Working Group on Indicators for Monitoring and Evaluation of Strategies for Health For All by the Year 2000, Manila, Philippines, 2-9 March 1982 : report

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WORKING GROUP ON INDICATORS FOR MONITORING AND EVALUATION OF STRATEGIES FOR HEALTH FOR ALL BY THE YEAR 2000

Convened by the REGIONAL OFFICE FOR TilE WESTERN PACIFIC OF TilE WORLD HEALTH ORGANIZATION Manila, Philippines 2-9 March 1982

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Not for sale Printed and distrihuted by the

Regional Office for the Western Pacific of the World Health Orp,anization Manila, Philippines Hay IQ82

NOTE The views expressed in this report are tho~e of the members of the Working Group and do not necessarily reflect the policies of the Organization.

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This report has been prepar~d hv the Regi ,'nil 1 Office for the '.Iestern Pacific of the World Health Organizlltion for governments of Memher States in the Region and for the memhers of the Workin~ Group on Indicators for Monitoring and Evaluation of Strategies for Health for All by the Year 2000, which was held in Manila, Philippines, from 2 to <I March 1<182.

Contents

1.

INTRODlTCTION ................................................................................................... .. OBJECTIVES ........................................................................................................ ..

2.

2 3

3.

DURATION, SCHEDULE AND PARTICIPANTS •••••••••••••••••••••••••••• STRATEGY ............................................................................................................ ..

4. 5.

PROCEEDINGS 5.1 5.2 5.3 5.4 5.5 Health for all bv the year 2000 and health system development .•••••••••••••••••.•••••••••••••• Indicators and managerial process for national health development ••••••••••••••••••••••••••• Conceptual and methodological considerations on indicators .•...•••••••.•.•.••••••.•...•• Global, regional and national activities and tre'nds ........................................................................

3

4 5 7 q

Data generation and integrated development of indicators ................................................................ 10 13

6.

CONCLUSIONS AND RECOMMENDATIONS •.•••••••••••••••••••••••••••••• LIST OF ANNEXES

ANNEX 1 ANNEX 2 ANNEX 3 ANNEX 4

AGENDA ............................................................................................... TIME SCHEDULE ....................................................

17 19

LIST OF MEMBERS

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

21 25

OPENING ADDRESS OF THE REGIONAL DIRECTO~, WHO REGIONAL OFFICE ,FOR THE WESTERN PACIFIC CLOSING ADDRESS BY DR S.T. HAN, DIRECTOR, PROGRAMME MANAGEMENT, ON IIEHAI.F OF THE REGIONAL DIRECTOR, WHO REGIONAL OFFICE FOR THE WESTERN PACIFIC •••••••••••••••••••••••• LIST OF DOCUMENTS

ANNEX 5

27

ANNEX 6 ANNEX 7 ANNEX 8

.................................................. 31

REGIONAL STRATEGY FOR HEALTH FOR ALL BY THE YEAR 2000 •••••••••••••••••• ,............... MANAGE~ffiNT

HEALTH AND HEALTH-RELATED INDICATORS IN THE OF HEALTH PROGRAMMES BY DR ABDUL KHALID BIN SAHAN •••••••••••••.•••••••••••••••

83

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ANNEX 9

SOCIAL INDICATORS AND THEIR APPLICATION FOR MEASURING THE PROGRESS OF DEVELOPMENT BY PROFESSOR JAN DREWNOWSKI ••••••••.•••.••••••••••••••• LIST OF INDICATORS FOR GLOBAL MONITORING OF PROGRESS TOWARDS HEALTH FOR ALL BY THE Y~AR 2000 ••••••• LIST OF INDICATORS FOR REGIONAL AND GLOBI\L liSE ••••••••• LIST OF INDICATORS FOR USE AT THE NATION\L LEVEL AVAILABILITY AND SOURCES OF DATA FOR GLOIlAI., REGIONAL AND NATIONAL INDICATORS •••••••.••••••••••••.•• COORDINATION FOR INTEGRATED DEVELOPMENT OF INDICATORS BY DR ABDUL KHALID BIN SAH.\N PRIORITY ACTIVITIES AT GLOBAL, REGIONAL AND NATIONAL LEVELS ••••••••••••••••••••••••••••••••••••

103 131 11') 141

ANNEX lOa ANNEX 10h ANNEX IOc ANNEX 11

147 153 159

ANNEX 12 ANNEX 13

1.

INTRODUCTION

The Thirtieth World Health Assembly resolved in 1977 that "the main social target of governments and WHO in the coming decades should be the attainment by all the citizens of the world by the year 2000 of a level of health that will permit them to lead a socially and economically productive life."l In 1979, the Thirty-second World Health Assembly, endorsing the report of the International Conference on Primary Health Care, including the Declaration of Alma-Ata,2 invited Member States to consider the immediate use of the document entitled Formulating strategies for health for all by the year 2000,3 individually as a basis for formulating national policies, strategies and plans of action, and collectively as a basis for formulating regional and global strategies. A number of Member States in the Western Pacific Region subsequently formulated their national strategies and on the basis of these national strategies, regional policies and strategies for health for all were developed, reviewed and approved by the WHO Regional Committee for the Western Pacific at its thirty-second session in Seoul in September 1981. 4 Based upon the strategies prepared in all the six regions of WHO, the Global Strategy for health for all by the year 2000 was then formulated and adopted by the Thirty-fourth World Health Assembly in May 1981, in which the Member States were invited inter alia "to enter into this solemn agreement for health of their own volition, to formulate or strengthen, and implement, their strategies for health for all accordingly, and to monitor their progress and evaluate their effectiveness, using appropriate indicators to this end." In this context, 12 indicators were agreed upon in the Global Strategy as a minimum for such monitoring at the global level. S . Likewise, as part of the regional strategy, indicators for the national and regional monitoring of strategy implementation were identified and the proposed list of indicators was approved by the Regional Committee

ISee resolution WHA30.43, WHO Handbook of Resolutions and Decisions, Vol. II, 4th ed., 1981, page 1. 2Alma-At.:! 1978: All" Series No. 1). Primary Health Care, WHO, Geneva, 1978 ("Health for

3Formulating strategies for health for all by the year 2000, WHO, Geneva, 1979 ("Health for All" Series No.2). 4See document WPR/RC32/6 Add. 1, Annex 1. SGlobal strategy for health for all by the year 2000. 1981 ("Health for All" Series No.3), pages 73-76. WHO, Geneva,

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at its thirty-first session after lengthy discussions on the subject,l The Sub-Committee on the General Programme of Work con~idered the subject of indicators during 1981, taking into consideration the various comments of representatives, and, after visiting a few Hemb~r States in this connexion, presented its recommendations to the Regional Committee at its thirty-second session in 1981. The Regional Cotmnittee then reviewed and approved the regional strategy document, which included indicators relevant to the regional and national monitoring of health for all strategies. 2. OBJECTIVES

In the light of these global and regional developments, th~ present meeting was scheduled to review further, in the country context, the status and role of health and health-related indicators, particularly with respect to the establishment and utilization of a minimum list of essential indicators for health programme management in the context of national health for all strategy and related data generation and processing an'! coordination procedures and mechanisms, with a view to formulating specific recommendations to the Regionsl Director, WHO Regionsl Office for the Western Pacific, on priority activities WHO should undertake to provide collaboration and support to Member States. The objectives of the Working Group were: (1) to review the current status of and recent developments in the arp.a of health and health-related indicators for the monitoring and evnluation of health programmes, and to identify problems with regard to their utilization; (2) to investigate the need for and feasibility of developing new health or health-related indicators, or to improve on the existing ones, and to establish a list of priority indicators for the monitoring and evaluation of health programes and subprogrammes; (3) to formulate a framework for the generation of health and heslth-related indicators to serve as operational tools to monitor and evaluate national health programmes at different echelons; (4) to evaluate different approaches and sources of information for improving the effective and efficient generation, processing and analysis of data for priority health and health-related indicators; (5) to outline procedures and mechanisms by which representatives from different health and health-related programmes call be brought together for the integrated development of indicators; (6) To recommend specific national and/or regional activities to be undertaken by WHO in the promotion, development and utilization of health and health-related indicators.

lSee document WPR/RC31/1S, Annex 2, Rev.l, pages 31-J4.

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·3.

DURATION, SCHEDULE AND PARTICIPANTS

The Working Group was held from;! to 9 March 1982. Annex 1 ~ives the agenda of the meeting lind Annex 2 the scheclule. There were thirteen mf'mbers in this Working Group, who are listed in Annex 3. 4. STRATEGY

The lvorking Group strategy consisted of plenary sessions ·on specific topics followed by group sessions for in-depth discussions of relevant issues. Participants were divided into two groups and the reports of the two groups were presented and discussed at the plenary sessions. The outcome of discussions at these sessions provided an appropriate basis for formulation of concrete recommendations with regard to the direction WUO· collaborative activities should take. Specific activities to be undertaken were outlined, including priorities at both national and regional levels and on a short- and medium-term basis. 5. PROCEEDINGS

The Workin~ Group was openeci hy nr Hiroshi Nakajima, Rigional Director, WHO Regional Office for the Western Pacific. In his opening address, the Regional Director referred to the need for health and health-related indicators to be releva~t, specific, sensitive and above all meaningful to the user if they were to provide effective support to the monitoring and evaluation of national, regionlll and global· strategies to achieve the health for all goal. He stressed the urgency of de~eloping simple yet effective and efficient procedures and mechanisms to generate and process the necessary statistical data for the purpose and to facilitate their utilization. The full text of the opening address is given in Annex 4. The Working Group designated Dr Chen Ai Ju as Chairman, Dr F.K.R. Wainiqolo, as Vice-Chairman, and Dr J.M. Martins as Rapporteur. The meeting was closed by Dr S.T. Han, Director, Programme Management, on behalf of the Regional Director. A full text of the closing address is given in Annex 5. . The following sections give a synthesis of the various topics discussed, issues raised and conclusions reached by the Working Group. Annex 6 gives a list of documents used by the Working Group as a hasis for their deliberations.

- 4 5.1 Health for all by the year 2000 and health system development

Achievemt'nt of health for all: by the year 2000 will only be possible through national efforts deployed both individually by countries and collectively. In this context, Member States have been articulating their national goals and aspirations, incorporating these in national policies, strategies and plans of action, and collectively providing these national strategies as a basis for the formulation of regional and global strategies. Based on the first drafts of na'tional strategies prepared by Member States in late 1979, a regional strategy for the Western Pacific Region was formulated and approved by the Regional Committee at its thirty-first session in 1980. The la,tter is set out in Annex 7. 'Ibis regional strategy was used as an input for the formula·tion of the global strategy. Thus, the Member States have had considerable influence in the development of both regional and global strategies. Health for all implies a state of health, which will permit all citizens to lead a socially and economically productive life. Hare specifically, it envisages a well-nourished population, safe drinking water for all, sanita,ry disposal of animal and human waste, minimal environmental pollution and hazards, elimination of communicable diseases as a major ~P'3lth problem, reduction in chronic diseases, psycho-social well-being and h.,.41tl.y life styles, no pockets of ill health, regulated fertility to ensure better health and social well-being, and acc~ss to appropriate health care for all. The pursuit of the goal of health for all requires main thrusts in; the development of health systems infrastructure; the dl!velopment of appropriate technology; intersectoral coordination; the establishment of a high degree of community partiCipation; and the mobilization of international support to facilitate these efforts. Changes to bring about the above thrusts through the primary health care approach are based on the principles of equity, broader concept of health, self-reliance and individual self-realization. Desirable attributes of the health syste~ fOT the realization of this goal include accessibility and relevance of the health services, functional integration of input and community development. The changes needed are reorientation of the existing health system, redistribution of resources, formulation of country-wide health programmes, reorientation of health manpower, improved planning and management methods, and the use of appropriate technology. In this context, activities required to bring out changes should be identified and directional plans formulated by individual countries as a framework for mediu~- and short-term action and then for annual budgetary priority setting and mobilization and allocation of resources.

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High priority should be given to the incorporation of rh~ primary health care approach in these directional plans and to the re-orientation of the present health care delivery system. Self-help and community participation need to be promoted and the community trained in skills related to the development 3nd maintenanc~ of information systems and review mechanisms, in order to monitor and evaluate progress being made. This will require the development of communication skills within the health care system, to allow for the understanding and discussion of goal~ and objectives at all levels, including local communities and health services providers. Statistical capability to facilitate the monitoring and evaluation of progress in the attainment of health for all goal at national and international levels should be further strengthened. 5.2 Indicators and managerial processes for national health development

Although the entry point of the goal of health for all will necessarily differ depending upon the state of development of individual countries, resources available and the political system, the basic managerial processes involved in national health development can be said to fall into a number of steps: (a)

Formulation of health policies

Health policies may be derived from national socioeconomic policies. After assessing the situation, objectives and commitment are established. (b) Formulation of health strategies Possible ways and means are identified and the most appropriate selected. (c) Broad programming (d) Detailed programming These steps involve determination of activities and organizations, allocation of resources, and scheduling of activities.

(e) Implementation The processes involved are directing, supervising, monitoring and controlling. (f)

Evaluation

Evaluation is concerned with the question of efficiency and effectiveness, relevance and impact. It can be applied to any of the preceding steps. (g) Re-programming The result of the evaluation will be fed back into the development processes. To support the above processes, appropriate health information, including indicators, is required.

- 6 Although in actual practice, it is not possible to identify with exactness particular managerial processes with different levels of management, it can be said that specific echelons of management focus more on certain issues than on others. The national or top level of management deals with strategic and long-term planning and broad programming, including mobilization of resources for defined priority activities. The sub-national or middle level deals with programme planning, programming, budgeting and evaluation. Its main concern is in the efficient use of resources. The operational level is responsible for implementation, and thus in directing, supervising, monitoring and control. since community involvement is a desirable attribute of the health system towards achieving the goal of health for all, it is necessary to recognize or develop another level of ''management'' and that is at the level of the community. The nature and role of this "community level management", and thus the degree of community involvement in health and health-related issues and other socioeconomic programmes, will depend upon the political system and the structures of government. But basically, community involvement can be in any of the following areas of programne development: planning - implementation - sharing the benefit of the programmes, and - evaluation For some programmes the community can be involved in all aspects of their development; for others community involvement may be restricted to their acceptance and usage. In many countries, the managerial processes for national health development are weak both in content and execution. To a large extent, planning is highly sectoral with focus on input rather than on outcome. As a result, the health programme is unbalanced and inadequste in scope and coverage. Basic health needs of the large majority of the people are not met. Preoccupation with diseases has also resulted in inadequate attention being given to such related problems as water supply, food consumption and family planning. Strengthening of these processes is necpssary if the goal of health for all is to be achieved. Individual countries will have to identify their present managerial weakness and takp appropriate action. Lack of expertise in planning and management and shortage of trained and experienced personnel appear to be common causes of the present weaknesses. It is ironic that countries with the biggest health and other socioeconomic problems appear to be the least prepared and endowed for thp desired vigorous programme of socioeconomic uplittment. Improvement of health and health-related information generally and of indicators in particular constitutes one of the important steps towards strengthening the managerial processes for national health development.

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A health programme can be conceived as an input - process - outcome system to achieve an objective. Thus indicators could be develnped to measure input (e.g. facilities per population), process (proportion of children immunized among the target population), snd outcome (e.g. disease-specific morbidity rate). Similarly indicators could be established to measure the extent of achievement of objectives, or of policies from which objectives are derived. Most readily available indicators are input or process oriented. The information and indicators provided should meet the particular needs of the managerial functions of various levels. Indicators for the national level are those related to policies, strategies and broad programming and impact whereas the sub-national or middle level requires indicators regarding resources. The operational level requires indicators relating to health services delivery. Some of these indicators, e.g. health services delivery indicat~rs, are generated internally whereas others, particularly those required by the national level, may have to be obtained from external sources. For a detailed description of these aspects, see Annex 8. Many indicators currently available are of doubtful relevance, accuracy, reliability and objectivity. They are not selective enough, too aggregated, or not timely. Many are collected with no apparent current purpose, while the usefulness of others is considerably reduced because data streams are not synchronized or integrated. Thus, for example, it is not possible to gauge efficiency because process indicators are not linked to input indicators. In some countries, a large volume of data is collected, but it is not processed. Health indicators are useful only if managers know how to use them properly. But in cases of lack of managerial expertise, even current, good indicators are not used adequately in planning and monitoring. The development of any decision support system, e.g. the system of health information and health indicators, must be management oriented in order to ensure their relevance, appropriateness and usefulness. It must take into account decision making structures, the requirement of the various managerial levels, and the need for intrasectoral and intersectoral coordination. Managers at all levels must therefore actively participate in the development of health information and indicators. 5.3 Conceptual and methodological considerations on indicators

The meeting considered a paper on the state of art of social indicators. (See Annex 9) Out of many tendencies and currents in the social indicator movement, one approach was selected for discussion, namely, that which offered the best possibilities for the practical application of indicators in monitoring the progress of development and in planning its course. A consensus was reached at the meeting that indicators reflecting objective observable conditions in which people live offer ~reater possibilities for practical application than those which are meant to rl'flect "perceived wei fare". It was further agreed that a clear distinction should be made between proper social indicators which are conceived as measures of people's welfare (or of its components, one of which is health) and those which measure economic conditions and/or resources constituting means which are necessary to achieve the improvement of welfare (health).

- 8 The merits of scaling the indicators were given some attention. was common agreement that unequal distribution of goods and services consequently unequal conditions of welfare (including health) should an expression in the values of indicators. The possibility of using that purpose a coefficient of distribution based on the Lorenz curve noted. There and find for was

The problems of indicator aggregation and of the distinction between flow and stock indicators, important as they are in the indicator methodology, were not considered immediately relevant to the tasks of the meeting and consequently were not discussed. The Group very strongly endorsed the view that full advantages can be obtained from indicators only when they are conceived as components of a coherent and properly structured system. Such systems constructed at the national level should be specific, i.e. reflect existing conditions and the development possibilities of the nation concerned. Thev should also be oriented toward action aiming at improving health conditions. A scheme for constructing such a system was presented. This reflected three stages of action aimed at "health generation", namely: mobilization of available resources, enlargement or improvement of health infrastructure, extension or improvement of health services, and finally the outcome of that action: improvement in health conditions. For each stage appropriate indicators were proposed (as examples). It was also stressed that, apart from well-established indicators reflecting conditions in each stage, there is a need for a new type of indicators which would reflect relations between indicators he longing to various stages. This type of indicators could be called "second generation indicators" to distinguish them from the traditional "first generation indicators". They would give numerical expression to the conditions (and effects) of the progress of the health generation process from one stage to the next, such as from "resources" to "infrastructure", from "infrastructure to services" and from "services to "health conditions". The scheme presented was discussed at some length. The merits of structuring the indicators systems were fully recognized. It was agreed that the second generation indicators are a promising concept but one which requires much further ~Iaboration and testing. It was stressed that the indicators of the second generation should be established only for such pairs of first gener3tion indicators between which there exists an obvious causal relation. Ignoring that principle might lead to misleading results. It was also recognized that health conditions can be improved by action taken bv agencies other than the ministry of health or the private he3lth s\'stem. This bct calls for cooperation between various agencies in achieving a common goal and opens a possibility for developing indicators which cOtlld rrflect the health impact of non-health agencies. It was felt, however, that at this sta~e a detailed discussion of indicators which would reflect this problem need not be undertaken.

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The Group considered a proposed list of indicators to be used at national level for monitoring the implementation of the health for all strategy.l It found a number of indicators acceptable and a number of other requiring clarification, more precise formulation or testing. It decided to propose a pilot study to be conducted as soon as practicable to test within a number of countries the feasibility of developing a system of health and health-related indicators to monitor and evaluate the health for all strategy. 5.4 Global, regional and national activities and trends

A review of activities undertaken by WHO at ~lobal and regional levels showed that greater emphasis is being given to reorientation and further development of health statistics system and services activities to provide effective support to health programmes development and management. Apart from the activities related to the development of health management information systems, specific activities related to better definition of information content in terms of health and health-related indicators have been or are being undertaken for priority programme areas. In the Western Pacific Region of WHO, a series of workshops at regional and country levels are being conducted for this purpose. The adoption of the regional strategy for health for all for the Western Pacific Region by the Regional Committee in 1980 and the Global Strategy by the World Health Assembly in 1981 has provided a new policy basis to national, regional and global activities concerning the gen~ration and use of relevant indicators for monitoring progress towards the health goal. At the global level, a publication entitled Development of indicators for monitoring progress towards health for all by the year 2000 ("Health for All" Series No.4, 1981) was issued to help Member States decide which indicators to use for this purpose. WHO's new activities in the area are being developed under the broad programme heading of "health situation and trend assessment". FAO has formulated 3 work plan, in the context of the World Conference on Agrarian Reform and Rural Development (WCARRD), to develop, test and finalize on the basis of country studies a draft list of indicators, to develop guidelines for use by governments to establish benchmarks for 1980, and then to support countries to develop, improve and institutionalize, within their statistical programme, the selection and use of appropriate indicators. 2 The FAO regional project on community level statistics aims to establish an information system at the village level and, supply meaningful information at the village level by way of extensive local training and with the people's involvement in the process of data collection. It will provide more solid baseline information for micro-level planning and for

ISee document WPR/WC!HFA!82.16 and annexes. 2Country studies have been done in Bangladesh, Republic of Korea, Malaysia, Philippines and Thailand.

- 10the monitoring and evaluation of socio-economic development programmes. l It is obvious that collaboration and consultation between WHO and FAO would be mutually beneficial and should be promoted in view of common areas of concern and objectives. From the country reports, it has become clear that traditional indicators are becoming irrelevant to some of the countries in the Western Pacific Region and there is an increasing emphasis to have indicators reflect the transitional problems of development like suicide, disability, etc. While not many activities have been undertaken in some of the countries, the Group noted that the development and utilization of indicators is emerging as a priority area for health system development and management and that population-based sample surveys and use of "polls" could be effective ways to generate needed data for quantifiable and objective indicators. An environment favourable to the development of more relevant and user-oriented indicators exists and the time seems to be ripe to initiate more systematic approaches to the development of indicators to support programme development and management in the context of health for all strategy. 5.5 Data generation and integrated development of indicators

The global and regional indicators are expressed in terms of the number of countries which have attained specified targets. (See Annex lOa and lOb) Expressed in this manner, these indicators will be of little use to the countries. The indicators, however, will be constructed at the global or regional level by consolidating the information on national progress in relation to the targets, i.e. comparisons of the actually observed level in each country with the respective targets. In this sense, most of the indicators can, indeed, be relevant in the specific national context. Indicators proposed for national monitoring of the health for sll strategy implementation are given as Annex LOco Nevertheless, the Group felt that two remarks need to be made on the relevance of the indicators. First, some of the targets set as the m;ni'Dum to be achieved by every country are not meaningfui to some countries. A target, once achieved, loses its relevance, whiCh is in fact alreJdy the case for some countries. Even though a more stringent national target may be established in such a situation, this may not be useful when the optimum level has ben reached, e.g. adult literacy ratio of almost lOOt. For the regional target of 1% per annum for the population growth, some countries do not consider it an appropriate policy to restrain their popUlation growth. Second, the Group felt that some of the specified targets are unlikely to be achieved by a large number of countries by the year 2000. Examples are the regional target for the occurrence of no cases of tuberculosis and the global target for 100% immunization of children against the six diseases. The Group suggested, therefore, that the lists of the global and regional indicators should be reviewed in due course when countries have acquired sufficient practical experience in the monitoring and evaluating of progress towards the health goal and should be adjusted if necessary.

lease studies on community level statistics were completed in Bangladesh, Republic of Korea and Philippines.

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Concerning the health policy indicators chosen for global monitoring, the Group considered it important that they should be defined in unambiguous operational terms. The Group recommended, therefore, that the WHO secretariat should issue detailed practical guidelines so as to facilitate the work of the countries in providing the relevant progress and evaluation reports to WHO. As for the other indicators of a statistical nature, it was suggested that the WHO secretariat should provide each country with the information kept in WHO on these indicators for the country concerned, for review and updating. The Group considered, in particular, that the following indicators are of common interest to the countries of the Region and important enough to be added to the list of regional indicators: Per capita daily calorie consumption (instead of availability) Per capita daily protein consumption (instead of availability) Disability prevalence rate The Group also recommended that the anthropometric measurements included in the list of regional indicators should apply specifically to preschool children. It was observed that in some countries it has been customary to compute life expectancy only for the period around the year in which a population census was carried out. It may therefore not be possible for such countries to include life expectancy at birth in every progress report to be produced at two years' interval. However, as life expectancy is computed on the basis of age-specific mortality rates, countries were encouraged to compute it by means of an abridged method l whenever the relevant mortality statistics are made available. Similarly, life expectancy can also be computed for different population groups, though this has not been the practice in the past in many countries. For a country with a small population, e.g. less than 200 000, however, life expectancy cannot be calculated with precision because of random fluctuations in mortality rates. The average age at death might be used as a proxy indicator in such cases. Indicators alone cannot give an adequate picture of a country's health situation and may even be misleading, unless accompanied by an appropriate analyticai text describing the significant developments in health policy and programmes as well as the socioeconomic background. Eight sources of data for indicators were recognized, viz. (1) (2) (3) (4) (5) (6) (7) (8) vital events registration; population and housing censuses; routine health service records; epidemiological surveillance data; sample surveys; disease registers; community organizations and community health workers; and other sources of data, including data from sectors other than health. health Series,

lDevelo ment of indicators for monitorin for all by the year 2000, WHO, Geneva, 1981, No.4), pages 70-74.

- 12 For each of the indicators required for global and regional monitoring and those suggested by the Regional Committee for use in national monitoring, the principal and auxili~ry sources of data are shown in Annex 11. Health service records are the principal source of data for many of the indicators but the relevant data have not necessarily been extracted for generating the indicators now required. These records, of course, cannot cover the part of the population which does not get in contact with the health services. Records of health care provided by the private sector are usually not available. Sample surveys of the population and private health care facilities need to be developed in many of the countries. The Group noted that the United Nations has recently launched the National Household Survey capability Programme, providing technical cooperation with countries in building up a permanent national infrastructure for survey taking. The availability of such an infrastructure within the country, e.g. at the central statistical office, will not only allow specialized ministries to make use of the facility to undertake surveys for obtaining data which cannot be generated otherwise, but also promote intersectoral collaboration in data generation, processing and use. The establishment of uniform standard terminology, definitions and procedures is essential in data collection and processing in order to make valid comparisons among geographical areas and population groups, as well as to achieve meaningful aggregation. The Group observed that one of the obstacles to the generation of indicators which frequently occurs is the long delay in compiling the basic statistics. For example, it is not infrequent that the data from population and housing censuses and vital statistics are produced with a delay of two to five years, which seriously undermines the usefulness of the derived indicators for the purpose of up-to-date monitoring and taking timely health action. In countries in which inadequate data processing capacity is a bottleneck, it is highly desirable to streamline the data collection scheme by eliminating irrelevant data and to expedite data processing and analysis through the use of computers. Recent technological developments in low-cost mini- and micro-computers have opened up new possibilities in decentralized data processing. In most countries there is a need for disaggregation of data according to geographical areas and population groups. Such disaggregation is essential for the detection of inequitable distribution of health resources and for the identification of high-risk population groups on which the national strategy for health development should focus its priority action. Voluntary community workers could be a useful source of data, provided they form a permanent community organization, e.g. a village development committee and a women's group, to ensure continuity and consistency in data collection. Such activities should be adequately supported by the government. A certain minimum amount of training of such workers would be needed to enhance the quality of data. However, a high degree of selectivity should be applied so as not to overload community workers with data generation. The Group was informed of FAO's activity in the

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development of a methodology for collecting community stat1stics with community participation, which could serve a~ a basis for further development regarding health and health-related indicators. The Group also observed that, as health and health-related indicators need to be obtained from a number of different agencies, inluding some outside the health sector, the importance of coordination both within the health sector itself and with other sectors cannot be overemphasized. The relevant agencies should be mutually informed of studies in progress and of the statistical series and indicators available nationally and internationally. Some specific indicators are best developed through interagency effort, e.g. 1n the area of community involvement. Within the ministry of health, it is necessary to involve fully all heads of programme departments in the development of indicators and the basic statistics required for their generation. It is essential that permanent staff working under a strong leadership should form the core of the coordination mechanism. An effective mechanism should also be created for interagency coordination, such as a national council for statistic~. for establishing statistical standards, approving the plans for major statistical enquiries, eliminating duplications in statistical work of different agencies, and acting as a clearing-house for information on the availability of various types of statistical indicators within the country. All the agencies concerned should participate in the work of such a coordinating body. This would in turn contribute to the enhancement of common interest in intersectoral collaboration. The practical arrangements, however, should depend upon the sources of information, working relationship among agencies and decision-making structures for planning and development. The working paper used as a basis for discussions on this aspect is given as Annex 12. 6. CONCLUSIONS AND RECOMMENDATIONS

In its deliberations, the Working Group took cognizance of the importance of the implementation of the Global Strategy for health for all by the year 2000, through concerted action in the pursuit of related objectives at regional and national levels. Following discussions on different aspects in use of indicators for monitoring and evaluation of health for all strategy implementation, the Working Group reached the following conclusions: The achievement of health for all will depend on the progress made by individual communities. This progress is the key to the attainment of national, regional and global targets. Consequently, the community (and groups "at risk") must become a focus for the efforts made at various levels in the pursuit of relevant Objectives. Long-term objectives, to be effective, must find expression in the actual delivery of services and commensurate allocation of resources. Accordingly, current plans and expenditures must be evaluated on the basis of indicators of reaource allocation, of services rendered and of outcomes in terms of changes in health status of target popUlations.

- 14 -

A great need exists to strengthen managerial processes for national health development, which will be characterized by policy development based on health conditions, planning, control of services and resources and evaluation of outcomes. These processes must incorporate the use of information in the monitoring and evaluation of activities and outcomes. Only in this way can corrective action be undertaken, when necessary. To enhance the development of a relevant and action oriented system of indicators, managers at all levpls must identify their common interests, and participate in decision-making concerning the collection, processing, analysis and use of information. Special attention must be given to the needs at community level. The indicators should be conceived as components of a coherent and structured system, developed as an integral component of the health information system, and giving special emphasis to the need for community-level indicators. Indicators should be specific and relevant to the country concerned and reflect different aspects of programme deVelopment, namely, mobilization of resources, provision of services, and changes in health status. Further work to improve the methodology of health indicators is necessary. Special attention should be given to the problem of distribution, which should find its expression in terms of indicators. Attention should also be given to the development of data bases for generation of indicators, which allow for disaggregation of data according to geographical areas and "at risk" groups. Uniform terminologies, definitions, standards and procedures should be established for data collection and processing to permit valid comparisons, among geographical areas, popUlation groups and over time. They should be accompanied by analytical texts describing significant developments in health policy and programmes as well as the socioeconomic background. pilot studies should be carried out in selected countries to specify and define a minimum data set of essential indicators, including identification of constituent variables and units of measurement, and to develop mechanisms and procedures for data collection and processing of indicators, periodic reporting to WHO, and use of indicators within each country. Capability of countries to carry out population-based sample surveys to generate data for quantifiable and objective indicators, to undertake an extensive statistical analysis of available data and to use computers and other electronic data processing (EDP) facilities should be strengthened. To enable all this to be aChieved, it will be necessary to undertake extensive training of personnel, to ensure the acquisition of new skills, including communication, data collection, processing. analysis and usc of indicators, to be applied in the relevant management processes. These skills must be supported by appropriate resources in terms of manpower, equipment and financial resources.

- IS -

Intersectoral collaboration in the generation, processing and use of inclicators should be promoted to improve the efficiency oi collf>ction and processing of data, and enhance the use of a conunon l,an~uaR" rf>gllrding development, through the use of a cOllUDon terminology and svstem or core of indicators. Collaboration and consultation between WHO and other agencies should be strengthened, in view of the common areas of concern and interest in the development of indicators. The efforts and resources of international agencies should be coordinated and fostered to strengthen capabilities at country level. In this context, the Group noted the effort of FAO to develop community level indicators. The adoption of indicators as a major monitoring, evaluation and policy development tool, however, will depend on the relevance of indicators to community and national goals. Although most of the approved global and regional indicators appear to be acceptable and useful, some require further specification, definition and testing. Global and regional indicators should be reviewed in due course and, based on country experience, modified as necessary to make them comprehensive enough and oriented towards action and change at all levels of the health care system of Member States. Perceived gaps in the present system of indicators should be investigated, particularly in such areas as community participation, family planning, traditional medicine, care of the aged, chronic or permanently disabled people, mental health and disability in general. Based on the above conclusions, the Working Group formulated a framework for priority activities at national, regional and global levels (Annex 13). Based on this framework, the Working Group recommends that WHO should (1)

issue detailed guidelines to facilitate prOV1S10n, by Member States, of relevant progress and evaluation reports givinK information on global and regional indicators, to WHO;

(2) provide each Member State in the Western Pacific Region, ~ith the information maintained by the WHO secretariat on indicators, particularly on those needed for global and regional monitoring for review, revision and addition by the Member State concerned; (3) review proposed glObal and regional indicators and, where necessary, introduce new indicators. It shoulcl also thus identify a core group of indicators which would be meaningful, relevant and useful to the Member States in the Region; (4) ensure that a further study is undertaken on the formulation and definition of community participation indicators and how they may be used; (5) facilitate and support feasibility studies regarding the collection, processing, analysis and presentation of indicators in selected countries in the Region;

- 16 -

(6)

identify areas of common interest and concern and promote intersectoral agency coordination at national, regional and global levels; support Member States in identifying and developing appropriate technology for the collection, processing and use of indicators, including where appropriate EDP and survey capability; promote the greater and better use of indicators 1n policy development, planning and management; collaborate with Member States in strengthening manpower skills through training of personnel at all levels; collaborate with Member States in identifying needs for health indicators, testing selected indicators and facilitating use of indicators for programme development and management; collaborate with Member States in strengthening capability for development and use of indicators, particularly in respect of survey, analytical and EDP capability; carry out, in collaboration with selected countries within a given time frame, pilot studies to specify and define a minimum data set of essential indicators, including identification of constituent variables and units of measurement; to develop mechanisms and procedures for data collection and processing of indicators, periodic reporting to WHO, and use of indicators within each country; carry out further studies to improve the methodology of structuring indicators and to incorporate distribution elements of indicators; facilitate and support the establishment of mechanisms for the generation and use of indicators at country level; encourage Member States to publish and disseminate information on goals, strategies, objectives and indicators of health for all at country level.

(7)

(8) (9)

(10)

(II)

(12)

(13)

(14) (IS)

- 17/18 ANNEX I AGENDA

1 2 3 4

Opening ceremony Health for all by the year 2000 and health systems development Managerial processes in national health development Social indicators anJ development monitoring Group session I

5

Health programme management and indicators Group session II

6

Recent trends and activities of WHO on indicatore Global activities Western Pacific Regional activitiee

7 8

Activitiee of other relevant international agencies Review of global and regional indicators Group session III: Problems and prospects for generation

9 10

Development and utilization of indicatore - a framework Indicators for national health/2000 strategy: criteria and poesible minimum liet Group session IV prioritization

II 12

Data generation and sources of data <Selection criteria for efficient procedures and effective sourcee) Coordination for integrated development of indicators Group session V

13

Priority activities: National and regional levele Priority areas for WHO collaboration Group session VI

14 15

Consideration of Working Group report Closing ceremony

Tnl! SCHEDULE WORKING GROUP ON INDICATORS FOR MONITORINC AlII) [VALUATION OF STRATEGIES FOR lI!ALlll nIB. ALL liT TIlE YEAll 2000

Manila. Tues., 2 March lim~_Age~.da Item

~

to 9 Harch 1982

Timel;-Wed .• 3H.rCht:Ti:~e_f; _ A~!'.<!.!...Item

.. _

_~ Item:

Thurs ••

4 March' T':::,-

I Fri .• ) March L__ ~~~~--.!.!em.__ + 10 Indicato':"'s for national

Sat •• 6

1I.~ch

1\8~l1ua Item

Mon •• "8 March Agend.a_Ite"!._

0830-1 Registration 0900

09000930

Croup sus ion I r.eports

09001000

8 Revi ew of global 0900 and regional 1100'J

j

12 Coord inat ion for i nteg-

'.'0' ",.". '~"OOreports 1200 :

1 ._.--t-____ r Time . __

Tues •• 9 March Agenda Item

indicators

health/2000 strategy: prioritization

rated develo".ent

Oq,lO 1 I Opening 0945 ceremony

10941101)

Health for 1l001200 I all by the 11200 year 2000 and hea 1 th systems deve lopment i 3 Manageria I

10:5- i

i

09301030

5 Hea 1 th program.e management

and indicators

--COFFEE BREAK

1030lIOO

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BREAK~OOO-

. Gro;;P- - session 11

1030 10)0= 11200

1 I

\ COFFEE BREAK

1000:-+

-Croup session III

1030 10301200

J' ""~-"" ~- ~-- L.-------1;:!:~~~: and --, -com,

of indicators

I

I I

F RE E REPORTS PREPARATION

,;.ou-p--msess;on TV

--Croup session \ --;-;---"'13"Pd~ri~--1 actlvitles

----I

I

.

I

I 1,,00 ,_"nM-

-_L 14451500 COFFEE BREAK 11 Data generat ion and sources of data

.",

.... ... o

....

1430-

1500 .

445

COFFEE

1500 1515 1515 1630

__L_ Croup session VI reports ~

500 500600

BREAK Group session I

9 Development and utilization of indicators a framework

15001600

5 Closing

ceremony

>

il

>< '"

1----L------1-------1...--

"

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(se1ection criteria for

...

efficient procedures and effect-

ive sources

- 21 ANNEX 3

List of Msnbers

1. Australia

MEMBERS Dr J .M. Martins Director Heal th Services Research Health Commission of New South Wales

Sydney Fiji Dr F .K.R Wainicplo Assistant Director Health Planning Ministry of Health Suva Mr T. Kagawa

Japan

Director Social Research Division ~c Planning Aqercy 'I'akyo Papua New Guinea Dr B.D. Taukuro Assistant Secretary Health Planning an:i Research Department of Health Konedobu

Philippines

Dr A. Galvez Chief Planning Service Ministry of Health Mmila Dr Sung Kyu AIm Chief an:i Fellow Health Services Research Division Korea Institute for Popliation an:i Health Seoul Dr Viopap;"l E. Annandale Acting Chief Division of Public Health Department of Health ~

Republic of Korea

SingaPJre

Dr Chen Ai Ju Director Research aoo Evaluation Section Ministry of Health Singap::>re

- 22 Annex 3

2.

OOSERVERS Dr H.K. Oh

Regional Statistician FAD Regional Office for Asia and the Pacific Bangkok Thailand

Qureshi Regional FOod Policy and Nutrition Officer FAD Regional Office for Asia and the Pacific Bangkok Dr R. U.

'lllailarrl 3. TEMroAARY ADVISER

Datuk (Dr) Atrlul Khalid bin Sahan

Director Planning and Developnent Ministry of Health Kuala Lurrplr

4.

CONSULTANT Dr J. Dr~ki

Professor Emeritus &:onanic and Social Planning Institute of Social Studies The Hague

Nether lands 5. SEX::REl'ARIAT Mr K. Uemura

Director Division of Health Statistics WHO Headquarters Geneva

Dr R.D. Mercado

Director Health Services Developnent arrl Planning WHO Regional Office for the Western Pacific P.O. Box 2932 Manila

- 23/24 -

Annex 3

...

Dr R.A. Noordin Medical Officer Health for All WHO Regional Office for the Western Pacific P.O. Box 2932 Manila Dr K.S. Lee Scientist Primary Health Care WHO Regional Office for the Western Pacific P.o. Box 2932 Manila

nr Y.H. Paik Chie f Research Promotion and Development WHO Regional Office for the Western Pacific P.o. Box 2932 Manila Mr Y. Sato Information Analyst WHO Regional Office for the Western Pacific P.o. Box 2932 Manila Mr M. Subramanian Operational Officer Regional Adviser in Health Information WHO Regional Office for the Weslern Pacific P.o. Box 21}12 Manila

-

2S -

ANNEX 4

OPENING ADDRESS OF THE REGIONAL DIRECTOR WHO REGIONAL OFFICE FOR THE WESTERN PACIFIC AT TilE

MEETING OF THE WORKING GROUP ON INDICATORS FOR MONITORING AND EVALUATION OF STRATEGIES FOR Hl':ALTH FOR ALL"BY THE YEAR 2000 HANlLA, PHILIPPINES, 2 TO 9 MARCil 1982 L<1oies dnd Gentlemen, It gives me greRt pleasure to welc\)lTIe you all to thi,; meeting of the Working Group. Since the Thirtieth World Health Assemhly resolved to achieve health for all by the year 2000, many Member States in the Western Pacific Region have formulated national strategies to achieve this goal in their own country's context. WHO for its part has formulated a global strategy for its collaborative activities with Member States, while a regional strate~v for the Western Pacific Region, geared to its priority requirements, was also fonnulated and endorsed by Membel- States at the thirty-second session of the Regional Committee, held in SeC'ul, in September 1981. To facilitate implementation and provide timely feedback, the global ano regional strategies included a minimum list of essential indicators for monitoring the implementation of the health for all strategy. As you all know, indicators for global and regional monitoring have relevance only ~Ien specific, sensitive and meaningful indicators exist to monitor the implementation of national strategies. Likt>wi.o;e the identification, selection and formulation of indicators are only appropriate when procedures and mechanisms are developed which can effectively and efficiently generate the necessary statistical data for them. Efforts are being intensified in this region to develop and e8tabli~h a user-oriented health management information system bv reorienting and strengthening the health statistical services in Member States. With the emerging needs for statistical data in the context of HFA/2000 strategy implementation, it is important that these efforts be reviewed and proposals for further improvement formulated. Since reports for the global monitoring of national HFA/2000 strategies implementation must be presented to the World Health Assembly in 1984 and for regional monitoring to the Regional Committee in 1983, this is now a matter of great urgency. I look forward therefore to your specific recommendations on activities that WHO should undertake to ~upport the Member States particularly with regard to the choice of indicators at national level and the procedures and mechanisms necessary to ensure the effective and efficient generation of data for them. It will also be necessary to take cognizance of the training, analytical and technological support that will be needed at country level for that purpose. I would like to welcome Professor Jan Drewnowski, who has kindly agreed to act as Consultant, and Dato (Dr) Abdul Khalid bin Sahan as Temporary Adviser. I am pleased to welcome Hr K. Uemura, Director, Division of Health Statistics, to represent WHO/HQ and provide guidance for the deliberations of the Working Group.

- 26 -

Annex 4 I ._pl-easedto welcome .Dr ,Db and Dr Qureshi, Representatives from FAO to this _-eti·ng. 11leirpart.ici.pat.ionat this _eting will greatly facilitate int.er-,agency 'Coordination in infonaation system develoyment and es tab lish_nti n 'Hewsber Stati!s m our .Reg ion. I ·note~ou have a heav.y <agenda. and J wi 11 not there fore take up morE' of your valuable ti_. I 'wi'sh you all a successful meeting and a pleasant stay in "Mani lao

- 27/28 ANNEX 5 CLOSING ADDRESS BY DR S.T. HAN, DIRECTOR, PROGRAMME MANAGEMENT, ON BEHALF OF THE REGIONAL DIRECTOR, WHO REGIONAL OFFICE FOR THE WESTERN PACIFIC AT THE MEETING OF THE WORKING GROUP ON INDICATORS FOR MONITORING AND EVALUATION OF STRATEGIES FOR HEALTH FOR ALL BY THE YEAR 2000 MANILA, PHILIPPINES, 2 TO 9 MARCH 19R2 Madam Chairman, Ladies and Gentlemen, This Working Group has brought together, for the first time, health planners and managers, statisticians and information analysts, and social indicator experts to study, and advise on, a p.iority area for collaboration with Member States in the context of the health for all goal. Your deliberation~ have called for nnt only a high level of expertise and experience but also considerable patience and perseverance in examining problems in this complex and difficult field of indicators. I am personally convinced that the most effective fuidance in our efforts to achieve the "health for all by the year 200d goal will be provided by information. The efficiency of the steering mechanism which eliminates redundant or irrelevant activities, strengthens those that are pertinent and critical, and initiates new ones is determined by information. The best way to pl"ovide usable information is, of course, through user-oriented indicators. Thus, I am pleased to note that your meeting provides a point o~ departure for the systematic development and use of indicators. It has also contributed to a better understanding of indicators, particularly their role, both real and potential, in the monitoring and evaluation of health for all strategy implementation. I see that you have placed increasing emphasis and importance on the dynamic role of indicators in health development, with improvement of the quality of life as the primary consideration, as opposed to their use only to reflect the health situation in a static context. Your conclusions and recommendations are of great importance in the context of the global goal of health for all by the year 2000, since they will enable this Organization to initiate, reorient and strengthen its collaborative activities at national and regional levels. Eventually, I expect we should be able to develop indicators to assess the actual "use of indicators" themselves. I see that your recolIDDendations are not only feasible but also indispensable in relation to the regional strategv to develop and establish a user-oriented health management information system for the purpose in Member States. I wish to thank the Chairman, Dr Chen Ai Ju, the Vice-Chairman, Dr F.K.R. Wainiqolo, and the Rapporteur, Dr J.M. Martins, for so ably conducting this meeting. I also wish to thank Professor J. Drewnowski and Dr Abdul Khalid bin Sahan for their readiness to help us as Consultant and Temporary Adviser, respectively. Special thanks are due to Mr K. Uemura, Director, Division of Health Statistics, WHO Headquarters, Geneva, and to Dr Oh and Dr Qureshi, Representativps from FAO, for their participation and for their contributions to the success of this meeting. I extend my best wishes to you all for the success of your work and a pleasant journey home.

- 29 -

AllNEX 6

LIST OF DOCUMENTS Title

DocUllent No. WPR/WG/HFA/82.1 WPR/WG/HFA/82.2 WPR/WG!HFAl82.3 WPR/WG/HFA/82.4 WPR/WG/HFA/82.5

1. 2.

Provisional agenda Objectives of the Working Group Global Strategy for HFA/2000 ("Health for All" Series No.3) Regional Strategy for HFA/2000 Managerial Process for National Health Development ("Health for All" Series No.5) Social Indicators and Their Application for Measuring the Progress of Development by Professor Jan Drewnowski Health and Health-Related Indicators in the Management of Health Programmes by Dr Abdul Khalid bin Sahan Health Indicators for Monitoring and Evaluation of the Strategy for HFA/2000 - A Global Summary by Mr K. Uemura Development of Indicators for Monitoring Progress Towards HFA/2000 ("Health for Al1" Series No.4) Approach and Activities of WHO in the Western Pacific Region in the Development and Use of Indicators by Mr M. Subramanian Final Report, National Health Information Systems (Kuala Lumpur, 16-25 June 1980)

3.

4.

5.

6.

WPR!WG/HFA/82.6

7.

WPR/WG!HFA/82.7

8.

WPR/WG/HFA/82.8

9.

WPR/WG!HFA/82.9

10.

WPR/WG/HFA/82.10

11.

WPR/WG/HFA/82.11

- 30 -

Annex 6

Title 12. Regional Expert Meeting on the Choice of Indicators for the Planning, Hanageaent and Evaluation of Health Indicators (AFRO Technical Report Series No. 12) Socioeconoaic Indicators and Benchaarks for Monitoring and Evaluation of Agrarian Reform and Rural Developaent List of Indicators for Regional and Global Use The Use of Health Indicators How to Hake Statistics Talk List of Indicators for Use at the National Level Recent Develo~nts in National and International Work on Social Indicators and Issues for International Review and Coordination Coordination for Integrated Development of Indicators by Dr Abdul Khalid bin Sahan

Docu.ent No. WPR/WG/HFA/82.l2

13.

WPR/WG/HFA/82.l3

14. 15. 16. 17.

WPR/WG/HFA/82.l4 WPR/WG/HFA/82.l5 WPR/WG/HrA/82.l6 WPR/WG/HrA/82.l7

18.

WPR/WG/HFA/82.l8

- 31/32 -

ANNEX 7

REGIONAL STRATEGY FOR HEALTH FOR ALL BY THE YEAR 2000

1

lWPRfRCJ2/6 Add. 1, Annex 1, pages 7-56.

- 33 Annex 7

CHAPTER 1:

MAIN HEALTH AND

HF.ALT~-RFLATED

PROBLEMS

1.1

Introduction

The strategy to achieve a levpl of health permitting all citi2ens (If the Western Pacific Region to lead a socially and economically productivf' life must sddreas both current and potential pr blems likely to impede health development. As the status of health is a result of factors which are behavioural, environmental and hereditary, the strategy ahould focus on those behavioural and environmental problems that are amenable to change. socioeconomic factors in the environment and the lifestyle of the people play a determining role in their health Itatul and health development. It is therefore precilely to thOle factorl that a Itratl'gy for health should be addressed. Elements of the Itrategy Ihould accordingly consider: the growth, composition and movement of the population the level and phase of economic development the health status of the people of the Region. the health care system, and the social values and forces shaping Rociety's behaviour 1.2

population countries of directly and for the npxt 2000.

Population growth, although it has slowed down in most the Region, remains a problem which affects health both indirectly. According to even the most optimistic projection two decades, this problem will continue to be felt by the year

The population structure of the Region is characterized by a predominant ly youn!!: population. Longer life expectancy will result in an increased proport ion 0 f elderly i nd i vidua Is (age-group 65 and over). The present high dependency ratio will thus increase further. Population characteristics other sources are given below: l The countries predicted countries and projections from country reports Bnd

annual growth rate during the period 1975-1980 or Breas of thp Region ranged from close to 0% to rangp by the year 2000 is from close to 0% to had annual growth rates of 2% and over in the 8ame

in the 32 3.35%; the 2.74'1. 14 period.

IFiF:ures !!ivpn in thi", and other sections of the document have heen "tot'lined fn>m different sources. They should be interpreted with csution.

- 34 -

Annex 7 In terms of actual populat ion size, in 1980 population in chI' various countries ranged from bOOO up to 960 mi Ilion, giving a totR 1 popu lat ion of 1300 mi 11 ion. Tn the vear 2000, tht> total population is predicted to reach 1600 million with a range from 7000 up tn 1200 million. In 1975-1980, thoussnd, wi th 7 and 24 of over 8 3 countries will thousand and 20 a the crude death rate varied countries reporting values of per thoussnd. It is predicted stil1 experience a crude death rate of over 8 per thousand. from over that rate 4.2 to 20.3 per 10 pt'r thousand in the year :WOO of over 10 per

The birth rates in 1975-1980 ranged from 15 to 44.1 per thousand, with 22 countries having birth rates of 30 per thousand or more. Tht> predicted range in the period 1995-2000 is frOID 14.1 to 31.9 ppr thousand, with only 5 cOUlltries or area. having rates of over 23 per thousand. In addition to population growth and changes in the age structure, movement of population should be noted. The trend of rural/urban migration is expected to continue and to aggravate social problems related to the disadvantaged caused by aubstandard housing, unemployment and poor watE'r supply, among them juvenile delinquency and drug and alcohol-relaterl problems. Emigration, particularly from small island countries towards larger and industrialized ones, may be E'xpected to continue.

1.3

Socioeconomic situation

uncertainty of peace, political instability and socisl unrt>st characterize the beginning of the two decades in the course of which a New International Economic Order is to be achieved. Shifting value systems are giving rise to new social relationships and new E'xpectationt!l. Economic systems are unable to respond adequately to these rising expectations, resulting 1n the unemployment, underemployment and low incomes characteristic of a period of financial insecuri ty and leading in extreme cases to social unrest. In 1977, the per capita GNP of the RE'p;ion ranged from US$90 to US$7340, while thE' annual growth ratE'S varied from 1.9% to 7.7% • Tht> ratE' C'f food production has at best been kE'eping pace with population growth; the food supply has not increased to the levels expectE'd to meet the dietary requirements. Moreover, thE' problem IS the unf'vt>n distribution among countries and within countries, as well as thp increasing cost to the consumer. Malnutrition of varying types and grades t>xists in developing countries and in certain areas of developed ones. Safe potable water IS still not available to a great segment of the population.

• 35 Annex 7

Educational systems in the Region are not able fully to meet the demand and rlo not always provide the relevant E'ducation to enable people to gain ,1n adequate livelihood. 24% to 97% of the school-age popUlation is enrolled in priDlary lI",i secondary schools. Statistics indicate that the probleDl of adult illiteracy exists in sODle countries. Women in many societies are confined to traditional occupations and roles. 'MIe probleDls affecting most countries in the Region can be summarized as follows: continuing rece •• ion high rates of inflation punctuated by periods of

chronic fluctuations in economic growth uneven distribution of income within and between countries continuing high levels of unemployment and underemployment increasing dependency on, and rising costs of, imports uncertain value of major export cOl1l\1lodities (largely agricultural in most developing countries) social pressure lifestyles. and stress brought about by rapidly changjn~

1.4

Health problems

In addition to the crude death rate, which was described earlier, the following observations on infant mortality, maternal mortality, life expectancy and causes of mortality and morbidity describe the health status of the Region. There are 13 countries with infant mortality tho\l!land snd 9 with rates of over 20 per thousand. Th~

rates of over

50 per

msternal mortality rates range from 0.1 to 17 per thousand.

The life expectancy at birth varies from 42 yesrs to 77 years in 1980, and is expected to be frolll 52 years to 78 years in the year 2000. 'MIere are 8 countries with a life expectancy of less than 60 years in 1980. This is expected to change to 5 countries in the year 2000.

- 36 Annex 7

In sunonary, the Region presents a variety of health problems, rangin~ from those found in agricultural countries to those of the industrial countries and comprising: cOlllllunicable diseases and malnutrition chronic degenerative diseases accidents, environmental heal th prob lems pollution, stress conditions and mental

health problems of the elderly problems related to high fertility. The socioeconomic environment also determines such factor!! as thE' nature, composition and distribution of the high-risk groups, the population deriving least benefit from economic growth, the population of remote areas, the rural and urban poor, and, within those groups, mothers snd children and elderly people. 1.5 Problems related to the health care system

The reports of most countries expressed varying degrees of satisfaction regarding the quality and quantity of coverage of the population with health care activities, as well as deep concern for the rising cost of medical care. The other problems report,-.! in a way ahed light on thesp two basic prohlems and may be enumerated as follows: 1.5.1 In a number of agricultural/rural countries Technology. Unsuitable, cumbersome, limited in impact and diffuaion and expensive or unacceptable to the population. Certain necessary technology is either absent or at a limited stage of development. This is the case, in a number of instances, with health administration, planning/programming, information systems, repair and maintenance of medical equipment, and the architectural design of health facilities. Manpower. Inadequate in quantity and quality, inefficient, maldistrihuted, lacking in motivation, and subject to an unsatisfactory career structure and difficult conditions of employment. In a number of instances, the development of health manpower has no relevance to the needs Llf the local situation. Furthermore, the possible contributions of trsditional healer!', hirth attendants and herbalists have not heen adequately explored or cons ide red •

- 37 IInll!''' 7

HeaLth facilitie.. III.ufficient, inadequately supported, poorly located, of un.uitable architectural design and badly maintained. Operational procedure.. Cumbersome and ti.e-con.umin" rigid, difficult to under.taad and unrespon.ive to .ervice demands. Ortyi.ation. Overlapping, duplication or confl ict betwee n re ated services, in.ufficient intersectoral coord~ation, inadequate integratioD of functions, imbalance. Policy. Lacking, unrealistic or outdated.

Acc ••• ibility. Problems are related to geography, transport difficulties, etc. Lo,istic problems lead to shortajl;e of drugs snd .uppli••• Financial. Some of ~ problems are insufficient funding, uneven distribution of fundi, and inefficient and inequitable provision of drusa, medical supplie. and equipment. Motivation. 11Ie population in a number of instances is unaware of, or dissatisfied with, the service. available.

1.5.2

In a number of urban/indu.trialized countriel Technology. Inappropriate and inefficient investment COlt technology, especially in the private aector. In high

Manpower. Overemphasil on training of highly specialized medical personnel and aenior-Ievel health workers. Overcentralization of tr~ining facilitie.. Proliferation of categories of health personnel. Facilitiea. overinwec.nt in ho.pital building. and inadequate facilities for basic h.al~ .ervice •• Operational procedure.. Underutilization of health penonnel at certain levels. Inappropriate u.e of .taff, ,upplieR and equipment. Organizstion. Lack of inter.ectoral coordination. Inadequate government control of standard. and quality of aervicell. Inadequate legislation for monitoring of the private lector. Policy aDd planning. identification mechanisms re IIOU rce s • Lack to of proper health problem ensure proper sllocation of

- 38 Annex 7

1.6

\!t"gree of aW"!','ness of Ihe al','v.'-mt'nl jC'n.'rl poI1cy-makers, health workers and the puhllC

problems

There seem to be varying degrt',·1' of awareness of the above-ment ioned problems smong policY-1l1skers and thE' public, who, it IIppears, are more prone to think of health in terms of hospitals and clinicf'. It aho appears that, in some countries, the health ministrips requirE' strengthening in order to influence top-level decision-makin~ to a ~reater extent. In Bomp countries, there appe"rs to be a gap in cOlllll1unication within the health ministry between operational-level staff and policy-level staff.

CHAPTER 2:

HEAL TH AND S(lr IOECONOHIC POLICIES

11le social objective of health for all by the year 2000, which was collectively adopted by the 'lbirtieth World Health Assembly,l is accepted by the leaders of all ....ber States and is explicitly lllentioned in the policy ~tateaents of many countries. 11le mission of the health ministries in the Region, in pursuing the goal (>f raising the level of health of thE' peoplE', is to improve the quantity and quality of health care available, especially to the underserved population, at a price the community and thE' nation can afford. 11le national policies to that end have not yet, however, been incorporated in exiating national health plans. It is recognized by Member States that the social goal will be realized through the primary health care approach in the spirit of the Alma-Ata Declaration. 11le trend is towards a broader, more holistic, approach to health development, viewing h.alth as an integral part of national social and economic development. Health leaders are thus in the proce88 of reinterpretin~ the concept of health and broadening their mission to include ~evelopment of the peOple's capabilities for leading a socially and economically productive life, thereby achieving connunity self-reliance in health. This trend is di8cernible in the thinking of health experts in all countries or areas of the legion. The c('ncept of c~uni tv invol vement is II vi ta I element in the extension of health care coverage, providing for the mohilization 0f community resourcE'S in both the planning ond the management of health care. It is reco~nized hy practically all Member States that vigorous efforts must be made t(> en('ouralle local communities actively to participate in health and development actions in such a way as to establish a working partnership bet\oleen communities and government and private agencies. However, experience in developinll such a p.:lrtnership is aa yet limited, though the principle of community self-relianc,' is universally accepted.

1See resolution WHA30.43, \',,). IT, r.th ed., 1981, page 1.

WP(I l1andbook of Resolutions and Decisions,

- 39 -

Annex 7'

Another new dimension is the recognItIon of the interdependt'nce of health and socioeconomic factors and the need for a multisectoral approach in health development. Althou~h interest in the multisectoral approach has bt"en expressed by prac t ica lly all HembE'I" States, a beginning has yet to bE' made in developing an effectivE' mechanism for continuing intersectoral coordination at all levels. In many cases, analysis of the priority problems is still confined to health st"ctor activities and does not fully tnke into account the related social and economic problems. Given the limited resources avai lable and the determination to expand and improve the coverage and quality of health services, much interest has been expressed in the development of appropriate health technology and research. Attempts to translate political will into action have led to the realization that the new approach, based on an active and continuing partnership between communities and government agenciel, will de.and a new outlook, a new orientation and new Ikills on the part of health and related staff, who will have to develop qualities of leaderlhip and managerial skills in order to facilitate and support the community development approach in health and to strengthen both intralectoral and intersectoral coordination. This recognition of the need for appropriate technology and health manpower development has brought into sharp focus the necessary interdependence of countries, which must share their limited resources for the training and reorientation of health manpower, development of appropriate technology and research, snd exchange of information and experience. In their efforts to evolve and implement policies and strategies for at taining the goal of hea lth/2000, hee I th minist ries in leveral countries are reexamining and adapting their structures and resources to meet this challenge during the next two decades. The main focus and area of concern is the improvement of managerial proces.es for health developtaent. In searching for solutions, some countries have embarked on the proceaa of country health programming wi th a more holistic and broa er view of health and its relationship to other aspects of social and economic development. HC'wf'ver. the process is slow, problema encountered are many and thf' n'!'ultant structural and legislative changes and reallocation of resources nf'eded are only t>eginning to emerge. The lack of reliable information and appropriate indicators is impeding progress. In the light of the above-mentioned policy issues expressed by Member StatE's, the regional strategy should aim at collaboration in: "improvin~ and developing mansgerial processes for health developmentj reorienting and training health and related personnel, particularly in management, nrl/:anizational development, cOllll\unication skills and community development approachesj developing reaearch on appropriate technology and health care df'livery systems; devising practical evaluation procedures to monitor both the processes for implementation and the impact of health development stratel/:ies; exchange of information and development of effective information systems; and mobilization of external resources in support of national f' fforts for heal th development.

- 40 -

l\l1n!' x

7

In the sphere of economic development, there IS a discernible trend towards the integrated area development approach, with the balanced development of various sectors. The value of traditional economlCindicators such as GNP and per capita income is being queationed and concern has been expressed that development should he conceived to mean not only economic development but also the well-being of the broad masses. It is in this context that Member States place emphasis on heal th all an integral and vital part of development, benefiting by and contributing to economic development,· a8 expressed in United Nations General Assembly resolution 34/58 on Health 8S an integral part of development. l In the spirit of the New International Development Strategy, the economic interdependence of countries has been recognized, regional groupings, such as the Association of South-East Asian Nations and the South Pacific Forum, are being strengthened, and emphasis is being placed on the need for improved trade relations, transfer of technology and resourcea and regional planning.

CHAPTER 3:

CONCEPTUAL FRAMEWORK FOR ACTION

The successful coordination of initiative and effort directed towares the atta inment 0 f the long-term ob jec t i ves wi 11 largely depend on the collective and individual ability of Member ~tates to function inte rsectora lly. Thus, a general framework within which action is to be taken to achieve health/2000 must be responsive to the conditions under which the population is provided with health services, such as: (a) the prevailing socioeconomic and health situation, which calls for a more balanced delivery of curative, preventive, promotive and rehabilitative health care, to meet the health needs of the majority of the people; and (b) an increasing population and the resultant demands for health services, which call for a reallocation of resources within the health and other sectors.

lSee United 29 November 1979.

Nations

General

Assembly

resolution

A/RES/34/58,

- 41 Annex 7

These considerations imply that tht> conceptual framework mus t essentially address itself to directing heal h knowledge and resources towards: (a) laying the foundations food, water and shelter; (b) for health, namely, providing adequate

developing individual and community self-reliance in health; and

(c) providing appropriate and affordabIt' heal th technology for th .. sick, the disabled, the chronicslly ill snd the socially maladjusted. In the light of the above-mentioned conditions and directions, B partnership involving the community, the government and private health organizations is suggested a8 a desirable conceptual framework for attaining health/2000. The partnership concept focuses on the mutual responsibilitiea, risks and rewards of all parties involved. Froar the point of view of the health authorities and the national governments, s number of important elements should be considered: (1) The government must lead and assume initial responsibility for building communi ty capabi li ty to plan, organize and implement beal th development activities. (2) Reliance .ust be placed on community initiative, cOllllllitaent and resources in identifying and resolving health development issues.

The government must permit and promote the sdaptation of approaches or technology to suit the needs of or the situation in the community. (3)

(4) Intersectoral and intrasectoral approaches must be adopted In problem-solving, planning, implementation and the development of appropriate technology. (5) The government and communities muat work together in monitoring the results of community health development programmes. (6) 'I1le government must prnvide communi ties wi th resources in terms of manpower with appropriate skills, technology, infoaDation and funds for the plannin~, implementation and monitoring of health development activities. In this way, the health care systems will become: (a) more responsive to the needs of communities;

(b) more capable of influencing other sectors and also more receptive to influence from other sectors; (c) more integrated in their approsch to the planning and ftlanagement of programmes; and

- 42 -

:\:"".'X

7

(d) more concerned with development of staff.

the

continuous

professional

and

personal

In brief, this will require government and private health workers to play the roles of health technician or scientiat and facilitator in developing coamunity aelf-reliance in health.

CHAPTER 4:

LONG-nlUl OBJECTIVES, TARGETS, AND APPROACHES

4.1

Introduction

Interpretation of the current regional aituation as it affecta the health of the population should be considered in the light of Member States' cOllllllitments to health development and the constraints on meeting such commitments. These cOllllllitments are themselves determined to a great extent by what is perceived to be a socially and economically productive life in this Region by the year 2000. At the very least, auch a picture will suggest that the baaic needs of food, water and shelter will have been met by all governments of the Region. The total fulfi lment of those needs will be reflected in a well-informed population with shared social values, the widespresd avsilsbility of food and drinkina water, the sanitary disposal of human snd animal waste, the control of environmental pollution, the absence OT reduction of preventable communicable diseases, the reduction of chronic diseases, and the psychosocisl well-being brou~ht about by harmonious lifestyles. However, this picture remains incomplete. Without socisl justice, health and its contribution to the quality of life can have little meaning. To ensure social justice, people must accept responsibility fOT their own health and develop their capacity for self-reliance. 4.2 CountrY statement synthesis

The statement of objectives was extracted from nstionsl pTo~Tess reports, the speeches of delegates of Member States of the Region at the Thirty-third World Peslth Assembly, and the country progrsmme statements on national health/2000 strategies submitted to the Regional Office 1n connexion with the proposed programme budget for 1982-1983.

- 43 -

Though all Member States expressed their commitment to the goal of health for all through primary health care, some statements understandably stopped short of providing specific details or time-bound objectives. Among the objectives reported were: 4.2.1 Objectives related to the health status (a) (b) (c) (d) (e) (f) Improvement of nutritional status Provision of safe drinking watt'r and a sanitary environment Control of environmental pollution Access to appropriate health care Control of caa-unicable diseases Control of noncommunicable diseases (cancer, heart diseaaes, cerebrovasculsr diseases, dental conditions, metabolic diseases and health problems of the elderly were among those commonly mentioned) Promotion of s lifestyle and habits conducive to health Promotion of psychosocial well-being Fertility regulation Drug production, essential drugs and drug policies Rehabilitation relaled to the health care system 24 ~Imber of countries or areas providing statements

22

23 11

25 17

(g) (h) (i)

6

12

20 7

(j) (k) 1. ') .,

8

Obj~ctives

(a)

Health ~ervices development, including for example, reorganization, dev~lopment of he~lth facilities and aupport mechanisms, development of referral systems, regionHlization, integration

- 44 -

Number of countrips cr areas providing statements (b) Health manpower development, including strengthening 0f institutions, curriculum review and rev is ion, reorient At ion 0 f exiating staff to primary health care, trainin~ of lay workers and medical assistants, training of specialists, control of speciali&ation, improvement of working conditions of staff, effective use of health manpower, more effective correlation of supply and demand for certain types of personnel Health services research, development and use of appropriate technology. biomedic~l research Development of planning and managerial skills, establishment of planning units, development of supervisors, improvement of managerial processes, including health management inforaation systems ~pproache8

26

"

(e)

15

(d)

22

4.3

Regional objectives, targets, and

Taking into account the expressed objectives of individu~l Hernhpr States, a regional framework for health objectives to he ... ttained hy the year 2000 has been developed 8S follows;

Obj~ct iveli.

t.ar?f"t~·

and appI'"Q,:Jche'l

Ov~rall

!oci~tal

lra.a~f'

~road

bv vear 200L So~ially and econoa.ica~ly productive- individual,' population with: 1. Lon~er life expectancy 2. Low infant mortality 1. Low maternal mortality 4. Les. disahility 5. Adequat~ shelter. education. and ~~n8 of livelihood; through strategies with the folloving e •• ential ch.r.cteriatics;

nhjectivps

Specific objectivf'5 1.1 Nutritious food availahlp 1.1 Good dietary habits established 1.3 Healthy chil~­ feeding practice5 1.4 Service6 available for the prevention and carp of malnu-

Activitie. a. b. c. F~uletion and imple.eDtation of food and nutrition policy Natrition education, both fo~al and informal Dewelop.ent of nutrition sarveillance and care rartifie.tion of food SupplelM'ntarv feedinl, with particular attention to hiSh-risk groupl

Health .tatu8 tar@et

Health lervice.

tar~et5

1. A we 11-nour i shed population

d. e.

I. eo.nunity involve.~"t

2. Inter.ector.! coordinated efforts 3. EquitAble diltrihution of health and oth~r re.oure f!& 4. Health 'Yltem. d~v~lo,..nt

trition 1.5 Endemic goitre. nutritional anaeeia. and xeropthal.ia no longer publ ic health probl .... I.b Humber of low birth-veight babie. reduced 1.7 PToblf>!D of obeSIty reduced 2. Safe drinkinll

a. Minimu. calorie and protein intake fOT all b. Goitre and xeropbthal.i. reduced to loveot .ttaia.ble leveto c. Nutritional anae.ia in pre,nant and lactatina .other. reduced to love.t attainable level. d. Proportion of law birt~ __ il~t b.bi .. reduced to 10% level e. No third-d~gree

I. Overall targets

• Univerlal avaiI.bility of h~.lth .erviee. in all countrieli • All communities with health committ~e8/councjl~

malnutrition in chi ldren

various levele partic ipat ing actively in th@ ..nage.ent of hellth lervicea; • At le.ot S% of the GNP expended in the area of health carp vi th ",pha. j .. or prevention; at .An~ffectivp

5. Development and of appropriate t~chnology

U~~

2.1 Saf ... water at; a COlt

e. F&asibility studies

e. Inc idence of ",ater-

at a coat of lound

water for all

the comlrltlni ty can

affordablp to all availabl~

.!ford 6. ~velo~nt

mAnagerial pToce •• el for health dev.lopment 7. Oevelo~ent of necel.ary health 8. Ie.earch manp~r

and acce •• ible 2.2 Safe storegf' and ule ot dTin\c.ing ",et~T

b. c.

d. e.

for ea.munity vater BuppJ.i,," Eat . . liahment/expan.ion of Go-munity water ~upply .r..... (piped) Purther developmentl improvement of other lllouree. of vatl"r. i.e. vetI_. 'pringe, rain water Qutlitr control ~.a.nce and r~oeir of _tet" .yate..

bornp. di sea.ea

eechani.m fOT inlPr-j aectorsl collaboTRtion in thf" ArPA of health e~[abliohed i .. all countrie~

~

VI

I

reduced to the current level. of countri •• with lafe drinking vater: ZOO/IOO!) • yur (diarrhoeal di.eaae.> b. Incidence of diarrhoell dieea.el .-on, ch i IdreD. under 5 years of ale reduced by 50%

2. Nutrition and . . ternal and chile!

f. eo....ity education and £...,1 ve.ent

£!!! At le .. t 80% 0 f pre~n.nt mothers, deliveriel, infanta .ad younl children receivinl apprcpri.te he.lth cere, including i~unizat ion; nutrition surveiJlaoce, carel . . intenan"'~ and education .v.il.ble in .11 c:a..uni t j~,

. Services

for

::l ::l rt>

»

><

...,

Overall locif-tal

imll~p

by year 1000

BrrHJd ob jec t i yes

Sppcific objective. 3.1 Sanitary toil~tl avail.hlp for all

Ac.tivitiea 8.

Aealth atatuB target e. Incidence of feec.tborne dilea.ee reduced to current level. of countriea with •• fe

Health

8ervic~8

target!

3. Sanitary disposal of human and ania.l waste

familie& 3.2 Proper disposal of refuse, garbage, and animal v•• tee

of facilities ( . . teTle1. and technical guidance) and appropriate technology b. Education and motivation for •• f~ w•• te di.po •• J c. Enforcement of regulaDevelopm~nt

3. Water

100% of the population ulinS •• fe drinking water in all communities

::l ::l

:>-> (])

tiona/legillation

l 1 4 1 •

I

v •• te diapo.al facilitie.: 200/1000 (diarrhoeal die ••••• ) b. Incidence of diarrhoeal di •••••• ..ang children under 5 yeara of age reduced by 50%

X

4. Wa.te dioeo.al 100% of the popul.tion with aanitary latrine. and rea.onable ••• te dilpo •• t and drainlRe faci-

.....

litie. Mini •• l environ.ental pollution and hazards 4.1 A <;:ode on J>Qllutlon

established and en f arc pd

e. Formulation and i.plementation of policy b. Oev.lo~nt of effective

I. Taraetl aha red with other activities. the iapact of which ~nitoring .y.t~ vill be on the overall c. Education on ~nvironmenr.l heelth ot.tuo of the prot~c:tion ca..unity .e •• ured by tI .. tnfore_nt of regulation/ ~aa. or indices to le~i.l.tion be developed e. I.provment of the ~nYir...-nt

s.

!nviro~ntal

po llut ion Sy.t~ to .onitor enviro. .entat pollution and to .. intain it at reaaonable levela uteblilhpd

~------------------------+---------------------------t-------------------------------+---------------------------I t).

\6.

CO!-'\JOicable dileasf"'s no longer a major probl",

I

!

\ I

5.1 The following abIent; smallpox, faucial diphtheria, tetanul ne"natorulll, polioeyelitil, me •• lea,

a. lsauniaation b. <l'1elnoprop"yla.i, e. Surveillance

a. Tncidence of . . . llpox,

Health cere • Availabilitv of e •• ~nti.l dru~6 in all cOrIalJnlr:ifl'8 enluT~d;

1

, I

a-

~

faucial diphtheria, tetanus neon.torUID,

• Adequate

d. Case/contact finding e. Specific treat.ent/cI.e ~anal~nt

polic.yeliti., .... les, cOII.enitl1 rubella Iyndra.e reduced to ,eroi .artality fro.

facilities Ivailah1E" at all h'vel" for

I

'I'

congenital rubella

~.2

_ort.lity fra. vhooplng cough and rabirl, ttlf' advanced stase of fillri •• i. (.1.phantia.il). "eV C.'''I of blindn~'1 due to rr.choe~ Tho follovin& controlled;

.yndr~.

f. fducation I_ [nviroa.entat control, inc ludi. . control of

vectora

Ichilto.oaia.i., •• laril. filaria.i., tuberculoai8, pJIguP. plr.aitic infestationl of the akin Ind inteatin~ ••

and rabie., the advaac.,d atase of filaria.ia (elephentieeiol end ~ ca •• 1 of bliadn"I' due to tracha-a abient b. Morbidity fra. the follovin. not to eaceed the Ipecified level. in any country or Irea: Mol.ri. - 10/10 000 annul t pa rl. i te incidencp rate (MPI)

vhoopin~ cough

delivery of bAsic health ,prvice. 8n~ aupport of primary heal th caTt'

7.

Di.~a ••

control

• Mrdicil n~@d. of 100% of th. populltio~ met - ,implr

care in ca.e of illne.a and injury available rear thp ha.e. of the poopl.; Servicl!' for tht' control of COlnlrlu-

,"ieable

111d

non-

~OftIIunic"blf'

di.easel eatablished and provjd.d to at 1. .lt RO% of t~.

t

NPr.a

11 <;f}C tPt at imsgp bv .... p..ar 2(JOO

8rns~

ot,ipCflY#8

SpPcific objectives cholera, typhoid, h~proIlY. viral hepatitis 8, trachOlDa, tetanue ~. 3 The fo 1 loving no longer .ajor public health probl_: diarrhoeal dilea.el. relpiratory infectionl in children, sexually tran. . itted dileaael, viral h~p.titi8 A

Activit iee

Health .tatul target Filaria.i. - SI prevalence rate TUberculoaia - 51 infection rat@ of Ichool entrantl Paralitie inleatation - 15% in age group below 15 yean Cbolera - 1/100 000 incidence Typhoid - 1/100 000 incidence Diarrhoeal dilea.es 200/1000 incidence Viral bepatitia A Ie .. than 25% population at ale 20 with antibody Viral h~patiti. B 1/1000 "h~ carrier rat~ T~t.nu. - 10/100 000 in agr group up to 10 yun LeproAy - 0.5/100 000 incidence S~hi.tO'08i •• i. ~rev.lenc~ redu~ed

Health

s~rvic~1

taTJets

target population, includins i-.unization, surveillance, ch~oproph~l.xi.,

I I

case/contact finding and early detection, specific treabDent/aanage.ent, envir~ntat control including vector control, and health educ:ation 8. Fertilitl re~latiQn

Infonlation and aervic@'8 for fertility res,d.ltion avai l.ble in all cOllWtlJnit iel. Appropri.t~

I I I

I I

knnvl~dge ~en.r.r.~

I I

I I

for prolr_e i~prov~~nt throuvh rf'8~ .. rch and a ~f h~alth

I

,....

~

n~tvork

I I

information ayatrms

I I

I I I , I I I

to at leut 40% of currft1t I ,.v~ 1 in endntic .Irea8 c. Mort.lity from the foll_inl not to eaceed the apecified lnel. in afty country or .r... : Pn9u.onia/influenza 100/100 000 in infantl; 10/10 ()(,O for lIe group 1-4 1'.a,._ Cholera - 0.1% ca •• fatality rate Typhoid - 0.11 ca •• ratality rate Diarrhoeal di •••••• 0.1% cau fatality rate

I I I I

:::l :::l ,~

>

:..:

I....

Overall .ocietal i .. ge by year 2000

Broad objectives 6. Olronic diseaaes

Specific objectives 6.1 The following reduced: congenital heart dilea.e., rheumatic heart dia ..... , d~gener.­ ti •• cardiovaacut.r di.e.ae •• chronic bronchitis, pulmonary e..,hYletne in the

Activities a. Education for b. 4.

Health st.tus target The following reduced to specified levels; - congenital heart di.e •• e. - rheuaat ic heart di.e •• e. - del.neT.tive c.rdiov •• eular di.eaaea (under 50) - chronic bronchitia (under 50) - pul.aDary e.phy.~a (under 50) - prevent.bl. c.ncer. - p«!pt ic ulcer - cirrhoais of the liver b. All diabetic. and hype<tenaiv~. controlled ... dically c. An aver.ge of 3 DMF or 1~8. per child at .~P 12 y.ar ••• intained The followin, reduced by at leaat SOl of current level.: cirrhoaia. alcoholrelated accidente, alcohol-dependence .yndra.e, alcohol conauaption, incidencr of dru~ drpendrncp. conau.ption 01 dependence-produci", dru.a for non. . dieal rea,onl b. IDokin. (tobacco conau.ption) ..ana .dulta reduced vith corr.aponding reduction 6f i.eh... ic he.rt di •••••• end luna c.ncer c. s.olrina in population 20 ye. ra and he 1m.I rf.ldtJC:ed to ztoro I.

Health services targets

reduced

c. d.

e.

f. g.

younger age group (below 50 year.), preventable cancer. peptic ulcer, cirrhoof the liver 6.2 Diabeteo and hypertens i on controlled 6.] Oral health in children at a BAtiafactory lev(>l

.i.

behaviour.l change Counoe I liDS Early detection eale aanaafWef1C E.tabliab.ent of reg i 8 t era Control of environ.ental f.ctor. Fluoridation of drinkioa vater .upply

:D ::l

....

x

~,

8;

7.

PlyCh080C

i.I

7.1 The followinll

well-being and 1 i h'atyl~ condue i ve to h.. lth

reduced; alcohol-relltted pToble. •• accidpntr~l.ted

s. Hpalth educatiof1 and supportive loci.t action and 1e8i.1at ion b. Proeotion of:

deaths and di.e'~PK

problema, Itrel&~l.ted

7.2 9.okinl and d<ug dependence controlled 7.) Good perIanal hYli.np and dietery habita p.tabl iahed 7.4 Ph)'sic4Il fitoe •• activitiea undertaken 7.5 ~n .~xu.lity better under.tood 7.~ Diacri.ination baled 00 ethoic, .ocial, ph,..ical and a,. factor. not encountered

- aocial/recreational activi tips - pareDtal and fail, hanDODY throulth cOlm •• 11 iaa - h.alth,. workinR enviro_nt and job a.tietaction c. Value clarification d. Formul.tion and impl~at.tion of

le,lliation/re&ulation8 . . . iat disc r i.i ... t ion

•

'.

'.

r"/Prllll

c;rv VP8

i pt

~ ~

Imall'~

RT03~

nhJ~~tiv~s

Specific objectives

by

r 200(,

Activities

Health status target

Health servicps targets

d. Incidence of neurosia,

i I ,

I

luicide. , and other for.a of maladjustment ~educed

to •• nageable

Ind. e. Social justice in hulth achieved

I I

I I I

8. N<> po<:kets of i ll-hesl th

la.l The folloving dis.dv.nta~~d

a. Identificatior: of

a. Health status of

I

I I

group. ~iyen adequ.te .tt~ncion: .1u. dwellers, econa.ically diaadvant_led populat ioal. populations in rewaote are •• f the

groups b. F.quitable distribution di8adv.nt.~ed

di.advantaged «roup. ohould u.prove at .. f •• ter rate than the

of services and opportunities

I I ~

national average to aehieve equity in health

I I I I ~.

eldeTly aDd di.abled

,

f~rtility

re"J!ater:! bett~r

!9.1 Acces. to knowledge

i I

i

to

~n~urp

he~lth

and social

w~11-bp.in~

i I

i

I

and to .ate flncj effective .eans of f~rtility regulation Bv.il.bIe to .11 9.2 Preanancy in .dol~.cent. reduced 9.3 ContraceptivP8 us~d for spacing of hirthe and fertility regulation ~.4 Population growth reduced in h.~ny with econoaic develo.-ent ...

..

Formulfltion ancj i.plementation of population policy b. Facilities for fertility regulation mad~ acce •• ibl~ c. Education in population and f.aily planning

:fI.

Population grovth rat~ reduced to lee'!! thfln 1% b. Incidencp of pr@Rnancy in adolt!:lc~nte redu('~d to zert]

I , I

>D

I I

,

I I

--_._-

;::l ()

»

::l

....

><

~

1",_"., 1

"io~iflt81

imagE"

Broad

obj~ctives

Specific

obj~ctive8

Activities a. b. c. d.

~_.

.EL vear

2000

j

In. Access to approprlatr health for a 11 carp

10. I An adequately functioning health lervice network accellible to all in tenas of reach aocl financial coalideration. deliYerin, CD acceptable level of eIre with active involv~nt of the people 10.2 Coeprehenoive health care, i Del ucI i "I health pra.otion, prevent ion. tre&tment and rehabilitation provided by the network

e.

f.

g. h.

of cORmunity participation/partnerlh;p for health D<!velo_ot of health care delivery IYltem ~alth aanpower made avai lable E•• entiat drugl made avai l.ble Df've los-ent of finane inl Icheael, including effiaieat Ule of relo.reel D<!velo.-,nt of appropriate technology for health Devel~nt of •• nlge1DE'nt aDd support .yst._ Formul.tion ~nd pnforcem~nt of aupportinR I"Fial.rion

~velopment

..

Heal th

'tatu~

t<"rget

Health lervicel target.

Target • • hared with other activitiel, the i~act of which wi 11 be oa the overall health Itatul of the ca..unity .ea.ured by ~an. or iadicel to be developed

!

;,.. I

(j) ~

.....

Ut '.:)

---

----

.'

- 51 -

An!1ex 7

CHAPTER 5:

DEVEl.OPMENT OF TIII-. HEALTH !:YS1 EM

BASED ON PR IHARY HEAITIt CARE

5.1

Modification of health care delivery systems

Exiating health care delivery systems wi 11 net'd to be modified in varying degrees, dept'nding on country conditiona, in order to _et the objectives and targets set out in Chapter 4, within tht' conceptual framework described in Chapter 3 and conaistent wi th the country heal th progra_e. As an initial step, countriea ",ill therefore need to review their health care delivery systems in the light of certain broad principles defined at the Thirty-fourth World Health Assembly, which are felt to be applicable to all health systems based on pri.ary health care. These are; (1)

The "ystem should encompass the entire population on a basis of equality and responsibility. It should includp components from the health sector and from other sectors whose interrelated actions contributp to health, such 8" education, the water board or its equivalent, social welfare, housing or human settlt'ment and agriculture. Primary health care, consisting of at least the elsential elements included in the Declaration of Alma-Ata, should be delivered at the first point of contact between individuals and the health system. The other levels of the health system should support tht' first contact lev!'l of primary health care to enable it to provide these esspntial elements on a continuing basis. At intermediate levels, morE' complex problems should be dealt with, .1nd more skil1ed and specialized care as wel1 a6 logistic suppe>n should be provided. More highly trained staff should give continuing trsining to primary health care workers, as well as guidance to communities and community health workers on political problems arisin~ In connexion with all a.pects of primary health care. 'l11e central level should coordinate all parts of the system, and provide planning and management expertise, highly specialized care, teaching for specialized staff, the expertise of such institutions as central laboratorips, and central logistic and financial support.

(2)

(3)

(4)

(S)

(6)

- 52 -

The structure of the hpalth carp Fv~tenl InUst providp for clear delineation of work and functions at it!' v;lrious lev!'ls. At mana!(eria1 level, it must be oriented towards I"roj.!1.1mmin,· and prohlpm-~olvin~. havf' research component and a planninjl. functioll, provininlZ the I"olicy ann operating framework f('lr health programmps, IIIHI permitting local 1pvt'], tr> respond to health needs that are consonant with the political, cultural and administrative traditions of the society conct'rned. Whi 11' planning sl<i 1 Is will be developed at all levels, considerable attentioll wi II need to he given to enhanced individual and community participati('ln 1n dpcidinl!: on health policy and in guiding the plannin!l:, management And control ('If thf' health infrastructure and the pro!l:rammes it delivers. In strengtheninl!: this "bottom-up" approach to planning and managemt'nt, R clt'ar national policy may be neE.'ded, as well as appropriate 1t'Fislat ive ;Inti hucigetarv lTot'aSlires if necessary. Existing mechanisms for thiS apPI-oach may hay!' to be reviewed and modified, or new ones introdllced. As a prprequisite to the success of this approach, the people will have to hf' well informed by the health pt'rsonnel themselves. Further detailf'd analysis shou1n identity the acti,,"S to he taken by the health sect0r and by other sector~ ann, which woulci constitute a plal1 of action for both. The problE.'ms relat.d to health care system!: SE.'t out in Chaptf'r I, section I.~, provide a startin~ point for such an analysis. Thf' implic:ltions, as far as thE.' ministry of health is ('oncf'rned. /Ire that it mll!'lt strengthen itself to enhancE.' its I"adership rolE' in health dl'vE.'lnl'ment and to develop the capacity to draw upon th., rE.'sourc.'s of other reJ.lted spctors and/or external technical and financial collaborat10n. In the case of external collaborat],)n. specific O1e;l~"'l'S will Ilef'd t" be taken to ensure continuous exchange and joint developmE.'ntal f'fforts (reDe) amonf( countries sharing similar interests or priori tips ill health. 5.2 Development of the required health manpower be of

The development of hpalth manpower will, as a genE.'ral principlE.'. I!:uided by the requi1ements of the proposed national health systems, which primary health carE' will he thf' central function.

Tn fulfilment of this principle, it will bE.' Ilf'cessary for educational institutions to collahorate I,ith the mi,ltstry ot health sno other ministries In planning for and pr('lducing an adeq"lItf' llumbE.'r of hl'alth personnel to promotE' a more ~alanc~d delivery of hP31th care in order to mE.'l't thl' neE.'ds or the entire ropulation. The necessary manpower planning activities should n('t only take into account the number C'f staff needE.'d t'ut also USf' "S a bAsis an analysis of the functiona requi r.'d for managing the heal til system. Such an analysis \oIi 11 E.'nable countl IE'S to ascE.'rtain the type~ of personnel t" be trained and will also SE.'rve as a basis for continuing E.'ducation. The success of this intersectoral approach will depE.'nd on the formulati~'1: and application ,'f policies pnsuring harmonious collaboration.

•

- 53 -

Anr.ex 7

to th~ actual development of will be paid to the following;

trAinin~

pro~ramm~s,

particular attpntion

(1) Strengthening training progrAnunes and institutions in teTllls of faculty development, reviewing curricula to improve their relevance and to emphasize promotive and preventive health care, developing manuals and textbooks, strengthening library facilities and teaching equipment, improving the assessment of atudent progress, and developing national institutes. (2) Where small countries or areas predominate, continuin~ the practice of sharing the facilities of one of the larger countries, with the prospect that the demands on ita facilities will continue to increa.e. This applies particularly to the South Pacific. (3) Training in health management and administration, which expected to be provided in health development centres or networks similar mechsnisms. is or

(4) Attracting appropriate staff into the community health field and correcting the maldistribution of heslth manpower by directing it from urban to rural areas. While there are various ways of achieving thi., the ministries concerned, as well a8 the public administration in general, will take steps to ensure that health workers are socially motivated and provided with the neces.ary incentives. It is expec ted that cont inuing educat ion, improved supervision and better career structures will be needed. The reorientation of health workers and other workers, such as teachers and community workers, towards primary health care and coordinated cooperative action at the community level for the development of community self-reliance, constitutes an essential activity planned by countries In their respective approaches to primary health care. (5) Action will be needed to identify thp strengths and deficienci('s of training institutions and to establish reciprocal arrangements whereby an activity in one institution can compensate for a deficiency in another. Meetings of heads of certain institutions, such as deans of public health ~chools, of medical schools, and of nursing schools, are considered very IIseflll in this regard. Support will be needed for national training courses And institlltion "trengthening. Tn ensure the highest lpvel of relevance in teaching, trainin~ institutions will he encouraged to engage in health services research.

- S4 -

Annex 7 CHAPTER 6; RfGJ0NAI. :;{lPPORT MEASURES

Country reports ind~cate various existing and planned support measures for health/2000 policiea and strategies. Political support is explicitly stated in some cases, while in others it is implied through the government's support of Health Assembly and Regional Committee resolutions. Requirements for economic support are indicated. Country reports emphasize in particular existing and future needs with regard to managerial support, research and information. 6.1 political support

Political support will be obtained through the involvement of political and soc ial leadera in appropriate regional and country act i vi ties. Thi 5 will be effected through both regional and national forums. The latter might include legislative meetings at all levels, cabinet meetings, meetings of political parties, labour organizations, and non-governmental organiZations, religious meetings and CIVIC meetings. The creation of national health councils that are essentially intersectoral is one of th(' measures that could be adopted to enlist political and legislative support. The enactment of new legislation may be necessary to facilitate the introduction of the necessary health reforms, for example, to define the rights and obligations of various categories of health worker and to permit communities to develop and manage their health and related social programmes and services. Intergovernmental groupinga, such as ASEAN, will also contribute to the promotion and formulation of national policies and atrategies by determining joint action in health development and bringing h~alth development iasues to the attention of Member States and other regional forums. The Regiona I COlllll1i t tee has the task of formulating, monitoring and evaluating regional policies and strategies. In so doing, it alao serves as a very important political mechanism for support of the regional strategy. In addition to the World Health Assembly and the Executive Board of WHO, global forums, both within and outside the health sector, should be used for the promotion of health development efforts and, in particulsr, the concept of health aa an integral part of socioeconomic development.

- 55 -

h.2

Economic support

The support of economic planners for the national health for all strategy is essential, and ministri"s of health should take advantage of every opportunity that occurs for enlisting that support. It ia also equally important for the ministries of heslth to detect any negative effecta on h.alth of development projects and to see to it that protective meaaures are .ade integral components of these projects, as, for ex ... ple, in irrigation schemes, dams and industrial development projects. Economic support will be . . cured from international development bsnk!' (World Bank, Asian Development Sank) and multilateral and bilateral agencies (Colombo Plan, USAID, ADAB, JICA, DANIDA, SIDA, SPEC) as well as from voluntary donors such a6 the -Japan Shipbuilding Industry Foundation. The strategy will be to channel resources into activities for integrated health development and in particular to emphasize the health component of development projects funded by international cooperation. It is important to stress that economic support should be used for development activities that will foster self-reliance and not aolely for the import and maintenance of technology. It will be necessary to develop and strengthen regional and global mechanis.s for attracting bilateral and multilateral funds and to ensurE' that they are channelled to priority activities and countries.

6.3

Technical support

Technical support will be ensured through promoting, in training institutions for medical and allied health personnel, the concept of equal right to health and primary health care. The teaching of specific subjects related to health development, such as health planning and management with emphasis on primary health care, will be strengthened or introduced in ~chools of public health. It will be of particular importance to obtain the support of health professional. through associations of doctora, nuraes and through othE'r technical nongovernmental organizations dealing with health and health-related problems. Activities to enlist such support will focus on mobilizing the health professionals and directing their activities towards the objectives and strategies of health/2000, both at national and regional level. Promotion and exchange of information with orgllnizations of health and related professional bodies through personal contact, formal and infon'lal meetings, written cOlIDunications and publications will be pncollraj!:E'd. Special efforts will be made to promote thE' support of medical and related industries by encouraging them to produce equipment for appropriatp technology and to manufacture essential dru~s at rea60nsble cost. In thosE' ... Horts, UNIDO, UNICEF and ESCAP will play an important role. Specific mech~nisms for this are being developed in the Region.

- 56 -

,\::I1l'X

7

111E' global strategy 5hould devE'l<,p mechaniFms to promote collf'ctive action at high international level involving governmental and nongovernmental organizations, to mobilizE' the health-related profession~ and generate the active support of the media throughout the ",<'rId.

6.4

Managerial and administrative support

Countries will need to strengthen their capacities for national health development to enable them to develop and implement their strategies. 111i5 should le.d to the following; (1) Review and revision of health policies to give a clear and morE' specifie direction to health resource. and activities.

(2) Improved planning, implementation and evaluation processes which will ensure the more effective delivery of health care and provide the means by which new knowledge with regard to the health development needs of the people can be converted into appropriate ac t ion. 111e new knowledge will also be used to change the role of health workers and to equip them with essential understanding and skills so as effectively to support health development. The ministries of health will establish mechanisms to develop and apply their managerial processes and to provide adequate training for all those who need it. The regional strategy will include tbe E'stablishment of, and support for, national health development centres/networks and n.tional health councils, or similar intersectoral coordinating bodies, and E'fforts to strengthen capabilities to devetop and apply the managerial process. It is fl'nvisaged that the national health development centres/networks will consist of a number of institutions which will have a working arrangement to share their resources and thereby overcome their deficiencies. 111e cE'ntres/networks are expected to conduct training in the managerial process, carry out health services research in identified priority area6, snd provide the ministry of health with advisory services. It is highly desirable that the staff of academic inst itutions should be pxposed to actual field experience in order to enhance their contributions. Initially six national hE'alth development centres/networks are proposed (<laina, Malaysia, Papua New Guinea, Philippines, Republic of Korea and South Pacific). Close cooperative relations wi 11 be established among them as well as with other selected institutions in other countries of the Region, thus constituting a regional network for health development. Relations will also be esUblietied with similar networks in other Regions to form a global network. (3) ProviFion of Member States in dealing with support to administrative problems, such as logistics, personnel matters, budgeting, accounts, rE'organization, pte.

- 57 -

Annf'x 7

The global strategy should devpJop support for managerial and administrative processes by providing technical expertise and exchange of information between Regions and obtaining finsncial assistance for national and regional health development networks. 6.5 Research support

Research will be particularly oriented towards the solution of problems related to the goal of health/2000. Emphasis will be placed on research in prilUry health care and health services development, appropriate technology, tropical diseases, human reproduction, chronic diseases and environmental health. Research will, therefore, be coordinated at national level by health relearch councils or their equivalent (existing health ralearch councill will be strengthened if strengthening is indicated, and where no luch council exists the establishment of one will be encouraged). At regional level, the Western Pacific Advisory Committee on Medical Research and its subcommittees will advise the Regional Committee on identifying priorities and improving coordination of, and extending support to, health and medical research. Health services research will be promoted as an integral function of a national health development centre/network. The global strategy will include: coordination through the global Advisory Committee on Medicsl Research, support to regional advisory committees on medical resesrch and estsblishment and strengthening of relations with global institutions concerned with research in health and related areas. Of particular importance in a global strategy is expertise through WHO expert advisory panels. 6.6 Information support the use of national

To support the development and implementation of national policies and strategies, exchanges of information among countries wi 11 be promoted and supported, using the TCDC and similar cooperative efforts slready mentioned under Sections 6.3 and 6.4. Of particular importance is the provision of relevant technical information. The WHO Secretariat, with WHO collaborating centres, will ensure- that countries are provided with relevant technical information for national health development. In that connexion, research findings and information on experienc, gained in, for example, the formulation and implementation of national policies and strategies, the introduction of administrative reforms and the development and use of indicators, will be widely disseminated. Information of the public will be a major component of support strategies. Public opinion will be IIIObilized at both regional and national level through the development of appropriate health education methods and approaches in community organization. The public will be kept informed throu~h the mass media and through personal contacts with health sector personne 1.

- 58 -

Annex 9

CHAPTER 7;

GENERA,'ON AND MOBILIZATION OF RESOI'RCES

7.1

Human reaources development

To implement the atrategy, two types of resourcea will have to be mobilized: human reaources, and financial and material reaources. nw strategy involves mobilizing all human resources, and not only health personnel. Realizing that the best way to mobilize people is to get them involved, ministries of health will explore appropriate ways of involving people in deciding on the health system required and the health technology they find acceptable, and of delivering part of the national health programme through self and family care and the involvement of local communities in action for health. The following are some of the measures that will be consider£'d, order to promote community involvement: in

(1) Delegation of responsibility, suthority and resources to eatablish primary health care in the community in such a way thst partnership with the community is developed in the delivery of health care. (2) Creation of community development committees concerned with health, composed of representatives of a cross-section of the community, to develop and support primary health care.

(3) Fostering individual responsibility for self and family care, and promoting a lifestyle conducive to health. (4) Ensuring representation from the community in national or intermediate-level health councils/bodies involved in the decision"'1llakin): process of the country's health system. (5) Ministries of health will launch nationwide health educational activities through health personnel, the mass medis and educational institutions of all types, with the aim of enlightening the whole population with respect to prevai ling health problems 10 their countries and communities and the most appropriate methods of preventing and controlling them.

(6) At the same time, full sttention will be given to the Tf'orientation and retraining, when' necessary, of existing health workers, including measur£'s to enable them to sssume an active role in community health education. Consideration will also be given to the development of new categories of health worker, the involvement and reorientation, whE're necessary, of traditional medical practitioners and birth attendants, wherE' applicable, and the lIBe of voluntary health workers.

- 59 -

Annex 7

(7) Voluntary organizations/community groups will be fully encouraged to participate in health-promoting activities, first-aid and other health care in accordance with agreed cour~e~ of action and distribution of responsibilities. 7.2 Financial and material resources

Though information on the resources required to implement progralllllles to attain the loal of health/2000 is limited at pre,ent, Hember States will soon be de~ining, with the development of activities in deuil, thp malnituoe of the resource. required. Particular attention will have to be given to the preferential allocation of resources to underserved population groups and leaat developed countries. Various mechanisms and po .. ibilities will be tried to generate funds and to ensure that effective and coordinated use is made of whatever funds become available: (1) National health councils or analogous bodies, with their expanded role, will be expected not only to stimulate multisectoral collaboration but also to take active ateps to generate funds for health development and to ensure the effective use of external resources. The latter can be promoted through joint progralNDing at national level, preferably preceded by country health programming. (2) Bilateral and multilateral agencies for international cooperation will be urged to make strong representations to their governments for a further increase in their budgetary allocations and to rationalize the use of their resources. (3) Private foundations functioning at likewise be urged to increase their aid. international level will

(4) The possibility of creating mechanisms at regional level (for example, donors' meetings, focal groups at the WHO Regional Office, advisory bodies) to attract funds and ensure that they are used rationally will be studied. In the "ame way, mechaniams to improve the coordination and effective use of funds available from other agencies will be considered, such 8S periodic meetings, at the regional level, of United Nations agencies and voluntary organizations (see Section 8.2.1). (5)

'I1Ie

mechanisms p;eneration throUjthout established m('chanism.

global strategy should include establishment of global to ensure continuous monitoring of the avai lability and of funds and their distribution to priority problelll areas the world and to priority programmes. The recently Hea I th Resources Group for Primary Hea lth Care is one such

- 60 -

Annex 7

CHAPTER 8.

COI.L.ABORATIVE MECHANISMS

8.1

Intrasectoral and intersectoral collaboration

8.1.1 Counta reports stress the importance of collaboration and coordination etween components of the health sector and sectors closely related to it. such as education. agriculture. public works. transport and human settlements. Preparation of an inventory of agencies covering the health and healthrelated sectors, and an analysis of their resources and functions. has been mentioned or implied in some reports as an initial activity towards the establishment of a collaborative mechanism. The issues to be considered by the analysis would include: delineation of the responsibilities of the health ministry and the medical csre insurance or social security system; the effectiveness of cooperation between the private and the public health sector as regards referral systems. extension of services, use of health facilities, and area/population coverage; the formulation of relevant curricula for the education and training of health manpower; policies with regard to nongovernme'ntal organizations, their participation in national decision-making, their complementary and supplementary roles. and the support they need from. as we 11 as what they can give to. the heal th ministry. Countries are unanimous in their opinlon that health/2000 cannot be achieved through the heal th sector alone. Intersectoral collaboration and coordination are expected to resolve policy and operational difficulties in many areas. inc ludi ng the deve lopment and ma intt'nance of cOll1llluni ty wa t t'r supplies. the control of environmental pollution, the promotion of nutrition and food produc t ion, the drug i nduB t ry. educat ion and hous ing, the construction of health facilities, drug and alcohol problems, and road traffic accidents. Country report s recogni~e the need for advi ct', coord inat ion or collaboration in ht'alth development activities at different levels of government, but especially at policy level. Some countries consider that nt'w mechanisms should be developed, while others believe that existinR ones are sufficient but need further strengthening. Some countries are apprehensive with regard to the proliferation of coordinating mechanisms and believe that rationalization of such mechanisms through an "umbrella" council would be useful. It is also quite likely that the mechanisms wi 1 t be given different advisory boards, and that they wi 11 include representatives of other sectors as members. Intersectoral governmental commi ttees are planned by some countries; for examplt', an interministeria 1 body for primary health care, or an intt'rministerial body for proRra..... e revit'ws.

- bl -

Annex 7

8.1.2 Regional action will consist in supporting countries in the establishment or strengthening ot their national mechanisms, throul!:h and through advi Bory services on the nature, promot iona I efforts composltl.On, level, function and wL'rk process of such mechanisms. lnfonnation will be disseminated on the experience of countries with such mechanillma. The need (a) for a better understanding of the role of health development in general social and economic development and for multisectoral support for health/2000 atrategies and (b) to provide expertise in theae mattera, pointa to the importance of establishing a mechanism to facilitate multisectoral consideration of health development policies. One such mechanism might be a regional health development advisory council. Such an advisory counci I wou ld he lp the Regiona I Di rec tor to support the Rep;ionsl Committee adequately on all issues involving multisectoral policy and action for health development. A reRional health development sdvisory council could derive support from, and in turn support, existin!! multisectoral national health councils or those that may be establiahed in the near future by Member States. 8.2 Intercountry collaboration

Support to the implementation of national strategiea for health development could be provided by a variety of organizations and institutions at regional level.

8.2.1

anizations

voluntar

a encies, a encies within

(a) Intergovernmental organizations such ss the Association of South-East Asian Nations (ASEAN) Bnd the South Pacific Forum offer opportunities for promoting intersectoral coordination of health-related activities and could identify resources and funds to facilitate TCDC processes for health development. (b) The Southeast Asian Ministers of Education Orgsnization (SEAMF.O) could provide resources for undertaking research, particularly in the areas of biomedical and appropriate technology, and means for the exchange of information and trainin~ of health workers. (c) The Southeast Asian Medical Information Centre (SEAMIC) could cooperate in the exchange of technical information. the support of technical studies and the promotion of activities for health development. 111f' SOllth Pac i fie Bureau for Economic Cooperat ion (SPEC) and the Pacific Commission (SPC) could provide promotional support to illtE'l"St'ctor.'lJ coordination and technical support to health development ':ll:ti,,;tips in countries or arl'as of the South Pacific. (.1)

~l)lIth

Annex 7

(e) 'n1e development banks, such as the Asian Development Bank (ASDB) and the World Bank (IBRD) are sources of funds for development and could be meana for integrating health with other development projeCt5. (f) Bilateral agencies such all the United States Agency for International Development (USAID), the Australian Development Assistance Bureau (ADAB) and the Japanese Internationsl Cooperation Agency (JICA), could play important roles in terms of technical and financial contributions.

(g) Nonlovernmental and voluntary organizations at the regional level could be aeen aa mechaniams for promotional act~vltiea, technical support and exchanae of information, including fund-raising from private sources aa contributions to health development; aa an initial step. a list of auch organizations will be developed. (h) Agencies and organs of the United Nations system provide direc t technical cooperation, support TCDC activities, integrate health with other related development activities and resources, including the coordination and mobilization of funds. and help implement national health development strategies. These include UNDP, UNICEF, UNFPA, UNEP, UNlDO, ILO, FAO, ESCAP. (i) 'n1e WHO Regional Committee for the Western Pacific, exerCiSinl'! its coordinating function in international health work, is expected to provide policy aupport, to play an important role in promotional activities, especially in bringing about important reforms in national health systems, and to monitor progress. 'n1e multisectoral advisory body mentioned under Section 8.1.2 would be a means of providing national health councils and health development centres/networks with technical aupport. 'n1e Regional committee Sub-Committee on the General Programme of Work will provide technical aupport and JOint technical monitoring of WHO collaboration in health systema development. Resources and mechanisms to support national health development efforts to attain the goal of health/2000 exist in abundance at the regional level. However, the organizations and agencies concerned have varying, and at times diverging, philosophies and approaches to, and concepts for, development. Accordingly, the principal strategy for implementing regional support for national health development processea will be to draw the national bodies towards a common underatanding, so that efforts and resources are mobilized, synchronized, and directed towards the goal of health/2000. It is proposed to organize coordination meetings and to strengthen mechanismll for closer cooperation with the agencies mentioned.

- 63 -

Annex 7

H.2.2

Technical cooperation among countries

Technical cooperation should illways be lin I'ssential consideration In any programming activity of an international a~ency. Member States an' also urged to take this into consideration in formulating their health plans and programmes. National and regional mechanisms will have to be stren!!;thened or developed in such areas ss information exchange, training, procurement and manufacture of equipment and supplies, intercountry exchang~ of expertise and collaborative research. In many instances such cooperation is already being developed, including, for example: the exchange of information on appropriate technology for health; the development of a South Pacific Pharmaceutical Service and the ASEAN Task Force on Drug Pol ic ies and Management j the strengthening of national training programmes and institutions in which other countries have a share, such as the training of health educators In Papua New Guinea and of assistant health inspectors in Solomon Islands; training in primary health care and traditional medicine in China; collaborative research in dengue fever; and the increased use of expertise from one developing country in another developing country. The important contribution developed countries can make by supportinl' the health development efforts of developing countries is well recognized. This will be encouraged and facilitated by providing information on the health situation in developing countries and the magni tude and types of resources needed in a priority basis. 8.2.3 Economic cooperation among developing countries

This will stimulate and faci !itate cooperation in the an'lI of health. Moreover, certain activities in the health field, such as drug production and manufacture of equipment, wi 11 fos ter economic coopera t ion. In bo th these areas, health ministries have an important role to play.

CHAPTER 9:

MONITORINC AND EVALUATI()t\

9.1

Framework

Strategies formulated at national and regional level are expected to ove rcome cons traint s, to enab Ie programmes to respond adequate ly to the nf'l'd to solve the main health and health-related problems. Thus monitoring and evaluation will have to focus on the following; (L) Development activities. Close attention will be glvl'n tp achIevements in the areas of managerial processes for development, appropriate technology, health manpower development and health systpms deve lopmen t, and the i r combined impac t on commun i ty se 1 f-re li.ance and on pro~ramrne delivery.

- 64 -

Annex 7

(2) Programme delivery. The effectiveness of monitored and evaluated through selected indicators.

programmes

will

be

(3) Health status. The impact on health status will be monitored and evaluated through selected indicators. Two types of impact will have to be considered: on a ,pecific health problem and on total health, such as the infant mortality rate, life expectancy at birth or the maternal mortality rate. 9.2 Level and proc.,s regional

Monitoring and evaluation will be csrried out at national, and global level. 9.2.1 National level

The guiding documents will be the country reports on national policies and strategies for health/2000 and the medium-term plans formulated, or to be formulated, within that context, special attention being given to the three elements mentioned under Section 9.1 above. Monitoring and evaluation will be carried out routinely, at fixed intervals, as part of the administrative process; for example in connexion with the formulation of annual budgets, the preparation of annual reports, mid-term reviews of the medium-term plan, or formulation of a new plan. It may need to be carried out at various leve Is, inc luding the communi ty level, by the health authorities themselves and national health councils snd agencies specially assigned for the purpose. 9.2.2 Regional level

Monitoring and evaluation will be carried out collectively by Hember States, through the WHO Secretariat, with emphasis on the involvement of participating countries. The WHO Secretariat IS expected to carry out appropriate tasks, such as requesting national authorities for progress reports, and to submit its findings to the Regional Committee, either directly or through any body that may be constituted or supported by the Regional Commmittee, such as the Sub-Committee on the General Programme of Work. It is recognized that there are at least two instances when Member States come together and report on their work in the field of health: sessions of the Regional eo-ittee and the World Health Assemblies. It is proposed that reports should be so structured as to be evaluative in nature as well as prospective. An intenaive evaluation of impact will be conducted in the third year of each general programme of work period, a regional analysis of the health situation being carried out in the final year.

- 65 -

Annex 7

9.3 9.3.1

Indicators proposed Indicators to monitor implementation of health/2000 strategy (national level) on their

The following indicator. could be considered, depending appropriatene •• and the infor.etioD available at national level: (a) Social and .ocioecono.ic dev.l0e-ent indicator. pri. . ry achool enrol. .nt secondary school entrance/completion GNP per capita calorie availability per capita population growth rate dependency ratio urban/rural population ratio adult literacy ratio (b)

Health status indicators (overall community health status) life expectancy at birth infant mortality mortality among children aged 1-4 age specific mortality rates for 15-24, 25-44, 45-54 age groups maternal mortality neonatal/post neonatal/perinatal mortality industrial abaenteeism due to illneas or injury weight at birth anthropometric measurements (height and weight children) develo~nt

in

- 66 -

.

,

Annex 7

(c) Specific health problem indicators (measures of reduction in specific health problems to a level acceptable technically and to the community) incidence/prevalence of communicable diseases incidence/prevalence of chronic/degenerative disea.es mortality due to chronic/degenerative disea.es incidence of specific nutritional deficiencies (nutritional anaemia, xerophthalmia and goitre) and metabolic diseases (diabetes, gout) disease specific mortality indicators for oral health status (in terms of DHF) (d) Health services improvement indicators [Simple specific developed} (i) and basic means of mea.urement of health have to be

Index of equitable distribution social justice in health

resources

health services' coverage and accessibility health services' quality and appropriateness community satisfaction with health services provision of essential drugs (ii) Means of meaauring community participation and support measurement of cOlmlunity resource allocation for heal th action assessment of health habits (use of latrines and safe water, personal hygiene, child-rearing practices, fertility regulation and immunization) measurement of community management of health services (iii) partie i pat ion in the

Ways of measuring the development and use of appropnatp technology index of the use of local resources in the production of essential drugs and construction of health facilities

- 67 -

AnnE'x 7

transfer of knowledge and skills to membE'rs commmunity in the spirit of self-reliance (iv) Ways of measuring intersectoral collaboration

of

the

horizontal intpgration at various levels (including nstional level) in thE' planning and management of health and health-related programmes establishment of intersectoral coordination councils (v) Measurement of the development of managerial processes mechanisms for developing national hea1th/200(1 policies, strategiE's and plans of action and for facilitating central planning and intersectoral coord ination measure of decentralization of prograalDe pl.nning and management to provincial, district and c~nity levels index of health legislation and enforcement (vi) Heaaurement of the development of health manpower programmes establishment of mechanisms of training needs for continuous monitoring the status and career

measures introduced' to improve prospecta of health manpower

indices of adequacy and distribution of health manpower (vii) Reaources allocation for health development budgetary allocation and relative terms to the health sector in abaolute

proportion of GNP for health changes in the pattern of resource allocation primary, secondary and tertiary health care priority of disadvantaged groups (viii) Measurement of improvement in the delivery of health care immuniaation coverage deliveries attended by trained health personnel to

- 68 -

Annex 7

pregnant mothers covered by essential antenatal care provision of nutrition supplements coverage with safe water supply coverage with sanitary latrines (e) Indicators of political cOllllllitment. These included under the different categories already enumerated.

indicators

are

9.3.2

Indicators for relional and global ule

Since average regional or global values of indicators have little meaning, monitoring and evaluation of implementation of the health/2000 strategy will rely on a .hort list of indicators. It is i_perative that Member States of the Region should provide the necessary reliable information on theae indicators. A list of indicators to be uaed for relional monitorinl and evaluation is givan below. Those with an aaterisk (*> are the indicator. to be used for global monitoring and evaluation of health/2000 atrategy implementation. 'ftiis list of indicators will be periodically reviewed relevance and aodified as necessary. 9.3.2.1 List of indicators l The number of countries 1n which: (a)

for

individua 1

Health policy indicators

* *

Heal-th for all has received endorsement the highest official as policy at level (1) Mechsnisms for involving people in the implementation of stretegies have been formed or strengthened, and are ae tua 11y functioning (2) At leas t 5% of the gros s product is spent on health (3) A reasonable percentage of health expenditure is devoted health care (4) national

,. *

national to local

IThe number in brackets shows the number given to the indicator in the global indicator lilt (Global Strate8~ for Health for All b~ the Year 1000, WHO, Geneva, 1981 ("Health for All" enes No. 3), page 75- 6.

- 69 -

Annl'x 7

*

Resources are equitably distributed (5) Defined strategies for health are accompanied by exp lic i t allocations (6)1 Defined strategies for health need external resources(6) for sll resource for /Ill

*

* *

The needs for external resources of defined strategies for health for all are receiving the sustained support of more affluent countries (6) At least 80% of local cOllWllunitiea st all levels have well-established voluntary and formal co~nity organizations, which srI' committed to continuous primary health care action programmes The community contributes in cssh and in kind to health or health related action.

(b)

Socioeconomic indicators

*

The percentage of population served with safe water in the home or within 15 minutes' walking distance is 100 (7) The percentage of population with adequate sanitary facilities in the home or immediate vicinity is 100 (7) The adul t Ii teracy rat io and women exceeds 70% (II) for both men

* *

*

The gross national product per head exceeds US$500 at 1980 market prices (12)2 The daily per capita calorie availability exceeds 2500 calories The daily per capita availability exceeds 70 grams protein

lIn the global list, indicator 6 is stated as "The nU1IIber of dl'veloping countries with well-defined strategies for health for all, accompanied by explicit resource allocations, whose needs for external resources are receiving sustained support from mOrl~ affluent countries". 21n the global list, indicator 12 is stated as "The gross national produc t per head exceeds llS$500".

- 70 -

Annex 7

(c)

~uality of life

Health status snd

*

At least 90% of newborn infants have a birth weight of at least 2500 gra.s (8) At least 90% of chi ldren have a weight for age that corresponds to reference values given in Annex I to Develop!llent of Indicators for Monitoring Prolress Toward a Health for All by the year 2000 (8) 'l1Ie infant mortality rate for all identifiable aub-croups is below 50 per 1000 live births (9) Life expectancy years (10) at birth is is over 3 60

1ndicators

*

*

*

Maternal mortality thousand live births

below

per

No casea of diphtheria, tetanus, whooping cough, measles, poliomyelitis and tuberculosis occur (d) Indicator of the delivery of health care Primary health care is the whole population with following; 1 available at least to

the

* *

'l1Ie percentage of deliveries by trained health personnel is 95 (7) 'l1Ie percentage of children i_unized against diphtheria, tetanua, whooping cough, meaales, pOliomyelitia and tuberculosis ia 95 (7) including Local health care, availability of at least 20 easential drugs, within one hour's wslk or travel is 100% (7) The percentage of children up to at leaat one year of age given routine child care by trained health personnel is 100 (7)

*

*

I In the global list, preciae values for different componenta of this indicator are not given. 'l1Ieae values are cODaidered relevant aa regional targets for the Weatern Pacific Region.

- 71 Annex 7

*

The percentage of pregnant women with at least three visits for antenatal care IS 100 (7) The population growth rate If'sS than 1% l!l

reduced tl

CHAPTER 10;

ROLE OF WHO WITH RESPFCT TO RF.GIONAL STRATEGY TSSllES

10.1

Issues for WOO

In accordance with the conatitution, the· role of WHO includes coordination of the action which Member States undertake to atta:in the goal of health/2000 and the provision of technical cooperation. The coordinating function ia the basis for, and is reinforced· by, the technical cooperation function, which may cover both· cooperation between Member States and WHO and cooperation among countries. Previous chapters of the present document have out 1 ined the proposed regional strategy for achieving the goal of health/2000. This chapter will describe how WHO intends to fulfil its role, given the functions described above. Several major issues will have to be faced by WHO in following the proposed regional strategy. OJanges wi 11 be necessary both within the Organization and w:ith respect to the relationship between WllO and Mf'mber States. The issues identified in previous chapters are the followin~:

(1) To realize thf' goal of health/2000, Member States will adopt II hroader approach to health development, which will bring together the community and all government sectors concerned.

(2) Member States and WHO are now IIwllre that the health/2000 strategy must tllke into consideration demographic, economic, social and behavioural, and f'pidemiological factors affecting health. To implement the new hoI istic approach to health development, may be required in the existin~ health systems, and above all in existing managerial processes. This of course applies to Member States and to WH0. chan~es

(3)

(4) The innovations required to carry out the strategy will need to he introduced on the baais of correct and relevant information.

- 72 Annex 7

accordin~ly,

the above""1llentioned issuf's and to modify its rol .. has been given fu 11 au thon ty by the Wor ld Hea 1 th Assemblyl and the Regional Committee 2 • Resolution A/RES/34/58 adopted by the United Nations General Assftlbly, also acknowledges the vital role that health and health care play in the developmf'nt of countries, particularly developing countries. and calls upon relevant bodies of the United Nations .yatem to coordinate with WHO in view of the Alma-Ata Declaration and the New International Development Strategy for the New International Economic Order. WHO

To

deal

with

A framework for action for the strategy has already been presented in Olapter 3. the fr_work is built on the concept of a partnership between the community. the goverll1llent and the private sector. The stepa involvpd in this partnership have been described. WHO will endeavour to promote acceptance and implementation of this concept.

10.2

Guiding principles for WHO action

To develop the issues described in the previous paragraphs, certain pnnciples can be listed. which will assist WHO in focusing its role in implementation of the regional strategy. (1) The health objectivee expressed by Melllber States in the country statement synthesis will be used by WHO in establishing its own priorities when planning future technical progralllJlles (eee sections 4.2.1 and 4.2.2>. The objectives form the basis of the regional objectives, targets and approaches {section 4.3}.

(2) At regional level, political, technical. economic, research and managerial support (including information) will be sought for the strategy.

(3) Emphasis will be placed on ~ati8fying the basic need for adequate food, water and shelter as a foundation for health, as well as on the dpvelopment of community self-reliancp. strat~gies

Joint planning, monitorin~ and evaluation of national health and programllles should be und.rtaken with health and healthincluding external bilateral and related sectors at natlonal level, international agencies 8S required. (4)

(5) The use of technical cooperation among countries in developing and lmplementlng nationsl strategies should be promoted. This should play a major role in the context of regional support for the strategy.

lSe~ resolution WHA33.24. 2~.!e resolution WPR/RC30.RII, Handbook pf Resolutions and Decisions thp WHO Regional Committee for the Western Pacific, Vol. II, 2nd ed., IQ~O. r~~es 1-2.

of

- 73 -

Annex

7

(6) In the spirit of thf' /I:(>w International Economic Ord(>r, thl' l-eSQUrces of WHO, from both the re~ular budget and extrabudgetary resources, should be allocated according to the priorities established by the 5trate~y.

10.3

Nature of WHO collaboration

The nature of WHO collaboration has already been considered 1n <lIapters 6, 7, 8 and 9. It involves regional support measures, generation and mobilization of resources, collaborative mechanisms, and monitoring and evaluation. Mechanisms for collaboration need to be reviewed and developed. At the regional level, WHO will: (I) enlist political support for programmes implementation of national health/2000 strategies;

related

to

the

(2) identify and mobilize sources of extrabudgetary funds to support the implementation of national strategies and coordinate the effective us of such funds;

(3) organize multidisciplinary teams to provide Member States with direct support in the development of national strategies and plans of action for achieving health/2000. (4) ensure the monitoring of WHO support by the Regional committee.

At the national level, WHO will; (1) support national officials strategies and plans of action;

in ~n

developing

national plans

health/2000 of action,

(2) includin~;

cooperate

when

so

requested

implementing

(a) the introduction of managerial processes for nationsl health deve lopment; (h) initiation of the primary health care approach, including research and development activitles at community level where applicable; (c) thE' strengthening of human resources development programmes in minIstries of health; (d) the design and development of coordination mechanisms human resources development and for health research; (e) the design and centres/networks; development of national for

health development

- 74 -

Annex 7

(f) the design and deve lopment nf mechanisms to coordinate and monitor the implementatlon of national heal th strategies through the establishment of adequate health management information systems in the ministries of health;

(g) the design councils;

and

development

of

national

health

advisorv

(3) initiate, encourage and maintain the implementation of priority technical programmes within the context of national strategies, for example. expanded immunization programmes, water supply and basic sanitation; (4) identify snd mobili:!:e sources of extrabudgetary funds to support the implementation of national strategies. 10.4 WHO's programme for the future

In the 1 ight of the foregoing, WHO wi 11 need to deve lop i til progra_e accordingly. For the first time, a planning perspective of 20 years has to be considp.red. Planning must be undertaken in the light of incomplete information and uncertainty with regard to future trends in the Region. At preaent, WHO plans its programmes in six-year periods known all General Programmes of Work. The current General Programme of Work ends in 1983, after which there will be three further General Programmes at Work up to the year 2000. For each WHO programme, there is a medium-term programme covering the six-year period nf the General Progranne of Work. The future programme structure and content, a5 far as the Region is concerned, will have to be reviewed in the light of the proposed regional atrategy. WHO is already undertaking activities in preparation for the Seventh General Programme of Work (1984 to 1989) and the strategy for attaining the goal of health/2000 will be, and will continue to be, the theme for this. The future programme structure and activitip.s of WHO will have to take into account the following: 10.4.1 Organizational structure therefore

At the regional level, the structure will allow WHO to; (a) approach heads of state and other national authorities to take the necessary steps to ensure that the goal of health/2000 is attained; (b) communicate and promote its vision of health/2000 in all sectors;

(c) establish intersectoral linkages between and among international organizations, for mutual collaboration and support in hea 1 th development;

- 75 -

Annex 7

(d) attract extrabudgetary development activities;

f"nd"

f.,r

national

and

regIonal

heal th new for (or the

(e) adopt a learninlt postun' which will generate and accept ideas, critically review iu t'xp"ri('IlCeS and develop a capacity problem-solving; and (f) respond appropriately anJ quickly to government requests cooperation, having regard to the priorities established throulth General Progrenme of Work. At national level, WHO will be organized in the following manner; (a) WHO Programme Coordinator Facilitator and technical adviser in implementation of national policies health/2000. Manager of leve 1. WHO

the and

development strategies

and for

activitie!' and

support programmes at national staff snd staff assigned to other including

Supervisor and supporter of all to his area of responsibility.

WHO

Technical adviser on health matter!' with respect international, bilateral and multilateral agencies, efforts to attract extrabudgetary reaources. (b)

Health programme teams Multidisciplinary groups of assembled: ( i)

WHO

staff,

formally or informally

to support the WHO Programme Coord ina tor 1n the development and implementation of national policies and strategies for health/lOOO; and to coordinate WHO technical under various programmes. collaborative activities

(ii) 10.4.2

Management of the strategy

While the scope for initiating managerial processes for health development is broad, a dual approach is proposed as an initial step in the implementation of the strategy. At national level, the approach wi 11 be to encourage and support national health administrators in the fOl'1'llulation and/or integration of national health policies consistent with the goal of health/2000, through primary health care.

- 76 -

Annex 7

At the periphery. the approach wi 11 be to encourage and support the health system in developing interactive processes with selected communitles leadinJ( to primary health care and to establish a monitoring system for the management of health development.

WHO will provide national health nevelopment centres/networks or similsr mecbanisms with timely and relevsnt support by coordinating lind functionally integrating national managerial processes for health development witb health services development and primary health care. Such support will be provided by multidisciplinary tea.. warkins in close coordination with a regional health development group establi.hed at the Regional Office. Teams will contain experts on the following:

(i) (ii) (iii) (iv) ( v)

community health development; policy and programme development; organizational development and planning; health systems development; health economics and behavioural sciences; health manpower development.

(vi)

The teams will work with the WHO Progrsmme Coordinstors snd the WHO health services planning and management projects within countries. For practical purposes. the teams will be composed of both Regional Office and field staff implementing a joint plan of action. The role of such teams will be to act as: (a) facilitators in initiating and processes for health development; supporting national managerial

(b) points of coordination for international and national management resources; and (c) collaborators in the approaches and methods. health development. development of approprlate managerial techniques. programmes and structures for

The functions of the teams will include: training consulting services research and development.

- 77 Annex 7

10.4.3

Programme content

The implications of the propof'pd region.11 strategy for WHO'~ programmes is that the following manngPrlal activities should be supported at regional, national and intermediate and local levels; (a) health policy and strategy formulation, planning and evaluation as a means of providing leadership trom nat ion81 c<' community level; (b) human resources development as a means of selecting, training and managing the human resources of the health system;

(c) information systems as a means of providing decision-makers and managers at all levels of the health system with relevant infonnation for its maintenance and development; (d) research and development as a means of monitoring health at the COllllllUnity level and providing appropriate and affordable health technology to meet the community's needs; (e) health development centres/networks, as a means of facilitating the process of intersectoral collaboration and providing hea I th systems with training, consulting and research support in the management of health development.

For WHO, this does not detract from t.he importance of its technical programmes. The objectives listed in sections 4.2.1 and 4.2.2 provide guidance with regard to the regional priorities as stated by Member States. WHO's specific technical collaborative programmes will be directed therefore towarda the ten broad objectives listed in aection 4.3 and organized and carried out through its General Programme of Work. For the last years of the Sixth General Programme of Work and the six years of the Seventh General Programme of Work, WHO will collaborate with countries/areas as follows: (a) A well-nourished popUlation: strengthening national and regional capabilities in the formulation and implementation of national food and nutrition policies and programmes; (b) Safe drinking water for all and sanitary disposal of human and animal waste: developing national capabilities in the formulation and management of plans to attain basic needs in safe drinking water and adequate sanitation for all, through primary health care; (c) Minimal environmental pollution and hazards: dpvelopin~ and. implementing national po lie ies and programmes for the cont ro 1 0 f environmental hazards.

- 78 -

Annex 7

(d) Communicab Ie diseases no longe I

;1

major prob lem

strengthening national capabilities in the plRnnlng and management of thp following programmes: immunIzation, control of priority vector-borne diseases such as filariasis, malaria, dengue haelllorrhagic fever and plague; control of diarrhopal diseases; tuberculosis control; control of sexually transmitted diseases; investigating and resolving technical problems encountprpd III malaria eradication programmps and in developing and mana)(lng optimal antimalaria programmes in countries where pradicat ion ia not at present applicable; strengthening operations for thp control of paraSItic diseases through appropriate technology; defining the scope and magnitude of acute respiratory infections and demonstratin~ the effectiveness of intervention~ in significantly reducing mortality due to such infections in defined populations; initiating surveillance activities in zoonoses and infections/ intoxications of animal origin; initiating activities to implement regional programmes for thp control/eradication of yaws, viral hepatitis and nosocomial infections, and identifying other emerging public hE'sltll problems that are communicahlp in nature. (e) Chronic diseases reduced: devploping and implementing programmes for the control of cardiovascular diseases and cancer as integra I parts of the general health services; strengthE-ning oral hE-alth programmes; and initiatin~ activities against other noncommunicable conditions, E'specially diabetes mellitus, gout. chronic non-specific respiratory diseases and chronic rheumatic diseases. (f)

Psychosocial well-being and a lifestyle conducive to hE'alth: promoting policies and programmE's on mental health, including the psychosocial factors involved in the prorn0c ion of heal th and human devE'lopment, and on the prevention and control of alcoholi~m, smokin~, drug abuse, mental and nE'urological disorders.

(g) No pockets of ill health developing national policips and strategies, and prepa Tl ng action plans for environmental health in rural and urban development and housing;

- 79 -

Annex 7

in co llaborat ion wi th Member States who have identifled the needs of the aged as a priority problem, formulating and implementing policies and programmes for the care of thE' aged as part of their overall ,,>cial welfare and health programmes with emphasis on community-based serVlces; developing national pro~rammes on rehabilitation with on community-based SerV1CE'S; identifying other disadvantaged groups strengthening health activities for them. (h) emphaai~

and

ini tlatlngi

ensure better health and soelsl Fertility regulated to well-being: strengthening fami ly planning as an integral p"rt 0 f a maternal and child health programme (see (j».

(i) Access to appropriate health care for all supporting health .ystems development through strengthening of capability in the analysis of the health situation and assessment of trends, implementation of the managerial process for national health devE'lopment, including development of health information systems, and the conduct of health systems research; promoting policies and programmes for thE' organir;ation of health systems based on primary health carE' to achieve total population coverage for the delivery of eaaentlal health programmes; promoting programmes for the development, application, and transfer of appropriate technology for diagnosis, treatment and rehabilitation and for the control of drug and vaccine quality, safety and efficacy. (j)

The objectives for nutrition, communlcable diaease control, psychosocial well-being, no pockets of ill-health, and access to appropriate health care: will also be met through a maternal and chdd health programme. In this connexion, WHO will collaboratf' with countries or areas in improving and strengthening their family health st>rvices fOT women of child-hearing age and children at all levels of the health system within the context of primarv health care in order to reduce maternal, perinatal, infant and childhood mortallty and morbidity, and 10 improving the physical and psychosocial development of children and adolescents, and reproductive health.

- 80 -

Annex 7

As a support to all the programmes, ""HO wi II ('011 Rborate wi th countries or areas in: promoting policies and programmes to meet the requ~rements of the health systems for health manpower and human resources development, production and management, using appropriate educational 8upport; promoting and streugthening health education of the public and the provision of the pUblic with health inforllation with a view to enlisting active community involvement In health activities, promoting healthy lifestyles self-reliance in health; and achievin~

communi tv

promoting nationsl capability in hea I th research tha t I S relevant to the solution of the major health problema focused on the objective of health/2000.

CHAPTER 11:

TENTATIVE PLAN FOR IMPLEMENTATION OF RF.GIONAL STRATEGIES, INCLUDING A TIMETABLE

The major milestones and targets f0r the fonnulation, implementation, evaluation and updating of policies, strategies, and plans of action for health/2000 at national and regional level include the followin!!:: (1) (2) Initial reports on national policies and strategies for health/2000 prepared National progress reports reviewed and a proposed regional strategy developed by the Regional COmmittee Sub-Committee on the General Programme of Work Rpgional strategy for health/2000 rev~ewed by the Regional Committee Commitment obtained by the Regional Committee for Member States, with cooperation from WHO, to implement, monitor and evaluate the regional strate!!:v April 19E10 June 1980

(3) (4)

Septembe r 1980 September 1980

- 81 Annex 7

(5 )

Extrabudgetary resources identified through joint planning; for example, joint prograuauing with l'NPP for the period 1982-1986 Policies and strategies reviewed and updated by Member States and plans of action developed Regional strategy reviewed and updated by the Regional Committee (a) Appropriate and relevant indicators to monitor and evaluate progress established (b) Monitoring and evaluation process introduced by Member States and the necessary mechanisms established for evaluating strategies (c) National health informat iOIl systems further strengthened to permit comprehensive monitoring, evaluation and updating of strategies

S.. ptember 1980

( f, )

I'!arch 1981 and subsequently as required (see

(9))

(7)

Septell1ber 1981 Rnd thereafter every 2 years by December 1981 June 1982

(8)

by December

19f\~

(9)

National policies, strategies and plans of action periodically reviewed and updated by Member States The following established: (a) intersectoral national health councils or similar mechanisms concerned with coordination, where appropriate (b) national health development centres/ networks

1983 and thereafter every 2 to 4 years

(10)

hy December 1983

hy December 1985 hy December 1982

(II)

The primary health care Rpproach introduced in selected areas of Member States Health systems development policies formulated and manpower and other requirements identified Manpower policies developed, personnel reorientated and institutions strengthened 1,'t<11 cov.'rage with primary health care II' all coul,tries, supported bv hpalth systems

(12)

by December 1982

(13)

by December 1985 hv Oecember lQ9('

(14)

- 82 -

Annex 7

(15)

Regional mechanisms following:

establlsll~d

tor the bv December 1982 by December 1982

(a) promotion and strengtlwning of technical cooperation among developing count rips (b) coordination with multilateral, bilateral and regional groupings in resource mobilization and implpmentation of strategies (c) coordination and collaboration within the United Nations system for developin~ a shared understanding and joint plannin~ and regionalization of resources (for example with UNDP) (16) Medium-term programmes developed in the Regional Office for the Western Pacific for supporting countries in the formulation, implementation, monitoring and updating of national strategies and plans of action The Seventh and the two subsequent General Programmes of Work developed to support the implementation of regional and national strategies (Headquarters and all regions) A regional strategy for managprial process for national health deve)opmpnt formulatf'd

by December 19B2

by December 198,

(17)

1982 and subsequently as required

(18)

1981

- 83/84 -

ANNEX 8

HEALTH AND HEALTH-RELATED INDICATORS IN THE MANAGEMENT OF HEALTH PROGRAMMES by

Dr Abdul Khalid bin Sahan l

lDirector, Planning and Development, Ministry of Health, Kuala Lumpur, Malaysia.

- 8S -

Annex 8

1.

Introduction

1.1 The social objective of health for all by the year 2000 was collectively adopted by the Thirtieth World Health Assembly. This globaJ objective will have to be implemented within the context of national goals and policies which may already be existing or yet to be developed. But basically, all countries seek to improve the quantity and quality of their health care, particularly to disadvantaged groups and areas and at a pricp which the community can afford. Many countries focus their objectives on such issues and problems as nutrition, safe drinking water and sanitary environment, pollution control, access to health care, control of communicable diseases, maternal and child health. population activities, health education and other promotive activities. Simultaneously, there are also objectives related to the health csre system such ss improvement of medical and health facilities and their coverage, training of personnel, research into new technology and approaches and improvement to the managerial processes of the health care system. 1.2 The entry point to the above-mentioned objective must necessarily differ from country to country, depending upon their current level of development, commitment, resources available and political systems. In Malaysia for example, the provision of highly subsidized basic health care using paramedical and auxiiiary personnel particularly in rural areas had been part and parcel of its socioeconomic development over the past twenty years. Now particularly in Peninsular Malaysia coverage with basic health care is good. On the other hand, in Sabah and Sarawak which joined the main stream of national development later, coverage with permanent health facilities is less than in Peninsular Malaysia. To correct this type of imbalance, greater emphasis is given to disadvantaged states in infrastructure development. Meanwhile, mobile clinics including by air are vIslting remote or inaccessible places to provide medical and health services until permanent facilities are created. 1.3 Current national socioeconomic goals and policies should be the fountain of all derivative policies, objectives, strategies, targets, and standards in the management Df all socioeconomic including health programmes. In Malaysia for example, the policy focuses on anti-poverty drives snd re-structuring of society. Development within the health sector will have to reflect this policy. Equity in resource allocation and emphasis on satisfaction of basic needs particularly for the poor and disadvantaged groups and areas are repeatedly stated. Community involvement in health and self-reliance are prDpagated. 1.4 In short, health has been politicised. This has a bearing not only on the way in which health programmes are planned and run, but also on the type of evidence that health status has in fact improved. Social impact indicators are preferred to such input measurement 8S increasing nu.ber of clinic attendances or facilities. Absence from schools or weight at birth are real terminal outcomes rather than attendances at achool clinics or volume of activities relating to nutrition or nutrition education. But what is important to be emphasized is that auch social impact takes a long time to be realized; in many instances it is not possible to say that the impact has been exclusively due to health programmes or the information required for evaluation may not be traditiDnally generated or may be generated from outside the health system. Even when they are available, the

- 86 -

Annex 8 question is how these impact indicators will be used in the management process particularly at the strategic planning level. At a lower level of decision-making, these indicators presumably are too aggregated or too late for control purposes. Through various management techniques, many countries are trying to improve the efficiency and effectiveness of their health programmes operation. This is because resources are not unlimited, health costs are escalating, and there is a general feeling that more could be done with the resources available if only management can be improved. Health administrators are increasingly called upon to give more convincing justification for their application for resources, decision or action. 1.6 In view of this trend, there is a need to develop not only indicators but also an understanding of decision-making processes and decision-making structures, and how such measurement of performance or information system relates to the objective of the organization and decision-making. There is also a need to link "medicalized" information or indicators with "dollar" information in V1ew of the present concern on escalating health cost.

1.S

Indicators for the following areas of concern are necessary: social and socio-economic impact of programmes health status and specific health problems improvement to health service delivery. This is related to coverage, equity, community support, intersectoral linkages and collaboration, and manpower. 1.7 For middle and operational level management, internally generated information may be adequate. But for strategic planning at the top level, information from external sources are required. To the extent that health programmes influence and are influenced by development in other socioeconomic sectors, use of a common data base and reference point for planning, sharing of information, commitment to common objectives and congruence and consistency of strategies are vital. Such information may not be easily available or are collected and presented in a manner not suitable for the purpose. Further, the decision-making process for strategic planning is different from that of management of operations. Hence, the information requirement for different levels of management will have to be identified, and indicators to be developed along these lines, if they are to assist decision makers and not to be merely indicators for comparison or of historical interest. 1.8 From the aforesaid, it is clear that indicators cannot be developed in isolation from managerial processes in general and management information system in particular. They have to be linked to the reasons for which an organization exist, in other words the objectives of its programmes; and 1n characteristics they must satisfy the needs of various levels of decision~aking. Thus, it may not be possible to develop indicators of universal application or of equal usefulness for differing circumstances. Even when such "universal indicators" are available, their interpretation can be difficult.

Furthermore, the health agency of a country e.g. Ministry or Department of Health is not the only generator of or agency responsible for health or health-related information. Unless these other sources are identified, and information is forthcoming from them, information will be incomplete.

- 87 -

Annex 8

2.

Organ icza_t ion ~ he-"l~~E'r~Eanunes

2.1 In many countries, the Ministry of Health (MOH) is not the only provider of health services, although it may be responsible for health care programmes. In Malaysia for example, the following agencies/sectors also provide health or health-related services; the Armed Forces, mninly for ,ts personne! and their families; the Department of Aboriglnes; university hospitals; local authorities, in sanitatIon allJ maternal and child health; industries e.g. rubber estates and tin mines; the Ministry of Education, mainly in the area of health education; and private clinics and hospitals. Although run independently, these subsystems are usually subject to certain common minimal requirements or standards. For example, they can employ only registered technical personnel, Or they have to comply with minimal physical standards. Certain health information, <'.g. notification of infectious diseases is required by law. There may even be sharing or interchange of resources. 2.2 The existence of so many health/health-related subsystems creates problems of planning, coordination and Interphase of services and facilities, and has a bearing on the design and development of a management information system relnting to health. For the purpose of this paper', hO"'t'vt'" health services only. 3. The health progranunes of the focus wi 11 be on the MOll

MOH_~ Org~nlzation

and Structure

3.1 A Ministry of Health usually provides a range of health services, namely, preventive, promotive, curative and rehabilitative health services. These services are organized into programmes, each with their own objectives which are derived from the general objective of the agency. As an example, Appendix I shows the progranune structures of the Ministry of Hpalth in Malaysia under the Fourth Malaysia Plan. Broadly there are 13 "service" programmes and 9 "support" progranunes. The "service" programmes are those which directly provide health care e.g. family health, outpatient and inpatient care, personal dental care and so on. The "support" programmes are those whose activities contrihute towards the delivery of health care. Examples are radiologic and laboratory services, training and manpower development, engineering services, research and so on. Whilst distinct programmes exist and can be identifIed, it should be noted, however, that many programmes are closely interlinked or even share facilities and resources. Under thIS circumstance, whIlst output in terms of so many patients being treated or so many children being vaccinated with BeG can be counted, it is more difficult to measure the input for each one of these activities.

3.2 Health services are usually provided through a hierarchy of facilities, ranging for example from a midwife clinic with one midwife to a large regional hospital offering a wide range of specialist services with mo~e than a thousand staff. This pattern can be sununarized as in Appendix 2.

- aa Annex 8 The hierarchical pattern provides an lncreasing range 8S well as 8 higher level of service as one moves from a peripheral to a higher facility.

4.1

A management information system has to be management oriented.

The management structure of many health systems follow more or less the pattern as shown in Appendix 3. 4.2 4.2.1 Basically, three management levels can be recognized. Top management

This is represented by the Ministry of Health which for the purpose of management may be departmentalized as follows: medical care health dental service or personnel finance pharmacy and supplies training and manpower planning and development engineering Covering one programme or more, each division or department is headed by a director or equivalent who is responsible to the chief executive of the Ministry. In addition to discharging staff functions. he may also exercise certain delegated line authorities. But in the main, this level of management deals with policies, objectives. plans, resources, targets, standards and procedures. In terms of job content, this level deals with long-term planning. The scope of activity is broad and the nature relatively unstructured. It uses a lot of externally generated information. and the work tends to be creative and innovative. The people involved are few. 4.2.2 Middle management

This level of management is represented by the state directorate of medical services. The state director is assisted by a number of senior officers. It is the middle management's job to acquire and control the necessary resources in order to implement the objectives of the Ministry of Health. A prime yardstick of the middle manager's job is how efficiently he accomplishes these objectives. The focus on control is more than on planning. His time reference IS usually up to a year. Whilst covering the entire functional areas, the activities at this level are more structured and involve more defined variables. The emphasis is more on implementation schedules and performance. Information used are usually internal to the system and hence more accurate.

- 89 -

Annex 8

4.2.3

Operating management

This level is typified by the district hospital. district health office or district dental clinic. Operating management is concerned with more finite and specific activities. Focus on control is heavy and the time frame is day to day. Activities are highly structured and straightforward. The emphasis is on efficiency and effectiveness. Information used are internally generated, historical and of a high level of accuracy. 4.2.4 Some recognize a fourth level, namely' the activity level. These are the departments of the hospital or the health centres/midwife clinics which constitute the actual service outlets. The level of management here is elementary and more in the form of direct supervision. 4.3 To summarize, information is required at different levels for differ~nt purposes. As one goes down with the management structure, the information required tends to be more finite. structured and repetitive, accurate and historic in nature. Decisions are essentially related to control, the concern being on efficiency and effectiveness of operations. A different set of information, however, or the same information presented in a different way is required for strategic planning at top management level. 5. Management information and decision_!truc!ures

5.1 The decision making structure as described above have a bearing on the information required by the various levels and hence on the development and design of the information system. 5.2 At the strategic or top l~~~, deCisions are concerned with opportunities, challenges and issues facing the organization. Decisions are futuristic, the decision process unstructured, moving forwards and backwards in search of choices. Uncertain future events renders the decision risky. Whilst historical events captured by the operational level are useful guidelines, the strategist decision maker is more concerned with overall objective of the organization and how they relate to the external environment in terms of plans and reSources. In the health sector, the health planner will have to take note of development in related fields and environmental changes that will alter needs and demands. For this type of decisions, information externally generated and presented in a particular manner is also reqired. The traditional mortality and morbidity measurements are inadequate. Since health programmes usually form a part of an integrated socioeconomic development, decisions on health programmes will inevitably be linked to such issues as equity in resource allocation, anti-poverty drives, problems of social concern, disadvantaged groups and areas, subsidies for health, diseases of mass occurances and basic needs approach. 5.3 The middle level management basically deals with how to utilize resources to achieve the objectives within the standards and procedures established by top management. The focus is on efficiency, which is measured by information obtained from operational levels. Performance are compared with targets, and dollars linked to non-dollar information. Information 1S required more frequently and in a more structured manner and format, and is internally generated.

Annex 8

5.4 At the operational level, the concern is on the control of individual operations, which could take the form of vaccination, outpatient treatment, laboratory investigation, preparation of meals for patients, indenting for drugs and supplies and so on. The issues under consideration would include input e.g. manpower, finance and supplie~; processes undertaken; operational output; level of performance e.g. covera~e, continuity of care; effect and impact. Information is captured at source routinely. frequently and in a highly programmed manner. Such information is used in planning the day-to-day operations, control and in justifying application for resources. The need for information at the operational lpvel is as important as that at the higher levp\s. Information is required faster and more frequently for quick ~ecision and action. Many indicators necessary to evaluate and monItor the achievement of Health for All goal will be baspd on data element captured by the operational level. Involvement of operational personnel in the development of indicators is therefore necessary. 6. Health management information system

6.1 What follows is a description of the methodology adopted in the development of the health management information system in Malaysia to illustrate some of the points and relevance of issues raised earlier. 6.2 The development of the information system could be said to have taken place in two phases. The first phase dealt with a review of existing situation, conceptualization, and specification of areas of managerial concern, information requirement and data elements. The second phase involved a bit of "back tracking", refinement and redefinition of programmes, and establishment of indicators, 6.2.1 A review of the existing information system of the Ministry of Health revealed the following: "( 1 )

(3)

widening gap between data generation And data utilization. particularly in respect of deci~ion-oriented information; imbalanced development of various components of information system; functional isolation of different divisional information subsystems."

Programme budgetting, introduced into the Ministry of Health, in the early 1970s and its further development over the years, had increased the urgency to develop an information system necessary for planning and measuring efficiency and effectiveness of programmes. 6.2.2 A project to develop a management information system was initiated in 1975. Its overall objective is "to provide right information at the right time, in the right form to the right person to assist in different managerial functions of the Ministry of Health". 6.2.3 The specific objectives of the information system are to support the managerial processes at various levels by: "(a)

(d)

identifying and coordinating all sources of information relevant to the management process and establishing links vith other health-related information sources; efficiently acquiring, processing (including storage and retrieval), analyzing and timely provision of relevant information; promoting training in all aspects of management infonaation system development, especially utilization; working with management to identify changing requirements for health information."

- 91 -

Annex 8

6.2.4 In developing the inforaation system, the Ministry of Health health services was considered as one system, made up of two subsystems, namely resource subsystems and programme subsystems. The former covers the areas of finance, personnel, training, supplies, facilities and research, whilst the latter include all "service" programmes such as outpatient care, inpatient care, maternal care, child care, tuberculosis control, personal dental care and so on. In other words, the resource subsystems provide the input into programme subsystems which deliver health care of all types. Please see Appendix 4. 6.2.5 In order to identify information requirement and the .ast appropriate information system design and structure, the objectives and activities of each subsystem or subsubsystem were analyzed. Managerial areas of concern were established together with managers at all levels, and based on these, information require.ent and their frequency were determined. Data elements that need to be captured were then ascertained and included in new source docuaents, registers and return for.s that were subsequently developed. Existing source docu.ents that were found adequate were left unchanged. Please see Figure 1 below. Figure 1 Identification of Information Requirement For System/Subsystem/Subsubsystem

;--.------------------------~

Objective Analysis of Managerial Processes & Activities

Area/s of Concern

1I

11 uirement

I

Data Element

I

I

Data Element

I

,.

Data EI_nt

J

This was the stage arrived at just before the preparation of the Fourth Malaysia Plan (FMP).

- 92 Annex 8

6.2.6 During the formulation of the FHP, the programme structure of the Ministry of Health was refined to reflect better grouping of related activities as well as to lend emphasis to certain priority areas. Please see Appendix 1. - Maternal care, child care, family planning and school health had been regrouped under "Family health". Fi lariasis control, vector control and malaria eradication are now grouped under vector-borne disease control programme. Health education and health service research had been identified as distinct programmes, whilst a new programme called "Engineering services" had been included. 6.2.7 As had been described earlier, all FMP programmes are supportive of the general objective of the Ministry of Health, and each programme has its own objective/s strategies, targets and activities. For example, under Family Health programme, the objectives are: To promote the development of a healthy family; To promote and maintain the health of women in the reproductive age group; To promote and maintain optimum health and development of children from infancy through childhood to school leaving age. Among the strategies are "risk approach" and emphasis on the role of the family in promoting and maintaining the health of its members. Activity target were set e.g. 100% coverage of pregnant mothers, infants, toddlers and pre-school children in operational areas, and coverage of all school children 1n Standard 1, VI and Form III and so on. 6.2.8 As a continuation of the action described earlier, and to refine further existing performance indicators, the Ministry of Health undertook the exercise of reviewing the current situation and drawing up new or updating existing indicators. Basically. the following steps were followed: Step 1 Recapitulate, and analyze the problemis for which the objective had been proposed. The problemis could be related to resources, facilities, needs and demands with all their various characteristics. Recapitulate or decide on the most appropriate intervention to overcome the problem/s. The intervention could very well be building facilities. training personnel, to provide family planning service. to detect and manage early high risk pregnancies and so on. Determine intermediate or proxy outcome indicators. These constitute the measurement of input, e.g. facilitY/population ratios. personnel/population ratios, rates of attendances at clinics, frequency of visits, rates of children immunized and so on. The bulk of present indicators fall into this category. Determine the final outcome indicators. This could be negative in dimension e.g. fall in morbidity and mortality rates or positive in nature, e.g. average birth weight, life expectancies. residual disabilities, waiting time and so on.

Step 2

Step J

Step 4

- 93/94 Annex 8 6.2.9 In this way, intermediate and final outcome indicators of 16 FMP programmes had been developed. They will constitute the basis of the information for management for the Ministry of Health, except for top level decision making for which additional information or information analysis will be required. 6.2.10 Currently, the new management information system IS being tried in one state. It will be extended to other states in phases to allow a gradual build-up of processing capability as well as expertise in its usage. 7. Problem encountered in developing the health management information system

Various problems were encountered in developing the management information systems. Among the major ones were: (a) Difficulty in conceptualizing systems, subsystems and subsubsystems rather than structures, interphasing issues, and the dominance of structures over programme objectives and operations; Difficulty in conceptualizing areas of concern, information requirement, intermediate and final outcome indicators; The need to interact with operators and managers and frequent changes in operators and managers, resulting in a long time frame for development; Tendency to overload the information system, "in case" somebody asks about a particular issue; Difficulty in deciding the most appropriate common data base because various programmes have their own peculiar information requirement. An example is the age grouping; State of preparedness of the system not only in absorbing a new way of doing things but also in exploring and accepting "non-medicalized" indicators and information; The large amount of data elements that need to be recorded in source documents, to be retrieved and processed; To get consensus on what information needs to be retrieved on a regular basis and at what frequency, and what other information is best obtained through surveys or random sampling; Linking the non-dollar with dollar information because of structural or operational constraints or barriers: The question of specificity and val idity of indicators, and clarity of definition and terms used.

(b) (c)

(d) (e)

(f)

(g) (h)

(i) (j)

8. The Malaysian experience in developing health management information system/indicators described above is one possible methodology. It is still too early to evaluate this experience. Whilst improvement to the system will be carried out concurrently with its phased implementation, its appropriateness and usefulness depends upon how well it can respond to management requirement for information as well as on management expertise and commitment to manage well.

- 95/9b -

Annex 8

APPENDIX 1

MOH HEALTH PROGRAMMES General Objective "In the Fourth Malaysia Plan, the objective of the Ministry of Health. 1n line with the New Economic Policy, is to facilitate the attainment and maintenance by the individual of a standard of health which will enable him to lead an economically and a socially productive life."

Service programmes Family health Occupational health Environmental sanitation Food quality control Vector-borne disease control Tuberculosis control Leprosy control Communicable diseases prevention and control Health education Inpatient care Outpatient care Personal dental care Preventive dental care "~~p'p'ort"

programmes

Laboratory services Radiologic services Health manpower planning and training Pharmacy and supplies Biomedical research Health service research Planning and development Engineering services Administration Each programme has its own programme objective/so strategies and activities. These are supportive of the Ministry of Health general objective. which in turn is derived from the New Economic Policy of the government.

- 97/98 Annex 8

APPENDIX 2

HIERARC»Y OF FACILITIES

I Regional HOSPitall

IGeneral HOSPital]

I General

HOSPital]

l i District

-------

HOSPita~l -

_1 ___ _ l ------1- -District HOSPital]

rL--,

I

idvife Clinic

ridvUe ,-CliniC

- 9<)/100 -

Annex 8

APPENDIX :3

MANAGEMENT OF THE MCH SYSTEM

Level "'ational or top level management

;-------------

--~-"

-,

"

State or middle level management

1 State Medica' ] Directorate

~~rectora:] ~-~-.---

____I

State MediCal] Directorate

1_-----

District or operational 'level management

" ____ J____

_==r--_ Health Centre \ ,

District Dental/ Centre :

J

Local

-----T ~idwife

Clinic

\ M~~if"e j Clinic 1. _ _ _ - "

.__ J ___ . Midwife ," Clinic

I

- 1011 102 -

Annex 8 APPENDIX 4

MOH HEALTH SERVICE SYSTEM

Subsystem Finance

Subsubsystem Budget Genera I finance

Subsystem Patient care

Subsubsystem Outpatient Inpatient Patient care support

Personnel

Manpower supply Hanpower maintenance Health Haternal care Chi ld care Fami \y planning School health Food sanitation General sanitation Filariasis control Disease control and international health Vector control Occupational health Halaria eradication Leprosy control Tuberculosis control Health supportive

Training

Technology for training Training of manpower Quality control Regulatory Supply Physical facilities

Supplies

Facil ities

Research Dental Personal dental care Fluoridation

- 103/104 -

ANNEX

9

SOCIAL INDICATORS AND rHEIK APPLICATION FOR MEASURING THE PROGRESS OF DEVELOPNI::NT by

Professor Jan Drewnowski

Iprofessor Emeritus, Economic and Social Plannin?, Institute of Social Studies, The Hague, Netherlands.

- 105 Annex 9 1. Introduction

When the problem of social indicators is presented and discussed it is useful to recall the way of thinking which has given rise to what is now known as the "social indicators movement". The "movement" has grown out of a conviction that policies and plans have been consistently biased toward strictly economic elements and were not giving enough attention to conditions in which people actually lived. It is not intended here to restate that very valid criticism or to repeat arguments in favour of a change in the orientation of development. They have been generally accepted as correct and convincing. What is still open to discussion is the methodology of devising social indicators and their usefulness in practice. The origin of this movement can he traced to .1 1954 United Nations report l where a number of indicators expressed in rhy~icRl units were proposed as a replacement for GNP as a yardstick by which "real" development could be measured. Another UN report followed in 1961 2 and then the work on social indicators was taken up by the United Nations Research Institute for Social Studies which has published a number of reports on the subject. 3 Apparently independently a similar movement has developed in the United States where the Government took interest in it. It has found its expression in several publications. 4 Official interest has also turned to social indicators in Europe where research work by governments 5 and international organizations 6 was undertaken. By the beginning of the 1970s interest in social indicators had spread to most parts of the world and many statistical bureaus substantially extended their collection of statistics referring to social conditions.

I Report on international definition and measurement of standards and levels of living (New York, United Nations, 1954). 2 International definition and measurement of levels of living, an interim guide (New York, United Nations, 1961). 3 UNRISD Reports: No.1 (965), Nos. 3 and 4 (1966), Nos. 70. 3, 70.5, and 70.10 (1970). The results of the work done in UNRISD by the present author have been presented in a book: J. Drewnowski: On measuring ~a~n~d~p~l~a~n~n~l~·n~g~~t~h~e~q~u~a~l~i~t~y~o~f~~l~i~f~e (The Hague/Paris Mouton, 1974). 4 US Department of Health, Education and Welfare: Toward a social report (Wash i ngton D. C. 1969). llS Departmen t of Commerce, Office of Federa 1 statistical Policy and Standards and Bureau of Census: Social indicators 1976 <Washington D.C. 1976). See also the Annals of the American Academy of Political and Social Science, No. 393 (January 1971) and No. 435 (January 1978) for information about the approach to social indicators taken in the United States. 5 France, Commissariat general au Plan: Indicateurs sociaux et economiques, rapport du groupe de travail (Paris, La Documentation francaise, 1976). Great Britain, Central Statistical Office: Social Trends, a periodical publication (London). 6 Social and demographic statistics - Draft guidelines on social indicators, Report of the Secretary-General, United Nations Economic and Social Council, Statistical Commission, 1976 (E/CN.3/3BB) (mimeographed). The use of socioeconomic indicators in development planning (Paris, The Unesco Press, 1976). List of social concerns common to most DECD countries (Paris, the DECO Social Indlcator Development Programme, 1973).

- 106 Annex 9

In spite, and perhaps because, of the rapid and extensive growth of the "movement" many methodological problems of social indicators have remained controversial l and the practical applicability of social indicators has remained rather limited. This is probably due to the fact that "measurement" was the focus of interest in the social indicators movement. Although the applicability of indicators to policy was assumed, their actual application was delayed as attention was concentrated on the elaboration of the methodology for formulating indicators and on making relevant statistics fully available. 2 This paper presents an approach to social indicators which is meant to ensure their applicability for measuring the progress of development understood as an improvement in the welfare of the people. Such a measurement may be used to assess and compare positions of welfare through time and space and for devising policies and formulating plans for future development. Essentially the paper is concerned with the methodology of computing indicators and of their subsequent application in assessing various aspects of development. The methodology adopted may be used in elaborating several systems of social indicators. The actual composition of each of such systems has to depend on the conditions prevailing and/or the changes envisaged for areas and populations to which those indicator systems are supposed to refer. As an example and possible starting point for discussion a system of social indicators presented in the form of a table has been provided as an Annex 4 to this paper. 2. Objective indicators

Objective social indicators are supposed to reflect social conditions of a population i.e. the conditions in which people actually live.

I The confusion was increased by the emergence of a new current in the movement concerned with the measurement of "perceived welfare". (See, e.g. B. Strumpel ed.; Economic means for human needs - Social indicators of well-being and discontent, Ann Arbor, 1976, for work done in the Institute for Social Research of the University of Michigan which is very representative of this approach). This was in fact a split of the movement into two distinct branches as measuring different conditions of people's life is an entirely different task from "measuring" their ideas about their condition. In the present paper the "perceived wel fare approach" is not considered. 2 Consequently. relatively little has been written on the application of social indicators to policies and planning. A proposal for including social indicators in a planning model is, however, contained in the author's book; On measuring and planning the quality of life, op.cit.

- 107 -

Annex 9

It is obvious that these conditions can be better or worse, that they can deteriorate or Unprove, yet the extent of these changes cannot be assessed, compared or planned unless a way is found of expressing social conditions in quantitative terms. To give social conditions a quantitative expression an instrument conceived for that purpose is needed. Social indicators are meant to be such instrument. Social conditions are reflected in many objective observable facts, some of which are liable to quantitative expression. A number of categories of such facts can be selected and the changes in their numerical values observed. Those changes can be assumed to reflect changes in social conditions of the population. A category of observable facts selected for that purpose would constitute a social indicator. A social indicator can be therefore defined as a variable whose numerical values are derived from observation of quantitative changes of a selected category of facts which reflect changes in social conditions. Social indicators used in the present paper conform to that definition. It must be, however, realized that not all concepts which pass for social indicators are covered by it. The definition adopted bases the indicators on observable objective facts and consequently it explicitly excludes what is called "indicators of perceived social conditions". "Perceived" indicators and "objective" indicators refer to two distinct categories of facts i.e. they do not try to measure the same thing in two different ways. The "objective" give numerical expression to actual conditions in which people live, whereas the "perceived" to people's ideas about their own conditions. This might be also of interest, but the data for such a study can hardly be collected on a national scale and are bound to be unreliable. Morever, the "objective" approach is more relevant for policies and plans. This is why it was adopted for the present paper. 3. Welfare indicators

Social indicators cannot pretend to measure all aspects of social conditions. Indeed some of these aspects cannot be even conceived as quantities. They concentrate on the measurement of the population's welfare, which is conceptually quantifiable (many attempts at its quantification were made in the past) and which constitutes a very substantial element in social conditions. To measure it is evidently most essential for both assessing the situation and for planning its improvement. In traditional economics the welfare of the population has been expressed by the total utility of the goods and services the population enjoys. But so far all attempts at measuring utility have met with great di fficul ties. The concept of social utility developed by welfare economics and expressed in a social welfare function has proved intractable and consequently of no use for practical policies.

-

IQl -

Annex 9

What was used in practice as a proxy for welfare were the commonly known national accounting variables such as Gross National Product. Disposable Income of Consu.ption per head. They are of course all legitimate instruments of economic analysis. but the trouble with them is that they measure (in monetary terms) various aggregates within the flow of resources on the national economy. but certainly not human welfare. As a proxy for welfare they are most imperfect. and putting them to this use is bound to lead to considerable errors in the assessment of welfare conditions and in planning them. l This is why the present paper is based on the assumption that social indicators are not only an indispensable instrument for the assessment of welfare conditions, but also that they constitute the only instrument which can actually perform the task. They are not one of the alternative ways of coming to Know the social situation but the only way in which the social situation can be presented in quantitative terms. 4. Social (welfare) indicators, and economic indicators (national accounting variables)

Social indicators which were conceived and presented in many publications on the subject are not all of them fit to perform the task of measuring welfare. They were simply not meant that way. It is therefore essential to make clear what are the special characteristics of indicators which are supposed to express welfare. It is also essential to understand the relation of such indicators to the traditional accounting variables. Such an explanation must begin with the following fundamental statement: both economic and social elements are involved in any development and also in the functioning of the society/economy. That implies that those processes cannot be explained by either economic or social elements taken alone. but by both elements considered jointly and by their interrelations. For the purpose of presenting the processes of functioning and development of the society/economy economic and social elements have to be seen in quantitative terms i.e. as economic and social variables. The economic variables would refer to the resources of the economy in the various stages of transformation: from primary factors to final goods. The social variables will be concerned with conditions in which people actually live i.e. with their welfare. It is obvious that those two categories of variables are very closely interrelated and that it is not possible to conceive changes in the econoaic variables which would not affect the social (welfare) variables and vice versa. They have also their proper places in the process of satisfaction of human needs and in development.

1 Is not possible to enter here into a detailed discussion of that question but see J. Drewnowski: On measuring and planning the quality of life. The Hague/Paris 1974 especially pages 13-16.

- 109 Annex 9 The respective places of economic and social elements in development depend on the idea about what is the purpose of development. It may be assumed that the aim of development is to ensure a steady improvement in the well-being of the population. This statement is evidently a value judgement of a political nature, but one which seems to find general acceptable nowadays, even if it is given manifold interpretation. Once it is accepted the respective places of social and economic elements become obvious. Welfare of the population takes place of development's final aim. That means that policies and plans should be oriented towards that aim and achievements of development (whether planned or not planned) are assessed in terms of the improvement in people's welfare. The quantitative expression for that welfare is found in a properly designed system of social indicators. All economic elements of development, which will have its quantitative expressions in traditional economic variables will represent the ~ which are used to achieve the aim of population's welfare. The relations between economic and social variables also become clear when we look at them in this way. They must be seen as relations between means and aims. The quantitative expression of this relation is found in transformation coefficients devised for the purpose, which would provide a link between the economic variables and the social ones. When the task for social indicators are established in this way, it is possible to determine the characteristics of the indicators which would be expected to fulfill these tasks. The indicators which are meant to measure welfare should be all oriented towards that task. That means that they should constitute a system of indicators which between them would cover what could be conceived as "welfare" to be measured. That coverage is certainly never complete, yet the crucial components of welfare should be included in the system. Such are: nutrition, housing, health, education and social security. System at social indicators can be extended beyond these components and cover in addition: leisure, recreation, and various aspects of environments. But extension of the system is not always practicable. The more extensive the system the more it is specific i.e. reflecting conditions for which it has been elaborated. And that implies limitations on its applicability. There is also a problem of the availability of statistical information. Consequently, more often than not, systems of indicators contain only components mentioned above and that is quite legitimate. The indicators which are oriented towards the measurement of welfare should of course correctly reflect welfare. This is the case when the indicators are "confluent" with welfare. Confluence means that a change in the numerical value of the indicators constituent variable may be assumed to imply changes of welfare in the same direction. l

1 E.g. in the indicator "calorie intake" the constituent variable is the number of calories taken per day per person. It may be assumed that within a certain range the more calories the higher the person's welfare. When the number of calories becomes too great and no longer contributes to the person's welfare, or even may be harmful to his health, that indicator ceases to be an adequate measure for welfare. Consequently the "calorie intake" indicator is approvable as a welfare indicator solely within a certain range of values of its constituent variable.

- 110 -

Annex 9

The system of indicators devised for measuring welfare should not contain any indicators not oriented towards that task. In particular, it should not contain any indicators which belong to the economic category of indicators i.e. referring to the resources available and not to actual conditions in which people live. To include economic indicators among those which are supposed to express welfare would be confusing means with ends and resources with the benefits derived from them. And that is one of the most fundamental methodological errors which can be committed (and unfortunately ~s fairly often committed) in constructing a system of social indicators. 5. Flow and state indicators

Objective social (welfare) indicators used in the present paper are all expressed in some kind of physical units. This problem of the units to be used requires, however, some further discussion. Welfare may be conceived in two distinct ways. The first sees welfare as a steady satisfaction of human needs taking place as time flows on. That means that everybody is fed, every day, that he has shelter, his health is protected and education provided. As the satisfaction of those needs occurs through time, this is a case of welfare being considered as a flow. This has of course implications for the indicators which are supposed to express welfare: they also must be flow indicators. That means that they must be expressed in their specific physical units per unit of time. Another concept of welfare is concerned with the state of the population at a given moment (at an instant of time). Indicators expressing the state concept of welfare will be set in terms of physical units with no time element present. It may perhaps be useful to give examples of that distinction between the flow and state concepts of welfare. Education is a component which enters both flow and state welfare. As a component of the flow of welfare education appears e.g. as a flow of teaching imparted to the popUlation over a period of time. Its indicator could be the enrolment ratio in a particular school year. In the state of welfare the education component refers to the state of education at a moment of time and will be represented e.g. by an indicator of literacy or of the proportion of school graduates within a population. The flow of welfare and the state of welfare are of course connected, the latter being a sort of accumulation of the former (just as capital is accumulated income); and so are consequently all other respective indicators. But the two categories of indicators should be never confused, they belong to two separate system which should be kept clearly apart. 6. Cardinal and ordinal indicators

The constituent variables of indicators are supposed to assume various numerical values which would express the levels of welfare within components concerned. Those numerical values are expressed in cardinal numerals and consequently indicators constructed in this way may be called cardinal indicators.

- 111 -

Annex

9

Unfortunately it is not always possible or practicable to find cardinal indicators for all components of welfare. An example of such a case is housing. It is very essential to have an indicator for the quality of housing. But there are so many elements which determine that quality that it would not be practicable to devise indicators for all of them. It is much more convenient to establish various classes of housing such as: good, satisfactory, less than satisfactory, unfit for habitation etc. That classification will reflect structural characteristics of houses and amenities available. This approach has also merit being adaptable to various climatic conditions which require different kinds of housing. When this approach is adopted the numerical value of the indicator will not be expressed by a sequence of cardinal numerals but by a few ordinal numerals designating grades of housing and namely first, second, third grade. Indicators constructed in that way may be called ordinal indicators. Ordinal indicators may be used in respect of all components of welfare alongside with cardinal ones. Apart from housing they will be particularly useful for expressing environment conditions. 7. Scaling of indicators

To convey properly the welfare position of the population the indicators should be scaled (or graded). Scaling consists in establishing so called critical points for the numerical values the indicator may take. The "zero point" ("0 point") determines the bottom of the indicator's scale. It might express a complete absence of satisfaction of the need in question (e.g. no education or health services available or an impossibly low level of that satisfaction (starvation point in nutrition). Then there is the "Minimum needs satisfaction point" or "M point" which designates the level of satisfaction of the need in question which is sufficient for people to conduct their normal life and work in conditions of human dignity. That "M point" may be considered as equivalent to poverty line. The conditions below it being defined as poverty. The third point is the "Afluence point" or "A point". It determines the level of satisfaction of a particular need above which there is not necessary to go. It constitutes therefore the top of the scale. It is assumed that going above this point does not increase welfare, it may even be harmful (e.g. over-eating). The critical points determined for each indicator divide all indicator values into four ranges: (1) Above A point (affluence); (2) between A and M points (satisfactory condition); (3) between M and 0 point (poverty); and (4) around or below 0 point (destitution). It is obvious that these ranges of cardinal indicator values correspond to the grades of ordinal indicators which were designated by ordinal numerals: first, second, third and fourth. That provides a link between the cardinal and ordinal indicators and justifies their inclusion into a single system of indicators.

- 112 Annex 9

A question arises what should be the criteria by which the critical points are established. They are bound to be of a mixed nature. In respect of some of them it is possible to obtain guidance from natural sciences. How much food is enough and how much is excessive is determined by the science of nutrition. What preventive measures (such as inoculation) are absolutely necessary is determined by medical science. Natural sciences cannot, however, provide guidance for all indicators. Many critical points have to be established according to prevailing attitudes derived from the cultural background of the population concerned or even from current political ideas. This is the case of critical points for ~ducation and also to a great extent for housing and en~ironment. This means that value judgements are bound to play an important role in the process of establishing critical points. It csnnot be otherwise as the critical points express norms (minima and maxima) for welfare which by its nature is a value loaded concept. It is evidently desirable that opinions about critical points should be widely accepted and well established. Some certainly are. They even have official endorsement of international organizations which determine norms for education (UNESCO) or health services (WHO). The wider the acceptance of such norm the wider the validity of indicators which embody them. It must be admitted, however. that the value system expressed in those generally accepted norms for human welfare is of Western (i.e. European-American) origin. It could be of interest to construct a system of indicators where both the selection and scaling would be based on some other value system. But this would be a separate pioneering task which has not been attempted in the present paper. 8. Indicator indices

Once indicators have been scaled, it is possible to transform them into indicator indices. The method adopted in the present paper for that purpose consists in making the numerical value of the indicator at its "0 point" equal to 0 value of the indicator index, and the indicator value at its "H point" equal to 100 value of the index. When this is done the transformation of all the indicated values into index values presents no difficulties. In the case of cardinal indicators, some conventional values must be given to the index. The grades below H point being given values less than 100 and those above it over 100. 9. Distribution

The indicators discussed so far were concerned with the whole population under investigation. Consequently, the numerical values of the indicators have expressed the averages per head of that population. That means that no distinction was made between groups of people within that population which were in better position and those who were in worse position in relation to the position reflected by the numerical value of the indicator in question.

- 113 -

Annex

I}

This is of course inacceptable. The actual conditions in which people live cannot be expressed in a valid way if distribution is not allowed for. The way to deal with this problem is to devise a distribution coefficient expressing the degree of inequality of distribution. That coefficient will have values between land O. It would have a value of 1 for a diatribution which is absolutely equal, and would take lesser values for distributions more and more unequal. l Distribution coefficients should be established for all indicators, and then indicator values expressing averages per head should be multiplied by distribution coefficients to obtain indicators adjusted for distribution. Only such indicators would truly reflect the level of living of the population. 10.

Aggregation

Social indicators have been conceived to give a numerical expression to conditions in which people live, i.e. to their level of living. This is why they are presented not singly but as systems of indicators which between them are supposed to express the condition of a given population in a given place and time. The condition of that population is therefore expressed by the numerical values of the indicators which constitute the system. That means it is expressed by a cluster of numbers. That method has significant disadvantages. It is not possible to tell which of the two clusters of numbers is the greatest (unless all the numbers in one are greater than 1n the other). Consequently, there is no way of telling where conditions are better and where they are worse or whether they have improved or deteriorated through time. It is obvious therefore that it would be most desirable to be able to express existing conditions in terms of a single number. That number could be derived at by aggregating all the numerical values of indicators in the system. It must be noted that it is necessary to have a single number expressing the level of living, to eliminate the use of the Gross National Product per head as a proxy measure of it. The GNP is a very imperfect yardstick for measuring the level of living, but it has to merit of being ~xpressed by a single number. So long as we do not have an alternative single number expression to replace it, the use of GNP will probably continue however illegitimate it is. There is consequently a very strong argument in favour of aggregation particular indicators (or more precisely indicator indices) into a single level of living index. Sometimes it is maintained that this is an impossible task and consequently it is not worthwhile undertaking it. The present author holds a different opinion although it is of course recognized that the task is indeed difficult.

I The ways in which the numerical values for the distribution coefficient can be established are discussed in more detail in Annex 1.

- ll4 Annex 9 . . The m~in.difficulty consists in assigning weights to particular 1nd1cator 1nd1ces. The proper solution of that problem consists in finding a system of weights which would have an objective basis. Evidently such weights must be influenced by value judgements. This is unavoidsble as they refer to the welfare impact of the satisfaction of various needs. Those value judgements should be revealed, if possible, by observable facts. If that kind of observation can be made, the problem of weights is solved in a methodologically correct way. It must be realized that observation of that kind is possible though certainly it is not simple or easy. In fact it can be made in more thsn one way. It is possible for instance to observe the pattern of consumer expenses and note what are substitution rates at the margin in the allocation of resources to the satisfaction of various needs. This method has the disadvantage of reflecting income distribution in the society in question, which may be inequitable, and of referring to the past conditions, which may be no longer acceptable. The most adequate basis for indicator weights are national plans. Plan targets reflect priorities given to various components of the population's level of living which are represented by social indicators. By analyzing the plans (i.e. the targets established and allocation of resources which they imply) it is possible to reveal what were their weight.s given by the planners to the improvement in the satisfaction of various needs i.e. to the Increase In the numerical values of respective indicators. That kind of analysis is not always easy as the plans may not contain all information needed. In principle it is however feasible. That means that an objective basis for indicator weights does exist. Consequently, it is possible to compute a component index of level of living being an aggregate of a number of indicator indices. There is also a simplified way of arriving at such an index. The rather complex analytical procedures for ariving at a methodologically correct system of weights are left aside. A conventional system of weights is used instead. The practice of using such weights when computing various composite indices is of course quite common. It cannot be defended as being scientifically based but it is not objectionable so far as there is a complete clarity about the procedures used. In fact many well established indices are based on conventional systems of weights. The simplest of such systems is of course the system of equal weights, when all indicators are considered equally important. The composite index will be then a simple arithmetic mean of all component indicator indices. The numerical value of such an average is certainly conveying relevant information about the popUlation in question. Once a system of weights has been adopted it is possible to construct composite weI fare indices. Aggregation of all "flow" indicators will result in a level of living (flow of welfare) index. Aggregation of "state" indicators will bring a state welfare index. Specific problems connected with these composite indices will not be however discussed here, as they depend very much on the specific characteristics of the populations to which the index is supposed to be applied.

- 115 -

Annex

9

11.

The welfare effect

The production process, as traditionally presented in economics ends by providing output of final products which are either consumed or invested or exported. The traditional economic national accounting variables express the size of this output in monetary terms as the gross national product and its various subdivisions. That kind of measurement does not provide any information about the satisfaction of the needs of the population by the goods produced. In the first place, it does not reflect in any way the inequality of distribution of that output among various social groups and secondly it is not concerned with the question whether the goods produced actually satisfy the needs of the people. These are certainly very serious deficiencies of the traditional econom1C approach. The aim of economic activity is after all the satisfaction of human needs. And here we see that when the provision of the GNP is considered to be the end of that activity, the crucial question of how well human needs are satisfied remains unanswered. There is an evident need for a reconsideration of this approach in the sense that the economic process should not be considered completed so long as it did not have an impact to the satisfaction of the needs of the population. The satisfaction of these needs should be expressed in quantitative terms. Social indicators will have to be used for that purpose. Consequently, the economic process should embrace not only the production process which ends with the provision of final products, but also the use of those products for the satisfaction of the needs of the population. It is obvious that the same amount of products (measured as they are in terms of their monetary values) would provide a different degree of satisfaction of needs depending on a number of conditions connected with the process of needs satisfaction. It is a matter of great interest to be able to understand those conditions. To see that problem clearly it is necessary to assume that the process of production (which provides products out of factors of production) is followed by the process of welfare generation which out of products provided generates welfare for the population. Once the problem is formulated in those terms it would become possible to make the evaluation of welfare generated by given amounts of products and consequently open the way to inquiries into the problem why sometimes more and sometimes less welfare is generated by the same amount of product. Two separate problems must be dealt with in this connection. The first is a methodological one: it is concerned with devising procedures for giving the process of welfare generation a quantitative expression i.e. of measuring the welfare effect. The second is concerned with analysis and policy. It consists in providing the explanation why the welfare effect 1S such as it is and in devising policies for improving it. It is with the methodological problem that we shall be concerned here.

- 116 Annex 9

The quantitative expression for welfare effect can be conceived as a ratio between the resources available and the welfare of the population brought about by thea. There m.y be, however. many fo~s for such an expression. l Another possible presentation of the welfare effect could be a welfare generation function. Just as the welfare effect coefficient the welfare generation function could be devised for the whole economy or sectorwise. In other words its dependent variable might be the overall welfare (level of living) of the population (expressed by a composite level of living index) or a component of welfare expressed by a particular social indicator index. In either case, the independent variables of the function will be the familiar factors of production. welfare generation function has been sometimes called of health. education or any other welfare component. aggregate welfare generation function will be: welfare generation Because of what the a production function The formula for an

where W = welfare (level of living) of the population expressed by a composite welfare (level of living) index Xl. X2, X3. etc. = various factors of production needed to generate welfare to the population For a sectoral function the expression will be the same, the only difference being the sectoral character of all the variables.

where Wj

a component of welfare expressed by a particular social indicator various factors of production needed to generate the "j" component of welfare

The welfare effect coefficients and welfare generation function bring to light different aspects of the relations between economic resources and the welfare of the population. They shall be made use of depending on the tasks of analysis or policy which have to be undertaken. Welfare effect coefficients are concerned about the ultimate welfare effectiveness of the production process. The welfare generation function with the contribution to welfare of various factors of production allocated to social sectors. It is essential that in both expressions social indicators are bound to playa decisive role. This is because welfare must always be expressed in terms of social indicators. The welfare effect observed in a national economy is not always satisfactory. There would be probably not much opposition to such a statement, as it is intuitively felt that in most cases it reflects the actual situation.

lThey are all presented in Annex 2 below.

- 117 -

Annex 9 Yet it must be admitted that so far no nor.s were developed which could serve as criteria for testing the correctness of such a statement. This is because we are still in the early stage of the analysis of welfare effects. The welfare effect coefficients must be first conceived and then applied to many empirical situations. Only after that is done it would be possible to establish what is the range of "normal" values of the welfare effect coefficients. When this is known it would be possible to assess the situation of the economy in respect of its welfare effectiveness as corresponding to requirements or falling short on them. Till this kind of research is done, it is possible to evaluate the welfare effectiveness as not being satisfactory by showing that in the existing conditions the whole economy or its sector (which is under investigation) could be better than it actually did. It would seem that a discussion of the achievements of the economy as of its developaent plans conducted in those terms will focus attention on welfare problems and would be a great improvement over traditional economic approach will still prevail in such discussions. 12. The productivity effect

Improving the welfare (level of living) of the people is considered to be the ultimate aim of development. When it is achieved, however, it does exert an influence on the production process. The impact of welfare on production is rather obvious. A population which is better fed, better housed and better educated provides a better quality of labour, which has a greater productive impact. That means that it is possible to increase the GNP by improving the welfare of the population i.e. by raising its level of living. It lS possible to measure the size of the productive impact of i_proved welfare which may be called "the productivity effect". Productivity effect coefficients are constructed according to the same principle as the welfare effect coefficients, but would have the GNP in the numerator and welfare in the denominator. The numerical expressions for them are shown in Annex 3 below. The productivity effect coefficients might refer not to the welfare as They may therefore express the productivity effect of better nutrition, or housing or health or education. Each of the three types of coefficients may be transformed in a component coefficient. a whole but to particular components of welfare.

The productivity effect of welfare may also find expression in a production function of a special type. Apart from capital and the quality of labour which appear as independent variables in traditional prOduction functions it would contain a variable representing the state of welfare of the popUlation or the quality of labour it provides. It is not possible here to discuss in detail either the concept of such functions or the methods of its empirical computation. All that can be done is to point out the relevance of such function for development planning. The recognition of the existence of the productivity effect has important policy implications.

- 118 Annex 9 First it exposes the insufficiency of policies and plans which deal exclusively with economic indicators. The inclusion of the welfare element in plans and policies becomes imperative not only because welfare IS considered to be the final aim of development but also because it constitutes a factor in the process of production. Consequently. the welfare element (expressed in terms of social indicators) must be taken into account whenever an increase in production is envisaged or planned. The second policy implication is even more important. In the traditional economic thinking the increase of production was supposed to be achieved through investments. Investments could be increased when more resources constituting the GNP were switched from consumption to capital accumulation. That meant "austerity" i.e. a policy of keeping low the level of living of the population. The existence of the productivity effect opens new possibilities in this respect. First of all it carries a warning ahout the austerity policy: keeping the level of living too low may have adverse productivity effects i.e. may diminish the increments of the GNP achieved through increased investments. But the main positive impact is to open the way to alternative policies: more product may be achieved not only through more investment hut also through a better quality of labour and its higher productivity. It means that the traditional capital accumulation may be accompanied or even partly replaced by what is sometimes called human capital accumulation. That would mean that the case for the application of the austerity policies would be considerahly weaker and consequently such policies would become less widespread or at least less strict. 13. Application of social (welfare) indicators to policies and planning

The evaluation of the popUlation welfare (level of living) and the assessment of the welfare effectiveness of the development process are important enough. but are only preliminary to the main task which is action aiming at the improvement of the welfare position of the popUlation i.e. of the conditions in which people live. That action may have a form of policies or plans. understood here as action aiming at the improvement of of that action are not expressed in quantitative terms limit is set for their implementation. Plans are such their aims formulated in terms of quantitative targets within a definite period of time. Policies would be welfare. where goals and no definite time actions which have to be implemented

Social (welfare) indicators can be useful to both policies and plans. They are. however. absolutely indi~pensahle for plans. This is because it is only by means of social indicators that welfare (level of living) can be given a quantitative expression. Social indicators used in planning are bound to be of two types described above. Belonging to the first type are strai~ht forward indicators expressing the flow of welfare and/or services which provide that welfare. The second type comprises indicators expressing ratios between various indicators significant for the generation of ~elfare. (Welfare effects and productivity effect indicators belong evidently to that second type.) It is only the contribution of both types of indicators which can become an effective planning instrument.]

IAn example of a system of indicators of both types which could be useful in the health generation process is presented in Annex 4.

- 119 -

Annex 9

Planning which makes use of social indicators is commonly called "social planning". The term can be given, however, various interpretations. At least two of its meanings call for more detailed explanation. Within every national economy there are sectors which are traditionally designated as "social sectors". They are health. education. housing, social security. This traditional classification cannot claim to have very solid foundations. Certainly those sectors contribute to the ~atisfaction of human needs and therefore to the improvement of social conditions. But so do other sectors designated as economic: agriculture. fishing, manufacturing, mining. transpo~tation etc. Also hoth social and economic sectol-S need and use economic resources to fulfill their tasks. Consequently. the distinction is nothing more than conventional. It reflects the economic oriented view that the economic sectors constitute the basis of the economic and social ones are sort of supplementary to them. This terminology is, however, well established and consequently, "social planning" is sometimes understood as "planning within social sectors". It is of course a perfectly legitimate use of the term. Planning in each sector has its own specific problema. It is obvious that this is true also of planning in "social sectors" enumerated above. Much has been written on the methodology of planning of health, education, housing and social services, but planning procedures are not our concern here. It can only be stated that there is no doubt that social indicators ought to play an important role in those sectoral plans. Social indicators were not conceived, however. as an instrument for planning in some sectors only. As explained above their task is to measure the total welfare of the population generated by the whole prOductive process i.e. by the so-called economic and social sectors alike. And that leads to another definition of "social planning". The term "social planning" may designate the social orientation of the general development planning. This is indeed the most relevant meaning "social planning" could take. It would not refer to some sectors or some aspects of planning but imply that all planning has become social in the sense that the ultimate aims of development planning refer to the improvement of the welfare of the population. That means that the final targets of development plans should be e~pressed in social (welfare) indicators. A socially oriented development plan is the natural outcome of the conviction that development should bring about an improvement in the population's welfare. The application of social indicators in expressing its targets is the outcome of the fact that it is only in terms of social indicators that welfare (level of living) can be expressed in practice. The welfare orientation may be appl ied also to policies. which do not set themselves numerical targets. to be fulfilled within a prescribed time. Such policies would simply aim at improving welfare at rate, which would prove practicable and without setting any timetable for achieving those goals. The results of such policies would have to be assessed from time to time again in terms of social indicators.

- 120 -

Annex

9

Plans and policies referred to so far were national plans or policies. But social orientation applies also on the project level. In fact in practice it is on the project level that some kinds of social indicators have been introduced first. l The new discipline of project analysis (or cost benefit analysis) came into being because of the obvious need of taking into account of social consequences of economic projects. Especially as those projects were 1n public domain or supported by public authorities. Benefits from such projects could not be conceived solely in terms of pecuniary profits alone, as their impact on the life of the population affected by the project could be considered and not devoid of political implications. Once criteria other than profits were introduced in the evaluation of projects a question was bound to arise what should be these criteria. Some of them evidently could be determined within the project itself being the result of specific local conditions. Some other, however, had to take into account broader considerations. That was absolutely necessary when costs and benefits of two or more projects had to be compared and their respective impacts on the life of the community assessed. It is not possible to discuss here all the devices which has been used for these purposes (such as shadow prices, which are supposed to reflect the interests of the society better than actual market prices). What is essential for the evaluation of project 1S a possibility of basing its criteria on a system of national aims. Only then criteria for the project evaluation can be inequivocably established and comparability between the projects assured. National aims formulated in the traditional exclusively economic terms cannot provide such a basis for project analysis, as project analysis 1S concerned with social consequences of the projects. But a system of national aims determined by socially oriented plans and/or policies can perform that function. It is when socially oriented plans have their final targets expressed in terms of social indicators that the significance of social indicators will have made their full impact.

1 The earliest attempts of applying social indicators in project evaluation have taken place in projects supported by the United States government. See A.L. Ferris: "The u.S. federal effort in developing social indicators", Social Indicators Research, Vol. 6, No.2, April 1979.

- 121 -

AnnC'x 9 ---.--

ANNEX 1 DISTRIBUTION COEFFICIENT AND LORENZ CURVE The exact values of the distribution coefficient can be derived from the familiar Lorez curve.

I

.A '0 The following notation is introduced: N is the number of population I = f (N) is the cumulative value of the indicator as shown by the Lorenz curve NI is the cumulative percentage distribution of the population with an indicator value less than or equal to a specified value i 11 is the cumulative percentage distribution of the total indicator value less or equal to a specified value i D is the distribution coefficient the value of which has to be established A is the area below the Lorenz curve B is the area of the triangle OO'P From the Lorenz curve, it can be derived:

0

1

D ..

- 122 Annex 9 Annex 1 It should be noted that the proposed distribution coefficient D has an affinity to the familiar Gini coefficient of concentration G, and namely that: D

=I

- G

As the distribution coefficient is derived from a Lorenz curve, it is necessary first to have empirical data to plot the curve. Accordingly to those data the population will have to be subdivided into a number of groups for which different levels of the indicator in question are observed. These groups should be ordered according to their values of the indicator, beginning with the group having the lowest value and ending with the one having the highest. That would be sufficient to draw a Lorenz curve of the broken line type. There is, however, a problem what are those groups for which empirical data are supposed to be available. This is not a simple question because it is well known that statistics on distribution are very imperfect. The standard way of solving that is to break down the population according to the range of values of the indicator in question. This is commonly done in the inquiries in the distribution of income: the population is divided into a number of income groups. To do that, however, it is necessary to know everybody's income and assign people to various groups according to that criterion. If that is often possible in respect of income, it is hardly practicable in respect of other indicators, because no data on the position of individuals are collected. What can be done therefore is to divide the population into groups which are assumed to possess common characteristics in respect of an indicator. Then assess the average values of that indicator for those groups and arrange them according to the increasing values of the indicator in question. To give an example for indicators referring to housing, the groups will be: shanty town dwellers, communal house dwellers, tenants, house owners; for health: migrant workers, peasants, working people living in towns, middle-clas people. In spite of inequalities within groups which would not be revealed by this method, it is better to use it even if it is imperfect, than not to allow for distribution at all. Another method 1S to divide the population by regions or provinces. This method again would not show inequalities within each province but will be telling enough in respect of inequalities occurring within the country.

- 123 -

ANNEX 2

WELFARE EFFECT

The a~ple8t expression for the welfare effect coefficient will be: WE (1 )

=-W GNP first type welfare (level of living of the population over a period of time) expressed in terms of a social indicator index gross national product per head expressed in monetary

where WE(l) W

= welfare effect coefficient of the = welfare understood as a flow of terms

GNP

The welfare effect coefficient devised in this form (lst type) may be used for comparing the welfare effect position as between various populations and also for comparisons through time over long periods. To express changes over short periods i.e. of one year or of a time span of a single development plan another expression will be more adequate, namely;

WE(2) = AW -6GNP where WE(2)

4W AGNP

welfare effect coefficient of the second type increment of welfare (level of living) over a period of time, expressed in terms of a social indicator index increment in gross national product per head over the same period, expn>ssed in monetary terms.

The welfare effect coefficient of the second type expressed the impact of the change of the GNP on the change of the welfare (level of living) position. It can be used for assessing the achievements of development in a past period, but it is also a necessary instrument in planning oriented towards improving people's welfare. It must be noted that in both welfare coefficients (1st and 2nd type) the numerator and the denominator of the fraction are expressed in different units (numerator in social indicator index numbers, denominator in monetary units per head). Consequently the value of the coefficient cannot be expressed as one number, but as a ratio. This may be sometimes inconvenient for making comparisons between countries especially as monetary units are involved in the denominator. ~~ose difficulties are avoided when a third type of welfare effect coefficient is used.

- 124 Annex 9 Annex 2 It takes the following form;

•

AW

w

AGNP GNP where WE(3} AW welfare effect coefficient of the 3rd type - increment of welfare (level of living) over a period of ti_ welfare (level of living) in the period preceeding the period to which the coefficient refers relative increment of welfare (level of living) over a period of time increment of GNP per head over a period of time GNP in the period preceeding the period to which the coefficient refers relative increment in the GNP over a period of time

K

W AW

W GNP

A GNP

..

I. GNP

GNP In tbe third type of coefficient both. the numerator and denominator are ratios. Consequently it is possible to have the numerical value of the coefficient expressed as a single figure which will show how the ratio of increase in welfare compares with the ratio of increase of the GNP. This is a very telling figure, absolutely necessary for assessing welfare effectiveness of a national economy. This is why the third type of welfare effect coefficient has been adopted in the present paper. All three types of welfare effect coefficients so far discussed referred to the over-all welfare (level of living) of the popUlation. That implied the assumption that a composite level of living (flow of welfare) index was available for the relevant periods. In practice however such an index is seldom calculated. The difficulties for computing it have been discussed at some length in section 10 above. It is not necessary however to have a composite level of living index to use welfare effect coefficients. They may refer to components of the level of living or even to particular indicators. It is also of great interest how welfare conditions reflected in a single indicator react (over a period of time) to changes in the GNP. Again it is possible to devise for particular indicators welfare effects coefficients of the three types presented above. they may be formulated as follows;

WE(l) • i

-

GNP

- 125/126 Annex 9

Annex 2

where WE(I).i Wi

• welfare effect coefficient of the first type for welfare expressed by indicator "i" = welfare expressed by indicator "i"

Welfare effect coefficient of the second type may also be devised for welfare expressed by a single indicator. It will take the form:

-

AGNP

And the same is true of the welfare effect coefficient of the third type, which can be written:

A GNP

GNP It would have been even better if we could put in the denominator of the expression not the overall GNP BUT THE PART OF THE GNP which provides resources serving to satisfy needs (provide welfare) covered by that particular indicator. It could have the following form:

AV J •

where GNPj

= that

part of GNP which provides resources serving to satisfy needs covered by indicator "j".

- 127/128 -

Annex 9

ANNEX 3

PRODUCTIVITY EFFECT The productivity effect coefficients would also be of the three types established for the welfare effect coefficients and namely

PE(l).. where PEel)

GNP W

3

GNP W

productivity effect coefficient of the first type national product per head .. state of welfare of the population

= gross .. 6

PE(2)

GNP AW

where productivity effect coefficient of the second type refers to incremental variables, and

•

.6 GNP

.!w

CNP

•

where productivity effect coefficient of the third type refers to relative increments of the two variables.

- l~ -

Annex 9

THE PRACTICAL APPLICATION OF INDlCATORS IN TilE HEALTH GENE~TlLlN PROCESS It is possible to construct a system of social indicators for the health sector at the national level which would comply with the principles presented in the paper. It is assumed that this should be a system oriented towards action and specific for every country (reflecting the country's conditions at the present time). Such a system could be constructed according to a scheme presented in the annexed table which could be called "Health Generation Table". It is asssumed that the process of health generation is set in motion by the action of policy makers. First row (at the bottom of the table) shows who are the policy makers. The next three rows (from the bottom upwards) refer to the three stages through which health generation is bound to proceed: (1) assessing the availability of resources health purposes, (2) supplementing the health infrastructure. (3) extending the health services. The top row refers to the outcome (impact) of the health generation process, i.e. to the health conditions of the population. In the second column, (rows 2, 3 and 4 from bottom) examples are given of what is meant by: (1) resources, (2) health infrastructures, (3) health services. The main elements of people's health conditions are shown in the top row. Examples of indicators for all stages are shown in column three. It must be stressed that health generation is bound to pass through those stages. It always had. And that even long before any social indicators were invented. The process was then adversely affected by the lack of exact (numerically expressed) knowledge about the conditions at its vario~s stages and about what exactly should be done to proceed from one stage to the next one. This is why social indicators become indeapensable for policy makers responsible for the whole process. Indicators give numerical expressions to the position at each of the stages. These are commonly known first generation indicators. To propell the process of health generation from one stage to the next in an effective way is necessary to know the ratios between the indicators of various stages. These ratios may be called second generation indicators. These may also be seen as effect indicators. They are crucial for correct planning and effective action directed towards the final aim of improving health conditions. A conclusion which could be drawn from the presentation given above is that a structured system of indicators ordered according to their places in the health generation process (which will include both first and second leneration indicators) is a necessary condition for the practical application of indicators in policies and planning.

Hea.!. :~: :ndicators (1st -:;eneratio:l \

Health indicators (2nd generation)

MORTALITY HEALTH MORBIDITY o u ::;

c

CONDITIONS SOMATIC CONDITIONS

LIFE EXPECTANCY AT BIRTH INFANT MORTALITY ,AGE SPECIFIC MORTALITY DISEASE SPECIFIC MORTALITY INCIDENCE OF VARIOUS DISEASES ABSENTEISM AT WORK DUE TO ILLNESS ANTHROPOMETRIC MEASUREMENTS

~ V """ -!ffecti .. ene •• of hospital treat.ent in reducin8 ~rC.lity Effectivenes8 of inoculation in reducing 80rbidity Effectiveness of health education in reducinl aorbidity

~

o

~

I Ir-I,

I

HEALTH "----tPR!I'IARy HEALTH CARE CURATIVE TREATMENT SERVICES PREVENTIVE ACTION HEALTH EDUCATION HEALTH--~-I HEALTH CENTRES

ADMISSIONS-fo HOSPITALS AS % OF NEEDS INOCULATED AS % OF rHOSE AT RISK PROVISION OF DRUGS % OF NEEDS ItioSPTTAL BEDS PER"lOOO PO;cP;;;ULA;;;-;;T::I"'O"'N:;-% OF POPULATION HAVING ACCESS TO MEDICAL CARE

., "

,)

e

"" ?: rl, t:

u

HOSPITALS INFRASTRUCTURE CLINICS MEDICAL & PARAMEDICAL UNITS RESOURCE AVAILABLE fOR HEALTH MANPOWER FUNDS State & municipal budgets

V

LabOUr effectiveness in health services Capital effectiveness in health services

Cost of oaaintaining a hospital bed

"Cost per patient of running a clinic

PHYSICIANS PER 1000 POPU~TION Various categories of medical PerB \% OF G,N.P. FOR HEALTH

~

~Labour/caPitat

ratio in health centres Cost of establishing a hospital bed Cost of att~nding health centres to cover more people

... o

,~--------~---

HEATH EXPENDITURE PER CAPITA

Business & Lndividual resource

I---

POLICY MAXERS

I PUBLIC

HEALTH SYSTEM

PRIVATE MEDICAL PRACTICE

I

)C

..,

. ~

> ~

- 131/132 ANNEX lOa

LIST OF INDICATORS FOR GLOBAL MONITORING OF PROGRESS TOWARDS HEALTH FOR ALL BY THE YEAR 2000 1

Source: Global Strategy for Health for All by the Year 2000 ("Health for All" Series No. J). pages 75-76.

1

- 133 Annex lOa

The "umber oj cOllnlries in which: ( I) Heallhfor aI/has rect'il'ed cndonelll(,111 m" policy £II Ihe hiKhesl

.

(!l.7iciallel'el, c.g., in thc form of a de("\aration of commitmelll by the head of state; allocation of adequate rl':'IlUrCCS equitably di~tributcd; a high degree of community involvement; and the establishment of a suitable organizational framework and manal!craal prol:css for national health development. tht' implemellialion of strategies "al'e been form('d or strengthelled, and are actua/~I'Junc" tiolling, i.e" active and cfTectivc mechanisms exist for peoplc to express demands and nceds; reprcsentativcs of political parties and organil.ed groups such as trade unions, women's organizations. farmers' or other occupational groups arc participating actively; and decision-making on health mattcrs is adequatcly decentralized to the various administrative levels. 11/

(:!) Mechal/isms

JCI,. illl'o/l'inK pl'opft'

(3) A I leasl 5 % oj Ihe gross nati(/I/ol product is spenl Oil ht'alth.

(4) A reasol/able percelllagt' (If the I//lliol/al "eallll expendilllre is del'oled 10 local health care, i.c., first· level contact. including com· munity health care, health centre care. dispensary care and the like. excluding hospitals. Thc percentage considered "reasonable" will be arrived at through country studies. (5) Resources are equitably distrihutt'd. in that the per capita

expenditure as well as the stafT and facilities devoted to primary health care are similar for various population groups or geographical areas, such as urban and rural areas. numbcr oj t/el'c/oping coul/trit's lI'ilh IH'lI·defilled strategies Jar health Jor all, accompallied by explicit rt'Source of/ocatiolls. ",'hose needs Jor external re.\Ources are receil'in!: sus· tained support/rom more afflu('nt c/lufltries. (7) Primary health care is aI'ai/liMe 10 Ihe whole population, with (It

(tl) The

leasl the fol/owing:

- 134 -

Annex lOa

- safc watcr ill the hvmc vr wilhin J -" minute!!' walkill~ dj!!lan~.:, and adequate sanitary f.l~ilities in Ihe hllllle or immediate vicinity; - immuniwtil)n again~1 diphtheria. tetanus, wl\l)oping·~ou~h, measles. puliomyelitis, and tuberculo~ls; - local health care. including availability of at least 20 ess.:nllal drugs, within one hour's walk. or travel; - trained personnel for attending pregnancy and childbirth, anJ caring for children up 10 al least 1 year of age.

lH) The flutriliul/al Sl.Jl liS (!J" chiMfl'1I is lIJl'I"IUIl', il/ Ihal: at least 90% o/" new burn infants have a hirth weight of at ka)t 2500 ~; - al kast 1J0'.!u of chilJren have a weight for age that ClIrrc spllllds tv the refcrelKe values given III AllllelL I to lkl't'/uplllt'lIl ({IJ"/icUlUrs/ur .\IollilOrill!: Progr,'\~ rOllllfll!> Jlt'u/lh/uf.-lll by tht' l't'Uf

:!lX)(), ..'iled abme.

(9) Tlit' illj'ul/tlllurtalily rate}ilf 1.111 id"llliji,Jhit' subgrollp., is h,'IuII' 50 per )()()U liI't'-blrths.

(10) Liji! expect/Jl/er

tU

binh is

1II','f

DO .J'elJn. 7U "v.

(II) The uJlIlt lit ..rucy lIIit');lr hvth

mell .W,} ll'UIII,'1l t' \"(',','d~'

(12) The gruss lIariullui prodllct IIt'r h.'wl t'.\,',','.!!; LS ~ 500.

7. III view of WHO':, role as Ihe directing and c\lorJlnaling authority on inlernational health work, in aCl.-mJ'lOce wilh Article 2 of ils Cl.mstitution, and the llbli~ation of MClllber State~ to suhmit reports to WHO in aCl'ordance wilh Arllch:s 61 and 62 of Its Constitution, cOulllril!s will USl! the lllechani~llls of WIIO for r~porl ing on progrl!'ss and assessing th~ impact lit" the Sirategy. Reporb on progress will be revicwed by regivnal cvlllmilll!eS every two year~. The regional reviews will bl!' followed by glvbal reviews by WIIO's EILccutive Board and World Health Assembly. A report on progre~s made towards attaining health for all by Ihe year 2000 will be published biennially beginning in 19H3. Every six years rcgional followed by glob;1I assessments will be made (0 evaluate the efTectivcness of the Strategy.

- 135/136 ANNEX lOb

LIST OF INDICATORS FOR REGIONAL AND GLOIIAL l'SE

1

1 Source: Regional Strategy for Health for All by the Year 2000, 16 November 1981, pages 36-39.

-

117 -

Annl'x IOh

INDICATORS FOR REGIONAL AND GLOBAL USE A list of indicators to be used for regional monitoring and evaluation is given below. Those with an asterisk (*) are the indicators to be used for global monitoring and evaluation of health/ 2000 strategy implementation. This list of indicators will be periodical Iv reviewed for individual relevance and modified as necessary.

List of indicators l The number of countries in which: (a) Health policy indicators

* *

Health for all has received endorsement as policy at the highest official level (1) Mechanisms for involving people in the implementation of strategies have been formed or strengthened, and are actually functioning (2) At least 51 of the gross national product is spent on health (3) A reasonable percentage of national health expenditure is devoted to local health care (4) Resources are equitably distributed (5) Defined strategies for health for all are accompanied by explicit resource allocation (6) 2 Defined strategies for health for all need external resources (6) The needs for external resources of defined strategies for health for all are receiving the sustained support of more affluent countries (6)

* *

* *

* *

The nuaber in brackets showa the nuaber given to the indicator in the global indicator list (Global Strategy for Health for All by the Year 2000, WHO, Geneva, 1981 ("He~lth for All" Series No.3). page 75-76. 2In the global lht, indicator 6 is stated a. "The nuaber of developing countries with well-defined strategies for health for all. accompanied by explicit resource allocations. whoae needs for external rL'sources are receiving sustained support from more affluent countries."

1

- 138 -

Annex lOb At least 807. of local communities at all levels have well-established voluntary and formal community organizations, which are committed to continuous primary health care action programmes The community contributes in cash and in kind to health or health related action. (b) Socioeconomic indicators

* *

The percentage of population served with safe water in the home or within 15 minutes' walking distance is 100(7) The percentage of population with adequate sanitary facilities in the home or immediate vicinity is 100(7) The sdult literacy ratio for both men and women exceeds 701. (11) The gross national product per head exceyds US$500 at IQ80 market prices (12)

* *

The daily per capita calorie availahility exceeds 2500 calories The daily per capita protein availability exceeds 70 grams (c)

Health status and quality of life indicators

* *

At least 90! of newborn infants have a birth weight of at least 2500 grams (8) At least Q07. of children have a weight for age that corresponds to reference values given in Annex I to Develo~nt of Indicators for Monito~rogress Towards Health for All by the year 2000 (8) The infant mortality rate for all identifiable sub-groups is helow 50 per 1000 live hirths (Q) Life expectancy at birth is over 60 years (10) Maternal mortality is below 3 per thousand live births No cases of diphtheria, tetanus, whooping cough, measles, poliomyelitis and tuberculosis occur

* *

lIn the global list, indicator 12 is stated as "The gross national product per head exceeds US$500".

- 139/140 Annex lOb

(d)

Indicator of the delivery of health care

Primary health care is available to the whole ropulation with at least the following:

* *

-

The percentage of deliveries by trained health personnel is 95 (7) The percentage of children imnruniy.ed against diphtheria, tetanus, whooping cough, measles, poliomyelitia and tuberculosis 1s 95 (7) Local health care, including availability of at least 20 essenti~l drugs, within one hour's walk or travel is 1001. (7) The percentage of children up to at least one year of age given routine child care by trained health personnel is 100 (7) The percentage of pregnant women with at least three visits for antenatal care is 100 (7)

*

-

*

-

*

-

- The population growth rate 1s reduced to less than It

lIn the global list, precise values for different components of this indicator are not given. These values are considered relevant as regional targets for the Western Pacific Region.

- l41/142 ANNEX IOc

LIST OF INDICATORS FOR liSE AT THE NATIONAL LEVELl

lSource: Re)l;ional Strate~v for Health for All bv the Year 2000, 16 Nl)Vembpr lqR I, pa~es 11-16.

- 143 Annex IOc INDICATORS TO MONITOR IMPLEKENTATION OF HEALTH/2000 STRATEGY (NATIONAL LEVEL)

The following indieator. could be eonsidered, depending on their appropriateness and the infor.ation available at national level: (a) Soeial and soeioeconomic development indicators primary school enrolment secondary school entrance/completion GNP per capita ealorie consumption per capita population growth rate dependeney ratio urban/rural population ratio adult literacy ratio (b) Health status indicators (overall com.unity health status) life expectancy at birth infant mortality mortality . .ong children aged 1-4 age specific mortality rates for priority age groups maternal mortality neonatal/post neonatal/perinatal mortality industrial absenteeism due to illness or injury weight at birth anthropometric measurements (height and weight development in preschool children) (c) Specific health problem indicators (measures of reduetion in specific health problems to a level acceptable technically and to the cOlDllluni ty) incidence/prevalence of cOllllllunic able diseases incidence/prevalanee of chronie/degenerative diseases mortality due to chronic/degenerative diseases

... /

- 144 -

Annex IOc incidence of specific nutritional deficiencies (nutritional anaemia, xerophthalmia and goitre) and metabolic diseases (diabetes, gout) disease specific mortality by age if relevant indicators for oral health status (in terms of DHF) (d) Health services improvement indicators LSimple specific and basic means of measurement have to be develope~1

(i)

Index of equitable distribution of health resources social justice in health health services' coverage and accessibility health services' quality and appropriateness community satisfaction with health services provision of essential drugs

(ii)

Means of measuring community participation and support measurement of community resource allocation for health action assessment of health habits (use of latrines and safe water, personal hygiene, child-rearing practices, fertility regulation and u..unization) measurement of community participation in the management of health services

(iii) Ways of measuring the development and use of appropriate technology index of the use of local resources in the production of essential drugs and construction of health facilities transfer of knowledge and skills to members of the community in the spirit of self-reliance (iv) Ways of measuring intersectoral collaboration horiEontal integration at various levels (including national level) in the planning and management of health and health-related progr ...es establishment of intersectoral coordination councils

... I

- 145/146 Annex 10c

(v)

Measurement of the development of .anagerial processes mechanisms for developing national health/2000 policies, strategies and plans of action and for facilitating central planning and intersectoral coordination measure of decentralization of programme planning and management to provincial, district and community levels index of health leglslation and enforcement

(vi)

Measurement of the develoe-ent of health manpower progra.mes establishment of mechanisms for continuous monitoring of training needs measures introduced to t.prove the status and career prospect~ of health manpower indices of adequacy and distribution of health manpower

(vii) Resource. allocation for health development budgetary allocation to the health sector in absolute and relative terms proportion of GNP for health changes in the pattern of resource allocation to primary, secondary and tertiary health care priority of disadvantaged groups (viii) Measurement of t.provement in the delivery of health care llDaunization coverage deliveries attended by trained health personnel pregnant mothers covered bv essential antenatal care provision of nutrition supplements coverage with safe water supply ceverage with sanitary latrines ,(e) Indicators of political commitment. These indicators are included under the different categories already enumerated.

- 147/148 -

ANNEX 11

AVAILABILITY AND SOURCES OF DATA FOR GLOBAL, REGIONAL AND NATIONAL INDICATORS

Availability and sources of data for global, regional and national indicators Availability: I a Reliable data available from a majority of countries II = Reliable data not available from a majority of countries

Indicator. (G) Adult literacy ratio ( G) GNP per capita (R) Daily per capita calorie availability (R) Daily per capita protein availability ( N) PrUDary school enrolment (N) Secondary school entrance/ completion , (N) Population growth rate (N) Dependency ratio ! eN) Urban/rural population ratio :

Avai labiUty of Reliable Data II I II I 1 ,

Source of Data (P Vital RelliRtr CenRuR P Service RecordA A

~

Primary; Epid.

As Alternative) Sample SurveyA A Disease RegiRter Community Worker Others P P P ,

l~~~:ili

?i .,. ;)

>C

......

,....

I 1

I

P

II I I

I 1

I I P

: 1 I

I I A P P

I I I

I

I

IndCators of provision of health care

I A

I I 1 ,

I I 1

I

P

1

i I I ,

I I I 1

P F P

A

I I

i A A

I 1

I P , ,

\;

I I \

I I , 1 I

( G) Prenatal care and deliveries I , 1 by trained personnel 1 ; (G) Infants given routine child carel I I (G) Children I_unization I (G) 1. accessible to local health I II I , care I 1 (N) Health services' quality and II I appropr iateness I 1 ! (N) Community satisfaction with II 1 , hea lth services , ! ! (N) Provision of euential drugs I I I (N) Provision of nu:rition IlJPPlement~ I , , IHealth status indicators

i,

I

I ,

I ! 1

I I 'J'

I I I I

I A

I !

P P P P

! i I

,

P A A

A A

I

:>

I 1

I

, ,

i I ,

I

I ,

P

I

i ,

I

\ I

P P

i I I

I I I , I 1

P

I I

I ,

i i I

I A A A

I

I !

I

:

(G) (G) (G) (G)

lIirthweight Weight for age for children Infant mortality rate Life expectancy at birth

:

11 II II II II

P P P

A

I

P P

i

A P

I i 1

I I I A A

, I

l

P A p

(R) Maternal mortality rate

P

Indicators ,

I

AvailabUityof Reliable Data

Source of Data (p - Primary; A - Alternative) r;plG. Disease Service Vital Surveil- Sample Relliater Surveys lance Records Redstr. Census P P

. .

Community Worker A A

Others

I

i , , ,

,

II (R) Incidence of 6 UmDunizable diseases II (R) Mortality at age 1-4 years (N) Mortality at age 15-24,25-44. II 45-54 II (N) Neonatal/post-neonatal/ perinatal mortality II (N) Industrial absenteeism due to illness or injury II (N) Height and weight development in children II (N) Incidence/,revalence of communicable diseases II (N) Incidence/prevalence of chronic/degenerative diseases II (N) Mortality due to chronic/ degenerative diseases (N) Incidence of specific nutritional 11 deficiencies and metabolic disease. II (N) Disease-specific mortality (N) DMF indicators (oral health) II

P , I I

A A

P

P P

A A A

I

A A

A A p

P P P

A P P A ; ,

P Ii. Ii.

P P

Ii.

I ,

P

A ,

A

-V\ V\ N

,...

I I P

P A A

A A

I

P A

I

P

I I I

i

I I

I I

I

I

I

i

I I

I I I

I I I

I

!

I

> =' =' ~ )(

!

I I

.-

....

-

153/154 -

ANNEX

12

COORDINATION FOR INTJ<:GRATED by

DEV~:LOPMENT

OF INDICATORS

Dr AbJul Khalid bin Sahan[

lDirector, Planning and l)evelopment, Ninistry ,)f Health,

Kuala Lumpur, Malaysia.

- ISS Annex 12 COORDINATION FOR INTEGRATED DEVELOPMENT OF INDICATORS

1. Health and health-related indicators are required by different people for different purposes at different times, even in the same agency. Some indicators are generated, processed and kept by agencies outside the health system. In a country where a mUltiplicity of agencies provide heal th or health-related care, information within the ministry of health will be incomplete unless there is an arrangement to collect information from the other providers of health or health-related services. Even within the ministry of health, there may already exist small separate information units attached to divisions or programmes, servicing principally the minor interests of the organization, unconnected to each other, using different types of classifications and concepts, and adding yet another load to the already overworked operational personnel, who are responsible for generating such information. Given such a situation, the coordination aspect in indicator development cannot ie overemphasized. The content and mechanism of such coordination will be (learer if one goes into the detailed reasons which make coordination very recessary. 2. Reasons for intra-agency 'coordination The reasons for coordination are summarized below. 2.1 Development of any decision support system such as information or indicators will have to be management-oriented. Since such a development will normally take place within a pre-existing framework or information system which may be highly departmentalized, there is a need to get the support and commitment of all heads of departments or programmes within the organization. The latter will have to be convinced that the changes are for the better, and that they will be getting high quality, timely and useable information. 2.2 Coordination of the indicator development activities and consultation with departmental/progra1llllle heads are also necessary because there 19 a definite assignment of responsibilities and duties and hence of accountability and control. Indicators must be developed together with managers. 2.3 Many programmes and programme activities are inter-relsted, in the sense that one programme creates a demand for another programme, activiti~s are sequential, or they share resources or facilities. Information/indicators for such programme or activities must therefore be linked to facilitate action, interaction or follow-through. 2.4 There is a need to base information and indicator development on mutually acceptable and agreed concept, classification, standards, benchmarks and terminology. This is necessary to facilitate cross references, adoption of common denominators, disaggregation of indicators, comparison and consistency of interpretation over time and space. 2.5 Indicator development must be balanced in scope, content and detail, taking into account the priority of the programme performance to be measured. Easily measured and familiar indicators may be developed extensively and in great detail, whereas non-traditional ones may not be given adequate attention.

- 156 -

Annex 12

2.6 There are many indicators or information which may be generated by different systems or subsystems, but when linked or considerf'd together, tell the stOry more convincingly or throw some doubts on the first conclusion. 2.7 More afproeriate indicators can be developed, and duplication of more or less S1m1 ar 1n31cators can be avoided. 2.8 Access to information by different subsystems of the organization can be facilitated. 2.9 Increasing use of household survey and census techniques to gather informat10n opens up greater possibility for interdisciplinary or inter-agency dimension of inputs. 2.10 The growth of computer-based information system not only makes possihle the handling of large volumes of data, but also the linking of sYstems, subsystems and data for informati?n generation.

3.

Reasons for inter-agency coordinat ion

3.1 Basically, the reasons for inter-agency coordination in the development of indicators is the same as for intra-agency coordination except that it is on a much wider scale in terms of interest and people involved, and there may be greater trade-offs.

3.2 Some specific indicators are best developed through inter-agency effort, e.g. in the area of community involvement. 3.3 Inter-agency coordination is also necessary to keep agencies informed of studies in progress and statistical series and indicators available nationally, as well as internationally. 3.4 Further, agreement can be reached on the type of information/indicators which will be developed by agencies according to their respective fields of specialization. 4. 4.1

Mechanisms for coordination

Within the agency itself, it is necpssary to involve all heads of programmes/departments in the development of information/indicators. A steering committee consisting of all heads of programmes/departments and chaired by the chief executive of the agency can be established to provide overall guidelines and agree on concepts. Depending upon the extent of the exercise and what is already available, there may be a need to establish a core working group or "Information Systems Development Group (ISDG) " , with members from various disciplines, either on full-time or part-time basis, to develop the information/indicators within the framework given by the steering committee. Where a medical record and health statistics unit already exists, the ISDG may be located in and draw secretariat support from this unit. 4.2 The steering committee and ISDG can he disbanded once the bulk of the developmental exercise is over. For further development and maintenance of the information syste.Jindicators, a coordinatin~ committpe consisting of heads of programmes/depart.ents can be set up.

- 157 Annex 12

4.3. Please see figure below which summarizes a schema for intra-agency coordination.

Schema for

Int~ency

Coordination

I

STEERING COMMITTEE

, L 1---

CHAIRMAN MEMBER MEMBER MEMBER

FEEDBACK

DECISION

MEMIIER ISDC Leader _a~~.cretary

l

INTERACTION

'v INFORMATION SYSTEM--, DEVEL.OPME~T GROUP ~~~)--i

r---------.!.SDC L_EADE~_

I

MEMBER f--

MEMBER MEMBER MEMBER SUPPORT STAFF SUPPORT STAFF

5. In the development of information/indicators, inter-a~ency coordination is required more for those information/indicators directly related to health policies, and socio-economic impact of pro~ramme, in other words in the area of strategic planning. The mechanism for coordination will depend upon the sources of information, working relationship among agencies and decision making structures for planning and development.

- 158 Annex 12 In many countries, there is a central economic planning unit in the Prime Minister's department. This unit is responsible for processing social and economic development proposals submitted by various agencies for approval by the government. In many countries, too, there is a department of statistics usually located also in the Prime Minister's department, which handles common-user social and economic information. In addition to this, each agency maintains agency-specific information. Some of this information is routinely captured, whereas other information is obtained through ad hoc surveys or studies. Relevant information may also be available at various research institutes. To coordinate the development of health and health-related information/indicators, the following schema is proposed.

Proposed Schema for Inter-Agency Coordination In Indicator Development

Data Bank Secretariat Chief

Agency Information S stem (IS)

Agency Information System (IS)

Agency Informa t ion L..::.S~ys_t _em_~(.I~

Agency Information SYstem (IS) ~. -"---~"-'-'

I

T

The schema proposes the establishment of a Council for National Statistics or equivalent in the economic planning unit of the Prime Minister's Department which will coordinate the development of information/indicators necessary for strategic planning. In-house information systems wilt be linked to a central data bank.

- 159/160 -

ANNEX 13

PRIORITY ACTIVITIES AT GLOBAL, REGIONAL AND NATIONAL LEVELS

PRIORITY ACTIVITIES AT GLOBAL, REGIONAL AND NATIONAL LEVELS

PROBLEM Lack of expertise - Trainin& thru:

ACTIVITY

GLOBAL B

REGIONAL B

NATIONAL A

study tour (inter/intercountry) formal training workshop technical and financial support planners .. nagel's at all level statistician health workers EDP techniques survey methodology analysis skill use of indicators methodology of elaborating and structuring indicators A

for

on

.<7'

Inadequacy of existing - Feasibility study at country level to indicators/infor.identify mini.~ list of essential ation/syateml indicators and mechanism for collection, ot' gan iza t ion processing and use of indicators. - Identification of comple. . ntary indicators. A A

I~ ><

r---- Review and change approved indicators periodically. A A C

I::;

---PROBLEM ACTIVITY GLOBAL REGIONAL A NATIONAL

" lC - Identification of core indicators at regional/country levels. i I

> =' =' ...... c.J

-

-

,

- Improvement in the methodology of elaborating and structuring of indicators including distribution element of indicators - Establishment of mechanism for the generation and use of indicators, including guidelines. !--

B

B

C

C

C

B

aN

i

Lack of standards for indicators f-

- Specification, definition of approved indicators. including the preparation of a glossary of terms. - Publication and disseaination of information on goals, strategies, objectives of HFA/2000 and indicators.

A

I

A

-

Lack of understanding for HFA/ 2000 at country level ~--

0

0

B

Problem of communication: - people - intragency i ntersectora 1 - intercountry

- Establishment of .echanis. for the generation and use of indicators. - Publication and di8seaination of information

C

C

B

0

0

B

-

'-----------

-

-~-

I

•

•

•

PROBLEM I

ACTIVITY - Identification of appropriate technology for the collection, processing and use of indicators, including the of EDP facilities, surveys and analyses. - Provision of indicators in planning. -------

GLOBAL C

REGIONAL C

NATIONAL B

I I !

I

Appropriate resources ! i i

I

I I ,

I I I

: Lack of ca-i tlDent

L_

-

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Desianations A, Band C given above reflect the priorities given by the group to the respective tasks at global, regional and national levels. (A designating a highest priority and C a low priority) Priorities should be interpreted in the broad sense: they refer to the efforts necessary for the fulfilment of these tasks in terms of resources and time. They reflect also the urgency of the task, yet they should never be interpreted as just a timetable of action. The taskl at various levels are obviously interrelated, but that does not necessarily i.ply that priorities at various levell .ust be the s ..e. The delignation 0 refers to talks which are obligatory. included to stress the fact that they are i.portant al well. They have been

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