo­ memorandum of understanding, it is expected sure to airborne fibres at work, with the support that collaboration will be strengthened with In­ of the International Fibre Safety Group and dia in the development of research capacity and Commission of the European Communities. the promotion of research in human reproduc­ Following a comparative analysis in 1992, the tion. methods were refined at two expert meetings (Sheffield, United Kingdom, February 1993; New Orleans, USA, May 1993).

Occupational health 10.46 The importance is now recognized of ob­ taining data on doses and health risks for biolog­ 10 42 In April1992 the Joint ILO/WHO Com­ ical monitoring of exposure to chemicals at mittee on Occupational Health reviewed pro­ work. Meetings organized in collaboration with grammes on occupational health and safety, dis­ the International Programme on Chemical Safe­ cussed aspects of occupational health in Member ty worked out strategies (Kyoto, Japan, October States, drew up general policies and designated 1992), identified chemicals requiring priority at­ areas for collaboration between the two agencies. tention (Geneva, December 1992) and drew up guidelines for data collection (Geneva, Novem­ 10.43 A first meeting of WHO collaborating ber 1993). centres in occupational health (Moscow, Septem­ ber 1992) discussed ways of strengthening "net­ 10 47 A workshop on medical surveillance of working" of institutions in this field, at national workers exposed to dusts inducing pneumo­ and international level. In support of this aim, coniosis, organized in collaboration with ILO WHO issued a directory of its collaborating cen­ and in association with an international confer­ tres in occupational health1 and launched a quar­ ence on occupational lung diseases (Prague, Sep­ terly newsletter. A planning group was set up to tember 1992), outlined requirements for improv­ coordinate the international activities of the col­ ing the prevention of occupational respiratory laborating centres and advise on the programme; diseases. Subsequently, technical guidelines on at its first two meetings, in December 1992 and the medical screening of workers exposed to June 1993, it surveyed global needs and deter­ mineral dusts were prepared for use in training mined priorities. programmes to improve medical surveillance in Member States. In addition, the interaction be­ 10 44 In May 1993 the Joint ILO/WHO Com­ tween smoking and workplace hazards was re­ mittee on the Health of Seafarers reviewed the viewed.2 occupational health problems of seafarers and formulated recommendations and guidance in 10.48 A J01llt WHO/ILO interregional task the following areas: injury prevention; preven­ group on health protection of workers in small­ tion of blood-borne and sexually transmitted in­ scale undertakings (Bangkok, November 1993) fections; education of seafarers on the dangers to reviewed the global situation and worked out their health and careers from abuse of drugs and acceptable, low-cost but effective measures. alcohol; prevention and control of mental diseas­ es and psychosocial disturbances; procedures for 10 49 In collaboration with the International periodic updating of the International medical Commission on Occupational Health, an inter­ national directory of occupational health data­ bases and data banks was issued in loose-leaf

1 leht1nen S Collaborotmg centres in occupational health· directoty, net· working, pnonties and future perspecttves Geneva, World Health Orgon1· zot1on, 1992 'Document WHO/OCH/TOH/92 1

62 PROTECTION AND PROMOTION OF THE HEALTH OF SPECIFIC POPULATION GROUPS format and on computer diskette. 1 The reports of 10.52 In the osteoporosis study, the hospital a WHO expert committee on health promotion discharge data survey and case-control study in the workplace in relation to alcohol and drug proposal were finalized in collaboration with the abuse,2 and a WHO study group on aging and coordinating centre at Stanford University working capacity3 were published. Activities (USA). The selection of instruments for the case­ dealing with safe use of pesticides included the control study was completed and approved by publication of guidelines4 and sponsorship of an the principal investigators from the participating international symposium on health and ergo­ centres (Brazil, China, Hong Kong, Hungary, nomic aspects of the safe use of chemicals in Iceland, Nigeria, Trinidad and Tobago) and from agriculture and forestry (Kiev, June 1993 ). parallel study centres (Chile, Italy, Poland) dur­ ing their first meeting in March 1993. Translation 10.50 The wide range of activities to promote of the study proposal and instruments and their the health of working populations at regional adaptation to each culture then began. A survey level included education and training in occupa­ on the prevalence of osteoporosis in the popula­ tional health in Africa, promotion of interagency tion of part of Beijing was started in 1992 under and intersectoral cooperation in the Americas contract with the University of California through the initiative "1992: Year of Workers' (USA). Health", integration of health care for workers in national health systems using the primary health 10 53 In the project on age-associated demen­ care approach in South-East Asia, strengthening tias, the pilot studies already carried out in 1991 of occupational health services with particular in Nigeria and the United States of America by attention to countries of central and eastern Eu­ participating centres were followed by studies in rope, framing of appropriate legislation in the Chile, Malta and Spain in 1992. The project coor­ Eastern Mediterranean, and safety promotion in dinating centre located in the office of the Studio small-scale undertakings in the Western Pacific. Multicentrico Italiano sulla Demenza in Flor­ ence (Italy) made an analysis of the pilot studies, following which the study instruments were fi­ nalized, translated, printed and distributed to all Health of the elderly participating centres. Data collection for the field study began in each centre in August 1993 and 10.51 During the biennium, as part of the inter­ data on the prevalence of dementia conditions national research programme on aging requested should be available by the end of 1994. The re­ by the World Health Assembly in 1987, the Or­ sults of standardization of the clinical diagnosis ganization proceeded with the development and of dementia carried out in 1991-1992 are now in implementation of three studies on osteoporosis, press. The results of the pilot study were submit­ age-associated dementias, and determinants of ted for publication at the end of 1993. healthy aging, as described below, while detailed planning was begun for a fourth (on immunolo­ 10.54 In 1992 a group of experts met to initiate gy and aging) following receipt of funding. An the project on determinants of healthy aging. The international study to assess home care needs was Centre for Ageing Studies of Flinders University also launched. The United States National Insti­ of South Australia was designated as coordinat­ tute on Aging continued its technical and finan­ ing centre and Costa Rica, Israel, Italy, Jamaica, cial support to research activities and additional Thailand and Zimbabwe were selected as partici­ funds became available for the implementation of pating countries. During 1993 the coordinating research projects in countries. centre, in collaboration with Yale University (USA) and Duke University (USA), drew up a proposal for a pilot study and prepared instru­ ments for assessing physical, mental and social functioning in the aged population. In March 1993 WHO hosted a meeting of the research 1 Sevdla JM InternatiOnal d11ectory of databases and data banks tn occupa­ tional health. Palma de Mallorca, World Health OrganiZation/International network on successful aging of the MacArthur Commission on Occupational Health, 1993 Foundation (USA). The subsequent selection of 2 WHO Techmcal Report Series, No. 833, 1993 the assessment instruments mentioned above 3 WHO Techmcal Report Se11es, No. 835, 1993 was based on recommendations made by the net­ 4 Control technology for the formulatron and packrng of pestiCides Geneva, work. Harmonization of these instruments and World Health Orgamzat1on, 1992. the feasibility and validation study in three of the

63 THE WORK OF WHO 1992-1993 participating countries (Costa Rica, Italy, Thai­ individuals in the home setting and for land) were completed. intercountry comparison. The home care initia­ tive was strengthened at international level by 10.55 In Europe another project on healthy ag­ the creation of a World Organization for Care in ing, established jointly with the European Com­ the Home and Hospice, with which WHO munity, focuses on health promotion for the eld­ forged close links. One aspect of home care - erly. A meeting (Heidelberg, Germany, October family support - was highlighted in a book pub­ 1992) examined the contribution of prevention lished in 1992 on WHO's behal£. 1 and rehabilitation to healthy aging, and urged life-long preparation for healthy aging through 10.57 WHO convened an interregional consul­ health promotion and the creation of environ­ tation (Alexandria, October 1992) to prepare a ments allowing elderly people to realize their strategy for health care of the elderly, which in potential and to remain in their own homes for as due course will be incorporated into the United long as possible. Nations strategy for aging populations. Follow­ ing the consultation, efforts have been made in 10.56 A major home care initiative was launched several regions to encourage Member States to during the biennium, recognizing that such care pay more attention to national policies and strat­ is given in many countries, affords the best qual­ egies for care of the rapidly expanding popula­ ity of life for most people and is often less expen­ tion group of the elderly. In Africa, for example, sive than many kinds of acute and chronic care in an average of 5. 9% of the population in Member institutions. It was stimulated by the recognition States is aged 60 years and over, while only 7% of in all WHO regions that well-planned home care the countries have policies for the care and wel­ may contribute appreciably to the containment fare of this age group. Thus much technical col­ of costs in providing good quality health services laboration at regional level has been aimed at for the elderly. Preliminary steps were taken to raising awareness and improving assessment of determine the need for home care from existing the health needs of the elderly; strengthening data from three developed and nine developing geriatric and gerontological services within the countries, analysed with the assistance of the framework of primary health care; and encour­ United States National Institutes of Health, aging health protection and promotion for the Duke University (USA) and the United States elderly with particular emphasis on involvement Bureau of the Census, as a basis for advice to be of the elderly themselves in these activities. given to individual countries on the needs of their elderly populations. WHO also participat­ ed in a project to design a valid and reliable sur­ vey instrument in various languages which 1 Kend1g Hl, Hashimoto A, Coppard LC, eds. Family support for the elderly would allow for both the assessment of needs of the international expenence. Oxford, Oxford University Press, 1992.

64 CHAPTER 11

Protection and promotion of mental health

and eastern Europe, supported by the European Mental health policy, and support Federation of Neurological Societies. The three to national programmes groups contributed substantially to a forthcoming publication on neurology and public health. 11.1 In its work to ensure that psychosocial and behavioural factors are fully taken into ac­ 11 4 Methods were devised for assessing cost­ count in the whole range of health care, and in its effectiveness in mental health programmes, infor­ specific activities related to mental and neurolog­ mation systems were established in support of ical disorders, WHO received support from the national mental health programmes, a national Carnegie Corporation (USA), Delagrange Inter­ workshop on computer-assisted mental health re­ national!Synthelabo Recherche (France), Digital cording and reporting was held in China, and na­ Equipment Corporation (USA), Johann Jacobs tional workshops were organized to share infor­ Foundation (Switzerland), the Laureate Founda­ mation about programme development in some tion (USA), the United States National Institute 40 countries. To facilitate national planning, of Mental Health, Ravizza Farmaceutici (Italy) WHO has started a new series of monographs on and the Upjohn Company (USA), as well as the epidemiology of mental disorders and psycho­ UNICEF and the World Bank. Work in the social problems; and the first three, dealing with Western Pacific was supported by the Sasakawa personality disorders, with dementia and with Foundation Qapan). schizophrenia, are being published1 in addition to a paper on the epidemiology of suicidal behav­ iour. A fourth edition of an annotated directory of mental health training manuals2 and a report on Development of national mental health WHO's research activities in mental health were programmes issued.

11.2 Guidelines on formulating national men­ tal health programmes and instruments for as­ sessing mental health policies and programmes Classification and assessment were produced in 1992 and are being field-tested. WHO collaborated with countries of central and 11 5 Building on the chapter of mental and be­ eastern Europe in strengthening their mental havioural disorders in the tenth revision of the health programmes. International Classification of Diseases (ICD- 10), diagnostic guidelines3 (so far issued in 11.3 To increase public and professional aware­ ness of the burden of neurological disorders, WHO organized meetings on neurology and pub­ 1 de Girolama G, Reich JH. Personality disorders. Geneva, World Health lic health: the first in May 1993 supported by the OrganiZation, 1993. International School of Neurological Sciences in Warner, R, de Grrolamo G. Schizophrenia. Geneva, World Health Orgama· Venice (Italy); the second in October 1993, for lion (in press). French-speaking countries, supported by the In­ Henderson, AS, Dementw Geneva, World Health OrganizatiOn (rn press) 2 stitute of Neurological Epidemiology and Tropi­ Document WHO/MNH/MND/92 15. 3 The /CD· I 0 classificatiOn of mental and behavioural d1sorders. Cltnical cal Neurology in Limoges (France); and a third in desmptions and diagnostic gu1delmes Geneva, World Health Organrza­ Berlin in December 1993, for countries of central tion, 1992.

6S THE WORK OF WHO 1992-1993

10 languages), diagnostic criteria for research, sionals working in camps. WHO helped to assess and tables for conversion between ICD-8, ICD-9 needs and provided mental health consultant and ICD-10 were published. 1 A primary health services in former Yugoslavia and in Somalia. care version of the chapter for field trials was The Organization also collaborated with psychi­ produced2 and a lexicon of alcohol and drug atrists in the Philippines to produce a manual on terms and another of psychiatric mental health psychosocial care for victims of natural disasters terms used in ICD-10 and related publications and provided training and education on psycho­ are in print. Several standardized assessment in­ social aspects of health as part of medical educa­ struments were produced and are now widely tion in China. A study in India classified ways in used by mental health workers. Experts and in­ which adolescents adopt risk-taking behaviour. stitutions in some 50 countries participated in the field work that led to the compilation of these 11 8 A document was issued on the psycho­ texts, and a network of WHO collaborating cen­ social and mental health aspects of women's tres was set up to provide training, compare ex­ health.4 In collaboration with UNICEF, a net­ perience and conduct further research. work of centres linked by a newsletter, Skills for life, was set up to promote communication or 11 6 A study was begun in five countries to other psychosocial skills as a means of helping investigate the somatic presentation of psycho­ children and adolescents to avoid behaviour del­ logical disorders in different cultural circum­ eterious to health. A WHO life-skills resource stances and develop diagnostic instruments for package is being tested in Colombia, Nigeria, their assessment. An adaptation of the Interna­ Thailand and Zimbabwe, to meet the needs of tional Classification of Diseases for neurology school-age children, particularly those actually was prepared in collaboration with a network of in school. Training guidelines were produced for centres and with major nongovernmental organi­ health workers on ways to improve parent-infant zations. In September-October 1992 a meeting interaction, and training workshops on this topic was held to discuss diagnostic criteria for acute were held in Brazil, Norway and Portugal. onset of flaccid paralysis. Three meetings took place as part of a new WHO study aimed at producing an instrument for assessing changes in quality of life due to health care interventions Prevention and control of (Geneva, February and June 1992; Paris, June alcohol and drug abuse 1993). 11 9 Evaluations of drug prevention and con­ trol programmes were undertaken or continued in several countries and areas5 and prevention of Psychosocial and behavioural psychoactive substance abuse was widely pro­ problems and relevant moted. Following a feasibility study, an abuse interventions trends linkage alerting system (ATLAS) was set up; it is compatible with other data reporting 11 7 A set of 25 papers was produced on be­ systems of the United Nations and provides a havioural approaches to medical problems and framework for revising existing WHO epidemi­ on the teaching of communication and interac­ ological instruments on drug abuse. This activity tion skills, for incorporation into teaching mod­ was supplemented by a number of regional initi­ ules for medical schools. Preliminary studies atives, especially in the Americas, South-East were undertaken in Belarus, Egypt, India and Asia and Europe, which should enhance Zimbabwe on measures to improve communica­ WHO's capacity to provide accurate informa­ tion skills in health workers. A booklet on the tion on patterns of substance abuse. Rapid as­ management of psychosocial consequences of sessment procedures, involving qualitative re- disasters was prepared/ as well as a draft manual on refugee mental health, for use by nonprofes-

4 Document WHO/FHE/MNH/92 1. 1 1 Document WHO/MNH/92.16 Afghanistan, BoliVIa, Brazil, Chile, Ch1na, Estonia, Hong Kong, Latv1a, 2 L1thuan1a, Macao, Maur1t1us, Myanmar, Nepal, Sri Lanka, and some mem· Document WHO/MNH/MND/93.1 bers of the Commonwealth of Independent States (Kazakhstan, 3 Document WHO/MNH/PSF/91 3 Kyrgyzstan, Tapk1stan, Turkmemstan, Uzbek1stan)

66 PROTECTION AND PROMOTION OF MENTAL HEALTH search, were developed and applied in various their integration with primary health care, are settings, including Central Africa and selected being evaluated with a view to using them in small island countries. A similar approach was areas with high rates of substance abuse. Work used for reviewing health aspects of drug use in was completed on a simple procedure for assess­ relation to sports and for gathering information ing the quality of care in the treatment of sub­ on drug use by women in 25 countries. As part of stance abuse; this, together with other training its contribution to the 1994 International Year of materials produced by WHO for use in the pri­ the Family, WHO prepared a position paper on mary health care setting, formed the basis for preventing substance abuse in families. It also training focusing on the needs of developing collaborated with theWorld Bank in incorporat­ countries. ing global data on substance abuse into the Bank's 1993 report.' 11 13 A matter of particular concern in Asia has been the rapid increase in HIV-infection caused 11 10 An expert committee report was issued by drug injection. Descriptive and epidemiologi­ dealing with the prevention of alcohol- and drug­ cal data on drug injection practices have been related problems in the workplace;2 it recom­ collected in Bangkok, with a view to designing mended in particular that their solution should and testing cost-effective interventions. combine comprehensive prevention policies and health promotion programmes. A joint UNDCP/ 11.14 In September-October 1992 a WHO ex­ ILO/WHO project on prevention of drug and pert committee updated the definition of drug alcohol use among workers and their families is dependence, linking it closely to the ICD-10 being implemented in Egypt, Mexico, Namibia, diagnostic criteria for the dependence syndrome, Poland and Sri Lanka. WHO has started a dia­ and made a number of recommendations on the logue with representatives of the alcoholic bever­ prevention and management of drug dependence age industry in order to alert them to the public and other drug-related problems.3 health consequences of trends in alcohol con­ sumption, including alcohol-related traffic 11 15 Several participating centres received sup­ accidents and violence. In 1992 the Regional port from the international drug monitoring pro­ Committee for Europe strongly endorsed a gramme in strengthening their capability for col­ European alcohol action plan, after which several lecting data on abuse-related adverse drug reac­ technical meetings were held to decide on how tions and recognizing early warning signs of the plan should be implemented in countries. non-medical use of newly marketed psycho­ Following earlier work on this subject, WHO be­ active drugs. As part of efforts to rationalize the gan a review of the health policy and legal aspects prescribing of psychotropic drugs in the Ameri­ of treatment and rehabilitation of persons de­ cas, a seminar was organized (Montevideo, Oc­ pendent on or suffering from abuse of drugs and tober 1993) to make government officials, pre­ alcohol. scribers and journalists more aware of the prob­ lem of inappropriate use of drugs. Collaboration 11.11 Qualitative and quantitative assessment was strengthened with professional bodies such techniques were designed to support studies on as the World Psychiatric Association, which has the WHO initiative on cocaine, including such set up an educational task force on the use of topics as the natural history of the substance and benzodiazepines. factors causing cocaine abuse and harm; drug use among street children and indigenous popu­ 11 16 The difficulties faced by small regulatory lations; the impact of intentional inhalation of agencies in controlling unofficial drug distribu­ volatile organic substances; and the health conse­ tion systems were examined at a consultation quences of cannabis use. (Vienna, June 1993) organized jointly with UNDCP, and guidelines for effective import 11.12 Cost-effective community-based ap­ control and inspection are being drawn up. proaches to treatment and rehabilitation, and Field-testing of a software package for compu­ ter-assisted regulatory procedures is in progress. WHO cooperated with Benin and Nigeria in

1 World Bank World development report 1993 tnvestmg tn health. New York, Oxford Unrversrty Press, 1993. 2 WHO Technical Report Serres, No. 833, 1993 3 WHO Technrcol Report Seties, No 836, 1993

67 THE WORK OF WHO 1992-1993 strengthening their national regulatory agencies. cation, were organized in several countries in Human resources development for regulatory 1992. Field-testing of instruments for quality as­ control was supported through a series of inter­ surance in mental health care began in 16 coun­ national training seminars (Beijing, June 1992; tries in all regions. Instruments for the assess­ Shanghai, June 1993; Abidjan, December 1992; ment of mental health services are now available Tokyo, July 1992 and July 1993). in eight languages.

11.18 Guidelines on treatment of epilepsy, on family care of schizophrenic patients (currently Mental and neurological available in six languages) and on case manage­ services ment of and housing for the mentally ill were produced, and a computer-based multi-media in­ 11.17 A major international review of laws on formation system on epilepsy is being estab­ promotion of mental health and support to the lished. mentally ill, covering 45 countries in all regions, was started with funding from the United States 11.19 Strategy reviews and implementation National Institute of Mental Health. Technical guidelines on the prevention of mental retarda­ advice was provided in drafting mental health tion, epilepsy, suicidal behaviour and staff legislation in China and Fiji, and updating legis­ "burn-out" syndrome were produced. In addi­ lation in Argentina, Brazil, Colombia, Panama tion, WHO supported a number of studies of and Venezuela. Training for mental health lead­ such topics as lithium prophylaxis in manic de­ ers as well as courses on psychosocial rehabilita­ pressive disorders (eight countries); depression tion, focusi ng on family training and patient edu- in old age (one country); eye movements in pa-

Creotive educolion for the mentolly hondicopped in finlond.

68 PROTECTION AND PROMOTION OF MENTAL HEALTH tients with schizophrenia (seven countries); and disorders in 10 countries were published.1 A fol­ combined utilization of antidepressants and anti­ low-up study on the long-term course and out­ oxidants in the treatment of therapy-resistant de­ come of schizophrenia in 15 countries is under pression (19 countries). way. A study was initiated on the psychopathol­ ogy of obsessive and compulsive disorders of indigenous populations in six countries.

Epidemiological studies 11.22 A study was carried out in nine countries on cultural differences relevant to the diagnosis 11.20 Several studies involving the differential and classification of mental disorders, especially diagnosis of dementia (six countries), the epide­ in respect of substance abuse, and on this basis to miology of cognitive impairment and dementia develop culturally relevant diagnostic instru­ (seven countries), and psychological problems in ments. A further study to evaluate the accuracy general health care (14 countries) were complet­ of epidemiological data obtained with the diag­ ed with WHO support. The preparatory phase nostic instruments began in 12 countries. A re­ was completed and data collection started for view of the effectiveness of treatment of mental several other studies and projects, including a disorders has been published.2 major study on the effects of radiation on brain development in utero that is being carried out as part of the international programme on the health effects of the Chernobyl accident (see 1 Jablensky Aet al. Schizophrenia: manifestations, inCidence and course in different cultures A World Health Organization study. Cambridge, Cam­ paragraph 12.31). bridge University Press, 1992 (Psychological medicine monograph supple­ ment 20). 11.21 The results of a WHO-coordinated study 2 Sartorrus, N et al. Treatment of mental disorders· a review of effective­ on the determinants of outcome of severe mental ness. Washington, American Psychiatric Press Inc., 1993.

69

CHAPTER 12 Promotion of environmental health

12 1 The WHO Commission on Health and En­ to the environment as defined by UNCED and vironment completed its work, and its report was WHO's global strategy for health and environ­ issued, 1 together with the reports of its panels on ment. Special attention was given to capacity­ energy, food and agriculture, industry, and urbani­ building at the national level, a major initiative zation.2 The series served as the basis for determin­ being the WHO/UNICEF joint water supply and ing the health aspects of Agenda 21, the action sanitation monitoring programme for the 1990s. programme for the 1990s and beyond, adopted by In 1992 subregional workshops in Africa 172 countries at the United Nations Conference on (Mbabane,June; Cotonou, Benin, September) and Environment and Development (UNCED), com­ the Caribbean (Kingston, February) introduced monly referred to as the "Earth Summit" and held monitoring procedures to almost 100 countries. at Rio de Janeiro, Brazil, in June 1992. Following these workshops, several countries,3 supported by WHO and UNICEF, started activi­ 12.2 A new global strategy for health and envi­ ties or established programmes to strengthen their ronment based on the recommendations of the monitoring capability. These procedures are being WHO Commission and prepared in response to modified in collaboration with UNRW A to re­ Agenda 21 was endorsed by the Health Assembly spond to needs in Gaza. As part of the WHO/ in May 1993. An interregional consultation (Oc­ UNICEF joint programme, information was col­ tober 1993) was convened to coordinate the devel­ lected on the status of water supply and sanitation opment of global and regional action plans for for 1990 and 1991, and annual reporting was con­ implementing the strategy, and a WHO council tinued for advocacy purposes. on the Earth Summit action programme for health and environment first met in January 1993 to ad­ 12.4 During the biennium particular emphasis vise on the institutional, financial and coordina­ was given to hygiene education associated with tion aspects. In pursuance of the council's rec­ water supply and sanitation. WHO collaborated ommendations, WHO, in collaboration with with theWorld Bank in producing training tools UNDP, provided support to countries incorpo­ and manuals, and with UNICEF in familiarizing rating health and environment considerations in regional and country sanitary engineers of both national plans for sustainable development. agencies with the latest hygiene education and community participation principles under a joint training programme.

Community water supply and 12 5 School sanitation and hygiene education sanitation were the subject of a consultation (Cali, Colom­ bia, March 1993) and a round-table (Hanoi, June 12.3 Meanwhile WHO directed its efforts to­ 1993). Hygiene education activities were spon­ wards ensuring that the development of water sored in Benin and Burkina Faso through a 4 supply and sanitation services proceeded in a nongovernmental organization (EAST ), and field manner consistent with the intersectoral approach

3 Ben1n, Bronl, Cope Verde, Egypt, lnd1o, Jomo1co, Popuo New Gu1neo, 1 Our planet, our health. Genevo, World Heolth Orgon1zot1on, 1992. Phil1pp1nes, Sri lonko, Togo, Vonuotu 1 Documents WHO/EHE/92 2; WHO/EHE/92 3; WHO/EHE/92.4; WHO/ 4 Acronym of "Eou, Agmultu1e et Sonte en Mil1eu trop1col" (Woter, AgTICul­ EHE/92.5. ture ond Heolth 1n the Trop1cs).

71 THE WORK OF WHO 1992-1993

demonstration projects were initiated in 12.10 Member countries received support in in­ Zimbabwe. Closer ties were established with stalling or improving systems for use of waste­ UNESCO in promoting school health and with water. Guidelines on the chemical and viral as­ UNICEF in formulating a joint strategy on hy­ pects of wastewater use were completed during giene education. the biennium. WHO held a regional workshop on wastewater (Amman, February 1992) and ini­ 12.6 Water resource management for the con­ tiated follow-up action in Bahrain, Cyprus, trol of disease vectors continued to receive em­ Egypt, Oman and Tunisia. phasis, largely through activities of the joint WHO/FAO/UNEP/United Nations Centre for 12.11 Work in pursuance of the policy of inten­ Human Settlements (UNCHS) panel of experts sified cooperation with countries and peoples in on environmental management. greatest need took place in Benin (monitoring, hygiene education and vector control), Guate­ 12 7 An interregional workshop considered mala (management and health education), ways to use agricultural extension programmes to Mozambique (information systems and cholera promote environmental management for disease control), Yemen (management and hygiene vector control (Tegucigalpa, October 1992). In education) and Zambia (cholera control and 1992 a national training course on health opportu­ school sanitation). nities in water resources development was organ­ ized in Zimbabwe in collaboration with the Dan­ 12 12 In September 1993 the Regional Commit­ ish Bilharziasis Laboratory; follow-up activities tee for Africa endorsed the establishment of Af­ included a joint FAO/WHO mission to the coun­ rica 2000, a programme to accelerate water-sup­ try and a national policy review by the Liverpool ply and sanitation development. School of Hygiene and Tropical Medicine and the Blair Research Institute (Harare, October 1993 ). 12.13 WHO continued to participate in the ACC Intersecretariat Group for Water Resourc­ 12.8 At the first meeting of the Water Supply es, which in 1993 became the ACC Subcommit­ and Sanitation Collaborative Council (Oslo, tee on Water Resources, and to act as secretariat September 1991), an operation and maintenance for the Interagency Steering Committee for Wa­ working group was constituted under WHO's ter Supply and Sanitation and host to the secre­ leadership, resulting in the organization of a na­ tariat of the Water Supply and Sanitation Collab­ tional workshop in the Philippines (Manila, Au­ orative Council. gust 1992), an intercountry workshop on leakage detection and reduction in Pakistan (Lahore, Oc­ tober 1992), and a conference on sustainability of rural and urban water supplies in Ghana (Accra, Environmental health in rural April 1993). The working group also drew up and urban development and guidelines for the formulation of technical and housing institutional development strategies and pre­ pared training packages on leakage control and 1214 Pursuant to resolution WHA44.27 on ur­ the management of rural water supply and sani­ ban health, the Organization accorded high pri­ tation facilities. The September 1993 meeting of ority to urban environmental health activities in the Collaborative Council endorsed the working view of the continued rapid growth and deterio­ group's activities and requested WHO to con­ rating environmental conditions in many of the vene a new working group on the promotion of world's cities. Comprehensive and integrated ur­ education in sanitation and hygiene. ban health development activities took place in an increasing number of cities in all regions. In 12 9 In response to the global cholera epidemic Africa three major meetings were convened dur­ (see paragraph 14.79), WHO prepared a series of ing the biennium: the first and second meetings fact sheets illustrating simple techniques in envi­ for French-speaking African countries under the ronmental sanitation and cholera prevention. Healthy Cities project (Dakar, July 1992; Tunis, The Organization installed 450 water supply September 1993) and a regional workshop on chlorinators in countries affected by cholera. In urban health (Harare, November 1993 ). Other Africa WHO organized cholera preparedness regional activities included an intercountry workshops and conducted rapid assessments of workshop on the improvement of health and en­ water and sanitation needs. vironmental conditions in urban slum areas

72 I'ROMOnON OF ENVIRONMENTAL HEALTH

Use of wostewoter in Cope Verde's Proio Negro project. This practical system comprises primary treatment units (foreground), stobilizotion ponds (centre) and agricultural fields (background). The effluent provides sole ond plentiful irrigation in semi·arid conditions fo r o variety of crops including onions, couliflowers, green peppe rs, gropes and pin eapples.

(New Delhi, August 1992), a joint meeting on on the subject (Nairobi, July 1993; Bangkok, Healthy Cities initiatives in Europe and the November 1993). Americas (Seville, Spain, October 1992), and an intercountry workshop on urban health (Manila, 12.16 Training of municipal managers in envi­ August 1993). A global Healthy Cities confer­ ronmental health was emphasized in Healthy ence was held (San Francisco, USA, December Cities projects. This was also the subject of a 1993). National Healthy Cities programmes separate project in Brazil which was launched in were launched in Bangladesh, Brazil, Ghana, Is­ collaboration with UNEP and in the course of lamic Republic of Iran, Pakistan, Saudi Arabia which a training workshop in Rio de Janeiro and Tunisia. involving some 35 municipal agencies drew up a municipal health plan that was subsequently put 12.15 The "supportive environments for into effect with outside financial support. Train­ health" approach, which focuses on the key set­ ing in municipal health planning carried out with tings of everyday life (home, neighbourhood, vil­ support from Japan included the preparation of lage, school, workplace, city) and encourages the plans in Chittagong (Bangladesh) and Ibadan participation of citizens and authorities in mak­ (Nigeria) in 1993. ing each setting conducive to good health, is be­ ing applied in various countries with projects 12.17 WHO activities in solid waste disposal in­ such as "healthy schools", "healthy villages", cluded an interregional consultation convened in and "healthy workplaces". A handbook on pro­ September 1992 to prepare technical guidelines motion of health-supportive environments is be­ on hospital and medical waste management in ing prepared, and regional workshops were held developing countries, and training workshops on

73 THE WORK OF WHO 1992-1993 solid waste management in Fiji in 1992 and the widely disseminated in all Member States through Philippines in January 1993. various publications meeting the needs of specific professional groups. During the biennium 28 vol­ umes of the Environmental Health Criteria series were published to review present knowledge and International Programme on evaluate risks associated with exposure to specific Chemical Safety chemicals; 10 Health and Safety Guides were pro­ duced, providing concisely evaluated information 1218 Programme development. The Interna­ on priority chemicals in non-technical language tional Programme on Chemical Safety (IPCS), for decision-makers and managers, including ad­ established in 1980 as a joint activity of ILO, vice on protective measures and emergency re­ WHO and UNEP, was designated by UNCED sponse action; and 179 International Chemical as the nucleus for international cooperation on Safety Cards were issued in several languages, environmentally sound management of toxic each summarizing essential product identity data chemicals. Resolution WHA45.32 of the World and health and safety information on one page for Health Assembly, adopted in 1992, has estab­ use at workplaces. lished mechanisms to coordinate WHO's con­ tribution to IPCS. To strengthen interagency co­ 1221 During three meetings of the Joint FAO/ ordination in this area, ILO, WHO and UNEP WHO Expert Committee on Food Additives cer­ developed a strategy in collaboration with other tain additives, contaminants, naturally occurring potentially interested international institutions toxicants and veterinary drug residues in food were such as FAO, OECD, UNIDO and the Com­ considered,2 and at the annual Joint FAO/WHO mission of the European Communities. Meetings on Pesticide Residues acceptable daily intakes were established.3 IPCS also worked on 1219 International conference on chemical safe­ questions concerning assessment and safe use of ty. UNCED requested the executive heads of pesticides with various organizations, whose activ­ ILO, WHO and UNEP to arrange for further ities are not always well coordinated. At a consulta­ consideration to be given to the recommendations tion held in July 1992 on consolidation of work on made by a group of experts in 1991 1 for increased pesticides, a proposal was made for core groups to coordination between United Nations bodies and assess toxicological and ecotoxicological data and other international organizations involved in for panels to draw up practical recommendations chemical risk assessment and management. The on pesticide levels in food, drinking-water, the government-designated experts called for appro­ workplace and the environment. priate measures to enhance the role of IPCS and for an intergovernmental forum on chemical risk 12 22 Methodology for health risk assessment. assessment and management to give policy guid­ IPCS continued to prepare monographs on prin­ ance, develop strategies in a coordinated manner, ciples for evaluating the toxicity of chemicals for provide the required political support and foster various organs and organ systems and is devising understanding of the issues by governments. Ac­ methods for quantitative risk assessment and for cordingly, all Member States and intergovern­ setting exposure limits for chemicals in air, water mental and nongovernmental organizations con­ and food. The monographs enable scientists and cerned have been invited to participate in an inter­ others to understand the process of risk evalua­ national conference on chemical safety to be held tion for chemicals, and assist countries in under­ in Stockholm in 1994. The Government of taking their own national risk evaluations and Sweden is acting as host to the conference and management. One of the earliest published was several governments have offered human and fi­ Principles for evaluating health risks to progeny nancial resources for its organization. associated with exposure to chemicals during pregnancy (Environmental Health Criteria 30); 12 20 Risk evaluation. Evaluation by IPCS of and in view of recent scientific developments in the risks to health and the environment from certain priority chemicals provides a basis for chemical risk management and the findings are 1 The reports were publ1shed 1n the WHO Techn1col Report Ser1es, No. 828 (1992), No 832 (1993) ond No 837 (1993) 3 The report of the f1rst wos publ1shed 1n FAO Plant Production and Protection 1 Document UNEP/IPCS/IMCRAM/exp/4 Papers, No. 116 (1992) and the second 1s 1n preparation

74 PROMOTION OF ENVIRONMENTAL HEALTH reproductive and developmental toxicology, it is tries in Africa and in central and eastern Europe. currently under review for updating and expan­ A comprehensive guide for assessing water qual­ sion. Several other monographs and reports were ity through sampling and analysis of biota, issued during the biennium, including Quality sediments and water was published in collabora­ management for chemical safety testing (Envi­ tion with UNEP and UNESC0.1 Training ronmental Health Criteria 141) and Principles for courses on monitoring methods were organized evaluating the effects of chemicals on the aged in support of programmes concerned with inter­ population (Environmental Health Criteria 144). national river basins (Mekong, Nile, Plate). Na­ tional and regional workshops on various aspects 12.23 Prevention and treatment of chemical poi­ of water quality monitoring were organized in soning. Guidelines on how to set up and operate Colombia, Fiji, and Trinidad and Tobago in poison control facilities, a manual to help labora­ 1993. tories in developing countries provide a basic analytical toxicology service using a minimum of 12.26 Additional parameters were included in complex apparatus, and a handbook containing the WHO/UNEP air quality monitoring project basic information on diagnosis and treatment of and the data were made more easily accessible. A poisoning were prepared in 1993. Several mono­ major WHO/UNEP assessment of air pollution graphs on antidotes were also in preparation. and its effects on health in 20 cities was complet­ Work on the INTOX software package for poi­ ed and the findings published.2 The WHO/ son information centres continued and a first UNEP human exposure assessment location version of the global database on chemical sub­ (HEAL) project continued to provide guidance stances, pharmaceuticals, poisonous plants and on exposure assessment and support for quality animals was made available in 1992. Several Poi­ assurance in monitoring several pollutants, in­ son Information Monographs were produced on cluding lead and nitrogen oxides. Twenty coun­ CD-ROM, containing evaluated information tries were represented at a meeting which re­ concerning the toxic properties of chemicals, on viewed work on assessment of exposure to lead how to diagnose and treat affected persons, and (Bangkok, November 1992). on how to prevent poisoning. lntercountry training workshops were held in Canada, Islamic 12.27 Education, training and research in envi­ Republic of Iran, Uruguay and Venezuela to ronmental health were promoted through the strengthen national capabilities for the preven­ WHO global environmental epidemiology net­ tion and management of poisoning. work, whose membership now includes about 2000 institutions and individuals in all regions. 12 24 Human resource development. Training One-week training workshops for national staff materials were produced on: the effect of metab­ were held in several countries.3 A variety of olism on toxicity; chemical safety; safe use of training materials were developed, including a pesticides; and environmental epidemiology. textbook on basic epidemiology.4 An extensive lntercountry workshops and training courses review of the potential public health impact of were organized on all aspects of chemical safety, global climate change began in collaboration including environmental epidemiology, in with WMO, UNEP and the Intergovernmental Costa Rica, Philippines, Venezuela, Viet N am Panel on Climate Change. The health effects of and Zimbabwe. Capacity-building is being pro­ ultraviolet radiation were assessed and an inter­ moted through expansion of IPCS's network national collaborative epidemiological research of national institutions concerned with chemical project on the health impact of solar ultraviolet safety, for example in Africa, and IPCS news is radiation and ozone layer depletion was started increasing public awareness of chemical risks jointly with WMO, UNEP and IARC. among the public at large.

1 Chopmon D, ed. Water quality assessments London, Chopmon and Hall, Control of environmental 1992 health hazards 2 World Health Organization. Urban an pollution m megaot1es of the world. Oxford, Blockwell, 1992. 3 Argentmo, Ch1no, Eth10p1o, Gabon, Hungary, Nicaragua, Philippines, 12.25 Monitoring and assessment of pollution. Poland, Thailand, Venezuela, Viet Nom. The WHO/UNEP global network for monitor­ 4 Beoglehole R, Bonito R, Kjellstrom T. Bas1c ep1dem1ology. Geneva, World ing water quality expanded to include new coun- Health Organization, 1993

75 THE WORK OF WHO 1992-1993

12.28 Control of environmental pollution. The pollution from motor vehicles were studied in revision of WHO's guidelines for drinking­ Manila and expertise was provided in drawing up water quality, last issued in 1984, was completed an air quality management plan for the Philip­ during the biennium; volume 1 was published in pines. In the Americas surveys on hazardous 1993/ and volumes 2 and 3 will appear in 1994. waste were carried out in more than 15 countries. An interregional workshop in May 1993 consid­ In Europe support was given in preparing guide­ ered the application of the WHO guidelines for lines for land-based pollution control and for air quality in Europe to different climates and control of microbiological and chemical pollut­ under different conditions. Research on epidemi­ ants in the Mediterranean. ological, social and technical aspects of the do­ mestic use of biomass fuel and coal were under­ 12 31 Radiation protection. Implementation of taken in Ethiopia (indoor air pollution and safety the international programme on the health ef­ aspects) and VietNam (health education as­ fects of the Chernobyl accident, endorsed by the pects). Health Assembly in 1991, continued during the biennium through five pilot projects concerned 12 29 As a contribution to capacity-building in with haematology, thyroid effects, brain damage environmental health risk monitoring and man­ in utero, epidemiological registration, and oral agement, guidelines were issued on the assess­ health (samples of tooth enamel being used for ment of sources of air, water and land pollution.2 individual dosimetry determination). WHO The WHO global environmental technology supported work in Belarus, Russian Federation network (GETNET), set up in 1991 to link spe­ and Ukraine through the supply of medical, cialists in environmental management technolo­ computer and auxiliary equipment and diagnos­ gy, expanded to include 340 members in 87 tic kits. Over 100 specialists were trained, either countries. Three workshops on different aspects in their own countries or abroad. Two meetings of environmental management and control were were held to strengthen coordination between held (Bangkok, August 1992; Amman, October health-related projects concerned with the con­ 1992; Bucharest, September 1993). sequences of the Chernobyl accident (Kiev, No­ vember 1992; Geneva, May 1993). A consulta­ 12.30 Member States in all regions were sup­ tion was organized on coordination of studies of ported in their efforts to control air and water health damage in workers responsible for clean­ pollution. For example, the health effects of air up following the Chernobyl accident and their offspring in the Baltic countries (Helsinki, May 1992). A fourth coordination meeting of parti­ cipants in the WHO radiation emergency medical preparedness and assistance network 1 Guidelines for d11nking·water quality, Vol I. Recommendations. World (REMPAN) endorsed a WHO plan for emer­ Health Organization, Geneva, 1993. gency assistance and the establishment of an in­ 2 Documents WHO/PEP /GETNET/93. l-A and B ternational database on radiation exposure.

76 CHAPTER 13 Diagnostic, therapeutic and rehabilitative technology

district hospital has been distributed. A meeting Clinical technology on the integration of basic surgery into primary health care (Irbid, Jordan, November 1992) re­ 13.1 During the biennium WHO paid particu­ sulted in the modification of programmes in lar attention to improving surgical and anaesthet­ Egypt and Sudan. ic services at district hospitals in developing countries. Health Volunteers Overseas (USA), a non-profit organization, financed the prepara­ tion of videotapes based on the orthopaedics sec­ Health laboratory technology tions of WHO handbooks. The scope, limita­ and blood safety tions and implications of providing day care sur­ gery in developing countries were examined in 13.3 Regional and interregional meetings were collaboration with the International Society of held on strengthening public health laboratories Surgery. Jointly with the International Society of at primary health care level, quality assurance, Orthopaedic Surgery and Traumatology, WHO standardization and quality assessment, produc­ assessed the suitability of a simplified modern tion of basic laboratory reagents, and blood safe­ technology for treating fractures in small hospi­ ty. A total of 320 laboratories in 111 countries are tals. A handbook describing simple surgical pro­ registered in five WHO international external cedures for correcting deformities in poliomyeli­ quality assessment schemes (see box); and two tis was published.1 N ongovernmental organiza­ additional schemes were established in 1992. tions concerned with improving care of patients in district hospitals cooperated with WHO in the 13.4 WHO collaborated with FINNIDA, the assessment of training needs and the organiza­ Finnish Red Cross and the French Red Cross in tion of refresher courses in a number of develop­ organizing courses on transfusion medicine and ing countries. transfusion services. Training courses on blood safety were held in five African countries. Re­ 13.2 The Organization evaluated the impact on gional training centres for blood transfusion Cameroon's health services of practical proce­ were established in Amman and Tunis. Two ma­ dures introduced into the undergraduate curric­ jor publications were issued on this subject.2 ulum in medical schools and during internship so as to prepare young doctors for district hospital 13 5 Studies were in progress during the work. It continued to support Cameroon, Mo­ biennium on the incidence of HIV transmission zambique and Niger in introducing appropriate through blood transfusion (in collaboration with technology for anaesthesiology and surgery in the United States Centres for Disease Control); peripheral areas. Training of clinical staff of pro­ transfusion requirements for anaemic pregnant vincial and district hospitals in Mozambique has women; the prevalence of markers of transfu­ shown very encouraging results. A Portuguese sion-transmissible infectious agents in seven version of the WHO handbook on surgery at the

2 Guidelines for quality assurance programmes for blood transfusion serv1ces. 1 Krol J, ed. Rehabilitation surgery for deformities due to poliomyelitiS. Geneva, World Health Organization, 1993; G1bbs WN, Britten AFH, eds. Techniques for the district hosp1tal. Geneva, World Health Organization, Gu1delmes for the organization of a blood transfusion service. Geneva, 1993. World Health Orgamzation, 1992.

77 THE WORK OF WHO 1992-1993

was provided to China, Cyprus, Mali and United WHO improves the performance of Republic of Tanzania in the rational planning laboratories and use of radiological diagnostic services.

• By establishing international external 13 7 Radiotherapy. WHO continued to collab­ quality assessment schemes (IEQAS) orate with IAEA in improving radiation dose WHO aims to improve the performance measurement and promoting technology trans­ and reliability of the participating labora­ fer through the secondary standard dosimetry tories (for instance, those dealing with laboratories network, comprising 71laboratories clinical chemistry, haematology, microbi­ in 50 countries, 36 of them developing. A consul­ ology, coagulation and parasitology) and tation on the design requirements for a new kind to encourage their staff to establish na­ of high voltage X-ray machine for use in devel­ tional or regional schemes. Laboratories oping countries was organized jointly with enrolled in the schemes perform tests on IAEA and UNIDO (Washington, December specimens received from the organizers 1993). and return the results to the organizers, who analyse them statistically, assess per­ 13.8 Radiation protection. In collaboration formance and send back confidential re­ with other international organizations, WHO ports and educational material. This pro­ continued to revise the basic safety standards for cedure provides a basis for comparing radiation protection, and the five-volume Manu­ laboratories' performance and also for as­ al on radiation protection in hospitals and general sessing kits, equipment and methods. practice published between 1974 and 1980. However, participation in an IEQAS is only part of a laboratory's quality assur­ ance procedures: each laboratory will have Technology development, established an internal quality control assessment and transfer programme (I QC), and poor performance in an IEQAS will prompt examination of that programme to determine and correct 13.9 Significant progress in interagency collabo­ the shortcoming. The ultimate goal is to ration was made through the convening of a meet­ arrange for those laboratories that per­ ing to establish an international network of agen­ form satisfactorily in an IEQAS to start cies for health technology assessment (Paris, Sep­ national or regional schemes. tember 1993). A second meeting on technology development, assessment and transfer (Alexan­ dria, October 1993) brought together representa­ tives of several international agencies as well as senior health officials. A cohesive collaborative programme was planned, leaving each region lati­ countries; virus inactivation of fresh frozen plas­ tude to decide its own priorities and pace of im­ ma and cryoprecipitate; production of cold­ plementation while all involved work together to chain equipment for blood and blood products; promote the programme at country level, sharing development of a cost-effective screening tech­ experiences and developing core activities such as nique for schistosomiasis detection in urine; and training, exchange of information and collabora­ assessment of a rapid diagnostic test for tion with nongovernmental organizations. Plasmodium falciparum.

Drug management and policies Radiation medicine 13.10 The Organization collaborates with na­ 13.6 Diagnostic imaging technology. New tional drug regulatory authorities in harmoniz­ technical specifications were drawn up for an ing approaches to drug registration and surveil­ improved "WHO radiographic unit" as a part of lance, establishing international standards for the WHO Imaging System. Training seminars in quality assurance, and exchanging information diagnostic ultrasound and in nuclear medicine on national regulatory decisions. The rational were held in cooperation with IAEA. Support use of drugs can be ensured only within a well-

78 DIAGNOSTIC, THERAPEUTIC AND REHABILITATIVE TECHNOLOGY defined framework of regulation. Through its 13.15 In April 1993 a meeting of interested par­ model lists of essential drugs and related pre­ ties was held in collaboration with CIOMS to scribing information, WHO helps countries to discuss means of advancing the principles em­ foster cost-effective drug use and procurement. bodied in WHO's Ethical Criteria for Medici­ nal Drug Promotion. Broad consensus was reached by industry representatives, consumers and other parties on the approaches required to Pharmaceuticals attain this objective.

13.11 The Organization continued to produce a 13 16 The participants in a meeting organized wide range of information, primarily for drug jointly in September 1993 with CIOMS and the regulatory authorities, which is made available in WHO collaborating centre for international the quarterly subscription periodical WHO drug drug monitoring in Uppsala (Sweden) stressed information, the monthly WHO pharmaceuticals the need for wider monitoring of the action of newsletter, the United Nations Consolidated drugs in routine use and more reliable compara­ List of Products whose Consumption and/or tive information on the risk/benefit ratio and Sale have been Banned, Withdrawn, Severely Re­ cost-effectiveness of drug use in both developed stricted or Not Approved by Governments, and developing countries. WHO's Model Prescribing Information series and the cumulative lists of international non­ 13.17 The databases that WHO maintains to proprietary names (INN). serve national drug regulatory authorities were broadened to include information not only on 13.12 To complement established normative in­ suspected adverse drug reactions, but also on struments such as The International Pharmaco­ spurious products, and on newly adopted na­ poeia, WHO's Good Practices in the Manufac­ tional regulations to control the labelling and ture and Quality Control of Pharmaceutical advertising of medicinal plants. Products, the WHO Certification Scheme on the Quality of Pharmaceutical Products moving in 13.18 An eighth revision of the Model List of International Commerce, and WHO's Guiding Essential Drugs was produced at a WHO expert Principles for Small National Regulatory Au­ committee meeting in November 1993. thorities, the Organization has developed, with financial support from Germany and Italy, a 13.19 A second international meeting on the computer package on drug registration for na­ role of the pharmacist (Tokyo, August-Septem­ tional drug regulatory authorities, now available ber 1993 ), organized in collaboration with the in English, French and Spanish and being used in International Pharmaceutical Federation and the some 20 countries. Commonwealth Pharmaceutical Association with financial support from Japan, made recom­ 1313 New normative texts being prepared un­ mendations for improving the quality of phar­ der WHO's aegis include international stand­ maceutical services and resultant benefits for ards for good clinical practice and for good labo­ governments and the public and propounded a ratory practice in the field of drug development, concept of pharmaceutical care. and criteria for interchangeable products from several sources. Collaboration continued with 13.20 Collaboration was maintained with the the International Conference on Harmonization International Federation of Pharmaceutical of Technical Requirements for Registration of Manufacturers Associations and the World Fed­ Pharmaceuticals for Human Use, which brings eration of Proprietary Medicine Manufacturers together representatives of regulatory bodies and with a number of national funding agencies, from Europe, North America and Japan. including in particular the German Foundation for International Development, in training key 13.14 A comprehensive set of recommendations staff in the various aspects of national regulatory on measures needed to deal with the alarming and enforcement activities. prevalence in some countries of spurious and substandard medicines was drawn up at a work­ 13.21 Training of staff for drug regulatory au­ shop convened in April 1992 by WHO and the thorities in developing countries continued. International Federation of Pharmaceutical Following satisfactory evaluation in June 1992 of Manufacturers Associations. seven courses sponsored by the German Foun-

79 THE WORK OF WHO 1992-1993 dation for International Development, regional tion collaborated with the World Conservation courses were organized in Benin and in Tunisia Union and the World Wide Fund for Nature in and Zimbabwe at the end of 1993. The model preparing guidelines on the conservation of me­ software package for handling drug regulatory dicinal plants; helped to draft a document on the data (see paragraph 13.12) was introduced in Af­ integration of traditional and modern medicines rica, the Americas and the Eastern Mediterranean in a project conducted under the aegis of the with financial support from Italy and Germany. Cooperation Council for Arab Gulf States; and WHO cooperated with UNDCP in organizing a participated in a UNIDO consultation on the technical workshop on parallel distribution sys­ industrial utilization of medicinal and aromatic tems for narcotic and psychoactive substances at plants in Asia and the Pacific (Vienna, July national level (Vienna, June 1993). 1993), which stressed the need for the develop­ ment of coherent national policies and effective regulation to control the quality and use of the Biologicals final products.

13 22 The Organization continued to work ·---··----~~-» •~•-H--~>~ ,,_ closely with national regulatory authorities, pro­ Action Programme on Essential viding guidance on the production and licensing Drugs procedures necessary to ensure the quality of biological products used in health care pro­ 13 26 Because of the global economic crisis and grammes. the shift from centrally planned to free market economies in various countries, new thinking 13.23 Guidelines were issued for national au­ and strategic planning were needed in the area of thorities on good manufacturing practices, quality essential drugs. Many developing countries, assurance and regulations. Several developing some eastern European countries and the Com­ countries participating in the Children's Vaccine monwealth of Independent States requested Initiative invited a team of experts to evaluate the WHO's cooperation in assessing new situa­ manufacture and regulation of locally produced tions. The technical support provided focused on vaccines; in all cases significant changes in admin­ setting priorities and determining strategies to istrative procedures were recommended. increase access to and appropriate use of essential drugs. This often meant redefining the responsi­ 13.24 In pursuance of WHO's constitutional bilities of the ministry of health and its relations functions in regard to the standardization of bio­ with other ministries. logical products, 19 new or replacement interna­ tional reference materials were established: six 13 27 No ready-made solutions were available; for the diagnosis or therapy of blood disorders emphasis was placed on finding innovative and and one for quantifying an antigen of HIV. Some rapid answers to various questions: how drugs 27 000 ampoules of international reference mate­ were to be financed; how public health goals, rials, prepared principally in national collaborat­ including equity, could be maintained in a chang­ ing laboratories in Denmark, Netherlands and ing combination of public and private sectors; United Kingdom, were made available for stand­ and how national regulatory authorities could ardizing product dosage and diagnostic proce­ control an increasingly complex pharmaceutical dures. New or revised production and quality sector, with particular regard to drug quality, control requirements were issued for six prod­ safety and the provision of accurate information ucts, including human plasma fractions and an for both prescribers and consumers alike. improved typhoid vaccine. 13 28 In face of the growing global disparity between needs and accessibility, WHO intensi­ fied its direct and operational country support Traditional medicine activities, particularly in Africa and the Ameri­ cas, but also in Asia, where Maldives and Mon­ 13 25 Work continued in drawing up guide­ golia joined the list of more than 80 developing lines on the standardization, assessment for effi­ countries that are receiving technical and/or fi­ cacy, and utilization of traditional medicines, nancial support. National capacity-building con­ including herbal preparations. The Organiza- tinued to be a major aim. At over 20 national

80 DIAGNOSTIC, THERAPEUTIC AND REHABILITATIVE TECHNOLOGY workshops in four WHO regions, and at three 13 32 WHO continued its vigorous information intercountry strategic planning workshops in and advocacy strategy exemplified by the March­ Africa, policy-makers from some 30 countries April 1992 issue of World health on essential met to develop or review their own national drug drugs, with a strong focus on national drug pol­ policies and to exchange experience. In Benin, icy and rational use, and the brochure "Essen­ Bolivia, Guinea and Nepal, ways of improving tial drugs, action for equity", produced in Eng­ technical and managerial methods used in the lish, French and Spanish. The expanded Essential pharmaceutical supply system were tested. drugs monitor, published in English, French and Spanish, reached an estimated 200 000 policy­ 13.29 To stimulate technical cooperation among makers, administrators, health workers, non­ developing countries, staff members from some governmental organizations, and industry and national essential drugs programmes in partici­ consumer organizations in 150 Member States pating countries acted as advisers or trainers in with news of policy developments, essential drug others; thus materials and procedures, such as programmes, research, and strategies for rational standard treatment guidelines or procurement use. Many copies of the Monitor, and particular­ specifications, developed in one country could ly of one issue on the theme of national drug be used and sometimes further developed by policy, were also provided as instructional mate­ others. rial on the subject of pharmaceuticals in primary health care for workshops and universities. The 13.30 More resources were devoted to training Organization developed a database consisting of and to the preparation of practical manuals and important but unpublished technical reports and materials, in collaboration with national and in­ guidelines, which provides rapid access to mate­ ternational partners. Subjects covered included rial relating to a given technical or geographical the technical and managerial aspects of financ­ area and is proving an invaluable tool. WHO's ing, rational use, procurement, quality assur­ documentation centre on essential drugs contin­ ance and registration of drugs, and information, ued to respond to the information needs of de­ education and communication strategies. A suc­ veloping countries, distributing an average of cessful field test at medical schools in seven 3000 documents per month to individuals, uni­ countries of a problem-based method of teach­ versities, and nongovernmental and other organ­ ing the principles of rational prescribing, 1 de­ izations. signed in collaboration with University of Groningen (Netherlands), aroused widespread 13.33 More than 20 global and national opera­ academic interest. tional research projects were carried out during the biennium, covering such topics as public atti­ 13.31 With WHO's technical and financial tudes to and use of drugs, injection practices, the support, a three-month course in drug manage­ stability of drugs during international transport, ment and rational drug use, designed to meet the and monitoring of price and availability. Of par­ needs of developing countries, was successfully ticular interest were the development and field­ launched at Robert Gordon University in Aber­ testing of indicators for monitoring national deen (United Kingdom). Practical drug procure­ drug policy implementation and, in collabora­ ment guidelines, developed and used at work­ tion with the International Network for the Ra­ shops attended by over 120 people from 14 de­ tional Use of Drugs, of standardized indicators veloping countries with the support of the to measure the impact of interventions designed Preferential Trade Area of Eastern and Southern to influence drug use. A 15-country study on the African States, were further improved. In the application of the WHO Certification Scheme Eastern Mediterranean a series of seminars on on the Quality of Pharmaceutical Products mov­ teaching rational drug use and the essential drugs ing in International Commerce revealed short­ concept were held for schools of medicine and comings in its functioning in both importing and pharmacy in 11 countries. Altogether, thousands exporting countries. Nine reports on WHO­ of health workers in over 40 countries attended supported research were issued during the WHO-supported training courses and work­ biennium, and a new database providing stand­ shops on drug management and use. ardized information on research completed or in progress was established.

13.34 The goal of formulating national drug poli­ 1 Document DAP /91/12. cies and launching essential drugs programmes in

81 THE WORK OF WHO 1992- 1993

at least 70 countries by 1995 is likely to be reached 13.36 Three intercounrry workshops (Harare, before the target date, but it is important to in­ July 1992; Saly Mbour, Senegal, October 1992; crease the number of countries involved and to Lima, May 1993), with participants from improve their policies and programmes. The need 46 countries, recommended ways to promote for close coordination of all the elements of a the incorporation of community-based rehabili­ na6onal drug policy, based on WHO guiding tation into national primary health care pro­ principles, has become increasingly evident as grammes and to strengthen referral services for large-scale financial support has become available people with disabilities. WHO cooperated with from other organizations, such as the World IMPACT, the international initiative against Bank, the European Community, the African De­ avoidable disability, in setting up a pilot project velopment Bank, non governmental organizations in India for inclusion of disability prevention in and the bilateral agencies. The concept of a stand­ primary health care. Egypt, Islamic Republic of ard policy framework to be developed with WHO Iran and Lebanon have incorporated commu­ support is therefore being energetically promoted nity-based rehabilitation into primary health among Member States and donors. care, with appropriate referral services, and sev­ eral other countries in the Eastern Mediterranean are establishing programmes. National seminars on community-based rehabilitation were organ­ Rehabilitation ized in several countries' and served as forums for the preparation of intcrsectoral plans for re­ 13.35 On completion of the United Nations habilitation involving health, education, social Decade of Disabled Persons (1983-1992) WHO and vocational services. In a number of coun­ carried out a review of the progress made. It tries2 WHO participated in planning or evalua­ showed that preventive measures had significant­ tion of community-based rehabilitation pro­ ly reduced the incidence of some diseases that grammes. cause disabilities; that public awareness about disability had increased during the decade, lead­ 13.37 The existing methodology for cost analy­ ing to modest improvements in the social inte­ sis in primary health care1 was adapted for use in gration of people with mild to moderate disabili­ determining the cost of rehabilitation services in ties in some countries; and that in most develop­ Mauritius and Zimbabwe, as a first step in the ing countries there had been no significant in­ preparation of general guidelines for cost analy­ crease in rehabilitation services. In the light of sis of community-based services and referral for these findings, the Health Assembly adopted res­ rehabilitation. olution WHA45.10 which outlined actions to strengthen disability prevention and rehabilita­ 13.38 A variety of training activities were carried tion and provided a framework for the pro­ out to promote community-based rehabilitation. gramme's work during the biennium. In 1992 physicians, nurses, therapists and middle­ level rehabilitation personnel were trained for community-based rehabilitation through national programmes in Ben in, China and Mongolia. In the Americas several workshops were organized to strengthen intersectoral action for rehabilitation. In 1993 WHO, in collaboration with the Interna­ tional Leprosy Association, provided training in the United States of America for professional staff of government and nongovernmentalleprosy pro­ grammes, with emphasis on integration of people with leprosy into community-based rehabilitation programmes.

' Benin, Burkino Foso, Czech Republ ic, COte d' lvoire, fquutoriol Guinea, Gohon, Indo nesia, lesotho. Swo1ilond. Amother helps her child , with the support of o community rehobilito· ' Eritreo, Glrono, Guyana, Indonesia, Konya, Mongolia, Thollond, Zimbabwe. lion worker. a Datument WHO/SHS/ NHP /90.S.

82 DIAGNOSTIC, THERAPEUTIC AND REHABILITATIVE TECHNOLOGY

13.39 Training materials produced during the fice at Vienna continued, for instance, in the im­ biennium included recommendations for plementation of a UNDP-supported project in middle-level rehabilitation workers, based on Ghana, the setting-up of a task force on disabled country experience, 1 a manual on promoting the children and women, the preparation of recom­ development of young children with cerebral mendations to countries for intersectoral rehabili­ palsy2 and guidelines for preventing deformities tation programmes, and the drafting of uniform 3 in poliomyelitis • guidelines for programme evaluation. WHO is collaborating with the Economic and Social Corn­ 1340 In November 1993 WHO hosted two mission for Asia and the Pacific to promote the meetings with representatives of 32 international Asia and Pacific Decade of Disabled Persons nongovernmental organizations that support re­ (1993-2002). A joint review was carried out with habilitation programmes in developing countries UNHCR of disabilities among refugees at 11 sites in order to discuss ways in which they can apply in Africa; and plans were made to organize com­ WHO guidelines in this effort. One outcome of munity-based rehabilitation in two of the areas in the discussions was a broad outline of action for early 1994. A plan for emergency rehabilitation of improving prosthetic and orthotic services in de­ people injured in war in former Yugoslavia was veloping countries. prepared, with emphasis on provision of prosthe­ ses and other procedures to deal with physical 13.41 Collaboration with UNDP, ILO, trauma. Together with the United Nations Statis­ UNESCO, UNICEF and the United Nations Of- tical Office, WHO reviewed databases on disabil­ ity in four countries, including data from commu­ nity-based rehabilitation programmes and nation­ 1 Document WHO/RHB/92.1 al census and survey data, with a view to preparing 2 Document WHO/RHB/93.1 guidelines on data collection for national planning 3 Document WHO/EPI/POLIO/RHB/91.1. and for programme monitoring and evaluation.

83

CHAPTER 14 Disease -e e I o n ontrol

14.2 There has been little progress in extending Immunization coverage to the bard-to-reach populations who bear a disproportionate burden of vaccine-pre­ 14.1 In the 1980s there was a steady annual ventable diseases, as well as from other condi­ increase in global immunization coverage reach­ tions preventable by primary health care. More­ ing, by 1990, 85% for the third dose of oral over, the worsening global economic situation is poliomyelitis vaccine, 83% for the third dose of placing a severe strain on health systems includ­ diphtheria-pertussis-tetanus (DP'I) vaccine, ing immunization programmes. Coverage is de­ 90% for BCG vaccine against tuberculosis, and clining in a growing number of countries severe­ 80% for measles vaccine (Figure 14.1). After ly affected by war, civil strife, debt and recession. 1990 there was a levelling-off of global immuni­ In Africa coverage of children is still significantly zation coverage (the corresponding global fig­ below the global average, except for BCG ures for 1992 were 80%, 79%, 85% and 78% (Figure 14.3). respectively) and a marked decrease in coverage in Africa (Figure 14.2), causing serious concern 14.3 Although still far lower than for immuni­ as it casts doubt on the sustainability of past zation of infants, tetanus toxoid coverage of accomplishments. pregnant wornen continued to rise, reaching a

Figure 14.1 Global immunization coverage of children in the first year of age, 1981 -1992

100 • BCG 80 - 0 orr, third dose b b b

Q) tJ en Poliomyelitis, e 0 third dose Q) b > 60 - 8 b en Meosles "'c:> 0 E rJ rJ ~ 40 - Tetanus toxoid, IJ ~ 0 second dose •

20 -l rn?, llln ~ 0 lrl lrl lrl 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 (data before 1984 are estimated) • induding booster dose in pregnant women

as THE WORK OF WHO 1992- 1993

Figure 14.2 Immunization coverage of children in the first year of age, by WHO region, 1992

80

Q) en E Q) 60 > 8 Q) en .E!c: Q) ::: Q) 40 c...

20

Africa Americas Eastern Europe South· East Western Global Mediterranean Asia Pacific

0 DPT, Poliomyelitis, Tetanus toxoid;• O Hepam~ 8, • BCG third dose 0 third dose O Measles• 0 second dose third dose • up to two years of age •• including booster dose in pregnant women

Figure 14.3 Immunization coverage of children in the first year of age, African Region, 1990·1992

100

1990 1991 1992 .--- 0 0 0 80 - 1--

Q) f-- en E Q) > 60 - .---,__ 8 Q) f-- 1-- 1-- ...--- =0 "E I-- Q) 40 - :::Q) ~ c...

20 -

0 BCG OPT, Poliomyelitis, Measles* Tetanus toxoid,** third dose third dose second dose • up to two yeors of age •• including booster dose in pregnant women

86 DISEASE PREVENTION AND CONTROL reported 4 3% for pregnant women in developing ority. Measles remains one of the greatest killers countries in 1992, compared with 39% in 1990 of children, causing an estimated 1.1 million (Figure 14.1); the highest coverage was achieved child deaths a year in developing countries. De­ in South-East Asia (Figure 14.2). clining or stationary immunization coverage and continued high case-fatality rates in many areas 14.4 During the biennium many countries add­ are clear warnings that efforts must be stepped ed yellow fever and hepatitis B vaccines to their up to reach the 1995 measles reduction goals. immunization programmes. Of the 33 African Crucial to the attainment of those goals are en­ countries at risk from yellow fever, 17 have poli­ suring coverage of over 90% in all districts and cies for provision of the vaccine; and in 1992 their intensified measures in urban areas. Outbreaks coverage reached 10% for children under one of the disease raise awareness of the importance year of age. Forty-eight countries in the world of universal child immunization and the need for established policies for routine hepatitis B im­ prevention and treatment of potentially lethal munization, and a system for monitoring the complications. coverage in children under one year was devel­ oped. 14.9 Diphtheria has been spreading in the Russian Federation and Ukraine over the last 14.5 On the basis of reported coverage and es­ two years; it is currently out of control and is timated vaccine efficacy and morbidity rates, affecting other republics of the former Soviet WHO calculated that in 1992 immunization pre­ Union. Growing numbers of cases have also been vented 2. 9 million deaths from measles, neonatal imported to countries in central and western tetanus and pertussis in developing countries, Europe. In the first 10 months of 1993 approxi­ and an estimated 4 36 000 cases of paralytic polio­ mately 12 000 cases of diphtheria were reported myelitis. Nevertheless, an estimated 2.1 million to the Regional Office for Europe, double the deaths from measles, neonatal tetanus and number for the whole of 1992. pertussis, and over 140 000 cases of poliomyelitis occurred in developing countries in 1992, indi­ 14 10 Kenya experienced an outbreak of yellow cating clearly a need to sustain and if possible fever for the first time in more than 40 years. Mass increase the immunization coverage. immunization was undertaken in response to the emergency in and around the area of the outbreak, 14.6 The greatest success in disease control has which has since been brought under control. been achieved in the Americas, where the last case of poliomyelitis due to wild virus was re­ 14.11 A global poliomyelitis diagnostic labora­ ported in August 1991. Other regions also tory network of 41 national laboratories, 17 re­ showed improvements: 131 countries reported gional reference laboratories and five special ref­ no poliomyelitis, as compared with 80 in 1985. erence laboratories was established. Initially, each of the national laboratories has been work­ 14 7 Efforts have been made to improve sys­ ing on poliovirus isolation and poliomyelitis tems for routine disease surveillance. Guidelines serotyping. Meanwhile, an immunofluorescent on bringing about such improvements as a neces­ test has been developed in a WHO-funded study sary step towards poliomyelitis eradication, that may prove to be a short cut in poliovirus neonatal tetanus elimination and measles control detection; this and other methods for diagnosing have been distributed. Numerous workshops on poliomyelitis are undergoing further study. disease surveillance for control were conducted Finally, one of the product development groups in all regions, and the quality of surveillance data of the Children's Vaccine Initiative has made has markedly improved in many countries. As­ progress in preparing a more heat-stable polio­ sessments of surveillance were conducted in 19 myelitis vaccine that could be used in immuniza­ countries in two regions. They will be continued tion programmes in the future. so that eventually countries can certify the eradi­ cation of poliomyelitis and elimination of 14.12 1992-1993 saw a stronger focus on mana­ neonatal tetanus. gerial considerations than in the previous biennium, when emphasis was on the introduc­ 14 8 Large outbreaks of measles, diphtheria tion of new technology for the logistics of immu­ and yellow fever continued to affect children nization services. Computer software was devel­ who could have been protected if immunization oped to improve the forecasting of needs for programmes had been given sufficiently high pri- vaccines and equipment. Following surveys that

87 THE WORK OF WHO 1992-1993 revealed widespread unsafe injection practices, 14.14 Important organizational developments global policies on safe injections were updated, during the biennium included the Health Assem­ and related training was given. Operational stud­ bly's endorsement in 1992 of goals, policies and ies of "missed immunization opportunities" were strategies for the Expanded Programme on Im­ completed in 49 countries and this follow-up pro­ munization in the 1990s (resolution WHA45.17); cedure was made part of routine supervision. A the establishment of regular formal meetings of new series of documents on the immunological interested parties for coordination of global sup­ basis of immunization became available. port for the Programme; revision of the global plans of action for poliomyelitis eradication, 14.13 There was extensive cooperation in sup­ neonatal tetanus elimination and measles control; port of immunization programmes at global, and the Health Assembly's reaffirmation in regional and country levels between govern­ 1993 of the goal of eradicating poliomyelitis by ments, WHO and a wide range of organizations the year 2000 (resolution WHA46.33). The Pro­ including the World Bank, UNICEF, UNDP, gramme's priorities were defined during the bilateral development agencies, and nongovern­ biennium as: first, to sustain the accomplish­ mental organizations such as Rotary Interna­ ments of the past years; secondly, to achieve the tional. Such cooperation has been one of the goals of immunization coverage and disease principal reasons for past successes in immuni­ eradication, elimination and reduction set by the zation programmes and it must be continued if a Health Assembly and the 1990 World Summit high standard of global coverage is to be for Children; and thirdly, to introduce new and achieved and maintained and the incidence of improved vaccines as they become available for disease further reduced. public health use.

Control of tropical diseases1

Table 14.1 Global estimates of populations at risk, morbidity and mortality from tropical diseases

Disease Countries Population at Annual morbidity and affected risk (millions) mortality

Afncan 36 50 25 000-30 000 new cases trypanosom1as1s Chagas disease 21 90 400 000 new cases, 40 000 deaths Dengue 100 2000 several mill1on new cases Dracuncul1as1s 18 140 2 million new cases Leishmaniasis 88 350 1-1 5 million new cases of cutaneous le1sh- man1asis and 0 5 m1lllon of visceral leishmaniasis; 75 000 deaths

Leprosy 87 2400 3.1 m1ll1on cases (cumulative), 2 3 million people VISibly disabled Lymphatic f1lanasis 76 750 30 million chronic cases Malana 100 2500 300-500 m1ll1on cases of clinical malana, 1.5-3 million deaths Onchocerciasis 34 90 40 000 new cases of blmdness per year Sch1stosom1as1s 74 500-600 Tens of m1ll1ons of new cases

' Th1s sect1on of the report deals w1th the current status of trop1cal d1seases 1n the world as summanzed 1n Table 14 1 as well as some of the measures undertaken by Member States and WHO for the1r prevention and control Act1v1t1es spec1f1cally concerned w1th research on trop1cal d1seases are descnbed 1n paragraphs 14 56 to 14 71

88 DISEASE PREVENTION AND CONTROL

the global malaria control strategy into action, Malaria and has prepared guidelines for strengthening national control activities in accordance with 14.15 Malaria threatens about two-fifths of the the global strategy by setting up programmes world's population, causing an estimated 300- which are flexible, cost-effective, sustainable and 500 million clinical cases and 1.5 to 3 million adapted to local conditions. deaths annually. More than 90% of clinical cases and the majority of deaths occur in tropical Afri­ 1417 In September 1993 WHO convened a ca, but serious malaria problems are reported also meeting of interested parties on malaria control in Afghanistan, Brazil, India, Sri Lanka, Thailand to consider the managerial and budgetary aspects and VietNam (see Figure 14.4). The situation is of the plan of work for 1993-1999. Representa­ exacerbated by the continuous intensification and tives of donor countries, international agencies, spread of resistance of parasites to antimalarial and intergovernmental and nongovernmental or­ drugs, especially in Africa. Multidrug resistance ganizations analysed the resource needs forma­ has led to a rise in the drug cost per simple case laria control at national and international levels, from about$ 0.15 to$ 2.00 in countries of South­ recommended coordination procedures and East Asia and in the Amazon region of Brazil; a specified sources and mechanisms for multilater­ similar development is foreseen in Africa. This al and bilateral support. Since this meeting over may put drugs beyond the means of populations $ 3.5 million has been pledged by donor coun­ at greatest risk, resulting in untreated or incom­ tries to help finance WHO's efforts to combat pletely treated cases, more complications and malaria in 1993-1994. more deaths. Incomplete treatment also probably contributes to the spread of drug resistance. 14 18 The first of a series of regional working group meetings (Brazzaville, March 1993) ap­ 14.16 For these reasons WHO convened the proved a plan of action and objectives for malaria Ministerial Conference on Malaria (Amsterdam, control in Africa and established guidelines for October 1992), which was attended by health evaluating programmes. The second and third leaders from 102 countries together with repre­ meetings in the series (New Delhi, March 1993; sentatives of United Nations bodies and non­ Kunming, China, November 1993) drew up guide­ governmental organizations. The conference en­ lines for the reorientation of malaria control in dorsed a global malaria control strategy! which South-East Asia and the Western Pacific and speci­ had been prepared by three interregional meet­ fied criteria and indicators for evaluating the im­ ings held in 1991 and 1992 in Brazzaville, New pact of the new strategy. Delhi and Brasilia, and whose goal was to pre­ vent mortality and reduce morbidity and the so­ 14.19 As a result of WHO's intensified efforts, cial and economic losses due to malaria through countries where malaria is endemic have shown progressive strengthening of local and national increased confidence in the potential benefits of capabilities. WHO's plan of work for malaria control programmes, with governments request­ control in 1993-1999 provides that by the year ing collaboration and support from WHO, from 1997 at least 90% of countries affected by the other international bodies within and outside the disease will be implementing appropriate control United Nations system, and from nongovern­ programmes,2 and that by the year 2000 malaria mental organizations. During the biennium mortality will have been reduced by at least 20% WHO joined with its collaborating centres in compared with the 1995 figure in at least 75% of providing technical support to 31 countries for affected countries. In May 1993 the Health As­ the preparation of plans of action and the sembly stressed the gravity of the malaria situa­ reorientation of malaria control programmes. In tion and urged Member States, interested parties addition, by responding to government requests and WHO to initiate effective and sustainable for drugs, insecticides, equipment and operation­ control programmes (resolution WHA46.32). al funds, the Organization jointly with various Since the ministerial conference WHO has acted bilateral agencies gave support to Burundi, at global, regional and country levels to translate Djibouti, Ethiopia, Madagascar, Namibia, R wanda and Somalia in combating epidemics and coping with emergency problems. 1 A global strategy for malarta control. Geneva, World Health Organization, 1993. 14.20 Until such time as a fully effective vaccine 2 See WHO Technical Report Series, No. 839, 1993. becomes available, the results of recent research

89 Figure 14.4 Malaria distribution and problem areas

Dry savanna and <::::>= <::Jo desert fringe lj 0 0 c::::l Central America Epidemics ore related to Ethiopia Afghanistan Cambodia, Lao People's Agricultural development, exceptional rains and Repeated epidemics occur in Over 300 000 cases ore Democratic Republic, irrigation schemes and population movements. the highlands due to degraded recorded yearly. Control Myanmar, Thailand and colonization, combined with There were some 50 000 environment, drought and has been interrupted by Viet Nom insecticide resistance, hove cases in Khartoum during famine, and large·scole war and displacement of Nearly 700 000 cases ore recorded caused a resurgence of malaria. the 1988 floods. resettlement schemes. populotions. yearly. The risk is increasing rapidly in frontier areas where African cities there is often illicit mining and civil The cities ore characterized unrest. This region has the most by severe drug resistance, severe drug resistance in the world. increasing deaths in young adults, inodeguate sanitation Papua New Guinea, and overburdened services. Philippines, Solomon Islands and Vanuatu Over 300 000 cases recorded ~ yearly, related to colonization of new areas. ~

WH094032 ~=

C)~ -'0 South Asia 0 ~ .!.. Over 2.5 million coses ore '0 recorded yearly, increasing ~ ~ ~ African savanna numbers of them in tribal, forest ~ and forest and hill areas, sometimes in \ Over 50% ofthe epidemic proportions. Amazonian rain forest population ore infected. Over 600 000 cases occur per year Malaria is the main cause in Brazil (>50% of malaria in the of death in young_ children, Americas), and on estimated 6 000 killing_ 1 in 20 before the East African highlands I to 10 000 deaths owing to new age of 5. There is and Madagascar () settlement and mining in forest increasing chloroquine Dramatic epidemics occur, related o?J areas. resistance. to changed agricultural patterns, interruption of control, and possibly increased temperatures. There were over 25 000 deaths in Madagascar in 1988. j j/ri>j Main areas where malaria transmission occurs DISEASE PREVENTION AND CONTROL

Preventing malaria: health education for young children in Cambodia.

on insecticide-impregnated bednets, the potent ture to enable the trainees to do the work for artemisinin derivatives and new diagnostic tools which they have been prepared. Steps have are now being applied in malaria control (see therefore been taken to ensure that the develop­ paragraph 14.45). In 1992 WHO collaborated ment of national programmes and of the neces­ with Thailand in establishing a surveillance sys­ sary human resources both move forward in a tem to monitor adverse reactions to artemisinin coordinated manner. Progress was made in derivatives and drew up methodological guide­ meeting the enormous demand for suitable lines that can be used by neighbouring countries training materials in English and French. for the next few years.

14.21 Few of the countries affected have Dracunculiasis (guinea-worm disease) enough well-trained, motivated personnel tO achieve and maintain a satisfactory level of ma­ laria control. During the biennium some 170 14.22 If the present momentum can be main­ nationals were trained in planning, implement­ tained for the control of dracunculiasis, the dis­ ing and evaluating malaria control programmes ease can be eradicated. In early 1980 the global in seven international courses for health person­ annual incidence was estimated at 5-10 million; nel of various levels. New manuals, visual aids the present estimate is less than 2 million. A sig­ and other teaching materials were prepared on nificant decrease in incidence has been observed basic epidemiology, entomology, treatment of in some endemic countries where active surveil­ severe malaria and training of trainers for the lance and notification have been carried out. control of tropical diseases. The increase in in­ During 1991 -1992 the incidence decreased by structional activities has not, however, been 68% in Cameroon, 50% in Ghana, 43% in India, matched by the availability of human and finan­ and 35% in Nigeria. Pakistan is on the verge of cial resources. Training is pointless without the eradicating the disease, with 23 cases in 1992 necessary supplies, equipment and infrastruc- compared with 160 in 1991.

91 ------THE WORK OF WHO 1992-1993

Schistosomiasis

14.24 The WHO Expert Committee on the Control of Schistosomiasis2 recognized that schistosomiasis is increasingly becoming an ur­ ban health problem in Africa and Brazil and af­ fects thousands of refugees, especially in Cambo­ dia. SchistOsomiasis is also causing increas­ ing concern in water resources development schemes, as emphasized in a new WHO publica­ tion.3 A Swahili version of the 1990 WHO publi­ cation Health education in the control of schistosomiasis was issued and distributed in Kenya and the United Republic of Tanzania. WHO supported Mali, Morocco and Yemen in long-term planning for control of the disease.

14.25 The high price of praziquantel is the single major impediment tO the implementation of na­ tional control programmes in all the countries concerned, although discussions with the manu­ facturers during the biennium have resulted in some price reductions. With support from Italy, WHO is collaborating with ministries of health tO improve the delivery of antischistosomal drugs. Ahouse wife's flour sieve con fil ter wo ter on d prevent transmi ssion of drocunculiosis. 1426 With the help of USAID, a geographical information system was developed to strengthen the management and control of schistosomiasis, 14.23 WHO convened a fourth regional confer­ and WHO joined with the International Devel­ ence on dracunculiasis in Africa (Enugu, Nigeria, opment Research Centre (Canada) in introduc­ March 1992) and, as in previous years, joined with ing it in Botswana and Senegal. UNDP and UNICEF in organizing reviews of national dracunculiasis eradication programmes. 14.27 A WHO study group (Manila, October A total of 16 national programmes were analysed, 1993) reviewed the current status of the epidemi­ including assessment of current epidemiological ology and control of food borne trematode infec­ trends and control activities; and in each case rec­ tions (see Figure 14.5). An estimated 40 million ommendations were made for continuation of the people are infected, although the pattern of mor­ programmes. The WHO/UNICEF interagency bidity is changing along with the environment technical team for the dracunculiasis eradication and people's habits. The study group recom­ programme in Africa, set up in Ouagadougou in mended a coordinated control strategy empha­ 1992, provides direct support to national pro­ sizing health education, food safety in domestic grammes in French-speaking Africa. In 1992 and commercial food processing, proper sanita­ WHO held a first formal consultation, in the Is­ tion to reduce faecal contamination of food lamic Republic of Iran, to initiate the process of production through use of wastewater, and sys­ certification of eradication. The following year tematic case detection and treatment within WHO experts discovered that transmission of the health care system. dracunculiasis probably still occurs in Yemen. Updated criteria for the certification of dracunculiasis eradication were issued in 1993}

7 WHO Technical Re por1 Selies, No . 830, 1993. 1 Hu nter JM et ol. Porositic dlseoses in woler resources development. 1 Documen1 WHO/Fil/93. 187 . Geneva, World Health Orgonizo1ion, 199 3.

92 Figure 14.5 Food borne trematode infections in the world

People are infected with Fasciola hepatica {liver fluke) is acquired by Fasciola hepatica (liver fluke l is Opisthorchis (liver fluke) More than 20 million people Nanophyetus, an intestinal eating aquatic plants of the Alliplono of acquired by eating aquatic infedions in freshwater fish have are infeded with trematode. The disease, originally Bolivia, the highlands of Peru and Ecuador, plants in the Aquitaine region of spread from Siberia to Ukraine. Paragonimus !lung fluke) limited to Siberia, has now been the Nile delta and the Islamic Republic south-west France, and Aboutl.5 million persons ore and 5 million with Clonorchis reported in Oregon, USA. of Iran. northern Portugal. infeded. !liver fluke) in China.

One intestinal trematode, Fibricola, is tronsmiHed to .. ~ 1'1/ / I '-...., \ 11 I ~ AI/-\ I '\.""'\,/ 1 peo~le from row frogs or ~ sno es and another, ~ Gymnophalloides, from row ...... 5:.: oysters in the Republic of ;;: Korea. ... a:~ ::::! ~ There is a high incidence of ~ cholangiocorcinoma, a form ~ of liver cancer related to sa: Opisthorchis or Clonorchis :iil infedion in Thailand and ~ Hong Kong. WH094021/E

? Paragonimus (lung fluke) t infections are caused by eating row crabs in the There has been a surge of \ Amazon lowlands of Opisthorchis and Clonorchis Ecuador and Peru, and !liver fluke) infedions from in Nigeria and People ore infected with freshwater fish in small water Cameroon, complicating Phagicola, an intestinal impoundments in China, or misdiagnosed as trematode, from mullet fish Lao People's Demoaatic () pulmonary tuberculosis. in Sfio Paulo, Brazil. Republic and Thailand. ~~ THE WORK OF WHO 1992-1993

alence rates in infected populations. WHO is lymphatic filar iasis actively encouraging the manufacture and distri­ bution of this salt through the private sector. 14.28 In 1991 the WHO Expert Committee on Filariasis' estimated that 78 million persons are infected throughout the world and that 750 mil­ Onchocerciasis lion persons are at risk. It stressed the importance of establishing the precise social, psychological and economic consequences of the disease in en­ 14.30 The last decade has seen a decline in the demic countries. prevalence of onchocerciasis infection, mainly due to the remarkable success of vector control 14.29 Strategies to reduce clinical disease in en­ in the Onchocerciasis Control Programme in demic areas through chemotherapy and vector West Africa. A symposium was organized (New control were initiated during the biennium. In York, September 1993) to mark the fifth anniver­ clinical trials it was found that single doses of sary of the donation of ivermectin by the manu­ ivermectin as well as diethylcarbamazine citrate facturer Merck & Co. Supply of this drug has (DEC) were highly effective in suppressing enabled a major breakthrough in onchocerciasis parasitaemia (see paragraph 14.60). Further, ex­ control, and so far six million treatments have perience in China has shown that the use of been distributed. Rapid assessment indicators DEC-medicated salt can effectively reduce prev- and drug supply processes were tested in opera­ tional research projects in endemic countries. It can now be concluded that annual treatment of 1WHO Technical Repo11 Series. No. 821 , 1992. endemic communities suffices to reduce the par-

Sofe woter: the ideol woy to preven t filoriosis.

94 DISEASE PREVENTION AND CONTROL asite load, prevent new cases of blindness and improve anterior segment eye lesions. In the Leishmaniasis Americas a strategic planning council coordinat­ ed by PAHO/WHO has been promoting a re­ 14.34 A WHO imtlatlve for research on gional initiative to eliminate onchocerciasis. leishmaniasis control led to the mobilization of funds for nine new projects aimed at validating new 14 31 Of the 34 countries where onchocerciasis vector and/or reservoir control methods. In a is endemic, 29 have implemented or prepared hyperendemic area of central Tunisia a technique plans to conduct regional or national pro­ to control zoonotic cutaneous leishmaniasis, based grammes for distributing ivermectin based on the on large-scale deep ploughing of rodent burrows 1993 guidelines and recommendations of the around a city, proved to be feasible and efficient; WHO Expert Committee on Onchocerciasis the project was strongly backed by the national Control. Effective cooperation has grown as a authorities and by regional and local institutions. result not only of political commitment by min­ istries of health but also of increasing interest 14.35 In the Indian state of Bihar the use of among national and international agencies con­ pyrethroid-impregnated bednets led to a dramat­ cerned with health and blindness. Currently 21 ic reduction in the density of the vector such agencies are involved in this cooperation, Phlebotomus argentipes in dwellings over a five­ more than twice as many as two years ago, with month period, suggesting that it could be anal­ WHO playing a coordinating role. ternative to classical house spraying with residual insecticide. The method was well accepted by local communities.

American trypanosomiasis (Chagas 14.36 With the spread of the AIDS pandemic, disease) the incidence of visceral leishmaniasis is expected to rise because of the increasing frequency of 14.32 The ministers of health of the countries of HIVI Leishmania eo-infections. WH 0 has es­ the Southern Cone1 have launched an initiative to tablished an international registry in Geneva to eliminate Chagas disease in the coming decade centralize and diffuse worldwide epidemiologi­ through control of vectors and blood banks. cal data on these eo-infections. A case report Technical representatives of each ministry have form was prepared and widely diffused to facili­ been designated to form an intergovernmental tate and standardize the collection of baseline commission overseeing the implementation and data for evaluating the severity of the problem evaluation of national control programmes. Field and its geographical extent. activities have been planned and budgeted and common indicators to assess impact and costs agreed upon. At their last meeting (Santa Cruz, Bolivia, October 1993) the representatives reiter­ African trypanosomiasis (sleeping ated their commitment to continue financing the sickness) activities in 1994-1995. 14.37 With the recrudescence of sleeping sick­ 14.33 A study carried out in Argentina, Chile, ness, a number of countries called for inter­ Honduras and Paraguay showed that rates of country coordination of surveillance and control house reinfestation by triatomines 18 months af­ activities, and various approaches have been de­ ter the application of insecticide paints are 1.5 to vised: in central Africa national control projects 3 times lower than those observed after tradi­ are being implemented under an initiative involv­ tional spraying. The paints, manufactured in Bra­ ing 10 countries; in west Africa projects are being zil, have already been applied routinely by the launched within the framework of the oncho­ control programme in the state of Ceara and cerciasis control programme; and in south-east operational costs have decreased, while vector Africa surveillance and control involving eight control has become more efficient. countries has been promoted through a regional tsetse control programme supported by the European Community.

14.38 A joint FAO/WHO project for training in 1 Argentina, Bolivia, Brazil, Chile, Paraguay, Uruguay trypanosomiasis control to support sustainable

95 THE WORK OF WHO 1992-1993 agricultural development should provide an insti­ adopted resolution WHA46.31 recognizing that tutional framework for training in this field, com­ dengue, dengue haemorrhagic fever and dengue plementing the training dispensed by WHO at shock syndrome are threatening lives and well­ national level. Training materials such as films, being in a large proportion of populations in manuals and modules have been prepared for use tropical regions and confirming that the preven­ in Chad, Congo, Uganda and other countries. tion and control of these conditions should be among the priorities of WHO. The resolution 14.39 To strengthen surveillance and control, called for the establishment of strategies to con­ WHO has set up a sleeping sickness epidemiologi­ tain the spread and increasing incidence of the cal "observatory" which will assess disease preva­ diseases in a manner sustainable by countries. lence, the extent of foci, patient status, drug availa­ bility and use, vector occurrence and distribution, and current methods for and progress in vector control. Geographical information systems greatly Disease vector control facilitate analysis of epidemiological and manageri­ al data collected in the field and allow effective 14.43 As from May 1993 the University Sains programme management. Malaysia undertook, on WHO's behalf, the preparation of insecticide-impregnated papers 14.40 As in past years a JOlllt FAO/OAU/ and solutions and the storage and dispatch of WHO training seminar was held (Kampala, Oc­ material for monitoring the insecticide suscepti­ tober 1993 ), fostering an exchange of views and bility of disease vectors, while WHO continued maintaining a high level of national conscious­ to coordinate the activities and to maintain a ness about the risk of sleeping sickness epidemics global database on this subject. as experienced recently by Sudan, Uganda and Zaire. 14 44 The WHO pesticides evaluation scheme (WHOPES), in operation since 1982, initiated 14 41 The establishment of a WHO revolving new procedures to facilitate contributions by the fund with support from the Netherlands has al­ national authorities and by industry in the evalu­ lowed rapid provision of standardized equipment, ation of pesticide products and formulations for material, reagents, test kits and drugs to national use in tropical disease vector control. Under the programmes. The annual donation by Rhone­ scheme, the Organization, through its collabo­ Poulenc (France) of 85 000 ampoules of rating centres in Gembloux (Belgium) and pentamidine for the treatment of early stage sleep­ Atlanta (USA), promoted research on pesticide ing sickness was a major contribution from the formulations and the setting of specifications, private sector. Other contributions have been made particularly by means of collaborative studies by nongovernmental organizations, such as with industry to design methods for analysis of Medecins sans Frontieres in northern Uganda, and insecticides in conjunction with the Collabora­ Fometro of Belgium which supplied 10 000 am­ tive International Pesticide Analytical Council; poules of eflornithine for the treatment of late stage routine analysis of samples of pesticides intended sleeping sickness cases resistant to melarsoprol. for national disease control programmes to en­ sure compliance with WHO specifications; and development of standardized chemical, physical and biological assays for the analysis of selected Dengue insecticides used in impregnation of nets and traps, including bednets. During the biennium 14 42 The frequency of dengue epidemics has WHO PES field trials on 11 chemicals, produced increased significantly in the past decade, and by seven pesticide manufacturers, were conduct­ dengue and dengue haemorrhagic fever epidem­ ed in 14 countries of Africa, South-East Asia and ics now threaten two-fifths of the world's pop­ the Western Pacific. Different formulations and ulation, or approximately 2000 million people types of application were evaluated, including living in urban areas in 100 countries in Africa, impregnation of nets and traps, indoor residual the Americas, Asia and the Pacific, causing mil­ spraying and ultra-low-volume application, lions of cases annually with thousands of deaths. against the vectors of African trypanosomiasis, An unknown number of people are also at risk in arboviral diseases and malaria. WHO's 1985 rural areas of China, India, Indonesia, Myanmar specifications for public health pesticides were and Thailand. In May 1993 the Health Assembly revised and produced in a new format suitable

96 DISEASE PREVENTION AND CONTROL for frequent updating. Following extensive re­ by-product of antimalaria operations; for indoor view by FAO and experts from industry, guide­ residual spraying, several insecticides were used. line specifications for household pesticides were prepared for joint publication by FAO and WHO. Leprosy 14.45 The Organization promoted personal protection measures, particularly the use of in­ 14.49 Good progress was again made against lep­ secticide-impregnated materials for bednets and rosy during the biennium. The disease burden was curtains. Pre-impregnated bednets are now com­ reduced by more than 40%; estimated cases de­ mercially available, and WHO tested their effica­ creased from 5.5 million to 3.1 million and regis­ cy in 1993 under field conditions in collaboration tered cases from 3.2 million to 1.9 million. In all, with regional organizations. Developed with the over the last eight years, 4.3 million patients have assistance of WHO, insecticide-treated bednets been cured through multidrug therapy, with a cu­ are now being used in national malaria control mulative coverage of 85% (see Table 14.2). How­ programmes in Benin, Burundi, Cameroon, ever, progress in introducing this therapy in the Cote d'Ivoire and other countries. To contain WHO regions has been rather uneven (see Figure malaria epidemics, large-scale vector control op­ 14.6 ), the highest levels of coverage being achieved erations were carried out in refugee camps in in the Western Pacific (97%) and South-East Asia Rwanda in 1993, and WHO provided guidance (88%), and the lowest in the Americas (46%). on the use of insecticide-treated bednets in refu­ gee camps in Bangladesh, Kenya and Mauritania. 14 50 Health Assembly resolution WHA44.9 In Ethiopia WHO was involved in the calling for the elimination of leprosy as a public reorientation and decentralization of national health problem by the year 2000 generated a vector control programmes to suit local epidemi­ wholehearted response from the main countries ological conditions. where the disease is endemic, which pledged in­ creased political commitment and priority for 14.46 A study group on the technical, opera­ leprosy control. With support from WHO, tional and managerial aspects of vector control countries have been able to formulate national for malaria and other diseases, including dengue, elimination strategies and plans of action. The was organized in November 1993. international donor community, particularly the member associations of the International Federa­ 14.47 Molluscicide use has continued to decline tion of Anti-Leprosy Associations as well as the owing to the rising cost of purchasing and deliv­ ering chemical molluscicides and training per­ sonnel to use them. In 1992 WHO issued a docu­ ment on mollusciciding in schistosomiasis con­ Table 14.2 leprosy situation, 1985 and 1993 trol, 1 emphasizing that the selective and appro­ priate use of molluscicides has a role in control, and providing practical guidelines for their appli­ 1985 1993 cation and for monitoring of their effects. Number of affected countries 124 87 14 48 Large-scale control of the tsetse fly by trapping vectors of trypanosomiasis was success­ Estimated cases 10-12 million 3 I mill1on fully carried out in Uganda. In the case of Reg1stered cases 54 m1ll1on I 9 m1ll1on sandflies, the diversity of ecological and epidemi­ ological entities means that vector control meas­ New cases per year na 650 000 ures have to be very specific. Insecticide-spray­ Cumulative total of ing was applied in termite hills in Kenya against pat1ents cured through Phlebotomus martini, and in acacia woodlands in mult1drug therapy 9 000 4.3 m1ll1on Sudan against P. orientalis. As regards leish­ Cumulative coverage maniasis, control of the vector was frequently a of multidrug therapy I 6% 85% Global reduction in prevalence over the last eight years 64% 1 Document WHO/SCHIST0/92.107.

97 THE WORK OF WHO 1992-1993

QJ Ql(') QJ 0 0 0 e; St>6S60HM @ ' 0 D'

<) b DISEASE PREVENTION AND CONTROL

Sasakawa Foundation, continued to provide sub­ 14 54 WHO continued to support the training stantial support to countries amounting to more of managers in leprosy control through the pro­ than$ 80 million per year. WHO is closely col­ vision of training modules and the organization laborating with nongovernmental and other or­ of national workshops. The modules were re­ ganizations particularly at country level, so that vised in 1993, based on experience over a two­ the goal of elimination can be attained. year period. Workshops were conducted in 14 countries in 1992-1993 for a total of 322 par­ 14.51 WHO's working group on leprosy con­ ticipants. trol, established in 1991, continued to oversee ac­ tivities, in which nongovernmental organizations 14.55 WHO continued to promote health sys­ increased their participation. The strategy of tar­ tems research in leprosy to facilitate problem­ geting high-priority countries is most appropriate solving at local level. For this purpose two work­ for leprosy in view of the very uneven distribution shops were held in Brazil and Thailand, and these of the disease; in fact, one country (India) contrib­ activities demonstrated the value of the WHO utes 52% of all estimated cases in the world and training modules. A task force for health systems five others (Bangladesh, Brazil, Indonesia, research in leprosy met in 1992 and 1993 to re­ Myanmar, Nigeria) a further 27%. The working view proposals emanating from the workshops. group endorsed the global strategy in July 1993 and countries are already preparing revised action plans based on it. WHO continued to assist in preparing plans of action for applying multidrug Tropical disease research therapy (Indonesia, Madagascar, Nigeria, Sudan) and in carrying out independent evaluations of 14 56 The prime responsibility of the UNDP/ programmes (China, India, Myanmar, VietNam). World Bank/WHO Special Programme for Re­ Coordination of activities between ministries of search and Training in Tropical Diseases is for health, nongovernmental organizations and research, whereas that of the WHO Division of WHO is steadily improving in a number of coun­ Control of Tropical Diseases is for control. Dur­ tries, sometimes through formal tripartite agree­ ing the biennium the Special Programme gave par­ ments (Papua New Guinea, T ogo ). ticular emphasis to product development and ap­ plied field research. It also undertook applied field 14 52 Improved monitoring and evaluation has research on the subject of women and tropical made it possible to produce half-yearly statistics on diseases, for example, dealing with factors affect­ the leprosy situation and coverage with multidrug ing women's use of community health services, therapy, to update case estimates for countries an­ self-medication practices, and sex differences in nually, and to identify unrealistic data on registered the clinical manifestations and impact of the dis­ cases. In some countries case registers were re­ eases; this activity will be jointly managed with viewed in order to remove inactive and non-exist­ the Division of Control of Tropical Diseases. The ent cases (Brazil, Nigeria). WHO promoted na­ Special Programme's dual roles of developing tional conferences on leprosy to increase awareness better tools against six groups of tropical diseases, of the disease and promote control strategies and of improving endemic countries' capacity (Brazil, Egypt, Islamic Republic of Iran). for relevant research, were increasingly combined.

14 53 While the number of leprosy sufferers 14 57 Malaria. Three steps were taken to im­ (i.e., patients in need of chemotherapy) is steadily prove treatment of cerebral malaria: phase Ill declining, the number of people disabled as a clinical trials of the drug artemether were begun result of the disease is not showing a similar in six centres; a clinical trial of an anti-TNF (tu­ decline because multidrug therapy has no direct mour necrosis factor) monoclonal antibody was impact on disability. WHO therefore promotes undertaken in Gambia; and studies of the toxi­ the prevention and management of disabilities cology of artemether injection were completed. within leprosy control; and a manual for health Phase I studies in healthy volunteers with the workers on this subject was published.1 related compound arteether showed injections to be safe and well tolerated. A randomized, placebo-controlled double-blind field trial of the Colombian SPf66 malaria candidate vaccine was 1 Srinivasan H. Prevention of dtsabthttes in patients with leprosy: a practtcal begun in children in the United Republic of guide. Geneva, World Health Orgamzation, 1993. Tanzania.

99 THE WORk OF WHO 1992-1993

14 58 Studies of insecticide-treated bednets, nancy. The drug also improved lichenform skin which have proved very successful in reducing lesions. Annual mass treatment was found to be child mortality in Gambia, were extended to acceptable to affected communities. Large-scale three other African countries; and research to use of six-monthly treatment with ivermectin in devise methods for genetic manipulation of mos­ Guatemala showed that the drug on its own was quito vectors was undertaken, with the long­ capable of interrupting transmission in the study term aim of reducing their ability to transmit area, and data from Ghana indicated that repeat­ malaria parasites. ed treatment might help reduce transmission in parts of Africa. 14.59 Schistosomiasis. Phase I studies of combi­ nations of praziquantel and albendazole (an 14.63 DNA probes were developed to detect antihelminthic) were completed in Sudan, and and differentiate between forest (less blinding) phase 11/111 studies begun in China, Kenya and and savanna (more blinding) Onchocerca, and Philippines. Preliminary indications were that between human and animal parasites, and are the combination is safe and effective. In vaccine now in routine use in the Onchocerciasis Con­ development, negotiations with manufacturers trol Programme in West Africa. on extending and improving the production of several antigens neared completion. An inde­ 14.64 Operational research in Nigeria demon­ pendent standard testing facility was set up, and strated the effectiveness and accuracy of simple preparations began for phase I trials of some visual assessment of skin nodules to identify promising schistosome antigens. high-risk communities in need of broad-based ivermectin treatment, thus reducing reliance on 14.60 Lymphatic filariasis and onchocerciasis. painful and risky skin-snipping. lvermectin, which has been successfully used in treating onchocerciasis, was tested against lym­ 1465 Leprosy. Follow-up of 14 000 person­ phatic filariasis. Clinical trials in nine endemic years of multidrug therapy revealed only four countries/territories1 showed that a single dose cases of relapse with skin lesions. Tests of po­ of 400 micrograms of ivermectin/kg of body tentially more rapid treatments including weight suppressed microfilarial production in ofloxacin were begun in 15 centres. A compara­ lymphatic filariasis for over a year, with equal tive study was started in India of BCG, BCG efficacy at one year to a 6 mg/kg dose of the with heat-killed Mycobacterium leprae, the In­ traditional drug diethylcarbamazine citrate dian Cancer Research Centre bacillus, and the (DEC). But a combination of low-dose iver­ Indian bacterium M. w. Preliminary results of a mectin (20 micrograms/kg) with a 6 mg/kg dose vaccine trial in Venezuela showed no substan­ of DEC gave the best overall results at one year. tial difference between the protection offered At the same time, ivermectin was shown to pro­ by BCG and BCG with heat-killed M. leprae. duce fewer side-effects. Cloning and sequencing of the M. leprae genome began. 14 61 Operational studies on the use of Bacillus sphaericus for control of the mosquito vector 14.66 African trypanosomiasis. In 1993 Uganda Culex quinquefasciatus were launched in Brazil, became the first African country to register Cameroon, India, Sri Lanka and United Repub­ eflornithine, the new drug for the gambiense lic ofTanzania. form of African trypanosomiasis which had pre­ viously been registered in the United States of 14.62 Yearly mass treatments for onchocerciasis America and the European Community. The an­ with ivermectin were shown to improve anterior tigen-ELISA test was modified as a "Card indi­ segment eye lesions and to reduce the incidence rect agglutination test for trypanosomiasis" of posterior segment lesions (and thus optic (CIATT). Preliminary field trials showed this nerve disease). Moreover, no evidence was found test to be highly specific and sensitive for both that ivermectin induced any life-threatening re­ the gambiense and the rhodesiense forms of Afri­ actions or had adverse effects when used in preg- can trypanosomiasis.

14.67 Chagas disease. A joint initiative for the elimination of Chagas disease transmission by 1 Brazil, French Polynesia, Ha1t1, lnd1a, lndones1a, Kenya, Malaysia, Papua Triatoma infestans was launched in late 1993 by New Gumea, Sn Lanka. Argentina, Brazil, Bolivia, Chile, Paraguay and

100 DISEASE PREVENTION AND CONTROL

Uruguay. Two types of blood screening kit were manufactured in Buenos Aires using molecularly Research capability strengthening defined antigens, and field trials were begun for screening blood bank products infected by 14.71 Nine new grants were awarded for Trypanosoma cruzi. strengthening the capacity of institutions in op­ erational research on malaria, and for research 14.68 Leishmaniasis. A field trial in Venezuela training in social sciences and economics. of killed Leishmania (L. braziliensis and Research training grants were awarded to 111 L. mexicana ), both separate and combined with young scientists including 34 women. Fourteen BCG vaccine, was undertaken in cooperation institutions submitted final reports on their use with the United States National Institutes of of institution-strengthening grants, while 45 oth­ Health, and is due to be completed in 1994. Clin­ ers continued to receive grants. The award of ical phase I-II studies of killed L. major with small grants proved very successful in supporting BCG were begun in the Islamic Republic of Iran, short-term research projects. In the Eastern and of a single-strain "Mayrinck vaccine" Mediterranean nine grants were awarded for re­ (L. amazonensis) in Brazil. search on leishmaniasis and 14 for research on schistosomiasis in 1993. 14.69 Clinical trials started of lipid-associated amphotericin B against visceral and mucosal leishmaniasis, and a randomized, double-blind controlled trial of allopurinol began m Diarrhoeal diseases Colombia. 14.72 In 1990, the latest year for which data are readily available, 12.9 million children under the age of five died in developing countries, and Social research nearly a quarter of them from diarrhoea; pre­ venting these deaths is a task of high priority for 14.70 Studies in Ghana and Nigeria showed WHO. that pregnant adolescent girls in whom the ma­ laria mortality risk is particularly high did not 14 73 Training activities emphasized case man­ attend malaria clinics for treatment because agement and better programme management. In their parents were ashamed of public recogni­ 1992 WHO's revised guidelines for conducting tion of their pregnancy. In Colombia a study clinical training courses at health centres and showed that women with malaria wait longer small hospitals' were widely used by national than other members of their families before programmes for the first time, reflecting a trend seeking treatment, and suffer worse conse­ towards decentralizing case management train­ quences from the disease. A multi-country ing. Over 1000 courses - more than triple the study in Africa showed that school question­ number in the previous biennium - were held, naires could be used for the rapid identification mainly in the upwards of 400 diarrhoea training of communities suffering high levels of urinary units in 80 countries throughout the world. The schistosomiasis, at one-thirtieth of the cost of Organization supported 38 national training egg examination by mobile teams. Several stud­ courses for programme managers in the largest ies also showed significant gender differences in countries (bringing the total since 1987 to 122), reporting of urinary schistosomiasis - because and nearly 150 courses for first-level supervisors among girls it was wrongly viewed as a sexually were held (a total of about 630 courses since their transmitted disease. A study was launched in revision in 1987). seven countries in Africa and Asia to determine the social and economic importance of lym­ 14 74 In an attempt to complement in-service phatic filariasis. An important component of training of physicians and eventually reduce the these studies will be the clinical investigation of need for it, WHO has for some time been in­ genital manifestations of the disease in women. volved in compiling instructional material on In one area of Nigeria communities considered diarrhoea! diseases for use in medical schools. the skin manifestations of onchocerciasis to be more important than blindness, because of their effect on relationships and marriage pros­ pects. 1 Document CDD/SER/90.2 Rev.1 1992.

101 THE WOilK OF WHO 1992- 1993

After successful field trials, the full series ap­ rhoea in infants, and also minimizes its adverse peared in 1992 in the form of a manual' and four nutritional effects. Epidemiological studies have guides.2 Materials for distance learning, training shown that exdusive breast-feeding in the first at nursing and paramedical schools, and training four to six months of life and continued breast­ of pharmacists and other purveyors of pharma­ feeding until the end of the first year are associat­ ceutical products were also prepared. ed with milder forms and lower incidence of diarrhoea and with lower mortality. To ensure 14.75 In 1992 WHO devised a new, more data­ appropriate support from health workers - often based and problem-specific method for review­ the main source of advice to breast-feeding ing progress in national programmes, known as mothers - WHO and UNICEF produced a train­ "focused programme review". The aim is to ing package on lactation management. ~ identify constraints o.n progress and then design specific activities to deal with them. During 1992 14.79 The global task force on cholera control and 1993 th.is method was successfully applied in continued to coordinate WHO support to af­ 13 countries, while six carried out other types of fected countr ies. Guidelines were issued5 and programme reVlew. control efforts were pursued in all the countries concerned, particularly in Africa, where there 14.76 WHO's 1990 monograph on the ration­ were many more deaths than in South America. al use of drugs in the management of acute diar­ In 1993 the Organization planned a series of rhoea in children was well received by responsi­ steps to support governments in improving the ble national authorities, and was translated into situation in southern Africa, notably by increas­ Bengali, Chinese, French, Spanish and Viemam­ ing health workers' case management skills; ese; since its publication a number of countries raising the capacity of district health teams to have banned or restricted the use of anti­ prepare for, detect and respond to outbreaks; diarrhoeal drugs. The provision of oral rehydra­ strengthening the capacity of laboratories to con­ tion salts (ORS) remained a key clement in the firm suspected cases; developing policies to re­ control of diarrhoea in children; at the end of duce the disruptive aspects of cholera epidemics 1992, the global access rate (the proportion of on trade and tourism; and determining long-term the population with a regular supply of ORS in infrastructural needs for food safety, water and their community) was estimated to be 73%, 5% sanitation systems, the lack of which is the main higher than at the end of 1991. cause of cholera. A resurgence of the disease in the Eastern Mediterranean elicited increased 14.77 Despite effective case management train­ technical and financial support to the countries ing in many countries, the essential function of concerned. In South-East Asia a new strain advising a mother on how to care for her child at of cholera, designated Vibrio cholerae 0139, home during an episode of diarrhoea remains one of the least practised features of case manage­ ment. To help resolve this problem, WHO .is­ sued a guide for health workers on counselling mothers;3 it will be used in clinical management training courses. The O rganization also complet­ ed a guide for national programme managers on the effective use of radio, which is vital for com­ munication in developing countries.

14.78 There is now conclusive evidence that breast-feeding gives significant protection against illness and death associated with diar-

A demonstration of how to chlorinate woler during o cholera out· break in Peru . ' Readings on diarrhoea: student manual. Geneva. World Health Orgonizo· lion, 1992. 7 Uocuments COD/SE R/93.1; COO/SfR/93.2; CDO/SER/93.3; COD/SER/ 93.4 • Documents WHO/CDR/ 93.4; WHO/ CDR/93. 5; WHO/ CDR/ 93.6. >Document C00/93.1. 1 Guidelines for cltolora control. Geneva, Wo1ld Health 01ganizotion, 1993.

102 DISEASE PREVENTION AND CONTROL emerged during the biennium to cause major ep­ Acute respiratory infections idemics and largely replaced Vibrio cholerae 01 as the predominant strain in several countries. 14.83 Acute respiratory infections, especially 14.80 WHO continued to support research for pneumonia, either directly caused or contributed the development and evaluation of new or im­ to about one-third of the 12.9 million deaths in proved methods of treatment and prevention of children under five in developing countries in 1990. diarrhoea; 35 new projects received support dur­ The central strategy for reducing this death rate is ing the biennium, bringing the total number of case management using a simple standard protocol WHO-sponsored projects to 453. Half of these for the diagnosis and treatment of pneumonia. new projects related to breast-feeding practices and nutrition. The search for better ORS formu­ 14.84 Training is one of the main channels lations continued: an outpatient study was con­ through which standard case management can be ducted in Bangladesh to compare treatment of introduced into primary health care. A new outpatients with rice-based and glucose-based training module on outpatient case management ORS solutions; and two large studies in Egypt was used for the first time in English at an and Pakistan showed that standard WHO ORS interregional course in Thailand in 1992, and was solution is as efficacious as rice-based solution subsequently translated into French and Spanish. for treating diarrhoea in infants and children. After two successful tests in Kenya in 1992, a Other research included a study among outpa­ course for training community health workers tients of the impact of zinc supplementation on was made available to national programmes; it persistent diarrhoea and the testing in six coun­ includes a guide for cultural and technical adapta­ tries of a model for clinical management of the tion of case management methods. Preparation of condition. A WHO-supported study in Bangla­ training materials for inpatient care was started. desh demonstrated that breast-feeding is of particular importance in the prevention of 14.85 In courses using materials produced in shigellosis among young and malnourished chil­ previous years, 274 officers were trained in pro­ dren. Other studies showed that for infants with gramme management and about 32 000 physi­ diarrhoea under six months of age fed exclusively cians and other health workers in case manage­ on animal milk or formula, these foods do not ment. By the end of 1993, 192 acute respiratory normally need to be diluted and should be given infection training units had been established in in full strength as soon as dehydration has been 28 countries. corrected. In Brazil the use of dummies was found to be associated with increased risk of 14.86 Childhood immunization against measles early termination of breast-feeding. and pertussis makes an important contribution to the reduction of deaths associated with acute 14.81 The Organization continued to support respiratory infections. In order to enlarge the research to evaluate candidate vaccines for the arsenal of preventive measures, WHO, in associ­ most important causes of acute diarrhoea, in­ ation with the London School of Hygiene and cluding rotavirus infection, cholera, shigellosis Tropical Medicine, commissioned a series of re­ and disease caused by enterotoxigenic Esche­ views to determine effective and feasible inter­ richia coli. An evaluation of the efficacy of tetra­ ventions for reducing morbidity from pneumo­ valent rhesus-human rotavirus vaccine was com­ nia in children in developing countries. The im­ pleted in Brazil, and a large trial involving a high­ pact of vitamin A supplementation on childhood er dose of the vaccine was initiated in Venezuela. pneumonia was one of the subjects investigated; A trial of the live oral cholera vaccine CVD- and data from 12 studies were analysed at a meet­ 103 HgR was begun in Indonesia. ing in March 1992.1 Groups of experts also met in March 1992 to analyse the first round of inter­ 14.82 It is generally recognized that WHO's vention reviews and in March 1993 to analyse the recommendations on diarrhoea case manage­ second round.2 They concluded that some three­ ment are much better understood when they are quarters of all pneumonia deaths result from bac­ formulated using local terms and concepts. A terial infection; that vitamin A supplementation protocol was therefore developed for the compi­ lation of descriptive data on beliefs and practices regarding diarrhoea to be used in the implemen­ 1 Document WHO/CDR/93.2. tation of national programmes. 2 Prevention of pneumonia 1n children. Lancet, 1993,341:821-822.

103 THE WORK OF WHO 1992-1993 has no beneficial impact on the mortality of 14.90 Review papers on overlap in the clinical pneumonia not associated with measles; that an­ presentation and treatment of malaria and pneu­ tibiotic treatment of upper respiratory infection monia in children, 1 the use of bronchodilators,Z plays no role in the prevention of acute lower and the management of fever in young children respiratory tract infections; and that pneumo­ with acute respiratory infections3 were issued, as coccal conjugate vaccine, if it proves effective, was the first volume of an annotated bibliogra­ could have a substantial impact in preventing phy of selected articles on pneumonia and related pneumoma. infections in young children.4 Six issues of ARI news were published by the Appropriate 14.87 One important target is the establishment Health Resources and Technologies Action by 1995 of acute respiratory disease control pro­ Group (United Kingdom) in collaboration with grammes in all countries with an infant mortality WHO. rate greater than 40 per 1000 live births. Among the 88 countries falling into this category, 56 14 91 On completion of a multicentre study on ( 64 %) had control programmes in at least one the clinical signs and etiological agents of pneu­ major administrative division by the end of 1993. monia, sepsis and meningitis in infants under Since progress is relatively slow in sub-Saharan three months of age, conducted in Ethiopia, Africa because of other priorities, more Gambia, Papua New Guinea and Philippines, a extrabudgetary funds were provided in that re­ meeting of the principal investigators and con­ gion. WHO organized a meeting with represent­ sultants was held to analyse the results (Beijing, atives of UNICEF and 15 nongovernmental or­ November 1993). The etiology of pneumonia in ganizations to plan joint action for the control of malnourished children was studied in Gambia, acute respiratory infections in Africa (Trieste, and the clinical significance of in vitro resistance Italy, December 1992) and a workshop to train of pneumonia-causing bacteria to cotrimoxazole African consultants in planning, evaluation and or amoxycillin in Pakistan. WHO collaborated problem-solving (Cotonou, Benin, November with other agencies in organizing a field trial of 1993). These activities were part of WHO's Haemophilus influenzae type b vaccine in Gam­ strategy of giving more direct technical support bia. A manual on the monitoring of antimicrobial to national programmes. resistance of Streptococcus pneumoniae and H. influenzae was field-tested in Egypt, Paki­ 14 88 During the biennium WHO developed a stan, Thailand and Viet N am. In Guatemala sup­ prototype home-care card to assist health work­ port was given in working out procedures for ers to improve communication with families. monitoring indoor air pollution from burning The results obtained by applying WHO's re­ biomass fuels and for using behavioural methods cently completed "focused ethnographic study to measure the duration of exposure of mothers protocol" are used to adapt messages contained in and their infants to smoke. the home-care card and to choose appropriate terminology for use at local level. As recom­ 14.92 In 1992 WHO and UNICEF began coop­ mended at a meeting in May 1992, new guide­ erating in the design of an integrated approach to lines are being developed to assist programme the management of the lethal scourges-pneumo­ managers in applying the results of ethnographic nia, diarrhoea, malaria, measles and malnutrition studies in programme planning and implementa­ -which cause almost three-quarters of deaths tion. A workshop was organized for ethnogra­ among children under five years in developing phers from several African countries in 1993. countries. The integrated approach is summa­ rized in a set of case management charts for the 14.89 WHO developed a survey instrument for health worker, entitled: "Assess the child and evaluating case management practices, including classify the illness", "Treat the child" and "Ad­ communication with families, at first-level health vise the mother". A separate chart deals with in­ facilities; it was field-tested in 1992 in India, fants under two months of age. The new ap- Papua New Guinea, Philippines and Swaziland, and completed in 1993. To obtain information on home management of children with acute res­ piratory infections, including care-seeking prac­ 1 Document WHO/ARI/92 23- WHO/MAL/92.1 065. tices, the Organization devised a procedure for 2 Document WHO/ARI/93.29. household surveys that also collect information 3 Document WHO/ARI/93.30. on diarrhoea! diseases and breast-feeding. 4 Document WHO/ARI/93 27.

104 DISEASE PREVENTION AND CONTROL proach facilitates case management of these dan­ tive cases and to detect 70% of infectious cases gerous conditions in children in outpatient set­ by the year 2000. This can be achieved by the use tings, increases efficiency in training and the or­ of WHO recommended short-course chemo­ ganization of services, and stresses the impor­ therapy, with supervision of drug consumption tance of "clinical encounters" to promote im­ and use of recording and reporting systems munization and improve infant feeding. which meet WHO's criteria. As districts achieve high cure rates, case detection activities can be intensified to find remaining cases.

Tuberculosis 14.96 During the biennium WHO issued guide­ lines on tuberculosis treatment1 and provided 14.93 One-third of the world's population is technical support to national control pro­ infected with the bacillus Mycobacterium tuber­ grammes in over 30 of the most seriously-affect­ culosis, and approximately one in ten of those ed countries. In China detailed monitoring was infected people will develop active tuberculosis carried out in a large project supported by the at some time. In 1992 there were over eight mil­ World Bank. A combined tuberculosis and lep­ lion new cases of the disease; the number of suf­ rosy control project was initiated in Bangladesh ferers will continue to increase and nearly 90 in 1993, also with World Bank support. Reviews million new cases are likely to occur in the period of national tuberculosis programmes in India and 1990-1999. Most cases and more than 98% of Zimbabwe in 1992 resulted in revision of deaths occur in the developing world, but the national policies and preparation of projects for incidence of the disease is also increasing for the external finance by the World Bank and other first time in many decades in some countries in institutions. One outcome of technical support Europe and North America. to Guinea was the compilation of a national tuberculosis control manual applicable to many 14.94 Tuberculosis is now the world's leading countries. Six countries in the Americas and one cause of death from a single infectious agent and in the Western Pacific carried out evaluations of accounts for over a quarter of avoidable deaths their programmes with WHO support. New among adults. An estimated 2.9 million persons methods of programme review and evaluation died of it in 1992: 1.2 million in South-East Asia, were devised in the light of experience gained in 679 000 in the Western Pacific, 493 000 in Africa these countries. and over half a million in the rest of the world. Deaths from the disease are expected to increase 14.97 Training materials for middle-level pro­ to over 3.5 million per annum by the year 2000. gramme managers and treatment guidelines for Moreover, the epidemic has become more diffi­ national programmes were prepared, tested, re­ cult to control because of the emergence of fined, issued in various languages, and used in multidrug-resistant strains of the bacillus and be­ workshops at global, regional or national level in cause of the HIV pandemic. For instance, several countries.2 Guidelines were produced for between 1985 and 1991 the annual number of setting up national control programmes and in­ tuberculosis cases more than doubled in ternational reference laboratories to monitor Malawi and nearly tripled in Zambia as a conse­ drug-resistant tuberculosis. quence of HIV infection. 14.98 A WHO information base was established 14.95 In 1993 the Health Assembly, recognizing to monitor the status of national tuberculosis the seriousness of the situation, called upon programmes. Based on information from 139 Member States to take rapid action regarding countries and territories surveyed, it was found case detection and registration, short-course that less than 40% routinely used short-course therapy, and supplies of antituberculosis drugs chemotherapy in sputum-positive cases of pul­ (resolution WHA46.36). By the end of the monary tuberculosis. Half reported drug short­ biennium recognition by Member States of the ages in 1991, over half were partially or fully magnitude of the problem was beginning to re­ sult in the mobilization of additional national and external resources to improve national pro­ 1 Treatment of tuberculosis. guidelines for natiOnal programmes. Geneva, grammes and intensify research. WHO's ob­ World Health Organization, 1993 jectives for global control of tuberculosis are to 2 Bangladesh, Egypt, Guinea, lnd1a, N1caragua, Philippines, Un1ted Republic treat successfully 85% of detected smear-posi- of Tanzania, Z1mbabwe.

105 THE WORK OF WHO 1992-1993 dependent on donors to meet needs for drugs, main cause of human deaths from rabies. In Afri­ and more than a third were uncertain whether ca and Asia WHO concentrated on research on funding would be sufficient to meet their current canine biology and oral immunization tech­ year's needs. Following this survey, case stud­ niques for dogs and the promotion of appropri­ ies have been undertaken in eight sub-Saharan ate strategies for the control and elimination of African countries to determine ways of improv­ canine rabies. A national rabies coordinating ing their supply systems. committee was established in Nigeria, and an informal group was set up for training and re­ 14 99 Research begun or under way during the search on rabies in southern and eastern Africa. biennium included studies on diagnostic methods, Fourteen Asian countries endorsed a common testing of new drugs, and trials of the operational strategy primarily based on parenteral vaccina­ feasibility of using isoniazid for preventive thera­ tion of dogs. py in persons with HIV infection. Operational research conducted in collaboration with control 14 103 Significant progress was made in oral vac­ programmes in Malawi, Mozambique and United cination of dogs and safety requirements were Republic of Tanzania demonstrated the remarka­ framed in order to reduce the risk of contact ble cost-effectiveness of short-course chemother­ between candidate vaccines and human beings apy for pulmonary tuberculosis. A further study during mass vaccination campaigns. A field in Botswana suggests that these results are valid study was carried out to evaluate several vaccine­ for middle-income developing countries. bait delivery techniques. Discussions on require­ ments for the release of live rabies vaccines for 14 lOO Research to quantify the impact of oral immunization of dogs were held with a HIV infection on tuberculosis continued in the number of Asian and north African countries. United Republic of Tanzania. Further work be­ gan in Malawi to determine the effect of HIV 14 104 Very encouraging results were reported in infection on the results of tuberculosis treatment, those western European countries which con­ and also to assess the efficacy of new treatment duct regular campaigns for oral vaccination of and supervision regimens aimed at mitigating the foxes against rabies. With the exception of a few enormous increase in workload brought about foci, the rabies front at the end of 1993 followed by the epidemic of combined HIV and tubercu­ approximately a line from W olin on the Baltic losis infection. Sea to Trieste on the Adriatic Sea (see Fig­ ure 14.7). A meeting on rabies control in Europe 14 101 The main obstacle to tuberculosis control (Piestany, Slovakia, October 1993) helped to is not lack of medical knowledge but inadequate strengthen scientific and field collaboration on political will. An effective and relatively inexpen­ wildlife rabies, especially between members of sive cure already exists, but it is not being widely the Commonwealth of Independent States and used. In 1993 WHO therefore initiated a vigor­ other European countries. ous publicity campaign to bring the tuberculosis crisis to the attention of governments, journal­ 14 105 WHO coordinated studies on canine biol­ ists, nongovernmental organizations, and health ogy in Turkey, Yemen and Zambia during 1992- and public interest groups. In furtherance of this 1993. In the first two countries a large proportion campaign, an information package presenting ba­ of the dog population, whether owned or sic facts about the disease to a non-scientific au­ unowned, could not be captured for parenteral dience was widely disseminated, and the July­ vaccination. In such cases oral vaccination may August 1993 issue of the magazine World health prove to be the only means of achieving suffi­ was devoted entirely to tuberculosis. cient coverage to eliminate the animal reservoir of the disease.

14106 In South-East Asia WHO provided con­ Zoonoses sultants, supplies, equipment and training of health personnel and helped to organize national 14.102 Rabies was a growing health problem and and regional workshops on rabies control. Sup­ economic burden in many parts of Africa, the port was given in particular to India, Indonesia, Americas and Asia, and was reported in more Nepal and Sri Lanka. In the Americas coopera­ than 90 countries. Dog rabies was present in tion focused on strengthening national pro­ about 65% of infected countries and was the grammes for the elimination of canine rabies.

106 DISEASE PREVENTION AND CONTROL

Figure 14.7 Rabies incidence in Europe, 1992 and 19931 Ten years of coordinated campaigns for oral vaccination of wildlife hove brought a dramatic reduction in the incidence of rabies over a large part of Europe - on example of what can be achieved through sustained international health cooperation.

Fro nee (114)

(robie! heel c 110 fcldigfi>OIIt case teporled r.. at least two )'till•

1 Incidence is shown in blue lor 1992 and in grey Ior 1993; figures in brodcets refer to coses reported during the first quorler of 1993. Source: WHOC ollaboroting Centre for Robies Surveillance, Tubingen, Germany.

Collaboration among countries in this region owing to the presence of Salmonella enteritidis .in was successfully promoted and resulted in agree­ poultry, gave cause for concern. In many coun­ ments regarding rabies control in border areas tries S. enteritidis accounted for more than 80% and sharing of rabies vaccines. of all foodborne salmonellosis infections report­ ed in man. These cases were associated mainly 14.107 Studies on animal brucellosis vaccines with the consumption of eggs and egg products. showed that strain Rev.l vaccine should contin­ A study coordinated by WHO showed that hu­ ue to be used for control of the disease in small man.-to-human transmission does not play a sig­ ruminants. Guidelines were prepared in collabo­ nificant role inS. enteritidis epidemiology. Expe­ ration with FAO and the International Office of rience in some countries demonstrated that com­ Epizootics for the control of brucellosis in many prehensive control programmes closely associat­ parts of the Eastern Mediterranean where it is ing the human and animal health sectors can lead showing signs of increase. The medium-term ob­ to the production of animals almost free of Sal­ jective of the regional brucellosis programme is monella, thereby drastically reducing the to control animal brucellosis, primarily through number of human cases. a comprehensive vaccination campaign, and to significantly reduce the number of human cases 14.109 For effective reduction of the entry of within ten years. S. enteritidis and other strains of Salmonella into the food chain, strict measures are necessary at 14.108 The unabated upsurge of salmonellosis in farm level. Guidelines for the cleaning and disin­ humans in many European countries, mainly fection of S. enteritidis-positive poultry farms

107 THE WORK OF WHO 1992-1993 are nearing completion. In 1993 an international perts from 34 Member States located through­ training course on Salmonella control held in out the world. Their output included guidelines Sweden, where consumers have access to food of for the surveillance and control of anthrax in animal origin which is practically Salmonella­ humans and animals and recommendations for free, brought together participants from more prevention and control of Rift Valley fever, up­ than 30 countries in Europe, North America, the dated in the light of the recent outbreak in Eastern Mediterranean, Asia and the Pacific. Egypt.

14.110 In May 1993 a consultation reviewing the 14.113 Support continued for national programmes current state of research on animal and human in the Eastern Mediterranean to control rabies, transmissible spongiform encephalopathies and brucellosis and Rift Valley fever. In 1992 the Re­ the results of epidemiological studies conducted gional Committee for the Eastern Mediterranean on bovine spongiform encephalopathy and drew the attention of Member States to the need to Creutzfeld-Jakob disease in the United King­ strengthen cooperation between national veteri­ dom concluded that there was no cause to extend nary and public health services in surveillance, di­ the list of specified offal currently under ban, and agnosis, prevention and control of zoonotic diseas­ that epidemiological investigations provide no es and exchange of relevant information. evidence of a change in the incidence of Creutzfeld-Jakob disease that might be attribut­ able to bovine spongiform encephalopathy. AIDS and other sexually 14 111 Two meetings were conducted for republics transmitted diseases of the former Soviet Union, the first to promote national zoonoses surveillance systems (T eramo, 14.114 During the biennium the AIDS pandemic Italy, July 1993), and the second to provide guid­ continued its relentless global spread so that it ance on the control of zoonoses, including now affects all continents and almost all coun­ food borne diseases (Berlin, December 1993 ). tries. By the end of 1993 more than 15 million HIV infections were estimated to have occurred 14.112 WHO coordinated 37 working groups since the beginning of the pandemic, over and subgroups dealing with major zoonoses and 14 million of them in adult men and women (see related subjects, and bringing together 229 ex- Figure 14.8). A cumulative total of 446 681 AIDS

Figure 14.8 Estimated distribution of cumulative HIV infections in adults, late 1993

Global total: 14 million +

108 DISEASE PREVENTION AND CONTROL cases had been reported by 164 countries or global AIDS strategy1 establishing the new direc­ areas as at 1 January 1992, and by 31 December tion to be taken by all partners in the global effort 1993 the total was 851 628 cases. However, against AIDS in the years ahead (resolution taking into consideration under-diagnosis, un­ WHA45.35). The three main objectives of the der-reporting and delays in reporting, WHO es­ strategy remain: to prevent infection with HIV, to timates that by the end of 1993 there had been a reduce its personal and social impact, and to mo­ cumulative total of over 3 million AIDS cases bilize and unify national and international efforts (see Figure 14.9). against AIDS. The strategy sets out ethically and technically sound approaches of known effective­ 14.115 For the year 2000 the current WHO ness for meeting the pandemic's new challenges: projection is for a cumulative total of 30-40 mil­ greater attention to care; better treatment for oth­ lion HIV infections in men, women and er sexually transmitted diseases; a stronger focus children, more than 90% of them in developing on preventing HIV infection by improving wom­ countries. The projected cumulative total of en's health, education and status; a more support­ adult AIDS cases is close to 10 million. During ive social environment for prevention pro­ the 1990s the impact of AIDS will be greatest in grammes; planning in anticipation of the socioe­ large urban areas of sub-Saharan Africa, especial­ conomic effects of the pandemic; and more em­ ly in eastern and central Africa. In such areas phasis on the public health dangers of stigmatiza­ AIDS deaths in young children and in those aged tion and discrimination. The Economic and Social 15-49 years may reduce expected population Council at its July 1992 session (resolution 1992/ growth by over 30%, and the adult mortality rate 33) and the United Nations General Assembly at may more than triple. The devastating effects of its forty-seventh session in December 1992 (reso­ the pandemic may spread throughout Asia-the lution 47 /40) endorsed the updated strategy as the home of more than half of the world's popula­ global policy framework. tion.

14.116 In May 1992 the Health Assembly en­ I rhe global A/OS strategy. Genevo, Wodd Health Organization, 1992 (WHO dorsed an updated, greatly expanded and refined AIDS Series, No . l ll

Figure 14.9 Cumulative numbers af AIDS cases in adults and children, late 1993

Reported: 851 628 Estimated: 3 000 000+ Europe Asia 5%

Americas• 12%

"Excluding USA

109 THE WORK OF WHO 1992-1993

14.117 At an extraordinary meeting in November creasing numbers of interested parties involved in 1992 the Management Committee of the Global AIDS activities in countries. It is of particular con­ Programme on AIDS recommended the establish­ cern that while the number of countries having a ment of a task force on HIVI AIDS coordination medium-term plan financially supported by WHO and proposed terms of reference and a member­ increased approximately five-fold between early ship of twelve divided equally among developing 1988 and the end of 1992, the amount of resources countries, donor countries, bodies within the allocated to national AIDS programmes during United Nations system, and nongovernmental or­ that time (including multibilateral contributions) ganizations. In May 1993 the Health Assembly has remained about the same. With the involve­ requested the Director-General to study the feasi­ ment of a growing number of donors from differ­ bility and practicability of establishing a joint and ent sectors in national AIDS programmes, coordi­ cosponsored United Nations programme on HIV nation has become an important requirement at and AIDS, in close consultation with the executive country level and globally. One step towards im­ heads ofUNDP, UNICEF, UNFPA, UNESCO proving coordination at country level was the de­ and the World Bank (resolution WHA46.37). In velopment in 1993 of a computerized database to July 1993 the Economic and Social Council ex­ facilitate monitoring of AIDS programmes. pressed its full support of that resolution and called upon the executive heads to cooperate fully 14.120 A national AIDS programme manage­ in the consultative process. ment course was successfully field-tested in Zim­ babwe in 1993. It is designed to help countries in 14.118 In order to strengthen multisectoral ac­ planning, implementing and evaluating their tion with other bodies in the United Nations programmes and, above all, in setting priorities. system, the Organization collaborated with A set of priority indicators of progress in preven­ UNDP in mobilizing external resources for tion was selected and a methodology devised for country programmes within the framework of their use in national programmes. Protocols were the WHO/UNDP alliance to combat AIDS; prepared for application of the indicators and with UNFPA through participation in studies field-tests completed in Cote d'Ivoire, Hondu­ on condom requirements and logistics manage­ ras, India, Sri Lanka and United Republic of ment for the 1990s; with the World Bank in the Tanzania. The population survey originally con­ preparation of its 1993 report, 1 through the pro­ cerned with measurement of prevention indica­ vision of estimates and projections of HIV and tors was expanded to include measurement of AIDS incidence and prevalence, global estimates care and support indicators. These evaluation ac­ of the cost of prevention and care, and estimates tivities took longer than anticipated, but the real of the possible impact on HIV transmission of progress made will result in the establishment of preventive activities worldwide; with UNESCO a global framework for reporting on national in issuing a guide for health education in schools, AIDS prevention and care activities. for use by policy-makers and education plan­ ners;2 and with UNICEF in the joint publication 14.121 Approximately 60 million condoms were of the booklet "Living with AIDS in the com­ procured for national AIDS programmes during munity", which was adapted for general use from the biennium. Attention was focused on supply the original produced for Uganda by the AIDS policy, quality assurance, logistics management Support Organisation, the national AIDS pro­ training and social marketing. The WHO con­ gramme, UNICEF and WHO. dom specifications were revised with respect to lubrication, elasticity and size in response to 14.119 WHO continued to strengthen national feedback from users. A training course on logis­ AIDS programmes by providing technical support tics was established and a project survey com­ through its regional offices. Steps were taken to pleted with support from major donors and non­ formulate second-generation medium-term plans governmental organizations. for national AIDS programmes that call for a multisectoral approach, bearing in mind the in- 14122 With regard to safe blood, distance learn­ ing materials were produced for training blood transfusion staff with the minimum disruption of daily routine and at minimal cost. Guidelines to 1 World Bank World development report 1993. investmg m health New York, Oxford University Press, 1993. assist countries in more cost-effective methods of 2 School health educatiOn to prevent AIDS and sexually transmitted d1seas· screening blood for HIV were also drafted (see es Geneva, World Health OrganiZatiOn, 1992 (WHO AIDS Ser1es, No. 10). also paragraphs 13.3-13.5).

110 DISEASE PREVENTION AND CONTROL

The young man on the rig ht is a salesman with Ethiopia 's condom social marketing prog ramme. He distributes co ndoms throug h oil kinds of comme rcial outl ets fromp harmacies to street kiosks, bors on d petrol stations. He and his colleag ues hove been so successful in overcoming public rel uctance to discu ss or use condoms that the programme hos diffi culty keeping up with demand.

14.1 23 Work in the field of sexually transmitted 14.125 In developing countries women who visit diseases expanded considerably during the maternal and child health care facilities fot: ante­ biennium, recognizing that their treatment is es­ natal care and family planning services can also sential for the prevention of HIV infection. WHO be diagnosed and treated for sexually transmitted recommends integrating control of these diseases diseases if the services are properly integrated; and AIDS in primary care and other services at protocols were developed to facilitate such inte­ national level. To improve the diagnosis and case gration. management of sexually transmitted diseases, es­ pecially in women, a simple approach based on 14.126 A meeting in September 1992 brought to­ risk assessment was developed. WHO's recom­ gether representatives of organizations of the Unit­ mendations for the management of sexually trans­ ed Nations system and bilateral agencies to discuss mitted diseases, originally issued in 1983, have the requirements for drugs for the treatment of been revised to include not only treatment t:egi­ sexually transmitted diseases. Work continued in mens but also effective case management methods. preparing guidelines to help countries select drugs to meet their local needs and in exploring with the 14.124 In recognition of the need to ascertain the pharmaceutical industry and countries ways to magnitude of sexually transmitted diseases, a sys­ make these drugs more readily available. tem was devised to enable countries to assess the situation while developing an appropriate control 14.127 Congenital syphilis can be prevented and programme. A separate module for planning and controlled by screening pregnant mothers and strengthening programmes for the prevention and treating positive cases with penicillin. Despite control of sexually transmitted diseases was pre­ this and despite the fact that in most countries pared for inclusion in training on national AIDS pregnant women attend health facilities for ante­ programme management. In addition, an analyti­ natal care, little has been done to take the oppor­ cal model was prepared for use in improving the tunity to carry out screening. Even in countries case management of sexually transmitted diseases. where screening takes place, this is not always

111 THE WORK OF WHO 1992-1993 ------followed by treatment. WHO therefore devel­ and fewer unwanted pregnancies, and may even oped operational guidelines for programme delay the onset of sexual activity. managers and health workers for the prevention and control of congenital syphilis, and supported 14.131 As increasing numbers of HIV infections operational research on this subject in Brazil. develop into AIDS cases, the need for care and support for patients and their families is growing 14.128 Responsibility for AIDS prevention and fast. WHO therefore continued to support gov­ care does not rest entirely with the government ernments in planning and strengthening health authorities in a country. A large number of care services, for instance by preparing guidelines nongovernmental organizations at community for clinical diagnosis and treatment of HIV infec­ and national level provide essential and appropri­ tion in adults and young children; updating mod­ ate support to individuals and communities. ules for basic HIV education for nurses and mid­ From 1990 to 1992 WHO supported 92 commu­ wives that emphasizes prevention and care; and nity projects undertaken by nongovernmental issuing an AIDS home care handbook' which organizations in 35 countries with a total alloca­ had been assessed in Uganda and Zambia. Fol­ tion of$ 3.1 million. However, in order to use its lowing a regional workshop on community­ limited resources more effectively, WHO has based care in Uganda in 1991, similar workshops gradually reduced this form of support and in­ were held in R wanda in 1992 and Thailand in stead now concentrates on helping nongovern­ 1993. A feasibility study on including community­ mental organizations to obtain the financial, ma­ based care in existing urban health centres was terial and technical resources they need, and to started in Nairobi in 1993. A study was under­ build working relations amongst themselves and taken in Uganda to assess the additional costs of with national AIDS programmes. providing preventive tuberculosis therapy to HIV-seropositive persons. 14.129 At a meeting in May 1992 to consider ef­ fective approaches to AIDS prevention, 15 types 14 132 Protocols were drawn up for three priori­ of measures aimed at enabling people to change ty areas of social and behavioural research: sexual risky sexual behaviour were presented by those behaviour, particularly among young people; involved in their design and implementation; dis­ household and community response to HIV and cussion centred on factors which contributed to AIDS in developing countries; and negotiation the success of the interventions, constraints en­ of safer sex by women. Following site assessment countered and lessons learned. A project to pro­ visits, proposals were made for conducting re­ vide sex workers and their clients in six districts search in 10 developing countries. of Abidjan with treatment for sexually transmit­ ted diseases, condoms and education on HIV 14.133 WHO provided support in implementing prevention led to greater use of health services national plans for infrastructure strengthening, and increased condom sales. Technical support training and vaccine-related research at four sites in was provided for similar projects in the Domini­ Brazil, Rwanda, Thailand and Uganda. Laborato­ can Republic, India and Mexico. The findings of ries in those countries collected specimens from two technical working groups held in November 222 recent seroconverters in study populations; and December 1992 to review recent experience specimens from 63 of these patients were then ex­ of outreach work with high-risk behaviour amined by the WHO network for HIV isolation groups are being incorporated into a guide for and characterization (comprising 12laboratories in the planning of interventions. North America and Europe). Initial results suggest that the distribution of HIV-1 anti genic subtypes is 14.130 Research was initiated in four countries constantly changing, with different subtypes rapid­ on the conditions under which peer education on ly replacing others in a given population- a situa­ HIV is effective in schools; and a guide for set­ tion that poses a considerable challenge for the ting up health promotion projects for AIDS pre­ development of an HIV vaccine. vention among young people not in school was finalized following field-testing in seven coun­ 14134 In November 1993 the Advisory Council tries. A major review of data from developed and on HIVI AIDS recommended that priority areas developing countries has provided convincing evidence that sex education in schools does not encourage or lead to increased levels of sexual activity; rather, it results in safer sexual practices 1 Document WHO/GPA/IDS/HCS/93 2.

112 DISEASE PREVENTION AND CONTROL for research relating to women and AIDS should policy should be submitted to the Administra­ include the development of female controlled tive Committee on Coordination, which ap­ methods for preventing HIV transmission, in­ proved it as the formal policy for the whole of cluding virucides, microbicides and mechanical the United Nations system at its October 1993 barrier methods; effective preventive approaches meeting. In 1993 WHO issued guidelines on for women sex workers; and rapid cost-effective HIV infection and AIDS in prisons, 1 providing diagnostic tests for sexually transmitted diseases. standards - from a public health perspective - Protocols for research on a safe and effective which prison authorities should strive to achieve vaginal microbicide were drawn up following in their efforts to prevent HIV transmission and strong endorsement of this approach at a major to provide care to those affected by HIVI AIDS. meeting in November 1993. 14 138 In April-May 1992 a WHO/UNICEF 14 135 A double-blind placebo controlled trial of consultation on HIV transmission and breast­ the use of low-dose oral interferon alpha in symp­ feeding issued a consensus statement recom­ tomatic HIV-infected patients in Uganda revealed mending that breast-feeding should continue in that it conferred no benefit as regards survival, all populations, irrespective of HIV infection progress of the disease or subjective symptoms. rates. In November 1992 a further consultation Other studies were carried out with WHO sup­ on HIV testing and counselling emphasized that port on short-course chemotherapy for tubercu­ mandatory testing has no place in AIDS control losis in HIV-infected people in Haiti and on the programmes, and that no benefits to the individ­ efficacy and optimal duration of tuberculosis ual or for public health derive from such testing chemoprophylaxis in tuberculin-positive, HIV­ that cannot be achieved by less intrusive means infected persons in Thailand, United Republic of such as voluntary testing and counselling. Tanzania and Zambia. Reduction of the use of the Western blot technique for HIV testing permitted 14.139 The Organization promoted the world­ a significant decrease in the cost of testing. The wide observance of the fifth and sixth World initial results of a study on the risk of nosocomial AIDS Days on 1 December 1992 and 1993 transmission of HIV in children admitted to pae­ respectively by disseminating information diatric wards in four African cities were reassuring packages and issuing press releases on the chosen and suggested that the various skin piercing pro­ themes. World AIDS Day is now an annual event cedures that they experienced accounted for little in most countries and provides an opportunity to if any HIV transmission. stimulate awareness of AIDS and of the efforts being made to fight the pandemic. The theme 14.136 At a meeting in June 1993 attended by "AIDS: a community commitment" was chosen representatives of regulatory agencies and phar­ for 1992 in order to highlight the importance of maceutical companies, it was agreed that efforts local communities combining their strengths in to develop and approve drugs and vaccines for the global fight. In 1993 the theme was "AIDS: HIVI AIDS should be accelerated in developed time to act", which underlined the need for ur­ countries and extended to developing countries. gent action and served as a rallying call for the A joint WHO/International Federation of Phar­ world to join in ensuring a multisectoral re­ maceutical Manufacturers Associations state­ sponse to the HIVI AIDS pandemic. ment on HIVI AIDS was drawn up, representing a major commitment to making drugs and vaccines of assured quality and efficacy available for both prevention and treatment. Other communicable diseases

14 137 In 1993 the Organization confirmed that it would not sponsor, cosponsor or financially Viral and bacterial diseases support international conferences or meetings on AIDS in countries with entry requirements that 14.140 Influenza. With a view to strengthening discriminate solely on the basis of a person's surveillance and increasing the chances of early HIV status, nor would representatives of WHO detection of new variants of the influenza virus, attend such conferences unless attendance is WHO started a collaborative study on the origin of deemed essential for promoting WHO's pro­ gramme. In April 1993 the Inter-Agency Advi­ sory Group on AIDS requested that WHO's 1 Document WHO/GPA/DIR/93.3

113 THE WORK OF WHO 1992-1993 ------pandemic strains in southern China. Studies com­ port. The Organization was also involved in paring the traditional inactivated influenza vaccine combating an outbreak of Lassa fever in Nigeria. with the less commonly used live virus vaccine showed the latter to be slightly more effective in 14.144 Yellow fever remains a major threat in children. Recommendations regarding the influen­ Africa and South America. In 1992 it occurred za virus strains to be included in vaccines in 1992 for the first time in Kenya, and WHO assembled and 1993 were made on the basis of information field teams to assist in investigating the outbreak, and virus isolates obtained in WHO's network of providing diagnostic reagents and equipment, national and international laboratories. and starting an emergency vaccination campaign.

14.141 Viral hepatitis. Hepatitis B vaccine is 14145 Japanese encephalitis is increasingly rec­ now being more widely included in national ognized as an important disease that can be pre­ immunization programmes: nearly 50 countries vented by immunization. WHO has sponsored have a national policy of universal administra­ efforts in several Asian countries to improve tion of the vaccine to infants. :Crogress is also methods for production of the vaccine and make being made in immunizing health care workers. it more readily available. During the biennium WHO continued to sup­ port laboratory research on the production of 14.146 Plague. Sporadic cases and periodic out­ plasma-derived hepatitis B vaccine in the Dem­ breaks of bubonic plague were reported in 12 coun­ ocratic People's Republic of Korea, Mongolia tries during the biennium; natural foci of the and Myanmar, and nationals of those countries disease exist in Africa, the Americas and Asia. and of Indonesia were awarded WHO fellow­ ships to train in the production of the vaccine. 14.147 Meningitis. Epidemic cerebrospinal men­ Safe and highly effective vaccines to prevent ingitis remained a problem, particularly in Africa hepatitis A are now licensed in many countries (see Figure 14.10). Surveillance of Neisseria and WHO prepared guidelines for their use in meningitidis strains continued, including moni­ immunizing travellers and other groups at risk. toring of susceptibility to antibiotics. WHO pre­ pared practi~al guidelines on the control of epi­ 14.142 Arthropod-borne viruses and viral haem­ demic meningococcal disease. orrhagic fevers are major causes of morbidity and mortality. Dengue viruses appear in new areas as 14 148 Legionellosis. A surveillance system in the mosquito vector Aedes aegypti invades addi­ 22 European countries for Legionella infections tional urban habitats. This spread is most notable in travellers was devised in cooperation with the in the Americas, where nearly all countries in WHO collaborating centre in Stockholm, and rec­ Central and South America and the Caribbean ommendations for further work on the control of are now at risk of epidemic dengue. An outbreak these infections were made during two WHO of dengue fever in Comoros showed that dengue consultations (Haniotis-Halkidiki, Greece, May is also a threat in Africa. WHO continues active­ 1992; Vienna, May 1993 ). ly supporting vaccine development, surveillance of infection, control of outbreaks, and vector 14.149 Streptococcal infections and their suppur­ control (see paragraph 14.42). ative and non-suppurative sequelae remain an important health concern. A WHO collaborative 14.143 Viral haemorrhagic fevers are an impor­ study on the production of group A strepto­ tant group of emerging infectious diseases. coccal M and OF typing sera resulted in the es­ WHO was active in the investigations that re­ tablishment of a standard set of typing sera for vealed the etiological role of the hantaviruses in use in regional and national programmes for the an outbreak of fatal adult respiratory distress prevention and control of rheumatic fever and syndrome in south-western United States of rheumatic heart disease. America. In recent years other emerging viral haemorrhagic fevers have been recognized as ma­ jor causes of fatal human infection (for instance, in Brazil and Venezuela). Rift Valley fever virus Antimicrobial resistance and hospital remains an important pathogen affecting man infections and domestic animals in much of Africa; during 1993 cases were diagnosed in Upper Egypt, and 14.150 WHONET computer software was used WHO responded to requests for technical sup- in monitoring resistance to antimicrobials in a

114 DISEASE PREVENTION AND CONTROL

Figure 14.10 Major epidemi(s of meningo(O((OI meningitis, 1970-1993

.- e serogroupA • serogroupB 0 serogroup(

pilot programme involving hospital laboratories nuaP appeared during the biennium, and train­ in the Americas, South-East Asia and the West­ ing programmes on laboratory safety were con­ ern Pacific. In Europe WHOCARE software for ducted through WHO's network of collabo­ computer-assisted registration of the effects of rating centres. surgery was developed for use by hospital-based health workers concerned with the control of nosocomial infections. Measures following smallpox eradication

14.152 The complete nucleotide sequence of the Rapid diagnosis of infectious diseases genomes of two variola virus strains and parts of three additional strains were determined, thus 14.151 Diagnostic reagents prepared for the fulfilling the requirements set in 1990 for the identification of respiratory and measles virus­ final destruction of the remaining stock of es, enteroviruses and herpesviruses were made variola virus; but during 1993 it became evident available for collaborative studies. One such that the recommendation to eliminate these vi­ study involving 16 laboratories was on the use ruses was controversial. WHO offered a forum of monoclonal antibodies for diagnosis of for the scientific and public health community to respiratory viruses.1 The reagents were also express their views in a round-table discussion at employed by 70 laboratories carrying out envi­ the IXth International Congress on Virology ronmental surveillance of enteroviruses in 21 (Glasgow, United Kingdom, August 1993). Oc­ countries. A revised laboratory biosafety ma- casional rumours of smallpox cases continued to

1 Laboratory b10safety manual, 2nd ed Geneva, World Health Orgon1ZOI1on, 1 Bulletin of the World Health Organization, 1992, 70 (6): 699·703. 1993

115 THE WORK OF WHO 1992-1993 circulate, particularly in areas of political unrest. A few were true cases of poxvirus infections, New vaccines against bacterial diseases including monkeypox in Africa, but none was due to variola virus; the WHO collaborating cen­ 14.155 There was substantial progress in the de­ tres on smallpox and other poxvirus infections velopment of new, more effective vaccines provided the laboratory diagnosis. against cholera and other diarrhoea! diseases. Several promising cholera vaccines are now at the clinical trial stage, and urgent work is in progress to produce a vaccine against cholera following Intestinal parasitic infections the appearance of the 0139 strain of Vibrio cholerae which is beginning to cause epidemics in 14.153 Major collaborative projects for the con­ South-East Asia. New Shigella vaccines are now trol of intestinal parasitic infections were being tested on human beings. launched in Addis Ababa, Rodrigues (Mauri­ tius), and Dhofar Governorate (Oman), and two 14.156 Vaccines suitable for inclusion in infant im­ national control programmes were in progress in munization schedules have been developed against Seychelles and in Zanzibar (United Republic of group A and C meningococcal meningitis and are Tanzania). Collaboration to combat these infec­ being tested in Gambia and other endemic areas, tions began in China, Maldives, Mexico and while vaccines against group B meningococcal Myanmar. A set of bench aids for the diagnosis meningitis produced in Cuba and Norway are of intestinal protozoa was under development being compared in clinical trials. following successful trials of such aids for the identification of intestinal helminths. A software 14 157 The search for vaccines against pneumo­ package for field evaluation of the impact of coccal species is complicated by the variability of helminth control programmes was devised and pathogenic polysaccharide serotypes and by the field-tested. absence of immunogenicity of polysaccharide vaccines in children under two years of age; but several vaccines have been developed to overcome these difficulties and will soon be in production. Research and development in the field of vaccines 14158 The effectiveness of BCG against tubercu­ losis varies considerably in different countries but, owing to important advances, this vaccine Children's Vaccine Initiative can now be engineered to improve the expression of potentially protective antigens. Alternatively, 14 154 This initiative provides a strategic frame­ site-directed mutagenesis of Mycobacterium tu­ work for work on vaccines undertaken within berculosis can make the bacterium harmless by WHO and elsewhere, including institutions in deleting selected virulence factors. the public and private sectors. It is sponsored jointly by UNICEF, UNDP, the World Bank and the Rockefeller Foundation, and its secretar­ iat is provided by WHO. It has two main work­ New vaccines against viral diseases ing components: product development groups, which promote, facilitate and manage projects 14 159 Dengue virus infection is spreading leading to the development of vaccines and relat­ throughout the tropical zone and vaccines are ur­ ed preparations, each group focusing on a partic­ gently needed; a candidate tetravalent live attenu­ ular vaccine; and task forces, which examine stra­ ated vaccine was developed in Thailand with the tegic, logistic and policy questions, such as prior­ support of WHO and may be produced commer­ ity-setting, demand and supply, and collabora­ cially in the near future. Substantial progress was tion with industry, relevant to the development also made in characterizing the genomes of the and introduction of vaccines. In addition, there is dengue and Japanese encephalitis virus, facilitating a management advisory group which reviews the development of a suitable vaccine. budgetary matters and progress of activities, and a consultative group which provides an interna­ 14 160 Many cases of measles occur before the tional forum for information exchange and con­ usual immunization age and there is a need for a sultation on priority activities. vaccine that can be given three to four months

116 DISEASE PREVENTION AND CONTROL after birth; several candidate preparations are now undergoing preclinical tests. Two other vi­ Training ral pathogens, respiratory syncytial virus and parainfluenza virus type 3, contribute to many 14.163 In 1992-1993 64 scientists from develop­ of the serious respiratory infections of infancy; ing countries were trained at the WHO Immu­ excellent progress has been made towards de­ nology Research and Training Centre located in fining antigenic formulations which may offer Geneva and Lausanne (Switzerland) in areas of protection against the first, and initial live vac­ immunology and biotechnology related to the cine studies with bovine and attenuated human evaluation of vaccine immunogenicity and effica­ strains of the second have produced vaccines cy. In 1992 a further 39 scientists from South­ that are both safe and immunogenic in East Asia participated in a refresher course in seronegative infants. Semarang (Indonesia); and a similar course was organized in Teheran with the support of the 14 161 An inactivated hepatitis A vaccine is now Islamic Republic of Iran. available, but the present cost of production lim­ its its use in the developing world. Combination vaccines in which hepatitis B vaccines will be added to new immunization formulations for in­ Blindness and deafness fants are now in prospect. Hepatitis C is emerg­ ing as a major cause of liver cirrhosis and cancer, 14.164 Further progress was made towards the especially in industrial countries, and studies are target of the establishment of national blindness in progress to define important antigens for vac­ prevention programmes in all countries where cine development; a WHO collaborating centre sight loss is a public health problem. In 1993 announced success in growing the virus in tissue WHO drew up an inventory of national plans, culture, a critical step in vaccine research. committees and programmes in 93 countries Hepatitis E poses a risk particularly in the devel­ out of an estimated 116 in need. 1 Thanks to the oping countries; however, substantial progress help of a contribution from the International was made in the application of recombinant Association of Lions Clubs, WHO was able to DNA technology to the production of protec­ coordinate its work in this area more effectively. tive immunogens. The Organization has also cooperated closely with a consortium of six nongovernmental or­ ganizations which is providing funds for distri­ bution of ivermectin against onchocerciasis, and Improvement of existing voccines is promoting common strategies and methods for control operations in 12 African and four 14 162 It would be preferable to find animal Latin American countries. Through this initia­ models other than non-human primates for as­ tive about 2.5 million people were treated in sessing the neurovirulence of new vaccine lots. 1993 (see also paragraphs 14.30 and 14.62). An advance in this area was the production, un­ Recommendations on management of severe der WHO auspices, of transgenic mice express­ visual disability in children2 were formulated at ing the human poliomyelitis virus receptor; the a meeting held jointly with the International Organization issued guidelines for the handling Council for Education of the Visually Handi­ of such mice. Other approaches based on genetic capped (Bangkok, July 1992). engineering showed encouraging progress and trials of a new genetically stable candidate re­ 14.165 Continued support from the Edna placement vaccine for the existing type 3 Sabin McConnell Clark Foundation enabled the Or­ poliomyelitis strain began in man, inspiring hope ganization to produce two manuals on the man­ that the dangers of reversion to virulence in at­ agement of trachoma within primary health care tenuated strains may soon be minimized. In re­ systems/ and training courses on simplified as- gard to tetanus, work proceeded on the elabora­ tion of a single-dose vaccine that would provide phased release of antigens and replace the current three-dose immunization. There are difficulties regarding the stability of the preparation, but it is 1 Document WHO/PBL/93.30. hoped that a single-dose tetanus vaccine may be 2 Document WHO/PBL/93 27 available by 1996. 3 Documents WHO/PBL/93 29 and WHO/PBL/93 33.

117 THE WORK OF WHO 1992-1993 sessment of this condition were conducted in Mali in 1992 and Kenya in 1993. Applied re­ • One problem in setting up national search on cost-effective cataract surgery was programmes to prevent hearing impair­ carried out in India and Mali. In September ment is the lack of epidemiological data on 1993 a WHO consultation considered the ef­ this condition. WHO has therefore de­ fects of solar ultraviolet radiation on the eye and signed a standardized examination form called for a major international study on this which makes it possible for a field survey subject. team with portable audiometers and low­ cost instruments to carry out a simple 14 166 Training of personnel in blindness pre­ hearing assessment on as many as two vention remained a priority in Africa. Strategies hundred people per day, using trained for national programme development were auxiliary staff for part of the procedure. planned at a workshop for Portuguese-speaking countries (Maputo, October 1993 ), supported by the Consultative Group of N ongovernmental Organizations.

14 167 In the Americas further progress was 14.172 With regard to the prevention of deafness made in setting up national programmes, and and hearing impairment, a working group in AGFUND made contributions to nine countries March 1992 devised a uniform ear examination for this purpose. WHO responded to an appeal record which was subsequently field-tested in for emergency relief to deal with an epidemic of Thailand in 1992 and India in 1993. The Founda­ neuropathy in Cuba. tion for Advanced Studies on International De­ velopment Qapan), Kansai Medical University 14.168 In South-East Asia aspects of programme Qapan) and the Tokyo-based Asian Interactive management were examined in 1993 during Association on the Hearing Impaired provided a course in Thailand supported by the Interna­ financial support for WHO's work in this field tional Association of Lions Clubs. WHO gave from March 1992 onwards. A task force on the technical advice on the preparation of a proposal prevention of deafness (Alexandria, October to the World Bank for strengthening the Indian 1992) reviewed the situation in the Eastern Med­ national programme. iterranean and called for urgent epidemiological assessment of hearing impairment and its causes 14 169 Several countries in eastern Europe re­ in different populations. vised their programmes for blindness prevention. A national seminar on this subject was organized in Romania in 1993 with support from Orbis Cancer International (USA).

14 170 In the Eastern Mediterranean, Sudan and • WHO estimates that 9 million cases of Tunisia revised their national programmes; Tuni­ cancer occur in the world every year. By sia also proceeded with a nationwide assessment the year 2015 the annual figure is expected of sight loss and its causes, as did Morocco. An to reach 15 million cases, two-thirds of intercountry meeting on national blindness pre­ them in developing countries, which have vention programmes (Cairo, April 1993) called only 5% of the resources available for can­ for a fuller evaluation of the programmes in most cer control in the world. countries

14.171 WHO support was provided to China in 1992 for a course on management of cataract and 14173 WHO's act1v1t1es in cancer control are in 1993 for a national seminar on prevention of based on the fact that enough is now known sensory impairments in the elderly. A Western about cancer for effective action to be taken that Pacific regional workshop on evaluation of na­ will significantly reduce morbidity and mortality tional blindness prevention programmes (Syd­ worldwide and that, given the right priorities and ney, Australia, October 1992) was held with sup­ approaches, even the limited resources available port from the Consultative Group of Nongov­ can be used in such a way as to have a real impact ernmental Organizations. on the problem.

118 DISEASE PREVENTION AND CONTROL

Primary prevention Treatment

14 174 Policies on healthy lifestyles and optimal 14.177 Mortality from cervical, breast, mouth and diet were worked out together with the WHO skin cancers, if they are detected early, can be cardiovascular diseases and nutrition pro­ significantly reduced by standard therapies. grammes. Various WHO programmes also con­ WHO encourages the provision of adequate serv­ tribute to the primary prevention of cancer. Ex­ ices, especially radiotherapy. Six radiotherapists/ amples are the programmes on tobacco or health oncologists were trained in a radiotherapy and and immunization against hepatitis B. Other con­ oncology project carried out in Zimbabwe in tributions are made by WHO collaborating cen­ 1989-1993 with Swiss support; and 14 others have tres. For instance, during the biennium a WHO been trained in Sri Lanka. WHO initiated the collaborating centre in Regensburg (Germany) be­ preparation of a manual on basic radiotherapy, gan work on tumours associated with the Epstein­ together with IAEA. Barr virus, that are found in countries with a high incidence of nasopharyngeal cancer. The 14178 During the biennium WHO prepared, melanoma programme, carried out by the Italian from among over 100 drugs, a model list of National Institute for Cancer Treatment and Re­ 22 essential drugs for cancer chemotherapy, se­ search on behalf of WHO, devised strategies to lected for their cost-effectiveness and efficacy prevent this disorder by informing the public about and designed to satisfy the needs of most patients the dangers of excessive exposure to sunshine, par­ in national programmes. ticularly in childhood; individuals at high risk can now be identified and offered preventive advice. Palliative care

Early detection 14 179 Palliative treatment and care, including symptom control and pain relief, will be important 14 175 Managerial guidelines for the control of for years to come for the large numbers of patients cervical cancer were issued' and innovative meth­ for whom curative therapy is not possible. More ods of early detection introduced and coordinat­ than 40 countries have established government pol­ ed. Cost-benefit evaluation of early detection pro­ icies on cancer pain and terminal care; and pain grammes for cancers of the breast, cervix, mouth relief or palliative care is included in several nation­ and skin was promoted in countries in Africa, the al cancer control programmes. WHO recommends Americas, South-East Asia and the Eastern Medi­ the use of a number of non-opioid and opioid anal­ terranean. A trial on self-examination of the breast gesics and adjuvants for relieving cancer pain. Oral is under way in the Russian Federation. morphine consumption in the world has increased five-fold in recent years, bringing a great improve­ 14.176 A new project was launched to promote ment in quality of life for many cancer patients. A simple methods for the early detection of cancer WHO working group (Banff, Canada, September of the mouth and cervix in developing countries. 1993) approved a manual on palliative care for WHO collaborated with the Indian Ministry of those providing home care. Joint meetings organ­ Health and Family Welfare in studies to detect ized by WHO and the International Association cases at an earlier stage by visual inspection. Sim­ for the Study of Pain (Arezzo, Italy, June 1993; ilar studies were begun in southern Africa and Paris, August 1993) prepared guidelines on cancer the Western Pacific in collaboration with the pain relief and supportive care for children. Eight World Bank. Once the results of these investiga­ WHO collaborating centres have been carrying out tions are available, it will be possible to decide research and training and applying methods for whether the approach can be recommended and cancer pain relief and palliative care. applied widely in developing countries.

National cancer control programmes

1 Miller AB. Cervical cancer screemng programmes Geneva, Warld Health 14 180 The cornerstone of WHO's approach to OrganiZatiOn, 1992. cancer control is the development of national

119 THE WORK OF WHO 1992-1993 programmes. WHO issued a handbook1 summa­ linked to known trends in smoking habits, for rizing ways to apply scientific knowledge in can­ lung cancer. IARC gave extensive support cer control, based on the experience of 12 coun­ for setting up and running cancer registries in tries. Requests have subsequently been received developing countries in Africa, Asia and Latin from 40 other countries to help them to set up America. such programmes. So far, WHO has provided guidance to over 40 countries, each of which is establishing a programme in accordance with its existing cancer care structure and resources. Ar­ Etiological studies rangements were discussed with 14 countries in the Eastern Mediterranean at an intercountry 14 183 Cancer related to occupational exposure workshop (Cairo, November 1993) and six com­ was studied with respect to phenoxy acid herbi­ mitted themselves to set up national programmes. cides, styrene, man-made mineral fibres, the pulp The target is that at least half of the Member States and paper industry, biological laboratory work, will have formulated strategies and programmes lead, the wood and leather industries, asphalt for cancer control by the year 2000. vapours, mercury, textile manufacture, the nu­ clear industry, steel works and the rubber indus­ 14 181 Six district cancer control demonstration try. Special attention was paid to the high levels projects are being established in India, making of occupational exposure often prevailing in de­ use of existing health infrastructure to cover a veloping countries. large population for the control of oral, cervical and breast cancers through primary prevention, 14.184 In a European prospective investigation early detection and referral for curative treat­ into cancer and nutrition, pilot studies were ment as well as palliative care; it is expected that completed on food composition and methods for they will become models for the whole country dietary assessment, and recruitment of an esti­ and possibly for other developing countries. mated 420 000 participants in seven countries was well advanced. Each participant's diet is be­ ing recorded, and blood samples are taken for biological measurements. International Agency for 2 Research on Cancer 14.185 Lymphomas in patients suffering from AIDS were studied to characterize interactions between HIV and Epstein-Barr virus. Various Descriptive epidemiology cancers in relation to HIV infection were the sub­ ject of an epidemiological study in central Africa. 14 182 In 1992 IARC published data on the inci­ dence of cancer in 46 countries ( 170 populations) 14 186 It was found that induction of the enzyme for the period 1983-1987.3 An estimated nitric oxide synthase in infected tissues may be 7.62 million new cases of cancer occurred in involved in the endogenous formation of carci­ 1985 (3.85 million males and 3.77 million fe­ nogenic nitrosamines, implicated in cancer of males), the lung being the commonest site (nearly vanous organs. 900 000 cases). Data on time trends~ show a de­ crease in stomach cancer, an increase in malig­ 14 187 A range of epidemiological studies in nant melanoma of the skin, and mixed patterns, Gambia and Thailand, including the develop­ ment of methods in !ARC's laboratories to measure exposures, yielded detailed information on the interaction between hepatitis virus infec­ tion and aflatoxin exposure in the etiology of 1 Document WHO/CAN/92.1. liver cancer. 2 For a more detailed description of IARC's activities 1n the b1enn1um, see International Agency for Research on Cancer, B1ennwl report, 1992-1993. Lyon, 1993. 14.188 Epidemiological results from investiga­ 3 Park1n OM et al. Cancer modence m five contments, Vol VI. Lyon, Interna­ tions in Colombia and Spain, using sensitive tional Agency for Research on Cancer, 1992 (IARC Scientific Publications, methods for detecting human papillomavirus, No 120) showed a close association between this agent 4 Coleman M et al Trends m cancer modence and mortality. Lyon, Interna­ tional Agency for Research on Cancer, 1993 (IARC SCJent1f1c Publications, and cervical cancer. The combined in vivo and in No 121) vitro evidence for the carcinogenicity of at least

120 DISEASE PREVENTION AND CONTROL some types of the virus has been assessed as being consistent enough for the relationship to be con­ Cancer prevention research sidered causal.1 14.193 In the hepatitis intervention study in Gambia, a good level of protection among vacci­ nated children continued to be observed. In par­ Genetics and cancer allel, appropriate measures to reduce exposure to aflatoxin were investigated. Cancer registration 14.189 It has become clear that genetic differen­ was set up in order to document the incidence of ces in enzymes that convert many substances cancer, particularly of the liver, over the forth­ into active carcinogens influence individual sus­ coming decades. ceptibility to certain forms of cancer. Thus smokers may react differently to the carcinogens 14.194 In a chemoprevention trial in Venezuela, in tobacco smoke, and aflatoxins ingested in over 1000 subjects were recruited and received foods may be converted more or less efficiently antioxidant vitamins. Precancerous lesions of the into DNA-binding agents. Differences in the en­ stomach are being monitored by immunochemical zymes that repair DNA damage can also affect and histological methods. A pilot study showed individual susceptibility to carcinogens. that treatment to eradicate infection with H elicobacter pylori was much less efficacious than 14.190 Attemps to map the breast cancer gene had been seen in developed countries and this located on chromosome 17q continued. Coun­ treatment was therefore not included in the trial. selling is being provided to women in families identified as being at high risk. Studies have sug­ gested that other genes predisposing to breast cancer also seem to exist. Information and training

14.195 Four new volumes were published in the IARC Monographs series. They dealt with Mechanisms of carcinogenesis strong acid mists, solar and ultraviolet radiation, food constituents and contaminants, and a range 14.191 Mutations in oncogenes are being meas­ of colouring matters and their use in hairdress­ ured at frequencies as low as one in 10-s DNA ing. Factors evaluated as carcinogenic to humans bases, as a method for detecting the very earliest were occupational exposure to strong inorganic molecular lesions in the pathway to cancer. Simi­ acid mists containing sulfuric acid, solar radia­ larly, specific forms of damage caused by ultra­ tion, Chinese-style salted fish, naturally occur­ violet radiation in the p53 tumour-suppressor ring mixtures of aflatoxins, and the manufacture gene in skin cells are being detected and quanti­ of the dyestuff magenta. Among other factors, fied. Mutations detected in these genes in oral, 1,3-butadiene and occupational exposures in oesophageal and stomach tumours throw light hairdressers and barbers were categorized as on the ways in which loss of control of cell pro­ probably carcinogenic. In addition, work started liferation can lead to cancer. Methods are also on the publication of a series of fascicles on the being refined for the detection of very low levels classification of rodent tumours. of carcinogen-DNA adducts as early markers of carcmogemc processes. 14.196 During the biennium 23 fellowships were awarded to young scientists from 12 countries, 14 192 Studies have shown that genes for and 10 training courses on various aspects of connexon proteins that form communicational cancer research were attended by a total of junctions between cells may act as tumour-sup­ 426 participants. pressor genes by improving the control of cellu­ lar growth and proliferation that results from such communication. Cardiovascular diseases

14.197 Activities under the WHO programme 1 Muiioz N. et al. The epidemiology of cefV!ca! cancer and human papillomavtrus lyon, International Agency for Research on Cancer, 1992 for the prevention of rheumatic fever and rheu­ (IARC Sctenttftc Publications, No 119) matic heart disease continued in close collabora-

121 THE WORK OF WHO 1992-1993 tion with the International Society and Federa­ vascular diseases in countries of the Eastern tion of Cardiology. Phase I (assessment) was Mediterranean; cardiovascular diseases in devel­ completed in 16 countries, with support from oping countries; and the establishment of a glo­ AGFUND, and phase II (community control) bal database. was begun. A further nine countries joined the programme during the biennium, bringing the 14.201 The data collection phase of the project total to 25. for cardiovascular diseases and alimentary com­ parison (CARDIAC), a multicentre study 14198 The WHO project for multinational moni­ launched in 1985 to assess the relation between toring of trends and determinants of cardiovascular food intake and cardiovascular diseases, was diseases (MONICA), the largest collaborative epi­ completed in 1992 and the WHO collaborating demiological study of these diseases ever carried centre in Izumo Qapan) began an analysis of the out, continued in 25 countries and entered the final results. stage of data collection. The first analyses of trends in risk factors, based on two population surveys, 14.202 Collection of specimens and data for the were prepared. A first cross-sectional comparison WHO/International Society and Federation of of morbidity data in stroke cases was prepared and Cardiology study on pathobiological determi­ a similar analysis for coronary events was submit­ nants of atherosclerosis in youth was also com­ ted for publication in the journal Circulation. The pleted. The data are now being analysed and spe­ third and final population survey was prepared and cial investigations are in progress at reference a special training workshop organized (Gargano, centres in Budapest, Geneva, Havana, Italy, March 1993). The steering committee for Heidelberg (Germany), Malmo (Sweden), Sienna MONICA met twice during the biennium and the (Italy) and St Louis (USA). principal investigators reviewed progress and took decisions on policy, publications and quality con­ 14 203 An education programme for patients with trol at a meeting supported by the regional author­ hypertension was started in 1990 by WHO and the ities of Catalonia and the Hospital Sant Pau (Barce­ World Hypertension League in Canada, China, lona, Spain, August 1992). At the same time coordi­ Cuba, Ghana, Hungary, India and the Russian nation meetings were held on MONICA optional Federation. The aim is to assess whether educating studies relating to vitamins and polyunsaturated patients influences compliance with treatment regi­ acids, dietary monitoring, drugs, physical activity mens and consequently management of the disease. and psychosocial factors. The main results from Each centre prepared a local protocol and complet­ MONICA to date concern: cross-sectional com­ ed the data collection phase at the end of 1993. parisons of risk factor levels; relations between var­ ious risk factors; five-year trends in risk factors; 14 204 In November 1992 a WHO scientific acute coronary care; medical services; cross-sec­ group assessed the influence of specific nutri­ tional comparisons of incidence rates for stroke; tional, metabolic and haemostatic factors, alco­ and management of stroke around the world. These hol, physical activity, sex hormones and results were presented at a number of conferences psychosocial and economic factors on cardiovas­ and congresses during the biennium. cular disease risk, and recommended areas for future research by WHO and other bodies. 14199 A meeting between WHO and the United States Institute of Medicine (Washington, October 14205 In October 1993 a WHO study group re­ 1992) worked out details of a joint study to review viewed global demographic changes in relation the current status of the epidemiology, prevention to the epidemiology of cardiovascular diseases in and control of cardiovascular diseases in develop­ the elderly, assessed the effectiveness and cost of ing countries and agreed upon a strategy for inter­ preventive strategies, and indicated policy op­ vention based on needs and priorities. A plan of tions and research priorities for prevention. action was drawn up covering health statistics and epidemiology, prevention and case management, 14.206 World Health Day 1992 was devoted to and an implementation committee was established cardiovascular diseases under the slogan to carry the work forward. "Heartbeat - the rhythm of health", and was marked by activities all over the world, in devel­ 14.200 As part of an international conference on oped and developing countries alike. WHO's preventive cardiology (Oslo, June-July 1993) concerns include physical activity and sport, as workshops were held on: prevention of cardia- demonstrated by a new technical cooperation

122 DISEASE PREVENTION AND CONTROL agreement with the International Olympic Com­ tional workshop on clinical epidemiology training mittee concluded in June 1993. in diabetes (Omiya, Japan, July-August 1993), cosponsored by WHO, drew up guidelines for 14 207 WHO's publications on cardiovascular future international training courses in this field. diseases during the biennium included a special edition of World health statistics quarterly! and 14.211 Chronic rheumatic diseases. The protocol an expert committee report on rehabilitation af­ was elaborated for the WHO multinational col­ ter cardiovascular diseases.2 laborative study on the predictors of osteo­ arthritis, with the aim of designing a scientifically based approach to primary prevention of osteoarthritis in the community. WHO cospon­ Other noncommunicable sored an international conference (Maastricht, diseases Netherlands, April-May 1992) which defined methods for measuring the results of treatment in 14.208 Diabetes mellitus. Global estimates of the clinical trials concerned with rheumatoid arthritis. prevalence of diabetes in adults were published.3 WHO cosponsored World Diabetes Days 14.212 A working group on Kashin-Bek disease (14 November 1992 and 1993) when many was organized in conjunction with the WHO col­ countries, both developed and developing, tried laborating centre for the epidemiology of rheu­ to increase local awareness of the growing prob­ matic conditions (Stockholm, May 1992), in lem of diabetes. In November 1992 a WHO which experts in clinical rheumatology, biochem­ study group meeting on the prevention of diabe­ istry and epidemiology from China, Germany, tes reviewed existing knowledge and recom­ New Zealand, Sweden, United Kingdom and mended preventive strategies that could be rele­ United States of America participated. vant to the prevention of other noncommu­ nicable diseases sharing common risk factors 14.213 A WHO study group on assessment of with diabetes. WHO's guidelines on the devel­ the risk of osteoporotic fracture and its role in opment of national diabetes programmes4 were screening (Rome, June 1992) reviewed the extent translated into French, Spanish and Russian. of the problem of osteoporosis, evaluated the risk and benefit of different screening techniques 14 209 The International Diabetes Federation and their impact on various target populations, and WHO convened a joint meeting (Budapest, and proposed strategies for preventing the condi­ March 1992) concerned with the implementation tion. In June-July the fifth meeting of the joint of the 1989 St Vincent declaration on diabetes WHO/International League of Associations for care and research in Europe, which called on Rheumatology task force examined the classifi­ Member States to establish national diabetes task cation of antirheumatic drugs and refined the forces. A meeting of the Eastern Mediterranean existing guidelines for their use. regional advisory panel for diabetes (Karachi, December 1992) prepared guidelines for diabetes 14 214 Chronic nonspecific pulmonary diseases. care and programme implementation. A subse­ These diseases, particularly asthma, are increas­ quent meeting (Alexandria, November 1993) ingly posing a problem in both developed and prepared materials for educating diabetes pa­ developing countries; in 1992 a number of con­ tients. sultations were held, leading to a meeting on asthma (Chicago, USA, March 1993) convened 14 210 Protocols were received from centres in jointly by WHO and the United States National 52 countries for participation in the WHO Heart, Lung and Blood Institute. The convening multinational project on childhood diabetes, and of a WH 0 scientific group on asthma in N ovem­ 30 participating centres were recruited for a diabe­ her 1993 was the first step in the formulation of a tes atherosclerosis intervention study. An interna- global strategy for asthma management.

14 215 Integrated programmes. WHO continued to promote its integrated programme for com­ 1 World health statrstics quarterly, 1993, 46 (2). munity health in noncommunicable diseases 1 WHO Technical Report Series, No. 831, 1993 (INTERHEALTH) with 16 demonstration 3 World health statrstics quarterly, 1992, 45 (4). projects in developed and developing countries 4 Document WHO/DBO/DM/91 1 in all regions. The European programme of

123 THE WORK OF WHO 1992-1993 countrywide integrated noncommunicable dis­ programmes based on WHO approaches and ease intervention (CINDI) has 14 demonstration recommendations. projects. During the biennium meetings took place of the INTERHEALTH steering commit­ 14 217 A WHO working group on haemo­ tee Goensuu, Finland, April 1992) and pro­ globinopathies with members from 15 countries gramme directors (Beijing, April 1993). A in Europe and the Eastern Mediterranean evalu­ teleconference on the prevention of chronic life­ ated and monitored national programme activi­ style diseases was organized during the latter ties (Nicosia, March 1993). Subsequently a re­ meeting. First results achieved at the national gional advisory working group on hereditary level are very encouraging. One example is Mau­ disorders was set up in the Eastern Mediter­ ritius, a country with a high prevalence of ranean. noncommunicable diseases, especially diabetes and arterial hypertension, where a comprehen­ 14 218 In view of the increasing awareness in sive preventive strategy has reduced the preva­ many countries of problems connected with he­ lence of hypertension, lowered the cholesterol reditary diseases, WHO prepared and issued ed­ levels of the population, and reduced tobacco ucational materials on haemophilia and the and alcohol consumption as well as promoting haemoglobinopathies as well as guidelines on physical activity. In other INTERHEALTH general principles involved in setting up national demonstration projects, comprehensive commu­ programmes for the control of congenital mal­ nity-based intervention programmes are being formations and the haemoglobinopathies. In undertaken following baseline surveys. 1992 support was given in organizing a training course in Cuba for personnel from Latin Ameri­ 14.216 Hereditary diseases. In November 1993 a can countries on the use of modern techniques in WHO scientific group recommended further use the control of hereditary diseases. of genetic technology in the prevention and con­ trol of hereditary diseases in view of results 14 219 To assist in assessing the role of modern achieved by national genetics services. WHO technology in the control of hereditary diseases, policy and recommendations concerning select­ WHO cosponsored a sixth international confer­ ed hereditary diseases were reviewed at WHO ence on early prenatal diagnosis of genetic dis­ meetings on haemophilia (Geneva, February eases (Milan, Italy, May 1992) at which the feasi­ 1992), neurofibromatosis (Vienna, June 1992), bility was considered of establishing a WHO cystic fibrosis (Washington, October 1992), international register on this subject. An interna­ haemoglobinopathies (Nicosia, April 1993) and tional multicentre study was initiated on the pre­ haemochromatosis (Kiryat Anavim, Israel, April dictive value of individual genetic and environ­ 1993). Several countries1 have developed control mental risk factors for familial hypercholes­ terolaemia. Ethical questions relating to clinical applications of genetics were reviewed at the sec­ 1 Australia, Brazil, China, Cyprus, India, Italy, Jamaica, Myanmar, Nrgerra, ond and third international bioethics seminars Pakistan, Saudi Arabra, Thailand, Tunrsia. (Fukui, Japan, March 1992 and November 1993 ).

124 CHAPTER 15 Health information support

dure. A major initiative was the launching of a Health literature services project for an African Index Medicus by the As­ sociation for Health Information and Libraries 15.1 During the biennium expanded informa­ in Africa, sponsored by WHO with support tion services were provided over the headquar­ from bilateral agencies. The aim is to create local ters local area network, backed by intensified databases in countries using a common proce­ training of technical staff throughout the Organ­ dure, and merge them into a regional product. ization, in order to improve access to scientific and technical information for Member States. 15 5 In October 1992 BIREME organized a Particular emphasis was given to health econom­ first regional congress on health sciences infor­ ics. Guidance was given to users in Member mation (Sao Paulo, Brazil, October 1992) to re­ States, including ministries of health, in reorgan­ view and upgrade cooperative information activ­ izing their information systems. ities in Latin America and the Caribbean. Profes­ sional workshops and interdisciplinary seminars 15.2 WHOLIS, the computerized WHO li­ were held during this meeting. brary information system, was enhanced by the addition of abstracts and was included in the 15.6 The health literature, library and informa­ Latin American health sciences literature data­ tion services network (HELLIS) for South-East base (LILACS) CD-ROM, which is distribut­ Asia was strengthened by the introduction of ed by BIREME, the Latin American and Carib­ new procedures for the development and provi­ bean Center on Health Sciences Information. sion of computerized databases, training of WHOLIS has become available on Internet. library staff and continued compilation of an In­ WHODOC, the regular listing of new WHO dex Medicus for South-East Asia. publications and documents, continued to be disseminated on diskette and through Internet as 15.7 WHO's European network of documenta­ well as in print. tion centres was enlarged and now consists of 25 centres in central and eastern Europe; a news­ 15.3 "Essential information kits" were produced letter, Ex libris, was issued to improve communica­ in cooperation with technical programmes; these tion between the centres. WHO also provided are subject packages that combine essential infor­ documentation modules to liaison and information mation sources with explanations for using them offices in countries of central and eastern Europe correctly. They fill a need in countries that have and in republics of the former Soviet Union. few information resources, and in others where it may be difficult to make the appropriate choice and 15.8 In the Eastern Mediterranean a project en­ use of information for specific applications. titled "ExtraMED" was set up to allow access on CD-ROM to full texts of selected health science 15.4 Relevant information is distributed periodicals issued in the developing countries. A through a monthly WHO Library Digest for health and biomedical information plan for the Africa, either electronically via satellite to Islamic Republic of Iran was drawn up and re­ groundstations or in printed form to WHO Rep­ viewed at an intercountry meeting (Alexandria, resentatives. In addition, 16 documentation cen­ February 1993); the intention is to produce tres were set up in the WHO Representatives' guidelines for the formulation of similar national offices using a common computer-based proce- plans in other Member States.

125 THE WORK OF WHO 1992-1993

15 9 MED LINE on CD-ROM was acquired the control of schistosomiasis and lymphatic by most Member States in the Western Pacific. filariasis, changing trends in the financing of The Chinese biomedical literature analysis and health services, and rehabilitation after cardio­ retrieval system (CBLARS) came into operation; vascular diseases. through collaboration between WHO and the Chinese Academy of Medical Sciences, 13 Chi­ 15 11 In the peer-reviewed research and review nese medical schools gained online access to this articles published in English or French in the database as well as to MEDLINE. Workshops bimonthly Bulletin of the World Health Organi­ and training courses were conducted in Cambo­ zation, tropical diseases and health conditions in dia, China, Malaysia, Philippines and VietNam developing countries took pride of place. Regu­ to upgrade the knowledge and skills of medical lar features included reports on WHO meetings, and health librarians and information providers, publications and activities, and updates on timely with emphasis on the application of new infor­ topics. The quarterly World health forum fo­ mation technology. cused on the following "round-table" themes: nurses, doctors and patients; substance abuse; screening for breast cancer; humanitarian or pragmatic approaches to medical practice; and WHO publications changes in medical education. The illustrated bi­ monthly magazine World health sought to in­ 15.10 Among the most important of the some form and instruct on a variety of subjects of 120 books published during the biennium were public health importance. 1 WHO drug informa­ the first two volumes of the tenth revision of The tion, the quarterly journal with reports on major international statistical classification of diseases drug regulatory action in different countries, and and related health problems (ICD-10), contain­ information on medicinal products and selected ing the tabular list of diseases and the instruction essential drugs from WHO's Model List, also manual; the third volume, containing the alpha­ ensured a wide circulation of the latest lists of betical index, is in press. Two key extensions of international nonproprietary names (INN) for ICD-10, Chapter V, were also published as The pharmaceutical substances. ICD-10 classification of mental and behavioural disorders: clinical descriptions and diagnostic 15.12 To enable health information from WHO guidelines and Diagnostic criteria for research. to reach targeted readers in countries through The second editions of three successful WHO national channels, 35 low-cost reprints of WHO handbooks appeared - On being in charge, publications were licensed in India; and 362 Teaching for better learning and the Laboratory agreements were prepared for translations of biosafety manual - as well as new guidelines for WHO books into 48 national or regional lan­ cholera control, treatment of tuberculosis, and guages by publishers, academic presses, minis­ quality assurance in blood transfusion services. tries and aid organizations, among others. Cop­ Our planet, our health, the report of the WHO ies of over 200 published translations of WHO Commission on Health and Environment, texts were received in WHO during 1992 and served as the Organization's published contri­ 1993. A much-translated title remained the joint bution to the 1992 United Nations Conference WHO/UNICEF statement on breast-feeding, on Environment and Development. On the which has appeared or is in preparation in more AIDS pandemic, WHO published a progress re­ than 40 languages, on a par with the 1986 classic port, a guide for epidemiological studies of oral Cancer pain relief The core classification ICD- manifestations of HIV infection, a physicians' 10, and the mental health extensions, were also manual on AIDS in Africa, and texts in the being translated for publication and use in nu­ WHO AIDS Series on school health education merous language versions. and the global AIDS strategy. A textbook on Basic epidemiology made a promising start. Many of the 24 reports of expert committees, study groups and scientific groups published in the WHO Technical Report Series contained further studies on biological standardization, 1 The themes of 1ssues were, in 1992, Heart health (World Health Day specifications for pharmaceutical preparations, issue), Essential drugs, Commun1ty health; Water; Nursmg care; Health and econom1c development, and, 1n 1993, Accidents and violence (World drug dependence, food additives, essential drugs, Health Day issue); Children's Vacc1ne Initiative, World health situation, and the like. Others addressed key topics such as Tuberculos1s; Chem1cal safety; Family health

126 HEALTH INFORMATION SUPPORT

Figure 15.1 Publications programme Malaria: books as weapons in the fight against disease

WHO publications are produced in various languages, cover numerous aspects of the Organization's work, and are designed for a wide range of readers. For instance, in the field of malaria, WHO publications include: details of a global strategy for controlling the disease, of interest to decision-makers and ad­ VOYA(;ES IN'IF.RNA110~AUX ministrators; training manuals on laboratory methods and E'I'SAN'm microscopy and illustrations of various stages in the life cycle of the malaria parasite, invaluable to technicians involved in the laboratory diagnosis of the disease; books for the clinician on how to treat malaria of various degrees of severity; and health information for travellers, with details of measures to be taken to avoid suffering from malaria.

Basic malaria Parasitic diseases . in water resources m1croscopy development "k k'\.\)1,1 IIUt'f'ol.\.hlf: fk~--: 'U

Part I. Learner's Guide -----

PLANCHES­ POUR LE DIAGNOSTIC DU - PAWDISME

PLANCHES N° 1-8

127 THE WORK OF WHO 1992-1993

15.13 In the regions PAHO focused on dissemi­ cific subjects, including food and nutrition and nating health-related information of particular environmental health, with support from national interest in the Americas through scientific publi­ research institutions and WHO collaborating cen­ cations and periodicals. Major publications in­ tres. Progress was made in the compilation of a cluded Pro salute novi mundi: a history of the WHO dictionary intended to facilitate exchange Pan American Health Organization, a substan­ of information on the Organization's pro­ tial volume on Reproductive health in the Amer­ grammes and activities through harmonization icas, and a collection of papers on Gender, wom­ and standardization of technical terminology. en and health in the Americas. In South-East Asia nine new titles were published in the region­ al series, together with the regional volume (Vol. 4) of the Eighth Report on the World Distribution and sales Health Situation. Among the books published in Europe were an updated edition of Health for all 1515 WHO publications were made more ac­ targets: the health policy for Europe and the col­ cessible in developing countries by strengthening lected papers from a symposium on Health pro­ the networks of health-related establishments motion and chronic illness. In the Eastern Medi­ and libraries receiving comprehensive or selec­ terranean a number of textbooks and dictionaries tive groups of publications. By the end of the were produced in connection with the arabi­ biennium 1008 libraries that receive WHO pub­ zation of medical education in the Arabic-speak­ lications free of charge or on subscription had ing countries; and translation of WHO publica­ expressed willingness to make their collections tions into other national languages of the Region accessible to the public without restriction. Dur­ was promoted. New publications in the Western ing 1992-1993 six new depository libraries were Pacific included Medicinal plants in Viet Nam, officially designated, bringing the total to 146 produced in collaboration with the Institute of now open to readers throughout the world for Materia Medica in Hanoi, as well as works on consultation. Health research methodology and District hospi­ tals: guidelines for development. 15.16 Annotated catalogues of publications were issued in English, French and Spanish. Nu­ merous subject catalogues were produced on dif­ ferent topics. Displays of WHO publications Technical terminology were arranged for over 200 specialized meetings and congresses. The momentum of sales of publi­ 1514 A major step in the development of cations achieved in the previous biennium was WHO's terminology information system maintained. In 1992-1993 the income from sales (WHOTERM) was taken with the release during reached a record level of $ 7.2 million; in fact, the biennium of the first terminology database 1993 was the eighth consecutive year showing a management system, for distribution to users in growth in income. New strategies were intro­ the Organization and to national and interna­ duced to enhance sales in developing countries tional institutions. Preparation of a multilingual and improve the performance of sales agents in terminology database started with work on spe- developed countries.

128 CHAPTER 16 Support services

of the appointments made in the period were of Personnel nationals of those countries. The number of un­ represented countries increased from 27 to 42 by 16.1 On 30 November 1993 the total number mid-biennium (mainly owing to the addition of of staff (excluding PAHO) was 4448, compared 13 newly independent countries, of which two with 4657 on 30 November 1992 and 4693 on were previously inactive, and four other new 30 November 1991 - a decrease of some 5.22% Member States), that of under-represented coun­ during the biennium November 1991 toNovem­ tries remained at 11, and that of over-represented ber 1993. The number of professional staff rose countries increased from 24 to 26. The number of from 1568 in November 1991 to 1587 in Novem­ adequately represented countries - the ultimate ber 1993, and that of general service staff de­ criterion for evaluating geographical representa­ creased from 3125 to 2861 in the same period. tion- increased from 101 to 103. The number of staff in excess of the upper limits of desirable 16.2 Although the proportion of women in ranges fell by 2.2%. established offices1 was still below the target of 30% set by the Health Assembly, steady progress was made. The proportion of profes­ sional and higher-graded posts in established Office accommodation offices filled by women increased from 23.2% in October 1990 to 25.1% in September 1992 16.4 The telephone exchange in the Regional (mid-biennium). During the same period the Office for Africa, which dated from the con­ number of posts in established offices at grades struction of the building, was replaced and the P.S and above filled by women increased from new facility should greatly improve external 11.2% to 13.5%. The percentage of women em­ communications. ployed as associate professional officers rose from 40% to 47.6%. The percentage of women 16.5 Because of the expansion of programmes employed as consultants in all locations rose supported by extra budgetary funds, the Regional from 23.3% in 1990 to 25.2% in 1992; at head­ Office for South-East Asia plans to add a floor to quarters 29.2% of all consultants and 38% of one of its buildings, which will provide 13 extra short-term professionals employed between offices; the construction should be completed in October 1990 and September 1992 were wom­ 1994. en. There was a small increase in the proportion of women members of WHO's 54 expert advi­ 16.6 Certain legal difficulties, arising from ne­ sory panels. gotiations with the Host Government, prevented the implementation of plans for the extension to 16.3 Although the target of 40% for appoint­ the Regional Office for the Eastern Mediterrane­ ments of nationals from unrepresented and an. Discussions are still under way between the under-represented countries was not met, 22% Regional Office and the local authorities to find an acceptable solution.

16 7 The extension to the Regional Office for 1 Established offices include headquarters, regronal offices, offrces of the the Western Pacific was completed and the WHO Representatives and IARC, but not projects. premises are now occupied.

129 THE WORK OF WHO 1992-1993

Budget and finance other sources. As at 31 December 1993 arrears of contributions in respect of 1992 and 1993 amount­ ed to$ 106 168 561. The obligations in respect of 16 8 The programme budget proposals for the regular budget for 1992-1993, shown as per­ 1994-1995, covering the third and last period of centages under the main categories of the Eighth the Eighth General Programme of Work, were General Programme of Work, were as follows: prepared and submitted to the Programme Com­ mittee of the Executive Board for review of the % global and interregional component in accord­ Direction, coordination ance with resolution EB79.R9. In parallel, the and management 11.02 regional components were reviewed by the re­ Health systems infrastructure 32.39 gional committees. After these reviews the Di­ Health science and technology 28.76 rector-General consolidated the programme budget proposals and submitted them to the Ex­ Programme support (including ecutive Board at its ninety-first session in Janu­ health information support) 27.83 ary 1993. The proposals were then modified to 100.00 take into account favourable exchange rate movements and to meet concerns expressed by the Executive Board during its review. The mod­ ified programme budget proposals for 1994-1995 1612 Obligations incurred under the 1992-1993 were subsequently approved by the Forty-sixth regular budget were considerably lower than the World Health Assembly in May 1993. The effec­ approved budget level of$ 734 936 000. This was tive working budget for 1994-1995 was estab­ due to an expected under-collection of assessed lished at $ 822 101 000, providing for a net de­ contributions, particularly from one of the larg­ crease in real terms of $ 24 112 200, or 3.28%. est contributors, which obliged the Director­ The overall cost increase in the approved budget General to reduce the implementation of the ap­ for 1994-1995 was $111277 200, or 15.14%, an proved programme for the biennium. Nonethe­ amount which incorporated considerable cost less, the Director-General endeavoured to imple­ increases that had occurred before the 1994-1995 ment the planned programme to the maximum biennium but had not been included in the ap­ extent possible. In spite of this programme re­ proved budget for 1992-1993. No provision was duction and the application of various economy made in the 1994-1995 budget for exchange rate measures, it was still necessary to use the internal fluctuations. borrowing facility granted to the Director­ General under Financial Regulation 5.1. The 16 9 In 1993 an interim financial report cover­ Director-General expressed to the Member ing the first year of the biennium 1992-1993 was States his concern over the weakened financial reviewed by the Committee of the Executive position of the Organization and its impact on Board to Consider Certain Financial Matters pri­ programmes. Financial data for all sources of or to the Forty-sixth World Health Assembly, funds, and financial statements at 31 Decem­ and was subsequently accepted by the Health ber 1993, with supporting schedules and tables, Assembly. are presented in the Director-General's finan­ cial report for the biennium to the Forty-seventh 16 10 Because of adverse exchange rate fluctua­ World Health Assembly. tions during the biennium in respect of the Swiss franc, the Danish krone, the CFA franc, the 1613 The integrated computer-based system Egyptian pound and the Philippine peso, it was for administration and finance information necessary for the Organization to use $ 8 840 500 (AFI) system is established on a large common against the exchange rate facility approved by the central database and provides information sup­ Health Assembly for 1992-1993, namely port for budget preparation, budget control, ex­ $ 31 million. The reduced use of this facility re­ penditure and general ledger accounting, pay­ sulted from improved exchange rates from the ments, treasury operations, supplies, personnel, latter part of 1992 to the end of 1993. payroll and the master mailing list. The records of expenditure accounting from the regions are inte­ 16 11 In 1992-1993 obligations totalling grated in the headquarters database each month $ 688 816 477 were incurred under the regular for information purposes. The system also allows budget and $ 756 715 939 under funds from technical programmes to query their allot-

130 SUPPORT SERVICES ments, earmark their funds, link obligations to number of requests received from non­ programme activities and transfer data to "local" governmental organizations. In particular, those microcomputers for further analysis. organizations, and also other bodies within the United Nations system, made more use of 16.14 During the biennium the administration WHO's services in procuring condoms and test and finance information system was expanded to kits for AIDS control programmes, thus benefit­ include data required for management of the in­ ing from the advantageous prices that WHO has vestment portfolio and shipping of supplies to their negotiated with manufacturers worldwide. destinations. The component for processing travel claims was redesigned. Studies were begun to de­ 16.18 Many urgent requests for supplies were vise system components to handle data on tempo­ received in Africa as a result of outbreaks of rary staff and consultants, and to process staff meningitis, cholera and yellow fever, and nation­ health insurance claims so as to allow a finer analy­ al emergencies related to civil unrest in some sis for cost-containment purposes. A project is un­ countries. Additional urgent procurement re­ der way to redesign the regional office administra­ quirements had to be met following the tion and finance information system, which sup­ regionalization of most of the AIDS control pro­ ports budget control, expenditure accounting and grammes. general ledger accounting. The new system will allow links to programme and project activities and 1619 PAHO/WHO continued to purchase provide all the budgetary and expenditure informa­ supplies, equipment and services in the Americas tion required for their management. in support of its own projects and on behalf of Member States against reimbursement or through established revolving fund arrangements for the Expanded Programme on Immunization. Equipment and supplies for The procurement value during the biennium Member States 1992-1993 was$ 93 662 011. A greatly increased demand for supplies was met during the peak of 1615 The total value of supplies and equipment the cholera outbreak in Peru. purchased by WHO (including PAHO) during the 1992-1993 biennium reached $255 511335. 16 20 Additional work arose in South-East Asia Compared with 1990-1991, this represents an in­ in connection with the purchase of supplies on crease of 3% in monetary terms. The staff work­ behalf of India for its national AIDS control pro­ ing in the supply services at headquarters was gramme. Also, staff had to be increased in order reduced by approximately 15%. to meet the extra demand from the fourth popu­ lation and health project in Bangladesh. 1616 In 1992-1993 the Global Programme on AIDS continued to be the largest user, in dollar 16.21 Most requests for supplies in Europe were terms, of the WHO procurement and supply serv­ in respect of republics of former Yugoslavia. At ices. Whereas procurement from regular budget the same time larger numbers of requests were sources decreased by approximately 20%, activi­ received from the Commonwealth of Independ­ ties in respect of emergency relief operations in­ ent States. creased substantially; countries benefiting includ­ ed Afghanistan, Iraq, Somalia and republics of 16.22 There was a heavy demand for medical former Yugoslavia. Pharmaceutical products and supplies and equipment to cope with natural dis­ hospital supplies and equipment constituted the asters and other emergencies in the Eastern Med­ major part of all commodities. The cost of sup­ iterranean. The transfer to that region of respon­ plies and equipment for republics of former Yu­ sibility for much of the Global Programme on goslavia amounted to more than $ 10 million. AIDS and also of Operation Salam for humani­ tarian assistance to Afghanistan widened the 1617 Member States continued to avail them­ scope of traditional supply work. selves of the services offered by WHO in the purchase of medical supplies and equipment for 16 23 In the Western Pacific local purchases for their health programmes, either through the projects and reimbursable procurement on be­ WHO Revolving Fund or against reimburse­ half of Member States increased. Project supplies ment in convertible and nonconvertible curren­ for all Member States remained at the same level cies. There was a considerable increase in the as during the previous biennium.

131 Regional offices and the areas they serve

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AREA SERVED, AS AT 31 DECEMBER 1993, BY: ~ ·~:::: hgionol Office for Regional Olfi

17.1 The sociopolitical upheavals concomitant intervention by WHO. A situation analysis of with the establishment of democratic institutions health care financing mechanisms and problems have ushered in a new period of hope and chal­ was consequently undertaken in Member States, lenge for Africa, mirrored in the health sector by and some innovative community health financ­ the adoption at the forty-third session of the ing schemes were reported. National experts Regional Committee in Gaborone in September were recruited as economists on WHO country 1993 of the minimum district health-for-all teams, and workshops were organized, stressing package - "the final common path" - for the the relation between economics and health. Con­ achievement of health for all through primary tacts were established with donors and develop­ health care in accordance with the African ment banks to solicit funding for programme Health Development Framework. activities on health care financing at country lev­ el. Technical support was given to some coun­ 17.2 Despite progress in some areas, the health tries for necessary health care financing reforms. situation in countries of the African Region is still of great concern. The high prevalence of 17.5 WH 0 provided support to 10 countries in parasitic and infectious diseases, the spread of the the elaboration of their national health develop­ AIDS pandemic, and the disturbing increase in ment plans and policies. A framework for the noncommunicable diseases continue to be formi­ reorientation and restructuring of hospitals was dable impediments to progress. Massive popula­ prepared, in pursuance of directives of the forty­ tion drifts and the settlement of displaced per­ second session of the Regional Committee in sons and refugees in camps lacking adequate wa­ 1992, to promote integration of hospital net­ ter supply and sanitation are the legacy of con­ works into health systems. Efforts were also flicts in certain countries of the Region. Inacces­ made to develop effective coordination mecha­ sibility of basic health care services, precarious nisms to assist Member States of the Region in nutrition and the consequences of drought have emergency and humanitarian relief. added to the difficulties. 17.6 With regard to health information and ep­ 17.3 Within this context of social, political and idemiological surveillance systems, WHO sup­ health crises, WHO pursued efforts to reduce ported training and development activities in five immediate suffering and to strengthen the capac­ countries. Close collaboration with the Associa­ ity of countries to cope with the multiple chal­ tion for Health Information and Libraries in Af­ lenges impeding their development. In the same rica reactivated a long-dormant project for an spirit, an unprecedented initiative for widespread African Index Medicus. By the end of 1993 cen­ social mobilization in favour of community tres in Ghana, Malawi, Mozambique, United Re­ health in Africa was launched by African minis­ public of Tanzania, Zambia and Zimbabwe were ters of health at the International Conference on participating in the project, and the inaugural Community Health in Africa (Brazzaville, Sep­ issue had been widely distributed. tember 1992). 17.7 The regionalization of technical and ad­ 17.4 Given the considerable deterioration in ministrative support under the Global Pro­ national capacities for financing health systems, gramme on AIDS to the African Region reached the African ministers of health decided to make an advanced stage. The programmes of 43 coun­ health care financing one of the priority areas for tries have been regionalized. Although the re-

133 THE WORK OF WHO 1992-1993

duction in financial support to countries and 17.10 Efforts were made to strengthen the man­ WHO from donors for AIDS control was a ma­ agement of national maternal and child health/ jor concern, national AIDS programmes made family planning programmes, with emphasis on significant progress in implementing appropriate service coverage, improved quality of care and strategies. Youth groups and clubs have been rapid reduction of morbidity and mortality formed in many countries. Communities have among mothers and neonates. Management sup­ set up associations, and over 1000 local port activities included collaboration in work­ nongovernmental organizations are engaged in shops on district team problem-solving methods the provision of care to AIDS patients and sup­ in Senegal and United Republic of Tanzania, as port to their families. Field-testing of indicators well as the finalization of a project on accelerated for assessing the impact of interventions at coun­ action for safe motherhood in the African Re­ try level was completed. A guide to national gion. A regional joint consultation on the pre­ AIDS programmes was issued, emphasizing the vention of maternal mortality and on infertility desirability of implementing programmes within in sub-Saharan Africa was organized at the Re­ the national health development framework, gional Centre for Training and Research in Fam­ with decentralization to district and community ily Health (Kigali, January 1992). The first of a levels in order to ensure sustainability of meas­ series of regional training courses in family ures, accelerate the dissemination of knowledge health research methods was successfully con­ about AIDS, and promote changes in behaviour ducted by the regional centre for 12 trainees from and the adoption of a healthy lifestyle by all, Burkina Faso, Cameroon, Cote d'Ivoire, particularly young people and children. Madagascar and R wanda. A regional data bank on selected maternal and child health/family 17 8 In preparation for the 1992 International planning indicators was established in the Re­ Conference on Nutrition (see paragraph 9.14), 39 gional Office, based on the global database at Member States made a comprehensive review of headquarters. Collaboration with UNFPA and their nutrition situation and two meetings were UNICEF was strengthened. held (Dakar, February 1992; Nairobi, March 1992) bringing together representatives of all 17 11 The final evaluation report on the Inter­ countries of the Region. One outcome of these national Drinking Water Supply and Sanitation meetings was the adoption, in principle, of an Decade ( 1981-1990) was presented to the Re­ International Decade on Food and Nutrition for gional Committee in 1992. In the course of the Africa. To follow up the recommendations of the Decade approximately 223 million people had international conference, steps were taken to es­ access to an adequate and safe water supply and tablish national plans for each country by the end 156 million access to appropriate sanitation in of 1994. Technical and financial support was pro­ the African Region. During the same period vided to several Member States1 under the initia­ approximately 226 million people remained tive for intensified cooperation with countries without satisfactory water supply and 333 mil­ and peoples in greatest need. lion without appropriate sanitation. WHO pro­ vided technical and financial support to 32 17 9 Particular attention was directed to con­ Member States for institutional and human re­ trol of iodine deficiency diseases in 1992. Preven­ sources development, and for construction and tive activities were undertaken in 23 countries, of rehabilitation of low-cost water supply and san­ which 17 had national control programmes. Em­ itation systems in rural areas. Member States phasis was put on iodized salt consumption, and affected by cholera were given special financial workshops on this subject were organized in and technical support to prepare short- and Botswana and Senegal in 1992. A survey on long-term plans for the prevention and control micronutrient deficiency in the Region, complet­ of outbreaks. National experts were recruited in ed in 1993, showed that 16 out of the 34 countries 15 countries to work as sanitary engineers in the where vitamin A deficiency is prevalent had al­ country support team, and they were included ready initiated preventive activities. among the experts participating in the second regional environmental health coordination meeting (Nairobi, March 1992). Collaboration continued with UNEP, FAO, UNESCO/ Intergovernmental Oceanographic Commis­ 1 Benrn, Central Afrrcan Republic, Chad, Guinea, Gurnea-Brssau, Madagascar, sion and IAEA in implementing the programme Mozambrque, Sao Tome and Principe, Uganda, Zambia on assessment and control of pollution in coast-

134 AFRICAN REGION

al and marine environments in west, central and 17.15 Following a review of the status of nation­ east Africa. al dracunculiasis eradication programmes at a fourth African regional conference (Enugu, Ni­ 17.12 Following activities to promote Healthy geria, March 1992), all endemic countries began Cities throughout the Region, a first meeting for implementing their workplans. The efficacy of French-speaking African countries was organ­ the regional eradication strategy was evident ized within the framework of collaboration be­ from the progress made in two of the most heav­ tween the Healthy Cities network of Quebec ily endemic countries, Ghana and Nigeria, as (Canada) and Dakar commune (Dakar, July well as in other less endemic countries. 1992). An outcome of the meeting was support for the preparation of action plans in five of the 17 16 Considerable strides were made in leprosy 14 cities participating in the meeting. A WHO/ control in Africa. Prevalence dropped as a result GTZ workshop (Harare, November 1993) of better coverage of multidrug therapy from brought together participants from 16 countries 27% in 1990 to 45.5% in 1993, with several coun­ to launch a regional Healthy Cities network. tries attaining 100% coverage. Support was pro­ vided to countries with severe leprosy problems 17.13 Immunization rates in the Region reached and inadequate multidrug therapy through con­ 82% for BCG, 57% for a third dose of poliomy­ sultant services for management training and ex­ elitis vaccine and 50% for a second dose of teta­ pansion of coverage. Outbreaks of type A nus toxoid. Efforts to improve disease surveil­ meningococcal meningitis, cholera and plague lance and control in countries focused on train­ were of particular concern. Support included ing of programme managers and district health consultant services, information exchange, pro­ teams in the use of indicators for monitoring vision of vaccines and drugs, and organization of progress. A number of Member States, mainly in training workshops. Training materials were southern Africa, reported no cases of poliomye­ elaborated and tested as part of an effort to pro­ litis and a very low incidence of neonatal tetanus. mote integrated disease control in countries, es­ Assessments in some of these countries con­ pecially at district level. firmed a virtual absence of poliovirus transmis­ sion, a very low incidence of neonatal tetanus, 1717 Human resource and material support for and a significant reduction in measles cases and health science training institutions continued, deaths. with efforts centring on the revision of medical training. A programme was set up to strengthen 17 14 The malaria control programme was ac­ continuing education, and steps were taken to corded the highest priority. Following the 1992 enhance the role of nurses and midwives in safe Ministerial Conference on Malaria (see para­ motherhood, research and epidemiological sur­ graph 14.16), tremendous progress was made in veillance. Incidents affecting security in several the African Region. More than 20 countries es­ countries caused disruption of technical pro­ tablished or reformulated malaria control pro­ grammes and required special efforts by WHO grammes with the technical support of WHO, staff. Responses were made, under emergency and some 25 organized training on control strat­ arrangements, to health-related problems caused egies for district health workers. A regional plan by extensive population movements resulting of action for the period 1994-1997 was adopted. from such incidents.

13S

CHAPTER 18 Region of the Americas

18.1 In 1992 the Pan American Sanitary Bureau cil of PAHO reviewed the proposed programme celebrated 90 years as the oldest continuously budget for 1994-1995. Some of the most note­ functioning international health agency in the worthy resolutions adopted at this session were world. The organizational structure of the Pan those urging Member States to comply with American Health Organization's secretariat, guidelines established for certifying eradication the Pan American Sanitary Bureau/WHO Re­ of poliomyelitis caused by indigenous wild gional Office for the Americas, was adjusted in poliovirus, to implement measures to eliminate early 1993 to better enable it to meet its constitu­ measles, to step up vaccination against all diseas­ tional obligations to assist Member States in es under the Expanded Programme on Immuni­ achieving health for the people of the Americas. zation, and to ensure the sustainability of all One of the purposes of this adjustment was to these efforts. The Regional Committee also ap­ strengthen the secretariat for improved imple­ proved resolutions aimed at strengthening HIVI mentation of the regional strategic orientations AIDS prevention and control programmes, and programme priorities in line with WHO's adopting measures to reduce maternal mortality, Ninth General Programme of Work. and establishing a regional programme of bioethics. A new health initiative on behalf of the 18.2 In 1993 PAHO/WHO started to assess indigenous peoples of the Americas was ap­ the impact of its strategic orientations and pro­ proved, as was the formulation of a regional plan gramme priorities on national health develop­ of action on violence and health, including vio­ ment, particularly on policy-making and health lence against women and all risk groups. activities in the Member States, and its technical cooperation. This evaluation is part of a biennial 185 During 1992-1993,16 joint evaluations of review to determine the progress made towards technical cooperation were carried out with the achievement of the Organization's quad­ Member States. Almost all the Member States rennial goals in 1991-1994. participated in the PAHO/WHO programme for technical cooperation among countries. 18.3 In 1992 the Regional Committee for the Training and the development of human resourc­ Americas reviewed and approved several plans of es were particularly emphasized; and the action for the Region, including programmes on subregional health initiatives in the Caribbean, adolescent health, elimination of leprosy, and Central America, the Andean Area and the elimination of vitamin A deficiency. Of particu­ Southern Cone1 continued to serve as an impor­ lar importance was the Committee's approval tant mechanism for implementing projects envis­ of a regional plan of action for investment in the aged under the technical cooperation pro­ environment and health which will marshal na­ gramme. A strategic plan was prepared to tional and international resources. The Commit­ strengthen the Andean Cooperation in Health tee also approved the promotion of activities to initiative and several national technical working link the health and tourism sectors in the Region groups prepared action plans in the priority areas and, in its capacity as the Directing Council of of maternal and child health, essential drugs, sub- PAHO, admitted Puerto Rico as an Associate Member.

18.4 In 1993 the forty-fifth session of the Regional Committee/XXXVII Directing Coun- 1 Argentrna, Bolrvra, Brazil, Chile, Paraguay, Uruguay

137 THE WORK OF WHO 1992-1993 stance abuse, environmental health and disaster a document on health with equity, which reviews preparedness. A draft health promotion charter health aspects of the economic transformation for Latin American countries was prepared at the currently under way in the Americas. International Conference on Health Promotion (Santafe de Bogota, November 1992); and a simi­ 18 8 The Organization participated in the first lar document was produced the following year meeting of the commission on health, labour and under the aegis of the Caribbean Cooperation in social security of the Latin American Parliament Health initiative. Significant progress was (PARLATINO) held in Havana in March 1993, achieved in the Central American Health Initia­ and over the next few years its technical coopera­ tive's four priority areas of health infrastruc­ tion will focus on the five health priorities identi­ ture, health promotion and disease control, fied during the meeting. A cooperation agreement health care for special groups, and the environ­ was reached with the Central American Parlia­ ment and health. The Southern Cone Health Ini­ ment, and progress was made in formalizing simi­ tiative was instrumental in the control of Chagas lar agreements with the Andean Parliament. The disease and cholera. Organization is also participating in a network of agencies that supports the formulation of integrat­ 18.6 During the biennium the Region contin­ ed social policies by governments. ued a movement towards democracy which in­ corporated constitutional reforms, free and open 18 9 The epidemiological profile of the Region electoral processes, and formal acceptance of the continued to change, especially regarding mor­ obligation to protect human rights. The econom­ tality. The relative importance of chronic and ic recovery that began in 1991 has reached a degenerative causes of disease is increasing, par­ phase of moderate expansion, gradual price ticularly in countries where total mortality and stabilization, alleviation of the debt burden, and fertility have already declined. The ever-growing a favourable net transfer of resources. The proc­ urban concentration and the increased life ex­ ess of market integration continued to intensify pectancy of the populations have resulted in the in the Region - for instance, within the frame­ simultaneous presence of "old" health problems work of the Southern Cone Common Market such as malaria, dengue, cholera, diarrhoea! dis­ (MERCOSUR), the Caribbean Community eases and acute respiratory infections and "new" (CARICOM) and the North American Free problems such as cardiovascular diseases, vio­ Trade Agreement (NAFTA). However, there lence, cancer and AIDS. was no significant reduction in unemployment levels as compared to previous years. Declining 18.10 Several innovations in the health sector family income left some 60 million people in during the biennium stand out clearly. In the poverty during the 1980s, a figure that reached a wake of the victories over smallpox, a series of very high level in 1991. regional, subregional and national plans and pro­ grammes have been launched for the purpose of 18.7 Efforts were made to increase the capabili­ eradicating, eliminating or controlling a wide va­ ty of the Organization's programmes and coun­ riety of infectious diseases. In August 1993 the try offices, as well as ministries of health, to en­ Region celebrated its second year free of con­ hance project preparation skills, strengthen firmed cases of poliomyelitis caused by indige­ project monitoring, successfully negotiate exter­ nous wild poliovirus, and countries have now nal financing for priority health areas, and expand entered the certification phase. As a result of resource mobilization for health by encouraging mass immunization campaigns, better surveil­ the full participation of ministries, other bodies lance of illnesses with rash and fever, and weekly within the United Nations system and non­ "negative reporting", there have been no con­ governmental organizations. The Organization firmed cases of measles in the English-speaking participated in the second and third Ibero-Ameri­ Caribbean in nearly two years. Argentina, Brazil, can conferences of Heads of State and Govern­ Chile, Colombia, Cuba, Dominican Republic, ment (Madrid, July 1992; Salvador, Brazil, July Peru and the Central American countries have 1993), which approved several proposals relating launched similar campaigns aimed at eliminating to health. Discussions continued with the United or controlling measles. The goal set at the 1990 Nations system in preparation for the 1995 world World Summit for Children of reducing the inci­ summit on social development. The Organization dence of neonatal tetanus to no more than one is collaborating with the Economic Commission case per 1000 live births has practically been for Latin America and the Caribbean in preparing reached in the Region. With surveillance and vac-

138 REGION OF THE AMERICAS cination of all women of childbearing age in ras, September 1993), convened to agree on na­ high-risk areas as the principal strategies, there is tional plans for implementing the resolutions of confidence that the commitment to eliminate this the 1992 United Nations Conference on Envi­ disease by 1995 will be fulfilled. ronment and Development (see paragraph 12.1).

18.11 The countries of the Southern Cone are 18.16 PAHO/WHO continued to support ef­ committed to an initiative to eliminate the forts to reorganize the health sector on the basis vectorial transmissiOn and interrupt the of decentralization and to cooperate with all transfusional transmission of Trypanosoma cruzi. Member States in setting up and evaluating local This initiative has stimulated cooperation among health systems; it worked out approaches for other countries with similar problems regarding applying the local health system strategy at dis­ Chagas disease. Similarly, the countries of the An­ trict or county level, and for supporting the es­ dean subregion have begun to implement a plan tablishment of "healthy counties". Progress was for the control of iodine deficiency disorders. also made in applying the local health system strategy in urban areas. 18.12 Despite reductions in their regular budg­ ets, health ministries, in close collaboration with 1817 With the advent of the United Nations the Organization, have managed to stem the International Decade for Natural Disaster Re­ cholera epidemic. National efforts for conscious­ duction, emphasis has shifted from preparedness ness-raising and emergency preparedness and re­ and relief to prevention and mitigation. PAHO/ lief, coupled with efforts to disinfect water sys­ WHO has broadened its objectives to include a tems, improve basic hygiene and monitor food wider range of disaster prevention and mitigation handling, have kept cholera at bay and resulted in activities in the health sector, including the deliv­ a near-30% reduction in all deaths from ery of emergency humanitarian assistance. The diarrhoea! diseases. crisis in Haiti has been attended to within this framework and in accordance with a plan for 18 13 Technical cooperation with national humanitarian action launched by the Organiza­ AIDS programmes in preparation for "second tion of American States and the United Nations. cycle" multisectoral medium-term plans contin­ PAHO/WHO has been designated as coordinat­ ued through 1993; national plans were completed ing body for the design and delivery of basic and technical reviews carried out in several coun­ health services under this plan and, since Decem­ tries. Technical cooperation activities included ber 1993, has managed the supply of fuel for all workshops on applied epidemiology and strate­ humanitarian activities. The terms of the Central gic planning. American development programme for refugees and displaced persons (PRODERE) were modi­ 1814 PAHO/WHO provided emergency tech­ fied to include mental health and physical reha­ nical support to control Cuba's epidemic of bilitation of war-related disabilities in several neuropathy with predominantly optic clinical countries. Many important lessons about inte­ manifestations, which has produced over 50 000 grated health care for special groups, interagency cases since it was first detected in 1992 and is now collaboration and promotion of peace have been under control. learned from PRODERE, which completed its third and final year in 1993. By the same token, 18.15 The declaration adopted at the 1992 Inter­ health has continued to serve as a "bridge for national Conference on Health Promotion (see peace" in Central America. In El Salvador the paragraph 18.5) set targets and advocated ap­ Chapultepec Peace Agreement resulted in a re­ proaches to encourage healthy behaviour. Mem­ quest from all parties to find ways to provide ber governments were urged to adopt public pol­ basic services to the demobilizing military forces icies aimed to strengthen health promotion and under the aegis of the United Nations. PAHO/ address emerging health problems. The Organi­ WHO responded by organizing and delivering zation promoted the first and second meetings of services to the former combatants and their Central American ministers of environment and dependents, with financial support from the in­ of health (El Salvador, September 1992; Hondu- ternational community.

139

CHAPTER 19 South·East Asia Region

19.1 With growing social awareness and con­ in most of the Member States, partly owing to sciousness among the people of the Region and the "brain drain" to more developed countries. the operation of free market forces, health devel­ WHO therefore collaborated in organizing opment has received a new impetus. The minis­ meetings, courses, fellowships and local training ters of health of the countries of the Region met in health management. Bangladesh, Bhutan, twice during the biennium and considered AIDS Maldives, Mongolia, Myanmar and Nepal bene­ control, trends in communicable diseases, tech­ fited from intensified WHO cooperation with nical cooperation among developing countries, countries and peoples in greatest need to im­ the combination of public and private provision prove national capability in these fields. of health care, and primary health care in a changing socioeconomic and epidemiological 19 4 Support was given to India, Indonesia, situation. They renewed their commitment to Nepal and Thailand in reviewing existing public improve the quality of services in their countries. health laws as well as draft legislation on AIDS. The health-for-all leadership initiative begun in Study tours were organized for officials to study 1985 continued to make progress in sensitizing health legislation abroad. decision-makers to critical aspects of health de­ velopment. An intercountry consultation was 19.5 Health infrastructure was expanded and held on the subject of strengthening women's service coverage improved in all the Member leadership for health for all (New Delhi, Febru­ States through training and deployment of vast ary 1992). numbers of community health volunteers and the involvement of the community in planning 19.2 The results of the second evaluation of the and management of local health activities. implementation of the health-for-all strategy, published in 1993,1 showed that significant 19.6 Bangladesh, Bhutan, Nepal, Maldives, achievements have been made in reducing mortal­ Mongolia, Myanmar and Sri Lanka are reviewing ity among infants, children and mothers. Substan­ current patterns of resource allocation and utili­ tial progress has also been made in immunizing zation in the health sector and revising their children against childhood diseases and introduc­ health policies and strategies. Indonesia has been ing family planning programmes in many coun­ analysing trends in the health system as a basis tries. However, there remain wide variations in for studying the implications of its policies and health status among and within countries. strategies. Mongolia is reviewing the structure and functions of its ministry of health. WHO 19 3 WHO provided technical support to will continue to support such reviews. In the Bangladesh, Bhutan, Indonesia, Nepal, Sri Lanka coming decade, further efforts must be made to and Thailand in formulating national health poli­ reach the underserved or underprivileged in both cies and plans. Other areas covered were health rural and urban areas, using primary health care economics, health care financing and manage­ approaches based on community involvement, ment. There is a dearth of skilled health planners leadership development for health for all, quality assurance, self-care, integration of services, and intersectoral collaboration.

1 Implementation of the global strategy for health for all by the year 2000, second evaluation: Eighth report on the world health situation. Vol. 4: 19.7 At its forty-fifth session the Regional South·Eost Asia Regron. Geneva, World Health Organrzat10n, 1993. Committee for South-East Asia discussed the

141 THE WORK OF WHO 1992-1993

subject of "Balance and relevance in human re­ in this field took place during the biennium. sources for health" and urged Member countries Family planning and birth-spacing have been ac­ to carry out a thorough analysis of the present cepted as a means of achieving better health for situation, with particular attention to imbalanc­ mothers and children, and WHO pays particular es. To improve methods for analysing policy on attention to improving the quality of family human resources for health and strengthen na­ planning services. tional capabilities in this area, WHO has devel­ oped tools, strengthened its information base, 1912 The socioeconomic and health implica­ and promoted research. It has also continued to tions of the changing demographic situation in support the development of nursing and medical some countries with large populations make it education systems. imperative to take timely decisions on introduc­ ing short- and long-term measures to protect and 19.8 There is increasing recognition in the Re­ promote the health of the elderly. Development gion of the importance of information and edu­ of policies and the design of services for the eld­ cation for health, as reflected in the inclusion of erly based on community approaches supported these activities in most health programmes. by appropriate institutional care have become an Health matters are being given better coverage in important feature of WHO's technical collabo­ the press, radio and television. School health ed­ ration with countries. ucation has come into sharper focus, as has the role of women in health development. 1913 Concern about drug abuse has been grow­ ing in several countries as a result of the epidem­ 19.9 A review was made of the current strate­ ics of HIV infection among drug injectors, who gies for health research in the Region and a publi­ now form substantial reservoirs of the virus in cation on this subject is under preparation. Myanmar, Thailand and some Indian states and cities. However, some approaches to the contain­ 19.10 Emphasis was given to health protection ment of these epidemics have not been found and promotion and their practical applications, acceptable because they have been seen as con­ particularly in respect of oral health and injury doning drug use. In a number of countries prob­ prevention, the creation of a supportive and safe lems of alcohol use are more serious, although work environment and the provision of health they have less visibility from a political point of and social services to disabled persons and view. A community approach, developed with groups such as women, children, adolescents and centres in India, Myanmar and Sri Lanka, has the elderly. Prevention of dental caries and oral proved very effective in curtailing urban heroin diseases and promotion of oral health are not yet abuse and rural opium and alcohol abuse. integrated in many health services. Collection of data on road and agricultural injuries was intensi­ 19 14 A number of countries experiencing rapid fied with the aim of strengthening measures to urbanization and industrialization have given check the continuing rise in mortality from inju­ high priority to community water supply and ries. In many countries comprehensive tobacco sanitation, and initiated other environmental control programmes have been established, in­ health activities. Training within countries and cluding epidemiological surveillance, public edu­ abroad was given on computer-based project cation, legislative and administrative measures, management and water and sanitation project and early detection and treatment of the conse­ implementation for engineers in Bangladesh, In­ quences of tobacco use such as oral cancer. dia, Maldives, Nepal and Sri Lanka. WHO con­ tinued to promote intersectoral community ap­ 19.11 All the Member States recognize the ad­ proaches to solve problems of rapid population vantages of a holistic approach to child survival growth and unplanned urbanization. Regional and development. WHO, together with consultations on sanitation, solid waste manage­ UNICEF, UNDP, UNFPA and other profes­ ment, surface water drainage and urban health sional and nongovernmental organizations, plays have highlighted some of the strategies and ac­ a leading role in establishing integrated systems tions that countries could adopt. for providing maternal and child health and fam­ ily planning services as a part of primary health 19 15 Collaborative efforts in the management care. However, maternal mortality remains un­ of environmental health hazards focused on acceptably high with considerable variations technical support in capacity-building for pre­ within countries. A number of training activities paring national action plans on health and envi-

142 SOUTH-EAST ASIA REGION ronment. WHO collaborated in studies on strengthening of technical and managerial capa­ groundwater pollution, industrial water con­ bilities in the area of drug information, organiza­ sumption, and pollution monitoring systems and tion of training courses and convening of a on environmental epidemiology in critically pol­ WHO intercountry consultative meeting on the luted areas in India. Air and water quality moni­ rational use of essential drugs in 1993. toring activities continued in India, Indonesia and Thailand. 19.20 The wealth of expertise in the well-accept­ ed systems of traditional medicine in the Region 19 16 A document was prepared giving an over­ has facilitated their development in various ways: view of the current situation and future perspec­ establishment of herbal gardens; production and tives for strengthening national food safety pro­ quality control of traditional medicines using grammes. Support to institutional development modern machinery and applying good manufac­ included the surveillance, prevention and control turing practices; improvement of traditional of food adulteration in India, training of food medical services in the public sector; and training safety staff at district and provincial levels in Indo­ of traditional medicine practitioners for delivery nesia and Sri Lanka, and the establishment of a of primary health care. computerized information network on food anal­ ysis and quality control in Thailand. Studies on 19 21 High immunization coverage has been street-vended foods, pesticide residues and plastic achieved in most of the Member States, but many food containers, and on dietary intake of heavy deaths still occur from measles, neonatal tetanus metals were conducted in various countries. Se­ and poliomyelitis. Surveillance has improved but lected Codex Alimentarius texts and guidelines remains the weakest component of most national were translated and published in Indonesia, and programmes. Vaccine supply is a matter of con­ national food standards were reviewed and har­ cern in several countries; and WHO, donor agen­ monized with the Codex standards in India. cies and governments are seeking ways to im­ prove self-sufficiency in this area. Local produc­ 19.17 Support for strengthening health labora­ tion of cold chain equipment (including com­ tories as part of primary health care included the plete solar systems) is progressing well. formulation of national policies, introduction of simple diagnostic tests at peripheral level, and 19 22 While the overall incidence of malaria in establishment of a quality assessment network. the Region has remained unchanged over the last Guidelines were issued on the organization of ten years, the situation in forest areas has become health laboratory service networks, including ap­ more serious. WHO has formulated technical propriate technology and quality assurance. and operational guidelines, indicators and crite­ ria to implement the new global strategy forma­ 19.18 National essential drug programmes have laria control, and all the malarious countries are been developed in Member countries, some­ preparing plans of operation. times with extra budgetary support. Although es­ sential drugs have generally become more readily 19.23 WHO continued to cooperate in all as­ available, there have been acute shortages in pects of prevention and control of intestinal par­ some countries owing to political disturbances. asitic infections, visceral leishmaniasis, filariasis, WHO has complied with requests for procure­ schistosomiasis and dracunculiasis. Intestinal ment of drugs to ameliorate the situation. parasitic infections are widespread in the Region. Strengthening of drug regulatory and quality Visceral leishmaniasis is still a problem in parts of control systems, improvement of good manufac­ India, as well as Bangladesh and Nepal, as is turing practices, studies on the bioavailability lymphatic filariasis in Bangladesh, India, Indone­ and stability of pharmaceutical preparations, and sia, Maldives, Myanmar, Nepal, Sri Lanka and drug evaluation were some of the areas in which Thailand. Schistosomiasis is endemic in parts of WHO collaborated with countries in 1992-1993. Indonesia and in limited areas of Thailand. Dracunculiasis is now a problem in India only, 19.19 Assessments of the operation of the but has shown a downward trend in recent years. WHO Certification Scheme on the Quality of Pharmaceutical Products moving in Internation­ 19.24 All the Member States now have well de­ al Commerce were undertaken in Myanmar and veloped programmes for the control of diar­ Sri Lanka. Other activities in this field included rhoea! diseases, implemented through primary the development of standard treatment regimens, health care. Training receives the highest priority

143 THE WORK OF WHO 1992-1993 and 10 countries have established some 55 units therapy helped to reduce the disease burden. giving health workers practical training in diar­ WHO collaborated in reviewing and modifying rhoea case management. Nine countries produce national plans for leprosy control, including pro­ their own oral rehydration salts. A new strain of vision for resource mobilization and coordina­ cholera, designated Vibrio cholerae 0139, was tion. In 1992 the Regional Committee adopted a first isolated in an outbreak in V ell ore (India) in regional strategy for leprosy elimination, which October 1992. It then spread rapidly to West provides a framework for the development of Bengal and some other states in India. Large out­ control programmes. breaks have since been reported from Bangla­ desh. A few cases have also been reported from 19 28 Some Member States continue to be Thailand and Nepal. Because there is very little plagued by rabies. WHO provided support in resistance to this new strain, it has the potential the form of consultant services, supplies and for pandemic spread. All countries have been equipment, training for health personnel and the alerted and advised to intensify surveillance ac­ organization of workshops on rabies control. tivities. Courses were conducted for provincial staff in Indonesia. Nepal intensified its control measures 19.25 Early diagnosis and treatment is a key and human deaths from the disease were reduced strategy for reducing mortality from acute respi­ in Sri Lanka through a project supported by ratory infections in children. Ten Member States WHO and AGFUND. In Mongolia the main have started control programmes, and substantial emphasis was on eradication of plague and con­ progress has been made in several of them. More trol of brucellosis. WHO supported several than 9000 doctors, 18 000 health workers and countries in the development of new vaccines 30 000 health volunteers have received training in and in transfer of technology for the production standard case management, facilitated by the of vaccine and sera, including plasma-derived translation of training materials in local languag­ hepatitis B vaccine in Mongolia and Myanmar, es. Health facility, household and mortality sur­ and tetanus toxoid and snake venom antisera in veys have been carried out in some countries for Bangladesh. Efforts were made in Thailand to evaluation purposes. improve the efficacy of vaccines used in the Ex­ panded Programme on Immunization as well as 19 26 Tuberculosis continues to be a serious vaccines against dengue haemorrhagic fever and public health problem. In 1991 about two million Japanese encephalitis. cases were reported in the Region, almost half the world total, and nearly one million deaths annu­ 19 29 HIV infection did not begin to spread ex­ ally. However, there is renewed interest in con­ tensively in South-East Asia until the mid-1980s, trol of the disease because of its relationship with but the impact is already severe. More than HIV infection and AIDS. WHO is providing 1.5 million people are estimated to have been support for the reorganization of control pro­ infected and about 20 000 have already devel­ grammes through evaluation and planning activ­ oped AIDS. In response to this threat, govern­ ities or the initiation of pilot projects, with em­ ments have set up national control programmes phasis on management at district level. Many with WHO support. Political commitment is nongovernmental organizations, the World growing and multisectoral action, including the Bank and bilateral agencies are involved in con­ involvement of nongovernmental organizations trol programmes in some countries. and the private sector, is being undertaken. The aim is to interrupt transmission by promoting 19.27 Despite the significant progress made in safer sexual behaviour including condom use, leprosy control during the past decade, South­ and to ensure early diagnosis and treatment of East Asia, with a registered case-load of sexually transmitted diseases. Emphasis is also 1 347 000 in 1993, accounts for 70% of all regis­ being given to safe and rational use of blood and tered cases in the world. Control activities were blood products and to prevention of transmis­ intensified in endemic countries and multidrug sion through contaminated injecting equipment.

144 CHAPTER 20 European Region

20.1 The dramatic changes sweeping through In the United Kingdom reform of health care the European Region in 1990-1991 continued in financing has allowed general practitioners to be­ 1992-1993. Nineteen new Member States emerg­ come independent fund holders; Germany has ed from the democratization process in countries introduced diagnosis-related groupings for the of central and eastern Europe and republics of remuneration of hospital services through the the former Soviet Union. In western Europe the health insurance system; Finland has introduced 1992 Maastricht Treaty on European Union was a model for subsidizing municipal services, in­ finally ratified and came into force on 1 Novem­ cluding health, through a global budget with less ber 1993. central control; and several countries of central and eastern Europe and newly independent 20.2 The economic recession and resulting un­ States are well on the way to implementing re­ employment in many countries is having an forms. In 1992, for example, Hungary enacted impact on health care. Although the situation in legislation on health insurance, government pri­ several countries of central and eastern Europe mary health care for outpatients, and public has started to return to normal after their politi­ health; there were similar examples in Albania, cal transition, they still face serious socioeco­ Kazakhstan, Poland and Romania. nomic problems. Conditions in republics of the former Soviet Union are generally more difficult, 20 5 Armed conflicts in Europe continue to particularly as a result of the collapse of indus­ cause suffering and loss of life. In the conflict in trial enterprises and the rise in unemployment former Yugoslavia, more than 150 000 people and inflation. The disturbing increase in the gap have reportedly been killed and hundreds of between "haves" and "have nots" is causing thousands wounded, close to four million people concern and has grave implications for the health have been made refugees, probably as many as of vulnerable people. 20 000 women have been raped, thousands of people have been tortured, and around 3000 have 20 3 Communicable diseases have reappeared been amputated. The consequences of the con­ in a number of newly independent States. The flicts affecting Armenia, Azerbaijan, Georgia and statistics on diphtheria are alarming and reflect Tajikistan are receiving less attention from the insufficient immunization coverage. Progress is outside world, yet the toll of human suffering is being made, however, in reducing the incidence considerable. of poliomyelitis, measles, mumps and rubella. A small number of cholera cases have occurred in a 20.6 In collaboration with other bodies of the few Member States, but most seem to be im­ United Nations system, intergovernmental and ported. AIDS is spreading at a slower pace than nongovernmental organizations and donors, in other regions, but the potential impact of this WHO carried out an intensive programme of disease in central and eastern Europe is worry­ humanitarian assistance in republics of former ing. The tobacco industry has continued to ex­ Yugoslavia, focusing on public health and nutri­ pand in that part of the Region, where countries tion, equipment, supplies and logistic support have not had time to establish appropriate legis­ and help to war victims. The policy of providing lation and health promotion programmes. a broad range of standardized "kits" ensured that the supply of pharmaceuticals and equip­ 20.4 Some interesting developments have ment closely matched needs. These kits are now taken place with regard to health service reforms. being widely used by other organizations. A

145 THE WORK OF WHO 1992-1993

WHO Special Representative in Tajikistan national medical associations calling for meas­ helped to coordinate humanitarian assistance. ures to ensure the quality of care.

20.7 Close cooperation continued with the 20.10 The European Healthy Cities network was Commission of the European Communities and expanded in central and eastern Europe. More the Council of Europe. One joint venture was than 600 cities are now linked through some 20 the establishment in 1993 of a European Net­ national networks to this successful movement, work of Health-promoting Schools, with a sec­ which requires participants to draw up and imple­ retariat located at the Regional Office. Its aim is ment local health-for-all policies and plans. Poli­ to make schools a healthy setting for living, cies have also been promoted through a newly learning and working. A joint two-year health created network of "regions for health", grouping care telecommunications project known as the 11 regions in 10 European countries. This net­ "European Nervous System" was launched with work has considerable potential, given that there the Commission. Its purpose is to demonstrate, are some 1500 regions in Europe. through selected pilot areas and in collaboration with national health administrations and indus­ 20.11 Two European action plans on alcohol try, ways of applying communications technol­ and on tobacco, endorsed by the Regional Com­ ogy to meet selected information needs. It is re­ mittee in 1992, were actively implemented. A garded as a first step towards the realization of a task force was set up for execution of the Action collaborative, trans-European health informa­ Plan for a Tobacco-free Europe, especially in tion network. central and eastern Europe. The European Alco­ hol Action Plan was translated into nine languag­ 20.8 Many countries now have their own na­ es, and a European network of national counter­ tional policies based on the European health-for­ parts in alcohol research centres and advocacy all policy. England is the most recent in that groups established. regard, with its "Health of the nation" policy document and rigorous implementation process. 20.12 A conference of ministers of health and Both the full text of the updated health policy for ministers of finance and planning on investment in Europe and summary were published and wide­ health (Riga, 1-2 April 1993 ), organized with the ly distributed during 1992-1993.1 help of voluntary donations, endorsed a Riga state­ ment on principles for action to invest in health, 20 9 The number of networks of key partners and adopted a Riga initiative outlining activities for concerned with health for all, whether institu­ implementation of AIDS programmes in central tions, groups or individuals, continued to grow. and eastern Europe. High priority has been given Some comprise general practitioners, diabetes to following up this conference. specialists, health care financing experts and con­ sumer organizations. Twenty countries have 20.13 During 1992 the Rome and Bilthoven joined the countrywide integrated noncom­ (Netherlands) divisions of the European Environ­ municable disease intervention (CINDI) pro­ ment and Health Centre became fully operational, gramme, 11 of them countries of central and east­ and in 1993 a project office was established in ern Europe or newly independent States. A Eu­ Nancy (France). Preparation continued of a com­ ropean Forum of Pharmaceutical Associations prehensive report on the current environmental and WHO was established in early 1992 to im­ situation entitled "Concern for Europe's tomor­ prove contacts and collaboration and to upgrade row". It will be Europe's contribution to the sec­ the role of the pharmacist in Europe through ond European conference on environment and joint activities. A European Forum of National health, to be convened in Helsinki in 1994 jointly Medical Associations and WHO was constituted with the Commission of the European Communi­ in 1991. At its first meeting in 1992 it issued a ties. WHO was actively involved in preparations declaration on tobacco which, among other for a ministerial conference on environment for points, urged physicians to stop smoking. At its Europe (Lucerne, Switzerland, April1993), which meeting in 1993 it adopted recommendations for endorsed a special action programme for central and eastern Europe.

2014 Major changes have taken place in health 1 Health for all targets: the health policy for Europe. Copenhagen, World services. In central and eastern Europe there is Health Organization, 1993 (Health for All Senes, No. 4). strong public pressure for privatization and the

146 EUROPEAN REGION introduction of new financing mechanisms and 20 16 After analysing vaccine needs in countries, health insurance systems. A permanent working WHO collaborated with UNICEF and other group was set up within the project on health major donors in meeting the most acute require­ care reform (EUROCARE) in order to monitor ments. Steps were also taken to supply necessary and stimulate regional developments. As part of pharmaceuticals in central and eastern Europe. the project, a series of overviews of health care in The European diabetes action plan endorsed by transition and health care reforms in central and the Regional Committee in 1991 has been pro­ eastern Europe are being produced, and will be gressing on schedule: 46 Member States have es­ regularly updated. tablished active national programmes related to the St Vincent Declaration on diabetes, and par­ 20.15 A "Second Declaration of Alma-Ata" ticular emphasis has been given to central and was made by nursing and midwifery leaders at­ eastern Europe and newly independent States. tending a first WHO meeting of government EUROHEALTH, the special programme for in­ chief nurses of newly independent States tensified cooperation with those countries, re­ (Almaty, September 1993). It states that training mained a top priority; and the network of WHO of nurses, midwives and other middle-level per­ "liaison offices" in the countries was expanded sonnel should be a priority for all countries, and to 16. highlights the advantages of preparing national action plans for nursing, endorsed by ministries 20.17 During the biennium the Regional Office of health. A special effort was made to distribute operated with a 10% freeze on its regular budget teaching/learning materials in central and eastern allocation, a situation that had serious implica­ Europe and to newly independent States, and a tions for programme delivery given the increased fund-raising project (LEMON) was launched to number of European Member States. Particular ensure their translation into as many languages as efforts were made to improve management pro­ possible. cedures and to introduce new management tools.

147

CHAPTER 21 Eastern Mediterranean Region

21.1 At its thirty-ninth session in 1992 the Re­ 21.4 Different approaches were used during gional Committee for the Eastern Mediterranean the biennium to maintain and improve quality of adopted 12 resolutions on topics including mem­ care. Consideration was also given to solutions bership of Palestine in the Committee, advocacy such as cost-sharing and insurance schemes to of health for all among medical practitioners, meet ever-rising costs. Two important meetings zoonotic diseases, promotion of healthy life­ were held to further interest in health systems styles, and reduction of maternal and infant mor­ research and development, bringing together tality. Technical Discussions were held on "The managers, directors and researchers: one to pro­ impact of rapid urbanization on health". At its mote cooperation between universities and min­ fortieth session in 1993 Palestine was welcomed istries of health in this field (Cairo, June 1992) as a member in the Committee in accordance and the other to discuss health systems research with Article 47 of the Constitution. Technical at the periphery (Damascus, October 1992). papers were presented on leishmaniasis and abuse of narcotic and psychoactive drugs, as 21 5 Health care promotion gained momentum were progress reports on malaria control, AIDS through the encouragement of multisectoral co­ prevention and control, poliomyelitis eradica­ operation. A special feature in the Region is the tion and WHO-sponsored research. The subject basic minimum needs/quality-of-life approach to of the Technical Discussions was "The role of health promotion and disease prevention, which women in support of health for all". has proved its value in many countries including Egypt, Jordan, Somalia and Sudan. 21 2 In the field of information systems sup­ port, the local area network in the Regional Office 21.6 Health legislation was drawn up to meet was expanded, and plans were made for imple­ the needs of national health-for-all strategies. Fi­ menting WHO's revised administration and fi­ nancial support was provided for the establish­ nance information system. The regional advisory ment of emergency medical services in Qatar, panel on health information systems undertook with support from AGFUND, and in certain the preparation of a manual on the establishment other areas, including Gaza, through UNRW A. of national health information systems. Training In Afghanistan, Egypt, Syrian Arab Republic, in management techniques and planning was car­ Tunisia and Yemen medical equipment mainte­ ried out in most countries. A regional advisory nance programmes were strengthened, following panel on health care financing was established. situation surveys, through the issue of new man­ uals and training of staff. Guidelines on manage­ 21 3 The development of health systems based ment of medical, surgical and accident emergen­ on primary health care progressed in all coun­ cies for physicians were prepared. tries. Access to health care services exceeded 80% in the Region as a whole. A number of 21.7 With the establishment of a reliable health Member States started to decentralize their information system, efforts were directed to the health services. Management of care through dis­ formulation of coordinated policies and plans for trict health systems was encouraged and a prob­ the production and management of human re­ lem-solving approach using district teams was sources for health. Most Member States no long­ widely accepted. T earns were formed for training er face serious shortages of health personnel; and supervisory tasks in several countries includ­ consequently, the emphasis is now on improve­ ingYemen. ment of quality. WHO promoted continuing ed-

149 THE WORK OF WHO 1992-1993 ucation programmes for all categories of person­ and socioeconomic status of adolescent girls. nel within national health systems. In June 1993 Safe motherhood programmes aimed at reducing the regional advisory panel on nursing drew up maternal and infant mortality were established in strategies to strengthen managerial capabilities several countries. Many were supported in ef­ and improve services, including the production forts to reduce the frequency of low birth of teaching/learning materials in national lan­ weight, which can affect 30% of babies. The guages. An intercountry workshop on training Baby-friendly Hospital Initiative was promoted. for trainers of health personnel (Damascus, No­ vember 1992) reviewed recent approaches in this 2114 Several countries sought cooperation in field and considered the use of national languages formulating multisectoral plans on health of the for teaching/learning materials. It was decided to elderly following the preparation, through re­ decentralize the health leadership development gional or intercountry activities, of a strategy for programme, the first course being held in English 1992-2001 and of regional and national plans to in Islamabad, starting in August 1993. promote health and psychosocial care for the elderly. 21.8 As part of continued cooperation in na­ tional health education programmes, a "proto­ 21 15 The main task of the mental health pro­ type action-oriented school health curriculum gramme during the biennium was to integrate for primary schools", developed by WHO and mental health into primary health care, with em­ UNICEF in collaboration with UNESCO and phasis on mental health promotion and the pre­ the Islamic Educational, Scientific and Cultural vention of mental and neurological disorders. Organization, has so far been introduced in 12 Drug abuse, however, remained a serious health countries. Intercountry activities focused on im­ and social problem in the Region. proving the quality of life of women in the Re­ gion and increasing their potential for health 21 16 All countries were supported in imple­ promotion. menting essential drugs programmes focused on the development of national drug policies, in re­ 21 9 WHO cooperated with Member States in viewing national lists of essential drugs, and in measures to prevent malnutrition due to insuffi­ improving drug quality assurance systems cient, excessive or unbalanced intake; protein­ through measures to strengthen quality control energy and micronutrient malnutrition, especially laboratories and train staff in drug inspection. iodine deficiency disorders; and anaemia and vitamin A deficiency. A manual on rapid nutri­ 2117 Health laboratory services were extended; tional assessment in emergencies is in preparation. efforts to improve their performance included the preparation of a manual on quality assurance 21.10 The Regional Training and Research Cen­ for peripheral and intermediate laboratories, and tre for Oral Health in Damascus conducted sev­ guidelines on the facilities needed to cope with eral training courses in the planning and manage­ emergencies as part of a national contingency ment of preventive oral health programmes. plan. Local production of reagents received high priority, and progress was made in developing 21 11 Accident prevention programmes focused blood transfusion services. on safety promotion and accident injury control, including advocacy of coordinated multisectoral 21.18 A regional strategy on health and environ­ action. National occupational health pro­ ment was drawn up at an intercountry meeting grammes have grown as the awareness and com­ (Amman, June 1993) and adopted by the Region­ mitment of governments increase. al Committee in October 1993.

2112 Programmes on tobacco or health were 21.19 As arid conditions and lack of water re­ established or strengthened in the Region. All sources pose considerable problems in the East­ countries produced education materials on the ern Mediterranean, activities concerned with wa­ hazards of smoking. ter quality control and wastewater use were in­ tensified in many areas. The high cost of city 2113 National capacity to implement maternal sewerage is a major constraint, but several gov­ and child health and family planning pro­ ernments have succeeded in providing a reasona­ grammes was strengthened. A consultation (Bei­ ble level of financial support for water supply rut, June 1993) was held to consider the health and sanitation.

150 EASTERN MEDITERRANEAN REGION

21 20 Rapid urbanization and urban population during outbreaks of disease or epidemics, and growth are causing severe health and environ­ continuing disease prevention and control pro­ mental problems. In some rural areas settlements grammes. have grown up which have the character of small urban communities, accommodating large num­ 21.25 Cholera epidemics affected seven Member bers of people who commute to nearby cities. An States, and malaria, leishmaniasis and Rift V alley integrated approach to the growing difficulties fever reached epidemic proportions in some are­ experienced by these settlements has been pro­ as. WHO's role has been to mobilize specialist moted through "healthy villages" programmes. consultant services, prepare guidelines and train­ ing aids, and provide emergency supplies. The 21 21 Industrialization and the use of pesticides, Organization has also fostered collaboration be­ herbicides and artificial fertilizers in agriculture tween neighbouring countries, as in the case of increase hazards due to toxic chemicals, and poliomyelitis eradication in the Gulf States and there has been little action to ensure their safe the Maghreb; the same approach is being tried for use. A number of countries, however, are show­ malaria control. ing a keen interest in national chemical safety programmes. WHO continued to promote train­ 21 26 The Eastern Mediterranean Region has ing in this field, as in other aspects of environ­ been relatively less affected by the rapid spread mental health such as monitoring and control of of HIV infection than some other regions. Ef­ air and water pollution, including bacterial pol­ forts in national programme planning, in train­ lution of the sea. Support was also given for food ing, and particularly in promoting the social and safety programmes, for instance, in the prepara­ cultural values of the Region that inculcate self­ tion of guidelines on integrating food safety into respect and morality in individual relationships, primary health care and the strengthening of have contributed to its prevention. food laboratory services. 21.27 The use of scientific methods for the pre­ 21.22 The Centre for Environmental Health vention and control of cardiovascular diseases, Activities in Amman conducted 40 national and cancer, diabetes and other noncommunicable 10 intercountry training and research courses, disorders is being promoted, along with initia­ and strengthened its network for disseminating tives to inform and motivate national authorities, environmental health information. nongovernmental organizations and communi­ ties. 21.23 The regional health and biomedical infor­ mation programme provided services and advice 21 28 The WHO standards for recruitment of to countries as well as maintaining its traditional international staff were applied in the Regional role of support for Regional Office programmes. Office. However, there were difficulties in meet­ A number of countries have been preparing na­ ing the target of 40% in the appointment of na­ tional plans in this field in cooperation with tionals from under-represented countries and in WHO. A collaborating centre for health and bio­ recruiting a greater proportion of women. The medical information was designated in the Islam­ plans to extend the Regional Office building ic Republic of Iran in February 1993. Other ac­ were delayed pending the solution of problems tivities included involvement in ExtraMED, a concerning the title to the land made available by global project in which the full text of over the Host Government. Steps were taken to im­ 200 health journals not contained in the main prove accountability in regard to supplies and databases such as MEDLINE will be placed on equipment ordered for Member States. CD-ROM monthly. 21.29 A 10% reduction in programme imple­ 21 24 The battle against communicable and mentation, imposed by the expected deficit in noncommunicable diseases is still the main area contributions, made it difficult to respond to of collaboration between WHO and the Member critical situations in times of unprecedented States, in respect of both emergency measures need, including emergencies, in the Region.

151

CHAPTER 22 Western Pacific Region

22.1 Socioeconomic and political change in the December 1993, products of a new academic Region has been swift and widespread. Positive strategy and curriculum that promises to be well and welcome developments included renewed suited to the needs of Pacific island nations. New optimism in Cambodia for peaceful economic approaches to medical education were reviewed growth. At the forty-fourth session of the Re­ and changes were made in the basic training of gional Committee, held in Manila in 1993, fur­ health workers such as nurses and dental health ther changes were recognized, for example, in the practitioners. Distance learning was promoted, presence ofTuvalu as a full member of the Corn­ as was postgraduate and continuing medical edu­ mittee. The participation of Macao on its own cation in various countries. behalf, though without voting rights, in future sessions of the Committee was also announced. 22 4 In the important area of disease preven­ tion and control, coverage of infants with the six 22.2 Demographic, environmental and eco­ antigens of the Expanded Programme on Immu­ nomic developments have also been changing the nization was over 90% during the biennium. Re­ patterns of disease in theWestern Pacific. Diseas­ maining pockets of low coverage are the target of es such as diabetes, heart disease and cancer that future action. Tuberculosis incidence remained are associated with unhealthy lifestyles have in­ high, but the rates for poliomyelitis, diphtheria creased generally. This is also true of the devel­ and pertussis declined significantly. Measles inci­ oping countries where traditional communicable dence has fallen significantly during the last dec­ diseases such as tuberculosis remained undimin­ ade as a result of immunization, but outbreaks ished. These developments have made it necess­ still occur in most countries. ary to review the way health services are organ­ ized. Health promotion as an extension of the 22.5 In 1992 there was a 21% reduction in cases primary health care strategy is now emphasized of poliomyelitis compared with the previous year, as the main approach to the solution of health and the lowest annual total ever reported: 2087 problems, and the training of health personnel at cases. Given sufficient vaccine and funding, it is all levels has had to be adjusted accordingly. expected that the regional goal of eradication of Other key approaches are surveillance to moni­ the disease by 1995 can be attained. Efforts were tor the changing health status of the Region, the directed to improving surveillance, even in coun­ collection and dissemination of accurate and tries reporting no cases of the disease, and to in­ timely health information from a broad geo­ creasing supplementary immunization. China, graphical base and greater attention to manage­ Lao People's Democratic Republic, Philippines ment issues such as financing and quality of care. and Vi et N am conducted national immunization days, during which 120 million children under the 22 3 The availability of adequate and appropri­ age of five years were protected with oral ate human resources is a critical component of poliovirus vaccine. In 1993 the Regional Commit­ the infrastructure needed for health develop­ tee recognized the need to ensure the potency, ment. The orientation of training towards com­ safety and efficacy of the vaccine, and adopted a munity-based primary health care services con­ resolution to that effect. tinued during the biennium. Sharing of the Re­ gion's health training resources was encour­ 22 6 Immunization against hepatitis B was in­ aged. A first group of primary care practitioners creased. Technical support was given for local graduated from the Fiji School of Medicine in production of plasma-derived vaccine in China

153 THE WORK OF WHO 1992-1993 and Vi et N am. By 1992, 27 countries had incor­ spread of drug resistant strains, an increasing porated the vaccine into their immunization trend can be expected in the future. Measures schedules, although only on a limited scale in such as short-course chemotherapy, appropriate some cases. Where vitamin A is deficient it is also care management and surveillance are being in­ given during immunization sessions, as in the tensified. Philippines. 2210 It is conservatively estimated that between 22.7 The goal has been adopted of eliminating 50 000 and 100 000 people are already infected leprosy as a public health problem (less than one with HIV in the Region and the numbers are case per 10 000 population) in all parts of the growing rapidly. However, all Member States Region by the year 2000. 1992 data indicated a now have national AIDS committees as well as reduction of about 10% in the number of report­ laboratory facilities to test for HIV antibody, ed cases compared with the previous year. Over­ and high priority is given to management and all prevalence in the Region is 0.44 per 10 000. control of sexually transmitted diseases. The Coverage of multidrug therapy was 70% in 1992. means of transmission have been evolving as in­ Extrabudgetary funding has been essential for formation, education and other health promotive this purpose and for other activities such as train­ activities help to alter behaviour patterns. In ing and programme evaluation. Australia, for example, the epidemic seems to be reaching a plateau. An evaluation of the national 22 8 Malaria control has been a focus of atten­ five-year strategy concluded that the most effec­ tion. The nine malarious countries in the Region tive interventions in the early days of the epi­ reported nearly 800 000 microscopically con­ demic were funding of sex worker groups and firmed cases in 1991, a total that was expected to the establishment of needle and syringe exchange fall in subsequent years. All the malarious coun­ schemes in major cities. In 1993 the Regional tries are currently implementing intensive con­ Committee called for the drafting of guidelines trol strategies, or plan to do so in the near future. for national authorities, greater involvement of More than two million cases are believed to be other government departments and nongovern­ unreported or incompletely treated. However, mental organizations in the planning of activities, following a reorientation of the malaria control better surveillance and more intensive exchange programmes, data are now collected and ana­ of information, particularly the results of scien­ lysed with greater emphasis on numbers of clini­ tific studies. cally diagnosed cases and amounts of drugs used. Impressive reductions in the numbers of micro­ 22.11 At its 1993 session the Regional Commit­ scopically confirmed cases have been achieved in tee endorsed the regional programme for health parts of the Solomon Islands and also in Viet promotion which stresses, on the one hand, ac­ N am where two million adult curative doses of tion by individuals to adopt healthy lifestyles artemisinin, a derivative of Artemisia annua, are and, on the other, the creation of supportive en­ being produced annually for use in areas with vironments for health and the mobilization of high levels of multidrug resistance. Two meet­ communities and governments to achieve health ings were held in Kunming (China) in November goals. The programme identifies and addresses 1993 for countries of the Western Pacific and health issues in relation to different age groups, South-East Asia sharing at least one national recognizing that the dominant diseases are those border with another malarious country. The influenced by changes in lifestyle as well as fac­ meetings made recommendations for strengthen­ tors external to the individual such as urbaniza­ ing a variety of malaria control measures within tion, industrialization, migration and environ­ countries, across common borders and between mental change. Moreover, chronic illness and de­ regions, including the establishment of networks generative changes will affect the Region's ag­ for information exchange, monitoring of drug ing populations. Strategies for health promotion resistance, operational research and training. therefore form a significant element of many programmes in the Region. 22 9 The number of cases of tuberculosis re­ ported in the Region possibly represents as little 22.12 Demographic changes in the Region have as one-third of the real total, estimated at 1. 9 continued to require new strategies to prevent million. There was no decline in the numbers of environmental degradation and safeguard envi­ new cases during the biennium and, given the ronmental health. Following the 1992 United disease's close link with HIV infection and the Nations Conference on Environment and Devel-

154 WESTERN PACIFIC REGION opment (see paragraph 12.1), an international have given good results. Urban health develop­ symposium on improving environmental man­ ment activities, closely linked with health pro­ agement in north-east Asia was convened in the motion and primary health care, are under way in Republic of Korea in 1992. Similarly, national several countries.1 workshops were organized in Malaysia and Philippines to draw up plans for follow-up activ­ 22.13 Directions for the future will be deter­ ities. The integration of environmental manage­ mined by the Region's main concerns as de­ ment in rural and urban development pro­ scribed above. Priority setting will be a crucial grammes has become a priority concern. Region­ exercise, and the first steps in this respect were al workshops have proved very helpful in dealing taken in 1992-1993. The coordinated and con­ with specific issues; for instance, one held in Fiji certed efforts of the Member States will, howev­ (Suva, May 1992) reviewed solid waste manage­ er, be the key to accomplishing the many and ment options for small island nations constrained ambitious goals of health for all in the Western by geographical limitations and shortages of fi­ Pacific. nancial and human resources. National training programmes, such as the series of environmental planning and management courses conducted in 1 Austrolio, Chrno, Jopon, Moloysro, Popuo New Gurneo, Philippines, Repub· collaboration with the Government of Malaysia, lie of Koreo, Vie! Nom.

ISS

Annexes

157

Annex I

Members and Associate Members of the World Health Organization

The membership of the World Health Organization reached 187 Member States during the biennium, with two Associate Members. They are listed below with the date on which each became a party to the Constitution or the date of admission to associate membership.

Afghanistan 19 April 1948 Cuba* 9 May 1950 Albania 26 May 1947 Cyprus* 16 January 1961 Algeria'f 8 November 1962 Czech Republic* 22 January 1993 Angola 15 May 1976 Democratic People's Republic Antigua and Barbuda* 12 March 1984 of Korea 19 May 1973 Argentina'' 22 October 1948 Denmark* 19 April1948 Armenia 4 May 1992 Djibouti 10 March 1978 Australia* 2 February 1948 Dominica* 13 August 1981 Austria~· 30 June 1947 Dominican Republic 21 June 1948 Azerbaijan 2 October 1992 Ecuador'f 1 March 1949 Bahamas'f 1 April1974 Egypt* 16 December 1947 Bahrain* 2 November 1971 El Salvador 22June 1948 Bangladesh 19 May 1972 Equatorial Guinea 5 May 1980 Barbados'f 25 April1967 Eritrea 24 July 1993 Belarus~· 7 April1948 Estonia 31 March 1993 Belgium'f 25June 1948 Ethiopia 11 April1947 Belize 23 August 1990 Fiji'f 1 January 1972 Benin 20 September 1960 Finland'f 7 October 1947 Bhutan 8 March 1982 France 16June1948 Bolivia 23 December 1949 Gabon'f 21 November 1960 Bosnia and Herzegovina 10 September 1992 Gambia* 26 April 1971 Botswana'' 26 February 1975 Georgia 26 May 1992 Brazil'f 2June 1948 Germany'f 29 May 1951 Brunei Darussalam 25 March 1985 Ghana'f 8 April1957 Bulgaria'f 9 June 1948 Greece* 12 March 1948 Burkina Faso'' 4 October 1960 Grenada 4 December 1974 Burundi 22 October 1962 Guatemala* 26 August 1949 Cambodia'' 17 May 1950 Guinea'' 19 May 1959 Cameroon* 6 May 1960 Guinea-Bissau 29 July 1974 Canada 29 August 1946 Guyana* 27 September 1966 Cape Verde 5 January 1976 Haiti* 12 August 1947 Central African Republic'' 20 September 1960 Honduras 8 April1949 Chad 1 January 1961 Hungary* 17 June 1948 Chile* 15 October 1948 Iceland 17 June 1948 China'f 22July 1946 India'f 12 January 1948 Colombia 14 May 1959 Indonesia'' 23 May 1950 Comoros 9 December 1975 Iran (Islamic Republic of)'f 23 November 1946 Congo 26 October 1960 Iraq'f 23 September 1947 Cook Islands 9 May 1984 Ireland* 20 October 1947 Costa Rica 17 March 1949 Israel 21 June 1949 Cote d'Ivoire'f 28 October 1960 Italy'' 11 April1947 Croatia* 11 June 1992 Jamaica'f 21 March 1963

* Member States that have acceded to the Convention on the Privileges and Immunities of the Specialized Agencies and its Annex VII.

1S9 THE WORK OF WHO 1992-1993

Japan':· 16 May 1951 Saint Vincent and Jordan* 7 April1947 the Grenadines 2 September 1983 Kazakhstan 19 August 1992 Samoa 16 May 1962 Kenya* 27 January 1964 San Marino 12 May 1980 Kiribati 26 July 1984 Sao Tome and Principe 23 March 1976 Kuwait'~ 9 May 1960 Saudi Arabia 26 May 1947 Kyrgyzstan 29 April1992 Senegal'~ 31 October 1960 Lao People's Democratic Seychelles'~ 11 September 1979 Republic'~ 17 May 1950 Sierra Leone':· 20 October 1961 Latvia 4 December 1991 Singapore'~ 25 February 1966 Lebanon 19 January 1949 Slovakia 4 February 1993 Lesotho'~ 7 July 1967 Slovenia 7 May 1992 Liberia 14 March 1947 Solomon Islands 4 April1983 Libyan Arab J amahiriya'~ 16 May 1952 Somalia 26January 1961 Lithuania 25 November 1991 South Africa 7 August 1947 Luxembourg'~ 3 June 1949 Spain'-· 28 May 1951 Madagascar'~ 16 January 1961 Sri Lanka 7 July 1948 Malawi'~ 9 April1965 Sudan 14 May 1956 Malaysia'-· 24 April1958 Suriname 25 March 1976 Maldives'~ 5 November 1965 Swaziland 16 April1973 Mali':· 17 October 1960 Sweden* 28 August 1947 Malta'~ 1 February 1965 Switzerland 26 March 1947 Marshall Islands 5 June 1991 Syrian Arab Republic 18 December 1946 Mauritania 7 March 1961 Tajikistan 4 May 1992 Mauritius'~ 9 December 1968 Thailand* 26 September 1947 Mexico 7 April1948 The Former Yugoslav Micronesia (Federated States of) 14 August 1991 Republic of Macedonia 22 April1993 Monaco 8 July 1948 Togo'~ 13 May 1960 Mongolia'-· 18 April1962 Tonga* 14 August 1975 Morocco'~ 14 May 1956 Trinidad and Tobago'~ 3 January 1 963 Mozambique 11 September 1975 Tunisia'~ 14 May 1956 Myanmar 1 July 1948 Turkey 2 January 1948 Namibia 23 April1990 Turkmenistan 2July 1992 Nepal'~ 2 September 1953 Tuvalu 7 May 1993 Netherlands'-· 25 April1947 Uganda'' 7 March 1963 New Zealand'~ 10 December 1946 Ukraine'-· 3 April1948 Nicaragua'~ 24 April1950 United Arab Emirates 30 March 1972 Niger'-· 5 October 1960 United Kingdom of Nigeria'-· 25 November 1960 Great Britain and Norway'-· 18 August 1947 Northern Ireland'-· 22July 1946 Oman 28 May 1971 United Republic of Tanzania'~ 15 March 1962 Pakistan'~ 23 June 1948 United States of America 21 June 1948 Panama 20 February 1951 Uruguay* 22 April 1949 Papua New Guinea 29 April1976 Uzbekistan 22 May 1992 Paraguay 4 January 1949 Vanuatu 7 March 1983 Peru 11 November 1949 Venezuela 7 July 1948 Philippines'~ 9 July 1948 VietNam 17 May 1950 Poland'~ 6 May 1948 Yemen 20 November 1953 Portugal 13 February 1948 Yugoslavia'-· 19 November 1947 Qatar 11 May 1972 Zaire'~ 24 February 1961 Republic of Korea* 17 August 1949 Zambia'~ 2 February 1965 Republic of Moldova 4 May 1992 Zimbabwe'~ 16 May 1980 Romania'-· 8 June 1948 Russian Federation 24 March 1948 Associate M embers R wanda'-· 7 November 1962 Saint Kitts and Nevis 3 December 1984 Puerto Rico 7 May 1992 Saint Lucia'' 11 November 1980 Tokelau 8 May 1991

'~ Member States that have acceded to the Convention on the Privileges and Immunities of the Specialized Agencies and its Annex VII.

160 ANNEXES

Annex 2

Regional Distribution of Members and Associate Members of the World Health Organization

African Region

Algeria Cote d'Ivoire Madagascar Seychelles Angola Equatorial Guinea Malawi Sierra Leone Benin Eritrea Mali South Africa Botswana Ethiopia Mauritania Swaziland Burkina Faso Gabon Mauritius Togo Burundi Gambia Mozambique Uganda Cameroon Ghana Namibia Cape Verde Guinea Niger United Republic Central African Republic Guinea-Bissau Nigeria of Tanzania Chad Kenya Rwanda Zaire Comoros Lesotho Sao Tome and Principe Zambia Congo Liberia Senegal Zimbabwe

Region of the Americas

Antigua and Barbuda Cuba Mexico United States of America Argentina Dominica Nicaragua Uruguay Bahamas Dominican Republic Panama Venezuela Barbados Ecuador Paraguay Belize El Salvador Peru Bolivia Grenada Saint Kitts and Nevis Associate M ember: Brazil Guatemala Saint Lucia Canada Guyana Saint Vincent Puerto Rico Chile Haiti and the Grenadines Colombia Honduras Suriname Costa Rica Jamaica Trinidad and Tobago

South-East Asia Region

Bangladesh India Myanmar Sri Lanka Bhutan Indonesia Nepal Thailand Democratic People's Maldives Republic of Korea Mongolia

161 THE WORK OF WHO 1992-1993

European Region

Albania France Malta Switzerland Armenia Georgia Monaco Tajikistan Austria Germany Netherlands The Former Yugoslav Azerbaijan Greece Norway Republic Belarus Hungary Poland of Macedonia Belgium Iceland Portugal Turkey Bosnia and Ireland Republic of Moldova Turkmenistan Herzegovina Israel Romania Ukraine Bulgaria Italy Russian Federation United Kingdom of Croatia Kazakhstan San Marino Great Britain and Czech Republic Kyrgyzstan Slovakia Northern Ireland Denmark Latvia Slovenia Uzbekistan Estonia Lithuania Spain Yugoslavia Finland Luxembourg Sweden

Eastern Mediterranean Region

Afghanistan Iraq Morocco Sudan Bahrain Jordan Oman Syrian Arab Republic Cyprus Kuwait Pakistan Djibouti Tunisia Egypt Lebanon Qatar United Arab Emirates Iran Libyan Arab Saudi Arabia (Islamic Republic of) Jamahiriya Somalia Yemen

Western Pacifi( Region

Australia Kiribati New Zealand Tonga Brunei Darussalam Lao People's Papua New Guinea Tuvalu Cambodia Democratic Republic Philippines Vanuatu China Malaysia Republic of Korea VietNam Cook Islands Marshall Islands Samoa Fiji Micronesia (Federated Singapore Associate M ember Japan States of) Solomon Islands Tokelau

162 ANNEXES

Annex 3

Organizational and related meetings

1. Meetings in 1992

Executive Board: Committee on Drug Policies Geneva, 17-18 January Executive Board, eighty-ninth session Geneva, 20-28 January Executive Board: Standing Committee on Nongovernmental Organizations Geneva, 21 January Executive Board: Committee to Consider Certain Financial Matters prior to the Forty-fifth World Health Assembly Geneva, 4 May Forty-fifth World Health Assembly Geneva, 4-14 May Executive Board, ninetieth session Geneva, 18-19 May Executive Board: Programme Committee Geneva, 24-28 August Regional Committee for Africa, forty-second session Brazzaville, 2-9 September Regional Committee for the Western Pacific, forty-third session Hong Kong, 7-11 September Regional Committee for South-East Asia, forty-fifth session Kathmandu, 7-13 September Regional Committee for Europe, forty-second session Copenhagen, 14-19 September Regional Committee for the Americas, forty-fourth session/ Washington, D.C., XXXVI Meeting of the Directing Council of P AHO 21-26 September Regional Committee for the Eastern Mediterranean, thirty-ninth session Alexandria, 3-7 October

2. Meetings in 1993

Executive Board, ninety-first session Geneva, 18-29 January Executive Board: Standing Committee on Nongovernmental Organizations Geneva, 19 January Executive Board: Committee to Consider Certain Financial Matters prior to the Forty-sixth World Health Assembly Geneva, 3 May Forty-sixth World Health Assembly Geneva, 3-14 May Executive Board, ninety-second session Geneva, 17-18 May Executive Board: Programme Committee Geneva, 5-9 July Executive Board: Programmee Committee Geneva, 29 November- 1 December Regional Committee for Africa, forty-third session Gaborone, 1-8 September Regional Committee for Europe, forty-third session Athens, 6-1 0 September Regional Committee for the Western Pacific, forty-fourth session Manila, 13-17 September Regional Committee for South-East Asia, forty-sixth session New Delhi, 21-27 September Regional Committee for the Americas, forty-fifth session/XXXVII meeting Washington, D.C., of the Directing Council of P AHO 27 September - 2 October Regional Committee for the Eastern Mediterranean, fortieth session Alexandria, 2-5 October

163 THE WORK OF WHO 1992-1993

Annex 4

Intergovernmental Organizations that have entered into Formal Agreements with WHO approved by the World Health Assembly, and Nongovernmental Organizations in Official Relations with WHO at 31 December 1993

I. Intergovernmental organizations

African Development Bank Islamic Development Bank International Committee of Military Medicine League of Arab States and Pharmacy Organization of African Unity International Office of Epizootics

2. Nongovernmental organizations

African Medical and Research Foundation International Association of Logopedics and International Phoniatrics Aga Khan Foundation International Association of Medical Laboratory Association of the Institutes and Schools of Tropical Technologists Medicine in Europe International Association for the Study of the Liver CMC- Churches' Action for Health International Association for the Study of Pain Christoffel-Blindenmission International Association for Suicide Prevention Collegium lnternationale N euro- International Association on Water Quality Psychopharmacologicum International Astronautical Federation Commonwealth Association for Mental International Bureau for Epilepsy Handicap and Developmental Disabilities International Catholic Committee of Nurses Commonwealth Medical Association and Medico-Social Assistants Commonwealth Pharmaceutical Association International Clearinghouse for Birth Defects Council for International Organizations of Medical Monitoring Systems Sciences International College of Surgeons Helen Keller International, Incorporated International Commission on Occupational Health Industry Council for Development International Commission on Radiation Units Inter-American Association of Sanitary and Measurements and Environmental Engineering International Commission on Radiological International Academy of Legal Medicine Protection and Social Medicine International Committee of the Red Cross International Academy of Pathology International Confederation of Midwives International Agency for the Prevention of Blindness International Conference of Deans of French- International Air Transport Association language Faculties of Medicine International Alliance of Women International Council on Alcohol and Addictions International Association for Accident International Council on Jewish Social and and Traffic Medicine Welfare Services International Association for Adolescent Health International Council for Laboratory Animal International Association of Agricultural Medicine Science and Rural Health International Council of Nurses International Association of Cancer Registries International Council of Scientific Unions International Association for Child and Adolescent International Council on Social Welfare Psychiatry and Allied Professions International Council of Societies of Pathology International Association of Hydatid Disease International Council for Standardization in International Association of Lions Clubs Haematology

164 ANNEXES

International Council of Women International Organization for Standardization International Cystic Fibrosis (Mucoviscidosis) International Organization against Trachoma Association International Pediatric Association International Dental Federation International Pharmaceutical Federation International Diabetes Federation International Physicians for the Preventiof\ of International Electrotechnical Commission Nuclear War International Epidemiological Association International Planned Parenthood Federation International Ergonomics Association International Radiation Protection Association International Eye Foundation International Society for Biomedical Research on International Federation on Ageing Alcoholism International Federation of Business and International Society of Biometeorology Professional Women International Society of Blood Transfusion International Federation of Chemical, Energy International Society for Burn Injuries and General Workers' Unions International Society of Chemotherapy International Federation of Clinical Chemistry International Society and Federation of Cardiology International Federation for Family Life International Society of Haematology Promotion International Society for Human and Animal International Federation of Fertility Societies Mycology International Federation of Gynecology and International Society of Orthopaedic Surgery Obstetrics and Traumatology International Federation of Health Records International Society of Nurses in Cancer Care Organizations International Society for Prosthetics and Orthotics International Federation of Hospital Engineering International Society of Radiographers and International Federation for Housing and Planning Radiological Technologists International Federation of Hydrotherapy and International Society of Radiology Climatotherapy International Society for the Study of Behavioural International Federation for Information Processing Development International Federation for Medical and Biological International Sociological Association Engineering International Solid Wastes and Public Cleansing International Federation of Medical Student Association Associations International Special Dietary Foods Industries International Federation of Multiple Sclerosis International Union of Architects Societies International Union of Biological Sciences International Federation of Ophthalmological International Union against Cancer Societies International Union for Conservation of Nature International Federation of Oto-Rhino­ and Natural Resources Laryngological Societies International Union of Family Organizations International Federation of Pharmaceutical International Union for Health Promotion Manufacturers Associations and Education International Federation of Physical Medicine International Union of Immunological Societies and Rehabilitation International Union of Local Authorities International Federation for Preventive and International Union of Microbiological Societies Social Medicine International Union of Nutritional Sciences International Federation of Red Cross and International Union of Pharmacology Red Crescent Societies International Union of Pure and Applied Chemistry International Federation of Sports Medicine International Union of Toxicology International Federation of Surgical Colleges International Union against Tuberculosis and Lung International Group of National Associations of Disease Manufacturers of Agrochemical Products International Union against the Venereal Diseases International Hospital Federation and the Treponematoses International Lactation Consultant Association International Water Supply Association International League of Dermatological Societies Inter-Parliamentary Union International League of Associations for Rheumatology Joint Commission on International Aspects of International League against Epilepsy Mental Retardation International Leprosy Association La Leche League International International Leprosy Union Medical Women's International Association International Life Sciences Institute Medicus Mundi Internationalis (International International Medical Informatics Association Organization for Cooperation in Health Care) International Medical Society of Paraplegia Mother and Child International International Organization of Consumers Unions National Council for International Health

165 THE WORK OF WHO 1992-1993

Network of Community-Oriented Educational W odd Federation for Mental Health Institutions for Health Sciences W odd Federation of Neurology OXFAM (Oxford Committee for Famine Relief) W odd Federation of Neurosurgical Societies Population Council W odd Federation of Nuclear Medicine and Biology Rehabilitation International W odd Federation of Occupational Therapists Rotary International W odd Federation of Parasitologists Royal Commonwealth Society for the Blind W odd Federation of Proprietary Medicine Save the Children Fund (UK) Manufacturers Soroptimist International W odd Federation of Public Health Associations W odd Assembly of Youth W odd Federation of Societies of Anaesthesiologists W odd Association of Girl Guides and Girl Scouts World Federation of United Nations Associations W odd Association of the Major Metropolises W odd Association for Psychosocial Rehabilitation W odd Hypertension League World Association of Societies of (Anatomic and W odd Organization of National Colleges, Clinical) Pathology Academies and Academic Associations of General World Blind Union Practitioners/Family Physicians W odd Confederation for Physical Therapy W odd Organization of the Scout Movement World Federation of Associations of Poisons Centres W odd Psychiatric Association and Clinical Toxicology Centres W odd Rehabilitation Fund W odd Federation of the Deaf W odd Veterans Federation W odd Federation of Hemophilia W odd Veterinary Association W odd Federation for Medical Education W odd Vision International

166 Annex 5

Structure of the World Health Organization at 31 December 1993 Structure of the Secretariat of the World Health Organization

Cabinet ol the Director-General (CDG) AdVISer on POlicy CooperatiOn (DGP) Adv1ser on Health and Development Policies (DGH) International Agency Headquarters Regional Offices for Research on Cancer

Division of Emergency and Act1on Programme on Essential Drugs (DAP) Programme Humanitarian Action (EHA) ' D1vis1on of Drug Management and Pollc1es Coordination, DIRECTOR Office of Legal Counsel (LEG) (DMP) Promotion and Off1ce of Internal Audit (OIA) DIVISIOn of Food and Nutntlon (FNU) Information Programme on Health Technology (PHn Secretariat Programme Division of Diarrhoea! and Acute Respiratory Management WHO lntercountry Health D1sease Control (GDR) Development Teams D1v1sion of Commumcable Diseases (CDS) WHO Representatives DIViSIOn of Control of TrOPICal Diseases (CTD) Support OnchocerciaSIS Control Expanded Programme on lmmumzat1on (EPI) Programme Programme in West Africa Special Programme for Research and Trammg in Tropical Diseases (TOR)

PAHOIWHO Representatives Division of Family Health (FHE) Assistant Director Programme Coordmat1on Division of Health Education (HED) Offices Division of Development of Human Resources Deputy Director Health Systems Infrastructure Caribbean Programme for Health (HRH) Coordmation Spec1al Programme of Research. Development WH094034/E and Research Trammg m Human Health Programmes Reproduction (HRP) Development

Health and Biomedical Information Programme (HBI) South-East Asia Programme Division of Epidemiological Surveillance and Management Health S1tuation and Trend Assessment WHO Representallves (HSn I Division of Strengthening of Health Serv1ces Support (SHS) Programme - DiviSIOn of Health ProtectiOn and Promotion - (HPP) - Division of Mental Health (MNH) Programme Division of Noncommunicable Diseases (NCD) Management Programme on Substance Abuse (PSA) Office of Research Promotion and WHO Representatives ' Includes the Representative of Development (RPD) I the Director-General of WHO to Support Programme the Umted Nat1ons system and - other intergovernmental bod1es Division of Budget and Fmance (BFI) at New York: the WHO Senior DiviSIOn of Conference and General Serv1ces Health Adviser to UNICEF, New (CGS) York; the Representative of the Division of lnteragency Affairs (INA) - Director-General of WHO to the Programme Division of Personnel (PER) Management European Community at Adviser on lnformatics (AOI) Brussels, and the WHO Office for WHO Representatives Information Technology Off1ce (ITO) Director of Health, UNRWA the Orgamzation of African Unity Management Development Off1ce (MOO) Support and the Economic Commission Programme for Resource Mobilization (RMB) Programme for Afnca, Addis Ababa - ' Includes the WHO Pan Afncan DIVISion of Environmental Health (EHE) Centre for Emergency Programme for the Promotion of Chemical Preparedness and Response, Safety (PCS) - AddiS Ababa Programme Management 'Regional Office for the Americas/ WHO Representatives Pan Amencan Samtary Bureau WHO Country Liaison Off1cers Support Programme Structure of the Secretariat at Headquarters

(DGH)

Division of Emergency and Humanitarian Action (EHA) Ombudsman Office of the Legal Counsel Off1ce of Internal Audit Afghanistan Programme (AFP) (OMB) (LEG) (OIA) Emergency information System (EIS) Emergency Preparedness Planning (EPP) Response for Afnca and the Middle East (RAM} Response for Asia and the Pac1f1c (RAP) Response for Europe and the Americas (REA)

ASSISTANT ASSISTANT EXECUTIVE EXECUTIVE DIRECTOR-GENERAL DIRECTOR· GENERAL DIRECTOR , DIRECTOR

Action Programme on Essential Division of Environmental Health Global Programme on AIDS (GPA) Drugs (OAP} OffiCe of (EHE} Sexually Transm1tted Diseases Country LiaiSOn (COL} International Community Water Supply and (VDT) Operational Research and CooperatiOn Sanitation (CWS) Planmng and Policy Coordination Development Work (ORD) (I CO) Prevention of Environmental (PPG) Training and Human Resources Pollution (PEP) Office of Cooperation w1th National (THR) Programmes (GNP) Programme for the Promotion of Off1ce oflntervent1on Development Division of Drug Management and Health and Biomedical Division of Health Profection and Chemical Safety (PCS) and Support (lDS) Policies jDMP} Information Programme IHBI} Promotion (HPP} Office of Research (RES) BIOIOQICa S(BLG) Distnbution and Sales (DSA) Health of the Elderly (HEE) Admimstrat1ve Support Services Drug Safety (DRS) Health Legislation (HLE) Prevention of Deafness and (ADS) Quality Assurance (QAS) Office of Library and Health Hearing Impairment (PDH) Regulatory Support (RGS) Literature Serv1ces (HLT) Rehabilitation (RHB) Wf-1094033/E Traditional Medicine (TRM) Off1ce of Publications (PUB} Injury Prevention (IPRJ Office of Language Serv1ces Occupational Health (OCH) Division of Food and Nutrition (TRA) Oral Health (ORH) (FNU} Prevention of Blindness (PBL) Food Aid Programmes (FAP) Division of Epidemiological Tobacco or Health (TOH) Food Safety (FOS) Surveillance and Health Nutrition (NUT) Situation and Trend Di~~~:n Resources for Health Assessmenf (HST} Programme on Health Technology IHRH} Epidemiological and Stat1st1cal (PHT) Educalianal Development of Methodology (ESM) Clm1cal Technology (CLI) Human Resources for Health Global Health S1tuat1on Health Laboratory Technology (EDH} Assessment and and Blood Safety (LBS) Health Learning Materials Projections (GSP) Radiation Med1cine (RAD) Programme (HLM) Momtonng, Evaluation and Human Resources Policy Projection Methodology (MEP/ Analyses (HPA) Strengthenmg of Epidemiolog1ca Human Resources Management and Statistical Services (SES) (HRM) Nursing (NUR) Division of Strengthening of Planning of Human Resources Health Services (SHS} for Health (PHR) D1stnct Health Systems (OHS) Research Traming Grants and Health Systems Research and Fellowships (RTG) Development (HSR) Staff Development Programme National Health Systems and (SDP} Policies (NHP)

on Technology lntroduclian and Transfer (HRC) Epidemiological Research (HRE) Soc1al Science Research (HRK) Essential NatiOnal Research (HRN) StatistiCS and Data Processing (HRS} Technology Development and Assessment (HRV)

Index

References are by paragraph. Main references are in heavy type.

Abortion, 10.11, 10.35 training, 7.12 ACC, see Administrative Committee on Coordina- United Nations joint programme, 2.13, 14.117 tion WHO/UNDP alliance, 14.118 Accidents, see Injury prevention World AIDS days, 7.3, 14.139 ACHR, see Advisory committees on health research see also Sexually transmitted diseases Administration and finance information system Albania, 10.11 (AFI), 16.13-16.14 Alcohol abuse, 11.10, 19.13 Administrative Committee on Coordination (ACC), European action plan, 20.11 2.11, 2.13, 14.137 Algeria, 5.3 Inter-Agency Committee on Sustainable Develop- American College of Clinical Engineering, 5.8 ment, 2.11 American International Health Alliance, 5.8 lntersecretariat Group for Water Resources, 12.13 American trypanosomiasis (Chagas disease), 14.32- Subcommittee on Statistical Activities, 4.9, 4.10 14.33, 18.11 Subcommittee on Water Resources, 12.13 Adolescent health, see Youth and adolescence research, 14.67 Advisory committees on health research (ACHR), Americas, Region of the, 18.1-18.17, Annex 2 global, 8.2-8.4 see also Pan American Health Organization and regional, 8.9, 8.10, 8.13 individual activities Afghanistan, 2.31, 5.8, 14.15, 16.16, 21.6 Anaesthesiology, 13.2 Operation Salam, 16.22 Andean Area, 18.8, 18.11 African Development Bank, 2.19, 2.26, 13.34 Andean Parliament, 18.8 African Development Fund, 2.19 Cooperation in Health initiative, 18.5 African Economic Community, treaty, 2.22 Anthrax, 14.112 African health development framework, 17.1 Appropriate Health Resources and Technologies Ac­ African Region, 17.1-17.17, Annex 2 tion Group, 14.90 see also individual activities Arab Gulf Programme for United Nations Develop­ African trypanosomiasis (sleeping sickness), 14.37- ment Organizations (AGFUND), 14.167, 14.197, 14.41, 14.44, 14.48 19.28, 21.6 research, 14.66 Arabic, use of, 6.22, 15.13 AGFUND, see Arab Gulf Programme for United Argentina, 8.9, 11.17, 14.33, 14.67,18.10 Nations Development Organizations ARI news, 14.90 Aging, see Elderly, health of Armenia, 2.30 AIDS (acquired immunodeficiency syndrome), 2.13, Arthritis, 14.211 2.22, 7.6, 9.3, 11.13, 14.36, 14.94, 14.99, 14.100, Arthropod-borne viral diseases, 14.142 14.114-14.124, 14.128-14.139, 14.185, 17.2, 17.7, ASEAN, see Association of South-East Asian Na- 18.12, 19.13, 19.26, 19.29, 21.26, 22.9, 22.10 tions blood and blood products, safety and screening, 13.5, 14.122 Asia and Pacific Decade of Disabled Persons, 13.41 discrimination, avoidance of, 2.13, 14.116 Asian Development Bank, 2.19 global programme and strategy, 2.13, 14.116, Asian Interactive Association on the Hearing Im­ 14.117, 17.7 paired, 14.172 health education and information, 7.10, 7.12, 14.130 Asia-Pacific Academic Consortium for Public Health, inter-agency advisory group, 14.137 6.25 legal and ethical aspects, 4.26, 4.28, 14.116 Assessments on Member States, 1.5 research, 4.24 Associate Members of WHO, 2.1, Annexes 1 and 2 Riga initiative, 20.12 Association for Health Information and Libraries in supplies, 16.16-16.18, 16.20, 16.22 Africa, 15.4, 17.6

171 THE WORK OF WHO 1992-1993

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Association of South-East Asian Nations (ASEAN), Cancer, 10.20, 14.161, 14.173-14.181,21.27 4.19 see also International Agency for Research on Can­ Asthma, 14.214 cer Atherosclerosis, 14.202, 14.210 Cardiovascular diseases, 14.197-14.207, 21.27 Australia, 6.16, 22.10 cardiovascular diseases and alimentary comparison Austria, 9.7 project (CARDIAC), 14.201 Auxiliary health personnel, see Community health multinational monitoring project (MONICA), workers and the various categories of health per­ 14.198 sonnel Caribbean Area, 3.9, 4.26, 7.8, 8.9, 10.39, 15.2, 15.5, Azerbaijan, 2.30 18.5, 18.10, 18.15 Cooperation in Health initiative, 4.19, 18.5 Community (CARICOM), 18.6 Epidemiology Centre (CAREC), 4.6 Baby-friendly Hospital Initiative, 9.17, 21.13 Carnegie Corporation (USA), 11.1 Bacterial diseases, 14.140-14.149 CCAQ, see Consultative Committee on Administra­ see also individual diseases tive Questions Bahrain, 2.3, 12.10 CCPOQ, see Consultative Committee on Pro­ Bamako initiative, essential drugs, 4.24 gramme and Operational Questions Bangladesh, 3.5, 9.43, 10.10, 12.14, 12.16, 14.45, 14.51, Central African Republic, 7.12 14.80, 14.96, 19.3, 19.6, 19.14, 19.23, 19.24,19.28 Central America, 4.6, 18.5, 18.8, 18.10, 18.17 fourth population and health project, 2.26, 4.3, 4.14, Chapultepec peace agreement, 18.17 4.16, 5.6, 6.4, 16.20 development programme for refugees and displaced Barbados, 6.5 persons (PRODERE), 18.17 Belarus, 2.3, 11.7, 12.31 health initiative, 18.5 Belize, 4.6 Benin, 7.13, 11.16, 12.5, 13.21, 13.28, 13.38, 14.45 Central and eastern Europe, 9.3, 9.44, 10.11, 11.2, Bhutan, 5.6, 19.3, 19.6 11.3, 13.26, 15.7, 20.2, 20.10, 20.12, 20.14, 20.15, Bilharziasis, see Schistosomiasis 20.16 Bioethics, 4.29, 14.219 European cooperative health programme Biologicals, 13.22-13.24 (EUROHEALTH), 20.16 Birth control, see Fertility regulation Cerebral palsy, 13.39 Blindness prevention, 14.164-14.171 Chad, 2.26, 3.9, 6.20, 7.12, 14.38 see also Onchocerciasis Chagas disease, see American trypanosomiasis Blood and blood products, screening and safety, 13.3- Changing medical education and medical practice, 13.5, 14.122 6.18 external quality assessment scheme, 13.3 Chemical safety, 10.49, 12.18-12.24,21.21 Bolivia, 3.9, 5.12, 5.18, 10.9, 13.28, 14.67 health and safety guides, 12.20 Borrow Dental Milk Foundation, 9.27 international cards, 12.20 Bosnia and Herzegovina, 2.3 international programme (IPCS), 10.46 Botswana, 5.4, 5.7, 7.12, 14.26, 14.99 management, 12.18, 12.19, 12.20 Brazil, 8.9, 9.17, 10.15, 10.16, 10.17, 10.33, 11.8, 11.17, occupational exposure, 10.46 12.14, 12.16, 14.15, 14.24, 14.33, 14.51, 14.52, poisons control and information, 12.23 14.55, 14.61, 14.67, 14.68, 14.80, 14.81, 14.127, risk evaluation, 12.19, 12.20, 12.22 14.133, 14.143, 18.10 see also Drugs Breast-feeding, 9.16, 9.17, 10.29, 14.78, 14.80, 14.89, Chernobyl accident, 2.15, 9.26, 11.20 14.138,21.13 international programme, 11.20, 12.31 Bridge, 4.21 Children, 2.25, 10.7-10.13, 11.8, 14.90-14.92, 14.164, Brucellosis, 14.107, 14.113,19.28 19.25 Budget, see Programme budget (WHO) AIDS/HIV infection, 7.6, 14.131, 14.135 Bulgaria, 9.27 Baby-friendly Hospital Initiative, 9.17, 21.13 Bulletin of the World Health Organization, 15.11 convention, rights of the child, 10.7 Burkina Faso, 12.5 diarrhoea! diseases, 9.12, 14.72, 14.76, 14.78, 14.80 Burn injuries, 9.37, 9.39 immunization, 14.1-14.14, 14.86, 14.156, 14.160, Burundi, 14.19, 14.45 Byelorussian SSR, see Belarus 14.161, 14.193,22.4 vaccine initiative, 13.23, 14.11, 14.154 world summit (1990), 2.18, 3.3, 4.7, 9.19, 10.7, 10.10, 14.14, 18.10 Cambodia, 2.32, 4.3, 9.25, 14.24, 15.9 see also Maternal and child health; Youth and ado­ Cameroon, 2.3, 4.3, 4.24, 5.7, 7.6, 7.12, 13.2, 14.22, lescence 14.45, 14.61 Chile, 9.42, 10.16, 10.17, 10.33, 10.39, 10.53, 14.33, Canada, 5.7, 14.203 14.67, 18.10

172 INDEX

China, 4.25, 4.27, 6.4, 6.5, 7.7, 7.8, 7.13, 9.17, 10.7, Consultative Group of Nongovernmental Organiza- 10.13, 10.21, 10.26, 10.52, 11.4, 11.7, 11.17, 12.27, tions, 14.166, 14.171 13.6, 13.38, 14.29, 14.42, 14.51, 14.59, 14.96, Continuing education, 6.14 14.140, 14.153, 14.171, 14.203, 15.9, 22.5, 22.6 Contraceptives, see Fertility regulation Cholera, 2.14, 4.6, 9.12, 12.9, 12.11, 14.79, 14.155, Contributions of Member States to WHO, incentive 16.18, 16.19, 17.11, 17.16, 18.12, 19.24, 21.25 scheme, 1.5 global task force, 14.79 Conventions, CIOMS, see Council for International Organizations privileges and immunities, specialized agencies, 2.3 of Medical Sciences rights of the child, 10.7 Circulation, 14.198 Convergencia initiative, health science and technolo­ Clinical technology, 13.1-13.2 gy, 8.9 Codex Alimentarius, FAO/WHO, 9.11, 19.16 Cooperation Council for Arab Gulf States, 13.25 Collaborating centres (WHO), 8.5, 14.151 Coordination and collaboration, 1.1, 2.10-2.27, 18.7- accident and injury prevention, 9.36, 9.37, 9.38 18.8 cancer, 14.174, 14.179 see also individual organizations and activities cardiovascular diseases, 14.201 Coronary heart disease, 9.20 community safety promotion, 9.32 Costa Rica, 9.6, 10.17, 10.54 drug monitoring, 13.16 Cote d'Ivoire, 14.40, 14.45, 14.120, 14.129 equipment maintenance and repair, 5.8 Council of Europe, 3.6, 4.29, 10.17, 20.7 health and biomedical information, 21.23 Council on Health Research for Development, 4.24, hepatitis, 14.161 8.7 hospitals and other health institutions, 5.21 Council for International Organizations of Medical human reproduction research, 10.37 Sciences (CIOMS), 4.29, 8.2, 13.15, 13.16 Council for Science and Technology (WHO), 8.4 legionellosis, 14.148 Country health information development, 4.3-4.5 malaria, 14.19 Creutzfeld-Jakob disease, 14.110 mental health, 11.5 Croatia, 2.3 occupational health, 10.43 Cuba, 8.9, 10.39, 14.156, 14.167, 14.202, 14.203, 18.10, oral health, 9.28, 9.30 18.14 pesticides, 14.44 Cyprus, 5.8, 12.10, 13.6 rheumatic conditions, 14.212 Cystic fibrosis (mucoviscidosis), 14.216 smallpox and other poxvirus infections, 14.152 Czech Republic, 2.3 Collaborative International Pesticide Analytical Council, 14.44 Colombia, 5.17, 10.15, 10.17, 10.33, 11.8, 11.17, 14.69, 14.70, 14.188, 18.10 Danish International Development Agency (DANI- Commission of the European Communities, see Eu­ DA), 5.21 ropean Communities Data processing, see Information systems Commission on Health and Environment (WHO), Deafness, 14.172 12.1-12.2, 15.10 Delagrange lnternational!Synthelabo Recherche Commission on Sustainable Development (United (France), 11.1 Nations), 2.12 Dementias, 10.51, 10.53, 11.20 Committee of the Executive Board to Consider Cer­ Democratic People's Republic of Korea, 14.141 tain Financial Matters, 16.9 Demography, see Population Commonwealth of Independent States, 9.30, 13.26, Dengue and dengue haemorrhagic fever, 14.42, 14.46, 14.104, 16.21 14.142, 14.159,19.28 Commonwealth Pharmaceutical Association, 13.19 Denmark, 13.24 Communicable diseases, see individual diseases Dental health, see Oral health Community health workers, 5.18, 6.23 Diabetes, 14.208-14.210, 14.215, 20.16, 21.27 Community safety and health, 3.5, 5.11, 5.18, 7.13, European action plan, 20.16 9.32-9.34, 14.215, 17.3 St Vincent declaration, 14.209, 20.16 Comoros, 14.142 Diarrhoea! diseases, 2.14, 9.12, 14.72-14.82, 14.89, Conferences, see individual topics 14.92, 14.155, 18.12,19.24 Congo, 7.12, 7.13, 14.38 see also Cholera Consortium for International Earth Science Informa­ Digital Equipment Corporation (USA), 11.1 tion Network (CIESIN), 4.9 Diphtheria, 14.1, 14.8, 14.9, 22.4 Constitutional and legal matters, 2.1-2.3 Director-General, reappointment, 1.3 Consultative Committee on Administrative Ques­ Disability prevention and rehabilitation, 2.15, 2.29, tions (CCAQ), 2.11 13.35-13.41 Consultative Committee on Programme and Opera­ Disaster relief, see Emergency relief and supplies tional Questions (CCPOQ), 2.11, 2.16 Disease vector control, see Vector control

173 THE WORK OF WHO 1992-1993

Displaced persons, see Refugees and displaced per- Environment and health, sons Americas, investment plan, 3.4 District health systems, 5.11-5.21 Central America, national plans, 18.15 Djibouti, 14.19 Eastern Mediterranean, regional strategy, 21.18 Documents (WHO), see Health literature services Europe, regional centre, 20.13 Dominican Republic, 5.12, 6.3, 14.129, 18.10 Environmental health, 1.2, 3.4, 7.5, 9.13, 12.1-12.31, Dracunculiasis (guinea-worm disease), 14.22-14.23, 18.15, 19.15, 20.13, 21.21, 21.22, 22.12 17.15, 19.23 global network, technology (GETNET), 12.29 Drugs, WHO commission, 12.1-12.2, 15.10 abuse, 9.3, 11.9-11.16, 11.22, 19.13 see also Chemical safety; Environmental pollution; alerting system (ATLAS), 11.9 Environment and development; Water supply control of narcotic drugs and psychotropic and sanitation substances, 2.15 Environmental Health Criteria, 12.20, 12.22 essential, 13.10, 19.18, 19.19, 21.16 Environmental health hazards, control, 12.25-12.31 action programme, 13.26-13.34 human exposure assessment location (HEAL) Bamako initiative, 4.24 project, 12.26 model list, 13.18, 14.178 Environmental management, panel of experts management and policies, 13.10 pharmaceuticals, 13.11-13.21, 13.33, 19.18, 19.19 (PEEM), 12.6 rational use, 13.33, 14.76,19.19 Environmental pollution, 12.25-12.30, 14.91, 19.15, international network, 13.33 21.21 see also Chemical safety; Water supply and sanita­ tion Epidemiology and statistical services, 4.6-4.9, 12.27, 12.31 EAST organization (water, agriculture and health in WHO statistical information system (WHOSIS), the tropics), 12.5 4.9 Eastern Mediterranean Region, 21.1-21.29, Annex 2 Epilepsy, 11.18, 11.19 see also individual activities Equipment management, 5.7-5.10 ECA, see Economic Commission for Africa Eritrea, 2.29 Economic Commission for Africa, 2.17 ESCAP, see Economic and Social Commission for Economic Commission for Europe, 2.17 Asia and the Pacific Economic Commission for Latin America and the Essential drugs, see Drugs Caribbean, 2.17 Essential drugs monitor, 13.32 Economic development, health aspects, 3.8-3.10 Estonia, 10.11 Economic and Social Commission for Asia and the Ethiopia, 2.29, 12.28, 14.19, 14.45, 14.91, 14.153 Pacific, 2.17, 13.41 European Bank for Reconstruction and Develop- Economic and Social Commission for West ern Asia, ment, 2.19 2.17 European Communities (Commission), 2.23, 3.6, Economic and Social Council of the United Nations, 5.19, 10.17, 10.45, 10.55, 12.18, 13.34, 14.37, 2.12-2-16, 9.53, 14.116, 14.117 14.66, 20.7, 20.13 Commission on Sustainable Development, 2.12 Treaty on European Union, 20.1 Ecuador, 9.6 · European cooperative health programme (EURO- Edna McConnell Clark Foundation, 14.165 HEALTH), 20.16 Education, see Health education; Medical education European Dialogue on Training in Public Health, 6.25 Egypt, 2.31, 5.8, 5.11, 5.17, 6.16, 6.22, 9.17, 10.21, 11.7, European Federation of Neurological Societies, 11.3 11.10, 12.10, 13.2, 13.36, 14.52, 14.80, 14.91, 14.143, 21.5, 21.6 European Forum of National Medical Associations El Salvador, 18.17 and WHO, 20.9 Elderly, health of, 9.37, 10.51-10.57, 14.171, 19.12, European Forum of Pharmaceutical Associations and 21.14 WH0,20.9 international research programme, 10.51 European Medical Research Council, 4.22, 8.11 Emergency relief and supplies, 2.15, 2.22, 2.28-2.33, European Network of Health-promoting Schools, 9.10, 11.7, 16.16, 16.18, 16.22, 17.5, 18.17, 20.6, 7.7, 20.7 21.6, 21.25 European Region, 20.1-20.17, Annex 2 international decade, natural disasters, 2.31, 18.17 see also individual activities Encephalitis, Japanese, 14.145, 14.159,19.28 European Union, see European Communities (Com­ Environment and development, United Nations con­ mission) ference (1992), 2.11, 7.2, 12.1-12.3, 12.18, 12.19, Evaluation and monitoring of programmes, see under 15.10, 18.15, 22.12 Health for all by the year 2000 and Health situa­ Agenda 21, 2.11, 2.12, 12.1, 12.2 tion and trend assessment

174 INDEX

Executive Board, 1.1, 1.4, 2.4, 16.8 food aid programmes, 9.10 Committee to Consider Certain Financial Matters, food safety, 12.21,14.108-14.111, 19.16, 21.21 16.9 international conference (1992), 7.2, 7.10, 9.9, 9.14, membership, 2.2 17.8 Programme Committee, 1.1, 1.4, 2.4, 16.8 international decade, Africa, 17.8 sessions, Annex 3 world declaration and plan of action, 9.14 resolutions, 1.1, 1.4, 2.19, 16.8 see also Micronutrient deficiencies working group, WHO response to global change, Food and Agriculture Organization of the United 1.1, 2.5 Nations (FAO), 9.13, 9.14, 9.20, 10.3, 12.6, 12.7, Ex libris, 15.7 12.18, 12.21, 14.38, 14.40, 14.44, 14.107, 17.11 Expanded Programme on Immunization, see Immu­ Foundation for Advanced Studies on International nization Development, 14.172 Expert advisory panels (WHO), 8.6 Foundation for Health Services Research, 4.21 Expert committees (WHO), France, 8.7, 9.35 alcohol- and drug-related problems in the work- French Red Cross, 13.4 place, 11.1 0 anthropometry, 9.15 cardiovascular diseases, 14.207 drug dependence, 11.14 Gambia, 10.8, 14.57, 14.58, 14.91, 14.156, 14.187, essential drugs, 13.18 14.193 filariasis, 14.28 General Agreement on Tariffs and Trade (GATT), health promotion in the workplace, 10.49 9.11 information systems, district level, 4.5 General Programme of Work of WHO, maternal and child health and family planning, 10.2 eighth, 16.8, 16.11 onchocerciasis, 14.31 ninth, 1.1, 2.4, 9.1, 18.1 schistosomiasis, 14.2 4 Genetics, 14.216, 14.219, 14.189-14-190, 14.191, Eye diseases, see Blindness prevention 14.192 Geriatrics and gerontology, see Elderly, health of German Foundation for International Development, 13.20, 13.21 German Technical Cooperation Agency (GTZ), 5.7, Family Care International, 10.9 5.8, 5.16, 5.19 Family Health International, 10.9 Germany, 13.12, 13.21, 14.202 Family planning, 9.4, 10.1-10.13, 10.32-10.33, 17.10, Ghana, 4.24, 5.1, 5.6, 12.14, 13.41, 14.22, 14.62, 14.70, 19.11, 21.13 14.203, 17.6, 17.15 see also Fertility regulation Global change, WHO response to, 1.1, 2.5 FAO, see Food and Agricultural Organization of the Global environmental epidemiology network, 12.27 United Nations Global Environmental Monitoring System (GEMS), Fellowships, 6.24, 7.12, 14.141,14.196 9.13 Fertility regulation, 10.25-10.30, 10.35 Global Policy Council (WHO), 2.5 contraceptives, 10.4, 10.13, 10.20-10.24, 10.35 Governing bodies, see Executive Board; Regional emergency contraception, 10.24 committees; World Health Assembly human reproduction research, 4.24, 10.19-10-41 Grants, research training, 6.24, 8.10, 8.13, 10.39, 14.71 infertility, 10.31, 10.38 GTZ, see German Technical Cooperation Agency intrauterine devices, 10.22-10.23 Guatemala, 4.16, 9.6, 9.18, 12.11, 14.62, 14.91 natural methods, 10.29-10.30 Guidelines for drinking-water quality, 12.28 regulation of male fertility, 10.25-10.26 Guinea, 3.9, 7.13, 13.28, 14.96 resources for research, 10.36-10.41 Guinea-Bissau, 3.9, 4.3, 4.12 social science research, 10.35 Guinea-worm disease, see Dracunculiasis technology transfer, 10.32-10.34 Guyana, 4.6 vaccine development, 10.27-10.28 Fiji, 4.3, 6.23, 11.17 Filariasis, 14.28-14.29, 19.23 research, 14.60, 14.70 see also Onchocerciasis Haemoglobinopathies, 14.216, 14.217, 14.218 Finnish International Development Agency Haemophilia, 14.216, 14.218 (FINNIDA), 2.26, 13.4 Haemorrhagic fevers, viral, 14.143 Finnish Red Cross, 13.4 see also Dengue and dengue haemorrhagic fever Fluoridation of milk, 9.27 Haiti, 5.12, 14.135, 18.17 Fometro, 14.41 Health education, 7.5-7.13, 14.130, 14.203, 19.8, 21.8 Food and nutrition, 2.22, 9.9-9.20, 14.80, 14.92, environmental health and sanitation, 12.4, 12.5, 14.184, 14.201, 17.2, 17.9, 21.9 12.8, 12.11

11S THE WORK OF WHO 1992-1993

Health for all by the year 2000, 3.1-3.10, 20.8, 20.9 Hospitals, 5.5, 5.19-5.21, 13.1, 13.2, 17.5 economic development and, 3.8-3.10 baby-friendly initiative, 9.17, 21.13 monitoring and evaluation, 3.1-3.3, 4.1, 19.2 core library for doctors, 5.20 see also Primary health care waste management, 12.17 Health information support, 4.9, 15.1-15.16, 17.6 Housing, 12.14-12.15 see also Health literature services; Information sys­ Human immunodeficiency virus (HIV), see AIDS tems; Publications Human reproduction research, 4.24, 10.19-10.41 Health laboratory technology, 13.3-13.5 Human resources for health, 6.1-6.27, 19.7, 21.7, 22.3 Health legislation, 4.25-4.29, 21.6 continuing education, 6.14 documentation system, Latin America and the Car­ management, 6.3-6.4, 6.11-6.13 ibbean (LEYES), 4.26 network of community-oriented educational insti- Health literature services, 15.1-15.9 tutions, 4.22 Africa (library digest, Index Medicus), 15.4 planning tools, 6.5-6.7 policy analysis, 6.3-6.4 Eastern Mediterranean (ExtraMED), 15.8, 21.23 see also Fellowships; Grants; Medical education; Latin America and the Caribbean (LILACS, Teaching/learning materials and the various BIREME), 15.2, 15.5 categories of health personnel medical literature retrieval system (MEDLINE), Human rights, 4.29, 9.3, 9.5 15.9 United Nations centre, 4.29 South-East Asia (HELLIS, Index Medicus), 15.6 United Nations conference (1993), 7.10 WHO database (WHOLIS), 15.2 Humanitarian assistance, 2.15, 2.22, 2.25, 2.28, 2.30, Health promotion, 2.31, 2.33, 20.6 Eastern Mediterranean, 21.5 Hungary, 14.202, 14.203 Europe, 7.7 Hypercholesterolaemia, 14.219 Latin America and the Caribbean, 18.5 Hypertension, 14.215 Western Pacific, 22.11 Health policy, 3.4-3.7, 3.9, 3.10 Health research, see Research Health services journal, 8.12 IAEA, see International Atomic Energy Agency Health situation and trend assessment, 4.1-4.2 IARC, see International Agency for Research on Can­ Health systems/services, cer based on primary health care, 5.1-5.21, 21.3, 22.2 IARC Monographs, 14.195 community participation, 5.11, 5.18 Ibero-American conferences of Heads of State and costs and financing, 3.8, 3.9, 5.1-5.3, 17.4, 20.4, Government, 3.4, 18.7 20.12, 20.14, 21.2 ICAO, see International Civil Aviation Organization development, 4.1-4.29 ICD, see International Classification of Diseases district and peripheral levels, 5.11-5.18 ILO, see International Labour Organisation Ain Shams project, 5.11 Immunization, 2.25, 14.1-14.14, 14.86, 14.174, 16.19, European project on health care reform (EURO- 17.13, 18.10, 19.21, 19.28, 22.4 CARE), 20.14 see also individual diseases European "regions for health" network, 3.7, 20.10 IMPACT (international initiative against avoidable management, 4.2, 5.7-5.10 disability), 13.36 national health systems and policies, 5.1-5.10, 21.3 Index Medicus, 15.4, 15.6, 17.6 organizational change, 5.4-5.6 India, 3.5, 4.3, 4.24, 4.25, 5.17, 6.21, 7.8, 9.37, 9.43, research, 4.20-4.24, 6.25, 21.4 10.41, 11.7, 13.36, 14.15, 14.22, 14.35, 14.42, structural aspects, 5.14 14.51, 14.61, 14.65, 14.89, 14.96, 14.106, 14.120, see also Primary health care 14.129, 14.165, 14.168, 14.172, 14.181, 14.203, Health Volunteers Overseas, 13.1 15.12, 16.20, 19.4, 19.13, 19.14, 19.15, 19.16, Healthy cities and villages, 5.15-5.16, 9.7, 12.14, 12.15, 19.23,19.24 12.16, 17.12, 20.10, 21.20, 22.12 Indonesia, 4.24, 5.17, 5.19, 6.4, 10.10, 10.16, 10.17, Hearing impairment, 14.172 10.25, 10.33, 14.42, 14.51, 14.81, 14.106, 19.3, 19.4, 19.6, 19.15, 19.16, 19.23 Hedip forum, 2.33 Industrial health, see Occupational health Helminth infections, 9.10 Industry Council for Development, 9.12 Hepatitis, viral, 14.4, 14.141, 14.161, 14.187, 14.193, Infectious diseases, rapid diagnosis, 14.151 19.28, 22.6 Infertility, 10.31, 10.38, 17.10 Hereditary diseases, 14.216-14.219 Influenza, 14.140 HFA 2000,7.10 Information systems, 2.9, 4.4, 6.11, 6.16, 12.23, 14.12, HIV infection, see AIDS 14.150, 14.153, 20.7 Honduras, 10.9, 14.33, 14.120 computer software (WHONET), 14.150 Hong Kong, 6.5 "European Nervous System", 20.7

176 INDEX

Information systems (continued) International Federation of Pharmaceutical Manufac­ health sciences information, Latin America and the turers Associations, 13.14, 13.20, 14.136 Caribbean, 15.2, 15.5 International Federation of Red Cross and Red Cres­ WHO statistics (WHOSIS), 4.9 cent Societies, 2.25 WHO terminology (WHOTERM), 15.14 International Fibre Safety Group, 10.45 Injury prevention, 9.5, 9.32-9.39, 11.10, 12.31, 21.11 International Forum for Social Sciences in Health, Intensified cooperation with countries and peoples in 4.22 greatest need, 2.26, 3.8, 4.3, 4.11-4.17, 5.3, 6.4, International Health Policy Programme, 4.24 12.11, 17.8, 19.3 International Hospital Federation, 5.10 lnteragency Steering Committee for Water Supply International Labour Organisation (ILO), 5.1, 10.3, and Sanitation, 12.13 10.42, 10.44, 10.47, 10.48, 11.10, 12.18, 12.19, lnter-American Center for Social Security Studies, 13.41 5.18 International League of Associations for Rheumatol- Inter-American Development Bank, 2.19 ogy, 14.213 Intergovernmental Oceanographic Commission, International Leprosy Association, 13.38 17.11 International Life Sciences Institute, 9.12 Intergovernmental organizations, Annex 4 International Monetary Fund, 2.19 see also Coordination and collaboration and indi­ International Office of Epizootics, 14.107 vidual organizations International Olympic Committee, 9.48, 14.206 Intergovernmental Panel on Climate Change, 12.27 International Pharmaceutical Federation, 13.19 International Agency for Research on Cancer International Planned Parenthood Federation, 10.18 (IARC), 2.5, 12.27, 14.182-14.196 International Programme on Chemical Safety, 10.46, International Alliance of Women, 2.5 12.18-12.24 International Association of Lions Clubs, 14.164, International Project Assistance Services, 10.9 14.168 International Society for Burn Injuries, 9.37 International Association for the Study of Pain, International Society and Federation of Cardiology, 14.179 14.197,14.202 International Atomic Energy Agency (IAEA), 9.13, International Society of Orthopaedic Surgery and 13.6, 13.7, 14.177, 17.11 Traumatology, 13.1 International Children's Centre, .1 0.8 International Society of Prosthetics and Orthotics, International Civil Aviation Organization (ICAO), 2.25 9.52 International Society on Quality Assurance, 5.21 International Classification of Diseases (ICD), 4.10, International Society of Surgery, 13.1 11.5, 11.6, 11.14 International Statistical Institute, 4.10 application to dentistry and stomatology, 9.29 International Union of Architects, 5.10 International Classification of Impairments, Disabili­ International Union against Cancer, 9.45 ties and Handicaps, 4.10 International Year of the Family, 2.15, 11.9 International Code of Marketing of Breast-milk Sub­ International Youth Foundation, 10.15 stitutes, 4.28, 9.18 Internet, international computer network, 4.9 International Commission on Occupational Health, Intestinal parasitic infections, 14.153 10.49 Investing in health, International Committee of the Red Cross, 2.25, 2.33 Riga statement, 20.12 International Confederation of Midwives, 10.6 women's health, 9.7 International Consultative Group on Food Irradia- Iodine deficiency disorders, 9.19, 17.9, 21.9 tion, 9.13 IPCS, see International Programme on Chemical International Council for Education of the Visually Safety Handicapped, 14.164 IPCS news, 12.24 International Decade on Food and Nutrition for Afri­ Iran, Islamic Republic of, 2.31, 5.19, 12.14, 13.36, ca, 17.8 14.23, 14.52, 14.68, 15.8 International Decade for Natural Disaster Reduction, Iraq, 2.31, 9.18, 16.16 2.31, 18.17 Islamic Educational, Scientific and Cultural Organi- International Development Research Centre (Cana- zation, 21.8 da), 3.10, 4.21, 4.23, 14.26 Israel, 10.54 International Diabetes Federation, 14.209 Italy, 10.9, 10.54, 13.12, 13.21, 14.25, 14.202 International digest of health legislation, 4.26 lvermectin, 14.29, 14.30, 14.31, 14.60, 14.62, 14.164 International Drinking Water Supply and Sanitation Decade, 17.11 International Federation of Anti-Leprosy Associa­ tions, 14.50 Jamaica, 9.6, 10.33, 10.54 International Federation for Medical and Biological Japan, 6.3, 6.5, 12.16, 13.19 Engineering, 5.8 Japanese encephalitis, 14.145, 14.159,19.28

177 THE WORK OF WHO 1992-1993

JohannJacobs Foundation, 11.1 Management Development Committee (WHO), 2.5 Joint Committee on Health Policy, UNICEF/WHO, Manpower, see Human resources for health 2.18 Marshall Islands, 4.3 Joint Committee on the Health of Seafarers, ILO/ Maternal and child health, 9.4, 10.1-10.13, 17.10, WHO, 10.44 19.11, 21.13 Joint Committee on Occupational Health, ILO/ Maternal mortality, 10.38 WHO, 1Q.42 Mauritania, 14.45 Joint Expert Committee on Food Additives, FAO/ Mauritius, 13.37, 14.153, 14.215 WHO, 12.21 Measles, 14.1, 14.5, 14.7, 14.8, 14.14, 14.86, 14.92, Joint Meetings on Pesticide Residues, FAO/WHO, 14.151, 14.160, 17.13, 18.10, 19.21, 22.4 12.21 Medecins sans Frontieres, 14.41 Jordan, 5.8, 9.17, 21.5 Medical education, 2.25, 6.14, 6.17-6.25, 9.30, 11.7, 13.2, 14.74, 17.17, 22.3 Meetings, see individual topics Member States, 2.1, 20.1, Annexes 1 and 2 Kazakhstan, 5.1 assessments, 1.5 Kellogg Foundation, 6.12, 10.9, 10.14, 10.15 contributions, incentive scheme, 1.5 Kenya, 4.24, 5.1, 5.4, 5.8, 7.12, 14.10, 14.24, 14.45, voting privileges and services, suspension, 2.2 14.48, 14.59, 14.84, 14.131, 14.144, 14.165 Meningitis, 14.91, 14.147, 14.156, 16.18, 17.16 Kiribati, 10.7 Mental health, 11.1-11.22, 21.15 Kyrgyzstan, 5.1 see also Alcohol abuse; Drugs, abuse Merck & Co. (USA), 14.30 Mexico, 2.9, 8.9, 9.42, 10.33, 11.10, 14.129,14.153 Micronesia, Federated States of, 4.3 Laboratory technology and blood safety, 13.3-13.5, Micronutrient deficiencies, 9.19, 17.9, 21.9, 22.6 14.151, 19.17, 21.17 Midwifery, see Nursing and midwifery La Leche League International, 2.25 Mifepristone, 10.24 Lao People's Democratic Republic, 4.12, 9.25, 22.5 Milk fluoridation, 9.27 Lassa fever, 14.143 Ministers of Health of Non-Aligned and Other De­ Latin America, 2.17, 3.9, 4.26, 8.9, 10.32, 18.5, 18.15 veloping Countries, 4.18 Latin American and Caribbean Center on Health Sci- Mongolia, 3.5, 4.11, 5.6, 5.19, 9.43, 13.28, 13.38, ences Information (BIREME), 15.2, 15.5 14.141, 19.3, 19.6, 19.28 Latin American Committee against Tobacco Use, 9.42 Morocco, 4.21, 9.18, 10.17, 14.24, 14.170 Latin American Parliament (PARLATINO), 18.8 Mozambique, 2.26, 2.29, 4.11, 4.15, 12.11, 13.2, 14.99, Laureate Foundation, 11.1 17.6 Learning materials, see Teaching/learning materials Myanmar, 4.24, 5.19, 6.21, 14.42, 14.51, 14.141, Lebanon, 9.17, 13.36 14.153, 19.3, 19.6, 19.13, 19.19, 19.23,19.28 Legionellosis (Legionnaires' disease), 14.148 Leishmaniases, 14.34-14.36, 14.48, 19.23, 21.25 research 14.68-14.69, 14.71 Leprosy, 14.49-14.55, 17.16, 19.27, 22.7 research, 4.24, 14.55, 14.65 Namibia, 4.21, 5.6, 6.12, 7.12, 11.10,14.19 Lesotho, 10.8 Nepal, 3.5, 3.9, 4.13, 5.18, 6.4, 9.43, 10.10, 13.28, Libraries, see Health literature services 14.106, 19.3, 19.4, 19.6, 19.14, 19.23, 19.24,19.28 Netherlands, 2.26, 4.24, 5.21, 9.18, 10.9, 13.24, 14.41 Network of Community-oriented Educational Insti- tutions for Health Sciences, 4.22 Macao, 22.1 Neurological disorders, see Mental health MacArthur Foundation, 10.54 Neuropathy, 18.14 Madagascar, 4.21, 14.19, 14.51 Nicaragua, 10.9, 12.27 Malaria, 2.14, 9.10, 14.15-14.21, 14.44, 14.45, 14.46, Niger, 13.2 14.48, 14.90, 14.92, 17.14, 19.22, 21.25, 22.8 Nigeria, 4.21, 4.24, 5.11, 5.14, 5.16, 9.28, 10.16, 10.53, ministerial conference (1992), 7.2, 7.10, 14.16, 17.14 11.8, 11.16, 12.16, 14.22, 14.51, 14.52, 14.64, research, 14.20, 14.57-14.58, 14.70, 14.71 14.70, 14.102, 14.143, 17.15 Malawi, 3.9, 6.20, 14.94, 14.99, 14.100, 17.6 Noncommunicable diseases, 9.20, 17.2 Malaysia, 5.13, 15.9, 22.12 country-wide intervention programme (CINDI), Maldives, 4.3, 6.21, 13.28, 14.153, 19.3, 19.6, 19.14, 14.215,20.9 19.23 integrated programme (INTERHEALTH), 14.215 Mali, 3.9, 13.6, 14.24, 14.165 see also individual diseases Malnutrition, see Food and nutrition N ongovernmental organizations in official relations Malta, 10.53 with WHO, 2.25, Annex 4

178 INDEX

North American Free Trade Agreement (NAFTA), Periodontal disease, 9.23 18.6 Pertussis, 14.1, 14.5, 14.86, 22.4 Norway, 9.7, 11.8,14.156 Peru, 10.9, 10.33, 10.39, 16.19,18.10 Norwegian Agency for International Development Pesticides, see Vector control (NORAD), 5.4, 5.7, 6.12 Pharmaceuticals, see Drugs Nosocomial infections, 14.150 Philippines, 4.21, 5.13, 5.17, 9.17, 10.7, 10.16, 11.7, Nursing and midwifery, 4.24, 6.11, 6.12, 6.15-6.16, 12.30, 14.59, 14.89, 14.91, 15.9, 22.5, 22.6, 22.12 9.39, 10.6, 14.131, 17.17, 20.15 Physical resources for health, management, 5.7-5.10 Nutrition, see Food and nutrition Plague, 14.146, 17.16,19.28 Pneumococcosis, 14.157 Pneumoconiosis, 10.47 Pneumonia, 14.83, 14.86, 14.90, 14.91, 14.92 OAU, see Organization of African Unity Poison Information Monographs, 12.23 Occupational health, 7.8, 10.42-10.50, 14.183, 14.195 Poland, 11.10 Occupied Arab territories, 2.31 Poliomyelitis, 13.1, 13.39, 17.13, 18.10, 19.21, 21.25, OECD, see Organisation for Economic Co-operation 22.4, 22.5 and Development immunization and vaccine development, 14.1, 14.5, OIE, see International Office of Epizootics 14.6, 14.7, 14.11, 14.14,14.162 Oman, 2.9, 7.12, 12.10, 14.153 Pollution, see Environmental pollution Onchocerciasis, 14.30-14.31, 14.164 Population, health and development, 2.21, 2.26 research, 14.30, 14.60-14.64, 14.70 Population Council, 10.9 Oncology, see Cancer Portugal, 11.8 Operation Salam for humanitarian assistance to Af- Preferential Trade Area of Eastern and Southern ghanistan, 16.22 African States, 13.31 Oral health, 9.21-9.31, 12.31, 21.10 Primary health care, 2.29, 5.1-5.21, 22.2, 22.3 Oral rehydration, 14.76, 14.80, 19.24 see also Community health workers; Health for all Orbis International, 14.169 by the year 2000; Health systems/services Organ transplantation, 4.26 Programme budgets (WHO), 2.6-2.8, 16.8-16.14 Organisation for Economic Co-operation and Devel- for 1992-1993, 16.8 opment (OECD), 2.23, 3.6, 12.18 for 1994-1995, 1.4, 1.5, 16.8 Organization of African Unity (OAU), 2.22, 14.40 Programme Committee of the Executive Board, 1.1, Organization of American States, 4.9, 18.17 1.4, 2.4, 16.8 Organizational and related meetings, Annex 3 Programme of WHO, development and management, Organizational structure of WHO, Annex 5 2.1-2.33 Orthopaedics, 13.1 see also General Programme of Work of WHO Osteoarthritis, 14.211 Prosthetic and orthotic services, 13.40 Osteoporosis, 10.51, 10.52, 14.213 Psychosocial and behavioural problems, see Mental health Public health training and research, 6.25 Public information, 7.1-7.4, 7.9, 7.10 Paediatrics, see Children see also Health education P AHO, see Pan American Health Organization Publications (WHO), 14.195,15.10-15.13 Pakistan, 4.3, 4.25, 6.16, 12.14, 14.22, 14.80, 14.91 distribution and sales, 15.15-15.16 Palestine, 21.1 listing of publications and documents Pan American Health Organization (PAHO), 2.9, (WHODOC), 15.2 9.42, 9.51, 10.15, 10.18, 14.30, 16.19, 18.1, 18.2, Puebla Group, 4.21 18.5, 18.14, 18.16, 18.17 Puerto Rico, 18.3 Directing Council, 3.4, 18.3, 18.4 Pulmonary diseases, chronic, 14.214 see also Americas, Region of the Pan American Sanitary Bureau, see Regional Office for the Americas Panama, 9.6, 10.39,11.17 Qatar, 21.6 Panel of Experts on Environmental Management for Vector Control (PEEM), 12.6 Papua New Guinea, 6.16, 7.12, 10.7, 10.13, 14.51, 14.89, 14.91 Rabies, 14.102-14.106, 14.113, 19.28 Paraguay, 14.33, 14.67 Radiation accidents and radiological emergenCles, Parasitic diseases, 14.153, 17.2, 19.23 11.20, 12.31 see also Tropical diseases; Vector control and indi­ emergency network (REMPAN), 12.31 vidual diseases see also Chernobyl accident Pelvic inflammatory disease, 10.23 Radiation medicine, 12.27, 12.31, 13.6-13.8

179 THE WORK OF WHO 1992-1993

Ravizza Farmaceutici (Italy), 11.1 Sasakawa Foundation, 11.1, 14.50 Refugees and displaced persons, 2.29, 2.32, 2.33, 11.7, Saudi Arabia, 5.21, 12.14 14.45, 17.2, 18.17 Schistosomiasis, 9.10, 12.7, 14.24-14.27, 19.23 Central American programme (PRODERE), 18.17 research, 14.59, 14.70, 14.71 Regional Committee for Africa, 5.5, 8.8, 17.1, 17.5, Schizophrenia, 11.18, 11.19, 11.21 17.11 Scientific groups (WHO): Regional Committee for the Americas, 3.4, 18.3, 18.4 asthma, 14.214 Regional Committee for the Eastern Mediterranean, cardiovascular diseases, 14.204 9.8, 14.113,21.1 hereditary diseases, 14.216 Regional Committee for Europe, 11.10, 20.11, 20.16 Senegal, 5.8, 5.15, 5.18, 9.41, 10.8, 12.14, 14.26, 17.12 Regional Committee for South-East Asia, 19.7, 19.27 Sexually transmitted diseases, 10.31, 14.123-14.127, Regional Committee for the Western Pacific, 9.46, 22.10 22.1, 22.5, 22.10, 22.11 see also AIDS and individual diseases Regional committees, 1.4, 16.8 Seychelles, 2.9, 6.10, 14.153 sessions, Annex 3 Shigellosis, 14.155 Regional Office for Africa, 16.4, 17.10 SIDA, see Swedish International Development Regional Office for the Americas, 18.1 Authority Regional Office for the Eastern Mediterranean, 16.6, Sierra Leone, 5.8 21.23, 21.28 Skills for life, 11.8 Regional Office for Europe, 2.9, 20.7, 20.17 Sleeping sickness, see African trypanosomiasis Regional Office for South-East Asia, 2.9, 16.5 Slovakia, 2.3 Regional Office for the Western Pacific, 16.7 Smallpox, 14.152, 18.10 Rehabilitation, 2.15, 2.29, 13.35-13.41 Smoking, see Tobacco Rehydration, 14.76, 14.80, 19.24 Solomon Islands, 22.8 Representatives (WHO), 2.33, 6.27 Somalia,2.31, 11.7, 14.19, 16.16,21.5 Research, 8.1-8.14, 19.9 South Asian Association for Regional Cooperation, Advisory committees on health research (ACHR), 10.10 8.2-8.4, 8.9, 8.10, 8.13 South-East Asia Region, 19.1-19.29, Annex 2 Council on Health Research for Development, see also individual activities 4.24, 8.7 Southern Cone, 14.32, 18.5, 18.11 ethical aspects, 8.2, 8.3 common market (MERCOSUR), 18.6 grants, 6.24, 8.10, 8.13, 10.39, 14.71 health initiative, 18.5 networking, 4.21, 4.22 Soviet Union, former, 2.27, 2.30, 14.9, 14.111, 15.7, prizes, 8.8, 20.2 see also Health systems/services, research and indi­ Spain, 10.53, 14.188,14.198 vidual subjects of research Special Programme of Research, Development and Respiratory infections, acute, 10.47, 14.83-14.92, Research Training in Human Reproduction, 14.151, 14.160,19.25 10.19-10.41 Rheumatic diseases, chronic, 14.211-14.213 Special Programme for Research and Training in Rheumatic fever and rheumatic heart disease, 14.149, Tropical Diseases, 14.56-14.71 14.197 Spongiform encephalopathies, 14.110 RhOne-Poulenc (France), 14.41 Sri Lanka, 6.21, 11.10, 14.15, 14.61, 14.106, 14.120, Rift Valley fever, 14.113, 14.143, 21.25 14.177, 19.3, 19.6, 19.13, 19.14, 19.16, 19.19, Road accidents, 9.38, 11.10 19.23,19.28 Rockefeller Foundation, 4.19, 5.7, 10.37, 14.154 Staff of WHO, 6.27, 9.2, 16.1-16.3, 21.28 Romania, 10.11, 14.169 Statistics, see Epidemiology and statistical services Rotary International, 2.25, 14.13 Sterility, see Infertility Rural development and housing, 12.14-12.17 Streptococcal infections, 14.149 Russian Federation, 4.25, 9.17, 10.11, 12.31, 14.9, Structure of WHO, Annex 5 14.175, 14.203 Study groups (WHO): Rwanda, 14.19, 14.45, 14.131,14.133 aging and working capacity, 10.49 cardiovascular diseases in the elderly, 14.205 diabetes, 14.208 foodborne trematode infections, 14.27 Safe motherhood, 10.5-10.6, 10.8, 10.12, 17.10, 21.13 osteoporotic fracture risk, 14.213 initiative, 10.10 vector control, 14.46 Saint Kitts and Nevis, 6.5 Substance abuse, 11.11, 11.12, 11.22 Saint Lucia, 6.5 see also Drugs, abuse Salmonellosis, 14.108-14.109 Sudan, 6.22, 13.2, 14.40, 14.48, 14.51, 14.59, 14.170, Samoa, 4.3 21.5 Sanitation, see Water Supply and Sanitation Support services (WHO), 16.1-16.23

180 INDEX

Supportive environments for health, 7.5, 12.15 Turkey, 14.105 Surgery, 13.1, 13.2 Tuvalu, 10.13, 22.1 computerized registration system (WHOCARE), 14.150 Sustainable development, 2.11, 2.12 Swaziland, 14.89 Uganda, 4.24, 5.4, 7.13, 14.38, 14.40, 14.41, 14.48, Sweden, 2.26, 9.7, 12.19, 14.109,14.202 14.66, 14.118, 14.131, 14.133, 14.135 Swedish International Development Authority Ukraine, 2.3, 12.31, 14.9 (SIDA), 9.18 UNDCP, see United Nations International Drug Switzerland, 4.10, 10.16, 14.177, 14.202 Control Programme Syphilis, 14.127 UNDP, see United Nations Development Pro­ Syrian Arab Republic, 2.9, 5.8, 6.22, 9.18, 9.28, 21.6 gramme UNEP, see United Nations Environment Programme UNESCO, see United Nations Educational, Scientific and Cultural Organization UNFPA, see United Nations Population Fund Tajikistan, 2.30, 20.6 UNHCR, see United Nations High Commissioner Tanzania, see United Republic of Tanzania for Refugees Teaching/learning materials, 5.13, 6.26, 12.24, 14.21, UNICEF, see United Nations Children's Fund 14.38, 14.84, 14.209, 17.16, 20.15, 21.7 UNIDO, see United Nations Industrial Development Technical cooperation among developing countries Organization (TCDC), 4.18-4.19 United Arab Emirates, 2.9 United Nations committee, 4.19 United Kingdom of Great Britain and Northern Ire­ UNDP special unit, 4.19 land, 13.24, 14.90, 14.110, 20.8 Technical Discussions, Overseas Development Administration, 5.7 Health Assembly, 1.2, 9.34 United Nations, 2.15, 2.16, 9.54, 13.41, 14.126, 14.137 regional committees, 5.5, 6.3, 21.1 General Assembly resolutions, 2.12, 2.16 Technology development, assessment and transfer, statistical activities, 4.9, 4.10, 13.41 8.9, 13.9 see also Coordination and collaboration, individual Terminology, WHO information system organizations and bodies (WHOTERM), 15.14 United Nations Centre for Human Rights, 4.29 Tetanus, 14.1, 14.3, 14.5, 14.7, 14.14, 14.162, 17.13, United Nations Centre for Human Settlements 18.10, 19.21, 19.28 (UNCHS), 12.6 Thailand, 3.5, 4.21, 5.3, 5.17, 6.8, 9.28, 9.43, 10.16, United Nations Children's Fund (UNICEF), 3.3, 10.33, 10.54, 11.8, 11.13, 14.15, 14.20, 14.42, 4.7, 5.8, 6.19, 7.7, 9.16, 9.17, 10.6, 10.7, 10.8, 10.9, 14.55, 14.84, 14.91, 14.131, 14.133, 14.135, 14.159, 10.14, 11.1, 11.8, 12.3, 12.4, 12.5, 13.41, 14.13, 14.168, 14.172, 14.187, 19.3, 19.4, 19.13, 19.15, 14.23, 14.78, 14.87, 14.92, 14.117, 14.118, 14.138, 19.16, 19.23, 19.24,19.28 14.154, 17.10, 19.11, 20.16, 21.8 Tobacco, 2.14, 4.26, 9.40-9.54, 10.47, 14.174, 20.11, United Nations Decade of Disabled Persons, 13.35 21.12 United Nations Development Programme (UNDP), European action plan, 20.11 2.20, 4.19, 6.19, 10.6, 10.10, 10.19, 12.2, 13.41, Latin American committee, 9.42 14.13, 14.23, 14.56, 14.117, 14.118, 14.154,19.11 world no-tobacco days, 7.3, 9.47 United Nations Educational, Scientific and Cultural Tobacco alert, 9.47 Organization (UNESCO), 4.29, 6.19, 7.7, 10.3, Togo, 4.3, 5.8, 14.51 10.7, 12.5, 12.25, 13.41, 14.117, 14.118, 17.11,21.8 Tonga, 4.3 United Nations Environment Programme (UNEP), Toxicology, see Chemical safety; Drugs 7.5, 9.13, 12.6, 12.16, 12.18, 12.19, 12.25, 12.26, Traditional birth attendants, 10.6 12.27, 17.11 Traditional medicine, 5.18, 13.25, 19.20 United Nations General Assembly, 2.12, 2.16, 14.116 Trinidad and Tobago, 9.6 United Nations High Commissioner for Refugees, Tropical diseases, Office of the (UNHCR), 2.29, 2.30, 2.32, 13.41 control, 14.15-14.42 United Nations High-Level Committee on the Re­ research and training, 14.56-14.71 view ofTechnical Cooperation Among Develop­ see also Vector control and individual diseases ing Countries, 4.19 Trypanosomiasis, see African Trypanosomiasis; United Nations Industrial Development Organiza­ American trypanosomiasis tion (UNIDO), 5.8, 12.18, 13.7, 13.25 Tuberculosis, 14.1, 14.93-14.101, 14.131, 14.135, United Nations International Drug Control Pro­ 14.158, 19.26, 22.4, 22.9 gramme (UNDCP), 11.10, 11.16, 13.21 research, 4.24 United Nations Population Fund (UNFPA), 2.21, Tunisia, 5.8, 6.22, 10.17, 10.33, 12.10, 12.14, 13.21, 9.4, 10.3, 10.6, 10.9, 10.14, 10.15, 10.16, 10.19, 14.34, 14.170,21.6 14.117, 14.118, 17.10,19.11

181 THE WORK OF WHO 1992-1993

United Nations Relief and Works Agency for Pales­ WFP, see World Food Programme tine Refugees in the Near East (UNRWA), 12.3, WHO drug information, 13.11, 15.11 21.6 WHO pharmaceuticals newsletter, 13.11 United Nations Research Institute for Social Devel­ WHO Representatives, 2.33, 6.27 opment, 8.4 WHO staff development, 6.27 United Republic of Tanzania, 4.22, 6.12, 9.18, 10.8, Women, health and development, 1.2, 1.3, 2.25, 9.1- 13.6, 14.24, 14.57, 14.61, 14.99, 14.100, 14.120, 9.8, 11.8, 14.56, 21.1, 21.8 14.135, 14.153, 17.6 see also Family planning; Maternal and child health United States of America, 5.8, 5.17, 6.21, 9.35, 9.36, Workers' health, see Occupational health 9.38, 9.42, 9.51, 10.9, 10.20, 10.22, 10.51, 10.53, World AIDS Day, 7.3, 14.139 10.56, 11.1, 11.17, 13.5, 14.66, 14.68. 14.143, World Alliance for Breastfeeding Action, 9.16 14.199, 14.202,14.214 World Assembly of Youth, 10.16 Agency for International Development (USAID), World Bank, 2.19, 2.26, 3.10, 4.3, 4.9, 4.14, 5.3, 5.6, 5.21, 9.17, 14.26 5.16, 6.4, 6.5, 6.19, 7.5, 10.19, 11.1, 11.9, 12.4, UNRWA, see United Nations Relief and Works 13.34, 14.13, 14.56, 14.96, 14.117, 14.118, 14.154, Agency for Palestine Refugees in the Near East 14.168, 14.176,19.26 Upjohn Company (USA), 11.1 World development report 1993, 4.9 Urban development and housing, 12.14-12.17 World Conservation Union, 13.25 see also Healthy cities World Diabetes Day, 14.208 Uruguay, 14.67 World Federation for Medical Education, 6.14, 6.19 USAID, see under United States of America World Federation of Proprietary Medicine Manufac- Uzbekistan, 5.1 turers, 13.20 World Food Programme (WFP), 9.10 World health, 13.32, 14.101,15.11 World Health Assembly, 1.2, 1.4, 1.5, 2.19, 3.1, 7.10, Vaccine research and development, 14.154-14.163 8.1, 10.51, 12.2, 12.31, 16.8, 16.9, 16.10, 16.12 Latin American and Caribbean initiative meetings, Annex 3 (SIREVA), 8.9 resolutions, 1.3, 1.5, 2.7, 2.13, 2.28, 9.5, 9.19, 9.53, see also Children, vaccine initiative; Immunization 9.54, 10.7, 12.14, 12.18, 13.35, 14.14, 14.16, and individual diseases 14.42, 14.50, 14.95, 14.116 Vector control, 10.49, 12.6, 12.7, 12.21, 14.43-14.48 Technical Discussions, 1.2, 9.34 Collaborative International Pesticide Analytical World Health Day, 7.3, 7.10, 9.5, 9.29, 9.35, 14.206 Council, 14.44 World health forum, 15.11 panel of experts (PEEM), 12.6 World health situation, eighth report, 3.1 pesticides evaluation scheme (WHOPES), 14.44 World health statistics annual, 4.1 Venereal diseases, see Sexually transmitted diseases World health statistics quarterly, 4.1, 14.207 Venezuela, 8.9, 11.17, 14.65, 14.68, 14.81, 14.143, World Hypertension League, 14.203 14.194 World Meteorological Organization, 12.27 Veterinary public health, 14.102-14.113 World No-Tobacco Day, 7.3, 9.47 Viet Nam, 5.3, 6.16, 7.12, 9.18, 10.7, 10.13, 12.28, World Organization for Care in the Home and 14.15, 14.51, 14.91, 15.9, 15.13, 22.5, 22.6, 22.8 Hospice, 10.56 Violence, 9.33, 9.35, 9.36, 11.10 World Organization of the Scout Movement, 10.16 against women, 9.5, 9.6 World Psychiatric Association, 11.15 Viral diseases, 14.140-14.149 World Wide Fund for Nature, 13.25 see also individual diseases and viruses Vitamin A deficiency, 9.19, 17.9, 21.9 Voting privileges and services, suspension, 2.2 Yellow fever, 14.4, 14.8, 14.10, 14.144,16.18 Yemen, 2.31, 4.11, 5.8, 6.16, 6.22, 12.11, 14.23, 14.24, Waste disposal and management, see Environmental 14.105, 21.3, 21.6 pollution; Water supply and sanitation Youth and adolescence, 7.6, 7.8, 10.14-10.18, 11.8, Water supply and sanitation, 3.4, 9.10, 12.3-12.13, 21.13 12.25, 12.28, 12.29, 14.24, 17.2, 17.11, 19.14, 21.19 behaviour, narrative research method, 10.16 ACC subcommittee, 12.13 Yugoslavia, former, 2.30, 4.3, 11.7, 13.41, 16.16, 16.21, Africa 2000 programme, 12.12 20.6 collaborative council, 12.8, 12.13 interagency committee, 12.13 international decade, 17.11 Zaire, 14.40 joint monitoring programme, 12.3 Zambia, 2.26, 4.3, 4.11, 4.16, 4.22, 5.6, 5.21, 7.5, 12.11, Weekly epidemiological record, 4.6 14.94, 14.105, 14.131, 14.135, 17.6 Wells tart International, 9.16 Zimbabwe, 4.22, 5.11, 5.17, 10.54, 11.7, 11.8, 12.5, Western Pacific Region, 22.1-22.13, Annex 2 12.7, 13.21, 13.37, 14.96, 14.120, 14.177, 17.6 see also individual activities Zoonoses, 14.102-14.113

182