Issues in enhancing continuing professional development for midwives in clinical practice in Mongolia.

Midwives are professionals who fulfill maternal and child health needs. In Mongolia, midwives were unable to transfer their knowledge and skills to the next generation midwives last few decades. The details of their experiences and the comprehensive aspects of continuing professional development (CPD) are still unclear. This study aimed to assess the current status of midwives in clinical practice through an online symposium. Relevant information was collected from presentations, question-and-answer sessions, and questionnaires. It was found that CPD has unclear training plans, no specialized training, and with them having little experience with CPD. Newly graduated midwives do not have an educational program. As of the current status, midwifery services are not provided at the clinical site in the scope of midwifery job descriptions. This study also discusses the situation of low status and salary in midwifery. Strengthening the system of midwifery CPD like development of the educational program is needed.

Comparison of the clinical competency of nurses trained in competency-based and object-based approaches in the Democratic Republic of the Congo: A cross-sectional study.

In the Democratic Republic of the Congo (DRC), the object-based approach (OBA) still remains mainstream in the basic nursing education program, despite the intention of the Ministry of Public Health to expand the competency-based approach (CBA) nationwide. This study aimed to compare the clinical competency of nurses trained with CBA and OBA. A cross-sectional, mixed study was conducted. We developed a self-assessment questionnaire consisting of an individual demographic information, a clinical competency assessment scale and the General Self-efficacy Scale. Nurses trained with CBA or OBA and currently working in health facilities with two to five years of clinical experience were purposively selected from ten cities across nine provinces in the DRC. We also conducted key informant interviews with the clinical supervisors at health facilities. In a comparison of 160 nurses trained with CBA and 153 with OBA, 3 competency domains ("establishing professional communication", "making decisions about health problems", and "performing nursing interventions") of the 5 domains required for nurses had significantly higher scores in the CBA group. The key informant interviews supported these results while revealing various issues in the basic nursing education program. The results support the strategic direction of the Ministry of Public Health in the DRC to expand CBA. Collaboration among education institutions, health facilities, and administrative bodies is crucial for clinical nurses to fully engage their competencies for the population. Other low- and middle-income countries with scarce resources can refer to the developed and implemented competency assessment method applied in this study.

Effectiveness of Infection Control Teams in Reducing Healthcare-Associated Infections: A Systematic Review and Meta-Analysis.

The infection control team (ICT) ensures the implementation of infection control guidelines in healthcare facilities. This systematic review aims to evaluate the effectiveness of ICT, with or without an infection control link nurse (ICLN) system, in reducing healthcare-associated infections (HCAIs). We searched four databases to identify randomised controlled trials (RCTs) in inpatient, outpatient and long-term care facilities. We judged the quality of the studies, conducted meta-analyses whenever interventions and outcome measures were comparable in at least two studies, and assessed the certainty of evidence. Nine RCTs were included; all were rated as being low quality. Overall, ICT, with or without an ICLN system, did not reduce the incidence rate of HCAIs [risk ratio (RR) = 0.65, 95% confidence interval (CI): 0.45-1.07], death due to HCAIs (RR = 0.32, 95% CI: 0.04-2.69) and length of hospital stay (42 days vs. 45 days, p = 0.52). However, ICT with an ICLN system improved nurses' compliance with infection control practices (RR = 1.17, 95% CI: 1.00-1.38). Due to the high level of bias, inconsistency and imprecision, these findings should be considered with caution. High-quality studies using similar outcome measures are needed to demonstrate the effectiveness and cost-effectiveness of ICT.

Early essential newborn care in national tertiary hospitals in Cambodia and Lao People's Democratic Republic: a cross-sectional study.

BACKGROUND: Ministries of health in collaboration with the World Health Organization Regional Office for the Western Pacific (WPRO) have been scaling up early essential newborn care (EENC). This study was carried out to understand current EENC practices at hospitals in two priority countries: the Kingdom of Cambodia (Cambodia) and Lao People's Democratic Republic (Lao PDR). METHODS: EENC is subdivided into 79 checkpoints, referencing the self-monitoring checklist developed by the WPRO. Each checkpoint is rated using a 0 to 2-point scale, and a percentage was calculated for the rate of practice of each checkpoint by dividing the total scores by the maximum possible scores. RESULTS: In total, 55 and 56 deliveries were observed in Cambodia and Lao PDR, respectively, and 35 and 34 normal deliveries were included in the analysis. The overall rates of the practices within the first 15 minutes after birth were high in both countries. The rates of the practices before birth and 15 minutes after birth were lower than the rates of the practices performed within the first 15 minutes after birth, especially "hand wash before preparation", "preparation for newborn resuscitation", and "monitoring of postpartum mothers and babies". A detailed analysis revealed that the quality of the practices differed between the two countries regarding skin-to-skin contact and breastfeeding support. CONCLUSIONS: The high rates of the practices within the first 15 minutes after birth suggest that the EENC coaching sessions supported by ministries of health and the WPRO have been effective. Differences in the quality of practices performed at a high rate between the two countries appeared to be related to factors such as the timing of the study, the perception of the staff, and the situation at the health facilities. These differences and identified practices with lower rates should be improved according to the situation in each country or health facility. Therefore, determining the quality of the practices in a country or a health facility is important. To further improve the quality of EENC, interventions tailored to the specific situation are necessary.

Lessons learned from the history of postgraduate medical training in Japan: from disease-centred care to patient-centred care in an aging society.

BACKGROUND: Health workers, the core of health service delivery and a key driver of progress towards universal health coverage, must be available in sufficient numbers and distributed fairly to serve the entire population. In addition, the planning and management of the health workforce must be responsive to the changing needs of society, including changes in age structure and epidemiology. Considering these issues, this paper examines in historical perspective the evolution of postgraduate medical training and practice in Japan, from the late nineteenth century to the present. MAIN TEXT: When the first medical schools were established in the country towards the end of the nineteenth century, Japan was a largely agrarian society, with a population of about 30 million and an average life expectancy of 30-40 years. During the twentieth century, life expectancy and the national population continued to increase in a context of rapid economic growth. Since the 1980s, another demographic transition has occurred: low fertility rates and an aging society. As a result, the inputs and skills required from health professionals have changed considerably over time, posing new challenges to the national health sector and the management of human resources for health. CONCLUSIONS: The case of Japan offers valuable lessons for other countries experiencing a rapid epidemiological and demographic transition. To provide medical care that meets health priorities in the communities, we must consider not only the training of specialists, but also ensure the availability of a large cadre of physicians who possess basic skills and can provide patient-centred care. Furthermore, the Japanese experience shows that a highly hierarchical system and organisational culture are ill-suited to respond quickly to the changing demands of society.

World Health Organization Recommendation for Using Uterine Balloon Tamponade to Treat Postpartum Hemorrhage.

The World Health Organization (WHO) recently published a new recommendation on the use of the uterine balloon tamponade for the treatment of postpartum hemorrhage. The recommendation that uterine balloon tamponade should be used only where there is already access to other postpartum hemorrhage treatments (including immediate recourse to surgery) has proved controversial. It is especially problematic for those working in low-level health care facilities in under-resourced settings, where there are already programs that have introduced low-cost uterine balloon tamponade devices for use, even in settings where recourse to surgical interventions is not possible. However, there are now two separate randomized trials that both unexpectedly show unfavorable outcomes in these settings when a condom catheter uterine balloon tamponade device was introduced. Considering the balance of potential benefits and these safety concerns, the WHO postpartum hemorrhage guideline panel therefore recommends that uterine balloon tamponade should be used only in contexts where other supportive postpartum hemorrhage interventions are available if needed.

"Staying at home" to tackle COVID-19 pandemic: rhetoric or reality? Cross-cutting analysis of nine population groups vulnerable to homelessness in Japan.

Although the "stay-at-home" order is advocated against the coronavirus disease 2019 (COVID-19), the lives of individuals lacking adequate housing are threatened. We developed a framework to assess various populations with unstable housing in terms of socio-economic consequences of COVID-19, risk of COVID-19 infection and progression, existing/urgent measures, and remaining challenges. Within the framework, nine groups vulnerable to homelessness in Japan were classified into (i) "people without accommodation," (ii) "people living in temporary or crisis accommodation," and (iii) populations that include "people living in severely inadequate and insecure accommodation." The assessment revealed that "staying at home" was physically and practically unattainable across groups. The study identified specific institutional, social, and cultural challenges apart from the common economic crisis, whereas the utilization of social welfare was low. Findings suggest that the rapid increase of groups classified as "(i)" and "(ii)" should be addressed by engaging stakeholders to enhance the availability and accessibility of social welfare and rescue measures, and to ensure safe and private accommodations for all groups. It is critical to enhance multi-sectoral collaboration in responding to the common and specific vulnerabilities of these population groups from health, socio-economic, and humanitarian perspectives. Under the pandemic, homelessness should be regarded less as a peculiar problem for specific populations but an extension of daily life. The framework can be a reference when planning the comprehensive yet concise assessment of populations with unstable housing in other countries to inform responses to the pandemic.

Can we apply lessons learned from Ebola experience in West Africa for COVID-19 in lower income countries?

The COVID-19 affects vulnerable groups disproportionally in a society where inequities are long-standing issue. Weak health system, especially the shortage and maldistribution of capable health workforce will be the main challenge in lower income countries to fight against the COVID-19. Applying the lesson learned and success from the Ebola outbreak in West Africa is important. International collaboration with already well functioned local mechanisms, such as the Network of Managers of Health Workforce in Francophone Africa is the key to provide prompt support. This approach contributes not only to the short-term COVID-19 control but also long-term strengthening of the sustainable and resilient health system in the lower income countries.

School-based interventions to promote adolescent health: A systematic review in low- and middle-income countries of WHO Western Pacific Region.

BACKGROUND: In the World Health Organization Western Pacific Region (WHO WPRO), most adolescents enroll in secondary school. Safe, healthy and nurturing school environments are critical for adolescent health and development. Yet, there were no systematic reviews found on the efficacy of school-based interventions among adolescents living in low and middle income countries (LMIC) in the Region. There is an urgent need to identify effective school-based interventions and facilitating factors for successful implementation in adolescent health in WPRO. METHODS: For this systematic review, we used five electronic databases to search for school-based interventions to promote adolescent health published from January 1995 to March 2019. We searched RCT and non-RCT studies among adolescents between 10 to 19 years old, done in LMIC of WHO WPRO, and targeted health and behaviour, school environment and academic outcomes. Quality of studies, risk of bias and treatment effects were analyzed. Effective interventions and implementation approaches were summarized for consideration in scale-up. RESULTS: Despite a broad key term search strategy, we identified only eight publications (with 18,774 participants). Most of the studies used knowledge, attitudes and behaviours as outcome measures. A few also included changes in the school policy and physical environment as outcome measures while only one used BMI, waist circumference and quality of life as their outcome measures. The topics in these studies included: AIDS, sexual and reproductive health, de-worming, nutrition, obesity, tobacco use, and suicide. Some interventions were reported to be successful in improving knowledge, attitudes and behaviours, but their impact and scale were limited. The interventions used by the different studies varied from those that addressed a single action area (e.g. developing personal skills) or a combination of action areas in health promotion, e.g. developing a health policy, creating a supportive environment and developing personal skills. No intervention study was found on other important issues such as screening, counseling and developing safe and nurturing school environments. CONCLUSIONS: Only eight school-based health interventions were conducted in the Region. This study found that school-based interventions were effective in changing knowledge, attitudes, behaviors, healthy policies and environment. Moreover, it was clarified that policy support, involving multiple stakeholders, incorporating existing curriculum, student participation as crucial factors for successful implementation.

Opportunities lost: Barriers to increasing the use of effective contraception in the Philippines.

BACKGROUND: In the Philippines, one in four pregnancies are unintended and 610 000 unsafe abortions are performed each year. This study explored the association between missed opportunities to provide family planning counseling, quality of counseling and its impact on utilization of effective contraception in the Philippines. METHODS: One-hundred-one nationally representative health facilities were randomly selected from five levels of the health system. Sexually-active women 18-49 years old, wanting to delay or limit childbearing, attending primary care clinics between April 24 and August 8, 2017 were included. Data on contraceptive use, counseling and availability were collected using interviews and facility assessments. Effective contraceptive methods were defined as those with rates of unintended pregnancy of less than 10 per 100 women in first year of typical use. FINDINGS: 849 women were recruited of whom 51.1% currently used effective contraceptive methods, 20.6% were former effective method users and 28.3% had never used an effective method. Of 1664 cumulative clinic visits reported by women in the previous year, 72.6% had a missed opportunity to receive family planning counseling at any visit regardless of level of facility, with 83.7% having a missed counseling opportunity on the day of the interview. Most women (55.9%) reported health concerns about modern contraception, with 2.9% receiving counseling addressing their concerns. Only 0.6% of former users and 2.1% never-users said they would consider starting a modern contraceptive in the future. Short and long acting reversible contraceptive methods were available in 93% and 68% of facilities respectively. CONCLUSIONS: Missed opportunities to provide family planning counseling are widespread in the Philippines. Delivery of effective contraceptive methods requires that wider legal, policy, social, cultural, and structural barriers are addressed, coupled with systems approaches for improving availability and quality of counseling at all primary health care contacts.

For more than money: willingness of health professionals to stay in remote Senegal.

BACKGROUND: Poor distribution of already inadequate numbers of health professionals seriously constrains equitable access to health services in low- and middle-income countries. The Senegalese Government is currently developing policy to encourage health professionals to remain in areas defined as 'difficult'. Understanding health professional's preferences is crucial for this policy development. METHODS: Working with the Senegalese Government, a choice experiment (CE) was developed to elicit the job preferences of physicians and non-physicians. Attributes were defined using a novel mixed-methods approach, combining interviews and best-worst scaling (Case 1). Six attributes were categorised as 'individual (extrinsic) incentive' attributes ('type of contract', 'provision of training opportunities', 'provision of an allowance' and 'provision of accommodation') or 'functioning health system' attributes ('availability of basic equipment in health facilities' and 'provision of supportive supervision by health administrators'). Using face-to-face interviews, the CE was administered to 55 physicians (3909 observations) and 246 non-physicians (17 961 observations) randomly selected from those working in eight 'difficult' regions in Senegal. Conditional logit was used to analyse responses. This is the first CE to both explore the impact of contract type on rural retention and to estimate value of attributes in terms of willingness to stay (WTS) in current rural post. RESULTS: For both physicians and non-physicians, a permanent contract is the most important determinant of rural job retention, followed by availability of equipment and provision of training opportunities. Retention probabilities suggest that policy reform affecting only a single attribute is unlikely to encourage health professionals to remain in 'difficult' regions. The relative importance of an allowance is low; however, the level of such financial incentives requires further investigation. CONCLUSION: Contract type is a key factor impacting on retention. This has led the Senegalese Health Ministry to introduce a new rural assignment policy that recruits permanent staff from the pool of annually contracted healthcare professionals on the condition that they take up rural posts. While this is a useful policy development, further efforts to retain rural health workers, considering both personal incentives and the functioning of health systems, are necessary to ensure health worker numbers are adequate to meet the needs of rural communities.

Integrated approach for triple elimination of mother-to-child transmission of HIV, hepatitis B and syphilis is highly effective and cost-effective: an economic evaluation.

BACKGROUND: The Regional Framework for Triple Elimination of Mother-to-Child Transmission (EMTCT) of HIV, Hepatitis B (HBV) and Syphilis in Asia and the Pacific 2018-30 was endorsed by the Regional Committee of WHO Western Pacific in October 2017, proposing an integrated and coordinated approach to achieve elimination in an efficient, coordinated and sustainable manner. This study aims to assess the population impacts and cost-effectiveness of this integrated approach in the Cambodian context. METHODS: Based on existing frameworks for the EMTCT for each individual infection, an integrated framework that combines infection prevention procedures with routine antenatal care was constructed. Using decision tree analyses, population impacts, cost-effectiveness and the potential reduction in required resources of the integrated approach as a result of resource pooling and improvements in service coverage and coordination, were evaluated. The tool was assessed using simulated epidemiological data from Cambodia. RESULTS: The current prevention programme for 370,000 Cambodian pregnant women was estimated at USD$2.3 ($2.0-$2.5) million per year, including the duration of pregnancy and up to 18 months after delivery. A model estimate of current MTCT rates in Cambodia was 6.6% (6.2-7.1%) for HIV, 14.1% (13.1-15.2%) for HBV and 9.4% (9.0-9.8%) for syphilis. Integrating HIV and syphilis prevention into the existing antenatal care framework will reduce the total time required to provide this integrated care by 19% for health care workers and by 32% for pregnant women, resulting in a net saving of $380,000 per year for the EMTCT programme. This integrated approach reduces HIV and HBV MTCT to 6.1% (5.7-6.5%) and 13.0% (12.1-14.0%), respectively, and substantially reduces syphilis MCTC to 4.6% (4.3-5.0%). Further introduction of either antiviral treatment for pregnant women with high viral load of HBV, or hepatitis B immunoglobulin (HBIG) to exposed newborns, will increase the total cost of EMTCT to $4.4 ($3.6-$5.2) million and $3.3 ($2.7-$4.0) million per year, respectively, but substantially reduce HBV MTCT to 3.5% (3.2-3.8%) and 5.0% (4.6-5.5%), respectively. Combining both antiviral and HBIG treatments will further reduce HBV MTCT to 3.4% (3.1-3.7%) at an increased total cost of EMTCT of $4.5 ($3.7-$5.4) million per year. All these HBV intervention scenarios are highly cost-effective ($64-$114 per disability-adjusted life years averted) when the life benefits of these prevention measures are considered. CONCLUSIONS: The integrated approach, using antenatal, perinatal and postnatal care as a platform in Cambodia for triple EMTCT of HIV, HBV and syphilis, is highly cost-effective and efficient.

Retention of qualified healthcare workers in rural Senegal: lessons learned from a qualitative study.

INTRODUCTION: Deployment and retention of a sufficient number of skilled and motivated human resources for health (HRH) at the right place and at the right time are critical to ensure people's right to access a universal quality of health care. Vision Tokyo 2010 Network, an international network of HRH managers at the ministry of health (MoH) level in nine Francophone African countries, identified maldistribution of a limited number of healthcare personnel and their retention in rural areas as overarching problems in the member countries. The network conducted this study in Senegal to identify the determining factors for the retention of qualified HRH in rural areas, and to explore an effective and feasible policy that the MoH could implement in the member countries. METHODS: Doctors, nurses, midwives and superior technicians in anesthesiology who were currently working (1) in a rural area and had been for more than 2 years, (2) in Dakar with experience of working in a rural area or (3) in Dakar without any prior experience working in a rural area were interviewed about their willingness and reasons for accepting work or continuing to work in a rural area and their suggested policies for deployment and retention of healthcare workers in rural areas. In-depth interviews were conducted with policy makers in MoH, asking for their perceptions on human resource management in health and about their suggested policies for deployment and retention. RESULTS: A total of 176 healthcare workers and eight policy makers were interviewed. The willingness to face challenges in a new place was one of the main reasons for accepting work in rural areas. The identified factors to motivate or demotivate healthcare workers in rural areas were related to pre-service and in-service education, regulatory systems, financial and non-financial incentive schemes and environmental support. Factors not included in WHO's global recommendation but highly valued in this study were (1) the fairness, transparency and predictability of human resource management by the MoH and (2) employment status, ie permanent government staff versus contract staff. Financial incentive schemes were less commonly suggested. Family bonding and religious-related non-financial incentive schemes were found to be specific factors in Senegal, but would also be applicable in countries where family and religion play important roles in the values of healthcare workers. CONCLUSIONS: Improved HRH management, eg the transparency of human resource management by the MoH, was identified as a pre-condition of any policy implementation related to HRH. This factor can be considered in other countries struggling to retain healthcare workers in rural areas. The Vision Tokyo 2010 Network or HRH managers' network in Francophone Africa, Senegal MoH and the research team plan to conduct a quantitative survey to confirm the generalizability of the results of this qualitative survey, and to identify the most effective combination of policies to improve the retention of qualified healthcare workers and seek their implementation in other countries in the region as network activities.

Integrating HIV, hepatitis B and syphilis screening and treatment through the Maternal, Newborn and Child Health platform to reach global elimination targets.

Every year, an estimated 180 000 babies in the Western Pacific Region are infected by hepatitis B, 13 000 by syphilis and 1400 by HIV through mother-to-child transmission. (1) These infections can be largely prevented by antenatal screening, treatment and timely vaccination for newborns. Despite challenges in controlling each disease, major achievements have been made. National immunization programmes have reduced the regional hepatitis B prevalence from over 8% in 1990 to 0.93% among children born in 2012. In addition, HIV testing and treatment have helped keep the regional prevalence of HIV infections at 0.1%. In contrast, the number of maternal syphilis cases is still high in the Western Pacific Region, with an estimated 45 million cases in 2012. Elimination of mother-to-child transmission of these infections cannot be achieved through vertically applied programming and require using and augmenting to the shared Maternal, Newborn and Child Health platform to coordinate, integrate and enable cost efficiencies for these elimination efforts. The Regional Framework for Triple Elimination of Mother-to-Child Transmission of HIV, Hepatitis B and Syphilis in Asia and the Pacific 2018-2030 offers such a coordinated approach towards achieving the triple elimination of mother-to-child transmission of HIV, hepatitis B and syphilis and provides guidance for decision-makers, managers and health professionals working in programmes addressing maternal, newborn and child health, HIV, hepatitis, sexually transmitted infections and immunization.

The Role of a Network of Human Resources for Health Managers in Supporting Leadership for Health Systems Strengthening in Francophone African Countries.

This article presents the Vision Tokyo 2010 Network, a unique model of peer learning and information sharing among human resources for health (HRH) managers in Francophone African countries. It describes the network's origins, achievements, and factors underlying its success. The network's origins lie in an overseas training program in Tokyo between 2010 and 2014. Participants included directors and heads of HRH management departments at federal and provincial levels across nine Francophone African countries: Benin, Burkina Faso, Burundi, the Democratic Republic of Congo, Côte d'Ivoire, Niger, Mali, Senegal, and Togo. The network itself was established in 2012 based on the common strategic vision (Vision Tokyo 2010) developed during the training program, with an objective of tackling major problems to improve the performance of human resource development systems in the health systems of participants' countries. Some of the main outcomes of the network, demonstrated during the Ebola outbreak include: improved use of human resource information systems in Senegal established as a result of peer learning within the network and technical cooperation between the Democratic Republic of Congo and Côte d'Ivoire to develop standard operational procedures and to train health workers in the management of Ebola. Having a common strategic vision and contextualized framework-African house of solidarity-as a symbol for HRH system development, strong ownership by core members, participatory processes, a positive peer learning environment, and coaching-style support by partners were key elements of success in this initiative. The biggest challenge for this network thus far has been financial sustainability. However, steps are being taken to demonstrate the cost-effectiveness of networks such as these in order to garner further support from partners to invest in networked approaches rather than siloed, country-specific programs.

Performance-based financing with GAVI health system strengthening funding in rural Cambodia: a brief assessment of the impact.

INTRODUCTION: Though Cambodia made impressive gains in immunization coverage between the years 2000 and 2005, it recognized several health system challenges to greater coverage of immunization and sustainability. The Global Alliance for Vaccines and Immunization (GAVI) opened a Health System Strengthening (HSS) funding window in 2006. To address the health system challenges, Cambodia has been receiving the GAVI HSS fund since October 2007. The major component of the support is performance-based financing (PBF) for maternal, neonatal and child health (MNCH) services. OBJECTIVE: To examine the impact of the PBF scheme on MNCH services and administrative management in rural Cambodia. METHODS: Quantitative and qualitative studies were conducted in Kroch Chhmar Operational District (OD), Cambodia. Quantitative analyses were conducted on the trends of the numbers of MNCH services. A brief analysis was conducted using qualitative data. RESULTS: After the commencement of the PBF support, the volume of MNCH services was significantly boosted. In addition, strengthened financial and operational management was observed in the study area. However, the quality of the MNCH services was not ensured. Technical assistance, rather than the PBF scheme, was perceived by stakeholders to play a vital role in increasing the quality of the services. DISCUSSION: To improve the quality of the health services provided, it is better to include indicators on the quality of care in the PBF scheme. Mutual co-operation between PBF models and technical assistance may ensure better service quality while boosting the quantity. A robust but feasible data validation mechanism should be in place, as a PBF could incentivize inaccurate reporting. The capacity for financial management should be strengthened in PBF recipient ODs. To address the broader aspects of MNCH, a balanced input of resources and strengthening of all six building blocks of a health system are necessary.

World Health Assembly agendas and trends of international health issues for the last 43 years: analysis of World Health Assembly agendas between 1970 and 2012.

OBJECTIVE: To analyse the trends and characteristics of international health issues through agenda items of the World Health Assembly (WHA) from 1970 to 2012. METHODS: Agendas in Committees A/B of the WHA were classified as Administrative or Technical and Health Matters. Agenda items of Health Matters were sorted into five categories by the WHO reform in the 65th WHA. The agenda items in each category and sub-category were counted. RESULTS: There were 1647 agenda items including 423 Health Matters, which were sorted into five categories: communicable diseases (107, 25.3%), health systems (81, 19.1%), noncommunicable diseases (59, 13.9%), preparedness surveillance and response (58, 13.7%), and health through the life course (36, 8.5%). Among the sub-categories, HIV/AIDS, noncommunicable diseases in general, health for all, millennium development goals, influenza, and international health regulations, were discussed frequently and appeared associated with the public health milestones, but maternal and child health were discussed three times. The number of the agenda items differed for each Director-General's term of office. CONCLUSIONS: The WHA agendas cover a variety of items, but not always reflect international health issues in terms of disease burden. The Member States of WHO should take their responsive roles in proposing more balanced agenda items.

Reconstruction of health service systems in the post-conflict Northern Province in Sri Lanka.

Public health problems in armed conflicts have been well documented, however, effective national health policies and international assistance strategies in transition periods from conflict to peace have not been well established. After the long lasted conflicts in Sri Lanka, the Government and the rebel LTTE signed a cease-fire agreement in February 2002. As the peace negotiation has been disrupted since April 2003, a long-term prospect for peace is yet uncertain at present. The objective of this research is to detect unmet needs in health services in Northern Province in Sri Lanka, and to recommend fair and effective health strategies for post-conflict reconstruction. First, we compared a 20-year trend of health services and health status between the post-conflict Northern Province and other areas not directly affected by conflict in Sri Lanka by analyzing data published by Sri Lankan government and other agencies. Then, we conducted open-ended self-administered questionnaires to health care providers and inhabitants in Northern Province, and key informant interviews in Northern Province and other areas. The major health problems in Northern Province were high maternal mortality, significant shortage of human resources for health (HRH), and inadequate water and sanitation systems. Poor access to health facilities, lack of basic health knowledge, insufficient health awareness programs for inhabitants, and mental health problems among communities were pointed by the questionnaire respondents. Shortage of HRH and people's negligence for health were perceived as the major obstacles to improving the current health situation in Northern Province. The key informant interviews revealed that Sri Lankan HRH outside Northern Province had only limited information about the health issues in Northern Province. It is required to develop and allocate HRH strategically for the effective reconstruction of health service systems in Northern Province. The empowerment of inhabitants and communities through health awareness programs and the development of a systematic mental health strategy at the state level are also important. It is necessary to provide with the objective information of gaps in health indicators by region for promoting mutual understanding between Tamil and Sinhalese. International assistance should be provided not only for the post-conflict area but also for other underprivileged areas to avoid unnecessary grievance.