The Work of WHO 1992-1993

Biennial Report of the Director-General

CORRIGENDUM

Page 2, column 1, line 1:

Delete 1993. The increase of$ 105 523 000 or 14.46% in

Insert 1993. The net increase of$ 87 165 000 or 11.86% in

The Work of WHO 1992·1993

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 of Resolutions 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 ACHR -Advisory Committee on Health Research AGFUND -Arab Gulf Programme for United Nations

Development Organizations ASEAN -Association of South-East Asian Nations CIDA -Canadian International Development

Agency CIOMS -Council for International Organizations of

Medical Sciences DANIDA -Danish International Development Agency ECA -Economic Commission for Africa ECE -Economic Commission for Europe ECLAC -Economic Commission for Latin America

and the Caribbean ESCAP - Economic and Social Commission for Asia

and the Pacific ESCW A - Economic and Social Commission for

Western Asia FAO -Food and Agriculture Organization of the

United Nations FINNIDA -Finnish International Development Agency GTZ -German Technical Cooperation Agency IAEA - International Atomic Energy Agency IARC -International Agency for Research on

ICAO IFAD

ILO

IMO ITU NORAD

Cancer -International Civil Aviation Organization -International Fund for Agricultural Devel-

opment - International Labour Organisation

(Office) - International Maritime Organization -International Telecommunication Union -Norwegian Agency for International

Development

OAU

OECD

PAHO

SAREC

SIDA

-Organization of African Unity

- Organisation for Economic Co-operation and Development

- Pan American Health Organization

- Swedish Agency for Research Cooperation with Developing Countries

- Swedish International Development Authority

UNCTAD -United Nations Conference on Trade and Development

UNDCP -United Nations International Drug Control Programme

UNDP -United Nations Development Programme

UNDRO -Office of the United Nations Disaster Relief Coordinator

UNEP -United Nations Environment Programme

UNESCO -United Nations Educational, Scientific and Cultural Organization

UNFPA -United Nations Population Fund

UNHCR -Office of the United Nations High Com­missioner for Refugees

UNICEF -United Nations Children's Fund

UNIDO -United Nations Industrial Development Organization

UNRWA -United Nations Relief and Works Agency for Palestine Refugees in the Near East

USAID -United States Agency for International Development

WFP -World Food Programme

WHO -World Health Organization

WIPO - World Intellectual Property Organization

WMO -World Meteorological Organization

The World Health Organization welcomes requests for permission to reproduce or translate its publications, in part or in full. Applications and enquiries should be addressed to the Office of Publications, World Health Organization, Geneva, Switzerland, which will be glad to provide the latest information on any changes made to the text, plans for new editions, and reprints and translations already available.

ISBN 92 4 156165 3 © World Health Organization 1994

Publications of the World Health Organization enjoy copyright protection in accordance with the provisions of Protocol2 of the Universal Copyright Convention. All rights reserved.

The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the Secretariat of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement.

The mention of specific companies or of certain manufacturers' products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters.

ISSN 0509 2558 PRINTED IN SWITZERLAND

93/9852-At.r-4700

iv

Introduction

1.

2.

3.

4.

5.

6.

Governing bodies

WHO's general programme development and management

Constitutional and legal matters WHO's programme development Informatics management External coordination for health and social development Emergency relief operations

Strategy for health for all

Monitoring and evaluation Regional and national activities and policies Health for all and economic development

Health system development

Assessment of global health situation and future trends Intensified cooperation with countries and peoples in greatest need Technical cooperation among developing countries Health systems research and development Health legislation

Organization of health systems based on primary health care

National health systems and policies District health systems

Development of human resources for health

Policy analysis, planning and management Nursing Educational development Staff development

V

Contents

IX

1

3

3 3 4 4 7

11

11 11 12

13

13 15 16 17 18

21

21 23

27

27 29 30 33

7.

8.

9.

THE WORK OF WHO 1992-1993

Public information and education for health

Public information Education for health

Research promotion and development

General health protection and promotion

Women, health and development Food and nutrition Oral health Injury prevention Tobacco or health

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

Maternal and child health and family planning Health of adolescents Human reproduction research Occupational health Health of the elderly

11. Protection and promotion of mental health

Mental health policy, and support to national programmes Psychosocial and behavioural problems and relevant interventions Prevention and control of alcohol and drug abuse Mental and neurological services and treatment

12. Promotion of environmental health

Community water supply and sanitation Environmental health in rural and urban development and housing International Programme on Chemical Safety Control of environmental health hazards

13. Diagnostic, therapeutic and rehabilitative technology

Clinical technology Health laboratory technology and blood safety Radiation medicine Technology development, assessment and transfer Drug management and policies Pharmaceuticals Biologicals Traditional medicine Action Programme on Essential Drugs Rehabilitation

vi

35

35 35

39

43

43 44 47 49 50

53

53 56 58 62 63

65

65 66 66 68

71

71 72 74 75

77

77 77 78 78 78 79 80 80 80 82

14. Disease prevention and control

Immunization Control of tropical diseases Disease vector control Leprosy Tropical disease research Diarrhoeal diseases Acute respiratory infections Tuberculosis Zoonoses

CONTENTS

AIDS and other sexually transmitted diseases Other communicable diseases Research and development in the field of vaccines Blindness and deafness Cancer International Agency for Research on Cancer Cardiovascular diseases Other noncommunicable diseases

15. Health information support

Health literature services WHO publications Technical terminology Distribution and sales

16. Support services

Personnel Office accommodation Budget and finance Equipment and supplies for Member States

Map showing regional offices and the areas they serve

17. African Region

18. Region of the Americas

19. South-East Asia Region

20. European Region

21. Eastern Mediterranean Region

vii

85

85 88 96 97 99

101 103 105 106 108 113 116 117 118 120 121 123

125

125 126 128 128

129

129 129 130 131

132

133

137

141

145

149

THE WORK OF WHO 1992-1993

22. Western Pacific Region

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

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

Annex 3. Organizational and related meetings, 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

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

Index

viii

153

159

161

163

164

167

171

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 envi­ronment.

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 of policies to the coordination and tightening of programme budget manage­ment procedures, in particular through the development and harmonization of infor­mation systems.

During this biennium WHO upheld its commitment to health for all through primary health care, increasing its direct technical support to countries, and coordinat­ing 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 collabora­tion, suggests a new "clustering" of programmes and activities around four interrelat­ed policy orientations: integration of health and human development in all public policies; equity in access to health services; promotion and protection of health; preven­tion 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 contribu­tion 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 informa­tion 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, includ­ing water supply and sanitation, for the prevention and containment of public 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 strong­er 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 Ameri­cas, 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 elimi­nation 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 nation­al 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 of justice and mutual respect.

Vf. •

Director-General

xi

1.1 With profound changes sweeping the world, the Organization has undertaken a careful re-examination of its mission and strategies. An important step in this process was the establish­ment in January 1992 of a working group on the WHO response to global change (decision EB89(19)) with responsibility for drawing up recommendations concerning the Organiza­tion's mission, leadership role, preparedness for changes in priorities, and structure; strength­ening of WHO's coordinating role within the United Nations system; orientation and prepara­tion of the Ninth General Programme of Work; and enhancement of the technical quality of the Organization's programmes. The group con­cluded its work during the biennium and submit­ted detailed recommendations on those points. A number dealt with the Executive Board's own method of work, and one in particular proposed that subgroups or committees of the Board should meet during the Executive Board sessions to review specific programmes. The Programme Committee of the Executive Board met in No­vember 1993 to review planning for the imple­mentation of the Working Group's recommen­dations prior to their consideration by the Board.

1.2 The interrelation of environment, health and development was highlighted by addresses to the Health Assembly in May 1992. Mr Mario Soares, President of Portugal, spoke of the need, following the ending of the cold war, for re­newed efforts to achieve "a new world order founded on law and greater equality of opportu­nity for all human beings". Dr J aime Paz Zamora, President of Bolivia, referred to the earth as one large ecosystem and life as a phenomenon of global interdependence. Technical Discussions were held on the related theme of "Women, health and development".

1.3 Health Assembly resolutions in 1992 in­cluded a request for the establishment of a global

CHAPTER 1

Governing bodies

commissiOn on women's health (resolution WHA45.25), which is to hold its first meeting shortly. In 1993 the Health Assembly called for budgetary reform (resolution WHA46.35), and decided to shorten the duration of the Health Assembly in even-numbered years when pro­gramme budgets are not discussed (resolution WHA46.11). Dr Hiroshi Nakajima was reap­pointed Director-General of the World Health Organization (resolution WHA46.2); he called for a "new partnership in health" to meet the challenge of increasing worldwide change.

1 4 In 1992 the regional committees reviewed the proposed activities to be carried out in each WHO Region1 during the 1994-1995 biennium in the same way that the Executive Board, through its Programme Committee and in ac­cordance with resolution EB79.R9, reviewed the proposed global and interregional activities. These proposals provided the basis for prepara­tion of the Organization's 1994-1995 pro­gramme budget, approved by the Health Assem­bly in May 1993. At the same time the regional committees in 1993, at the request of the Execu­tive Board, studied the implications of recom­mendations made by the Board's working group on the WHO response to global change, as applicable to regional and country activities, with a view to reporting to the Board in January 1994.

1.5 The Forty-sixth World Health Assembly approved for 1994-1995 an effective working budget level of$ 822 101 000.2 This represents a decrease of 3.5% in real terms when compared with the approved programme budget for 1992-

1 See Annex 2 for d1stnbut1on of Member States and Associate Members 1n the SIX WHO regions: Africa, Americas, South-East Asia, Europe, Eastern Mediterranean, Western Pac1fic.

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 1994-1995, compared with 1992-1993, is attrib­utable to estimated inflationary cost increases of almost 11% as well as statutory salary and other unavoidable cost increases for which adequate budgetary provision has not been made in recent

2

years. The Health Assembly agreed to reduce assessments on individual Members by their share of the amount of interest earned and availa­ble for appropriation($ 12 741 000), credited to them in accordance with the incentive scheme established by resolution WHA41.12.

CHAPTER 2

WHO's general programme development and management

Constitutional and legal matters

2.1 Several changes occurred in the membership of the Organization during the biennium (see An­nex 1 ), with the result that there were 187 Members and two Associate Members as at 31 December 1993. Ukraine notified WHO that it wished to reactivate its membership in the Organization.

2 2 During the biennium 34 instruments of acceptance were deposited for the amendment of Articles 24 and 25 of the Constitution to provide for an increase in the membership of the Execu­tive Board from 31 to 32 (resolution WHA39.6); this brought the number of acceptances to 118, the requirement for adoption being two-thirds of the Organization's membership. No instru­ment of acceptance was deposited for the amend­ment of Article 7 on suspension of rights and privileges of Members (resolution WHA18.48), so the number of acceptances remained 53. Simi­larly, no instrument of acceptance was deposited for the amendment of Article 74 to include an Arabic version among the authentic texts of the Constitution (resolution WHA31.18), and the number of acceptances remained 34.

2.3 Cameroon and Bahrain acceded to the Convention on the Privileges and Immunities of the Specialized Agencies with respect to WHO on 30 April and 17 September 1992 respectively. Ukraine and Belarus, which had previously ac­ceded to the Convention with respect to other agencies, submitted notifications of application of the Convention with respect to WHO. Instru­ments of succession to the Convention were sub­mitted by Bosnia and Herzegovina, Czech Republic, Croatia, Slovakia and Slovenia. As a result, 102 Member States had accepted the Con­vention with respect to WHO by the end of the biennium.

3

WHO's programme development

Ninth General Programme of Work

2.4 Preparation of WHO's Ninth General Programme of Work covering a specific period (1996-2001), initiated by the Executive Board at its January 1992 session, was pursued by the Board's Programme Committee, the regional committees and staff at all levels of the Organiza­tion throughout the biennium; a final draft will be submitted to the Board for review in January 1994. It emphasizes WHO's role in supporting countries and the international health communi­ty, and in reducing inequities in the health sector. It provides a global framework for health policy by defining goals and targets. The targets include specific improvements in health, access to care and services of good quality, and policy design and implementation, and are presented as the minimum of what should be achieved by the year 2001. Four related orientations are proposed to reach the goals.

Programme development and management

2 5 To strengthen WHO's policy-making capacity and to ensure effective implementation of programmes and application of the recom­mendations of the Executive Board's working group on the WHO response to global change (see paragraph 1.1), the Director-General has es­tablished a Global Policy Council. The members are the Director-General, the Regional Direc­tors, the Assistant Directors-General and the Di­rector of IARC. The Council's mandate is to restate the mission of WHO in the light of world

THE WORK OF WHO 1992-1993

changes; to review the global and regional strate­gies for health for all; to ensure the monitoring of the attainment of health-for-all targets and their periodic updating; to ensure that, through the necessary coordination, programme implemen­tation at headquarters, regional and country lev­els conforms to the global policy, while giving due respect to national priorities; and to adjust WHO's managerial structure to reforms stem­ming 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 Man­agement Development Committee, particularly in matters of management coordination through­out the Organization.

Programme budgeting

2 6 Zero budget growth for six consecutive bienniums has led to a real reduction in the Or­ganization's regular budget and a greater de­pendence on extrabudgetary resources; this has accentuated the need to be selective in develop­ing WHO's programmes. The Director-Gen­eral has continued to transfer some resources from existing activities to areas of high priority determined in previous bienniums.

2.7 Resolution WHA46.35 called for pro­found changes in the way the Organization's programme budget is prepared, starting with the 1996-1997 biennium. It stressed the importance of setting realistic targets and describing "meas­urable outcomes", and of ensuring the highest standards of accountability and transparency. It expressed concern about the complexity and lack of clarity of the existing budget documents, par­ticularly about the failure to relate financial allo­cations and staff costs to specific priorities. As a result, the programme budget for the financial period 1996-1997 will be prepared in a simplified form. It will show how strategic and financial 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 tracks progress towards the agreed targets. There will be fewer budgetary tables and more infor­mation about sources of financing, both regular and extrabudgetary.

2.8 At regional level several measures were taken to strengthen WHO's programme devel­opment and management. In the Americas

4

PAHO/WHO started to assess the effects of "strategic orientations and programme priori­ties" on policy-making and health development in Member States and on technical cooperation. In the Eastern Mediterranean visits were ar­ranged to enable senior health officials to study WHO's policies and strategies and to exchange views on ways to ensure optimal allocation of resources to priorities.

lnformatics management

2 9 More WHO staff throughout the world were assured of access to a microcomputer con­nected to a local area network. A new network was commissioned for the Regional Office for South-East Asia in September 1992. WH 0 head­quarters became a node of the Internet "net­work of communications networks" as a first stage in establishing economical and effective communications within and outside the Organi­zation. Central management for both adminis­trative and health databases was updated using new software. PAHO/WHO began replacing its computerized administrative system, and the system in the Regional Office for Europe was also updated. In general, regional offices and cer­tain country offices continued to make more ef­fective use of their administrative and pro­gramme management systems. Steps were taken to foster closer interregional cooperation in the use of these systems. WHO supported several Member States in developing their health infor­mation systems and improving their reporting systems, including Mexico, Oman, Seychelles, Syrian Arab Republic, United Arab Emirates and six countries in the Western Pacific. The Organization also played an active part in inter­national conferences on health cards (Marseille, France, September 1993) and on health informatics in Africa (Ile-Ife, Nigeria, April 1993).

External coordination for health and social development

2.10 The biennium was marked by the contin­uing concern of all organizations of the United Nations system to streamline structures and inte­grate development cooperation programmes with those for humanitarian assistance and peace-keeping. The financial resources of the

WHO'S GENERAL PROGRAMME DEVELOPMENT AND MANAGEMENT

system were stretched as never before, with a vast discrepancy between the tasks assigned and funds available.

2 11 Restructuring of the social and economic sectors of the United Nations system moved ahead. To be able to respond more effectively to the new international situation, the Administra­tive Committee on Coordination (A CC) carried out a review of its role and functioning. WHO was fully involved in this review process, which began with a meeting in April 1992 at WHO headquarters in Geneva, and was completed at a meeting in April 1993 at FAO headquarters in Rome. WHO is a member of the two consulta­tive bodies reporting to ACC - the Consultative Committee on Administrative Questions (CCAQ) and the Consultative Committee on Programme and Operational Questions (CCPOQ). WHO is one of the nine core mem­bers of the ACC Inter-Agency Committee on Sustainable Development which was set up to consider policy relating to follow-up of the 1992 United Nations Conference on Environment and Development and to monitor implementa­tion of Agenda 21 (see paragraph 12.1).

212 The Commission on Sustainable Devel­opment was established as a 53-member inter­governmental body by the Economic and Social Council (resolution 1993/207) at the request of the United Nations General Assembly (resolu­tion 471191). At its first meeting in June 1993 this body agreed on a programme of work for the period 1993-1996. WH 0 has been assigned the responsibility for implementation of the health chapter of Agenda 21.

213 WHO provided documentation, technical information and guidance for the discussions with the Economic and Social Council and other organizations of the United Nations system on the prevention and control of HIVIAIDS, lead­ing to a better understanding at political level of the magnitude of the problem and the responsi­bility of governments. The Council recognized the urgent need to invest in preventive measures and to avoid discrimination against those infect­ed with HIV or suffering from AIDS, approved the activities of the Commission on Human Rights in this respect, endorsed the updated glo­bal AIDS strategy and gave its full support to resolution WHA46.37 concerning the feasibility and practicability of establishing a joint, cosponsored United Nations programme on HIV I AIDS. In addition, ACC in October 1993

s

endorsed the WHO policy on non-sponsorship of international conferences on AIDS in coun­tries with HIV I AIDS-specific travel restrictions (resolution WHA45.35) and recommended that all organizations of the United Nations system adopt this policy.

2.14 The Council gave greater prominence to health and social development in its deliberations during 1992 and 1993. WHO, in collaboration with 11 other organizations of the United Na­tions system, prepared the Secretary-General's report to the 1993 Council's substantive session on preventive action and intensification of the struggle against malaria and diarrhoea! diseases, especially cholera; in 1994 the Secretary-General of the United Nations will submit a report on improved coordination to the Council, specify­ing goals, workplans, schedules and the resources required to combat these scourges. The Council also adopted a resolution on the subject of tobac­co or health (see paragraph 9.53).

2.15 WHO participated in Council discussions on enhancing international cooperation for de­velopment, covering the role of the United Na­tions system, assistance in the eradication of pov­erty and support to vulnerable groups, the coor­dination of humanitarian assistance, emergency relief and the "continuum" from relief to reha­bilitation and development. WHO was also in­volved in Council deliberations on the Interna­tional Year of the Family (1994 ), control of nar­cotic drugs and psychotropic substances, and strengthening of international cooperation and coordination of efforts to minimize the conse­quences of the Chernobyl disaster.

216 Together with other agencies, WHO re­ported to the Council on the implementation of United Nations General Assembly resolution 471199 concerning operational activities of the United Nations system, which called for a sub­stantial increase in multilateral resources for de­velopment. WHO emphasized, particularly through CCPOQ, the importance of making ac­tion of the United Nations system more respon­sive to national objectives and more efficient. For instance, WHO supported the establishment of United Nations country offices and confirmed its interest in sharing premises that are being established in Moscow.

217 WHO held discussions and exchanged in­formation with the five United Nations regional commissions: the Economic Commissions for Af-

THE WORK OF WHO 1992-1993

rica, for Europe, and for Latin America and the Caribbean, and the Economic and Social Commis­sions for Asia and the Pacific, and for Western Asia.

218 The UNICEF/WHO Joint Committee on Health Policy met at WHO headquarters in 1992 and 1993 to discuss, in particular, ways and means to achieve the goals set by the 1990 World Summit for Children, and improved manage­ment of district health systems as an essential element of infrastructure.

2.19 From early 1992 WHO joined the World Bank in preparing and launching the Bank's 1993 report, 1 which examines the interplay be­tween health, health policy and economic devel­opment. In addition to attending the meeting of the boards of governors of the World Bank and the International Monetary Fund, WHO partici­pated in the annual meetings of the boards of governors of the African Development Bank, the Asian Development Bank, the European Bank for Reconstruction and Development, and the Inter-American Development Bank, all of which are increasingly active in the social sector. In accordance with Executive Board resolution EB92.R4, a draft cooperation agreement is being used as a framework for relations between WHO and the African Development Bank and the Afri­can Development Fund prior to submission of this document to the World Health Assembly in May 1994. Opportunities to enhance the collab­orative framework and pursue existing and new areas of cooperation were discussed with these multilateral financial institutions on several occa­sions in 1992 and 1993.

2 20 Joint UNDP/WHO activities were con­solidated, and new areas for collaboration deter­mined, particularly at country level.

2 21 WHO coordinated act1v1t1es with UNFPA through that body's technical support services, which include multidisciplinary, inter­agency country support teams in eight locations throughout the world. The administrative arm of the technical support services is the UNFP A interagency task force, which meets once or twice a year, bringing together organizations within the United Nations system, including WHO. WHO was represented at expert group meetings on population and development and at

1 World Bank. World development report 1993 mvestmg tn health New York, Oxford Unrversity Press, 1993.

6

meetings convened by UNFP A to prepare for the 1994 international conference on population and development.

2 22 WHO expanded collaboration with the Organization of African Unity (OAU) through the WHO Office for OAU and ECA on several subjects including malaria, AIDS, nutrition, hu­manitarian action and emergency assistance, and on the formulation of a health protocol for the Treaty Establishing the African Economic Com­munity.

2 23 Following the signature of a letter of in­tent between WHO and the Commission of the European Communities early in 1992, a repre­sentative of the Director-General was appointed to facilitate cooperation with the European insti­tutions, concentrating on providing technical ex­pertise for the Commission's regulatory activi­ties and on promoting the health aspects of the European Community's development work. In May 1993 the Council of Ministers invited the Commission to ensure closer cooperation with WHO. Collaboration was also intensified with OECD and other intergovernmental organiza­tions outside the United Nations system.

2 24 During the biennium WHO undertook policy and technical reviews with various govern­ments to strengthen existing collaboration, devise new forms of cooperation, and solicit extra­budgetary support for the Organization's health programmes at global, regional and country lev­els. The government officials participating in the reviews represented multilateral and bilateral co­operation departments in the appropriate minis­tries, thus ensuring a comprehensive approach to meeting health needs. Representatives from sever­al countries2 were particularly active in securing support for health programmes coordinated by WHO. Despite the global economic recession af­fecting official development assistance levels, extrabudgetary support for the Organization's work was maintained. Additional policy consulta­tions organized in 1993 resulted in long-term agreements on financial and other support being offered to WHO so that it can accomplish the work approved by the Member States.

2 25 The work of WHO continued to benefit from the resources made available by the

2 Austrra, Canada, France, Germany, Ireland, Italy, Japan, Netherlands, Nor­way, Sweden, Swrtzerland, United Krngdom, Unrted States of America.

WHO'S GENERAL PROGRAMME DEVELOPMENT AND MANAGEMENT

nongovernmental community, especially those of the 177 nongovernmental organizations in of­ficial relations, a further twelve of which were admitted during the biennium. Examples of this wide-ranging collaboration are humanitarian as­sistance with the International Federation of Red Cross and Red Crescent Societies and the Inter­national Committee of the Red Cross; training of medical personnel with the International Society for Prosthetics and Orthotics and La Leche League International; community mobilization for vaccination programmes with Rotary Inter­national; and advocacy in relation to the special needs of women and female children with the International Alliance of Women and Sorop­timist International.

2 26 In addition to its work related to the strat­egy of intensified cooperation with countries and peoples in greatest need, the Organization pro­moted partnership between governments and co­operating agencies (United Nations, multilateral, bilateral and nongovernmental organizations) so that external resources could be provided for maximum effect in support of overall health de­velopment. WHO participated in reviews of bi­lateral support to certain countries, for instance, support from the Netherlands and Sweden to Zambia. Another example of cooperative work was the fourth population and health project ( 1992-1996) in Bangladesh, costing $ 600 million and managed by the World Bank through a mul­ti-donor consortium in which WHO has an in­fluential voice as well as being executing agency for 21 of the 65 project components. Further examples were a review in Chad carried out in coordination with the African Development Bank, and cooperation in Mozambique in pre­paring a 12-year development programme for implementation with FINNIDA support.

2.27 The international community's concern about deteriorating health in the former Soviet Union found expression in the convening of a ministerial-level coordinating conference on as­sistance to the new republics (Washington, Janu­ary 1992). During the conference a medical working group was set up to meet regularly and conduct missions to assess health needs in the republics. This group agreed on terms of refer­ence for a clearing-house for information on health assistance to the republics; and responsi­bility for administering it was entrusted to WHO at a second coordinating conference (Lis­bon, May 1992). The clearing-house's tasks in­clude collating, analysing and disseminating in-

1

formation on health needs in the republics, and drawing them to the attention of the internation­al community; setting up databases; monitoring the health situation in each republic; and main­taining country information profiles. So far ex­isting WHO information sources have been used to prepare an operational database on the repub­lics, and a health news bulletin issued in English, French and Russian for exchange of information on the health situation, on assistance received and on cooperation established.

Emergency relief operations

2 28 In addition to communicable diseases and other long-standing problems affecting health in many Member States, ecological change, rural-urban migration and severe natu­ral or man-made disasters have posed threats to the very existence of health services in some countries in recent years. WHO has therefore strengthened its mechanisms for emergency preparedness, humanitarian assistance, and re­lief and rehabilitation in situations of armed conflict. A number of Health Assembly resolu­tions have endorsed increased involvement by WHO in this field. 1

2.29 Some 20 African countries have benefited from enhanced relief activities. In Eritrea WHO is cooperating in UNHCR efforts to resettle some half a million refugees. In the next phase it is planned to strengthen provincial health ser­vices to meet the needs of returning refugees and displaced persons, thus ensuring a continuum of support from relief to rehabilitation. One of sev­eral emergency health programmes in Ethiopia provides for the rehabilitation of about 40 pro­vincial hospitals, health centres and health posts. In Mozambique WHO is helping to implement a programme of primary health care for some 100 000 demobilized soldiers, including on-the­spot treatment of ailments, health education, col­lection of epidemiological data, and provision of supplies and equipment.

1 Emergency and humamtarian relief operations (WHA46.6) Health condr­trons of the Arab population rn the occupied Arab terrrtorres, rncluding Polestrne (WHA46 26) Collaboration withrn the United Notrons system health assistance to specrfrc countries - Cuba (WHA46 28) Colloboro­tron withrn the Unrted Notrons system health assistance to specrfrc coun­trres (WHA46.29). Health and medrcol servrces in trmes of armed conflict (WHA46.39)

THE WORK OF WHO 1992-1993

2.30 WHO participated in the work of the UNHCR-coordinated interagency task force set up to determine the requirements of republics of the former Soviet Union for humanitarian assist­ance (see paragraph 2.27), and drew up a health sector plan of action for the consolidated appeal launched for Armenia, Azerbaijan, Georgia and Tajikistan. Activities in the war-afflicted areas of former Yugoslavia included the establishment of programmes for health monitoring, nutritional surveillance, rehabilitation of war victims, provi­sion of medical supplies and additional support in winter.

2.31 WHO is contributing to United Nations programmes for humanitarian assistance to a number of countries in the Eastern Mediterrane­an; emergency medical supplies and equipment were provided to war-torn regions of Afghani-

stan; considerable quantities of medicines and medical supplies were distributed in Iraq to alle­viate extreme shortages resulting from the Gulf conflict; and support was given in setting up a central pharmacy and a reference laboratory and in providing urgent medical assistance in Soma­lia. WHO is also working closely with local health institutions and experts, as well as Pales­tinians from the occupied Arab territories, in preparing a master plan for transfer of authority and responsibility for health services and the promotion of broader regional cooperation in health matters. In Egypt a national emergency plan was prepared and a conference organized (Cairo, November 1993) in conjunction with the annual promotion day for the International Dec­ade for Natural Disaster Reduction. Other inter­ventions included support to the Islamic Repub­lic 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 quickly available source of the essential drugs (none of them injectable), 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 health core worker with li mited training who treats symptoms rather thon diagnosing diseases. Eoch kit is sufficient for about I 0 000 outpatient consultations ond con serve o population of I 0 000 people for o period of ap proximately three months.

8

WHO'S GENERAL PROGRAMME DEVELOPMENT AND MANAGEMENT

2.32 WHO provided medical kits and other emergency supplies to several countries affected by natural disasters.1 Tuberculosis drugs and technical services were supplied to Cambodia, where WHO is cooperating with UNHCR in the ·repatriation of refugees.

2.33 Workshops were held for training emer­gency health managers from Asia and the Pacific

1 Albama, Bangladesh, Egypt, Eritrea, Kyrgyzstan, Lebanon, Lesotho, Mada­gascar, Malawr, Namibia, Pakistan, Phrlrpprnes, Rwanda, Srerra Leone, Swaziland, Unrted Republrc of Tanzania, Yemen, Zambia.

9

(Bangkok, February 1993) and Africa (Tangiers, Morocco, May 1993). Training in emergency re­lief and humanitarian assistance was organized for WHO Representatives and staff in the East­ern Mediterranean. WHO and the International Committee of the Red Cross cosponsored two emergency preparedness training courses in Ge­neva and Manila. A consultation convened in 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, was launched in April 1993, and pilot pro­grammes are under way in several countries.

CHAPTER 3

Strategy for health for all

Monitoring and evaluation

3 1 In May 1992 the Health Assembly ap­proved the report on the second evaluation of the implementation of the Global Strategy for Health for All by theY ear 2000, which is also the eighth report on the world health situation and is based on national and regional evaluation re­ports. A total of 151 Member States with a popu­lation of 5200 million reported their findings concerning advances made and constraints en­countered in improving health throughout the world and in providing services on a basis of equity. The global review and reports from the six WHO regions have been published.1

3.2 A common framework was developed for use by Member States in carrying out a third exercise in monitoring progress in the implemen­tation of the health-for-all strategy, from late 1993 to early 1994. It will enable Member States to review achievements in the application of their national health-for-all strategies and report the findings to WHO, using common criteria. Par­ticular importance is attached to the collection and presentation of data broken down according to geographical area, sex, age and priority popu­lation groups.

3.3 WHO and UNICEF have agreed on a set of indicators for monitoring progress towards the health goals set by the 1990 World Summit for Children. Joint activities by WHO and UNICEF should prove helpful to both organi­zations in their efforts to monitor implementa­tion of the health-for-all strategy and attainment

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. Geneva, World Health Organization, 1993

11

of the World Summit goals. At a meeting in October 1993 it was agreed that a joint UNICEF/WHO statement should be issued ex­pressing commitment to the monitoring process agreed to at the Summit, including assessment of mid-decade achievements. It was also agreed to expedite the preparation of comprehensive guidelines on health indicators.

Regional and national activities and policies

3 4 In the Americas the Second Ibero-Ameri­can Conference of Heads of State and Govern­ment and the XXXVI meeting of the Directing Council of PAHO/forty-fourth session of the Regional Committee for the Americas in Sep­tember 1992 adopted, in pursuance of the region­al strategy for health for all, a regional plan for investment in the environment and health. The plan, which specifies investments that will need to be made in Latin America and the Caribbean over the next 12 years, will be useful for guiding countries, institutions financing development, and cooperation agencies in remedying deficien­cies in drinking-water supply, wastewater treat­ment, basic sanitation services and other envi­ronmental health measures.

3 5 WHO supported activities to improve the health of the underprivileged in Bangladesh, India, Mongolia, Nepal and Thailand, following a 1991 consultation on this subject which had recommended the adoption of a strategy linking 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 underprivi­leged at their ninth meeting (Male, March-April 1993).

THE WORK OF WHO 1992-1993

3 6 Implementation of the health-for-all poli­cy in Europe progressed steadily despite major changes and the diversity of conditions in the Member States, many of which now have nation­al policies based on the European regional poli­cy, an updated version of which was published in 1993\ or have explicitly incorporated elements of it into their legislation and policy documents. Meetings and other activities took place during the biennium in preparation for a 1994 European conference on health policy, at which partici­pants will take stock of developments, explore new avenues for participation with organizations such as the Council of Europe, the Commission of the European Communities and OECD, and consider ways to ensure that health for all is the goal pursued by European Member States for the remainder of the century and beyond.

3.7 In Europe a "regions for health" network was established in 1992, with an initial grouping of 11 regions: 10 in Belgium, France, Germany, Spain, Sweden, Switzerland and the United King­dom, and a Baltic region comprising Estonia, Latvia and Lithuania. In order to accelerate the implementation of national health policies, it was felt that regions should work together to promote the health-for-all policy according to a strategy that emphasizes dynamic alliances, cooperation to improve health at regional and local levels, trans­fer of knowledge, the organization of high-quali­ty, effective services without waste or unnecessary duplication, and intersectoral action that makes health for all a common responsibility. A first annual meeting (Barcelona, Spain, October 1993) examined practical examples of ways to orient health professionals towards health promotion.

Health for all and economic development

3 8 In many of the poorest countries, public resources for health have been seriously reduced owing to recent macroeconomic developments,

1 Health for all targets the health polrcy for Europe Copenhagen, World Health Organization, 1993 (Health for All Senes, No 4).

12

and it has therefore become even more necessary than ever for decision-makers to design health policies that take this fact into account. Deter­mining and assessing economically feasible op­tions for the financing, delivery and administra­tion of health services is an important compo­nent of WHO's initiative for intensified coop­eration with countries and peoples in greatest need, which tackles urgent problems but is also concerned with priorities among human needs (see paragraph 4.11).

3 9 In June 1992 an international conference considered the link in countries in greatest need between the macroeconomic environment and health, examining in detail such issues as health and economic growth, policies for macroeco­nomic adjustment and for the elimination of pov­erty, and macroeconomic aspects of health financ­ing. Case studies were presented on Bolivia, Chad, Guinea, Guinea-Bissau, Malawi, Mali and Nepal as well as Latin America and the Caribbean as a whole; they showed how the macroeconomic en­vironment affects health conditions and how it influences the establishment or adjustment of health policies and health financing schemes.

310 WHO contributed to the preparation of the World Bank's 1993 report,2 which examines the interplay between human health, health policy and economic development. This report was used as a point of departure by more than 150 repre­sentatives of bilateral and multilateral aid agencies, foundations, international organizations and de­veloping countries at a major conference support­ed by WHO and the World Bank and hosted by the International Development Research Centre (Ottawa, October 1993 ); this conference provided an opportunity to establish a framework for pro­moting partnerships so that external aid can be used more effectively for improving health in the developing world. One of the main aims of WHO's contribution will be to reinforce the capacity of countries to formulate and implement effective health policies, thereby facilitating their access to external support.

2 World Bank. World development report 1993 rnvestmg in health. New York, Oxford Unrversity Press, 1993

CHAPTER 4

Health system development

Assessment of global health situation and future trends

4.1 Data collected during the second evalua­tion of the Global Strategy for Health for All by the Year 2000 have been entered into WHO's health-for-all database. Two documents in­tended as an aid to ensuring consistency of data disseminated by WHO programmes were updat­ed: one, on global health situation and projec­tions1, provides agreed estimates for many dis­eases and causes of death, and the other, on de­mographic data for health assessment and projec­tions2, presents United Nations data in a conven­ient tabular format. The World health statistics annual provided analyses of the health situation and trends in addition to the latest statistics on causes of death. The World health statistics quar­terly dealt with such themes as demographic trends, aging and noncommunicable diseases, di­abetes, violence and health, and mortality from cardiovascular diseases in developing countries. A regional bulletin provided information on the health situation, health programmes, demogra­phy and socioeconomic conditions in South-East Asia during the period 1988-1990.3

4.2 A network of over 300 experts on health monitoring, evaluation and "futures studies" has proved useful for sharing findings with a view to better management of health systems. In July 1993, a consultation on "health futures" 4 looked at ways to apply futures studies to support health policy formulation and health system reform; many methods, including some from developing countries, were considered promising. It is pro-

1 Document WHO/HST/92 1. 2 Document WHO/HST/GSP /93.2. 3 Document SEA/HS/186 4 Document WHO/HST/93 4.

13

posed to set up an enhanced network for sharing methods, expertise and training opportunities, and WHO will apply some of these techniques in its analysis and formulation of health policy and strategy. A regional consultation (Prague, July 1992) discussed the present environment and fu­ture trends of health in Europe, and considered the implications for health action.

Country health information development

4 3 Missions were organized to Cambodia, Guinea-Bissau and Maldives under WHO's in­tensified cooperation initiative and also to Bangladesh where WHO is responsible for de­veloping the management information system for health and for strengthening the Institute of Epidemiology, Disease Control and Research in Dhaka as part of the World Bank's fourth pop­ulation and health project. Support, including the organization of workshops, was given for strengthening national health information sys­tems including the improvement of medical records systems in Cambodia, Fiji, Marshall Is­lands, Micronesia (Federated States of), Samoa and T onga; surveillance of childhood diseases in Cameroon; phased implementation of a health information system in India; strengthening of national epidemiological capacity in Pakistan; health information support at district level in Togo; and cholera surveillance in Zambia. WHO also advised on the establishment of an emergen­cy monitoring system for former Yugoslavia.

4.4 As shown by the dramatic changes in Eu­rope, there is now an unprecedented demand for health information within national information systems. At the same time it is important to make health managers more "information-sensitive". For this purpose projects for training epidemiol­ogists in decision-making and management have

THE WORK OF WHO 1992-1993

been undertaken in the Americas and WHO is providing support for a special course on health data management in the Western Pacific. In the Eastern Mediterranean intercountry activities in­volving senior national staff were organized to promote the use of epidemiology for disease pre­vention and control; a regional advisory panel on health information systems was established; and a plan of action for the creation or improvement of a health statistics information system was prepared.

4 5 Progress has been made in developing methods for rapid evaluation and problem-solv­ing procedures for district teams. These have proved effective both for staff training and for planning and improvement of services, and have already been applied in programmes such as that on safe motherhood. Taking into account the new emphasis on public health action at district level, the type of information system required and the means for generating information to sup­port work at this level were discussed by an ex­pert committee in November 1993.

Epidemiological surveillance and statistical services

4 6 WHO continued to support Member States in the implementation of the International health regulations and to disseminate informa­tion through the Weekly epidemiological record and an annual update of the International travel and health booklet. A project on epidemiological surveillance systems was developed for the Cen­tral American countries. The risk of introduction of cholera in this subregion was assessed and disease outbreaks in Belize and Guyana were investigated by the Caribbean Epidemiology Centre (CAREC).

4.7 An informal WHO/UNICEF consulta­tion in December 19921 made operational recom­mendations for measuring cause-specific and overall mortality in children, especially in the absence of civil registration systems, in the con­text of monitoring the health goals set by the 1990 World Summit for Children. A subsequent meeting of experts drafted questionnaires to be used during verbal autopsies as well as a protocol for their evaluation.

1 Document WHO/ESM/UNICEF /CONS/92 5

14

4.8 Epidemiological and statistical support was given to various WHO technical programmes such as those on cardiovascular and tropical dis­eases. Advice was given on database management for national control programmes, including geo­graphical information systems; development of new health and service indicators; and evaluation of health care systems. Work is also being done on developing methods for the analysis of data from multiple sources as well as new epidemiological methods, including non-conventional procedures and multiple-cause analysis. Countries in Europe are being asked to study and describe the measures they use and report their findings in order to iden­tify cultural differences that may affect measure­ments of the quality of life.

4 9 The WHO statistical information system (WHOSIS) was upgraded to make it more func­tional and accessible, and a limited version is now available internationally over Internet, the worldwide computer network. WHO also col­laborates within the Consortium for Interna­tional Earth Science Information Network (CIESIN) to ensure international access to its databases. The Regional Office for the Eastern Mediterranean now has its own health statistics database on its local area network system, thus facilitating the use of health information by pro­grammes and countries. WHO cooperated with the United Nations Statistical Commission, no­tably by presenting a review of statistical activi­ties related to health at the twenty-sixth session of the ACC Subcommittee on Statistical Activi­ties in April 1992. WHO contributed to the World Bank's 1993 report/ especially in the assessment of the global burden of disease. PAHO/WHO continued to collaborate with the Organization of American States on strategies to improve the coverage and quality of vital statis­tics in the Americas.

International classification of diseases and other health-related classifications

4.10 Volume 1 (tabular list)3 of the tenth revi­sion of the International Classification of Dis-

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· /ems. Vol. 1 Geneva, World Health Organizatron, 1992

HEALTH SYSTEM DEVELOPMENT

eases (ICD-10) was published in English in 1992 and French in 1993; volume 2 (instruction manu­al)1 was published in English in 1993, and the French version is in preparation; volume 3 (al­phabetical index) is in press in English and in preparation in French. PAHOIWHO is prepar­ing the Spanish versions. National versions and other health-related classifications are being pro­duced in collaboration with WHO technical pro­grammes, scientific associations and nongovern­mental organizations. A three-character version of I CD-1 0, containing the rules, definitions, standards and its own index, is being prepared in English and French to meet the needs of develop­ing countries. The mechanism for updating ICD between revisions has been tested and proved to be feasible. A first international computer-based course for reorientation of trained coders in the use of ICD-10 (Southampton, United Kingdom, April 1992) brought together participants from five regions, who will now be able to train other national coders. Regional training courses for early implementation of ICD-10 have been un­dertaken. A meeting was held to prepare the revision of the International Classification of Impairments, Disabilities and Handicaps2

(Zoetermeer, Netherlands, March 1992), and a reprint incorporating a foreword and a number of corrections to the original version was issued in January 1993. On the occasion of the twenty­seventh session of the ACC Subcommittee on Statistical Activities held in Geneva, the cente­nary of the ICD was commemorated on 7 Sep­tember 1993 in collaboration with the Interna­tional Statistical Institute, the Swiss Federal Of­fice of Statistics and the United Nations Statisti­cal Division.

Intensified cooperation with countries and peoples in greatest need

4.11 Health policy and strategy development is a crucial issue for countries undergoing political and economic reforms and/ or transition from emergency to recovery and rehabilitation. It is therefore a major thrust of the WHO initiative

1 International statistical classdlcat/On of d1seases and related health prob· /ems. Vol 2 Geneva, World Health OrganiZatiOn, 1993

1 InternatiOnal classification of lmpalfments, d1sabiilt1es and hand1caps A manual relatmg to the consequences of disease. Geneva, World Health Organization, 1980.

IS

Intensified WHO cooperation

• The chronic global economic recession of the past decade has made it even more difficult for very poor countries to meet the health needs of their populations, and consequently the gap in health service coverage between these countries and the rest of the world has widened. It was against this background that WHO, in 1989, launched the initiative that has come to be known as intensified cooperation with countries and peoples in greatest need. It seeks to coordinate resources and programmes and mobilize international commitment to meet health and develop­ment needs on a country-by-country ba­SIS.

The initiative is country-specific since it is recognized that there are considerable varia­tions not only in the health problems of countries but also in their human and finan­cial resources and the effectiveness of their health systems. The aim is therefore not merely to provide expert advice, but to en­sure that staff of both governmental and other agencies are equipped to fulfil their responsibilities. This is a particularly impor­tant requirement for ensuring sustainability of health development in very poor coun­tries.

Agreement to launch activities under the WHO initiative in a given country is fol­lowed by a joint analysis by WHO and national staff of the different aspects of health development, including the eco­nomic and institutional environment for the provision of health care, and an assess­ment of the form and volume of contribu­tions by donor agencies and the role of private and nongovernmental organiza­tions. The aim is to identify critical strate­gic issues in health development, areas where resources are most urgently needed, and options for action.

for intensified cooperation with countries and peoples in greatest need (see box).3 Activities in

'The 1n1t1at1ve 1s currently being Implemented in 25 countr1es. Bangladesh, Ben1n, Bol1v1a, Cambod1a, Cape Verde, Central Afr1can Republic, Chad, Dpbouti, Eth1op1a, Guatemala, Guinea, Gu1nea·B1ssau, Ha1t1, Loo People's Democratic Republ1c, Mald1ves, Mongol1a, Mozambique, Myanmar, Nepal, Sao Tome and Pr1ncipe, Uganda, V1et Nom, Yemen, Za1re, Zamb1a

THE WORK OF WHO 1992-1993

this area during the biennium included support to the ministries of health in Mongolia, Mozambique, Yemen and Zambia in reviewing their health policy and implementing health systems reform.

4 12 National policy-making is not the only entry-point for WHO intervention; attention is also given to decentralization and reorganization of health systems. Provincial and district man­agement was in fact the immediate priority in Guinea-Bissau and the Lao People's Demo­cratic Republic. However, strengthening of health management at this level was not an end in itself, and the management teams were subse­quently able to play a more active role in national policy development, with a clearer idea of how the other levels should be supported from the centre.

4 13 Developing capacity for economic analy­SIS 1s another important element of the WHO initiative. In Nepal WHO helped to establish an interministerial task force on health economics, which is now in a position to analyse the health development implications of different scenarios in relation to economic growth and the availabil­ity of external financing.

4.14 Partnership with other development agen­cies (see paragraph 2.26) ensures conformity with national policy, joint project preparation and co­ordination of funding and is likewise an important feature of the WHO initiative. In Bangladesh do­nor coordination for the country's fourth popu­lation and health project is managed by theW orld Bank through a donor consortium. WHO is the executing agency for 21 of the 65 project compo­nents, making it possible to coordinate all the dis­ease control components and giving the Organi­zation an influential voice in the consortium.

415 The WHO initiative is also concerned with supporting governments on aid manage­ment. The new national health policy in Mozam­bique, for instance, forms the basis of a long­term health development plan, which the Gov­ernment will be able to use to coordinate external cooperation and ensure that it focuses on the country's priority needs. For this purpose, WHO staff introduced Ministry of Health offi­cials to computer software programmes that can be used to keep track of the volume, purpose and disbursement of donor funds.

4.16 Finally, strengthening and integration of disease control is an important thrust of the

16

WHO initiative, as in the Bangladesh project. In Guatemala a training programme on acute com­municable diseases control and sanitation sur­veillance on farms with migrant workers was set up, and has significantly reduced cholera out­breaks. Similarly, an intersectoral approach to cholera control was developed in Zambia.

4.17 Demand for support through the WHO initiative is expected to increase in the future and experience indicates a need to concentrate on the following areas: integration of health into overall socioeconomic development, and poverty allevi­ation; better use of economic analysis in identify­ing policy options and guiding health sector re­form; improved management of external aid; bet­ter coordination of support by different United Nations bodies at country level; and establish­ment of a stronger link between activities of the WHO initiative and the Organization's overall resource allocation to the countries concerned, so as to focus WHO country budgets on key strategic issues.

Technical cooperation among developing countries (TCDC)

4.18 An interregional consultation on pro­gramming of technical cooperation among devel­oping countries in health Qakarta, February 1993) examined country experiences and made recommendations for strengthening this initia­tive. It considered strategies for promotion and advocacy, recommended the establishment of national focal points for TCDC in health and considered the monitoring, evaluation and fi­nancing of activities. The report of the consulta­tion was discussed by the seventeenth meeting of Ministers of Health of Non-Aligned and Other Developing Countries (Geneva, May 1993), who adopted a resolution on this subject.

419 Examples of global and regional activities undertaken during the biennium include support to the Caribbean Cooperation in Health initia­tive; technical cooperation in pharmaceuticals among ASEAN countries; and TCDC in re­search, development and research training in hu­man reproduction, including family planning (see paragraphs 10.36-10.41). In the latter activity encouragement is given to efforts such as prepa­ration of research protocols whereby advanced institutions in developing countries support in­stitutions in other developing countries. It is

HEALTH SYSTEM DEVELOPMENT

planned to invest some $ 1 million in these coop­erative activities during the next biennium, with the Rockefeller Foundation providing one-half of this sum. WHO actively participates in interagency work in TCDC, including that of the United Nations High-Level Committee on the Review of Technical Cooperation Among De­veloping Countries and the UNDP Special Unit for TCDC.

Health systems research and development

4 20 Many countries have initiated activities in health systems research, which is now generally recognized as an effective method for acquiring information needed for rational decision-making in health management. WHO has sought to en­courage such work, to strengthen national capaci­ties and to ensure sustainability in these efforts. A global working group (Lilongwe, November 1993), bringing together international experts and representatives of nongovernmental organiza­tions, international health research programmes and donor agencies, endorsed this strategy and set long-term priorities for the strengthening of re­search institutions, cooperation with other insti­tutions and individuals, and consolidation of knowledge in areas of concern to many countries.

4.21 Bridge, the international newsletter on health systems research supported by the Interna­tional Development Research Centre (Canada), continued to appear three times a year in English and- in collaboration with WHO regional offices­Arabic and Spanish. It currently covers some ten international health research networks informally organized into a consortium known as the Puebla Group which facilitates cooperation among health researchers in Africa, Latin America and Asia. A first directory of training programmes in health services research, providing practical information on some 150 training programmes, was produced in collaboration with the Foundation for Health Services Research (USA). WHO supported re­gional meetings in Africa (Kampala, April 1992; Mbabane, May 1993; Lilongwe, November 1993) and theW estern Pacific (Malaysia, 1993) as well as country meetings (Madagascar, Morocco, Namibia, Nigeria, Philippines, Thailand), bring­ing together decision-makers in governments, nongovernmental organizations, the academic world and research, in order to reinforce commit­ment to health systems research.

17

4.22 Through the Network of Community­oriented Educational Institutions for Health Sci­ences, WHO has promoted health systems re­search in some 15 medical schools in different regions. University task forces to strengthen re­search capacity were established in the United Republic of Tanzania, Zambia and Zimbabwe. An anthology of health services research was published by PAHO/WH0.1 A separate budg­etary allocation for institutional strengthening grants was established in South-East Asia, and response to this scheme has been generally fa­vourable. A workshop was held in collaboration with the European Medical Research Council to support countries of eastern and central Europe in reorganizing their health research administra­tions and to promote information exchange among European countries. A meeting was con­vened to devise strategies to improve coopera­tion between ministries of health and universities in the Eastern Mediterranean (Cairo, June 1992). To increase inputs from social sciences into health systems research, collaborative activities have been pursued with the International Forum for Social Sciences in Health and its regional net­works. A third interregional training work­shop for senior research managers (Cuernavaca, Mexico, July 1992) was held to promote net­working in this field between lead institutions; this was followed in 1993 by regional training courses in Malawi and Thailand.

4.23 WHO, PAHO and the International De­velopment Research Centre (Canada) have pro­duced a five-volume set of training guides2 pro­viding instruction for all levels of health profes­sionals, researchers and managers in the concepts and practice of health systems research; volume 2 contains the core course, volume 1 is intended for decision-makers, volume 3 for researchers and academics, volume 4 for research managers and volume 5 for those who plan to teach.

4.24 The project on health systems research for southern Africa, administered jointly by WHO and the Ministry for Development Cooperation and the Royal Tropical Institute of the Nether­lands, has been extended for a second phase of four years (1992-1995) during which infrastruc-

1 White KL et al., eds Health se!VIces research an anthology. Washrngton, Pan American Health Organizatron, 1992 (Screntrfrc Publication, No. 534).

2 Available from. Communications Drvisron, IDRC, PO Box 8500, Ottawa, Ontarro, Canada KIG 3H9.

THE WORK OF WHO 1992-1993

ture and institutional arrangements in the 13 par­ticipating countries will be further strengthened and the experience applied to other countries (Cameroon, Ghana, Kenya, Nigeria, Uganda) and other regions. The fourth intercountry workshop on this project (Lilongwe, November 1993) reviewed achievements, identified areas re­quiring additional efforts, and recommended strategies for consolidating this work. Innovative approaches for further institutionalizing health systems research have been developed through regional task forces and meetings (Teheran, J anu­ary, 1992; Cuernavaca, Mexico, August 1992; Copenhagen, October, 1993; Y angon, October, 1993). A number of countries (India, Indonesia and Myanmar) have made specific provision for health systems research in their national budgets. Effective partnerships for the application of re­search in solving priority problems have been established both within the Organization, for in­stance with the leprosy, human reproduction, tuberculosis, nursing and AIDS programmes, and with other bodies such as the nongovern­mental Council on Health Research for Devel­opment, UNICEF in respect of the Bamako Ini­tiative, and the Washington-based International Health Policy Programme.

Health legislation

4.25 Major developments in health and envi­ronmental legislation occurred in many Member States during the biennium, for example in sup­port of the health reforms in countries of central and eastern Europe. WHO seeks to facilitate such reforms, notably by supplying reliable in­formation but also through direct technical co­operation. Thus consultant services were provid­ed to some 20 countries, and national workshops were organized in several countries, including China, India and Pakistan. WHO also cooperat­ed extensively with the Russian Federation. In an innovative project PAHO/WHO worked di­rectly with legislatures in the Americas, drawing up model health legislation in priority areas and preparing comparative analyses.

4 26 The cornerstone of WHO's work in in­formation transfer at global level remains the quarterly International digest of health legisla­tion, which serves as a clearing-house to give Member States necessary information in user­friendly form. Documentation available to WHO is also communicated in forms such as

18

databases; so far these are available in priority fields of legislation including HIV I AIDS, tobac­co or health, and organ transplantation. The LEYES database, containing an index to Latin American and Caribbean health legislation, con­tinues to be produced by PAHOIWHO, and is now available on compact disc. A computerized listing of health legislation enacted or issued in Europe in 1990-1991 was produced in 1992.

4.27 Technical support took diverse forms in the different regions. The Regional Office for Africa has received an unprecedented number of requests for cooperation, and has undertaken an evaluation to measure the impact of legislation at national, district and community levels. A high level of interest in patients' rights in Europe led to a study on this subject, the results of which have been published.1 WHO is working closely with Member States in the Eastern Mediterra­nean to establish, on the basis of precise legal standards, an appropriate health legislation framework which is perceived as a prerequisite for effective utilization of health resources. In the Western Pacific WH 0 is cooperating with coun­tries in the formulation or revision of legislation, so as to provide a sound foundation for the pro­motion and implementation of national health policies and strategies. Indeed, in most parts of that Region, health legislation is now seen as a means of promoting beneficial change rather than merely curbing abuses. In China coopera­tive activities focus on the development of new forms of legislation to deal with priority issues such as health care financing and the registration of health professionals. Throughout theW estern Pacific particular emphasis is placed on using legislation to support action on health priorities such as the effective deployment of human re­sources, financial viability and quality of care.

4.28 WHO monitors and reports on all signifi­cant international, national and subnationallegal instruments dealing with HIV I AIDS, and was closely involved in meetings at which legal, hu­man rights and ethical aspects were discussed. It also monitors laws and other measures for imple­mentation of the International Code of Market­ing of Breast-milk Substitutes. Workshops were convened to discuss policy issues relating to ap­plication of the Code at national level, and direct

1 See Leenen HJJ, Gevers JKM, Prnet G. The nghts of patients m Europe· a comparative study. Deventer, Kluwer Law and Taxation Publrshers, 1993

HEALTH SYSTEM DEVELOPMENT

support was given to countries in the preparation of implementing legislation.

4 29 An intercountry meeting on health legis­lation (Cairo, December 1993) provided an opportunity to exchange information and expe­rience and to promote the concept of health legislation as a tool for strengthening health pol­icies and strategies. WHO was involved in prepa­rations for the World Conference on Human Rights (Vienna, June 1993), for which it drew up position papers and commissioned a major re-

19

port on human rights in relation to women's health (see paragraph 9.3). The Organization was also represented at United Nations meet­ings on human rights issues and cooperates closely with the United Nations Centre for Hu­man Rights. Similarly, close working relations are maintained with other agencies and bodies with an interest in health legislation, within and outside the United Nations system. In the field of bioethics, close links were maintained, in par­ticular with UNESCO, the Council of Europe and CIOMS.

CHAPTER 5

Organization of health systems based on primary health care

National health systems and policies

Health economics and financing

5.1 A guidebook on health insurance for poli­cy-makers was prepared jointly with ILO and used as a basis for appraising insurance options in Ghana. It proved useful in reaching agreement among interest groups concerning the benefit package provided as part of a new social insur­ance scheme, and showed that partial population coverage would be necessary at first. A Russian version was used as a background document for an intercountry consultation on health financing, attended by m1msters from Kazakhstan, Kyrgyzstan and Uzbekistan (Almaty, December 1993). Further studies on cost recovery mecha­nisms were supported in several countries. Of particular interest are the effects of charges on service utilization by women and children, and the reactions of communities. Studies in Ghana and Kenya led to reviews of exemptions practice and of banking arrangements for the protection of revenues. Studies of alternative financing op­tions were undertaken in several countries.

5.2 In its report' a WHO study group re­viewed recent changes in the methods used in different countries to finance health services. A network was established to provide expert advice on the financing and economics of health services in central and eastern Europe. Similarly, a perma­nent forum for the exchange of views and experi­ence was established to support European Mem­ber States undergoing reforms in health care management and financing. A meeting was held

1 WHO Techn1cal Report Series, No. 829, 1993.

21

to look at ways of coping with the increasing demand for health services with limited resourc­es (Kiel, Germany, November 1992). Health leaders from 12 countries met (Madrid, June 1992) to discuss such issues as contracting of health services, and public and private responsi­bility for health care. An intercountry consulta­tion of ministers of health (Windhoek, October 1993) reviewed experience of user fees, social in­surance innovations, management of private in­surance and of the non-profit nongovernmental sector, and identified needs for technical cooper­ation.

53 In June 1993 a 12-month international master's programme in health economics began at Chulalongkorn University in Bangkok, cosponsored by WHO and the World Bank; some fellowships were reserved for participants from countries such as VietNam that are receiv­ing intensified WHO cooperation. Intercountry seminars and workshops on health economics were organized with WHO and World Bank support at the National Institute of Public Health in Algiers, which now has a health eco­nomics unit and resource centre.

Organizational change

5.4 Many countries have expressed the inten­tion to pursue decentralization policies, but have not made significant progress; and in some in­stances decentralization has led to neglect of so­cial services in favour of directly productive sec­tors. A series of studies was therefore undertaken with support from NORAD to examine the question of decentralization and health develop­ment in the light of experience in countries, par­ticularly Botswana, Kenya and Uganda. Prelimi­nary findings indicate that inadequate capacity at the periphery to take on enlarged responsibilities

THE WORK OF WHO 1992-1993

and to demonstrate results are obstacles to the implementation of sometimes ambitious decen­tralization policies.

5 5 In Africa the accent was on reorienting health systems towards clear implementation of primary and community health care. Thus the Regional Committee examined the question of restructuring provincial and local hospital net­works in 1992, and related activities are in progress. Infrastructure development was the subject of the 1993 Technical Discussions, with emphasis on the formulation of national plans of action.

5.6 Bangladesh, with WHO support, under­took a review of the functions and structure of the Ministry of Health and prepared several pro­grammes for financing by the World Bank and donor agencies. Bhutan reviewed its health de­velopment programme in the context of its na­tional plan. A radically revised organizational structure for the Ministry of Health in Ghana was established with WHO support. One inno­vation was the replacement of vertical pro­grammes by a central coordination and research division with an advisory and standard-setting role; new procedures for resource allocation and financial management were also introduced. Sim­ilarly, Mongolia reviewed the structure and func­tions of its Ministry of Health. A WHO team helped to assess obstacles to integrated service delivery in Namibia, and proposed a restructur­ing of the Ministry of Health and Social Services on a functional basis rather than according to professional allegiances and interests. The Organization also worked with the Ministry of Health of Zambia in planning sweeping policy reforms in respect of decentraliza­tion, public participation, financing and relations with the nongovernmental sector. Joint pro­gramme reviews were carried out by WHO and national staff in most Eastern Mediterranean countries.

Management of physical resources for health

57 Studies on health care equipment manage­ment were carried out in Botswana in coopera­tion with GTZ, NORAD, the British Overseas Development Administration and the University of Sussex (United Kingdom), and in Cameroon with support from GTZ, the Rockefeller Foun-

22

dation, and the British Columbia Institute of Technology (Canada). A paper was prepared on the planning and financing of medical equip­ment.

5.8 Close cooperation continued with train­ing institutions in London, Lyon, Mbabane and Nicosia. Following the closure of WHO projects in Sierra Leone and Togo, agreement was reached for GTZ-supported centres in Mombasa (Kenya) and Diourbel (Senegal) to serve as regional training centres. Training courses for republics of the former Soviet Un­ion and countries of central and eastern Europe and Latin America were organized in Boston (USA) jointly with the American College of Clinical Engineering, the American Interna­tional Health Alliance, the International Feder­ation for Medical and Biological Engineering, UNICEF and UNIDO. Support was given to workshops on maintenance and repair of health care equipment in Afghanistan, Cyprus, Egypt, Jordan, Syrian Arab Republic, Tunisia and Yemen. The WHO collaborating centre in Cy­prus continued to offer training for staff from Africa, South-East Asia and the Eastern Medi­terranean. A centre for the maintenance and repair of medical equipment was opened in Damascus in 1992.

5.9 In the area of physical infrastructure and maintenance, PAHO/WHO cooperated directly with 14 engineering and maintenance pro­grammes at health establishments in the Ameri­cas, and disseminated technical information, bib­liographic material, and information on profes­sional and technical training facilities to all such establishments.

5.10 The role of health facilities planning for quality improvement was discussed at an inter­national public health seminar (Buenos Aires, May 1992) organized by the International Hos­pital Federation, the public health group of the International Union of Architects and WHO. Guidelines for health facilities planning were dis­cussed at a follow-up meeting. Problems of physical infrastructure faced by countries of cen­tral and eastern Europe were examined during the conference of the International Hospital Fed­eration (London, October 1992); and questions of cost-conscious planning, design and mainte­nance of health care facilities were subsequently explored at a joint conference of WHO and the International Union of Architects (Chicago, USA, June 1993).

ORGANIZATION OF HEALTH SYSTEMS BASED ON PRIMARY HEALTH CARE

District health systems

Improved service delivery

5.11 A community-based development strategy in which components for health, functional litera­cy and income generation are integrated was test­ed in an urban slum district of Cairo (see box). A national agency for primary health care promo­tion was established in Nigeria with WHO sup­port following a review in 1992. The Ministry of Health of Zimbabwe tried out different strategies for linking community health development with the district health system, whereby people in com­munities have, for instance, been trained by health centre staff to carry out basic preventive and cura­tive procedures. Participants in an interregional consultation (Bandung, Indonesia, 1993) noted that the main lesson to be learned from experience in countries is that a district health system cannot work without simultaneous changes in central ad­ministration and regulation.

5.12 As part of efforts to strengthen local health systems, meetings were organized in seven Latin American countries and for the English-speaking Caribbean countries, to analyse local management processes and to introduce managerial and leader­ship mechanisms. The organization and financing of health services, administration in local health systems, leadership, management information systems, project management and strengthening of training institutions received particular atten­tion 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 dis­seminate a methodology for comprehensive eval­uation, with a view to promoting greater efficien­cy, effectiveness and equity. An intercountry con­sultation (Lome, September 1992) brought to­gether 14 national experts from five African coun­tries to discuss information support for district management.

5 13 In response to repeated complaints by ministries of health about lack of coordination and wasted time and effort when several training programmes are arranged for the same staff, in 1992 WHO embarked on a project to produce learning materials that concentrate on problem­solving, and to build up the technical and mana-

23

The Ain Shams proiect

• Vulnerable groups exist in all societies: women and children are especially likely to lack access to food, water, shelter and sanitation and consequently to be in poor health. Such was the case in the Ain Shams district of Cairo, which gave its name to a project involving five countries (Egypt, Ghana, Nigeria, Zambia and Zimbabwe) aimed at improving the health of the poor­est women. In five districts - one in each country- there was emphasis on function­alliteracy for women, viable economic ac­tivities and community-based health serv­ices as the key components in improving women's health and that of their families and the community as a whole. The Ain Shams project, now completed, provided lessons in the empowerment of vulnerable groups. It resulted in improved literacy among women with little or no education, and the setting up of community-based health services including a health centre and clinics, 24-hour emergency services, outreach services for maternal and child health, and a referral system. In addition, profit-making economic activities were established and community-managed de­velopment projects were organized, such as creating a park, building sanitary facili­ties and improving roads and lighting.

gerial capacity of health teams at local and dis­trict levels, using such materials, combined with supportive supervision and performance moni­toring, to enable better integration of health serv­ices. The importance of improved management at district level for overall programme coordina­tion was demonstrated in Malaysia and the Phil­ippines in the course of a 1992 review of projects in the Western Pacific.

Health development structures

5.14 A study of the effectiveness of the health committees and boards and other health devel-

THE WORK OF WHO 1992-1993

opment structures that have been established at various levels of district health systems in many countries began after a global framework had been agreed upon at a planning meeting attended by investigators from Colombia, Indonesia, Jamaica, Nigeria, Philippines, Senegal, Sudan and Yemen in February-March 1993. An inter­country workshop on primary health care devel­opment (Cairo, April 1993) devised approaches for strengthening local and district planning so as to ensure that each health facility, public and nongovernmental, has clearly defined responsi­bilities for health care within its specified catch­ment area.

Urban health

5.15 Following a WHO workshop in March 1993 hosted by the urban health group of Nijmegen Catholic University (Netherlands) with the collaboration of the Swiss Tropical In­stitute and the London School of Hygiene and Tropical Medicine, proposals on research and de­velopment were prepared for the cities of Dar es Salaam, Jakarta, Kingston, Managua and Mirzapur (India) and presented to the Nether­lands Government for financing. In Africa a first 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 repre­sentatives of 14 cities and five nongovernmental organizations from eight countries. A network of African Healthy Cities is being set up, for which preparatory activities were initiated in Accra and Ibadan (Nigeria).

5.16 Approaches to urban health development were discussed at a regional meeting (Harare, November-December 1993) jointly sponsored by WHO and GTZ. Preparations were made for studies of the effects of environmental and hous­ing factors on urban public health, to be carried out in Ibadan (Nigeria) in 1994. Most cities in South-East Asia have launched extensive urban development programmes for slum-dwellers. The European Healthy Cities project expanded to involve over 500 cities. Guidelines for project development were issued. 1 Policies for improv­ing the health of the urban poor were discussed at an interregional meeting (Manila, August 1993 ). The topics covered included ways of extending coverage through health care reform, and ap­proaches for achieving environmentally sustain-

24

able urban development. The World Bank and other agencies support these initiatives, in which WHO plays an important technical role, includ­ing the publication of materials.

5.17 One aspect of urban health development is the correct role to be played by each level of health facility. Self-referral to hospital, by-pass­ing the health centre, is a common phenomenon in urban areas where hospitals are the sole pro­viders of complex care. In addition, health servic­es in urban areas are frequently organized in a way that is not conducive to community involve­ment. 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, pre­viously requiring hospital admission. Known as "reference health centres" to distinguish them from traditional first-contact health centres, these facilities have been shown to bring appro­priate care closer to the population at only 25% of the cost of hospital interventions.2 Following pioneering work in Cali (Colombia) and cities in the United States of America, Europe and Asia, WHO is supporting the establishment of refer­ence health centres in Bangkok, Cairo, Harare, Jakarta and Manila as well as Bombay, Calcutta, Delhi and Madras in India.

Community involvement in health

518 The use of volunteer health workers was reviewed in several countries. The experience of Thailand's self-care programme was shared with other South-East Asian countries. An intercountry study on self-medication was be­gun in that region. Following a global study showing that traditional healers can be efficient community health workers, investigations were started in Africa, Asia and Latin America to de­termine the conditions necessary for success. Case studies of community involvement in health in Bolivia, Nepal and Senegal were repeat­ed in 1993; the findings underlined the impor­tance of national political leadership for the suc­cess of programmes, although a surprising degree of sustainability was found even without clear

1 Twenty steps for developmg a Healthy City pro1ect. Copenhagen, World Heolth Orgomzotion, 1992.

2 WHO Technrcol Report Serres, No. 827, 1992.

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 AT THE

DISTRICT HOSPITAL

Moellatl B. Oobsoo

GENERAL SURGERY AT THE

DISTRICT HOSPITAL

John Cook Batu S•nkate"

Ambfose e o. w .,.unna

SURGERY IT THE DISTRICT

HOSPITAL: OBstETRICS,

GYNAECOLOGY, ORTHOPAEDICS,

IMD TRAUMATOLOGY

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 radio­graphic 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 treat­ment 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 se­curity agencies, PAHOIWHO participated in work undertaken at the Inter-American Center for Social Security Studies (Mexico) relating to community participation and setting up manage­ment information systems. Globally, the move­ment towards participatory health development continues to grow slowly but surely, especially at local level.

Hospital performance and quality of core

5 19 Studies indicate that too little attention is paid to the performance of hospitals, a disturbing situation in view of the amount spent on them. An international workshop (Yaounde, November 1992), sponsored by WHO, GTZ and the Prince Leopold Tropical Institute (Belgium), drew atten­tion to the crisis affecting small hospitals that pro­vide services for large rural and urban populations while receiving little support from governments and donors. A seminar on hospital cooperation in Europe was convened jointly with the European Community (Strasbourg, France, November 1992). WHO gave support to Indonesia in testing 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 Mongolia in upgrading facilities such as peripheral hospitals; and to Myanmar in producing hospital procedure manuals. PAHO/WHO continued to provide technical support for the strengthening of hospitals in the Americas. Workshops and semi­nars were held in 10 countries for the purpose of revising hospital accreditation arrangements.

26

5 20 During the biennium WHO issued the re­port of a study group on the hospital in rural and urban districts/ documents on the hospital of to­morrow2 and on hospital economics and financ­ing,3 and guidelines for the development of district hospitals.4 A limited number of reference works were selected to form a "core library for doctors working in small hospitals" and this package was used in many countries (see Figure 5.1).

5.21 An interregional meeting (Pyongyang, October 1992) stressed the need to incorporate quality assurance in all aspects of a health sys­tem.5 WHO encouraged collaboration between institutions active in this field in developing countries, such as DANIDA, USAID, the Nether lands Government and the International Society on Quality Assurance. A joint consulta­tion on quality assurance in developing countries (Maastricht, Netherlands, June 1993) was organ­ized with WHO support through the collaborat­ing centre for hospitals and other health institu­tions in Utrecht. WHO issued a document on the use of standards, and cooperated with Saudi Arabia in producing a manual.6 A national work­shop on quality assurance was held in Zambia jointly with USAID and DANIDA.

1 WHO Techn1cal Report Series, No 819, 1992. 2 Document WHO/SHS/CC/92.1 3 Document WHO/SHS/NHP /92.2 4 D1stnct hosp1tals: gu1delmes for development. Manila, World Health Organ­

Ization, 1992 (Western Pac1f1c Ser1es, No 4). 5 Document SEA/HSD/180. 6 Guideline manual on quality of pnmary health care. R1yodh, M1n1stry of

Health of Saud1 Arab1a, 1993

CHAPTER 6

Development of human resources for health

6.1 Optimal performance by health personnel depends on effective training and management as well as proper planning. Rapid socioeconomic, political and technological changes have made planning difficult, yet the demand for cost-effec­tiveness, efficiency and accountability has ren­dered it more necessary than ever.

6 2 Against this background, budgetary con­straints have obliged WHO to explore new modalities of cooperation in the development of human resources for health. In particular more emphasis has been given to the involvement of collaborating centres, nongovernmental organi­zations, institutions and individuals in the Or­ganization's work. This experience has mostly been positive and has enabled WHO to maintain the scope of its activities despite the resource constraints.

Policy analysis, planning and management

6 3 Policy analysis for human resources de­velopment was given high priority during the biennium, with financial support from Japan. WHO prepared a draft manual on the subject, which was reviewed by an intercountry group (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 Mediterranean. Central American countries and the Dominican Republic have been involved in the development of methods to ensure better in­tegration of health teams and enhance their capa­bility to analyse local health conditions. The Technical Discussions held during the 1992 ses­sion of the Regional Committee for South-East Asia (Kathmandu, September) dealt with the bal­ance and relevance of human resources for

27

health, focusing on maldistribution and imbal­ance of staff, and the appropriateness of training to work requirements. Policy analysis was seen as vital to the solution of specific problems.

6.4 World Bank health sector loans to such countries as Bangladesh, China, Indonesia and Nepal have required the preparation of master plans for health personnel which pay particular attention to numbers, types and distribution. WHO has been involved in this process either directly (Bangladesh, Nepal) or in conjunction with World Bank consultants (China). Existing planning methods were reviewed by an interregional consultation (Bangkok, March 1992) which stressed the importance of decen­tralizing planning to the implementation level and of involving interest groups. A regional workshop (New Delhi, February 1993) dis­cussed planning and policy development for countries concerned by the WHO intensified support 1mt1at1ve; participants recommended that Member States carry out national reviews of their human resources for health, and draw up guidelines for this purpose. In China WHO organized a workshop (Shanxi, June-July 1992) to identify problems in planning for decentral­ized health management. Several other national workshops on different aspects of health person­nel planning and management were conducted.

Planning tools

6.5 Computerized planning tools were tested and improved with support from Japan. A com­pendium on planning is now available on dis­kette, with an operational manual. 1 Computer­ized supply and requirement projection models

1 Document HRH/93 5.

THE WORK OF WHO 1992-1993

were field-tested in the Caribbean (Barbados, Saint Kitts and Nevis, and Saint Lucia), China and Hong Kong. The work in China included the development of an information system in connec­tion with a World Bank health sector loan, and use of the projection models to determine whether the existing data were adequate for planning and whether the existing infrastructure would be re­ceptive to change; this approach highlighted the multisectoral nature of health workforce plan­ning. In the light of the positive experience, it is expected that these projection models will prove useful in a variety of ways ranging from the crea­tion of scenarios to the monitoring of staffing plans. A revised version of the models, based on the field-test results, will be available in 1994 to­gether with an operating manual. Health work­force planning manuals were also prepared in col­laboration with the Western Pacific Regional Training Centre in Sydney, Australia.

6.6 As a basis for planning, it is important for countries to develop their own health workforce norms in accordance with their policies and situa­tion. In this respect WHO is examining two methods: workload indicators of staffing need (WISN) and functional job analysis (FJA). WISN has been tried out in several countries in Africa, South-East Asia and theW estern Pacific, and FJA is seen as having the potential for overcoming traditional professional divisions of labour and thus allowing more efficient deployment of staff.

6.7 An interregional consultation Q akarta, June 1993) reviewed country experiences and identified areas for further study with regard to methodology for multiprofessional policy and 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 also tend to concern tertiary care settings in de­veloped countries. The WHO choice therefore reflects a compromise: methods that are relative­ly simple to use, but capture only significant events. One of the strategies being pursued is to form a core of people to help countries in their own region or outside it to use the methods.

Optimizing human resources for health

6 8 In many countries the problem is no longer one of shortage of health professionals but rather of establishing or maintaining the

28

right balance between them to ensure that the necessary knowledge and skills are available. A year-long experience in Thailand with the RADICAL~ method for optimizing human re­sources for health provided some information on its strengths and weaknesses, which were re­viewed at three meetings (Ayutthaya, Thailand, July 1992 and July 1993; Jakarta/Bandung, Indo­nesia, July 1993). There are indications that the method might be appropriate for countries with­out a strong planning tradition, although it clear­ly needs further refinement.

6.9 The public/private mix of human resour­ces for health was the subject of a meeting (Bang­kok, June-July 1992) which examined ways of harmonizing the two sectors, and in particular recommended strengthening the capacity of ministries of health to formulate national policies and plans covering both sectors. A consultation with leading medical practitioners in March 1993 examined political and practical aspects of pri­vate practice and public responsibility; it stressed the need to use both public and private services to provide improved access to affordable and high-quality health care. •

6 10 In Seychelles WHO supported a 1992 study on staff requirements and supply projec­tions, as well as management and training issues, and this was expanded in 1993 to cover capacity­building for planning and management within the Ministry of Health and strengthening of training programmes. The study gave high prior­ity to review of the responsibilities of nurses. This step-by-step approach may serve as a refer­ence for other countries with similar problems.

Management

6 11 Efforts are being made to create a health workforce information system that will capture data from both public and private sectors. A specific system for nursing/midwifery personnel is also being developed as an integral part of country and global data banks. This professional category poses a particular problem as the desig­nation "nurse" includes a wide range of educa­tional levels and responsibilities. The only corn-

1 RADICAL rs on acronym for Rapid DiagnoSIS, lmmedrote Concern, Action for Lasting Change.

DEVELOPMENT OF HUMAN RESOURCES FOR HEALTH

mon factor is educational level, which it is hoped will be translatable into comparable competencies.

6.12 Participants from Lesotho, Namibia, Swaziland and Zambia attended an intercountry workshop on leadership and management for nurses (Mbabane, April1992) with financial sup­port from the Kellogg Foundation. National meetings were subsequently held on this subject in the United Republic of Tanzania (Morogoro, October 1993) with NORAD support, and in Namibia (Windhoek, November 1993) with sup­port from the Kellogg Foundation. Requests for further support in management and leadership training have been received. To become truly self-sustaining, these activities have to be inte­grated into national action plans.

6.13 National workshops were organized on 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, particularly to make it less culture-specific, and the new version was used in a further workshop (Khartoum, October-November 1993 ). An intercountry workshop (Beirut, June 1993) pro­vided an opportunity for health managers to ana­lyse tasks and work out clear job descriptions, which should help to avoid duplication and strengthen management.

Continuing education

6 14 If there is one area where much has been talked about and consensus reached on its impor­tance, but without this being reflected in action, it is continuing education. Where difficulties exist to provide even basic training, this is not surprising. At the same time not everyone is convinced that continuing education should be an integral part of basic education. Fortunately there are some ex­ceptions. In the Americas work continued on the conceptual and methodological development of continuing education as an alternative approach to training in such fields as management, epidemiol­ogy, public health and nursing. Continuing edu­cation 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 projects with priority to district health personnel (Rabat, May 1992); it was hoped to extend this approach to other countries, but paradoxically

29

project implementation has not been very success­ful owing to lack of country support. N everthe­less, a first regional meeting (Tunis, June 1992) issued a statement underlining the need for each country to have a continuing education pro­gramme for all categories of health personnel as an integral part of its national health system. It rec­ommended the creation of a structure within the ministry of health that would be responsible for the planning, implementation and evaluation of the programmes. A manual on continuing educa­tion for health personnel has also been proposed. In Europe WHO is cooperating with the World Federation for Medical Education in a study on how continuing medical education could be im­plemented and supported. The possibility is being explored of establishing a forum to promote con­tinuing medical education to support health sector reforms in eastern and central Europe.

Nursing

6.15 A global advisory group on nursing and midwifery was established in response to Health Assembly resolution WHA45.5, and a first meet­ing held in November-December 1992; it rec­ommended that nursing/midwifery be declared a priority area for WHO action, that strategies be 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 prior­ity areas identified by the group, and attempts are being made to fill information gaps so as to facilitate monitoring and evaluation as well as planning and deployment. A headquarters coor­dinating committee streamlines the work of the different technical programmes in strengthening nursing/midwifery services and reviews WHO vacancies to ensure that whenever possible pro­fessionals other than physicians can also apply. A WHO study group on nursing beyond the year 2000, convened in July 1993, recognized that a multisectoral and multiprofessional ap­proach would be needed to prepare health care providers to work in a rapidly changing environ­ment. A European regional publication2 provid-

1 Document WHO/HRH/NUR/93 1. 2 Salvage J ed Nursing m actton strengthenmg nursmg and mtdwtfery to

support health for all World Health OrganiZation, Copenhagen, 1993 (European Ser1es, No 48).

THE WORK OF WHO 1992-1993

ed useful background information for the study group, whose conclusions in turn were used as input for the meeting of the global advisory group in November 1993.

6 16 In South-East Asia nursing education has tended to make greater progress than nursing services. An intercountry consultation on reorientation of nursing services in support of health for all (Kathmandu, December 1992) identified and promoted new approaches to col­laboration between nursing education and serv­ices in order to achieve the goal of providing high-quality nursing care. Both basic and further training of nursing personnel are a priority in all countries in the Eastern Mediterranean. In Egypt teaching modules and training packages have been developed and teacher training promoted. Pakistan has approved a new curriculum with emphasis on community orientation, and Yemen now offers a bachelor of science degree in nurs­ing in addition to a community-oriented pro­gramme. In the Western Pacific WHO cooper­ates with Member States in planning for nursing development. Ministries of health have estab­lished nursing units or strengthened nursing ex­pertise at central level. Computerized nursing management information systems have been cre­ated to support national planning units in Aus­tralia, Papua New Guinea and VietNam.

Educational development

6.17 Although a great deal of innovation has occurred in the education and training of health personnel, there seems as yet little consensus that it should be generally applied. As stressed by a study group on this subject in October 1992,1

problem-based learning must extend beyond lim­ited clinical confines into social and community issues if it is to realize its full potential. Although educational experience can undoubtedly be en­hanced if teaching institutions assume new re­sponsibilities in health care organization and serv­ice, this is beyond their traditional mandate and they will therefore need to build up new alliances and partnerships with professional associations, service organizations and the community.

618 Although WHO has moved away from the concept of global curricula, attempts are be-

1 WHO Techn1cal Report Series, No 838, 1993

30

ing made to identify those elements which define the quality of educational experience.2 Similarly, efforts are being made to understand the factors which facilitate change, and to establish common criteria so that monitoring of improvements in medical education and practice can be carried out globally. Four issues of a new bulletin, Changing medical education and medical practice, were dis­tributed during the biennium as well as a revised edition of the WHO guide for teachers of prima­ry health care staff.3

6.19 To build on the work of the 1988 World Conference on Medical Education, the World Federation for Medical Education, with support from WHO, UNICEF, UNESCO, UNDP and the World Bank, organized a further major con­ference in Edinburgh (August 1993) on the theme of societal changes and their implications formed­ical education. The conference considered such issues as the new skills being demanded of physi­cians, the economic impact of medical decisions, the importance of better communication with the community and individuals, and the growing con­sensus that radical reform is required to ensure that the skills of graduates who will practise in the 21st century will be relevant to the needs.

6.20 In Africa support was given in strengthen­ing the College of Medicine in Blantyre (Malawi) and the Faculty of Health Sciences in N'Djamena. Workshops were organized with the aim of adapt­ing medical education to community needs.

6 21 Participants in a regional consultation (New Delhi, February 1993) underlined the need for holistic strategies to achieve meaningful reorientation of medical education, as many ac­tivities at country level are still confined to the arena of institutional reform. To accelerate ac­tion, it was agreed that more attention must be paid to such issues as organizational develop­ment, programme evaluation, the use of health systems research and team approaches. A con­sortium of medical schools in India continued the second phase of the innovative project on "Inquiry-driven strategies for changing medical education". In Myanmar a twinning initiative was launched with the University of New Mexico in Albuquerque (USA) to test a strategy to reorient medical education using continuing edu-

2 Document WHO/HRH/92.7 3 Abbatt FR. Teachmg for better learnmg. a guide for teachers of p(lmary

health care staff, 2nd ed. Geneva, World Health Organization, 1992.

DEVELOPMENT OF HUMAN RESOURCES FOR HEALTH

cation and the medical association as entry-points. Activities related to training of allied health work­ers focused on improving staff capacity and curric­ulum reform. WHO supported Sri Lanka's Na­tional Institute of Health Sciences in making a comprehensive evaluation of different programmes for training allied health workers, and the Institute of Health Personnel in Maldives in upgrading the country's training programmes.

6.22 An intercountry workshop on training of trainers of health personnel in Eastern Mediter­ranean countries (Damascus, November 1992) discussed existing programmes in this region, the role of educational development centres in teach­er training and ways to increase trainer capabili­ty. Activities to promote the use of national lan­guages in medical education also progressed. WHO sponsored briefing visits of medical pro­fessors from Egypt, Sudan, Tunisia and Yemen to faculties in the Syrian Arab Republic for this purpose. Packages containing selected medical texts and reference works in Arabic have been distributed to all medical faculties.

6.23 In the South Pacific a three-point plan was introduced to revitalize the Fiji School of Medi­cine. A new category of health workers known as primary care practitioners graduated at the end of 1993 and will undergo one year's internship in their countries under the supervision of senior medical officers, for whom a workshop was or­ganized with WHO support (Suva, July 1993). Young health officers were recruited as faculty for the new programme.

6 24 Fellowships still remain an important part of the Organization's work, although there has been a falling trend in recent years and the figure for the 1992-1993 biennium (see Table 6.1) repre­sents a reduction of 875 over 1990-1991. To help ensure relevance of training to country priorities, the application form was revised to provide more details of applicants. A total of 207 new research training grants were processed in the areas of tropical diseases and human reproduction.

Public health training and research

6.25 A meeting of directors of schools of pub­lic health (Douala, Cameroon, December 1992), decided to establish a network of African institu­tions in order to strengthen training and research in this field. In the Americas analysis of current theo-

31

ry and practice of public health has become an important area of work, and two publications were issued.1 2 The seventh and eighth groups taking part in the regional residency programme in inter­national health graduated during the biennium. Learning modules produced in 1991 for a Euro­pean master of public health course are being re­vised. Educational policies, basic competencies and learning environments were discussed at a first meeting of the European Dialogue on Training in Public Health (Rome, June 1992) with a view to development of the course. A further meeting was held to review a strategy for training and research in public health (Copenhagen, November-Decem­ber 1993 ). Following discussion of aspects of pub­lic health training by the Regional Committee for the Western Pacific (Manila, September 1993 ), a database was established to promote cooperation between institutions and sharing of resources; this activity is a collaborative undertaking by WHO, the Asia-Pacific Academic Consortium for Public Health and the Regional Training Centre in Syd­ney (Australia). An intercountry workshop at which ten countries were represented (Sydney, July 1993) considered three aspects of public health training: availability and organization of resources, scope and approaches, and required developments. Participants prepared plans of action for their own countries.

Health learning materials

6.26 Technical support to networks of more than 30 developing countries was increased un­der the interregional health learning materials programme, which is financed largely from extrabudgetary sources. Meetings were held to plan future strategies and collaboration between projects (Harare, April1992), to examine project evaluation and planning in South-East Asian countries (Colombo, August 1992) and to ex­change experience of projects in nine English­speaking African countries (Nairobi, December 1993). An intercountry workshop (Damascus, November 1992) provided an opportunity for country coordinators to initiate research on the development of distance learning. Other work-

1 The msis of public health: reflections for the debate Washington, Pan American Health OrganiZation, 1992 (Scientific Publication, No. 540).

2 International health a north south debate. Washmgton, Pan American Health Organization, 1992 (Human Resources Development Series, No. 9 5).

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 or­ganized on key issues such as project manage­ment, writing and editing, distance learning and educational methods, and also on field-testing and evaluation, which was the subject of a meeting (Kigali, September 1993) with participants from nine French-speaking countries. Unfortunately there has been a significant fall in extrabudgetary support in spite of the stated needs.

Staff development

6.27 High priority was again given to the train­ing of WHO Representatives, and three seminars

33

were organized for them during the biennium. A series of workshops on macroeconomics was or­ganized for WHO Representatives and senior staff in Africa. These workshops have enabled WHO Representatives to interact more effec­tively with members of country support teams responsible for economics. The 1993 seminar for WHO Representatives took into account rele­vant 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 curtailed owing to budget cuts, workshops con­tinued to be held on such topics as report writ­ing, teamwork, time management and cross­cultural effectiveness.

CHAPTER 7

Public information and education for health

Public information

7.1 WHO's public information programme enhances awareness of the Organization's work among the general public and transmits important public health messages. Growing gen­eral interest in health issues is reflected in the increased time and space now being devoted to health matters in the media. This situation offers more opportunities for WHO to publicize its work and to disseminate authoritative informa­tion on health questions. WHO continued to strengthen its contacts with all branches of the news media- wire services, newspapers and mag­azines, television and radio. Radio programmes were produced and distributed to over 200 radio stations. WHO also worked with international television news and features syndicators of audi­ovisual material as well as national broadcasters to ensure appropriate distribution through their networks. A large number of briefings, press conferences and interviews were arranged.

7.2 Materials produced to meet requests from 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 their language, and to time their distribution so as to attract maximum attention. Topics dealt with included WHO's global drug policy, immuniza­tion of children, tropical diseases, AIDS, cholera, tuberculosis and emergency relief. Press kits in different languages were prepared for the United Nations Conference on Environment and Devel­opment (Rio de Janeiro, Brazil, June 1992), the International Conference on Nutrition (Rome, December 1992) and the Ministerial Conference on Malaria (Amsterdam, October 1992).

7.3 A variety of materials were distributed in connection with the special days designated to

35

focus world attention on particular health issues: World Health Day (7 April) on the theme "Heartbeat: the rhythm of health" in 1992 and "Handle life with care: prevent violence and negligence" in 1993; World No-Tobacco Day (31 May) on the theme "Tobacco-free workplaces: safer and healthier" in 1992 and "Health services: our window to a tobacco-free world" in 1993; and World AIDS Day (1 Decem­ber) on the theme "AIDS: a community com­mitment" in 1992 and "AIDS: time to act" m 1993.

7 4 WHO continued to provide public infor­mation services for a broad range of users through visits and publications and by respond­ing to enquiries. The brochure, Facts about WHO, and the video, The battle for health- a global challenge, produced during the previous biennium, were used for briefing purposes. A large number of enquiries were dealt with and 300 group visits to WHO headquarters were conducted in six languages; by 30 September 1993 there had been about 10 000 visitors from over 60 countries during the biennium.

Education for health

7.5 WHO's three main health education strategies are: advocacy of healthy public poli­cies, "empowerment" of people by increasing their knowledge and skills in health matters, and building social support for health. Within this framework WHO and UNEP cooperated in or­ganizing meetings on supportive environments for health (Nairobi, June 1993; Bangkok, No­vember 1993) for countries in Africa, South-East Asia and theW estern Pacific. Both meetings pro­duced statements that identified important chal­lenges and strategies for action. An outcome of the 1991 conference in Sundsvall (Sweden) has

THE WORK OF WHO 1992-1993

been the preparation of a handbook on promo­tion of health-supportive environments, to be published in 1994. A joint WHO/World Bank mission assisted in reviewing and strengthening Zambia's national health education infrastruc­ture, with emphasis on health education in schools and on environmental health; a WHO team then visited the country to advise on curric­ulum development and programme planning.

7 6 Intercountry meetings in Sri Lanka and Costa Rica (Colombo, October 1992; SanJose, November 1993) produced guidelines for intro­ducing comprehensive approaches to school health education for countries in South-East Asia and the Americas. Two national workshops were organized in Argentina and Namibia on the same subject. A health education curriculum for pri­mary schools in Cameroon was designed and reviewed. During two international AIDS con­ferences (Amsterdam, July 1993; Berlin, June 1993), working groups were organized on strengthening the role of schools in preventing HIV infection. In November 1993 an informal meeting on school-based surveillance of health­risk behaviour among secondary school students drafted a protocol for such surveillance in devel­oping countries.

7 7 By the end of the biennium 28 countries had formally joined the European Network of Health Promoting Schools, established in 1991. A strategy for action in 1992-1993 was formulat­ed during a first international consultation with national coordinators of the network (Stras­bourg, France, May 1992). Two workshops were organized for teachers from eastern European countries (Budapest, September 1992; Prague, April 1993). Prototype action-oriented school health education programmes were introduced in 12 Eastern Mediterranean countries in collab­oration with UNICEF and UNESCO. In 1992 a national training course on rural school health education and a national symposium on school health education were held in China with WHO support. Teacher training workshops took place in a number of African countries.

7.8 A WHO intercountry workshop on youth involvement in health promotion was held in Barbados (Bridgetown, November 1992); it formulated a regional youth statement on action for health and helped to initiate a Caribbean youth network. A national workshop on youth and health development took place in India. A brochure entitled "Health facts for youth" was

36

prepared as an aid to youth leaders in promoting action among young people in support of health. In 1993 an informal consultation with workers' organizations proposed ways in which trade un­ions could be involved in promoting health edu­cation at the worksite. A four-year project on health promotion among industrial workers was launched in China.

7 9 During the biennium at least 25 WHO programmes were supported in the production and dissemination of educational materials, ex­change of materials and audiovisual coverage of educational events. Sixteen educational video films were produced as were 22 newsreels, which were distributed through television networks worldwide. Similarly, video footage from WHO's image library was made available to external production companies and television networks. An interagency database for the ex­change of video materials was established in 1993.

7.10 Radio programmes on priority health is­sues continued to be provided regularly to over 200 radio stations. On average 13 000 print photographs are distributed each year to the press, publishers, nongovernmental organiza­tions and training institutions. In 1992-1993, 48 exhibitions and displays were prepared for technical meetings, conferences and international health events such as World Health Days, World Health Assemblies, the Ministerial Conference on Malaria (Amsterdam, October 1992), the In­ternational Conference on Nutrition (Rome, December 1992), the two international confer­ences on AIDS mentioned above, and the United Nations Conference on Human Rights (Vienna, June 1993). In South-East Asia information kits on various health issues were prepared and dis­seminated and a regional newsletter, HF A 2000, is distributed quarterly.

7.11 In November 1992 an interagency meet­ing on strategies for health advocacy was organ­ized to continue the work of the 1991 third interagency round-table on communication for development. It was concerned particularly with strategies to enlist decision-makers' support for health. The fourth round-table (Lima, Febru­ary 1993) considered ways to strengthen training in communication for development.

7.12 Health education staff were trained in Botswana, Chad, Congo, Kenya and Namibia with the help of WHO fellowships. In 1993 a

PUBLIC INFORMATION AND EDUCATION FOR HEALTH

manual for training community health workers in human relations, communications and leader­ship skills was successfully tested during a train­ing session for supervisors and community health workers in Kenya. An intercountry work­shop was organized for radio and television health communicators from Cameroon, Central African Republic and Congo (Y aounde, April 1993). A training guide on HIV/AIDS was pro­duced for use by health workers in the Eastern Mediterranean. Four teaching centres in that re­gion are providing training for national health education staff. WHO supported the authorities in Oman in designing a programme to train women health educators for work in health cen­tres. An intercountry workshop was held to dis­cuss ways of integrating health education and promotion into the training of health personnel (Sydney, Australia, July 1992). Technical sup­port for this purpose was provided to Papua New Guinea. A video on the health aspects of household energy use was produced in VietNam with WHO support.

7.13 Support was given to several African countries in strengthening the management of health education programmes and organizing

37

their decentralization to intermediate and dis­trict levels. An international conference on community health, with emphasis on commu­nity participation and exchange of educational experience, was held in cooperation with the Congolese Government (Brazzaville, Septem­ber 1992). Following reviews, proposals were made for strengthening national health educa­tion programmes in Benin, Guinea and Uganda. Five intercountry working groups were formed and three intercountry workshops organized to strengthen health education programmes and enhance community participation in health in the Americas. Intercountry workshops were conducted in the Eastern Mediterranean to pro­mote the planning of health education pro­grammes (Manama, July 1992) and the produc­tion of health education materials for urban health development (Sanaa, July 1993 ). A work­ing group reviewing the health education pro­gramme for the Western Pacific (Singapore, March 1993) called for greater emphasis on both community and government action. An inter­national symposium on health education was organized in collaboration with the All China Health Education Association (Shanghai, Octo­ber 1992).

CHAPTER 8

Research promotion and development

8.1 In a wide-ranging discussion of the role of health research, the Health Assembly in May 1992 provided policy guidance on this subject, stressing a number of points: the multidisci­plinary nature of health research, and the need to concentrate on particular themes (health policy research, research on methods to support deci­sion-making, health systems research, and re­search on nursing); constant updating and refine­ment of coherent research strategies; strengthen­ing research capability; the role of scientific and technological infrastructure in facilitating appli­cation of findings of health research; the evalua­tion of technology, using both qualitative and quantitative indicators for measuring progress; financing of health research at all levels; and WHO's role in bioethics.

8 2 At its thirty-first session in September­October 1992 the Advisory Committee on Health Research (ACHR) directed its attention to improving coordination between global and regional research activities; appraising the work of ACHR's task forces and subcommittees and planning their future tasks; providing guidance for updating WHO's health research strategy; reviewing the work of several WHO pro­grammes that have substantial research compo­nents; and considering ethical aspects of health research, particularly the productive cooperation between WHO and CIOMS.

8 3 One outcome of the 1992 session was a meeting of an ACHR working group (Salisbury, United Kingdom, April1993) called to prepare a framework for updating WHO's research strategy. The outline proposed was as follows: objectives of health research; restatement of cur­rent strategy and new dimensions of research (in view of scientific advances); emerging problems and forecasting (especially related to science and technology, biotechnology and health care); strengthening research capabilities, including re-

39

sources for research; international cooperation in health research; ethical aspects of health research; and recommendations on priorities. The strategy document will provide a set of guiding principles for health research priorities at global, regional and country levels so as to deal with emerging health problems and a changing health situation. It will apply not only to WHO but also to the scientific community in the health field, deci­sion-makers, donor agencies and concerned nongovernmental organizations.

8 4 During the biennium WHO's Council for Science and Technology, composed of staff concerned with research, met several times to discuss ways of improving communication and cooperation among the various WHO pro­grammes that have a research component. Priori­ty-setting and extrabudgetary support of re­search were found to be matters requiring de­tailed investigation. In July 1993 the Council held a joint meeting with the Standing Commit­tee of ACHR, providing an opportunity to ex­change views and information about ACHR's work. Collaboration also continued with the United Nations Research Institute for Social De­velopment on the subject of qualitative indica­tors of development.

8 5 WHO's collaborating centres perform an invaluable service in promoting health re­search throughout the world. In 1992-1993 the network of centres continued to expand, reach­ing a total of 1221 centres (see Figure 8.1). A global review and evaluation of the centres was begun.

8.6 Expert advisory panels constitute another major source of expertise. The 54 panels, com­prising more than 2000 experts, provide impor­tant scientific advice to the Organization. During the biennium 16 expert committee meetings were held.

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

Figure 8.1

8.7 WHO provided scientific and technical support to the French Ministry of Cooperation and Development in organizing an international symposium on "technology, health and devel­opment" (Paris, December 1992). Cooperation with the Council on Health Research for Devel­opment was initiated following the creation of that nongovernmental organization in March 1993. Formal mechanisms for strengthening this cooperation are being explored.

8.8 In Africa a fund was created for the pro­motion of health systems research and develop­ment. Prizes were awarded to eight research workers in African medical schools in acknowl­edgement of their publications and theses. "Public health research" was the subject of the Technical Discussions held during the 1992 ses­sion of the Regional Committee.

8 9 In the Americas an analysis was made of health research in Argentina, Brazil, Cuba, Mexico and Venezuela', with the aim of improv­ing health research policies. A total of 39 research

1 Pellegrim Filho A. Health research 10 Latm America. Bulletin of the Pan Ameffcan Health Organization, 1993. 27(2): 168-182.

40

1973 1978 1983 1988 1993

projects were funded in priority areas. The re­gional system for vaccine development in Latin America and the Caribbean (SIREV A) was fur­ther developed. There were several meetings of "Convergencia", an interagency initiative to promote cooperation in health science and tech­nology. The PAHO/WHO Advisory Commit­tee on Health Research held its twenty-ninth meeting in August 1993.

8.10 In South-East Asia current research strat­egies were reviewed and updated. The eighth meeting of directors of medical research councils and analogous bodies (Bangkok, November 1992) stressed the essential role of WHO in pro­moting the establishment or strengthening of such bodies. Further funding was provided for training in research, provision of grants for visit­ing scientists, and other activities directed to­wards strengthening research capacity. Meetings of the South-East Asia Advisory Committee on Health Research continued to be held on a yearly basis.

8.11 In Europe a joint workshop was organ­ized with the European Medical Research Council (Prague, January 1993) to help the countries of central and eastern Europe to reor­ganize their national health research administra-

RESEARCH PROMOTION AND DEVELOPMENT ----------------------------------------------

tions and to increase the effectiveness of con­tacts between western and eastern Europe. It was recommended that those countries should consider establishing independent national health research institutions as part of a national science research council.

8.12 In the Eastern Mediterranean support was given to several research projects in priority areas such as nutrition, primary health care, health systems research and assessment of ma­ternal and child health services. Research infor­mation was disseminated through a Health services journal.

8.13 In the Western Pacific human resources for health research were promoted by means of train­ing grants, short courses on research design and

41

methods, and the publication of a manual.1 A joint meeting in August 1992 of the regional ACHR and directors of health research councils or analo­gous bodies stressed the value of networking ar­rangements between experts and research insti­tutes, and the importance of adequate infrastruc­ture, information exchange and quality control in health research.

8.14 Details of research on particular subjects (for instance, human reproduction, immuniza­tion and tropical diseases) may be found in the chapters and sections of this report dealing with the WHO programmes concerned.

1 Health research methodology. a guide for training m research methods. Manila, World Health OrganizatiOn, 1992.

CHAPTER 9

General health protection and

Women, health and development

9.1 WHO is concerned with the way in which the health of women affects and is affected by their social, political, cultural and economic sta­tus, and with their contribution to health and overall development. An interdivisional steering committee on women, health and development has been set up with the task of ensuring that WHO's technical programmes and the Ninth General Programme of Work give proper atten­tion to matters affecting women's health in all areas. The committee has prepared a checklist of indicators for programme managers, including indicators relating to differences between the sexes in health and access to and use of health services; the impact of activities on the health of women; and the participation of women and women's organizations in health promotion and disease prevention. It has also indicated areas where research is needed on matters of concern to women. It will work with the Director-Gen­eral's adviser on health and development policies in preparations for the fourth world conference on women, to be held in Beijing in 1995, and ensure that due importance is given to women's health in the proposed "platform for action".

9.2 The Director-General has appointed an adviser on the employment and participation of women to help achieve WHO's objective of increasing the number of women in professional and higher-graded posts and ensuring their par­ticipation in the Organization's activities. Simi­larly, a multidisciplinary coordination group has been set up to ensure that nurses have access to certain kinds of WHO assignment in which there has been a strong bias towards physicians.

9.3 The United Nations is preparing a report on the subject of women, drug abuse and HIV I

43

• promot1on

AIDS, taking into account the work of a consul­tation on women and drugs in August 1993. Par­ticipants stressed that problems of substance abuse occur among women in all countries, re­gardless of their cultural, social and economic circumstances, and that priority must therefore be given to public education, treatment and reha­bilitation specific to women's needs, and to devising measures and policies that take those needs fully into account. A report on human rights in relation to women's health, which ex­amines the implicit and explicit threats to wom­en's health, was commissioned for the confer­ence on the health of women in central and east­ern Europe, to be held in Vienna in 1994. WHO maintains databases on women's health, in­cluding bibliographies and lists of indicators.

9 4 The network of multisectoral teams on women's leadership and participation was fur­ther strengthened following a fourth UNFPA­supported interregional workshop on leadership and participation of women in maternal and child health and family planning (Washington, November 1992); it now encompasses 42 coun­tries.

9.5 In the context of the 1993 World Health Day on the theme of accident and injury preven­tion, particular attention was drawn to violence affecting girls and women, including not only physical and mental abuse but also the hidden violence of discrimination or denial of the basic human rights where food, medical care, educa­tion and a safe environment are concerned. Reso­lution WHA46.18 highlighted the importance of eliminating such harmful practices as female gen­ital mutilation and other social and behavioural obstacles affecting the health of women and chil­dren. Technical and financial support was pro­vided for national surveys on such practices and for measures to combat them, including training of traditional birth attendants and midwives.

THE WORK OF WHO 1992-1993

9 6 Work continued in the Americas to strengthen national capability for using a method 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 Rica, Ecuador, Guatemala, Jamaica, Panama, and Trinidad and Tobago. Research focused on vio­lence against women, quality of care in service delivery for women, and women and tropical diseases; the findings on violence were taken into account in formulating policy proposals and re­viewed by a Central American seminar on its public health aspects (Managua, March 1992). A publication on gender, women and health1 was prepared by a multidisciplinary group.

9.7 As part of a European initiative, "Invest­ing in women's health", supported by Austria, Norway and Sweden, a preparatory meeting (Copenhagen, March 1993) drew up a plan for a European women's health forum, to be offi­cially inaugurated at the conclusion of the Vien­na meeting in 1994. Within the context of the Healthy Cities action plan on women's health, an information network is being established that will link all parts of Europe and provide a specif­ically urban input for the forum.

9 8 Concerted efforts have been made through intercountry activities in the Eastern Mediterranean to improve quality of life for women and utilize their potential for health promotion and development. For this purpose contributions are being made in several coun­tries to activities outside the health field, such as functional literacy training and income genera­tion. A regional commission for Arab women is being set up, with the participation of interested agencies and influential nongovernmental or­ganizations. The Regional Committee for the Eastern Mediterranean held technical discus­sions in 1993 on the theme "The role of wom­en in support of health for all". Participants stressed that there should be greater acknowl­edgement of women's contribution to the health of families and communities, and noted that their involvement in health can be enhanced by using women's networks and community groups to disseminate information on the health risks they face, their right to health care and the

1 Gender, women and health. Washington, Pan American Health Orgamza­tiOn, 1993 (Scientrfrc Publicatron, No. 541)

44

options available to them for promoting and protecting their health.

Food and nutrition

9.9 In response to the recommendations in the world declaration and plan of action adopted by the International Conference on Nutrition (Rome, December 1992) the Director-General, reaffirming WHO's continuing commitment to proper food and nutrition for a healthy life, de­cided in May 1993 to establish a new division to be responsible for all WHO's activities con­cerned with food aid, food safety and nutrition. It will strengthen the Organization's capacity for action in those areas and support Member States in implementing national plans of action for nu­tritional improvement, giving priority to the countries that are least developed, have low in­come or are affected by disasters.

Food aid programmes

9.10 WHO continued to advise on the health aspects of food-assisted development projects supported by the World Food Programme, and is cooperating with WFP to assess the effectiveness of such projects in improving health and to deter­mine whether they should be continued, phased out or modified. The Organization also continued to participate in WFP-financed interagency mis­sions for the design and evaluation of the health aspects of development projects, and to a lesser degree for the design of health-related compo­nents of school feeding projects aimed at improv­ing attendance and performance. In such projects particular importance is attached to providing reg­ular treatment for intestinal helminths in areas of high prevalence, and to ensuring a healthy school environment with emphasis on safe water supply and sanitation. Unfortunately, the attention paid to the health aspects of rural development projects supported by food aid is not commensurate with the gravity of the problems encountered and does not suffice to offset the adverse effects associated with some interventions, such as the transmission of malaria and schistosomiasis in rural irrigation schemes. WHO continued its involvement with health and nutrition aspects of emergency opera­tions, particularly in long-term projects for refu­gees and displaced persons (see paragraphs 2.28 to 2.33).

GENERAL HEALTH PROTECTION AND PROMOTION

Food safety

9.11 Work on the development of internation­ally agreed food standards continued through WHO's contribution to the Codex Alimentarius Commission. Codex provisions offer adequate health protection and are recognized under the General Agreement on Tariffs and Trade (GATT) as providing sufficient justification for import restrictions. In accordance with the Final Act of the "Uruguay Round" of multilateral trade negotiations launched by GATT, countries could be required to furnish justification for any restrictions based on national regulations that are stricter than the Codex provisions.

9 12 A review article1 and fact-sheet were is­sued on unsafe food - a common cause of infant diarrhoea. Since cholera and other food-borne diseases may be transmitted by street-vended foods, a document was issued setting out essen­tial safety requirements for such foods. 2 This subject was discussed at an Asian conference on street foods (Beijing, October 1993 ), convened in collaboration with the International Life Scienc­es Institute. WHO worked with the Industry Council for Development in conducting training courses in Asia and Africa and preparing training materials and a document3 on the use of the sys­tem of hazard analysis critical control point eval­uations, which should be of value to national authorities and the food industry in improving food safety.

913 WHO cooperated with FAO and UNEP in the food contamination monitoring compo­nent of the Global Environmental Monitoring System (GEMS), and with FAO and IAEAin the work of the International Consultative Group on Food Irradiation. In addition, food process­ing technologies were assessed, workshops were held, and texts were prepared on food irradia­tion4 and biotechnology.5

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. 3 Document WHO/FNU/FOS/93.3. 4 Safety and nutritional adequacy of 11radwted food. Geneva, World Health

Organization (In press). 5 Document WHO/FNU/FOS/93.6.

4S

Nutrition

914 The International Conference on Nutri­tion (Rome, December 1992) was the culmination of more than two years' joint effort by WHO and FAO to promote awareness of the extent and seriousness of nutritional and diet-related prob­lems and to achieve consensus on how to deal with them. It was attended by more than 1300 people representing 159 governments and some 160 inter­national and nongovernmental organizations. Ini­tial preparatory work for the conference focused on stimulating effective intersectoral cooperation in countries so as to improve nutritional well­being. Regional and subregional meetings were then organized to assess common food and nutri­tion problems. Information on the resulting coun­try and regional consensus provided background material for a preparatory committee that met in August 1992 to review the main findings and draft a world declaration and plan of action which were subsequently adopted by the conference.6 As they represent a global consensus on the nature and causes of nutritional problems, the declaration and plan now provide a basis for WHO support to national plans of action. In response to requests from governments, WHO has so far provided technical support and funds to 14 least developed countries in Africa, to one each in the Americas, South-East Asia and the Eastern Mediterranean and three in the Western Pacific.

9.15 Accurate assessment of body mass and growth, which is indispensable to interventions aimed at improving physical welfare, remains a much debated topic. In November 1993 WHO convened an expert committee to consider con­flicting ideas on this subject and more particular­ly reference data and guidelines for their use and interpretation at all stages of life.7

916 WHO, UNICEF, Wellstart International (a WHO collaborating centre in San Diego, USA), and the World Alliance for Breastfeeding Action jointly sponsored three lactation man­agement training workshops for 65 Russian­speaking health workers (Saint Petersburg, Rus­sian Federation, August 1993 ). This provided an

6 World declaratiOn and plan af act10n for nutnt10n. Rome, FAO/WHO, 1992.

7 Physical status· the use and interpretation of anthropometry. Report of a WHO Expert Committee. Geneva, World Health Organization (in prepara· lion).

THE WORK OF WHO 1992-1993

opportunity to prepare Russian-language edi­tions of two of WHO's most popular publica­tions: the WHO/UNICEF statement on breast­feeding and the role of maternity services1 and a summary of the latest scientific findings on the physiological basis for infant feeding. 2

9 17 In support of countries implementing the WHO/UNICEF Baby-friendly Hospital Initia­tive (see box), WHO provided training for health professionals to serve as hospital assessors in China, Egypt, Jordan, Lebanon, Philippines and Russian Federation; prepared guidelines for baby­friendly training workshops; and helped establish lactation management training centres in Manila and in Sao Paulo (Brazil). With financial assistance from USAID, the WHO data bank on breast­feeding was expanded, using a revised set of inter­nationally agreed indicators; it now contains in­formation from more than 2000 surveys or studies carried out in over 170 countries or territories.

9.18 Financial contributions from the Govern­ment of the Netherlands and SIDA enabled WHO to provide technical support in translating the International Code of Marketing of Breast­milk Substitutes into appropriate national meas­ures in Guatemala, Iraq, Morocco, Syrian Arab Republic, United Republic of Tanzania, and Viet Nam; to organize a workshop (Cairo, September 1993) on the implementation of the Code for par­ticipants from 15 Eastern Mediterranean coun­tries; and to brief 12 consultants (Geneva, Septem­ber 1993) who can be called upon to help the Organization respond to requests from Member States for technical support on this subject.

9 19 New evidence of the importance of vitamin A nutriture in the broader realm of child health and survival and renewed commitment by national health authorities and international or­ganizations and bodies alike provided the impe­tus for producing a third revised and expanded edition of WHO's 1978 best-selling field man­ual for assessing vitamin A deficiency.3 Technical

1 Protectmg, promotmg and supportmg breast-feedmg the speoal role of matern1ty sefVIces. A tomt WHO/UNICEF statement Geneva, World Health Orgamzat1on, 1989 Available or in preparation 1n more than 40 language ed1t1ons

2 Akre J ed. Infant feedmg the physiOlogical baSIS (Supplement to Vol 67 of the Bulletm of the World Health Orgamzat1on), Geneva, 1990 Availa­ble or 1n preparation 1n 13 language editions

3 Sommer A V1tamin A defiCiency and 1ts consequences: a f1eld gu1de to thelf detection and control, 3rd ed. Geneva, World Health OrganiZation (in press)

46

The Baby-friendly Hospital Initiative

• The Baby-friendly Hospital Initiative is a global movement, spearheaded by WHO and UNICEF, that aims to give every baby the best start in life by creating a health care environment where breast-feeding is a norm. To become truly baby-friendly, hospitals and maternity wards around the world will want to give practical effect to the principles set out in the joint WHO/ UNICEF statement on breast-feeeding and maternity services.1 WHO and UNICEF are supporting national authori­ties responsible for designating maternity wards and hospitals as baby-friendly in a variety of ways, including the issue of guidelines and support for training. The initiative is based on the principles de­scribed in the joint statement, which are synthesized in "Ten steps to successful breast-feeding":

Every facility providing maternity services and care for newborn infants should:

• have a written breast-feeding policy that is routinely communicated to all health care staff;

• train all health care staff in skills neces­sary to implement this policy;

• inform all pregnant women about the benefits and management of breast­feeding;

• help mothers initiate breast-feeding within a half-hour of birth;

• show mothers how to breast-feed, and how to maintain lactation even if they should be separated from their infants;

• give newborn infants no food or drink other than breast milk, unless medical­ly indicated;

• practise rooming-in - allow mothers and infants to remain together -24 hours a day;

• encourage breast-feeding on demand; • give no artificial teats or pacifiers (also

called dummies or soothers) to breast­feeding infants;

• foster the establishment of breast­feeding support groups and refer mothers to them on discharge from the hospital or clinic.

GENERAL HEALTH PROTECTION AND PROMOTION

consultations were held to revise the criteria for assessing iodine deficiency disorders (November 1992), vitamin A deficiency (November 1992), and iron deficiency anaemia (December 1993). The updated criteria represent a major advance in unifying international efforts to prevent, control or eliminate these serious health problems and are essential for monitoring progress towards the goals adopted by the World Health Assembly in 1990 (resolution WHA43.2) and 1992 (resolu­tion WHA45.33) and by the World Summit for Children in 1990. They have also contributed to the development of WHO's global micro­nutrient deficiency information system, in which three linked databases covering prevalence, sta­tus of control programmes and reference data are being compiled for iodine, vitamin A and iron deficiencies. The first report1 produced on this basis provides the most comprehensive estimates so far on the global prevalence of iodine deficien­cy, suggesting that there are 655 million people with goitre in 118 countries in all WHO regions.

9 20 WHO and FAO jointly organized a con­sultation (Rome, October 1993) on the role of fats and oils in human nutrition, particularly in relation to chronic noncommunicable diseases. So much new evidence had accumulated since 1977, when the subject was last reviewed, that it was considered imperative to reassess the ques­tion and the dietary implications for coronary heart disease in developed and developing coun­tries alike. The consultation made recommenda­tions of direct relevance to Member States' nu­trition policies and to the development of nation­al dietary guidelines.

Oral health

9 21 As comparable oral health data have accu­mulated from about 160 countries, global trends are becoming sufficiently clear for WHO to for­mulate a coherent oral health strategy for Mem­ber States. Surveys using WHO-recommended methods and standard recording forms contin­ued to supply data for the WHO global oral data bank. In order to promote common strategies or methods for oral health surveys, WHO also pro­duced a document containing the standard de-

1 WHO/UNICEF /InternatiOnal Council for Control of lod1ne Def1c1ency Disor­ders_ Global prevalence of 10dme defiCiency disorders Geneva, World Health Orgamzat1on, 1993

47

scriptive tables used in its oral epidemiological studies.2 The booklet on dental caries levels was updated.3

9 22 The 1993 figures on caries collected by the global oral data bank (see Figure 9.1) show a small further improvement for both developing and industrialized countries. However, the trend is consistent only for the latter. It is now quite clear that in countries which have espoused the "prevention first" strategy, oral health will con­tinue to improve in the immediate future. Mean­while, in view of reiterated reports of growing caries prevalence in the most populous develop­ing countries, comprehensive preventive pro­grammes must be launched or at least formulated for rapid implementation when the need arises.

DMFT

Figure 9.1 Mean numbers of decoyed, missing or filled teeth (DMFT) ot12 years, 1980-1993 (weighted averages by size of population)

5-.---------------------------.

4

3

2

1981 1983 1985 1987 1989 1991 1993

Figure 9.1

9.23 The "community periodontal index of treatment need" was developed in recognition of the serious lack of epidemiological data on perio­dontal diseases. It rapidly became the standard index for oral health surveys and for several years has provided a robust database covering

1 Document WHO/ORH/EIS/ICS-11/91. 3 Dental caries levels at 12 years Geneva, World Health OrganiZation,

1993

THE WORK OF WHO 1992-1993

113 countries; a compilation of data for age­groups 15-19 years and 35-44 years, issued in 1992,1 has significantly changed global and na­tional estimations of the need for prevention and treatment of periodontal diseases, and thus pro­vides a basis for goal-setting.

9 24 Eight sites in six countries have reported results from the second international collabora­tive study of oral health outcomes, in which clin­ical and sociological data are collected in stand­ard form together with data from care providers and administrators. The information obtained is of value for the preparation of guidelines for improved oral health.

9 25 A new "atraumatic restorative treat­ment", in which dental cavities are cleaned with hand instruments only and then filled with glass ionomer cement, is being tested in several villages in the province of Khon Kaen in Thailand. Pre­liminary results indicate that it may prove the most appropriate technology for rural and disad­vantaged communities that at present have no access to oral care. Short courses on the tech­nique were given for dental nurses in Cambodia and the Lao People's Democratic Republic.

9.26 Extrabudgetary funds were obtained for a project to provide special curative and preventive services to populations living in zones contami­nated as a result of the Chernobyl accident. An international action network on oro-facial muti­lations and noma (gangrenous stomatitis) in Af­rica has been set up; its aim is to combine primary prevention with the availability of moderately complex treatment and with a referral system for very complex care.

9 27 A number of projects have been undertak­en as part of the continuing effort to demonstrate the effectiveness of oral disease prevention. With support from the Borrow Dental Milk Founda­tion (United Kingdom), WHO launched an inter­national milk fluoridation programme; it includes community projects and laboratory and feasibility studies, and is being implemented in nine coun­tries. A five-year community project successfully completed in Bulgaria confirmed that milk can be used like water or salt as a vehicle for fluoride to combat dental caries in children. In other projects, fluoride-containing toothpastes and sealants im-

1 Document WHO/ORH/EIS/CPITN/92.

48

pregnated with prophylactic agents are being used to widen the choice of preventive methods and to convince communities of the prime importance of prevention within the framework of primary health care.

9 28 Intercountry centres for oral health in Ni­geria, Syrian Arab Republic and Thailand, to­gether with the WHO collaborating centre for oral health in Europe, recently designated in Minsk, continued to support WHO's strate­gies. More than 30 WHO collaborating centres in 19 countries have made effective contributions to country activities, for instance by updating situation analyses, formulating national plans of action, and providing training in the planning and management of oral health programmes.

9 29 Considerable work was done in updating existing methods and devising new ones. The fourth edition of Oral health surveys: basic methods is in final draft form as is the third edi­tion of Application of the International Classifi­cation of Diseases to dentistry and stomatology. Guidelines on hygiene and infection control in oral care settings, mouth care for severely ill pa­tients, training of examiners for oral health sur­veys, and hand instruments for community and restricted referral level oral care were completed for distribution. Extensive information material was prepared for World Health Day 1994 on the theme "Oral health for a healthy life".

9.30 Training of oral health personnel remains a major priority for most countries, and in some cases there is a strong focus on situating oral health within the overall context of the health sciences. Methods for training undergraduates and auxiliary personnel using performance simu­lation have been developed jointly with several collaborating centres, and a manual has been completed. Following a detailed review of cur­rent dental education in countries belonging to the Commonwealth of Independent States, pro­posals were made for radical changes, particular­ly in orienting the curriculum towards the "health sciences" approach and gearing it to so­ciety's health priorities and needs.

9 31 Different aspects of the work were em­phasized in the various regions: planning of ser­vices and development of human resources and technology (Africa; Americas); application of primary health care principles to the develop­ment of services (South-East Asia); quality assur­ance through information systems, situation

GENERAL HEALTH PROTECTION AND PROMOTION

analysis and implementation of planned services (Eastern Mediterranean; Europe); and surveil­lance of populations at risk and promotion of preventive measures through the adoption of measurable targets for oral health improvement (Western Pacific).

lniury prevention

9.32 Under the technical coordination of the WHO collaborating centre for community safe­ty promotion at the Karolinska Institute in Stockholm, the network of demonstration projects on community safety expanded to in­volve ten countries.1

9.33 A WHO-sponsored second international conference on safe communities (Glasgow, United Kingdom, September 1992) included violence pre­vention in its agenda. The results of case studies were used in an analysis of the concept of safety that took into account the community's views on how it should be protected from a variety of haz­ards, including natural disasters and willful vio­lence. The conference also examined the inadequa­cy of political or administrative mechanisms in the area of safety promotion.

9.34 Programme leaders who met on the occa­sion of a WHO interregional seminar on methods for planning community safety programmes (Toulouse, France, November 1993) decided to produce reference material for health planners and workers in response to the increasing demand for guidance on methodology and information on ex­perience. The group also produced a document on community action for safety in preparation for the 1994 Technical Discussions on the subject of "Community action for health".

9.35 World Health Day 1993 provided an op­portunity to present the theme of violence from a public health viewpoint. It was followed by inten­sive consultation both in the Organization and between WHO and institutes in France and the United States of America with a view to building up a pool of technical expertise and establishing a network of public health experts concerned with the prevention of intentional injury.

1 Argentma, Australia, Denmark, France, lnd10, lndonesta, Sweden, That­land, Untied Ktngdom, United States of Amertca

49

9.36 A second world conference on injury con­trol (Atlanta, USA, May 1993), organized by the United States National Center for Injury Pre­vention and Control, a WHO collaborating cen­tre, with support from other WHO collaborat­ing centres, was the occasion for a thorough eval­uation of injury control programmes throughout the world. The conference succeeded in its three objectives: to strengthen technical cooperation between research institutes, including WHO col­laborating centres; to further the adoption of commonly agreed standards for developing ana­lytical methodology for injury control, including control of violence; and to arouse broad interest in the WHO programme for community safety.

9.37 Using research protocols prepared by WHO in cooperation with nongovernmental or­ganizations and collaborating centres, two epide­miological studies are under way, one (in Tou­louse, France; and Albuquerque, USA) dealing with falls in the elderly, and the other with burns, on the basis of a,n epidemiological analysis being carried out in India and several European coun­tries. The International Society for Burn Injuries and WHO are jointly preparing a manual on the epidemiology, prevention and care of burns.

9.38 In connection with the safety helmet initi­ative carried out under the leadership of the United States National Center for Injury Pre­vention and Control, WHO convened a sympo­sium on neurotrauma prevention and manage­ment (Brussels, December 1993 ). Participants were reminded that brain injuries represent about half of all severe injuries from road acci­dents and a large proportion of injuries from other causes; they are frequently associated with spinal cord trauma. The symposium initiated an epidemiological analysis based on common protocols, set up a network of research centres to develop protective techniques, formulated strat­egies to promote the use of such techniques, and established an international forum for improving the medical management of brain-injured per­sons and for enhancing rehabilitation techniques and services. These activities will be coordinated by WHO collaborating centres.

9.39 WHO collaborated with seven Member States in the Eastern Mediterranean in strength­ening measures to promote safety and prevent accidental injury. In 1993 a course on the man­agement of burn injuries was held for nurses, dealing with nursing care, treatment of cases and prevention of sequelae.

THE WORK OF WHO 1992-1993

Tobacco or health

Strengthening notional programmes

9.40 WHO's direct support to Member States included involvement in establishing and strengthening comprehensive national tobacco control programmes in all regions.

9 41 WHO cosponsored an all-Africa confer­ence on tobacco control (Harare, November 1993 ). Tobacco-producing countries in Africa took initial steps towards harmonizing their na­tional tobacco control programmes and consid­ered possible ways of reducing their economic dependence on this product. There was general realization of the need for greater efforts in all countries to counter the growing presence of to­bacco advertising, mainly by transnational to­bacco companies; in Senegal, for example, ex­penditure on tobacco advertising exceeds 1000 million CFA francs annually.

942 In the Americas PAHO/WHO partici­pated actively in a meeting of the Latin American Committee against Tobacco Use (San Jose, June 1993) and collaborated with the United States National Institutes of Health in setting up tobac­co control projects in Chile and Mexico.

9 43 In South-East Asia WHO cooperated with Bangladesh, India, Mongolia, Nepal and Thailand in strengthening national action plans to combat tobacco use.

9 44 Missions were sent to eight countries of central and eastern Europe to assist in imple­menting national tobacco control programmes. Among other regional and national meetings in Europe, the Organization supported the second and third European seminars on tobacco or health for national policy advisers and pro­gramme managers (Budapest, January 1992; Vi­enna, March 1993 ), which brought together par­ticipants from 35 countries.

9 45 In the Eastern Mediterranean a consulta­tion (Alexandria, May 1992) reviewed national tobacco control policies and programmes and formulated guidelines. A joint consultation be­tween WHO and the International Union against Cancer (Cairo, February 1993) discussed the political manipulation of tobacco control and the role of physicians in antismoking activities.

50

9 46 In the Western Pacific WHO participated in a variety of activities undertaken by Member States and supported the work of non­governmental organizations concerned with to­bacco control, including regional and national conferences, meetings and workshops. By the end of the biennium nine countries and areas had established tobacco control policies backed by at least some legislative measures, and most Mem­ber States had designated national focal points. The majority of countries and areas had taken steps towards implementing the Western Pacific regional action plan on tobacco or health for 1990-1994 but, as the Regional Committee noted in 1992, more vigorous action is needed.

Health promotion, advocacy and public information

9 47 The 1992 and 1993 World No-Tobacco Days were widely observed throughout the world and were well reported in the news media. WHO issued information and recommendations on tobacco-free workplaces and on the role of health services and health personnel in attaining a tobacco-free society, and awarded medals to anti-tobacco campaigners from all regions. Worldwide distribution of the quarterly news­letter Tobacco alert continued.

9.48 WHO promoted tobacco control meas­ures at several international conferences includ­ing a world conference on tobacco or health (Buenos Aires, March-April 1992). The agree­ments reached to hold smoke-free Olympic Games in 1992 at Albertville (France) and Barce­lona (Spain) and in 1994 at Lillehammer (Nor­way) were of great publicity value. Throughout the world action was stepped up to encourage Member States to adopt comprehensive tobacco control policies.

Data collection and research

9 49 Research findings were published in the form of monographs on women and tobacco1

and on tobacco controllegislation2 and a techni-

1 Women and tobacco Geneva, World Health Orgamat1on, 1992 1 Roemer R Legtsfative actton to combat the world tobacco epidemtc, 2nd

ed1t1on. Geneva, World Health Orgamzation, 1993.

GENERAL HEALTH PROTEUION AND PROMOTION

cal document on the interaction of smoking and workplace hazards.1

9 50 In conjunction with the University of Ox­ford (United Kingdom), WHO initiated and sup­ported a series of prospective epidemiological stud­ies to monitor the health effects of tobacco use in several countries.2

9 51 PAHO/WHO published a report on to­bacco use, tobacco-related diseases and preven­tion and control measures in the Americas.3 The Organization also collaborated with the Office of the Surgeon General of the United States of America in preparing a wide-ranging report on the problems posed by tobacco consumption in the Americas4 and stressing the need for regional coordination and cooperation to create a smoke­free society.

1 Document WHO/OCH/TOH/92 1 2 Argentrna, Chrna, Cuba, Egypt, India, Mexrco, Poland, Unrted Kingdom,

Unrted States of America 3 Tobacco or health. status 1n the Amencas. Washrngton, Pan Amerrcon

Health Orgonrzotron, 1992 (Scientific Publrcot10n, No 536). 4 Unrted States Deportment of Health and Human Servrces Smoking and

health 1n the Amencas· a 1992 report of the Surgeon General, in collabora· t10n with the Pan Amencan Health Organization. Atlanta, 1992 (OHHS Publrcotion, No. (CD() 92-8420)

SI

lnteragency collaboration

9.52 WHO worked closely with ICAO and participated in the twenty-ninth session of its Assembly (Montreal, September 1992), which decided to urge all contracting States to take measures to restrict smoking progressively on all international passenger flights, with the objective of completely banning smoking by July 1996.

9.53 In response to Health Assembly resolu­tion WHA45.20, the Director-General submit­ted a report on tobacco or health to the Eco­nomic and Social Council of the United Nations, which in July 1993 adopted a resolution request­ing the Secretary-General of the United Nations to set up a focal point for multisectoral collabo­ration on the economic and social aspects of to­bacco production and consumption, taking into account the serious health consequences of to­bacco use.

9.54 In pursuance of the further Health As­sembly resolution WHA46.8, the Director­General has urged the Secretary-General of the United Nations to ban the sale and use of tobacco products in all workplaces and public areas in buildings owned, operated or con­trolled by organizations of the United Nations system.

CHAPTER 10

Protection and promotion of the health of specific population groups

Maternal and child health, and family planning

10.1 During the biennium WHO gave priori­ty to the integration of family planning in pri­mary health care, and the achievement of high quality, sustainable care and management in maternal and child health and family planning services. The health of women and children continued to improve in many countries. How­ever, in the least developed countries the various indicators (maternal mortality, anaemia during pregnancy, low birth weight) have remained unchanged or have deteriorated and in other countries certain subgroups of women and chil­dren show little progress. In yet other countries the level of improvement falls short of what might be expected, considering the coverage of services. Among the problems encountered are:

-insufficient resources allocated to services, lack of integration, and failure of services to take proper account of women's needs. Two fea­tures mark countries that have made the greatest advances in improving the health of women and children: the essential elements of maternal and child health and family planning services have been fully implemented and are equitably pro­vided, managed and financed; and family plan­ning services with a wide range of methods are readily accessible to all.

10.2 In December 1993 a WHO expert committee considered the situation of maternal and child health and family planning in the 1990s, reviewed recent trends and technical advances and their applicability to national programmes, and stressed the need for support­ing action by various other sectors. It drew at­tention to required changes and recommended that policies, services and care should be reoriented to meet the real needs of the popula­tion. It also proposed the adoption of new ter-

53

minology to reflect the wider nature of the pro­gramme.

Family planning and population

103 WHO worked with FAO, UNESCO, ILO and UNFP A in providing multidisciplinary technical cooperation and support to national family planning and population programmes through eight regionally based teams, composed of staff from WHO and the other four organiza­tions. At an interregional meeting (Bangkok, May 1993) national programme managers, policy makers, and representatives of nongovernmental organizations and bodies in the United Nations system agreed on strategies for increasing the choice of contraceptive methods and ensuring a high quality of care in family planning pro­grammes. A good service was defined as one whose clients can decide on the basis of full and accurate information about a particular contra­ceptive method, can expect to receive good fol­low-up care and can consult well-trained staff who communicate clearly and honestly with them. Various related concepts were reformulat­ed: safety (to reflect concern about the side­effects of contraceptives); effectiveness (reflect­ing not merely the prevention of unwanted preg­nancies but also the effects that a method has on sexual relationships, the sense of control over the method, freedom to use it when the person wish­es and its efficacy in preventing infection); ac­ceptability (reflecting satisfaction and dissatisfac­tion with p~rticular methods, rather than looking only at the numbers of people starting a method and contining to use it); and availability (reflect­ing not only accessibility but also affordability). Countries are being encouraged to increase fami­ly planning services for adolescents and for mi­grants, refugees and other minorities lacking them.

THE WORK OF WHO 1992-1993

A community health worker explains details of birth·spacing to a mother, using a home·based maternal record.

10.4 Guidelines1 have been drawn up to assist programme managers and staff in dealing with questions of contraceptive choice and to ensure that the user's perspective is taken into ac­count in programme formulation, implementa­tion and evaluation. In addition, updated tech­nical and managerial guidelines are being pre­pared on services for intrauterine devices, and others have been issued on use of the rapid evaluation method2 and district team problem­solving in maternal and child health and family planning services.3

1 (ontwceptive method mix: guidelines for policy and service delivery. Geneva, World Heollh Organization (in press).

1 Document WHO/MCH·FPP /MEP / 931 . 3 Document WHO/ MCH·FPP / MEP / 93.2.

54

Maternal health and safe motherhood

10.5 The Organization contributed to the prep­aration of national safe motherhood plans in 28 countries by cooperating in research, devising training plans and collecting and applying data. Decentralization of care and reinforcement of the health infrastructure at district level were advocat­ed. A framework for national action plans to re­duce maternal and neonatal mortality was pre­pared: 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.

10.6 In 1992 WHO, UNFPA and UNICEF issued a joint statement on traditional birth at­tendants, outlining their value and limitations; WHO also produced a training package for these

PROTECTION AND PROMOTION OF THE HEALTH OF SPECIFIC POPULATION GROUPS

practitioners. In 1993 WHO and UNDP initiat­ed a project to strengthen national capacity to reduce maternal mortality and disabilities. In collaboration with the International Confedera­tion of Midwives and UNICEF, the Organiza­tion convened an international workshop (V an­couver, Canada, May 1993) to examine ways of improving the quality of maternal health care.

Child health and development

10 7 The Organization concentrated its efforts in this area on the promotion of perinatal and neonatal health; breast-feeding; growth, develop­ment and care of children in difficult social cir­cumstances; application of the Convention on the Rights of the Child; and action following the 1990 World Summit for Children. Health Assembly resolution WHA45.22 served as a basis for adapt­ing and applying an integrated strategy for mater­nal care and care of the newborn in district-based programmes. Findings of earlier studies on locally­produced kits were applied in national pro­grammes to promote clean delivery practices (for instance, in China, Philippines and VietNam) as a complement to administration of tetanus toxoid to eliminate neonatal tetanus and reduce maternal and neonatal sepsis. Guidelines and training mate­rials for the management of hypothermia, an im­portant and often unrecognized underlying cause of neonatal mortality and morbidity, were field­tested. Methods and materials were devised for the successful management of birth asphyxia, another major cause of early neonatal mortality, and protocols and training materials were tested for the management of sick newborn infants. A sim­ple method for assessment of gestational age was developed to identify newborns requiring special care or possible referral. On the basis of earlier research, the home-based growth and develop­ment record was widely used in China in primary health care and day-care centres in collaboration with UNESCO and UNICEF; this type of record was also used in Kiribati, Papua New Guinea, Philippines and Viet N am, and enables both preg­nant women and health workers to recognize risks and take appropriate action.

Regional activities

10 8 In Africa particular attention was paid to extending the coverage of services, improving the

ss

quality of care and reducing maternal and neonatal mortality and morbidity. Following a regional consultation on prevention of maternal mortality and on infertility in sub-Saharan Africa (Kigali, January 1992), a regional task force was created to plan a centre for training and research on safe motherhood and the status of women. Workshops on problem-solving for district teams were organized in Senegal and United Re­public of Tanzania and a regional support project, "Accelerated action for safe mother­hood in the African Region", was launched. WHO assisted in the design of a national mater­nal health and safe motherhood programme in Lesotho and participated in programme evalua­tion in Gambia. As part of efforts to strengthen national capacity, an intercountry workshop (Brazzaville, February 1993) was held to brief representatives from 37 countries, UNICEF and the International Children's Centre on a number of topics including data collection for the regional family health data bank, which was started during the biennium. Collaboration with UNICEF was strengthened through the merging of existing interagency task forces into a single joint UNICEF/WHO technical advisory group.

10 9 Activities in the Americas focused on perinatal conditions and low birth weight as leading causes of neonatal deaths. Development of specific perinatal care was supported and training in aspects of maternal and child health services and research was strengthened. Mem­ber States made particular efforts to integrate maternal and child health programmes. The Or­ganization undertook joint activities with na­tional and nongovernmental organizations in­cluding Family Health International, Interna­tional Project Assistance Services (USA), Family Care International, the Population Council and the United States Centers for Disease Control. Financial support was received from Italy, Neth­erlands, the Kellogg Foundation, UNICEF and UNFP A. Work continued on perinatal health projects in Bolivia, Honduras, Nicaragua and Peru, together with the promotion of maternal and child health education in nursing schools in eight countries.

1010 Further progress was made in South-East Asia in developing well-integrated maternal and child health and family planning services as part of primary health care. The safe motherhood ini­tiative was successfully promoted at country lev­el: for example, the Ministry of Health of Indo­nesia drew up a strategy and plan of action for

THE WORK OF WHO 1992-1993

1992-1996 in close cooperation with WHO and UNDP, a multisectoral task force in Nepal draft­ed a national plan of action for 1993-1997, and Bangladesh adopted the long-term objective of building up an effective, realistic and compre­hensive programme of care to reduce maternal and neonatal mortality and morbidity. The Or­ganization took an active part in a ministerial conference on children organized by the South Asian Association for Regional Cooperation (Colombo, September 1992), which outlined challenges, opportunities and future tasks and drew up strategies for achieving the goals of the 1990 World Summit for Children as part of over­all development strategy.

10.11 In countries of central and eastern Europe emphasis was given to assisting specific groups such as teenagers and socially deprived women in overcoming barriers to family planning. Reduc­ing the high rate of abortion in those countries, accounting for a sizeable proportion of maternal deaths, is a key goal of the programme "From abortion to contraception", resulting from the 1990 Tbilisi conference on this subject. WHO cooperated with Estonia, Romania and Russian Federation in improving maternal and child health care and family planning, and with Alba­nia in upgrading family planning and gynaeco­logical services.

1012 In the Eastern Mediterranean activities fo­cused on strengthening national capacity for planning and implementing effective maternal and child health and family planning pro­grammes. Support was provided to countries in setting up safe motherhood programmes and in reducing maternal and infant mortality rates. In a number of countries the prevalence of low birth weight remains high, even though maternal and child health programmes have been in operation for decades. An intercountry consultation on ways to reduce the frequency of low birth weight (Rabat, June 1992) reviewed past efforts, identi­fied reasons for failures, and drew up an im­proved strategy for combating this problem.

1013 Activities in the Western Pacific were largely devoted to strengthening the manage­ment of national maternal and child health pro­grammes. WHO's "rapid evaluation method", which combines various epidemiological and service research procedures, was used for collect­ing information on the performance, strengths and weaknesses of maternal and child health and family planning services in China, Papua New

S6

Guinea and VietNam as a guide to improving the services. An integrated management informa­tion system for maternal and child health and family planning services was used experimentally in some areas of China after training of all health workers involved. In most Member States family planning has become an integral part of family health services, including the introduction of new contraceptive methods such as subdermal implants and long-acting injectable contracep­tive hormones. The family planning acceptance rate is generally low, varying between 2% (Papua New Guinea) and 35% (Tuvalu) of women of reproductive age; the low rate is attributable to such factors as religious beliefs, lack of aware­ness, misconceptions, poor logistics, insufficient managerial skills, and financial problems.

Health of adolescents

1014 WHO, with support from UNFPA and UNICEF, launched a new initiative to promote the healthy development of young people, in­cluding strengthening of the information base, a review of the current health status of young people in developing countries, and technical support to countries. This initiative has also strengthened WHO's collaboration with non­governmental organizations at country level. In the Americas activities accelerated following the approval in 1991 of a regional plan of action to promote the health of adolescents; and a network of institutions in this field in 10 countries was set up with support from the Kellogg Foundation.

10.15 Materials issued during the biennium in­cluded a publication on the health of young people1

; two documents prepared jointly with the International Youth Foundation, one on principles of success in programming for young people2 and the other containing summaries of more than 400 exemplary programmes or projects3

; and a module for training in counsel­ling skills in adolescent sexuality and reproduc­tive health.4 In the Americas documentation cen­tres were established in Brazil and Colombia,

1 The health of young people a challenge and a promrse. Geneva, World Health OrganiZatiOn, 1993.

2 Document WHO/ADH/92 3. 3 Document WHO/ADH/92.4. 4 Document WHO/ADH/93.3

PROTEaiON AND PROMOTION OF THE HEALTH OF SPECIFIC POPULATION GROUPS ~~~~--------~~--~- ----------~----~-~---~~-

and PAHOIWHO developed instruments for service evaluation, care of adolescents, and clini­cal history-taking. A manual on health in adoles­cence was widely disseminated, and an informa­tion system to provide data on adolescents was designed in Brazil in cooperation with UNFPA and the Kellogg Foundation.

10.16 Research on the interaction of adolescents, adults and health providers was expanded. The "narrative research method" 1 (see box) was used in Africa, and a meeting was held (Dakar, April 1993) to bring young people together with representatives of ministries of health to decide on future action. The method was also used in Brazil, Chile, Switzerland and Thailand. A survey in In­donesia, Nigeria and Philippines explored the ex­tent to which services for maternal and child health, for family planning and for the control of sexually transmitted diseases are meeting the needs of young people. In Nigeria a review of law and policy on adolescent health was completed. The research instruments from these studies are being elaborated for wider use.

10.17 A number of countries formulated national policies for adolescent health, including Brazil, Chile, Colombia, Costa Rica and Indonesia. An intercountry consultation involving representa­tives of governments and nongovernmental or­ganizations in the Eastern Mediterranean (Beirut, June 1993) prepared a social profile of adolescent girls, including adverse lifestyle factors that may impair their reproductive health, and suggested action at country level to provide special services for this group. An intersectoral meeting on the health of young people was held in Morocco (Rabat, June 1992), and a school sentinel service for adolescent health was set up in Tunisia. A joint project with the Council of Europe and the Com­mission of the European Communities was un­dertaken on health promotion for children and adolescents in schools. Health education courses and workshops on adolescent health were held in countries of the Western Pacific.

10.18 Training in counselling on adolescent sex­uality and reproductive health was carried out with national affiliates of the International Planned Parenthood Federation in 10 countries in South-East Asia, the Eastern Mediterranean

1 Document WHO/ADH/93.4.

57

The narrative research method

• Today the health of young people is of growing concern in most parts of tli.e world as changing behaviour patterns confront them with new health hazards. This is espe­cially true of sexual and reproductive health. WHO together with UNFPA, the World

Assembly of Youth and the World Organi­zation of the Scout Movement and their af­filiates undertook a study of the sexual be­haviour of young people in 11 countries of sub-Saharan Africa, with over 12 000 re­spondents. It was carried out using a tech­nique known as the "narrative research method", which was designed for this pur­pose but can be used for any research that lends itself to a storyline. In the present study selected young people from the youth organizations used role play to develop a story which they regarded as most typical of the way in which a relationship between two young people in their communities leads to an unwanted pregnancy. This story was then presented to representative sam­ples of young people in each of their coun­tries for modification. The resulting aggre­gated story, as well as differences among adolescents of different sex, age and resi­dence, were reviewed by the youth organi­zations to plan future action. The intention of the study was to capitalize on those who know most about young people's behav­iour- young people themselves. It emerged from the study that there was substantial agreement on the choice of story in all the countries, suggesting the existence of a common adolescent culture that crosses national and cultural boundaries. Moreover, the predominant story tended to be shared by respondents of both sexes. It was also clear that there is a great need to prepare young people for dealing with relationships and sexual encounters, and also to prepare families and responsible adults such as teach­ers, so that they can give the necessary sup­port. Health services too must be adapted so that young people are able and willing to use them for prevention, care and treatment. This method will be of value in designing programmes for adolescents throughout the world, spearheaded by youth leaders who, because of their age, motivation and experi­ence, are in the best position to learn about the realities of young people's lives and provide that information to those who make policy and implement programmes for ado­lescent health and development, including youth organizations.

THE WORK OF WHO 11JIJ2-11JIJ3

and the Western Pacific, using the WHO mod­ule. PAHO/WHO supported 11 regional meet­ings for training and sensitization on adolescent health for multidisciplinary teams. A core curric­ulum for professional training in adolescent health and development is being prepared.

Human reproduction research

1019 1992 marked the twentieth anniversary of the Special Programme of Research, Develop­ment and Research Training in Human Repro­duction, which is funded almost exclusively from extra budgetary contributions and is cosponsored by UNDP, UNFPA, WHO and the World Bank. To mark this occasion, a special report on the global status of reproductive health was is­sued as part of the Programme's 1990-1991 bi­ennial report. 1

Contraceptive safety

10.20 In May 1993 a group of experts met to review available data on the use of depot­medroxyprogesterone acetate (DMP A) and the risk of cancers of the breast, cervix, endometrium and ovary, including data from the large WHO collaborative study of neoplasia and steroidal contraceptives. The experts concluded that there was no evidence for an overall increase in the risk of cancer at any of the four sites reviewed, associ­ated with the use of DMPA, and therefore did not recommend restricting its use as a contracep­tive on the grounds of risk of neoplasia. Al­though 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 ob­served represented new tumours caused by DMP A. On the other hand there was good evi­dence of protection against endometrial cancer. It was also recommended that further studies should be conducted to collect data on long-term DMPA use by young women and the effect of its use in combination with estrogen. In 1992, fol­lowing the publication of results of the WHO study of DMPA and breast cancer, the United

1 Khanna J, Van look PFA, Gr1ff1n PO, eds Reproducttve health· a key to a bnghter future Geneva, World Health Organ1zat1on, 1992.

ss

States Food and Drug Administration approved its use as a contraceptive.

New monthly injectable contraceptive preparations

10.21 In 1992 major phase Ill clinical trials were completed on two once-a-month injectable preparations, Mesigyna (50 mg of norethisterone enantate plus 5 mg of estradiol valerate) and Cyclofem (25 mg of medroxyprogesterone ace­tate and 5 mg of estradiol cypionate), developed by WHO. One of the trials, conducted in 12 centres in Egypt, evaluated the two prepara­tions and the results will be taken into account in deciding whether to approve them for the na­tional family planning programme. The second trial, in China, compared the same preparations and Chinese Injectable No. 1. Preliminary analy­ses confirmed the high efficacy and superior clin­ical efficacy of Mesigyna and Cyclofem; and this may lead to a shift to use of these preparations in China. In June 1993 a consultation of experts reviewed the available data on the new prepara­tions and confirmed that they were safe and ef­fective in preventing pregnancy. They also offer significant advances over progestogen-only injectables owing to the relatively high frequency of predictable menstrual patterns. Preliminary data suggest that return to ovulation occurs within a reasonable time, but further work is required to confirm return to fertility. The ex­perts recommended these methods for routine use in family planning clinics, bearing in mind that they have contraindications similar to those applicable to oral contraceptives.

Intrauterine devices

10 22 Until recently many of the copper-bear­ing intrauterine devices (IUDs) were approved by national drug regulatory authorities for up to only four years of continuous use as there was little information on their efficacy beyond that period. Long-term studies by WHO on two cop­per-bearing IUDs- the TCu220C and TCu380A - have now provided data on up to nine years of continuous use. The pregnancy rates for the de­vices at nine years of use represented an annual risk of accidental pregnancy of less than 1% with one device and less than 0.5% with the other. Comparative trials of these devices are continu-

PROTEatON AND PROMOTION OF THE HEALTH OF SPECIFIC POPULATION GROUPS

ing and will provide information on their safety and efficacy up to and beyond ten years of use. In the light of these studies, the United States Food and Drug Administration decided in August 1991 to extend the approved duration of use of the TCu380A from six to eight years.

10.23 An important issue in recent years has been whether use of the IUD is related to pelvic inflammatory disease (PID) and whether long­term use is associated with severe forms of the disease. A study of the large database on IUDs maintained by WHO has shown that in a total of 22 908 insertions in 12 trials, the overall rate of PID was 1.6 cases per 1000 woman-years of use, i.e. only three cases of PID could be expected in two thousand women using an IUD for one year. The study also showed that the risk of PID was seven times higher than the above rate in the 20 days following insertion of the device, but there­after was low and remained constant for at least eight years of use. There was no evidence of an increase in the severity of PID with increasing duration of use. Because of the greater risk of PID associated with insertion, IUDs should be left in place up to their maximum lifespan and not be routinely replaced earlier, if there are no contraindications to continued use and the wom­an wishes to continue with the method.

Mifepristone for emergency contraception

10.24 Antiprogestogens have been shown to have potential for use in emergency contracep­tion. These compounds neutralize the action of the hormone progesterone and can block ovula­tion or retard the preparation of the uterus for implantation, depending on whether they are ad­ministered before or after ovulation. WHO funded two randomized trials to compare the efficacy and side-effects of a single dose of 600 mg of mifepristone with those of the stand­ard Yuzpe regimen ("morning-after" pill), 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 treated with the Yuzpe regimen. The women treated with mifepristone reported less nausea and vomiting, as well as lower rates of other side­effects, than the women treated with the Yuzpe regimen; but the onset of their next menstrual period was more likely to be delayed. In view of the encouraging results, it is now planned to con-

59

duct a multicentre trial to determine the lowest effective dose of mifepristone for emergency contraception.

Methods for the regulation of male fertility

10.25 Work continued in evaluating hormonal contraceptive options for men and assessing the safety and efficacy of various methods for occlu­sion of the vas deferens. A five-centre study in Indonesia on sperm suppression induced by combined androgen-progestogen administration was completed in 1992, and the results submitted for publication. It was found that testosterone enantate or 19-nortestosterone ester plus DMPA resulted in much higher rates of azoospermia in Indonesian men (97%) than previously observed with such drug combinations in Caucasian men. The multicentre study on the contraceptive relia­bility of testosterone-induced severe oligozoo­spermia continued in 15 centres in nine coun­tries. Previous studies had revealed variations in the responsiveness of men of different ethnic ori­gins to contraceptive steroids, and the underly­ing mechanisms are being explored further in investigations supported by WHO and collabo­rating agencies.

10.26 A study is under way in China on the safety and efficacy of three different methods of vas occlusion, the "no-scalpel method", percu­taneous injection of a sclerosing agent, and injec­tion of a polyurethane plug into the lumen of the vas deferens. A consultation was held in Septem­ber 1992 to review progress in research on Tripterygium wilfordii, which is used in tradi­tional Chinese medicine for the treatment of pso­riasis; it recommended setting up a programme of limited duration to determine whether an antifertility drug could be developed from the active compounds identified in extracts of this plant.

Vaccines for fertility regulation

10.27 It is proposed to develop a birth-spacing vaccine that will be effective for a period of up to 18 months, since this is perceived to be a useful interval for users at practically all stages in their reproductive lives. A prototype anti-hCG vac­cine was developed solely to demonstrate the

THE WORK OF WHO 1992-1993

safety and feasibility of the approach and not as a final product. It had therefore been envisaged that this vaccine would not be used beyond the phase I clinical trial stage, and that an improved anti-hCG vaccine would be prepared for further clinical testing and product development. How­ever, the results of the phase I trial were consid­ered sufficiently encouraging to proceed with a phase II trial to determine whether the level of anti-hCG antibodies produced in response to the vaccine does in fact provide protection against pregnancy in fertile women.

10.28 Studies to develop an anti-trophoblast vaccine continued. This research concentrated on the use of monoclonal antibodies and molecular genetics techniques in order to identify and char­acterize tissue-specific antigens, with particular emphasis on antigens that may be suitable for the development of a vaccine which will have an effect prior to the completion of implantation.

Methods for the natural regulation of fertility

10.29 The highest research priority for WHO in this area continued to be lactation and its role in the suppression of ovulation. In addition, re­search was conducted on indicators of the fertile period, including new possibilities for the meas­urement of urinary steroid glucuronides, and on natural family planning. The prospective multicentre study of the relation of breast-feed­ing practices to the duration of lactational amenorrhoea continued. The purpose of this study, which involves 3850 mother-infant pairs, is to elucidate the factors that determine lactational infertility. Other current research in­cluded studies on the effects of supplementary nutrition to nursing mothers on the return of ovulation, studies on the immunoactivity and bioactivity of luteinizing hormone and prolactin, and studies on the interface between breast-feed­ing and the adoption of other methods of contra­ception.

10 30 Accurate estimation of the fertile interval in women is vital to the efficacy of family plan­ning methods based on periodic abstinence. Re­search concentrated on inexpensive and simple methods or devices that can be used in the home to measure biochemical or biophysical markers of the fertile period. The measurement of cervico-vaginal fluid volume using a simple de-

60

vice was tested in a multicentre trial, as was the measurement of guaiacol peroxidase, an enzyme with a concentration in cervical mucus that is inversely related to blood estrogen levels during the follicular phase of the cycle. WHO also pro­vided support for the development of assays of urinary steroid glucuronides that require only the collection of urine on to filter paper, thus avoiding the problems of storage and transport of liquid urine.

Prevention and management of infertility

10.31 Research has focused on the prevention of infertility caused by sexually transmitted diseas­es and the management of infertility, especially in developing countries. This work includes stand­ardizing the investigation of infertile couples, evaluating certain treatments of infertility in the male and the female, developing and evaluating kits for simplified diagnosis of sexually transmit­ted diseases, and estimating their prevalence through seroprevalence studies in developing countries. Also under way are the development of a vaccine against genital infection with Chlamydia trachomatis and the evaluation of barrier methods for the prevention of sexually transmitted diseases. In 1992 WHO was instru­mental in introducing polymerase chain reaction (PCR) methodology for chlamydial antigen de­tection in tertiary health care centres in six de~el­oping countries.

Introduction and transfer of technology

10 32 A strategy for the introduction of new and underutilized methods of fertility regulation was drawn up during the biennium. The strategy shifts the emphasis in the introduction of methods from the product itself to users' needs and programme capabilities, and also provides background infor­mation for decisions by national family planning programmes concerning additional methods. It takes into account not only the potential demand for a method but also the capability of services to cope with the demand and to back up the method with the appropriate care. The strategy will be implemented initially in selected countries in Lat­in America and sub-Saharan Africa.

10 33 Studies on the introduction of the once-a­month injectable contraceptive, Cyclofem, into

-------------------- -----

PROTECTION AND PROMOTION OF THE HEALTH OF SPECIFIC POPULATION GROUPS

national family planning programmes in Indone­sia, Jamaica, Mexico, Thailand and Tunisia have been completed or are being assessed. They exam­ine such factors as use-effectiveness, reasons for discontinuation of methods and service delivery constraints in each of these countries, based on the experience of 7700 women, and the findings are now being written up. After completion of the pilot phase, the study in Chile was extended to additional clinics at the end of 1992. New studies were begun in Brazil, Colombia and Peru in 1993.

10_34 Following a 1991 meeting on women's perspectives in the selection and introduction of fertility regulation methods, representatives of women's health groups, researchers and policy­makers from Bangladesh, India, Indonesia and Philippines met for further discussion of this topic (Manila, October 1992).

Social science research

10J5 Work continued in the major research ini­tiative on the determinants of induced abortion, launched in 1991. Of 27 projects supported by WHO, about half were completed by the end of 1993. In the area of male fertility and contracep­tion, studies supported thus far under the con­dom acceptability initiative were completed by the end of 1992, and new studies continue to be accepted. Research was begun on the role of men in determining family size and in making deci­sions about contraceptives. Acceptability studies of contraceptive methods including vasectomy, female sterilization, the diaphragm, IUDs and monthly injectable preparations are under way. Several studies concerned with gender roles are proceeding. Factors affecting contraceptive use continue to be of major interest to researchers in the developing world, and remain a priority sub­ject for research supported by WHO.

Resources for research

10.36 WHO seeks to strengthen the capabilities of developing countries to plan and carry out pri­ority research in reproductive health. It also main­tains contacts with a network of research centres that participate in global research activities.

10_37 A total of 105 institutions in 56 countries were working with WHO during the biennium;

61

of these, 50 (in 30 countries) were designated as WHO collaborating centres for research in hu­man reproduction, while the remainder were in­volved in research capability strengthening. Ef­forts were made to encourage and support tech­nical cooperation among developing countries. A special fund has been set aside for this purpose, to which the Rockefeller Foundation contrib­utes.

10.38 In Africa emphasis continued to be given to the least developed countries and to the pro­motion of "South-South" collaboration for re­search capability strengthening. A task force on the prevention of maternal mortality and infertil­ity was established following a regional consulta­tion on this subject (Kigali, January 1992). A research management workshop (Harare, March 1992) brought together scientists from eight countries.

10.39 Assessments of research needs in reproduc­tive health were supported in Chile, Panama, Peru and English-speaking countries of the Caribbean. These were followed by interagency coordination and fund-raising to meet the research challenges identified. Promotion of training capabilities in the Americas included support for a master's degree course in reproductive epidemiology and a one-year course in the organization of clinical tri­als. Much of the responsibility for the award of short-term training grants has been delegated to regional research and training organizations. This policy improves coordination, reduces costs and administrative time spent, and encourages in­volvement of researchers themselves in decision­making. A regional network for epidemiological research is now fully operational and a regional programme on social science research is under way. Reproductive health research will benefit from strengthening of non-human primate facili­ties in Chile, research on molecular biology in 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 leading research institutions in developed coun­tries. Workshops on scientific writing were con­ducted in Argentina, Brazil, Chile and Venezuela.

10.40 Two intercountry meetings organized in Cairo to assess research needs, one dealing with maternal and child health (November 1991) and the other with reproductive health (December 1992), provided a basis for formulating an East­ern Mediterranean regional strategy to promote

THE WORK OF WHO 1992-1993

research and strengthen national research capaci­ty in these fields.

10 41 A shift of emphasis in support in South­East Asia and the Western Pacific led to a sub­stantial increase in collaboration with least devel­oped countries, which now receive about 50% of the available funds. Following the signature of a memorandum of understanding, it is expected that collaboration will be strengthened with In­dia in the development of research capacity and the promotion of research in human reproduc­tion.

Occupational health

10 42 In April1992 the Joint ILO/WHO Com­mittee on Occupational Health reviewed pro­grammes on occupational health and safety, dis­cussed aspects of occupational health in Member States, drew up general policies and designated areas for collaboration between the two agencies.

10.43 A first meeting of WHO collaborating centres in occupational health (Moscow, Septem­ber 1992) discussed ways of strengthening "net­working" of institutions in this field, at national and international level. In support of this aim, WHO issued a directory of its collaborating cen­tres in occupational health1 and launched a quar­terly newsletter. A planning group was set up to coordinate the international activities of the col­laborating centres and advise on the programme; at its first two meetings, in December 1992 and June 1993, it surveyed global needs and deter­mined priorities.

10 44 In May 1993 the Joint ILO/WHO Com­mittee on the Health of Seafarers reviewed the occupational health problems of seafarers and formulated recommendations and guidance in the following areas: injury prevention; preven­tion of blood-borne and sexually transmitted in­fections; education of seafarers on the dangers to their health and careers from abuse of drugs and alcohol; prevention and control of mental diseas­es and psychosocial disturbances; procedures for periodic updating of the International medical

1 leht1nen S Collaborotmg centres in occupational health· directoty, net· working, pnonties and future perspecttves Geneva, World Health Orgon1· zot1on, 1992

62

guide for ships; and harmonization of medical examination requirements for seafarers. The Committee appealed to all the parties concerned to collect comparable statistics concerning acci­dents and other health problems of seafarers.

10.45 Work continued on reference methods and quality assurance in the evaluation of expo­sure to airborne fibres at work, with the support of the International Fibre Safety Group and Commission of the European Communities. Following a comparative analysis in 1992, the methods were refined at two expert meetings (Sheffield, United Kingdom, February 1993; New Orleans, USA, May 1993).

10.46 The importance is now recognized of ob­taining data on doses and health risks for biolog­ical monitoring of exposure to chemicals at work. Meetings organized in collaboration with the International Programme on Chemical Safe­ty worked out strategies (Kyoto, Japan, October 1992), identified chemicals requiring priority at­tention (Geneva, December 1992) and drew up guidelines for data collection (Geneva, Novem­ber 1993).

10 47 A workshop on medical surveillance of workers exposed to dusts inducing pneumo­coniosis, organized in collaboration with ILO and in association with an international confer­ence on occupational lung diseases (Prague, Sep­tember 1992), outlined requirements for improv­ing the prevention of occupational respiratory diseases. Subsequently, technical guidelines on the medical screening of workers exposed to mineral dusts were prepared for use in training programmes to improve medical surveillance in Member States. In addition, the interaction be­tween smoking and workplace hazards was re­viewed.2

10.48 A J01llt WHO/ILO interregional task group on health protection of workers in small­scale undertakings (Bangkok, November 1993) reviewed the global situation and worked out acceptable, low-cost but effective measures.

10 49 In collaboration with the International Commission on Occupational Health, an inter­national directory of occupational health data­bases and data banks was issued in loose-leaf

'Document WHO/OCH/TOH/92 1

PROTECTION AND PROMOTION OF THE HEALTH OF SPECIFIC POPULATION GROUPS

format and on computer diskette. 1 The reports of a WHO expert committee on health promotion in the workplace in relation to alcohol and drug abuse,2 and a WHO study group on aging and working capacity3 were published. Activities dealing with safe use of pesticides included the publication of guidelines4 and sponsorship of an international symposium on health and ergo­nomic aspects of the safe use of chemicals in agriculture and forestry (Kiev, June 1993 ).

10.50 The wide range of activities to promote the health of working populations at regional level included education and training in occupa­tional health in Africa, promotion of interagency and intersectoral cooperation in the Americas through the initiative "1992: Year of Workers' Health", integration of health care for workers in national health systems using the primary health care approach in South-East Asia, strengthening of occupational health services with particular attention to countries of central and eastern Eu­rope, framing of appropriate legislation in the Eastern Mediterranean, and safety promotion in small-scale undertakings in the Western Pacific.

Health of the elderly

10.51 During the biennium, as part of the inter­national research programme on aging requested by the World Health Assembly in 1987, the Or­ganization proceeded with the development and implementation of three studies on osteoporosis, age-associated dementias, and determinants of healthy aging, as described below, while detailed planning was begun for a fourth (on immunolo­gy and aging) following receipt of funding. An international study to assess home care needs was also launched. The United States National Insti­tute on Aging continued its technical and finan­cial support to research activities and additional funds became available for the implementation of research projects in countries.

1 Sevdla JM InternatiOnal d11ectory of databases and data banks tn occupa­tional health. Palma de Mallorca, World Health OrganiZation/International Commission on Occupational Health, 1993

2 WHO Techmcal Report Series, No. 833, 1993 3 WHO Techmcal Report Se11es, No. 835, 1993 4 Control technology for the formulatron and packrng of pestiCides Geneva,

World Health Orgamzat1on, 1992.

63

10.52 In the osteoporosis study, the hospital discharge data survey and case-control study proposal were finalized in collaboration with the coordinating centre at Stanford University (USA). The selection of instruments for the case­control study was completed and approved by the principal investigators from the participating centres (Brazil, China, Hong Kong, Hungary, Iceland, Nigeria, Trinidad and Tobago) and from parallel study centres (Chile, Italy, Poland) dur­ing their first meeting in March 1993. Translation of the study proposal and instruments and their adaptation to each culture then began. A survey on the prevalence of osteoporosis in the popula­tion of part of Beijing was started in 1992 under contract with the University of California (USA).

10 53 In the project on age-associated demen­tias, the pilot studies already carried out in 1991 in Nigeria and the United States of America by participating centres were followed by studies in Chile, Malta and Spain in 1992. The project coor­dinating centre located in the office of the Studio Multicentrico Italiano sulla Demenza in Flor­ence (Italy) made an analysis of the pilot studies, following which the study instruments were fi­nalized, translated, printed and distributed to all participating centres. Data collection for the field study began in each centre in August 1993 and data on the prevalence of dementia conditions should be available by the end of 1994. The re­sults of standardization of the clinical diagnosis of dementia carried out in 1991-1992 are now in press. The results of the pilot study were submit­ted for publication at the end of 1993.

10.54 In 1992 a group of experts met to initiate the project on determinants of healthy aging. The Centre for Ageing Studies of Flinders University of South Australia was designated as coordinat­ing centre and Costa Rica, Israel, Italy, Jamaica, Thailand and Zimbabwe were selected as partici­pating countries. During 1993 the coordinating centre, in collaboration with Yale University (USA) and Duke University (USA), drew up a proposal for a pilot study and prepared instru­ments for assessing physical, mental and social functioning in the aged population. In March 1993 WHO hosted a meeting of the research network on successful aging of the MacArthur Foundation (USA). The subsequent selection of the assessment instruments mentioned above was based on recommendations made by the net­work. Harmonization of these instruments and the feasibility and validation study in three of the

THE WORK OF WHO 1992-1993

participating countries (Costa Rica, Italy, Thai­land) were completed.

10.55 In Europe another project on healthy ag­ing, established jointly with the European Com­munity, focuses on health promotion for the eld­erly. A meeting (Heidelberg, Germany, October 1992) examined the contribution of prevention and rehabilitation to healthy aging, and urged life-long preparation for healthy aging through health promotion and the creation of environ­ments allowing elderly people to realize their potential and to remain in their own homes for as long as possible.

10.56 A major home care initiative was launched during the biennium, recognizing that such care is given in many countries, affords the best qual­ity of life for most people and is often less expen­sive than many kinds of acute and chronic care in institutions. It was stimulated by the recognition in all WHO regions that well-planned home care may contribute appreciably to the containment of costs in providing good quality health services for the elderly. Preliminary steps were taken to determine the need for home care from existing data from three developed and nine developing countries, analysed with the assistance of the United States National Institutes of Health, Duke University (USA) and the United States Bureau of the Census, as a basis for advice to be given to individual countries on the needs of their elderly populations. WHO also participat­ed in a project to design a valid and reliable sur­vey instrument in various languages which would allow for both the assessment of needs of

64

individuals in the home setting and for intercountry comparison. The home care initia­tive was strengthened at international level by the creation of a World Organization for Care in the Home and Hospice, with which WHO forged close links. One aspect of home care -family support - was highlighted in a book pub­lished in 1992 on WHO's behal£.1

10.57 WHO convened an interregional consul­tation (Alexandria, October 1992) to prepare a strategy for health care of the elderly, which in due course will be incorporated into the United Nations strategy for aging populations. Follow­ing the consultation, efforts have been made in several regions to encourage Member States to pay more attention to national policies and strat­egies for care of the rapidly expanding popula­tion group of the elderly. In Africa, for example, an average of 5. 9% of the population in Member States is aged 60 years and over, while only 7% of the countries have policies for the care and wel­fare of this age group. Thus much technical col­laboration at regional level has been aimed at raising awareness and improving assessment of the health needs of the elderly; strengthening geriatric and gerontological services within the framework of primary health care; and encour­aging health protection and promotion for the elderly with particular emphasis on involvement of the elderly themselves in these activities.

1 Kend1g Hl, Hashimoto A, Coppard LC, eds. Family support for the elderly the international expenence. Oxford, Oxford University Press, 1992.

CHAPTER 11

Protection and promotion of mental health

Mental health policy, and support to national programmes

11.1 In its work to ensure that psychosocial and behavioural factors are fully taken into ac­count in the whole range of health care, and in its specific activities related to mental and neurolog­ical disorders, WHO received support from the Carnegie Corporation (USA), Delagrange Inter­national!Synthelabo Recherche (France), Digital Equipment Corporation (USA), Johann Jacobs Foundation (Switzerland), the Laureate Founda­tion (USA), the United States National Institute of Mental Health, Ravizza Farmaceutici (Italy) and the Upjohn Company (USA), as well as UNICEF and the World Bank. Work in the Western Pacific was supported by the Sasakawa Foundation Qapan).

Development of national mental health programmes

11.2 Guidelines on formulating national men­tal health programmes and instruments for as­sessing mental health policies and programmes were produced in 1992 and are being field-tested. WHO collaborated with countries of central and eastern Europe in strengthening their mental health programmes.

11.3 To increase public and professional aware­ness of the burden of neurological disorders, WHO organized meetings on neurology and pub­lic health: the first in May 1993 supported by the International School of Neurological Sciences in Venice (Italy); the second in October 1993, for French-speaking countries, supported by the In­stitute of Neurological Epidemiology and Tropi­cal Neurology in Limoges (France); and a third in Berlin in December 1993, for countries of central

6S

and eastern Europe, supported by the European Federation of Neurological Societies. The three groups contributed substantially to a forthcoming publication on neurology and public health.

11 4 Methods were devised for assessing cost­effectiveness in mental health programmes, infor­mation systems were established in support of national mental health programmes, a national workshop on computer-assisted mental health re­cording and reporting was held in China, and na­tional workshops were organized to share infor­mation about programme development in some 40 countries. To facilitate national planning, WHO has started a new series of monographs on the epidemiology of mental disorders and psycho­social problems; and the first three, dealing with personality disorders, with dementia and with schizophrenia, are being published1 in addition to a paper on the epidemiology of suicidal behav­iour. A fourth edition of an annotated directory of mental health training manuals2 and a report on WHO's research activities in mental health were issued.

Classification and assessment

11 5 Building on the chapter of mental and be­havioural disorders in the tenth revision of the International Classification of Diseases (ICD-10), diagnostic guidelines3 (so far issued in

1 de Girolama G, Reich JH. Personality disorders. Geneva, World Health OrganiZation, 1993. Warner, R, de Grrolamo G. Schizophrenia. Geneva, World Health Orgama· lion (in press). Henderson, AS, Dementw Geneva, World Health OrganizatiOn (rn press)

2 Document WHO/MNH/MND/92 15. 3 The /CD· I 0 classificatiOn of mental and behavioural d1sorders. Cltnical

desmptions and diagnostic gu1delmes Geneva, World Health Organrza­tion, 1992.

THE WORK OF WHO 1992-1993

10 languages), diagnostic criteria for research, and tables for conversion between ICD-8, ICD-9 and ICD-10 were published. 1 A primary health care version of the chapter for field trials was produced2 and a lexicon of alcohol and drug terms and another of psychiatric mental health terms used in ICD-10 and related publications are in print. Several standardized assessment in­struments were produced and are now widely used by mental health workers. Experts and in­stitutions in some 50 countries participated in the field work that led to the compilation of these texts, and a network of WHO collaborating cen­tres was set up to provide training, compare ex­perience and conduct further research.

11 6 A study was begun in five countries to investigate the somatic presentation of psycho­logical disorders in different cultural circum­stances and develop diagnostic instruments for their assessment. An adaptation of the Interna­tional Classification of Diseases for neurology was prepared in collaboration with a network of centres and with major nongovernmental organi­zations. In September-October 1992 a meeting was held to discuss diagnostic criteria for acute 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 (Geneva, February and June 1992; Paris, June 1993).

Psychosocial and behavioural problems and relevant interventions

11 7 A set of 25 papers was produced on be­havioural approaches to medical problems and on the teaching of communication and interac­tion skills, for incorporation into teaching mod­ules for medical schools. Preliminary studies were undertaken in Belarus, Egypt, India and Zimbabwe on measures to improve communica­tion skills in health workers. A booklet on the management of psychosocial consequences of disasters was prepared/ as well as a draft manual on refugee mental health, for use by nonprofes-

1 Document WHO/MNH/92.16 2 Document WHO/MNH/MND/93.1 3 Document WHO/MNH/PSF/91 3

66

sionals working in camps. WHO helped to assess needs and provided mental health consultant services in former Yugoslavia and in Somalia. The Organization also collaborated with psychi­atrists in the Philippines to produce a manual on psychosocial care for victims of natural disasters and provided training and education on psycho­social aspects of health as part of medical educa­tion in China. A study in India classified ways in which adolescents adopt risk-taking behaviour.

11 8 A document was issued on the psycho­social and mental health aspects of women's health.4 In collaboration with UNICEF, a net­work of centres linked by a newsletter, Skills for life, was set up to promote communication or other psychosocial skills as a means of helping children and adolescents to avoid behaviour del­eterious to health. A WHO life-skills resource package is being tested in Colombia, Nigeria, Thailand and Zimbabwe, to meet the needs of school-age children, particularly those actually in school. Training guidelines were produced for health workers on ways to improve parent-infant interaction, and training workshops on this topic were held in Brazil, Norway and Portugal.

Prevention and control of alcohol and drug abuse

11 9 Evaluations of drug prevention and con­trol programmes were undertaken or continued in several countries and areas5 and prevention of psychoactive substance abuse was widely pro­moted. Following a feasibility study, an abuse trends linkage alerting system (ATLAS) was set up; it is compatible with other data reporting systems of the United Nations and provides a framework for revising existing WHO epidemi­ological instruments on drug abuse. This activity was supplemented by a number of regional initi­atives, especially in the Americas, South-East Asia and Europe, which should enhance WHO's capacity to provide accurate informa­tion on patterns of substance abuse. Rapid as­sessment procedures, involving qualitative re-

4 Document WHO/FHE/MNH/92 1. 1 Afghanistan, BoliVIa, Brazil, Chile, Ch1na, Estonia, Hong Kong, Latv1a,

L1thuan1a, Macao, Maur1t1us, Myanmar, Nepal, Sri Lanka, and some mem· bers of the Commonwealth of Independent States (Kazakhstan, Kyrgyzstan, Tapk1stan, Turkmemstan, Uzbek1stan)

PROTECTION AND PROMOTION OF MENTAL HEALTH

search, were developed and applied in various settings, including Central Africa and selected small island countries. A similar approach was used for reviewing health aspects of drug use in relation to sports and for gathering information on drug use by women in 25 countries. As part of its contribution to the 1994 International Year of the Family, WHO prepared a position paper on preventing substance abuse in families. It also collaborated with theW orld Bank in incorporat­ing global data on substance abuse into the Bank's 1993 report.'

11 10 An expert committee report was issued dealing with the prevention of alcohol- and drug­related problems in the workplace;2 it recom­mended in particular that their solution should combine comprehensive prevention policies and health promotion programmes. A joint UNDCP/ ILO/WHO project on prevention of drug and alcohol use among workers and their families is being implemented in Egypt, Mexico, Namibia, Poland and Sri Lanka. WHO has started a dia­logue with representatives of the alcoholic bever­age industry in order to alert them to the public health consequences of trends in alcohol con­sumption, including alcohol-related traffic accidents and violence. In 1992 the Regional Committee for Europe strongly endorsed a European alcohol action plan, after which several technical meetings were held to decide on how the plan should be implemented in countries. Following earlier work on this subject, WHO be­gan a review of the health policy and legal aspects of treatment and rehabilitation of persons de­pendent on or suffering from abuse of drugs and alcohol.

11.11 Qualitative and quantitative assessment techniques were designed to support studies on the WHO initiative on cocaine, including such topics as the natural history of the substance and factors causing cocaine abuse and harm; drug use among street children and indigenous popu­lations; the impact of intentional inhalation of volatile organic substances; and the health conse­quences of cannabis use.

11.12 Cost-effective community-based ap­proaches to treatment and rehabilitation, and

1 World Bank World development report 1993 tnvestmg tn health. New York, Oxford Unrversrty Press, 1993.

2 WHO Technical Report Serres, No. 833, 1993

67

their integration with primary health care, are being evaluated with a view to using them in areas with high rates of substance abuse. Work was completed on a simple procedure for assess­ing the quality of care in the treatment of sub­stance abuse; this, together with other training materials produced by WHO for use in the pri­mary health care setting, formed the basis for training focusing on the needs of developing countries.

11 13 A matter of particular concern in Asia has been the rapid increase in HIV -infection caused by drug injection. Descriptive and epidemiologi­cal data on drug injection practices have been collected in Bangkok, with a view to designing and testing cost-effective interventions.

11.14 In September-October 1992 a WHO ex­pert committee updated the definition of drug dependence, linking it closely to the ICD-10 diagnostic criteria for the dependence syndrome, and made a number of recommendations on the prevention and management of drug dependence and other drug-related problems.3

11 15 Several participating centres received sup­port from the international drug monitoring pro­gramme in strengthening their capability for col­lecting data on abuse-related adverse drug reac­tions and recognizing early warning signs of non-medical use of newly marketed psycho­active drugs. As part of efforts to rationalize the prescribing of psychotropic drugs in the Ameri­cas, a seminar was organized (Montevideo, Oc­tober 1993) to make government officials, pre­scribers and journalists more aware of the prob­lem of inappropriate use of drugs. Collaboration was strengthened with professional bodies such as the World Psychiatric Association, which has set up an educational task force on the use of benzodiazepines.

11 16 The difficulties faced by small regulatory agencies in controlling unofficial drug distribu­tion systems were examined at a consultation (Vienna, June 1993) organized jointly with UNDCP, and guidelines for effective import control and inspection are being drawn up. Field-testing of a software package for compu­ter-assisted regulatory procedures is in progress. WHO cooperated with Benin and Nigeria in

3 WHO Technrcol Report Seties, No 836, 1993

THE WORK OF WHO 1992-1993

strengthening their national regulatory agencies. Human resources development for regulatory control was supported through a series of inter­national training seminars (Beijing, June 1992; Shanghai, June 1993; Abidjan, December 1992; Tokyo, July 1992 and July 1993).

Mental and neurological services

11.17 A major international review of laws on promotion of mental health and support to the mentally ill, covering 45 countries in all regions, was started with funding from the United States National Institute of Mental Health. Technical advice was provided in drafting mental health legislation in China and Fiji, and updating legis­lation in Argentina, Brazil, Colombia, Panama and Venezuela. Training for mental health lead­ers as well as courses on psychosocial rehabilita­tion, focusing on family training and patient edu-

Creotive educolion for the mentolly hondicopped in finlond.

68

cation, were organized in several countries in 1992. Field-testing of instruments for quality as­surance in mental health care began in 16 coun­tries in all regions. Instruments for the assess­ment of mental health services are now available in eight languages.

11.18 Guidelines on treatment of epilepsy, on family care of schizophrenic patients (currently available in six languages) and on case manage­ment of and housing for the mentally ill were produced, and a computer-based multi-media in­formation system on epilepsy is being estab­lished.

11.19 Strategy reviews and implementation guidelines on the prevention of mental retarda­tion, epilepsy, suicidal behaviour and staff "burn-out" syndrome were produced. In addi­tion, WHO supported a number of studies of such topics as lithium prophylaxis in manic de­pressive disorders (eight countries); depression in old age (one country); eye movements in pa-

PROTECTION AND PROMOTION OF MENTAL HEALTH

tients with schizophrenia (seven countries); and combined utilization of antidepressants and anti­oxidants in the treatment of therapy-resistant de­pression (19 countries).

Epidemiological studies

11.20 Several studies involving the differential diagnosis of dementia (six countries), the epide­miology of cognitive impairment and dementia (seven countries), and psychological problems in general health care (14 countries) were complet­ed with WHO support. The preparatory phase was completed and data collection started for several other studies and projects, including a 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 paragraph 12.31).

11.21 The results of a WHO-coordinated study on the determinants of outcome of severe mental

69

disorders in 10 countries were published.1 A fol­low-up study on the long-term course and out­come of schizophrenia in 15 countries is under way. A study was initiated on the psychopathol­ogy of obsessive and compulsive disorders of indigenous populations in six countries.

11.22 A study was carried out in nine countries on cultural differences relevant to the diagnosis and classification of mental disorders, especially in respect of substance abuse, and on this basis to develop culturally relevant diagnostic instru­ments. A further study to evaluate the accuracy of epidemiological data obtained with the diag­nostic instruments began in 12 countries. A re­view of the effectiveness of treatment of mental disorders has been published.2

1 Jablensky A et al. Schizophrenia: manifestations, inCidence and course in different cultures A World Health Organization study. Cambridge, Cam­bridge University Press, 1992 (Psychological medicine monograph supple­ment 20).

2 Sartorrus, N et al. Treatment of mental disorders· a review of effective­ness. Washington, American Psychiatric Press Inc., 1993.

CHAPTER 12

Promotion of environmental health

12 1 The WHO Commission on Health and En­vironment completed its work, and its report was issued, 1 together with the reports of its panels on energy, food and agriculture, industry, and urbani­zation.2 The series served as the basis for determin­ing the health aspects of Agenda 21, the action programme for the 1990s and beyond, adopted by 172 countries at the United Nations Conference on Environment and Development (UNCED), com­monly referred to as the "Earth Summit" and held at Rio de Janeiro, Brazil, in June 1992.

12.2 A new global strategy for health and envi­ronment based on the recommendations of the WHO Commission and prepared in response to Agenda 21 was endorsed by the Health Assembly in May 1993. An interregional consultation (Oc­tober 1993) was convened to coordinate the devel­opment of global and regional action plans for implementing the strategy, and a WHO council on the Earth Summit action programme for health and environment first met in January 1993 to ad­vise on the institutional, financial and coordina­tion aspects. In pursuance of the council's rec­ommendations, WHO, in collaboration with UNDP, provided support to countries incorpo­rating health and environment considerations in national plans for sustainable development.

Community water supply and sanitation

12.3 Meanwhile WHO directed its efforts to­wards ensuring that the development of water supply and sanitation services proceeded in a manner consistent with the intersectoral approach

1 Our planet, our health. Genevo, World Heolth Orgon1zot1on, 1992. 1 Documents WHO/EHE/92 2; WHO/EHE/92 3; WHO/EHE/92.4; WHO/

EHE/92.5.

71

to the environment as defined by UNCED and WHO's global strategy for health and environ­ment. Special attention was given to capacity­building at the national level, a major initiative being the WHO/UNICEF joint water supply and sanitation monitoring programme for the 1990s. In 1992 subregional workshops in Africa (Mbabane,June; Cotonou, Benin, September) and the Caribbean (Kingston, February) introduced monitoring procedures to almost 100 countries. Following these workshops, several countries,3

supported by WHO and UNICEF, started activi­ties or established programmes to strengthen their monitoring capability. These procedures are being modified in collaboration with UNR W A to re­spond to needs in Gaza. As part of the WHO/ UNICEF joint programme, information was col­lected on the status of water supply and sanitation for 1990 and 1991, and annual reporting was con­tinued for advocacy purposes.

12.4 During the biennium particular emphasis was given to hygiene education associated with water supply and sanitation. WHO collaborated with theW orld Bank in producing training tools and manuals, and with UNICEF in familiarizing regional and country sanitary engineers of both agencies with the latest hygiene education and community participation principles under a joint training programme.

12 5 School sanitation and hygiene education were the subject of a consultation (Cali, Colom­bia, March 1993) and a round-table (Hanoi, June 1993). Hygiene education activities were spon­sored in Benin and Burkina Faso through a nongovernmental organization (EAST4

), and field

3 Ben1n, Bronl, Cope Verde, Egypt, lnd1o, Jomo1co, Popuo New Gu1neo, Phil1pp1nes, Sri lonko, Togo, Vonuotu

4 Acronym of "Eou, Agmultu1e et Sonte en Mil1eu trop1col" (Woter, AgTICul­ture ond Heolth 1n the Trop1cs).

THE WORK OF WHO 1992-1993

demonstration projects were initiated in Zimbabwe. Closer ties were established with UNESCO in promoting school health and with UNICEF in formulating a joint strategy on hy­giene education.

12.6 Water resource management for the con­trol of disease vectors continued to receive em­phasis, largely through activities of the joint WHO/FAO/UNEP/United Nations Centre for Human Settlements (UNCHS) panel of experts on environmental management.

12 7 An interregional workshop considered ways to use agricultural extension programmes to promote environmental management for disease vector control (Tegucigalpa, October 1992). In 1992 a national training course on health opportu­nities in water resources development was organ­ized in Zimbabwe in collaboration with the Dan­ish Bilharziasis Laboratory; follow-up activities included a joint FAO/WHO mission to the coun­try and a national policy review by the Liverpool School of Hygiene and Tropical Medicine and the Blair Research Institute (Harare, October 1993 ).

12.8 At the first meeting of the Water Supply and Sanitation Collaborative Council (Oslo, September 1991), an operation and maintenance working group was constituted under WHO's leadership, resulting in the organization of a na­tional workshop in the Philippines (Manila, Au­gust 1992), an intercountry workshop on leakage detection and reduction in Pakistan (Lahore, Oc­tober 1992), and a conference on sustainability of rural and urban water supplies in Ghana (Accra, April 1993). The working group also drew up guidelines for the formulation of technical and institutional development strategies and pre­pared training packages on leakage control and the management of rural water supply and sani­tation facilities. The September 1993 meeting of the Collaborative Council endorsed the working group's activities and requested WHO to con­vene a new working group on the promotion of education in sanitation and hygiene.

12 9 In response to the global cholera epidemic (see paragraph 14.79), WHO prepared a series of fact sheets illustrating simple techniques in envi­ronmental sanitation and cholera prevention. The Organization installed 450 water supply chlorinators in countries affected by cholera. In Africa WHO organized cholera preparedness workshops and conducted rapid assessments of water and sanitation needs.

72

12.10 Member countries received support in in­stalling or improving systems for use of waste­water. Guidelines on the chemical and viral as­pects of wastewater use were completed during the biennium. WHO held a regional workshop on wastewater (Amman, February 1992) and ini­tiated follow-up action in Bahrain, Cyprus, Egypt, Oman and Tunisia.

12.11 Work in pursuance of the policy of in ten­sified cooperation with countries and peoples in greatest need took place in Benin (monitoring, hygiene education and vector control), Guate­mala (management and health education), Mozambique (information systems and cholera control), Yemen (management and hygiene education) and Zambia (cholera control and school sanitation).

12 12 In September 1993 the Regional Commit­tee for Africa endorsed the establishment of Af­rica 2000, a programme to accelerate water-sup­ply and sanitation development.

12.13 WHO continued to participate in the ACC Intersecretariat Group for Water Resourc­es, which in 1993 became the ACC Subcommit­tee on Water Resources, and to act as secretariat for the Interagency Steering Committee for Wa­ter Supply and Sanitation and host to the secre­tariat of the Water Supply and Sanitation Collab­orative Council.

Environmental health in rural and urban development and housing

1214 Pursuant to resolution WHA44.27 on ur­ban health, the Organization accorded high pri­ority to urban environmental health activities in view of the continued rapid growth and deterio­rating environmental conditions in many of the world's cities. Comprehensive and integrated ur­ban health development activities took place in an increasing number of cities in all regions. In Africa three major meetings were convened dur­ing the biennium: the first and second meetings for French-speaking African countries under the Healthy Cities project (Dakar, July 1992; Tunis, September 1993) and a regional workshop on urban health (Harare, November 1993 ). Other regional activities included an intercountry workshop on the improvement of health and en­vironmental conditions in urban slum areas

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 for o variety of crops including onions, couliflowers, green peppers, gropes and pineapples.

(New Delhi, August 1992), a joint meeting on Healthy Cities initiatives in Europe and the Americas (Seville, Spain, October 1992), and an intercountry workshop on urban health (Manila, August 1993). A global Healthy Cities confer­ence was held (San Francisco, USA, December 1993). National Healthy Cities programmes were launched in Bangladesh, Brazil, Ghana, Is­lamic Republic of Iran, Pakistan, Saudi Arabia and Tunisia.

12.15 The "supportive environments for health" approach, which focuses on the key set­tings of everyday life (home, neighbourhood, vil­lage, school, workplace, city) and encourages the participation of citizens and authorities in mak­ing each setting conducive to good health, is be­ing applied in various countries with projects such as "healthy schools", "healthy villages", and "healthy workplaces". A handbook on pro­motion of health-supportive environments is be­ing prepared, and regional workshops were held

73

on the subject (Nairobi, July 1993; Bangkok, November 1993).

12.16 Training of municipal managers in envi­ronmental health was emphasized in Healthy Cities projects. This was also the subject of a separate project in Brazil which was launched in collaboration with UNEP and in the course of which a training workshop in Rio de Janeiro involving some 35 municipal agencies drew up a municipal health plan that was subsequently put into effect with outside financial support. Train­ing in municipal health planning carried out with support from Japan included the preparation of plans in Chittagong (Bangladesh) and Ibadan (Nigeria) in 1993.

12.17 WHO activities in solid waste disposal in­cluded an interregional consultation convened in September 1992 to prepare technical guidelines on hospital and medical waste management in developing countries, and training workshops on

THE WORK OF WHO 1992-1993

solid waste management in Fiji in 1992 and the Philippines in January 1993.

International Programme on Chemical Safety

1218 Programme development. The Interna­tional Programme on Chemical Safety (IPCS), established in 1980 as a joint activity of ILO, WHO and UNEP, was designated by UNCED as the nucleus for international cooperation on environmentally sound management of toxic chemicals. Resolution WHA45.32 of the World Health Assembly, adopted in 1992, has estab­lished mechanisms to coordinate WHO's con­tribution to IPCS. To strengthen interagency co­ordination in this area, ILO, WHO and UNEP developed a strategy in collaboration with other potentially interested international institutions such as FAO, OECD, UNIDO and the Com­mission of the European Communities.

1219 International conference on chemical safe­ty. UNCED requested the executive heads of ILO, WHO and UNEP to arrange for further consideration to be given to the recommendations made by a group of experts in 1991 1 for increased coordination between United Nations bodies and other international organizations involved in chemical risk assessment and management. The government-designated experts called for appro­priate measures to enhance the role of IPCS and for an intergovernmental forum on chemical risk assessment and management to give policy guid­ance, develop strategies in a coordinated manner, provide the required political support and foster understanding of the issues by governments. Ac­cordingly, all Member States and intergovern­mental and nongovernmental organizations con­cerned have been invited to participate in an inter­national conference on chemical safety to be held in Stockholm in 1994. The Government of Sweden is acting as host to the conference and several governments have offered human and fi­nancial resources for its organization.

12 20 Risk evaluation. Evaluation by IPCS of the risks to health and the environment from certain priority chemicals provides a basis for chemical risk management and the findings are

1 Document UNEP/IPCS/IMCRAM/exp/4

74

widely disseminated in all Member States through various publications meeting the needs of specific professional groups. During the biennium 28 vol­umes of the Environmental Health Criteria series were published to review present knowledge and evaluate risks associated with exposure to specific chemicals; 10 Health and Safety Guides were pro­duced, providing concisely evaluated information on priority chemicals in non-technical language for decision-makers and managers, including ad­vice on protective measures and emergency re­sponse action; and 179 International Chemical Safety Cards were issued in several languages, each summarizing essential product identity data and health and safety information on one page for use at workplaces.

1221 During three meetings of the Joint FAO/ WHO Expert Committee on Food Additives cer­tain additives, contaminants, naturally occurring toxicants and veterinary drug residues in food were considered,2 and at the annual Joint FAO/WHO Meetings on Pesticide Residues acceptable daily intakes were established.3 IPCS also worked on questions concerning assessment and safe use of pesticides with various organizations, whose activ­ities are not always well coordinated. At a consulta­tion held in July 1992 on consolidation of work on pesticides, a proposal was made for core groups to assess toxicological and ecotoxicological data and for panels to draw up practical recommendations on pesticide levels in food, drinking-water, the workplace and the environment.

12 22 Methodology for health risk assessment. IPCS continued to prepare monographs on prin­ciples for evaluating the toxicity of chemicals for various organs and organ systems and is devising methods for quantitative risk assessment and for setting exposure limits for chemicals in air, water and food. The monographs enable scientists and others to understand the process of risk evalua­tion for chemicals, and assist countries in under­taking their own national risk evaluations and management. One of the earliest published was Principles for evaluating health risks to progeny associated with exposure to chemicals during pregnancy (Environmental Health Criteria 30); and in view of recent scientific developments in

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 Papers, No. 116 (1992) and the second 1s 1n preparation

PROMOTION OF ENVIRONMENTAL HEALTH

reproductive and developmental toxicology, it is currently under review for updating and expan­sion. Several other monographs and reports were issued during the biennium, including Quality management for chemical safety testing (Envi­ronmental Health Criteria 141) and Principles for evaluating the effects of chemicals on the aged population (Environmental Health Criteria 144).

12.23 Prevention and treatment of chemical poi­soning. Guidelines on how to set up and operate poison control facilities, a manual to help labora­tories in developing countries provide a basic analytical toxicology service using a minimum of complex apparatus, and a handbook containing basic information on diagnosis and treatment of poisoning were prepared in 1993. Several mono­graphs on antidotes were also in preparation. Work on the INTO X software package for poi­son information centres continued and a first version of the global database on chemical sub­stances, pharmaceuticals, poisonous plants and animals was made available in 1992. Several Poi­son Information Monographs were produced on CD-ROM, containing evaluated information concerning the toxic properties of chemicals, on how to diagnose and treat affected persons, and on how to prevent poisoning. lntercountry training workshops were held in Canada, Islamic Republic of Iran, Uruguay and Venezuela to strengthen national capabilities for the preven­tion and management of poisoning.

12 24 Human resource development. Training materials were produced on: the effect of metab­olism on toxicity; chemical safety; safe use of pesticides; and environmental epidemiology. lntercountry workshops and training courses were organized on all aspects of chemical safety, including environmental epidemiology, in Costa Rica, Philippines, Venezuela, Viet N am and Zimbabwe. Capacity-building is being pro­moted through expansion of IPCS's network of national institutions concerned with chemical safety, for example in Africa, and IPCS news is increasing public awareness of chemical risks among the public at large.

Control of environmental health hazards

12.25 Monitoring and assessment of pollution. The WHO/UNEP global network for monitor­ing water quality expanded to include new coun-

75

tries in Africa and in central and eastern Europe. A comprehensive guide for assessing water qual­ity through sampling and analysis of biota, sediments and water was published in collabora­tion with UNEP and UNESC0.1 Training courses on monitoring methods were organized in support of programmes concerned with inter­national river basins (Mekong, Nile, Plate). Na­tional and regional workshops on various aspects of water quality monitoring were organized in Colombia, Fiji, and Trinidad and Tobago in 1993.

12.26 Additional parameters were included in the WHO/UNEP air quality monitoring project and the data were made more easily accessible. A major WHO/UNEP assessment of air pollution and its effects on health in 20 cities was complet­ed and the findings published.2 The WHO/ UNEP human exposure assessment location (HEAL) project continued to provide guidance on exposure assessment and support for quality assurance in monitoring several pollutants, in­cluding lead and nitrogen oxides. Twenty coun­tries were represented at a meeting which re­viewed work on assessment of exposure to lead (Bangkok, November 1992).

12.27 Education, training and research in envi­ronmental health were promoted through the WHO global environmental epidemiology net­work, whose membership now includes about 2000 institutions and individuals in all regions. One-week training workshops for national staff were held in several countries.3 A variety of training materials were developed, including a textbook on basic epidemiology.4 An extensive review of the potential public health impact of global climate change began in collaboration with WMO, UNEP and the Intergovernmental Panel on Climate Change. The health effects of ultraviolet radiation were assessed and an inter­national collaborative epidemiological research project on the health impact of solar ultraviolet radiation and ozone layer depletion was started jointly with WMO, UNEP and IARC.

1 Chopmon D, ed. Water quality assessments London, Chopmon and Hall, 1992

2 World Health Organization. Urban an pollution m megaot1es of the world. Oxford, Blockwell, 1992.

3 Argentmo, Ch1no, Eth10p1o, Gabon, Hungary, Nicaragua, Philippines, Poland, Thailand, Venezuela, Viet Nom.

4 Beoglehole R, Bonito R, Kjellstrom T. Bas1c ep1dem1ology. Geneva, World Health Organization, 1993

THE WORK OF WHO 1992-1993

12.28 Control of environmental pollution. The revision of WHO's guidelines for drinking­water quality, last issued in 1984, was completed during the biennium; volume 1 was published in 1993/ and volumes 2 and 3 will appear in 1994. An interregional workshop in May 1993 consid­ered the application of the WHO guidelines for air quality in Europe to different climates and under different conditions. Research on epidemi­ological, social and technical aspects of the do­mestic use of biomass fuel and coal were under­taken in Ethiopia (indoor air pollution and safety aspects) and VietNam (health education as­pects).

12 29 As a contribution to capacity-building in environmental health risk monitoring and man­agement, guidelines were issued on the assess­ment of sources of air, water and land pollution.2

The WHO global environmental technology network (GETNET), set up in 1991 to link spe­cialists in environmental management technolo­gy, expanded to include 340 members in 87 countries. Three workshops on different aspects of environmental management and control were held (Bangkok, August 1992; Amman, October 1992; Bucharest, September 1993).

12.30 Member States in all regions were sup­ported in their efforts to control air and water pollution. For example, the health effects of air

1 Guidelines for d11nking·water quality, Vol I. Recommendations. World Health Organization, Geneva, 1993.

2 Documents WHO/PEP /GETNET/93. l-A and B

76

pollution from motor vehicles were studied in Manila and expertise was provided in drawing up an air quality management plan for the Philip­pines. In the Americas surveys on hazardous waste were carried out in more than 15 countries. In Europe support was given in preparing guide­lines for land-based pollution control and for control of microbiological and chemical pollut­ants in the Mediterranean.

12 31 Radiation protection. Implementation of the international programme on the health ef­fects of the Chernobyl accident, endorsed by the Health Assembly in 1991, continued during the biennium through five pilot projects concerned with haematology, thyroid effects, brain damage in utero, epidemiological registration, and oral health (samples of tooth enamel being used for individual dosimetry determination). WHO supported work in Belarus, Russian Federation and Ukraine through the supply of medical, computer and auxiliary equipment and diagnos­tic kits. Over 100 specialists were trained, either in their own countries or abroad. Two meetings were held to strengthen coordination between health-related projects concerned with the con­sequences of the Chernobyl accident (Kiev, No­vember 1992; Geneva, May 1993). A consulta­tion was organized on coordination of studies of health damage in workers responsible for clean­up following the Chernobyl accident and their offspring in the Baltic countries (Helsinki, May 1992). A fourth coordination meeting of parti­cipants in the WHO radiation emergency medical preparedness and assistance network (REMPAN) endorsed a WHO plan for emer­gency assistance and the establishment of an in­ternational database on radiation exposure.

CHAPTER 13

Diagnostic, therapeutic and rehabilitative technology

Clinical technology

13.1 During the biennium WHO paid particu­lar attention to improving surgical and anaesthet­ic services at district hospitals in developing countries. Health Volunteers Overseas (USA), a non-profit organization, financed the prepara­tion of videotapes based on the orthopaedics sec­tions of WHO handbooks. The scope, limita­tions and implications of providing day care sur­gery in developing countries were examined in collaboration with the International Society of Surgery. Jointly with the International Society of Orthopaedic Surgery and Traumatology, WHO assessed the suitability of a simplified modern technology for treating fractures in small hospi­tals. A handbook describing simple surgical pro­cedures for correcting deformities in poliomyeli­tis was published.1 N ongovernmental organiza­tions concerned with improving care of patients in district hospitals cooperated with WHO in the assessment of training needs and the organiza­tion of refresher courses in a number of develop­ing countries.

13.2 The Organization evaluated the impact on Cameroon's health services of practical proce­dures introduced into the undergraduate curric­ulum in medical schools and during internship so as to prepare young doctors for district hospital work. It continued to support Cameroon, Mo­zambique and Niger in introducing appropriate technology for anaesthesiology and surgery in peripheral areas. Training of clinical staff of pro­vincial and district hospitals in Mozambique has shown very encouraging results. A Portuguese version of the WHO handbook on surgery at the

1 Krol J, ed. Rehabilitation surgery for deformities due to poliomyelitiS. Techniques for the district hosp1tal. Geneva, World Health Organization, 1993.

77

district hospital has been distributed. A meeting on the integration of basic surgery into primary health care (Irbid, Jordan, November 1992) re­sulted in the modification of programmes in Egypt and Sudan.

Health laboratory technology and blood safety

13.3 Regional and interregional meetings were held on strengthening public health laboratories at primary health care level, quality assurance, standardization and quality assessment, produc­tion of basic laboratory reagents, and blood safe­ty. A total of 320 laboratories in 111 countries are registered in five WHO international external quality assessment schemes (see box); and two additional schemes were established in 1992.

13.4 WHO collaborated with FINNIDA, the Finnish Red Cross and the French Red Cross in organizing courses on transfusion medicine and transfusion services. Training courses on blood safety were held in five African countries. Re­gional training centres for blood transfusion were established in Amman and Tunis. Two ma­jor publications were issued on this subject.2

13 5 Studies were in progress during the biennium on the incidence of HIV transmission through blood transfusion (in collaboration with the United States Centres for Disease Control); transfusion requirements for anaemic pregnant women; the prevalence of markers of transfu­sion-transmissible infectious agents in seven

2 Guidelines for quality assurance programmes for blood transfusion serv1ces. Geneva, World Health Organization, 1993; G1bbs WN, Britten AFH, eds. Gu1delmes for the organization of a blood transfusion service. Geneva, World Health Orgamzation, 1992.

THE WORK OF WHO 1992-1993

WHO improves the performance of laboratories

• By establishing international external quality assessment schemes (IEQAS) WHO aims to improve the performance and reliability of the participating labora­tories (for instance, those dealing with clinical chemistry, haematology, microbi­ology, coagulation and parasitology) and to encourage their staff to establish na­tional or regional schemes. Laboratories enrolled in the schemes perform tests on specimens received from the organizers and return the results to the organizers, who analyse them statistically, assess per­formance and send back confidential re­ports and educational material. This pro­cedure provides a basis for comparing laboratories' performance and also for as­sessing kits, equipment and methods. However, participation in an IEQAS is only part of a laboratory's quality assur­ance procedures: each laboratory will have established an internal quality control programme (I QC), and poor performance in an IEQAS will prompt examination of that programme to determine and correct the shortcoming. The ultimate goal is to arrange for those laboratories that per­form satisfactorily in an IEQAS to start national or regional schemes.

countries; virus inactivation of fresh frozen plas­ma and cryoprecipitate; production of cold­chain equipment for blood and blood products; development of a cost-effective screening tech­nique for schistosomiasis detection in urine; and assessment of a rapid diagnostic test for Plasmodium falciparum.

Radiation medicine

13.6 Diagnostic imaging technology. New technical specifications were drawn up for an improved "WHO radiographic unit" as a part of the WHO Imaging System. Training seminars in diagnostic ultrasound and in nuclear medicine were held in cooperation with IAEA. Support

78

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

13 7 Radiotherapy. WHO continued to collab­orate with IAEA in improving radiation dose measurement and promoting technology trans­fer through the secondary standard dosimetry laboratories network, comprising 71laboratories in 50 countries, 36 of them developing. A consul­tation on the design requirements for a new kind of high voltage X-ray machine for use in devel­oping countries was organized jointly with IAEA and UNIDO (Washington, December 1993).

13.8 Radiation protection. In collaboration with other international organizations, WHO continued to revise the basic safety standards for radiation protection, and the five-volume Manu­al on radiation protection in hospitals and general practice published between 197 4 and 1980.

Technology development, assessment and transfer

13.9 Significant progress in interagency collabo­ration was made through the convening of a meet­ing to establish an international network of agen­cies for health technology assessment (Paris, Sep­tember 1993). A second meeting on technology development, assessment and transfer (Alexan­dria, October 1993) brought together representa­tives of several international agencies as well as senior health officials. A cohesive collaborative programme was planned, leaving each region lati­tude to decide its own priorities and pace of im­plementation while all involved work together to promote the programme at country level, sharing experiences and developing core activities such as training, exchange of information and collabora­tion with nongovernmental organizations.

Drug management and policies

13.10 The Organization collaborates with na­tional drug regulatory authorities in harmoniz­ing approaches to drug registration and surveil­lance, establishing international standards for quality assurance, and exchanging information on national regulatory decisions. The rational use of drugs can be ensured only within a well-

DIAGNOSTIC, THERAPEUTIC AND REHABILITATIVE TECHNOLOGY

defined framework of regulation. Through its model lists of essential drugs and related pre­scribing information, WHO helps countries to foster cost-effective drug use and procurement.

Pharmaceuticals

13.11 The Organization continued to produce a wide range of information, primarily for drug regulatory authorities, which is made available in the quarterly subscription periodical WHO drug information, the monthly WHO pharmaceuticals newsletter, the United Nations Consolidated List of Products whose Consumption and/ or Sale have been Banned, Withdrawn, Severely Re­stricted or Not Approved by Governments, WHO's Model Prescribing Information series and the cumulative lists of international non­proprietary names (INN).

13.12 To complement established normative in­struments such as The International Pharmaco­poeia, WHO's Good Practices in the Manufac­ture and Quality Control of Pharmaceutical Products, the WHO Certification Scheme on the Quality of Pharmaceutical Products moving in International Commerce, and WHO's Guiding Principles for Small National Regulatory Au­thorities, the Organization has developed, with financial support from Germany and Italy, a computer package on drug registration for na­tional drug regulatory authorities, now available in English, French and Spanish and being used in some 20 countries.

1313 New normative texts being prepared un­der WHO's aegis include international stand­ards for good clinical practice and for good labo­ratory practice in the field of drug development, and criteria for interchangeable products from several sources. Collaboration continued with the International Conference on Harmonization of Technical Requirements for Registration of Pharmaceuticals for Human Use, which brings together representatives of regulatory bodies from Europe, North America and Japan.

13.14 A comprehensive set of recommendations on measures needed to deal with the alarming prevalence in some countries of spurious and substandard medicines was drawn up at a work­shop convened in April 1992 by WHO and the International Federation of Pharmaceutical Manufacturers Associations.

79

13.15 In April 1993 a meeting of interested par­ties was held in collaboration with CIOMS to discuss means of advancing the principles em­bodied in WHO's Ethical Criteria for Medici­nal Drug Promotion. Broad consensus was reached by industry representatives, consumers and other parties on the approaches required to attain this objective.

13 16 The participants in a meeting organized jointly in September 1993 with CIOMS and the WHO collaborating centre for international drug monitoring in Uppsala (Sweden) stressed the need for wider monitoring of the action of drugs in routine use and more reliable compara­tive information on the risk/benefit ratio and cost-effectiveness of drug use in both developed and developing countries.

13.17 The databases that WHO maintains to serve national drug regulatory authorities were broadened to include information not only on suspected adverse drug reactions, but also on spurious products, and on newly adopted na­tional regulations to control the labelling and advertising of medicinal plants.

13.18 An eighth revision of the Model List of Essential Drugs was produced at a WHO expert committee meeting in November 1993.

13.19 A second international meeting on the role of the pharmacist (Tokyo, August-Septem­ber 1993 ), organized in collaboration with the International Pharmaceutical Federation and the Commonwealth Pharmaceutical Association with financial support from Japan, made recom­mendations for improving the quality of phar­maceutical services and resultant benefits for governments and the public and propounded a concept of pharmaceutical care.

13.20 Collaboration was maintained with the International Federation of Pharmaceutical Manufacturers Associations and the World Fed­eration of Proprietary Medicine Manufacturers and with a number of national funding agencies, including in particular the German Foundation for International Development, in training key staff in the various aspects of national regulatory and enforcement activities.

13.21 Training of staff for drug regulatory au­thorities in developing countries continued. Following satisfactory evaluation in June 1992 of seven courses sponsored by the German Foun-

THE WORK OF WHO 1992-1993

dation for International Development, regional courses were organized in Benin and in Tunisia and Zimbabwe at the end of 1993. The model software package for handling drug regulatory data (see paragraph 13.12) was introduced in Af­rica, the Americas and the Eastern Mediterranean with financial support from Italy and Germany. WHO cooperated with UNDCP in organizing a technical workshop on parallel distribution sys­tems for narcotic and psychoactive substances at national level (Vienna, June 1993).

Biologicals

13 22 The Organization continued to work closely with national regulatory authorities, pro­viding guidance on the production and licensing procedures necessary to ensure the quality of biological products used in health care pro­grammes.

13.23 Guidelines were issued for national au­thorities on good manufacturing practices, quality assurance and regulations. Several developing countries participating in the Children's Vaccine Initiative invited a team of experts to evaluate the manufacture and regulation of locally produced vaccines; in all cases significant changes in admin­istrative procedures were recommended.

13.24 In pursuance of WHO's constitutional functions in regard to the standardization of bio­logical products, 19 new or replacement interna­tional reference materials were established: six for the diagnosis or therapy of blood disorders and one for quantifying an antigen of HIV. Some 27 000 ampoules of international reference mate­rials, prepared principally in national collaborat­ing laboratories in Denmark, Nether lands and United Kingdom, were made available for stand­ardizing product dosage and diagnostic proce­dures. New or revised production and quality control requirements were issued for six prod­ucts, including human plasma fractions and an improved typhoid vaccine.

Traditional medicine

13 25 Work continued in drawing up guide­lines on the standardization, assessment for effi­cacy, and utilization of traditional medicines, including herbal preparations. The Organiza-

80

tion collaborated with the World Conservation Union and the World Wide Fund for Nature in preparing guidelines on the conservation of me­dicinal plants; helped to draft a document on the integration of traditional and modern medicines in a project conducted under the aegis of the Cooperation Council for Arab Gulf States; and participated in a UNIDO consultation on the industrial utilization of medicinal and aromatic plants in Asia and the Pacific (Vienna, July 1993), which stressed the need for the develop­ment of coherent national policies and effective regulation to control the quality and use of the final products.

·---··----~~-» •~•-H--~>~ ,,_

Action Programme on Essential Drugs

13 26 Because of the global economic crisis and the shift from centrally planned to free market economies in various countries, new thinking and strategic planning were needed in the area of essential drugs. Many developing countries, some eastern European countries and the Com­monwealth of Independent States requested WHO's cooperation in assessing new situa­tions. The technical support provided focused on setting priorities and determining strategies to increase access to and appropriate use of essential drugs. This often meant redefining the responsi­bilities of the ministry of health and its relations with other ministries.

13 27 No ready-made solutions were available; emphasis was placed on finding innovative and rapid answers to various questions: how drugs were to be financed; how public health goals, including equity, could be maintained in a chang­ing combination of public and private sectors; and how national regulatory authorities could control an increasingly complex pharmaceutical sector, with particular regard to drug quality, safety and the provision of accurate information for both prescribers and consumers alike.

13 28 In face of the growing global disparity between needs and accessibility, WHO intensi­fied its direct and operational country support activities, particularly in Africa and the Ameri­cas, but also in Asia, where Maldives and Mon­golia joined the list of more than 80 developing countries that are receiving technical and/or fi­nancial support. National capacity-building con­tinued to be a major aim. At over 20 national

DIAGNOSTIC, THERAPEUTIC AND REHABILITATIVE TECHNOLOGY

workshops in four WHO regions, and at three intercountry strategic planning workshops in Africa, policy-makers from some 30 countries met to develop or review their own national drug policies and to exchange experience. In Benin, Bolivia, Guinea and Nepal, ways of improving technical and managerial methods used in the pharmaceutical supply system were tested.

13.29 To stimulate technical cooperation among developing countries, staff members from some national essential drugs programmes in partici­pating countries acted as advisers or trainers in others; thus materials and procedures, such as standard treatment guidelines or procurement specifications, developed in one country could be used and sometimes further developed by others.

13.30 More resources were devoted to training and to the preparation of practical manuals and materials, in collaboration with national and in­ternational partners. Subjects covered included the technical and managerial aspects of financ­ing, rational use, procurement, quality assur­ance and registration of drugs, and information, education and communication strategies. A suc­cessful field test at medical schools in seven countries of a problem-based method of teach­ing the principles of rational prescribing, 1 de­signed in collaboration with University of Groningen (Netherlands), aroused widespread academic interest.

13.31 With WHO's technical and financial support, a three-month course in drug manage­ment and rational drug use, designed to meet the needs of developing countries, was successfully launched at Robert Gordon University in Aber­deen (United Kingdom). Practical drug procure­ment guidelines, developed and used at work­shops attended by over 120 people from 14 de­veloping countries with the support of the Preferential Trade Area of Eastern and Southern African States, were further improved. In the Eastern Mediterranean a series of seminars on teaching rational drug use and the essential drugs concept were held for schools of medicine and pharmacy in 11 countries. Altogether, thousands of health workers in over 40 countries attended WHO-supported training courses and work­shops on drug management and use.

1 Document DAP /91/12.

81

13 32 WHO continued its vigorous information and advocacy strategy exemplified by the March­April 1992 issue of World health on essential drugs, with a strong focus on national drug pol­icy and rational use, and the brochure "Essen­tial drugs, action for equity", produced in Eng­lish, French and Spanish. The expanded Essential drugs monitor, published in English, French and Spanish, reached an estimated 200 000 policy­makers, administrators, health workers, non­governmental organizations, and industry and consumer organizations in 150 Member States with news of policy developments, essential drug programmes, research, and strategies for rational use. Many copies of the Monitor, and particular­ly of one issue on the theme of national drug policy, were also provided as instructional mate­rial on the subject of pharmaceuticals in primary health care for workshops and universities. The Organization developed a database consisting of important but unpublished technical reports and guidelines, which provides rapid access to mate­rial relating to a given technical or geographical area and is proving an invaluable tool. WHO's documentation centre on essential drugs contin­ued to respond to the information needs of de­veloping countries, distributing an average of 3000 documents per month to individuals, uni­versities, and nongovernmental and other organ­izations.

13.33 More than 20 global and national opera­tional research projects were carried out during the biennium, covering such topics as public atti­tudes to and use of drugs, injection practices, the stability of drugs during international transport, and monitoring of price and availability. Of par­ticular interest were the development and field­testing of indicators for monitoring national drug policy implementation and, in collabora­tion with the International Network for the Ra­tional Use of Drugs, of standardized indicators to measure the impact of interventions designed to influence drug use. A 15-country study on the application of the WHO Certification Scheme on the Quality of Pharmaceutical Products mov­ing in International Commerce revealed short­comings in its functioning in both importing and exporting countries. Nine reports on WHO­supported research were issued during the biennium, and a new database providing stand­ardized information on research completed or in progress was established.

13.34 The goal of formulating national drug poli­cies and launching essential drugs programmes in

THE WORK OF WHO 1992- 1993

at least 70 countries by 1995 is likely to be reached before the target date, but it is important to in­crease the number of countries involved and to improve their policies and programmes. The need for close coordination of all the elements of a na6onal drug policy, based on WHO guiding principles, has become increasingly evident as large-scale financial support has become available from other organizations, such as the World Bank, the European Community, the African De­velopment Bank, non governmental organizations and the bilateral agencies. The concept of a stand­ard policy framework to be developed with WHO support is therefore being energetically promoted among Member States and donors.

Rehabilitation

13.35 On completion of the United Nations Decade of Disabled Persons (1983-1992) WHO carried out a review of the progress made. It showed that preventive measures had significant­ly reduced the incidence of some diseases that cause disabilities; that public awareness about disability had increased during the decade, lead­ing to modest improvements in the social inte­gration of people with mild to moderate disabili­ties in some countries; and that in most develop­ing countries there had been no significant in­crease in rehabilitation services. In the light of these findings, the Health Assembly adopted res­olution WHA45.10 which outlined actions to

strengthen disability prevention and rehabilita­tion and provided a framework for the pro­gramme's work during the biennium.

A mother helps her child, with the support of o community rehobilito· lion worker.

82

13.36 Three intercounrry workshops (Harare, July 1992; Saly Mbour, Senegal, October 1992; Lima, May 1993), with participants from 46 countries, recommended ways to promote the incorporation of community-based rehabili­tation into national primary health care pro­grammes and to strengthen referral services for people with disabilities. WHO cooperated with IMPACT, the international initiative against avoidable disability, in setting up a pilot project in India for inclusion of disability prevention in primary health care. Egypt, Islamic Republic of Iran and Lebanon have incorporated commu­nity-based rehabilitation into primary health care, with appropriate referral services, and sev­eral other countries in the Eastern Mediterranean are establishing programmes. National seminars on community-based rehabilitation were organ­ized in several countries' and served as forums for the preparation of intcrsectoral plans for re­habilitation involving health, education, social and vocational services. In a number of coun­tries2 WHO participated in planning or evalua­tion of community-based rehabilitation pro­grammes.

13.37 The existing methodology for cost analy­sis in primary health care1 was adapted for use in determining the cost of rehabilitation services in Mauritius and Zimbabwe, as a first step in the preparation of general guidelines for cost analy­sis of community-based services and referral for rehabilitation.

13.38 A variety of training activities were carried out to promote community-based rehabilitation. In 1992 physicians, nurses, therapists and middle­level 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 Interna­tional Leprosy Association, provided training in the United States of America for professional staff of government and nongovernmentalleprosy pro­grammes, 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.

' Eritreo, Glrono, Guyana, Indonesia, Konya, Mongolia, Thollond, Zimbabwe. a Datument WHO/SHS/ NHP /90.S.

DIAGNOSTIC, THERAPEUTIC AND REHABILITATIVE TECHNOLOGY

13.39 Training materials produced during the biennium included recommendations for middle-level rehabilitation workers, based on country experience, 1 a manual on promoting the development of young children with cerebral palsy2 and guidelines for preventing deformities in poliomyelitis3

•

1340 In November 1993 WHO hosted two meetings with representatives of 32 international nongovernmental organizations that support re­habilitation programmes in developing countries in order to discuss ways in which they can apply WHO guidelines in this effort. One outcome of the discussions was a broad outline of action for improving prosthetic and orthotic services in de­veloping countries.

13.41 Collaboration with UNDP, ILO, UNESCO, UNICEF and the United Nations Of-

1 Document WHO/RHB/92.1 2 Document WHO/RHB/93.1 3 Document WHO/EPI/POLIO/RHB/91.1.

83

fice at Vienna continued, for instance, in the im­plementation of a UNDP-supported project in Ghana, the setting-up of a task force on disabled children and women, the preparation of recom­mendations to countries for intersectoral rehabili­tation programmes, and the drafting of uniform guidelines for programme evaluation. WHO is collaborating with the Economic and Social Corn­mission for Asia and the Pacific to promote the Asia and Pacific Decade of Disabled Persons (1993-2002). A joint review was carried out with UNHCR of disabilities among refugees at 11 sites in Africa; and plans were made to organize com­munity-based rehabilitation in two of the areas in early 1994. A plan for emergency rehabilitation of people injured in war in former Yugoslavia was prepared, with emphasis on provision of prosthe­ses and other procedures to deal with physical trauma. Together with the United Nations Statis­tical Office, WHO reviewed databases on disabil­ity in four countries, including data from commu­nity-based rehabilitation programmes and nation­al census and survey data, with a view to preparing guidelines on data collection for national planning and for programme monitoring and evaluation.

Disease -e e I o n CHAPTER 14

ontrol

Immunization

14.1 In the 1980s there was a steady annual increase in global immunization coverage reach­ing, by 1990, 85% for the third dose of oral poliomyelitis vaccine, 83% for the third dose of diphtheria-pertussis-tetanus (DP'I) vaccine, 90% for BCG vaccine against tuberculosis, and 80% for measles vaccine (Figure 14.1). After 1990 there was a levelling-off of global immuni­zation coverage (the corresponding global fig­ures for 1992 were 80%, 79%, 85% and 78% respectively) and a marked decrease in coverage in Africa (Figure 14.2), causing serious concern as it casts doubt on the sustainability of past accomplishments.

14.2 There has been little progress in extending coverage to the bard-to-reach populations who bear a disproportionate burden of vaccine-pre­ventable diseases, as well as from other condi­tions preventable by primary health care. More­over, the worsening global economic situation is placing a severe strain on health systems includ­ing immunization programmes. Coverage is de­clining in a growing number of countries severe­ly affected by war, civil strife, debt and recession. In Africa coverage of children is still significantly below the global average, except for BCG (Figure 14.3).

14.3 Although still far lower than for immuni­zation of infants, tetanus toxoid coverage of 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

Q) en e 60 Q) > 8 "' en c:> E ~ 40 ~

- 0 orr, third dose b b b

Poliomyelitis, b tJ

- 0 third dose b rJ 0 Meosles

IJ rJ - Tetanus toxoid, 0 second dose •

20

0 -l rn?, llln ~ 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 60 Q)

> 8 Q)

en .E! c: Q)

40 ::: Q)

c...

20

Africa Americas

• BCG 0 DPT, third dose

• up to two years of age •• including booster dose in pregnant women

Eastern Mediterranean

0 Poliomyelitis, third dose

Europe South· East Asia

Western Pacific

Global

O Measles• 0 Tetanus toxoid;• O Hepam~ 8, second dose third dose

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

100

80 -

Q) en E 60 Q)

> 8

-Q)

= 0 "E 40 Q)

::: -Q)

c...

20 -

0

.---1--

f--

BCG

• up to two yeors of age

.---,__ f--

OPT, third dose

•• including booster dose in pregnant women

0

1--

Poliomyelitis, third dose

86

1990 0 1991

1--

Measles*

0 1992

...---I--

~

Tetanus toxoid,** second dose

DISEASE PREVENTION AND CONTROL

reported 4 3% for pregnant women in developing countries in 1992, compared with 39% in 1990 (Figure 14.1); the highest coverage was achieved in South-East Asia (Figure 14.2).

14.4 During the biennium many countries add­ed yellow fever and hepatitis B vaccines to their immunization programmes. Of the 33 African countries at risk from yellow fever, 17 have poli­cies for provision of the vaccine; and in 1992 their coverage reached 10% for children under one year of age. Forty-eight countries in the world established policies for routine hepatitis B im­munization, and a system for monitoring the coverage in children under one year was devel­oped.

14.5 On the basis of reported coverage and es­timated vaccine efficacy and morbidity rates, WHO calculated that in 1992 immunization pre­vented 2. 9 million deaths from measles, neonatal tetanus and pertussis in developing countries, and an estimated 4 36 000 cases of paralytic polio­myelitis. Nevertheless, an estimated 2.1 million deaths from measles, neonatal tetanus and pertussis, and over 140 000 cases of poliomyelitis occurred in developing countries in 1992, indi­cating clearly a need to sustain and if possible increase the immunization coverage.

14.6 The greatest success in disease control has been achieved in the Americas, where the last case of poliomyelitis due to wild virus was re­ported in August 1991. Other regions also showed improvements: 131 countries reported no poliomyelitis, as compared with 80 in 1985.

14 7 Efforts have been made to improve sys­tems for routine disease surveillance. Guidelines on bringing about such improvements as a neces­sary step towards poliomyelitis eradication, neonatal tetanus elimination and measles control have been distributed. Numerous workshops on disease surveillance for control were conducted in all regions, and the quality of surveillance data has markedly improved in many countries. As­sessments of surveillance were conducted in 19 countries in two regions. They will be continued so that eventually countries can certify the eradi­cation of poliomyelitis and elimination of neonatal tetanus.

14 8 Large outbreaks of measles, diphtheria and yellow fever continued to affect children who could have been protected if immunization programmes had been given sufficiently high pri-

87

ority. Measles remains one of the greatest killers of children, causing an estimated 1.1 million child deaths a year in developing countries. De­clining or stationary immunization coverage and continued high case-fatality rates in many areas are clear warnings that efforts must be stepped up to reach the 1995 measles reduction goals. Crucial to the attainment of those goals are en­suring coverage of over 90% in all districts and intensified measures in urban areas. Outbreaks of the disease raise awareness of the importance of universal child immunization and the need for prevention and treatment of potentially lethal complications.

14.9 Diphtheria has been spreading in the Russian Federation and Ukraine over the last two years; it is currently out of control and is affecting other republics of the former Soviet Union. Growing numbers of cases have also been imported to countries in central and western Europe. In the first 10 months of 1993 approxi­mately 12 000 cases of diphtheria were reported to the Regional Office for Europe, double the number for the whole of 1992.

14 10 Kenya experienced an outbreak of yellow fever for the first time in more than 40 years. Mass immunization was undertaken in response to the emergency in and around the area of the outbreak, which has since been brought under control.

14.11 A global poliomyelitis diagnostic labora­tory network of 41 national laboratories, 17 re­gional reference laboratories and five special ref­erence laboratories was established. Initially, each of the national laboratories has been work­ing on poliovirus isolation and poliomyelitis serotyping. Meanwhile, an immunofluorescent test has been developed in a WHO-funded study that may prove to be a short cut in poliovirus detection; this and other methods for diagnosing poliomyelitis are undergoing further study. Finally, one of the product development groups of the Children's Vaccine Initiative has made progress in preparing a more heat-stable polio­myelitis vaccine that could be used in immuniza­tion programmes in the future.

14.12 1992-1993 saw a stronger focus on mana­gerial considerations than in the previous biennium, when emphasis was on the introduc­tion of new technology for the logistics of immu­nization services. Computer software was devel­oped to improve the forecasting of needs for vaccines and equipment. Following surveys that

THE WORK OF WHO 1992-1993

revealed widespread unsafe injection practices, global policies on safe injections were updated, and related training was given. Operational stud­ies of "missed immunization opportunities" were completed in 49 countries and this follow-up pro­cedure was made part of routine supervision. A new series of documents on the immunological basis of immunization became available.

14.13 There was extensive cooperation in sup­port of immunization programmes at global, regional and country levels between govern­ments, WHO and a wide range of organizations including the World Bank, UNICEF, UNDP, bilateral development agencies, and nongovern­mental organizations such as Rotary Interna­tional. Such cooperation has been one of the principal reasons for past successes in immuni­zation programmes and it must be continued if a high standard of global coverage is to be achieved and maintained and the incidence of disease further reduced.

Control of tropical diseases1

14.14 Important organizational developments during the biennium included the Health Assem­bly's endorsement in 1992 of goals, policies and strategies for the Expanded Programme on Im­munization in the 1990s (resolution WHA45.17); the establishment of regular formal meetings of interested parties for coordination of global sup­port for the Programme; revision of the global plans of action for poliomyelitis eradication, neonatal tetanus elimination and measles control; and the Health Assembly's reaffirmation in 1993 of the goal of eradicating poliomyelitis by the year 2000 (resolution WHA46.33). The Pro­gramme's priorities were defined during the biennium as: first, to sustain the accomplish­ments of the past years; secondly, to achieve the goals of immunization coverage and disease eradication, elimination and reduction set by the Health Assembly and the 1990 World Summit for Children; and thirdly, to introduce new and improved vaccines as they become available for public health use.

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

Malaria

14.15 Malaria threatens about two-fifths of the world's population, causing an estimated 300-500 million clinical cases and 1.5 to 3 million deaths annually. More than 90% of clinical cases and the majority of deaths occur in tropical Afri­ca, but serious malaria problems are reported also in Afghanistan, Brazil, India, Sri Lanka, Thailand and VietNam (see Figure 14.4). The situation is exacerbated by the continuous intensification and spread of resistance of parasites to antimalarial drugs, especially in Africa. Multidrug resistance has led to a rise in the drug cost per simple case from about$ 0.15 to$ 2.00 in countries of South­East Asia and in the Amazon region of Brazil; a similar development is foreseen in Africa. This may put drugs beyond the means of populations at greatest risk, resulting in untreated or incom­pletely treated cases, more complications and more deaths. Incomplete treatment also probably contributes to the spread of drug resistance.

14.16 For these reasons WHO convened the Ministerial Conference on Malaria (Amsterdam, October 1992), which was attended by health leaders from 102 countries together with repre­sentatives of United Nations bodies and non­governmental organizations. The conference en­dorsed a global malaria control strategy! which had been prepared by three interregional meet­ings held in 1991 and 1992 in Brazzaville, New Delhi and Brasilia, and whose goal was to pre­vent mortality and reduce morbidity and the so­cial and economic losses due to malaria through progressive strengthening of local and national capabilities. WHO's plan of work for malaria control in 1993-1999 provides that by the year 1997 at least 90% of countries affected by the disease will be implementing appropriate control programmes,2 and that by the year 2000 malaria mortality will have been reduced by at least 20% compared with the 1995 figure in at least 75% of affected countries. In May 1993 the Health As­sembly stressed the gravity of the malaria situa­tion and urged Member States, interested parties and WHO to initiate effective and sustainable control programmes (resolution WHA46.32). Since the ministerial conference WHO has acted at global, regional and country levels to translate

1 A global strategy for malarta control. Geneva, World Health Organization, 1993.

2 See WHO Technical Report Series, No. 839, 1993.

89

the global malaria control strategy into action, and has prepared guidelines for strengthening national control activities in accordance with the global strategy by setting up programmes which are flexible, cost-effective, sustainable and adapted to local conditions.

1417 In September 1993 WHO convened a meeting of interested parties on malaria control to consider the managerial and budgetary aspects of the plan of work for 1993-1999. Representa­tives of donor countries, international agencies, and intergovernmental and nongovernmental or­ganizations analysed the resource needs forma­laria control at national and international levels, recommended coordination procedures and specified sources and mechanisms for multilater­al and bilateral support. Since this meeting over $ 3.5 million has been pledged by donor coun­tries to help finance WHO's efforts to combat malaria in 1993-1994.

14 18 The first of a series of regional working group meetings (Brazzaville, March 1993) ap­proved a plan of action and objectives for malaria control in Africa and established guidelines for evaluating programmes. The second and third meetings in the series (New Delhi, March 1993; Kunming, China, November 1993) drew up guide­lines for the reorientation of malaria control in South-East Asia and the Western Pacific and speci­fied criteria and indicators for evaluating the im­pact of the new strategy.

14.19 As a result of WHO's intensified efforts, countries where malaria is endemic have shown increased confidence in the potential benefits of control programmes, with governments request­ing collaboration and support from WHO, from other international bodies within and outside the United Nations system, and from nongovern­mental organizations. During the biennium WHO joined with its collaborating centres in providing technical support to 31 countries for the preparation of plans of action and the reorientation of malaria control programmes. In addition, by responding to government requests for drugs, insecticides, equipment and operation­al funds, the Organization jointly with various bilateral agencies gave support to Burundi, Djibouti, Ethiopia, Madagascar, Namibia, R wanda and Somalia in combating epidemics and coping with emergency problems.

14.20 Until such time as a fully effective vaccine becomes available, the results of recent research

Figure

14.4

M

alaria

dist

ributi

on a

nd p

roble

m ar

eas

Cent

ral A

meri

ca

Agric

ultura

l dev

elopm

ent,

irriga

tion

schem

es an

d co

loniza

tion,

comb

ined w

ith

insect

icide

resis

tance

, hov

e ca

used

a re

surge

nce o

f mala

ria.

Amaz

onian

rain

fore

st Ov

er 60

0 000

cases

occu

r per

year

in Br

azil (

>50%

of m

alaria

in th

e Am

ericas

), an

d on

estim

ated

6 00

0 to

1 0 00

0 dea

ths ow

ing to

new

settle

ment

and

minin

g in f

orest

areas

.

Dry

sava

nna

and

dese

rt fri

nge

Epide

mics

ore r

elated

to

exce

ption

al rai

ns an

d po

pulat

ion m

ovem

ents.

Th

ere w

ere so

me 50

000

cases

in K

harto

um d

uring

the

198

8 floo

ds.

Afric

an c

ities

Th

e citie

s ore

chara

cteriz

ed

by se

vere

drug

resis

tance

, inc

reasin

g de

aths i

n you

ng

adult

s, ino

degu

ate sa

nitati

on

and

overb

urde

ned s

ervice

s.

Afric

an s

avan

na

and

fore

st Ov

er 50

% of

the

popu

lation

ore

infec

ted.

Mala

ria is

the m

ain ca

use

of de

ath in

youn

g_ ch

ildren

, kil

ling_

1 in 2

0 befo

re the

ag

e of

5. Th

ere is

inc

reasin

g ch

loroq

uine

resist

ance

.

<::::

>=

<::J

o lj 0

0

c::::

l

Ethio

pia

Repe

ated

epide

mics

occu

r in

the hi

ghlan

ds du

e to d

egrad

ed

envir

onme

nt, d

rough

t and

fam

ine, a

nd la

rge·sc

ole

resett

lemen

t sch

emes.

Afg

hani

stan

Over

300 0

00 ca

ses or

e rec

orded

yea

rly. C

ontro

l ha

s bee

n int

errup

ted by

wa

r and

disp

lacem

ent o

f po

pulot

ions.

Sout

h As

ia Ov

er 2.5

milli

on co

ses o

re rec

orded

yea

rly, i

ncrea

sing

numb

ers of

them

in tr

ibal,

forest

an

d hil

l area

s, so

metim

es in

epide

mic p

roport

ions.

East

Afric

an h

ighl

ands

I

and

Mad

agas

car

()

Dram

atic e

pidem

ics oc

cur,

relate

d to

chan

ged

agric

ultura

l patt

erns,

interr

uptio

n of c

ontro

l, an

d po

ssibly

incre

ased t

empe

ratur

es.

There

were

ove

r 25 0

00 d

eaths

in

Mad

agasc

ar in

1988

. j j

/ri>j M

ain a

reas w

here

malar

ia tra

nsmi

ssion

occu

rs

Cam

bodi

a, La

o Pe

ople

's De

moc

ratic

Repu

blic,

Mya

nmar

, Tha

iland

and

Vi

et No

m Ne

arly

700 0

00 ca

ses or

e rec

orded

ye

arly.

The r

isk is

incre

asing

rap

idly i

n fro

ntier

areas

whe

re the

re is

often

illici

t mini

ng an

d civi

l un

rest. T

his re

gion

has t

he m

ost

seve

re dru

g res

istan

ce in

the w

orld.

Papu

a Ne

w Gu

inea

, Ph

ilipp

ines

, Solo

mon

Islan

ds

and

Van

uatu

Ov

er 30

0 000

cases

reco

rded

yearl

y, rel

ated t

o colo

nizati

on of

ne

w are

as.

WH

09

40

32

0

~

~ ~

\

o?J

~ ~ =

~ ~ C

) -'0 ~ .!..

'0

~

DISEASE PREVENTION AND CONTROL

Preventing malaria: health education for young children in Cambodia.

on insecticide- impregnated bednets, the potent artemisinin derivatives and new diagnostic tools are now being applied in malaria control (see paragraph 14.45). In 1992 WHO collaborated with Thailand in establishing a surveillance sys­tem to monitor adverse reactions to artemisinin derivatives and drew up methodological guide­lines that can be used by neighbouring countries for the next few years.

14.21 Few of the countries affected have enough well-trained, motivated personnel tO

achieve and maintain a satisfactory level of ma­laria control. During the biennium some 170 nationals were trained in planning, implement­ing and evaluating malaria control programmes in seven international courses for health person­nel of various levels. New manuals, visual aids and other teaching materials were prepared on basic epidemiology, entomology, treatment of severe malaria and training of trainers for the control of tropical diseases. The increase in in­structional activities has not, however, been matched by the availability of human and finan­cial resources. Training is pointless without the necessary supplies, equipment and infrastruc-

91

ture to enable the trainees to do the work for which they have been prepared. Steps have therefore been taken to ensure that the develop­ment of national programmes and of the neces­sary human resources both move forward in a coordinated manner. Progress was made in meeting the enormous demand for suitable training materials in English and French.

Dracunculiasis (guinea-worm disease)

14.22 If the present momentum can be main­tained for the control of dracunculiasis, the dis­ease can be eradicated. In early 1980 the global annual incidence was estimated at 5-10 million; the present estimate is less than 2 million. A sig­nificant decrease in incidence has been observed in some endemic countries where active surveil­lance and notification have been carried out. During 1991 -1992 the incidence decreased by 68% in Cameroon, 50% in Ghana, 43% in India, and 35% in Nigeria. Pakistan is on the verge of eradicating the disease, with 23 cases in 1992 compared with 160 in 1991.

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

A housewife's flour sieve con fil ter wo ter ond prevent transmission of drocunculiosis.

14.23 WHO convened a fourth regional confer­ence on dracunculiasis in Africa (Enugu, Nigeria, March 1992) and, as in previous years, joined with UNDP and UNICEF in organizing reviews of national dracunculiasis eradication programmes. A total of 16 national programmes were analysed, including assessment of current epidemiological trends and control activities; and in each case rec­ommendations were made for continuation of the programmes. The WHO/UNICEF interagency technical team for the dracunculiasis eradication programme in Africa, set up in Ouagadougou in 1992, provides direct support to national pro­grammes in French-speaking Africa. In 1992 WHO held a first formal consultation, in the Is­lamic Republic of Iran, to initiate the process of certification of eradication. The following year WHO experts discovered that transmission of dracunculiasis probably still occurs in Yemen. Updated criteria for the certification of dracunculiasis eradication were issued in 1993}

1 Documen1 WHO/Fil/93. 187 .

92

Schistosomiasis

14.24 The WHO Expert Committee on the Control of Schistosomiasis2 recognized that schistosomiasis is increasingly becoming an ur­ban health problem in Africa and Brazil and af­fects thousands of refugees, especially in Cambo­dia. SchistOsomiasis is also causing increas­ing concern in water resources development schemes, as emphasized in a new WHO publica­tion.3 A Swahili version of the 1990 WHO publi­cation 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 na­tional control programmes in all the countries concerned, although discussions with the manu­facturers 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.

1426 With the help of USAID, a geographical information system was developed to strengthen the management and control of schistosomiasis, and WHO joined with the International Devel­opment Research Centre (Canada) in introduc­ing it in Botswana and Senegal.

14.27 A WHO study group (Manila, October 1993) reviewed the current status of the epidemi­ology and control of food borne trematode infec­tions (see Figure 14.5). An estimated 40 million people are infected, although the pattern of mor­bidity is changing along with the environment and people's habits. The study group recom­mended a coordinated control strategy empha­sizing health education, food safety in domestic and commercial food processing, proper sanita­tion to reduce faecal contamination of food production through use of wastewater, and sys­tematic case detection and treatment within the health care system.

7 WHO Technical Re por1 Selies, No. 830, 1993. 1 Hu nter JM et ol. Porositic dlseoses in woler resources development. Geneva, World Health Orgonizo1ion, 1993.

Figure

14.5

Fo

od bo

rne t

rem

atode

infec

tions

in th

e wo

rld

Peop

le are

infec

ted w

ith

Nano

phyet

us, an

intes

tinal

trema

tode.

The d

isease

, orig

inally

lim

ited t

o Sibe

ria, h

as no

w be

en

report

ed in

Oreg

on, U

SA.

.. ~

1'1/

Parag

onim

us (lu

ng fl

uke)

infec

tions

are c

aused

by

eatin

g row

crab

s in t

he

Amazo

n low

lands

of

Ecua

dor a

nd P

eru,

and

in Ni

geria

and

Cam

eroon

, com

plicat

ing

or mi

sdiag

nosed

as

pulm

onary

tube

rculos

is.

/ I

'-..

..,

Fasci

ola he

patic

a {liv

er flu

ke) i

s acq

uired

by

eatin

g aq

uatic

plan

ts of

the A

lliplon

o of

Boliv

ia, th

e high

lands

of P

eru an

d Ecu

ador

, the

Nile

delta

and t

he Is

lamic

Repu

blic

of Ir

an.

\ 1

1

I ~

AI/-\

Peop

le ore

infec

ted w

ith

Phag

icola,

an in

testin

al tre

matod

e, fro

m mu

llet fi

sh in

Sfio P

aulo,

Braz

il.

Fasci

ola he

patic

a (liv

er flu

ke l is

ac

quire

d by e

ating

aqua

tic

plants

in th

e Aqu

itaine

regio

n of

south

-west

Fran

ce, a

nd

north

ern P

ortu

gal.

There

has b

een a

surge

of

Opisth

orchis

and

Clono

rchis

!liver

fluke

) infe

dions

from

fre

shwa

ter fi

sh in

small

wate

r im

poun

dmen

ts in

China

, La

o Pe

ople'

s D

emoa

atic

Repu

blic a

nd T

haila

nd.

Opisth

orchis

(live

r fluk

e) inf

edion

s in f

reshw

ater f

ish h

ave

sprea

d from

Sibe

ria to

Ukr

aine.

Abou

tl.5 m

illion

perso

ns or

e inf

eded

. I '\

.""'\

,/

?

() ~~ Mo

re tha

n 20

milli

on pe

ople

are in

feded

with

Pa

ragon

imus

!lung

fluke

) an

d 5 m

illion

with

Clon

orchis

!liv

er flu

ke) i

n Chin

a.

One i

ntesti

nal t

remato

de,

Fibric

ola, is

tron

smiH

ed to

1

peo~le fr

om ro

w fro

gs or

sno e

s and

anoth

er,

Gymn

opha

lloide

s, fro

m row

oy

sters

in the

Rep

ublic

of

Korea

.

There

is a h

igh in

ciden

ce of

chola

ngioc

orcino

ma, a

form

of liv

er can

cer re

lated

to

Opisth

orchis

or C

lonorc

his

infed

ion in

Tha

iland

and

Hong

Kon

g. W

H0

94

02

1/E

t \

~ ~

5:.: .... ... ;;: ... ~ a:

::::! ~ ~

~ s a:

:iil ~

THE WORK OF WHO 1992-1993

lymphatic filariasis

14.28 In 1991 the WHO Expert Committee on Filariasis' estimated that 78 million persons are infected throughout the world and that 750 mil­lion persons are at risk. It stressed the importance of establishing the precise social, psychological and economic consequences of the disease in en­demic countries.

14.29 Strategies to reduce clinical disease in en­demic areas through chemotherapy and vector control were initiated during the biennium. In clinical trials it was found that single doses of ivermectin as well as diethylcarbamazine citrate (DEC) were highly effective in suppressing parasitaemia (see paragraph 14.60). Further, ex­perience in China has shown that the use of DEC-medicated salt can effectively reduce prev-

1 WHO Technical Repo11 Series. No. 821 , 1992.

Sofe woter: the ideol woy to prevent filoriosis.

94

alence rates in infected populations. WHO is actively encouraging the manufacture and distri­bution of this salt through the private sector.

Onchocerciasis

14.30 The last decade has seen a decline in the prevalence of onchocerciasis infection, mainly due to the remarkable success of vector control in the Onchocerciasis Control Programme in West Africa. A symposium was organized (New York, September 1993) to mark the fifth anniver­sary of the donation of ivermectin by the manu­facturer Merck & Co. Supply of this drug has enabled a major breakthrough in onchocerciasis control, and so far six million treatments have been distributed. Rapid assessment indicators and drug supply processes were tested in opera­tional research projects in endemic countries. It can now be concluded that annual treatment of endemic communities suffices to reduce the par-

DISEASE PREVENTION AND CONTROL

asite load, prevent new cases of blindness and improve anterior segment eye lesions. In the Americas a strategic planning council coordinat­ed by PAHO/WHO has been promoting a re­gional initiative to eliminate onchocerciasis.

14 31 Of the 34 countries where onchocerciasis is endemic, 29 have implemented or prepared plans to conduct regional or national pro­grammes for distributing ivermectin based on the 1993 guidelines and recommendations of the WHO Expert Committee on Onchocerciasis Control. Effective cooperation has grown as a result not only of political commitment by min­istries of health but also of increasing interest among national and international agencies con­cerned with health and blindness. Currently 21 such agencies are involved in this cooperation, more than twice as many as two years ago, with WHO playing a coordinating role.

American trypanosomiasis (Chagas disease)

14.32 The ministers of health of the countries of the Southern Cone1 have launched an initiative to eliminate Chagas disease in the coming decade through control of vectors and blood banks. Technical representatives of each ministry have been designated to form an intergovernmental commission overseeing the implementation and evaluation of national control programmes. Field 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 reiter­ated their commitment to continue financing the activities in 1994-1995.

14.33 A study carried out in Argentina, Chile, Honduras and Paraguay showed that rates of house reinfestation by triatomines 18 months af­ter the application of insecticide paints are 1.5 to 3 times lower than those observed after tradi­tional spraying. The paints, manufactured in Bra­zil, have already been applied routinely by the control programme in the state of Ceara and operational costs have decreased, while vector control has become more efficient.

1 Argentina, Bolivia, Brazil, Chile, Paraguay, Uruguay

95

Leishmaniasis

14.34 A WHO imtlatlve for research on leishmaniasis control led to the mobilization of funds for nine new projects aimed at validating new vector and/ or reservoir control methods. In a hyperendemic area of central Tunisia a technique to control zoonotic cutaneous leishmaniasis, based on large-scale deep ploughing of rodent burrows around a city, proved to be feasible and efficient; the project was strongly backed by the national authorities and by regional and local institutions.

14.35 In the Indian state of Bihar the use of pyrethroid-impregnated bednets led to a dramat­ic reduction in the density of the vector Phlebotomus argentipes in dwellings over a five­month period, suggesting that it could be anal­ternative to classical house spraying with residual insecticide. The method was well accepted by local communities.

14.36 With the spread of the AIDS pandemic, the incidence of visceral leishmaniasis is expected to rise because of the increasing frequency of HIV I Leishmania eo-infections. WH 0 has es­tablished an international registry in Geneva to centralize and diffuse worldwide epidemiologi­cal data on these eo-infections. A case report form was prepared and widely diffused to facili­tate and standardize the collection of baseline data for evaluating the severity of the problem and its geographical extent.

African trypanosomiasis (sleeping sickness)

14.37 With the recrudescence of sleeping sick­ness, a number of countries called for inter­country coordination of surveillance and control activities, and various approaches have been de­vised: in central Africa national control projects are being implemented under an initiative involv­ing 10 countries; in west Africa projects are being launched within the framework of the oncho­cerciasis control programme; and in south-east Africa surveillance and control involving eight 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 trypanosomiasis control to support sustainable

THE WORK OF WHO 1992-1993

agricultural development should provide an insti­tutional framework for training in this field, com­plementing the training dispensed by WHO at national level. Training materials such as films, manuals and modules have been prepared for use in Chad, Congo, Uganda and other countries.

14.39 To strengthen surveillance and control, WHO has set up a sleeping sickness epidemiologi­cal "observatory" which will assess disease preva­lence, the extent of foci, patient status, drug availa­bility and use, vector occurrence and distribution, and current methods for and progress in vector control. Geographical information systems greatly facilitate analysis of epidemiological and manageri­al data collected in the field and allow effective programme management.

14.40 As in past years a JOlllt FAO/OAU/ WHO training seminar was held (Kampala, Oc­tober 1993 ), fostering an exchange of views and maintaining a high level of national conscious­ness about the risk of sleeping sickness epidemics as experienced recently by Sudan, Uganda and Zaire.

14 41 The establishment of a WHO revolving fund with support from the Netherlands has al­lowed rapid provision of standardized equipment, material, reagents, test kits and drugs to national programmes. The annual donation by Rhone­Poulenc (France) of 85 000 ampoules of pentamidine for the treatment of early stage sleep­ing sickness was a major contribution from the private sector. Other contributions have been made by nongovernmental organizations, such as Medecins sans Frontieres in northern Uganda, and Fometro of Belgium which supplied 10 000 am­poules of eflornithine for the treatment of late stage sleeping sickness cases resistant to melarsoprol.

Dengue

14 42 The frequency of dengue epidemics has increased significantly in the past decade, and dengue and dengue haemorrhagic fever epidem­ics now threaten two-fifths of the world's pop­ulation, or approximately 2000 million people living in urban areas in 100 countries in Africa, the Americas, Asia and the Pacific, causing mil­lions of cases annually with thousands of deaths. An unknown number of people are also at risk in rural areas of China, India, Indonesia, Myanmar and Thailand. In May 1993 the Health Assembly

96

adopted resolution WHA46.31 recognizing that dengue, dengue haemorrhagic fever and dengue shock syndrome are threatening lives and well­being in a large proportion of populations in tropical regions and confirming that the preven­tion and control of these conditions should be among the priorities of WHO. The resolution called for the establishment of strategies to con­tain the spread and increasing incidence of the diseases in a manner sustainable by countries.

Disease vector control

14.43 As from May 1993 the University Sains Malaysia undertook, on WHO's behalf, the preparation of insecticide-impregnated papers and solutions and the storage and dispatch of material for monitoring the insecticide suscepti­bility of disease vectors, while WHO continued to coordinate the activities and to maintain a global database on this subject.

14 44 The WHO pesticides evaluation scheme (WHOPES), in operation since 1982, initiated new procedures to facilitate contributions by the national authorities and by industry in the evalu­ation of pesticide products and formulations for use in tropical disease vector control. Under the scheme, the Organization, through its collabo­rating centres in Gembloux (Belgium) and Atlanta (USA), promoted research on pesticide formulations and the setting of specifications, particularly by means of collaborative studies with industry to design methods for analysis of insecticides in conjunction with the Collabora­tive International Pesticide Analytical Council; routine analysis of samples of pesticides intended for national disease control programmes to en­sure compliance with WHO specifications; and development of standardized chemical, physical and biological assays for the analysis of selected insecticides used in impregnation of nets and traps, including bednets. During the biennium WHO PES field trials on 11 chemicals, produced by seven pesticide manufacturers, were conduct­ed in 14 countries of Africa, South-East Asia and the Western Pacific. Different formulations and types of application were evaluated, including impregnation of nets and traps, indoor residual spraying and ultra-low-volume application, against the vectors of African trypanosomiasis, arboviral diseases and malaria. WHO's 1985 specifications for public health pesticides were revised and produced in a new format suitable

DISEASE PREVENTION AND CONTROL

for frequent updating. Following extensive re­view by FAO and experts from industry, guide­line specifications for household pesticides were prepared for joint publication by FAO and WHO.

14.45 The Organization promoted personal protection measures, particularly the use of in­secticide-impregnated materials for bednets and curtains. Pre-impregnated bednets are now com­mercially available, and WHO tested their effica­cy in 1993 under field conditions in collaboration with regional organizations. Developed with the assistance of WHO, insecticide-treated bednets are now being used in national malaria control programmes in Benin, Burundi, Cameroon, Cote d'Ivoire and other countries. To contain malaria epidemics, large-scale vector control op­erations were carried out in refugee camps in Rwanda in 1993, and WHO provided guidance on the use of insecticide-treated bednets in refu­gee camps in Bangladesh, Kenya and Mauritania. In Ethiopia WHO was involved in the reorientation and decentralization of national vector control programmes to suit local epidemi­ological conditions.

14.46 A study group on the technical, opera­tional and managerial aspects of vector control for malaria and other diseases, including dengue, was organized in November 1993.

14.47 Molluscicide use has continued to decline owing to the rising cost of purchasing and deliv­ering chemical molluscicides and training per­sonnel to use them. In 1992 WHO issued a docu­ment on mollusciciding in schistosomiasis con­trol, 1 emphasizing that the selective and appro­priate use of molluscicides has a role in control, and providing practical guidelines for their appli­cation and for monitoring of their effects.

14 48 Large-scale control of the tsetse fly by trapping vectors of trypanosomiasis was success­fully carried out in Uganda. In the case of sandflies, the diversity of ecological and epidemi­ological entities means that vector control meas­ures have to be very specific. Insecticide-spray­ing was applied in termite hills in Kenya against Phlebotomus martini, and in acacia woodlands in Sudan against P. orientalis. As regards leish­maniasis, control of the vector was frequently a

1 Document WHO/SCHIST0/92.107.

97

by-product of antimalaria operations; for indoor residual spraying, several insecticides were used.

Leprosy

14.49 Good progress was again made against lep­rosy during the biennium. The disease burden was reduced by more than 40%; estimated cases de­creased from 5.5 million to 3.1 million and regis­tered cases from 3.2 million to 1.9 million. In all, over the last eight years, 4.3 million patients have been cured through multidrug therapy, with a cu­mulative coverage of 85% (see Table 14.2). How­ever, progress in introducing this therapy in the WHO regions has been rather uneven (see Figure 14.6 ), the highest levels of coverage being achieved in the Western Pacific (97%) and South-East Asia (88%), and the lowest in the Americas (46%).

14 50 Health Assembly resolution WHA44.9 calling for the elimination of leprosy as a public health problem by the year 2000 generated a wholehearted response from the main countries where the disease is endemic, which pledged in­creased political commitment and priority for leprosy control. With support from WHO, countries have been able to formulate national elimination strategies and plans of action. The international donor community, particularly the member associations of the International Federa­tion of Anti-Leprosy Associations as well as the

Table 14.2 leprosy situation, 1985 and 1993

1985 1993

Number of affected countries 124 87

Estimated cases 10-12 million 3 I mill1on

Reg1stered cases 54 m1ll1on I 9 m1ll1on

New cases per year na 650 000

Cumulative total of pat1ents cured through mult1drug therapy 9 000 4.3 m1ll1on

Cumulative coverage of multidrug therapy I 6% 85%

Global reduction in prevalence over the last eight years 64%

<)

b

THE WORK OF WHO 1992-1993

QJ 0

0

0

@

QJ Ql(')

0 e; St>6S60HM

' ' D

DISEASE PREVENTION AND CONTROL

Sasakawa Foundation, continued to provide sub­stantial support to countries amounting to more than$ 80 million per year. WHO is closely col­laborating with nongovernmental and other or­ganizations particularly at country level, so that the goal of elimination can be attained.

14.51 WHO's working group on leprosy con­trol, established in 1991, continued to oversee ac­tivities, in which nongovernmental organizations increased their participation. The strategy of tar­geting high-priority countries is most appropriate for leprosy in view of the very uneven distribution of the disease; in fact, one country (India) contrib­utes 52% of all estimated cases in the world and five others (Bangladesh, Brazil, Indonesia, Myanmar, Nigeria) a further 27%. The working 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 therapy (Indonesia, Madagascar, Nigeria, Sudan) and in carrying out independent evaluations of programmes (China, India, Myanmar, VietNam). Coordination of activities between ministries of health, nongovernmental organizations and WHO is steadily improving in a number of coun­tries, sometimes through formal tripartite agree­ments (Papua New Guinea, T ogo ).

14 52 Improved monitoring and evaluation has made it possible to produce half-yearly statistics on the leprosy situation and coverage with multidrug therapy, to update case estimates for countries an­nually, and to identify unrealistic data on registered cases. In some countries case registers were re­viewed in order to remove inactive and non-exist­ent cases (Brazil, Nigeria). WHO promoted na­tional conferences on leprosy to increase awareness of the disease and promote control strategies (Brazil, Egypt, Islamic Republic of Iran).

14 53 While the number of leprosy sufferers (i.e., patients in need of chemotherapy) is steadily declining, the number of people disabled as a result of the disease is not showing a similar decline because multidrug therapy has no direct impact on disability. WHO therefore promotes the prevention and management of disabilities within leprosy control; and a manual for health workers on this subject was published.1

1 Srinivasan H. Prevention of dtsabthttes in patients with leprosy: a practtcal guide. Geneva, World Health Orgamzation, 1993.

99

14 54 WHO continued to support the training of managers in leprosy control through the pro­vision of training modules and the organization of national workshops. The modules were re­vised in 1993, based on experience over a two­year period. Workshops were conducted in 14 countries in 1992-1993 for a total of 322 par­ticipants.

14.55 WHO continued to promote health sys­tems research in leprosy to facilitate problem­solving at local level. For this purpose two work­shops were held in Brazil and Thailand, and these activities demonstrated the value of the WHO training modules. A task force for health systems research in leprosy met in 1992 and 1993 to re­view proposals emanating from the workshops.

Tropical disease research

14 56 The prime responsibility of the UNDP/ World Bank/WHO Special Programme for Re­search and Training in Tropical Diseases is for research, whereas that of the WHO Division of Control of Tropical Diseases is for control. Dur­ing the biennium the Special Programme gave par­ticular emphasis to product development and ap­plied field research. It also undertook applied field research on the subject of women and tropical diseases, for example, dealing with factors affect­ing women's use of community health services, self-medication practices, and sex differences in the clinical manifestations and impact of the dis­eases; this activity will be jointly managed with the Division of Control of Tropical Diseases. The Special Programme's dual roles of developing better tools against six groups of tropical diseases, and of improving endemic countries' capacity for relevant research, were increasingly combined.

14 57 Malaria. Three steps were taken to im­prove treatment of cerebral malaria: phase Ill clinical trials of the drug artemether were begun in six centres; a clinical trial of an anti-TNF (tu­mour necrosis factor) monoclonal antibody was undertaken in Gambia; and studies of the toxi­cology of artemether injection were completed. Phase I studies in healthy volunteers with the 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 begun in children in the United Republic of Tanzania.

THE WORk OF WHO 1992-1993

14 58 Studies of insecticide-treated bednets, which have proved very successful in reducing child mortality in Gambia, were extended to three other African countries; and research to devise methods for genetic manipulation of mos­quito vectors was undertaken, with the long­term aim of reducing their ability to transmit malaria parasites.

14.59 Schistosomiasis. Phase I studies of combi­nations of praziquantel and albendazole (an antihelminthic) were completed in Sudan, and phase 11/111 studies begun in China, Kenya and Philippines. Preliminary indications were that the combination is safe and effective. In vaccine development, negotiations with manufacturers on extending and improving the production of several antigens neared completion. An inde­pendent standard testing facility was set up, and preparations began for phase I trials of some promising schistosome antigens.

14.60 Lymphatic filariasis and onchocerciasis. lvermectin, which has been successfully used in treating onchocerciasis, was tested against lym­phatic filariasis. Clinical trials in nine endemic countries/territories1 showed that a single dose of 400 micrograms of ivermectin/kg of body weight suppressed microfilarial production in lymphatic filariasis for over a year, with equal efficacy at one year to a 6 mg/kg dose of the traditional drug diethylcarbamazine citrate (DEC). But a combination of low-dose iver­mectin (20 micrograms/kg) with a 6 mg/kg dose of DEC gave the best overall results at one year. At the same time, ivermectin was shown to pro­duce fewer side-effects.

14 61 Operational studies on the use of Bacillus sphaericus for control of the mosquito vector Culex quinquefasciatus were launched in Brazil, Cameroon, India, Sri Lanka and United Repub­lic ofT anzania.

14.62 Yearly mass treatments for onchocerciasis with ivermectin were shown to improve anterior segment eye lesions and to reduce the incidence of posterior segment lesions (and thus optic nerve disease). Moreover, no evidence was found that ivermectin induced any life-threatening re­actions or had adverse effects when used in preg-

1 Brazil, French Polynesia, Ha1t1, lnd1a, lndones1a, Kenya, Malaysia, Papua New Gumea, Sn Lanka.

100

nancy. The drug also improved lichenform skin lesions. Annual mass treatment was found to be acceptable to affected communities. Large-scale use of six-monthly treatment with ivermectin in Guatemala showed that the drug on its own was capable of interrupting transmission in the study area, and data from Ghana indicated that repeat­ed treatment might help reduce transmission in parts of Africa.

14.63 DNA probes were developed to detect and differentiate between forest (less blinding) and savanna (more blinding) Onchocerca, and between human and animal parasites, and are now in routine use in the Onchocerciasis Con­trol Programme in West Africa.

14.64 Operational research in Nigeria demon­strated the effectiveness and accuracy of simple visual assessment of skin nodules to identify high-risk communities in need of broad-based ivermectin treatment, thus reducing reliance on painful and risky skin-snipping.

1465 Leprosy. Follow-up of 14 000 person­years of multidrug therapy revealed only four cases of relapse with skin lesions. Tests of po­tentially more rapid treatments including ofloxacin were begun in 15 centres. A compara­tive study was started in India of BCG, BCG with heat-killed Mycobacterium leprae, the In­dian Cancer Research Centre bacillus, and the Indian bacterium M. w. Preliminary results of a vaccine trial in Venezuela showed no substan­tial difference between the protection offered by BCG and BCG with heat-killed M. leprae. Cloning and sequencing of the M. leprae genome began.

14.66 African trypanosomiasis. In 1993 Uganda became the first African country to register eflornithine, the new drug for the gambiense form of African trypanosomiasis which had pre­viously been registered in the United States of America and the European Community. The an­tigen-ELISA test was modified as a "Card indi­rect agglutination test for trypanosomiasis" (CIA TT). Preliminary field trials showed this test to be highly specific and sensitive for both the gambiense and the rhodesiense forms of Afri­can trypanosomiasis.

14.67 Chagas disease. A joint initiative for the elimination of Chagas disease transmission by Triatoma infestans was launched in late 1993 by Argentina, Brazil, Bolivia, Chile, Paraguay and

DISEASE PREVENTION AND CONTROL

Uruguay. Two types of blood screening kit were manufactured in Buenos Aires using molecularly defined antigens, and field trials were begun for screening blood bank products infected by Trypanosoma cruzi.

14.68 Leishmaniasis. A field trial in Venezuela of killed Leishmania (L. braziliensis and L. mexicana ), both separate and combined with BCG vaccine, was undertaken in cooperation with the United States National Institutes of Health, and is due to be completed in 1994. Clin­ical phase I-II studies of killed L. major with BCG were begun in the Islamic Republic of Iran, and of a single-strain "Mayrinck vaccine" (L. amazonensis) in Brazil.

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 Colombia.

Social research

14.70 Studies in Ghana and Nigeria showed that pregnant adolescent girls in whom the ma­laria mortality risk is particularly high did not attend malaria clinics for treatment because their parents were ashamed of public recogni­tion of their pregnancy. In Colombia a study showed that women with malaria wait longer than other members of their families before seeking treatment, and suffer worse conse­quences from the disease. A multi-country study in Africa showed that school question­naires could be used for the rapid identification of communities suffering high levels of urinary schistosomiasis, at one-thirtieth of the cost of egg examination by mobile teams. Several stud­ies also showed significant gender differences in reporting of urinary schistosomiasis - because among girls it was wrongly viewed as a sexually transmitted disease. A study was launched in seven countries in Africa and Asia to determine the social and economic importance of lym­phatic filariasis. An important component of these studies will be the clinical investigation of genital manifestations of the disease in women. In one area of Nigeria communities considered the skin manifestations of onchocerciasis to be more important than blindness, because of their effect on relationships and marriage pros­pects.

101

Research capability strengthening

14.71 Nine new grants were awarded for strengthening the capacity of institutions in op­erational research on malaria, and for research training in social sciences and economics. Research training grants were awarded to 111 young scientists including 34 women. Fourteen institutions submitted final reports on their use of institution-strengthening grants, while 45 oth­ers continued to receive grants. The award of small grants proved very successful in supporting short-term research projects. In the Eastern Mediterranean nine grants were awarded for re­search on leishmaniasis and 14 for research on schistosomiasis in 1993.

Diarrhoeal diseases

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 nearly a quarter of them from diarrhoea; pre­venting these deaths is a task of high priority for WHO.

14 73 Training activities emphasized case man­agement and better programme management. In 1992 WHO's revised guidelines for conducting clinical training courses at health centres and small hospitals' were widely used by national programmes for the first time, reflecting a trend towards decentralizing case management train­ing. Over 1000 courses - more than triple the number in the previous biennium - were held, mainly in the upwards of 400 diarrhoea training units in 80 countries throughout the world. The Organization supported 38 national training courses for programme managers in the largest countries (bringing the total since 1987 to 122), and nearly 150 courses for first-level supervisors were held (a total of about 630 courses since their revision in 1987).

14 74 In an attempt to complement in-service training of physicians and eventually reduce the need for it, WHO has for some time been in­volved in compiling instructional material on diarrhoea! diseases for use in medical schools.

1 Document CDD/SER/90.2 Rev.1 1992.

THE WOilK OF WHO 1992- 1993

After successful field trials, the full series ap­peared in 1992 in the form of a manual' and four guides.2 Materials for distance learning, training at nursing and paramedical schools, and training of pharmacists and other purveyors of pharma­ceutical products were also prepared.

14.75 In 1992 WHO devised a new, more data­based and problem-specific method for review­ing progress in national programmes, known as "focused programme review". The aim is to identify constraints o.n progress and then design specific activities to deal with them. During 1992 and 1993 th.is method was successfully applied in 13 countries, while six carried out other types of programme reVlew.

14.76 WHO's 1990 monograph on the ration­al use of drugs in the management of acute diar­rhoea in children was well received by responsi­ble national authorities, and was translated into Bengali, Chinese, French, Spanish and Viemam­ese; since its publication a number of countries have banned or restricted the use of anti­diarrhoeal drugs. The provision of oral rehydra­tion salts (ORS) remained a key clement in the control of diarrhoea in children; at the end of 1992, the global access rate (the proportion of the population with a regular supply of ORS in their community) was estimated to be 73%, 5% higher than at the end of 1991.

14.77 Despite effective case management train­ing in many countries, the essential function of advising a mother on how to care for her child at home during an episode of diarrhoea remains one of the least practised features of case manage­ment. To help resolve this problem, WHO .is­sued a guide for health workers on counselling mothers;3 it will be used in clinical management training courses. The O rganization also complet­ed a guide for national programme managers on the effective use of radio, which is vital for com­munication in developing countries.

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

' Readings on diarrhoea: student manual. Geneva. World Health Orgonizo· lion, 1992.

7 Uocuments COD/SER/93.1; COO/SfR/93.2; CDO/SER/93.3; COD/SER/ 93.4

>Document C00/93.1.

102

rhoea in infants, and also minimizes its adverse nutritional effects. Epidemiological studies have shown that exdusive breast-feeding in the first four to six months of life and continued breast­feeding until the end of the first year are associat­ed with milder forms and lower incidence of diarrhoea and with lower mortality. To ensure appropriate support from health workers - often the main source of advice to breast-feeding mothers - WHO and UNICEF produced a train­ing package on lactation management.~

14.79 The global task force on cholera control continued to coordinate WHO support to af­fected countr ies. Guidelines were issued5 and control efforts were pursued in all the countries concerned, particularly in Africa, where there were many more deaths than in South America. In 1993 the Organization planned a series of steps to support governments in improving the situation in southern Africa, notably by increas­ing health workers' case management skills; raising the capacity of district health teams to prepare for, detect and respond to outbreaks; strengthening the capacity of laboratories to con­firm suspected cases; developing policies to re­duce the disruptive aspects of cholera epidemics on trade and tourism; and determining long-term infrastructural needs for food safety, water and sanitation systems, the lack of which is the main cause of cholera. A resurgence of the disease in the Eastern Mediterranean elicited increased technical and financial support to the countries concerned. In South-East Asia a new strain of cholera, designated Vibrio cholerae 0139,

A demonstration of how to chlorinate woler during o cholera out· break in Peru.

• Documents WHO/CDR/ 93.4; WHO/ CDR/93. 5; WHO/ CDR/ 93.6. 1 Guidelines for cltolora control. Geneva, Wo1ld Health 01ganizotion, 1993.

DISEASE PREVENTION AND CONTROL

emerged during the biennium to cause major ep­idemics and largely replaced Vibrio cholerae 01 as the predominant strain in several countries.

14.80 WHO continued to support research for the development and evaluation of new or im­proved methods of treatment and prevention of diarrhoea; 35 new projects received support dur­ing the biennium, bringing the total number of WHO-sponsored projects to 453. Half of these new projects related to breast-feeding practices and nutrition. The search for better ORS formu­lations continued: an outpatient study was con­ducted in Bangladesh to compare treatment of outpatients with rice-based and glucose-based ORS solutions; and two large studies in Egypt and Pakistan showed that standard WHO ORS solution is as efficacious as rice-based solution for treating diarrhoea in infants and children. Other research included a study among outpa­tients of the impact of zinc supplementation on persistent diarrhoea and the testing in six coun­tries of a model for clinical management of the condition. A WHO-supported study in Bangla­desh demonstrated that breast-feeding is of particular importance in the prevention of shigellosis among young and malnourished chil­dren. Other studies showed that for infants with diarrhoea under six months of age fed exclusively on animal milk or formula, these foods do not normally need to be diluted and should be given in full strength as soon as dehydration has been corrected. In Brazil the use of dummies was found to be associated with increased risk of early termination of breast-feeding.

14.81 The Organization continued to support research to evaluate candidate vaccines for the most important causes of acute diarrhoea, in­cluding rotavirus infection, cholera, shigellosis and disease caused by enterotoxigenic Esche­richia coli. An evaluation of the efficacy of tetra­valent rhesus-human rotavirus vaccine was com­pleted in Brazil, and a large trial involving a high­er dose of the vaccine was initiated in Venezuela. A trial of the live oral cholera vaccine CVD-1 03 HgR was begun in Indonesia.

14.82 It is generally recognized that WHO's recommendations on diarrhoea case manage­ment are much better understood when they are formulated using local terms and concepts. A protocol was therefore developed for the compi­lation of descriptive data on beliefs and practices regarding diarrhoea to be used in the implemen­tation of national programmes.

103

Acute respiratory infections

14.83 Acute respiratory infections, especially pneumonia, either directly caused or contributed to about one-third of the 12.9 million deaths in children under five in developing countries in 1990. The central strategy for reducing this death rate is case management using a simple standard protocol for the diagnosis and treatment of pneumonia.

14.84 Training is one of the main channels through which standard case management can be introduced into primary health care. A new training module on outpatient case management was used for the first time in English at an interregional course in Thailand in 1992, and was subsequently translated into French and Spanish. After two successful tests in Kenya in 1992, a course for training community health workers was made available to national programmes; it includes a guide for cultural and technical adapta­tion of case management methods. Preparation of training materials for inpatient care was started.

14.85 In courses using materials produced in previous years, 27 4 officers were trained in pro­gramme management and about 32 000 physi­cians and other health workers in case manage­ment. By the end of 1993, 192 acute respiratory infection training units had been established in 28 countries.

14.86 Childhood immunization against measles and pertussis makes an important contribution to the reduction of deaths associated with acute respiratory infections. In order to enlarge the arsenal of preventive measures, WHO, in associ­ation with the London School of Hygiene and Tropical Medicine, commissioned a series of re­views to determine effective and feasible inter­ventions for reducing morbidity from pneumo­nia in children in developing countries. The im­pact of vitamin A supplementation on childhood pneumonia was one of the subjects investigated; and data from 12 studies were analysed at a meet­ing in March 1992.1 Groups of experts also met in March 1992 to analyse the first round of inter­vention reviews and in March 1993 to analyse the second round.2 They concluded that some three­quarters of all pneumonia deaths result from bac­terial infection; that vitamin A supplementation

1 Document WHO/CDR/93.2. 2 Prevention of pneumonia 1n children. Lancet, 1993,341:821-822.

THE WORK OF WHO 1992-1993

has no beneficial impact on the mortality of pneumonia not associated with measles; that an­tibiotic treatment of upper respiratory infection plays no role in the prevention of acute lower respiratory tract infections; and that pneumo­coccal conjugate vaccine, if it proves effective, could have a substantial impact in preventing pneumoma.

14.87 One important target is the establishment by 1995 of acute respiratory disease control pro­grammes in all countries with an infant mortality rate greater than 40 per 1000 live births. Among the 88 countries falling into this category, 56 ( 64 %) had control programmes in at least one major administrative division by the end of 1993. Since progress is relatively slow in sub-Saharan Africa because of other priorities, more extrabudgetary funds were provided in that re­gion. WHO organized a meeting with represent­atives of UNICEF and 15 nongovernmental or­ganizations to plan joint action for the control of acute respiratory infections in Africa (Trieste, Italy, December 1992) and a workshop to train African consultants in planning, evaluation and problem-solving (Cotonou, Benin, November 1993). These activities were part of WHO's strategy of giving more direct technical support to national programmes.

14 88 During the biennium WHO developed a prototype home-care card to assist health work­ers to improve communication with families. The results obtained by applying WHO's re­cently completed "focused ethnographic study protocol" are used to adapt messages contained in the home-care card and to choose appropriate terminology for use at local level. As recom­mended at a meeting in May 1992, new guide­lines are being developed to assist programme managers in applying the results of ethnographic studies in programme planning and implementa­tion. A workshop was organized for ethnogra­phers from several African countries in 1993.

14.89 WHO developed a survey instrument for evaluating case management practices, including communication with families, at first-level health facilities; it was field-tested in 1992 in India, Papua New Guinea, Philippines and Swaziland, and completed in 1993. To obtain information on home management of children with acute res­piratory infections, including care-seeking prac­tices, the Organization devised a procedure for household surveys that also collect information on diarrhoea! diseases and breast-feeding.

104

14.90 Review papers on overlap in the clinical presentation and treatment of malaria and pneu­monia in children, 1 the use of bronchodilators,Z and the management of fever in young children with acute respiratory infections3 were issued, as was the first volume of an annotated bibliogra­phy of selected articles on pneumonia and related infections in young children.4 Six issues of ARI news were published by the Appropriate Health Resources and Technologies Action Group (United Kingdom) in collaboration with WHO.

14 91 On completion of a multicentre study on the clinical signs and etiological agents of pneu­monia, sepsis and meningitis in infants under three months of age, conducted in Ethiopia, Gambia, Papua New Guinea and Philippines, a meeting of the principal investigators and con­sultants was held to analyse the results (Beijing, November 1993). The etiology of pneumonia in malnourished children was studied in Gambia, and the clinical significance of in vitro resistance of pneumonia-causing bacteria to cotrimoxazole or amoxycillin in Pakistan. WHO collaborated with other agencies in organizing a field trial of Haemophilus influenzae type b vaccine in Gam­bia. A manual on the monitoring of antimicrobial resistance of Streptococcus pneumoniae and H. influenzae was field-tested in Egypt, Paki­stan, Thailand and Viet N am. In Guatemala sup­port was given in working out procedures for monitoring indoor air pollution from burning biomass fuels and for using behavioural methods to measure the duration of exposure of mothers and their infants to smoke.

14.92 In 1992 WHO and UNICEF began coop­erating in the design of an integrated approach to the management of the lethal scourges- pneumo­nia, diarrhoea, malaria, measles and malnutrition -which cause almost three-quarters of deaths among children under five years in developing countries. The integrated approach is summa­rized in a set of case management charts for the health worker, entitled: "Assess the child and classify the illness", "Treat the child" and "Ad­vise the mother". A separate chart deals with in­fants under two months of age. The new ap-

1 Document WHO/ARI/92 23- WHO/MAL/92.1 065. 2 Document WHO/ARI/93.29. 3 Document WHO/ARI/93.30. 4 Document WHO/ARI/93 27.

DISEASE PREVENTION AND CONTROL

proach facilitates case management of these dan­gerous conditions in children in outpatient set­tings, increases efficiency in training and the or­ganization of services, and stresses the impor­tance of "clinical encounters" to promote im­munization and improve infant feeding.

Tuberculosis

14.93 One-third of the world's population is infected with the bacillus Mycobacterium tuber­culosis, and approximately one in ten of those infected people will develop active tuberculosis at some time. In 1992 there were over eight mil­lion new cases of the disease; the number of suf­ferers will continue to increase and nearly 90 million new cases are likely to occur in the period 1990-1999. Most cases and more than 98% of deaths occur in the developing world, but the incidence of the disease is also increasing for the first time in many decades in some countries in Europe and North America.

14.94 Tuberculosis is now the world's leading cause of death from a single infectious agent and accounts for over a quarter of avoidable deaths among adults. An estimated 2.9 million persons died of it in 1992: 1.2 million in South-East Asia, 679 000 in the Western Pacific, 493 000 in Africa and over half a million in the rest of the world. Deaths from the disease are expected to increase to over 3.5 million per annum by the year 2000. Moreover, the epidemic has become more diffi­cult to control because of the emergence of multidrug-resistant strains of the bacillus and be­cause of the HIV pandemic. For instance, between 1985 and 1991 the annual number of tuberculosis cases more than doubled in Malawi and nearly tripled in Zambia as a conse­quence of HIV infection.

14.95 In 1993 the Health Assembly, recognizing the seriousness of the situation, called upon Member States to take rapid action regarding case detection and registration, short-course therapy, and supplies of antituberculosis drugs (resolution WHA46.36). By the end of the biennium recognition by Member States of the magnitude of the problem was beginning to re­sult in the mobilization of additional national and external resources to improve national pro­grammes and intensify research. WHO's ob­jectives for global control of tuberculosis are to treat successfully 85% of detected smear-posi-

105

tive cases and to detect 70% of infectious cases by the year 2000. This can be achieved by the use of WHO recommended short-course chemo­therapy, with supervision of drug consumption and use of recording and reporting systems which meet WHO's criteria. As districts achieve high cure rates, case detection activities can be intensified to find remaining cases.

14.96 During the biennium WHO issued guide­lines on tuberculosis treatment1 and provided technical support to national control pro­grammes in over 30 of the most seriously-affect­ed countries. In China detailed monitoring was carried out in a large project supported by the World Bank. A combined tuberculosis and lep­rosy control project was initiated in Bangladesh in 1993, also with World Bank support. Reviews of national tuberculosis programmes in India and Zimbabwe in 1992 resulted in revision of national policies and preparation of projects for external finance by the World Bank and other institutions. One outcome of technical support to Guinea was the compilation of a national tuberculosis control manual applicable to many countries. Six countries in the Americas and one in the Western Pacific carried out evaluations of their programmes with WHO support. New methods of programme review and evaluation were devised in the light of experience gained in these countries.

14.97 Training materials for middle-level pro­gramme managers and treatment guidelines for national programmes were prepared, tested, re­fined, issued in various languages, and used in workshops at global, regional or national level in several countries.2 Guidelines were produced for setting up national control programmes and in­ternational reference laboratories to monitor drug-resistant tuberculosis.

14.98 A WHO information base was established to monitor the status of national tuberculosis programmes. Based on information from 139 countries and territories surveyed, it was found that less than 40% routinely used short-course chemotherapy in sputum-positive cases of pul­monary tuberculosis. Half reported drug short­ages in 1991, over half were partially or fully

1 Treatment of tuberculosis. guidelines for natiOnal programmes. Geneva, World Health Organization, 1993

2 Bangladesh, Egypt, Guinea, lnd1a, N1caragua, Philippines, Un1ted Republic of Tanzania, Z1mbabwe.

THE WORK OF WHO 1992-1993

dependent on donors to meet needs for drugs, and more than a third were uncertain whether funding would be sufficient to meet their current year's needs. Following this survey, case stud­ies have been undertaken in eight sub-Saharan African countries to determine ways of improv­ing their supply systems.

14 99 Research begun or under way during the biennium included studies on diagnostic methods, testing of new drugs, and trials of the operational feasibility of using isoniazid for preventive thera­py in persons with HIV infection. Operational research conducted in collaboration with control programmes in Malawi, Mozambique and United Republic of Tanzania demonstrated the remarka­ble cost-effectiveness of short-course chemother­apy for pulmonary tuberculosis. A further study in Botswana suggests that these results are valid for middle-income developing countries.

14 lOO Research to quantify the impact of HIV infection on tuberculosis continued in the United Republic of Tanzania. Further work be­gan in Malawi to determine the effect of HIV infection on the results of tuberculosis treatment, and also to assess the efficacy of new treatment and supervision regimens aimed at mitigating the enormous increase in workload brought about by the epidemic of combined HIV and tubercu­losis infection.

14 101 The main obstacle to tuberculosis control is not lack of medical knowledge but inadequate political will. An effective and relatively inexpen­sive cure already exists, but it is not being widely used. In 1993 WHO therefore initiated a vigor­ous publicity campaign to bring the tuberculosis crisis to the attention of governments, journal­ists, nongovernmental organizations, and health and public interest groups. In furtherance of this campaign, an information package presenting ba­sic facts about the disease to a non-scientific au­dience was widely disseminated, and the July­August 1993 issue of the magazine World health was devoted entirely to tuberculosis.

Zoonoses

14.102 Rabies was a growing health problem and economic burden in many parts of Africa, the Americas and Asia, and was reported in more than 90 countries. Dog rabies was present in about 65% of infected countries and was the

106

main cause of human deaths from rabies. In Afri­ca and Asia WHO concentrated on research on canine biology and oral immunization tech­niques for dogs and the promotion of appropri­ate strategies for the control and elimination of canine rabies. A national rabies coordinating committee was established in Nigeria, and an informal group was set up for training and re­search on rabies in southern and eastern Africa. Fourteen Asian countries endorsed a common strategy primarily based on parenteral vaccina­tion of dogs.

14 103 Significant progress was made in oral vac­cination of dogs and safety requirements were framed in order to reduce the risk of contact between candidate vaccines and human beings during mass vaccination campaigns. A field study was carried out to evaluate several vaccine­bait delivery techniques. Discussions on require­ments for the release of live rabies vaccines for oral immunization of dogs were held with a number of Asian and north African countries.

14 104 Very encouraging results were reported in those western European countries which con­duct regular campaigns for oral vaccination of foxes against rabies. With the exception of a few foci, the rabies front at the end of 1993 followed approximately a line from W olin on the Baltic Sea to Trieste on the Adriatic Sea (see Fig­ure 14.7). A meeting on rabies control in Europe (Piestany, Slovakia, October 1993) helped to strengthen scientific and field collaboration on wildlife rabies, especially between members of the Commonwealth of Independent States and other European countries.

14 105 WHO coordinated studies on canine biol­ogy in Turkey, Yemen and Zambia during 1992-1993. In the first two countries a large proportion of the dog population, whether owned or unowned, could not be captured for parenteral vaccination. In such cases oral vaccination may prove to be the only means of achieving suffi­cient coverage to eliminate the animal reservoir of the disease.

14106 In South-East Asia WHO provided con­sultants, supplies, equipment and training of health personnel and helped to organize national and regional workshops on rabies control. Sup­port was given in particular to India, Indonesia, Nepal and Sri Lanka. In the Americas coopera­tion focused on strengthening national pro­grammes for the elimination of canine rabies.

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.

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

Fro nee (114)

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

Collaboration among countries in this region was successfully promoted and resulted in agree­ments regarding rabies control in border areas and sharing of rabies vaccines.

14.107 Studies on animal brucellosis vaccines showed that strain Rev.l vaccine should contin­ue to be used for control of the disease in small ruminants. Guidelines were prepared in collabo­ration with FAO and the International Office of Epizootics for the control of brucellosis in many parts of the Eastern Mediterranean where it is showing signs of increase. The medium-term ob­jective of the regional brucellosis programme is to control animal brucellosis, primarily through a comprehensive vaccination campaign, and to significantly reduce the number of human cases within ten years.

14.108 The unabated upsurge of salmonellosis in humans in many European countries, mainly

107

owing to the presence of Salmonella enteritidis .in poultry, gave cause for concern. In many coun­tries S. enteritidis accounted for more than 80% of all foodborne salmonellosis infections report­ed in man. These cases were associated mainly with the consumption of eggs and egg products. A study coordinated by WHO showed that hu­man.-to-human transmission does not play a sig­nificant role inS. enteritidis epidemiology. Expe­rience in some countries demonstrated that com­prehensive control programmes closely associat­ing the human and animal health sectors can lead to the production of animals almost free of Sal­monella, thereby drastically reducing the number of human cases.

14.109 For effective reduction of the entry of S. enteritidis and other strains of Salmonella into the food chain, strict measures are necessary at farm level. Guidelines for the cleaning and disin­fection of S. enteritidis-positive poultry farms

THE WORK OF WHO 1992-1993

are nearing completion. In 1993 an international training course on Salmonella control held in Sweden, where consumers have access to food of animal origin which is practically Salmonella­free, brought together participants from more than 30 countries in Europe, North America, the Eastern Mediterranean, Asia and the Pacific.

14.110 In May 1993 a consultation reviewing the current state of research on animal and human transmissible spongiform encephalopathies and the results of epidemiological studies conducted on bovine spongiform encephalopathy and Creutzfeld-Jakob disease in the United King­dom concluded that there was no cause to extend the list of specified offal currently under ban, and that epidemiological investigations provide no evidence of a change in the incidence of Creutzfeld-Jakob disease that might be attribut­able to bovine spongiform encephalopathy.

14 111 Two meetings were conducted for republics of the former Soviet Union, the first to promote national zoonoses surveillance systems (T eramo, Italy, July 1993), and the second to provide guid­ance on the control of zoonoses, including food borne diseases (Berlin, December 1993 ).

14.112 WHO coordinated 37 working groups and subgroups dealing with major zoonoses and related subjects, and bringing together 229 ex-

perts from 34 Member States located through­out the world. Their output included guidelines for the surveillance and control of anthrax in humans and animals and recommendations for prevention and control of Rift Valley fever, up­dated in the light of the recent outbreak in Egypt.

14.113 Support continued for national programmes in the Eastern Mediterranean to control rabies, brucellosis and Rift Valley fever. In 1992 the Re­gional Committee for the Eastern Mediterranean drew the attention of Member States to the need to strengthen cooperation between national veteri­nary and public health services in surveillance, di­agnosis, prevention and control of zoonotic diseas­es and exchange of relevant information.

AIDS and other sexually transmitted diseases

14.114 During the biennium the AIDS pandemic continued its relentless global spread so that it now affects all continents and almost all coun­tries. By the end of 1993 more than 15 million HIV infections were estimated to have occurred since the beginning of the pandemic, over 14 million of them in adult men and women (see 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 areas as at 1 January 1992, and by 31 December 1993 the total was 851 628 cases. However, taking into consideration under-diagnosis, un­der-reporting and delays in reporting, WHO es­timates that by the end of 1993 there had been a cumulative total of over 3 million AIDS cases (see Figure 14.9).

14.115 For the year 2000 the current WHO projection is for a cumulative total of 30-40 mil­lion HIV infections in men, women and children, more than 90% of them in developing countries. The projected cumulative total of adult AIDS cases is close to 10 million. During the 1990s the impact of AIDS will be greatest in large urban areas of sub-Saharan Africa, especial­ly in eastern and central Africa. In such areas AIDS deaths in young children and in those aged 15-49 years may reduce expected population growth by over 30%, and the adult mortality rate may more than triple. The devastating effects of the pandemic may spread throughout Asia- the home of more than half of the world's popula­tion.

14.116 In May 1992 the Health Assembly en­dorsed an updated, greatly expanded and refined

global AIDS strategy1 establishing the new direc­tion to be taken by all partners in the global effort against AIDS in the years ahead (resolution WHA45.35). The three main objectives of the strategy remain: to prevent infection with HIV, to reduce its personal and social impact, and to mo­bilize and unify national and international efforts against AIDS. The strategy sets out ethically and technically sound approaches of known effective­ness for meeting the pandemic's new challenges: greater attention to care; better treatment for oth­er sexually transmitted diseases; a stronger focus on preventing HIV infection by improving wom­en's health, education and status; a more support­ive social environment for prevention pro­grammes; planning in anticipation of the socioe­conomic effects of the pandemic; and more em­phasis on the public health dangers of stigmatiza­tion and discrimination. The Economic and Social Council at its July 1992 session (resolution 1992/ 33) and the United Nations General Assembly at its forty-seventh session in December 1992 (reso­lution 47 /40) endorsed the updated strategy as the global policy framework.

I rhe global A/OS strategy. Genevo, Wodd Health Organization, 1992 (WHO AIDS Series, No. l ll

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

Reported: 851 628

"Excluding USA

Americas• 12%

109

Estimated: 3 000 000+

Europe Asia 5%

THE WORK OF WHO 1992-1993

14.117 At an extraordinary meeting in November 1992 the Management Committee of the Global Programme on AIDS recommended the establish­ment of a task force on HIV I AIDS coordination and proposed terms of reference and a member­ship of twelve divided equally among developing countries, donor countries, bodies within the United Nations system, and nongovernmental or­ganizations. In May 1993 the Health Assembly requested the Director-General to study the feasi­bility and practicability of establishing a joint and cosponsored United Nations programme on HIV and AIDS, in close consultation with the executive heads ofUNDP, UNICEF, UNFPA, UNESCO and the World Bank (resolution WHA46.37). In July 1993 the Economic and Social Council ex­pressed its full support of that resolution and called upon the executive heads to cooperate fully in the consultative process.

14.118 In order to strengthen multisectoral ac­tion with other bodies in the United Nations system, the Organization collaborated with UNDP in mobilizing external resources for country programmes within the framework of the WHO/UNDP alliance to combat AIDS; with UNFP A through participation in studies on condom requirements and logistics manage­ment for the 1990s; with the World Bank in the preparation of its 1993 report, 1 through the pro­vision of estimates and projections of HIV and AIDS incidence and prevalence, global estimates of the cost of prevention and care, and estimates of the possible impact on HIV transmission of preventive activities worldwide; with UNESCO in issuing a guide for health education in schools, for use by policy-makers and education plan­ners;2 and with UNICEF in the joint publication of the booklet "Living with AIDS in the com­munity", which was adapted for general use from the original produced for Uganda by the AIDS Support Organisation, the national AIDS pro­gramme, UNICEF and WHO.

14.119 WHO continued to strengthen national AIDS programmes by providing technical support through its regional offices. Steps were taken to formulate second-generation medium-term plans for national AIDS programmes that call for a multisectoral approach, bearing in mind the in-

1 World Bank World development report 1993. investmg m health New York, Oxford University Press, 1993.

2 School health educatiOn to prevent AIDS and sexually transmitted d1seas· es Geneva, World Health OrganiZatiOn, 1992 (WHO AIDS Ser1es, No. 10).

110

creasing numbers of interested parties involved in AIDS activities in countries. It is of particular con­cern that while the number of countries having a medium-term plan financially supported by WHO increased approximately five-fold between early 1988 and the end of 1992, the amount of resources allocated to national AIDS programmes during that time (including multibilateral contributions) has remained about the same. With the involve­ment of a growing number of donors from differ­ent sectors in national AIDS programmes, coordi­nation has become an important requirement at country level and globally. One step towards im­proving coordination at country level was the de­velopment in 1993 of a computerized database to facilitate monitoring of AIDS programmes.

14.120 A national AIDS programme manage­ment course was successfully field-tested in Zim­babwe in 1993. It is designed to help countries in planning, implementing and evaluating their programmes and, above all, in setting priorities. A set of priority indicators of progress in preven­tion was selected and a methodology devised for their use in national programmes. Protocols were prepared for application of the indicators and field-tests completed in Cote d'Ivoire, Hondu­ras, India, Sri Lanka and United Republic of Tanzania. The population survey originally con­cerned with measurement of prevention indica­tors was expanded to include measurement of care and support indicators. These evaluation ac­tivities took longer than anticipated, but the real progress made will result in the establishment of a global framework for reporting on national AIDS prevention and care activities.

14.121 Approximately 60 million condoms were procured for national AIDS programmes during the biennium. Attention was focused on supply policy, quality assurance, logistics management training and social marketing. The WHO con­dom specifications were revised with respect to lubrication, elasticity and size in response to feedback from users. A training course on logis­tics was established and a project survey com­pleted with support from major donors and non­governmental organizations.

14122 With regard to safe blood, distance learn­ing materials were produced for training blood transfusion staff with the minimum disruption of daily routine and at minimal cost. Guidelines to assist countries in more cost-effective methods of screening blood for HIV were also drafted (see also paragraphs 13.3-13.5).

DISEASE PREVENTION AND CONTROL

The young man on the right is a salesman with Ethiopia 's condom social marketing programme. He distributes condoms through oil kinds of commercial outlets from pharmacies to street kiosks, bors ond petrol stations. He and his colleagues hove been so successful in overcoming public reluctance to discuss or use condoms that the programme hos diffi culty keeping up with demand.

14.123 Work in the field of sexually transmitted diseases expanded considerably during the biennium, recognizing that their treatment is es­sential for the prevention of HIV infection. WHO recommends integrating control of these diseases and AIDS in primary care and other services at national level. To improve the diagnosis and case management of sexually transmitted diseases, es­pecially in women, a simple approach based on risk assessment was developed. WHO's recom­mendations for the management of sexually trans­mitted diseases, originally issued in 1983, have been revised to include not only treatment t:egi­mens but also effective case management methods.

14.124 In recognition of the need to ascertain the magnitude of sexually transmitted diseases, a sys­tem was devised to enable countries to assess the situation while developing an appropriate control programme. A separate module for planning and strengthening programmes for the prevention and control of sexually transmitted diseases was pre­pared for inclusion in training on national AIDS programme management. In addition, an analyti­cal model was prepared for use in improving the case management of sexually transmitted diseases.

111

14.125 In developing countries women who visit maternal and child health care facilities fot: ante­natal care and family planning services can also be diagnosed and treated for sexually transmitted diseases if the services are properly integrated; protocols were developed to facilitate such inte­gration.

14.126 A meeting in September 1992 brought to­

gether representatives of organizations of the Unit­ed Nations system and bilateral agencies to discuss the requirements for drugs for the treatment of sexually transmitted diseases. Work continued in preparing guidelines to help countries select drugs to meet their local needs and in exploring with the pharmaceutical industry and countries ways to make these drugs more readily available.

14.127 Congenital syphilis can be prevented and controlled by screening pregnant mothers and treating positive cases with penicillin. Despite this and despite the fact that in most countries pregnant women attend health facilities for ante­natal care, little has been done to take the oppor­tunity to carry out screening. Even in countries where screening takes place, this is not always

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

followed by treatment. WHO therefore devel­oped operational guidelines for programme managers and health workers for the prevention and control of congenital syphilis, and supported operational research on this subject in Brazil.

14.128 Responsibility for AIDS prevention and care does not rest entirely with the government authorities in a country. A large number of nongovernmental organizations at community and national level provide essential and appropri­ate support to individuals and communities. From 1990 to 1992 WHO supported 92 commu­nity projects undertaken by nongovernmental organizations in 35 countries with a total alloca­tion of$ 3.1 million. However, in order to use its limited resources more effectively, WHO has gradually reduced this form of support and in­stead now concentrates on helping nongovern­mental organizations to obtain the financial, ma­terial and technical resources they need, and to build working relations amongst themselves and with national AIDS programmes.

14.129 At a meeting in May 1992 to consider ef­fective approaches to AIDS prevention, 15 types of measures aimed at enabling people to change risky sexual behaviour were presented by those involved in their design and implementation; dis­cussion centred on factors which contributed to the success of the interventions, constraints en­countered and lessons learned. A project to pro­vide sex workers and their clients in six districts of Abidjan with treatment for sexually transmit­ted diseases, condoms and education on HIV prevention led to greater use of health services and increased condom sales. Technical support was provided for similar projects in the Domini­can Republic, India and Mexico. The findings of two technical working groups held in November and December 1992 to review recent experience of outreach work with high-risk behaviour groups are being incorporated into a guide for the planning of interventions.

14.130 Research was initiated in four countries on the conditions under which peer education on HIV is effective in schools; and a guide for set­ting up health promotion projects for AIDS pre­vention among young people not in school was finalized following field-testing in seven coun­tries. A major review of data from developed and 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

112

and fewer unwanted pregnancies, and may even delay the onset of sexual activity.

14.131 As increasing numbers of HIV infections develop into AIDS cases, the need for care and support for patients and their families is growing fast. WHO therefore continued to support gov­ernments in planning and strengthening health care services, for instance by preparing guidelines for clinical diagnosis and treatment of HIV infec­tion in adults and young children; updating mod­ules for basic HIV education for nurses and mid­wives that emphasizes prevention and care; and issuing an AIDS home care handbook' which had been assessed in Uganda and Zambia. Fol­lowing a regional workshop on community­based care in Uganda in 1991, similar workshops were held in R wanda in 1992 and Thailand in 1993. A feasibility study on including community­based care in existing urban health centres was started in Nairobi in 1993. A study was under­taken in Uganda to assess the additional costs of providing preventive tuberculosis therapy to HIV -seropositive persons.

14 132 Protocols were drawn up for three priori­ty areas of social and behavioural research: sexual behaviour, particularly among young people; household and community response to HIV and AIDS in developing countries; and negotiation of safer sex by women. Following site assessment visits, proposals were made for conducting re­search in 10 developing countries.

14.133 WHO provided support in implementing national plans for infrastructure strengthening, training and vaccine-related research at four sites in Brazil, Rwanda, Thailand and Uganda. Laborato­ries in those countries collected specimens from 222 recent seroconverters in study populations; specimens from 63 of these patients were then ex­amined by the WHO network for HIV isolation and characterization (comprising 12laboratories in North America and Europe). Initial results suggest that the distribution of HIV -1 anti genic subtypes is constantly changing, with different subtypes rapid­ly replacing others in a given population- a situa­tion that poses a considerable challenge for the development of an HIV vaccine.

14134 In November 1993 the Advisory Council on HIV I AIDS recommended that priority areas

1 Document WHO/GPA/IDS/HCS/93 2.

DISEASE PREVENTION AND CONTROL

for research relating to women and AIDS should include the development of female controlled methods for preventing HIV transmission, in­cluding virucides, microbicides and mechanical barrier methods; effective preventive approaches for women sex workers; and rapid cost-effective diagnostic tests for sexually transmitted diseases. Protocols for research on a safe and effective vaginal microbicide were drawn up following strong endorsement of this approach at a major meeting in November 1993.

14 135 A double-blind placebo controlled trial of the use of low-dose oral interferon alpha in symp­tomatic HIV -infected patients in Uganda revealed that it conferred no benefit as regards survival, progress of the disease or subjective symptoms. Other studies were carried out with WHO sup­port on short-course chemotherapy for tubercu­losis in HIV -infected people in Haiti and on the efficacy and optimal duration of tuberculosis chemoprophylaxis in tuberculin-positive, HIV­infected persons in Thailand, United Republic of Tanzania and Zambia. Reduction of the use of the Western blot technique for HIV testing permitted a significant decrease in the cost of testing. The initial results of a study on the risk of nosocomial transmission of HIV in children admitted to pae­diatric wards in four African cities were reassuring and suggested that the various skin piercing pro­cedures that they experienced accounted for little if any HIV transmission.

14.136 At a meeting in June 1993 attended by representatives of regulatory agencies and phar­maceutical companies, it was agreed that efforts to develop and approve drugs and vaccines for HIV I AIDS should be accelerated in developed countries and extended to developing countries. A joint WHO/International Federation of Phar­maceutical Manufacturers Associations state­ment on HIV I AIDS was drawn up, representing a major commitment to making drugs and vaccines of assured quality and efficacy available for both prevention and treatment.

14 137 In 1993 the Organization confirmed that it would not sponsor, cosponsor or financially support international conferences or meetings on AIDS in countries with entry requirements that discriminate solely on the basis of a person's HIV status, nor would representatives of WHO attend such conferences unless attendance is deemed essential for promoting WHO's pro­gramme. In April 1993 the Inter-Agency Advi­sory Group on AIDS requested that WHO's

113

policy should be submitted to the Administra­tive Committee on Coordination, which ap­proved it as the formal policy for the whole of the United Nations system at its October 1993 meeting. In 1993 WHO issued guidelines on HIV infection and AIDS in prisons, 1 providing standards - from a public health perspective -which prison authorities should strive to achieve in their efforts to prevent HIV transmission and to provide care to those affected by HIV I AIDS.

14 138 In April-May 1992 a WHO/UNICEF consultation on HIV transmission and breast­feeding issued a consensus statement recom­mending that breast-feeding should continue in all populations, irrespective of HIV infection rates. In November 1992 a further consultation on HIV testing and counselling emphasized that mandatory testing has no place in AIDS control programmes, and that no benefits to the individ­ual or for public health derive from such testing that cannot be achieved by less intrusive means such as voluntary testing and counselling.

14.139 The Organization promoted the world­wide observance of the fifth and sixth World AIDS Days on 1 December 1992 and 1993 respectively by disseminating information packages and issuing press releases on the chosen themes. World AIDS Day is now an annual event in most countries and provides an opportunity to stimulate awareness of AIDS and of the efforts being made to fight the pandemic. The theme "AIDS: a community commitment" was chosen for 1992 in order to highlight the importance of local communities combining their strengths in the global fight. In 1993 the theme was "AIDS: time to act", which underlined the need for ur­gent action and served as a rallying call for the world to join in ensuring a multisectoral re­sponse to the HIV I AIDS pandemic.

Other communicable diseases

Viral and bacterial diseases

14.140 Influenza. With a view to strengthening surveillance and increasing the chances of early detection of new variants of the influenza virus, WHO started a collaborative study on the origin of

1 Document WHO/GPA/DIR/93.3

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

pandemic strains in southern China. Studies com­paring the traditional inactivated influenza vaccine with the less commonly used live virus vaccine showed the latter to be slightly more effective in children. Recommendations regarding the influen­za virus strains to be included in vaccines in 1992 and 1993 were made on the basis of information and virus isolates obtained in WHO's network of national and international laboratories.

14.141 Viral hepatitis. Hepatitis B vaccine is now being more widely included in national immunization programmes: nearly 50 countries have a national policy of universal administra­tion of the vaccine to infants. :Crogress is also being made in immunizing health care workers. During the biennium WHO continued to sup­port laboratory research on the production of plasma-derived hepatitis B vaccine in the Dem­ocratic People's Republic of Korea, Mongolia and Myanmar, and nationals of those countries and of Indonesia were awarded WHO fellow­ships to train in the production of the vaccine. Safe and highly effective vaccines to prevent hepatitis A are now licensed in many countries and WHO prepared guidelines for their use in immunizing travellers and other groups at risk.

14.142 Arthropod-borne viruses and viral haem­orrhagic fevers are major causes of morbidity and mortality. Dengue viruses appear in new areas as the mosquito vector Aedes aegypti invades addi­tional urban habitats. This spread is most notable in the Americas, where nearly all countries in Central and South America and the Caribbean are now at risk of epidemic dengue. An outbreak of dengue fever in Comoros showed that dengue is also a threat in Africa. WHO continues active­ly supporting vaccine development, surveillance of infection, control of outbreaks, and vector control (see paragraph 14.42).

14.143 Viral haemorrhagic fevers are an impor­tant group of emerging infectious diseases. WHO was active in the investigations that re­vealed the etiological role of the hantaviruses in an outbreak of fatal adult respiratory distress syndrome in south-western United States of America. In recent years other emerging viral haemorrhagic fevers have been recognized as ma­jor causes of fatal human infection (for instance, in Brazil and Venezuela). Rift Valley fever virus remains an important pathogen affecting man and domestic animals in much of Africa; during 1993 cases were diagnosed in Upper Egypt, and WHO responded to requests for technical sup-

114

port. The Organization was also involved in combating an outbreak of Lassa fever in Nigeria.

14.144 Yellow fever remains a major threat in Africa and South America. In 1992 it occurred for the first time in Kenya, and WHO assembled field teams to assist in investigating the outbreak, providing diagnostic reagents and equipment, and starting an emergency vaccination campaign.

14145 Japanese encephalitis is increasingly rec­ognized as an important disease that can be pre­vented by immunization. WHO has sponsored efforts in several Asian countries to improve methods for production of the vaccine and make it more readily available.

14.146 Plague. Sporadic cases and periodic out­breaks of bubonic plague were reported in 12 coun­tries during the biennium; natural foci of the disease exist in Africa, the Americas and Asia.

14.147 Meningitis. Epidemic cerebrospinal men­ingitis remained a problem, particularly in Africa (see Figure 14.10). Surveillance of Neisseria meningitidis strains continued, including moni­toring of susceptibility to antibiotics. WHO pre­pared practi~al guidelines on the control of epi­demic meningococcal disease.

14 148 Legionellosis. A surveillance system in 22 European countries for Legionella infections in travellers was devised in cooperation with the WHO collaborating centre in Stockholm, and rec­ommendations for further work on the control of these infections were made during two WHO consultations (Haniotis-Halkidiki, Greece, May 1992; Vienna, May 1993 ).

14.149 Streptococcal infections and their suppur­ative and non-suppurative sequelae remain an important health concern. A WHO collaborative study on the production of group A strepto­coccal M and OF typing sera resulted in the es­tablishment of a standard set of typing sera for use in regional and national programmes for the prevention and control of rheumatic fever and rheumatic heart disease.

Antimicrobial resistance and hospital infections

14.150 WHONET computer software was used in monitoring resistance to antimicrobials in a

DISEASE PREVENTION AND CONTROL

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

pilot programme involving hospital laboratories in the Americas, South-East Asia and the West­ern Pacific. In Europe WHOCARE software for computer-assisted registration of the effects of surgery was developed for use by hospital-based health workers concerned with the control of nosocomial infections.

Rapid diagnosis of infectious diseases

14.151 Diagnostic reagents prepared for the identification of respiratory and measles virus­es, enteroviruses and herpesviruses were made available for collaborative studies. One such study involving 16 laboratories was on the use of monoclonal antibodies for diagnosis of respiratory viruses.1 The reagents were also employed by 70 laboratories carrying out envi­ronmental surveillance of enteroviruses in 21 countries. A revised laboratory biosafety ma-

1 Bulletin of the World Health Organization, 1992, 70 (6): 699·703.

115

e serogroupA

• serogroupB 0 serogroup(

.-

nuaP appeared during the biennium, and train­ing programmes on laboratory safety were con­ducted through WHO's network of collabo­rating centres.

Measures following smallpox eradication

14.152 The complete nucleotide sequence of the genomes of two variola virus strains and parts of three additional strains were determined, thus fulfilling the requirements set in 1990 for the final destruction of the remaining stock of variola virus; but during 1993 it became evident that the recommendation to eliminate these vi­ruses was controversial. WHO offered a forum for the scientific and public health community to express their views in a round-table discussion at the IXth International Congress on Virology (Glasgow, United Kingdom, August 1993). Oc­casional rumours of smallpox cases continued to

1 Laboratory b10safety manual, 2nd ed Geneva, World Health Orgon1ZOI1on, 1993

THE WORK OF WHO 1992-1993

circulate, particularly in areas of political unrest. A few were true cases of poxvirus infections, including monkeypox in Africa, but none was due to variola virus; the WHO collaborating cen­tres on smallpox and other poxvirus infections provided the laboratory diagnosis.

Intestinal parasitic infections

14.153 Major collaborative projects for the con­trol of intestinal parasitic infections were launched in Addis Ababa, Rodrigues (Mauri­tius), and Dhofar Governorate (Oman), and two national control programmes were in progress in Seychelles and in Zanzibar (United Republic of Tanzania). Collaboration to combat these infec­tions began in China, Maldives, Mexico and Myanmar. A set of bench aids for the diagnosis of intestinal protozoa was under development following successful trials of such aids for the identification of intestinal helminths. A software package for field evaluation of the impact of helminth control programmes was devised and field-tested.

Research and development in the field of vaccines

Children's Vaccine Initiative

14 154 This initiative provides a strategic frame­work for work on vaccines undertaken within WHO and elsewhere, including institutions in the public and private sectors. It is sponsored jointly by UNICEF, UNDP, the World Bank and the Rockefeller Foundation, and its secretar­iat is provided by WHO. It has two main work­ing components: product development groups, which promote, facilitate and manage projects leading to the development of vaccines and relat­ed preparations, each group focusing on a partic­ular vaccine; and task forces, which examine stra­tegic, logistic and policy questions, such as prior­ity-setting, demand and supply, and collabora­tion with industry, relevant to the development and introduction of vaccines. In addition, there is a management advisory group which reviews budgetary matters and progress of activities, and a consultative group which provides an interna­tional forum for information exchange and con­sultation on priority activities.

116

New vaccines against bacterial diseases

14.155 There was substantial progress in the de­velopment of new, more effective vaccines 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 the appearance of the 0139 strain of Vibrio cholerae which is beginning to cause epidemics in South-East Asia. New Shigella vaccines are now being tested on human beings.

14.156 Vaccines suitable for inclusion in infant im­munization schedules have been developed against group A and C meningococcal meningitis and are being tested in Gambia and other endemic areas, while vaccines against group B meningococcal meningitis produced in Cuba and Norway are being compared in clinical trials.

14 157 The search for vaccines against pneumo­coccal species is complicated by the variability of pathogenic polysaccharide serotypes and by the 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.

14158 The effectiveness of BCG against tubercu­losis varies considerably in different countries but, owing to important advances, this vaccine can now be engineered to improve the expression of potentially protective antigens. Alternatively, site-directed mutagenesis of Mycobacterium tu­berculosis can make the bacterium harmless by deleting selected virulence factors.

New vaccines against viral diseases

14 159 Dengue virus infection is spreading throughout the tropical zone and vaccines are ur­gently needed; a candidate tetravalent live attenu­ated vaccine was developed in Thailand with the support of WHO and may be produced commer­cially in the near future. Substantial progress was also made in characterizing the genomes of the dengue and Japanese encephalitis virus, facilitating the development of a suitable vaccine.

14 160 Many cases of measles occur before the usual immunization age and there is a need for a vaccine that can be given three to four months

DISEASE PREVENTION AND CONTROL

after birth; several candidate preparations are now undergoing preclinical tests. Two other vi­ral pathogens, respiratory syncytial virus and parainfluenza virus type 3, contribute to many of the serious respiratory infections of infancy; excellent progress has been made towards de­fining antigenic formulations which may offer protection against the first, and initial live vac­cine studies with bovine and attenuated human strains of the second have produced vaccines that are both safe and immunogenic in seronegative infants.

14 161 An inactivated hepatitis A vaccine is now available, but the present cost of production lim­its its use in the developing world. Combination vaccines in which hepatitis B vaccines will be added to new immunization formulations for in­fants are now in prospect. Hepatitis C is emerg­ing as a major cause of liver cirrhosis and cancer, especially in industrial countries, and studies are in progress to define important antigens for vac­cine development; a WHO collaborating centre announced success in growing the virus in tissue culture, a critical step in vaccine research. Hepatitis E poses a risk particularly in the devel­oping countries; however, substantial progress was made in the application of recombinant DNA technology to the production of protec­tive immunogens.

Improvement of existing voccines

14 162 It would be preferable to find animal models other than non-human primates for as­sessing the neurovirulence of new vaccine lots. An advance in this area was the production, un­der WHO auspices, of transgenic mice express­ing the human poliomyelitis virus receptor; the Organization issued guidelines for the handling of such mice. Other approaches based on genetic engineering showed encouraging progress and trials of a new genetically stable candidate re­placement vaccine for the existing type 3 Sabin poliomyelitis strain began in man, inspiring hope that the dangers of reversion to virulence in at­tenuated strains may soon be minimized. In re­gard to tetanus, work proceeded on the elabora­tion 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 hoped that a single-dose tetanus vaccine may be available by 1996.

117

Training

14.163 In 1992-1993 64 scientists from develop­ing countries were trained at the WHO Immu­nology Research and Training Centre located in Geneva and Lausanne (Switzerland) in areas of immunology and biotechnology related to the evaluation of vaccine immunogenicity and effica­cy. In 1992 a further 39 scientists from South­East Asia participated in a refresher course in Semarang (Indonesia); and a similar course was organized in Teheran with the support of the Islamic Republic of Iran.

Blindness and deafness

14.164 Further progress was made towards the target of the establishment of national blindness prevention programmes in all countries where sight loss is a public health problem. In 1993 WHO drew up an inventory of national plans, committees and programmes in 93 countries out of an estimated 116 in need. 1 Thanks to the help of a contribution from the International Association of Lions Clubs, WHO was able to coordinate its work in this area more effectively. The Organization has also cooperated closely with a consortium of six nongovernmental or­ganizations which is providing funds for distri­bution of ivermectin against onchocerciasis, and is promoting common strategies and methods for control operations in 12 African and four Latin American countries. Through this initia­tive about 2.5 million people were treated in 1993 (see also paragraphs 14.30 and 14.62). Recommendations on management of severe visual disability in children2 were formulated at a meeting held jointly with the International Council for Education of the Visually Handi­capped (Bangkok, July 1992).

14.165 Continued support from the Edna McConnell Clark Foundation enabled the Or­ganization to produce two manuals on the man­agement of trachoma within primary health care systems/ and training courses on simplified as-

1 Document WHO/PBL/93.30. 2 Document WHO/PBL/93 27 3 Documents WHO/PBL/93 29 and WHO/PBL/93 33.

THE WORK OF WHO 1992-1993

sessment of this condition were conducted in Mali in 1992 and Kenya in 1993. Applied re­search on cost-effective cataract surgery was carried out in India and Mali. In September 1993 a WHO consultation considered the ef­fects of solar ultraviolet radiation on the eye and called for a major international study on this subject.

14 166 Training of personnel in blindness pre­vention remained a priority in Africa. Strategies for national programme development were 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 made in setting up national programmes, and AGFUND made contributions to nine countries for this purpose. WHO responded to an appeal for emergency relief to deal with an epidemic of neuropathy in Cuba.

14.168 In South-East Asia aspects of programme management were examined in 1993 during a course in Thailand supported by the Interna­tional Association of Lions Clubs. WHO gave technical advice on the preparation of a proposal to the World Bank for strengthening the Indian national programme.

14 169 Several countries in eastern Europe re­vised their programmes for blindness prevention. A national seminar on this subject was organized in Romania in 1993 with support from Orbis International (USA).

14 170 In the Eastern Mediterranean, Sudan and Tunisia revised their national programmes; Tuni­sia also proceeded with a nationwide assessment of sight loss and its causes, as did Morocco. An intercountry meeting on national blindness pre­vention programmes (Cairo, April 1993) called for a fuller evaluation of the programmes in most countries

14.171 WHO support was provided to China in 1992 for a course on management of cataract and in 1993 for a national seminar on prevention of sensory impairments in the elderly. A Western Pacific regional workshop on evaluation of na­tional blindness prevention programmes (Syd­ney, Australia, October 1992) was held with sup­port from the Consultative Group of Nongov­ernmental Organizations.

118

• One problem in setting up national programmes to prevent hearing impair­ment is the lack of epidemiological data on this condition. WHO has therefore de­signed a standardized examination form which makes it possible for a field survey team with portable audiometers and low­cost instruments to carry out a simple hearing assessment on as many as two hundred people per day, using trained auxiliary staff for part of the procedure.

14.172 With regard to the prevention of deafness and hearing impairment, a working group in March 1992 devised a uniform ear examination record which was subsequently field-tested in Thailand in 1992 and India in 1993. The Founda­tion for Advanced Studies on International De­velopment Qapan), Kansai Medical University Qapan) and the Tokyo-based Asian Interactive Association on the Hearing Impaired provided financial support for WHO's work in this field from March 1992 onwards. A task force on the prevention of deafness (Alexandria, October 1992) reviewed the situation in the Eastern Med­iterranean and called for urgent epidemiological assessment of hearing impairment and its causes in different populations.

Cancer

• WHO estimates that 9 million cases of cancer occur in the world every year. By the year 2015 the annual figure is expected to reach 15 million cases, two-thirds of them in developing countries, which have only 5% of the resources available for can­cer control in the world.

14173 WHO's act1v1t1es in cancer control are based on the fact that enough is now known about cancer for effective action to be taken that will significantly reduce morbidity and mortality worldwide and that, given the right priorities and approaches, even the limited resources available can be used in such a way as to have a real impact on the problem.

DISEASE PREVENTION AND CONTROL

Primary prevention

14 174 Policies on healthy lifestyles and optimal diet were worked out together with the WHO cardiovascular diseases and nutrition pro­grammes. Various WHO programmes also con­tribute to the primary prevention of cancer. Ex­amples are the programmes on tobacco or health and immunization against hepatitis B. Other con­tributions are made by WHO collaborating cen­tres. For instance, during the biennium a WHO collaborating centre in Regensburg (Germany) be­gan work on tumours associated with the Epstein­Barr virus, that are found in countries with a high incidence of nasopharyngeal cancer. The melanoma programme, carried out by the Italian National Institute for Cancer Treatment and Re­search on behalf of WHO, devised strategies to prevent this disorder by informing the public about the dangers of excessive exposure to sunshine, par­ticularly in childhood; individuals at high risk can now be identified and offered preventive advice.

Early detection

14 175 Managerial guidelines for the control of cervical cancer were issued' and innovative meth­ods of early detection introduced and coordinat­ed. Cost-benefit evaluation of early detection pro­grammes for cancers of the breast, cervix, mouth and skin was promoted in countries in Africa, the Americas, South-East Asia and the Eastern Medi­terranean. A trial on self-examination of the breast is under way in the Russian Federation.

14.176 A new project was launched to promote simple methods for the early detection of cancer of the mouth and cervix in developing countries. WHO collaborated with the Indian Ministry of Health and Family Welfare in studies to detect cases at an earlier stage by visual inspection. Sim­ilar studies were begun in southern Africa and the Western Pacific in collaboration with the World Bank. Once the results of these investiga­tions are available, it will be possible to decide whether the approach can be recommended and applied widely in developing countries.

1 Miller AB. Cervical cancer screemng programmes Geneva, Warld Health OrganiZatiOn, 1992.

119

Treatment

14.177 Mortality from cervical, breast, mouth and skin cancers, if they are detected early, can be significantly reduced by standard therapies. WHO encourages the provision of adequate serv­ices, especially radiotherapy. Six radiotherapists/ oncologists were trained in a radiotherapy and oncology project carried out in Zimbabwe in 1989-1993 with Swiss support; and 14 others have been trained in Sri Lanka. WHO initiated the preparation of a manual on basic radiotherapy, together with IAEA.

14178 During the biennium WHO prepared, from among over 100 drugs, a model list of 22 essential drugs for cancer chemotherapy, se­lected for their cost-effectiveness and efficacy and designed to satisfy the needs of most patients in national programmes.

Palliative care

14 179 Palliative treatment and care, including symptom control and pain relief, will be important for years to come for the large numbers of patients for whom curative therapy is not possible. More than 40 countries have established government pol­icies on cancer pain and terminal care; and pain relief or palliative care is included in several nation­al cancer control programmes. WHO recommends the use of a number of non-opioid and opioid anal­gesics and adjuvants for relieving cancer pain. Oral morphine consumption in the world has increased five-fold in recent years, bringing a great improve­ment in quality of life for many cancer patients. A WHO working group (Banff, Canada, September 1993) approved a manual on palliative care for those providing home care. Joint meetings organ­ized by WHO and the International Association for the Study of Pain (Arezzo, Italy, June 1993; Paris, August 1993) prepared guidelines on cancer pain relief and supportive care for children. Eight WHO collaborating centres have been carrying out research and training and applying methods for cancer pain relief and palliative care.

National cancer control programmes

14 180 The cornerstone of WHO's approach to cancer control is the development of national

THE WORK OF WHO 1992-1993

programmes. WHO issued a handbook1 summa­rizing ways to apply scientific knowledge in can­cer control, based on the experience of 12 coun­tries. Requests have subsequently been received from 40 other countries to help them to set up 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. Ar­rangements were discussed with 14 countries in the Eastern Mediterranean at an intercountry workshop (Cairo, November 1993) and six com­mitted themselves to set up national programmes. The target is that at least half of the Member States will have formulated strategies and programmes for cancer control by the year 2000.

14 181 Six district cancer control demonstration projects are being established in India, making use of existing health infrastructure to cover a large population for the control of oral, cervical and breast cancers through primary prevention, early detection and referral for curative treat­ment as well as palliative care; it is expected that they will become models for the whole country and possibly for other developing countries.

International Agency for Research on Cancer2

Descriptive epidemiology

14 182 In 1992 IARC published data on the inci­dence of cancer in 46 countries ( 170 populations) for the period 1983-1987.3 An estimated 7.62 million new cases of cancer occurred in 1985 (3.85 million males and 3.77 million fe­males), the lung being the commonest site (nearly 900 000 cases). Data on time trends~ show a de­crease in stomach cancer, an increase in malig­nant melanoma of the skin, and mixed patterns,

1 Document WHO/CAN/92.1. 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.

3 Park1n OM et al. Cancer modence m five contments, Vol VI. Lyon, Interna­tional Agency for Research on Cancer, 1992 (IARC Scientific Publications, No 120)

4 Coleman M et al Trends m cancer modence and mortality. Lyon, Interna­tional Agency for Research on Cancer, 1993 (IARC SCJent1f1c Publications, No 121)

120

linked to known trends in smoking habits, for lung cancer. IARC gave extensive support for setting up and running cancer registries in developing countries in Africa, Asia and Latin America.

Etiological studies

14 183 Cancer related to occupational exposure was studied with respect to phenoxy acid herbi­cides, styrene, man-made mineral fibres, the pulp and paper industry, biological laboratory work, lead, the wood and leather industries, asphalt vapours, mercury, textile manufacture, the nu­clear industry, steel works and the rubber indus­try. Special attention was paid to the high levels of occupational exposure often prevailing in de­veloping countries.

14.184 In a European prospective investigation into cancer and nutrition, pilot studies were completed on food composition and methods for dietary assessment, and recruitment of an esti­mated 420 000 participants in seven countries was well advanced. Each participant's diet is be­ing recorded, and blood samples are taken for biological measurements.

14.185 Lymphomas in patients suffering from AIDS were studied to characterize interactions between HIV and Epstein-Barr virus. Various cancers in relation to HIV infection were the sub­ject of an epidemiological study in central Africa.

14 186 It was found that induction of the enzyme nitric oxide synthase in infected tissues may be involved in the endogenous formation of carci­nogenic nitrosamines, implicated in cancer of vanous organs.

14 187 A range of epidemiological studies in Gambia and Thailand, including the develop­ment of methods in !ARC's laboratories to measure exposures, yielded detailed information on the interaction between hepatitis virus infec­tion and aflatoxin exposure in the etiology of liver cancer.

14.188 Epidemiological results from investiga­tions in Colombia and Spain, using sensitive methods for detecting human papillomavirus, showed a close association between this agent and cervical cancer. The combined in vivo and in vitro evidence for the carcinogenicity of at least

DISEASE PREVENTION AND CONTROL

some types of the virus has been assessed as being consistent enough for the relationship to be con­sidered causal.1

Genetics and cancer

14.189 It has become clear that genetic differen­ces in enzymes that convert many substances into active carcinogens influence individual sus­ceptibility to certain forms of cancer. Thus smokers may react differently to the carcinogens in tobacco smoke, and aflatoxins ingested in foods may be converted more or less efficiently into DNA-binding agents. Differences in the en­zymes that repair DNA damage can also affect individual susceptibility to carcinogens.

14.190 Attemps to map the breast cancer gene located on chromosome 17q continued. Coun­selling is being provided to women in families identified as being at high risk. Studies have sug­gested that other genes predisposing to breast cancer also seem to exist.

Mechanisms of carcinogenesis

14.191 Mutations in oncogenes are being meas­ured at frequencies as low as one in 10-s DNA bases, as a method for detecting the very earliest molecular lesions in the pathway to cancer. Simi­larly, specific forms of damage caused by ultra­violet radiation in the p53 tumour-suppressor gene in skin cells are being detected and quanti­fied. Mutations detected in these genes in oral, oesophageal and stomach tumours throw light on the ways in which loss of control of cell pro­liferation can lead to cancer. Methods are also being refined for the detection of very low levels of carcinogen-DNA adducts as early markers of carcmogemc processes.

14 192 Studies have shown that genes for connexon proteins that form communicational junctions between cells may act as tumour-sup­pressor genes by improving the control of cellu­lar growth and proliferation that results from such communication.

1 Muiioz N. et al. The epidemiology of cefV!ca! cancer and human papillomavtrus lyon, International Agency for Research on Cancer, 1992 (IARC Sctenttftc Publications, No 119)

121

Cancer prevention research

14.193 In the hepatitis intervention study in Gambia, a good level of protection among vacci­nated children continued to be observed. In par­allel, appropriate measures to reduce exposure to aflatoxin were investigated. Cancer registration was set up in order to document the incidence of cancer, particularly of the liver, over the forth­coming decades.

14.194 In a chemoprevention trial in Venezuela, over 1000 subjects were recruited and received antioxidant vitamins. Precancerous lesions of the stomach are being monitored by immunochemical and histological methods. A pilot study showed that treatment to eradicate infection with H elicobacter pylori was much less efficacious than had been seen in developed countries and this treatment was therefore not included in the trial.

Information and training

14.195 Four new volumes were published in the IARC Monographs series. They dealt with strong acid mists, solar and ultraviolet radiation, food constituents and contaminants, and a range of colouring matters and their use in hairdress­ing. Factors evaluated as carcinogenic to humans were occupational exposure to strong inorganic acid mists containing sulfuric acid, solar radia­tion, Chinese-style salted fish, naturally occur­ring mixtures of aflatoxins, and the manufacture of the dyestuff magenta. Among other factors, 1,3-butadiene and occupational exposures in hairdressers and barbers were categorized as probably carcinogenic. In addition, work started on the publication of a series of fascicles on the classification of rodent tumours.

14.196 During the biennium 23 fellowships were awarded to young scientists from 12 countries, and 10 training courses on various aspects of cancer research were attended by a total of 426 participants.

Cardiovascular diseases

14.197 Activities under the WHO programme for the prevention of rheumatic fever and rheu­matic heart disease continued in close collabora-

THE WORK OF WHO 1992-1993

tion with the International Society and Federa­tion of Cardiology. Phase I (assessment) was completed in 16 countries, with support from AGFUND, and phase II (community control) was begun. A further nine countries joined the programme during the biennium, bringing the total to 25.

14198 The WHO project for multinational moni­toring of trends and determinants of cardiovascular diseases (MONICA), the largest collaborative epi­demiological study of these diseases ever carried out, continued in 25 countries and entered the final stage of data collection. The first analyses of trends in risk factors, based on two population surveys, were prepared. A first cross-sectional comparison of morbidity data in stroke cases was prepared and a similar analysis for coronary events was submit­ted for publication in the journal Circulation. The third and final population survey was prepared and a special training workshop organized (Gargano, Italy, March 1993). The steering committee for MONICA met twice during the biennium and the principal investigators reviewed progress and took decisions on policy, publications and quality con­trol at a meeting supported by the regional author­ities of Catalonia and the Hospital Sant Pau (Barce­lona, Spain, August 1992). At the same time coordi­nation meetings were held on MONICA optional studies relating to vitamins and polyunsaturated acids, dietary monitoring, drugs, physical activity and psychosocial factors. The main results from MONICA to date concern: cross-sectional com­parisons of risk factor levels; relations between var­ious risk factors; five-year trends in risk factors; acute coronary care; medical services; cross-sec­tional comparisons of incidence rates for stroke; and management of stroke around the world. These results were presented at a number of conferences and congresses during the biennium.

14199 A meeting between WHO and the United States Institute of Medicine (Washington, October 1992) worked out details of a joint study to review the current status of the epidemiology, prevention and control of cardiovascular diseases in develop­ing countries and agreed upon a strategy for inter­vention based on needs and priorities. A plan of action was drawn up covering health statistics and epidemiology, prevention and case management, and an implementation committee was established to carry the work forward.

14.200 As part of an international conference on preventive cardiology (Oslo, June-July 1993) workshops were held on: prevention of cardia-

122

vascular diseases in countries of the Eastern Mediterranean; cardiovascular diseases in devel­oping countries; and the establishment of a glo­bal database.

14.201 The data collection phase of the project for cardiovascular diseases and alimentary com­parison (CARDIAC), a multicentre study launched in 1985 to assess the relation between food intake and cardiovascular diseases, was completed in 1992 and the WHO collaborating centre in Izumo Qapan) began an analysis of the results.

14.202 Collection of specimens and data for the WHO/International Society and Federation of Cardiology study on pathobiological determi­nants of atherosclerosis in youth was also com­pleted. The data are now being analysed and spe­cial investigations are in progress at reference centres in Budapest, Geneva, Havana, Heidelberg (Germany), Malmo (Sweden), Sienna (Italy) and St Louis (USA).

14 203 An education programme for patients with hypertension was started in 1990 by WHO and the World Hypertension League in Canada, China, Cuba, Ghana, Hungary, India and the Russian Federation. The aim is to assess whether educating patients influences compliance with treatment regi­mens and consequently management of the disease. Each centre prepared a local protocol and complet­ed the data collection phase at the end of 1993.

14 204 In November 1992 a WHO scientific group assessed the influence of specific nutri­tional, metabolic and haemostatic factors, alco­hol, physical activity, sex hormones and psychosocial and economic factors on cardiovas­cular disease risk, and recommended areas for future research by WHO and other bodies.

14205 In October 1993 a WHO study group re­viewed global demographic changes in relation to the epidemiology of cardiovascular diseases in the elderly, assessed the effectiveness and cost of preventive strategies, and indicated policy op­tions and research priorities for prevention.

14.206 World Health Day 1992 was devoted to cardiovascular diseases under the slogan "Heartbeat - the rhythm of health", and was marked by activities all over the world, in devel­oped and developing countries alike. WHO's concerns include physical activity and sport, as demonstrated by a new technical cooperation

DISEASE PREVENTION AND CONTROL

agreement with the International Olympic Com­mittee concluded in June 1993.

14 207 WHO's publications on cardiovascular diseases during the biennium included a special edition of World health statistics quarterly! and an expert committee report on rehabilitation af­ter cardiovascular diseases.2

Other noncommunicable diseases

14.208 Diabetes mellitus. Global estimates of the prevalence of diabetes in adults were published.3

WHO cosponsored World Diabetes Days (14 November 1992 and 1993) when many countries, both developed and developing, tried to increase local awareness of the growing prob­lem of diabetes. In November 1992 a WHO study group meeting on the prevention of diabe­tes reviewed existing knowledge and recom­mended preventive strategies that could be rele­vant to the prevention of other noncommu­nicable diseases sharing common risk factors with diabetes. WHO's guidelines on the devel­opment of national diabetes programmes4 were translated into French, Spanish and Russian.

14 209 The International Diabetes Federation and WHO convened a joint meeting (Budapest, March 1992) concerned with the implementation of the 1989 St Vincent declaration on diabetes care and research in Europe, which called on Member States to establish national diabetes task forces. A meeting of the Eastern Mediterranean regional advisory panel for diabetes (Karachi, December 1992) prepared guidelines for diabetes care and programme implementation. A subse­quent meeting (Alexandria, November 1993) prepared materials for educating diabetes pa­tients.

14 210 Protocols were received from centres in 52 countries for participation in the WHO multinational project on childhood diabetes, and 30 participating centres were recruited for a diabe­tes atherosclerosis intervention study. An interna-

1 World health statrstics quarterly, 1993, 46 (2). 1 WHO Technical Report Series, No. 831, 1993 3 World health statrstics quarterly, 1992, 45 (4). 4 Document WHO/DBO/DM/91 1

123

tional workshop on clinical epidemiology training in diabetes (Omiya, Japan, July-August 1993), cosponsored by WHO, drew up guidelines for future international training courses in this field.

14.211 Chronic rheumatic diseases. The protocol was elaborated for the WHO multinational col­laborative study on the predictors of osteo­arthritis, with the aim of designing a scientifically based approach to primary prevention of osteoarthritis in the community. WHO cospon­sored an international conference (Maastricht, Netherlands, April-May 1992) which defined methods for measuring the results of treatment in clinical trials concerned with rheumatoid arthritis.

14.212 A working group on Kashin-Bek disease was organized in conjunction with the WHO col­laborating centre for the epidemiology of rheu­matic conditions (Stockholm, May 1992), in which experts in clinical rheumatology, biochem­istry and epidemiology from China, Germany, New Zealand, Sweden, United Kingdom and United States of America participated.

14.213 A WHO study group on assessment of the risk of osteoporotic fracture and its role in screening (Rome, June 1992) reviewed the extent of the problem of osteoporosis, evaluated the risk and benefit of different screening techniques and their impact on various target populations, and proposed strategies for preventing the condi­tion. In June-July the fifth meeting of the joint WHO/International League of Associations for Rheumatology task force examined the classifi­cation of antirheumatic drugs and refined the existing guidelines for their use.

14 214 Chronic nonspecific pulmonary diseases. These diseases, particularly asthma, are increas­ingly posing a problem in both developed and developing countries; in 1992 a number of con­sultations were held, leading to a meeting on asthma (Chicago, USA, March 1993) convened jointly by WHO and the United States National Heart, Lung and Blood Institute. The convening of a WH 0 scientific group on asthma in N ovem­her 1993 was the first step in the formulation of a global strategy for asthma management.

14 215 Integrated programmes. WHO continued to promote its integrated programme for com­munity health in noncommunicable diseases (INTERHEALTH) with 16 demonstration projects in developed and developing countries in all regions. The European programme of

THE WORK OF WHO 1992-1993

countrywide integrated noncommunicable dis­ease intervention (CINDI) has 14 demonstration projects. During the biennium meetings took place of the INTERHEALTH steering commit­tee Goensuu, Finland, April 1992) and pro­gramme directors (Beijing, April 1993). A teleconference on the prevention of chronic life­style diseases was organized during the latter meeting. First results achieved at the national level are very encouraging. One example is Mau­ritius, a country with a high prevalence of noncommunicable diseases, especially diabetes and arterial hypertension, where a comprehen­sive preventive strategy has reduced the preva­lence of hypertension, lowered the cholesterol levels of the population, and reduced tobacco and alcohol consumption as well as promoting physical activity. In other INTERHEAL TH demonstration projects, comprehensive commu­nity-based intervention programmes are being undertaken following baseline surveys.

14.216 Hereditary diseases. In November 1993 a WHO scientific group recommended further use of genetic technology in the prevention and con­trol of hereditary diseases in view of results achieved by national genetics services. WHO policy and recommendations concerning select­ed hereditary diseases were reviewed at WHO meetings on haemophilia (Geneva, February 1992), neurofibromatosis (Vienna, June 1992), cystic fibrosis (Washington, October 1992), haemoglobinopathies (Nicosia, April 1993) and haemochromatosis (Kiryat Anavim, Israel, April 1993). Several countries1 have developed control

1 Australia, Brazil, China, Cyprus, India, Italy, Jamaica, Myanmar, Nrgerra, Pakistan, Saudi Arabra, Thailand, Tunrsia.

124

programmes based on WHO approaches and recommendations.

14 217 A WHO working group on haemo­globinopathies with members from 15 countries in Europe and the Eastern Mediterranean evalu­ated and monitored national programme activi­ties (Nicosia, March 1993). Subsequently a re­gional advisory working group on hereditary disorders was set up in the Eastern Mediter­ranean.

14 218 In view of the increasing awareness in many countries of problems connected with he­reditary diseases, WHO prepared and issued ed­ucational materials on haemophilia and the haemoglobinopathies as well as guidelines on general principles involved in setting up national programmes for the control of congenital mal­formations and the haemoglobinopathies. In 1992 support was given in organizing a training course in Cuba for personnel from Latin Ameri­can countries on the use of modern techniques in the control of hereditary diseases.

14 219 To assist in assessing the role of modern technology in the control of hereditary diseases, WHO cosponsored a sixth international confer­ence on early prenatal diagnosis of genetic dis­eases (Milan, Italy, May 1992) at which the feasi­bility was considered of establishing a WHO international register on this subject. An interna­tional multicentre study was initiated on the pre­dictive value of individual genetic and environ­mental risk factors for familial hypercholes­terolaemia. Ethical questions relating to clinical applications of genetics were reviewed at the sec­ond and third international bioethics seminars (Fukui, Japan, March 1992 and November 1993 ).

CHAPTER 15

Health information support

Health literature services

15.1 During the biennium expanded informa­tion services were provided over the headquar­ters local area network, backed by intensified training of technical staff throughout the Organ­ization, in order to improve access to scientific and technical information for Member States. Particular emphasis was given to health econom­ics. Guidance was given to users in Member States, including ministries of health, in reorgan­izing their information systems.

15.2 WHOLIS, the computerized WHO li­brary information system, was enhanced by the addition of abstracts and was included in the Latin American health sciences literature data­base (LILACS) CD-ROM, which is distribut­ed by BIREME, the Latin American and Carib­bean Center on Health Sciences Information. WHOLIS has become available on Internet. WHODOC, the regular listing of new WHO publications and documents, continued to be disseminated on diskette and through Internet as well as in print.

15.3 "Essential information kits" were produced in cooperation with technical programmes; these are subject packages that combine essential infor­mation sources with explanations for using them correctly. They fill a need in countries that have few information resources, and in others where it may be difficult to make the appropriate choice and use of information for specific applications.

15.4 Relevant information is distributed through a monthly WHO Library Digest for Africa, either electronically via satellite to groundstations or in printed form to WHO Rep­resentatives. In addition, 16 documentation cen­tres were set up in the WHO Representatives' offices using a common computer-based proce-

125

dure. A major initiative was the launching of a project for an African Index Medicus by the As­sociation for Health Information and Libraries in Africa, sponsored by WHO with support from bilateral agencies. The aim is to create local databases in countries using a common proce­dure, and merge them into a regional product.

15 5 In October 1992 BIREME organized a first regional congress on health sciences infor­mation (Sao Paulo, Brazil, October 1992) to re­view and upgrade cooperative information activ­ities in Latin America and the Caribbean. Profes­sional workshops and interdisciplinary seminars were held during this meeting.

15.6 The health literature, library and informa­tion services network (HELLIS) for South-East Asia was strengthened by the introduction of new procedures for the development and provi­sion of computerized databases, training of library staff and continued compilation of an In­dex Medicus for South-East Asia.

15.7 WHO's European network of documenta­tion centres was enlarged and now consists of 25 centres in central and eastern Europe; a news­letter, Ex libris, was issued to improve communica­tion between the centres. WHO also provided documentation modules to liaison and information offices in countries of central and eastern Europe and in republics of the former Soviet Union.

15.8 In the Eastern Mediterranean a project en­titled "ExtraMED" was set up to allow access on CD-ROM to full texts of selected health science periodicals issued in the developing countries. A health and biomedical information plan for the Islamic Republic of Iran was drawn up and re­viewed at an intercountry meeting (Alexandria, February 1993); the intention is to produce guidelines for the formulation of similar national plans in other Member States.

THE WORK OF WHO 1992-1993

15 9 MED LINE on CD-ROM was acquired by most Member States in the Western Pacific. The Chinese biomedical literature analysis and retrieval system (CBLARS) came into operation; through collaboration between WHO and the Chinese Academy of Medical Sciences, 13 Chi­nese medical schools gained online access to this database as well as to MEDLINE. Workshops and training courses were conducted in Cambo­dia, China, Malaysia, Philippines and VietNam to upgrade the knowledge and skills of medical and health librarians and information providers, with emphasis on the application of new infor­mation technology.

WHO publications

15.10 Among the most important of the some 120 books published during the biennium were the first two volumes of the tenth revision of The international statistical classification of diseases and related health problems (ICD-10), contain­ing the tabular list of diseases and the instruction manual; the third volume, containing the alpha­betical index, is in press. Two key extensions of ICD-10, Chapter V, were also published as The ICD-10 classification of mental and behavioural disorders: clinical descriptions and diagnostic guidelines and Diagnostic criteria for research. The second editions of three successful WHO handbooks appeared - On being in charge, Teaching for better learning and the Laboratory biosafety manual - as well as new guidelines for cholera control, treatment of tuberculosis, and quality assurance in blood transfusion services. Our planet, our health, the report of the WHO Commission on Health and Environment, served as the Organization's published contri­bution to the 1992 United Nations Conference on Environment and Development. On the AIDS pandemic, WHO published a progress re­port, a guide for epidemiological studies of oral manifestations of HIV infection, a physicians' manual on AIDS in Africa, and texts in the WHO AIDS Series on school health education 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, specifications for pharmaceutical preparations, drug dependence, food additives, essential drugs, and the like. Others addressed key topics such as

126

the control of schistosomiasis and lymphatic filariasis, changing trends in the financing of health services, and rehabilitation after cardio­vascular diseases.

15 11 In the peer-reviewed research and review articles published in English or French in the bimonthly Bulletin of the World Health Organi­zation, tropical diseases and health conditions in developing countries took pride of place. Regu­lar features included reports on WHO meetings, publications and activities, and updates on timely topics. The quarterly World health forum fo­cused on the following "round-table" themes: nurses, doctors and patients; substance abuse; screening for breast cancer; humanitarian or pragmatic approaches to medical practice; and changes in medical education. The illustrated bi­monthly magazine World health sought to in­form and instruct on a variety of subjects of public health importance. 1 WHO drug informa­tion, the quarterly journal with reports on major drug regulatory action in different countries, and information on medicinal products and selected essential drugs from WHO's Model List, also ensured a wide circulation of the latest lists of international nonproprietary names (INN) for pharmaceutical substances.

15.12 To enable health information from WHO to reach targeted readers in countries through national channels, 35 low-cost reprints of WHO publications were licensed in India; and 362 agreements were prepared for translations of WHO books into 48 national or regional lan­guages by publishers, academic presses, minis­tries and aid organizations, among others. Cop­ies of over 200 published translations of WHO texts were received in WHO during 1992 and 1993. A much-translated title remained the joint WHO/UNICEF statement on breast-feeding, which has appeared or is in preparation in more than 40 languages, on a par with the 1986 classic Cancer pain relief The core classification ICD-1 0, and the mental health extensions, were also being translated for publication and use in nu­merous language versions.

1 The themes of 1ssues were, in 1992, Heart health (World Health Day issue), Essential drugs, Commun1ty health; Water; Nursmg care; Health and econom1c development, and, 1n 1993, Accidents and violence (World Health Day issue); Children's Vacc1ne Initiative, World health situation, T uberculos1s; Chem1cal safety; Family health

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 ad­ministrators; training manuals on laboratory methods and 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.

PLANCHES­POUR LE DIAGNOSTIC DU -PAWDISME

PLANCHES N° 1-8

Basic malaria .

m1croscopy

Part I. Learner's Guide

-----

127

VOYA(;ES IN'IF.RNA110~AUX

E'I'SAN'm

Parasitic diseases in water resources

development "k k'\.\)1,1 IIUt'f'ol.\.hlf: fk~--: 'U

THE WORK OF WHO 1992-1993

15.13 In the regions PAHO focused on dissemi­nating health-related information of particular interest in the Americas through scientific publi­cations and periodicals. Major publications in­cluded Pro salute novi mundi: a history of the Pan American Health Organization, a substan­tial volume on Reproductive health in the Amer­icas, and a collection of papers on Gender, wom­en and health in the Americas. In South-East Asia nine new titles were published in the region­al series, together with the regional volume (Vol. 4) of the Eighth Report on the World Health Situation. Among the books published in Europe were an updated edition of Health for all targets: the health policy for Europe and the col­lected papers from a symposium on Health pro­motion and chronic illness. In the Eastern Medi­terranean a number of textbooks and dictionaries were produced in connection with the arabi­zation of medical education in the Arabic-speak­ing countries; and translation of WHO publica­tions into other national languages of the Region was promoted. New publications in the Western Pacific included Medicinal plants in Viet Nam, produced in collaboration with the Institute of Materia Medica in Hanoi, as well as works on Health research methodology and District hospi­tals: guidelines for development.

Technical terminology

1514 A major step in the development of WHO's terminology information system (WHOTERM) was taken with the release during the biennium of the first terminology database management system, for distribution to users in the Organization and to national and interna­tional institutions. Preparation of a multilingual terminology database started with work on spe-

128

cific subjects, including food and nutrition and environmental health, with support from national research institutions and WHO collaborating cen­tres. Progress was made in the compilation of a WHO dictionary intended to facilitate exchange of information on the Organization's pro­grammes and activities through harmonization and standardization of technical terminology.

Distribution and sales

1515 WHO publications were made more ac­cessible in developing countries by strengthening the networks of health-related establishments and libraries receiving comprehensive or selec­tive groups of publications. By the end of the biennium 1008 libraries that receive WHO pub­lications free of charge or on subscription had expressed willingness to make their collections accessible to the public without restriction. Dur­ing 1992-1993 six new depository libraries were officially designated, bringing the total to 146 now open to readers throughout the world for consultation.

15.16 Annotated catalogues of publications were issued in English, French and Spanish. Nu­merous subject catalogues were produced on dif­ferent topics. Displays of WHO publications were arranged for over 200 specialized meetings and congresses. The momentum of sales of publi­cations achieved in the previous biennium was maintained. In 1992-1993 the income from sales reached a record level of $ 7.2 million; in fact, 1993 was the eighth consecutive year showing a growth in income. New strategies were intro­duced to enhance sales in developing countries and improve the performance of sales agents in developed countries.

Personnel

16.1 On 30 November 1993 the total number of staff (excluding PAHO) was 4448, compared with 4657 on 30 November 1992 and 4693 on 30 November 1991 - a decrease of some 5.22% during the biennium November 1991 toN ovem­ber 1993. The number of professional staff rose from 1568 in November 1991 to 1587 in Novem­ber 1993, and that of general service staff de­creased from 3125 to 2861 in the same period.

16.2 Although the proportion of women in established offices1 was still below the target of 30% set by the Health Assembly, steady progress was made. The proportion of profes­sional and higher-graded posts in established offices filled by women increased from 23.2% in October 1990 to 25.1% in September 1992 (mid-biennium). During the same period the number of posts in established offices at grades P.S and above filled by women increased from 11.2% to 13.5%. The percentage of women em­ployed as associate professional officers rose from 40% to 47.6%. The percentage of women employed as consultants in all locations rose from 23.3% in 1990 to 25.2% in 1992; at head­quarters 29.2% of all consultants and 38% of short-term professionals employed between October 1990 and September 1992 were wom­en. There was a small increase in the proportion of women members of WHO's 54 expert advi­sory panels.

16.3 Although the target of 40% for appoint­ments of nationals from unrepresented and under-represented countries was not met, 22%

1 Established offices include headquarters, regronal offices, offrces of the WHO Representatives and IARC, but not projects.

129

CHAPTER 16

Support services

of the appointments made in the period were of nationals of those countries. The number of un­represented countries increased from 27 to 42 by mid-biennium (mainly owing to the addition of 13 newly independent countries, of which two were previously inactive, and four other new Member States), that of under-represented coun­tries remained at 11, and that of over-represented countries increased from 24 to 26. The number of adequately represented countries - the ultimate criterion for evaluating geographical representa­tion- increased from 101 to 103. The number of staff in excess of the upper limits of desirable ranges fell by 2.2%.

Office accommodation

16.4 The telephone exchange in the Regional Office for Africa, which dated from the con­struction of the building, was replaced and the new facility should greatly improve external communications.

16.5 Because of the expansion of programmes supported by extra budgetary funds, the Regional Office for South-East Asia plans to add a floor to one of its buildings, which will provide 13 extra offices; the construction should be completed in 1994.

16.6 Certain legal difficulties, arising from ne­gotiations with the Host Government, prevented the implementation of plans for the extension to the Regional Office for the Eastern Mediterrane­an. Discussions are still under way between the Regional Office and the local authorities to find an acceptable solution.

16 7 The extension to the Regional Office for the Western Pacific was completed and the premises are now occupied.

THE WORK OF WHO 1992-1993

Budget and finance

16 8 The programme budget proposals for 1994-1995, covering the third and last period of the Eighth General Programme of Work, were prepared and submitted to the Programme Com­mittee of the Executive Board for review of the global and interregional component in accord­ance with resolution EB79.R9. In parallel, the regional components were reviewed by the re­gional committees. After these reviews the Di­rector-General consolidated the programme budget proposals and submitted them to the Ex­ecutive Board at its ninety-first session in Janu­ary 1993. The proposals were then modified to take into account favourable exchange rate movements and to meet concerns expressed by the Executive Board during its review. The mod­ified programme budget proposals for 1994-1995 were subsequently approved by the Forty-sixth World Health Assembly in May 1993. The effec­tive working budget for 1994-1995 was estab­lished at $ 822 101 000, providing for a net de­crease in real terms of $ 24 112 200, or 3.28%. The overall cost increase in the approved budget for 1994-1995 was $111277 200, or 15.14%, an amount which incorporated considerable cost increases that had occurred before the 1994-1995 biennium but had not been included in the ap­proved budget for 1992-1993. No provision was made in the 1994-1995 budget for exchange rate fluctuations.

16 9 In 1993 an interim financial report cover­ing the first year of the biennium 1992-1993 was reviewed by the Committee of the Executive Board to Consider Certain Financial Matters pri­or to the Forty-sixth World Health Assembly, and was subsequently accepted by the Health Assembly.

16 10 Because of adverse exchange rate fluctua­tions during the biennium in respect of the Swiss franc, the Danish krone, the CF A franc, the Egyptian pound and the Philippine peso, it was necessary for the Organization to use $ 8 840 500 against the exchange rate facility approved by the Health Assembly for 1992-1993, namely $ 31 million. The reduced use of this facility re­sulted from improved exchange rates from the latter part of 1992 to the end of 1993.

16 11 In 1992-1993 obligations totalling $ 688 816 477 were incurred under the regular budget and $ 756 715 939 under funds from

130

other sources. As at 31 December 1993 arrears of contributions in respect of 1992 and 1993 amount­ed to$ 106 168 561. The obligations in respect of the regular budget for 1992-1993, shown as per­centages under the main categories of the Eighth General Programme of Work, were as follows:

% Direction, coordination and management 11.02

Health systems infrastructure 32.39

Health science and technology 28.76

Programme support (including health information support) 27.83

100.00

1612 Obligations incurred under the 1992-1993 regular budget were considerably lower than the approved budget level of$ 734 936 000. This was due to an expected under-collection of assessed contributions, particularly from one of the larg­est contributors, which obliged the Director­General to reduce the implementation of the ap­proved programme for the biennium. Nonethe­less, the Director-General endeavoured to imple­ment the planned programme to the maximum extent possible. In spite of this programme re­duction and the application of various economy measures, it was still necessary to use the internal borrowing facility granted to the Director­General under Financial Regulation 5.1. The Director-General expressed to the Member States his concern over the weakened financial position of the Organization and its impact on programmes. Financial data for all sources of funds, and financial statements at 31 Decem­ber 1993, with supporting schedules and tables, are presented in the Director-General's finan­cial report for the biennium to the Forty-seventh World Health Assembly.

1613 The integrated computer-based system for administration and finance information (AFI) system is established on a large common central database and provides information sup­port for budget preparation, budget control, ex­penditure and general ledger accounting, pay­ments, treasury operations, supplies, personnel, payroll and the master mailing list. The records of expenditure accounting from the regions are inte­grated in the headquarters database each month for information purposes. The system also allows technical programmes to query their allot-

SUPPORT SERVICES

ments, earmark their funds, link obligations to programme activities and transfer data to "local" microcomputers for further analysis.

16.14 During the biennium the administration and finance information system was expanded to include data required for management of the in­vestment portfolio and shipping of supplies to their destinations. The component for processing travel claims was redesigned. Studies were begun to de­vise system components to handle data on tempo­rary staff and consultants, and to process staff health insurance claims so as to allow a finer analy­sis for cost-containment purposes. A project is un­der way to redesign the regional office administra­tion and finance information system, which sup­ports budget control, expenditure accounting and general ledger accounting. The new system will allow links to programme and project activities and provide all the budgetary and expenditure informa­tion required for their management.

Equipment and supplies for Member States

1615 The total value of supplies and equipment purchased by WHO (including PAHO) during the 1992-1993 biennium reached $255 511335. Compared with 1990-1991, this represents an in­crease of 3% in monetary terms. The staff work­ing in the supply services at headquarters was reduced by approximately 15%.

1616 In 1992-1993 the Global Programme on AIDS continued to be the largest user, in dollar terms, of the WHO procurement and supply serv­ices. Whereas procurement from regular budget sources decreased by approximately 20%, activi­ties in respect of emergency relief operations in­creased substantially; countries benefiting includ­ed Afghanistan, Iraq, Somalia and republics of former Yugoslavia. Pharmaceutical products and hospital supplies and equipment constituted the major part of all commodities. The cost of sup­plies and equipment for republics of former Yu­goslavia amounted to more than $ 10 million.

1617 Member States continued to avail them­selves of the services offered by WHO in the purchase of medical supplies and equipment for their health programmes, either through the WHO Revolving Fund or against reimburse­ment in convertible and nonconvertible curren­cies. There was a considerable increase in the

131

number of requests received from non­governmental organizations. In particular, those organizations, and also other bodies within the United Nations system, made more use of WHO's services in procuring condoms and test kits for AIDS control programmes, thus benefit­ing from the advantageous prices that WHO has negotiated with manufacturers worldwide.

16.18 Many urgent requests for supplies were received in Africa as a result of outbreaks of meningitis, cholera and yellow fever, and nation­al emergencies related to civil unrest in some countries. Additional urgent procurement re­quirements had to be met following the regionalization of most of the AIDS control pro­grammes.

1619 PAHO/WHO continued to purchase supplies, equipment and services in the Americas 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. The procurement value during the biennium 1992-1993 was$ 93 662 011. A greatly increased demand for supplies was met during the peak of the cholera outbreak in Peru.

16 20 Additional work arose in South-East Asia in connection with the purchase of supplies on behalf of India for its national AIDS control pro­gramme. Also, staff had to be increased in order to meet the extra demand from the fourth popu­lation and health project in Bangladesh.

16.21 Most requests for supplies in Europe were in respect of republics of former Yugoslavia. At the same time larger numbers of requests were received from the Commonwealth of Independ­ent States.

16.22 There was a heavy demand for medical supplies and equipment to cope with natural dis­asters and other emergencies in the Eastern Med­iterranean. The transfer to that region of respon­sibility for much of the Global Programme on AIDS and also of Operation Salam for humani­tarian assistance to Afghanistan widened the scope of traditional supply work.

16 23 In the Western Pacific local purchases for projects and reimbursable procurement on be­half of Member States increased. Project supplies for all Member States remained at the same level as during the previous biennium.

- w ....,

~

@

Regio

nal O

flice

Regio

nal o

ffice

s an

d th

e ar

eas

they

ser

ve

AREA

SERV

ED, A

S AT

31 D

ECEM

BER

1993

, BY:

Regio

nal O

ffice

for A

frica

~

Regio

nal O

ffice f

or ~

the A

meric

as/PA

SB

-

hgion

ol Of

fice f

or So

uth-E

ast A

sia

Regio

nal O

ffice

for E

urope

t JtfM

NilA

~~

4r~"

~

[]]] Re

giona

l Olfi<

e for

the E

astern

Med~erranean

~

Regio

nal O

ffice

for

~

the W

estern

Paci

fic

t

\

/~ t

4. ·~:::

: ~ ~

17.1 The sociopolitical upheavals concomitant with the establishment of democratic institutions have ushered in a new period of hope and chal­lenge for Africa, mirrored in the health sector by the adoption at the forty-third session of the Regional Committee in Gaborone in September 1993 of the minimum district health-for-all package - "the final common path" - for the achievement of health for all through primary health care in accordance with the African Health Development Framework.

17.2 Despite progress in some areas, the health situation in countries of the African Region is still of great concern. The high prevalence of parasitic and infectious diseases, the spread of the AIDS pandemic, and the disturbing increase in noncommunicable diseases continue to be formi­dable impediments to progress. Massive popula­tion drifts and the settlement of displaced per­sons and refugees in camps lacking adequate wa­ter supply and sanitation are the legacy of con­flicts in certain countries of the Region. Inacces­sibility of basic health care services, precarious nutrition and the consequences of drought have added to the difficulties.

17.3 Within this context of social, political and health crises, WHO pursued efforts to reduce immediate suffering and to strengthen the capac­ity of countries to cope with the multiple chal­lenges impeding their development. In the same spirit, an unprecedented initiative for widespread social mobilization in favour of community health in Africa was launched by African minis­ters of health at the International Conference on Community Health in Africa (Brazzaville, Sep­tember 1992).

17.4 Given the considerable deterioration in national capacities for financing health systems, the African ministers of health decided to make health care financing one of the priority areas for

133

CHAPTER 17

African Region

intervention by WHO. A situation analysis of health care financing mechanisms and problems was consequently undertaken in Member States, and some innovative community health financ­ing schemes were reported. National experts were recruited as economists on WHO country teams, and workshops were organized, stressing the relation between economics and health. Con­tacts were established with donors and develop­ment banks to solicit funding for programme activities on health care financing at country lev­el. Technical support was given to some coun­tries for necessary health care financing reforms.

17.5 WH 0 provided support to 10 countries in the elaboration of their national health develop­ment plans and policies. A framework for the reorientation and restructuring of hospitals was prepared, in pursuance of directives of the forty­second session of the Regional Committee in 1992, to promote integration of hospital net­works into health systems. Efforts were also made to develop effective coordination mecha­nisms to assist Member States of the Region in emergency and humanitarian relief.

17.6 With regard to health information and ep­idemiological surveillance systems, WHO sup­ported training and development activities in five countries. Close collaboration with the Associa­tion for Health Information and Libraries in Af­rica reactivated a long-dormant project for an African Index Medicus. By the end of 1993 cen­tres in Ghana, Malawi, Mozambique, United Re­public of Tanzania, Zambia and Zimbabwe were participating in the project, and the inaugural issue had been widely distributed.

17.7 The regionalization of technical and ad­ministrative support under the Global Pro­gramme on AIDS to the African Region reached an advanced stage. The programmes of 43 coun­tries have been regionalized. Although the re-

THE WORK OF WHO 1992-1993

duction in financial support to countries and WHO from donors for AIDS control was a ma­jor concern, national AIDS programmes made significant progress in implementing appropriate strategies. Youth groups and clubs have been formed in many countries. Communities have set up associations, and over 1000 local nongovernmental organizations are engaged in the provision of care to AIDS patients and sup­port to their families. Field-testing of indicators for assessing the impact of interventions at coun­try level was completed. A guide to national AIDS programmes was issued, emphasizing the desirability of implementing programmes within the national health development framework, with decentralization to district and community levels in order to ensure sustainability of meas­ures, accelerate the dissemination of knowledge about AIDS, and promote changes in behaviour and the adoption of a healthy lifestyle by all, particularly young people and children.

17 8 In preparation for the 1992 International Conference on Nutrition (see paragraph 9.14), 39 Member States made a comprehensive review of their nutrition situation and two meetings were held (Dakar, February 1992; Nairobi, March 1992) bringing together representatives of all countries of the Region. One outcome of these meetings was the adoption, in principle, of an International Decade on Food and Nutrition for Africa. To follow up the recommendations of the international conference, steps were taken to es­tablish national plans for each country by the end of 1994. Technical and financial support was pro­vided to several Member States1 under the initia­tive for intensified cooperation with countries and peoples in greatest need.

17 9 Particular attention was directed to con­trol of iodine deficiency diseases in 1992. Preven­tive activities were undertaken in 23 countries, of which 17 had national control programmes. Em­phasis was put on iodized salt consumption, and workshops on this subject were organized in Botswana and Senegal in 1992. A survey on micronutrient deficiency in the Region, complet­ed in 1993, showed that 16 out of the 34 countries where vitamin A deficiency is prevalent had al­ready initiated preventive activities.

1 Benrn, Central Afrrcan Republic, Chad, Guinea, Gurnea-Brssau, Madagascar, Mozambrque, Sao Tome and Principe, Uganda, Zambia

134

17.10 Efforts were made to strengthen the man­agement of national maternal and child health/ family planning programmes, with emphasis on service coverage, improved quality of care and rapid reduction of morbidity and mortality among mothers and neonates. Management sup­port activities included collaboration in work­shops on district team problem-solving methods in Senegal and United Republic of Tanzania, as well as the finalization of a project on accelerated action for safe motherhood in the African Re­gion. A regional joint consultation on the pre­vention of maternal mortality and on infertility in sub-Saharan Africa was organized at the Re­gional Centre for Training and Research in Fam­ily Health (Kigali, January 1992). The first of a series of regional training courses in family health research methods was successfully con­ducted by the regional centre for 12 trainees from Burkina Faso, Cameroon, Cote d'Ivoire, Madagascar and R wanda. A regional data bank on selected maternal and child health/family planning indicators was established in the Re­gional Office, based on the global database at headquarters. Collaboration with UNFP A and UNICEF was strengthened.

17 11 The final evaluation report on the Inter­national Drinking Water Supply and Sanitation Decade ( 1981-1990) was presented to the Re­gional Committee in 1992. In the course of the Decade approximately 223 million people had access to an adequate and safe water supply and 156 million access to appropriate sanitation in the African Region. During the same period approximately 226 million people remained without satisfactory water supply and 333 mil­lion without appropriate sanitation. WHO pro­vided technical and financial support to 32 Member States for institutional and human re­sources development, and for construction and rehabilitation of low-cost water supply and san­itation systems in rural areas. Member States affected by cholera were given special financial and technical support to prepare short- and long-term plans for the prevention and control of outbreaks. National experts were recruited in 15 countries to work as sanitary engineers in the country support team, and they were included among the experts participating in the second regional environmental health coordination meeting (Nairobi, March 1992). Collaboration continued with UNEP, FAO, UNESCO/ Intergovernmental Oceanographic Commis­sion and IAEA in implementing the programme on assessment and control of pollution in coast-

AFRICAN REGION

al and marine environments in west, central and east Africa.

17.12 Following activities to promote Healthy Cities throughout the Region, a first meeting for French-speaking African countries was organ­ized within the framework of collaboration be­tween the Healthy Cities network of Quebec (Canada) and Dakar commune (Dakar, July 1992). An outcome of the meeting was support for the preparation of action plans in five of the 14 cities participating in the meeting. A WHO/ GTZ workshop (Harare, November 1993) brought together participants from 16 countries to launch a regional Healthy Cities network.

17.13 Immunization rates in the Region reached 82% for BCG, 57% for a third dose of poliomy­elitis vaccine and 50% for a second dose of teta­nus toxoid. Efforts to improve disease surveil­lance and control in countries focused on train­ing of programme managers and district health teams in the use of indicators for monitoring progress. A number of Member States, mainly in southern Africa, reported no cases of poliomye­litis and a very low incidence of neonatal tetanus. Assessments in some of these countries con­firmed a virtual absence of poliovirus transmis­sion, a very low incidence of neonatal tetanus, and a significant reduction in measles cases and deaths.

17 14 The malaria control programme was ac­corded the highest priority. Following the 1992 Ministerial Conference on Malaria (see para­graph 14.16), tremendous progress was made in the African Region. More than 20 countries es­tablished or reformulated malaria control pro­grammes with the technical support of WHO, and some 25 organized training on control strat­egies for district health workers. A regional plan of action for the period 1994-1997 was adopted.

13S

17.15 Following a review of the status of nation­al dracunculiasis eradication programmes at a fourth African regional conference (Enugu, Ni­geria, March 1992), all endemic countries began implementing their workplans. The efficacy of the regional eradication strategy was evident from the progress made in two of the most heav­ily endemic countries, Ghana and Nigeria, as well as in other less endemic countries.

17 16 Considerable strides were made in leprosy control in Africa. Prevalence dropped as a result of better coverage of multidrug therapy from 27% in 1990 to 45.5% in 1993, with several coun­tries attaining 100% coverage. Support was pro­vided to countries with severe leprosy problems and inadequate multidrug therapy through con­sultant services for management training and ex­pansion of coverage. Outbreaks of type A meningococcal meningitis, cholera and plague were of particular concern. Support included consultant services, information exchange, pro­vision of vaccines and drugs, and organization of training workshops. Training materials were elaborated and tested as part of an effort to pro­mote integrated disease control in countries, es­pecially at district level.

1717 Human resource and material support for health science training institutions continued, with efforts centring on the revision of medical training. A programme was set up to strengthen continuing education, and steps were taken to enhance the role of nurses and midwives in safe motherhood, research and epidemiological sur­veillance. Incidents affecting security in several countries caused disruption of technical pro­grammes and required special efforts by WHO staff. Responses were made, under emergency arrangements, to health-related problems caused by extensive population movements resulting from such incidents.

CHAPTER 18

Region of the Americas

18.1 In 1992 the Pan American Sanitary Bureau celebrated 90 years as the oldest continuously functioning international health agency in the world. The organizational structure of the Pan American Health Organization's secretariat, the Pan American Sanitary Bureau/WHO Re­gional Office for the Americas, was adjusted in early 1993 to better enable it to meet its constitu­tional obligations to assist Member States in achieving health for the people of the Americas. One of the purposes of this adjustment was to strengthen the secretariat for improved imple­mentation of the regional strategic orientations and programme priorities in line with WHO's Ninth General Programme of Work.

18.2 In 1993 PAHO/WHO started to assess the impact of its strategic orientations and pro­gramme priorities on national health develop­ment, particularly on policy-making and health activities in the Member States, and its technical cooperation. This evaluation is part of a biennial review to determine the progress made towards the achievement of the Organization's quad­rennial goals in 1 991-1994.

18.3 In 1992 the Regional Committee for the Americas reviewed and approved several plans of action for the Region, including programmes on adolescent health, elimination of leprosy, and elimination of vitamin A deficiency. Of particu­lar importance was the Committee's approval of a regional plan of action for investment in the environment and health which will marshal na­tional and international resources. The Commit­tee also approved the promotion of activities to link the health and tourism sectors in the Region and, in its capacity as the Directing Council of PAHO, admitted Puerto Rico as an Associate Member.

18.4 In 1993 the forty-fifth session of the Regional Committee/XXXVII Directing Coun-

137

cil of PAHO reviewed the proposed programme budget for 1994-1995. Some of the most note­worthy resolutions adopted at this session were those urging Member States to comply with guidelines established for certifying eradication of poliomyelitis caused by indigenous wild poliovirus, to implement measures to eliminate measles, to step up vaccination against all diseas­es under the Expanded Programme on Immuni­zation, and to ensure the sustainability of all these efforts. The Regional Committee also ap­proved resolutions aimed at strengthening HIV I AIDS prevention and control programmes, adopting measures to reduce maternal mortality, and establishing a regional programme of bioethics. A new health initiative on behalf of the indigenous peoples of the Americas was ap­proved, as was the formulation of a regional plan of action on violence and health, including vio­lence against women and all risk groups.

185 During 1992-1993,16 joint evaluations of technical cooperation were carried out with Member States. Almost all the Member States participated in the PAHO/WHO programme for technical cooperation among countries. Training and the development of human resourc­es were particularly emphasized; and the subregional health initiatives in the Caribbean, Central America, the Andean Area and the Southern Cone1 continued to serve as an impor­tant mechanism for implementing projects envis­aged under the technical cooperation pro­gramme. A strategic plan was prepared to strengthen the Andean Cooperation in Health initiative and several national technical working groups prepared action plans in the priority areas of maternal and child health, essential drugs, sub-

1 Argentrna, Bolrvra, Brazil, Chile, Paraguay, Uruguay

THE WORK OF WHO 1992-1993

stance abuse, environmental health and disaster preparedness. A draft health promotion charter for Latin American countries was prepared at the International Conference on Health Promotion (Santafe de Bogota, November 1992); and a simi­lar document was produced the following year under the aegis of the Caribbean Cooperation in Health initiative. Significant progress was achieved in the Central American Health Initia­tive's four priority areas of health infrastruc­ture, health promotion and disease control, health care for special groups, and the environ­ment and health. The Southern Cone Health Ini­tiative was instrumental in the control of Chagas disease and cholera.

18.6 During the biennium the Region contin­ued a movement towards democracy which in­corporated constitutional reforms, free and open electoral processes, and formal acceptance of the obligation to protect human rights. The econom­ic recovery that began in 1991 has reached a phase of moderate expansion, gradual price stabilization, alleviation of the debt burden, and a favourable net transfer of resources. The proc­ess of market integration continued to intensify in the Region - for instance, within the frame­work of the Southern Cone Common Market (MERCOSUR), the Caribbean Community (CARICOM) and the North American Free Trade Agreement (NAFTA). However, there was no significant reduction in unemployment levels as compared to previous years. Declining family income left some 60 million people in poverty during the 1980s, a figure that reached a very high level in 1991.

18.7 Efforts were made to increase the capabili­ty of the Organization's programmes and coun­try offices, as well as ministries of health, to en­hance project preparation skills, strengthen project monitoring, successfully negotiate exter­nal financing for priority health areas, and expand resource mobilization for health by encouraging the full participation of ministries, other bodies within the United Nations system and non­governmental organizations. The Organization participated in the second and third Ibero-Ameri­can conferences of Heads of State and Govern­ment (Madrid, July 1992; Salvador, Brazil, July 1993), which approved several proposals relating to health. Discussions continued with the United Nations system in preparation for the 1995 world summit on social development. The Organization is collaborating with the Economic Commission for Latin America and the Caribbean in preparing

138

a document on health with equity, which reviews health aspects of the economic transformation currently under way in the Americas.

18 8 The Organization participated in the first meeting of the commission on health, labour and social security of the Latin American Parliament (PARLATINO) held in Havana in March 1993, and over the next few years its technical coopera­tion will focus on the five health priorities identi­fied during the meeting. A cooperation agreement was reached with the Central American Parlia­ment, and progress was made in formalizing simi­lar agreements with the Andean Parliament. The Organization is also participating in a network of agencies that supports the formulation of integrat­ed social policies by governments.

18 9 The epidemiological profile of the Region continued to change, especially regarding mor­tality. The relative importance of chronic and degenerative causes of disease is increasing, par­ticularly in countries where total mortality and fertility have already declined. The ever-growing urban concentration and the increased life ex­pectancy of the populations have resulted in the simultaneous presence of "old" health problems such as malaria, dengue, cholera, diarrhoea! dis­eases and acute respiratory infections and "new" problems such as cardiovascular diseases, vio­lence, cancer and AIDS.

18.10 Several innovations in the health sector during the biennium stand out clearly. In the wake of the victories over smallpox, a series of regional, subregional and national plans and pro­grammes have been launched for the purpose of eradicating, eliminating or controlling a wide va­riety of infectious diseases. In August 1993 the Region celebrated its second year free of con­firmed cases of poliomyelitis caused by indige­nous wild poliovirus, and countries have now entered the certification phase. As a result of mass immunization campaigns, better surveil­lance of illnesses with rash and fever, and weekly "negative reporting", there have been no con­firmed cases of measles in the English-speaking Caribbean in nearly two years. Argentina, Brazil, Chile, Colombia, Cuba, Dominican Republic, Peru and the Central American countries have launched similar campaigns aimed at eliminating or controlling measles. The goal set at the 1990 World Summit for Children of reducing the inci­dence of neonatal tetanus to no more than one case per 1000 live births has practically been reached in the Region. With surveillance and vac-

REGION OF THE AMERICAS

cination of all women of childbearing age in high-risk areas as the principal strategies, there is confidence that the commitment to eliminate this disease by 1995 will be fulfilled.

18.11 The countries of the Southern Cone are committed to an initiative to eliminate the vectorial transmissiOn and interrupt the transfusional transmission of Trypanosoma cruzi. This initiative has stimulated cooperation among other countries with similar problems regarding Chagas disease. Similarly, the countries of the An­dean subregion have begun to implement a plan for the control of iodine deficiency disorders.

18.12 Despite reductions in their regular budg­ets, health ministries, in close collaboration with the Organization, have managed to stem the cholera epidemic. National efforts for conscious­ness-raising and emergency preparedness and re­lief, coupled with efforts to disinfect water sys­tems, improve basic hygiene and monitor food handling, have kept cholera at bay and resulted in a near-30% reduction in all deaths from diarrhoea! diseases.

18 13 Technical cooperation with national AIDS programmes in preparation for "second cycle" multisectoral medium-term plans contin­ued through 1993; national plans were completed and technical reviews carried out in several coun­tries. Technical cooperation activities included workshops on applied epidemiology and strate­gic planning.

1814 PAHO/WHO provided emergency tech­nical support to control Cuba's epidemic of neuropathy with predominantly optic clinical manifestations, which has produced over 50 000 cases since it was first detected in 1992 and is now under control.

18.15 The declaration adopted at the 1992 Inter­national Conference on Health Promotion (see paragraph 18.5) set targets and advocated ap­proaches to encourage healthy behaviour. Mem­ber governments were urged to adopt public pol­icies aimed to strengthen health promotion and address emerging health problems. The Organi­zation promoted the first and second meetings of Central American ministers of environment and of health (El Salvador, September 1992; Hondu-

139

ras, September 1993), convened to agree on na­tional plans for implementing the resolutions of the 1992 United Nations Conference on Envi­ronment and Development (see paragraph 12.1).

18.16 PAHO/WHO continued to support ef­forts to reorganize the health sector on the basis of decentralization and to cooperate with all Member States in setting up and evaluating local health systems; it worked out approaches for applying the local health system strategy at dis­trict or county level, and for supporting the es­tablishment of "healthy counties". Progress was also made in applying the local health system strategy in urban areas.

1817 With the advent of the United Nations International Decade for Natural Disaster Re­duction, emphasis has shifted from preparedness and relief to prevention and mitigation. PAHO/ WHO has broadened its objectives to include a wider range of disaster prevention and mitigation activities in the health sector, including the deliv­ery of emergency humanitarian assistance. The crisis in Haiti has been attended to within this framework and in accordance with a plan for humanitarian action launched by the Organiza­tion of American States and the United Nations. PAHO/WHO has been designated as coordinat­ing body for the design and delivery of basic health services under this plan and, since Decem­ber 1993, has managed the supply of fuel for all humanitarian activities. The terms of the Central American development programme for refugees and displaced persons (PRODERE) were modi­fied to include mental health and physical reha­bilitation of war-related disabilities in several countries. Many important lessons about inte­grated health care for special groups, interagency collaboration and promotion of peace have been learned from PRODERE, which completed its third and final year in 1993. By the same token, health has continued to serve as a "bridge for peace" in Central America. In El Salvador the Chapultepec Peace Agreement resulted in a re­quest from all parties to find ways to provide basic services to the demobilizing military forces under the aegis of the United Nations. PAHO/ WHO responded by organizing and delivering services to the former combatants and their dependents, with financial support from the in­ternational community.

CHAPTER 19

South·East Asia Region

19.1 With growing social awareness and con­sciousness among the people of the Region and the operation of free market forces, health devel­opment has received a new impetus. The minis­ters of health of the countries of the Region met twice during the biennium and considered AIDS control, trends in communicable diseases, tech­nical cooperation among developing countries, the combination of public and private provision of health care, and primary health care in a changing socioeconomic and epidemiological situation. They renewed their commitment to improve the quality of services in their countries. The health-for-all leadership initiative begun in 1985 continued to make progress in sensitizing decision-makers to critical aspects of health de­velopment. An intercountry consultation was held on the subject of strengthening women's leadership for health for all (New Delhi, Febru­ary 1992).

19.2 The results of the second evaluation of the implementation of the health-for-all strategy, published in 1993,1 showed that significant achievements have been made in reducing mortal­ity among infants, children and mothers. Substan­tial progress has also been made in immunizing children against childhood diseases and introduc­ing family planning programmes in many coun­tries. However, there remain wide variations in health status among and within countries.

19 3 WHO provided technical support to Bangladesh, Bhutan, Indonesia, Nepal, Sri Lanka and Thailand in formulating national health poli­cies and plans. Other areas covered were health economics, health care financing and manage­ment. There is a dearth of skilled health planners

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: South·Eost Asia Regron. Geneva, World Health Organrzat10n, 1993.

141

in most of the Member States, partly owing to

the "brain drain" to more developed countries. WHO therefore collaborated in organizing meetings, courses, fellowships and local training in health management. Bangladesh, Bhutan, Maldives, Mongolia, Myanmar and Nepal bene­fited from intensified WHO cooperation with countries and peoples in greatest need to im­prove national capability in these fields.

19 4 Support was given to India, Indonesia, Nepal and Thailand in reviewing existing public health laws as well as draft legislation on AIDS. Study tours were organized for officials to study health legislation abroad.

19.5 Health infrastructure was expanded and service coverage improved in all the Member States through training and deployment of vast numbers of community health volunteers and the involvement of the community in planning and management of local health activities.

19.6 Bangladesh, Bhutan, Nepal, Maldives, Mongolia, Myanmar and Sri Lanka are reviewing current patterns of resource allocation and utili­zation in the health sector and revising their health policies and strategies. Indonesia has been analysing trends in the health system as a basis for studying the implications of its policies and strategies. Mongolia is reviewing the structure and functions of its ministry of health. WHO will continue to support such reviews. In the coming decade, further efforts must be made to reach the underserved or underprivileged in both rural and urban areas, using primary health care approaches based on community involvement, leadership development for health for all, quality assurance, self-care, integration of services, and intersectoral collaboration.

19.7 At its forty-fifth session the Regional Committee for South-East Asia discussed the

THE WORK OF WHO 1992-1993

subject of "Balance and relevance in human re­sources for health" and urged Member countries to carry out a thorough analysis of the present situation, with particular attention to imbalanc­es. To improve methods for analysing policy on human resources for health and strengthen na­tional capabilities in this area, WHO has devel­oped tools, strengthened its information base, and promoted research. It has also continued to support the development of nursing and medical education systems.

19.8 There is increasing recognition in the Re­gion of the importance of information and edu­cation for health, as reflected in the inclusion of these activities in most health programmes. Health matters are being given better coverage in the press, radio and television. School health ed­ucation has come into sharper focus, as has the role of women in health development.

19.9 A review was made of the current strate­gies for health research in the Region and a publi­cation on this subject is under preparation.

19.10 Emphasis was given to health protection and promotion and their practical applications, particularly in respect of oral health and injury prevention, the creation of a supportive and safe work environment and the provision of health and social services to disabled persons and groups such as women, children, adolescents and the elderly. Prevention of dental caries and oral diseases and promotion of oral health are not yet integrated in many health services. Collection of data on road and agricultural injuries was intensi­fied with the aim of strengthening measures to check the continuing rise in mortality from inju­ries. In many countries comprehensive tobacco control programmes have been established, in­cluding epidemiological surveillance, public edu­cation, legislative and administrative measures, and early detection and treatment of the conse­quences of tobacco use such as oral cancer.

19.11 All the Member States recognize the ad­vantages of a holistic approach to child survival and development. WHO, together with UNICEF, UNDP, UNFPA and other profes­sional and nongovernmental organizations, plays a leading role in establishing integrated systems for providing maternal and child health and fam­ily planning services as a part of primary health care. However, maternal mortality remains un­acceptably high with considerable variations within countries. A number of training activities

142

in this field took place during the biennium. Family planning and birth-spacing have been ac­cepted as a means of achieving better health for mothers and children, and WHO pays particular attention to improving the quality of family planning services.

1912 The socioeconomic and health implica­tions of the changing demographic situation in some countries with large populations make it imperative to take timely decisions on introduc­ing short- and long-term measures to protect and promote the health of the elderly. Development of policies and the design of services for the eld­erly based on community approaches supported by appropriate institutional care have become an important feature of WHO's technical collabo­ration with countries.

1913 Concern about drug abuse has been grow­ing in several countries as a result of the epidem­ics of HIV infection among drug injectors, who now form substantial reservoirs of the virus in Myanmar, Thailand and some Indian states and cities. However, some approaches to the contain­ment of these epidemics have not been found acceptable because they have been seen as con­doning drug use. In a number of countries prob­lems of alcohol use are more serious, although they have less visibility from a political point of view. A community approach, developed with centres in India, Myanmar and Sri Lanka, has proved very effective in curtailing urban heroin abuse and rural opium and alcohol abuse.

19 14 A number of countries experiencing rapid urbanization and industrialization have given high priority to community water supply and sanitation, and initiated other environmental health activities. Training within countries and abroad was given on computer-based project management and water and sanitation project implementation for engineers in Bangladesh, In­dia, Maldives, Nepal and Sri Lanka. WHO con­tinued to promote intersectoral community ap­proaches to solve problems of rapid population growth and unplanned urbanization. Regional consultations on sanitation, solid waste manage­ment, surface water drainage and urban health have highlighted some of the strategies and ac­tions that countries could adopt.

19 15 Collaborative efforts in the management of environmental health hazards focused on technical support in capacity-building for pre­paring national action plans on health and envi-

SOUTH-EAST ASIA REGION

ronment. WHO collaborated in studies on groundwater pollution, industrial water con­sumption, and pollution monitoring systems and on environmental epidemiology in critically pol­luted areas in India. Air and water quality moni­toring activities continued in India, Indonesia and Thailand.

19 16 A document was prepared giving an over­view of the current situation and future perspec­tives for strengthening national food safety pro­grammes. Support to institutional development included the surveillance, prevention and control of food adulteration in India, training of food safety staff at district and provincial levels in Indo­nesia and Sri Lanka, and the establishment of a computerized information network on food anal­ysis and quality control in Thailand. Studies on street-vended foods, pesticide residues and plastic food containers, and on dietary intake of heavy metals were conducted in various countries. Se­lected Codex Alimentarius texts and guidelines were translated and published in Indonesia, and national food standards were reviewed and har­monized with the Codex standards in India.

19.17 Support for strengthening health labora­tories as part of primary health care included the formulation of national policies, introduction of simple diagnostic tests at peripheral level, and establishment of a quality assessment network. Guidelines were issued on the organization of health laboratory service networks, including ap­propriate technology and quality assurance.

19.18 National essential drug programmes have been developed in Member countries, some­times with extra budgetary support. Although es­sential drugs have generally become more readily available, there have been acute shortages in some countries owing to political disturbances. WHO has complied with requests for procure­ment of drugs to ameliorate the situation. Strengthening of drug regulatory and quality control systems, improvement of good manufac­turing practices, studies on the bioavailability and stability of pharmaceutical preparations, and drug evaluation were some of the areas in which WHO collaborated with countries in 1992-1993.

19.19 Assessments of the operation of the WHO Certification Scheme on the Quality of Pharmaceutical Products moving in Internation­al Commerce were undertaken in Myanmar and Sri Lanka. Other activities in this field included the development of standard treatment regimens,

143

strengthening of technical and managerial capa­bilities in the area of drug information, organiza­tion of training courses and convening of a WHO intercountry consultative meeting on the rational use of essential drugs in 1993.

19.20 The wealth of expertise in the well-accept­ed systems of traditional medicine in the Region has facilitated their development in various ways: establishment of herbal gardens; production and quality control of traditional medicines using modern machinery and applying good manufac­turing practices; improvement of traditional medical services in the public sector; and training of traditional medicine practitioners for delivery of primary health care.

19 21 High immunization coverage has been achieved in most of the Member States, but many deaths still occur from measles, neonatal tetanus and poliomyelitis. Surveillance has improved but remains the weakest component of most national programmes. Vaccine supply is a matter of con­cern in several countries; and WHO, donor agen­cies and governments are seeking ways to im­prove self-sufficiency in this area. Local produc­tion of cold chain equipment (including com­plete solar systems) is progressing well.

19 22 While the overall incidence of malaria in the Region has remained unchanged over the last ten years, the situation in forest areas has become more serious. WHO has formulated technical and operational guidelines, indicators and crite­ria to implement the new global strategy forma­laria control, and all the malarious countries are preparing plans of operation.

19.23 WHO continued to cooperate in all as­pects of prevention and control of intestinal par­asitic infections, visceral leishmaniasis, filariasis, schistosomiasis and dracunculiasis. Intestinal parasitic infections are widespread in the Region. Visceral leishmaniasis is still a problem in parts of India, as well as Bangladesh and Nepal, as is lymphatic filariasis in Bangladesh, India, Indone­sia, Maldives, Myanmar, Nepal, Sri Lanka and Thailand. Schistosomiasis is endemic in parts of Indonesia and in limited areas of Thailand. Dracunculiasis is now a problem in India only, but has shown a downward trend in recent years.

19.24 All the Member States now have well de­veloped programmes for the control of diar­rhoea! diseases, implemented through primary health care. Training receives the highest priority

THE WORK OF WHO 1992-1993

and 10 countries have established some 55 units giving health workers practical training in diar­rhoea case management. Nine countries produce their own oral rehydration salts. A new strain of cholera, designated Vibrio cholerae 0139, was first isolated in an outbreak in V ell ore (India) in October 1992. It then spread rapidly to West Bengal and some other states in India. Large out­breaks have since been reported from Bangla­desh. A few cases have also been reported from Thailand and Nepal. Because there is very little resistance to this new strain, it has the potential for pandemic spread. All countries have been alerted and advised to intensify surveillance ac­tivities.

19.25 Early diagnosis and treatment is a key strategy for reducing mortality from acute respi­ratory infections in children. Ten Member States have started control programmes, and substantial progress has been made in several of them. More than 9000 doctors, 18 000 health workers and 30 000 health volunteers have received training in standard case management, facilitated by the translation of training materials in local languag­es. Health facility, household and mortality sur­veys have been carried out in some countries for evaluation purposes.

19 26 Tuberculosis continues to be a serious public health problem. In 1991 about two million cases were reported in the Region, almost half the world total, and nearly one million deaths annu­ally. However, there is renewed interest in con­trol of the disease because of its relationship with HIV infection and AIDS. WHO is providing support for the reorganization of control pro­grammes through evaluation and planning activ­ities or the initiation of pilot projects, with em­phasis on management at district level. Many nongovernmental organizations, the World Bank and bilateral agencies are involved in con­trol programmes in some countries.

19.27 Despite the significant progress made in leprosy control during the past decade, South­East Asia, with a registered case-load of 1 347 000 in 1993, accounts for 70% of all regis­tered cases in the world. Control activities were intensified in endemic countries and multidrug

144

therapy helped to reduce the disease burden. WHO collaborated in reviewing and modifying national plans for leprosy control, including pro­vision for resource mobilization and coordina­tion. In 1992 the Regional Committee adopted a regional strategy for leprosy elimination, which provides a framework for the development of control programmes.

19 28 Some Member States continue to be plagued by rabies. WHO provided support in the form of consultant services, supplies and equipment, training for health personnel and the organization of workshops on rabies control. Courses were conducted for provincial staff in Indonesia. Nepal intensified its control measures and human deaths from the disease were reduced in Sri Lanka through a project supported by WHO and AGFUND. In Mongolia the main emphasis was on eradication of plague and con­trol of brucellosis. WHO supported several countries in the development of new vaccines and in transfer of technology for the production of vaccine and sera, including plasma-derived hepatitis B vaccine in Mongolia and Myanmar, and tetanus toxoid and snake venom antisera in Bangladesh. Efforts were made in Thailand to improve the efficacy of vaccines used in the Ex­panded Programme on Immunization as well as vaccines against dengue haemorrhagic fever and Japanese encephalitis.

19 29 HIV infection did not begin to spread ex­tensively in South-East Asia until the mid-1980s, but the impact is already severe. More than 1.5 million people are estimated to have been infected and about 20 000 have already devel­oped AIDS. In response to this threat, govern­ments have set up national control programmes with WHO support. Political commitment is growing and multisectoral action, including the involvement of nongovernmental organizations and the private sector, is being undertaken. The aim is to interrupt transmission by promoting safer sexual behaviour including condom use, and to ensure early diagnosis and treatment of sexually transmitted diseases. Emphasis is also being given to safe and rational use of blood and blood products and to prevention of transmis­sion through contaminated injecting equipment.

20.1 The dramatic changes sweeping through the European Region in 1990-1991 continued in 1992-1993. Nineteen new Member States emerg­ed from the democratization process in countries of central and eastern Europe and republics of the former Soviet Union. In western Europe the 1992 Maastricht Treaty on European Union was finally ratified and came into force on 1 Novem­ber 1993.

20.2 The economic recession and resulting un­employment in many countries is having an impact on health care. Although the situation in several countries of central and eastern Europe has started to return to normal after their politi­cal transition, they still face serious socioeco­nomic problems. Conditions in republics of the former Soviet Union are generally more difficult, particularly as a result of the collapse of indus­trial enterprises and the rise in unemployment and inflation. The disturbing increase in the gap between "haves" and "have nots" is causing concern and has grave implications for the health of vulnerable people.

20 3 Communicable diseases have reappeared in a number of newly independent States. The statistics on diphtheria are alarming and reflect insufficient immunization coverage. Progress is being made, however, in reducing the incidence of poliomyelitis, measles, mumps and rubella. A small number of cholera cases have occurred in a few Member States, but most seem to be im­ported. AIDS is spreading at a slower pace than in other regions, but the potential impact of this disease in central and eastern Europe is worry­ing. The tobacco industry has continued to ex­pand in that part of the Region, where countries have not had time to establish appropriate legis­lation and health promotion programmes.

20.4 Some interesting developments have taken place with regard to health service reforms.

145

CHAPTER 20

European Region

In the United Kingdom reform of health care financing has allowed general practitioners to be­come independent fund holders; Germany has introduced diagnosis-related groupings for the remuneration of hospital services through the health insurance system; Finland has introduced a model for subsidizing municipal services, in­cluding health, through a global budget with less central control; and several countries of central and eastern Europe and newly independent States are well on the way to implementing re­forms. In 1992, for example, Hungary enacted legislation on health insurance, government pri­mary health care for outpatients, and public health; there were similar examples in Albania, Kazakhstan, Poland and Romania.

20 5 Armed conflicts in Europe continue to cause suffering and loss of life. In the conflict in former Yugoslavia, more than 150 000 people have reportedly been killed and hundreds of thousands wounded, close to four million people have been made refugees, probably as many as 20 000 women have been raped, thousands of people have been tortured, and around 3000 have been amputated. The consequences of the con­flicts affecting Armenia, Azerbaijan, Georgia and Tajikistan are receiving less attention from the outside world, yet the toll of human suffering is considerable.

20.6 In collaboration with other bodies of the United Nations system, intergovernmental and nongovernmental organizations and donors, WHO carried out an intensive programme of humanitarian assistance in republics of former Yugoslavia, focusing on public health and nutri­tion, equipment, supplies and logistic support and help to war victims. The policy of providing a broad range of standardized "kits" ensured that the supply of pharmaceuticals and equip­ment closely matched needs. These kits are now being widely used by other organizations. A

THE WORK OF WHO 1992-1993

WHO Special Representative in Tajikistan helped to coordinate humanitarian assistance.

20.7 Close cooperation continued with the Commission of the European Communities and the Council of Europe. One joint venture was the establishment in 1993 of a European Net­work of Health-promoting Schools, with a sec­retariat located at the Regional Office. Its aim is to make schools a healthy setting for living, learning and working. A joint two-year health care telecommunications project known as the "European Nervous System" was launched with the Commission. Its purpose is to demonstrate, through selected pilot areas and in collaboration with national health administrations and indus­try, ways of applying communications technol­ogy to meet selected information needs. It is re­garded as a first step towards the realization of a collaborative, trans-European health informa­tion network.

20.8 Many countries now have their own na­tional policies based on the European health-for­all policy. England is the most recent in that regard, with its "Health of the nation" policy document and rigorous implementation process. Both the full text of the updated health policy for Europe and summary were published and wide­ly distributed during 1992-1993.1

20 9 The number of networks of key partners concerned with health for all, whether institu­tions, groups or individuals, continued to grow. Some comprise general practitioners, diabetes specialists, health care financing experts and con­sumer organizations. Twenty countries have joined the countrywide integrated noncom­municable disease intervention (CINDI) pro­gramme, 11 of them countries of central and east­ern Europe or newly independent States. A Eu­ropean Forum of Pharmaceutical Associations and WHO was established in early 1992 to im­prove contacts and collaboration and to upgrade the role of the pharmacist in Europe through joint activities. A European Forum of National Medical Associations and WHO was constituted in 1991. At its first meeting in 1992 it issued a declaration on tobacco which, among other points, urged physicians to stop smoking. At its meeting in 1993 it adopted recommendations for

1 Health for all targets: the health policy for Europe. Copenhagen, World Health Organization, 1993 (Health for All Senes, No. 4).

146

national medical associations calling for meas­ures to ensure the quality of care.

20.10 The European Healthy Cities network was expanded in central and eastern Europe. More than 600 cities are now linked through some 20 national networks to this successful movement, which requires participants to draw up and imple­ment local health-for-all policies and plans. Poli­cies have also been promoted through a newly created network of "regions for health", grouping 11 regions in 10 European countries. This net­work has considerable potential, given that there are some 1500 regions in Europe.

20.11 Two European action plans on alcohol and on tobacco, endorsed by the Regional Com­mittee in 1992, were actively implemented. A task force was set up for execution of the Action Plan for a Tobacco-free Europe, especially in central and eastern Europe. The European Alco­hol Action Plan was translated into nine languag­es, and a European network of national counter­parts in alcohol research centres and advocacy groups established.

20.12 A conference of ministers of health and ministers of finance and planning on investment in health (Riga, 1-2 April 1993 ), organized with the help of voluntary donations, endorsed a Riga state­ment on principles for action to invest in health, and adopted a Riga initiative outlining activities for implementation of AIDS programmes in central and eastern Europe. High priority has been given to following up this conference.

20.13 During 1992 the Rome and Bilthoven (Netherlands) divisions of the European Environ­ment and Health Centre became fully operational, and in 1993 a project office was established in Nancy (France). Preparation continued of a com­prehensive report on the current environmental situation entitled "Concern for Europe's tomor­row". It will be Europe's contribution to the sec­ond European conference on environment and health, to be convened in Helsinki in 1994 jointly with the Commission of the European Communi­ties. WHO was actively involved in preparations for a ministerial conference on environment for Europe (Lucerne, Switzerland, April1993), which endorsed a special action programme for central and eastern Europe.

2014 Major changes have taken place in health services. In central and eastern Europe there is strong public pressure for privatization and the

EUROPEAN REGION

introduction of new financing mechanisms and health insurance systems. A permanent working group was set up within the project on health care reform (EUROCARE) in order to monitor and stimulate regional developments. As part of the project, a series of overviews of health care in transition and health care reforms in central and eastern Europe are being produced, and will be regularly updated.

20.15 A "Second Declaration of Alma-Ata" was made by nursing and midwifery leaders at­tending a first WHO meeting of government chief nurses of newly independent States (Almaty, September 1993). It states that training of nurses, midwives and other middle-level per­sonnel should be a priority for all countries, and highlights the advantages of preparing national action plans for nursing, endorsed by ministries of health. A special effort was made to distribute teaching/learning materials in central and eastern Europe and to newly independent States, and a fund-raising project (LEMON) was launched to ensure their translation into as many languages as possible.

147

20 16 After analysing vaccine needs in countries, WHO collaborated with UNICEF and other major donors in meeting the most acute require­ments. Steps were also taken to supply necessary pharmaceuticals in central and eastern Europe. The European diabetes action plan endorsed by the Regional Committee in 1991 has been pro­gressing on schedule: 46 Member States have es­tablished active national programmes related to the St Vincent Declaration on diabetes, and par­ticular emphasis has been given to central and eastern Europe and newly independent States. EUROHEALTH, the special programme for in­tensified cooperation with those countries, re­mained a top priority; and the network of WHO "liaison offices" in the countries was expanded to 16.

20.17 During the biennium the Regional Office operated with a 10% freeze on its regular budget allocation, a situation that had serious implica­tions for programme delivery given the increased number of European Member States. Particular efforts were made to improve management pro­cedures and to introduce new management tools.

CHAPTER 21

Eastern Mediterranean Region

21.1 At its thirty-ninth session in 1992 the Re­gional Committee for the Eastern Mediterranean adopted 12 resolutions on topics including mem­bership of Palestine in the Committee, advocacy of health for all among medical practitioners, zoonotic diseases, promotion of healthy life­styles, and reduction of maternal and infant mor­tality. Technical Discussions were held on "The impact of rapid urbanization on health". At its fortieth session in 1993 Palestine was welcomed as a member in the Committee in accordance with Article 47 of the Constitution. Technical papers were presented on leishmaniasis and abuse of narcotic and psychoactive drugs, as were progress reports on malaria control, AIDS prevention and control, poliomyelitis eradica­tion and WHO-sponsored research. The subject of the Technical Discussions was "The role of women in support of health for all".

21 2 In the field of information systems sup­port, the local area network in the Regional Office was expanded, and plans were made for imple­menting WHO's revised administration and fi­nance information system. The regional advisory panel on health information systems undertook the preparation of a manual on the establishment of national health information systems. Training in management techniques and planning was car­ried out in most countries. A regional advisory panel on health care financing was established.

21 3 The development of health systems based on primary health care progressed in all coun­tries. Access to health care services exceeded 80% in the Region as a whole. A number of Member States started to decentralize their health services. Management of care through dis­trict health systems was encouraged and a prob­lem-solving approach using district teams was widely accepted. T earns were formed for training and supervisory tasks in several countries includ­ingYemen.

149

21.4 Different approaches were used during the biennium to maintain and improve quality of care. Consideration was also given to solutions such as cost-sharing and insurance schemes to meet ever-rising costs. Two important meetings were held to further interest in health systems research and development, bringing together managers, directors and researchers: one to pro­mote cooperation between universities and min­istries of health in this field (Cairo, June 1992) and the other to discuss health systems research at the periphery (Damascus, October 1992).

21 5 Health care promotion gained momentum through the encouragement of multisectoral co­operation. A special feature in the Region is the basic minimum needs/quality-of-life approach to health promotion and disease prevention, which has proved its value in many countries including Egypt, Jordan, Somalia and Sudan.

21.6 Health legislation was drawn up to meet the needs of national health-for-all strategies. Fi­nancial support was provided for the establish­ment of emergency medical services in Qatar, with support from AGFUND, and in certain other areas, including Gaza, through UNR W A. In Afghanistan, Egypt, Syrian Arab Republic, Tunisia and Yemen medical equipment mainte­nance programmes were strengthened, following situation surveys, through the issue of new man­uals and training of staff. Guidelines on manage­ment of medical, surgical and accident emergen­cies for physicians were prepared.

21.7 With the establishment of a reliable health information system, efforts were directed to the formulation of coordinated policies and plans for the production and management of human re­sources for health. Most Member States no long­er face serious shortages of health personnel; consequently, the emphasis is now on improve­ment of quality. WHO promoted continuing ed-

THE WORK OF WHO 1992-1993

ucation programmes for all categories of person­nel within national health systems. In June 1993 the regional advisory panel on nursing drew up strategies to strengthen managerial capabilities and improve services, including the production of teaching/learning materials in national lan­guages. An intercountry workshop on training for trainers of health personnel (Damascus, No­vember 1992) reviewed recent approaches in this field and considered the use of national languages for teaching/learning materials. It was decided to decentralize the health leadership development programme, the first course being held in English in Islamabad, starting in August 1993.

21.8 As part of continued cooperation in na­tional health education programmes, a "proto­type action-oriented school health curriculum for primary schools", developed by WHO and UNICEF in collaboration with UNESCO and the Islamic Educational, Scientific and Cultural Organization, has so far been introduced in 12 countries. Intercountry activities focused on im­proving the quality of life of women in the Re­gion and increasing their potential for health promotion.

21 9 WHO cooperated with Member States in measures to prevent malnutrition due to insuffi­cient, excessive or unbalanced intake; protein­energy and micronutrient malnutrition, especially iodine deficiency disorders; and anaemia and vitamin A deficiency. A manual on rapid nutri­tional assessment in emergencies is in preparation.

21.10 The Regional Training and Research Cen­tre for Oral Health in Damascus conducted sev­eral training courses in the planning and manage­ment of preventive oral health programmes.

21 11 Accident prevention programmes focused on safety promotion and accident injury control, including advocacy of coordinated multisectoral action. National occupational health pro­grammes have grown as the awareness and com­mitment of governments increase.

2112 Programmes on tobacco or health were established or strengthened in the Region. All countries produced education materials on the hazards of smoking.

2113 National capacity to implement maternal and child health and family planning pro­grammes was strengthened. A consultation (Bei­rut, June 1993) was held to consider the health

150

and socioeconomic status of adolescent girls. Safe motherhood programmes aimed at reducing maternal and infant mortality were established in several countries. Many were supported in ef­forts to reduce the frequency of low birth weight, which can affect 30% of babies. The Baby-friendly Hospital Initiative was promoted.

2114 Several countries sought cooperation in formulating multisectoral plans on health of the elderly following the preparation, through re­gional or intercountry activities, of a strategy for 1992-2001 and of regional and national plans to promote health and psychosocial care for the elderly.

21 15 The main task of the mental health pro­gramme during the biennium was to integrate mental health into primary health care, with em­phasis on mental health promotion and the pre­vention of mental and neurological disorders. Drug abuse, however, remained a serious health and social problem in the Region.

21 16 All countries were supported in imple­menting essential drugs programmes focused on the development of national drug policies, in re­viewing national lists of essential drugs, and in improving drug quality assurance systems through measures to strengthen quality control laboratories and train staff in drug inspection.

2117 Health laboratory services were extended; efforts to improve their performance included the preparation of a manual on quality assurance for peripheral and intermediate laboratories, and guidelines on the facilities needed to cope with emergencies as part of a national contingency plan. Local production of reagents received high priority, and progress was made in developing blood transfusion services.

21.18 A regional strategy on health and environ­ment was drawn up at an intercountry meeting (Amman, June 1993) and adopted by the Region­al Committee in October 1993.

21.19 As arid conditions and lack of water re­sources pose considerable problems in the East­ern Mediterranean, activities concerned with wa­ter quality control and wastewater use were in­tensified in many areas. The high cost of city sewerage is a major constraint, but several gov­ernments have succeeded in providing a reasona­ble level of financial support for water supply and sanitation.

EASTERN MEDITERRANEAN REGION

21 20 Rapid urbanization and urban population growth are causing severe health and environ­mental problems. In some rural areas settlements have grown up which have the character of small urban communities, accommodating large num­bers of people who commute to nearby cities. An integrated approach to the growing difficulties experienced by these settlements has been pro­moted through "healthy villages" programmes.

21 21 Industrialization and the use of pesticides, herbicides and artificial fertilizers in agriculture increase hazards due to toxic chemicals, and there has been little action to ensure their safe use. A number of countries, however, are show­ing a keen interest in national chemical safety programmes. WHO continued to promote train­ing in this field, as in other aspects of environ­mental health such as monitoring and control of air and water pollution, including bacterial pol­lution of the sea. Support was also given for food safety programmes, for instance, in the prepara­tion of guidelines on integrating food safety into primary health care and the strengthening of food laboratory services.

21.22 The Centre for Environmental Health Activities in Amman conducted 40 national and 10 intercountry training and research courses, and strengthened its network for disseminating environmental health information.

21.23 The regional health and biomedical infor­mation programme provided services and advice to countries as well as maintaining its traditional role of support for Regional Office programmes. A number of countries have been preparing na­tional plans in this field in cooperation with WHO. A collaborating centre for health and bio­medical information was designated in the Islam­ic Republic of Iran in February 1993. Other ac­tivities included involvement in ExtraMED, a global project in which the full text of over 200 health journals not contained in the main databases such as MEDLINE will be placed on CD-ROM monthly.

21 24 The battle against communicable and noncommunicable diseases is still the main area of collaboration between WHO and the Member States, in respect of both emergency measures

151

during outbreaks of disease or epidemics, and continuing disease prevention and control pro­grammes.

21.25 Cholera epidemics affected seven Member States, and malaria, leishmaniasis and Rift V alley fever reached epidemic proportions in some are­as. WHO's role has been to mobilize specialist consultant services, prepare guidelines and train­ing aids, and provide emergency supplies. The Organization has also fostered collaboration be­tween neighbouring countries, as in the case of poliomyelitis eradication in the Gulf States and the Maghreb; the same approach is being tried for malaria control.

21 26 The Eastern Mediterranean Region has been relatively less affected by the rapid spread of HIV infection than some other regions. Ef­forts in national programme planning, in train­ing, and particularly in promoting the social and cultural values of the Region that inculcate self­respect and morality in individual relationships, have contributed to its prevention.

21.27 The use of scientific methods for the pre­vention and control of cardiovascular diseases, cancer, diabetes and other noncommunicable disorders is being promoted, along with initia­tives to inform and motivate national authorities, nongovernmental organizations and communi­ties.

21 28 The WHO standards for recruitment of international staff were applied in the Regional Office. However, there were difficulties in meet­ing the target of 40% in the appointment of na­tionals from under-represented countries and in recruiting a greater proportion of women. The plans to extend the Regional Office building were delayed pending the solution of problems concerning the title to the land made available by the Host Government. Steps were taken to im­prove accountability in regard to supplies and equipment ordered for Member States.

21.29 A 10% reduction in programme imple­mentation, imposed by the expected deficit in contributions, made it difficult to respond to critical situations in times of unprecedented need, including emergencies, in the Region.

CHAPTER 22

Western Pacific Region

22.1 Socioeconomic and political change in the Region has been swift and widespread. Positive and welcome developments included renewed optimism in Cambodia for peaceful economic growth. At the forty-fourth session of the Re­gional Committee, held in Manila in 1993, fur­ther changes were recognized, for example, in the presence ofT uvalu as a full member of the Corn­mittee. The participation of Macao on its own behalf, though without voting rights, in future sessions of the Committee was also announced.

22.2 Demographic, environmental and eco­nomic developments have also been changing the patterns of disease in theW estern Pacific. Diseas­es such as diabetes, heart disease and cancer that are associated with unhealthy lifestyles have in­creased generally. This is also true of the devel­oping countries where traditional communicable diseases such as tuberculosis remained undimin­ished. These developments have made it necess­ary to review the way health services are organ­ized. Health promotion as an extension of the primary health care strategy is now emphasized as the main approach to the solution of health problems, and the training of health personnel at all levels has had to be adjusted accordingly. Other key approaches are surveillance to moni­tor the changing health status of the Region, the collection and dissemination of accurate and timely health information from a broad geo­graphical base and greater attention to manage­ment issues such as financing and quality of care.

22 3 The availability of adequate and appropri­ate human resources is a critical component of the infrastructure needed for health develop­ment. The orientation of training towards com­munity-based primary health care services con­tinued during the biennium. Sharing of the Re­gion's health training resources was encour­aged. A first group of primary care practitioners graduated from the Fiji School of Medicine in

153

December 1993, products of a new academic strategy and curriculum that promises to be well suited to the needs of Pacific island nations. New approaches to medical education were reviewed and changes were made in the basic training of health workers such as nurses and dental health practitioners. Distance learning was promoted, as was postgraduate and continuing medical edu­cation in various countries.

22 4 In the important area of disease preven­tion and control, coverage of infants with the six antigens of the Expanded Programme on Immu­nization was over 90% during the biennium. Re­maining pockets of low coverage are the target of future action. Tuberculosis incidence remained high, but the rates for poliomyelitis, diphtheria and pertussis declined significantly. Measles inci­dence has fallen significantly during the last dec­ade as a result of immunization, but outbreaks still occur in most countries.

22.5 In 1992 there was a 21% reduction in cases of poliomyelitis compared with the previous year, and the lowest annual total ever reported: 2087 cases. Given sufficient vaccine and funding, it is expected that the regional goal of eradication of the disease by 1995 can be attained. Efforts were directed to improving surveillance, even in coun­tries reporting no cases of the disease, and to in­creasing supplementary immunization. China, Lao People's Democratic Republic, Philippines and Vi et N am conducted national immunization days, during which 120 million children under the age of five years were protected with oral poliovirus vaccine. In 1993 the Regional Commit­tee recognized the need to ensure the potency, safety and efficacy of the vaccine, and adopted a resolution to that effect.

22 6 Immunization against hepatitis B was in­creased. Technical support was given for local production of plasma-derived vaccine in China

THE WORK OF WHO 1992-1993

and Vi et N am. By 1992, 27 countries had incor­porated the vaccine into their immunization schedules, although only on a limited scale in some cases. Where vitamin A is deficient it is also given during immunization sessions, as in the Philippines.

22.7 The goal has been adopted of eliminating leprosy as a public health problem (less than one case per 10 000 population) in all parts of the Region by the year 2000. 1992 data indicated a reduction of about 10% in the number of report­ed cases compared with the previous year. Over­all prevalence in the Region is 0.44 per 10 000. Coverage of multidrug therapy was 70% in 1992. Extrabudgetary funding has been essential for this purpose and for other activities such as train­ing and programme evaluation.

22 8 Malaria control has been a focus of atten­tion. The nine malarious countries in the Region reported nearly 800 000 microscopically con­firmed cases in 1991, a total that was expected to fall in subsequent years. All the malarious coun­tries are currently implementing intensive con­trol strategies, or plan to do so in the near future. More than two million cases are believed to be unreported or incompletely treated. However, following a reorientation of the malaria control programmes, data are now collected and ana­lysed with greater emphasis on numbers of clini­cally diagnosed cases and amounts of drugs used. Impressive reductions in the numbers of micro­scopically confirmed cases have been achieved in parts of the Solomon Islands and also in Viet N am where two million adult curative doses of artemisinin, a derivative of Artemisia annua, are being produced annually for use in areas with high levels of multidrug resistance. Two meet­ings were held in Kunming (China) in November 1993 for countries of the Western Pacific and South-East Asia sharing at least one national border with another malarious country. The meetings made recommendations for strengthen­ing a variety of malaria control measures within countries, across common borders and between regions, including the establishment of networks for information exchange, monitoring of drug resistance, operational research and training.

22 9 The number of cases of tuberculosis re­ported in the Region possibly represents as little as one-third of the real total, estimated at 1. 9

million. There was no decline in the numbers of new cases during the biennium and, given the disease's close link with HIV infection and the

154

spread of drug resistant strains, an increasing trend can be expected in the future. Measures such as short-course chemotherapy, appropriate care management and surveillance are being in­tensified.

2210 It is conservatively estimated that between 50 000 and 100 000 people are already infected with HIV in the Region and the numbers are growing rapidly. However, all Member States now have national AIDS committees as well as laboratory facilities to test for HIV antibody, and high priority is given to management and control of sexually transmitted diseases. The means of transmission have been evolving as in­formation, education and other health promotive activities help to alter behaviour patterns. In Australia, for example, the epidemic seems to be reaching a plateau. An evaluation of the national five-year strategy concluded that the most effec­tive interventions in the early days of the epi­demic were funding of sex worker groups and the establishment of needle and syringe exchange schemes in major cities. In 1993 the Regional Committee called for the drafting of guidelines for national authorities, greater involvement of other government departments and nongovern­mental organizations in the planning of activities, better surveillance and more intensive exchange of information, particularly the results of scien­tific studies.

22.11 At its 1993 session the Regional Commit­tee endorsed the regional programme for health promotion which stresses, on the one hand, ac­tion by individuals to adopt healthy lifestyles and, on the other, the creation of supportive en­vironments for health and the mobilization of communities and governments to achieve health goals. The programme identifies and addresses health issues in relation to different age groups, recognizing that the dominant diseases are those influenced by changes in lifestyle as well as fac­tors external to the individual such as urbaniza­tion, industrialization, migration and environ­mental change. Moreover, chronic illness and de­generative changes will affect the Region's ag­ing populations. Strategies for health promotion therefore form a significant element of many programmes in the Region.

22.12 Demographic changes in the Region have continued to require new strategies to prevent environmental degradation and safeguard envi­ronmental health. Following the 1992 United Nations Conference on Environment and Devel-

WESTERN PACIFIC REGION

opment (see paragraph 12.1), an international symposium on improving environmental man­agement in north-east Asia was convened in the Republic of Korea in 1992. Similarly, national workshops were organized in Malaysia and Philippines to draw up plans for follow-up activ­ities. The integration of environmental manage­ment in rural and urban development pro­grammes has become a priority concern. Region­al workshops have proved very helpful in dealing with specific issues; for instance, one held in Fiji (Suva, May 1992) reviewed solid waste manage­ment options for small island nations constrained by geographical limitations and shortages of fi­nancial and human resources. National training programmes, such as the series of environmental planning and management courses conducted in collaboration with the Government of Malaysia,

ISS

have given good results. Urban health develop­ment activities, closely linked with health pro­motion and primary health care, are under way in several countries.1

22.13 Directions for the future will be deter­mined by the Region's main concerns as de­scribed above. Priority setting will be a crucial exercise, and the first steps in this respect were taken in 1992-1993. The coordinated and con­certed efforts of the Member States will, howev­er, be the key to accomplishing the many and ambitious goals of health for all in the Western Pacific.

1 Austrolio, Chrno, Jopon, Moloysro, Popuo New Gurneo, Philippines, Repub· lie of Koreo, Vie! Nom.

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 1 993 Belgium'f 25June 1948 Ethiopia 11 April1947 Belize 23 August 1990 Fiji'f 1 January 1972 Benin 20 September 1 960 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'I voire'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':· Jordan* Kazakhstan Kenya* Kiribati Kuwait'~

Kyrgyzstan Lao People's Democratic

16 May 1951 7 April1947 19 August 1992 27 January 1964 26 July 1984 9 May 1960 29 April1992

Republic'~ 17 May 1950 Latvia 4 December 1991 Lebanon 19 January 1949 Lesotho'~ 7 July 1967 Liberia 14 March 1947 Libyan Arab J amahiriya'~ 16 May 1952 Lithuania 25 November 1991 Luxembourg'~ 3 June 1949 Madagascar'~ 16 January 1961 Malawi'~ 9 April1965 Malaysia'-· 24 April1958 Maldives'~ 5 November 1965 Mali':· 17 October 1960 Malta'~ 1 February 1965 Marshall Islands 5 June 1991 Mauritania 7 March 1961 Mauritius'~ 9 December 1968 Mexico 7 April1948 Micronesia (Federated States of) 14 August 1991 Monaco 8 July 1948 Mongolia'-· 18 April1962 Morocco'~ 14 May 1956 Mozambique 11 September 1975 Myanmar 1 July 1948 Namibia 23 April1990 Nepal'~ 2 September 1953 Netherlands'-· 25 April1947 New Zealand'~ 10 December 1946 Nicaragua'~ 24 April1950 Niger'-· 5 October 1960 Nigeria'-· 25 November 1960 Norway'-· 18 August 1947 Oman 28 May 1971 Pakistan'~ 23 June 1948 Panama 20 February 1951 Papua New Guinea 29 April1976 Paraguay 4 January 1949 Peru 11 November 1949 Philippines'~ 9 July 1948 Poland'~ 6 May 1948 Portugal 13 February 1948 Qatar 11 May 1972 Republic of Korea* 17 August 1949 Republic of Moldova 4 May 1992 Romania'-· 8 June 1948 Russian Federation 24 March 1948 R wanda'-· 7 November 1962 Saint Kitts and Nevis 3 December 1984 Saint Lucia'' 11 November 1980

Saint Vincent and the Grenadines

Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal'~

Seychelles'~ Sierra Leone':· Singapore'~

Slovakia Slovenia Solomon Islands Somalia South Africa Spain'-· Sri Lanka Sudan Suriname Swaziland Sweden* Switzerland Syrian Arab Republic Tajikistan Thailand* The Former Yugoslav

Republic of Macedonia Togo'~

Tonga* Trinidad and Tobago'~ Tunisia'~

Turkey Turkmenistan Tuvalu Uganda'' Ukraine'-· United Arab Emirates United Kingdom of

Great Britain and Northern Ireland'-·

United Republic of Tanzania'~ United States of America Uruguay* Uzbekistan Vanuatu Venezuela VietNam Yemen Yugoslavia'-· Zaire'~

Zambia'~

Zimbabwe'~

Associate M embers

Puerto Rico Tokelau

2 September 1983 16 May 1962 12 May 1980 23 March 1976 26 May 1947 31 October 1960 11 September 1979 20 October 1961 25 February 1966 4 February 1993 7 May 1992 4 April1983 26January 1961 7 August 1947 28 May 1951 7 July 1948 14 May 1956 25 March 1976 16 April1973 28 August 1947 26 March 1947 18 December 1946 4 May 1992 26 September 1947

22 April1993 13 May 1960 14 August 1975 3 January 1 963 14 May 1956 2 January 1948 2July 1992 7 May 1993 7 March 1963 3 April1948 30 March 1972

22July 1946 15 March 1962 21 June 1948 22 April 1949 22 May 1992 7 March 1983 7 July 1948 17 May 1950 20 November 1953 19 November 1947 24 February 1961 2 February 1965 16 May 1980

7 May 1992 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

Algeria Angola Benin Botswana Burkina Faso Burundi Cameroon Cape Verde Central African Republic Chad Comoros Congo

Antigua and Barbuda Argentina Bahamas Barbados Belize Bolivia Brazil Canada Chile Colombia Costa Rica

Bangladesh Bhutan Democratic People's

Republic of Korea

African Region

Cote d'Ivoire Madagascar Equatorial Guinea Malawi Eritrea Mali Ethiopia Mauritania Gabon Mauritius Gambia Mozambique Ghana Namibia Guinea Niger Guinea-Bissau Nigeria Kenya Rwanda Lesotho Sao Tome and Principe Liberia Senegal

Region of the Americas

Cuba Mexico Dominica Nicaragua Dominican Republic Panama Ecuador El Salvador Grenada Guatemala Guyana Haiti Honduras Jamaica

India Indonesia Mal dives Mongolia

Paraguay Peru Saint Kitts and Nevis Saint Lucia Saint Vincent

and the Grenadines Suriname Trinidad and Tobago

South-East Asia Region

161

Myanmar Nepal

Seychelles Sierra Leone South Africa Swaziland Togo Uganda United Republic

of Tanzania Zaire Zambia Zimbabwe

United States of America Uruguay Venezuela

Associate M ember:

Puerto Rico

Sri Lanka Thailand

Albania Armenia Austria Azerbaijan Belarus Belgium Bosnia and

Herzegovina Bulgaria Croatia Czech Republic Denmark Estonia Finland

Afghanistan Bahrain Cyprus Djibouti Egypt Iran

(Islamic Republic of)

Australia Brunei Darussalam Cambodia China Cook Islands Fiji Japan

THE WORK OF WHO 1992-1993

European Region

France Malta Georgia Monaco Germany Netherlands Greece Norway Hungary Poland Iceland Portugal Ireland Republic of Moldova Israel Romania Italy Russian Federation Kazakhstan San Marino Kyrgyzstan Slovakia Latvia Slovenia Lithuania Spain Luxembourg Sweden

Eastern Mediterranean Region

Iraq

Jordan

Kuwait

Lebanon

Libyan Arab Jamahiriya

Morocco

Oman

Pakistan

Qatar

Saudi Arabia

Somalia

Western Pacifi( Region

Kiribati Lao People's

Democratic Republic Malaysia Marshall Islands Micronesia (Federated

States of)

162

New Zealand Papua New Guinea Philippines Republic of Korea Samoa Singapore Solomon Islands

Switzerland Tajikistan The Former Yugoslav

Republic of Macedonia

Turkey Turkmenistan Ukraine United Kingdom of

Great Britain and Northern Ireland

Uzbekistan Yugoslavia

Sudan

Syrian Arab Republic

Tunisia

United Arab Emirates

Yemen

Tonga Tuvalu Vanuatu VietNam

Associate M ember Tokelau

ANNEXES

Annex 3

Organizational and related meetings

1. Meetings in 1992

Executive Board: Committee on Drug Policies Executive Board, eighty-ninth session Executive Board: Standing Committee on Nongovernmental Organizations Executive Board: Committee to Consider Certain Financial Matters prior

to the Forty-fifth World Health Assembly Forty-fifth World Health Assembly Executive Board, ninetieth session Executive Board: Programme Committee Regional Committee for Africa, forty-second session Regional Committee for the Western Pacific, forty-third session Regional Committee for South-East Asia, forty-fifth session Regional Committee for Europe, forty-second session Regional Committee for the Americas, forty-fourth session/

XXXVI Meeting of the Directing Council of P AHO Regional Committee for the Eastern Mediterranean, thirty-ninth session

2. Meetings in 1993

Executive Board, ninety-first session Executive Board: Standing Committee on Nongovernmental Organizations Executive Board: Committee to Consider Certain Financial Matters

prior to the Forty-sixth World Health Assembly Forty-sixth World Health Assembly Executive Board, ninety-second session Executive Board: Programme Committee Executive Board: Programmee Committee

Regional Committee for Africa, forty-third session Regional Committee for Europe, forty-third session Regional Committee for the Western Pacific, forty-fourth session Regional Committee for South-East Asia, forty-sixth session Regional Committee for the Americas, forty-fifth session/XXXVII meeting

of the Directing Council of P AHO Regional Committee for the Eastern Mediterranean, fortieth session

163

Geneva, 17-18 January Geneva, 20-28 January Geneva, 21 January

Geneva, 4 May Geneva, 4-14 May Geneva, 18-19 May Geneva, 24-28 August Brazzaville, 2-9 September Hong Kong, 7-11 September Kathmandu, 7-13 September Copenhagen, 14-19 September Washington, D.C.,

21-26 September Alexandria, 3-7 October

Geneva, 18-29 January Geneva, 19 January

Geneva, 3 May Geneva, 3-14 May Geneva, 17-18 May Geneva, 5-9 July Geneva, 29 November-

1 December Gaborone, 1-8 September Athens, 6-1 0 September Manila, 13-17 September New Delhi, 21-27 September Washington, D.C.,

27 September - 2 October Alexandria, 2-5 October

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 International Committee of Military Medicine

and Pharmacy International Office of Epizootics

Islamic Development Bank League of Arab States Organization of African Unity

2. Nongovernmental organizations

African Medical and Research Foundation International

Aga Khan Foundation Association of the Institutes and Schools of Tropical

Medicine in Europe CMC- Churches' Action for Health Christoffel-Blindenmission Collegium lnternationale N euro-

Psychopharmacologicum Commonwealth Association for Mental

Handicap and Developmental Disabilities Commonwealth Medical Association Commonwealth Pharmaceutical Association Council for International Organizations of Medical

Sciences Helen Keller International, Incorporated Industry Council for Development Inter-American Association of Sanitary

and Environmental Engineering International Academy of Legal Medicine

and Social Medicine International Academy of Pathology International Agency for the Prevention of Blindness International Air Transport Association International Alliance of Women International Association for Accident

and Traffic Medicine International Association for Adolescent Health International Association of Agricultural Medicine

and Rural Health International Association of Cancer Registries International Association for Child and Adolescent

Psychiatry and Allied Professions International Association of Hydatid Disease International Association of Lions Clubs

164

International Association of Logopedics and Phoniatrics

International Association of Medical Laboratory Technologists

International Association for the Study of the Liver International Association for the Study of Pain International Association for Suicide Prevention International Association on Water Quality International Astronautical Federation International Bureau for Epilepsy International Catholic Committee of Nurses

and Medico-Social Assistants International Clearinghouse for Birth Defects

Monitoring Systems International College of Surgeons International Commission on Occupational Health International Commission on Radiation Units

and Measurements International Commission on Radiological

Protection International Committee of the Red Cross International Confederation of Midwives International Conference of Deans of French-

language Faculties of Medicine International Council on Alcohol and Addictions International Council on Jewish Social and

Welfare Services International Council for Laboratory Animal

Science International Council of Nurses International Council of Scientific Unions International Council on Social Welfare International Council of Societies of Pathology International Council for Standardization in

Haematology

ANNEXES

International Council of Women International Cystic Fibrosis (Mucoviscidosis)

Association International Dental Federation International Diabetes Federation International Electrotechnical Commission International Epidemiological Association International Ergonomics Association International Eye Foundation International Federation on Ageing International Federation of Business and

Professional Women International Federation of Chemical, Energy

and General Workers' Unions International Federation of Clinical Chemistry International Federation for Family Life

Promotion International Federation of Fertility Societies International Federation of Gynecology and

Obstetrics International Federation of Health Records

Organizations International Federation of Hospital Engineering International Federation for Housing and Planning International Federation of Hydrotherapy and

Climatotherapy International Federation for Information Processing International Federation for Medical and Biological

Engineering International Federation of Medical Student

Associations International Federation of Multiple Sclerosis

Societies International Federation of Ophthalmological

Societies International Federation of Oto-Rhino­

Laryngological Societies International Federation of Pharmaceutical

Manufacturers Associations International Federation of Physical Medicine

and Rehabilitation International Federation for Preventive and

Social Medicine International Federation of Red Cross and

Red Crescent Societies International Federation of Sports Medicine International Federation of Surgical Colleges International Group of National Associations of

Manufacturers of Agrochemical Products International Hospital Federation International Lactation Consultant Association International League of Dermatological Societies International League of Associations for Rheumatology International League against Epilepsy International Leprosy Association International Leprosy Union International Life Sciences Institute International Medical Informatics Association International Medical Society of Paraplegia International Organization of Consumers Unions

165

International Organization for Standardization International Organization against Trachoma International Pediatric Association International Pharmaceutical Federation International Physicians for the Preventiof\ of

Nuclear War International Planned Parenthood Federation International Radiation Protection Association International Society for Biomedical Research on

Alcoholism International Society of Biometeorology International Society of Blood Transfusion International Society for Burn Injuries International Society of Chemotherapy International Society and Federation of Cardiology International Society of Haematology International Society for Human and Animal

Mycology International Society of Orthopaedic Surgery

and Traumatology International Society of Nurses in Cancer Care International Society for Prosthetics and Orthotics International Society of Radiographers and

Radiological Technologists International Society of Radiology International Society for the Study of Behavioural

Development International Sociological Association International Solid Wastes and Public Cleansing

Association International Special Dietary Foods Industries International Union of Architects International Union of Biological Sciences International Union against Cancer International Union for Conservation of Nature

and Natural Resources International Union of Family Organizations International Union for Health Promotion

and Education International Union of Immunological Societies International Union of Local Authorities International Union of Microbiological Societies International Union of Nutritional Sciences International Union of Pharmacology International Union of Pure and Applied Chemistry International Union of Toxicology International Union against Tuberculosis and Lung

Disease International Union against the Venereal Diseases

and the Treponematoses International Water Supply Association Inter-Parliamentary Union Joint Commission on International Aspects of

Mental Retardation La Leche League International Medical Women's International Association Medicus Mundi Internationalis (International

Organization for Cooperation in Health Care) Mother and Child International National Council for International Health

THE WORK OF WHO 1992-1993

Network of Community-Oriented Educational Institutions for Health Sciences

OXFAM (Oxford Committee for Famine Relief) Population Council Rehabilitation International Rotary International Royal Commonwealth Society for the Blind Save the Children Fund (UK) Soroptimist International W odd Assembly of Youth W odd Association of Girl Guides and Girl Scouts W odd Association of the Major Metropolises W odd Association for Psychosocial Rehabilitation World Association of Societies of (Anatomic and

Clinical) Pathology World Blind Union W odd Confederation for Physical Therapy World Federation of Associations of Poisons Centres

and Clinical Toxicology Centres W odd Federation of the Deaf W odd Federation of Hemophilia W odd Federation for Medical Education

166

W odd Federation for Mental Health W odd Federation of Neurology W odd Federation of Neurosurgical Societies W odd Federation of Nuclear Medicine and Biology W odd Federation of Occupational Therapists W odd Federation of Parasitologists W odd Federation of Proprietary Medicine

Manufacturers W odd Federation of Public Health Associations W odd Federation of Societies of Anaesthesiologists World Federation of United Nations Associations W odd Hypertension League W odd Organization of National Colleges,

Academies and Academic Associations of General Practitioners/Family Physicians

W odd Organization of the Scout Movement W odd Psychiatric Association W odd Rehabilitation Fund W odd Veterans Federation W odd Veterinary Association W odd Vision International

Annex 5

Structure of the World Health Organization at 31 December 1993

Division of Emergency and Humanitarian Action (EHA) ' Office of Legal Counsel (LEG) Off1ce of Internal Audit (OIA)

' Includes the Representative of the Director-General of WHO to the Umted Nat1ons system and other intergovernmental bod1es at New York: the WHO Senior Health Adviser to UNICEF, New York; the Representative of the Director-General of WHO to the European Community at Brussels, and the WHO Office for the Orgamzation of African Unity and the Economic Commission for Afnca, Addis Ababa

' Includes the WHO Pan Afncan Centre for Emergency Preparedness and Response, AddiS Ababa

'Regional Office for the Americas/ Pan Amencan Samtary Bureau

Headquarters

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)

Act1on Programme on Essential Drugs (DAP) D1vis1on of Drug Management and Pollc1es

(DMP) DIVISIOn of Food and Nutntlon (FNU) Programme on Health Technology (PHn

Division of Diarrhoea! and Acute Respiratory D1sease Control (GDR)

D1v1sion of Commumcable Diseases (CDS) DIViSIOn of Control of TrOPICal Diseases (CTD) Expanded Programme on lmmumzat1on (EPI) Special Programme for Research and Trammg

in Tropical Diseases (TOR)

Division of Family Health (FHE) Division of Health Education (HED) Division of Development of Human Resources

for Health (HRH) Spec1al Programme of Research. Development

and Research Trammg m Human Reproduction (HRP)

Health and Biomedical Information Programme (HBI)

Division of Epidemiological Surveillance and Health S1tuation and Trend Assessment (HSn

Division of Strengthening of Health Serv1ces (SHS)

DiviSIOn of Health ProtectiOn and Promotion (HPP)

Division of Mental Health (MNH) Division of Noncommunicable Diseases (NCD) Programme on Substance Abuse (PSA) Office of Research Promotion and

Development (RPD)

Division of Budget and Fmance (BFI) DiviSIOn of Conference and General Serv1ces

(CGS) Division of lnteragency Affairs (INA) Division of Personnel (PER) Adviser on lnformatics (AOI) Information Technology Off1ce (ITO) Management Development Off1ce (MOO) Programme for Resource Mobilization (RMB)

DIVISion of Environmental Health (EHE) Programme for the Promotion of Chemical

Safety (PCS)

South-East Asia

-

Regional Offices

Programme Coordination,

Promotion and Information

Programme Management

Support Programme

Assistant Director

Deputy Director

Programme Management

Support Programme -

-Programme Management

Support Programme -

-Programme Management

Support Programme -

-Programme Management

Support Programme

I

I

WHO lntercountry Health Development Teams

WHO Representatives OnchocerciaSIS Control

Programme in West Africa

Health Systems Infrastructure

Health Programmes Development

WHO Representallves

WHO Representatives

WHO Representatives Director of Health, UNRWA

WHO Representatives WHO Country Liaison Off1cers

International Agency for Research on Cancer

DIRECTOR

Secretariat

PAHOIWHO Representatives Programme Coordmat1on

Offices Caribbean Programme

Coordmation

WH094034/E

ASSISTANT DIRECTOR-GENERAL

Action Programme on Essential Drugs (OAP} Country LiaiSOn (COL} Operational Research and

Development Work (ORD) Training and Human Resources

(THR)

Division of Drug Management and Policies jDMP} BIOIOQICa S (BLG) Drug Safety (DRS) Quality Assurance (QAS) Regulatory Support (RGS) Traditional Medicine (TRM)

Division of Food and Nutrition (FNU} Food Aid Programmes (FAP) Food Safety (FOS) Nutrition (NUT)

Programme on Health Technology (PHT) Clm1cal Technology (CLI) Health Laboratory Technology

and Blood Safety (LBS) Radiation Med1cine (RAD)

Division of Emergency and Humanitarian Action (EHA) Afghanistan Programme (AFP)

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)

Di~~~:n Resources for Health IHRH} Educalianal Development of

Human Resources for Health (EDH}

Health Learning Materials Programme (HLM)

Human Resources Policy Analyses (HPA)

Human Resources Management (HRM)

Nursing (NUR) Planning of Human Resources

for Health (PHR) Research Traming Grants and

Fellowships (RTG) Staff Development Programme

(SDP}

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)

Structure of the Secretariat at Headquarters

Ombudsman (OMB)

ASSISTANT DIRECTOR· GENERAL

OffiCe of International CooperatiOn

(I CO)

Health and Biomedical Information Programme IHBI} Distnbution and Sales (DSA) Health Legislation (HLE) Office of Library and Health

Literature Serv1ces (HLT) Off1ce of Publications (PUB} Office of Language Serv1ces

(TRA)

Division of Epidemiological Surveillance and Health Situation and Trend Assessmenf (HST} Epidemiological and Stat1st1cal

Methodology (ESM) Global Health S1tuat1on

Assessment and Projections (GSP)

Momtonng, Evaluation and Projection Methodology (MEP/

Strengthenmg of Epidemiolog1ca and Statistical Services (SES)

Division of Strengthening of Health Services (SHS} D1stnct Health Systems (OHS) Health Systems Research and

Development (HSR) National Health Systems and

Policies (NHP)

(DGH)

Division of Health Profection and Promotion (HPP} Health of the Elderly (HEE)

Prevention of Deafness and Hearing Impairment (PDH)

Rehabilitation (RHB) Injury Prevention (IPRJ Occupational Health (OCH) Oral Health (ORH) Prevention of Blindness (PBL) Tobacco or Health (TOH)

Office of the Legal Counsel (LEG)

Off1ce of Internal Audit (OIA)

EXECUTIVE DIRECTOR

Division of Environmental Health (EHE} Community Water Supply and

Sanitation (CWS) Prevention of Environmental

Pollution (PEP)

Programme for the Promotion of Chemical Safety (PCS)

EXECUTIVE , DIRECTOR

Global Programme on AIDS (GPA) Sexually Transm1tted Diseases

(VDT) Planmng and Policy Coordination

(PPG) Office of Cooperation w1th National

Programmes (GNP) Off1ce oflntervent1on Development

and Support (lDS) Office of Research (RES) Admimstrat1ve Support Services

(ADS)

Wf-1094033/E

Index

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

Abortion, 10.11, 10.35 ACC, see Administrative Committee on Coordina-

tion Accidents, see Injury prevention ACHR, see Advisory committees on health research Administration and finance information system

(AFI), 16.13-16.14 Administrative Committee on Coordination (ACC),

2.11, 2.13, 14.137 Inter-Agency Committee on Sustainable Develop-

ment, 2.11 lntersecretariat Group for Water Resources, 12.13 Subcommittee on Statistical Activities, 4.9, 4.10 Subcommittee on Water Resources, 12.13

Adolescent health, see Youth and adolescence Advisory committees on health research (ACHR),

global, 8.2-8.4 regional, 8.9, 8.10, 8.13

Afghanistan, 2.31, 5.8, 14.15, 16.16, 21.6 Operation Salam, 16.22

African Development Bank, 2.19, 2.26, 13.34 African Development Fund, 2.19 African Economic Community, treaty, 2.22 African health development framework, 17.1 African Region, 17.1-17.17, Annex 2

see also individual activities African trypanosomiasis (sleeping sickness), 14.37-

14.41, 14.44, 14.48 research, 14.66

AGFUND, see Arab Gulf Programme for United Nations Development Organizations

Aging, see Elderly, health of AIDS (acquired immunodeficiency syndrome), 2.13,

2.22, 7.6, 9.3, 11.13, 14.36, 14.94, 14.99, 14.100, 14.114-14.124, 14.128-14.139, 14.185, 17.2, 17.7, 18.12, 19.13, 19.26, 19.29, 21.26, 22.9, 22.10

blood and blood products, safety and screening, 13.5, 14.122

discrimination, avoidance of, 2.13, 14.116 global programme and strategy, 2.13, 14.116,

14.117, 17.7 health education and information, 7.10, 7.12, 14.130 inter-agency advisory group, 14.137 legal and ethical aspects, 4.26, 4.28, 14.116 research, 4.24 Riga initiative, 20.12 supplies, 16.16-16.18, 16.20, 16.22

171

training, 7.12 United Nations joint programme, 2.13, 14.117 WHO/UNDP alliance, 14.118 World AIDS days, 7.3, 14.139 see also Sexually transmitted diseases

Albania, 10.11 Alcohol abuse, 11.10, 19.13

European action plan, 20.11 Algeria, 5.3 American College of Clinical Engineering, 5.8 American International Health Alliance, 5.8 American trypanosomiasis (Chagas disease), 14.32-

14.33, 18.11 research, 14.67

Americas, Region of the, 18.1-18.17, Annex 2 see also Pan American Health Organization and

individual activities Anaesthesiology, 13.2 Andean Area, 18.8, 18.11

Andean Parliament, 18.8 Cooperation in Health initiative, 18.5

Anthrax, 14.112 Appropriate Health Resources and Technologies Ac­

tion Group, 14.90 Arab Gulf Programme for United Nations Develop­

ment Organizations (AGFUND), 14.167, 14.197, 19.28, 21.6

Arabic, use of, 6.22, 15.13 Argentina, 8.9, 11.17, 14.33, 14.67,18.10 ARI news, 14.90 Armenia, 2.30 Arthritis, 14.211 Arthropod-borne viral diseases, 14.142 ASEAN, see Association of South-East Asian Na-

tions Asia and Pacific Decade of Disabled Persons, 13.41 Asian Development Bank, 2.19 Asian Interactive Association on the Hearing Im­

paired, 14.172 Asia-Pacific Academic Consortium for Public Health,

6.25 Assessments on Member States, 1.5 Associate Members of WHO, 2.1, Annexes 1 and 2 Association for Health Information and Libraries in

Africa, 15.4, 17.6

THE WORK OF WHO 1992-1993 -----------------------~----

Association of South-East Asian Nations (ASEAN), 4.19

Asthma, 14.214 Atherosclerosis, 14.202, 14.210 Australia, 6.16, 22.10 Austria, 9.7 Auxiliary health personnel, see Community health

workers and the various categories of health per­sonnel

Azerbaijan, 2.30

Baby-friendly Hospital Initiative, 9.17, 21.13 Bacterial diseases, 14.140-14.149

see also individual diseases Bahrain, 2.3, 12.10 Bamako initiative, essential drugs, 4.24 Bangladesh, 3.5, 9.43, 10.10, 12.14, 12.16, 14.45, 14.51,

14.80, 14.96, 19.3, 19.6, 19.14, 19.23, 19.24,19.28 fourth population and health project, 2.26, 4.3, 4.14,

4.16, 5.6, 6.4, 16.20 Barbados, 6.5 Belarus, 2.3, 11.7, 12.31 Belize, 4.6 Benin, 7.13, 11.16, 12.5, 13.21, 13.28, 13.38, 14.45 Bhutan, 5.6, 19.3, 19.6 Bilharziasis, see Schistosomiasis Bioethics, 4.29, 14.219 Biologicals, 13.22-13.24 Birth control, see Fertility regulation Blindness prevention, 14.164-14.171

see also Onchocerciasis Blood and blood products, screening and safety, 13.3-

13.5, 14.122 external quality assessment scheme, 13.3

Bolivia, 3.9, 5.12, 5.18, 10.9, 13.28, 14.67 Borrow Dental Milk Foundation, 9.27 Bosnia and Herzegovina, 2.3 Botswana, 5.4, 5.7, 7.12, 14.26, 14.99 Brazil, 8.9, 9.17, 10.15, 10.16, 10.17, 10.33, 11.8, 11.17,

12.14, 12.16, 14.15, 14.24, 14.33, 14.51, 14.52, 14.55, 14.61, 14.67, 14.68, 14.80, 14.81, 14.127, 14.133, 14.143, 18.10

Breast-feeding, 9.16, 9.17, 10.29, 14.78, 14.80, 14.89, 14.138,21.13

Bridge, 4.21 Brucellosis, 14.107, 14.113,19.28 Budget, see Programme budget (WHO) Bulgaria, 9.27 Bulletin of the World Health Organization, 15.11 Burkina Faso, 12.5 Burn injuries, 9.37, 9.39 Burundi, 14.19, 14.45 Byelorussian SSR, see Belarus

Cambodia, 2.32, 4.3, 9.25, 14.24, 15.9 Cameroon, 2.3, 4.3, 4.24, 5.7, 7.6, 7.12, 13.2, 14.22,

14.45, 14.61 Canada, 5.7, 14.203

172

Cancer, 10.20, 14.161, 14.173-14.181,21.27 see also International Agency for Research on Can­

cer Cardiovascular diseases, 14.197-14.207, 21.27

cardiovascular diseases and alimentary comparison project (CARDIAC), 14.201

multinational monitoring project (MONICA), 14.198

Caribbean Area, 3.9, 4.26, 7.8, 8.9, 10.39, 15.2, 15.5, 18.5, 18.10, 18.15

Cooperation in Health initiative, 4.19, 18.5 Community (CARICOM), 18.6 Epidemiology Centre (CAREC), 4.6

Carnegie Corporation (USA), 11.1 CCAQ, see Consultative Committee on Administra­

tive Questions CCPOQ, see Consultative Committee on Pro­

gramme and Operational Questions Central African Republic, 7.12 Central America, 4.6, 18.5, 18.8, 18.10, 18.17

Chapultepec peace agreement, 18.17 development programme for refugees and displaced

persons (PRODERE), 18.17 health initiative, 18.5

Central and eastern Europe, 9.3, 9.44, 10.11, 11.2, 11.3, 13.26, 15.7, 20.2, 20.10, 20.12, 20.14, 20.15, 20.16

European cooperative health programme (EUROHEALTH), 20.16

Cerebral palsy, 13.39 Chad, 2.26, 3.9, 6.20, 7.12, 14.38 Chagas disease, see American trypanosomiasis Changing medical education and medical practice,

6.18 Chemical safety, 10.49, 12.18-12.24,21.21

health and safety guides, 12.20 international cards, 12.20 international programme (IPCS), 10.46 management, 12.18, 12.19, 12.20 occupational exposure, 10.46 poisons control and information, 12.23 risk evaluation, 12.19, 12.20, 12.22 see also Drugs

Chernobyl accident, 2.15, 9.26, 11.20 international programme, 11.20, 12.31

Children, 2.25, 10.7-10.13, 11.8, 14.90-14.92, 14.164, 19.25

AIDS/HIV infection, 7.6, 14.131, 14.135 Baby-friendly Hospital Initiative, 9.17, 21.13 convention, rights of the child, 10.7 diarrhoea! diseases, 9.12, 14.72, 14.76, 14.78, 14.80 immunization, 14.1-14.14, 14.86, 14.156, 14.160,

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 see also Maternal and child health; Youth and ado­

lescence Chile, 9.42, 10.16, 10.17, 10.33, 10.39, 10.53, 14.33,

14.67, 18.10

China, 4.25, 4.27, 6.4, 6.5, 7.7, 7.8, 7.13, 9.17, 10.7, 10.13, 10.21, 10.26, 10.52, 11.4, 11.7, 11.17, 12.27, 13.6, 13.38, 14.29, 14.42, 14.51, 14.59, 14.96, 14.140, 14.153, 14.171, 14.203, 15.9, 22.5, 22.6

Cholera, 2.14, 4.6, 9.12, 12.9, 12.11, 14.79, 14.155, 16.18, 16.19, 17.11, 17.16, 18.12, 19.24, 21.25

global task force, 14.79 CIOMS, see Council for International Organizations

of Medical Sciences Circulation, 14.198 Clinical technology, 13.1-13.2 Codex Alimentarius, FAO/WHO, 9.11, 19.16 Collaborating centres (WHO), 8.5, 14.151

accident and injury prevention, 9.36, 9.37, 9.38 cancer, 14.174, 14.179 cardiovascular diseases, 14.201 community safety promotion, 9.32 drug monitoring, 13.16 equipment maintenance and repair, 5.8 health and biomedical information, 21.23 hepatitis, 14.161 hospitals and other health institutions, 5.21 human reproduction research, 10.37 legionellosis, 14.148 malaria, 14.19 mental health, 11.5 occupational health, 10.43 oral health, 9.28, 9.30 pesticides, 14.44 rheumatic conditions, 14.212 smallpox and other poxvirus infections, 14.152

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

Commission of the European Communities, see Eu­ropean Communities

Commission on Health and Environment (WHO), 12.1-12.2, 15.10

Commission on Sustainable Development (United Nations), 2.12

Committee of the Executive Board to Consider Cer­tain Financial Matters, 16.9

Commonwealth of Independent States, 9.30, 13.26, 14.104, 16.21

Commonwealth Pharmaceutical Association, 13.19 Communicable diseases, see individual diseases Community health workers, 5.18, 6.23 Community safety and health, 3.5, 5.11, 5.18, 7.13,

9.32-9.34, 14.215, 17.3 Comoros, 14.142 Conferences, see individual topics Congo, 7.12, 7.13, 14.38 Consortium for International Earth Science Informa­

tion Network (CIESIN), 4.9 Constitutional and legal matters, 2.1-2.3 Consultative Committee on Administrative Ques­

tions (CCAQ), 2.11 Consultative Committee on Programme and Opera­

tional Questions (CCPOQ), 2.11, 2.16

INDEX

173

Consultative Group of Nongovernmental Organiza-tions, 14.166, 14.171

Continuing education, 6.14 Contraceptives, see Fertility regulation Contributions of Member States to WHO, incentive

scheme, 1.5 Conventions,

privileges and immunities, specialized agencies, 2.3 rights of the child, 10.7

Convergencia initiative, health science and technolo­gy, 8.9

Cooperation Council for Arab Gulf States, 13.25 Coordination and collaboration, 1.1, 2.10-2.27, 18.7-

18.8 see also individual organizations and activities

Coronary heart disease, 9.20 Costa Rica, 9.6, 10.17, 10.54 Cote d'Ivoire, 14.40, 14.45, 14.120, 14.129 Council of Europe, 3.6, 4.29, 10.17, 20.7 Council on Health Research for Development, 4.24,

8.7 Council for International Organizations of Medical

Sciences (CIOMS), 4.29, 8.2, 13.15, 13.16 Council for Science and Technology (WHO), 8.4 Country health information development, 4.3-4.5 Creutzfeld-Jakob disease, 14.110 Croatia, 2.3 Cuba, 8.9, 10.39, 14.156, 14.167, 14.202, 14.203, 18.10,

18.14 Cyprus, 5.8, 12.10, 13.6 Cystic fibrosis (mucoviscidosis), 14.216 Czech Republic, 2.3

Danish International Development Agency (DANI-DA), 5.21

Data processing, see Information systems Deafness, 14.172 Delagrange lnternational!Synthelabo Recherche

(France), 11.1 Dementias, 10.51, 10.53, 11.20 Democratic People's Republic of Korea, 14.141 Demography, see Population Dengue and dengue haemorrhagic fever, 14.42, 14.46,

14.142, 14.159,19.28 Denmark, 13.24 Dental health, see Oral health Diabetes, 14.208-14.210, 14.215, 20.16, 21.27

European action plan, 20.16 St Vincent declaration, 14.209, 20.16

Diarrhoea! diseases, 2.14, 9.12, 14.72-14.82, 14.89, 14.92, 14.155, 18.12,19.24

see also Cholera Digital Equipment Corporation (USA), 11.1 Diphtheria, 14.1, 14.8, 14.9, 22.4 Director-General, reappointment, 1.3 Disability prevention and rehabilitation, 2.15, 2.29,

13.35-13.41 Disaster relief, see Emergency relief and supplies Disease vector control, see Vector control

THE WORK OF WHO 1992-1993

Displaced persons, see Refugees and displaced per-sons

District health systems, 5.11-5.21 Djibouti, 14.19 Documents (WHO), see Health literature services Dominican Republic, 5.12, 6.3, 14.129, 18.10 Dracunculiasis (guinea-worm disease), 14.22-14.23,

17.15, 19.23 Drugs,

abuse, 9.3, 11.9-11.16, 11.22, 19.13 alerting system (ATLAS), 11.9 control of narcotic drugs and psychotropic

substances, 2.15 essential, 13.10, 19.18, 19.19, 21.16

action programme, 13.26-13.34 Bamako initiative, 4.24 model list, 13.18, 14.178

management and policies, 13.10 pharmaceuticals, 13.11-13.21, 13.33, 19.18, 19.19 rational use, 13.33, 14.76,19.19

international network, 13.33

EAST organization (water, agriculture and health in the tropics), 12.5

Eastern Mediterranean Region, 21.1-21.29, Annex 2 see also individual activities

ECA, see Economic Commission for Africa Economic Commission for Africa, 2.17 Economic Commission for Europe, 2.17 Economic Commission for Latin America and the

Caribbean, 2.17 Economic development, health aspects, 3.8-3.10 Economic and Social Commission for Asia and the

Pacific, 2.17, 13.41 Economic and Social Commission for West ern Asia,

2.17 Economic and Social Council of the United Nations,

2.12-2-16, 9.53, 14.116, 14.117 Commission on Sustainable Development, 2.12

Ecuador, 9.6 · Edna McConnell Clark Foundation, 14.165 Education, see Health education; Medical education Egypt, 2.31, 5.8, 5.11, 5.17, 6.16, 6.22, 9.17, 10.21, 11.7,

11.10, 12.10, 13.2, 13.36, 14.52, 14.80, 14.91, 14.143, 21.5, 21.6

El Salvador, 18.17 Elderly, health of, 9.37, 10.51-10.57, 14.171, 19.12,

21.14 international research programme, 10.51

Emergency relief and supplies, 2.15, 2.22, 2.28-2.33, 9.10, 11.7, 16.16, 16.18, 16.22, 17.5, 18.17, 20.6, 21.6, 21.25

international decade, natural disasters, 2.31, 18.17 Encephalitis, Japanese, 14.145, 14.159,19.28 Environment and development, United Nations con­

ference (1992), 2.11, 7.2, 12.1-12.3, 12.18, 12.19, 15.10, 18.15, 22.12

Agenda 21, 2.11, 2.12, 12.1, 12.2

174

Environment and health, Americas, investment plan, 3.4 Central America, national plans, 18.15 Eastern Mediterranean, regional strategy, 21.18 Europe, regional centre, 20.13

Environmental health, 1.2, 3.4, 7.5, 9.13, 12.1-12.31, 18.15, 19.15, 20.13, 21.21, 21.22, 22.12

global network, technology (GETNET), 12.29 WHO commission, 12.1-12.2, 15.10 see also Chemical safety; Environmental pollution;

Environment and development; Water supply and sanitation

Environmental Health Criteria, 12.20, 12.22 Environmental health hazards, control, 12.25-12.31

human exposure assessment location (HEAL) project, 12.26

Environmental management, panel of experts (PEEM), 12.6

Environmental pollution, 12.25-12.30, 14.91, 19.15, 21.21

see also Chemical safety; Water supply and sanita­tion

Epidemiology and statistical services, 4.6-4.9, 12.27, 12.31

WHO statistical information system (WHOSIS), 4.9

Epilepsy, 11.18, 11.19 Equipment management, 5.7-5.10 Eritrea, 2.29 ESCAP, see Economic and Social Commission for

Asia and the Pacific Essential drugs, see Drugs Essential drugs monitor, 13.32 Estonia, 10.11 Ethiopia, 2.29, 12.28, 14.19, 14.45, 14.91, 14.153 European Bank for Reconstruction and Develop-

ment, 2.19 European Communities (Commission), 2.23, 3.6,

5.19, 10.17, 10.45, 10.55, 12.18, 13.34, 14.37, 14.66, 20.7, 20.13

Treaty on European Union, 20.1 European cooperative health programme (EURO-

HEALTH), 20.16 European Dialogue on Training in Public Health, 6.25 European Federation of Neurological Societies, 11.3 European Forum of National Medical Associations

and WHO, 20.9 European Forum of Pharmaceutical Associations and

WH0,20.9 European Medical Research Council, 4.22, 8.11 European Network of Health-promoting Schools,

7.7, 20.7 European Region, 20.1-20.17, Annex 2

see also individual activities European Union, see European Communities (Com­

mission) Evaluation and monitoring of programmes, see under

Health for all by the year 2000 and Health situa­tion and trend assessment

Executive Board, 1.1, 1.4, 2.4, 16.8 Committee to Consider Certain Financial Matters,

16.9 membership, 2.2 Programme Committee, 1.1, 1.4, 2.4, 16.8 sessions, Annex 3 resolutions, 1.1, 1.4, 2.19, 16.8 working group, WHO response to global change,

1.1, 2.5 Ex libris, 15.7 Expanded Programme on Immunization, see Immu­

nization Expert advisory panels (WHO), 8.6 Expert committees (WHO),

alcohol- and drug-related problems in the work-place, 11.1 0

anthropometry, 9.15 cardiovascular diseases, 14.207 drug dependence, 11.14 essential drugs, 13.18 filariasis, 14.28 health promotion in the workplace, 10.49 information systems, district level, 4.5 maternal and child health and family planning, 10.2 onchocerciasis, 14.31 schistosomiasis, 14.2 4

Eye diseases, see Blindness prevention

Family Care International, 10.9 Family Health International, 10.9 Family planning, 9.4, 10.1-10.13, 10.32-10.33, 17.10,

19.11, 21.13 see also Fertility regulation

FAO, see Food and Agricultural Organization of the United Nations

Fellowships, 6.24, 7.12, 14.141,14.196 Fertility regulation, 10.25-10.30, 10.35

contraceptives, 10.4, 10.13, 10.20-10.24, 10.35 emergency contraception, 10.24 human reproduction research, 4.24, 10.19-10-41 infertility, 10.31, 10.38 intrauterine devices, 10.22-10.23 natural methods, 10.29-10.30 regulation of male fertility, 10.25-10.26 resources for research, 10.36-10.41 social science research, 10.35 technology transfer, 10.32-10.34 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

Finnish International Development Agency (FINNIDA), 2.26, 13.4

Finnish Red Cross, 13.4 Fluoridation of milk, 9.27 Fometro, 14.41 Food and nutrition, 2.22, 9.9-9.20, 14.80, 14.92,

14.184, 14.201, 17.2, 17.9, 21.9

INDEX

11S

food aid programmes, 9.10 food safety, 12.21,14.108-14.111, 19.16, 21.21 international conference (1992), 7.2, 7.10, 9.9, 9.14,

17.8 international decade, Africa, 17.8 world declaration and plan of action, 9.14 see also Micronutrient deficiencies

Food and Agriculture Organization of the United Nations (FAO), 9.13, 9.14, 9.20, 10.3, 12.6, 12.7, 12.18, 12.21, 14.38, 14.40, 14.44, 14.107, 17.11

Foundation for Advanced Studies on International Development, 14.172

Foundation for Health Services Research, 4.21 France, 8.7, 9.35 French Red Cross, 13.4

Gambia, 10.8, 14.57, 14.58, 14.91, 14.156, 14.187, 14.193

General Agreement on Tariffs and Trade (GATT), 9.11

General Programme of Work of WHO, eighth, 16.8, 16.11 ninth, 1.1, 2.4, 9.1, 18.1

Genetics, 14.216, 14.219, 14.189-14-190, 14.191, 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,

5.8, 5.16, 5.19 Germany, 13.12, 13.21, 14.202 Ghana, 4.24, 5.1, 5.6, 12.14, 13.41, 14.22, 14.62, 14.70,

14.203, 17.6, 17.15 Global change, WHO response to, 1.1, 2.5 Global environmental epidemiology network, 12.27 Global Environmental Monitoring System (GEMS),

9.13 Global Policy Council (WHO), 2.5 Governing bodies, see Executive Board; Regional

committees; World Health Assembly Grants, research training, 6.24, 8.10, 8.13, 10.39, 14.71 GTZ, see German Technical Cooperation Agency Guatemala, 4.16, 9.6, 9.18, 12.11, 14.62, 14.91 Guidelines for drinking-water quality, 12.28 Guinea, 3.9, 7.13, 13.28, 14.96 Guinea-Bissau, 3.9, 4.3, 4.12 Guinea-worm disease, see Dracunculiasis Guyana, 4.6

Haemoglobinopathies, 14.216, 14.217, 14.218 Haemophilia, 14.216, 14.218 Haemorrhagic fevers, viral, 14.143

see also Dengue and dengue haemorrhagic fever Haiti, 5.12, 14.135, 18.17 Health education, 7.5-7.13, 14.130, 14.203, 19.8, 21.8

environmental health and sanitation, 12.4, 12.5, 12.8, 12.11

THE WORK OF WHO 1992-1993

Health for all by the year 2000, 3.1-3.10, 20.8, 20.9 economic development and, 3.8-3.10 monitoring and evaluation, 3.1-3.3, 4.1, 19.2 see also Primary health care

Health information support, 4.9, 15.1-15.16, 17.6 see also Health literature services; Information sys­

tems; Publications Health laboratory technology, 13.3-13.5 Health legislation, 4.25-4.29, 21.6

documentation system, Latin America and the Car­ibbean (LEYES), 4.26

Health literature services, 15.1-15.9 Africa (library digest, Index Medicus), 15.4 Eastern Mediterranean (ExtraMED), 15.8, 21.23 Latin America and the Caribbean (LILACS,

BIREME), 15.2, 15.5 medical literature retrieval system (MEDLINE),

15.9 South-East Asia (HELLIS, Index Medicus), 15.6 WHO database (WHOLIS), 15.2

Health promotion, Eastern Mediterranean, 21.5 Europe, 7.7 Latin America and the Caribbean, 18.5 Western Pacific, 22.11

Health policy, 3.4-3.7, 3.9, 3.10 Health research, see Research Health services journal, 8.12 Health situation and trend assessment, 4.1-4.2 Health systems/services,

based on primary health care, 5.1-5.21, 21.3, 22.2 community participation, 5.11, 5.18 costs and financing, 3.8, 3.9, 5.1-5.3, 17.4, 20.4,

20.12, 20.14, 21.2 development, 4.1-4.29 district and peripheral levels, 5.11-5.18

Ain Shams project, 5.11 European project on health care reform (EURO-

CARE), 20.14 European "regions for health" network, 3.7, 20.10 management, 4.2, 5.7-5.10 national health systems and policies, 5.1-5.10, 21.3 organizational change, 5.4-5.6 research, 4.20-4.24, 6.25, 21.4 structural aspects, 5.14 see also Primary health care

Health Volunteers Overseas, 13.1 Healthy cities and villages, 5.15-5.16, 9.7, 12.14, 12.15,

12.16, 17.12, 20.10, 21.20, 22.12 Hearing impairment, 14.172 Hedip forum, 2.33 Helminth infections, 9.10 Hepatitis, viral, 14.4, 14.141, 14.161, 14.187, 14.193,

19.28, 22.6 Hereditary diseases, 14.216-14.219 HFA 2000,7.10 HIV infection, see AIDS Honduras, 10.9, 14.33, 14.120 Hong Kong, 6.5

176

Hospitals, 5.5, 5.19-5.21, 13.1, 13.2, 17.5 baby-friendly initiative, 9.17, 21.13 core library for doctors, 5.20 waste management, 12.17

Housing, 12.14-12.15 Human immunodeficiency virus (HIV), see AIDS Human reproduction research, 4.24, 10.19-10.41 Human resources for health, 6.1-6.27, 19.7, 21.7, 22.3

continuing education, 6.14 management, 6.3-6.4, 6.11-6.13 network of community-oriented educational insti-

tutions, 4.22 planning tools, 6.5-6.7 policy analysis, 6.3-6.4 see also Fellowships; Grants; Medical education;

Teaching/learning materials and the various categories of health personnel

Human rights, 4.29, 9.3, 9.5 United Nations centre, 4.29 United Nations conference (1993), 7.10

Humanitarian assistance, 2.15, 2.22, 2.25, 2.28, 2.30, 2.31, 2.33, 20.6

Hungary, 14.202, 14.203 Hypercholesterolaemia, 14.219 Hypertension, 14.215

IAEA, see International Atomic Energy Agency IARC, see International Agency for Research on Can­

cer IARC Monographs, 14.195 Ibero-American conferences of Heads of State and

Government, 3.4, 18.7 ICAO, see International Civil Aviation Organization ICD, see International Classification of Diseases ILO, see International Labour Organisation Immunization, 2.25, 14.1-14.14, 14.86, 14.174, 16.19,

17.13, 18.10, 19.21, 19.28, 22.4 see also individual diseases

IMPACT (international initiative against avoidable disability), 13.36

Index Medicus, 15.4, 15.6, 17.6 India, 3.5, 4.3, 4.24, 4.25, 5.17, 6.21, 7.8, 9.37, 9.43,

10.41, 11.7, 13.36, 14.15, 14.22, 14.35, 14.42, 14.51, 14.61, 14.65, 14.89, 14.96, 14.106, 14.120, 14.129, 14.165, 14.168, 14.172, 14.181, 14.203, 15.12, 16.20, 19.4, 19.13, 19.14, 19.15, 19.16, 19.23,19.24

Indonesia, 4.24, 5.17, 5.19, 6.4, 10.10, 10.16, 10.17, 10.25, 10.33, 14.42, 14.51, 14.81, 14.106, 19.3, 19.4, 19.6, 19.15, 19.16, 19.23

Industrial health, see Occupational health Industry Council for Development, 9.12 Infectious diseases, rapid diagnosis, 14.151 Infertility, 10.31, 10.38, 17.10 Influenza, 14.140 Information systems, 2.9, 4.4, 6.11, 6.16, 12.23, 14.12,

14.150, 14.153, 20.7 computer software (WHONET), 14.150 "European Nervous System", 20.7

Information systems (continued) health sciences information, Latin America and the

Caribbean, 15.2, 15.5 WHO statistics (WHOSIS), 4.9 WHO terminology (WHOTERM), 15.14

Injury prevention, 9.5, 9.32-9.39, 11.10, 12.31, 21.11 Intensified cooperation with countries and peoples in

greatest need, 2.26, 3.8, 4.3, 4.11-4.17, 5.3, 6.4, 12.11, 17.8, 19.3

lnteragency Steering Committee for Water Supply and Sanitation, 12.13

lnter-American Center for Social Security Studies, 5.18

Inter-American Development Bank, 2.19 Intergovernmental Oceanographic Commission,

17.11 Intergovernmental organizations, Annex 4

see also Coordination and collaboration and indi­vidual organizations

Intergovernmental Panel on Climate Change, 12.27 International Agency for Research on Cancer

(IARC), 2.5, 12.27, 14.182-14.196 International Alliance of Women, 2.5 International Association of Lions Clubs, 14.164,

14.168 International Association for the Study of Pain,

14.179 International Atomic Energy Agency (IAEA), 9.13,

13.6, 13.7, 14.177, 17.11 International Children's Centre, .1 0.8 International Civil Aviation Organization (ICAO),

9.52 International Classification of Diseases (ICD), 4.10,

11.5, 11.6, 11.14 application to dentistry and stomatology, 9.29

International Classification of Impairments, Disabili­ties and Handicaps, 4.10

International Code of Marketing of Breast-milk Sub­stitutes, 4.28, 9.18

International Commission on Occupational Health, 10.49

International Committee of the Red Cross, 2.25, 2.33 International Confederation of Midwives, 10.6 International Consultative Group on Food Irradia-

tion, 9.13 International Council for Education of the Visually

Handicapped, 14.164 International Decade on Food and Nutrition for Afri­

ca, 17.8 International Decade for Natural Disaster Reduction,

2.31, 18.17 International Development Research Centre (Cana-

da), 3.10, 4.21, 4.23, 14.26 International Diabetes Federation, 14.209 International digest of health legislation, 4.26 International Drinking Water Supply and Sanitation

Decade, 17.11 International Federation of Anti-Leprosy Associa­

tions, 14.50 International Federation for Medical and Biological

Engineering, 5.8

INDEX

177

International Federation of Pharmaceutical Manufac­turers Associations, 13.14, 13.20, 14.136

International Federation of Red Cross and Red Cres­cent Societies, 2.25

International Fibre Safety Group, 10.45 International Forum for Social Sciences in Health,

4.22 International Health Policy Programme, 4.24 International Hospital Federation, 5.10 International Labour Organisation (ILO), 5.1, 10.3,

10.42, 10.44, 10.47, 10.48, 11.10, 12.18, 12.19, 13.41

International League of Associations for Rheumatol-ogy, 14.213

International Leprosy Association, 13.38 International Life Sciences Institute, 9.12 International Monetary Fund, 2.19 International Office of Epizootics, 14.107 International Olympic Committee, 9.48, 14.206 International Pharmaceutical Federation, 13.19 International Planned Parenthood Federation, 10.18 International Programme on Chemical Safety, 10.46,

12.18-12.24 International Project Assistance Services, 10.9 International Society for Burn Injuries, 9.37 International Society and Federation of Cardiology,

14.197,14.202 International Society of Orthopaedic Surgery and

Traumatology, 13.1 International Society of Prosthetics and Orthotics,

2.25 International Society on Quality Assurance, 5.21 International Society of Surgery, 13.1 International Statistical Institute, 4.10 International Union of Architects, 5.10 International Union against Cancer, 9.45 International Year of the Family, 2.15, 11.9 International Youth Foundation, 10.15 Internet, international computer network, 4.9 Intestinal parasitic infections, 14.153 Investing in health,

Riga statement, 20.12 women's health, 9.7

Iodine deficiency disorders, 9.19, 17.9, 21.9 IPCS, see International Programme on Chemical

Safety IPCS news, 12.24 Iran, Islamic Republic of, 2.31, 5.19, 12.14, 13.36,

14.23, 14.52, 14.68, 15.8 Iraq, 2.31, 9.18, 16.16 Islamic Educational, Scientific and Cultural Organi-

zation, 21.8 Israel, 10.54 Italy, 10.9, 10.54, 13.12, 13.21, 14.25, 14.202 lvermectin, 14.29, 14.30, 14.31, 14.60, 14.62, 14.164

Jamaica, 9.6, 10.33, 10.54 Japan, 6.3, 6.5, 12.16, 13.19 Japanese encephalitis, 14.145, 14.159,19.28

THE WORK OF WHO 1992-1993

JohannJacobs Foundation, 11.1 Joint Committee on Health Policy, UNICEF/WHO,

2.18 Joint Committee on the Health of Seafarers, ILO/

WHO, 10.44 Joint Committee on Occupational Health, ILO/

WHO, 1Q.42 Joint Expert Committee on Food Additives, FAO/

WHO, 12.21 Joint Meetings on Pesticide Residues, FAO/WHO,

12.21 Jordan, 5.8, 9.17, 21.5

Kazakhstan, 5.1 Kellogg Foundation, 6.12, 10.9, 10.14, 10.15 Kenya, 4.24, 5.1, 5.4, 5.8, 7.12, 14.10, 14.24, 14.45,

14.48, 14.59, 14.84, 14.131, 14.144, 14.165 Kiribati, 10.7 Kyrgyzstan, 5.1

Laboratory technology and blood safety, 13.3-13.5, 14.151, 19.17, 21.17

La Leche League International, 2.25 Lao People's Democratic Republic, 4.12, 9.25, 22.5 Lassa fever, 14.143 Latin America, 2.17, 3.9, 4.26, 8.9, 10.32, 18.5, 18.15 Latin American and Caribbean Center on Health Sci-

ences Information (BIREME), 15.2, 15.5 Latin American Committee against Tobacco Use, 9.42 Latin American Parliament (PARLATINO), 18.8 Laureate Foundation, 11.1 Learning materials, see Teaching/learning materials Lebanon, 9.17, 13.36 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 Lesotho, 10.8 Libraries, see Health literature services

Macao, 22.1 MacArthur Foundation, 10.54 Madagascar, 4.21, 14.19, 14.51 Malaria, 2.14, 9.10, 14.15-14.21, 14.44, 14.45, 14.46,

14.48, 14.90, 14.92, 17.14, 19.22, 21.25, 22.8 ministerial conference (1992), 7.2, 7.10, 14.16, 17.14 research, 14.20, 14.57-14.58, 14.70, 14.71

Malawi, 3.9, 6.20, 14.94, 14.99, 14.100, 17.6 Malaysia, 5.13, 15.9, 22.12 Maldives, 4.3, 6.21, 13.28, 14.153, 19.3, 19.6, 19.14,

19.23 Mali, 3.9, 13.6, 14.24, 14.165 Malnutrition, see Food and nutrition Malta, 10.53

178

Management Development Committee (WHO), 2.5 Manpower, see Human resources for health Marshall Islands, 4.3 Maternal and child health, 9.4, 10.1-10.13, 17.10,

19.11, 21.13 Maternal mortality, 10.38 Mauritania, 14.45 Mauritius, 13.37, 14.153, 14.215 Measles, 14.1, 14.5, 14.7, 14.8, 14.14, 14.86, 14.92,

14.151, 14.160, 17.13, 18.10, 19.21, 22.4 Medecins sans Frontieres, 14.41 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

assessments, 1.5 contributions, incentive scheme, 1.5 voting privileges and services, suspension, 2.2

Meningitis, 14.91, 14.147, 14.156, 16.18, 17.16 Mental health, 11.1-11.22, 21.15

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 Micronutrient deficiencies, 9.19, 17.9, 21.9, 22.6 Midwifery, see Nursing and midwifery Mifepristone, 10.24 Milk fluoridation, 9.27 Ministers of Health of Non-Aligned and Other De­

veloping Countries, 4.18 Mongolia, 3.5, 4.11, 5.6, 5.19, 9.43, 13.28, 13.38,

14.141, 19.3, 19.6, 19.28 Morocco, 4.21, 9.18, 10.17, 14.24, 14.170 Mozambique, 2.26, 2.29, 4.11, 4.15, 12.11, 13.2, 14.99,

17.6 Myanmar, 4.24, 5.19, 6.21, 14.42, 14.51, 14.141,

14.153, 19.3, 19.6, 19.13, 19.19, 19.23,19.28

Namibia, 4.21, 5.6, 6.12, 7.12, 11.10,14.19 Nepal, 3.5, 3.9, 4.13, 5.18, 6.4, 9.43, 10.10, 13.28,

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 Neurological disorders, see Mental health Neuropathy, 18.14 Nicaragua, 10.9, 12.27 Niger, 13.2 Nigeria, 4.21, 4.24, 5.11, 5.14, 5.16, 9.28, 10.16, 10.53,

11.8, 11.16, 12.16, 14.22, 14.51, 14.52, 14.64, 14.70, 14.102, 14.143, 17.15

Noncommunicable diseases, 9.20, 17.2 country-wide intervention programme (CINDI),

14.215,20.9 integrated programme (INTERHEAL TH), 14.215 see also individual diseases

N ongovernmental organizations in official relations with WHO, 2.25, Annex 4

North American Free Trade Agreement (NAFTA), 18.6

Norway, 9.7, 11.8,14.156 Norwegian Agency for International Development

(NORAD), 5.4, 5.7, 6.12 Nosocomial infections, 14.150 Nursing and midwifery, 4.24, 6.11, 6.12, 6.15-6.16,

9.39, 10.6, 14.131, 17.17, 20.15 Nutrition, see Food and nutrition

OAU, see Organization of African Unity Occupational health, 7.8, 10.42-10.50, 14.183, 14.195 Occupied Arab territories, 2.31 OECD, see Organisation for Economic Co-operation

and Development OIE, see International Office of Epizootics Oman, 2.9, 7.12, 12.10, 14.153 Onchocerciasis, 14.30-14.31, 14.164

research, 14.30, 14.60-14.64, 14.70 Oncology, see Cancer Operation Salam for humanitarian assistance to Af-

ghanistan, 16.22 Oral health, 9.21-9.31, 12.31, 21.10 Oral rehydration, 14.76, 14.80, 19.24 Orbis International, 14.169 Organ transplantation, 4.26 Organisation for Economic Co-operation and Devel-

opment (OECD), 2.23, 3.6, 12.18 Organization of African Unity (OAU), 2.22, 14.40 Organization of American States, 4.9, 18.17 Organizational and related meetings, Annex 3 Organizational structure of WHO, Annex 5 Orthopaedics, 13.1 Osteoarthritis, 14.211 Osteoporosis, 10.51, 10.52, 14.213

Paediatrics, see Children P AHO, see Pan American Health Organization Pakistan, 4.3, 4.25, 6.16, 12.14, 14.22, 14.80, 14.91 Palestine, 21.1 Pan American Health Organization (PAHO), 2.9,

9.42, 9.51, 10.15, 10.18, 14.30, 16.19, 18.1, 18.2, 18.5, 18.14, 18.16, 18.17

Directing Council, 3.4, 18.3, 18.4 see also Americas, Region of the

Pan American Sanitary Bureau, see Regional Office for the Americas

Panama, 9.6, 10.39,11.17 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 Paraguay, 14.33, 14.67 Parasitic diseases, 14.153, 17.2, 19.23

see also Tropical diseases; Vector control and indi­vidual diseases

Pelvic inflammatory disease, 10.23

INDEX

179

Periodontal disease, 9.23 Pertussis, 14.1, 14.5, 14.86, 22.4 Peru, 10.9, 10.33, 10.39, 16.19,18.10 Pesticides, see Vector control Pharmaceuticals, see Drugs Philippines, 4.21, 5.13, 5.17, 9.17, 10.7, 10.16, 11.7,

12.30, 14.59, 14.89, 14.91, 15.9, 22.5, 22.6, 22.12 Physical resources for health, management, 5.7-5.10 Plague, 14.146, 17.16,19.28 Pneumococcosis, 14.157 Pneumoconiosis, 10.47 Pneumonia, 14.83, 14.86, 14.90, 14.91, 14.92 Poison Information Monographs, 12.23 Poland, 11.10 Poliomyelitis, 13.1, 13.39, 17.13, 18.10, 19.21, 21.25,

22.4, 22.5 immunization and vaccine development, 14.1, 14.5,

14.6, 14.7, 14.11, 14.14,14.162 Pollution, see Environmental pollution Population, health and development, 2.21, 2.26 Population Council, 10.9 Portugal, 11.8 Preferential Trade Area of Eastern and Southern

African States, 13.31 Primary health care, 2.29, 5.1-5.21, 22.2, 22.3

see also Community health workers; Health for all by the year 2000; Health systems/services

Programme budgets (WHO), 2.6-2.8, 16.8-16.14 for 1992-1993, 16.8 for 1994-1995, 1.4, 1.5, 16.8

Programme Committee of the Executive Board, 1.1, 1.4, 2.4, 16.8

Programme of WHO, development and management, 2.1-2.33

see also General Programme of Work of WHO Prosthetic and orthotic services, 13.40 Psychosocial and behavioural problems, see Mental

health Public health training and research, 6.25 Public information, 7.1-7.4, 7.9, 7.10

see also Health education Publications (WHO), 14.195,15.10-15.13

distribution and sales, 15.15-15.16 listing of publications and documents

(WHODOC), 15.2 Puebla Group, 4.21 Puerto Rico, 18.3 Pulmonary diseases, chronic, 14.214

Qatar, 21.6

Rabies, 14.102-14.106, 14.113, 19.28 Radiation accidents and radiological emergenCles,

11.20, 12.31 emergency network (REMP AN), 12.31 see also Chernobyl accident

Radiation medicine, 12.27, 12.31, 13.6-13.8

THE WORK OF WHO 1992-1993

Ravizza Farmaceutici (Italy), 11.1 Refugees and displaced persons, 2.29, 2.32, 2.33, 11.7,

14.45, 17.2, 18.17 Central American programme (PRODERE), 18.17

Regional Committee for Africa, 5.5, 8.8, 17.1, 17.5, 17.11

Regional Committee for the Americas, 3.4, 18.3, 18.4 Regional Committee for the Eastern Mediterranean,

9.8, 14.113,21.1 Regional Committee for Europe, 11.10, 20.11, 20.16 Regional Committee for South-East Asia, 19.7, 19.27 Regional Committee for the Western Pacific, 9.46,

22.1, 22.5, 22.10, 22.11 Regional committees, 1.4, 16.8

sessions, Annex 3 Regional Office for Africa, 16.4, 17.10 Regional Office for the Americas, 18.1 Regional Office for the Eastern Mediterranean, 16.6,

21.23, 21.28 Regional Office for Europe, 2.9, 20.7, 20.17 Regional Office for South-East Asia, 2.9, 16.5 Regional Office for the Western Pacific, 16.7 Rehabilitation, 2.15, 2.29, 13.35-13.41 Rehydration, 14.76, 14.80, 19.24 Representatives (WHO), 2.33, 6.27 Research, 8.1-8.14, 19.9

Advisory committees on health research (ACHR), 8.2-8.4, 8.9, 8.10, 8.13

Council on Health Research for Development, 4.24, 8.7

ethical aspects, 8.2, 8.3 grants, 6.24, 8.10, 8.13, 10.39, 14.71 networking, 4.21, 4.22 prizes, 8.8, see also Health systems/ services, research and indi­

vidual subjects of research Respiratory infections, acute, 10.47, 14.83-14.92,

14.151, 14.160,19.25 Rheumatic diseases, chronic, 14.211-14.213 Rheumatic fever and rheumatic heart disease, 14.149,

14.197 RhOne-Poulenc (France), 14.41 Rift Valley fever, 14.113, 14.143, 21.25 Road accidents, 9.38, 11.10 Rockefeller Foundation, 4.19, 5.7, 10.37, 14.154 Romania, 10.11, 14.169 Rotary International, 2.25, 14.13 Rural development and housing, 12.14-12.17 Russian Federation, 4.25, 9.17, 10.11, 12.31, 14.9,

14.175, 14.203 Rwanda, 14.19, 14.45, 14.131,14.133

Safe motherhood, 10.5-10.6, 10.8, 10.12, 17.10, 21.13 initiative, 10.10

Saint Kitts and Nevis, 6.5 Saint Lucia, 6.5 Salmonellosis, 14.108-14.109 Samoa, 4.3 Sanitation, see Water Supply and Sanitation

180

Sasakawa Foundation, 11.1, 14.50 Saudi Arabia, 5.21, 12.14 Schistosomiasis, 9.10, 12.7, 14.24-14.27, 19.23

research, 14.59, 14.70, 14.71 Schizophrenia, 11.18, 11.19, 11.21 Scientific groups (WHO):

asthma, 14.214 cardiovascular diseases, 14.204 hereditary diseases, 14.216

Senegal, 5.8, 5.15, 5.18, 9.41, 10.8, 12.14, 14.26, 17.12 Sexually transmitted diseases, 10.31, 14.123-14.127,

22.10 see also AIDS and individual diseases

Seychelles, 2.9, 6.10, 14.153 Shigellosis, 14.155 SIDA, see Swedish International Development

Authority Sierra Leone, 5.8 Skills for life, 11.8 Sleeping sickness, see African trypanosomiasis Slovakia, 2.3 Smallpox, 14.152, 18.10 Smoking, see Tobacco Solomon Islands, 22.8 Somalia,2.31, 11.7, 14.19, 16.16,21.5 South Asian Association for Regional Cooperation,

10.10 South-East Asia Region, 19.1-19.29, Annex 2

see also individual activities Southern Cone, 14.32, 18.5, 18.11

common market (MERCOSUR), 18.6 health initiative, 18.5

Soviet Union, former, 2.27, 2.30, 14.9, 14.111, 15.7, 20.2

Spain, 10.53, 14.188,14.198 Special Programme of Research, Development and

Research Training in Human Reproduction, 10.19-10.41

Special Programme for Research and Training in Tropical Diseases, 14.56-14.71

Spongiform encephalopathies, 14.110 Sri Lanka, 6.21, 11.10, 14.15, 14.61, 14.106, 14.120,

14.177, 19.3, 19.6, 19.13, 19.14, 19.16, 19.19, 19.23,19.28

Staff of WHO, 6.27, 9.2, 16.1-16.3, 21.28 Statistics, see Epidemiology and statistical services Sterility, see Infertility Streptococcal infections, 14.149 Structure of WHO, Annex 5 Study groups (WHO):

aging and working capacity, 10.49 cardiovascular diseases in the elderly, 14.205 diabetes, 14.208 foodborne trematode infections, 14.27 osteoporotic fracture risk, 14.213 vector control, 14.46

Substance abuse, 11.11, 11.12, 11.22 see also Drugs, abuse

Sudan, 6.22, 13.2, 14.40, 14.48, 14.51, 14.59, 14.170, 21.5

Support services (WHO), 16.1-16.23

Supportive environments for health, 7.5, 12.15 Surgery, 13.1, 13.2

computerized registration system (WHOCARE), 14.150

Sustainable development, 2.11, 2.12 Swaziland, 14.89 Sweden, 2.26, 9.7, 12.19, 14.109,14.202 Swedish International Development Authority

(SIDA), 9.18 Switzerland, 4.10, 10.16, 14.177, 14.202 Syphilis, 14.127 Syrian Arab Republic, 2.9, 5.8, 6.22, 9.18, 9.28, 21.6

Tajikistan, 2.30, 20.6 Tanzania, see United Republic of Tanzania Teaching/learning materials, 5.13, 6.26, 12.24, 14.21,

14.38, 14.84, 14.209, 17.16, 20.15, 21.7 Technical cooperation among developing countries

(TCDC), 4.18-4.19 United Nations committee, 4.19 UNDP special unit, 4.19

Technical Discussions, Health Assembly, 1.2, 9.34 regional committees, 5.5, 6.3, 21.1

Technology development, assessment and transfer, 8.9, 13.9

Terminology, WHO information system (WHOTERM), 15.14

Tetanus, 14.1, 14.3, 14.5, 14.7, 14.14, 14.162, 17.13, 18.10, 19.21, 19.28

Thailand, 3.5, 4.21, 5.3, 5.17, 6.8, 9.28, 9.43, 10.16, 10.33, 10.54, 11.8, 11.13, 14.15, 14.20, 14.42, 14.55, 14.84, 14.91, 14.131, 14.133, 14.135, 14.159, 14.168, 14.172, 14.187, 19.3, 19.4, 19.13, 19.15, 19.16, 19.23, 19.24,19.28

Tobacco, 2.14, 4.26, 9.40-9.54, 10.47, 14.174, 20.11, 21.12

European action plan, 20.11 Latin American committee, 9.42 world no-tobacco days, 7.3, 9.47

Tobacco alert, 9.47 Togo, 4.3, 5.8, 14.51 Tonga, 4.3 Toxicology, see Chemical safety; Drugs Traditional birth attendants, 10.6 Traditional medicine, 5.18, 13.25, 19.20 Trinidad and Tobago, 9.6 Tropical diseases,

control, 14.15-14.42 research and training, 14.56-14.71 see also Vector control and individual diseases

Trypanosomiasis, see African Trypanosomiasis; American trypanosomiasis

Tuberculosis, 14.1, 14.93-14.101, 14.131, 14.135, 14.158, 19.26, 22.4, 22.9

research, 4.24 Tunisia, 5.8, 6.22, 10.17, 10.33, 12.10, 12.14, 13.21,

14.34, 14.170,21.6

INDEX

181

Turkey, 14.105 Tuvalu, 10.13, 22.1

Uganda, 4.24, 5.4, 7.13, 14.38, 14.40, 14.41, 14.48, 14.66, 14.118, 14.131, 14.133, 14.135

Ukraine, 2.3, 12.31, 14.9 UNDCP, see United Nations International Drug

Control Programme UNDP, see United Nations Development Pro­

gramme UNEP, see United Nations Environment Programme UNESCO, see United Nations Educational, Scientific

and Cultural Organization UNFPA, see United Nations Population Fund UNHCR, see United Nations High Commissioner

for Refugees UNICEF, see United Nations Children's Fund UNIDO, see United Nations Industrial Development

Organization United Arab Emirates, 2.9 United Kingdom of Great Britain and Northern Ire­

land, 13.24, 14.90, 14.110, 20.8 Overseas Development Administration, 5.7

United Nations, 2.15, 2.16, 9.54, 13.41, 14.126, 14.137 General Assembly resolutions, 2.12, 2.16 statistical activities, 4.9, 4.10, 13.41 see also Coordination and collaboration, individual

organizations and bodies United Nations Centre for Human Rights, 4.29 United Nations Centre for Human Settlements

(UNCHS), 12.6 United Nations Children's Fund (UNICEF), 3.3,

4.7, 5.8, 6.19, 7.7, 9.16, 9.17, 10.6, 10.7, 10.8, 10.9, 10.14, 11.1, 11.8, 12.3, 12.4, 12.5, 13.41, 14.13, 14.23, 14.78, 14.87, 14.92, 14.117, 14.118, 14.138, 14.154, 17.10, 19.11, 20.16, 21.8

United Nations Decade of Disabled Persons, 13.35 United Nations Development Programme (UNDP),

2.20, 4.19, 6.19, 10.6, 10.10, 10.19, 12.2, 13.41, 14.13, 14.23, 14.56, 14.117, 14.118, 14.154,19.11

United Nations Educational, Scientific and Cultural Organization (UNESCO), 4.29, 6.19, 7.7, 1 0.3, 10.7, 12.5, 12.25, 13.41, 14.117, 14.118, 17.11,21.8

United Nations Environment Programme (UNEP), 7.5, 9.13, 12.6, 12.16, 12.18, 12.19, 12.25, 12.26, 12.27, 17.11

United Nations General Assembly, 2.12, 2.16, 14.116 United Nations High Commissioner for Refugees,

Office of the (UNHCR), 2.29, 2.30, 2.32, 13.41 United Nations High-Level Committee on the Re­

view ofT echnical Cooperation Among Develop­ing Countries, 4.19

United Nations Industrial Development Organiza­tion (UNIDO), 5.8, 12.18, 13.7, 13.25

United Nations International Drug Control Pro­gramme (UNDCP), 11.10, 11.16, 13.21

United Nations Population Fund (UNFPA), 2.21, 9.4, 10.3, 10.6, 10.9, 10.14, 10.15, 10.16, 10.19, 14.117, 14.118, 17.10,19.11

THE WORK OF WHO 1992-1993

United Nations Relief and Works Agency for Pales­tine Refugees in the Near East (UNRWA), 12.3, 21.6

United Nations Research Institute for Social Devel­opment, 8.4

United Republic of Tanzania, 4.22, 6.12, 9.18, 10.8, 13.6, 14.24, 14.57, 14.61, 14.99, 14.100, 14.120, 14.135, 14.153, 17.6

United States of America, 5.8, 5.17, 6.21, 9.35, 9.36, 9.38, 9.42, 9.51, 10.9, 10.20, 10.22, 10.51, 10.53, 10.56, 11.1, 11.17, 13.5, 14.66, 14.68. 14.143, 14.199, 14.202,14.214

Agency for International Development (USAID), 5.21, 9.17, 14.26

UNRWA, see United Nations Relief and Works Agency for Palestine Refugees in the Near East

Upjohn Company (USA), 11.1 Urban development and housing, 12.14-12.17

see also Healthy cities Uruguay, 14.67 USAID, see under United States of America Uzbekistan, 5.1

Vaccine research and development, 14.154-14.163 Latin American and Caribbean initiative

(SIREVA), 8.9 see also Children, vaccine initiative; Immunization

and individual diseases Vector control, 10.49, 12.6, 12.7, 12.21, 14.43-14.48

Collaborative International Pesticide Analytical Council, 14.44

panel of experts (PEEM), 12.6 pesticides evaluation scheme (WHOPES), 14.44

Venereal diseases, see Sexually transmitted diseases Venezuela, 8.9, 11.17, 14.65, 14.68, 14.81, 14.143,

14.194 Veterinary public health, 14.102-14.113 Viet Nam, 5.3, 6.16, 7.12, 9.18, 10.7, 10.13, 12.28,

14.15, 14.51, 14.91, 15.9, 15.13, 22.5, 22.6, 22.8 Violence, 9.33, 9.35, 9.36, 11.10

against women, 9.5, 9.6 Viral diseases, 14.140-14.149

see also individual diseases and viruses Vitamin A deficiency, 9.19, 17.9, 21.9 Voting privileges and services, suspension, 2.2

Waste disposal and management, see Environmental pollution; Water supply and sanitation

Water supply and sanitation, 3.4, 9.10, 12.3-12.13, 12.25, 12.28, 12.29, 14.24, 17.2, 17.11, 19.14, 21.19

ACC subcommittee, 12.13 Africa 2000 programme, 12.12 collaborative council, 12.8, 12.13 interagency committee, 12.13 international decade, 17.11 joint monitoring programme, 12.3

Weekly epidemiological record, 4.6 Wells tart International, 9.16 Western Pacific Region, 22.1-22.13, Annex 2

see also individual activities

182

WFP, see World Food Programme WHO drug information, 13.11, 15.11 WHO pharmaceuticals newsletter, 13.11 WHO Representatives, 2.33, 6.27 WHO staff development, 6.27 Women, health and development, 1.2, 1.3, 2.25, 9.1-

9.8, 11.8, 14.56, 21.1, 21.8 see also Family planning; Maternal and child health

Workers' health, see Occupational health World AIDS Day, 7.3, 14.139 World Alliance for Breastfeeding Action, 9.16 World Assembly of Youth, 10.16 World Bank, 2.19, 2.26, 3.10, 4.3, 4.9, 4.14, 5.3, 5.6,

5.16, 6.4, 6.5, 6.19, 7.5, 10.19, 11.1, 11.9, 12.4, 13.34, 14.13, 14.56, 14.96, 14.117, 14.118, 14.154, 14.168, 14.176,19.26

World development report 1993, 4.9 World Conservation Union, 13.25 World Diabetes Day, 14.208 World Federation for Medical Education, 6.14, 6.19 World Federation of Proprietary Medicine Manufac-

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,

8.1, 10.51, 12.2, 12.31, 16.8, 16.9, 16.10, 16.12 meetings, Annex 3 resolutions, 1.3, 1.5, 2.7, 2.13, 2.28, 9.5, 9.19, 9.53,

9.54, 10.7, 12.14, 12.18, 13.35, 14.14, 14.16, 14.42, 14.50, 14.95, 14.116

Technical Discussions, 1.2, 9.34 World Health Day, 7.3, 7.10, 9.5, 9.29, 9.35, 14.206 World health forum, 15.11 World health situation, eighth report, 3.1 World health statistics annual, 4.1 World health statistics quarterly, 4.1, 14.207 World Hypertension League, 14.203 World Meteorological Organization, 12.27 World No-Tobacco Day, 7.3, 9.47 World Organization for Care in the Home and

Hospice, 10.56 World Organization of the Scout Movement, 10.16 World Psychiatric Association, 11.15 World Wide Fund for Nature, 13.25

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,

14.105, 21.3, 21.6 Youth and adolescence, 7.6, 7.8, 10.14-10.18, 11.8,

21.13 behaviour, narrative research method, 10.16

Yugoslavia, former, 2.30, 4.3, 11.7, 13.41, 16.16, 16.21, 20.6

Zaire, 14.40 Zambia, 2.26, 4.3, 4.11, 4.16, 4.22, 5.6, 5.21, 7.5, 12.11,

14.94, 14.105, 14.131, 14.135, 17.6 Zimbabwe, 4.22, 5.11, 5.17, 10.54, 11.7, 11.8, 12.5,

12.7, 13.21, 13.37, 14.96, 14.120, 14.177, 17.6 Zoonoses, 14.102-14.113