vJORLD HEl1.LTH ORGii.lUZ.ATION REGIONAL C01>1HITTEE
REGIONIIL OFFICE FOR THE ·vlESTERN PACIFIC TECHNICJI.L DISCUSSIONS
Fifth Session Manila 10-16 September 1954
WP/RC5/'IDl' 5 10 September 1954 ORIGINAL: ENGLISH
EViliUATION QUESTIONS
for Technical Discussions
1. \ihat did you like BEST about the Technical Discussions? (Consider both the subject matter and the techniques used.)
2. What did you like LEhST about the Technical Discussions? (Consider both the subject matter and the techniques used,)
3. What should be done to improve next year 1s Technical Discussions?
Vl:>RLD HEALTH ORGANIZATION REGIONAL COMMITTEE Fifth Session Manila 10-16 September 1954
REGIONAL OFFICE FOR THE \vESTERN PACIFIC TECHNICAL DISCUSSIONS 14 September 1954
ORI GINALI
ENGLISH
REPORT OF DISCUSSION GROUP A The group met between 9t00 a.m. and 12100 noon, and 2t00 p.•m. and
5t00 p.m. on September 14, 1954. Drs. Regala and Soda were una:n:imously elected as the group-rapporteurs. very freely. There was a full attendance of 20 members and practically all took part in the proceeding of discussion From the three general topics as provided for discussion 1 the group took its own initiative in choosing the specific topics and sub-topics of mutual interest for actual discussion and a brief summary of this proceeding is given as followsa
I
FDINTS TAKEN UP IN OONNEcriON \rliTH UNIT II A. Preventive and Curative Medicine There was divergence of opinion as regards this topic. One th,at curative medicine might need more emphasis than Another ..felt that preventive medicine should be After a prolonged discussion
group
thoug~t
preventive medicine.
more emphasized than curative medicine.
and exchange of opinions, it was agreed that emphasis should depend upon the conditions of the particular area and the stages of health development, but both preventive and curative medicine should be given by the health unit. Of course curative medicine should be limited to the essential minimum and no hospital bed is needed at the unit. B. The Basic Health Unit in Areas where Limited or no Health Services Exist A question was brought out as to what a health unit was. stimulated a lively discussion. This It was pointed out that the area of a ;health unit
Group A Page 2 health unit should take into account the size of the population., the geographical area to be covered and their position to the political and/or administrative unit, as well as the availability of resources such as supplies, equipment, etc. Ma~
members elaborated on this particular point
on the basis of their own experiences in varying areas, i.e. from the sparsely inhabited to those where the population was more or less wellcircumscribed. Another opinion was that the health uhit should, as far as possible, correspond to the existing administrative unit of a suitable population of not less than 10,000 inhabitants. When the size of the population was greater than a certain number (not specified), it was believed that -there should be sub-units.
c. taken up.
Categories of Personnel The functions of the basic health unit in this connection were It was emphasized that a survey of local conditions and needs Although the
should be made before health .programmes are imple.mel.lted. functionS should be agreed upon.
conditions would probably vary, it $eemed .tl::J..a.t --~ IJlin:imum scope _of its. . At this juJXture, the group took into consideration the recommendations of the 2nd Report of the Bxper' Committee on Public Health Administration where the following 7 functions were outlineds
(1) Maternal and child health (2) (3)
Communicable-disease control Environmental sanitation Maintenance of records for statistical purposes Health· education of the public Public-health nursing
(4)
(5) (6)
Medical car.e (to an e~ent varying_ with the needs of the area and the accessibility of larger hospitalcentres).
(7)
/After discussing
Group A Page 3
After discussing the functions, it was agreed that the following minimum categories of health personnelwere found necessary for a health unit in order to fulfil the above functions. (1) Doctor (2) (:3)
(4) (5)
Sanitarian Clerk
Nurse Mi. dwif e
It was further thought that a separate health educator would not be feasible inthe basic health unit but that all health personnel in the unit should serve to propagate the health education aspect. areas where special needs existed and resources are available, the categories could be increased. The number of each type of the health personnel would depend upon the needs of the area. It was also pointed out that personnel in the basic health uni~
In
might be utilized to carry aut multi-purpose work in the sense that the activities recommended in the report of the Expert Committee on Public Health Administration could be performed by the above mentioned personnel of the basic health unit. The utilization of the local health and medical concepts was
A connnent was made to the effect that in order to obtain the cooperation of the people in the area, local and medical concepts then raised. should be recognized wherever possible and, at every opportunity, attempts should be made to correct those concepts which were not desirable or even harmful from the point of vi ew of health. ticular~
This was necessary par-
in the beginning stages; otherwise the people in the area
might develop a resistance to any health programme which w .a s being designed for them. D. Funds The question was r aised as to whether planning should be done ;before funds
Group A Page 4 before funds were made available. It was the general opinion that plans If funds
could be made according to the needs and resources available.
were not sufficient, then part of the programme should be implemented within the limitations of existing funds. II POINTS Ti.KEN UP IN CONNEGriON WITH UNIT I It was the general observation that there was not much provision in the undergraduate medical curriculum in many of the countries within the area at the present time. sented in medi~al
In connection with this aspect, attention was
drawn to the need for the health administration being sufficiently reprecolleges so that in the preparation of the curricula Where postgraduate course in public they coilld be in a better position to lay the -necessary emphasis on courses in social and preventive medicine. me~
health is being given in a universit.y, it was thought that the health departshould take an active part in the conduction of the course and its field health unit be utilized as far as practicable. As far as in-service· training is concerned, it was felt' that this should be the function of the health department. As to whether or riot rotation of services such as quarantine, hospital administration, sanitation, vital statistics, etc., be made as a part of the training for health administrators·, it was felt that unless it was the intention to build up individuals· for a position with wide responsibility it woUld be inadvisable to rotate personnel in the various sections of publi-c health. A. Public Health Engineering It was recognized that public health engineerin~
is an essential
aspect of public health, although in maqy health administrations within the area at the present time there were no fully qualified public health engineers on the staff. /I'he question
Group A Page 5 The question as to the proper placement of the public health engineer was brought up, i.e. whether he should be placed in the Public Works Department or in the Health Department? After some discussion, it was felt that what was . necessary was a very close working relationship between the Public Works Department and the Health Department so as .to .obtain .the maximum benefit from public health engineering activities. B• Public Health l'furses The importance of the public health nurse was appreciated. The scope of the functions of public health nurses in a basic health unit was considered to be generalized public health nursing. consultant services at a high level. It was believed that the utilization of nurses in the fiela of public health had not been too wide. public health nurses were not utilized. III POINTS Ti~KEN
However,
to ensure efficiency, provision should be made for supervisory and
In many areas, the services of
UP IN CONNECTION vJITH UNIT III
There was no doubt that in all instances outside help had been found beneficial to Governments. However, in order to be fully able to utilize multi- or bilateral assistance, it was thought that the following points should be borne in mindt (l) The programme should be planned in such a way that In other words, it should be within the
it would not cause any budgetary burden on the part of the requesting country. (2) actual budgetary possibilities. Assurance should be given that the programme could If the programme is a long-term one, the Government be carried out fully according to the projected plans.
(3)
should be able to continue it after assistance is withdrawn, /otherwise the
Group A Page 6
otherwise the aid wo:uld not be of real benefit.
Regarding snort-term consultants, the need.for this type of assistance in certain instances had been well pointed out •.
As to the question whether or not utilization of supplies without technical advice from the Organization is possible, it was thought ·that when the requesting count~
has the available technical staff the supplies
can be utilized without outside technical adxi.c. e.
****~!-*
WORLD HEALTH ORGl•NIZll TION
REGIONaL OFFICE FOR 'IHE WES 'IERN Pl1.CIFIC
REGIONAL COMMITTEE
'IECHNICllL DISCUSSIONS
Fifth Session Manila 10..16 September 1954
14 Septemb:er 1954 ORIGINAL: ENGLISH
REPORT OF DISCUSSION GROUP B
I.
THE BASIC HEALTH UNITS IN AREiiS WHERE LIMI'IED OR NO HEllLTH SERVICES EXIST .
First of all the group discussed what a basic health unit should be, and it was generally agreed that it should be the smallest government unit which has a population of 5 to 10 thousand persons. Members of the group from va~ious
countries described the type of unit
envisaged in their countries.
In Cambodia, it wasibur nurses and one
or no midwives for 150,000 people.
In Malaya, the minimum health team
consisted of an assistant nurse, a midwife, a dispenser and a sanitary overseer. In the Philippines (81 health units had been set up), it was
1 doctor, l public health nurse, 1 midwife, and 1 sanitary inspector. In China, a health station (of which there were 360)· each had 1 medical officer, l nurse, 1 nurse-midwife, and a sanitary inspector. In New
Caledonia, for a population of 5,000, 1 doctor, 1 midwife, and 1 sanitary officer were used. It was . finally agreed that the minimum
health unit should be a midwife, a sanitary ?verseer or inspector, and a nurse, with a minimum of 2 years' training. was the most important member of the team. In the event of a full team of this nature not being available, it was agreed that the midwife There was some discussion
as to the minimum services which the health .units should supply and it was agreed that they ~hould
supply maternal and child health services,
including domiciliary midwifery, medical care, environmental hygiene, /health education
GROUP B Page .2 health education and the prevention of communicable diseases, including immunization. Regarding the keeping of statistics, it was general~ agreed that the basie health statistics, such as population, births, and deaths should be the function of a local registration unit and not a health unit, but that normal morbidit,y statistics should be kept b,y the health .... un~ .... School health was also included in the normal functions of a unit and considerable discussion resulted from the suggestion that dental heal.th should also be included, but it was finally agreed that this might be too much for the basic unit. Laboratory services were also considered, but· it was decided tlat apart from the minimum, such as examination for malaria parasites, this could not be undertaken by a health unit. Turning to medical care, it was felt that medical care should be limited to the treatment of simple and conunon diseases, such as malaria, dysenter.y, yaws and scabies, and should also include first aid. It was emphasized that prevention should predominate and that medical care should only be sufficient to attract the cooperation of people who attend the centre. 11.
Staff With regard to staffing, there was considerable argument
about the need for doctors •. Same held that doctors were essential in the basic unit, others considered that it might be impossible to obtain the services of tffi doctor in a basic unit. level. Medical supervision, however, was deemed to be essential and, if necessary, at a higher It was also pointed out that inducements must be offered to These inducements staff to attract them to wrk in the rural areas.
might be classified as good salaries, S'atisfactor.y housing, some form /of transportation
GROUP B Page .3 of transportation in difficu~t
areas and opportunities for intervals to
practice outside their areas. B. Community Involvement It wa·s suggested that contribution from the government matched by contribution· from the community raised by taxation would be a suitable means of involving the community in the finances of the health unit, but it was agreed that this was not possible or advisable. value of associations such as women's rural institutes, red cross associations, tuberculosis associations and leprosy aid associations was discussed and it was generally agreed that they were a good means of arousing the interest of the communit,y in health development. It was also agreed that the advice of local authorities should not be sought when planning was being done and that all planning should be by a central agency. The
c.
Finance llfter some discussion it was agreed tho'. t the government
should contribute to the finance of a health project at the first instance, at least, and that local taxation was not advisable until the value of the health project had been firmly established in the community. At that stage, it might be possible to invite the local community to cantrioute a part of the funds to the project. It was felt, however, that the most useful contribution that could be made by tpe local community would be land, for building health centres, etc.,and even by erecting the buildings at the expense of the community. D. J.dministration It was agreed that the following lines of administration should generally be followed from the central government to the periphery, executive or judicial authority and pass to the state or provincial governments as the case might be and from them, through the district authorities to the local basic health teams. Nurse control /was also
GROUP B
Page 4 was also discussed and the view of the group was that control of nurses in the basic health units should be from a person such as a nursing supervisor on a professional level. In countries which had a large number of provinces, it was agreed that it would be advisable to bring into force a regional control, bringing together 8 to 10 provinces under the one direction. thought t~at
With regard to .the basic unit, it was felt that they
should be grouped into supervisory units at a district level and it was this could best be done by bringing 5 such units under the Even within the basic team, the one district supervisory authority.
question of who should be responsible was raised and it was the general feeling of the group that. one member of the basic unit should be held responsib.le, and, in view of the fact that the nurse was usually the best educated and most highly trained member of tbe unit, that that duty would usually be hers. II. OB'D'.INING SUITl'.BLE WORKERS FOR HEALTH DEPJ~RTh'IEN'IS
The discussion in this group fell into two categories only that of the training of doctors and of auxiliary personr;1el. The native medical practitioner who is training in the Western Pacific, was cited as an example of a low or sub-standard type of doctor who could be used in health projects in isolated areas. It was, however, generally agreed that it was inadvisable to train doctors under two standards and to discourage the training of . the lower type of medical practitioner. A. i~uxiliary
Personnel
A definition of auxiliar,y personnel was given, this was fUl auxiliary personnel was defined as any type of health worker whose
training was below the official standard for that particular category of health. work. The question of assessing the needs for auxiliar.y personnel was discussed in relation to various countries represented and ': in certain countries this had been assessed, particularly in the case of nurses
/and/ or auxiliary
GROUP B Page 5 and/or auxiliary sanitary personnel. In training, emphasis should be..
placed <m the practical rather tl;lan the theoretical training and efforts should be made to limit their sprvices commensurate with their training. The danger that auxiliary workers might seek full professional recognition without actually meeting educational standards was discussed and it was felt that under no circumstances should auxiliary personnel be allowed to arise from the auxiliary grade unless they fulfill the full educational requirements. The question was asked as to what could be done with auxiliary personnel who proved to be exceedingly expert in their duties and it was suggested that special grades in their own category should be created as a reward for their skill.
Finally, it was suggested that while it was necessary to employ auxiliary personnel or health workers in most countries in the development stages of health programmes, it was fully realized that when an adequate supply of the higher grades were available, these grades should be utilized. III. 'IHE UTILIZJ.TION OF MULTI l.ND BILl-~.'IEfulL J:.SSISTl!NCE FOR COD1l1RIES OR 'IERRI 'IORIAL HEJ~.L TH PRO GRJJIJMES
Only a short time was available for discussion of this subject. No decisive answer could be agreed upon concerning the minimum stage of development required for profitable utilization of outside assistance. It was suggested that the basic assessment of the capacit.y of a country to utilize outside aid was actual evidence of willingness to pass laws ~d
make appropriations which would ensure the permanence of
the programme. It was agreed that the value of short-term consultants would depend upon the project and the person. Usually, a visit by a short-term
7cohsultant
GROUP B Page 6
consultant at least served as a st:i.mulus to bring together these groups of the country to discuss the problem and at the same time contribute 3pecialised knowledge to the local staff. _ Their reports also strengthened the hand of the local administration.
1JORLD ffil\.L TH
RLGI01~~1
ORGANIZATION R!;.GIONAL COMMITTim Fifth Session Manila 10-16 September 1954
OFFICL FOR THE \'fSST.ERN P-"CIFIC TECHNICAL DISCUSSIONS
14 September 1954
ORIGINAL: REPORT OF DISCUSSION GROUP C
ENGLISH
I
OBT.hiNING SU IT.t~BLJ:.
HLi\.LTH bORK.LRS
a.
Health Officers. The group discussed first the obtaining of suitable workers
for health departments and considered that there exists a general difficulty in recruiting·medical officers of health. It was considered that the reasons which have led to. the unpopularity of health work are: 1. 2. insufficient remuneration as compared with the earnings of insufficient attention to preventive medicine in the curri~IHO
clinical doctors; culum of the medical student. It was suggested that medical students. B. Public Health Nurses. It was agreed that there is no similar difficulty in the recruitment of public health nurses as compared with ordinary nurses. It was agre ed that public health nurses · should be used also for curative services at the bedside, but that great care should be taken that their curative nursing does not exclude their public health duties of propaganda and teaching. C. Public Health Engineers. It was agreed that sanitary engineers are essential to any modern health project and that they should be on the staff of the health department rather than officers of a public works department. /D. Sanitary or Health might be able to assist by representing to universities the need for a greater attention to preventive health in teaching
D.
Sanitary or Health Inspectors. It was agreed that a health service should have qualified health
inspectors who have been given specific training for their vocation; that they should be used more as health educators and l ess as law administrators, and that their functions in a health department should be more clearly defined than they are at present. II BASIC Hru~LTH
UNITS
Considering the need of an area in which limited or no health services exist, it was agreed that curative services must be given as an introduction to preventive and environmental health services. provided with the following qualified personnel: public health nurse, public health inspector. added. It was agreed that the local people of the community should be encouraged to take part in the health programme from the very beginning and that their participation should include a contribution of services or of cash within their means. It may inde ed be good policy to find out what services the people want and to supply such wants first and f or emost. III UTILIZATION OF MJLTI AND BIIATEru:..L ASSISTANCE It is very necessary to assess the capacity of a country or t erritory to absorb outside aid without embarrassment to future economy. It was felt, however, that no criterion could be l aid down as t o how such an ass essment can be achieved; each problem irfust· be assess ed on its own merits. /Delegates in this For this purpose, the group . considered that the minimum basic health unit must be medical officer
of
health,
At a later date, as condi-
tions and finances permit, additional personnel such as midwives could be
ll'.ttUU.t"
v
Page 3 Delegates in this group were all satisfied 1vith the advice, assistance and implementation given by outside agencies in their territories. It was agreed that short-term consultants were of value in providing an answer to a specific pr()blcm and also at the time of initiation of any longterm programme they could be us ed also from time to time to assist in the evaluation .o f a programme. It was agreed that in underdeveloped countries especially, there is a danger in providing supplies and equipment without technical advice, but in those countries where satisfactory technical personnel could be found, assistance in the form of supplies might be given apart from any technical expert to . go with them. It was agreed that fellowships should be used to train personnel who might return to train others in the same field. While priority should always be given to the training of local personnel, fellowships might be given to expatriate staff when suitable local personnel were not available. It was agreed that it is essential to have some co-ordinating body to prevent re-duplication and/or overlapping of assistance given by international aid. Finally, the committee considered that no general answer could be given to the question of how international aid has influenced morbidity and mortality • Such an ans>ver can be given only in s ome specific programmes and in countries where facilities exist for statistical assessment before and after. EVAlUATION OF THE T~HNICAL
DISCUSSION
Of the sub-heads for discussion, the group found that the one on the basic health unit was the most valuable and productive. They felt, however, that the subject for this session had been too broad and discussive with the result that no time could be given to any detailed answer to any part of the headings discussed. /The group appreciated
GROUP C
Page 4 The group appreciated the infomality of the discussions and considered that such informal discussions represent the right method and technique. The group recommends that next year French-speaking delegates should be placed in a separate group, together with some bilingual sentativcs. r~pre
They also recommend that the subject for next y'ear's technical
discussions should centre around a specific health problem common to all countries and directly related to \V"RO assistance. Final~,
the group wished to express their gratitude and ap-
preciation of the trouble taken by the liHO staff to prepare the briefs and to supply so much material for consideration.
* * * *