WORLD HEALTH ORGANIZATION
REGIONAL OFFICE FOR THE WESTERN PACIFIC BUREAU RifGIONAL DU PACIFIQUE OCCIDENTAL
•
ORGANISATION MQNDIALE , DE LASAN1E
REGIONAL COMMITTEE Thirty-second session Seoul 22-28 September 1981 Provisional agenda item 12
WPR/RC32/6 Add.l 3 August 1981 ORIGINAL: ENGLISH
REPORT OF THE SUB-COMMITTEE OF THE REGIONAL COMMITTEE ON THE GENERAL PROGRAMME OF WORK PART II Strategies for Health for All by the Year 2000
REVIEW AND UPDATING OF THE REGIONAL STRATEGY IN THE LIGHT OF THE GLOBAL STRATEGY
After reviewing the Global and Regional Strategies for health for all,1,2 the Sub-Committee noted that, while there was no inconsistency in the contents of the two documents, certain parts of the Regional Strategy could be improved. The Sub-Committee accordingly made the following specific recommendations for change, which have already been incorporated in Annex 1. In Annex 1, the recommendations for change appear in doublespacing with a descriptive annotation in the margin. 1. Chapter 3: Conceptual framework for action
In describing the conditions under which health services were provided, mention should be made of the downward trend of the population growth rate. 2. Chapter 4: Long-term objectives, targets, and approaches
The specific objectives for a well-nourished population should include reduction of the prqblem of obesity. In enumerating activities for chronic diseases, fluoridation of water supply should be added.
lGlobal Strategy for Health for All by the Year 2000, WHO Geneva, 1981 ("Health for All" Series No.3). 2See document WPR/RC31/l5, Annex 2, Rev.1.
WPR/RC32/6 Add.l page 2
3.
Chapter 5: care
Development of the health system based on primary health
A new chapter (Chapter 5) was proposed because the Sub-Committee felt that Chapter 4 should be followed by a chapter describing the health system and the health manpower development activities required. The description of the health system in the Regional Strategy should include the characteristics of the health system, as given in the Global Strategy, Section III, paragraph 2, and the idea of social control of the system, as given in the Global Strategy, Section III, paragraph 27. The health manpower component of the chapter should include the section on human resource development of the original Chapter 6 of the Regional Strategy (which would become Chapter 7).
4.
Chapter 6:
Regional support measures (formerly Chapter 5)
.--
The changes recommended were: 4.1 Chapter 6.1: Political support. Reference to the types of meeting which could provide the forum for securing political support should be e.xpanded. The statement on national health councils should be rephrased in a less definitive way, as there were reservations with regard to their applicability in some countries. The statement on a regional health development advisory council should be deleted, since there appeared to have been no progress so far in resolving this issue at global leveJ. A short paragraph on health legislation should be added in support of the introduction of reforms. 4.2 Chapter 6.2: Economic support. A statement should be added to the effect that health was essential to general development, and that there was a need to be alert to the negative effects on health of development projects. The importance of gaining the support of economic planners should also be mentioned. 4.3 Chapter 6.4: Managerial and administrative support. A statement should be added to the effect that countries would strengthen their managerial capacities for national health development and for the provision of training to all those in need. The functions of a national health development network should be given and the importance of academics becoming familiar with field conditions through field experience should be cited. The number of national health development centres/networks should be changed from five to six by adding China to the list. 5. Chapter 7: Generation and mobilization of resources (formerly Chapter 6)
....
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As stated under section 3 above, it was recommended that the entire section on human resource development in the original should be transferred to the new Chapter 5. Replacing this would be a discussion on the mobilizing of the human resources of the community, incorporating the thoughts expressed in the Global Strategy, Section v, paragraphs 2-8.
WPR/RC32/6 Add.l page 3/4
6.
Chapter 9:
Monitoring and evaluation (formerly Chapter 8)
The Sub-Committee reviewed the list of indicators to monitor implementation or the health for all strategy at national level proposed in the Regional Strategy. I t considered that they should be specific enough to describe the present health situation and sensitive enough to reflect changes in health systems as they developed and became more complex. It thus recommended a revised lis t of indicators relevant for monitoring the implementation of the health for all strategy at national level, from which indicators to be used could be chosen or to which additional indicators could be added, depending on their appropriateness for the country concerned and the availability of information. The Sub-Committee also reviewed the lis t of indicators to be used for monitoring the implementation of the health for all strategy at regional level and recommended a revised list for the purpose. The Sub-Committee also discussed the indicators proposed for monitoring the implementation of the health for all strategy at global level and commented that a number were not specific and that some needed clarification, e.g. "endorsement as policy at the highest official 1evel"(l), "involving people in implementation of strategies"(2), "resources are equitably distributed", (5) and "well defined strategies for health for a11"(6). The Sub-Committee requested the Secretariat to obtain information on the basis used in arriving at the minimum value of "at least 5% of the gross national product is spent on health". A revised list of indicators recommended by the Sub-Committee for monitoring the implementation of the health for all strategy at national and regional levels, which incorporates those adopted by the World Heal th Assembly for the global leve 1, is given in section 9.3 of the attached Annex 1.
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7.
Cha ter 10: Role of (formerly Chapter 9
WHO with
res ect
to
re ional
strate
issues
Minor alterations were made to the existing text. The Sub-Committee, however, recommended a substantial addition to the text relating to discussions on ~HO's collaboration with countries or areas in pursuance of the ten broad objectives of the regional strategy. 8. Chapter 11: Tentative plan for implementation of regional strategies, including a timetable (formerly Chapter 10) The Sub-Committee recommended some changes in sequencing and dates.
WPR/RC32/6 Add.1 page 5 ANNEX 1
REGIONAL POLICIES AND STRATEGIES FOR HEALTH FOR ALL BY THE YEAR 2000 1
CONTENTS
CHAPTER 1: 1.1 1.2
MAIN HEALTH AND HEALTH-RELATED PROBLEMS Introduction Population
7 7 7 8 9
••••••••••••.•••••••••••••••••••••••••••• .......................................... .
1.3 1.4 1.5 1.6
Socioeconomic situation .........••.•.•••.•••••••••••• Health problems .........................•......•.....
Problems related to the health care system ••••••••••• Degree of awareness of the above-mentioned problems among po1icy-makers, health workers and the public •••••••••••••••••••••••••••••••••••• HEALTH AND SOCIOECONOMIC POLICIES CONCEPTUAL FRAMEWORK FOR ACTION LONG-TERM OBJECTIVES, TARGETS, AND APPROACHES Introduction .... ..•..... .. . ... . .. .. . . . .... . . ...•. ... •
10 12 12 14 ·16 16
"'"
CHAPTER 2: CHAPTER 3: CHAP.TER 4: 4.1 4.2 4.3 CHAPTER 5: 5.1 5.2 CHAPTER 6: 6.1 6.2 6.3 6.4 6.5 6.6
.................
Country statement synthesis .•••.••••••••••••••••••••• Regional objectives, targets and approaches •••••••••• DEVELOPMENT OF THE HEALTH SYSTEM BASED ON PRIMARY HEALTH CARE • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • Modification of the Health Care Delivery System •••••• Development of Required Health Manpower •••••••••••••• REGIONAL SUPPORT MEASURES Political support .•••.••••••••..••••.•...•.•...••..•. Economic support .•••...•••..•...••••••.•••.•••.•••..• Technical support •••••••••••••••••••••••••••••••••••• Managerial and administrative support •••••••••••••••• Research support •••••••••••.•••••••••••••.•••..•.•..• Infonnation support . .. ..... ....... .... ......... ......
16 18 25 25 27
30 30 31 31 32 33 34
lOriginally issued as document WPR/RC31/15, Annex 2, Rev.1.
WPR/RC32/6 Add.1 Annex 1 page 6
34 34
CHAPTER 7:
GENERATION AND MOBILIZATION OF RESOURCES Human resources development •••••••••••••••••••••••••• Financial and material resources ••••••••••••••••••••• COLLABORATIVE MECHANISMS
7.1 7.2 CHAPTER 8: 8.1 8.2 CHAPTER 9: 9.1 9.2 9.3
36 37 37 38
.......................... .........................
Intrasectoral and intersectoral collaboration •••••••• Intercountry collaboration ••••••••••••••••••••••••••• MONITORING AND EVALUATION Fr amework
40 40 40
••••••••••••••••••••••••••••••••••••••••••••
-.
Level and process ••••.••••••••••••••••••••••••••••••• Indicators proposed ..•.•••••••••••.•••••••.••••••••••
41 48
CHAPTER 10: 10.1 10.2 10.3 10.4
ROLE OF WHO WITH RESPECT TO REGIONAL STRATEGY ISSUES •••••••••••••••••••••••••••••••••••••••
Issues for WOO
Guiding principles for WHO action •••••••••••••••••••• Nature of WHO collaboration •••••••••••••••••••••••••• WHO's programme for the future ••••••••••••••••••••••• TENTATIVE PLAN FOR IMPLEMENTATION OF REGIONAL STRATEGIES, INCLUDING A TIMETABLE
48 49 49 51 58
CHAPTER 11:
.................
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...
WPR/RC32/6 Add.l Annex 1 page 7
CHAPTER 1:
MAIN HEALTH AND HEALTH-RELATED PROBLEMS
1.1
Introduction
The strategy to achieve a level of health permitting all citizens of the Western Pacific Region to lead a socially and economically productive life must address both current and potential problems likely to impede health development. As the status of health is a result of factors which are behavioural, environmental and hereditary, the strategy should 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 status and health development. It is therefore precisely to those factors that a strategy for health should be addressed. Elements of the strategy should accordingly consider: the growth, composition and movement of the population the level and phase of economic development the social values and forces shaping society's behaviour, and the health status of the people of the Region. 1.2 Population countries of directly and for the next 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 predominantly young population. Longer life expectancy will result in an· increased proportion of elderly individuals (age-group 65 and over). The present high dependency ratio will thus increase further. Population characteristics other sources are given below: l and projections from country reports and
The annual growth rate during the period 1975-1980 countries or areas of the Region ranged from close to 0% to pred ic ted range by the year 2000 is from c lose to 0% to countries had annual growth rates of 2% and over in the same
in the 32 3.35%; the
2.74%. period.
14
lFigures given in this and other sections of the document have been obtained from different sources. They should be interpreted with caution.
WPR/RCJ2/6 Add.1 Annex 1 page 8
from over that rate 4.2 to 20.3 per 10 per thousand in the year 2000 of over 10 per
In terms of actual population Sl.ze, the 1980 population ranges from 6000 to 960 million, giving a total population of 1. 3 billion. In the year 2000~ the total population is predicted to reach 1.6 billion with a range of from 7000 to 1.2 billion. In 1975-1980, the crude death rate varied thousand, with 7 countries reporting values of and 24 of over 8 per thousand. It is predicted 3 countries will still experience a crude death thousand and 20 a rate of over 8 per thousand.
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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. The predicted range in the period 1995-2000 is from 14.1 to 31.9 per thousand, with only 5 countries or areas 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 substandard housing, unemployment and poor water supply, among them juvenile delinquency and drug and alcohol-related problems. Emigration, particularly from small island countries towards larger and industrialized ones, may be expected to continue. 1.3 Socioeconomic situation
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uncertainty of peace, political instability and social unrest 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 expectations. Economic systems are unable to respond adequately to these rising expectations, resulting in the unemployment, underemployment and low incomes characteristic of a period of financial insecurity and leading in extreme cases to social unrest. In 1977, the per capita GNP of the Region ranged from US$90 to US$7 340, while the annual growth rates varied from 1. 9% to 7.7% • The rate of food production has at best been keeping pace with population growth; the food supply has not increased to the levels expected to meet the dietary requirements. Moreover, the problem is the uneven distribution among countries and within countries, as well as the increasing cost to the consumer. Malnutrition of varying types and grades exists in developing countries and in certain areas of developed ones. Safe potable water is still not available to a great segment of the population.
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WPR/RC32/6 Add.1 Annex 1 page 9
Educational systems in the Region are not able fully to meet the demand and do not always provide the relevant education to enable people to gain an adequate livelihood. 24% to 97% of the school-age popUlation is enrolled in primary and secondary schools. Statistics indicate that the problem of adult illiteracy exists in some countries.
Women roles.
In many
societies
are confined
to traditional occupations
and
The problems affecting most countries in the Region can be summarized as follows: continuing recession 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 commodities in most developing countries) social pressure lifestyles. and sfress brought about (largely agricultural
by
rapidly
changing
1.4
Health problems
~
In addition to the crude death ra~e, 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 thousand and 9 with rates of over 20 per thousand. rates of over 50 per
The maternal mortality rates range from 0.1 to 17 per thousand. The life expectancy at birth varies from 42 years to 77 years in 1980, and is expected to be from 52 years to 78 years in the year 21)00. 'fhere 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.
WPR/RC32/6 Add.l Annex 1 pa~e 10
In summary, the Region presents a variety of health problems, ranging from those found in agricultural countries to those of the industrial countries and comprising: communicable diseases and malnutrition chronic degenerative diseases accidents, environmental health problems pollution, stress conditions and mental
health problems of the elderly problems related to high fertility. The socioeconomic environment also determines such factors 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 and 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 reported in a way shed light on these two basic problems and may be enumerated as follows:
1.5.1
In a number of agricultural/rural countries Technology. Unsuitable, cumbersome, limited 1n impact and diffusion 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, maldistributed, lacking 1n 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 of the local situation. Furthermore, the possible contributions of traditional healers, birth attendants and herbalists have not been adequately explored or considered.
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WPR/RC32/6 Add.l Annex 1 page 11
Health facilities. Insufficient, inadequately supported, poorly located, of unsuitable architectural design and badly maintained. Operational procedures. Cumbersome and time-consuming, rigid, difficult to understand and unresponsive to service demands. Organization. Overlapping, duplication or conflict between related services, insufficient intersectoral coordination, inadequate integration of functions, imbalance. Policy. Lacking, unrealistic or outdated.
1.5.2
Accessibility. Problems are related to geography, transport difficulties, etc. Logistic problems lead to shortage of drugs and supplies. Financial. Some of the problems are insufficient funding, uneven distribution of funds, and inefficient and inequitable provision of drugs, medical supplies and equipment. Motivation. The population in a number of instances 1.S unaware of, or dissatisfied with, the services available. In a number of urban/industrialized countries Technology. Inappropriate and inefficient investment cost technology, especially in the private sector. in high
Manpower. Overemphasis on training of highly specialized medical personnel and senior level health workers. Overcentralization of training facilities. Proliferation of categories of health personnel. Facilities. Overinvestment 1.n hospital buildings and inadequate facilities for basic health services. Operational procedures~ Underutilization of health personnel at certain levels. Inappropriate use of staff, supplies and equipment. Organization. Lack of intersectoral coordination. Inadequate government control of standards and quality of services. Inadequate legislation for monitoring of the private sector. Policy and planning. Lack identification mechanisms to resources. of proper health problem ensure proper allocation of
WPR/RC32/6 Add.l Annex 1 page 12
problems among
1.6
Degree of awareness of the above-mentioned policy-makers, health workers and the public
There seem to be varying degrees of awareness of the above-mentioned problems among policy-makers and the public, who, it appears, are more prone to think of health in terms of hospitals and clinics. It also appears that, in some countries, the health m1n1stries require strengthening in order to influence top-level decision-making to a greater extent. In some countries, there appears to be a gap in communication within the health ministry between operational level staff and policy level staff •
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CHAPTER 2:
HEALTH AND SOCIOECONOMIC POLICIES
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The social objective of health for all by the year 2000, which was collectively adopted by the Thirtieth World Health Assembly, 1 is accepted by the leaders of all Member States and is explicitly mentioned in the policy statements of many countries. The mission of the health ministries in the Region, in pursuing the goal of 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. The national policies to that end have not yet, however, been incorporated in existing national health plans. It is recognized by Member States that the social goal will be realized through the primary health care approach in the Sp1rl.t of the Alma-Ata declaration. The trend is towards a broader, more holistic, approach to health development, viewing health as an integral part of national social and economic development. Health leaders are thus in the process of reinterpreting the concept of health and broadening their mission to include development of the people's capabilities for leading a socially and economically productive life, thereby achieving community self-reliance in health. This trend is discernible in the thinking of health experts in all countries or areas of the Region. The concept of community involvement is a vital element in the extension of health care coverage, providing for the mobilization of community resources in both the planning and the management of health care. It is recognized by practically all Member States that vigorous efforts must be made to encourage local communities actively to participate in health and development actions in such a way as to establish a working partnership between communities and government and private agencies. However, experience in developing such a partnership is as yet limited, though the principle of community self-reliance is universally accepted. lSee resolution WHA30. 43. WHO Handbook of Resolutions and Decisions, Vol. II, 4th ed., 1981, page 1.
.
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• WPR/RC32/6 Add.1 Annex 1 page 13
Another new dimension is the recognition of the interdependence of health and socioeconomic factors and the need for a multisectoral approach in health development. Although interest in the multisectora1 approach has been expressed by practically all Member 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 sector activities and does not fully take into account the related social and economic problems. Given the limited resources available 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 agencies, will demand a new outlook, orientation and skills on the part of health and related staff, who will have to develop qualities of leadership and managerial skills in order to facilitate and support the community development approach in health and to strengthen both intrasectoral 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, who must share their limited resources for the training and reorientation of health manpower, development of appropriate technology and research, and exchange of information and experience. In their efforts to evolve and implement policies and strategies for attaining the goal of health/2000, health ministries in several 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 processes for health development. In searching for solutions, some countries have embarked on the process of country health programming with a more holistic and broader view of health and its relationship to other aspects of social and economic development. However, the process is slow, problems encountered are many and the resultant structural and legislative changes and reallocation of resources needed are only beginning 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 States, the regional strategy should aim at collaboration in: improving and developing managerial processes for health development; reorienting and training health and related personnel, particularly in management, organizational development, communication skills and community development approaches; developing research on appropriate technology and health care delivery systems; devising practical evaluation procedures to monitor both the processes for implementation and the impact of health development strategies; exchange of information and development of effective information systems; and mobilization of external resources in support of national efforts for health development.
WPR/RC32/6 Add.l Annex 1 page 14
A
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 economic indicators such as GNP and per capita income is being questioned' and concern has been expressed that development should be 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 health as an integral and vital part of development, benefiting by and contributing to economic development, as expressed in United Nations General Assembly resolution 34/58 on Health as 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 resources and regional planning.
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CHAPTER 3:
CONCEPTUAL FRAMEWORK FOR ACTION
The successful coordination of initiative and effort directed towards the attainment of the long-term objectives will largely depend on the collective and individual ability of Member States to function intersectorally. Thus, a general framework within which action is to be taken to achieve health/2000 must be responsive to the conditions under which health services are provided to the population, 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 The underlined phrase added (b) an increasing population, notwithstanding the downward trend of
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population growth, and the resultant demands for health services, which call for a reallocation of resources within the health and other sectors.
ISee United 29 November 1979.
Nations
General
Assembly
resolution
A/RES/34/58,
WPR/RC3216 Add. 1 Annex 1 page 15
These considerations imply that the conceptual framework must essentially address itself to directing health 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 affordable health technology for the sick, the disabled, the chronically ill and the socially maladjusted. In the light of the above-mentioned conditions and directions, a partnership involving the community, the government and private health organizations is suggested as a desirable conceptual framework for attaining health/2000. The partnership concept focuses on the mutual responsibilities, risks and rewards of all parties involved. From the point of view of the health authorities and the national governments, a number of important elements should be considered: (1) The government must lead and assume initial responsibility for building community capability to plan, organize and implement health development activities. (2) Reliance must be placed on community initiative, commitment and resources in identifying and resolving health development issues.
(3) The government must permit and promote the adaptation of approaches or technology to suit the needs or the situation in the community. (4) Intersectoral and intrasectoral approaches must be adopted problem solving, planning, implementation and development appropriate technology. in of
(5) The government and commun1t1es must work together in monitoring the results of community health development programmes. (6) The government must provide communities with resources in terms of manpower skills, technology, information and funds for the planning, implementation and monitoring of health qevelopment activities. In this way, the health care systems will become: (a) more responsive to the needs of communities; receptiv~
(b) more capable of influencing other sectors and also more to influence from other sectors;
(c) more holistic and integrated in their approach to the planning and management of programmes; and
WPR/RC32/b Add. 1 Annex 1 page 16
the continuous professional and personal
(d) more concerned with development of staff.
In brief, this will require government and private health workers to play the roles of health technician or scientist and facilitator in developing community self-reliance in health.
CHAPTER 4:
LONG-TERM OBJECTIVES, TARGETS, AND APPROACHES
4.1
Introduction
Interpretation of the current regional situation as it affects the health of the population should be considered in the light of Member States I commitments to health development and the constraints on meeting such commitments. These commitments 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, such a picture will suggest that the basic needs of food, water and shelter will have been met by all governments of the Region. The total fulfilment of those .needs will be reflected in a well-informed population with shared social values, the widespread availability of food and drinking water, the sanitary disposal of human and animal waste, the control of environmental pollution, the absence or reduction of preventable communicable diseases, the reduction of chronic diseases, and the psychosocial well-being brought about by harmonious lifestyles. However, this picture remains incomplete. Without social justice, health and its contribution to the quality of life can have little meaning. To ensure social justice, people must accept responsibility for their own health and develop their capacity for self-reliance. 4.2 Country statement synthesis
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-.
The statement of objectives was extracted from national progress reports, the speeches of delegates of Member States of the Region at the Thirty-third World Health Assembly, and the country programme statements on national health/2000 strategies submitted to the Regional Office in connexion with the proposed programme budget for 1982-1983.
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WPR/RC32/6 Add.l Annex 1 page 17
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)
Number of countries or areas providing statements 22 23 11
Improvement of nutritional status Provision of safe drinking water and a sanitary environment Control of environmental pollution Access to appropriate health care Control of communicable diseases Control of noncommunicable diseases (cancer, heart diseases, cerebrovascular diseases, dental conditions, metabolic diseases and health problems of the elderly were among those commonly mentioned) Promotion of lifestyle and habits conducive to health Promotion of psychosocial well-being Fertility regulation Drug production, essential drugs and drug policies Rehabilitation
(d) (e) (f)
22
25 17
(g) (h) (i)
6
12 20
(j) (k) 4.2.2
7 8
Objectives related to the health care system (a) Health services development, including for example, reorganization, development of health facilities and support mechanisms, development of referral systems, regionalization, integration 24
WPR/RC32/6 Add.l Annex 1 page 18
... Number of countries or areas providing statements
(b)
Health manpower development, including strengthening of institutions, curriculum review and revision, reorientation of existing staff to primary health care, training of lay workers and medical assistants, training of specialists, control of specialization, 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, biomedical research Development of planning and managerial skills, establishment of planning units, development of supervisors, improvement of managerial processes, including health management information systems
26
(c)
15
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(d)
22
4.3
Regional objectives, targets, and approaches
Taking into account the expressed objectives of individual Member States, a regional framework for health objectives to be attained by the year 2000 has been developed as follows:
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-
",
)J
)
)'1
)
"
1',
J}
Objectivea, targets, and approaches
Overall societal image by year 2000 Socially and economically productive individual I population with: 1. Longer life expectancy 2. Low infant mortality 3. Low maternal mortality 4. Less disability 5. Adequate shelter, education, and means of livelihood: through strategies with the following essential characteristics: 1. Community ihvolvement 2. Int~rsectoral coordinated efforts 3. Equitable distribution of health and other resources 4. Health systems development 5. Development and use of appropriate technology at a cost the community can afford 6. Development of sound managerial processes, for health development 7. Development of necessary health manpower 8. Research
Broad objectives
Specific objectives
Activities
Health status target
Health ,erv:cea targets
1. A veIl-nourished population
1.7 added
1.1 Nutritious food available 1.2 Good dietary habits established 1.3 Healthy childfeeding practices 1.4 Services available for the prevention and care of ,..lnutrition 1.5 Endemic goitre, nutritional anaemia, and xeropthalmia no longer public health problems 1.6 Number of low birth-weight babies reduced 1.7 Problem of obesity reduced 2.1 Safe water at a cost affordable to all available and accessible 2.2 Safe storage and use of drinking water
a. Formulation and implementation of food and nutrition policy b. Nutrition education, both formal and informal c. Development of nutrition surveillance and care d. Fortification of food e. Supplementary feeding, with particular attention to high-risk groups
a. Minimum calorie and protein intake for all b. Goitre and xerophthalmia reduced to lowest manageable levels c. Nutritional anaemia in pregnant and lactating mothers reduced to minimal manageable levels d. Proportion of low birth-weight babies reduced to 10% level e. No third degree malnutrition in children
1. Overall targets • Universal availability of health services in all countries; All c~nities with health committees/councils at various levels participating actively in the manage.ent of health services; • At least 5% of the GNP expended in the area of health care with ,,",phasis on
prevention; • An effective mechania. for intersectoral collaboration in the area of health established in all countries 2. Nutrition and maternal and child care :-At least 80% of pregnant mothers, deliveries, infants and young children receiving appropriate health care, including immunizationj Services for nutrition surveil-
2. Safe drinking water for all
a. Feasibility studies for community water supplies b. Establishment/expansion of community water supply systems (piped) c. Further development/ improvement of other sources of water, i.e. wells, springs, rain water d. Quality control e. Maintenance and repair of water systems f. Community education and involvement
a. Incidence of waterborne diseases reduced to the current levels of countries with safe drinking water: 200/1000 a year (diarrhoeal diseases) b. Incidence of diarrhoeal diseases among children under 5 years of age reduced by 50%
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lance, care, maintenance and education available in all communities
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Overall societal image by year 2000
Broad objectives 3. Sanitary disposal of human and animal waste
Specific objectives 3.1 Sanitary toilets available for all families 3.2 Proper disposal of refuse, garbage, and animal wastes
Activities a. Development of facilities (materials and technical guidance) and appropriate technology b. Education and motivation for safe waste disposal c. Enforcement of regulations/legislation
Be.ltb status target a. Iocidence of faecalborne diseases reduced to current levels of countries with safe waite disposal facilities: 200/1000 (diarrhoeal diseases) b. Iocidence of diarrboeal diseases among children under 5 years of age reduced by 50%
Health services-targets 3. Water 100% of the population u.sing safe drinking water in all communities 4. Waste di8*osal 100% of t e population with sanitary latrines and reasonable waste disposal and drainage facilities 5. Environmental ystems to monitor environmental pollution and to maintain it at reasonable levels established ~ollution
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4. Minimal environmental pollution and hazards
4.1 A code on pollution estab lished and enforced
a. Formulation and implea. Targets shared with mentation of policy other activities, b. Development of effective tbe impact of which monitoring systems vilt be on the overall c. Education on environmental he2lth status of the protection coaaunity measured by d. Enforcement of regulationl means or indices to legislation be developed e. Improvement of the environment a. b. c. d. e. Innnunization Chemoprophylaxis Surveillance Case/contact finding Specific treatment/case management f. Education g. Environmental control, including control of vectors
5. CODDDunicable diseases no longer a major problem
5.1 The following absent: smallpox, faucial diphtheria, tetanus neonatorum, poliomyelitis, measles, congenital rubella syndrome, mortality from Whooping cough and rabies, the advanced stage of filariasis (elephantiasis), new cases of blindness due to trachoma 5.2 The following controlled: schistosomiasis, malaria, filariasis, tuberculosis, plague, parasitic infestations of the skin and intestines,
6. Health care • Availability of essential drugs in a. In~idence of smallpox, all cODDDunities faucial diphtheria, ensured; tetanus neonatorum, Adequate poliomyelitis, measles, facilities available congenital rubella at all levels for syndrome reduced to delivery of basic zero; mortality from health services and vbooping cough and support of primary rabies, the advanced health care stage of filariasis (elephantiasis) and 7. Disease control new cases of blindness • Medlcal needs of 100% of the populadue to trachoma absent tion met - simple care in case of b. Morbidity from the following not to illness and injury available near the exceed the specified levels in any country homes of the people; Services for the or area: Malaria - 10/10 000 control of communicable and nonannual parasite incidence rate (HPI) cODDDunicable diseases established and provided to at least 80% of the
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Overall societal iaage by year 2000
Broad objectives
Specific objectives cholera, typhoid, leprosy, viral hepatitis B, trachoma, tetanus 5.3 The following no longer major' pub lic health problems: diarrhoeal diseases, respiratory infections in children, sexually transmitted diseases, viral hepatitis A
Activities
Health status target Filariasis - 5% prevalence rate Tuberculosis - 5% infection rate of school entrants Parasitic infestation - 15% in age group below 15 ,years Cholera - 1/100 000 incidence
Typhoid - 1/100 000 incidence Diarrhoeal diseases 200/1000 incidence Viral hepatitis A less than 25% population at age 20 with antibody Viral hepatitis B 1/1000 HBsAg carrier rate Tetanus - 10/100 000 in age group up to 10 years Leprosy - 0.5/100 000 incidence Schistosomiasis prevalence reduced to at least 40% of current level in endemic areas c. Mortality from the following not to exceed the specified leve Is in any country or area: Pneumonia/influenza 100/100 000 in infants; 10/10 000 for age group 1-4 years Cholera - 0.1% case fatality rate Typhoid - 0.1% case fatality rate Diarrhoeal diseases 0.1% case fatality rate
Appropriate knowledge generated for programme improvement through research and a network of health information systems
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Overall societal image by year 2000
Broad objectives 6. Chronic diseases reduced
Specific objectives __ ____ 6.1 The following reduced: congenital heart diseases, rheumatic heart diseases, degenerative cardiovascular diseases, chronic
_ _______ _
Activities
Health status target a. The following reduced to specified levels: - congenital heart diseases
Health services targets
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bronchitis, pulmonary emphysema in the younger age group (below 50 years), preventable cancer, peptic ulcer, cirrho-
a. Education for behavioural change b. Counselling c. Early detection d. Case management e. Establishment of registers f. Control of environmental factors g. Fluoridation of crinking water supply
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- rheumatic heart diseases
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degenerative cardiovascular diseases
sis of the liver 6.2 Diabetes and hypertension controlled 6.3 Oral health in children at a satisfac tory leve 1
(under 50) - chronic bronchitis (under 50) - pulmonary emphysema (under 50) - preventable cancers - peptic ulcer - cirrhosis of the liver b. All diabetics and hypertensives controlled medically c. An average of 3 DMF or less per child at age 12 years maintained a. The following reduced by at least 50% of current levels: cirrhosis, alcoholrelated accidents, alcohol-dependence syndrome, alcohol consumption, incidence of drug dependence, consumption of dependence-producing drugs for nonmedical reasons b. Smoking (tobacco consumption) among adults reduced with corresponding reduction of ischaemie heart diseases and lung cancer c. Smoking in population 20 years and below reduced to zero
7. Psychosoc ial we ll-being and lifestyle conducive to
7.1 The following reduced: alcohol-related problems, accident-
a. Health education and supportive social action and legislation b. Promotion of:
health
related deaths and problems, stress-
- social/recreational activities
related diseases 7.2 Smoking and drug dependence controlled 7.3 Good personal hygiene and dietary habits established 7.4 Physical fitness activities undertaken
- parental and family harmony through counse 11 ing - healthy working environment and
7.5 Human sexuality better understood 7.6 Discrimination based on ethnic, social, phys ical and age factors not encountered
job satisfaction c. Value clarification d. Formulation and implementation of legislation/regulations against discrimination
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Broad objectives
Specific objectives
Activities
Health status target d. Incidence of neurosis, suicides, and other
Health services targets
forms of maladjustment reduced to manageable levels e. Social justice in health achieved 8. No pockets of ill-health 8.1 The following disadvantaged groups given adequate attention: slum dwellers, economically disadvantaged populations, populations in remote areas, the
a. Identification of disadvantaged groups b. Equitable distribution of services and opportunities
a. Health status of disadvantaged groups should improve at a faster rate than the national average to achieve equity in health
elderly and disabled 9. Fertility regulated to ensure better
health and social well-being
9.1 Access to knowledge and to safe and effective means of fertility regulation available to all 9.2 Pregnancy in adolescents reduced 9.3 Contraceptives used for spacing of births and fertility regulation
a. Formulation and implementation of population policy b. Facilities for fertility regulation made accessible c. Education in population and family planning
a. Population growth rate reduced to less than 1% b. Incidence of pregnancy in adolescents reduced to zero
9.4 Population growth reduced in harmony with economic
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Overall societal image by year 2000
Broad objectives 10. Access to appropriate health care for all
Specific objectives 10.1 An adequately funct ioning heal th service network
Activities a. Development of community participation/partnership for health b. Development of health care delivery system c. Health manpower made available d. Essential drugs made available e. Development of financing schemes, including efficient use of resources
Health status target 8.
Health services targets
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accessible to all in terms of reach and financial consideration, delivering an acceptable level of care with active involvement of the people 10.2 Comprehensive health care, including health promotion, prevention, treatment and rehabilitation provided by the network
Targets shared with other activities, the impact of which wi 11 be on the overall health status of the co.munity measured by means or indices to be developed
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,f. Development of appropriate technology for health g. Development of management and support systems h. Formulation and enforcement of supporting legislation
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WPR/RC32/6 Add.1 Annex 1 page 25
NEW CHAPTER
CHAPTER 5: DEVELOPMENT OF THE HEALTH SYSTEM BASED ON PRIMARY HEALTH CARE
5.1
Modification of health care delivery systems Existing health care delivery systems will need to be modified in
varying degrees,
depending on country conditions,
in order to meet the
objectives and targets set out in Chapter 4, within the conceptual framework described in Chapter 3. As an initial step, countries will 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 primary health care. These are:
(1)
The system should encompass the entire population on a basis of equality and responsibility.
(2)
It
should
include
components
from
the health sector and
from
other sectors whose interrelated actions contribute to health, such as education, the water board or its equivalent. social
welfare, housing or human settlement and agriculture.
(3)
Primary elements
health
care, in
consisting the
of
at of
least
the
essential should be
included
Declaration
Alma-Ata.
delivered at the first point of contact between individuals and the health system •
...'
WPR/RC32/6 Add.l Annex 1 page 26
levels of of the health health system should support care to enable it the to first level primary provide
(4)
The other contact
these essential elements on a continuing basis.
(5)
At
intermediate
levels,
more
complex
problems
should
be
dealt
with,
and more skilled and specialized care as well as should be provided. training More to highly trained care
logistic should as
support provide
staff
cont inuing
primary health
workers,
-
well as guidance to communities and community health workers on political problems arising 1n conneX1on with all aspects of
primary health care.
(6)
The central level should coordinate all parts of the system, provide care, planning teaching as and for management specialized expertise, staff, the highly
and
specialized of such and
expertise
institutions
central
laboratories,
and
central
logistic
financial support.
The
structure
of and
the
health
care at its
system
must
provide
for
clear
-
delineation of work level,
functions
var10US
levels.
At managerial have a research and operating
it must be programme and and
problem-solving oriented, providing the policy
component
a
planning
function,
framework for health programmes, and penn.itting local levels to respond to hea 1 th needs that are consonant of the with the political, cuI tural and be
administrative
traditions levels,
society.
While planning skills will
developed at all
considerable attention will need
to be given to
...
the enhancement of participation of individuals and communities 1n deciding
WPR!RC32!6 Add.l Annex 1 page 27
on health policy and in guiding the planning, management and control of the health infrastructure and the programmes it delivers. In strengthening this
"bottom-up" approach to planning and management, a clear national policy may be needed, necessary. as well as appropriate legislative and budgetary measures if
Existing mechanisms for this approach may have to be reviewed As a prerequisite to the success of to be well-informed by the health
and modified, or new ones introduced. this approach, the people wi 11 have
personnel themselves.
Further detailed analysis should
identify the actions to be taken by
the health sector and by other sectors, which would constitute a plan of action for both. Chapter 1, The problems related to health care systems set out in starting point for this analysis. The
section 1.5, provide a as far as
implications,
the ministry of health 1.S concerned,
are that it
must strengthen itself to enhance its leadership role 1.n health development and to develop the capacity to draw upon the resources of other related
sectors and/or external technical and financial collaboration.
In the case of external collaboration, specific measures will need to be taken to ensure continuous exchange and joint developmental efforts
(TCDC) among countries sharing similar interests or priorities in health.
5.2
Development of required health manpower
The development of health manpower will,
as a general principle, national health systems,
be of
...
guided
by
the
requirements
of
the
proposed
which primary health care will be the central function.
WPR/RC32/6 Add.l Annex 1 page 28
In fulfilment of this principle, it will be necessary for educational institutions to collaborate with the ministry of health and other ministries in planning for and producing an adequate number of health personnel to promote a more balanced delivery of health care in order to meet the needs of the entire population. The necessary manpower planning activities should -
\
not only take into account the number of staff needed but also use as a basis an analysis of health system. types of the functions which are required for managing the
Such an analysis will enable countries to ascertain the to be trained and will also serve as a basis for
-
personnel
continuing education.
This intersectoral approach will be made possible by
the formulation and application of policies permitting such an approach to function harmoniously.
In the actual development of training programmes, particular attention will be paid to the following;
(1)
Strengthening
training programmes and
institutions
1.n terms of
faculty development, reviewing curricula to improve their relevance and to emphasize textbooks, improving institutes. promotive and preventive library of health care, facilities progress, developing manuals teaching and
-
strengthening the assessment
and and
equipment, national
student
developing
....
WPI{/I{C32/b Adel.l Annex 1 page 29
(2)
Where
small
countries
or
areas
predominate,
continuing
the
practice of sharing the facilities of one of the larger countries, with the prospect that the demands on its facilities will continue to increase. applies particularly to the South Pacific. This
(3)
Training
in
health
management
and
administration,
which
is
-.
expected to be provided in health development centres/networks or similar mechanisms.
(4)
Attracting appropriate staff into the community health field and
correcting the maldistribution of health manpower by directing it from urban to rural areas. While there are various ways of achieving this, the
ministries concerned as well as the public administration in general will take steps to ensure that health workers are socially motivated and provided with the necessary incentives. It is expected that continuing education,
improved supervision and better career structures will be needed.
The reorientation of health workers and other workers, such as teachers and communi ty 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 1.n
their respective approaches to primary health care.
(5)
Action will be needed to identify the strengths and deficiencies
of training institutions and to establish reciprocal arrangements whereby
...
an activity 1.n one institution can compensate for a deficiency in another • Meetings of heads of certain institutions, such as deans of public health
WPR/RC32/6 Add.l Annex 1 page 30
schools, of medical schools, and of nursing schools, are considered very useful in this regard. Support will be needed for national training courses To ensure the highest level of relevance in be encouraged to engage in health
and institution strengthening. teaching,
training institutions will
services research.
CHAPTER 6:
REGIONAL SUPPORT MEASURES
Country reports indicate various existing and planned support measures for health/2000 policies 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 Connnittee 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
Underlined phrases additions Sentence on national health councils rephrased
Political support will be obtained through the involvement of political and social leaders in appropriate regional and country activities. This 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 I and non-governmental organizations, religious meetings and civic meetings. The creation of
-
national health councils that are essentially intersectoral is one of the measures that could be adopted to enlist political and legislative support.
The enactment of new legislation may be necessary to facilitate the The whole paragraph an addition 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
progrannnes and services.
WPR/RC32/6 Add.l Annex 1 page 31
Intergovernmental groupings, such as ASEAN, will also contribute to the promotion and formulation of national pot,..cie,s< and strategies by determining joint action in health development and bringing health development issues to the attention of Member States and other regional forums. The Regional Committee has the task of fopnulating, monitoring and Statement on evaluating regional policies and strategies. In so doing, it also serves regional as a very important political mechanism for support of the regional development strategy. advisory council In addition to the World Health Assembly and the Executive Board of deleted WHO, global forums, both within and outside the health sector, should be used for the promotion of health development efforts and, in particular, the concept of health as an integral part of socioeconomic development. 6.2 Economic support The The whole paragraph an addition support of economic planners to the national health for all
....
strategy is essential, and ministries of health should take advantage of whatever opportunity may be presented in enlisting this support. It
..0;
is
also equally important for the ministries of health to detect any negative effects on health of development projects and to see to it that protective measures are made integral components of these projects, as, for example, in irrigation schemes, dams and industrial deve1op~ent \
projects.
Economic support will be secured from interna~iona1 development banks (World Bank, Asian Development Bank) and mul~ilatera1 and bilateral agencies (Colombo Plan, USAID, ADAI), JICA, DAN IDA , ISIDA, SPEC) as well as from voluntary donors such as ther Japan Shipbuildiilg Industry Foundation. The strategy will be to channe:J.a. resources into activities for integrated health development, in partiCUlar to emphasize th~' health component of development projects funded by lnternationa1 cooperation. It is important to stress that economic support 'should be used for development activities which will foster se1 f-reliance and not solely for the import and maintenance of technology. It will be necessary to develop and strengthen regional and global mechanisms 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 schools of public health.
WPR/RC32/6 Add.l Annex 1 page 32
The underlined phrase an and related professional bodies throu~h personal co~tact, formal and addition informal meetings, written communicat10ns and publ1cat10ns will be encouraged. Special efforts will be made to promote the support related industries by encouraging them to produce equipment technology and to manufacture essential drugs at reasonable efforts, UNIDO, UNICEF and ESCAP will play an important mechanisms for this are being developed in the Region. of medical and for appropriate cost. In those role. Specific
It will be of particular importance to obtain the support of health professionals through associations of doctors, nurses and through other 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 organizations of health
~
The global strategy should develop mechanisms to promote collective action at high international level involving governmental and nongovernmental organizations, to mobilize the health related professions and generate the active support of the media worldwide. 6.4 This paragraph an improvement on the original Managerial and administrative support Countries will need to strengthen their capacities for national health development to enable them to develop and implement their strategies. should lead to the following: Review and reV1S10n of health policies to give a clear and more specific direction to health resources and activities. (1)
This
~
(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 action. The 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. This paragraph an addition The ministries of health will establish mechanisms to develop and apply their managerial processes and to provide adequate training to all those who need it. I't' The regional strategy will include the establishment of, and support for; national health development centres/networks and national health coupcils, or similar intersectoral coordinating bodies, and efforts to stt~ngthen capabilities to develop and apply the managerial proc~s s. :.
. jl
.....
\ ,
WPR/RC32/6 Add.l Annex 1 page 33
This paragraph an addition
It is envisaged that the national health development centres/networks will consist of to a
number
of
institutions resources
which
will
have
a
working their
arrangement deficiencies. managerial
share
their
and
thereby
overcome
The centres/networks are expected to conduct training in the carry out health services to research in identified
process,
priority areas, It
and provide advisory services that, to in the case of
the ministry of health. institutions, the
is highly desirable should be exposed
academic
staff
actual
field
experience
in order
to enhance
their contributions. Five is changed to six. '" China is added
Initially six national health development centres/networks are proposed (China, Malaysia, Papua New Guinea, Philippines, Republic of Korea and South Pacific). Close cooperative relations will 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 established with similar networks in other Regions to form a global network. (3) Provision of support administrative problems, such as accounts, reorganization, etc. to Member States in dealing with logistics, personnel matters, budgeting,
-
The global strategy should develop support for managerial and administrative processes by providing technical expertise and exchange of information between Regions and obtaining financial 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 primary 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 research councils or their equivalent (existing health research councils will be strengthened if strengthening is indicated, and where no such council exists establishment will be encouraged). At regional level, the Western Pacific Advisory Committee on Medical Research and its sub-committees 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.
WPR/RC32/6 Add.l Annex 1 page 34
-
The global strategy will include: coordination through the global Advisory Committee on Medical Research, support to regional advisory committees on medical research and establishment and strengthening of relations with global institutions concerned with research in health and related areas. Of particular importance in a global strategy is the use of national expertise through WHO expert advisory panels. 6.6 Information support
-
To support the development and implementation of national policies and strategies, exchanges of information among countries will be promoted and supported, using the TCDC and similar cooperative efforts already mentioned under Sections 6.3 and 6.4. Of particular importance 1S 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 experience 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. Provision of information to the public will be a major component of support strategies. Public opinion will be mobilized 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 through the mass media and through personal contacts with health sector personnel.
-
CHAPTER 7:
GENERATION AND MOBILIZATION OF RESOURCES
-
7.1
Human resources development
This section To implement the strategy, two types of resources will have to be completely replaces mobilized: human resources, and financial and material resources. The section 6.1 of the strategy involves mobilizing all human resources, and not only health original version. personnel. Realizing that the best way to mobilize people is to involve them, 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 involvement of local communities in action for health.
WPR/RC32/6 Add.l Annex 1 page 35
The following are some of the measures that will be considered, order to promote community involvement: (1)
in
Delegation primary
of
responsibility, care 1n the
authority community in
and such
resources a way
to that
establish
health
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 members 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 people's representation in national or intermediate
level health councils/bodies involved in the decision-making process of the country's health system. (5) activities institutions Ministries of health will through of all health types, launch nationwide health educational the a1m mass of media and educational the whole
personnel, with the
enlightening
population with respect to prevailing health problems in their countries and communities and the most appropriate methods of preventing and
controlling them. (6) At the same time, full attention will be given to the
reorientation and retraining, where necessary, of existing health workers, inc luding measures to enable them to assume an active role in community health education. Consideration will also be given to the development of the involvement and reorientation, where
new categories of health worker,
necessary, of traditional medical practitioners and birth attendants, where applicable, and the use of voluntary health workers.
WPR/RC32/6 Add.l Annex 1 page 36
(7)
Voluntary
organizations/community
groups
will
be
given
full
encouragement to participate in health promoting activities, other health care in accordance with agreed courses
first aid and action and
of
distribution of responsibilities. 7.2 Financial and material resources
....
Though information on the resources required to implement programmes to attain the goal of hea1th/2000 is limited at present, Member States will soon be determining, with the development of activities in detail, the magnitude of the resources required. Particular attention will have to be given to the preferential allocation of resources to underserved popUlation groups and least developed countries. Various mechanisms of possibilities 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 mu1tisectora1 collaboration but also to take active steps to generate funds for health development and to ensure the effective use of external resources. The latter can be promoted through joint programming 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 same way, mechanisms to improve the coordination and effective use of funds available from other agencies will be considered, such as periodic meetings, at the regional level, of United Nations agencies and voluntary organizations (see Section 8.2.1). (5) The global strategy should include establishment of global mechanisms to ensure continuous monitoring of the availability and generation of funds and their distribution to priority problem areas throughout the world and priority programmes. The recently established Health Resources Group for Primary Health Care is one such mechanism.
...
WPR/RC32/6 Add.l Annex 1 page 37
CHAPTER B.
COLLABORATIVE MECHANISMS
B.l
Intrasectoral and intersectoral collaboration
B.l.1 Country reports stress the importance of collaboration and coordination between components of the health sector and sectors closely related to it, such as education, agriculture, 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 care 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 nongovernmental organizations, their participation in national decision-making, their complementary and supplementary roles, and the support they need from, as well as what they can give to, the health ministry. Countries are unanimous in their opl.nl.on that health/2000 cannot be achieved through the health sector alone. Intersectoral collaboration and coordination are expected to resolve policy and operational difficulties in many areas, including the development and maintenance of community water supplies, the control of environmental pollution, the promotion of nutrition and food production, the drug industry, education and housing, the construction of health facilities, drug and alcohol problems, and road traffic accidents. Country reports recognize the need for advice, coordination or collaboration in health development activities at different levels. of government, but especially at policy level. Some countries consider that new mechanisms should be developed, while others believe that existing 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 will be given different advisory boards, and that they will include representatives of other sectors as members. Intersectoral governmental committees are planned by some countries; for example, an interministerial body for primary health care, or an interministerial body for programme reviews. B.l.2 Regional action will consist in supporting countries in the establishment or strengthening of their national mechanisms, torough promotional efforts and through advisory services on the nature, composition, level, function and work process of such mechanisms. Information will be disseminated on the experience of countries with such mechanisms.
WPR/RC32/6 Add.l Annex I page 38
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 strategies and (b) to provide expertise in these matters, points 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 council would help the Regional Director to support the Regional Committee adequately on all issues involving multisectoral policy and action for health development. A regional health development advisory council could derive support from, and in turn support, existing multisectoral national health councils or those that may be established in the near future by Member States. 8.2 Intercountry collaboration
Support to the implementation of national strategies for health development could be provided by a variety of organizations and institutions at regional level. 8.2.1 Intergovernmental organizations, voluntary agencies, agencies within the United Nations system (a) Intergovernmental organizations such as the Association of South-East Asian Nations (ASEAN) and 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 Organization (SEAMED) could provide resources for undertaking research, particularly in the areas of biomedical and appropriate technology, and means for the exchange of information and training of health workers· (c) The Southeast Asian Medical Information Centre (SEAMIC) could cooeperate in the exchange of technical information, the support of technical studies and the promotion of activities for health development. (d) The South Pacific Bureau for Economic Cooperation (SPEC) and the South Pacific Commission (SPC) could provide promotional support to intersectoral coordination and technical support to health development activities in countries or areas of the South Pacific. (e) The development banks, such as the Asian Development Bank (ASDB) and the World Bank (IBRD) are sources of funds for development and could be means for integrating health with other development projects. (f) Bilateral agencies such as the United States Agency for International Development (USAID), the Australian Development Assistance Bureau (ADAB) and the Japanese International Cooperation Agency (JICA), could play important roles in terms of technical and financial contributions.
-
,.
WPR/RC32/6 Add.l Annex 1 page 39
(g) Nongovernmental and voluntary organizations at the regional level could be seen as mechanisms for promotional activities, technical support and exchange of information, including fund-raising from private sources as contributions to health development; as an initial step, a list of such organizations will be developed. (h) Agencies and organs of the United Nations system provide direct 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, UNIDO, ILO, FAO, ESCAP. (iJ The WHO Regional Committee for the Western Pacific, exercising its coordinating function in international health work, is expected to provide policy support, to play an important role in promotional activities, especially in bringing about important reforms in national health systems, and to monitor progress.
...
The mu1tisectoral advisory body mentioned under Section 8.1.2 would be a means of providing technical support to national health councils and health development centres/networks • The Regional Committee Sub-Committee on the General Programme of Work will provide technical support and J01nt technical monitoring of WHO collaboration in health systems 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 processes will be to draw the national bodies towards a common understanding, 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 mechanisms for closer cooperation with the agencies mentioned. 8.2.2 Technical cooperation among countries
Technical cooperation should always be an essential consideration in any programming activity of an international agency. Member States are also urged to take this into consideration in formulating their health plans and programmes. National and regional mechanisms will have to be strengthened or developed in such areas as information exchange, training, procurement and manufacture of equipment and supplies, intercountry exchange 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 Policies and Management; the
WPR/RC32/6 Add.1 Annex 1 page 40
-
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 supporting the health development efforts to developing countries is well recognized. This will be encouraged and facilitated by providing information on the health situation in developing countries and the magnitude and types of resources needed in a priority basis. 8.2.3 Economic cooperation among developing countries
This will stimulate and facilitate cooperation in the area of health. Moreover, certain activities in the health field, such as drug production and manufacture of equipment, will foster economic cooperation. In both these areas, health ministries have an important role to play~
--
CHAPTER 9;
MONITORING AND EVALUATION
9.1
Framework
Strategies formulated at national and regional level are expected to overcome constraints, to enable programmes to respond adequately to the need to solve the main health and health-related problems. Thus monitoring and evaluation will have to focus on the following; (1) Development activities. Close attention will be given to achievements in the areas of managerial processes for development, appropriate technology, health manpower developmment and health systems development, and their combined impact on community self-reliance and on programme delivery. (2) Programme delivery. The operational output of programmes will be monitored and evaluated through selected indicators. (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 specific 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 process
-
Monitoring and evaluation will be carried out at national, regional and global level.
~
.... 9.2.1 National level
WPR/RC32/6 Add.l Annex 1 page 41
The guiding documents will be the country reports on national policies and strategies for hea1th/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 levels, including the community level, by the health authorities themselves and national health councils and agencies specially assigned for the purpose. 9.2.2 Regional level
Monitoring and evaluation will be carried out collectively by Member States, through the WHO Secretariat, with emphasis on the involvement of part1.c1.pating 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 Comrnmittee, 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 1.n the field of health: sessions of the Regional Committee 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 intensive 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. 9.3 This is .... revised list 9.3.1 Indicators proposed Indicators to monitor im lementation of health/2000 strate national level) on their
The following indicators could be considered, depending appropriateness and the information available at national level: (a) Social and socioeconomic development indicators primary school enrolment secondary school entrance/completion GNP per capita calorie availability per capita population growth rate
WPR/RC32/6 Add.12 Annex I page 42
dependency ratio urban/rural population ratio adult literacy ratio (b) Health status indicators (overall community health status) life expectancy at birth infant mortality t~ddler
mortality
age specific mortality rates for 15-24, 25-44, 45-54 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 children) (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 diseases mortality due to chronic/degenerative diseases 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 DMF)
.~ ~
WPR/RC32/6 Add.l Annex I page 43
(d)
Health services improvement indicators lSimple specific and basic measures have to be develope~7 (i) Index of equitable distribution social justice in health of health resources
health services coverage and accessibility health services quality and appropriateness community satisfaction with health services
-( ii)
provision of essential drugs Measures of community participation and support measures of community action resource allocation for health
measures of the health habits (use of latrines and safe water, personal hygiene, child-rearing practices, fertility regulation and immunization) measures of community participation in the management of health services (iii) Measures of technology the development and use of appropriate
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 commmunity in the spirit of self-reliance (iv) Measures of intersectoral collaboration horizontal integration at various levels (including national level) in the planning and management of health and health-related programmes establishment of intersectoral coordination councils (v) Measures of development of managerial processes mechanisms for developing national health/2000 policies, strategies and plans of action and for facilitating central planning and intersectoral coordination measures of decentralization of programme planning and management to provincial, district and community levels index of health legislation and enforcement of the
WPR/RC32/6 Add.l Annex 1 page 44
(vi)
Measures of development of health manpower programmes establishment of mechanisms of training needs for continuous monitoring the status and career
measures introduced to improve prospects of health manpower
indices of adequacy and distribution of health manpower (vii)
.-
Resources 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 primary, secondary and tertiary health care priority of disadvantaged groups to
(viii)
Measures of improvement in the delivery of health care coverage with immunization deliveries attended by trained health personnel pregnant mothers covered with minimal antenatal care provision of nutrition supplements coverage with safe water supply coverage with sanitary latrines
have little
(e) Indicators of political commitment. These indicators are included under the different categories already enumerated. This is a revised list 9.3.2 Indicators for regional and global use Since meaning, average regional or global values of indicators the
monitoring and evaluation of
implementation of It the 1S
health/2000
strategy will rely on a short list of indicators. Member States on of the Region should provide of
imperative that reliable for
necessary
information
these
indicators.
A list
indicators
to be used
WPR/RC32/6 Add.l Annex 1 Page 45
regional asterisk
monitoring
and
evaluation
1S
g1ven used
below. for
Those
with
an and
(*)
are
the
indicators
to be
global monitoring
evaluation of health/2000 strategy implementation. This list of indicators will be periodically reviewed for the
relevance of each one and modified as necessary. 9.3.2.1 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 5% of the gross product is spent on health (3) A reasonable percentage of health expenditure is devoted health care (4) national national to local
*
* * * *
Resources are equitably distributed (5) Defined strategies for health for all are accompanied by explicit resource allocations (6)2 Defined strategies for health need external resources(6) for all
1The number in brackets shows the number given to the indicator in the global indicator list (Global Strate for Health for Al1 b the Year 2000, WHO, Geneva, 1981 ("Health for All Series No.3, pages 7 -7 • 2In the global list, indicator 6 is stated as "The number of developing countries ~ith well-defined strategies for health for all, accompanied by explicit resource allocations, whose needs for external resources are receiving sustained support from more affluent countries."
WPR!RC32!6 Add.l Annex 1 page 46
*
The needs for external resources of defined strategies for health for all are recel.vl.ng the sustained support of more aifluent countries (6) At least having w.ell community continuous programmes, 80% of local communities, established voluntary formal organizations committed to primary health care action exist at all levels
-
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 adult literacy ratio and women exceeds 70% ( 11) for both men
...
* * *
The gross national product per head exceeds US$500 at 1980 market prices (12) 1
The daily per capita calorie availability exceeds 2500 calories The daily per capita availability exceeds 70 grams (c) Health status and quality of life indicators protein
...
*
At least 90% of newborn infants have a birth weight of at least 2500 grams (8) At least 90% of children have a weight for age that corresponds to reference values given in Annex 1 to Development of Indicators for Monitoring Progress Towards Health for All by the year 2000 (8) The infant mortality rate for all identifiable sub-groups is below 50 per 1000 live births (9)
*
*
lIn the global list, indicator 12 is stated as "The gross national product per head exceeds US$500".
""
WPR/RC32/6 Add.1 Annex 1 page 47
*
Life expectancy years (10)
at
birth is
is
over 3
60
Maternal mortality thousand live births
below
per
No cases of diphtheria, tetanus, whooping cough, measles, poliomyelitis and tuberculosis occur Indicator of the delivery of health care Primary health care is the whole population with fo llowing: 1 available at least to the
*
The percentage of deliveries by trained health personnel is 95 (7) The percentage of children immunized against diphtheria, tetanus, whooping cough, measles, poliomyelitis and tuberculosis is 95% (7) Local health care, including availability of at least 20 essential drugs, within one hour's walk or travel is 100% (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 is reduced to less than 1%
*
*
*
*
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.
WPR/RC32/6 Add.1 Annex 1 page 48
CHAPTER 10:
ROLE OF WHO WITH RESPECT TO REGIONAL STRATEGY ISSUES
10.1
Issues for WHO
In accordance with the Constitution, the role of WHO includes coordination of the action which Member States undertake to attain the goal of hea1th/2000 and the provision of technical cooperation. The coordinating function is 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 outlined the proposed regional strategy for achieving the goal of health/2000. This chapter will describe how WHO intends to fulfill its role, given the functions described above. Several major issues will have to be faced by WHO in following the proposed regional strategy. Changes will be necessary both within the Organization and with respect to the relationship between WHO and Member States. The issues identified in previous chapters are the following: (1) To realize the goal of health/2000, Member States will adopt a broader approach to health development, which will bring together the community and all government sectors concerned.
(2) Member States and WHO are now aware that the health/2000 strategy must take into consideration demographic, economic, social and behavioural, and epidemiological factors affecting health. (3) To implement the new holistic approach to health development, changes may be required in the existing health systems, and above all in existing managerial processes. This of course applies to Member States and to WHO.
-
(4) The innovations required to carry out the strategy will need to be introduced on the basis of correct and relevant information. To deal with the above-mentioned issues and to modify its role accordinfly, WHO has been given full authority by the World Health Assembly and the Regional Committee 2 • Resolution A/RES/34/58 adopted by the United Nations General Assembly, also gives cognizance to the vital role that health and health care play in the development of countries,
lSee resolution WHA33.24. 2See resolution WPR/RC30.Rll, Handbook of Resolutions and Decisions of the WHO Regional Committe for the Western Pacific, Vol. II, 2nd ed., 1980, pages 1-2.
WPR/RC32/6 Add.l Annex I page 49
particularly developing countries, and calls upon relevant bodies of the United Nations system to coordinate with WHO in view of the Alma-Ata Declaration and the New International Development Strategy for the New International Economic Order. A framework for action for the strategy has already been presented in Chapter 3. The framework is built on the concept of a partnership between the community, the government and the private sector. The steps involved in this partnership have been described. For WHO, a similar framework will be followed. 10.2 Guiding princieles for WHO action
To develop the issues described in the previous paragraphs, certain principles can be listed, which will assist WHO in focusing its role in implementation of the regional strategy. (1) The health objectives expressed by Member States in the country statement synthesis will be used by WHO in establishing its own priorities when planning future technical programmes (see 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 satisfying th~ basic need for adequate food, water and shelter as a foundation for health, as well as on the development of community self-reliance. (4) Joint planning, monitoring and evaluation of national health strategies and programmes should be undertaken with health and healthrelated sectors at national level, including external bilateral and international agencies as required. (5) The use of technical cooperation among countries in developing and implementing national strategies should be promoted. This should play a major role in the context of regional support for the strategy. (6) In the spirit of the New International Economic Order, the resources of WHO, from both the regular budget and extrabudgetary resources, should be allocated according to the priorities established by the strategy. 10.3 Nature of WHO collaboration
The nature of WHO collaboration has already been considered in Chapters 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.
WPR/RC32/6 Add.l Annex 1 page 50
At the regional level, WHO will: (1) 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 1n
developing
national plans
health/200D of action,
(2) cooperate including:
when
so
requested
implementing
(a) the introduction of managerial processes for national health development; (b) initiation of the primary health care approach, including research and development activities 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 development centres/networks; for -
of national health development
(f) the design and deve lopment of mechanisms to coordinate and monitor the implementation of national health strategies through the establishment of adequate health management information systems in the ministries of health;
(g) the design councils;
and
development
of
national
health
advisory
...
(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;
WPR/RC32/6 Add. 1 Annex 1 page 5i
(4) identify and mobilize sources of extrabudgetary funds to support the implementation of national strategies. 10.4 WHO's programme for the future
In the light of the foregoing, WHO will need to develop its programme accordingly. For the first time, a planning perspective of 20 years has to be considered. Planning must be undertaken in the light of incomplete information and uncertainty with regard to future trends in the Region. At present, WHO plans its programmes in six-year periods known as General Programmes of Work. The current General Programme of Work ends in 1983, after which there will be three further General Programmes of Work up to the year 2000. For each WHO programme, there is a medium-term programme covering the six-year period of the General Programme of Work. The future programme structure and content, as far as the Region is concerned, will have to be reviewed in the light of the proposed regional strategy. WHO is already undertaking act1v1t1es 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 activities of WHO will therefore have to take into account the following; 10.4.1 Organizational, structure
~
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 health development;
(d) attract extrabudgetary development activities;
funds
for national
and
regional health
(e) establish a learning posture which will generate and accept new ideas, critically review its experiences and develop a capacity for problem solving; and (f) respond appropriately and quickly to government requests for cooperation, having regard to the priorities established through the General Programme of Work.
WPR/RC32/6 Add.l Annex 1 page 52
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 WHO activities and level. the and development strategies and for
support programmes at national
Supervisor and supporter of all WHO staff and staff assigned to his area of responsibility. Technical adviser on health matters with respect to other
-
international,
bilat~ral
and multilateral agencies,
including
efforts to attract extrabudgetary resources. (b) Health programme teams Multidisciplinary groups of WHO staff, assembled: (i) formally or informally
to support the WHO Programme Coordinator in the development and implementation of national policies and strategies for health/2000; and to coordinate WHO technical under various programmes. collaborative activities
(ii)
10.4.2
Management of the strategy
While the scope for initiat:ingmanagerial 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 will be to encourage and support
.#.
national health administrators in the formulation and/or integration of national health policies consistent with the goal of health/2000, through pr1mary health care. At the periphery, the approach will be to encourage and support the
health system in developing interactive processes with selected communities leading to primary health care and to establish a monitoring system for the management of health development.
~.
WPR/RC32/6 Add. 1 Annex 1 page 53
WHO will provide timely and relevant support to national health development centres/networks or similar mechanisms by coordinating and functionally integrating national managerial processes for health development with health services development and primary health care. Such support will be provided by multidisciplinary teams working in close coordination with a regional health development group established at the Regional Office. Teams will have the following expertise: (i)
community health development; policy and programme development; organizational development and planning; health systems development; health economics and behavioural sciences; health manpower development.
(i i)
( iii) (iv) (v)
(vi)
The teams will work with the WHO Programme Coordinators and the WHO For health services planning and management projects within countries. 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) (b) (c)
facilitators in initiating and supporting processes for health development;
national
managerial
points of coordination for international and national management resources; and collaborators in the development of appropriate managerial approaches and methods, techniques, programmes and structures for health development.
The functions of the teams will include: training consulting services research and development. 10.4.3 Programme content
The implications of the proposed regional strategy for WHO's programmes is that the following managerial activities should be supported at regional, national and intermediate and local levels:
WPR/RC32/6 Add.l Annex 1 page 54
(a) health policy and strategy formulation, planning and evaluation as a means of providing leadership from national to 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 information for its maintenance and development; (d) research and development as a means of monitoring health at the community 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 health systems with training, consulting and research support in the management of health development. For WHO, this does not detract from the 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. This portion up to letter" j" is an addition WHO's therefore specific towards technical the ten collaborative objectives programmes listed in will be directed
broad
section
4.3 and For the
organized and carried out through its General Programme of Work.
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: capabilities in the strengthening national and regional and implementation of national
....
formulation
food and nutrition policies and programmes; (b) Safe drinking water for all and sanitary disposal of human and animal waste: developing national capabilities 1n
the
formulation and management of plans to attain basic needs in safe drinking water and adequate sanitation for all, health care; through primary
WPR/RC36/6 Add.l Annex 1 page 55
(c)
Minimal
environmental
pollution
and
hazards:
developing
and
implementing national policies and programmes for the control of environmental hazards. (d) Communicable diseases no longer a major problem strengthening national capabilities 1n the planning and
management of the following programmes:
immunization, control
of priority vector-borne diseases such as filariasis, malaria, dengue haemorrhagic fever and plague; control of diarrhoeal
diseases; tuberculosis control; control of sexually transmitted diseases; investigating and resolving technical problems encountered in
malaria eradication programmes and in developing and managing optimal antimalaria programmes in countries where eradication is not at present applicable; strengthening operations for the control of parasitic diseases through appropriate technology; defining the scope and magnitude of acute respiratory
infections and demonstrating the effectiveness of interventions in significantly reducing mortality due to such infections in defined populations; initiating surveillance activities 1n zoonoses and infections/ intoxications of animal origin; initiating activities to implement regional programmes for the control/eradic"ation of infections, and yaws, viral other hepatitis emerging and nosocomial health
identifying
public
problems that are communicable in nature.
WPR/RC32/6 Add.l Annex I page 56
(e)
Chronic diseases reduced:
developing and implementing programmes
for the control of cardiovascular diseases and cancer as integral parts of the general health services; programmes; noncommunicable and initiating strengthening oral health against other gout,
activities
conditions,
especially
diabetes mellitus,
chronic non-specific respiratory diseases, diseases. (f) Psychosocial well-being and life style
and chronic rheumatic
conducive
to
health:
-
promoting policies and programmes on mental health, psychosocial factors involved 1n the promotion
including the of health and
human development, and on the prevention and control of alcohol, smoking, drug abuse, mental and neurological disorders. (g) No pockets of ill health developing action national for policies and strategies, 1n and preparing and urban
plans
environmental
health
rural
development and housing; in collaboration with Member States who needs of the aged have identified formulating the and
as
a
priority
problem,
-
implementing policies and programmes for the care of the aged as part of their overall social welfare and health programmes with emphasis on community-based services; developing national programmes on rehabilitation with emphasis on community-based services; identifying other disadvantaged groups and initiating/
strengthening health activities for them. (h) Fertility well-being: regulated to ensure better health and social
strengthening family planning as an integral part of
a maternal and child health programme (see
(j»).
WPR/RC32/6 Add.l Annex 1 page 57
(i)
Access to appropriate health care for all supporting health systems development through strengthening of capability in the analysis of the health situation and
assessment of trends, for national health
implementation of the managerial process development, including development of
health information systems, research; promoting policies and
and the conduct of health systems
programmes
for
the
organization
of
health systems based on primary health care to achieve total population programmes; promoting transfer and programmes of for the development, for application, and coverage for the delivery of essential health
appropriate and
technology for the
diagnosis,
treatment
rehabilitation
control of drug
and vaccine
quality, safety and efficacy. (j) The objectives for nutrition, communicable disease control,
-
psychosocial well-being, no pockets of ill-health. and access to appropriate health care: child health programme. with countries or areas will also be met through a maternal and In this connexion, WHO will collaborate in improving and strengthening their
family health services for women of child-bearing age and children at all levels of the health system within the context of primary health care in order to reduce maternal, perinatal, infant and
childhood mortality and morbidity, and psychosocial development of
and in improving the physical children and adolescents, and
reproductive health.
WPR/RC32/6 Add.1 Annex 1 page 58
As a support to all the programmes, WHO will collaborate with countries or areas in: promoting policies and programmes to meet the requirements of the health systems development, for health manpower and and management, human resources
production
using
appropriate
educational support; promoting and strengthening health education of the public and the provision of health information to the public with a view to enlisting active community involvement in health activities, promoting healthy lifestyles and achieving community
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self-reliance in health; promoting national capability 1n health research that is
relevant to the solution of the major health problems focused on the objective of health/2000.
CHAPTER 11:
TENTATIVE PLAN FOR IMPLEMENTATION OF REGIONAL STRATEGIES, INCLUDING A TIMETABLE
A
The major milestones and targets for the formulation, implementation, evaluation and updating of policies, strategies, and plans of action for health/2000 at national and regional level include the following: (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 Regional strategy for health/2000 reviewed by the Regional Committee Commitment obtained by the Regional Committee for Member States, with cooperation from WHO, to implement, monitor and evaluate the regional strategy April 1980 June 1980
(3) (4)
September 1980 September 1980
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WPR/RC32/6 Add.l Annex 1 page 59
( 5)
Extrabudgetary resources identified through joint planning; for example, joint programming with UNDP 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 information systems further strengthened to permit comprehensive monitoring, evaluation and updating of strategies
September 1980
( 6)
March 1981 and subsequently as required (see (9» September 1981 and thereafter every 2 years by December 1981 June 1982
(7)
-.
(a) is the) )
(8)
former 10-cj) ) of the (b) the ) original ) document former 8; )
"'1 c)
)
the
) )
by December 1985
former 12
) (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
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(10)
by December 1983
by December 1985 by December 1982 by December 1982
(11) (12)
The primary health care approach 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 Total coverage with primary health care in all countries, supported by health systems
(13) (14)
by December 1985 by December 1990
WPR/RC32/6 Add.l Annex 1 page 60
(15) changed from 1981
Regional mechanisms established for the following: (a) promotion and strengthening of technical cooperation among developing countries (b) coordination with multilateral, bilateral and regional groupings in resource mobilization and implementation of strategies by December 1982 by December 1982
changed from 1981
(c) coordination and collaboration within the United Nations system for developing a shared understanding and joint planning 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 managerial process for national health development formulated
by December 1982
changed from 1981
by December 1982
changed from 1981
(17)
1982 and subsequently as required
changed from 1980
(18)
1981
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WORLD
HEALTH ORGANIZATION
REGIONAL OFFICE FOR THE WESTERN PACIFIC BUREAU RitGIONAL DU PACIFIQUE OCCIDENTAL
•
ORGANISATION MONOIALE , DE LA SANTE
REGIONAL COMMITTEE Thirty-second session Seoul 22-28 September 1981
WPR/RC32/6 Add.1 Corr.1 13 August 1981 ORIGINAL; ENGLISH
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Provisional agenda item 12 REPORT OF THE SUB-COMMITTEE OF THE REGIONAL COMMITTEE ON THE GENERAL PROGRAMME OF WORK PART II Strategies for Health for All by the Year 2000 REVIEW AND UPDATING OF THE REGIONAL STRATEGY IN THE LIGHT OF THE GLOBAL STRATEGY Corrigendum Annex 1, page 7, 1.1 Introduction, paragraph three For the existing text substitute: Elements of the strategy should 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 society's behaviour.
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