PART I GENERAL REVIEW OF ACTIVITIES 1. STRENGTHENING OF HEALTH SERVICES
1.1 Planning and Development of Health Services
The interest of governments in planning for health as a component of overall socio-economic development has been maintained, with a growing application of country health programming to the formulation of health plans and projects. The development of integrated rural health services continued to receive attention, with emphasis on primary health care and increased coverage. Ways and means of reaching the rural population, which accounts for approximately 80% of the total, have received the active consideration of governments in those countries which have not yet been able to achieve full coverage. Some of the steps which have been taken to increase coverage include: the establishment of multipurpose health workers schemes; the education of village health workers, selected and supported by the community; the training and utilization of practitioners of traditional systems of medicine; community participation and involvement, and the establishment of new health centres and upgrading of the existing ones. WHO has collaborated in these activities at both national and regional levels.
The Joint WHO/UNICEF Study on Community Participation in Health Services, organized on a global scale, selected three projects in the Region, but the study was conducted in only one project - the Kottar project in Tamil Nadu, India. The findings of this study will be incorporated in the joint WHO-UNICEF report and submitted to the Joint Committee on Health Policy in 1977.
1.1.1 Health Planning, Program Formulation and Evaluation
In collaboration with WHO, more and more countries of the Region are planning their health development programmes through country health programming. Systematic planning and efficient management, combined with the judicious investment of available resources, are being improved.
Following the completion of country health programudng in IVepal and Thailand respectively in 1974 and 1975, the formulation of projects in all priority health sectors was undertaken in the two countries. A similar exercise was completed in 1976 in Bum, where the formulation of projects is now under way.
In Bangladesh, work continued on the development of a planning cell in the Ministry of Health and Family Planning and the building up of a health information system on sound lines.
WHO collaborated with Indonesia's Planning Bureau in reviewing the guidelines used for annual planning, and in formulating the first step of Pelita I11 (Third Five-Year Development Plan). In addition, a systems analyst assisted in the selection of the method for the formulation of the Third Plan, with special reference to the formulation of individual programmes and projects at provincial and SEA/RC29/2 Page 2
central levels and their synchronization with the national framework. An expert in health systems management and an economist have been assisting the Planning Bureau in health centre progradng, annual planning and the improved management of health services.
Nepal also received assistance in the further development of a national health planning unit and in the conduct of a national workshop on health planning for senior health personnel.
In Thailand, following project formulations, the National Five-Year Development Plan for the health sector was prepared and submitted to the National Social and Economic Development Board. Assistance is being given in the planning, management and development of a health information system encompassing three Divisions in the Ministry of Health - Planning, Vital and Health Statistics and Epidemiology. The attempt is not only to introduce modem management methods but to adapt them to the country's administrative structure and social and cultural background. A WHO systems analyst and a management officer from the Swedish International Development Authority (SIDA) also provided assistance.
An inter-country project for the strengthening of health services through training in planning, which helped with the country health programming exercise in Bunna, also assisted with national training courses in health planning and/or management in Indonesia, India and Mongolia. In addition, the team assisted MongoZia with a two-day seminar for senior government officials to familiarize them with the concepts of country health progradng. A medical educator visited Burma, India, Indonesia, Sri Lanka and Thailand and another was assigned to ~on~otiato advise the teaching and training institutions in these countries on developing need-based and effective training courses in health planning and health systems management with a view to strengthening the administration of the health services.
An inter-regional training seminar on health project analysis was organized at the Asian Development Institute, Bangkok, with the support of the WHO team at the Institute. To provide material for courses on health planning, the team also assisted in the preparation of a report on "Assessment of a Least Developed Country's Health Situation - The case of Nepal".
The Charter for Health Development in the countries of the Region, a draft of which was presented to the Twenty-eighth Session of the Regional Committee in August 1975, was revised in order to incorporate the suggestions made at the session. Subsequently, it was sent to governments for comments; so far five countries - Bangladesh, Mongolia, Maldives, Sri Lanka and Thailand - have expressed their agreement to the draft Health Charter.
The Regional Committee at its twenty-eighth session discussed with critical interest the Sixth General Programme of Work of WHO (1978-1983). SEA/RC29/2 Page 3
This discussion led to further elaboration of the Programme in terms of defining regional priorities and targets, approaches and activities as well as output indicators. A medium-term programme is in the process of preparation in the lightof the Sixth General Programme of Work, for implementation during the period 1978-81.
1.1.2 Organization of Basic Health Services
There has been increasing concern over the lack of health coverage for the rural population, and both governments and WHO continued to attach high priority to plans for the organization and development of rural health services and primary health care. A regional plan of action for the development of primary health care was finalized, and the Regional Office participated in the second HeadquartersIRegional Meeting on Primary Health Care, which took place in Manila in March.
The situation in the various countries was as follows:
Assistance continued to be given to Bhutan in the establishment of basic health units and the training of auxiliaries to man these units. The Government also received advice on the role of the health services in nutrition.
In collaboration with WHO, the National Institute of Health Administration and Education in India undertook a study of the problems of implementing the multi-purpose health workers scheme. The study was progressing in the States of Uttar Pradesh, Andhra Pradesh and Maharashtra.
In Indonesia, a three-week seminar was organized on methods of planning and health centre programming at kabupaten (regency) level. 'Itro consultants were provided - one to assist with the child care "package" and in the further development of the manual on "The Child in the Health Centre", and the other to advise on the creation of a nucleus of national expertise to undertake training activities for the establishment of a health care delivery system. Work was initiated on the preparation of another manual (in Indonesian) entitled "Home Care Manual", considered useful for family health work, especially for primary health nurses and less qualified personnel such as village health workers. WHO also assisted in the formulation of a programme for the training of the primary health nurse.
At the Annual National Health Conference, held in Jakarta in January and attended by provincial health officers and the staff of the Ministry of Health, the main points discussed included: the present policy on community health services, including primary health care; the programming of health centre services for the third, fourth and fifth years of the Third Five-Year Development Plan; the training of primary health nurses and sanitarians, and the reorganization of health services at the provincial level. As a follow up of the Conference, further improvements were made in the health centre programme in relation to manpower and financial resources. The research project "Strengthening of Kabupaten Health Services" and the training of village SEA/RC29/2 Page 4
health promoters recorded further progress. Courses in research methods were organized in Jakarta and Surabaya. The Joint WHO/Indonesia Co-ordination Committee met twice during the year - in November 1975 and April 1976 - to review the progress of the three components of the project - health planning and evaluation, research and development and the health care delivery system. The April meeting was preceded by a two-day seminar on primary health care which was attended by representatives of several ministries and international and bilateral agencies.
Health services in the MaZdives received support through the assignment of a team of two consultants - a surgeon and an anaesthetist - twice during the year. Also, a number of short-term consultants were assigned in other special fields described elsewhere in this report. Health centres were opened in a further two atolls during the year, bringing the number of atolls served to 16.
In MongoZia, a plan of operation for the strengthening of emergency health services was finalized in October and one for the management of health services was initiated. The services of a toxicologist were made available. In addition, two public health administrators assisted the national authorities in evaluating the emergency medical care services.
In Nepal, as a follow up of country health programming, a project formulation for basic health services was finalized in January. A preliminary survey of the state of health was made in the mountainous district of Kaski to ascertain the percentage of the population using the services of traditional practitioners and birth attendants, in order to estimate the needs for primary health care services. Also, a proposal was drawn up to train Ayurvedic practitioners to provide selected aspects of basic health services. Assistance was provided to the Institute of Medicine, Tribhuvan University, Kathmandu, in the teaching of anaesthesiology.
In ThdZand, further financial assistance was provided for the development of primary health care through the training of tambon doctors and traditional midwives. In 1975, 320 tambon doctors and 1200 traditional midwives were trained.
1.1.3 Medical Care
Two important meetings took place in this field: an inter-country Seminar on Peripheral Medical Care Services was held in Thailand in September with participants from seven countries of the Region. The other activity, which was also regional in nature, was a Seminar on ways to achieve increased health coverage, which was organized in February in the Regional Office with 16 participants from seven countries.
Bunna and Indonesia received assistance with short training courses for medical record keepers as well as in the establishment of model medical records departments. SEA/RC29/2 Page 5
With WHO assistance, two further national orientation courses for hospital administrators from provincial, base and district hospitals were organized in Sri Laaka in October 1975 and MarchfApril 1976.
The card system for stock-accounting in health institutions was introduced in Nepal.
Electro-medical engineers assisted Nepal and Sri kmka in the repair and maintenance of health equipment. In-service training of national technicians and artisans in the maintenance and repair of such equipment was also undertaken.
1.1.4 Operational Studies
In Indonesia, assistance continued to be given to training courses in operational research and systems analysis. A nuder of case studies on health and health-related management problems is under preparation, to strengthen training in operational research.
1.1.5 Rehabilitation
The inter-country medical rehabilitation project located in Dr Kariyadi Hospital, Semarang, Indonesia, assisted in the organization of a comprehensive rehabilitation programme for the orthopaedically handicapped, for patients with cardiovascular diseases, neurological disorders and for post-mastectomy cases. The Academy of Physiotherapy and the Rehabilitation Centres in Solo and Fatmawati Hospital in Jakarta also received assistance in strengthening their services and training programmes. The team devised a method for surveying disability in a community and, based on the information collected, developed a community-oriented programme for disability prevention and rehabilitation. The protocol developed is being adopted by the Faculty of the Medical School in Denpasar, Bali, for similar rehabilitation activities. The team continued to assist in the development of community-oriented rehabilitation programmes with adequate referral services at the provincial level - a direct result of a national course organized by the team for rehabilitation personnel in Indonesia.
The team also organized a three-week inter-country course, which was held in Semarang, Solo and Jakarta during February-March. The course, which was attended by orthopaedic surgeons, psychiatrists and physiotherapists from six countries of the Region, discussed orientation in community surveys to determine the pattern of disability and morbidity, the development of services employing local resources with community participation, the establishment of comprehensive referral services for larger population groups in the provinces, the organization of training for health and allied personnel, and the planning of services for the prevention of disability.
The services of an expert in occupational therapy were made available to Bum to train personnel and assist in the organization of occupational therapy services in Rangoon. Efforts were made to mobilize SEAIRC2912 Page 6
resources from international and non-governmental agencies for the development of rehabilitation programmes.
In India, a corporation for the manufacture of orthotic and prosthetic components (ALIMCO) went into production in Kanpur. Also, the National Institute for Orthotist and Prosthetist Training (NIPOT) started the training of specialists to meet the manpower requirements of the six regional centres in Jaipur, Lucknow, Madras, Trivandrum, Calcutta and Nagpur. A national workshop is scheduled for July-August 1976 to plan the development of a comprehensive and co-ordinated rehabilitation programme in the country. The School of Physiotherapy in Baroda continued to receive assistance in its training programme.
In Indonesia, in addition to the promotion of programmes in Semarang, Solo and Jakarta, an inter-country team is assisting with the development of rehabilitation services in other provinces. Programmes for the rehabilitation of crippled children will also be promoted.
A team of specialists in physical medicine, orthotics and prosthetics and physiotherapy was assigned to MongoZia to assist in the organization of training and services.
In Sri Lanka, a consultant in physical medicine assisted in the organization of training and rehabilitation facilities in Ragama Hospital and other provincial hospitals. A notable feature of these efforts is the involvement of local expertise and the use of local material in the design of orthotic and prosthetic appliances.
1.2 Family Health
During the period under review, assistance continued to be given to governments in the planning, implementation and evaluation of family health programmes, covering maternal and child health, school health and family planning services. Family health programmes also received support from the United Nations Fund for Population Activities and other United Nations agencies, particularly UNICEF, with all of which WHO worked in close collaboration.
The main thrust in family health in all countries has been in the development of primary care as an integrated package, including nutrition, immunization and health education, and the strengthening of referral services in maternal and child health and family planning in support of the peripheral health services.
The various meetings and educational activities in family health which were organized during the year are described elsewhere in this report (see 7.2, Paediatric Education, and Annex 3).
Progress recorded in different countries is described below, with special reference to the achievement of milestones and evaluation.
In Bangladesh, the WHO medical officer in family health continued to assist the national authorities in planning and implementing the family SEAIRC29 12 Page 7 health programme. The implementation of the programme was somewhat hampered in the latter part of 1975, resulting in modification of the milestones and a shortfall in achievements. By the early part of 1976 more vigorous steps had, hmever, been taken by the Government in the field of family planning. In keeping with national efforts, therefore, the UNFPA project documents were reviewed and the activities were rephased, and, at the time of writing, action for achieving planned targets was progressing satisfactorily. Additional projects for UNFPA support with a view to strengthening the family health programme further were also developed.
In Burma, family health was identified during country health programming as one of the priority health programmes to be carried out during the period 1977-1982. Action was, therefore, initiated for the assignment of a specialist in maternal and child health to assist in the development of the family health programme along the lines of the strategies identified.
Also in Burma, a study on perinatal mortality and low birth-weight was initiated with WHO assistance. The pilot phase of this study, which consists of a community-based investigation of perinatal morbidity and mortality patterns and the incidence of low birth-weight babies, has already begun.
Assistance in the development of health manpower for maternal and child health and school health services was provided by the award of training fellowships in maternal and child health administration, school health and neonatology. The extent of the achievement of targets in this activity can be considered very satisfactory.
Based on the work of a study group convened during 1975, senior educationists who met in the Regional Office in March 1976 framed a new course for the integrated teaching of maternal and child health to medical students. This is being pre-tested during 197611977; at the same time, a manual on maternal and child health is being developed as a companion to the course.
WHO continues to assist India in the development of a training base for the country's medical termination of pregnancy programme. Carried out under an inter-regional project and augmented also by funds at the regional level, this programme is co-ordinated by a WHO consultant, and sixty clinical teachers and ten administrators have completed an international study tour of European and Asian centres. Sixty national training centres in the medical termination of pregnancy have been equipped for teaching these procedures and additional sets of apparatus have been supplied to 65 physicians receiving training under this programme. This programe was also the subject of a workshop held in the Regional Office in July 1975 which brought together representatives of professional bodies and senior health officials.
A consultant was assigned to Indonesia to follow up the further development of school health services and to assist a national workshop SEAfRC29 12 Page 8 supported by WHO. Towards the end of the period under review (June 1976), a meeting on operational research for the delivery of family health services was held in Surabaya, with funds provided by UNFPA.
The long-term WHO staff member in obstetrics and gynaecology who had been assisting MongoZia since 1974 completed his assignment early in 1976; further assistance was provided through a short-term consultant. The plan of operation for the maternal and child health project was finalized and signed by the Government, WHO and UNICEF.
Assistance in the development of health manpower for maternal and child health and school health services was provided through fellowships in maternal and child health administration, school health, mental health and paediatrics. The overall achievements of the project have been satisfactory.
One of the priorities of the Fifth Economic Development Plan in NepaZ for the period 1975-1980 will be the implementation of the country-wide family planning and maternal and child health programme so as to control the increase in the population in order to maintain the balance of economic development.
Among the major health concerns identified during the country health programming exercise were the high mortality and morbidity among infants and preschool children, high fertility, high maternal morbidity and mortality, diarrhoea1 diseases, and protein-calorie deficiency.
After a long period of delay, the UNFPA-funded project to assist the family planning aspects of integrated health services got off the ground in 1975.
The UNFPA-supported family health programme in Sri Lmka continues to record satisfactory progress. An external review of the project was undertaken in October 1975 with assistance from Regional Office and field staff. The Government adopted the review team's recommendations, and appropriate reprogramming embodying these suggestions has been carried out for the remaining two years of the project.
In Thailand, based on the strategies identified during country health progradng in 1975, maternal and child health and family planning activities will be integrated into and carried out through the provincial health care and urban health care programmes during the next Five-Year Plan. UNFPA budgetary constraints posed problems to programme planning and management at the country level. A positive improvement in the health services has, however, resulted from these projects. In Bangkok Metropolis there has been an increase in the number of clinic services and domiciliary visits, improvement in referral services, and an expansion of services for the low-income population, including those in the slum areas. In the four north-eastern provinces improvement in the health services has resulted from increased training of personnel, better supervision, and provision of better supplies and equipment. Births among high-risk women have been prevented as a result of the expanded sterilization programme. SEAIRC2912 Page 9
At the request of the Government to extend the life of the four health- related projects funded by UNFPA through December 1976, the work plans for the projects were revised to modify the targets and, where necessary, to provide additional funds.
At the regional level, the activities of the inter-country Team on Family Health were reviewed and the team was reorganized during the year, in keeping with the technical requirements of the family health programme in the Region. The medical officer of the team has been assisting the national authorities in the various countries in the management and administration of the familv health projects and with the provision of technical advisory services.
1.3 Nursing
All over the world, attention is being given to rural populations, their needs for economic and social development, education and health services. Traditionally, nurses and midwives have comprised the largest category of health workers serving at the periphery, and the increasing attention being paid to the expansion and improvement of services in rural areas has necessitated reappraisal of the functions and responsibilities of nursing personnel. In many instances, national nursing leaders and WHO nurses have participated in planning and implementing major changes in the infrastructure, organization and management of health services, with parallel changes in systems of training. In several countries assistance has been given for the preparation of manuals, guides and teaching aids in support of the new trends.
In Indonesia, large-scale changes are under way for reorganizing the whole nursing system in the country so as to ensure equitable distribution and utilization of adequately trained nursing manpower. A major feature of the first phase of this reorganization, started in 197511976, is the amalgamation of several categories of nursing/ midwifery personnel into one category, the primary health nurse. In the second phase, university-based nursing education programmes will be established for the preparation of professional level nursing personnel.
In India, assistance was given in the organization of community health nursing services at all levels in two States. The aim is to improve staffing patterns, strengthen supervisory support, develop in-service education programmes, and improve the logistical operations of health centres and sub-centres.
In Bangladesh, where major changes in the staffing pattern and job function of nursing personnel are contemplated, the nursing service in the Directorate of Health was assisted in consolidating its administrative position, and the Government is now taking action to appoint a national nursing adviser to the Ministry of Health.
In Thailand, a new category of worker, the nurse practitioner, is being prepared to diagnose and treat minor illnesses and to recognize conditions requiring referral to other sources of medical care. SEA/RC29/2 Page 10
Throughout the Region, the trend is toward increasing the numbers of nursing personnel, expanding their functions into those of a multi- purpose worker, and devising means for more equitable distribution of personnel in peripheral areas. In order to ensure successful attainment of these aims, intensive efforts must be made toward the preparation of well-qualified teachers and supervisory level nursing personnel.
Assistance given for strengthening hospital nursing services has been directed towards administrative policies and procedures and the improvement of patient care in selected clinical areas.
The introduction of individual Kardex records for paediatric patients resulted in improvements in the planning and provision of nursing care and the saving of staff time. Teanwork between doctors and nurses, and applied epidemiological measures led to a reduction in cross-infection in a paediatric unit and in a premature nursery. In-service education programmes for staff and classes for mothers of hospitalized children were educational features introduced in one hospital in India.
Assistance has been given to several countries in the Region in orthopaedic and rehabilitation nursing, medical and surgical patient care, and ward management. In the Maldives, nurse-aides are being trained for hospital work, and in Burma a course was given on ward administration and ward teaching. An inter-country course on hospital administration was held in Indonesia, attended by teams consisting of medical superintendents and hospital matrons. In Thailand, a series of courses for chief nurses from hospitals and public health agencies begun in 1974 was completed in 1975.
In the field of mental health, where needs are great and which invariably receives minimal attention, it is encouraging to note an increasing trend toward introduction of mental health concepts into curricula for the training of nurses and other health workers. In India, assistance was given for revision of the programe for psychiatric nurse training, for in-service education, and for other measures designed to improve patient care. It is also encouraging to note increasing efforts at developing various types of community mental health programmes, in which nurses share responsibilities with other health workers.
The first major input for assistance in the field of nursing research became operational in June 1976 with the opening of a project based at the Rajkumari Amrit Kaur College of Nursing in New Delhi. This project is to aid the development of nursing research in other colleges of nursing in India, with emphasis on applied research which can lead to positive changes in standards of patient care, the delivery of services, and improvements in educational programs.
1.4 Health Education
A review of health education services in the countries of the Region carried out during the year has revealed a need for re-orientation of these services to enable them better to support health education SEA/RC29/2 Page 11
activities as an essential and integral component of different health programmes. This re-orientation has, in turn, called for changes in the present methods of health education, audio-visual aids and communication media, training of health professionals in health education, training of health education specialists, operational research and school health education. Since these changes should necessarily be brought about by health education services in each country, WHO has assisted the countries concerned in strengthening or reorganizing their present services. Such assistance has been given to India, Indonesia, Maldives, Mongolia, Nepal, Sri Lanka and Thailand.
Along with the intensification of efforts to make health education an integral part of health programmes, the need to adopt more effective participatory techniques as opposed to the methods currently employed was clearly recognized, and WHO collaborated with several countries in planning, developing, implementing and evaluating community action programmes through health education.
The emphasis on the integration of health education with health programmes requires greater attention to be paid to the preparation of health professionals in health education than to the training of health education specialists. WHO health education specialists assigned to India, Indonesia, NepaZ, Sri Lanka and Thailand assisted in these activities, and plans were being prepared to intensify such training in the future.
Assistance continued to be given to countries in the Region in the development of health education specialist manpower through WHO'S fellowship programme. These specialists, returning from post-graduate training in institutions both within the Region and outside, have helped to increase the available manpower in their countries. At the same time, with a view to training health education specialists within the Region itself, WHO has collaborated in the further development of the existing facilities - the master of public health (MF'H) Programme in Health Education at the University of Indonesia, Jakarta, and the diploma programmes in health education offered in India by the Institute of Rural Health and Family Planning, Gandhigram, the All-India Institute of Hygiene and Public Health, Calcutta, and the Central Health Education Bureau, New Delhi. The Organization also helped in the development of the curriculum for a new MF'H programme in health education at the Faculty of Public Health, Mahidol University, Thailand. It is to be noted that the integration of health education as a part of health programmes, and the corresponding responsibility which devolves on health professionals for health education, also calls for changes in the training of health educators so that they are better equipped to function in a mutually beneficial relationship, working with and through health professionals in the different health programmes. This implies that the curriculum, especially for the field training of health education specialists, needs changing, and the Organization is seeking to bring about this change through its staff at the regional and country levels. SEA/RC29/2 Page 12
In the field of research, emphasis is being placed on the operational aspects of health education rather than on theoretical issues. Of significance in this context was the WHO Headquarters-assisted operational research conducted in India, Indonesia and Thailand. Greater assistance to research on the operational aspects of health education is planned for the future.
Two specific health programmes which received the Organization's attention during the year were school health education and health education in family health. It was increasingly being recognized that health education should form an integral part of school curricula and that the Organization should assist its Member countries to do this. In this context, significant assistance has been provided to India, Indonesia, Nepal and Sri Lanka.
WHO also collaborated with countries in this region in the development of the health education component of family health programes. The UNFPA-supported projects in Indonesia and Sri Lanka made particular progress in this regard. Further assistance was provided through an inter-country health education project funded by UNFPA. In addition, an inter-country workshop on Assessment of Mass Cormunication Media in Family Health Education was held in the Regional Office with 19 participants from six countries. Preparations were in an advanced stage for two more inter-country workshops scheduled for the last quarter of 1976 - one on Health Education Services in Family Health and the other on a Manual for Audio-visual and Mass Communication Strategies in Support of Family Health Education.
It is expected that the changing needs of health education in the Region and the consequent reorientation of the Organization's efforts in support of health education in Member countries will result in greater involvement of the people in the development, delivery and evaluation of health services through their own efforts.
1.5 Nutrition
During the year, the Organization continued to impress upon governments in the Region the need for a concerted approach to solving nutritional problems and successfully promoted the idea that the health sector should be used as a base for establishing nutrition cells capable of initiating the necessary inter-aectoral co-ordination. Governments were assisted in reorienting the efforts of the health sector in order to strengthen the nutritional aspects of the basic health services. Special support was given to nutrition education in health, the use of feeding programmes as a vehicle for nutrition education, as well as the training of the necessary personnel in relevant nutrition education. Assistance was provided to other nutrition activities of the health services, such as nutrition surveys, the use of growth charts and nutrition rehabilitation of malnourished children.
In Burma, a consultant assisted with the training of township medical and health officers in nutrition and demonstrated the development of nutrition and health education programmes at the peripheral level with SEA/RC29/2 Page 13
the active participation of the community. An operational study was conducted, as a result of which nutrition rehabilitation programmes were established in Rangoon and Mandalay Divisions; also, a growth chart for children was devised. The activities of the nutrition project's laboratory were reviewed and recommendations were made for raising its status to that of a reference laboratory for the whole of the country.
In Bhutan, a consultant assisted the Government in identifying the nutritional problems in the country and also made recommendations on the future course of action, with particular reference to international assistance.
In India, a workshop for State nutrition officers was conducted in New Delhi in September 1975 under the joint sponsorship of WHO, UNICEF and the World Food Programme. The workshop reviewed the nutrition programmes in the various States, defined the role of State nutrition officers, considered measures for strengthening State nutrition units, and formulated plans for co-ordinating the nutrition activities in different States and securing the active participation of the community in nutrition programs.
Two guest lecturers were provided to the National Institute of Nutrition, Hyderabad, to deliver lectures at the two nutrition courses organized by the Institute annually - the three-month certificate course and the one-year degree course.
WHO collaborated with the World Food Programme and UNICEF in a workshop that reviewed the curricula of home science colleges in India in relation to the nutrition education component of the WFP's supplementary feeding programme in the country.
Plans were under way to assign a consultant to Indonesia to assist in developing community nutrition education programmes, in devising curricula and syllabi for the training of various community workers, in developing criteria for an evaluation and monitoring system, and in planning the training of manpower for this programme.
In Sri Lanka, a consultant reviewed the nutrition activities being carried out by the Family Health Bureau and the training courses in nutrition being conducted, and advised the Government on bilateral and international assistance. His main recommendations included the establishment of a nutrition training and education unit in the Ministry of Health, the development of a national food and nutrition policy and of a system for nutritional surveillance.
Preliminary steps were taken to hold an inter-regional meeting on the integration of nutrition and family planning programmes, scheduled to take place in New Delhi in October 1976 with the participation of four countries from the Eastern Mediterranean Region and five from South- Eaet Asia. SEA/RG29 12 Page 14
I: hs which visited India and . .' e.health components bf WFP project31 ratat5ttg nutrll.ll.tLon; &hrirobnneittal sanitation and malatie were !in#rodured;~ih:idi.fi5ecrenti $norjec~~~documentsfor, find lapproval by , .~ thei ..pouemments $-Cem&dl an&:~i': ' ,. . . . ,:I Support was given to WHO Headquarters-sponsored collaborative research activtH@? rhlsted.to3 ege-a*f.Lxcz &#iclien'eirsi prevalen4 in the Regidd, p:art~tculaw~p..~~eropht~&nda~mid;~ahe.ilutrit+&nal anaeinias; I , , . , . , , . ' r.i,; ! r . ,> ,,., . 1.6 Oral Health . , I,,
Asslshancsi,was provided!, fba the.:p.lanning.: and s trengttienkng of oral:' he~l~b:~serp.i~qri;land.~b~~~t~ein~ng:i6f:dencal'~health:tdnp&@t, ' a& wel'f' as withiepideaioXog&ceEi+nveqhigdtd~ns:i'forehe planing hnif.prdmo.tid'af community ,dental hebath jrierv8ce9,.6n, the, Countries. of ,t!h&'~egion;~. I' ; , . , .. , ,., > , .. ,,,. , i A dental tutor December. l'975. : Aftkt stud9llng the ghyatcal) ,:available ah the dental nir~&&:~ school in Rangoon, he prepared a revised curricuhum:,fol: the,trrllning of dental auxiliaries. ,. , ,:j ':, ..,- > ' ; ' . . ! : ! : 8' , . , , , ., . , , , . With lWHC! ,col~abormim";a:::natiidal isemixiar-'on public ;h&dithdentidtiy was qrganized, in [email protected]:!Sepbernbe$ :1-W5im iotder .,to abimlate ohe. : development of this discipline .ia:thp com:eiy's 'ilenr&l''&ll.&ges: The seminar reviewed the available facilities for services, training and research ,;in .p&llc ~hsalbhfjdwbiktry ,I discdsed the pub.1,'i.a ' h:eaith "' '.' aspec:ts o,£.~eriodon;tdl~ddseae8s~ dawldped iodrieula [email protected] of I~9~iC~Wnta~kiiealith~.i.;aplrl~,foIrmulat&d: reco~h~d~tida4 'fbr tbe ' teaching of public health dentistry in Aenxa1.-tollieps'iildd-lthe.: i' '~ organization of services within the public health delivery system. ,,.,. , , ..~,.: .. ..> . :: -\, ;,, A;::,., L:>.t2;,. , ;, ,,, ,;, . . . ,.. ., In Indoneeia, a b&O:,;~onqhanh3-lexrtewed. t%apragress.of..bral' heAlW as r.el&& to; the sacondi;fdxa-)imr; iprlak'(Pe4ita' TI)' atid! 'evdlliatdd 3he ' impliewntatioq, od: itbrderttral thedchHtpan for Pelita '11,with: s'pedlal' emphasis on edwc9r&pn* ;&8ngesi fmdevtsl schotfls ,anti dhtdl. rl~xili&~ training, progress recorded in projects on applied dental research,and cha9ges ; mde: in;.the delibeq' oEi ilearali care-;:th& centres ',hd scb.oql: H8:w&.+~nec~d6ribhs danc.eLaLi ,ser.&i@s~,!j e . . ,.I , . . ;.,i.~. m~dificat~a,,tet-hbr~aia.:,;ii:;! r. ., . , ., , ,. . , . . ; . ,; ! r,,, ,,,, , ., 1 : ,:, .,3;[,.~~>.,l,!:i,.! :, <::l,j,j .>:!, ,,. , . ' Mongotim ar1~0.1r@cerivefl.:asB&sitanqi~ 'from B cotlbltlt:anc, orhot irviewieh che magnitudg~df:~denh&l health maopbveE~.pmblemd,i* ' the:! tbd; try. and' (~s'sdated in organizing progmmkbi fnniahkcptre~hntioni'of ,aehrd ~akl&-wsthih the existing public health delivery system and in developing education, t.raindn@$is@aaikesr:iqhresearchn ihidriwall eriflee.-$tid.;pbb'liC h@81th'7'1
. . ,;, ,a .!,> ;I,, ;i !k;
implementation of an evaluation system for the preventive part of the national dental plan, and, in Thailand, assisted with a situational analysis and a preliminary outline of a national plan for the prevention of oral diseases.
1.7 Mental Health
The Regional Adviser on Mental Health, who took up his duties in September 1975, paid visits to several States in India and to Bangladesh, Indonesia and Thatand to obtain information about developments in the field of mental health and to explore possibilities for the further strengthening of mental health services. Following each visit, strategy guidelines and recommendations were prepared and sent to the governments concerned.
A draft que~tionnaire~designedto map the organization, administration and supervision as well as the extent and distribution of mental health services and manpower in the Region,was prepared for circulation to governments. The questionnaire will also elicit information on planned reforms in legislation governing involuntary admission procedures, and on actual or planned alternatives to traditional hospital-centred care.
A follow-up study of the effectiveness of a refresher course for general practitioners and nurses, held in Mandalay (Burma) in March 1975 as part of the health manpower development programme, was made. A study of the psychiatric component of basic nursing education in India was also undertaken.
A study was made of proposed research involving countries in the Region, on mental health legislation, studies of the long-term effects of cannabis abuse, monitoring of mental health needs as part of the health statistical system, teaching of psychiatry in schools of public health and the delivery of simple psychiatric care by non-professional workers. Priorities for further research, especially in the field of psychosocial factors and health, were considered.
The effectiveness of projects of long duration in Sri Lanka and Thailand was reviewed and modifications were made in two inter-country projects. In one of them provision was made for conducting, in collaboration with Headquarters, advanced training courses for selected professional and health administrative personnel in psychiatric epidemiology and allied subjects, as an approach to the strengthening of national mental health services. In the other project, the terms of reference, initially confined to assistance in the assessment and strengthening of services in drug dependency, were widened to include also other appropriate special clinical areas of significance in the Region, including mental retardation, child psychiatry and alcohol-related disabilities.
A new project to promote the refresher training of general physicians in India was formulated and the UNDP has been approached for financial support. A consultant, provided in March, has been assisting the National Institute of Mental Health and Neurosciences, Bangalore, in the development of psychiatric teaching. SEAl~C2912 Page 16
Sri Lanka also received assistance from a WHO consultant, who advised on the development of a course in psychopathology and psychotherapy at the Department of Psychiatry of the University of Sri Lanka, Peradeniya Campus.
The Region was represented at the First Meeting of the Co-ordinating Group for the Mental Health Programme, held at WHO Headquarters in February. A paper reviewing problem and listing the current and planned programmes in mental health was presented at the meeting. The Organization was represented at several other conferences and meetings on mental health topics.
The Department of Psychiatry at the Institute of Post-graduate Medical Education, Chandigarh, India, and Seth G.S. Medical College. Bombay, were nominated as WHO Collaborating Centres to participate in inter- regional research programmes sponsored by WHO Headquarters. The Mental Hospital, Agra (India), continued as a field research centre for the International Pilot Study of Schizophrenia. Also, the Post-graduate Institute, Chandigarh, was designated as a field research centre for the International Collaborative Study on Depression.
Fellowships were awarded to candidates from Bum, Indonesia, MongoZia, Sri Lanka and Thailand for training in centres of social psychiatry and clinical psychology in the United Kingdom, Netherlands, Canada. USSR and Australia. Fellowship placements in mental health were revised and greater use made of the co-ordinated training programmes in psychiatric epidemiology designed by WHO Headquarters.
1.8 Drug Dependence
The programme on drug abuse in Thailand, assisted by the United Nations Fund for Drug Abuse Control, continued during the year. An appraisal of the treatment and rehabilitation component was made by a consultant who made recommendations for strengthening research in these areas. A similar programme in Burma (United NationsIBurma Drug Abuse Control Programme) was formulated and accepted by the Government.
India and Indonesia received support for studies on, among other things, the long-term effects of cannabis and opium, side-effects and pharmacological action of commonly used fertility regulation agents and psychotropic drugs, and the developmnt of instruments for the reporting of drug dependency treatment programmes.
A seminar held in Jakarta in December 1975 for officers involved in the prevention and control of drug abuse was assisted by a WHO consultant.
1.9 Quality Control of Pharmaceutical and Biological Products
Areas receiving the attention of governments in this field were: the development of national drug policies; the preparation of medium and long-term plans for self-sufficiency in the therapeutic, diagnostic and prophylactic substances needed for primary health care; the SEA/RC29 12 Page 17
standardization and quality control of preparations; the strengthening of the machinery for supervision and distribution; studies in the bioavailability and biotransformation of pharmaceuticals, and the education and training of health and allied personnel in pharmacy, clinical pharmacology and biomedical research.
A WHO electro-medical engineer assisted the Government of Bangladesh in strengthening existing facilities for the repair and maintenance of equipment used in the Pharmaceutical Manufacturers Laboratory of the Central Medical Stores. He repaired and put into operation a number of items, trained technicians and advised on the planning of hospital workshops. A national seminar-cwworkshop on the repair and maintenance of electro-medical equipment was also organized. Another consultant was under recruitment to advise the Government on the formulation of a national drug policy, and a pharmaceutical chemist, also to be assigned shortly, will assess the current state of pharmaceutical manufacturing, distribution, drug control and legislation. and also advise on training.
A team of consultants in biologicals, vaccine production and pharmaceutical economics from Australia was being assigned to Bumta to review the existing facilities and formulate a plan of action for bilateral assistance towards enhancing national potential for the production and quality control of biologicals.
In Sri Lanka, a consultant studied the organization of pharmacy departments, the distribution of pharmaceutical products in national health services, the training of personnel and the system for the quality control of drugs. Considerable progress in establishing a national quality control laboratory, in training personnel, in implementing the policy of the National Formulary Codttee, and in rationalizing the import of medicines,was noted. It was observed, however, that there was a need for faster development of the pharmaceutical industry, improvement in the standard of education and training in pharmacy, and co-ordination of the authority and direction for the surveillance of all operations related to the quality of medicines.
Assistance provided to Thailand for improving the quality of medicines on the market and developing a training centre in Bangkok for pharmaceutical analysts contributed towards establishing a good national system for the quality control of legitimately produced or imported medicines. Most manufacturers have become aware of the meaning and requirements of the code of good manufacturing practice, and technical personnel have been trained for inspection. Automation of product registration records has improved the efficiency of planned sampling of pharmaceuticals. With the extension of these developments in Bangkok to the provinces, there should be improvement in the quality control of medicines and in the prevention of illicit manufacturing and trafficking in medicines.
In April 1976, an International Meeting on Transfer of Technology in the field of Drugs was organized in Lucknow, India, jointly by the SEAIRC2912 Page 18
United Nations Industrial Development Organization and the Council of Scientific and Industrial Research of the Government 05 India. Representatives from 22 developing countries took part in this meeting, which was also attended by a Regional Office staff member. The participants agreed to draw up a list of essential drugs to be manufactured in their countries and collaborate in the transfer of technology, provision of know-how and exploitation of indigenous resources in the manufacture of drugs.
1.10 Medical Stores Management
Assistance continued to be provided to Nepal in medical stores management. A number of steps were taken to bring about improvements in the supply and distribution systems in the medical stores. Training courses were organized; the record card system was introduced in many hospitals and health institutions and the indent and procurement procedure was streamlined and reorganized. It is planned to establish model stores in the country to serve as centres for the in-service training of medical storekeepers and personnel in charge of hospital pharmacies.
Supplies provided by UNICEF were very useful in the establishment of medical stores.
2. DISEASE PREVENTION AND CONTROL - COMMUNICABLE DISEASES
Communicable diseases have continued to pose health problems in countries of the Region, and governments have been encouraged to give these diseases appropriate priority in their programws. Epidemiological surveillance, which is steadily improving, has been an important factor in disease prevention and control.
Remarkable success was achieved in eradicating smallpox - Bangladesh, India and Nepal having become smallpox-free during the year. Malaria continues to show an upward trend, however, and an inter-country consultative meeting held in the Regional Office in April provided guidelines for developing policies for the ioplementation of anti- malaria programmes (see also Section 2.2).
The development of the WHO Programme of Expanded Immunization is being accorded high priority in this Region. Steps have been initiated to explore the feasibility of and possible scope for expanding the existing national immunization programmes and to identify national resources for such increased activities. A Regional Seminar on Epidemiological Surveillance of Communicable Diseases (Immunization Programmes) was organized in the Regional Office in November 1975.
Human plague continues to be reported from Burma, and tuberculosis control has been receiving the attention of governments. In view of the considerable concern of governments over the extent of leprosy in the Region, an inter-country consultative meeting was organized in the