The evolution of WHO
The first World Health Assembly, held in June 1948 and attended by 53 delegates from WHO’s 55 Member States, approved a programme of work that listed its top priorities as malaria, maternal and child health, tuberculosis, venereal diseases, nutrition and environmental sanitation.
Today, 47 years later, in spite of significant improvements in human health, great burdens of suffering and disease are still with us. Half a century of lessons learned in eradicating and controlling diseases, expanding health care coverage and making the best use of available resources have guided the world community, including WHO, on the way to further progress.
The need for a world health organization
At the end of the second world war the majority of the world’s people were still living in extreme poverty and suffering from chronic malnutrition, communicable diseases and parasitic infections to name a few. Many existing health services were severely disrupted and huge segments of the population were excluded from them. The imperative need was therefore recognized for a new world body capable of grouping resources for health, concerting health goals and providing a forum for the exchange of health information. The result was the setting up by the United Nations of a specialized agency to fulfil that need – the World Health Organization.
Declaring war on disease
WHO’s first two decades were dominated by mass campaigns to control diseases such as leprosy, malaria, smallpox, syphilis, tuberculosis and yaws. Between 1950 and 1965, for instance, 46 million patients in 49 countries were successfully treated with penicillin against the tropical disease yaws, making it no longer a significant public health problem in most of the developing world. By 1955 the number of malaria cases worldwide had dropped by at least one-third; but by 1970 eradication of the disease was seen to be impracticable.
The same was not true of smallpox. An eradication campaign that began in 1966, when up to 2 million people a year were dying of smallpox, ended in 1980, when the disease had disappeared from the face of the earth.
These mass campaigns against single diseases gave way to WHO’s Expanded Programme on Immunization aimed at protecting by the year 2000 all children against six vaccine-preventable diseases – measles, diphtheria, pertussis, tetanus, poliomyelitis and tuberculosis. Global coverage with the vaccines reached its peak in 1990, when the goal of immunizing 80% of all children by the age of 1 year was achieved. The long-term goal of the multiagency children s vaccine initiative, launched in 1990, is to achieve a world in which all people at risk are protected against vaccine-preventable diseases, if possible by means of a single procedure.
Health for all
In 1979 the World Health Assembly unanimously endorsed the Declaration of Alma-Ata, which stated that primary health care was to be the key to attaining the goal of health for all by the year 2000.
Consequently global targets for health were established and have since been the norms against which all health development efforts have been measured. The strategy of health for all has been endorsed at the highest political level, but a gap remains between what is preached and what is practised.
Setting the standards
The establishment of standards in such fields as vaccines, drugs and laboratory tests has been a permanent part of WHO’s work. The WHO Expert Committee on Biological Standardization has met every year since 1951 to formulate standards which are recognized worldwide. The scientific credibility of WHO provides a guarantee that everyone accepts.
Training physicians, raising the standards of medical schools in developing countries and helping countries organize schools for nurses and midwives has also been a permanent feature of WHO’s work. The concept of primary health care has switched much of the emphasis to training directed towards a wide range of health care workers at community level, particularly in developing countries, rather than towards health professionals as such.
The way ahead
WHO’s general programmes of work, now covering periods of six years, set out principles and policies for the functioning of the Organization. They also provide a framework for detailed workplans and budgeting. Over the years the programmes have responded to, and often anticipated, the major health concerns of Member countries. The ninth programme (1996-2001) fixes goals and targets for WHO’s global health action. It focuses on lessening of inequities in health, control of rising costs, the eradication or elimination of selected infectious diseases, the fight against chronic diseases, and the promotion of healthy behaviour and a healthy environment.
The challenge for the future is to mobilize WHO’s Member States to adopt policies and plans that will guarantee the provision of comprehensive integrated health services to each and every member of the community.
WHO’s contributions to world health
Within the framework of the organization’s constitution and the guidance given in the periodic general programmes of work, all WHO activities are geared to respond to the priority problems of the age groups referred to in this summary. The full extent of WHO’s work at national, regional and global levels cannot be reflected here, but examples are given of different types of action.
Child and adolescent health
WHO encourages self-reliance of countries in conducting immunization through basic health services. It cooperates with UNICEF in its initiative of supplying vaccines to over 100 countries. Major priorities are to at least sustain the accomplishments of previous years and to continue to strive for achievement of the 1992 World Summit for Children goal of immunization against the six vaccine-preventable diseases (diphtheria, pertussis, tetanus, measles, poliomyelitis, tuberculosis).
In an effort to make the best use of limited resources to eliminate neonatal tetanus, WHO has given priority to countries that account for 80% of total cases and have an estimated mortality of 5 or more per 1 000 live births. WHO initiated a series of measures to arrest the spread of diphtheria in eastern Europe, including the formulation of a plan of action and the establishment of a European task force. In 1993 progress towards the poliomyelitis eradication goal was heartening. Efforts are being made to develop a more heat-stable poliovirus vaccine that can be delivered with a less rigorously maintained cold chain. Large donations for poliomyelitis eradication were coordinated with different organizations. In 1994 the region of the Americas committed itself to eliminating measles by the year 2000, and incidence is now at the lowest level ever. If the momentum is sustained the Americas may well lead the way towards global elimination of this major killer of children.
By the end of 1994 virtually all developing countries had implemented plans of action against diarrhoeal diseases in children. Nearly 42% of health staff in the countries had been trained in supervisory skills using materials developed by WHO, and almost 30% of doctors and other health workers had been trained in diarrhoea case management, many of them in the more than 420 diarrhoea training units established in over 90 countries. It is estimated that nearly 85% of the population of the countries had access to oral rehydration salts at the end of 1994.
Particular emphasis is given to training in the management of acute respiratory infections WHO supports courses for workers in first-level health facilities and referral hospitals on standard case management, and distributes training and technical materials. More than 190 000 health managers, doctors, nurses and community health workers in over 60 countries have been trained so far. WHO is involved in numerous studies on acute respiratory infections in Africa, Asia and Latin America.
Activities for better nutrition are promoted in 62 countries, mostly in collaboration with FAO and UNICEF. A global database on child growth was established and more than 90 countries are receiving technical and financial support to give effect to the International Code of Marketing of Breast-milk Substitutes. The new WHO/UNICEF “baby-friendly hospital initiative” has proved hugely successful in encouraging proper infant feeding practices, starting at birth. It has already been implemented in two-thirds of African countries. A number of countries have introduced national nutrition policies with WHO support.
A wide range of WHO programmes focus on the needs of adolescents in such fields as nutrition, mental health, sexuality, disease and injury prevention, and substance abuse. A joint UNICEF/WHO/UNFPA policy statement on the reproductive health of adolescents was disseminated. WHO supported the formulation of policies on adolescent health in 20 countries.
Health of adults
WHO activities broadly seek to improve and maintain the economic and social productivity of adults by promoting health and reducing premature morbidity and mortality.
As far as the major communicable diseases are concerned, efforts are being made to mobilize financial support to combat tuberculosis, which recently has shown a worrying resurgence. Control programmes were reorganized in several countries, and operational and other studies were supported. The research has produced some important results which may have major implications for policy. A study of rifapentine suggests that it is a promising new drug. A large trial is being organized on the efficacy of sparfloxacin, another new drug, against multidrug-resistant tuberculosis. A study in Uganda on the feasibility of tuberculosis chemoprophylaxis for HIV-infected persons suggests that this intervention is not easily applicable on a large scale in a developing country setting. WHO’s global task force on cholera control continues to support activities to strengthen national capacity to prepare for and respond to epidemics. Several cholera vaccines are at different stages of development. All 45 countries where malaria is endemic received WHO financial support for control activities. National plans of work, based on a revised regional control strategy, were drawn up in a number of African countries. WHO, together with other agencies and NGOs, responded promptly to requests for assistance in combating malaria epidemics in seven countries, including outbreaks among the 500 000 or so Rwandan refugees. In view of the rapid spread of chloroquine-resistant and multidrug-resistant falciparum malaria, a multicentre research programme has been initiated to study ways of retarding development of drug resistance. The synthetic Colombian malaria vaccine Spf66 has been shown to be safe, to induce antibodies and to reduce the risk of clinical malaria by around 30% among children aged under 5 in the United Republic of Tanzania.
With regard to the other communicable diseases, all countries where leprosy is endemic have implemented national strategies and plans for elimination of the disease as a public problem by the year 2000. The onchocerciasis control programme in West Africa, executed by WHO with support from UNDP, FAO and the World Bank, has succeeded in eliminating the disease as a public health problem in 11 endemic countries. Remarkable progress has been made in eradication of dracunculiasis. National eradication programmes are under way in the 18 endemic countries. A reliable village-based surveillance system has also been implemented, with monthly reporting in operation in all countries. WHO is supporting a campaign to eliminate Chagas disease from the Southern Cone of the Americas. Activities include the development of slow-release insecticidal paints which have shown to be nearly twice as effective as traditional sprays in controlling the triatomine vectors and about half as expensive. Seven-day treatments with eflornithine have been shown to be effective against trypanosomiasis. As the drug is expensive, WHO has arranged to provide it to four countries on a cost-recovery basis, and is participating in the development of a low-cost synthesis and production method. Support is given for research and training in the epidemiology and control of schistosomiasis, and a new candidate vaccine has been identified. Emergency supplies for serological diagnosis and drug treatment of visceral leishmaniasis were provided by WHO and UNICEF during a recent epidemic in Sudan. The outbreak of pneumonic plague in India in 1994 was a stern reminder that the disease often regarded as a scourge of the past still exists. WHO intervened promptly at the request of the Indian authorities. Travel advice was issued based on the International Health Regulations and an international team of experts was set up to conduct a thorough investigation. The results suggested that the outbreak involved far fewer cases than the number reported. No evidence was found of the plague spreading outside the focus; and no imported, confirmed plague was detected in any other country.
Programmes against HIV/AIDS are under way with WHO support in most Member States, including HIV surveillance activities in some 80 developing countries. Similarly, staff from 80 countries were trained in HIV/AIDS programme management. Agreements were concluded for bulk purchase of HIV test kits, ensuring quality and the best possible price for developing countries. A safety trial of a candidate vaccine against HIV, endorsed by WHO, was conducted for the first time in a developing country. Policy guidance is given in such fields as blood safety, restrictions on HIV-positive travellers and HIV testing. Hundreds of NGOs and networks of organizations work with WHO in the fight against HIV/AIDS.
WHO is developing a network of centres and a database in support of a global programme to monitor and prevent cardiovascular diseases, and continues to coordinate the 10-year, 26-country MONICA project which monitors trends and determinants in cardiovascular diseases and measures the effectiveness of interventions. National programmes for the prevention of coronary heart disease were introduced in 41 countries. Sixteen INTER-HEALTH demonstration projects have been set up worldwide (9 of them in developing countries) to assess the effectiveness of integrated community-based intervention. The related CINDI programme now covers 21 countries in Europe. WHO supports the implementation of national cancer pain relief and palliative care policies in 46 countries, and participates in the development of national cancer registers. A model list of 24 essential drugs for cancer chemotherapy was updated. Guidelines were produced on ethical issues in human genetics, and on the provision of genetic services for control of hereditary diseases. National programmes for control of diabetes and rheumatic diseases were established in several countries.
Guidelines on mental retardation, epilepsy and suicide and other aspects of mental health were issued. Studies are promoted on the long-term course and outcome of schizophrenia and obsessive/compulsive disorders. An international review of mental health legislation was undertaken. As part of efforts to prevent substance abuse, recommendations were made on international control of psychoactive substances and support is given to Member States in revising policies and legislation on treatment and rehabilitation of drug and alcohol dependence.
“Africa 2000”, a new investment initiative aimed at providing universal coverage of water supply and sanitation services, was launched. A broad programme of hygiene education and promotion of low-cost sanitation is being developed in cooperation with UNICEF and other organizations. Training packages and manuals on the proper operation, maintenance and optimization of systems are being prepared, and one on health in water resources development is being tested. The healthy cities initiative now covers over 650 cities worldwide. The global WHO/UNEP networks for monitoring air and water quality are operational in more than 60 countries. Revised WHO guidelines on drinking-water quality were issued. WHO and FAO support the Codex Alimentarius Commission in promoting the adoption of scientifically-based national food legislation. Together with FAO, WHO has established acceptable daily intakes for well over 700 food additives, contaminants and veterinary drug residues in food.
WHO/UNICEF/UNFPA policy statements were issued on promotion of the health of women. National safe motherhood action plans were formulated in 10 countries. Databases for monitoring patterns and trends in maternal health are being disseminated. A total of 87 research projects are funded, many dealing with the causes of maternal death and disability. A project was launched to promote simple methods for early detection of cancer of the cervix and breast in developing countries.
A key objective for WHO is to enable the elderly to exercise their full potential as a community resource, and to give them a satisfactory quality of life. Many WHO programmes are involved in this effort, including those concerned with nutrition, cardiovascular diseases, cancer and palliative care. A multinational collaborative study on the predictors of osteoarthritis was launched. In pursuance of the United Nations international plan of action on aging, WHO is setting up an integrated programme on aging and health, which will become fully operational in 1996.
General health issues
A global strategy on occupational health was formulated, and country activities supported. Guidelines and monographs were produced on such subjects as the health implications of occupational exposure to organic dust and sensitizing agents as well as selected metals, solvents and pesticides. Since 1976 WHO has evaluated the health risks posed by exposure to some 200 industrial chemicals and other substances. An international collaborative oral health research initiative is being set up in collaboration with the International Dental Federation among others. An international action network was established on noma and other mutilating diseases and accidents of the face. Significant progress was made in meeting the rehabilitation needs of the 35 million persons with disabilities in Africa, using the community-based district health approach. WHO’s global data on blindness were updated. Training and research in this field is supported by WHO jointly with NGOs. Quality standards were prepared for small-scale manufacturers of intraocular implants used in cataract surgery.
As a part of activities to promote healthy lifestyles, a school health education resource centre and databases were established as well as two regional networks of health promoting schools. The regions for health network in Europe was expanded to include 20 regions. National tobacco control programmes are supported. Recent Winter Olympic events have been smoke-free, thanks to collaboration between the International Olympic Committee and WHO.
WHO provides countries with information and guidelines on the organization of health systems based on primary health care. Technical guidance is given on the formulation of new health policies and strategies and the reorganization of health care financing systems.
WHO promotes information exchange between countries in relation to the development of human resources for health. It has launched an initiative to determine optimum approaches to the training of health personnel under changing socioeconomic conditions. Reviews of public health training and medical education are supported. Fellowships are provided for training in many health and related fields. National, regional and interregional action plans for upgrading nursing and midwifery practice are being drawn up through a network of WHO collaborating centres.
In the field of pharmaceuticals guidelines for drug prescribing are being expanded. National systems for drug registration, surveillance and quality assurance are being established in a number of countries with WHO collaboration. The WHO model list of essential drugs is being revised and updated. Working with bilateral agencies, other United Nations bodies and NGOs, WHO collaborates with 55 countries in framing national policies in such areas as drug selection and legislation. Operational research is carried out on the rational use of drugs. Guidelines, tools and training materials have been prepared on many aspects of drug management.
The WHO Global Commission on Women s Health has drawn up an agenda for action relating to women, health and development. Under the auspices of the commission, a scheme to provide credit and banking facilities to the most vulnerable and disadvantaged is being implemented in Africa. At the 1994 International Conference on Population and Development in Cairo, WHO played a key role in helping to reach a consensus and transcend political and religious differences. This was made possible by the Organization’s medical and ethical credibility and its inclusive approach to health.
Together with UNDP, WHO promotes recognition of health and environment concerns in national plans for sustainable development and has given financial and technical support to six countries for this purpose. WHO has been designated task manager for the “health chapter” of the 1992 United Nations Conference on Environment and Development (UNCED). In collaboration with several United Nations bodies it has prepared a progress report on health, environment and sustainable development, stressing the importance of reform with respect to community development, environmental health, national decision-making and national accounting. Materials produced by WHO included guidelines on the operation of poisons control facilities, 15 health and safety guides, and over 200 international chemical safety cards providing basic information on the diagnosis and treatment of poisonings. Training and research on the broad topic of health and environment are supported.
WHO worked with 26 countries in greatest need in planning and implementing health reforms as part of an overall effort for strengthening of national managerial capabilities. A third report on progress towards health for all by the year 2000 was prepared for submission to the WHO governing bodies in 1995. Research on health futures was organized; and assessment of the global health situation and trends in priority diseases and conditions continued. A total of 184 nongovernmental organizations are now in official relations with WHO. The growing awareness among Member States of the need to improve health care delivery systems, and a notable interest on the part of the World Bank to promote improvements in the social sector, provided a timely opportunity to forge closer links between WHO, the Bank and governments. Collaboration was also strengthened with the five major regional development banks. The traditional good working relations with UNICEF, UNFPA, FAO, ILO and UNESCO continued.
WHO continues to strengthen national capacity for emergency preparedness and relief. Technical expertise and emergency medical supplies were provided to a number of countries including Afghanistan, Angola, Burundi, Iraq, Rwanda, Somalia, Sudan and some new independent states in 1994. WHO cooperated closely with the European Union on assistance for the countries of former Yugoslavia. Ten joint missions were undertaken with WFP for the organization of food aid in support of human resources development.
Handbooks and guidelines in different fields of health technology were produced. Progress was made in developing portable laboratory instruments, solar-run equipment and other types of appropriate technologies.
Up-to-date, authoritative health information is provided to all Member States through a large number of publications, a series of widely-distributed periodicals, electronic networks and library services. WHO facilitates access by countries to a number of databases containing information on such subjects as communicable diseases and HIV/AIDS. For many health workers in developing countries, WHO materials are often the only source of reliable information on health.
Source: World Health Report 1995