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Meeting of the scientific group on health services research, Alexandria, 1-2 August 1977

31 décembre 1977 Organisation mondiale de la santé

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EM/RSR/4 EM/PlTG S C F GRP HS RSR/5

. . . .

S e p t e m b e r 1977

MEETING O F THE S C I E N T I F I C GROUP ON HEALTH S E R V I C E S RESEARCH

Alexandria, 1

2 A u q u s t 1977

WHO EMRO

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TABLE OF CONTENTS

page I I1 INTRODUCTICN ELECTION OF OFFICERS AND ADOPTION OF AGENDA 1 2 3

I11 PROCEDURE FOR IDENTIFICATION OF RESEARCHABLE QUESTIONS AND ESTABLISHMENT OF A SET OF CRITERIA FOR HEALTH SERVICESRESEARCH PROJECTS IN EMR A.

Characteristics of Health Services Research 1. The health care system 2. Health manpower development 3. Organizational factors 4. Social/cultural demographic factors The Selection of a Research Programme

3 3 3

4 4 5 7

B., IV

REVIEW OF RESEARCH DRAFT PROPOSALS 1. Resetrch on Expanded Programme of Ir~ur~uniza,tion Comparative Costing of Methods of Administering Triple Vaccine Research on Expanded Programme of Immunization Comparative Evaluation of Techniques of achieving Maximum Coverage of Immunization in Infancy Research on Health Information Research towards an Effective Recording and Reporting System in Primary Health Care Research on the Integration of Health Workers of Specialized Campaigns within General Health Services Research on Prophylactic, Diagnostic and Therapeutic Substances - Drug Utilization Research Studies with Special Reference to Primary Health Care Research and Development Project Community Participation in Primary Health Care Programme in Western and Southern Sudan Orientation Course in Evaluative Health Services Research

EM/RSR/4 EM/MTG. SCF .GRP .HS.RSR/5 TABLE OF CONTENTS (Cont'd)

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Challenges t n Effective Hea1t.h Coverage Cofl~arativeEvaluative Study The Place of Traditional Medicine in the Promotion of Primary H c a l t h Care

10.

The Development of a Co-ordinated Health Services and Manpower Development Progrqmme in Hamadan and West Azerbaijan, Iran

V VI VII

IGENTIFICATION OF OTHER "PROBLEMS" OR RESEARCH AREAS IDENTIFICATION OF RESEARCHERS AND INSTITUTIONS INFORMATION ON HEALTH SERVICES RESEARCH

14 19

VIII MECHANISM OF RESEARCH PROMOTION AND CO-0RD.INATION 21 AT THE REGIONAL OFFICE IX RECOMYENDATIONS 24

ANNEX I ANNEX 11

AGENDA LIST OF PARTICIPANTS HEALTH SERVICES RESEARCH PROPOSALS

ANNEX 111

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INTRODUCTION

The Meeting o f t h e S c i e n t i f i c Group on H e a l t h S e r v i c e s Research was h e l d i n t h e E a s t e r n M e d i t e r r a n e a n R e g i o n a l O f f i c e of WHO,

Alcxandria, t h e f i r s t and s e c o n d of August 1 9 7 7 .

The

Group was s e t up t o g i v e i t s a d v i c e on how b e s t t o implement r e s e a r c h p r o j e c t p r o p o s a l s f o r h e a l t h s e r v i c e s and manpower development i n a c c o r d a n c e w i t h t h e R e g i o n a l D i r e c t o r ' s e x p r e s s i o n of i n t e n t at t h e Second F e e t i r ~ yof t h e R e g i o n a l Advisory Committee on Biomedical R e s e a r c h , A l e x a n d r i a , 2 3 - 2 6 March 1977. I n h i s welcoming remarks t o t h e S c i e n t i f i c Group, Taba, D i r e c t o r , LJHO EMRO, r e f e r r e d t o t h e h i g h p r i o r i t y g i v e n by him, and by t h e Advisory Committee on Biomedical R e s e a r c h , t o t h e s u b j e c t o f " H e a l t h S e r v i c e s R e s e a r c h " , ( a s i m p l i f y i n g t e r m which i n c l u d e s what h a s sometimes been c a l l e d E v a l u a t i v e H e a l t h S e r v i c e s R e s e a r c h , o r H e a l t h Systems R e s e a r c h , and which i n c l u d e s a l s o r e s e a r c h i n t o a l l a s p e c t s o f H e a l t h Planpower Development). D r Taba s t r e s s e d t h a t h a v i n g s e t o v e r a l l r e g i o n a l p r i o r i t i e s and g e n e r a l -rogramme g u i d e l i n e s a t t h e f i r s t two m e e t i n g s o f t h e R e g i . m a l A d v i s o r y Committee on Biomedical R e s e a r c h , WHO EMRO must p r o c e e d t o d e v e l o p s p e c i f i c r e s e a r c h a c t i v i t i e s i n c o l l a b o r a t i o n w i t h Plember c o u n t r i e s and t h e i r a p p r o p r i a t e institutions. The R e g i o n a l D i r e c t o r e n c o u r a g e d t h e S c i e n t i f i c Group t o s t u d y t h e documents and p r o p o s a l s p r e p a r e d f o r r e v i e w and t o p r o v i d e g u i d a n c e a s f o l l o w s : D r A.H.

1. S u g g e s t s p e c i f i c new a p p r o a c h e s t o s o l v e t h e p r e s s i n g problems r e g a r d i n g d e l i v e r y o f h e a l t h s e r v i c e s e c o n o m i c a l l v and w i t h b e t t e r u t i l i z a t i o n o f t h e e x i s t i n g n a t i o n a l r e s o u i c e s . 2. ~ d e n t i f yt h e most i m p o r t a n t p r e c i s e t a r g e t s , w i t h i n t h e t o t a l p o s s i b l e broad f i e l d of h e a l t h s e r v i c e s r e s e a r c h , t h a t WHO i n t h e E a s t e r n M e d i t e r r a n e a n Region can most p r o f i t a b l y e n c o u r a g e t h e s c i e n t i s t s , i n s t i t u t i o n s and governments o f o u r Region t o a t t a c k .

3. Decide on t h e p r i o r i t i e s o f t h e s e v e r a l r e s e a r c h p r o p o s a l s p r e s e n t e d and t h o s e which w i l l be p r e s e n t e d i n t h e future.

4. P r o v i d e t e c h n i c a l views and recommendations on t h e s o u n d n e s s of t h e p a r t i c u l a r a p p r o a c h e s t h a t have s o f a r been d e v e l o p e d a t t h e i n i t i a l - s t a g e of t h e WHO EMRO programme. 5. E s t a b l i s h p r o c e d u r e s and r e q u i r e m e n t s f o r management of HEALTB SERVICES RESEARCH i n t h e Region.

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ELECTION OF OFFICERS AND ADOPTION OF AGENDA

The participants (Annex 11) elected Dr Ch. Mofidi, Deputy Chancellor, Teheran University, Teheran, as CHAIRMAN and it was agreed that he and Dr Shubbar Kasan, Public Eealth Administrator, (Community Health) , WHO EMRO, would serve as RAPPORTEURS of the Meeting. The Agenda (Annex I) was adopted with some amendments.

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I11

PROCEDURE FOR IDENTIFICATION OF RESEARCHABLE QUESTIONS AND ESTABLISHMENT OF A SET OF CRITERIA FOR HEALTH SERVICES RESEARCHPROJECTS IN EMR Characteristics of Health Services Research Health Services Research is likely to include at the

very least the systematic study of four major clcmcnts;

The health care svstem

health care needs organization for delivery of care management of health care organizations costs of basic care and of increments beyond the base cost of efficiency cost effectiveness quality of care delivered preparation of consumers for their role in the system etc.

Health manpower development

manpower planning to meet health care system needs manpower mix and distribution determination of manpower competence planning, organization, implementation and evaluation of basic and continuing educational programmes for health workers teamwork manpower m a n a y e n ~ e r l t (incentives , career

schemes, etc. )

etc.

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Orqanizational factors

characteristics of health service and health prafessi~nseducation institutions characteristics of pr~fessionalhealth worker organizations or unions (e.g. orientatiqn, values, etc. ) community development systems etc.

Social/cultural demographic factor9

resources available for health care community aspirations, behaviqurs and values (e.g. health care vs. other desirable things) political philosophy as it influences health services demographic features (e.g. age, distribution, climatic conditions) etc.

Such categories are not intended to imply that these components represent independent ends, but rather that their interlocking and overlapping elements convey the essential

nature of Health Services Re~earch. Health ServicesResearch generally is, or should be, rooted in problems found in the field and articulated, at least initially, by those who experience them. Hepce, the identification of the objectives of such research is, or should emerge as, an outcome of activities or programmes for which alternative solutions are required. Not only is the identification of the problems for which research is required essentially the responsibility of thase who experience them, but the research ifself, by being "action-oriented", needs to involve all concerned in the research in its planning and implementation, Consequently, for the purpose of this Meeting, the Group agreed that Health ServicesResearch should be viewed as "action research", integrated into the total fabric of ongoing programmes and developmental activities, or as an extension of them. It may include a variety of approaches

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ranging from simple descriptive analysis and collection of information to the "case-study method", i . e . an 'in-depth analysis of a programme in action including its rationale and evolution, activities, accompli'Shments and difficulties. By developing a l L e 1 1 1 a t i v e dpproaches, Health ServicesKesearch formulation should help the decision makers in the formulation of policy, lead to strengthening of health services, better utilization of resources, contribute directly and significantly tv the improvement of the health status of the population, and make use of a methodology,that can be applied now and at a cost which countries can afford. B.

The Selectiofi of a Research Programme

The basic principle which must guide the determination of what problems should be investigated is that a need for the study has been identified by the persons, institutions or countries experiencing the problem. An excellent set of criteria for the identification of the rese, rch projects is presented in the WHO Director-General's Report on the Development and Co-ordination of Biomedical and Health Services Research to the Thirtieth Vorld Health Assembly For proposed research projects, the (dvcument A30/9). Scientific Group agreed to adopt the following general criteria, subject to further elaboration in the future: 1.

Relevance Importance

filaximum return (impacts on other socio-economic sectors or fringe-benefits).

The proposed research should also be integrated into health services manpower development activities at the country level, and the dissemination,adaptation and application of results should form part of and meet acceptable standards of research design and scientific enquiry. Such a proposal will permit confidence in the results attained. The selection of research problems should further take into account the potential the research project may have for increasing the self-reliance of countries upon its trained research manpower, and the training of research workers can be an integral part of any given research project. kcseorch which promotes c o - o p e r a t i o n b e t w e e n c u u r l t r i e s

and the development of joint solutions to common problems, would provide an additional rationale for the selection of a given problem relative to others.

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The Scientific Group also suggested that research projects selected for F7HO support and participation should: 1. Be developmental in nature Call for multidisciplinary co-operation between medical/biological and social/medical personnel Be based upon o team approach (Ministry/Univ$rsity,

2. 3.

GovernrnenWPrivate Sector, Physicians/Social Scientists, etc.)

Promote the scientific potential of the country or countries.

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The Scientific Group reviewed eleven draft research proposals prepared in advance or submitted during the Each document was introduced by meeting (Annex 111). its author or one of the technical officers of the Regional Office in charge of the related programme. Discussions and opinions expressed by the Group are summarized below: Research on Expanded Programme of Immunization Comparative Costing of r.!ethods of ~dministering Triple Vaccine ent EM/MTG.SCF.HS.RSR/4.2 introduced by Dr R. Cook, Regional Adviser on IIUT/MCH) The project was judged an important component of a series of research projects that should be carried out as an integral part of the Expanded Programme of Immunization, which calls for a fifteen-year WHO effort to immunize up to 80 per cent of the children under five years in the developing world. In E E l R a107 e, between thirty million (optimum) and ten million (minimum) triple vaccine injections are projected each year. The Scientific Group suggested t h a t a n o t h e r r e s e a r c h

programme on viral hepatitis, using samples of the population receiving injections and control groups, should be developed and carried out parallel to this project. Special attention should be paid to thc training and supervision of the immuniza-

tion team workers. The projected costs of different methods under study should be identified carefully in both rural and urban settings. For example jet injectors might be more d p y r u p r i d l e in cities and among organized groups and dizposablc

syringes and needles in rural areas. The preference or refusal of some people to be injected by one or another method has an important socio-behavioural aspect and this should be considered with particular attention. Recommendation The Group recommended that this project be accepted with high priority.

' s e e Annex I11 for complete text of the eleven research dratt proposals

Research on Expanded Programme of Immunization Comparative Evaluation of Techniques of achieving Maximum Coverage of Immunization in Infancy (document EM/PITG.SCF.GRP.HS.RSR/~.~ introduced bv . '

Cook, R e g i o n a l Adviscr on NUT/MCH)

The project was considered as another important part of .the series of research on Expanded Programmes of Immunization, (EPI); the Group p o i n t e d out h o w e v e r , the difficulty ot designing and carrying out such programmes without knowledge of obstacles to success and of the reasons why present immunization schemes achieve different success. An in-depth study of present practices, popular customs, beliefs and values is needed. A great deal of sound socio-behavioural and anthropological research has already been carried out (e.g. acceptance breast-feeding versus of family planning, nutrition education artificial feeding, etc.).

Recommendation It was proposed that all these data should be taken into consideration during the re-writing of the project protocol and that the advice of a small Scientific Steering Group, composed of experts in the fields of immunization, communication and particularly social science, be sought at this preparatory Stage. Furthermore, it was deemed advisable that this group be called upon later for review and evaluation. It was stressed that this is an important project for EPI and has a specific requirement of social science input aspect which will constitute a major study contributing to the study of community participation. 3.

Research on Health Information Research towards an Effective Recording and Reporting System in Primary Health Care (document EM/PITG.SCF.GRP.HS.RSR/4.4 introduced by Dr E.I. Hammoud, Regional Adviser on Vital and Health Statistics)

The Group agreed that, as stated in the proposal itself, the examination of objectives in recording and reporting and decisions on an appropriate system are even more important in terms of primary health care, (i.e. front-line contact between health services and the majority of people). It expressed the opinion that recording and reporting at the primary health care level depends upon the nature of the overall information system used for the health sector. The obvious purposes of these records and reports are to obtain a new estimate of epidemiological status, the socio-behavioural and cultural . attitudes, a personal record for the patient and referral, and for evaluative and management requirements. Furthermore,

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it was suggested that additional consideration should be given to effective use of simple records, data linkage, linkage techniques (e.g. identification number, etc.), computerization, confidentiality of records and their use in management, cost and effectiveness e v a l u a t i o n -

Recommendation The Group concluded that this project i d e a i s of paramount.

importance and it should be carried out after a revision of the project protocol in the light of the above observations. 4. Research on the Integration of Health Workers of Specialized Campaigns within General Health Services introduced by (document EM/MTG.SCF.GRP.HS.RSR/4.5 Dr Shubbar Hasan, Public Health Administrator, Community Health)

The Group endorsed the importance of this project but pointed out that prior to the integration of health workers, there is 3 great need to study the various aspects of the integratl~nof the specialized programmes within general health services. The important issue is the development of a new health care delivery system on the basis of the existing one, which can absorb workers in malaria and other specialized programmes in a manner that will ensure a better health coverage of the population. At the same time, specialized campaigns should continue to attack the specific problems with the same efficiency as before. In other words, the question of integration of health workers should be subsidiary to the main objective of general health services. Recommendation It was suggested that the project be revised and implemented in the light of the above observations. 5.

Research on Prophylactic, Diagnostic and Therapeutic Substances - Drug Utilization Research Studies with Special Reference to Primary Health Care introduced by (document EM/MTG.SCF.GRP.HS.RSR/4.6 Dr G. Rifka, Public Health Administrator, Health Organization)

The Group noted that the proposal is an extension of similar research on a smaller scale carried out in Yemen. It expressed the opinion that this kind of research is not only vital to the development of health services but also to the development of the countries, since expenditure for drugs draws enormously on the resources of the country. The study is related to primary health care,

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page 10 the information system, the indiscriminate use of drugs available to the population, polypharmacy, drug abuses, ineffective prescription, the source of the drugs, the "itinerant vendor", control of toxic drugs, popular attitudes toward health care and traditional drugs, etc. The proposal should also contrast the drugs utilized with drugs actually required by the people. Recommendation

The Scientific Group concluded that this project, although a valid one, needs a great deal of social science input in its design and implementation (e.g. visiting participant-observation techniques) and suggested that it should be revised and re-written in the light of the above observations.

Dr Shubbar Hasan, Public Health Administrator, Community Health) The Scientific Group endorsed the r e l e v c i r ~ c eand the importance of this project, but noted that this is a major research undertaking calling for elaborate design and controls. It was further expressed that several of this type of study have already been carried out in other F-egionswith an enormous amount of expertise and research sophistication, as well as great social science input, ( e . g . Peru, Colombia and other programmes supported by WHO Headquarters). It was pointed out that the present project relies heavily on experts in social administration, and as such, it needs input from experts in research methods in social sciences and anthropology. Furthermore, the indicators listed in the project would be very complicated to collect and analyse. Recommendation It was suggested that the magnitude and the diversity of this project calls for the appointment of a multidisciplinary Scientific Steering C~mrnittee,drawn from different experts in the field, including social scientists and those who have experience with the various programmes in other Regions, to revise the project protocol in the light of what is happening already in Other areas and the suggestions prcsented here. The Steering Committee would continue to assist in the review and evaluation of the project's outcome, and the participation of the experts from WHO HQ would be welcome.

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Orientation Course in Evaluative Health ServicesResearch (document EEI/IITG. SCF.GRP.HS .RSR/4.8 introduced bv Dr P7.A. ~assouna,Consultant, Institute of National Planning, Cairo)

The Group endorsed the important role that courses of this nature will play to prepare research workers for Health Services Research and to emphasize HSR in research programmes a n d i n thc t r a i n i n g a n d s e l e c t i o n u 1 p u l t l ~ ~ t i d research l workers. Students of HSR could become true agents of change, and the selection of students will be an important task. Recommendation It was suggested that the word "Evaluative" be deleted throughout the document. The course should be extremely useful for the purpose of Health Services Research and suitable for WHO collaboration and support. It ~ 7 a salso suggested that this type of course is necessary for the preparation of research workers needed for the implementation of the proposed project on challenges to effective health CL verage (see project point 4.9)

Challengsto Effective Health Coverage ~ o m p a r a t s eEvaluative Study (document EI?/MTG.SCF.GRP.HS.RSR/~.~ introduced by Dr W.A. Hassouna, Consultant, Institute of National Planning, Cairo

The Group considered this proposal of utmost importance to the main concern of governments and WHO, i.e. to provide effective health cnverage for the majority of people. This

project would require a great amount of preparatory work in the elaboration of the protocols for its research component, and the training and co-ordination of research workers in different countries. In the design of this proposal research projects that have been or are being carried out by different countries of the Region, or with the support of P7H0, as well as those that have been discussed in this Meeting, would be A new type of research is called for: taken into account. i . e . research in designing research programmes in order to develop manageable programmes, with carefully prepared protocols and provisions for costing, training, co-ordination and evaluation. Recommendation Because of ~ t s ~mportance,the Group recommended that WHO EMRO give this proposal high priority and arrange for a top expert (to be assisted by other suitable health and social scientists if necessary) to elaborate a detailed plan.

EM/RSR/4 EM/MTG.SCF.GRP.HS.RSR/5 page 12 9.

The Place of Traditional Medicine in the Promotion of Primary Health Care (document EM/MTG.SCF.GRP.HS.RSR/4.10 introduced by Dr T.A. Baasher, Regional Adviser on Mental Health)

The Scientific Group agreed that no truly systematic survey has been carried out yet on this subject. The positive aspects and values of traditional healinq and its contribution to the promotion of primary health care are subjects that deserve study. It would be important to carry out a carefully designed analytical study of all the "unorganized health services" that are used by the population and the underlying socio-behavioural factors. For example, systematic study of the "Hakim" and his functions might suggest ways to collaborate with such practitioners. Research is necessary to find out how many they are, what they do, what they prescribe, how their patients behave, and the impact of the "Hakim" on health services. Finally, the term "traditional medicine" should be given a working definition. Recommendation The Scientific Group endorsed the importance of the subject, and recommended the preparation of a more detailcd projcct, taking

into consideration the suggestions of experienced social scientists and the observations of the Scientific Group. The Development of a Co-ordinates Health Services and

Manpower ~evelopmehtProgramme in Hamadanand West Azerbaijan, Iran (document EM/MTG.SCF.GRP.HS.RSR/4.11 introduced bv DL F. ~ d t ,' z C h i e f , ~ducational. Evaluation, V ? H 0 HQ, Geneva 1 This project is the natural outcome and extension of the HSMD research project which has been going on for the last several years in West Azerbaijan with the assistance of WHO. It represents the beginning of a new development taking place, namely the establishment of educational institutions 'EU Ali Sina University, Health Sciences Cluster in Hamadan ar~d the University of Rezaiyeh, Faculty of Health Sciences in Rezaiyeh, West ~zerbaijan)based on all the information gathered and evaluative research carried out in these areas. It aims at the joint co-operation of the Ministry of Health and Social Welfare and the respective universities in planning and delivery of health care and training of health manpower. Fortunately, the people in charge of these developments have all been working in the on-going HSMD project in Rezaiyeh and are capable health services research workers.

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The Scientific Group agreed that it is difficult to alter the programme of an established academic institution; therefore the careful advanced planning envisaged in this project was welcomed. It was also recalled that WHO opposes the importation of irrelevant models for the training of health personnel and is already supporting several similar projects in various countries, including Iran and others within SIIP,. Recommendation

It was proposed that WHO HQ and Et4RO should relate the proposed project to similar programmes in other areas, as was done in the case of Ben Gurion University, Israel and in wellknown projects in Mexico, Brazil, the Netherlands and elsewhere. This developmental research project was considered a valuable and rational case-study of an existing programme, and it would require feasibility study in planning: i.e. research into the WHO support for methodology and effectiveness of research. this type of research was strongly recommended.

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IDENTIFICATION OF OTHER "PROBLEMS" OR RESEARCH AREAS

The Scientific Group expressed its concern that, in the short time available for its work, it would not be possible to produce an exhaustive list of other "problems" or research areas, but attempted to suggest additional "researchable topics". The required orientation of Health Services Research haf already been discussed by the RACMR in its two previous reports Furthermore, thc Group was in lull agreement w l t h the future directions presented in the paper on Health Systems Research to the Global Advisory Committee on Biomedical Research during its Nineteenth session2, which indicates that Health Systems Research should:

.. .

resources --dology . 2.

Contribute to a more equitable distribution of national through improvement in health planning metho-

Suggest ways in which communities are motivated to become involved in health care, employing appropriate and effective technology. Propose methods by which required categories of health personnel, acceptable to the communities, a r e selected, tralned, supervised and supported in such a way that the health care they deliver is medically effective and humane. Identify strategies by which communities are motivated to become involved in health care delivery and by which the resources of the communities are increased, mobilized and better used. Propose alternative approaches that will strengthen the support of all components of the health services to the underserved people of the world in a co-ordinated fashion and in a way compatible with the resources of the country concerned.

Report of the Regional Advisory Committee on Biomedical Research, First Meeting, Alexandria, 6-8 April 1976 (document EM/RSR/l) Report of the Regional Advisory Committee on Biomedical Research, Second Meeting, Alexandria, 23-26 Ilarch 1977 (document EM/RSR/~) Health Systems Research. Advisory mnittee on Medical Research, Nineteenth Session, 13-17 June 1977, Geneva (document ACMR19/77, . INF.DOC./1)

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EM/RSR/4 EM/MTG.SCF.GRP.HS.RSR/5 page 15 Contribute to the continuous improvement of health care and health, by suggesting more effective, more objective, and more feasible ways of evaluating activities, costs, and impact of health care delivery s y s t e ~ ~i ~ r ls c l u i i i n y improvement of knowledge Of the economics of health. Use the best innovative methods of financing health SerVlCeS, with special emphasls on extension of health care to the underserved communities.

The Group felt that the development of a workable classification of research topics in Health Services Research would be of great help in planning, promotion, administration, co-ordination and evaluation of research programmes. This need became clear during the review of the research proposals and deliberations of A suggestion by the Regional Office for the classifithe Group. cation of research projects was presented. It includes the division of Health Services Research topics into broad categories and several sub-categories. The main five categories are:

I 2.

Pol'icy and Planning D e l i v q r y a n d Y a n a g e m e n t n f H e a l t h Services

(or Organization and Management of Health Services)

Utilization of Health Services Financing of Health Services (Economics) Formation of Health Planpower (HMD).

4. 5.

The Scientific Group felt that additional work is needed in the classification of research topics and recommended that the PACMR and the Regional Office give particular attention to this important subject. The Group agreed that the following problem areas are of.paramount importance for research in this Region : 1.

Social science input for all health research programmes -The role and effectiveness of primary health care Expansion of research on Health Coverage Information system (preparation of a basic manual) Development of appropriate technology

Elementary test methods for village use Dip sticks E u r urine, blood, faeces, Sputum Charts, check lists, algorythus, etc.

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New diagnastic approaches How to convince governments of the importance of Health Services Research and'researcli in Social Sciences How so up-grade the quality of vital statistics (in many areas death certific'ates are made by elderly people and policemen),use of algorythus, death certificates, etc. New evaluation approaches w e of private practice

10. 11. 12.

Impact of health insurance Researchable areas in Health Planpower Development

With regard to item No.12 above, the Group had the benefit of an excellent document on Health Manwower ~ebelo~rnent Research - .. - - - -- - . . as one element af Health Services ~esearch (docimint EM/EITG.SCF. It endorsed fully all ~rowosalsput forward GRP.HS.kSR/4.1). for research in this paper1, but ag;eed that-the foilowing topics are of special concern t o t h i s Region and m e r i t further s t u d y ; 1. =assurance of adequate health manpower planning capability and 'thedevelopment of'manpower plans which will lead to a more balanced d i s t r i b u t i o n of m a n p o w e r :

For a defined population what is the optimal mix of health workers (e.g. primary health care workers, m i d d l e level health workers, medical doctors, dentists, etc.) to provide a specified level of primary health care? What mechanisms are effective in stimulating health personnel to work in rural areas? What educational programmes or processes (basic or continuing) facilitate health personnel practising in rural areas?

Development of mechanisms for co-ordination of health services and manpower development:

what management functions optimize co-ordination between health services and manpower development?

'~ecause of its importance and usefulness, this paper is annexed (See Annex TI11 to this report in full.

WHO EMRO

EM/RSR/~ EM/MTG.SCF.GRP.HS.RSa/S page 17

Development of special regard

teams to deliver health care, with to primary care, characterized by greater health service responsiveness to community needs, significantly improved coverage and existence

of operational referral and supcrvisory systems;

What kinds of teams now operate in the delivery of health care; what are the functional and authority rclstionships among team m e n i l e r s ; dnd

what factors were responsible for the establishment and the effective (or ineffective) function of the teams? 4. Develop for existing and/or new categories of health workers basic and continuing education programmes to satisfy the qualitative and quantitative needs:

What is the current method of organization, support, planning, and implementation of continuing education programmes for health personnel in a sample of countries (developed and developing) representing different social/political systems; and what is the evidence that such programmes influence the quality or nature of health care?

Develop task- and community-oriented educational programmes for health workers, especially those involved in primary health care delivery, in an increased number of educational institutions:

What are the distinctive features of effective and efficient i n s t i t i i t i n n s for education of health personnel and health care delivery, and how may such institution building or strengthening best be accomplished?

Increase the number of full-time teaching staff with competence in the application of a systematic approach to educational planping, methodology and evaluation:

What alterations in current evaluation systems or modification of current evaluation practices are required to improve feedback on performance to health professions' students, teachers, practitioners and programme administrators? What improvements are possible in the selection of students tor health professions education in order to assure the most appropriate non-academic as well as academic qualifications, to encourage greater career mobility, and to avoid excessive waste of human talent and resources?

EM/RSR/4 page 1 8 7.

E!l/MTG. SCF GRP HS RSR/5

. . .

Increase the number of training programmes for health personnel with sufficient relevant learning rnateriqls and evaluation instruments, and effective methodology for their application including student-oriented learning systems, efficient communication channels, and feedback on effectiveness and relevance: What mechanisms might be developed to assure greater involvement of the recipients o f health services in identifying the needs for, and providing feedback on the effectiveness of educational programmes which produce the providers of health services?

Among the researchable areas in Health Manpower Development the Scientific Group recommended that special emphasis be given to the following:

Alternative approaches to categorization, preparation and utilization of health workers Development of appropriate health learning materials Progress study of the teacher training programmes Selection of students for health work oftudents.

Use of government hospitals and centres for training

GJHO

EMRO

EM/F,SR/I EM/MTG.SCF.GRP.HS.RSR/5 page 19

The Scientific Group considered that the on-going activities of the Regional Office in the construction of an inventory of research workers, groups or institutions, both governmental and

non-governmental, are of great importance and use for the purpose of identification in certain areas. PJHO has already identified several suitable institutions to act as WHO collaborating centres. The Group was in full agreement with thc critcria for selection

of WHO collaborating centres which were presented as follows: Criteria for Selection of Institutions for Designation by WHO The criteria to be taken into consideration in selecting an institution for designation as a WHO collaborating centre are:

The standing of the institution at the international and national level in the particular field of research The staff and facilities it offers for the services to be rendered to WHO Its prospective stability in terms of personnel and funds Its capacity and ability to serve one or several WHO programmes Its capacity to continue to provide services over a prolonged period and not merely for a single distinct research task.

The weight given to these criteria will naturally vary according to the function or functions to be carried out by the centre: international standing, for instance, would have a high degree of importance for a centre required to propose an internationally acceptable terminology. The criteria could be applicable also for the selection of those institutions that will be entrusted with research support or grants. The Group also expressed the opinion that another major task of 1 0 would be the identification of those research workers and i ~ ~ s L i L u L i v rL~i ts d t h d v e r l u t err~bdrked on Health Services Research but have ample potentialities to do so. The assistance of WHO, under its programme of research promotion to those workers and institutions, would help to establish a foundation or nucleus of Health Services Research capability needed tor the ruture development and promotion of general health services in the countries of the Region.

EM/RSR/~ EM/MTG,SCF.GRP.HS.RSR/~ page 20

WHO EMRO

VII

INFORMATION ON HEALTH SERVICES RESEARCH The activities of WHO in the dissemination of information

on Health Services Research was highly commended by the Scientific Group. Xt was also recommentled that to promote regional involvement in research a list of research questions should be distributed to research workers and institutions in the Region. With particular reference to research in the Health Manpower aspect of Health Services Research, one issue of The Learner could be devoted to this subject, particularly since its readership may include a high proportion of those individuals in the Region likely to become actively interested in such research.

WHO EMRO

EM/RSR/4 EM/MTG.SCF.GRP.HS.RSR/5 page 21

VIII MECHANISM OF RESEARCH PROMOTION AND CO-ORDINATION AT THE REGIONAL OFFICE The Scientific Group estimated that about 90 per cent of on-going rcscarch in the Region as a whole is biomedical

(clinical, biological, etc.), and in some cases the research is limited to certain subjects, some of which are not relevant to WHO'S main objectives. There is a great need to shift some uf t h e e m p h a s i s toward H e a l t h Services R e s e a r c h . T h e way t o

promote this idea constitutes a complex subject, worthy of further study. It should be stated, however, that current efforts by WHO to promote Health Services Research are highly commendable and headed in the right directions. Current WHO activities in Health Services Research include: 1. 2.

Development of -

a Health Services Research policy

Attempt to identify areas of research Registration and distribution of research workers Establishment of WHO Programmeof Health Services Research Support of Health Services Research Programmes in countries Dissemination of Information on Health Services Research Co-ordination of Health Services Research activities Research training awards, research grants, research contracts Regional visiting scientists and health workers' programme Fellowship programme Provision - of consultants and temporary advisers Assistance to libraries and training of librarian personnel Provision of equipment and supplies Assistance through WHO revolving tund and reimbursable procurement

4. 5. 6.

7. 8.

10. 11. 12. 13. 14.

EM/RSR/4 EM/MTG.SCF.GRP.HS.RSR/5 page 22

WHO EMRO

The Group was of the opinion that WHO support and guidance given to qualified or potential research workers and institutions would be of major importance in achieving Health Services Research capability; however, conditions may vary among:

Countries with Academic and Technical Institutions, schools of Public Health, Planning Institutes, Schools or Institutes of Public Administration, Research Councils, efc. countries with few institutions (or with institutions that lack Health Services Research capabilities) Countries with no research institutions,

The ap~roachin different countries would obviouqly vary, from a catalytic action to WHO assistance in improving cooperation and involvement of research workers and institutions, and, in some cases, to the establishment of the first nucleus of research. The Scientific Group was impressed by the understanding of Health Services Research priorities shown by officers of WHO EMRO who participated in the Meeting; however, it was suggested that an extensive research programme requires the services in EMRO of a full-time Research Officer, to be the focdl point of researcn in the Region as in the Medical Research Council (UK) o r the National Institutes of Health (USA). The new Research Officer skould not divert the Technical Cfficers from their involvement in "action-oriented" resedrch as part of their on-going developmental. programmes. Depending upon the amount of and the speciql emphasis given to medical research, in general, and to Health Services Research, in particular, by h%G EMRO, the proposed Officer may be assigned to work on all research programmes or on Health Services Research only. Of course there would be a danger of reclassifying normal programmes (that should be carried out any way) as research programmes, however, it is important that research consciousness and evaluation mechanisms be built into all programmes from their inception. The Group also recommended that satisfactory provision be made for the management of the overall research programme and its component parts in relation to the overall work of the Regional Office. Concerning the development of specific proposals for research, the Scientific Group endorsed the intent of WHO to formulate (as recommended by RACMR) guidelines and specifications as to the content of the protocol (including clear objectives, a review of the works carried out on the same subject in the Region and elsewhere, a plan of work, a method of evalunti~n,etc.). It would be necessary, however, that a multidisciplinary Steering Group be appointed from the start to guide and advise in the planning phase of any (but the smaller) research projects.

FIGURE 1

Small Scientific Grocp on o t h e r Research

a Project

LE_I

Project

& O

EMRO

EM/RSR/4 EM/MTG.SCF.GRP.HS.RSR/5 page 23

These Scientific Steering Groups may be involved in a series of research projects or only in one project depending on the nature and extent of each. It is advisable that these steering groups be called upon as well for a review and evaluation of the conduct and results of each project-. The Scientific Group on Health Services Research would be in charge of co-ordination of all Health Services Research projects and the Steerinq Groups would allow the Scientific

Group to operate with more confidence and flexibility. Other small scientific groups (to be assisted by the related Scientific Steering Groups) may be formed as needed to deal with projects in other research areas. These scientific groups may work in relation to the RACMR and as instructed by the Regional Director in the manner shown in the accompanying chart (see Figure 1). The Scientific Group also recommended that every opportunity be used at workshops, seminars, group meetings and conferences

organized by WHO EMRO to emphasize the research aspects of the problems under discussion and to formulate some of their recommendations in research terms. These recommendations would then form a useful list of suggestions for research, based on which suitable proposals could be formulated.

EM/RSR/4 EM/MTG.SCF.GRP.HS.RSR/5 page 24

T f H O EMRO

The Scientific Group for Health Services Research would like to draw the attention of the Regional Director to the recommendations and suggestions contained in the text of this report and particularly to the following recommendations summarized below: 1. That the term HEALTH SERVICES RESEARCH be used to describe research into all aspects of Health Services and Manpower Development. That Health Services Research (HSR) be "action-oriented": i.e. rooted in problems found in the field and identified by persons, institutions or countries experiencing the problem. That the following general criteria (to be detailed later), for the selection of the proposed HSR research projects, be considered:

RELEVANCE IMPORTANCE FEASIBILITY (ACCEPTABILITY) MAXIMUM RETURN ( SOCIAL-ECONOMIC

IMPACT)

That selection of research projects should:

Be integrated into Health Services and Manpower Development activities at the country level

Include dissemination, adaptation

and application of results as part of the research design Take account of the potential for increasing self-reliance of countries on their trained research manpower.

Promote co-operation between countries (where possible) and the development of joint solutions to common problems Be developmental in nature Call for multidisciplinary co-operation Be based on a team approach Promote the scientific potential of the country or countries of the Region.

.?HO EMRO

EM/RSR/4 EM/MTG.SCF.GRP.HS.RSR/5 page 25 That the eleven research draft proposals (Annex 111) presented at this Meeting be accepted in principle, subject to specific comments and recommendations on each proposal (presented in Chapter IV - REVIEW OF RESEARCH DRAFT PROPOSALS, pp. 9 - 17). That WHO EMRO efforts in the development of a workable classification of research topics in Health Services Research be continued.

That the following subjects for research should be of paramount importance in EMR:

Social science input for all health research projects Role and effectiveness of primary health care Health coverage Information System (preparation of basic manual) Development of technology (e.g., elementary test methods) New diagnostic approaches Promotion of Health Services Research and social -science research among governments --- -

Up-grading vital statistics systems New evaluation approaches Role of private practice Impact of Health Insurance Researchable areas in Health Manpower Development

That the following criteria should be considered in selecting WHO EMRO collaborating centres:

The standing of the institution at the international and national level in the particular field of research The staff and facilities it otters for the

services to be rendered to WHO Its prospective stability in terms of personnel and funds

EEI/RS R/ 4 EM/MTG.SCF.GRP.HS.RSR/5 page 26

WHO EMRO

Its capacity and ability to serve one or several WHO programmes Its capacity to continue to provide services over a prolonged period and not merely for a single distinct research task.

That WHO EMRO identify on a continuing basis those research workers and institutions in the Region that have not embarked on Health Services Research, but which have the capacity for HSR, and that EMRO distribute a list of research questions to various research workers, academies and institutions in EFR. The appointment at EllRO of a full-time Research Officer (Co-ordination) to be the focal point for Health Services Research in the Region. The endorsement of the intent of WHO (as recommended by RACMR) to formulate clear guidelines and objectives for the review and evaluation of research projects in the Region, and, in this regard, the suggested formulation of "Scientific multidisciplinary Steering Groups" and other small scientific research groups (see chart, figure 1) to bc called upon for guidance and planniny

10.

11.

in the initial phases of HSR projects and for review and evaluation of the conduct and results of each project. 12. That every opportunity should be used at all workshops, seminars, group meetings and conferences organized by WHO EYRO to emphasize the research aspects of problems under dlscussion and to toymulate some recommendations in research terms in order to establish a useful list for suitable research proposals for future consideration.

WHO EMRO

EM/RSR/4 EM/MTG.SCF.GRP.HS.RSR/5 Annex I ANNEX I AGENDA

1. 2. 3.

Opening Address by Dr A.H. Taba, KHO Director, Eastern Mediterranean Region Election of Officers: Method of work" Review of research draft proposals and "researchable questions" in health services, presented in documentation as a means for: - identifying regional or country problems of major significance (relevance) establishing a set of criteria for selection of research projects in EMR Chairman and Ra~porteur

Pracedures and requirements for management of health services research in Region e.g. a) selection of problems

b) development of proposals C) selection of researchers and institutions d) supervision - evaluation 6.

Identification of other "problems" or research areas in the light of criteria as established in 4 above and in relation

to other regional activities - e.g. Ministerial Consultation on Health Services and Manpower Development and the Working Group on Social and Behavioural Sciences in Health Services and Manpower Development; Primary Health Care Programme, etc. 7.

Summary report Closure.

recommendations

1) 2) 3) 4)

More detailed objective of meeting Brief statement on present status of HSR in Region Comment on dccumentation Concern with guidance to RO:

selection of projccts to support

- identification of support needed Participants will meet on Monday afternoon if necessary

WHO EMRO

EM/RSR/~ EM/MTG.SCF.GRP.HS.RSR/5 Annex I1 page i ANNEX I1 L I S T O F PARTICIPANTS

nr Abdel Rahman

A 1

Awadi

Minister of Public Health Ministry - of Public Health Kuwait KUPJAIT Dr E.M. Backett Professor of Community Health University of Nottingham Nottingham ENGLAND Dr James McEwen Senior Lecturer uepartment of Community Health University of Nottinqham ~ottingham ENGLAND Dr W.A. Hassouna Consultant Institute of National Planning Cairo

EGYPT

Dr Chamseddine Mofidi Deputy Chancellor University of Teheran Teheran ---IRAN

---did not attend

EM/RSR/~ EM/MTG.SCF.GRP.HS.RSR/5 Annex I1 page ji

hrHO EMRO

WHO SECRETARIAT Ur A.H. Taba Director Regional Office for the Eastern Mediterranean, Alexandria Regicnal Office for the Eastern Mediterranean, Alexandria

Dr Shubbar Hasan

Public Health Administrator Community Health, Secretary of the Meeting Public Health Administrator Health Manpower Development Public Health Administrator Health Organization Chief, Educational Evaluation Regional Adviser on Vital and Health Statistics Corlference Officer

Dr A. Robertson

Regional Office for the Eastern Mediterranean, Alexandria Regional Office for the Eastern Mediterranean, Alexandria WHO Headquarters, Geneva Regional Office for the Eastern Mediterranean, Alexandria Regional Office for the Eastern Mediterranean, Alexandria Regicnal Office for the Eastern Mediterranean, Alexandria.

Dr G. Rifka

Dr F. Katz Dr E . I . Hammoud

Mrs C. Putnoky

Secretary

WHO EMRO

EM/RSR/4 EM/MTG.SCF.GRP.HS.RSR/~ Annex I11

ANNEX I11

HEALTH SERVICES RESEARCH PROPOSALS

-NHO EMRO

EM/RS R/4 EM/MTG.SCF.GRP.HS.RSR/~ Annex I11 ANNEX I11 TABLE OF CONTENTS

Research on Health Manpower Development EM/MTG.SCF.GRP.HS.RSR/4.1 as an Element of Research on Health Services Research on Expanded Programme of Immunization (EPI) Comparative costing of methcds of administering triple vaccine EM/MTG.SCF.GRP.HS.RSR/4.2

Research on Expanded Programme of Immunization (EPI) - Comparative evaluation of techniques of achieving maximum coverage of immunization in . . n f ancy Research on Health Information Research on the Integration of Health Workers of Specialized Campaigns within General Health services Research on Prophylactic, Diagnostic and Therapeutic Substances (PDT1 Research and Development Project Community Participation in Primary Health Care Programme in Western and Southern Sudan Orientation Ccurse in Evaluative Health ServicesResearch Challenges to Effective Health Coverage - A Comparative Evaluative Study Research Proposal R e s e a r c h Prupusdl

EM/MTG.SCF.GRP.HS.RSR/~.~

4. 5.

EM/MTG.SCF.GRP.HS.RSR/~.~ EM/MTG.SCF.GRP.HS.RSR/~.~

6. 7.

EM/MTG.SCF.CFiP.HS.RSR/4.6

Erl/MTG.SCF.GRP.HS.RSR/4.7

8. 9.

EM/MTG.SCF.GRP.HS.RSR/~.~

EM/MTG SCF GRP HS RSR/4 .9

. . . .

10. 11.

The Gevelopment of a Co-ordinated Health Services and Manpower Development Programme in Hamadan

-WHO EMRO

Research Proposal 1. Major SVHO programme area Fromotion and Development of Traditional Medicine Programme. 2.

Project Title

The place of traditional medicine in the promotion of primary health care. 3.

Country or area of execution

Project duration and estimated cost (global figure) Duration: two years (1978/1979) $ 55

Cost estimated: 5.

000.-

Background and Justification

It is generally known that there is a wide range of traditional healing practices, particularly birth attendance and mental healing (there are, for example, 3 5 000 recognised traditional practitioners in Pakistan). However, there is a dismal lack of scientific data in this field. There is, therefore, an urgent need to collect and collate information from selected countries (e.g. Afghanistan, Iran, Pakistan, Sudan, Somalia, Tunisia and Yemen). 6.

Main purpose of the project

to assess the extent and e f f ~ c ~ i v e n e sn sf the present contribution of traditional medicine in the promotion of prinary health care; to provide information on community resources for potential involvement in primary health care; the collected data may form useful background material for training programmes and public education.

Cost Estimation STCs (including travel) Supplies and others

1978 $ 25

000

$ 2 5 000

3 000

Grand Total

h3G

EMRO

RESEARCH PROPOSAL THE DEVELOPMENT OF A CO-ORDINATED HEALTH SERVICES AND MANPOWER DEVELOPMENT PROGRAMME IN HAPMDAN 1. Background The Government of Iran has decided to develop seven new provincial institutions to train health personnel including

phys-icians. One of these institutions,the Bu Ali University, was set up in 1974 and is committed to develop a Health Science Cluster which will be responsible for training a variety of health personnel (already, since 1976 - it is training nurses and environmental health workers and from 1977 onwards physicians). These training programmes will be co-ordinated with the development of a locally relevant health care system. The present plan envisages that: a. b. the development of health manpower will be an integrated part of the development of the health services; the training programmes will seek to prepare different cadres of personnel for comprehensive primary care, involving where possible on the job training.

There are a number of conditions which favour the introduction of such an innovative approach:

the leadership of the institutions is committed to the development of a programme relevant to the health needs of the people in the Region;

some of these leaders have had previous experience of primary health care programmes and are conversant with approaches used in other programmgwith similar objectives; the programmes appear at this stage at least, to have the opportunity to be flexible and to depart from the normal; there are adequate resources available to permit the development of a programme with such goals.

N.B.

As an action research project the prepared study could provide an example of an alternative approach to the education of health personnel for Iran and other countries.

WHO EMRO

Objectives of the proposed project as described above ---

TO plan, implement and evaluate an educational programme

for health personnel oriented to primary care in coordination with a similarly oriented health care system.

More specifically:

To plan, implement an educational programme for a variety of health workers; to maximize the likelihood of such health personnel being able to function as members of a multiprofes$ional health team; to plan and implement a health service which would provide effective health care qs well as relevant learning experiences for trainees.

Approaches TO prepare a detailed project proposal on the basis of an

initial review of the eyisting situation in the province. Determine the health status of the population to be served i n c l u d i n g major health r t q y i r e r n e n t s ~f the population. Prepare a detailed set of specificatiorsfor an educational programme which would seek to maximize training opportunities for trainees tu dttain competences needed; whicn maximizes flexibility, the development of an ability to solve problems; and is relevant to the service needs. Revise a plan in co-ordination with ( 3 ) above, for an appropriate health care system. Identify appropriate educational processes (e.g. problem solving approach, modular curriculum, experiential learning); select and train teachers; identify and if necessary produce learning materials; identify appropriate student-teacher evaluation processes. Determine appropriate management processes and functions of supervisors. Establish a continuing education programme for health personnel those already practising and those to be graduated. D e t e r m i n e a n appxopriate programme evaluation proce$s

- t o ensuze that informed judgements can be made about the programme and that all participants can obtain continuous feedback. Requirements

RESEARCH ON HEALTH PiANPOWER DEVELOPMENT AS AN ELEMENT OF RESEARCH ON HEALTH SERVICES

...

The attached document i s an amalgamation of the opinions and suggested approaches of the M I 0 s t a f f concerned with h e a l t h manpower development, both at WHO I I e a d q u a r t e r s and in the Regional Offices.

Presented t o the Group a s a background paper, i t may be u s e f u l i n the consideration of ways to carry out t h e p r o j e c t proposals f o r research i n h e a l t h s e r v i c e s and manpower development.

fiEAL1'H MANPOWER DEVELOPMENT HESEAHCti AS ONE ELEMENT OF HEALTlI SERVICE RESEARCH

A n o u t l i n e of HMD r e s e a r c h a s p a r t o f t h e o v e r a l l programme t o s t r e n g t h e n h e a l t h s e r v i c e s manpower development

........... 2. H e a l t h s e r v i c e s and 1iMD r e s e a r c h . 3 . ( : h a r a c t e r i s t i c s uf 11MU r e s e a r c h . 4. E x a n ~ p l c s0 1 r e s e a r c h p r o b l e m s . . 1

Introduction

. . . .

5 6

. .

'I'hc s e l e c t i o n o f a r e s e a r c h prugrallhme Prupusetl a c Llorrs

. . . . .

2 3

4 9

. . . . . . . . . . . . . .

ANNEX I ANNEX I 1

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

11 13

IIEAL'I'II MANPOWER DEVEI,OPMEN'I' HESEAHCII A S ONE ELEMENT OF HEALTI1 SEHVlCE RESEAllCH

1. 1 111 r c s p o l l s e t u r e s u l u t l o l r WllA30.4 r e c l u c s t l n g t h e D l r e c t u r - ( ; e ~ ~ e r1 d t o " i u r t h e r e l a b o r a t e t h e M I 0 long-tern1 programme I n t h e f i e l d o i d e v e l u p n l e ~ ~ t and courbdlr~dtlun of b l ( , n i e d l c a l a n d h e a l t h s e r v l c e s r e s e a r c h " , a n d u r p l n g e x p a n s i o n ui r e s e a r c h ~ n IIMD ds a n ~ n t c g r a le l e m e n t o i t h c h e a l t h s e r v l c e s r e s e a r c h e f f o r t , t h i s d u c u n ~ e n t h a s t ~ e e np r e p a r e d t o d e s c r i b e more f u l l y t h e p o t e n t l a 1 c o r l t e t ~ t of IIM1) r e s e a r c h d r ~ d t o o u t l i n e a p p r o a c h e s w h l c h n u g h t be u s e d I n i t s ~nrplemeritatlon.

1.2 'l'he principles a n d a i m s of t h e r e s e a r c h a r e t h o s e w h i c h g u i d e t h e These a r e set O r g a n i z a t i o r ) i 11 i t s programnlrj; o f h e a l t h manpower devel'opment u u t i n t h e World l i e a l t h Assembly dvcurncnt ~ 2 9 / 1 5 a n d a r e o r i e n t e d t o w a r d s t h e a t t a l n l n e n t o f two o b j e c t i v e s o f t h e s i x t h g e n e r a l programme o f w o r k , n a m e l y :

"'L'v prornote t h e d e v e l o p m e n t o f a p p r o p r i a t e h e a l t h p e r s o n n e l , t o mt : t t h e n e c d s u f e n t i r e p o p u l a t i o n s " a n d "'Po prolllo t e t h e dt!velopmen t a n d a p p l l c a t i o n o f r e l e v a n t p r o c e s s e s f o r b a s i c arid curl t i r i u i r i g e d u c a t i o n " .

Just d s a l l uther a c t l v t ~l c s , r e s e a r c h w l l l b e u n d e r t a k e n o n t h e b a s i s o f t h e e x p r e s s e d w l s h e s o l Member b t a t e s f o r s u c h r e s e a r c h o n p r o b l e m s w h i c h t h e y h a v e i d c r i t ~ led. i

1.3 A l r e a d y , c o ~ ~ s i d e r a b leef f o r t h a s been e x p a n d e d by t h e O r g a n i z a t i o r ~ I n prurrroling a n d i m p l e n ~ e n t i r i gr e s e a r c h a s a n i r i t e r r a l D a r t o f i t s programme a r t i v i t i r s ( A b r i e f r e v i e w o f t h e s e a c t i v i t i e s i s a t t a c h e d a s Annex I . A l i s t i n g of present a c t i v i t i e s w i l l be c o m p i l e d a n d s u b m i t t e d a t a l a t e r s t a g e . ) However, i t i s r e c u g n i z e d t h a t t h e r e i s a n u r g e n t n e e d f o r a ruuch g r e a t e r e f f o r t n o t o n l y b e c a u s e o f t h e many u n a n s w e r e d p r o b l e m s t o w h i c h s o l u t i o n s n e e d t u t)e f o u n d , b u t a l s o b e c a u s e i t i s r e c o g n i z e d t h a t w i t h o u t new s o l u t i o n s t o t h e h e a l t h manpower d e v e l o p m e n t p r o l ) l e n ~ si n Member S t a t e s t h e r e c a n be n o r e a l improven,ents i n h e a l t h c a r e . F u r t h e r , a n a c t i v e involvement i n a p r o c e s s o f p l a n ~ ~ i narid g i ~ n p l e m e nit n g r e s e a r c h 1s i t s e l f a n i m p o r t a n t s t i m u l u s f o r c h a n g e , a r ~a d a p t a t i o n t u new r e q u i r e n ~ e n t s a n d c o ~ ~ d i t i o n s . M o r e o v e r , a n e n g a g e m e n t i r ~ r e s e a r c h a c t l v l t i e s i n c r e a s e s t h e r e s e a r c h c a p a b i l i t i e s o f Member S t a t e s i n a r e a s where a t p r e s e n t t h e r e i s a d e a r t h o t a d e q u a t e l y t r a i n e d r e s e a r c h workers. 1.4 'l'he d e v e l o p m e n t o f a r : l n t ~ a l m e d i u m - t e r m p r o g r a m m e for thc health. .. . olanpower d e v e l o p m e n t programme f u r t h e r s t r e n g t h e n s b o t h t h e n e c e s s i t y a n d t h e a p p r o p i - l a t c ~ l c s so f d e v e l o p i n g a n o r g a ~ l i z a t i o n - w i d e r e s e a r c h programme a t t h e preserit time. 'rhe r e s e a r c h programme i s n e c e s s a r i l y a n i n t e g r a l p a r t of t h e p l a n r l u d a c t I v i t i e s d i r e c t e d t o w a r d s i d e n t i f i e d t a r g e t s , s i n c e r e s e a r c h activities l o r m b o t h a n i n t e g r a l p a r t a n d a n e x t e n s i o n of a l l d e v e l o p m e n t a l a c t i v i t i e s .

H e a l t h s e r v i c e s and IIMU r e s e a r c h

2.1 R e s e a r c h 111 t i r e f i e l d o f h c i ) l t h nla~lpower d e v a l o p ~ n e n t i s a n i n t e g r a l p a r t o f h e a l t h s e r v i c e s r e s e a r c h , s i n c e t h e v e r y o s s e r i c e o f h e a l t h manpower i s t o providt-. s e r v i c e s n e e d e d f o r h e a l t h c a r e . Research hence i s both o r i e n t e d t o w a r d s arid irrdeed . j u s t i f i e d by t h e c o l l t r i b u t i o n i t c a n make t o i m p r o v e h e a l t h s e r v i c e sySLetIlS.

2.2 Given t h a t is~proveltlent i r l ht!a Lth c a r e p r o v i d e s t h e j u s t i f i c a t i o n , alld h e a l t h s e r v i c e r e s e a r c h t h e broad c : l = s i f i palory framework, W D r e s q a r c h is c o n c e r n e d w i t h a s p e c i f i c set o f p r o b l e m s a n d u t i l i z e s p a r t i c u l a r m e t h o d o l o g i e s . Ilence, i t i s a n e n t i t y w h i c h i t s e l f f o r m s p a r t o f a s y s t e m , J u s t a s b i u n ~ e d i c a l r e s e a r c h i s a term t o o b r o a d a n d c o m p r e h e n s i v e t o be d e a l t w i t h i n a s i m p l i s t i c f a s h i o n a n d must i n s t e a d be b r o k e n down i n t o component p a r t s b e f o r e i t calb be c o n d u c t e d i r ~ a m e a n i n g f u l way, s o t o o i s i t e s s e n t i a l t o i d e n t i f y t h e components o f h o a l t h s e r v i c e r e s e a r c h . Each component p a r t c e n t h e n be s t u d i e d , g i v e n t h a t f i n a l l y t h e r e i s effective i n t e g r a t i o n o f f i n d i n g s , l e a d i n g t o a c u m p r e h e n s i v e u n d e r s t a n d i n g 01 what c o n t r i b u t e s t o t h e s t r e n g t h o f , o r i n a d v e r t e n t l y weakens, t h e h e a l t h s e r v i c e s system. 2.3 Health services research i s l i k e l y t o i n ~ l u d e a t t h e very l e a s t the s y s t e m a t i c s t u d y o f f o u r major elements: 1)

The h e a l t h c a r e s y s t e m health c a r e needs organization f o r delivery of c a r e - manogomer~t of' h e a l t h care o r g o n i z a t i u ~ > b c o s t s o f b a s i c c a r e a n d o f i n c r e m e n t s beyond t h e b a s e cost efficiency cost effectiveness q u a l i t y of c a r e d e l i v e r e d p r e p a r a t i o n o f Consumers f o r t h e i r r o l e i n t h e s y s t e m etc.

H e a l t h marrpower d e v e l v p ~ l r e n t

manpower p l a n n i n g t o meet h e a l t h c a r e s y s t e m n e e d s manpower mix a n d d i s t r i b u t i o n d e t e r m i n a t i o n o f manpower c o m p e t e n c e p l a n n i n g , o r g a n i z a t i o n , implelnen t a t i o n a n d e v a l u a t i o n o f b a s i c a n d c o n t i n u i n g e d u c a t i o n 4 1 programmes f o r h e a l t h workers te$mwork manpower management ( i n c e n t i v e s , c a r e e r s c h e m e s . e t c ) etc.

O r g a n i z a t i o r ~ a lf a c t o r s

c h a r a c t e r i s t i c s of h e a l t h s e r v i c e autl h e a l t h p r o f e s s i o l ~ s education i n s t i t u t i o n s c h a r a c t e r i s t i c s o f p r o f essj o n a l h c a 1 t l ~ worker o r g a n i z a t i o n s o r unions (e.g. o r i e n t a t i o n , values, c t c . ) community d e v e l o p m e n t s y s t e m s etc.

page 3

s o c i a l / c u l t u r a l , demographic f a c t o r s

resources available for health care coninlulli t y a s p i r a t i o n s , b e h a v i o u r s a n d v a l u e s (e.g. h e d l t h c a r e v s o t h e r d e s i r a b l e t h i n g s ) p o l i t i c a l philosophy a s i t i n f l u e n c e s h e a l t h s e r v i c:es d e ~ n o g r a p h i cf e a t u r e s ( e . g . a g e , d i s t r i b u t i o n , clirnatic conditions) etc.

S u c h a c a t e g o r i z a t l o n i s not. i11Lcrlded t o i m p l y t h a t t h e s e c o m p o n e n t s r e p r a s e r l t independer~ t e n d s , b u t r a tlier t h a t t h e i r i n t e r l o c k i n g a n d o v e r l a p p i n g e l e m e n t s convey t h e e s s e n t i a l n a t u r e of h e a l t h s e r v i c e s r e s e a r c h :

C h a r a c t e r i s t i c s o f IIhlD r e s e a r c h

3.1 He:suar.c:h, a s t h c s y s t e m a t i c e l l q u l r y t o d i s c o v e r a n s w e r s t o p r o b l e m s , e s s e n t i a l l y t h e same I n t h e a r e a o f 1IMD a s i n 1 ) i o m e d i c a l f i e l d s . However, t h e r e a r e scme a s p e c t s , a ~ specifically ~ d t h e m e t h o d o l o g y u s e d , w h i c h t o some extent dis t i n g u ~ s h IIMD r e s c a r c h from b i o m e d i c a l r e s e a r c h . IS

3.2 Most i l n p o r t a n t l y , IlhlD a n d f o r t h a t m a t t e r h e a l t h s e r v i c e r e s e a r c h g e n e r a l l y i s , o r s h o u l d Lie, r o o t e d i n p r o b l e n r s f o u n d i n t h e f i e l d a n d a r t i c u l a t e d , Hence t h e i d e n t i f i c a t i o n o f a t l e a s t 1 1 1 1 t i a l l y , Ily t h o s e who e x p e r i e n c e them. o b j e ~ t i v e of ~ r e s e a r c h i s o r s h o u l d e m e r g e a s a n o u t c o m e o f a c t i v i t i e s o r programmes f o r which a 1 t e r n a t i v e s o l u t i o r l s a r e r e q u i r e d . 3.3 Not orlly 1s t h e ~ d c ~ l t l f i c a t l o of r ~ the p r o l > l c n ~ s tor w h i c h r e s e a r c h I S r e q u i r e d essc.11 t l a l l ) t h e r e s p u n s i b l l l t y of t h o s t ) who e x p e r i e n c e them, b u t t h e r e s e a r c h i t s e l f Ily l ~ e i r l g4~ t i o n - o r i e n t e d n e e d s t o I n v o l v e a l l c o n c e r n e d I n t h e r t ? s e a r c h l r l ~ t psl d n n l r ~ ganti l m p l e l n e n t a t l o n . 4 t3t.caust. i,f t h e w a y t h e p r o l ~ l e r n sa r c ~ d c l r t i f i e d , ~ t a s c t ~ o nu r i e ~ r L a L i u n , a r ~ db e c a u s e of Lhc c:on~plcx i r l t e r r e l a t i o r l s h i p s t h a t a r e s u c h a f e a t u r e of tlMD r e s e a r c h p r o l ) l t : r l ~ s , i t 1s a l s o t r u e t h a t t h e r i g i d l y c o n t r o l l e d , s t a t i s t i c a l l y o r i e n t e d h y p u t h c s i s t e s t i n g w h i c h o f t e n c h a r a c t e r i z e s b i o m e d i c a l r e s e a r c h may be f a r l e s s promirrorlt i l l r e s c a r c l l w h i c h a d d r t t s s e s q u e s t i o n s of h e a l t h manpower

developmtm t ttcrc o t h e r r e s e a r c h d e s i g n s a r e e q u a l l y i m p o r t a n t , and e q u a l l y w o r t h y e v e n t h o u g h t h e y lllay seem " s o f t " t o a b i o p t t y s i c i s t o r m o l e c u l a r b i o l o g i s t who i s a c c u s t o m e d t o u s i n g Itleasurenlcllt i n s t r u l s e n t s u f exquisite p r e c i s i o n , a n d t o a s s u r i n g experimental c c ) n d i t l o n s i n w h i c h o n l y orlc v a r i a b l e a t a t i m e i s manipulated. Thus i n i t d d i t l o n t o t h e c l a s s i c a l t e c h n i q u e s o f s c i e n t i f i c r e s t ? a r c h , experirnerlt a 1 o r q u a s i - c x p e r i n i e n t a l d e s l g r i s , t h e r e a r e o t h e r m e t h o d s by w h i c h u s e f u l r e s e a r c t l car] be c a r r i o d o u t . IJ<)r i n s t a n c e , t h e " c a s e s t u d y m e t h o d " , arl i n - d e p t h a n a l y s i s o f a programnit-: 1 1 ) a r . t i o n is now recognized a s a p o w e r f u l nicarls t o g a i n u n d e r s t a n d i n g o f a progranlme a s a w h o l e , i n c l u d i n g r t s r a t i o n a l e and e v o l u t i o n , a c t i v i t i e s , accumplishmcnts and d i f f i c u l t i e s . S y s t e m a t l c a e s c r i p t l o n and e v a l u a t i o n s employing r i g o r o u s p r o c e d u r e s a r e n o t o n l y appropriate t o t h e p r o b l e n ~ so f IIMD, b u t c a n m e e t t h e c r i t e r i a o f s c i e n t i f i c enquiry. 3.5 The d i f f e r e n c e b e t w e e n b i o m e d i c a l r e s e a r c h a n d r e s e a r c h i n t h e a r e a o f HM1) ( o r h e a l t h s e r v i c e s r e s e a r c h a s a w h o l e , f o r t h a t m a t t e r ) i s h e n c e p e r h a p s more a p p a r e n t t h a n r e a l , g i v e n t h a t a c c e p t a b l e l e v e l s o f s c i e n t i f i c enquiry pertain.

Examples o f r e s e a r c h problems

4.1 P r o b l e m s f o r w h i c h r e s e a r c h i s r e q u i r e d must be i d e n t i f i e d by Member S t a t e s , a r i s i n g o u t o f t h e a c t i v i t i e s engaged i n o r planned t o a c h i e v e improved health care. The f o l l o w i n g r e s e a r c h p r o b l e m s a r e h e n c e e x a m p l e s o n l y o f p r o b l e m s w h i c h have a l r e a d y been i d e n t i f i e d a s r e q u i r i n g s o l u t i o n s . They d e r i v e f r o m t h e planned a c t i v i t i e s set out in t h e medium-tcrnr programme o f t h e O r g a n i z a t i o n w h i c h i t s e l f was d e v e l o p e d o n . t h e b a s i s o f i d e n t i f i e d n e e d s o f Member S t a t e s .

By l i s t i n g t h e s e e x a m p l e s i t i s i n t e n d e d t o i n d i c a t e t h e t y p e o f protllern f o r which s o l u t i o n s a r e needed and which a r e amenable t o r e s e a r c h .

4.2 T h e e x a m p l e s a r e g r o u p e d a c c o r d i n g t o t h e t a r g e t s o f t h e g l o b a l ttMD medium-term programme w h i c h i n t u r n h a v e been d e r i v e d f r o m t h e S i x t h G e n e r a l Although e a c h p r o j e c t h a s been i d e n t i f i e d P r o g r a m n ~ e o f Work o f t h e Organization. u n d e r a s i n g l e h e a d i n g , 1 t w i l l be e v i d e n t t h a t many m i g h t f a l l u n d e r s e v e r a l , b u t f o r c o n v e n i e n c e e a c h h a s been n o t e d o n l y orrct?. Annex I 1 p r o v i d e s sunle s a m p l e s o f u o r e d e t a i l e d o u t l i n e s o f some o f (Note t h e s e r e s e a r c h problems. )

?rogramme a r e a : Mdr~puwer p l a n n l l l g arld mar~agemerit t u meet h e a l t h s e r v l c e r e q u i r e l n e r l t s ( ~ r ~ c l u d l rt ~ he g p r o r n u t i o ~o ~ f mechanis~rrs f o r i n t e g r a t i n g h e a l t h s e rI ~c e a ~ rnar~powcr ~ d development) . ' I ' a r g e t 1 : 'I'kle a s s u r a l l c e u f e f ' i e c L i v e c o o r d i n a t i u n between e d u c a t i o n a l a n d s e r . v i c c ager1c:ies c:rlgaged i r ~ Ileal t h a c t j v i t i e s . Rt:search p r o b l e m 1 . 1 : What p o l i t i c a l , v r g a n i z a t i o n a n d b e h a v i v u r a l f a c t o r s f a c i l i t a t e a n d impede c o n u n u ~ ~ i c a t i oa n n d c o l l a b o r a t i o n amung g r o u p s w i t h r e l a t e d o r o v e r l a p p i n g r e s p o n s i b i 1 i t i e s f o r hea 1 t h d h e a l t h 3ttrvice d c l i v e r y ( e . g . M i n i s t r i c r lliarryuwel- c l e v u l u p ~ ~ i u a ~n it o f H e a l t h and E d u c a t i o n , a c a d e m i c and p r a c t i t i o n e r g r o u p s , s p e c i a l i s t s and gr:r1c:ralisl s , p h y s i c l a r l s a n d n u r s e s , e t c . ) ? R e s e a r c h p r o b l e n ~1 2 : What p r u f e s s l o n a l a n d t e c h n i c a l c o m p e t e n ~ e I S r e q u l r e d f o r optlmcil a d ~ ~ ~ l n i s t r a t a ln ud~ l management o f h e a l t h professions c d u c a 11 o n a l i n s t l t u t i o n s a n d h e a l t h c a r e s e r v i c e s , w h a t p r a c t ~ c ' a l neth hods a r e a v a i l a b l e o r s h o u l d be d e v e l o p e d t o a s s u r e t h a t Vlce-C h d n c e l l u r s , D e a n s , d e p a r t m e n t h e a d s , n a t i o n a l o r r e g i o n a l o r l o c a l h e a l t h s e r v i c e system d i r e c t o r s , h o s p ~ t a l d l r e c t o r s , a n d h e a l t h team l e a d e r s a c q u i r e t h i s c o m p e t e n c e ? R e s e a r c h probleni 1.3: What o r g a n i z a t i o n a l a n d a d m i n i s t r a t i v e n l c c h a r ~ i s m s a r e r e q u i r e d a n d what p a r t i c u l a r s k i l l s a n d a t t i t u d e s arnot~g l e a d e r s must 11e a c q u i r e d o r r e k l n e d i n o r d e r t o a s s u r e g r e a t e r t e c h n i c a l c u o p e r a t l o n amung d e v e l o p i n g countries? T a r g e t 2 : 'I'he as5uranr.ri n f arierlua te h e a l t h manpower p l a n n i n g c a p a b i l l t y a n d t h e d e v e l o p m e n t o f nianpower p l a n s w h i c h w l l l l e a d t o a more b a l a n c e d d i s t r l b u t i u ~ lo f manpower.

I.'oI. a d e i i n e d p o p u l a t i o n what i s t h e o p t i m a l Research prut,le~i~ 2.1: rnlx o f h e a l t h w u r k e r s ( e . g . p r i m a r y h e a l t h c a r e w o r k e r s , m i d d l e l e v e l h e a l t h w o r k e r s , ~ i r e d i c a l doc t o r s , d e n t i s t s , e t c . ) t o p r o v i d e a spec:lficd l e v e l o f primary h e a l t h c a r e ?

I l e s ~ : a r < : hp r o b l e n ~2.2: llow c a n c u r r e r l t arid f u t u r e manpower ls e ,v e l o f p r e p a r a t i o n , be requirements, i .e. t y p e s , ~ ~ u r n t ~ e r assessed'? 1test.arch p r o b l e m 2 . 3 : What ~ n u c h a ~ r i s r na sr c e f f e c t i v e i n s t i m u l a t i ~ l g What e d u c a t i ona 1 programmes h e a l t h p e r s o r r r l e l t o wurk l r l r u r a 1 a r e a s ' ? o r p r o c e s s t . ~( b a s i c : o r c ~ ) r ~ t i r ~ u i f ra ~cgi )l i t a t e h e a l t h p e r s o n n e l practising l r n r u r a l a r r : a s ? U u v c l o p n ~ c n to f ~ r ~ e c h a r ~ l s ln o~ r s c , o u r d i r l a t l u n of h e a l t h s e r v l c e s Target 3: a n d marlpower d c v t l opnicn t

I t e s e a r ' c l ~pr.ul~1e111 3 . 1: W I I U L Illarragell~er~L Iulrr: i ~ u ~ u rp s t i n ~ i o r .c u v r - d i ~ r a t l u r ~ b e t w e e n h e a l t h s e r v i c e s a n d manpower drtvelopment'?

Target 4: Establishment of operational career development programmes and effective incentive schemes with supportive systems of continuing education and inlprovenlent in career mobility

Research problem 4.1 :

Ifow,effective are different incentive schemes?

Target 5: Implementation of measures to control migration of health professionals with resultant reduction in undesirable migration. What forces influence the distribution of beiwaan countries; and how might such forces be altered to achieve more favourable patterns? health manpower within a country and m i g r a t i u n

Research problem 5.1:

Programme area: Promotion of training for all categories of health staff (including the promotion of health teams for primary care, and continuing education). Target 1: Development of teams to deliver health care, with special regard t o primary care, characterized by greater health service responsiveness to community needs, significantly improved coverage, and existence of operational referral and supervisory systems. Research problem 1.1: What kinds of teams now operate in the delivery of health care; what are the functional and authority relatiunships a r u o r l p Laam memDers; and what factors were responsible for the establishment and the effective (or ineffective) function of the teams? Research problem 1.2: What skills and attitudes are required for effective health care teamwork; how might they be developed in potential team members through planned educational programmes? Target 2: Develop for existing and/or new categories of health workers basic and continuing education programmes to satisfy the qualitative and quantitative needs. Research problem 2.1: What alternatives in the preparation, cost, and utilization of several categories of health workers can be identified in reference to the delivery of a specified level of care for the major health problems of a nation? Research problem 2 . 2 : What is the current method of organization, support, planning, and implementation of continuing education programmes for health personnel in a sample of countries (developed and developing) representing different social/poli tical systems: and what is the evidence that such programmes influence the quality or nature of health care? Research problem 2 . 3 ; What m o d i f i ~ a t i o r ~i s n role are required, and what new skills may be needed in order to expand the present supervisory function from that of policing the work of lower level personnel to that of helping those personnel upgrade their performance and career opportunities?

H c s e a r c h p r u b len~2 .4: What a r e t h e y u a n t l t a t l v e and q u a l i t a t i v e requirerrrerlts f o r b a s i c arid c l i r l i c a l b l u n ~ c d l c a l r e s e a r c h w o r k e r s 111 c , r d e r t o n l a l n t a i n a n of f e c t i v e / e f f i c i e r ] t h e a l t h p r o f c s s i o r l s c d u c a t ~ u r l i h e a l t h s e r v i c e d e l i v e r y s y s t e m i n d e v e l o p i n g n a t i o n s , and what a r e tile o p t i m a l m e t h o d s t o a s s u r e a c h j u v c m e n t o f r e s e a r c h competerrce aorcrrig t r a i r ~ e c sa s w e l l a s o p p o r t u r i i t i e s f u r them t o u s e t h e c o m p e t o n c e tlltly f ~ a v t : ac:qulredY 'Sarget 3 : Develop t a s k and comnuf~ity-or1 e n t c d e d u c a t i u n a 1 progranunes f o r sr nl p r i m a r y h c a l t h c a r e d e l i v e r y , hca 1 t h workers. espec:ially t h o s e i n v o l r ~ ~ ~ 01 e d u c a t i o n a l i n s t i t u t i o n s . iri all i n c r e a s e d rrurr~be~. Research problem 3 . 1 : What i s t h e p r e s e n t s t a t u s o f community-oriented, p r o i ) l e m - b a s e d , l r l t e r p r o I e s s l o n a l e d u c a t i o n a l programmes; what f a c t o r s f a c i l i t a t e o r impede t h e d e v e l o p n ~ t ? r l ta n d i l r r p l e m e n t a t i o n of s u c h p r o granunes; and what 1s t h e o u t c o m e o f s u c h e d u c a t i o n i n t e r m s of t h e p r o f e s s i o n a l c a r e e r s f o l l o w e d by t h e g r a d u a t e s ? What s p e c i f i c e l e m e n t s o f c o m p e t e n c e must be Research problem 3 . 2 : e x h l t i l t e d by p r i r n a r y h e a l t h c a r e w o r k e r s ; how i s t h i s competorice c l r r r e n t l y berrrg a s s e s s e d ; what a d d i t i u r i a l i n s t r u m e n t s must be d a v e l o p e d t o c o m p l e t e t h e a s s e s s m e n t ; a n d u s i n g s u c h a b a t t e r y 111 s u i t a b l y v a r i e d s e t t i r r g s , t o what e x t e n t i s t h a t c o m p e t e n c e a c t n e v e d i n cc,nt,en t 1 oria 1 l y u r y a n ~ z e da c a d c : ~ l lc l p r o g r a n u n e s arid Lllrough e x p e r l e n t l a 1 l e a r n i n g e i t h e r i n f o r m a l progralnrrres o r t h r o u g h a p p r e n t i c e s h i p s y s t e m s ' ? R e s e a r c h p r o b l e n ~ 3 . 3 : What a r e t h e d i s t i r l c t i v e i e a t u r e s o f e f f e c t ~ v e a n d e f f i c i e n t i n s t i t u t i o n s f o r education o f h e a l t h p e r s o n n e l a n d h e a l t h c a r e d e l i v e r y , arid how rnay s u c h i n s t l t u t i o r l b u i l d i n g o r s t r e r l g t h e n i r l g b e s t be ac:cornplished'? Programme a r e a : Educa t l u r r a 1 d e r e l o p m e n t a n d s u p p o r t (including e d u c a t l o l l a l teac.hr n g , ' l e a r l i l n g nlethods a n d materials, t e a c h e r t r a l n l n g , a n d e v a l u d t l < ~ ~ l ) I n c r e a s e t h e rlunrber o f f u l l - t i m e t e a c h i n g s t a f f w i t h c o m p e t e n c e l'arge t 1 : i n t h e application u f a s y s t e m a t i c a p p r o a c h t o e d u c a t i o n a l p l a n n i n g , nicthodology, and e v a l u a t i o n . I i e s e a r c h p r o b l c m 1 . 1 : What L S t h e i m p a c t o f t e a c h e r t r a i n l n g prugranrnres t h a t h a v e bt?cn i n i t l a t c ? d d u r i n g t h e l a a t d e c a d e , e . g . I l e g l o n a l l e a c h e r ' l ' r a i r r l n g Centre: progranunes a r ~ d s h o r t - t e r m w o r k s h o p s i n r e g i o n s w h e r e n o K'lVSC h a s been e s t a l ) l i shod'? R e s e a r c h prob1c:rn 1.2: What p r i r i c i p l e s , > 1 raciucation ( l o n r n i r l g , t c a c : h ~ ~ l g , .. e v a l u a t i o n , a d n ~ i r ~ l s ttri a o n ) h a v e g e n e r a l a p p l i c a l ~ l l i t y ,w h i c h way be u s e d w i t h nt?c(tssar,v a d a p t a t i o n s d i c t a t e d by c u l t u r a l i a c t o r s , a n d what t e c h r i l q u e s [nay l)c r e c l u l r c t i bv t h e u n i q u e c h a r a c t e r i s t l c s of s p c c l f l c oul t u r p 1 g l - O L I ~ ~ ' ? R e s e a r c h prot)lcrll 1 . 3 : Wlra t a 1 t c r a t i u n s i n c u r r e r r t e v a l u a t i o n s y s t e m s o r modi f i c a t ion o f c:urrerr t e v a l u a t i o n p r a c t i c e s a r e r e q u ~ r e dt o i m p r o v e f e e d b a c k on pt'r t'ornrar~cc t o h r l a l t h p r o f e s s i o r l s ' s t u d e n t s , t e a c h e r s , p r a c t~ t i o n e r s a n d progranlnre adnrini s t r a t u r s ?

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Utiat a r e t h t p r e s c ~ i ta v a l ~a b 1 l l t y a n d u t l l i ~ tdl o n Hf,search problem 2 . 1 : o f p r i n t a n d n o n - p r i n t c d u c a t i o r \ d l materials I n s ~ h o u l s of hedlth p e r s o n n e l i n developing c c ~ u r ~ t l - i e s ;w h a t a r e t h e b a s i c r e c l u l r u n l t . n t s f o r s u c - h m a t e r i a l s a n d how c a n s u c h r c c l u l r e n l e n t s be i u l i i l l e d when they a r e nut c u r r e ~ ~ t l nret':' y flescarch problenl 2 . 2 : What 1s Lllc. p a t t e r n uf u t l~ l z a t l o l ~ ,a n d w h a t 1s t h e e v l d e n c e of l r n p a c t o f t h e m a t c r l a l s t h a t h a v e b e e n p u l ~ l l s h e da r ~ d H O (e.g. E d u c a t l oria 1 G u i d e , Wurkshop P l a r u i i r ~ g ( ; u l d e , d l s s e ~ n l n a t e dby W I % i r L h A t t e n d a n t t i u l d e , M c d l c a l A s s ~ s t a n tG u i d e , W l l ~ , ' ~ d u c s . ,c x t c . . ):' What mcc,hani stns m i g h t b e d e v e l o p e d t o a s s u r e i l l 1 c l e i ~ l Ly ~l r ~ g t h o n e e d s f o r , a r ~ dproviding f e e d b a c k c)n t h e e f f e c t i v e n e s s 0 1 , educ'a t l u r l a l programmes whlch p r o d u c e t h e p r o v i d e r s o f h e a l t h s e r v ~ I , i - s ? I i t . s e a r c h p r o b l a n l 2 .3: grea t n r invol v c l m r ? n t of tho r c r c l p ~ e n t so f h e a l t h a e r v 1 c c s

a,t l n ~ l r l l s t r a l o r s , a n d t e a c h e ~ . ~ L ,~ , at1 ' I ' a r g e t 3 : A s s u r e a c c t : s s of g ~ ) v e r . r i n l t : r ~ t s HMD i r ~ f u r m a t i u n s y s t e l r i I l l a t w l l l p r o v l t l e a p p r u p r i a t e d a t a t o a s s l s t thcnr 111 decislorl-making i n t h e 1 I e l d o f h e a l t h nlarlpower d e v e l o p r n e ~ l . t Whd L

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5.1 'Ihe b d s ~ cp r l r r c l p l e wh1c.h r~rwst guide t t r c d e t e r m l r r a t i o r l o f w h a t 1 1 1 v e s t l g d t f : d 1s t h a t a n c e d i o r t h e s t u d y h a s b e e n i d e n t l f l e d p r o b l e l ~ ~sst i ~ u l c !I J ~ t ~ yt l ~ ep e r s o n s who e x p e r ~ e t r c e t h e p r o t ~ l e m . I t l o l l o w s t h a t t h e development o f a r b tlhW I e e o a r c l ~prcJgraniluc, a n d f o r t h a t m a 1 i e ~ h c a l L11 s e r v l c e s r e s e a r c l i , m u s t b e ~ S t a t e s themselves. I ~ d s e d or1 p r u b l e m s ~ d e r ~ t l l ~ an edd articulated I J Member 5.2 Once p r u l , l e n ~ s h a v e Lee11 i d e r r t i f i c t i , ( a s a m p l e o f t h e s e h a s b e e n In i d e n t i f y i n g p r e s e n t e d a b o v e ) , i t w i l l LIG r i c c e s s a r y t o a 1 1oc:ate priorr t i e s . t h e r e s e a r c : h t h a t s h o u l d be p r o n l o t c d t h e f o l l u w i r ~ gc r i t e r i a , a s p r e s e n t e d i n t h e I ) ~ r e c t o r - G e n e r a l ' s r e p o r t o n ttit: d e v a l o p n ~ e r i t a n d c o o r d i r i a t i o n o f b i o m e d i c a l a n d h e a l t h s c ? r v i c e s rt:scarc:h t o t h e ' I ' h i r t i e t h World Ht!alth A s s e m b l y ( d o c u m e n t ~30,'s). apply:"1) t h e n ~ a g r ~ l t u do ef t h e p r o b l e m , e s p c c l a l l y i n t h e d e v e l o p i n g c o u n t r i e s ; t h e s u l t a b l l i t y o f t h e p r o b l e m f o r i r ~ t e r n a t i o r r a lcollaborative r e s e a r c h ; t h e p r l o r l t y o f t h e prub1e111a s perceived by t h e c o u n t r l e s t h e m s e l v e s ; t h e r e l e v a n c e of s u c c e s s f u l r e s e a r c h t o t h e socioeconomic development o f t h e countrj es; t h e p r o b a t ) r l i t y o i f i r ~ d i n gs o l u t i o n s a n d t h e f e a s i b i l i t y o f a p p l y i n g them 11atio1lall.y; t h e a v a l l a t ~ l l l t yo f m a n p o w e r , facilities a n d f u r l d s t o c a r r y o u t t h e research; t h e p a r t ~ c ~ p a t i oon f corlcerned; t h e s c l e n t l s t s and l n s t l t u t l o n s o f t h e c o u n t r l e s

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t h e l e v e l o f r l a t i o t r a l a n d ~ n t e r n a t i o n a lr e s e a r c h b e i n g c a r r i e d o u t o n t h e problem; t h e p o t e n t i a l u s e f u l n e s s o f t h e r e s u l t s uf t h e r e s e a r c h f o r t h e s o l u t l o r l o f o t h e r prot>lt:ms."

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5.4 'l'lle s e l r ? c t l v n o f r c s e a r ( : h p r o b l e r ~ ~ ss h o u l d f u r t l l c r t a h t l icccuunt uf ~ h c p o t e r ~ t l a l t t ~ c~ , e s ( c a l ' c h p r . u j c : c t h a s l o r inc:rt:aslrig t h e s e l f - r e l l d r ~ o e of c u u r l t r l e s tra~r~ct ru l s t : a r c h Illailpower, s l r l c e t h e imp1t:rnt:nta t i o r 1 o f ' a r e 5 e a r c . h p I . t > ~ e c tcar1 b c u s e d t o t r a i r ~r e s e a r c h w o r k e r s . 5.5 l{t:scarch whic:h prollluttts c o o p e r a t l o l 1 l ~ e t w e ec~ u~ u r l t r l c s , t i l e duvt:lupmerlt o i .I,.)I I I t s o l u t i ( J I I S t o C V I I U I I U I I p r o l ~ l e r n s , wuultl p r o v i tit- a d d l t ~ o n a lr a t l v r ~ l ae f u r t h e s e l e c : t i u r ~u l Chat prc)blcm r e l a t l v e t o o t h e r s . 5.6 M ~ s tl r r ~ p o r t a n t l y , I L i s a g a i n s t r e s s e d t h a t t h c o l ~ j e c t l v e so f t h e r ' e s t : a r c h rliust l ~ e d e r i v e d iroln i d e l l t i f l e d n e e d s , p a r t i c u l a r l y of d e v e l o p i n g cou~~trles w, l ~ i c hh a v e a h i g l ~d e g r e e uf s o c : ~ a l rolr:\~ancu f u r M o ~ ~ ~ t > cE r .t a t c s , a n d a r e h e n c e d i I-cc t e d t o w a r d s d e f i n e t l h e a l t h g o a l s , c o ~ i t rL i ute d i r e c t l y and s ~ g r ~ i f i c a ~ r to l y t h e i m p r o v e n r e r ~ t uf t h e h e a l t h s t a t u s o f t h e p o p u l a t i o n , a n d u s e a n~ethodulogyt h a t can l~e a p p l l e d riow a n d a t a c o s t w h i c h c u u n t r i e s c a n a i f o r d .

l o f u r t h e r t h e p l a r ~ n i n ga n d l n ~ p l e n l u r ~ t a t l o orf~ d \ Y I ~ ~ , ' I I M r De s e a r c h progratrrrlld e o v e r a l l c o r k t e x t o f t h e h e a l t h s e r v l c e r e s e a r c h progrdnune, t h e f u l l u w l r ~ g a c t l o n s a r e proposed: W L ~ ~ L t I h I

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t h e c o l l e c t i o n u f i n f u r n ~ a t l u nor1 o n g o i r ~ gWIO-sponsored a n d na t l u ~ l a l t1R.U) r e s e a r c h a c t i v i t i e s r e l a t e d t o t h e t a r g e t s a s s p e c i f i e d I n t h e medium tcr.rrl prugramnte a n d t h e p r e s e n t d o c u m e n t ; t h e p r e p a r a t l u n u f a f i n a l p r o p o s a l by a consultation t o be h e l d 1-3 F e t ~ r u a r y 1 9 7 8 ; t h e p r e s e n t a t i o n o f t h l s p r o p o s a l t u r e g l o n a l AChfRs a n d t h e ACMII; ttrc ranking 0 1 rcsc:arch p r o b l e r n s 111 a p r l v r l t y o r d e r , a s a c u l l a t ) t ) r d t l ~ ~ , c r i d c a v o u r h e t w e c r ~ na t l o n a 1 guvctrrllnerr t s a r ~ dWHO s t a f f ; developn\ent < ) f dc:tailcd r e s e a r c h p r u p o s a l s l o r s e l e c t e d problems; c u n s u l t a t l v r ~ui t h d u n o r a g e n c l o s t u s e c k c x t r a - b u d g e t a r y irnp1ernr:nta t l o r i o f r e s e a r c h p r u , j e c t s ; r e g u l a r r e v l s l o r i 01 r e s e a r c h p r o g r e s s , ~ i tcl v l t ~ c s and r e s u l t s a n d rnaklng ad.lustrnc.r~ts a s n e e d e d . suppor 1 ;

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p a g e 11 ANNEX I

TIIC l < a i~ U U J I I 1 ~ 5 d b1 i t ' 1 r ~ v l e w ( ~ fsornta r a s e a r c l ~ a c t l v l t i e s c a r r i e d o u t 111 r e c e n t yt-alSs. I t 1 s e ~ r ~ p h a s l ~t e hd a t o n l y uxalnples a r e p r e s e n t e d ; henc e r t 1s r ~ o t t o t l t v l c w c d a s dn a c c o u r r l o f t t l r g l o l j d l llMU r e s e a r c h e f i o r t .

111 p u r s u a r l c e 01 reso l u t I C ) L ~ WtLA21 . 5 Y , atrd w l t i 1 a v l e w t u b e t t e r adapting hed 1 t l ~ pr-rsonnc.1 t r n l n l n y prwgralnmcs t o l o ~ ld 1 o n d l ~ ~ C I I I S , t h e O r g a r ~ l z a t l o nh a s d e v e l o p e d a new a p p r o d c 11 w t i ~ c h l r l t e g r a tcs h e a 1 t h manpuwur d e v e l o p m e n t w l t h h e a l t h s o r v r c . r s d e \ v l o p m e n t (IISMI)). I n v e s t l g a t l c ~ ni n t h l s f l e l d h a s b e e n c a r r l e d o u t ~ l l o r c spct:ld 1 l y 1 1 1 I s r d e l , w h c r e t h e C t w t r e f u r I l e a l t h S c l e n c e s o i & e n - G u r l o n U r ~v l e r s i t y o t t h e N e g c v , a t I t c e r s h e v a , 1s a ~ t l t ~ as g " W t 1 0 Collaborating C e n t r e f u r I n t e g r a t e d S e r v I c e s a r ~ dIlual t h hlanpower L ) e v t ~ l v p ~ ~ ~ e r i t "Uy . means o f a ) lolrilny a l l h e a l t h c a r e s e r v i c e s 1 1 1 t h e r e g 1 0 1 1 111tc) orle i n t e g r a t e d s y s t e m , a n d b ) l n e r g l n g I ti1 s s y s t e m w l t h r n e d l c a l I d u ~ d 1011, l t h e C e n t r e l o r I i e a l t h b c l e r l c e s 1s a L t t : n ~ p L l r ~ g t o p r o d u c e a t y p e o i p h y s i c ~ a n 1 ~ 0 t h f a ~ n r l i a rw l t h t h e s y s t e m ' s n e e d s a n d m o t l v a t c d t o s e r v e t h e p e o p l e and connrunlty ( ~ r ~ s t e a od f i ~ e ~ n di gs e a s e - a n d hospital-oriented). A s t l y w a s r e c e n t l y 1 1 1 1 L ~ a t e d0 1 1 c a r e e r d e v e l o p n l e n t I n t h e h e a l t h p r o l e s s i u r ~ s , whic11 c n ~ b r a ~ e th s e various possibrlltles for career moblllty, lncludlng recurrent t d u c a t l u n and t r a l r i l n g . I h e Cell t e r t o r E d u t a t l o n a l I ) t ~ v e l o p m e t r~ , Uriiversi t y o i I l l l n o i s c o l l e g e o i hlcd~clnt , ( l l l c d g o , USA, w h l c h o p e r a t e d during f o u r y e a r s a l s o a s WHO I n t e r - r e g l u n a l I ~ o ticr c ? r d r~l l r l g C - n t l C , t ~ ~ ~ a ran s e u f 196'3 WHO C o l l a b o r a t l n g L e n t r e f o r P o s t g r a d u a t e I d u ~ . a ttu r l . I t 1s c a r r y l n g o u t s t u d l e s r e l a t e d m o r e especially t o t e a c h e r training. I tlc \ V l l o C o l l a b o r a t l n g C e n t r t . f o r P o s t g r a d u a L e E d u c a t i o n a t t h e C e n t r a l I n s t i t S t u d l c s , Mosc'ow, 1s c a r r y l n g o u t a c o m p a r a t i v e s t u d y o f c v ~ i t l n u l r i f ie d u c a t l u n f o r p h y s ~ c l a ~ l sa, s w e l l a s a s t u d y o n m o d e r n t e n d e n c i e s An t h t . d c v c l o p n r e r r t rif p o s t g r d t l u a t e ~ l t e d l c a l education I n t h e w o r l d . l o r Advarlcecl M e d i c a l I I ~ P

'I'hc 1)epartlnerlt o f hledi(:al E d u c a t l o n , I ' a h l a v i l l 1 1 1 v e r s i t . y M e d i c a l F a c u l t y , a s W l l O Hogi o ~ r a 1 'I'oacher ~ r a i r l i n C~ entre, I r a r ~ , u t ~ i c hi s o p e r a t ~ n y r e c e n t l y t ~ e c a ~ r la e l s o W 1 1 0 C ' o l l a b o r a 11rlg ( : t . n t r e l o r I k s e a r c h i n t o t h e t l e a l t h hlanpuwer Pr.ocess. 111 t h l s l a t t e r r a p a c i t y l t i s u n d c r t a k j n g a s t u d y w i t h a v l e w t o e v a l u a t i r ~ gthe, i m p a r t i . f f t t c : L i v e r ~ e s s o f t e a c h o r t r a i n l n g a c t i v i t i e s . The r e s u l ts "1' t h ~ s t u d y w l l l I)e u s e l ' u l t u t e a c h e r t r a l n i r ~ gc e r l t r e s i n t h e o t h e r WHO r e g l o n s . l r i Shl r a z ,

>....

'I'he " l ) l . a l n d r a i n " o r o u t f l o w o l t r a l n e c l I l e a l L h 1nanpL)wer iron1 sonl~, d e v e l o p l n g t o a f e w highly c o u n t r i e s - w h i c h r a n l e a s t a f f o r d t o l o s e s u c h manpower i r l d u s t r i a l i z e d devcl~.)pr rl rbr>es c.or1.c t i t u t e s a m a j o r p r o b l c m requiring i r l v e s t i l ; a t i u i r . I n r e s p o n s e t o A s s e m b l y r c s u l u t l o n s Wt1A24. 5 9 a n d WtlA25.42. W10 u n d e r t o o k a nrul t i r:ational s t u d y o f t h e i n t e r n a t i o n a l m i g r a t i o n o f phpsiciarls and n u r s e s . 'I'he o u t c o m e of t h i s s t u d y s h o u l d , i r ~ the f i r s t instarice, enable the Organizatiaa t ~ . . . a s s ; s t c o u n t r i ~ s , on t h e 1 r r e c l u t : s t , 111 s e l e c t i n g a n d a p p l y i n g s t r a t e g i e s f o r d e a l i n g w i t h t h e p r o b l e m s either c:ausirlg o r r e s u l t i n g f r o m u n d e s i r a b l e i ~ ~ t e r n a t i o n a l mlgra t i ~ ~ o fn h e a l t h nranpowcr; t t ~ cn e x t s t e p w o u l d b e t h e d e v e l o p ~ ~ ~ e on lt r c a l l s t ~ c h e a l t h uraripuwer p o l i c l c s a ~ r dp l a n s t o < : o p e w i t h t h i s p h e n o m e n o n .

p a g e 12 1 . 1 . 1

ANNEX I

A study wag begun l r r l e 6 H i n L j r l ) ~ $ I , Lgypt and Iluqgary, w h ~ c l ,r e ~ u l t t d111 a n a n a l y s i s o f t h a tabkh (11, e a c h melnbsr o f t h e r u r a l I w a l t h toam w i t h a v i e w t u i l llg t o t h e p o p p l a t l o n ' s ht:a 1 t h r o d e f i n i n g t h e i r r u l e s arbd t o a d a p t l n ~t h e r r t ~ l la n e e d s , a s well a $ t o t h e t l c a l t t ) S P P V ~ C o ~fS tllc c o u r ~ t r y .

eduratlon I n 1974 q d(tskgr\ was dcvulupt'd f u r t h e evaluation u i n u $ s l ~ ( g i t hag s i r ~ v eI)o@Q f l o l d - t e p f o d p r l u r t u p y 4 l r c ; a t l ~ n . programmt:s; W i t ) ) a - v i e w t o Jeveloprrly now toaolung ~nothr~drr 4 1 1 miLIwirery, a s t u d y was i n i t & a t o d on t h e usu s f r ~ d u l a ra p p ~ o a ~l h u r t h c development o f m ~ d w i f e r y curricula.

For s e v e r a l year* now W 1 1 0 h a s conduotcd a c t J v i t l s s 11, ~ ~ p l i t l re ds e a r c h a s a s u p p o r t t o programlllas Z P e r l u e a t i o p a l methodology and cuplr(~ur>lcat,ion. In l l n e w i t h t h e Orgar\lzatiol\'a p o l i c y , t h a ~ ~ e g c a r c ph a s boun e x t e n d a d t o ernbyace h e a l t h and r e l a t e d techr~ulugjieri fnc a p p l i c a t i o n i n prilnqry h e a l t h c a r e . The f o l l v w i n g a r e example$ t a k e n fro^ q l a y q 3 nunrber o$ a o t j v q t 4 e 8 c a r ~ l e du u t i n t h i s field: one ilt lg c o u n t r y Lsyel t h e a ~ e t l ~ o d os f conveying e d u c a t i o n a l s u c h prugrilruno i s ~ x p l o ~ i ~ m e s s a g e s t u i l l i t e r a t e v l l l a y e h e q l t p woyl$prs, 411 the #bgt?nct: o f f o r m a l t e a c h e r s ; i n a s g o c i s t ~ o nwath t h e L u n d ~ nlichoul uf P r i n t i n g , WIU i s soek+ng new m t h u d s o f d e v e 1 o ~ ) a n pl a t e n t T s p r a J u c t +on w i t h l o n g a h e l f - 1 1 $ a , t u 8 l l o w t e e srmplt: and I n e x p e n s r y e d u p l i c a t i o t ) of s ~ m l r l a t s r lproblerng i n d # v ~ l ~ p u io ~u g p t r y situations ( t h o WlIO CuLlatcurqt~1~)6. C~IILFU f o r l r ) P I i v i ( I ~ a II,uaqn$ng M q t e r x a l s i n Medical E d u ~ a t l u r r . Londuu, 1s a s g i s t l n q by nor~atnrltlg: t h ~ p s r u , l e c ; t ) ; y p t firjother a c t i v a t y 1s t h e of devel~~tnen t computer a p p l i c a t i ~ n soi chasts dtrectly a p p r o p r i a t e t o l o c a l e p i d e m ~ o l o g i c a ls i t u a f a a n s , f o r use by a l l l e v e l s o f a u x i l i a ~ y h e a l t h w o r k e r s .

'I'he WHO C o l l a b o r a t r n g C e n t r e f o r t h e Evalua L+on o f Haal t b P e r s o n n e l P e r f o r m a n c e , yf t h e Medicgl F a c u l t y , a t t h e I t l s t l t u t fur A u s b l l d u n y s - wnd E x s m e n s f a ~ s c h u r ~p Unvversity ~ l f Uurne, 1s c a r r y l r l g o u t s t u d i e s un s t u d g n t p e r f o r m a n c e t e s t s .

'rbu Uni t of Ued+ca$ Educa t j on, Chulalungkorfr U n l v e r s &t y , Uangkok, and t h e Departulerrt of C o m u n l t y MuJlctne, Pahlavk U l n l u s r s l t y School o f Medicine, S h l r a ~ , ts o r a s s a s s i n g the oumpetence of p r l m a r y a r e engaged i n dav#lup&qlg i ~ ? s t r u t n e ~ ] f h e a l t h c a r e wppkeys, G u a d c l l n e a f o r progrldmnle e v g l u a t 4 o n h a v e been prspi3m3d and f i e l d - t e s t e d .

page 1 3 ANNEX I 1

1I.I.LIS'I'IW'L'l VE IllllD I ~ E S ~ I ~ C I I 'The, 1 ' ~ ) l l o w i l r arc: ~: propusals. SlJlllC!

e x a m p l e s u f more d c t a l l e d o u t l i n e s o f r e s e a r c h

J I What a l t c ~ ~ n d t l v e ps r t 7 s e l l t l . y e x l s t 111 t h e p r e p a r a t l o r ~ , c o s t arld u t l l I L a t l u l l u f s e v e r a l c a t c g o r i c s C J ~h c a l t h w o k ~c r s 1 1 1 d c a l i n v w i t h m a j o r hedl t t ~ pruble~t~s'.'

Study: U c s c ~ r s p t l u ro ~i l e v e l s i u r ~ c t l u r l s t u b e c a r r l c d o u t 111 o r d e r t o tile Ilea1 ( 1 1 lleecls alld rlcnlatlcls 0 1 a we1 1 - c l e r i n e d g r o u p 01 p ~ ) p u l a t i o n ; d c t e r l n i n a t i o n of t h e l e v e l o i c:on~p~.tet~c r~ c? ccdud t u f u l f i l t h e s e f u r ~ c t i o n s ; ~dentificatiu o~ f ~ c o s t s t o achieve t h i s c r > l n p c t e n c c arid t o p e r f o r m t h e s e t a s k s ; d t - l i r ~ e a t l o no f l ' o r c e s t h a t i r ~ lfu e n c e t h e d e t e r n ~ i n a t l o no f w h i c h w o r k e r s a r e u s e d a n d u n d e r wllat c : i r c u m s t a ~ l c e st o c a r r y ~ ~ tu h ots e f u n c t i o n s ; d e f i n i t i o n o f a l t e r n a t i v t t s of. tcanl (mix) o f h e a l t h p e r . s o n n e 1 w i t h a t t a c h e d c o s t / l e f f i c i e n c y arid c o s t / / u f l e c t ~ v e n c s s . IIICG

A p p r c ~ a c t i : 'l'he s e q u e l ~ t l a l s t e p s this p a t t e r r ~ :

i l l

c a r r y i n g uut such a s t u d y might f o l l o w

i e r ~ t l l yd e t a i l e d t a s k s t o bt. perfurmt,d

t o ~neeth e a l t h n e e d s .

U c t e r l n l n e ~nir~lrnum co~rlpetarlcer e q u j r c d t o c a r r y o u t t h e s e t a s k s w i t h v a r i a l ~ l e"autonunly". l l e v e l o p a m a t r i x oi c o m p e t e n c i e s a n d f u n c t i o n s w h l c l ~n ~ i g h t t a k e t h e f u l l o w i n g f o r m

( ' o m p l e t e s u c h a nlat r l x I r . , > l i ~ a n a l y ~ s i of' p r c , s e n t e d u c a t i c > n and presorlt f u r ~ c t i o n , i n d i c a t i r ~ g tttr. 1evt:l u f c l u a 1 i t i c : a t i c m (e.g. o n e f u l l y q u a l i f i e d , two p a r t i a l l y q u a l i f i e d , t h r e e n o t c l u a l ~ i l c d ) f o r e a c h c a t e g o r y of h e a l t h w o r k e r i n d e a l i n g w I t h c?ac:h o f 20 Illa.lc,r h c a l t h p r o b l e m s (e.g. n u t r i t i o n , a c c i d e n t s a r ~ di n . j u r i e s , p r t ? g n a n c y arid riel i v e r y , d i a r r h o e a 1 d i s e a s e , c c J r l t a g i o u s d l s e a s e , d c l l t a l c a r i e s , p t ? r l otlollta 1 d i s e a s e , m a l i g n a n t d l s e a s e , cardiovascular disease, e t c )

ANNEX 1 I

L)t?ternrinc? l e v e l ( i t corlrpeterrce a t wlric:h s ~ ~ tc as l k~ s a r e carried out 'I'his w i l l p r o b a b l y r e q u r r e by t h o s e who a r c ,ludgc:d t o b e c l u a l i l ' i e c i . t.htt d ~ ~ v e l o p r n c r 01' ~ t rlcw a s s u s s l n e r l t p l c t h u d s , b u t w i l l a t l e a s t demand e x p l i c i t statelnt:riI t h e ( : r l t c r i a uporr w h i c h j u d g c m e n t s a r e t o L J ~ 1 ~ a s t . d . a n d a n o u t l illu 01' t h o lllcaris by w h i c h p c r i o r l n a r ~ c e d a t a ( 1 1 1 r e a l o r s i m u l a t e d s i l u a t i o r ~ s )w i 11 be g a t h e r e d . Deter~nirret h e c ~ . ~ s o tf I r a r r i i n g a ~ r dr ~ t i n ~ l ) u r s i r d~ if pf e r e n t l e v e l s o f h e a l t h w o r k e r s who a r t ! q u a l i f i c d a n d c:o~npt-'tcnt t o p e r f o r m c o m p a r a b l e f u n c t i o ~ i s( t ? . g . r r u r s e n ~ i d wf i e and p t ~ y s i i c a ~ if o r n o r m a l d e l i v e r y , v i l l a g e h e a l t h w o r k e r arid s a n i t a r y e ~ ~ y i r ~ e l'ur e r p r u v e n t l o n of diarrhoea1 di seases). I d e ~ i t l f y f o r c e s w h i c h impede a n d f a c r l l t a t e a c c e p t a n c e o f t h o s e with l e s s p r e s t i g i o u s c r e d e n t . i a l s who a r e I i t ) l l e t h e l c s s q u a l i f i e d t o p e r f o r m s p e c i f i c t a s k s a t a n a c c e p t a b l e l e v e l of competence ( e . g . d e n t a l a s s i s t a n t ra l h e r than d e n t i s t i n c a r i e s preverrtion, a u x i l i a r y r a t h e r than p r o f e s s i o n a l riurse i n sylnptoriatic c a r e o f c o n t a g i o u s d i s e a s e ) . l d e n t i f y f o r c e s w h l c h impede a n d f a c i l i t a t e p r e v e l l t l v e , d i a g n o s t i c , t h e r a p e u t i c and r e h a b i l i t a t i v e t a s k s i n a r e g i o n o r n a t i o n .

Suggested r e s p o n s i b i l i t y : S i r ~ c et h e most i n r p o r t a n t issues may show some. v a r i a t r o l i from p l a c e t u p l a c e , and s i n c e t h e p u r p o s e o f t h e r e s e a r c h i s t o p r o v i d e r e l e v a n t d a t a where a c t i o n i s t o o c c u r , l o c a l and n a t i o n a l a u t h o r i t i e s Iiut s i n c e c o m p a r a t i v e d a t a may lnust p l a y a p r o n ~ i n e n t r o l e i l l a n y s u c h s t u d y . i l l u m i n a t e t h e q u e s t i o n s t o be d e a l t w i t h a t i r r d i v i d u a l s i t e s , a n d i n t h e f a c e of l l m l t c d p r o f e s s i o n a l r e s o u r c e s Tor d a v a l c , p m e n t a l tasks, a n d the i n e s c a p a b l e economy o f s c a l e i n s u c h r e s e a r c h , i t i s a l s o i m p o r t a ~ r t t o a s s u r e r e g i o n a l a n d i n t e r r e g i o n a l c o o p e r a t i o n and c o l l a b o r a t i o n . I t 1s w i t h t h e s e two g o a l s i n mind t h a t the s p e c i f i c suggestions w h l c h f o l l o w a r e made. Local 1,

Na t l u n a l

Regional

Interregional

Iderltllication of h o a l t t ~ marlpower c a t e g o r i e s errti ma.lor h e a l t h p r o b l e m s Ar~a 1y s ~ s of preserrt educa tiurr a n d furrc t i o n Competence l e v e l Dcvelopmer~ t o f ~ n trumcn s ts Asseml)ly u f d a t a Analysls of data T r a i n i n g costs

2. 3.

Reimbursement c o s t s

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page 15 ANNEX I 1

Pru1,lt~ln: What 1s Lhtt p r e s w t s t a t u s v f ~ : c ) I I ~ I L I ~ L ~ ~ - o r prob1ee1-based, iented, ir~tcrproi'cssio~la el d u c a t i o n progralnnles; wha L f a r . t u r . s f a c i l i t a t e o r ~ m p e d et h e d e v e l o p m e ~ r l a l ~ d~ m p l o n ~ c ~ i t a t i o f r l s u c h progralllllles; what i s t h e o u t c o m e u f sue11 the p r o f a s s i o ~ ~ a c la r e e r s f u l l o w e d b y t h e g r a d u a t e s . e d u c a t i 0 1 1 111 terlns G I ~

Stucly: l d c r ~ t i f i c a t i o r lof a g r o u p o f l r ~ s t i t u t i o n sw h i c h e s p o u s e s u c h o b j t ~ c t l r , t : s ; d e t c r n ~ i r l a t i o n o f t h o c ? x l . t ? n I t o w h i c h programme i m p l e m e n t a t i u ~ r nla t r : h e s i r l t e r i t ; i d e n t i f i c a tior1 ol' o r g a l l i z a t i o n a l a n d c u l t u r a l a n d p e r s o l i n e l a n d f l s c a l f o r c e s t h a t h a v e f a c i 1 i t a t t : d o r impeded p r o g r e s s t o w a r d s u c h o b j e c t i v e s ; d e t e r ~ n l t~ io ~n a o f which m a t t ? r i a l s a ~ l dm e t h o d s of instruction m i g h t be s h a r e d among L I I ~ L I L U L ~ Ow ~ lS x t l l l l c s e colrurlun g o a l s ; a n d s y s t e m a t i c e x a m i n a t i o n o f t h e o u t c o m e o P s u c h progranmles. Appruach: 1. 1)otermlrle t h e c r i t e r l a w l ~ l c hw l l l a l l o w l d e r i t l f l c a t l o n o f i n s t l t u t l u r ~ s connnltted t o t h e g e n e r a l ~ ) I J j t . c t l v e s noted. b t ~ l e c ta suitably v a r l e d s a n ~ p l e( l n t e r m s o f s u c h t h i n g s a s geographic locat~~)n s ,l ~ e , w h e t h e r 11ew o r o l d , w h e t h e r u r b a n o r r u r a l , w h e t h e r i n developetl o r tlcveloplng Lountry, e t ~ . ) o f institutions f o r d e t a i l e d ,t u d y . ('onverre a meet ~ r r go f r u p 1 , e s c n t a t i v e s from t h e i n s t i t u t i o n s s e l e c t e c i t o r u v i e w t h c s t u d y p u r p o s e arid t o p a r t i c i p a t e i n developing a p r o t o c o l t h a t must i n c . l u d c t h e o t ~ s e r v a t i o n st o be made i n t h e c o u r s e o f i n s t i t u t i o r i a l s i t e v i s i t s t ~ yn e u t r a l o b s e r v e r s ( e . g . r e l a t i o n s h i p s b e t w e e n 11-a 1 t t l s G r v l c t t a u t h u l t i e s a r ~ de d u c a t i o n a l programme l e a d e r s , ~ r ~ t e r p r o f ' e s s ~ ( > in na plu t I n t o prugralnme p l a n n i n g a n d i m p l e m e n t a t i o n , lia I u r c o f cooununi t y r e s o u r c e s u s e d 1 1 1 t h e e d u c a t i o n a l programme a r ~ d intensity of t h a t u s e , b a c k ~ r o u n d o f f a c u l t y and n a t u r e of t h e i r p r o f e s s i o l ~ a l w o r k , u r g a l ~ l z a t i o n a lprinciples a r o u n d w h i c h t h e c u r r l c u l u r n i s b u l l t , e x t e n t o f i n s t i t u t ~ o r r a li n v o l v e m e n t i n p r i m a r y h e a l t h c a r e prograriunus, n a t u r e o f c d u c a t i o r l f o r teamwork a n d t e a m m o d e l s t o w h i c h s t u d e n t s a r c exposed, e x t e n t of r e s e a r c h i n t o h e a l t h s e r v i c e s and u s e of s u c h d a t a i n u r g a r l l z l l l g e d u c a t i o n a l programmes, n a t u r e o f s t u d e n t evalua tlon, e t c . ). S l tc V I S A t s o f o n e week t ~ yo~lc?o f a c o n s t a n t p a i r o f i n v e s t i g a t o r s ( t o assurt? a hlyh l c v e l o i ~ n t c r - u b s c r v e r r e l l a b l l l t y ) , and one representative o t a n o t h e r l ~ ~ s t l t u t l o In t h e s t u d y sample ( t o f o s t e r t n 1 c 1 1t arld c r e d l L ) A 11 t y ) 1 ~ 0 t hc~)mnll

P r e p a r c . a p r e l l n l l l l a r v s t u d y I t ' p u r t uf t h e i l n d l n g s , w i t h p a r t i c u l a r J d e r l t r f l c a t l v r ~o f u<,nunon ~ m p s d ~ ~ a a ra ln ld s Supporting a t t t n t ; o r l g l v c ~ r )t , ~ i e a t u r e s a s w e l l a s ~ ~ ~ s t rt c lo l rc l a l d e v i c e s t h a t c o u l d be s h a r e d among inst1tutlons co~nm t t~ e d t o t h l s educa L l o ~ ~ a programme l orlentation.

PGa-

ANNEX 1 1

Convene a 111cct1rlg(of p a r t j c ~ p a t i l l gi r i s t i t u t i o n s a ~ a ~n dt ? q u a l number w h i c h had n u t bt!er~ i n c l u d e d i n t h e s t u d y t o r e v l e w t h e f i n d l l r g s and t o e x t r a c t f r o r ~tllcrlr ~ general p r i n c i p l e s a s w e l l a s s p e c i f i c suggestlolls t h a t m i g h t p r o v i d e t r s u f u l guidelines f o r ut11er school^ whic:h 1111ghtwant t o d e v e l o p s u c h I,r.~Igranmles. Identify a c<,lrc>l.t c , f s t u d ~ r l t si n f-nr,h r , f

suvcral participatlr~g

i r r s t i t u t i o r i s a ~ i dPoLluw t h e i r p r c ) f e s s i o n a l d e v e l o p m e n t i n o r d e r t o d e t e r m i n e t h e e x t e n t t o w h i c h t h e e d u c a t i o r ~ a lprogrdnlme h a s i r i f l u e n c e d c a r e c r c h o i c e and t h e n a t u r e o f t h e i r p r o f e s s i u n a l work. i t y: Stlgges Led r e s p o r l s i 1~11 Regional staff Interreg'ional s t a f f and c o n s u l t a n t s

P r o b l e n ~ : What s k i l l s a n d a t t i t u d e s a r e r e q u i r e d f o r e f f e c t i v e h e a l t h c a r e t e a m w o r k ; how m i g h t t h e y b e d e v e l o p e d i n p o t e r l t i a l team members t h r o u g h p l a n n e d e d u c a t i o n a l programmes? Study: E l u c i d a t i o r i o f t h e d y n a ~ n i c : of ~ e f f c c . t l v e teamwork; ~dentiilcatlon o f particularly r e l e v a n t c o m p u n e n t s i o r p r l r n a r y h t a l t h c a r e t e a m s , a s w e l l a s t h e s u p p o r t i n g s t r u c t u r c r e q u l r e d t o a s s u r e l n d l v l d u a l couunl t m e n t t o teamwork, arid t h e a l t e r r r a t i v e s a v a i 1 a l ) l e i u r a ( h i e v i ~ i g t h t , s e i u n c t l o n a l u b . l e c t i v e s t h r o u g h e d u c a t 1011. Approach:

S y s t e m a t i c r e v l c w arrd sunlrllary u f r e l e v a r r t l i t e r a t u r e . Observational a r l a l y s l s o f r e p r e s e l r t a t i v e h e a l t h c a r e teams t o d e t e r m l n c t h e c x t e l i t t o wlilch t h e key p r l r l c ~ p l o so f e i f e c t i v c teamwork a r e p r e s e r i t 1 y ~ r l c o r p o r a t e d 1 1 1 what t h e y d o .

Where d i s c : r e p a r i c l e s bet W ~ ~ princ.1 I I p l e a r ~ dp r a c t i c e a r e i d c ~I ~ f lte d d e t e r m i n e w h y s u c h a g a p r ? x i s t s (e.g. i g ~ ~ o r a r i coef t h e principles, l a c k of' s k i l l i n t h e a p p l i c a l i o n o f p r i n c : i p l c s w e l l known t u p a r t i c i p a n t s , administ r a t i v e u l ~ s t a c ~ l c ~ c:ul s, tura 1 ~n~pediments, a b s e r ~ c eo f r e w a r d s f o r e f i e c t i v e team f u n c t i o n , e t c . ) .

page 17 ANNEX

F o r m u l a t i o n o f g u l d c ? l ~ r r t : s t o k e p cc,ir t e l r t alld p r o c e s s i t e a i s u s e f u l f o r a ) i i l i t i a l t r a i n i n g o f h c a l t h workers i c i t h e s k i l l s of e f i s c t l v e t e a n ~ w o r k , a n d b ) c o r r e c : t i u l l o f tht: k i n d s of f i r r l c t i u n a l p r o b l e n ~ s i d e l i t 1 l ' i e d i n t h e s l u d i r - s ol' s e l e c t e d t e a m s .

S u g g t . Lad ~ r'esporrs L 1 ~ 1 1I t y : Local Ilagi o n a l Interregional (experts)

What a r e t h c p r e s e n t d v a i l a l r l l l t y arid u t l l l z a t l o n of p r l n t a n d Prt,l,lenr: rluri-prlrit e d u c a t i o n a l r n a t c r l a l s i n s c h o o l s o f h c a l t h p e r s o n n e l a n d e d u ~ a t i o n a l p r u g r a n n n c s ~ n developing c o u ~ r t r l e s ; w h a t a r e t h e 1 1 a s l c r e q u i r e m e i l t s f o r s u c h ma t u r I a l s ?ird how car1 s u c h r e q u i r e m c r i t s be f u l l u l l e d wlrerr t h e y a r e n o t c u r r e n t l y llle t .

categories o l h e a l t h w o r k e r s i n a c o u n t r y .

I d e n t l f y t h e n u m l ~ c rant1 s l ~ e o1 111stl tutrvris f o r t r a i n l n g dlffererlt t h e n u m t ~ c r n f students ~ r re d c h c a t e g o r y , a n d f u t u r e p r u , l e c t l u n s o l s t u d e n t n u m b e r s .

t o r a represents t i v e salrlplo uf' t l l o s e ~ n s I i tutiuris, analyze i n d c t a l l t.Ilr; p r u K l a r ~ u ~ ~ ~v I I Uc o u r s e U U , I O ( : L I V C S d, uratiorr and t s p e o f i n s t r u c t i o n ( I r i c l u d i rrg t h e l a l l g u a g e u s e d ) , a n d t i l e n a t u r e o f e v a l u a t i o n p r o c e d u r e s t!nlployed. I ) t . t e r n ~ ~ n teh e e r i t r a l ~ c cq u a 1 J l t e r m s of l a r l g u a g u s k l l l s ) . ~ t l u~ rls a of s t u d e n t s ( p a r t i c u l a r l y i n

Docurrrer~t t11t: r ~ a t . u r earitl a v a l l a b i l i t y 0 1 l e a r n i n g m a t e r i a l s recommended a~>d,'or p r o v i cled for s t u d e n t s , d e t e r r n l r r i l r g w h e t h e r t h e s e m u s t b e p e r s o i ~ a l l ) a c c l u i r e d u r arc! rnerel). a v a i l a b l e i r r t h e l i b r a r y , n ~ ~ t i r l g t h e p r o s e l l t c:us t o f S U C ~r r ~ a t e r l a l s t o l r ~ s tt iu t i o n s o r i n d i v i d u a l l e a r r ~ e r s I d u ~ i t l l y t h c c l e g ~ c eo f m a t c h I~cltwl educational o t ) . ] e c t l v e s a n d l e a r r l l r r g n l a t u r l a l s , a s w c - 1 1 4 s t h d t Lwtweerr t h e l a n g u a g e s k l l l s o t s t u d e n t s a n d t h ~ s er t ? q u l r e d t o u s e s u c h m a t e r i a l s e f f e c t i v e l y . Ut3tt:rmlne t h e m a t c h I ) t . t u e c : ~c ~o s t o f w h a t 1s r e q u l r e d a n d i n d i v ~ d u a l s. o r i n s t i t u t i ( m a 1 r e s o u r c e s a v a l 1 n I ) l c t u Iucet L h ~ s t :~ o L s

page 1 8 ANNEX I I

Where d i s c r e p a ~ ~ c l c asr e i d e l l t i f i r d i n ( 5 ) a n d ( 6 ) , d e t e r n u n e what is reqlllred ( c r e a t i o n , t r a n s l a t i o ~ ~ ilrrprovud , production o r d i s t r i h i r t l o n ) t u c o r r e c t thc, g a p , a n d w h a t c o s t s w o i ~ l d be i n v o l v e d i n doing so.

S u g g e s t e d r o s p u n s i b i 1.1 t y : I,Ocal g r o u p 1. 2.

National group 2;

Consultants

X X

3. 4.

X X X

X X X X

5. 6. 7.

X X

Problem: What i s t h e i m p a c t o f t e a c h e r t r a i n i n g programmes t h a t h a v e been i n i t i a t e d d u r i n g t h e l a s t ducade? Study. T h e e v a l u a t ~ c l no f Ilr.gl t811al T e a r - h e r T r a i n l n g C e n t r e s , the l o c a l a n d r e g l o n a l expectations o f what t h e y were t o d o ; the resources required t h o work t h e y h a v e d o n e ; a n d a n d p r o v i d e d t o a l l o w then1 t o du t h e s e t h i n g s ; t h e i r perceived o r d o c u m e n t e d Ampact upon t h e c o n s t i t u e n c y t h e y were t o s e r v e .

Approach : 1 Review the circumstances w h i c h led t u o s t a b l l s h m o ~ l tof t h c w o r l d w i d e programme a n d i t s o b j e c t i v e s ; a s w e l l a s t h e f o r c e s w h l c h l e d t o t h e c r e a t i o n of e a c h r e g i o n a l c e n t r e .

Analyze t h e i n s t i t u t i o n a l , n a t i o n a l and r e g i o n a l s u p p o r t systems ( p h y s i c a l , p h i l o s o p h i c a l , o r g a n i z a t i o n a l and f i s c a l ) f o r e a c h c e n t r e , t h e i n l p e d i m e n t s e n c o u n t e r e d i n a t t e m p t i ~ i gt o i n ~ p l e m e n t t h e progranune were d e a l t with. a n d t h e ways i n w h i c h t h o s e i m p c d i m e ~ ~ t s Document t h e l o c a l , n a t l o n a l a n d r e g l o r l a 1 e d u c a t l o n a l r e s e a r c h a n d d e v e l o p m e n t , a $ w e l l a s t e a c h e r t r a l r i l n g , a c t l v ~ t i e s ,w h l c h h a v e been c a r r i e d o u t by t h e c e n t r e . I d e n t i f y i n d l v i d u a l b o r l n s t l l u t l u n s (0.g. h e a l L h p e r s o r i n e l e d u c a t l o n a l h e a l t h s e r v i c e d v l l v ~ r y ,M l ~ ~ i s c i l eo s r IlealLIl anU E Q u C a t l o r i , p r o l e s s l u f l a l o r g a n l z a t l o n s , e t c . ) upon w h i c h t h e s e a [ t l v l t l u s a r e b e l l e v o d t o h a v e had some u f f e c t

page 19

ANNEX I I

l'lirouyh s a l n p l l ~ l gS I t e v ~ s ts i tu ~ r ~ s tu t ti i o r ~ sand i n t e r v i e w s i n d j v i d u a l s c a r r y out P I ) indcper>dt-rrt a s s e s s m e n t oi t h e n a t u ~ . eoi t h J s i rupa i: 1 .. Sunrlnarl zo t h e l l l l d i r ~ g s , n o t i r ~ gs l n u l a r i t i e s a n d d i f f e r e n c e s alllung Lhe ceritr'r:s, cuaunon impcdlnlellts u r s u p p o r L l u g l o r c e s , a s s e s s l l l g ~ n r p a c t , a n d s y n t h e s i z e tc s o t o f g u j d u l i n u s w h i c h m i g h t be u s e f u l t u o t h e r i n s t i t i i t i o r i s o r o r g a n i z a t i o n s which u r ~ d e r t a k et h e e s t a b l i s h ment o f tcachc-I, t r a i n i n g pn) gr'anmles.

Reg i ona 1

Interregional

X X

RESEARCH ON EXPANDED PROCRAbPlE OF" IMMUNIZATION (EPI) Com~arativec o s t i n n of methods of administerinq t r i p l e vaccine Suggested a r e a : Afghanistan, S y r i a o r Pakistan ( o r o t h e r country when EPI has begun on a s i g n i f i c a n t s c a l e )

Problem Because of the danger of v i r a l h e p a t i t i s , w e a r e confronted a t p r e s e n t with a choice between only t h r e e methods of i n j e c t i o n viz.:

A s t e r i l e syringe ( g l a s s o r p l a s t i c re-usable) usual kind f o r each i n j e c t i o n . A disposable syringe and needle.

, and

s t e r i l e needle of t h e

A J e t i n j e c t o r , of which two models a r e a v a i l a b l e a w e l l - t r i e d " P e d - 0 - ~ e t " (I1S) c o s t i n g US $ 1 m 0 with s p a r e s , and a prototype French machine P i s t o l e t , s i m i l a r , but simpler and c o s t i n g somwhere i n t h e region of $ 700 t o $ 9 0 , with spares.

ObJectiv2.: of t h e research To d i s c o v e r which of t h r e e methods over a one-year period, c o s t s l e a s t and is most p r a c t i c a b l e , a t 50 inJe;tions a day I1 I1 " 100 I1 I1 It I' 200 J u s t i f i c a t i o n and expected b e n e f i t of t h e research Obviously the ~ u e s t i o nis c r l ~ c i a li n money terms and i n terms of e f f i c i e n c y a t a period when w e a r e e n t e r i n g a f i f t e e n - y e a r WHO e f f o r t t o immunize up t o In o u r Region alone 80 per cent of the c h i l d r e n a f thr developing world. between m i l l i o n ( o p t i m a l l y ) and 10 m i l l i o n ( a t l e a s t one hopes) t r i p l e vaccine A very l a r g e sum of money and an immense inJ ~ c t i o n s a r e involved each year. The r e s u l t s a s between amount o f man-hol~rs a r e involved i n t h i s question. T J e t i n j e c t o r s and s y r i n g e s may a l s o be a p p l i c a b l e t o o t h e r vaccines, e.g. I i n school immunization programmes; and between disposable and re-usable s y r i n g e s may a l s o be a p p l i c a b l e t o t e t a n u s toxoid and measles vaccines.

Method Within a l a r g e expanded programme of irmunization once f u n c t i o n i n g properly (say Afghanistan o r Pakistan o r S y r i a i n 1978 o r 1979) a meticulous record is This means of t o be made of all t h e c o s t s involved i n each of t h e methods. course t h a t the c o s t of s t e r i l i z i n g p l a s t i c re-usable o r g l a s s s y r i n g e s and needles In terms o f marl-hours and f u e l , as w e l l as a capital invcstmcnt i n s t e r i l i z e r and c o s t s of replacement of blunted needles and broken ( g l a s s ) o r i l l - f i t t i n g ( p l a s t i c re-usable) s y r i n g e s a r e t o be taken i n t o account. I n r e s p e c t of disposable s y r i n g e s , time s p e n t i n counting a t d a i l y i s s u e and d a i l y r e t u r n and t a l l y i n g number used w l t h vacclne usage and =corded numbers of immunizations, must be taken i n t o account a s well a s t h e c o s t s of t r a n s p o r t of what is a l i g h t but bulky a r t i c l e t o t h e country and w i t h i n the country. For J e t i n J e c t o r s , t h e t r u e usage of spare p a r t s and t h e i r replacement must be accounted f o r .

page 2

I n a d d i t i o n , o t h e r Inconveniences and p r a c t i c a l problems must a l l be caref u l l y t a k e n i n t o t h e f i n a l balance; e .g. breaking O X immunization s e s s i o n s f o r r e s t e r i l i z a t i o n o r because of r a i l u r e of j e t i n j e c t o r ; whether t h i s i a t t e r happens o f t e n enough t o n e c e s s i t a t e c a r r y i n g a s p a r e j e t i n j e c t o r t o avoid t h i s , thus increasing the costs. Duration Two y e a r s (6 months plan and o r d e r , L y e a r implermnt, 6 months analyse and report)

Supplies :

3 P r e s s i ~ r es t e r i l i z e r s , 800 conventional 2 m l s y r i n g e s ( g l a s s o r nylon) !lo0 x 12 needles 100 000 d i s p o s a b l e s y r i n g e s and needles

$ i 000

4 000

3 " ~ e d - O - J e t s "w i t h spare$ 2 " ~ i s t o l e t s "with s p a r e s

C l e r i c a l a s s i s t a n c e f o r t i r n e o f ponsumption and a c t i v i t y data

1 full-time c l e r k f o r

L year inaluding d a b a n a l y s i s

Research a s s i s t a n t

, 1 year

6 000

Additional t r a n s p o r t c o s t s f o r above and EPI Adviser o r Manager, 1 y e a r Incentives f o r immunization workers f a r extra recording t a s k s

3 000 3 000

(WHO Adviser w i l i provide h$s s e r v i c g s without e x t r a c o s t f o r planning and s u p e r v i s i o n and f u e l w r i t e -up) Total : Supply and t r a n s p q r t c o a t s may c w e from t h e EPI T h i s is maximal. p r o j e c t i t s e l f , and a n a t i o n a l o r p r o v i n c i a l Operation O f f i c e r may do t h e work of r e s e a r c h a s s i s t a n t a t l i t t l e e x t r a c o s t . )

WORLD HEAL1H ORGANIZATION

R E S O L U T I O N

EM/RC~~A/R, 10 13 October 1976 ORIGITL'LL: ENGLISH

, ' ; ; ; i n 3 3 itcn 10(bl

The % 4 ! 0 i d t t c c , H a v i r ~ ;studied with i n t e r e s t t h e technic71 pq-por on Viral I ~ c p - t i t i s prcsdntcd by t h e Regional DirccZsr 1 ; ConsiLerin< t h a t t h c ;iublic h c ? l t h i n p ~ r t a c o3f t h i s d i s c a s e i n increasiw md bccollin~ r. s e r i o u s conccrn t o r.mny of t h c l~.cr~lt!i ~uth~ritie bf s the I l o ~ i o n ;

f t h e 17egi3n a r c g i v i ~ l ~ ; Notil~ with s?.tisf2 c t i . m t k t s:.;:lc c n n t r i c s u p r i o r i t y t o t h c s t u z i c s ,.)n v i m 1 hcp-ititis, 1 . UiIGES t h e Govcrnncnts of the iic;jion:

( a ) . t o intr,xluce up-to-d,?-te t ~ c h n i q u c sf -2 t h ~ I c t c c . t i , n of Viral H e p a t i t i s B by u s i n g a s e n s i t i v c ncthod c . ;. RaSioiru;nulsasscry o r pefembly ;nssive haenagglutination r c n c t i o n ;

(b) t o u t i l i z c dis;~osczblc syringes t c t h c e x t e n t p ~ > s s i b l e ,in o r d e r t o rocluce t h c Qccurrencc sf V i r a l H c p 7 t i t i s B; 2. ill%COitIEM)Stk.t , I ~ X L 's t u d i e s

be un(1crtakcn on t h e epidcniology of V i r a l i I c p c t i t i s L , e s p e c i a l l y as fnr as i t s t r m s u i s s i o n through food is concerned, a s wcll na t h c olir;linr?tion of t h e v i r u e from water and doncstic waet~.-w3tcrs; ./a.

3. -

REQUESTS the ilegional Director t o continue t o d i s s e a i m t e i n f ~ r ~ . t i o n on tke recent advances i n V i r a l h e p a t i t i s studies and t o ;ronote f a c i l i t i e s

f o r the training ?t various levels o f s p c i l l i s t s required t o o w r a t e , nanagc and mzintain t e s t s f o r the detection of HB#g i n b l ~ o d banks.

Comparative e v a l u a t i o n of techniques of a c h i e v i n q maximum coveraue of immunization i n infancy S u a ~ e s t e da r e a : Problem , It i s v i r t u a l l y a u n i v e r s a l t r u t h a p p l i c a b l e t o every country. developing Polio, o r i n d u s t r i a l i z e d , t h a t more f a c i l i t i e s a r e o f f e r e d f o r immunization (Dm, BCG, Measles) t h a n a r e taken advantage o f by t h e p a r e n t s of t h e i n f a n t s e l i g i b l e . The t i i s a d v a n t a g ~ o u s r e s u l t of t h i s f a i l u r e t o use o f f e r e d s e r v i c e s is twofold: (1) epidemiological: h ~ r d immunity is riot a t t a i n e d , t h e i n r e c t i v e organisms c o n t i n ~ ~t e o c i r c u l a t e i n t h e c h i l d community and cause morbidity and mortality (2) f i n a n c i a l The average c o s t p e r completely immunized c h i l d is increased, s t a f f time and equipment c a p a c i t y being u n d e r - u t i l i z e d .

1. Sudan

2. Yemen

3. Afghanistan

Yet t h e response of communities i n developing c o u n t r i e s t o an o f f e r o f s e r v i c e can vary very wddely indeed from s a y 20 p e r c e n t t o 90 p e r c e n t , tak:ng a d v a n t a - e of f i r s t dose O ? a 3-dose schedule and from 5 t o 70 p e r c e n t completing t h e schedule. 111 v i e w u f the heavy i n v e s t m e n t s to be made i n EPI, WHO 0 should try to g a i n by r e s e a r c h widely a p p l i c a b l e knowledge a s t o which t e c h n i q u e s o f p u b l i c communication and promotion w i l l r e s u l t in t h e h i g h e s t p r o p o r t i o n s of e l i g i b l e i n f a n t s being immunized.

Objective To compare ( i n s e v e r a l c o u n t r i e s i n o r d e r t o minimize e f f e c t of l o c a l , c u l t u r a l and s o c i a l v a r i a t i o n s ) d i f f e r e n t techniques and combinations of techniques of persuasion o f p a r e n t s t o b r i n g t h e i r i n f a n t s f o r immunization and t o e v a l u a t e t h e r e s u l t i n terms of percentage of e l i g i b l e s a c t u a l l y completing a t h r e e - v i s i t schedule w i t h i n t h e c o r r e c t age p e r i o d , Method To use t h e s e r v i c e s of e x p e r t s i n mass communication a v a i l a b l e through t h e UN system o r from commercial a g e n c i e s prepared t o a c t p h i l a n t h r o p i c a l l y (examples, a d d r e s s e s a t t h e end of t h i s proposal) t o d e v i s e t r i a l s i n v o l v i n g i n each of t h e c o u n t r i e s mentioned s e p a r a t e l y and t o g e t h e r d i f f e r e n t t e c h n i q u e s , such a s :

use o f mass media ( r a d i o and/or ?X and/or newspapers and/or cinema a d v e r t s ) house t o nouse v l s l t i n g , w i t h o r wlthout leaflets use of community, r e l i g i o u s o r p o l i t i c a l p a r t y groups "advance men" w l t h p u b l l c a d d r e s s system competition between v i l l a g e s / d l s t r i c t s w i t h p r i z e s and numerous o t h e r i d e a s which could be d e v i s e d no doubt.

Duration I n any p a r t i c u l a r country t e s t i n g of a p a r t i c u l a r method o r combination would t a k e s a y 8-10 months from campaign t o 3rd v i s i t i n a 3 - v i s i t schedule. W e ought t h e r e f o r e t o look upon t h i s as an e f f o r t which w i l l probably continue f o r about f o u r y e a r s before we could have enough d a t a on d i f f e r e n t techniques t o draw reasonably widely a p p l i c a b l e conclusions of real vahle ta the f u t u r e of EPI

Cost T h i s is a l s o r a t h e r d i f f i c u l t t o e s t i m a t e , s i n c e much of t h e m a t e r i a l c o s t w i l l be met by Governments from EPI o r g e n e r a l h e a l t h education p r o j e c t s . Probably t h e b e s t allowance would be 3 STC months p l u s $ 6 000 s u p p l i e s and equipment g r a n t p e r y e a r f o r 4 y e a r s . P o s s i b l e research persons/agencies 1. WHO/)@, -, Health Education s t a f f . 2. /

UNICEF P r o j e c t Support Communlcat i o n Experts.

3. M r Andreas Fugelsang, I n t e r n a t i o n a l Development Communications Consultant, c/o United Nations S t a f f , P.O.B. 4.

20, Grand C e n t r a l PO, New York 10017, USA.

Mr Hlchard K. Manhol's, Lnairman, Hichard K. Manhoff brc., 845 Third Avenue, New York 16022, USA.

Other A d v e r t i s i n g Agencies contacted f o r us by WHO/HQ through p h i l a n t h r o p i c o r g a n i z a t i o n s ( I n t e r n a t i o n a l Lions, Kiwanis, Rotarians, e t c .)

Research towards a 1 eCfeu L l v r ~ v u o ~ d i n and g r e p o r t i n g system i n primary. h e a l t h care Backp;round and J u s t i f i c a t i o n Recording and r e p o r t i n g a r e t r a d i t i o n a l a c t i v i t i e s of h e a l t h e s t a b l i s h An e f f e c t i v e recording and r e p o r t i n g system is e s s e n t i a l for: ments. ( a ) improving the d e l i v e r y of h e a l t h c a r e t o t h e i n d i v i d u a l and t o the community, ( b ) improving the f'unctioning of t h e h e a l t h establishment i t s e l f and ( c ) improving, a s well, t h e h n c t i o n i n g of t h e h e a l t h s e r v i c e s i n general. Therefore, recording and r e p o r t i n g are not ends i n themselves ht uu An i n e f f e c t i v e recording and r e p o r t i n g meant t o serve c e r t a i n objectives. system w i l l be a waste of time, e f f o r t and money, and w i l l be a n o b s t a c l e alon; t h e road t o e f f e c t i v e d e l i v e r y of h e a l t h care. Experience i n severe1 c o u n t r i e s i n t h e Eastern Mediterranean Region o v e r past years has shown that there is often a tendencg to pro2ifermto

and complicate recording and r e p o r t i n g forms and procedures. It i s o f t e n d i f f i c u l t lo achieve c o r r e c t p a t i e n t i d e n t i f i c a t i o n . The t e c h n i c a l q u a l i t y of the contents i s r a t h e r marginal. Systematic s t o r a g e and r e t r i e v a l are u s u a l l y nisslng. m e end r e s u l t Is t h a t whatever Infom&.on Is c o n W n e d t h e r e i n o r i n t h e secondary d a t a production is rarely properly u t i U z d . The heaps oi" record fonns become d i f f i c u l t t o maintain and c o n s t i t u t e a l i a b i l i t y r a t h e r than an a s s e t . More important, too high a proportion of the time of the t e c h n i c a l s t a f f i n a h e a l t h establishment i s being spent on bookkeeping and i n w r i t i n g forms, leaving "hem w i t h too l i t t l e time t o oamy o u t t h e i r main r e s p o n s i b i l i t y , which is t o serve t h e p a t i e n t and t h e camnunlty. There is no proper recording a d r e p o r t i n g system that can be u n l v e r s i l l y I n t h e developing c o u n t r i e s i n p a r t i c u l a r , the adopted i n a l l countries. systems should be t a i l o r e d t o s u i t l o c a l ciroumstances i n t h e b r o d sense. Moreover, a recording and r e p o r t i n g system should be developed w i t h l n t h e context o i t h e h e a l t h care system i t s e l f . The examination of o b j e c t i v e s i n recording and r e p o r t i n g and deciding on an appropriate system are even more important when thinking i n tenns of prbmry h e a l t h care, which is f r o n t - l i n e contact between t h e h e a l t h s e r v i c e and the Primary h e a l t h c a m t a k e s d i f f e r e n t forms, U i n g majority of ' h e people. Meanwhile, t h e r e is u s u a l l y only a f o r numerous and varied a c t i v i t i e s . s k e l e t o n staff directly Involved i n primary heal- c a r e , w ~ t h mat a m Il]relg t o be widely varying educational and t r a i n i n g bnakgrourads.

Although more and more countries i n t h i s Region a r e embarking on primary h e a l t h care development, t h e r e is s o f a r no co-ordination body of knowledge on how d i f f e r e n t countries a r e handling the recording and r e p o r t i n g of information i n primary h e a l t h care programmes. Clear Any f i n a l version of such guidelines guidelines have not y e t been drawn up. It may would need t o allow, of course, f o r individual country v a r i a t i o n s . be noted here t h a t , on t h e o t h e r hand, i n t h e f i e l d of h o s p i t a l medical records, WHO has been c o l l a b o r a t i n g with Member countries f o r some years with good success, and guidelines f o r h o s p i t a l medical record p r a c t i c e have been prepared. Objectives of t h e P r o j e c t To determine a n e f f e c t i v e recording and r e p o r t i n g system i n primary h e a l t h care programme. This involves i d e n t i f y i n g , f o r the various l e v e l s of the system f o r d e l i v e r y of primary h e a l t h care, the information required t o be recorded and reported, t h e forms t o be used, procedures f o r completion, f i l i n g and r e t r i e v a l , a s well a s secondary d a t a production and t o i n v e s t i g a t e i t s usefulness i n t h e management of h e a l t h s e r v i c e s . 'The e f f e c t i v e n e s s of a 'recording and r e p o r t i n g system can be indicated by:

its s u i t a b i l i t y f o r a p p l i c a t i o n , ensuring its relevance, s i m p l i c i t y and economy, a t the various levels of the system for delivery of primary

h e a l t h care, taking i n t o consideration t h e manpower and m a t e r i a l resources available;

improved delivery of health c a r e t o the l n d l v l d u a l and t o t h e community;

improved u t i l i z a t i o n of t h e information contained i n the records and o f t h e secondary s t a t i s t i c a l d a t a produced f o r management and o t h e r purposes.

Country o r Area of Execution

1 . ,

Pneparatory Phase 1 . 1

Observe t h e primary h e a l t h c a r e recording and r e p o r t i n g systems operating i n s e l e c t e d c o u n t r i e s i n t h e Region, w i t h i n the context of t h e general h e a l t h c a r e system; C o l l e c t samples of a l l r e l e v a n t c u r r e n t recording and r e p o r t i n g forms Consult w i t h a l l a p p r o p r i a t e n a t i o n a l a u t h o r i t i e s involved i n t h e c u r r e n t systems, seeking t h e i r views on t h e i r information needs, accuracy, usefulness and a c t u a l u t i l i z a t i o n of w h a t is being recorded and reported, and on problems and p o s s i b l e ways f o r t h e i r solution.

1.2

1.3

Such a c t i v i t i e s a r e u s u a l l y c a r r i e d o u t by t h e Regional Adviser on Health S t a t i s t i c s during his country v i s i t s . However, a short-term consultant may undertake then and be allowed enough time t o make the review i n depth.

C o u : l ~ r i e st o be v i s i t e d may be s e l e c t e d among those w i t h ongoing primary h e a l 91c a r e programmes, Lhose where country h e a l t h pro;;rmming e x e r c i s e s !)age been undertaken, those i n which WHO s t a t i s t i c i a n s a r e working 01- tilose w i t h g r a d u a t e s from Lhe Regional T r a i n i n g Centre f o r ,~edical I:ecord Science. Also, a s f a r a s p o s s i b l e , they should be representative of d i f f e r e n t k i n d s of h e a l t h c a r e systems.

i t i s proposed t h a t t h i s p r e p a r a t o r y phase should be c a r r i e d o u t i n I h h r a i n , Egypt, I r a n , Pakistan, Sudan and Yemen, over a p e r i o d of a minimum of t w o weeks in each c n t ~ n t t y .

Pfeld Work 2.1 neview t h e c o l l e c t e d forms i n t h e l i g h t of t h e r e s u l t s of s t u d i e s made d u r i n g t h e P i r s t phase, w i t h t h e o b j e c t of r a t i o n a l i z a cion and s i m p l i f i c a t i o n of both forms and procedures; T r a i n primary h e a l t h c a r e s t a f f i n t h e new system; Operate p i l o t schemes t o t e s t the new system.

2.2 2.3

This p!lase may be extended over e i g h t e e n t o twenty-four months. The Training c o n s u l t a n i w i l l continue, a f t e r t h e f i r s t phase, w i t h item 2.1. and f i e l d t r i a l s ( i t e m s 2.2 and 2.3) can be c a r r i e d o u t by t h e a p p r o p r i a t e n a t i o n a l s t a r f , a l o n e o r p r e f e r a b l y w i t h continued WHO t e c h n i c a l i n p u t .

Hevieti of Progress

3.1 3.2

Evaluate the r e s u l t of t h e p i l o t schemes. Uiscuss t h e experience i n t h e v a r i o u s c o u n t r i e s a t a r e z i o n a l meeting t o be convened. i i e d r a f t t h e system a s necessary i n t h e l i g h t of t h e p r a c t i c a l knowledge gained.

3.3

'l'he a b ~ v e a c t i v i t i e s would t a k e a b o u t f o u r months and should preferabl:,~ be undertaken by t h e same c o n s u l t a n t who c a r r i e d o u t this e a r l i e r work. S e l e c t e d c o u n t r i e s may be r e v i s i t e d .

A f u r t h e r p e r i o d of two y e a r s may o p t i o n a l l y be used t o follow u p on t h e implementation of t h e recommended system. T h i s follow-up can be done by t n e 3 e g i o n a l Adviser on Iiealth S t a t i s t i c s .

Duration of P r o j e c t Y ~

and O a h a l f ' t o three years.

page 4 '

Cost Estimate i n US Dollars

1 9 7 8 STC 4 m (including t r a v e l ) f o r Phase 1 2rn( "

18 000

4 m (

" '

) for Phase 2

) f o r Phase 3

Assistance t o c o l l a b o r a t i n g national institutions Regional meeting Supplies and o t h e r expenses Total

24 0 0 0 74 000

1000

GRAND TOTAL

RESEARCH ON THE INTEGRATION OF HEALTH T n O rm F S t OF

SPECIALIZED CAMPAIGW WITHIN GENERAL HEALTH SERVICES

Problem W i t h the recognition that m a l a r i a e r a d l c a t l o n 1s n o t wlthln a time-limited reach f o r many of t h e c o u n t r i e s which embarked on such a programme i n t h e Region, s e v e r a l malaria e r a d i c a t i o n programmes had t o r e v e r t t o t r a d i t i o n a l malaria ccjntrol. With such a p o l i c y change, t h e question immediately came up whether -; would be J u s t i f i e d t o maintain a v e r t i c a l set-up t o deal s i n e d i e with j u s t or:, of t h e h e a l t h problems a f c l i c t i n g some c o u n t r i e s where malaria i s endemic. The i n t e g r a t i o n of malaria a c t i v i t i e s (and s e r v i c e s ) within e x i s t i n g h e a l t h s e r v i c e s (and h e a l t h set-ups) has been s i n c e advocated. However, how t o go about it without l o s i n g whatever gains had been a t t a i n e d i n t h e c o n t r o l of malaria through a v e r t i c a l approach is a question t h a t has, s o f a r , n o t been s a t i s f a c t o r i l y answered. The proposed p i l o t p r o j e c t would study how t o develop a new h e a l t h care d e l i v e r y system on t h e b a s i s of t h e e x i s t i n g one, which can absorb malaria and o t h e r s p e c i a l i z e d programmes' workers i n a manner t h a t w i l l ensure a b e t t e r h e a l t h coverage of t h e population and, a t t h e same time, d e l i v e r y of s p e c i a l i z e d a c t i v i t i e s meant t o c o n t r o l t h e s p e c i f i c problems which are concern of d i f f e r e n t programmes.

Objectives The p i l o t p r o j e c t would be a f e a s i b i l i t y study which should t e s t :

1. t h e f e a s i b i l i t y of t r a i n i n g h e a l t h workers of s p e c i a l i z e d programmes t o d e l i v e r a defined number of t a s k s of primary h e a l t h care; 2.

t h e f e a s i b i l i t y of t r a i n i n g t h e personnel of general h e a l t h s e r v i c e s t o d e l i v e r t a s k s of s p e c i a l i z e d programmes; t h e f e a s i b i l i t y of changing t h e h e a l t h s e r v i c e system t o guarantee t h e e f f e c t i v e d e l i v e r y of i n t e g r a t e d care.

Methods It w i l l evolve i n t h r e e main s t a g e s :

1. 2.

d e s c r i p t i o n of t h e baseline s i t u a t i o n of t h e e x i s t i n g system; change of t h e system and o p e r a t i o n of t h e new system, with i n - b u i l t c o n t r o l , and evaluation and revlew ancl re-deslgn oi' t h e system.

...

A Protocol prepared f o r a p i l o t study i n a d i s t r i c t of Pakistan i s attached t o descrlbe t h e methodology I n d e t a l l .

PROTOCOL OF A PILOT PROJISCT FOR IEJTZGRATION O F HEALTH WORKtR3 O F SPECIALIZED CAEEsE.1GN.Y WITHIN GENERAL H E A L T H SERVICES I N THATTA DISmICT, SIND, PAKISTAN

Background

There have been s e v e r a l attempts t o develop a h e a l t h care system in Pakistan t h a t w i l l provide b e t t e r coverage of t h e population, t h e b e s t known being p i l o t s t u d i e s i n Northern D i s t r i c t , f o r development of " h e a l t h guards" and in Peshawar, "Pesh-imm". The i:ouqt~?i Health Programming p r n p o s a l s t r e s s e d the importance of trairiLng of a u x i l i a r i e s as basic h e a l t h workers who w i l l d e l i v e r primary h e a l t h care (PHC) t o t h e population. The Workshop on Training A u x i l i a r i e s conducted with t h e c o l l a b o r a t i o n of "MEDM" of University of Hawaii and WHO, produced valuable m a t e r i a l f o r developing t~aining programnes and c u r r i c u l a f o r a u x i l i a r i e s . All these endeavours s t a r t e d from scratch, i.e., from the assumption t h a t a l a r g e p a r t of rural a r e a s was 1ackLa.g any h e a l t h f a c i l i t i e s and such f a c i l i t i e s should be developed s t a r t i n g from the very beginning. A single attempt was made t o approach this problem from another angle: recognizing the existence of h e a l t h workers belonging t o d i f f e r e n t s p e c i a l i z e d h e a l t h programmes, l i k e Malaria Control Programme, l b e r c u l o s i s Control Programme, etc., the P i l o t P r o j e c t in T h a t t a t r i e d t o involve the personnel of those progrannaes in d e l i v e r y of P H C t o population, continuing: a t t h e same time t o work in t h e s p e c i f i c f i e l d of t h e programme. Because of p a r t i c u l a r circumG ~ M C C G a o o o c i n t e d w i t h the conduct of the above p r o j e c t , It Was d l f f l c u l t t o a s s e s s i t s r e s u l t s . For this reascm, it has been decided t o set-up a new p i l o t p r o j e c t in t h e same d i s t r i c t , with well defined o b j e c t i v e s and a c t i v i t i e s , with i n - b u i l t c o n t r o l system and evaluation c r i t e r i a . This document i s t h e basis f o r implementatiorl, moriitoring eValuatl0n O f the project. 2.

Introduction

The problem t o be s t u d l e d Ln 'l'hatta P i l o t P r o j e c t (TPP) i s a complex one: t h e development of a new h e a l t h c a r e d e l i v e r y system on t h e b a s i s of t h e e x i s t i n g one, which can absorb malaria and o t h e r s p e c i a l i z e d programmes' workers on a manner t h a t w i l l ensure a b e t t e r h e a l t h coverage of t h e popul a t i o n and, a t t h e same time, d e l i v e r y of s p e c i f i c a c t i v i t i e s meant t o c o n t r o l t h e s p e c i f i c problems which a r e concern of d i f f e r e n t programmes. ("Coverage" has been defined in terms of ( a ) number of c o n t a c t s of populatior, with h e a l t h s e r v i c e s , and (b) geographical a c c e s s i b i l i t y of h e a l t h services within a defined time f a c t o r . )

Objectives: Thatta P i l o t P r o j e c t i s a f e a s i b i l i t y study whichEkDuld t e s t :

3.1 3.2

the f e a s i b i l i t y of t r a i n i n g h e a l t h workers of s p e c i a l i z e d programmes, t o d e l i v e r a defined ni~mherof tasks of PHC; t h e f e a s i b i l i t y of t r a i n i n g t h e personnel of g e n e r a l h e a l t h s e r v i c e s t o d e l i v e r t a s k s of s p e c i f i c programnes; t h e f e a s i b i l i t y of changlng t h e d i s t r i c t h e a l t h s e r v i c e s system t o guarantee t h e e f f e c t i v e d e l i v e r y of i n t e g r a t e d services.

3.3

Area, Population and Health Services

Thatta d i s t r i c t has a surface of sq. miles and population of approximately 7 lacs. Xxcept f o r two towns, Thatta and Sujawal, the populatim i s mainly rural. There a r e v i l l a g e s 5 n the d i s t r i c t and small towns. The e x i s t i n g h e a l t h f a c i l i t i e s in the d i s t r i c t are as follons;

a) b)

c) d) e) f)

M s t r i c t hospital, Thatta, provides e f f e c t i v e coverage t o a population of Taluka Hospital, Suj awal Rural Health Centres 2 x 15 000 Sub-centres 6 x 5 000 Dispensaries with M O s 7 x 1 0 000 S t a t e dispensary 1 Dispensaries without NOS 31 x 5 000 Total population covered

30 OOo 20 000

30 00

NO00 70 00 1 0 000 155 OOo

345 000

The l i s t of health workers employed in the above health f a c i l i t i e s i s given as Annex I. The following personnel work outside the above f a c i l i t i e s : a)

M s t r i c t Health Gfficer

b) c) d) e)

P H Inspectors Malaria supervisors Smallpox workers BCG technicians

1 1 1

lr8 27 4

The above health workers, 1 MO and 90 awulliaries, are f o r the time being used f o r specific tasks delivered l n the whole d i s t r i c t area.

TPP w i l l be conducted a s an aotion study. main stages :

It w i l l evolve in three

a) b) c)

description of the base-line s i t u a t i o n of the system, change of the system and operation of the new system, with i n - b u i l t ocmtrol, and evaluation and review and re-design of the system.

The description of base-line s i t u e t i a n and evaluation w i l l be made in follterms: a) aooeptability by populatian,

b) c) d)

aoceptabllity b j health workers, ooverage of the population, oost.

The changes t o be implemented during the study can be summaxized a s follows : i) the existing h e a l t h f a c i l i t i e s w i l l be entrusted the delivery of a l l basic health tasks (BHT) t o the population f o r which they c a t e r ( a s shown in section 4. of this protocol);

i l ) t h e delivery of BHT t o the uncovered population of cca. 355 000 w i l l be entrusted t o the auxiliary workers of specialized campaigns/ programmes; f o r which purpose these workers w i l l be evenly d i s t r i b u t e d in the uncovered area; Health workers of cateaories (i) and ( i i ) who a r e trained t o deliver BHT, w i l l function a s multipurpose health workers (MHW). i i i ) certain health f a c i l i t i e s w i l l d e l i v e r teaching, supervisory and r e f e r r a l functians t o other f a c i l i t i e s and health workers of speeialized programmes working as multipurpose workers.

6. TPP.

Activities Detailed description of a e t i v i t i e s w i l l be made before the s t a r t of The following m a i n a c t i v i t i e s w i l l be conducted: 6.1 6.2 6.3 description of the base-line health care system; t r a i n i n g of perscanel a ) of existing health f a c i l i t i e s

of s p e c i a l i z e d pro~ramaes,

6.4

6.5

I n t r o d u c i q changes of the system; operating of the system under control; evaluation, one year a f t e r t h e change was completed.

Recording

A l l relevant events during the duration of TPP w i l l be properly recorded on a way that I s expected t o Fnterfere with t h e normal a c t i v i t i e s of health workers as l e s s a s possible. Observations made by researchers w i l l be recorded on fonns attached. Observations w i l l be made a t the following points in time and l o c a l i t i e s :

7.1

Points of observation in time a) b) c)

d) e)

before change of t h e system before t r a i n i n g of health workers a f t e r eompletian of t r a i n i n g a-job 12 months a l t e r t r a i n i n g

7 . 2

Point of observation

a) b) c ) r e f e r r a l health f a c i l i t y

- loaallties: aommunity place of delivery of PHC - f a c i l i t i e s

Three methods of observation w i l l be employed: observation and interview.

d i m c t o b s e m t i o n , indirect

The behaviour of health personnel w i l l be assessed i n three aspects: knowledge, s k i l l s and a t t i t u d e .

Data analysis

Data w i l l be edited, coded and processed by the IMRC, according t o the attached dunnny tables. A coding manual w i l l be drawn up a s appendix t o the f i n a l protoool.

Organization

The study w i l l be planned, conducted and analysed Jointly by the Provincial S e c r e t a r i a t of Health, Karachi and the PMRC.

The Provincial Secretary Health w i l l be the Study Director, and the Dlrector of PMRC w i l l be Study Co-director. A Scientist/PH S p e c i a l i s t o r Social S c i e n t i s t , w a l l be appointed Chief Researcher.

Field observations w i l l be made and recorded by s o c i a l workers specially trained on-job f o r the purpose.

A n interim report w i l l be prepared by Study Director, Study Co-director and The Chief Researcher, and suhnitted t o the Oovernnent of the Province of Sind. interim report should contain c l e a r reconmendations regarding a p p l i c a b i l i t y of researah findings

A report on the study w i l l be published in a s u i t a b l e Journal under the authorship of Study Director, Study Co-director and Chief Researcher.

1 1 .

Resources

The t r a i n i n g of a u x i l i a r i e s w i l l be done l o c a l l y and w i l l not incur any costs. A s f a r a s possible, it w i l l be conducted on-Job. 11.1 Planning f o r Study

0.2 Month

a) b) c) d) e) 11.2

Study Director Study Co-director Chief Researcher Statistician Typistflecretary

0.4 2 0 5 0.5

" n "

h s c r i p t i o n of the base-line health care system a) b) c) Chief Researcher Health ~ l a n n e r b y s t e m sAnalyst ~ypist/Secretarg

0.5

month

0.5

0.2 trainers

" "

11.3 'haining of health personnel a) b) Chief R e s e a r b r Sanitarian

- t r a i n i n g of

1.0 month

0 . 5 -- -

11.4

Prcmotion of the new health care system a) b) c) Study Director Study CO-director Chief Researcher

0.2 inonth

0.5 1.0

11.5 Introducing changes i n t h e system a) b)

0.5 month 0.5 1.0 0.4 " " "

c) d)

Study Director Study Co-director Chief Researcher ~yplst/Secretary

11.6 Training of observers a) b) c) d) 11.7 Social S c i e n t i s t Chief Researcher Statistician Typist/Secretary

0.5 month

0.5 0.5 0.2

" "

Monitoring of new system

1.0 month 2 months 0.5 month

a) Study Co-director b) c) Chief Researcher Statistician

11.8 Evaluation of new system a ) Study Co-director b) c)

2.0 months

d) e) f)

Chief Researcher 6 Observers a 3 months each Statistician Health Planner/Systems Analyst ~~~lst/Secretary

1.0 month " 1.0 1.0 'I

11.9 Data processing b) c) 11.10

4.0 months 1.0 month " 1.0

a) S t a t i s t i c a l Assistant Statistician 'Typist/Secretary

Reporting a) b)

0.3 month 2.0 0.5 " 2.0 months 4.0 " 1.0 month

c) d) e) f)

Study Director Study Co-director Chief Researcher Statistician S t a t i s t i c a l Assistant Typist/Secretary

1 1 . 1 1 Other resources

Rs. Rs. Rs. Rs,

Foms and s t a t i o n e r y

b) c) d)

Transport of study staff Data processing Miscellaneous

11.12

Summary of resources Study Mrector Study Co-director Chief Researcher Statistician

1.2 months

4.9

Health planner/Systers Analyst

Social S c i e n t i s t Sanitarian Observers s t a t l s t i c a i Assistant ~~~ist/Secretary Other resources 12.

0.5 month

18 months 8.0 " 4.3 "

0.5

Scheduling of a c t i v i t i e s Scheduling of a c t i v i t i e s is shown i n the attached planning table.

The follow in^ annexes represent p a r t of the Protocol: Basic health tasks 'of MHW L i s t of health f a c i l i t i e s and personnel A concept of a health care system t h a t will absorb M H W Regionalizationof basic health care Training programme f o r MHW Coding manual Register of basic health t a s k s Referral s l i p 2

Annex 1 " 2

' "

3 4

" " U It

Form Thatta 1 n I1 I*

" " " ' n

3 4

5 6

Monthlyreport PersonalfonnofMHW Out-patient s l i p Interview of medical o f f i c e r of referral I n s t i t u t i o n Interview of village leader

Thatta Annex 1 BASIC HEALTH TASKS

OF THE MULTIPURPCGE HEALTH WORKERS (MHW)

Health Problems

Basic Health Tasks MCH PP (b)

CDC

MAL (d)

(a) 1. 2.

(c)

(e 1

Ment. Health Health Educ. (f) (R)

Env. Health (h)

Med. Care (i)

lnterview of Pat. necking temperature Inspection of Pat.

+ + +

+ +

+ + +

+ -

+ + +

4. Blood c o l l e c t i o n 5. Sputum c o l l e c t i o n Stool collection Drugs p r e s c r i b i n g & dispensing+ Injections

+ +

+ + + +

+ -

+ + +

7. 8.

+ +

10. Dressing wounds

+ +

12. I n s p e c t i n g homes

13. Inspecting water

1 4 . Chlorination 15. Spraying

+ C

+ +

+ + +

17. Referral 18. Recording & r e p o r t i n g

DRUGS AVAILABIE W I T H MHW:

contraceptive a s p i r i n , chloroquine, i s o n i a z i d , TB 1, streptomycin, p e n i c i l l i n t a b l . , t e t r a c y c l i n t a b l . , p h t h a l y l s u l f a t h i a z o l , f e r r o tabl., ointment, serum a n t i v i r x r i nun, d r e s s i n g material.

EXPLAINING:

contraceptive techniques, general and peraonal hygiene, prevention of communicable d i s e a s e s , including malaria, t u b e r c u l o s i s , f a e c a l i - t r a n s m i t t e d diseases, mental d i s o r d e r s , use of drugs, drainage of stagnant waters, provision of s a f e water and e x c r e t a d i s p o s a l .

T h a t t a Annex 1 page 2 MCH = m a t e r n i t y and c h i l d h e a l t h PP = population planning CDC = communicable d i s e a s e s control MAL = m a l a r i a TI3 = t u b e r c u l o s i s . A suitable t i m e - d i s t r i b u t i o n o f t a s k s during t h e day should be e s t a b l i s h e d before

t h e s t a r t of implementation of the pilot study.

Thatta Annex 3

A CONCEPT OF A HEALTH CAFE SYSTEM THAT W I L L ABSORB MULTIPURPOSE HEALTH WORKERS (NHW) 1. P'nysical proximity is the main factor which determines the accessibilltj' of health services when they are delivered free-of charge. For this reason, the delivery of basic health tasks (BHT) should De organized on a i i r c r r i t r a l i z e d manner, from facilities wfiich are close to the people. BHT for a population residing not far than

Each existing health facility in T h e district will take care of delivery 5 miles from facility (hospltals, health centres, dispensaries, etc. ) In non-covered area of the district, workers of specialized programmes nil1 be allocated on such a way that they cover areas with radius 5 miles, without overlapping with areas rorered by existing facilities. It is hoped that on this way all the population will be provided with faailities not further than 5 miles from their homes (to be checked on the map of Thatta district). 2 .

The delivery of BHT in existing facilities should be entrusted to auxiliaries in those facilities : rompounders, lady health visitors, sanitary inspectors, etc., after they have been trained for this purpose. They will have the same . ) . working programme as independent MHW in the field (see 4 3.

Health workers of specialized health progranmes will be trained for delivery 4. They will work in independent dispensaries equipped with the most of EHT. The f e a s i b i l i t y of providing necessary equlprnent (the list to be uompleted). small refrigerators for keeping perishable supplies, like sera, vaocines, etc., should be considered. A strict working schedule, daily, weekly and monthly should be drawn-up. The daily distribution of time may be as follows : work in dispensary In early morning, for patients from vioinity; work in the field, home visits, etc.; work in the evening, for patients from other places. 8 ) The weeklz sohedule should ensure the regularity of visiting anlocalitles of the area. In aertain seasons, it rill be ooncerned wlth special tasks, like imunization, spraying, etc. a) b) The monthly progranae will include a one-day meeting at the referral institution, for on-job training, oonsultation and replenishing of supplies. Medioal offirers in existing institutions will examine 9 patients referred 5. They will also do supervision of MHW in the area attarhed to their to by MHWs. institution, as well as training on-Job of the same workers. The c0nnrMni~ati0n between MHW and referral institutions will be materialized through : a) referral, b) on-job training c ) reporting, d) mlperrision, and e) supplies. 6. a) b)

The training of MHW will be conduoted in two phases : six weeks course of malnly practical t r a i n i n g in parforaing 18 BHTs, continuing on-job training every month, through discussion of cas8s referred to by MHW and demonstration of cases in the referral institution.

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Thatta Annex 5 Specimen TRAINING P R O G R A k M E

MODULE 1 Task: INTERVIEW OF PATIEhFm

Training objectives:

TO IMPAm SKILLS I N ELICITING SBIHXNS AND THEIR IN'I'ERR O ; PRETATION, R E G A R D I N G SPECIFIC HEALTH P TO IMPAHP G I ( I L I 3 IN ELICITING SOCIO-MEDICAL PROFLEB.

Training Methodology: 1. t r a i n i n g w i l l be purely p r a c t i c a l , conducted by demonstration of patients/ b a l t h problems t o t r a i n e e s ; t h e o r e t i c a l statement8 w i l l be made only when s a t i s f y i n g the needs of t r a i n e e s , e.1. when t r a i n e e s ask questions r e l a t e d t o the background of symptoms/problema; a l i s t of symptoms, t h e i r i n t e r p r e t a t i o n and a c t i o n s that should be taken t o a l l e v i a t e t h e symptoms/problems w i l l be given t o trainees, best as a manual comprising a l l t r a i n i n g modules f u l l y developed; t r a i n i n g w i l l be conducted in two phases a ) intensive t r a i n i n g of 6 weeks duration a t the beginning; b) continuing on-Job t r a i n l n e , one day every month.

Contents of Training: ( t o be developed a s a part of a manual) 1.

Most oownnan

symptoms

1.1 PAIN, c l a s s l f l e d by localisation - ohrrroter duration

CHOICE O F ACTION

1.2 EWER, c l a s s i f i e d by duration repetition degree

CHOIm OF ACTION

1.3 DIAMOEA, c l a s s i f i e d by

- age of p a t i e n t 1.4 COUB1 AND HEAVY BAEAPIING, c l a s e l f i e d by

- character - duration

O f C E OF ACTION

- age of p a t i e n t - smoking h a b i t duration - repettitian - degree

mxm O F ACTION

- phlegm

1.5 VCMITINQ, c l a s s i f i e d by

- duration - repetition - contents of

CHOICE OF ACTION

vomited material

T h a t t a Annex 5 Page 2

1.6 WEAKNESS, c l a s s i f i e d by

CHOICE O F ACTION

degree: f a i n t i n g , dizziness, syncQpe, epilepsy character: physical, mental duration repetition

1.7 -DING,

c l a s s i f i e d by -- eduration x t e r n a l vs. i n t e r n a l amount of blood l o s t repetition C H O I m O F ACTION

1.8 SKIN SYMFCQbB, c l a s s i f i e d as

rashes boils infections

CHOICE O F ACTION

1.9 I N J U R I E S , c l a s s i f i e d by localisation - severity broken bones dislocation

QIOICE O F ACTION

1.10 PREGNANCY, c l a s s i f i e d by duration number

CHOICE OF ACTION

- complicationfi

1 . 1 1 COMBINATION O F SYMFTOMS AND CHOICE OF ACTION

1.12 ANY SYMPMM OR SYMPTOM COMBINATION OF MORE THAN THWZ W Y DURATION SHOULD BE C O S I D E R E D A SERIOlR CONDITION AND EVEVNALLY REFERFED M AN 1 I W I " M I I O N WITH A DOCTOR I N CHARGE. IF S'IMPTCMS Wl! SUBSID3 IN THREE DAYS THE PATIEElT MUST BE REWRRED TO DOrnR

Requests of population 2.1 f o r immunization consider t h e age of person t o be imnunized - the h e a l t h s t a t u s of same person

- presence of symptoms

2.2 f o r population planning number of children age of parents h e a l t h s t a t u s of parents and children

2.3 f o r advice, regarding persorial hygiene nutrition keeping t h e household clean clean water d i s p o s a l of excreta prevention of diseases, e s p e c i a l l y aoute comunicable diseases, malaria and t u b e r c u l o s i s

2.4 f o r drugs f o r a proxi f o r treatment of a chronic disease

Thatta Annex 5 Page 7 Method of Evaluation: t r a i n e e s w i l l be evaluated by requesting them t o e l i c i t and i n t e r p r e t symptoms/health prpblems under t h e observation of an examiner,

Note This Module is a d r a f t intended t o show an a ~ p r ~ a c to h fomulating training programne f o r MHW, The p r o g m e is performance-oriented and should n o t present knowledge systematized by d i q c i p l i n e , but develop SQLU on t h e way on whfch they will be applied by M W on Job. This Module should be used a s an example how t o develop madules f o r t h e o t h e r b a s i c h e a l t h t a s k s defined i n t h e Protocol.

A manual should be drawn-up based on t h e o u t l i n e of t h i s Module, including a l l eighteen t a s k s .

Form Thatta

of M.H.W.: f o r month:

Number of t a s k s delivered: Drugs' Account Received Dispensed Balance

1. 2.

Contraceptive p i l l s Aspirin t a b l . Chloroquine t a b l . Isoniazid tabl.

3. 4.

5. 6.

TB 1 t a b l . Streptomycin v i a l s Penicillin tabl. Tetracyclin t a b l . Phthalilsulfatiazol tabl.

7. 8.

10. Ferro t a b l .

1 1 . Ointment 12. Gauze

13. Bandages 14. S e m Antiviperinurn

Signature:

Form Thsrtta 6 Date of interview: INTERVIEW O F MEDICAL OFFICER O F REFE-UUL I ~ T I T U I X O N

Name of the i n s t i t u t i o n :

Name of t h e Medical O f f i c e r : 'Number of W s under h i s ,supervision:

Opinion of t h e i r knowledge : Opinion of t h e i r s k i l l s : Opinion of t h e i r a t t i t u d e : Number of case$ r e f e r r e d by i n d i v i d u a l MHWS

. Corree$ly 1. MHW: 2.

Incorrectly

MHW:

3. MMJ: 4.

5. w: 6. MHW:

7. MHW: 8. M:

g. MIIW: 10. MHW:

Remarks and notes:

Form Thatta 7

Locality: Name : Function i n the community: Name of MHW: Opinion of MIIW's knowledge:

H W 1 sskills: Opinion of M Opinion of MHW1s a t t i t u d e : Opinion regarding e x i s t i n g h e a l t h problems in t h e comunity: Opinion on current d e l i v e r y of h e a l t h s e r v i c e s i n c m u n l t g : Remarks and notes:

Research Proposal 1.

Major WHO programme area Prophylactic, diagnostio and therapeutic substances (WT)

Pmjeot t i t l e Drug U t i U z a t i o n Reseer~h Studlus with

Special RefeTenCe t o A'qmary Heti&

Cwe

Country o r area of execution Interoountry

4 .

Projeot duration and estimate@ cost (global figure) Duration: two years (1978/1979) $ 42 000.

Cost estimate:

Backsround and J u s t i f i c a t i o n (the m b l e m )

There is a need t o c o l l e c t and correlate data i n r e l a t i o n t o mlnianua drug requiremepts i n wimary health care. The data a r e intended t o provide iflormation on drugs used a t the primary health oare l e v e l a s well a s on drug requirements under apmopp.iate treatment conditions. The colleot,ton of relevant a t a i n selected oountries (e.g. Afghanistan, Demoratio Yemen, Iran, Baq, Jolban, Pakistan, Sudan, yemen) is l i k e l y t o take about one year. A PlarUling Group f o r Studies on Drug Utilization met i n the WHO Reglonal Office f o r the Eastern Mediterranean from 23 t o 25 Uarch 1976. Ir)Ns opening address t o the meting, Dr. A.H. Taba, Regional Director, mentioned that the aim t o p;Lan studies aimed a t providing preolse informelion of the Working Group was on the need for and use o f drugs by ancuviduals a m groups of I#tiej~ts." The Planning Group reooa~endedtheit drug u t i l i r a t i o n studies should be o m l e d out t o f a c i l i t a t e t h e phuaing CX extension of health services, esppaially i n the The attached report outlines certain alternative approaches. primary health oare area. '

"...

...

So f a r . d r q u t I l i % B t i ~ studies n have been i n i t i a t e d in a few countries with W O ooUaboration, inoludine p a r t i o u h r l y Demoaratle Yemen and Egypt. A simple methodolow h a been used; it oomprises the seleotion of a number of peripheral health u n i t s i n t h e r u r a l areas, establishment of the validity of the records maintained a t the units, and oolleotion of data about patients (sex, age, diagnosis often syllptomafio and treatment given or presaribed). The I R f o r a ~ ~ t i o n required is normally ertraoted from the reoords of the u n i t s on a nonthly basis. The infornration thus colleated w i l l be o a r e f U 4 reviewed, anelyzed and made available t o other o w t r i e s .

The above " f e a s i b i l i t y studies" have produced encouraging r e s u l t s t o expand drug u t i l i z a t i o n s t u d i e s i n t h e other countries of t h e Region, with p a r t i c u l a r

focus on those en&avouring t o develop prlmary h e a l t h oare network. 6.

Main W p s e of t h e project

To provide information on t h e b a s i s of which continuing improvement i n clrug supply and u t i l i z a t i o n can be aohieved i n t h e primary h e a l t h oare area.

Cost esimates STZs

* be r e c r u i t e d l o c a l l y a t country l e v e l

- might

Travel grants Grand T o t a l

$8000 10 000

10 000 1 0 000

$42

ooo

*I n

t h e Proposed Brogramae and Budget Estimates 1978/l979 t h e r e i s already provision f o r $ 13 000 and $ 14 000 in 1978 and 1979 E6peotivelg, under t h e interccountry wodeot " ~ e s e a r c haeveloplent on drug u t i l i z a t i o n " I C P ~ ~ P ~ O O ~ .

A p r i l 1376

P L N I N G GROUP FOR STUiIIES ON DRUG U T I L T Z A T I Q K

Alexandria, 23

25 March 1 9 7 6

WHO EMRO

TABLE OF CONTENTS

TNTRODUCTION WORKING PLAN

Drug u t i l i z a t i o n s t u d i e s

1.1 1.2 1.3 1.4

Objectives Subject Subject Subject

Drug u t i l i z a t i o n s t u d i e s

2.1 2.2 2.3 2.4 3. ANNFXI AVNrX I 1

Objective

Area Procedure T i m e - t a b l e for i m p l e m e n t a t i o n

Concluding remarks PROC,WLhITIE LIST OF PARTICIPANTS

WHO EMRO

INTRODUCTION

The Director of the Eastern Mediterranean Region of the World Health Organization, Dr A.H. Taba, in his opening address formulated the aim of the Working Group as follows:

to plan studies aimed atproviding precise information on the need for and use of drugs by individuals and groups of patients.

Drug utilization studies were strongly recommended by the Working Group on Rational Drug ~ h e r a ~ which ~ l met in the Regional Office one year ago. This topic was also discussed by the Executive Board at its Fifty-fifth Session, which decided that WHO should collaborate with Member States in the monitoring of drug utilization. The Working Group on Rational Drug Therapy felt that drug utilization studies should be used as one of several tools to achieve rational and optimal drug therapy. In other words, the studies should help to improve the efficiency of patient care. Improvement of the efficiency of drug treatment in health care institutions requires the identification of irrational prescribing, of insufficient information to patients on the use of drugs, and of deviations in the use of druas by the patient. The Working Group on Rational Drug Therapy was of the opinion that whilst general information on these problems is available, more precise information is needed if the In particular, problems are to be adequately analyzed and solved in the Region. studies in different countries of the Region, and of populations within these countries, are needed on such matters as: influences exerted upon the physician, which determine his prescribing pattern: the drug-takin~ h~hnvinurof the population: attitudes towards prescription of drugs; and popular knowledge of the properties and proper use of products. In brief, scientific drug utilization studies will help to uncover and define deviations from rational drug use, and provide the knowledge which is needed to improve such use.

In this connexion, the role of medical and pharmacy schools is particularly important because of their far-reaching influence on the professions in their countries, and their role in undergraduate and post-graduate training. Drug control authorities can also play an important part in ensuring that physicians and patients are provided with adequate instructions for the use of drugs. Drug utilization studies are, furthermore, an important means of assessing the effects of such corrective activities by universities and control authorities. They are particularly helpful in this respect when conducted over long periods of time. In this Region, where the needs for an extension of health services are pressing in many countries, drug utilization studies will also facilitate the planning of extension of services, especially in the rural and primary health care area. The kind and cost of drugs which have to be supplied to newly established health care services can be reliably assessed if appropriate statistics on existing drug consumption are available. Miscalculations in this respect can threaten the functioning

'EM/PHARM/~~,Alexandria, 3

- 5 March

1975

WHO EMRO

of otherwise well-planned projects. Continuing surveillance of drug utilization provides indispensable information for health planners and supply organizations of countries where up to 20 per cent of the total health budget has to be spent on the purchase of drugs, where drug consumption increases yearly by 15 to 25 per cent or where drug orders have to be placed six to twelve months in advance of their use. Authorities of these countries may also be interested to know whether the consumption of drugs appears to be justified or exaggerated in view of the experience in other countries with a similar structure. In brief, drug utilization studies provide valuable information for health planners and governmental drug supply organizations. This Planning Group was convened to review the scope, function and organization of drug utilization studies, and to plan the establishment of such studies in :n:tntries of the Eastern Mediterranean Region. The participants discussed the matter and agreed to submit the following working plan:

WORKING PLAN

1.1

Objectives

(;ollection of information on physicians' drug prescribing pattern and drug utilization hy patients in a manner as precise as possible. The study results are aimed (a)

to assist health educators in training their students in the rational use to inform the proTessions on the efficiency of their drug utilization.

of drugs, (b)

1.2

Subject A

study concerning physician's views about his drug prescribinp,.

General practitioners will he requested to answer the following questions. Can y o u p r t s c r i l i r tlte d r u g s

(a)

you

wanL Lo

resc scribe?

In private practice: Yes

...

No...

if no, please specify. In the service of the government, health insurance scheme or other (to he specified) :

WHO EMRO

Yes

...

if no, please specify. (b) Do you feel that your average patient is satisfied with your prescribing? In private practice: Yes

... ..

No...

if no, please specify. In o t h e r service:

Yes.

No... 4

if no, please specifv. (c) HOW many minutes do you have in average for the diagnosis and the writing'of the prescription per patient?

... In other service: (minutes) . . . (minutes)

In private practice:

(d) 1iow many minutes would you like to have to elaborate an appropriate diagnosis and to write a rational prescription? (i) In private practice.

(ii) In other service.

(e) How often are you requested by your patient to prescribe specific drugs for them? Please give yollr assessment of percentage of the total of patients. (i)

in private practice in other service

(ii)

(f) Which are the main sources of information for your knowledge on drugs and drug use? (i) Information provided by the industry

- mailed

(ii) (iii) (iv) (v) (R)

visit of representative

Information received in symposia, seminars and other meetings Information from colleagues Information from medical journals and textbooks Information from other sources (please specify)

Are you satisfied with the information on therapeutics available to you?

Yes If no. please specify.

...

No...

The applicability of this questionnaire will be explored by university instructors. Corrections will be made if necessarv. The use of the final questionnaire will be

kYO EMRO

explained to medical students who visit general practitioners in private practice and the government health care service. The completed questionnaires are to be returned to the studv team leader. provides for evaluation. t i e

It is assessed that about 100 general practitioners can be visited in rural areas 0 0 general practitioners can be visited in the two cities, Cairo and dnother 1 Alexandria. About forty students are deemed necessarv to make these contacts. T h e s e students are to be informed and controlled bv four instructors who have experienre in guiding students.

April 1976 Mav 1 9 7 6 June 1976 ) Julv August ) Sep temher)

Preparati~nof questionnaire-form Conduct of feasibility study by instructors Conduct of the s t r ~ d vb v

students

Tabulation of data bv instructors tor presentatinri

October 1976 1. 3

Results to be sent to Regional Office

Subject S t r ~ d v concerning

patients' utilization of drugs.

Pat ients will be requested to answer the (a)

followlnp, questions:

Is this the first prescription which vau ~ o t for the present disease?

Yes (h)

...

N o . . .

Are vou collecting t h e d 1 t 1 g for vourself or your child'

For myself (c)

. .

For my child

...

Do you know how to take (or to give) the drug? Yes

...

No...

(ri)

Mere you able to huy all the prescribed drugs (if private patient)? Yes.

No.,.

If no, give the reason. The applicability of this questionnaire will be explored by a small group of university instructors (pharmaceutical and/or medical). Corrections will he made if necessary. T h e final questionnaire will he explained to students especially selected

and instructed in the conduct of the study. The patient to be interviewed will be contacted outside pharmacies. (The pharmaceutical profession will be informed in advance about the study). Patients visiting rural health centres will be included.

WHO EMRO

The interrogators can be students of pharmacy or medicine. They have to return completed questionnairesto their instructors for further handling. It is assessed that about 1 000 patients can be contacted in this way, if one student can fill in about ten questionnaires. Under these conditions about fifty eeudents froin each faculcy will be involved and about five instructors from each The completed questionnaires will be studied and the results tabulated by faculty. instructors involved in this study.

April 1976 May 1976

Establishment of questionnaire Feasibility studies conducted by instructors Final tabulation of results Transmission of result to Regional Office

1 June July ) ) August September) October 1976 1.4

Subject Study concerning the prescribing pattern in hospital and.genera1 practice.

1.4.1 Method

Some data on drug prescribing patterns which can be collected from prescriptions written in in-patient and out-patient departments of hospitals, in rural health centree, in health insurance polyclinics and private practice, will be collected and tabulated for further study. The following will be recorded: (a) Number of items per prescription (b) Categories of prescribed drugs (c) Whether information on use is given on the prescription (d) Whether information is given on how long the drug should be taken (e) (f) Sex

of the patient

Age of the patient (if recorded)

It has to be recorded whether the prescription was written in private practice, health insurance care, or governmental health care institution, further, whether for hospitalized patient, or out-patients. For the conduct of this study, three graduate pharmacists are available. Their work will be supervised by the High Institute of Public Health, Alexandria, and the It is assessed that each of the three Faculty of Pharmacy, llniversity of Alexandria. could tabulate data from 600 to 1 2 0 0 prescriptions, each being responsible for one of the three health care areas: hospital (in- and out-patient), health insurance institutions, private practice. Data should be collected in different social environments as far as accessible. Tabulation should be supervised by the team. The drugs Should be classified according to the EphMRA classification system as recorded on pages 13 to 18 of the Drug Dose Statistics edited by the Norsk Medisinaldepot, Oslo, Norway. It is recommended that a set of model tables be produced to ensure uniformity of data collection and presentation.

WHO EMRO

A p r i l 1976 June 1 July 1 1 August September) October

P r e p a r a t i o n of f o r m s T a b u l a t i o n o f daca

Transmission of r e s u l t s t o Regional O f f i c e

(The work d e s c r i b e d u n d e r 1.2.1.3 and 1.4 w i l l b e s t e e r e d and s u p e r v i s e d i n C a i r o by P r o f e s s o r H. G h a l e b , P r o f e s s o r o f Pharmacology, U n i v e r s i t v o f C a i r n ; i n A l e x a n d r i a by P r o f e s s o r M.H. Ghanem, P r o f e s s o r o f I n t e r n a l M e d i c i n e , P n i v e r s i t y o f A l e x a n d r i a and P r o f e s s o r S.A. K h a l i l , P r o f e s s o r o f P h a r m a c e u t i c s , F a c u l t y of tJharmac]i, J l n i v e r s i t y of Alexandria). 2. Drug u t i l i z a t i o n s t u d i e s

The c o l l e c t i o n and c o r r e l a t i o n of d a t a i n r e l a t i o n t o minimum d r u g r e q u i r e m e n t s i n p r i m a r y h e a l t h c a r e ; t h e d a t a a r e aimed a t i n f o r m i n g a b o u t drugs u s e d i n c u r r e n t n r i m a r y h e a l t h c a r e and d r u g r e q u i r e m e n t s u n d e r a y p r % p r j q t e t r cln:,len! cnr : I L C TI-.

The s t u d v w i l l b e c o n d u c t e d i n i t i a l l y i n D e m o c r a t i c Yemen, E t h i o p i a , Sudan and Tunisia.

2.3

Procedure

The s e l e c t i o n o f c h r e e c o m p a r a b l e b a s l c h e a l r h u n i t s I n e a c h c o u n t r y a t t h e l o w e s t c f f ~ c t f v el e v e l f o r t h e c o l l e c t i o n of d a t a .

E s t a b l i s h m e n t o f t h e v a l i d i t y o f t h e r e c o r d s m a i n t a i n e d a t each u n i t . The d a r a r e q u i r e d about each p a t i e n t w i l l h e :

(a) (b)

SPX

age diagnosis treatment

The p e r i o d f o r t h e c o l l e c t i o n o f t h e d a t a w i l l h e o n e y e a r . The I n f o r n a t i o n w i l l b e e x t r a c t e d trom t h e r e c o r d s o f t h e u n i t s o n a monthly h a s is. Exchange o f d a t a between c o u n t r i e s w i l l b e q u a r t e r l y w i t h c o p i e s s u p p l i e d t o t h e Off i c e .

530 R e g i o n a l

The f o r m a t f o r t h e e x c h a n g e o f i n f o r m a t i o n w i l l b e s t a n d a r d i z e d t o p r o v i d e :

WHO Em0

(a) (b) (c) (dl

no. of patients sex distribution aEe distribution

diagnosis as made

(e) drug treatment provided The treatment given will be classified into the following groups: Analgesics Antacids Antidiarrhoeals Antihistamines Antibiotics, systemic Chemotherapeotics, systemic Anti-parasitic products Cough and cold preparations Laxatives Psycholeptics (Tranquillizers: ilvpqoti~sand Sedatives) Vitamins Mineral supplements Skin p t ~ p a r t ai o n s

Other drugs It will be appreciated that adjustment may be necessary to adapt: the prop,ramme to each country's conditions, additionally the list may be adjqsted t o ronform in principle to the Drug Dose Statistics (List of Defined Doses for Drugs, Reeistered in Norway, 1975).

2 . 4

Time-table for implementation

The study will commence on 1 April 1976. During April. there will be selection of appropriate (primary) health units at which the study nav be conducted and invalvement of associated workers, where desirahle and possible. It is considered that a month is the minimum period required for the setting up of facilities. May will be the first month during which data will be collected from the three basic health units in each country.

The following format will be followed:

WHO

EMRO

Monthly Data Extraction Total No. of patients Age Distribution 0 - 1 yr

.. .... . 5

Males

....... 15

Females

......... ----

5 yrs

15 yrs

30 yrs

Over 30 vrs

Diagnosis: (Here will be listed the various diagnoses, reported in frequencv of occurrence, most frequent first. A multiple diagnosis will be listed in eacicategory). (Here the treatments provided will be listed in order of frequency and in alphabetical order as given above). As the study proceeds an attempt wlll he made to determine the dosage schedules and/or total quantity of each drup utilized. The target date for the first quarterly exchange of data between countries will be Aujwst 1976. Thereafter, o~tarterlv results will he exchanged in November 1976, February 19i7 and May 1977. During the period of the study each participant will reassess the procectures followed and, in consultation with his colleagues and thr Regional Clffice, make adjustments as considered to be desirable. In March 1977, a further meeting may be considered under the auspices of the \\'I10 Regional Office to evaluate the material obtained and to formulate further objectives. 3. rnncl~~rli rn em ~a r k s

It is understood by the participants that the Working Plan a ? a whole represents a feasibility studv for the conduct of further drug utilization str~dies. Further, it is understood that both partners involved, governments and kW0, approve the tentative programme. The results can only be discussed or used internally unless hot11 partners agree on publication. Success in the conduct of these studies may necessitate the ccnvening of a further plannjng p,roup meeting in March 1977.

WHO EMRO

EM/PHARM/ 73

EM/PL.GR.STD.UTZ./E Annex I Page i ANNEX I

PROCRAMME Tuesday, 23 March 1976 8.30 a . m . 9.00 a.m. Kegistratlon of Parclcipancs Opening address by Dr A.H. Taba, WHO Director, EMRO Election of Officers Adoption of Agenda Coffee break Drug Utilization in EM countries; a Review Discussion Methodology for drug utilization studies elaborated by study groups of European countries Discussion Lunch Break Experience gained during data collection and their evaluation by national and international teams in Europe 16.30 p.m. Dr B. Westerholm Dr P.K.M. Lunde Dr H. Friebel

17.30 p.m.

Discussion

Wednesday, 24 March 1976 8.30 a . m . 10.00 a.m. Objectives of drug utilization studies in Eastern Mediterranean countries Coffee break Discussion Methods for and conduct of utilization studies Lunch break Evaluation of study results in-country, and inter-country The Group The Group Drs H. Ghaleb A. Kabbashi

Mr N.P.H.

Milner

10.00 a.m. 10.30 a . m . 12.00

10.30 a . m .

12.00 noon

13.00 p.m.

EM/PHARM/~~ EM/PL.GR.STD.UTZ./~ Annex I page ii

WHO EMRO

Thursday, 25 March 1976 8.30

a.m.

9.00 a.m.

Drafting: Objectives of drug utilization studies in Eastern Medlcerranean counrrles Drafting: Conclusions concerning study subjects Drafting: Conclusions concerning methodolo~ical approach Coffee break Drafting: work in^ plans at national and inter-count 1.y level Tnterruption

The Group

The Croup

The (:roup

1,11nch break

S u m m a w report on planninp, Closing S e s s i o n

The Croup

WHO EMRO

EM/PHARM/73 EM/PL.cR.sTD.UTZ. Annex I1 page ANNEX I1 LIST OF PARTICIPANTS

DEMOCRATIC YEMEN

Mr N.P.H. Milner WHO Pharmacist Institute of Health Manpower Development Crater Aden

EGYPT

Dr Haider Ghaleb Professor of Pharmacology Department of Pharmacology Faculty of Medicine Cairo University Cairo nr S.A. Khalil Professor of Pharmaceutics Faculty of Pharmacy Alexandria University

Alexandria ETHIOPIA Mr N.S. Lane WHO Pharmaceutical Services Adviser

Pharmaceutical Services Project Addis Ababa IRAN Dr Kazem Yazdi Director General for Pharmaceutical Affairs Ministry of Health and Social Welfare Teheran Dr A . Khalidi Professor of Pharmacology Department of Pharmacology Faculty of Medicine University of Baghdad Baghdad Dr A . Kabbashi Director-Ccneral

1RAQ

SUDAN

Rural Health Services Ministry of Health Khartoum TUNISIA Dr M. Riotte WHO Visiting Professor of Pharmacology Department of Pharmacology Faculty of Medicine Tunis

EM/PHARM/73 EM/PL.GR.STD.UTZ./Z Annex I1 page ii OBSERVERS Dr H. El ~akim* Under-Secretary of Health Ministry of Public Health Cairo Dr M.H. Ghanem Professor of Internal Medicine Faculty of Medicine Alexandria University Alexandria SECRETARIAT Temporary Advisers nr P.K.M. Lunde Associate Professor in Clinical Pharmacology Universitv of Oslo, and Mead, Division of Clinical Pharmacologv and Toxicology The Central Laboratory Oslo KORWAY U l l c v c ~ o l Hospital

WHO EMRO

Dr B. Westerholm Associate Professor of Pharmacology Department of Clinical Phannacologv liuddinge Universitv Hospi tal and Pedical Advlser, National Corporation of Swedish Pharmacies Stockholm SWEDEN IGl'Hn-- Secretariat

Or A.H.

Taba

Director Director Health Services Public Health Administrator Health Organization

Regional Office for the Eastern Fledi terranran Ke):lon Regional Office for the Eastern Yediterranean Region Reeional Office for the Eastern blediterranean Region

Dr M.O. Shoib Dr G. Rifka Dr H . H . Friebel

Regional Adviser on Prophy- Regional Officq for the lactic and Therapeutic sub- Eastern Msditerranean Region stances and Secretary of the Planning Croup for

Studies on Drug Utilization

did not attend

WHO EMRO

EM/PHARM/73 EM/PL.GR.STD.UTZ./Z Annex I1 page iii Conference Officer Regional Office for the Eastern Mediterranean Region Regional Office for the

Miss C. Cartoudis Mrs M. El Guindy

Secretary

Eastern Mediterranean Region

THE UXMOCkdTIC HKPUIILIC OF TllE SUDAN

November

1976 PROJECT

RESEARCH

A mD m = STUDY

PHOPOSAL

COMMUNITY PARTICIPATION I N PRIMARY HEALTH CARE PHOL~RAI<ME I N lii2STERE.I A N D .SOUTHERN SUDAN

$?HEPARED

BY:

THE GOVLRNMLNT OF THE SUDAN:

Dr.

A.R.

- _.

Kabbashi, Director-General of Rural H e a l t h and t h e P r i m a r y H e a l t h C a r e Programme, N i n i s t r y o f H e a l t h , Khartoum

Dr.

L o l i k , I l i r e c t o r Primary H e a l t h Care, Southern Region, Juba

BY:

TIiE W(;HLI) I1L:AI TH ORGANIZATION:

Dr. Dr.

Raf i q u e - K h a n , A.

R e p r e s e n t a t i v e i n Sudan

TABLE U P CONTENTS:

B e n y o u s s e f , WHO H e a d q u a r t e r s , Geneva

PAGE the S t u d y

Abstract i n English S t a t e m e n t o f t h e Problem Hclevance of

Proposed Plan of Study Selected Health, Sob-economic Expected R e s u l t s of t h e Study Annex I Annex 11

Indicators

principal

Budget

Annex III

B i b l i o g r a p h i c i n f o r m a t i o n on investigators Bibliography

ABSTRACT

IN ENGLISH

Within the context of the new government plan petting forth social and economic development policy obJectives with the Democratic Republic of Sudan over the next six years, this pnoposal sets as Its major objective: to undertake applied research over a two-year period in fourrural/numadic communities of the Western and Southern Sudan in order to identify and document ways and means to link the existent self help ethos within comn~uniLy participation to the Primary Health Care Programme. Such a study will be the first in the Sudan to focus on the potential links between already exletlng vlllage level values and lnstltutlons orleni,eQ toward developlncr~t and primary health care programmes. Hence it promises ta sgrve as a framework for the development of methodologies focussgd on the introductiorl of change in health care system and community development so essential throughout the developing world. In order to accomplish this stated objective, several relgted strategies of applied research will be undertaken within two fie$d sites representing differing ecological areas and life styles: one, rural settled and the ottier, nomadic; both located near El Obeid in the Province of Northern Kordofau in the Western and Southern Regions of the Sudan. In, addition to ~JI experienced rural development economist who will serve as the Principal Investigator, regional and community manpower regources will be trained and utilized to capitalize on their broad experiential knowledge of the area as this relates to community development processes. The study focusse~on selected health, soclo-economic and cultural indicators in order to assess those specific conditbnq tlpt may operate as barriers to or facilitators of overall comnunity development. Althovgh it is recognized that a two year study will not yield taqible results of chon$e, it w i l l provide basio k n o w l ~ d g oupon which directional d s v e l a p w n t

trends might be predicted. It will provide the polioy makers as the provincial and district levels and the comnunity leaders with more s o ) $ d bases upon which more effective community development strategies would be planned and implemented. The implications of this study are rnultlalmenslonal involving the comnunity, provincial and ministerial level* within the Sudan as well as WHO and member states embarked on similar programmes of primsry health care. A t the cornunity level this study should not oqly provide better health care services, but also create new solid grounds for further development activities leading to better living standards at the comnunity level. At the provincial level it ~houldhelp identify means of more appropriate qlLocation and integration of comnity participation and self-help schemes within provincial level development projects. At the national and internat%on@l levels this mtudy would provide additional measures and indicatars for the evaluation of the Sudan's Primary Health Care Prograrome as well as planning for similar programmes in ~ther developing countries. It must be kept in mind that this proposal is not a medical study but a health care and rural development proJect with a budget that i q well under the costs of similar projects undertaken in Tanzania, Mexico and Ira. In addition it promises to seek to defray up to 20% of the estimated costs through self-help contributions from the communities themselves. In order to initiate the preparatory work in the communities concerned and to mobilize r ~ u L l ~ n a 1provincial , and comnunity rcoourcea as planned, w e h o p t i l a t a fundire

agency

would be in a position to indicate $ts support by mid-February 1977.

Community P a r t i c i p a t i o n i n t h e Primary tiealth Care Programne i n t h e Western and Southern Sudan

Statement of' t h e Problem:

The Sudanese government has embarked on what may be considered one of t h e most e x c i t i n g and r a d i c a l l y irmovative comprehensive h e a l t h coverage schemes of developirlg countries1. The s i g n i f i c a n c e of t h i s Natlonal Hen1t.h Policy is t h a t i t consciously s e t s out t o l i n k h e a l t h promotiori and h e a l t h c a r e t o o v e r a l l s o c i a l and economic development i n t h e Democratic Republic of Sudan. A s s t a t e d i n t h e S i x Year Plan 197-1983: "While emphasis i n t h e Plan has been placed on building up the growth p o t e n t i a l of the economy t o the l e v e l where i t can be s e l f supporting. t h e need f o r f u r t h e r expansion and pror:rotion of the s o c i a l servl.ces has been taken i n t o account which would f o s t e r such a r e a s a s education, h e a l t h s e r v i c e s , housing, s o c i a l welfare, public administration, trairiirw arid o t h e r r e l a t e d s o c i a l a c t i v i t i e s with more emphasis on r u r a l development and t h e l e s s p r i v i l e g e d regions of t h e a r e a . The s t r a t e g y f o r the h e a l t h s e c t o r , among o t h e r means, would address i t s e l f t o problems i n environmental s a n i t a t i o n ( i . e . h e a l t h education) and t h e inadequacy of preventive medical s e r v i c e s , g r e a t e r a t t e n t i o n would be devoted t o problems of m a l n u t r i t i o n and provision of potable water s u p p l i e s f o r populations, e s p e c i a l l y i n t h e rural/nomadic centers2." I n t h e context of t h i s o v e r a l l s t r a t e g y of development, t h e Democratic Republlc of Sudan has formulated a Yrimary Health Care Programne whose o v e r a l l o b j e c t i v e is t o achieve maximum h e a l t h coverage f o r t h e r u r a l arid nomadic populations throughout t h e n a t i o n by 1984.3 With reference t o t h i s programme, which l a y s considerable s t r e s s on s e l f - h e l p and cornunity p a r t i c i p a t i o n . i t is e s s e n t i a l t o study means and channels t o f o s t e r and d i r e c t community p a r t i c i p a t i o n and s e l f - h e l p towards ultimate policy o b j e c t i v e s . Thus t h i s major problem and primary obJective of t h i s proposed study is t o i d e n t i f y within rural settled and nomadic communities those existing structui-as and

lnechanisms based on community p a r t i c i p a t i o n upon which community development can be b u i l t and community h e a l t h can be promoted u t i l i z i n g community resources and experiences. S p e c i f i c a l l y the study proposes t o undertake applied research i n two a r e a s of t h e Western Sudan with t h e obJective t o i d e n t i f y and docuir~entways and means t o l i n k cornunity p a r t i c i p a t i o n t o Primary Health Care a t t h e comnunity l e v e l by involving t h e community a c t i v e l y i n t h e d a t a generating development process. Thus t h i s study promises t o serve a s a franewox-k t o be extended t o o t h e r r u r a l and nomadic communities throughout t l ~ ecountry.

11. Relevance of t h e Studx: Despite the number of monographs w r i t t e n on s e t t l e d and r~omadic communities i n the Sudan very few, i f any, have addressed the problem of comnunity development .4 One of the f e w exceptions to this trend hac bocn thc worlc

of t h e new cadre of government t r a i n e d r u r a l development workers notably t h a t of the P r i n c i p a l I n v e s t i g a t o r (See Annex III). A s t h e Primary HealLii Care Programme is j u s t beginning no one has yet undertaken t o study t h e p o t e n t i a l link between community p a r t l c l p a t l o n I n r u r a l and nomadic comrnun3tics and primary h e a l t h c a r e although i t is very c l e a r t h a t such a study is a ma.]or

o b j e c t i v e of t h e planning and implementation process now u n d e ~ w a ~ A . ~r e l a t e d s t u d y conducted i n I r a n has f u r t h e r demonstrated t h e need t o study l o c a l l e v e l s o c i a l s t r u c t u r e s and decision-making processes t h a t c o n t r i b u t e t o p a r t i c i p a t i o n i n government supported development p r o j e c t s t h a t w i l l be both f e a s i b l e and s u s t a i n e d . 6 T h i s s t u d y has both r e s e a r c h and a p p l i e d relevance. O n t h e one hand such a study w i l l generate b a s i c knowledge about the a c t u a l on-going o p e r a t i o n s of c o m n i t y development through s e l f - h e l p schemes t h a t could s e r v e as a framework i n t h e irltroduction of change i n h a a l t h c a r e systems s o e s s e n t i a l throughout the develoging world.7 On the other ilarld, t h i s Study addresses a very p r a c t i c a l problem f a c i n g t h e Sudan a t t h i s juncture of i t s h i s t o r i c a l development: how t o f u r t h e r promote h e a l t h through s e l f - h e l p among t h e many r u r a l and nomadic communities of t h e country?

III. Proposed Plan of Study Methodology Given t h e n a t u r e of t h e problem which involves a n understanding of communities as f u n c t i o n i n g wholes, t h e i n t e r r e l a t i o n s h i p of s e v e r a l methodologies w i l l be necessary. I n t e n s i v e ethnographic fieldwork w i l l be undertaken by two s o c i a l workers under t h e s u p e r v i s i o n of a n a t i o n a l t e c h n i c a l p r o j e c t manager (an experienced r u r a l development economist) and a n a t i o n a l a s s i s t a n t p r o J e c t manager f o r a d m i n i s t r a t i o n (an experienced r u r a l public h e a l t h worker) both s t a t i o n e d i n t h e a r e a s t o be s t u d i e d . This w i l l provide t h e in-depth d e s c r i p t i v e knowledge of t h e comnunity as it p e r t a i n s t o t h e everyday l i f e of t h e v i l l a g e r s and nomads a s w e l l a s t h e network of r e l a t i o n s and o v e r a l l s o c i o - c u l t u r a l p a t t e r n s of comnunity p a r t i c i p a t i o n i n development schemes. Secondly, an o v e r a l l micro-demographic and socio-economic survey w i l l be undertaken involving workers from t h e v i l l a g e s concerned on h e a l t h and s o c i o c u l t u r a l i n d i c a t o r s t o o b t a i n b a s e l i n e information (See s e c t i o n TV). Open ended quest,ionnaires and interviews will bc conducted w i t h key informants r e p r e s e n t i n g t h e l e a d e r s h i p of t h e v a r i o u s s e l f - h e l p and community development i n s t i t u t i o n s w i t h i n t h e two f i e l d s i t e s . Using t h i s s t r a t e g y of r e l a t e d methodologies f u l f i l s one of t h e mador g o a l s of t h e study: trahinp, and u t i l i z i n g t h e e x i s t i n g r e g i o n a l and comnnmity manpower resources t o make use of t h e i r broader e x p e r i e n t i a l knowledge of t h e r e g i o n a t l a r g e . A.

S e l e c t i o n of F i e l d S i t e s To g e t t h e b e s t r e s u l t s from t h e s t u d y it i s proposed t o s e l e c t two c o r n u n i t i e s r e p r e s e n t i n g d i f f e r i n g e c o l o g i c a l a r e a s and l i f e s t y l e s : one rural s e t t l e d and one nomadic, both l o c a t e d in t h e Province of Northern Itordofan, Western region of t h e Sudan. Also two r u r a l c o n m n i t i e s i n t h e Equatoria Province, Southern Region of t h e Sudan.

1. Western Region Ben Gadeed T h i s is a r u r a l s e t t l e d v i l l a g e of approximately 2,000 persons l o c a t e d t e n miles South of E l Obeid. Nnrthern Kordofan Provinae in the savanna region which h a s an annual r a i n f a l l of 350mm and t h r e e c l i m a t i c seasons - r a i n y ( J u l y / ~ c t o b e r ) ; w i n t e r (November/February); and sdmmer (March/June). Moderate savanne v e g e t a t i o n predominates. Topographically t h e a r e a Is l e v e l with minor s e a s o n a l water courses and s c a t t e r e d h i l l s . A number of p r i v a t e w e l l s supply water t o t h e comnunity. The a r e a is populated by people r e l a t e d t o d i f f e r e n t t r i b a l groups a s t h e Bederga, Sheable and Oidyat, whose main economic a c t i v i t y is c u l t i v a t i o n by r a i n a)

a11d i f r i g a t lo11 by s u r f a f s e w e l l s . dliat rnakcs t h i s v i l l a g e i d e a l f o r p u r p o s e s of t l ~ es t u d y i s tile p r e s e n c e of a nurnber of g o v e r r m n t s e ~ v i c e s narrtely: 11ealtJ1 (d i s p e a s d r y ) , educal t o n ( t w c r primary s c h o o l s ) one r.eekly market, d l ell[ yolol~.gy st &Lion aid a pi'0villdldl prxi,.on w i t t , a t rdirlirlt: cerlt,er ( f o d u s b i ~ i gc n . ~ r . t ! i .*dI't i.11, t i c c i i i o n of f ' l v i t s and v e C ; e t a b l e s ) . I r i a d d i t i o n t ht4r.e dr e d l 1 i ' e r e n t 1 ocdl i n s t i t u t i o r i s i n c l u d l r l g a Village Development Corrun[t t e e and a S u d a r 1 t . r ; ~.;ociaList lJr~lonD a s l c U r i i t . El Mazroub T h i s i s a v i l l a g e s i t u a t e d t j ' r m i l e s Northwest of E l Obeld, Nortr, Kordofan ProvIrlce III t h e poor savanna belt r e o c i v i w an a n n u a l r d i n f a l l o f 250m and h a v i n g t h r e e major c l i m a t i c s e a s o n s s i m i l a r t o t h o s e d e s c r i b e d f o r Ben Gadeed. The area h a s g e n e r a l l y poorv v e g e t a t i o n a l c o v e r , l e v e l wl t h a predonlinant s a n d sheet. c o v e r . T I I ~ a r e a s u r r o u n d i n g E l Mazrout is p o p u l a t e d by one main t r i b e known a s b k j a n e e d ( a s e c t o r o f LtLe Dar Part of t h e p e o p l e i n t h e a r e a a r e c o m p l e t e l y s e t t l e d , t h e Hamid T r i b e ) . o t h e r s a r e norrrads. The major economic a c t i v i t i e s a r e c u l t I v a t i o n a r ~ d a n i m a l b r e e d i n g (camel and c a t t l e ) D1r.1~1:: tire s e t t lirg s e a s o n (October~ u n e )t h e number o f p e o p l e l i v i n g i n E l Mazroub r e a c h e s c l o s e Lo 3.000 p e r s o n s . Government s e r v i c e s i n t h e a r e a i n c l u d e : h e a l Lh ( d i s p e n s a r y ) , e d u c a t i o n (two primary s c h o o l s ) , watcr. s u p p l y s t a t i o n , m a r k e t , r e s t house i n a d d i t i o n t o e f f e c t , i v e s o c i a l co1:lnmnity oraganization witii s t r o n g l e a d e r s h i p a V i l l a g e Developnent Committee arvl a :;uclanese Y o c i a l i s t Union B a s i c U n i t . b)

S o u t h e r n Region Lirlya T h i s is a r u r a l s e t t l e d v i l l a g e of a p p r ~ x i m a t e l y1,000 p e r s o n s l o c a t e d forty-five miles b a s t s f J I I L ~ , E a s t e n i E q u a t o r i a l Province i n t h e Savarula regiori wtiich n a s a r l annual r a i r ~ f n l lof 800nun a~id ?wo c l l m a t l c seasons r a i n y (April/Ndvernber), d r y s e a s o n ( w i n t e r - Decemter/Marcki). T h i c k savanna v e g e t a t lor, pr-edclilinates. Topogr-aphical l y r hi? <i:.rtn I : , 1 i. : t l 'I s c ~ a s o r l a lw a t e r c c ~ u r ~ and s~s ocattcred l i i l l s . A ilualhe?' of w e l l s a n d s f reams s u p p l y w a t e r t o tkie comurli t y The a r e a is populat e l ! tzy p e o p l e o r i g i n a t i r g frorn v a r i o u s t r i b a l g r o u p s as Lokoya and I J n l t ? t . ~ a!thougk~ '.lie f o r m e r p r e d o m i n a n t l y , wIlcse ~ r ~ d i n econornlc a c t i v i t ; i s . l i l t l"d1,:o!. by r i i i l i . ~ihlat makes t h i s v i l l a g e i d , ~ , ~ l f o r p u r p o s e s of t h e s t u d y i s Lt,e prest nce of d number o f gLvernnienL s e r v i c e s rlamely: h e a l t h ( d i s p e n s a r y ) , e d u c a t i o n (two prlnlary s c h o c l s ) , twice-weekly market and a p o l i c e p o s t . I n a d d i t j o n t h e r e a r e d i f f e r e r ~ t l o c a l i n s t i t u t i o n s i n c l u d l r q a V i l l a g e 1)eveloornenL Committee and a S u d a n e s e S o c i a l i s t Union M s l c U i ~ l t . T t is a l s o a c ~ > n L r e of C h i e f s C o u r t .

Wanduruba T h i s i s a village .;it u a t x d 3 3 m; .e;.s v J ~aL f I .Juba, Easter11 E2quatul-ia P r o v i n c e i n t h i c k savanna t)ely r e c ~ i v ! r i q an a u i l l a l r a i n f a l l o f tiOOmnl and h a v i n g two ma,]or c l i m a l i c seasolls strnllar t o t h o s e d e s c r i b e d for- l , i r i y d . The arca ha3 t h i c k uugt:tatlorldl COVE^‘, eve1 w i t h s c a L t e r e d h i l l s all a r o u n d . The a r e a is p ~ p u l a t e db j ' h , , . i n rities of F e . g ~ l u and N j a r ~ : L a r a . st : t !td. 1 1 r clki,)ori.ro~lomica c t i v i : i~ s a r c The p e o p l e a r e curnpletel c u l t i v a t i o n by r a l n . The p o p u l a t i o n o f Ltil.; v i l l a ~ ei s apprnx1m:tt l y &0 p e r s o n s . Government s c s r v i c e s i n LJIP i r e a I n c l u d e : flea1 t h ( d i a p r l s a r y ) , e d u c a t i o n (two p r i m a r y s c h o o l s ) , p o l i c e p o s t , r e s t house, nlarhc3L and c h i e f s c o u r t . I n a d d i t i o n t h e r e a r e l o c a l i n s t i t t ~ t i o n si n c l u d i n g a V i l l a g e Development Committee a n d a Sudanese S o c i a l i s t Union B a s i c U n i t . L

C. Field Personnel

I n addition to the field staff and comnunity manpower mentioned under 111-A, the following personnel will be utilized in this study: one raedical assistant from each area with a minimum of five years experience in rural/ nomadic health and community development; one rural nurse from each area; one statistical clerk for both areas; members of inter-departmental provincial committees including cornunity representatives. These will be involved in overall planning, implementation and supervision in addition to part-Lime WHO advisor/consultant (not in the study area). This advisor will time his field advisory services acoording to the overall requirements of the Primary HealLh Care Programme for the Province of North Kordofan. D . Support Facilities One Land Rover will be provided by the provincial authorities; three camels (when needed) will be provided by village committees. Accomodation and food will be partly provided by the village committees where feasible or in the case when the working personnel is from the villages themselves. Fuel and maintenance of the Land Rover and the food and accomnodation not provided are itemized in the Budget (See Annex I ) .

Timing

Preliminary discussions with provincial authorities and leaders of the comrnunities concerned will be undertaken i n December 1976. The study protocal and field instruments (questionnaire specimen, surveys, interview schedules) will be pl-spar-ad with the village leaders a r i d social workers of the comunitles concerned beginning January 1977 and completed Aprilmy 147. The first test run of the instruments and the general survey will be conducted July/November 1977. Preliminary data analysis and refinement of field methodologies and reporting, January 1978. The second test run and survey will be conducted July/November 1378 with data analysis and reporting completed by January 1979. The final Lechnical report and related sclentlflc papers will be written and finalized through March/July 149.

N. Selected Health, Socio-Economic and Cultural Indicators Since the primary obJective of this study is to identify and documnt ways and means to better link community participation to the Primary Health Care Programne at the community level, it is essential to examine specific development indicators, principally the health, demographic, social and cultural conditions as presently found in the communities in order to assess these conditions as possible barriers to or facilitators of overall comunlty development. The justification for focussing on these indicators is related to the overall objectives of the study. For example, we need: 1. To obtain some baseline indications of the possible impact of the wo1,k of the community health worker on the community and his role in community development; 2 . to foster future evaluation work subsequent to the 1ntr~oducLion of the community health worker in these areas; 3 . to create viable ways for integratlng health services into overall comm~iriity development schemes; 4. A comparative baseline for amending the job description of the community health worker as well as a baseline for future restudy of the communities to determine patterns of change in community development over time.

Pliyzic_i'i . ~ x a i l t l ~ I~ .~ . ;~r ? c; i;,cjk t'..~r h?.1 t.!;,ii,~i d ! ~ ~ d . ; e t,kiat ~ tilt; c ~ i i s n l l ~ ~ i t , h e a l t h wcirker. is L ~ L i,.:i13tld t o d e a l wi.t,tl, ~ ! ~ ~ Examp1.e~ ~ ~ off suci: i ~ ~ . i , . l - . c I L~ ,.,,, 3 L,,, t!.; C A S ; , . ~ ~ ~ (-) d,, y c , ~ ILL".% a f e v ~ r ' ?(b) tlc4 y ~ , u ! a v s J i a ~ ~ r l ~ c ~ u ~ ' ? (c) r i ~ ; . i ~ , i Lt*. L:- a c i o , ; ~rriiiuh ~! has la:; tztl nicjrae than one moiiLi~? 'Pl~e number of ctil ldr*eii lilrmimized and by what i,>pis cjf irnmurilzat ion d c t i . ~ i t i d ~

A n ewa!..l~~litrli <if . . v e r y person i n each v i l l a g e , a f t e r obtalniry; p ~ p u l ~ t i o r ~ f ig~rres. K t ~ o w l e a egputered slur* these lirles, I n adrl~LltmL o o t n e r arta:, t o be discussed with cotrmlmitits, could allow 11s t o s p e c i f y c e r t a j c ~i l ~ ~ i i c d t c ~ l , de~nonst,ratlrigpt~L t,exnsof I ~ e a l t t idevelopment. For example, Llle incr'ecae i l l b i r t h r a t e arid t t ~ e decredse of ct~ildkioud~ r ~ o r t a l i twould y s p e c i ~ ys,,r,lc. r r l s ~ s i ~ r e of hea1ti.i development. O r an i n c r e a s e i n d a i l y patierlt v i s i t s t o tic f l c a l i ~ i u n i t would i n d l c a t e incrcaded v i l l a g e r awareness of t h e i r healti1 rit:eds those t needs. 1 1 wci.ld governiner~t s e r v i c e s a v a i l a b l e i n tile villagt-. t o r ~ ~ e c a l s o be an irldicator~of t h e 11calt.h eclucatiol~a c t i v i t y of the oorrunulilty r l c ~ t :~ 1 . war-her a t e s t of h i s e f f e c t i v e n e s s .

B. 1. 2.

Demographic and Soc io-.Economic Indicator-s9 Population survey on a r ~ age-group b a s i s ; Whether o r not a V i l l a g e Developtnent Cormittee, a V i l l a g e o r Ncighbc?r~rl~ooci Council, a " f a r i q " Council o r a Sudanese S o c i a l i s t Urlio~iI h s i c TJni t 2x1, I ? ' t h e number of c a t t l e owned by the community; whether o r not a cash crop is produced; whether or not o t n e r farm mllrrals o r p o u l t r y are kept; t h e number of braidges and roads; ttie number of WJI

3. 4. 5 .

6. 7. 8.

.=r a c ! l i v o r p p o l i ~ t s ;

tile ~limli.ien.G L p i [ lut~.irie:, i n the v i l l a g e ; whether 01. riot an organized aystem f o r t h e dispL,siil ,JS rt?fusv c x i s t and i f so, wklether o r not, I t i s i n a reasonable s t a t e .

, ,

, , 111 ~ i 3 9 i L i ~ tn o u t f ~ z rarea:, Knowledge gat.hr,red a l n i % t 1 1 ~ b c l i 1 1 , . t o be discussed with t h e c o m ~ ~ n i t i c s c:ottlJ , allow 11s t o s p e c i f y c e r t a i n i n d i c a t o r s denlorihtrating p a t t e t n s of socic~-econumic development. For, exarn,~le. i s t h e r e ariy increase i n i n c ~ n ~ per e capita? O r drke tilere any ctidiwes i n occupational pattei-ns? C.

C u l t u r a l ----l n d j cutor% -What i s t h e degree of I i teracy arid e d ~ c c a t l ~ ~ n le av lel? H o w tnarly possess radi~,:;? Wt is t.11~ denree of e x ~ o s u r et.n i n the village? I : t r c t i 1 it~:DLt!l'~ and ~ , I ~ \ IJ I <I:.-I of dependence on Lt~est gdr*s,~n antolg ct~rrrilulll i y nr-wspapi?rLs

1. 2. j.

Inidi.rivzs aild tile ~~c-.~l;r.,-e cjrs

Whether. or not I.di~vus e x i s t oil f i s l i , rnoat, eggs,

o t h e r foods.

. 6.

I d e n t i f i c a t i o n of r i t u a l p r a c t i c e s that nlay be hannfbl t o h e a l t h . L l s t i n g the expressed needs of the conm~uiity.

Knowledge gathered along t h e s e l i n e s , i n a d d i t i o n t o o t l ~ e ra r e a s t o be d i s c u s s e d with communities, could allow us t o s p e c i f y ce1'tal.n i n d i c a t o r s demonstrating p a t t e r n s of c u l t u r a l development. For example, Illcreased n~jmber~s of v i l l a g e r s being a b l e t o read and w r i t e would i n d i c a t e c u l t u r ~ a ldevelopr~~ent I n c r e a s e d ~~urnbers l i s t e n i n g t o r a d i o s , reading newspaperss would i n d i c a t e ways and means of u t i l i z i n g mass media t o extend information and 1iealt.h t-tiucation m a t e r i a l s from urban c e n t e r s . Determining t h e numLer of t r a d i t iona 1 hea1er.s and t h e degree and n a t u r e of t h e i r cooperation betwee11 tf~emand t h e c u n ~ u i i t y h e a l t h worker would i n d i c a t e t h e c u l t u r a l development. of a t t i t u d e s and p r a c t i ~ o s promoting cornunity health and development. This kind of data n ~ i g l ~dtl s o p r - c . ide a u s e f u l franlework f o r t h e e v a l u a t i o n of c o m i t y involvcmerit f o r h e a l t h s e r v i c e s development. 10 Systematic i n v e s t i g a t i o n i n t o a l l t h r e e c a t e g o r i e s of i n d i c a t o r s w i l l g i v e t h e policy-maker a wide range of information with which more e f f e c t i v e c o m n i t y developn~entschemes can be planned. It is well understood t11at change i n one s e c t o r of a c o m n i t y w i l l have i t s e f f e c t s on o t h e r dimensions of community l i f e . Hence, t h e n e c e s s i t y t o s e e t h e s e varaious i n d i c a t o r s a s d i f f e r e n t a s p e c t s of the same problem: o b j e c t i v e expressions of cclrlununi t y development.

V. A.

Expected R e s u l t s of t h e Studx Comnunity Level The r e s u l t s of t h i s s t u d y sllould b e n e f i t t h e c o r n u n i t i e s concer,rled by: 1. Providing a b e t t e r h e a l t h s e r v i c e d e l i v e r y system from the conununities' p o i n t s of view. 2. I d e n t i f y i n g and exploring new means and approaches of f o s t a r o i n g self -1tely aui~ernesur~dmechanisms. 3 . S t r e n g t h e n i n g l o c a l socio-economic development a c t i v i t i e s . 4. C r e a t i n g new s o l i d grounds f o r f u r t h e r development activities t h a t may l e a d t o b e t t e r l i v i n g s t a n d a r d s at t h e community l e v e l . P r o v i n c i a l Authority Level R e s u l t s a t t h i s l e v e l should: 1. Lead t o t h e dlscovery of new measures and means of betLer hcalt11 c a r e d e l i v e r y from t h e p r o v i d e r ' s p o i n t of view. 2. I d e n t i f y new o r b e t t e r approaches f o r s e l f - h e l p and comnunity p a r t i c i p a t i o n i n p r o v i n c i a l development schemes. 3. I d e n t i f y means of a p p r o p r i a t e a l l o c a t i o n and i n t e g r a t i o n 01' corn:~uni ty p a r t l o i p a t i o n and s e l f - h e l p schemes w i t h i n p r o v i n c i a l development projects. 4. Provide s c i e n t i f i c e v a l u a t i o n of p r e s e n t means of s e l f - h e l p .

Mational and I n t e r n a t i o n a l Level The expected r e s u l t s a t t h e government m i n i s t e r i a l and WHO l e v e l include: 1. The review and e v a l u a t i o n of t h e r o l e given t o s e l f - h e l p and cor!ununity p a r t i c i p a t i o n i n t h e Primary Health Care Programme of t h e Sudan. 2. Finding out new methods and approaches t o c o m u n i t v p a r t i c i p a t i o n in ~ t t t ? d e l i v e r y of h e a l t h s e r v i c e s a s p a r t of t h e rural/nomadic process of comnunity development. 3 . Finding out a d d i t i o n a l measures and i n d i c a t o r s f o r t h e e v a l u a t i o n of the Pr-i~turx-yHaaltk~C a r e Programme and/or' planning s i m i l a r programnlfs i n o t h e r developing c o u n t r i e s . The o v e r a l l r e s u l t of t h i s study is t h e g e n e r a t i n g of knowledge t h a t w i l l make a d i r e c t c o n t r i b u t i o n t o p o l i c y developmerit i n tile Sudan, p a r t i c u l a r l y a s t h i s r e l a t e $ t o t h e p r i o r i t i e s of t h e Six-Year Plan arid tile I J a t i ~ n a l Health Programme.

A N N E X I

FSTIMAW BUWET

Western Region

ITfa 1. Technical Manager (~uraD l e i r . Economist) 2. A s s ' t Adm. Manager

M O N T H L Y COST IS

'YJOHK/frlOm

'L'UTAL I S

1x80 1 x 25

24 24

1 b00

3. WIIO Aclvlsur

1 x 345.5

1382

4. S o c i a l Workers

5. Medical Ass'ts 6. Nurse

7. Clerk

8. Community Health Worker 9. Fuel and Maintenance 10. Equipment and S t a t i o n a r y

2 x

?4 20

1440

1 x 8 0

1v 0 0

1.1. T r a n s p o r t a t i o n A i r Ticket E l Obeid/Khartoum/El Obeid 12. Accommodation and Food

( p a r t l y provided by communities)

Unforaqeable? 10%

1.006

Price Incr. Twelve Thousand and One Hundred and Seventy-Five Sudanese Pounds

10%

11,008 1 ,lo'(

TOTAL 12,1';.1lS

I n Dollars

12,175 x 2,9 =

$35, 375.00

T h i r t y Five Thousand and Three Hundred and Seventy Five D o l l a r s

11. Southern Region S i m i l a r estimated budget a s f o r t h e Western Region:

$35, 375.00

111. T o t a l estimated budget: NOTE: -

$35, 375.00 x 2 = $70, 150.00

(1) It I s expected t h a t , following d i s c u s s i o r s of t h i s p r o j e c t w i L t l a u t h o r i t i e s w i t h i n t h e two communities, w e s h a l l most l i k e l y recelvt. c o n t r i b c ~ ioil; t t h a t w i l l d e f r a y up t o 20% of the t o t a l budget. de (2) It i s expected L b a L P r o v i n c i a l Ciovernmunt author1 t j cs st la1 1 p r ~ iv trarisport f a c i l i t i e s @and Hover) I n a d d i t i o n L o development s q p p o ~ , f ~d c i 1 i ~i t.5 Including t e c h n i c a l resources, drugs, f e r ~ i l i z e r s ,pumps, e t o . ( 3 ) It should also be pointed o u t t h a t t h e cosL budgeL of t h i s prri.,ect t o t a l s considerably l e s s t h a n s i m i l a r p l ~ o J e c t sunder8taken i n T q z a n i d . Mcxlco and Iran.

ANNEX I1

Bibliographic Inforlmtion on principal investigators

I. Western Region 1. Prir~cipalInvestl~ator - Mr M.A. Baroudi, Rural Development Econumist

Educational Background B . A . , Rural Ecorlomics, Faculty of Arts, University of Kt~ar- tour^^, 13/0. Post-Graduate Diploma in African-Asian Studies, Institute of' AfricanAsian Studies, University of Khartoum, 1974.

B .

Professioxlal and Field Experience 1971-1975 Assistant Rural Development Inspector, Department of Rural Development and Water Supply, Ministry of Agriculture 1975-Present Rural Development Inspector, Department of Rural Development and Water Supply, Ministry of Agriculture lql-Present has been engaged in several rural-economic studies with special reference to rural water supply programmes at the comnunity level, North Kordofan Province in addition to planning rural development schemes.

Published Work Life and Traditions of the Hamar Tribe (In Arabic) University Khartoum, 1971. of

Kababish Rural Council (In Arabic) Department of Rural Ikvelopment and Water Supply. Ministry of Agricillture, 1975.

Contributed reports on "Situation Analysis" and "Nomads" in Primary Health Care Programme Eastern, Northern, Central and Western Regions of the Sudan. Khartoum, May 1976. Worker for the Primary Health Care Programme 1977 - 1984, Khartoum, November 1976. h Conunun i t y H e a l t h Participated in the preparation of the Manual for t

1 1 . Southern Region 1. Principal Investigator A.

- Mr

Nathan WaJia Pltla

Educational Background Diploma in Theology 2Y2 years at Bishops Tucker College (Uganda) Diploma in Social Policy and Administration Swansea University, United Kingdom Work Experience Worked as a Social Worker at the Friends Community Centre in Nairobi (1964-1969) - Jolned the Mlnlstry of Informatioll as a Senior Social WorKur 111 1 Y p Transfered to the Ministry of Health and Social Welfare wiLh the same post with more executive and researckl responsibilities.

A p r i n c i p a l S o c i a l Worker i n Headquarters of t t ~ e Hegiorldl YlirlisLr.y of H a a l t l l and S o c i a l Welfare. And now Acting I n s p e c t o r of 3cjcial We1t'ar.e f o r F a s t e r n E q u a t o r l a Province. A s s i s t i n g t h e A c t i r a B u n i o r I r ~ j p c t ca r and the D i r e c t o r of ttie Primary H e a l t h Care Progr-mrne

- A

nernber of t h e R u r a l Development C o r o d i r ~ a ~ i r C ~og~ l r ~ c f il or L t x Southern Region

Planning U n i t of t h e Mirristry of H e a l t h and S o c i a l Welfare Headquarters A member of the

A member of t h e Programrne Formulation Team f c r tile P.H.C.P. f o r the S o u t h e r n Region ( ~ e f Group . A)

A member of t h e Programme Formulation Team f o r P.H.C.P. f o r the r e s t of t h e Sudan (Ref. Group A ) And a member of t h e E d i t i n g Committee f o r P.II.C.P. t'or Hest of' t.he Sudan.

m I11

BIBLIOGRAPHY

Sudan, Democratic Republic o f , National Health Programme l 1 W - 7 8 N I C E F W H O J o i n t Committee 1()83/84, Khartoum (April 1075). U on Health Policy, W H O U N I C E F J o i n t Study of Alternative Approaches t o Meeting Bas1 c Health Needs of Populations i n Developing Countries (Geneva: WHO, 1375)

Sudan, Democratic Republic o f , "The Six-Year Plan

(1m-83) for Economic and Social Development i n Sudan" an unpublished report by Mahammad El Kheir Abdel Gabir, Acting Undersecretary f o r Planning, Ministry of Finance, Planning and National Economy, Khartoum, October l T 6 .

Sudan, Democratic Republic o f , Primary Health Care Programme, Eastern, Northern, Central and Western Regions, 1977/78-1983/84 Khartoum ( 1 ~ 6 ) . A. A. I d r i s s , P. Lolik, R. A . Khan, and A . Benyoussef, nSudan National Health Programme and Primary Health Caren, B u l l e t i n , WHO, Vol. 54, September 8, 1 ~ 6 and ; "The Primary Health Care Programme i n t h e Sudan", WHO Chronicle, 3: 370-774, (1176)

Ian Cumison, Baggara Arabs, Clarendon Press (1966). E. E. Evans-Pri tchard , The Nuer, Oxford University Press (1940). S i r H. MacMickiael , The Tribes of Northern and Central Kordofan, Cass (1967). Talad Asad The Kababiah , C. Hurst , London ( 1 ~ 0 ) . S F. Nadel , The Nuba, Oxford University Press (lc)47).

Sudan, Democratio Republio o f , Primary Health Care Programme op. c s . pp. 125-128.

B. and M. J. Good, "Health Services Development Research P r o j e c t " , West Azerbaijan, Iran. WHO Assignment Report EM/RH/30 JulyAugust ( 1 4 5 )

Kenneth Newel1 Health by t h e People ( ~ e n e v a , WHO 1975) s e e e s p e c i a l l y Introductory and Conoludlng ohaptera. Sudan, Democratic Republic o f , Primary Health Care Programme 9. G. p. 129.

10. 1 1 .

B. and M. J . Good, op. c i t . Sudan. Dmocrati c Republic of, Primary Health Care Programme, 2 . pp. 28-30.

- -

Draft ~ r o p o s a lfor discussion

ORIENTATION COURSE IN EVALUATIVE HEALTH SERVICE RESEARCH

DURATION

four ( 4 ) weeks; 6 hours per day;

five days a week; 6th day field visits.

PARTICIPANTS

Ministry of Health personnel from countries in the Eastern Mediterranean Region involved in planning and evaluation of health programs and projects including.but not limited to administrators, physicians, nurses &

sanitary

engineers holding bachelors degrees or professional equivalents.

COURSE FORMAT SPONSORING AGENCIES

: :

Lecture-Discussion and Demonstration. EMRO/WHO, Alexandria; USAID, Cairo;

Institute of National Planning, Cairo.

COURSE OBJECTIVES: --

The purpose of this course is to provide a rather intensive introduction to the field of evaluative social research especially of evaluation of health programs and projects. The behavioural aims of the course are to instill in the participants:

an awareness of what is involved in the evaluative process; an awareness of the kinds of problems

that are peculiar to this type of policy oriented research;

an understanding and appreciation of the various methodologies and of under what circumstances each is appropriate;

an understanding and appreciation of the multidisciplinary nature of the evaluative process and h e n c e of t h c need for a team

approach to health system evaluation.

In addition the participants will be given the opportunity through weekly practicums to formulate evaluative research designs. Some

attention will be devoted to a presentation of various statistical techniques. The emphasis

of the course however is on the broader area of design and it is assumed that participants have some familiarity with statistical procedures.

COURSE EVALUATION:

The participants will, as part of their practicum, be asked to develop an evaluative design

for this course.

The basic structure will

include evaluation of content, topic and presentation of each of the elements in the course. Further they will be asked to develop

criteria according to which they themselves should be evaluated.

COURSE LECTURERS :

Consultants will be drawn from EMRO, AID

INP

the High Institute of Public Health, Alexandria to serve as professors for the course lecturers.

ADMINISTRATION

A Consultant/Coordinator will be selected to refine the design,implement and administer the course.

The course will be held at the INP or partially at INP and partially in Alexandria at the High Institute of Public Health.

LANGUAGE

The course will be conducted in English.

DATES

The course is tentatively scheduled for January 1978.

COURSE CONTENT

GENERAL PRINCIPLES OF RESEARCH DESIGN: Problem formulation; theory: explanatory and predictive hypothesis formulation;

power of t h e o r e t i c a l frameworks;

operationalization of variables hypothesis testing methodology; Duration: analysis; day presentation of results.

One

11.

EVALUATIVE RESEARCH:

AIMS

OBJECTIVES:

The basic question evaluative research is intended to answer is how well does a social program or project work 0

In what ways is evaluative research a guide to decision making? Clarification of aims and objectives in evaluation of health programs and projects is a major topic in this section. Specification of objectives and the question of replicability criterions will also be treated. Duration: One day

111. OVERVIEW OF PROBLEMS: RESEARCH DESIGN:

THE FIRST STEP IN EVALUATIVE

Inherent complexity of social policy areas makes it difficult to conceptualize the problem adequately and at the same time in a manner r i g i o r o u s enough so that results are meaningful.

S o c i a l s c i e n c e methods and f i e l d p r o c e d u r e s a r e n o t o f t e n adequate f o r producing e v a l u a t i v e r e s u l t s nor a r e t h e y sound enough t o w a r r a n t u s e i n t h e s o c i a l policy process. T e c h n i c a l d e f e c t s s u b j e c t t h e metho-

d o l o g y employed t o l e g i t i m a t e a t t a c k .

S h o r t a g e s o f p r o f e s s i o n a l r e s e a r c h e r s t r a i n e d i n eval u a t i o n o f s o c i a l programs and i n t h e f i e l d o f e v a l u a t i o n i n g e n e r a l o f t e n hampers e v e n ' t h e b e s t d e s i g n e d research projects.

B u r e a u c r a t i c problems a l w a y s a r i s e .

One o f t h e more Of

s e r i o u s i s t h a t of managerial r e s i s t a n c e .

ten projects

o r program managers do n o t l i k e t o b e g r a d e d and t h i s

i s v s u a l l y how t h e y see e v a l u a t i v e r e s e a r c h .

As partial

s o l u t i o n t o t h e problem t h e b e n e f i t s o f t h e change o r i e n t e d approach over t h e control oriental approach

t o e v a l u a t i o n w i l l be e x p l a i n e d .

A l l p u b l i c programs b u t p e r h a p s e s p e c i a l l y h e a l t h a r e

p o l i t i c a l i n nature.

O f f i c i a l s make l i f e and d e a t h

a f f e c t i n g d e c i s i o n s when t h e y i n t r o d u c e o r modify programs. H e a l t h programs a r e a l s o h i g h l y v i s i b l e .

These f a c t o r s make e v a l u a t i v e s t u d i e s d i f f i c u l t t o c a r r y out.

The l a r g e - s c a l e m u l t i d i s c i p l i n a r y e f f o r t s n e c e s s a r y t o c o n d u c t e v a l u a t i v e s t u d i e s demand h i g h l e v e l s o f t e c h n i c a l , a d m i n i s t r a t i v e and o r g a n i z a t i o n a l s k i l l b u t seldom a r e governments o r t h e s o c i a l s c i e n t i s t s s t a f f e d and o t h e r w i s e e q u i p e d t o c a r r y o u t s u c h s t u dies.

A l l t o o f r e q u e n t l y a l l b u t t h e m e t h o d o l o g i c a l problems a r e

i g n o r e d and r e s e a r c h f l o u n d e r s .

In t h i s course considerable

a t t e n t i o n w i l l be devoted t o an in-depth e x p l o r a t i o n of each o f t h e s e problems u s i n g s p e c i f i i c c a s e m a t e r i a l drawn from t h e experience of t h e countries i n the region. The i n t e r -

p l a y between e a c h o f t h e above c o n s i d e r a t i o n s w i l l a l s o be e x p l o r e d .

Duration:

/days 1 day

Field V i s i t s :

End o f F i r s t Week

IV.

SCOPE

CHARACTERISTICS OF EVALUATIVE HEALTH SYSTEM RESEARCH:

E v a l u a t i v e h e a l t h s y s t e m r e s e a r c h and t h e s c i e n t i f i c method; t h e aims o f e v a l u a t i v e r e s e a r c h i n h e a l t h a s r e s u l t o r i e n t e d ; qims t o p r o v i d e f a c t u a l b a s i s f o r d e c i s i o n making and i s c h a r a c t e r i z e d by: a) b) c) d) System O r i e n t a t i o n , M u l t i d i s c i p l i n a r y approach, Use o f S c i e n t i f i c Methods, o b j e c t i v i z a t i o n o f d e c i s i o n making p r o c e s s .

Attention will be devoted to a clarification of the above concepts and of the types of evaluative research especially outcome evaluation (that which is concerned with measuring the effects of existing projects on their direct participants, other groups and/or specific institutions) and field experiments (those which are designed to assess the merits of new policy ideas). Duration: 1 /day

METHODOLOGY IN EVALUATIVE HEALTH SYSTEM RESEARCH

In this section attention will be devoted to an examination of the various approaches that have been or can be used in evaluative health research: A. Process evaluation and outcome evaluation

Evaluation Models 1. Preex~erimentaldesians

factors affecting the internal validity of pre-experimental designs: history; maturation; testing; instrumentation; statistical reqression; selection-maturation; interaction; selection; mortality.

factors affecting the external validity (generalizability : a) units sampled:

b) factors sampled; c) outcome measures sampled; d) reactive effects; e) naturally correlated variables.

Types of pre-experimental designs: *Post-~est-OnlyDesigns

a) Description; b) ~equirements ; c) Limitations; d) Utility of Results; e) Region case examples. *One-Group Pretest-Posttest Design a) Description; b) Requirements;

c) Limitations ; d) Case examples. The Impact-Effectiveness Model

Description and Historical Development of; Theoretical Justification for Use of; Requirements for Implementation of; Validity of Results (Internal &

External Validity) ;

Difficulties Encountered and Ways of Overcoming them;

- Case Examples from the Region Illustrating the correct

and incorrect applications of the model;

Participants Practicum:

Develop an Impact-Effecti-

veness Research Design for Evaluating a Health Project or Program.

Duration:

3 /days

Field Visit:

End of Second Week

The Cost-Benefit Model and Evaluation of Health Programs

Description and historical development; A

priori and ex-post cost-benefit analyses;

Problems in applying the model; Requirements for its application; Measurement of costs and benefits; Relationship of program evaluation and the planning process;

Case studies (e.g. the cardiac handicapped youth study by W.A. HASSOUNA).

- Participants practicum: evaluation. Duration: 3 /days

design a cost-benefit

Field Experiments Description; problems of implementation; validity; case examples from the region; participants practicum: design

of a field experiment to evaluate a health project or program. Duration: 3 /days End of Third Week - 9 -

--.

E v a l u a t i o n Techniques A.

The e v a l u a t i o n models p r e s e n t e d i n S e c t i o n V. a r e designed t o e n s u r e g r e a t e r o b j e c t i v i z a t i o n of r e s u l t s . I t is assumed that p a r t i c i p a n t s have

a b a s i c u n d e r s t a n d i n g of d e s c r i p t i v e and i n f e r e n t i a l s t a t i s t i c s and p r o b a b i l i t y t h e o r y y e t some a t t e n t i o n w i l l be g i v e n t o c l a r i f i c a t i o n o f t h e c o n d i t i o n s of u s e when a p p l i e d t o evaluative health research. analysis i n

O p e r a t i o n s Research Techniques and E v a l u a t i o n o f h e a l t h p r o j e c t s , programs, s e r v i c e s and p r a c t i c e s . (1) O p e r a t i o n a l i z a t i o n of v a r i a b l e s , o r d i n a l , nominal,

and i n t e r v a l measures and a p p r o p r i a t e n e s s o f c o r r e l a t i o n , m u l t i p l e r e g r e s s i o n and m u l t i v a r i a t e analysis: d e s c r i p t i o n , requirements f o r applica-

t i o n , l i m i t a t i o n s , examples i n t h e h e a l t h f i e l d . (2)

I n v e n t o r y modeling; CPM ( c r i t i c a l p a t h method), PERT (program e v a l u a t i o n and review t e c h n i q u e ) GERT (Graphic e v a l u a t i o n and review t e c h n i q u e :

d e s c r i p t i o n of each; u t i l i t y of t h e techniques i n h e a l t h p r o j e c t e v a l u a t i o n s and r e q u i r e m e n t s f o r u s e ; examples of a p p l i c a t i o n s of each of t h e techniques; l i m i t a t i o n s .

(3)

Input/Output Analysis and Linea$.Programming: description; requirements for use; limitations; examples from countries in the region in the health field.

(4)

Queueing techniques f o r p r e d i c t i o n in h e a l t h

practice research: description of techniques, requirements for application; limitations; case examples where utilization of the technique would be useful in health.

(5)

Simulation 9s an evaluative managerial tool in health: description of techniques; computer

assisted qnd non-computerized simulations techniques; requirements for use; limiations; case examples in health.

Duration-: 4 days

Field Trip: 1 € l a y

VII.

Course Conclusion, Recommendations and Evaluation. 1 day End of Course

Duration:

End of Fourth Week

Draft p r o ~ o s a lf o r discussion

EM/blTrJ.SCF.GRP .HS .F€3~/4.g

CHALLENGES TO E F F E C T I V E HEALTH COVERAGE A COMPARATIVE EVALUATIVE STUDY

INTRODUCTION :

In spite of the significant variations in the quantity and quality of health resources in various countries of the Eastern Mediterranean Region (EMR) let along sociocultural differences, almost all health authorities in these (EMR) countries aspire to achieve effective coverage of their populations through adoption of a model for health service delivery in which the focus is almost entirely on the delivery of curative and rehabilitative personal health services.

The tendency has been and still is within

the

EMR to adopt such a model because it happens to be that

model which is fairly well suited to meet the health challenge faced by highly industrialized Eastern or Western countries which happen at the time to be the "significant other" countries with which EMR countries strongly identify and perceive to be "modern".

In most cases this decision to adopt the physician-centered personal-service model which emphasises illness is done without any reflection either about:

(1) the conditions prevailing in the Eastern or Western country selected for imitation;

(2)

t h e h i s t o r i c a l development of h e a l t h systems i n t h e country s e l e c t e d f o r i m i t a t i o n ;

(3)

t h e n e c e s s i t y f o r modeling t h e h e a l t h system anyplace n o t on what o t h e r s do b u t f a c i n g t h e c h a l l e n g e of t h e p r e v a i l i n g p a t t e r n o f d i s e a s e and w i t h an assessment o f r e s o u r c e c o n s t r a i n t s such a s manpower, f i n a n c i a l , l o g i s t i c , o r g a n i z a t i o n a l , and p a r t i c i p a t i v e systems w i t h i n t h e country.

To c i t e b u t one example, i t i s i n t e r e s t i n g t o n o t e , reviewing

t h e h i s t o r y of h e a l t h c a r e development i n U.S.A. t h e l a t t e r h a l f o f t h e 1 3 t h . century

t h a t from

(1876) through t h e f i r s t

World War t h e p r e v a i l i n g p a t t e r n o f d i s e a s e more c l o s e l y approximated t h a t of a dominantly communicable d i s e a s e p r o f i l e such a s i s found i n EMR c o u n t r i e s today. A t t h a t time t h e

s t r i k i n g c h a r a c t e r i s t i c o f t h e h e a l t h e f f o r t s i n t h e U.S.A. was t h e s t r o n g emphasis on t h e development of good p u b l i c s a n i t a t i o n and p r e v e n t i v e s e r v i c e s . The need f o r and t h e

emphasis on p r o v i s i o n o f u n i v e r s a l l y a v a i l a b l e and a c c e s s i b l e s a f e d r i n k i n g w a t e r , t o i l e t f a c i l i t i e s , s a f e and adequate sewerage and r e f u s e d i s p o s a l , and t h e development o f mass comp a i g n s t o i n s t i l l good p e r s o n a l h i g i e n e h a b i t s i n t h e people a r e examples of s u c c e s s f u l h e a l t h s e r v i c e d e l i v e r y which charac-

t e r i z e d t h i s period. general practitioner

These, t o g e t h e r w i t h t h e d e v o t i o n o f t h e ( f a m i l y d o c t o r i s t h e term used i n t h e

s t a t e s t h e n a s now) who t r a v e l e d f a r and o f t e n a t g r e a t p e r s o n a l

r i s k t o s e r v e t h e r u r a l p o p u l a t i o n were t h e main c h a r a c -

t e r i s t i c s o f p u b l i c h e a l t h and h e a l t h s e r v i c e s .

They

were s u c c e s s f u l l a r g e l y b e c a u s e it was t h e a p p r o p r i a t e h e a l t h s y s t e m r e s p o n s e i n f a c e o f t h e c h a l l e n g e posed by t h e pattern of d i s e a s e prevailing a t f h a t t i m c i n t h a t

country. The o b s e s s i o n i n EMR c o u n t r i e s w i t h t h e p h y s i c i a n o r i e n t e d c u r a t i v e - r e h a b i l i t a t i v e model i n s p i t e o f t h e a c c u m u l a t i n g e v i d e n c e o f i t s l a c k of r e l e v a n c e at this

p o i n t i n t i m e f o r them h a s s e r i o u s l y s h i f t e d t h e e m p h a s i s o f h e a l t h a u t h o r i t i e s i n t h e s e c o u n t r i e s from m e e t i n g t h e real h e a l t h needs of their p o p u l a t i o n t o meecing t h e needs

o f t h e h e a l t h s y s t e m i t s e l f and h e a l t h p r a c t i t i o n e r s on t h e f a l l a c i o u s assumption o f a l i n e a r c a u s e - e f f e c t r e l a t i o n s h i p between t h e two. T h i s i s c l e a r l y e v i d e n t i n most h e a l t h

p l a n s o f t h e s e c o u n t r i e s where t h e m a j o r p o r t i o n o f r e s o u r c e s

i s i n v e s t e d i n c o n s t r u c t i o n o f huge c u r a t i v e h e a l t h f a c i l i t i e s , w i t h r e q u i s i t e s u p p l i e s and e q u i p m e n t and m e d i c a l d r u g s . a d d i t i o n v a s t i n v e s t m e n t s and e x p e n d i t u r e s a r e a b s o r b e d i n t h e p r o d u c t i o n o r a c q u i s i t i o n o f h e a l t h manpower t o m e e t t h e needs o f the h e a l t h system. Whil'e t h e p h y s i c i a n - o r i e n t e d

c u r a t i v e model i s s l i g t l y more r e l e v a n t w i t h i n u r b a n s e t t i n g s i n some EMR c ~ u n t r i e s , i t s r e l e v a n c e to rural communities i s

extremely doubtful.

I n s p i t e of t h a t , t h e extension of a

m i n i a t u r e o f t h e same model t o s e r v e r u r a l communities h a s l e d t o i n e f f e c t i v e u t i l i z a t i o n o f r u r a l h e a l t h s e r v i c e s and

hence l i t t l e impact on h e a l t h s t a t u s .

Utilization

s t u d i e s of r u r a l h e a l t h s e r v i c e s i n v a r i o u s c o u n t r i e s o f t h e r e g i o n have r e p e a t e d l y r e v e a l e d p h y s i c a l , s o c i a l , c u l t u r a l , managerial and economic f a c t o r s as t h e main

reasons f o r u n d e r - u t i l i z a t i o n .

Hassouna's s t u d y on

B e l i e f s , P r a c t i c e s , Environment and S e r v i c e s A f f e c t i n g t h e S u r v i v a l , Growth and Development o f Young Egyptian C h i l d r e n (1975) i n d i c a t e s s o c i o - c u l t u r a l impediments a r e numerous and s t r o n g e s p e c i a l l y among v i l l a g e r s .

Attemps t o a d a p t t h e p h y s i c i a n - o r i e n t e d c u r a t i v e model and e x p e r i m e n t a t i o n w i t h new models t o meet t h e r e a l

h e a l t h need of t h e pebple i n v a r i o u s EMR c o u n t r i e s a r e c l e a r evidence of the strong d e s i r e among health autho-

r i t i e s i n t h e s e c o u n t r i e s t o f i n d ways and means t o meet t h e chddlenge and achieve t h e u l t i m a t e goal of e f f e c t i v e

coverage.

N a t u r a l l y t h e p a t h t o a c h i e v e e f f e c t i v e coverage

d i f f e r s from one c o u n t r y t o a n o t h e r s i n c e it i s mainly a f u n c t i o n of i t s s o c i o - c u l t u r a l , economic and p o l i t i c a l

c h a r a c t e r i s t i c s and hence no u n i v e r s a l o r even r e g i o n a l path is available.

Thus t h e o n l y r a t i o n a l way t o f i n d t h e

a p p r o p r i a t e p a t h s h o u l d be based on e v a l u a t i v e h e a l t h s e r vices research. While each c o u n t r y w i l l have i t s unique

f e a t u r e s a comparative e v a l u a t i v e h e a l t h r e s e a r c h can p r o v i d e u s w i t h a l o t of t r a n s f e r a b l e p r i n c i p l e s i n a c h i e v i n q

an a p p r o p r i a t e s o l u t i o n .

Based on t h e above r a t i o n a l e it i s s u g g e s t e d t h a t EMRO/ WHO s h o u l d s t a r t i t s a c t i v i t i e s i n e v a l u a t i v e h e a l t h s e r v i c e s research by supportiny a c o m p a r a t i v e s t u d y o f

t h e r e a l challenges f o r e f f e c t i v e h e a l t h coverage facing three d i f f e r e n t countries i n the region, i . e . , Egypt and Yemen. Kuwait,

The t h r e e c o u n t r i e s a s p i r e t o a c h i e v e curative-

e f f e c t i v e coverage through t h e physician-oriented

r e h a b i l i t a t i v e model y e t e a c h o f t h e s e t h r e e c o u n t r i e s i s t r y i n g t o m e e t t h e c h a l l e n g e i n t h e f a c e o f d i f f e r e n t sets o f c o n s t r a i n t s and c h a r a c t e r i s t i c s , e . g . manpower c o n s t r a i n t s

i n Kuwait, c a p i t a l c o n s t r a i n t s i n Egypt and b o t h i n Yemen.

FRAME O F ANALYSIS I n t h e p r o p o s e d s t u d y h e a l t h s e r v i c e s a r e viewed a s a s y s t e m which r e w i v e s a v a r i e t y of i n p u t s which a r e h i g h l y d e p e n d e n t on t h e development l e v e l o f t h e community, t o m e e t t h e demand on i t s s e r v i c e s and i n t u r n p r o d u c e s o u t p u t s

which h a v e q u a l i t a t i v e and q u a n t i t a t i v e i m p a c t s on t h e p o p u l a t i o n o f t h e community s e r v e d which l e a d s t o q u a l i t a t i v e

and q u a n t i t a t i v e c h a n g e s i n b o t h t h e development l e v e l o f t h e community and t h e demand on i t s h e a l t h s y s t e m .

(see d i a g r a m ) .

LEVEL OF

1 \

'Jl:VET,OPMCNT

P U

%EMAND

S13RVICE

\/ LOGISTIC FINANCIAL

SYSTEM SYSTEM

R E

A L

I.II\NPOIJCR

SYSTEM

H S

Y E

T M

Based on t h e above r a t i o n a l e t h e e f f e c t i v e n e s s o f t h e h e a l t h s y s t e m s h o u l d b e measured by changes i n h e a l t h s t a t u s and c o n t r i b u t i o n t o development l e v e l . The

p r a c t i c a l d i f f i c u l t i e s of accounting f o r a t t r i b u t i o n makes s u c h an e n d e a v o r e x t r e m e l y d i f f i c l l l t . This forces

u s t o resort t o t h e n e x t l e v e l o f a n a l y s i s , i . e . : o u t p u t and h e n c e w e measure e f f e c t i v e n e s s by m e a s u r i n g

i t s l e v e l o f u t i l i z a t i o n and a n a l y s i n g v a r i o u s f a c t o r s a f f e c t i n g it. T h i s a n a l y s i s s h o u l d i n c l u d e t h r e e main

groups of f a c t o r s : (1) f a c t o r s e x t e r n a l t o t h e h e a l t h s y s t e m .

i.e.:

b e l i e f s and p r a c t i c e s , s i z e o f

resources a l l o c a t e d t o t h e h e a l t h system.

(2)

f a c t o r s i n t e r n a l t o t h e h e a l t h system such

a s organization,

personnel,

supply etc...

(3)

f a c t o r s r e s u l t i n g from t h e i n k e r a c t i o n between i n t e r n a l and e x t e r n a l f a c t o r s m a i n l y r e f l e c t i n g d i s c r e p a n c i e s between p r o f e s s i o n a l and p o p u l a r perceptions concerning u t i l i z a t i o n of services.

OBJECTIVES OF THE STUDY To assess t h e e f f e c t i v e n e s s of h e a l t h s e r v i c e s a t t h c primary

l e v e l i n Kuwait, Egypt and Yemen and s u g g e s t c h a n g e s n e c e s s a r y

to a c h i e v e e f f e c t i v e coverage w i t h i n a r e a s o n a b l e t i m e period. e.g.:

5 t o 10 y e a r s .

E f f e c t i v e n e s s of t h e h e a l t h system i s d e f i n e d a s t h e ability of the system to:

.%-

(1) d e t e c t and respond t o t h e r e a l h e a l t h needs

of t h e community, and; (2)

follow-up and e v a l u a t e measures t a k e n t o sat i s f y t h e s e needs.

I n o p e r a t i o n a l terms e f f e c t i v e n e s s c o u l d be measured through: (1) H e a l t h S t a t u s ;

(2) (3)

Utilization Patterns: Community P a r t i c i p a t i o n P a t t e r n s .

A s y s t e m ' s a b i l i t y t o d e t e c t h e a l t h needs i n t h e community

i s b a s i c a l l y a f u n c t i o n o f i t s ability f o r s u r v e i l l a n c e

o f h e a l t h s t a t u s of t h e p o p u l a t i o n .

Hence t h e e f f e c t i v e n e s s

o f d e t e c t i o n can be measured by t h e e x t e n t t o which t h e s u r v e i l l a n c e system i s a b l e t o d e s c r i b e and p r e d i c t t h e h e a l t h s t a t u s o f c r i t i c a l groups. e.g.: aged. ,

mothers,

children,

workCI ers,

Likewise a s y s t e m t . s a b i l i t y t o respond t o h e a l t h n e e d s 8 i s dependent on i t s a b i l i t y t o d e t e r m i n e p r i o r i t i e s and a l l o c a t e resources accordingly. Hence t h e effectiveness of i t s response

c a n b e m e a s u r e d by t h e e x t e n t t o which s e r v i c e s t h a t are n e e d e d a r e a c t u a l l y r e n d e r e d a t t h e l o c a l l e v e l a n d

t h r o u g h a s t u d y o f t h e p a t t e r n s o f u t i l i z a t i o n a n d ref e r r a l of s u c h services.

The e f f e c t i v e n e s s o f f o l l o w - u p a n d e v a l u a t i o n i s d e p e n d e n t on t h e i n f o r m a t i o n s y s t e m o f t h e u n i t r e n d e r i n g s e r v i c e . Hence f o l l o w - u p c a n be m e a s u r e d by t h e e x t e n t t o w h i c h t h e u n i t r e c o r d s on c l i e n t s a r e c o m p l e t e a n d a c c u r a t e a n d by t h e e x t e n t t o w h i c h management c a n a n d i s w i l l i n g t o u s e t h e information t o s t r u c t u r e i t s response t o m e e t t h e c l i e n t ' s i n d i v i d u a l needs and t o a g g r e g a t e t h e i n f o r m a t i o n o b t a i n e d a s f e e d b a c k i n t o t h e p r o c e s s o f d e t e c t i o n and r e s p o n s e .

I n o r d e r t o m e a s u r e t h e s y s t e m ' s overall effectiveness

is u s e f u l t o i d e n t i f y a r e a s of p o s s i b l e discrepancy. F u r example:

(1) The e x t e n t a n d a r e a o f t h e d i s c r e p a n c y between p r o f e s s i o n a l and p o p u l a r percept i o n s o f community h e a l t h n e e d s w i l l i n d i c a t e where p r o b l e m s i n h e a l t h e d u c a t i o n o f c o m m u n i t i e s a n d i n h e a l t h manpower t r a i n i n g a r e t o b e f o u n d .

(2)

t h e e x t e n t and t y p e o f d i s c r e p a n c y between h e a l t h s e r v i c e s r e n d e r e d and t h e s e r v i c e

needs a s i n d i c a t e d by t h e d i s e a s e p a t t e r n i n t h e community i n d i c a t e s problems of i n - e f f e c t i v e p r i o r i t y d e t e r m i n a t i o n and r e s o u r c e a l l o c a t i o n .

(3)

D i s c r e p a n c i e s between who needs t o u t i l i z e t h e s e r v i c e and who a c t u a l l y u t i l i z e s it and t h e d i s c r e p a n c y between t h e magnitude of s e r v i c e r e n d e r e d t o r e g u l a t e c e r t a i n d i s e a s e s and t h e a c t u a l magnitude o f t h e same d i s e a s e s i n t h e community axe b o t h l i k e w i s e i n d i c a t i v e o f t h e systems i n a b i l i t y t o respond a d e q u a t e l y t o t h e c h a l l e n g e of t h e need f o r h e a l t h s e r v i c e s .

SUMMARY AND CONCLUSIONS

The aim o f t h e h e a l t h s e r v i c e s i n t h e t h r e e c o u n t r i e s under s t u d y i s t o have e f f e c t i v e coverage of t h e m a j o r i t y o f t h e i r population. The p a t h s t o a c h i e v e t h a t aim a r e n o t n e c e s s a r i l y

t h e same b u t depend t o a c e r t a i n d e g r e e on t h e s t a t e o f a number o f systems which have a d i r e c t b e a r i n g on t h e c a p a c i t y f o r and s t y l e of t h e d e l i v e r y o f h e a l t h s e r v i c e s . Hence it i s h e l p f u l

t o b r i e f l y c a t e g o r i z e i n a p u r e l y normative way t h e s t a t e of each o f t h e s e systems i n t h e t h r e e c o u n t r i e s a s a s u g g e s t e d guide i n implementing t h e e v a l u a t i v e r e s e a r c h d e s i g n p r e s e n t e d

i n t h i s paper.

TABLE I . :

QCALITY O F INPUT SYSTEMS AFFECTING

HEALTH SERVICE DELIVERY I N THREE E M

SYSTEMS AFFECTING DELIVERY OF HEALTH SERVICSS

K U W A I T

E G Y P T

Population F i n a n c i a l System

= 1 Million

= 39 M i l l i

Governmert a b l e t o f i n a n c e f r e e good q u a l i t y h e a l t h care for all. T a x e s as a s o u r c e o f f u n d s f o r financing h e a l t h services.

Y 2 s

Y e s

L o g i s t i c System

G e o g r a p h i c a l a r e a t o be c o v e r e d S c a t t e r e d n e s s o f human s e t t l e m e n t s Roads a ) Public b) Private

Limited Low

extensiv ~edium Good

- Transportation: (car ownership)

.-Yrlr r High High High

v e r y good

qcry POLow Medium Medium

H e a l t h U n i t s & Services: a) Availability b) Accessability -

Table I . ; Q u a l i t y o f I n p u t Systems A f f e c t i n g t h e Health S e r v i c e D e l i v e r y i n t h r e e EMR C o u n t r i e I I K U W A I T I I E

SYSTEMS AFFECTING DELIVERY O F HEALTH SERVICES

A d m i n i s t r a t i v e System

I I

Absorptive c a p a c i t y . Management of Health U n i t s Facility Infrastructure Quantity & Q u a l i t y of Equipment & Drugs.

Very Good I I Poor I Very Good I I Very Good I I 1

Manpower System

Q u a n t i t y of P r o f e s s i o n a l manpower Q u a n t i t y of P a r a - P r o f e s s i o n a l manpower

Scarce Scarce

I I I I I I I I

P a r t i c i p a t i v e System

P a r t i c i p a t i o n i n Design and Implementation Popular O r g a n i z a t i o n

N o n e Low

I I I I I

I I I

Kuwait h a s t h e money t o e x p r e s s i t s c u l t u r a l p r e f e r e n c e f o r a h i g h l y c a p i t a l i n t e n s i v e e q u i p m e n t f o c u s which s e e k s t o implement t h e p h y s i c i a n - c e n t e r e d model f o r p r o v i s i o n o f health care. E g y p t i s less f a v o r e d w i t h f i n a n c i a l r e s o u r c e s t o t a k e advantage of i t s supply of t r a i n e d

b u t s t i l l unable

manpower by f o c u s i n g on a l a b o r i n t e n s i v e a p p r o a c h a n d a t t e m p t i n g t o move away f r o m a s t r i c t l y p h y s i c i a n - c e n t e r e d model t o a model i n c l u d i n g p a r a p r o f e s s i o n a l s a s p r o v i d e r s o f serv i c e s i n t h e i r own r i g h t . I n Yemen t h e p a t h t o a c h i e v e

e f f e c t i v e coverage i s n o t c l e a r y e t .

Hence w e may s a y t h a t K u w a i t ' s p r o b l e m i s how t o make b e t t e r u s e o f c a p i t a l t o s o l v e i t s m a n a g e r i a l a n d manpower p r o b l e m s w h i l e E g y p t ' s i s t o make b e t t e r u s e o f manpower g i v e n t h e financial constraints it faces. Yemen h a s t h e d u a l p r o b l e m

o f s h o r t a g e s o f money and manpower a n d y e t s e e k s t o p r o v i d e maximum c o v e r a g e g i v e n t h e s e c o n s t r a i n t s . mb re

The p r o p o s e d e v a l u a t i v e r e s e a r c h w i l l r e v e a l i n a m u c h , p r e c i s e way t h e e x t e n t o f t h e p r o b l e m s r e f e r r e d t o above a n d w i l l suggest alternative courses of action f o r arriving a t solutions which a r e f e a s i b l e , a p p r o p r i a t e f o r a n d a c c e p t a b l e t o t h e countries concerned.

Informations clés

Organisation Organisation mondiale de la santé (OMS)

Type de document Meeting reports

Date d'adoption 31 décembre 1977

Source Organisation mondiale de la santé