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Title : UNICEF/WHO Joint Committee on Health Policy
Document Type : Executive Board Decisions - Programme
Country : Global Document Symbol/Series: 1992/29
Year Published : 1992 PDF Link :
OSEB Doctype : Executive Board Decisions
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Executive Summary:



Document Text:

On the recommendation of the Programme Committee,

The Executive Board,

Noting the report of the UNICEF/World Health Organization (WHO) Joint Committee on Health Policy (JCHP) special session held at WHO Headquarters in Geneva on 30-31 January 1992,

Endorses the following recommendations contained in paragraphs 23, 29, 42, 45, 52, 56 and 61 of document E/ICEF/1992/L.18:
I. WORLD SUMMIT FOR CHILDREN: FOLLOW-UP ACTION

1. The principal action to be supported by WHO and UNICEF is the strengthening of the national health system with a focus on the district health system based on primary health care (PHC). JCHP recommends that priority attention be given to:

(a) Training and supervision of all categories of national personnel with an emphasis on the team approach;

(b) Logistics and supplies in particular drugs, vaccines and other needs (on which programmes such as the Expanded Programme on Immunization (EPI), the Global Programme on AIDS, as well as programmes on diarrhoeal diseases, acute respiratory infections (ARI), malaria and schistosomiasis depend); this requires intensified use of the Action Programme on Essential Drugs, the Bamako Initiative, other community-based initiatives, and the UNICEF field operation support system;

(c) Community and health education to serve the interests of all programmes by creating public awareness and supplying the basic knowledge people need to take charge of their own health, a critical factor for example in the prevention and control of AIDS - extensive promotion of the booklet, Facts for Life, 1/ will empower families to improve their health and strengthen linkages between the community and local health services;

(d) Community involvement and empowerment to ensure people's full participation in planning for and meeting their own needs;

(e) Surveillance, information gathering, monitoring and evaluation with the aim of strengthening national epidemiological capacity to enhance the delivery of strategies, better manage the supply line, and more effectively monitor impact and quality control at all levels of the health system, in particular the district health system, as well as within each programme area; the crucial element to be promoted is routine information exchange to obtain and feed back regular assessments of programme progress as well as suggestions from health workers about solving operational problems;

(f) Biomedical and operational research to harness science to improve the available tools to strengthen the biomedical research required to ensure the highest possible technical standards, and to meet the management needs of the system.

2. JCHP recommends the following specific programme areas, among others, for collaboration between WHO and UNICEF in support of countries:

(a) Reduction of infant and child mortality - ensuring that in all activities related to reduction of infant mortality there is (i) better application of epidemiological principles and methods; and (ii) the screening of every child brought to a health clinic for any reason, and the linkage of care to ensure that the other elements of health promotion, protection and care are provided;

(b) Women's health, safe motherhood and newborn care - (i) extending technical cooperation in the development of national programmes for maternal and neonatal health within PHC, and encouraging national programmes to establish a focal point for the programme; (ii) research on the organization of maternal health services, and on interventions and programme management of specific conditions such as postpartum haemorrhage and anaemia, unclean delivery/obstetric sepsis, hypertensive diseases of pregnancy, and unwanted pregnancy and unsafe abortion; (iii) training and community education in the context of the district health system; and (iv) the analysis of data from various databases on maternal and newborn health to be issued periodically to facilitate advocacy and information dissemination;

(c) EPI - (i) developing overall immunization plans of action within PHC through the formation and strengthening of technical advisory groups at regional and country level; (ii) training in the management of immunization programmes and disease surveillance and control to strengthen the managerial capacity for implementing PHC activities; (iii) research on improved disease control strategies, improved methods and materials for diagnosis of the EPI target diseases, improved surveillance and programme monitoring tools, and improved methods and materials for the cold-chain and logistic support; (iv)/ensuring the supply of vaccines including new vaccines, as well as the quality of vaccines, in the face of increasing costs;

(d) Diarrhoeal diseases - (i) mobilization and advocacy at the highest political level; (ii) promoting correct home management of diarrhoea; (iii)/training at all levels of the health system with special emphasis on four-day clinical training courses at health centres and small hospitals; (iv)/establishing oral rehydration therapy (ORT) units; (v) ensuring availability of oral rehydration salts (ORS); (vi) improving communications/- both interpersonal and by way of the mass media and health education; (vii)/evaluation through health facility surveys, household surveys and programme reviews; and (viii) prevention, including promotion of breast-feeding, especially exclusive breast-feeding for the first four to six months of life, measles immunization and personal and food hygiene;

(e) ARI - case management is the essential strategy to avert pneumonia deaths and make an immediate impact on mortality from ARI; WHO and UNICEF will concentrate their support to countries on (i) sound technical and managerial policies and planning, including measures which will enable control activities to reach the people; (ii) training in all these aspects; (iii) ethnographic studies to serve as the basis for local adaptation of generic communication messages; (iv) development of a checklist for supervision of case management; (v)/ensuring supplies, particularly through the essential drugs programme and the Bamako Initiative; (vi) monitoring and evaluation of programme activities and health systems research;

(f) Nutrition - WHO/UNICEF collaborative activities include supporting countries (i) to develop and strengthen national nutrition policies; (ii)/to combat deficiencies in iodine (in order to eliminate goitre, cretinism and related disorders), vitamin A deficiencies (to combat blindness) and iron deficiencies (to fight nutritional anaemia); (iii) to bring protein-energy malnutrition under control through strategies to ensure household food security, correcting inappropriate feeding practices (particularly in women and children) and to prevent and manage infection and parasite infestation, with a special focus on least developed countries and pockets of poverty in others; (iv) to develop national nutritional surveillance capabilities, strengthen nutrition-related information, education and training, and foster nutrition research;

- An action plan emanating from the major international conference on micronutrient malnutrition jointly convened in October 1991, in Montreal, had been drawn up for presentation to the WHO Executive Board 2/ and the World Health Assembly in 1992: WHO and UNICEF will support country efforts leading to virtual elimination of vitamin A deficiency and iodine deficiency diseases and significant reduction of iron deficiency anaemia; jointly sponsored workshops on micronutrient deficiencies will also be convened at the regional level;

(g) Breast-feeding - common actions include: (i) advocacy and health education adapted to socio-cultural settings; (ii) development of education and information materials; (iii) promoting lactation management and breast-feeding training through a regional network of training centres; (iv)/encouraging the provision of social support for breast-feeding women; (v)/technical support for the national application of the International Code of Marketing of Breast Milk Substitutes; (vi) operational research, in particular to facilitate the achievement by all women of the infant feeding ideal set out in the Innocenti Declaration;

- The joint launching and support given to the WHO/UNICEF "baby-friendly" hospital initiative provides a focus and starting point for country and community-based action on many of these activities; promotion and support of the concept of "baby-friendly" hospitals should result in their establishment all over the world by the end of 1992;

(h) Water and sanitation - the WHO/UNICEF Joint Monitoring Programme for the Water and Sanitation Sector was signed in March 1990; data relevant to the achievement of the World Summit goals are to be obtained from studies on rural and urban populations with access to safe water supply and sanitation, and on utilization of these systems especially by low-income groups; the Joint Monitoring Programme is planned to be implemented throughout the 1990s with the initial seven countries acting as regional focal points;

(i) Dracunculiasis (guinea worm disease) - WHO and UNICEF will continue to work together to improve and implement: (i) community surveillance methodologies; (ii) vector control strategies; (iii) case containment strategies; (iv) mapping of remote villages; (v) strategies for targeting and monitoring the impact of water supply;

(j) Malaria control - collaborative efforts will continue in many endemic countries: (i) to identify those populations at risk to malaria and to improve the diagnosis and management of the disease, particularly severe and complicated cases; (ii) to support operational research on the efficacy of impregnated bednets; (iii) to provide intensified support in health education, the provision of essential supplies and in social mobilization;

- Concerning prophylaxis, which is still desirable in pregnancy, it is necessary to weigh the risks and benefits of the drug available in each local situation; the Ministerial Conference on Malaria (Amsterdam, 26-27 October 1992), organized by WHO and supported by UNICEF, will indicate new areas for intensive collaboration;

(k) Schistosomiasis - (i) the pricing structure of the drug praziquantel is being negotiated with manufacturers, and it is anticipated that UNICEF will participate with WHO in this endeavour; (ii) UNICEF-supported water supply programmes will also be encouraged to consider schistosomiasis as a health monitoring indicator wherever appropriate;

(l) Essential drugs - (i) continuing collaborative operational research activities including drug stability during international transport; (ii) the WHO Action Programme on Essential Drugs will continue to work with UNICEF to establish community-based projects supported by strong drug-sector infrastructures; (iii) the programme in collaboration with UNICEF will continue, through information campaigns, to help educate health care providers and the public in general in the rational use of drugs and will strengthen in particular the capacities at the district level through training in drug management, rational use and monitoring;

(m) Prevention and control of AIDS - (i) world-wide advocacy for implementation of AIDS prevention and control activities by many sectors and ministries; (ii) adoption of quantitative programme goals in order to achieve the reduction of infant and child mortality called for by the World Summit; (iii)/educational programmes for youth, both in and out of school, emphasizing safer sexual behaviour and the use of condoms as the main preventive strategy; (iv)/social and economic support to children orphaned as a consequence of AIDS, especially in sub-Saharan Africa; (v) collaboration on research and development of vaccines and on interventions to reduce female vulnerability; (vi)/using the Bamako Initiative to provide essential drugs for treatment of sexually transmitted diseases and opportunistic infections;

(n) Healthy life-styles for youth - (i) collaboration with other organizations such as the United Nations Population Fund (UNFPA) and youth non-governmental organizations (NGOs) to promote policies and programmes for adolescent health in a variety of international forums; (ii) development of a strategic, long-term plan for joint country activities to be implemented using the integrated, intersectoral and inter-agency approach recommended by JCHP; (iii)/initiation of a joint pilot training programme in three countries for personnel working with street children to better deal with the problems associated with substance abuse.

Monitoring and evaluation

3. JCHP recommends that immediate action be taken on the following in areas relating to health, taking into account the discussion in the Committee:

(a) The responsible technical programme in WHO, in consultation with counterparts in UNICEF, to confirm the definitions of proposed indicators related to each health goal;

(b) UNICEF and WHO to identify and agree upon the set of core primary indicators to be initially used for global monitoring;

(c) Prepare a monitoring guideline to be issued, which, as a minimum, should contain: (i) the agreed principles for monitoring the World Summit goals; (ii) the criteria for acceptable indicators; (iii) the current list of proposed indicators giving for each the agreed technical definition, the recommended sources of data and methods of data collection; (iv) the list of types of country level collaboration which UNICEF and WHO can jointly provide from country, regional, and global levels;

(d) Strengthen collaboration with the United Nations Statistical Office, the United Nations Development Programme and UNFPA by broadening a proposed project for monitoring social (human) development beyond household survey methods to include a variety of data sources, and the involvement of a number of agencies in a coordinated manner; a special effort to develop and document methods for measuring mortality and its causes should be included in this proposal, for implementation by the WHO programme on epidemiological surveillance and health situation and trend assessment;

(e) Coordinate monitoring methods development with the World Bank programme on social dimensions of adjustment and the United States Agency for International Development demographic and health survey activity;

(f) Compile a description of indicator databases maintained by various programmes in WHO, Geneva, and UNICEF, New York, to facilitate data-sharing and to reduce duplicate database maintenance;

(g) Compile and share a schedule of global, regional and country level meetings and workshops on the subject of monitoring and evaluation to be convened by either or both organizations.

4. JCHP recommends that the next steps might be: (a) to finalize jointly the choice and definition of core indicators; (b) to produce jointly monitoring guidelines for the country offices of both organizations; (c) to identify country and regional workshops for training staff and nationals and coordinate the staff and financial support for those workshops; (d) to identify specific countries requiring special efforts for the establishment of baseline data for which support is needed; and, (e) to strive to assure that the national input to the health aspects of the mid-decade review be accomplished through the 1994 Health for All monitoring exercise in order to minimize national reporting burdens and that the guidelines for that report be prepared together with UNICEF.
II. MEETING VACCINE NEEDS FOR THE EXPANDED PROGRAMME ON IMMUNIZATION IN THE 1990s

5. JCHP expressed concern about the potential shortfall of high-quality vaccines for national immunization programmes. The WHO and UNICEF Executive Boards and governing bodies should consider urgent action on the following strategies to avert this emerging crisis:

(a) Support to countries which have the capacity to produce vaccines, noting the national commitment and managerial resources required to produce high-quality vaccines, to become self-sufficient, including support to national control authorities to ensure that such locally produced vaccines are of high quality;

(b) Soliciting the support of the donor community to provide greater resources for the procurement of high-quality vaccines for EPI, as well as to consider ways to encourage vaccine producers to provide vaccines at lower prices;

(c) Facilitating, through the Vaccine Independence Initiative, the procurement of high-quality vaccines on behalf of Governments, either with convertible or local currencies;

(d) Establishing the supply of much greater quantities of vaccines of assured quality through current and/or new sources;

(e) Utilizing the Children's Vaccine Initiative to help make the use of vaccines more effective (by developing products that are heat stable, involve fewer doses, less wastage and longer shelf-life, and have higher efficacy, etc.), to strengthen the epidemiological capacity to guide use of vaccines, to strengthen capacity to assure quality of current and new vaccines, and to develop and strengthen mechanisms for the supply of vaccines;

(f) Reviewing possible mechanisms for establishing multi-year contracts for vaccine purchase.
III. RESPONSE TO THE CHOLERA EPIDEMIC: POINTS FOR ACTION

6. JCHP recommends that WHO and UNICEF assist Governments in providing emergency responses to cholera outbreaks by:

(a) Establishing intersectoral national cholera control committees;

(b) Conducting initial assessments and identification of high-risk groups;

(c) Developing effective surveillance systems to detect outbreaks and track the spread of the disease;

(d) Supporting measures to disinfect water supplies, identify and control likely major sources of food-borne spread, disseminate key health education messages to affected populations and restrict access to contaminated areas;

(e) Establishing/training mobile teams to organize initial activities in newly affected areas, e.g., set up emergency treatment centres;

(f) Assessing emergency supply needs, procuring these supplies and ensuring timely distribution, e.g., of ORS, intravenous fluids, utensils, antibiotics and laboratory supplies;

(g) Involving community organizations in all phases of emergency action, especially in health education and the setting up of emergency treatment centres.

7. JCHP recommends that WHO and UNICEF assist Governments to achieve cholera preparedness by:

(a) Incorporating cholera control as part of the national diarrhoeal diseases control programme as well as part of five-year programmes of cooperation;

(b) Including cholera control activities as part of the diarrhoeal diseases control component of UNICEF country programmes;

(c) Promoting broad-based community involvement in all aspects of cholera control and prevention, thus empowering communities to respond rapidly and effectively, e.g., through the establishment of community oral rehydration units in cholera-prone areas and among vulnerable groups;

(d) Planning and implementing broad-based health education efforts (through media, schools and other channels) geared towards correct treatment, controlling transmission and preventing cholera incidence;

(e) Consolidating improvements in surveillance, laboratory and reporting systems, which result from experience in controlling cholera outbreaks;

(f) Assessing supply needs, procuring supplies and ensuring timely distribution, especially to particularly cholera-prone areas.

8. JCHP recommends that WHO and UNICEF assist Governments in cholera prevention by:

(a) Developing comprehensive plans for improved water and sanitation systems;

(b) Training food handlers and establishing good manufacturing practices in food processing plants;

(c) Further strengthening health education efforts to promote improved personal, domestic, community and food hygiene practices;

(d) Further improving case management of all diarrhoea episodes, both at home and within health facilities;

(e) Continuing to expand the number and range of ORT providers both within and outside the health system;

(f) Supporting key research projects related to cholera control, e.g., the development of a cholera vaccine, improved formulations of ORS, simple tools for investigation of outbreaks, etc.
IV. MANAGEMENT OF THE DISTRICT HEALTH SYSTEM BASED ON PRIMARY HEALTH CARE

9. JCHP recommends the following common action points for WHO and UNICEF support to the strengthening of district health systems, and submits them to the Executive Boards of WHO and UNICEF for their consideration and endorsement:

(a) The district is the key level of the health system to implement, monitor and expand the health delivery system. Many lessons have been learned from national efforts to improve the management of district health systems, in many cases with support from WHO and UNICEF. The challenge for the future is for WHO and UNICEF to work together effectively and efficiently to further support the strengthening of district health systems through a variety of programme approaches, including the Bamako Initiative;

Country level action - participation and management

(b) Policy analysis and promotion. WHO and UNICEF should work with countries in the analysis of existing policies and programmes, with a view to developing a policy framework to support district health systems. Elements of the required framework include decentralization of health management to the district level, provision for community participation in health development, a strong essential drugs policy, development of appropriate cost-sharing mechanisms, and improved financial management systems. The analysis should ensure that all existing delivery structures, including those of EPI and the programme on maternal and child health and family planning, are reviewed and integrated into the district health system. External agencies are in a key position to cooperate in the provision of technical as well as financial resources to carry out such policy analysis. A variety of processes, which include involvement of national committees and working groups focused on specific issues, can be used to coordinate the reviews and the actions required;

(c) Baseline assessment of progress in implementing PHC at the district level. WHO and UNICEF should work with countries to support and/or assist in sectoral reviews and planning in each of the four areas which have been identified for strengthening of PHC:

(ii) Community participation. Existing experiences should be examined to provide a picture of workable approaches for representation, control and responsibilities. Information should also be obtained on management skills and capacity at the community level, and community skills should be enhanced through such measures as functional literacy and numeracy;

(iii) Resource mobilization and allocation. To fully understand the resource requirements at the district level, information is needed on existing community resources and expenditures. The resource gap can be estimated through an assessment of health service needs and resource requirements, and thus permit an analysis of feasible alternatives for obtaining and managing additional resources;

(iv) Management support. The district health system's capacity and materials for in-service training and supervision, as well as the requirements for staff development support, should be ascertained. Estimates of available capacity for transport and or the procurement and distribution of drugs and supplies are needed as a basis on which to plan support to health workers in these areas;

(d) Planning for the strengthening of district health systems. At the district level, plans should be prepared based on the assessment of health service progress and problems. The planning process should include a prioritization of problems, a listing of corrective actions and the levels at which they should be taken, and the identification of steps to address the problems. A critical element of the plan will be the preparation of a budget which details the recurrent and capital costs of implementing the plan;

(e) Support for training, supervision and logistics. Based on the assessments of the gaps in technical and managerial skills of communities and district staff (see (c) (ii) above), WHO and UNICEF can assist in the development of training materials and the training of trainers to work with communities and health workers;

(f) Support for monitoring, evaluation and operational research. The development of district strategies and plans to address the needs identified in the assessment will necessitate the development of indicators for purposes of regular monitoring and evaluation. WHO and UNICEF should assist in the development of management information systems to facilitate these management processes, enabling comparative indicators to be reviewed across districts as a basis for monitoring the improvement of performance. Persistent problems or those that appear across several districts would warrant the design of operational studies to determine solutions;

(g) Planning and resource mobilization at the national level. WHO and UNICEF should collaborate in the setting of national targets for strengthening district health systems, in terms of health units and districts providing effective health services, population coverage and health status improvements. National plans should be prepared, based on the individual district plans. The national plans should clearly indicate health system inputs and outputs and their phasing. The national plan for district health strengthening should be developed as part of the national plans of action, agreed to by countries at the World Summit for Children, detailing how the national goals for the 1990s will be achieved. The national plan will also indicate how WHO and UNICEF will support national actions under the district approach;

Global and regional level action

(h) Support for national capacity-building. WHO and UNICEF should continue to enhance national capacity for strengthening of district health systems through various initiatives, including the Bamako Initiative. Intercountry workshops represent one vehicle for this effort. The workshops should address the different fields of joint activity identified above for the country level. In addition, streamlining and adaptation of training materials, and testing their use in different settings, will facilitate the training of district health staff and community representatives in management and technical skills. WHO and UNICEF should facilitate the gathering and dissemination of appropriate and tested staff training materials used by districts in different countries;

(i) Advocacy and coordination. WHO and UNICEF should systematically incorporate advocacy for district health systems into their discussions with government and external agencies. With Governments, the organizations should stress fulfilment of the policy conditions for strengthening district services, in collaboration with other agencies engaged in these areas. In discussions with other international agencies, WHO and UNICEF should encourage involvement in support of district health systems, and should make efforts to coordinate these activities in order to ensure that district goals are most effectively pursued. WHO and UNICEF should also promote the development of alliances with and among NGOs, in order to influence their strategies for support of district health systems;

(j) Monitoring and evaluation. WHO and UNICEF should bring together and disseminate the results of monitoring and evaluation studies carried out at the national level. The organizations should promote the documentation, exchange and adaptation of experiences with district health systems. Progress in district health system strengthening and the Bamako Initiative should be reviewed regularly by the two organizations, based on the monitoring data collected at national level and compared against the targets which have been set by countries;

(k) Operational research. WHO and UNICEF should promote operational research as an applied tool for strengthening management. It could be used for systematic examination of innovations in such areas as community financing, intersectoral action, management improvements, etc. Emphasis should be placed on finding practical solutions to problems which are common to many countries. The findings should be documented, disseminated and followed up.

10. JCHP recommends that the above points form the basis for the beginning of discussions and planning in practical terms between UNICEF and WHO with a view to supporting countries in the management of their district health systems. The two organizations are requested to develop a specific plan of action and to report on this plan, along with the progress made in achieving it, to the next session of the JCHP.
V. "BABY-FRIENDLY" HOSPITALS: A BREAST-FEEDING INITIATIVE

11. JCHP takes note of the following common action points and recommends their submission to the Executive Boards of UNICEF and WHO for consideration and endorsement. WHO and UNICEF should:

(a) Continue to mobilize various sectors of society globally to be aware of the critical importance of breast-feeding and act accordingly; these sectors include religious institutions, professional organizations, the infant food industry and community organizations;

(b) Strengthen the technical capacity in countries to implement the "baby-friendly" hospital initiative through establishing lactation training and resource centres;

(c) Support countries with programme guidelines to enable them to incorporate the "baby-friendly" hospital initiative in ongoing development of health and nutrition programmes;

(d) Increase the flow of and access to factual information on all areas of infant and child feeding;

(e) Strengthen and extend the existing network of WHO collaborating centres for training of trainers, development of training materials and research, as part of the "baby-friendly" hospital initiative;

(f) Further development, evaluation and widespread application of relevant indicators for infant and young child feeding, for programme monitoring, evaluation and planning, and for certifying a hospital as "baby-friendly";

(g) Facilitate and encourage within-country dialogue and cooperation in support of the "baby-friendly" hospital initiative among the various interested parties, under the direction and guidance of national authorities;

(h) After sufficient experience has been gained with the "baby-friendly" hospital initiative, promote and technically support the extension of the practical application of the concepts of the "baby-friendly" hospital initiative to other aspects of infant and young child nutrition, child survival and maternal health, nutrition, safe motherhood and family planning.
VI. THE ROLE OF UNICEF IN THE PROMOTION AND SUPPORT OF BREAST-FEEDING

12. JCHP endorses, in principle, operative paragraphs 1 to 7 of UNICEF Executive Board decision 1991/22 on the role of UNICEF in the promotion and support of breast-feeding 3/ and recommends their endorsement by WHO and UNICEF.

13. JCHP recognizes the need of a number of countries for additional information regarding marketing practices for breast milk substitutes and recommends the dissemination of this information to help countries in developing national legislation or other suitable action related to implementation of the principles and aim of the International Code of Marketing of Breast Milk Substitutes.

14. In this connection, and in regard to paragraph 6 of UNICEF Executive Board decision 1991/22, JCHP recommends that future studies of marketing practices be conducted by countries, with the assistance of WHO and UNICEF. JCHP encourages the use of the new methodology of the Common Review and Evaluation Framework, inter alia, to support countries in making such reviews. It is understood that the UNICEF Executive Board resolution refers to breast milk substitutes and not infant foods in a broader sense.
VII. DATE AND PLACE OF THE NEXT REGULAR SESSION OF JCHP

15. It was recommended that, with the consent of the Executive Boards of WHO and UNICEF, the next regular session of JCHP should be held in Geneva immediately following the ninety-first session of the WHO Executive Board in January 1993.


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1/ Joint UNICEF, WHO and United Nations Educational, Scientific and Cultural Organization (UNESCO) publication, available from UNICEF, New York.

2/ Document EB89/20.

3/ Economic and Social Council. Documents E/1991/33, E/ICEF/1991/15, New York, 12 June 1991.