ICP/SHS/OIO
25 Oct'OHr 1976
ORIGINAL:
ENGLISH
~flST REGIONAL WORKING GROUP ON BASIC HEALTH SERVICES
Convened by the
WORLD HEALTH ORGANIZATION REGIONAL OFFICE FOR THE WESTERN PACIFIC and the
INTERNATIONAL EPIDEMIOLOGICAL ASSOCIATION
Manila, Philippines 21-29 September 1976
FINAL REPORT
Not for sale Printed and distributed by the
Regional Office for the Western Pacific of the World Health Organization Manila. Philippines
CONTENTS
1.
INTRODUCTION OBJECTIVES
........................................ ............................................
1
2. 3.
2 2 2 3 3
ORGANIZATION AND ADMINISTRATION J .1
..................... .•.••••••••••••••••••••
3.2
Topics covered ................................ . Work plan .................. "................. .
3.3 4.
Working Group Officials
SUMMARY AND CONCLUSIONS 4.1 4.2 4.3
.............................
4
COQcepts of basic health services with particular reference to primary health care •••••••••••••• Community involvement in primary health care •• Various approaches in the planning, implementation and evaluation of basic health services ••••••• 4.3.1 4.3.2 4.3.3 Systems approach .••••.•••.•.••.••••••• Operations research ••••.•••••••••••••• Epidemiological approach ••••••••••••••
4 5 7 7 8 9 9
4.4
Present status and trends of basic health services in the Western Pacific Region •••••••• China ....... , ................... , •...• 4.4.1 Fij i ..•••.•••••••...•.••.•..•..•.•.... 4.4.2 Lao People's Democratic Republic •••••• 4.4.3 Malaysia .............................. . 4.4.4 Philippines .......................... . 4.4.5 Republic of Korea ..•••.....•••••.••••• 4.4.6 Solomon Islands ....................... . 4.4.7 Papua New Guinea ...................... . 4.4.8 Wes tern Samoa .............................. . 4.4.9 4.4.10 Conclusions ................................ .
10 11 11
12 12 13 13 13 14 14 15
5.
GUIDELINES FOR THE FUTURE DEVELOPMENT OF BASIC HEALTH SERVICES WITH EMPHASIS ON PRIMARY HEALTH CARE ••••••• 5.1 Role of family ..................................... .
5.2 5.3 5.4 5.5 5.6 5.7 5.8
Minimum services at community level •.••••••••• Types of personnel to be utilized ••••••••••••• Training, supervision and logistics support Organizational structure for primary health care Identification of underserved areas ••••••••••• Identification of local resources ••••••••••••• Evalua tion ........................................................ .
15 16 16 17 18 19 19 20
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•
CONTENTS
6.
ROLE OF WHO AND OTHER EXTERNAL AGENCIES IN THE DEVELOPMENT OF BASIC HEALTH SERVICES ••••••••••••••••••••• 6.1 6.2 6 .. 3 6.4 Role Role Role Role of of of of WHO ......................................... UNICEF • • • • • • • • • • • • • • • • • • • • • • • • .. .. .. .. • .. .. .. .. .. .. . .. UNDP .. .. .. .. .. .. .. .. .. .. .. • .. .. .. .. .. .. .. .. .. .. .. .. .. • .. .. .. .. .. .. .. .. .. .. .. .. .. USAID ........••.••.....•.......•....•...•..
40 20 21 21 21
6.5 6.6 6.7
Role of International Epidemiological Association Other international agencies ••••••••••••••••••••••• General recollllllendations on the role of external agencies ...............................................................................
22 22 22
ANNEXES
Annes
1-
List of Temporary Advisers. Observers and Secretariat ........................ , ......................... ".... ..
Annex 2- Lis t of Work Groups ............................................... .. Annex 3- Work Group Discussion (Topics 1 to 8) ....... . Annex 4- Agenda of Working Group .•.•.••••.••..•••••••• Annex 5- List of Working Group Officials ••••••••••••••• Annex 6- Background paper - Concepts and functions of primary health care ............................................ ..
23 29 31 35 41
43 47 55 61 69
Annex Annex Annex Annex Annex
Consumers of Health Care and Approaches to Strengthen Services in Response to Their Needs 8- Community Involvement in Primary Health Care 9- Operations Research Studies in Western Pacific: Some Experiences in WHO-Assisted Projects 10 - Approaches to Planning. Implementation and Evaluation of Basic Health Services Programmes 11 - The Use of Epidemiology in Basic Health Care 7-
75
1.
INTRODUCTION
In the Western Pacific Region, strengthening the organization and delivery of health care has been a major activity of WHO for over twenty-five years. From a modest beginning in the fifties major programmes aimed at increasing the effectiveness and efficiency of the basic health services have been developed in many countries and territories of the Region. However, examination of the health services of most developing couDtries has revealed that despite the efforts of governments and international organizations to provide relatively comprehensive health services staffed by qualified personnel, there bas been failure to cover up 80% of the population namely, those living in rural areas and urban sl.-. In a number of countries successful or potentially succeasful PI'OII'.....s bad been established. WHO and UNICEF decided to carry out a study of some of these which was commenced in December 1973. The flo&! report of the study "Alternative Approaches to Meeting lauc Health Services in Developing Countries" was presented to the twentieth seasion of tbe UNICEF/WHO Joint Committee on Health Policy in February 1975. In Hay 1975, the study was endorsed by the UNICEF Executive Board. Later in the same month the Twenty-Eighth World Health Assembly considered the study which had been placed before it as a background document to serve as the basis for a major worldwide action programme for primary health care. This programme was approved by the World Health Assembly. At the Regional Office level in 1974, in view of the need to reexamine the delivery of health care at the periphery, prOVision was made in the 1966 budget for a "regional workshop on basic health services". Discussions with the International Epidemiological Association in 1975 led to the co-sponsoring of the First Regional Working Group on Basic Health Services by WHO and lEA. The Working Group met at the WHO Regional Office in Manila from 21 to 29 September 1976. The meeting was officially opened and closed by the WHO Regional Director, Dr Francisco J. Dy.
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2.
OBJECTIVES
The Working Group met with the following objectives: (a) to exchange views and information on the concepts, trends and present status of basic health services in the Region with particular reference to primary health care; (b) to consider the application of the results of operational research studies on basic health services Which have been or are being carried out in the Region; (c) to prepare guidelines for the future development of basic health services with emphasis on primary health care; (d) to consider the role of international agencies in the promotion and development of basic health services.
3. 3.1 Topics covered
ORGANIZATION AND ADMINISTRATION
In order to meet the above objectives, the following topics were presented for discussion by the Working Group at the plenary sessions: Topic 1: Topic 2: Topic 3: Concepts of basic health services with particular reference to primary health care. QBackground paper) Present status and trends of basic health services in the WPR. (Presentation by temporary advisers) Consumers of health care and approaches to strengthening services in response to their needs. (Working Paper No.1) Community involvement in health care. (Working Paper No.2) Examples of specific operational studies on basic health services in developed and developing countries. (Working Paper No.3) Approaches to planning and implementation and evaluation of basic health services programmes. (Working Paper No.4) The use of epidemiology in basic health care. (Working Paper No.5) Role of tIlO and other external agencies in the development of basic health services.
Topic 4: Topic 5:
Topic 6:
Topic 7: Topic 8:
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Topic 9:
Recommendations and guidelines for the future development of basic health services with emphasis on primary health care.
Discussions on the above topics generally came under five main headings: 1. Concepts and trends of basic health services with particular reference to primary health care. (Topics 1 and 2) 2. Community involvement in primary health care. (Topics 3 and 4) 3. Various approaches in the planning, implementation and evaluation of basic health services. (Topics 5, 6 and 7) 4. Recommendations and guidelines for the future development of basic health services with empbasis in primary health care. (Topic 9) 5. 3.2 Role of WHO and other external agencies. (Topic 8)
Work plan
Of these areas, the first four were examined in detail at three working sessions for which the temporary advisers and observers were divided into three Work Groups. In order to facilitate discussion, each Work Group was assigned specific areas for discussion in a specific order of priority. so that between them all discussion areas could be equally covered. The list of participants is given in Annex 1. The grouping of temporary advisers and observers into three Work Groups is given in Annex 2. Work Group discussion a~eas
are given in Annexes 3, 4 and 5.
The Working Group time table is given in Annex 6. 3.3 Working Group Officials
Prior to the convening of the Working Group, Dr Raja A. Noordin was appointed as Working Group Director, to work out details of the meeting with WHO's planning committee under the chairmanship of Dr George M. Emery, Operational Officer for the Working Group.
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At the plenary session on the first day of the Working Group, the following were unanimously elected as Working Group officials: General Chairman General Vice-Chairman Chairman Group A Chairman Group B Chairman Group C Dr Juan K. Flavier Dr J.O. Tuvi Dr Florentino Solon Dr Sale Ieremia Dr Park Hyung Jong
Rapporteurs to cover each plenary and Work Group session were also assigned. A list is given in Annex 7. 4. SUMMARY AND CONCLUSIONS
4.1
Concepta of basic health services with particular reference to primary health care
The Working Group generally agreed with the concepts of primary health care as ambo died in the report of the WHO/UNICEF combined study of "Alternative Approaches to Meeting Basic Health Needs in Developing Countries" which bad formed a background document to serve as the basia for a major worldwide action programme for primary health care. approved by the World Health Assembly in 1975. It also generally agreed with the concepts as atated in Annex III of the Report of Headquarters/Regional Consultation on Primary Health Care. Geneva. 4-11 June 1975. Among the specific components of primary health care approach are: Primary health care consists of simple efficacious and effective measures which include preventive. promotive. curative and rehabilitative activities. Primary health care is carried out at the peripheral level of the health services. It ~plies
-
an intersectoral approach.
Community involvement is necessary for its effective functiOning. It is mutually supportive of community development. However, the appropriateness of the term "primary" health care was questioned by a section of the Working Group which felt that as such services would reach the basic grassroots level "basic" health care would be a more appropriate term to use. "Baa1c" health care would, with the amphasis on community participation and involvement, be broader in scope than many existing institutionalized health care systems. "Basic" health care is concerned with people and the environment, life
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styles and with health care technology and organization structures, encompassing other sectors which influence health, such as education, agriculture and community development. ''Basic'' health care could generally be defined as health care at the periphery given by the people, for the people through their active participation and organization. It was pointed out that in China, such services which cover the total population and reaching down to the basic grassroots level, are called "basic" health care services. On the other hand it was also noted that the existing "basic" health services infrastructure in many countries in the Western Pacific Region still have some way to go in terms of total population coverage, and the idea of providing simpler and even more basic services through the ones existing to cover the underserved areas wuld have to be taken into consideration. In such cases the appropriateness of the term "basic" health care was questioned. As for the operational level of primary health care, there is agreement that it operates at the grassroots level particularly in the UDderaened areas which need not be confined solely to rural areas. The involvement of family units, households, neighborhood, as well as the community, is a necessary factor. In fact, primary health care is taken as the first contact of health services reaching down to the masses at the lowest level. Stress is laid on the maximum reliance being placed on community resources in the provision of primary health care. However, it is recognized that there can also be a mix of resources utilization, both saenc), and community in the provision of primary health care. Whether the co-.un!ty bwman resources are paid or not would depend on the local situstion. Regarding the scope and intensity of primary health care activities a& compared to those of the institutionalized health services, it is difficu~t to make a distinction between the two services. Primary health care and general health services are seen as a continuum of services, with primary health care being an integral part of the national health services. However, it is recognized that as far as specific activities or services are concerned, those of primary health care would be more simple and ~ basic than those of the institutionalized health services. The interrelationship between the two types of activities is also recognized with the general or institutionalized health services haVing a supervisory and supportive role over primary health care activities. Referral also has to be made to the more sophisticated and specialized general health services from the primary health care level. 4.2 CommunitX involvement in primary health care
The active involvement and participation of the community at the grassroots level is seen as an important factor in the effective functioning of primary health care activities. The need for an orlanlaational structure within the ~unity to facilitate involvement and pa~ticipation even down to the family, household and neighborhood level was stressed. The community should be aware of its own needs.
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problAaa _d priorities, uaiDi quatltative d'tutes .. If Mcesaary theae needs Ibould be explaiuci to· the COIIIII1UIlity in order to eaab1e them to make intellllent dec1aiona OIl &CUritl. to meet thUe D1Mde. Here .... media plays _ uaportant 101e to INPpl......t eclucatiODal. activitiaa at the 1l'0UDd level. Another :laportant factor 18 the Geed for ROUtical co.1t!!n' to pr1Jllary health care. With the support of pol1tical J.....ra, 1avol~t of the C01IIIIlWl1ty 1& enhanced. Various conatra1nta are. re.~OID1&ed Mlch . . lacJL of cleu _d.oaal policies and priorities and other inadequaciaa in the _thode of approach to the COIaunity; cooatrainu in the propu ut:J..lJ.&adoa of _r:vicu both goverDlllellt and communi ty; • • iA the pural aUUCtuXe of MaltA servieea . . wll .. technical CGUtra14t8 inclucl1.aa 1Mdeq,uate healtb education.
ka.....
loot !!!l!c;ti,ou of ptr.o!!t!tl .,dc.1q at arUUoota .1&'1e1 baa resulted in DOIl-aeceptance of health serlk.. ." the COIIDUtlity in lI&I1y iDataacea. Another coustraint w:l.thiu the 1000erumentagency 18 rea1stallce by _ profe"1ousl groups to the iDIloVative approaches 1u pr:tmary health care. This 18 attributed to a lAP in cra i Bin, reaultiq in inadequate kDowledse or undexstand1D& of the coucepta. of the comeunity approach. ScmetUlea lea.l cooatry,nta can al80 lJait die type of actiVities that 18 to be carried out by priaary b&altb workers at the araul'Oota leYel. It 18 . . accepted. pri.Ac1p1e in CO'IAIImi t1 dl!ft1opmat that the involveaellt of the comaunity would belin with the community defining its own needs and priorities aud then working out action prolra.es or activities to tackle thoae needs. The Working Group recognized that in some instances, a C911P1lunity m1Sht not perceive their own health needs; on the other hand, their own perceived needs might be different from the real needs in terms of primary health care. It was agreed that at least a8 a startlD1 pOint, health worker8 should try to solve tbe community's immediate pe.J;ce1ved needs. Such an approach would esubU.sh relationah1p with the coaunity and at the same tiJlle serve as a spearhead for other projecu. the gtoup felt that health workex. abould know the c~a.ity particularly It. leader.hi., pattun, lta needaaDCl pr1orld.u, . . well . . local avaUable resourc. . aD .s to enable plarmins to be carried out in a rea11at1e !!I81mU. One. role of a health worker La to belp the ~ty def1De their own needs in a nHi.atle _81' in orelet' taU_C. a favourable cu.e. in. orier to facUitate the co ma,.-. ldelt1Hcattoa. ofpr1.or1.d.ea aD4 lta puticlpad.ou.
1fanr teclm1ques can be. aed in oreler to stJaulate the ~t,. towards the desiJ;e.d action. One _thad 18 tbe ccabi.Ded approach. in wtdclL the desirec1 actiVity is eoab1ned nth another activity which. aat1afiea tile perceived needs of the co.nm1ty. In such au approach, i t 18 Deceaaary for the. bealthagency to maintain a clo.e relationship with otbel' ag_du. SylCh education actiri.tfaa ce be carr1e4 oat. 1n.erder to .oUnte the c 1 i t1. One _thod ls the !!l!ct1'ft approach 1u wbich a eo .1 ty is aeleec.l to aerve. as cl.-oDat'nd.ou for a particular actlY1t7 to tbe other c mid... Self-.un!l by a particular ~ty _y alao at:laulate
=
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the community to take appropriate action to overcome a particular problem which has been discovered. The importance of epidemiological data as a basis for colIUDunity action was stressed, although it must be admitted that at times colIUDunity action has been motivated, not by a desire to solve a particular problem, but by some other basic need such as the desire for status. The role of the cOIIUDunity is seen as that of collective effort by the community Which maintains a close relationship with the health agency. The community provides the link between the government agency and individual families. One important role of the community is to identify its own needs and problems and work out priorities of problems to be tackled. In this respect, the community provides information to the agency concerned and the role of the health worker is to listen and facilitate identification of priorities as well as determination of programmes. There are certain specific areas in which the community's role is well defined in the context of primary health care. They include: dissemination of health information to the individual members of the community collection of data regarding vital events such as birth and death reporting of outbreaks of diseases improvement of environmental sanitation participation in iIIUDunization progFammes The community also participates in the selection of candidates as primary health workers and supports training by the health department. 4.3 4.3.1 Various approaches in the planning, implementation and evaluation of basic health services Systems approach
In the past, the empirical and normative approaches to planning basic health services have had limited success because they have not considered important related factors such as socio-economic conditions health resource limitations, prograIIUDe priorities, etc., which affect the type and amount of services to be rendered. The systems approach embraces the study of the total system and its component parts through available information. This approach involves problem identification, identification of related factors, problem definition, establishment of objectives to overcome the problem defined and design of alternative solutions. The systems approach has been used successfully in the preparation of national health plans. Based on the systems approach, three methods have been used to translate national health plans into specific action plans to
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be implemented at lower levels. These are the programming method which translates the national health plan into an intermediate level medium-term plan; the project planning method, which prepares alternative designs of the changes/innovations required in a health service at a project level and the operations research method, which determines the most efficacious, effective and efficient way of operating health services within the limitations of existing resources. The differences among the methods used 11e primarily in the scope of the study undertaken and the techniques used. Thus while national health planning and the programming methods are considered to be macro approaches to planning, operations research involves a micro approach to planning. The implementation of the systems approach involves the translation of objectives into specific activities and resource allocations. Evaluation is concerned with assessment of needs, plans and designs as well as of performance and effect. On a long-term basis, evaluation is concerned with an assessment of the impact of a programme or activity on the overall standard of health. There was general agreement by the Working Group that the systems approach embraces the other approaches being used in the planning, implementation and evaluation of basic health services. Systems analysis covers both macro and micro levels and is considered to be an effective approach for identifying and solving problems related to the basic health services. Since there are several methods which use this approach, it is important that the method selected is appropriate to the planning needs of the decision makers and will provide them with the answers they require.
4.3.2
Operations Research (OR)
The main objective of Operations Research is to develop ways of further improving the effectiveness in the utilization of existing health services. It is realized that many of the existing basic health services delivery systems are becoming overloaded due to increasing demands made on them by the populations served, thereby making them less effective and efficient in providing hea~th care. Thus OR studies have been used in the Western Pacific Region in solving problems of organization and delivery of health services to provide better coverage and quality of care within existing resources. These studies have led to innovations in delivery designs and have stimulated health services development in the countries concerned. Studies undertaken in Malaysia, the Philippines and Korea were described. The use of OR approaches in the development of basic health services in China was also described. Here a selective approach had been adopted to solve special problems. Experiences with different models had been tried. The model health village of Ta Chai in Shiyang county Shansi province was described. This village had undergone an agricultural and health revolution and had developed remarkably. The Changes in Ia Chai village can be grouped under five heads:
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improved housing new health care facilities new health habits new health situation (elimination of the major health problems) new mental outlook of the masses. The Working Group co~cluded that while the project planning method could be used in the developing countries in developing primary health care, Operation Research could assist in improving the effectiveness and efficiency of a primary health care system.
4.3.3
Epidemiological approach
This approach is being increasingly used in studying basic health care and in defining community health problems because health improvement requires a continuous input of epidemiological data. which may cover demographic. gprtality. morbidity, environmental and health service data, depending on the situation. While systematic data collection is a necessary basis for health improvement, the epidemiological approach advocates COIIIIIIunity involvement as being essential in data collection because such an involvement may lead to community action in solving the problem discovered. In discussing the epidemiological approach the Working Group agreed that the scope of epidemiology could be broadened in its application to basic health services development and could involve other diSciplines such as sociology and demography. To determine the usefulness of health services, epidemiological methods could measure the outcome of such services. The need to measure the impact of health services on the 5 "Ds" of Disease, Disability, Death, Dissatisfaction, Discomfort, was mentioned. An addi tional ''D'' was added, Dis tress. There was agreement that there was a need for an epidemiological approach by health administrators but it was noted that there was a gap between academic studies often carried out by universities and the absence of epidemiological viewpoints in the field services and health administration. There is a need to involve health managers in the epidemiological approach. There is a need to develop a health management information system which will help to narrow the gap in the delivery of information and thus will assist health decision makers in reViewing on-going programmes. This is in fact the second prong in the Operations Research methodology. 4.4 Present status and trends of basic health services in the Western Pacific Region
The countries considered by the meeting during discussions of this topic were: China, Fiji, Lao people's Democratic Republic, Malaysia. Philippines, Republic of Korea, Solomon Islands, Papua New Guinea and Western Samoa.
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4.4.1
China
China has already developed a health care system that covers the population down to the grassroots level. The peasants. workers and soldiers. are especially the target for basic health services. The emphasis on basic health care services especially in rural areas was greatly increased as a result of the cultural proletarian revolution. Thus there is now a health care system developed within a strong political and social organization and health is an integral part of overall socio-economic and political developm~t. The development of the Chinese basic health care system depends mainly on the provision of services through "barefoot doctors". Barefoot doctors are selected by the people. There are now 1 500 000 such doctors who provide preventive and curative services to communities. Training of barefoot doctors is adapted to the local situation. Generally barefoot doctors are trained in the commune hospital initially for 3 Jll)nths (2 months theory and one month practice). The next year. they have a refresher of 3 months (2 months theory and one month practice). After a few years practical work various forms of refresher measures are used. Some may be called to the commune or county hospital for a total of two years for concentrated study. Medical teams also go to the brigade level to coach them and may replace barefoot doctors who then go to commune hospitals to work in the hospital to raise their technical skills. Rarefoot doctors are taught traditional as well as modern medicine. and emphasis is given in training to the development of a positive attitude towards service to the people. Below the barefoot doctors at the commune level are also health aides and family planning workers. The barefoot doctors and other health workers at this level are not full-tiJne workers but carry out other work, usually working with the community they serve. The income they earn is based on work points. equated to the manpower earnings in the production brigade, and equivalent to the general income of the others. A feature of the Chinese primary health care system is its flexibility in operating in many different situations such as; urban, rural, agricultural, industrial, areas of high population density and scattered inaccessible communities. The health personnel in this system operate in communities where the people themselves are also mobilized to promote health. Households are encouraged to e1iJninate the four pests: rats. bedbugs. flies and mosquitoes. A good example of the collective action of the people to solve health problems is the control of schistosomiasis where all commune members are mobilized in activities to eliJninate the snail responsible for tranamitting the disease.
II
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Priority in the early years was given to the control of major communicable diseases such as smallpox, cholera, plague, kala azar and venereal diseases. Vaccination is provided free of charge. Schistosomiasis in many areas is now eliminated. There are still common colds, arthritis and enteric diseases but compared to the past these are greatly reduc~u. In summary, there is no doubt that the Chinese health services system fulfils the health needs of the majority of the people in a highly flexible and responsive manner. 4.4.2 Fiji
Fiji has a comprehensive decentralized health care system modelled on conventional lines. Services are provided for preventive and curative medicine. Administratively the Fiji medical service is divided into Divisions, Sub-divisions and Areas. The Area is the basic medical unit under the care of Area Medical Officers. Areas are divided into District Zones under the care of District Nurses. District Nurses provide maternal and child health care, family planning, treatment of minor ailment and domiciliary nursing. Medical Assistants are now being trained to provide clinical and public health service in the remote and scattered areas in the country. Coverage is as complete as possible given the difficulties of travel and communication due to the geography of the country. In addition to medical care, maternal and child health and family planning services, environmental sanitation is also given emphasis, including the provision of a safe water supply in the rural areas. 4.4.3 Lao People's Democratic Republic
Health services in the rural areas are generally poor and personnel resources generally inadequate. Problems are compounded by the aftermath of war. The population is scattered. Mortality rate is 23 per thousand and infant mortality 60 per thousand. With the recent change in government, a major change in the health system is under way. The proposed primary health care system will be community-based, with strong emphasiS being given to community participation, as well as a mix of traditional and modern medicine. A health animator is being appOinted for 5-10 households. This person performs enVironmental sanitation and simple health duties. There are village nurses whose task is to distribute medicine and give immunizations. Assistant medical officers have been trained. The training is four years. Health animators' training is short to meet demands and diff~r~ according to tasks require - one to two weeks and then refresher tra~n~ng. Nurses are trained 3 months to one year depending on circumstances. Each district has a hospital with 25-30 beds and 2-3 assistant medical officers plus nurses.
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4.4.4
Malaysia
The population is 70% rural. Since independence in 1957 a three-tier system of rural health units has been developed, consisting of midwife clinics (MCQ) for 2000 people, sub-health centres for 10 000 people and main health centres for 50 000 people. These are staffed by supervisory personnel and auxiliary personnel of whom 75% are nursing personnel, with a doctor and dental officer and other supervisory personnel at the main health centre level. Basic services are offered including medical care, maternal and child health care, environmental sanitation, communicable disease control and health education of the public. Although there has been a tremendous development of rural health infrastructure since 1950, generally population coverage on paper is less than 50%. New developments and trends including the integration of family planning with the rural health services have increased workload and reduced effectiveness and efficiency. Based on an operations research carried out in 1969-1971, the rural health infrastructure has now been reorganized from the three-tier system to a two-tier system, in which the midwife clinic is being upgraded to a multipurpose rural clinic for 3000-4000 people (each staffed by two midwives retrained as multipurpose community nurses) and the sub-health centre upgraded to main health centre to cover 15 000-20 000 people. This conversion is expected to take at least 15 years. A stop-gap measure in the form of primary health care is indicated in the meantime. The rural community development infrastructure and government's commitment to the integrated approach in tackling community problems are expected to facilitate the development of primary health care in the underserved areas. 4.4.5 Philippines
Major health problems such as communicable diseases, malnutrition, malaria, and schistosomiasis still exist. Other problems include rising costs of health care and maldistribution of health facilities. A government health administration of orthodox structure provides health services through rural health units and provincial and regional hospitals. The need for expanded coverage of basic health services is recognized by the government and energetic and innovative programmes are being developed. The system of rural health units and barangay centres is being restructured. The barangay clinic is staffed by a retrained midwife with multipurpose activities. A programme to develop a community health worker called a barangay health technician is in progress. Another type of worker called a communicator is being considered. To improve the environment of the low-income populations, the national housing authority is taking steps to provide low-cost housing and to control land speculation.
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4.4.6
Republic of Korea
The Government now attaches high priority to providing health and social services to all the people. At present delivery of health services is not equitable although the structure of a comprehensive service has been established. At present, basic health services are provided through a system of health centres at country level and sub-centres. These subcentres are staffed by a physician and three health workers. It is recognized that these services are not yet comprehensive in terms of coverage and experimental programmes are in progress to determine the appropriate system of primary health services. During the period of the fourth five-year development plan, the health services system will be developed and implementation on a national scale will follow. Of particular interest in the Korean setting are experimental programmes looking at community involvement in health activities and methods of funding primary health care systems. 4.4.7 Solomon Islands
The health services are organized and administered by the Ministry of Health. The country is divided into four administrative districts and decentralization of services is government policy. At the local level, there is full integration of services. Rural health units are run jointly by central and local authorities. There are some services provided by independent agencies. Half of peripheral clinic staff are touring outlying areas while the other half are permanently located at the clinics. These clinics are set up in villages serving 1000 to 3000 people as a rule but smaller coverage could be necessary in isolated places. Efforts are being made to strengthen the existing services by: (a) (b)
involving the family - providing first-aid boxes to families for self-care; developing health aides to work in the villages on a part-time basis. These staff to be funded by the local councils; adding health centre function to some rural hospitals.
(c) 4.4.8
Papua New Guinea
The basic health services have the following structure. At the village level there is a village aide post. This is organized and supported by local efforts. The orderlies staffing the aide posts perform simple health tasks and give environmental sanitation and health education services. It is planned to expand further the functions of the village aide posts.
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The next level is the health centre staffed by a medical officer, nurses and orderlies. Many health centres are supported by the community. Mobile teams from the health centre supervise the work at the village aide posts. At provincial level there is a provincial hospital and the hospital staff visit and supervise the health centres. The same pattern of services exists in urban areas. Special features of the services in this country appears to be the expanding role of the orderly at a village level and the integration of the basic health services with the hospital services with supervision coming from the hospitals. 4.4.9 Western Samoa
A conventional basic health service structure exists and this network covers the ~ole country. There are district hospitals, health ~rps (with beds) and subcentres. In the districts the health team consists of a medical officer, staff nurses, nurse aides, laboratory technician and a dental officer. The district nurse and health inspector provide the basic health services at village level. A programme of training traditional birth attendants has been started. Linked to this system of basic health services is the Women's Committee organized at the village level. This is of major importance in ensuring a primary health care component of the health services. The Women's Committee is socially and culturally accepted and has authority. These committees work closely with the health team and provide a dynamic link between the health personnel and the community. Through this highly effective system of basic health services working through the women's committees, Western Samoa has achieved virtually complete coverage of the country with primary health care services. 4.4.10 Conclusion
It would appear that the trend towards the development of primary health care is already being noted in the Western Pacific Region. China has already developed a health care system which covers the total population down to the grassroots level with a framework of a social and political organization in which basic health care is an integral part of overall socio-economic and political development. Three elements are identified as conducive to the primary health care approach. These are: the specified roles of each family and community in the development of health standards, a basic health care system which is accessible and available at all times, and a social and political organization in which health has a specific and recognized role to play. Parallel with China, Western Samoa appears to have covered the total population with its health services infrastructure, with women's committees playing a dominant role in getting community involvement and participation. The Republic of Korea,
- 15 -
Malaysia and the Philippines have a strong potential for communi tv involvement in the provision of primary health care because ct go~ernmental commitment and policy regarding community development and the presence of an infrastructure for community development and for intersectoral coordination. With its experimental programmes, the Republic of Korea appears to be well on the way to the development of a viable primary health care system. Solomon Islands, Papua New Guinea and Fiji, with relatively small populations, nevertheless have a good potential for the development of primary health care, because of past and present experiences in getting community involvement and participation in health matters. Finally. the health infrastructure in the Lao People's Democratic Republic is being reorganized in line with a national policy for socio-economic and political development, in which emphasis is given to the involvement of the community at the grassroots level. It can be perceived that primary health care services have developed or are being developed in the Western Pacific Region following two main patterns: (i) (ii) where primary health care is seen as an extension of existing general health services; where the starting point of primary health care is evolved from a national policy made within the country1s overall political framework of organization. GUIDELINES FOR THE FUTURE DEVELOPMENT OF BASIC HEALTH SERVICES WITH EMPHASIS ON PRIMARY HEALTH CARE
5.
The following guidelines are laid down, taking into consideration two possible patterns of development of primary health care in the Westl:!rn Pacific Region. In one pattern, the starting point of primary health care may evolve from a national policy made within the country's overall political framework of organization. An example is Laos. In the second pattern, primary health care is seen as an extension of the existing general health services to cover geographical areas or pockets of population previously underserved by the existing services.
5.1
Role of the family
A pre-requisite for effective primary health care is for each family to have a sense of responsibility and to understand and accept that the first step to good health must come by their own efforts. This should be emphasized in any campaign to involve the community in the promotion of health standards. The family should be aware of their own health problems and of resources which are available to help solve their problems.
- 16 -
The minimum role of the family at the community level is to practise: personal cleanliness home and compound cleanliness food sanitation and storage control of disease vectors control measures for common infectious diseases family planning utilization of health facilities 5.2 Minimum services at community level The minimum services at community level should cover: first-aid and treatment of minor ailments care of normal pregnancy child care good nutrition through home gardening or similar local level activity to increase production of protective foods immunization provision of wholesome drinking water waste disposal health education through local activities and the mass media referral services In all the above services the element of community self-help should be emphasized. 5.3 Types of personnel to be utilized
The type(s) of personnel to be utilized in primary health care would depend on each local situation. Primary health care personnel could be male or female. full-time or part-time, government employed or community provided, residing in the community or visiting from outside. They can be single-purpose or multipurpose in function.
I
,
I
- 17 -
The following types of personnel are listed: 5.3.1 Government health workers (unipurpose or multipurpose) medical and health auxiliaries paramedical personnel 5.3.2 Other government agency workers agricultural extensiOn workers community development workers home economis ts teachers 5.3.3 Community resources (individual) traditional birth attendants traditional healers 5.3.4 Community resources (supportive role) women's groups youth clubs farmers' organizations par ty cadres political workers labour unions, etc. 5.4 Training, supervision and logistics support
There should be a clear understanding of the respective roles of the government and community in the provision of primary health care so that the responsibilities of both will complement one another. 5.4.1 Training
Training should be done at the most peripheral level, and as near the place of work as possible. Training should be brief and repeated refresher courses given. Proper operational manuals and educational materials that are clear and limited to priority activities should b~ used in training. Cross-training of primary health care workers in modern, scientific as well as traditional medicine should be given. Only those traditional practices found to be harmful could be discarded. Incentives for training may be provided.
- 18 -
5.4.2
Supervision
Technical supervision will come from health services but should be conducted by personnel with proper orientation to primary health care. There should be community supervision through the community organization involved in the primary health care services. 5.4.3 Logistics support
Drugs and supplies will come from the government. Simple and traditional medicines and certain supplies may be provided by the community. 5.4.4 Referral
A referral system will need to be worked out from the periphery to the centre and vice-versa. The above activities imply that the existing health services may have to be strengthened if necessary. in order to respond to the community demands for primary health care. The health infrastructure may need to be reorganized if necessary so as to strengthen the referral system from the periphery to the centre. The health administration may also need to be strengthened in order to intensify and maintain supervision of primary health care activities. Training of health workers. especially health extension workers in the community approach is desirable. In fact, it is even desirable to extend the training in the community approach to all types of extension workers including teachers, agricultural extension workers, etc. 5.5 Organizational structure for primary health services
The following organizational structure is suggested at various levels in order to facilitate the provision of primary health care at the grassroots level. 5.5.1 National level
There shOUld be inter-ministerial coordination and participation by the private sector. Consumers, professionals. training institutes and elected people's representatives should be represented. 5.5.2 Intermediate level
There should be a committee with coordinating. supportive and planning functions. Especially this committee should support primary health services at the development stage.
- 19 -
5.3.3
Local level A committee selected by the people is a key feature of the services.
The committee should be truly representative of the people's needs aRd
political will, within the overall structure of the country's socio-economic and political system. 5.6 Identification of underserved areas
Geographic areas which are under served by the existing health services will need to be identified and preferably mapped out. This can be done by: (a) using geographical, sociological and epidemiological approach in making a community diagnosis. Systematically gathered data as well as information on perceived needs will be required. The constraints in the management and operation of existing health services should be identified. Feedback of information by the communities themselves on need for health services should be obtained.
(b)
After the underserved areas have been identified further steps can be taken to identify the community's problems and needs as well as local resources which may be utilized in planning the type of primary health care to be provided. In this exercise there should be full intersectoral collaboration. Identification of overserved areas is also desirable, in order to facilitate relocation of resources, if necessary, in the provision of primary health care to the underserved areas. 5.7 Identification of local resources Local resources to be identified will include: 5.7.1 Human resources
Human resources, both governmental and community include individuals and groups. Examples are: traditional local resources such as traditional birth attendants and healers religious leaders, political leaders, traditional leaders, etc. community groups such as women's groups, youth groups, farmers' associations, etc. labour force for special projects
- 20 -
5.7.2
Material resources Material resources both government and community, such as: location of community halls, midwife clinics, schools or other buildings, as possible health posts sites for health posts availability of simple and traditional drugs and supplies availability of transportation and other communication resources
5.7.3
Financial resources
Possibility of fund-raising for local services through revolving fund or health insurance .scheme can be looked into. 5.8 Evaluation Evaluation should be both short- and long-term. Simple social and health indicators need to be developed to allow the community to monitor the service, using population-based approaches
including simple sample surveys. Performance, effect and impact should be evaluated. Performance evaluation includes: monitoring of supplies and equipment, performance of primary health care workers, and assessment of the attitudes and activities of the planners, workers and consumers of the primary health care services. Effect evaluation measures the health situation in the community, e.g. the disease pattern, assessment of living standards and changes in health activities and practices. Long-term evaluation of the impact of primary health care will include the use indicators of socio-economic improvement. A simple information system that will provide initial baseline data and permit continuous evaluation will be needed.
- 21 -
6.
ROLE OF WHO AND OTHER EXTERNAL AGENCIES: DEVELOPMENT OF BASIC HEALTH SE~VICES .~
tN·
THE
"
6.1
Role of WHO
WHO is involved in health service devleopment at international. regional and country levels. For primary health care development. WHO activities and assistance can be at the following stages at the country level: (a) (b) Overall design. WHO can collaborate in promotional activities to gain acceptance of the primary health care approach. Situational analysis. An example of WHO collaboration in country health programming as had been done in Laos, Fiji and Western Samoa. Problem identification Alternative design Political decision on alternatives. for WHO. Here there is. no role
(c) (d) (e) (f)
Design development. implementation and monitoring.
In considering the role of WHO, the Working Group recommended that: WHO should try and gain agreement on a common terminology 'in health services development. WHO should lead the way towards a broader approach to health services development and away from a conventional medical service structure. WHO should encourage countries to integrate health planning activities with social and economic development planning. 6.2 Role of UNICEF
UNICEF now gives top priority for primary health care services because the target population for UNICEF is women and children below the poverty line. UNICEF strongly supports an integrated approach to social development. Depending on the level of development of the country, UNICEF assistance will be directed towards: development of national capacity for primary health care service development and where necessary direct assistance for primary health service development.
- 22 -
6.3
lWle of UNDP
UNDP supports the concepts of basic health care. The nature and scope of UNDP assistance to a country depends on the priority given by the govel'lllllent concerned to primary health care at the time the country progr.... is drawn up. United Nations volunteers could be requested by countries to participate in health projects. 6.4 lWle of USAID
USAlD is moving from vertical health progr..... bGWard more _pbaBis CD assistance to primary .health care services. USAID bas the policy tbat countriea should develop their own solutiona to problems of health service development. USAID encouraaea health planners and econOll1c planners to work closely together.
6.S
Role of International Epidemiololical Aasociation (IIA)
lEA aims at promoting epidemiological concepts and can provide expertise needed for colllllunity d1qnosis. identification of health prohl... and for developing appropriate health intervention techniques in the delivery of prilllary health care. 6.6 Other international as~
Apart from the above agencies which were represented at the Working Group. the Working Group identified other international agencies which can play a role directly or indirectly in promoting primary health care. Of these IBRD. UNUA. FAO and lLO are concerned with specific aspects of health service delivery, whereas SlDA, CIDA and DANIDA are involved with bilateral assistance. 6.7 General recommendations on the role of external asencies The
Working Group recommended that: external agencies should coordinate their efforts through the government concerned; external agencies should support the multi-sectoral approach to baalth services development at all levels in a couQtry; external agencies should assist countries to develop basic health services suitable for the needs of the country aDd not based on a traditional or foreign pattern.
-
- 23 -
ANNEx
1
LIST OF TEMPORARY ADVISERS. OBSERVERS AND SECREl'ARIAT LISTE PROVISOIRE DES CONSEILIERS TEMPORAIRES. OBSERVATElJRS ET SECRETARIAT
1.
1. TEMPORARY ADVISERS CONSEILIERS'l'EMPORAIRES
CHINA CHINE
. Dr Chen Hai- ferlg Director Department of Education ann Ministry of Health
:~eI('nt.1flc
ftesearch
Peking Dr Huang YU-hsiang
Jiang-zhen Commune Hospi 1.nl Chuang8ha County Dr Chin HlSiang-lruan Rarefoot Doctor
(jJ
Lo-yuan People's Commune Chang Yang County Hupei Province Mr Li Ching Hsiu Bureau of Foreign Relations Mini8try of Health Peking Mr Tsao Yung-lin
Bureau of Foreign he~ ations Ministry of Healul Peking
- 24 -
Annex
1
FIJI FIDJI
Mr Peter Peter Divisional Health Inspector Levuka. Ovalau Dr K~o Phlmpnachanh Ministire de la Sante publlque Vientiane Dr Raja Ahmad Noordin (Working Group Dirt!clor) Director of Health Services Ministry of Health Kuala Lumpur Mias Norma Baba Health Matron Directorate of Medical and Health Services Neleri Sembllan
LAO r I:;OPLE ' S DeMOCRATIC REPUBLIC REPUBLIQUE DEMOCRATIQUE POPULAIRE LAO :I,\LAYSIA Mt\LAISIE
PHILIPPINES
Dr Juan M. Flavier Vice President International Institute of Rural Reconstruction 512 R. Salas Street Ermita. Manila Dr Florentino Solon Executive Director Nutrition Center of the Philippines Makat!
REPUJrLrr. OF KOREA REPUBLlQUE DE COREE
Dr Park Hyung Jong President Korean Health Development Institute 2-10, I-Ga, Do-dong. Yongsan-ku Seoul Mrs Jin Soon Kim NurRing Officer Ministry of Health and Social Affairs Seoul 110
SOWt'10N ISLANDS lLE:- S '\LOMON
Dr Peter Beck Permanent Secretary Ministry of Health and Welfare Honiara
- 25 -
~.:...-
Armf'x
I
PAPUA NEW GUINEA PAPOUASIE-NOUVELLE-GUINEE
Dr J.O. Tuvi First Assistant Secretary for Health (Health Care) Department of Health Konedobu Dr Sale Ieremia Chief Public Health Division Health Department Apia
WES TERN SAMOA SAMOA-OCCIDENTAL
2. IIN1TED NAl'lONS CHILDREN'S FUND (UNICEF) FONDS DES NATIONS UNIES POUR L' ENFANCE (FISE)
OBSERVERS/OBSERVATEURS Hr Roberto Esguerra-Barry Regional Director UNICEF East Asia and Pakistan Regional Office P.O. Box 2-154 Bangkok, Thailand Dr Wah Wong UNICEF Representative P.O. Box 883 Manila Mr Michael M. Park Programme Officer UNICEF Korea Office 17-1 Changsung-dong Chongno-ku c.p.a. Box 1930 ~
UNITED STATES AGENCY FOR [NTE&~ATIONAL lJEVELOPMENT
--
Dr James R. Brady Chief Office of Health and Population United States Agency for International Development Seoul
- 26 -
Annex 1
UNITED NATIONS DEVELOPMENT PROORAMME
PROGRAftt4E DES NATIONS UNIES POUR IE DEVELOPPMENT
r-tr John Melford Deputy Hesiaent Representative of the United Nations Development Programme in the Philippines
P .0. Box 1864 MlDila
UNIVERSITY OF THE PHILIPPINES (UP) UN~ITE IS3 PHILIPPINES
Dr Alberto Romualdez Institute of Health Sciences Tacloban
,. SECRETARIAT INTERNATIONAL EPIDEMIOUXl ICAL ASSOCIATION (1AE) CONSULTAHl'S CONSULTANTS DE L'ASSOC1ATION INTERNATIONALE D'EPIDEMIOLOGIE Dr Kerr White (Chairman, IEA) Professor of Health Care Organ1zat10n School of Hygiene end Public Health Johns Hopkins University 615 North Wolfe Street Baltimore, Maryland 21205 USA Dr Basil Hetzel Chief CSIRO Division of Human Nutrition Kintore Avenue Adelaide South Australia 5000 Dr R. Sharma
Professor and Head Department of Prevent.ive and Social Medicine S.M.S. Medical College Jaipur 4, India Dr Paulo Campos President. Medical Center Manila
- 27/28 -
Armex 1
WHO STAFF/RESOORCE PERSONS PERSONNEL DE L'OJlf)
Dr George M. Emery (Operational Officer) Regional Adviser on Strengthening of Health Services WHO Western Pacific Regional Office Manila Dr B. Akerren Medical Officer. General Health Services Development Project in the Philippines WHO Regional Office for the Western Pacific Manila Miss N. Gelina Nurse. General Health Services Development Project in the Philippines WHO Regional Office for the Western Pacific Manila Mr H.K. Chang Sanitarian. General Health Services Development Project in the Philippines WHO Regional Office for the Western Pacific Manila
Dr R. Herniman Medical Officer. General Health Services Development Project in the Republic of Korea Seoul R. Pottier Sociologist. Development of Health Services Project in Lao People's Democratic Republic Vientiane Mr
- 29 -
ANNEX 2
LIST OF WORK GROUPS Temporary advisers and observers were d1v1ded 1nto three working groups for the purpose of discussion as follows: GRCUP A Temporary Advisers 1.
2.
3. 4.
5.
Dr Chin Hs1ang-lruan Dr Chen Ha1-feng Mr Peter Peter Dr Keo Ph1mphachanh Dr Florentino Solon
Observers 1. 2.
Roberto Esguerra-Barry Dr James R. Brady Mr
GRCUP B Temporary Advisers 1.
2. 3. 4.
Mr Li Ching Hsiu Dr Huang Yu-hsiang Miss Norma Baba Dr Sale Ieremia
Observers 1. 2. Dr Wah Wong Dr Alberto Romualdez
- 30 -
Annex 2 GROOP C Temporary Advisers 1.
2. 3. 4. 5.
Dr Park Hyung Jong Dr Juan M. Flavier Mrs Jin Soon Kim Dr Peter Beck Dr J .0. TUvi
Observers 1. 2.
Mr Michael M. 'Park Mr John Melford
lEA Consultants and members of the secretariat rotated as follows: Dr B. Hetzel Dr B. Akerren TUesday, 21 September - Group A Thursday, 23 September - Group B Fr1day, 24 September) and ) - Group C Monday, 27 September) TUesday, 21 September - Group B Thursday, 23 September - Group C Friday, 24 September) and ) - Group A Monday, 27 September) Tuesday, 21 September Thursday, 23 September Friday, 24 September) and ) Monday, 27 September) Group C - Group A - Group B
Dr R. Sharma
Miss N. Gel1na Dr R. Herrl1man
Dr P. Campos
MY' H.K. Chang
Mr R. Pottier
- 31 -
ANNEX 3
WORK GROUP DISCUSSION
Topic 1 - Concepts of basic health services with particular reference to primary health care ~:
Each work group discussed the following areas in the following order: Group A Group B Group C
1, 2, 3 and 4 1, 2, 4 and 3
4, 3,
1 and
2
DiscuSSion areas
1. 2.
How is primary health care defined. To what extent are the scope and intensity of primary health care activities different from those of the general health services? Discuss possible interrelationship between the two. What factors will facilitate community involvement and participation in the provision of primary health care? What are the main constraints to the development of primary health care in the Western Pacific Region and how can they be overcome?
3.
4.
Topic 3 - Consumers of health care and approaches to strengthening services ~esponse to their needs Topic 4 - Community involvement in primary health care Note: Each work group will discussed the following areas in the following order: Group A Group B Group C
1, 2, 3 and 4 4, 2. 3 and 1 2. 3. 1 and 4
- 32 -
Annex 3 Discussion areas 1. Based on a community development principle. the community should be actively involved in the provision of primary health care in line with their felt needs. If such needs are not perceived by the community or if the community's felt needs are not the real needs. what implications are foreseen and how can they be minimized or overcome? What is the possible role of the community in the provision of primary health care under different community or country situations in the Western Pacific Region? What local resources (agency and community. human and material) may be utilized in the provision of primary health care at the peripheral level. Is it perceived that the general health services should be strengthened in order to respond to the needs of the community for primary health care? If so, what areas.
2.
3.
4.
Topic 8 - Recommendations and guidelines for the future development of basic health services with emphasis on primary health care (Based on Topic 5 - Operational studies. Topic 6 - Systems Analysis and Topic 7 - Role of epidemiology. as well as on previous working group discussions). Note: (1) For the purpose of discussion by the Work Groups, patterns of primary health care within the Western Pacific Region are classified under 2 categories: Category 1 - Where primary health care is seen as an extension of the existing general health services to cover geographical areas or pockets of population previously underserved by the general health services. Category 2 - Where the starting point of primary health care may evolve from a national policy made within the country's overall political framework of organization and not necessarily basing on Category 1.
- 33/34 -
Annex 3
(2)
Groups B and C discussed the set up in Category 1 while Group A based its discussion on the set up of Category 2. The order of priority of discussion areas to be covered by each group was as follows: Group B (Category 1) 6. 7. 8. 5, 1. 2. 3 and 4 Group A (Category 2) 1. 2, 3, 4, 5, 6, 7 and 8 Group C CCategory 1) 1, 2, 3, 4, 5, 6, 7 and 8
Discussion areas 1. What is the minillJ.1m role expected of each family at the peripheral level in promoting their own health standards through their own efforts and in the utilization of existing health services. What minimum services are envisaged for primary health care at the peripheral level. What type(s) of personnel can be utilized in the provision of primary health care at the local level. How can training. supervision and logistics support be provided to primary health care activities. What are the implications in terms of strengthening the existing institutionalized health services. Suggest an organizational structure that may be necessary at national, intermediate and local levels for facilitating inter-sectoral coordination as well as for facilitating community involvement and participation. How can the underserved areas be identified in order to determine the extent of the problem. What information would be required for this exercise. What local resources (agency and community. human and material) will need to be identified in order to plan the scope and nature of primary health care activities to be provided. If such resources are inadequate or non-existent how can they be developed (involving policy decisions if necessary) taking into consideration the need for community involvement and for an intersectoral approach as well as the need to maximize the utilization of local resources. How can primary health care be evaluated?
2. 3.
4.
5.
6.
7.
8.
- 35 -
ANNEX 4 AGENDA Tuesday, 21 September
8:30
- 9:30
Registration Official opening of the Working Group by the Regional Director Self-introduction Coffee Election of General Chairman Election of General Vice Chairman Election of Chairmen of the Working Groups Designation of rapporteurs Explanation of procedures Topic 1: Concepts of basic health services with particular reference to primary health care Continuation of Topic 1 lAmch Continuation of Topic 1 Coffee Continuation of Topic 1 Meeting of Steering Committee. (Group) (Group)
9:30 - 9:45
9:45 - 10:15 10:15 - 10:45
10:45
- 11:15
(Plenary) (Group)
11:15 - 12:15 12:15 1:15
- 1:15 2:15
2:15 - 2:45 2:45 - 3:45 3:45 - ·4:15 Wednesday, 22 September
8:00 - 9:00 9:00 - 10:15
Presentation by rapporteur of each group and summing up by Director
(Plenary)
Topic 2: Present status and trends of basic health services in the Western Pacific Region Presentation by each temporary adviser and discussion (Plenary)
- 36 -
Annex 4
Wednesday, 22 September (cont'd) 10:15 - 10:45 10:45 - 12:15 12:15 1:15 2: 15 1:15 2:15 2:45 4:15 4:45 Coffee Continuation of Topic 2 Lunch Continuation of Topic 2 Coffee Completion of Topic 2 Meeting of Steering Committee. (Plenary) (Plenary) (Plenary)
-
-
2:45 4:15 -
Thursdal: ! 23 Se2tember 8:00 8:30 Report on previous day by rapporteurs and summing up by Director Topic 3 - Working Paper 1: Consumers of Health Care and Approaches to Strengthen Services in Response to their Needs. Topic 4 - Working Paper 2: Community Involvement in Primary Health Care. 10 : 15 - 10: 45 10:45 - 12:15 12: 15 1:15 2:15 2:45 3:45 1:15 2:15 2:45 3:45 4:15 Coffee Continuation of Topics 3 and 4 Lunch Continuation of Topics 3 and 4 Coffee Continuation of Topics 3 and 4 Meeting of Steering Committee (Group) (Group) (Group) (Plenary)
8:30 - 10:15
(Plenary)
Fridal:! 24 Se2tember 8:00 9:00 Presentation by the rapporteur of each group and summing up by the Director. Topic 5 - Working Paper 3: Operations Research Studies in the Western Pacific: Some experiences in WHO-Assisted Projects. (Plenary) (Plenary)
9:00 - 10:15
- 37 -
Annex 4 Friday, 24 September (cont'd) 10:15 Topic 6 - Working Paper 4: Approaches to Planning, Implementation and Evaluation of .Basic Health Services Programmes. Topic 7 - Working Paper 5: The Use cf ~pidemiology in Basic Health Care. 10:15 - 10:45 10:45 - 12:15 12:15 1:15 2:15 2:45 4:00 1:15 2:15 2:45 4:00 4:30 Coffee Continuation of Topics, 5, 6 and 7 Lunch Continuation of Topics 5, 6 and 7 and discussion of Topic 8 Coffee Continuation of Topics 5, 6 and 7 and discussion of Topic 8 Meeting of Steering Committee. (Group) (Group) (Group) (Plenary)
Monday, 27 September 8:00 - 10:15 10:15 - 10:45 10:45 - 12:15 Continuation of Topics 5, 6 and 7 and discussion of Topic 8 Coffee Topic 8: Role of WHO and other external agencies in the development of basic health services. Lunch Continuation of Topic 8 Coffee Presentation by the rapporteur of each group, discussion of Topic 8 and summing up by Director. (Plenary) (Group)
(Plenary)
12: 15 1:15 2:30 3:00 -
1: 15 2:30 3:00 4:30
(Plenary)
TuesQay, 28 September Field Visit to Rizal - Primary care clinics - Expanded programme of immunization - Barangay health workers. (8:00 onwards) Meeting of the Steering Committee.
- 38 -
Annex 4 Wednesday, 24 September 8:00 - 10:15 Presentation of Report Recommendations and guidelines 10:15 - 10:45 10:45 12:15 Coffee Discussion of Report Recommendations and guidelines 12:15 - 1:15 2:15 - 2:45 Lunch
(Plenary)
(Plenary)
Closing ceremony
- 39/40 -
Annex 4
FIEID VISIT TO RIZAL ITINERARY FOR PARTICIPANrS
Tuesday, 2M September 1916 Tim!'! Activity ~:,o
8:00 -
Travel from WHO to Provincial Health Office, Pasig, Rizal Orientation to the health services of the Province ot" Rizal - Dr Pablo Capati and staff Travel to Rural Health Unit, Tansy, Rizal Orientation to the health service system of the Rural Heal th Unit, Tanay, Rizal and to the Baranga;y Midwife Clinic in Wswa, Tansy Lunch in Tanay Travel to Sampaloc, Tanay, Barangay Supervising Midwife Clinic Orientation to the Barangay Health Workers activities discussion with BHW's from remote mountain areas. Travel to WHO, Manila
ts:45 - 9:15 9:30 -10:,0
10:4? -12:00
12:15 - 1:15 1:,0 - 1:45
2:00 - 3:15 3:30 - 5:00
- 41 -
ANNEX 5
LIST OF WORKING GROUP OFFICIALS
')e'lernl Chul'IIan (Jeneral Vioe-Cl.alnl&ll Chairman. Group A
Dl'
Juan M. Flavier
Dr J.O. Tuvi
Dr F. Solon lJr Sale Jeremia
C/;alA1a'l. Group C
(le:lf!rlll Rapporteur
Plenary SCR!lions Group A
Dr R.
Shllnllll
Dl' J. Brady
a,'oup B Group C
Dr Nah Wong Dr P. t3<'ck
Morning
1'1,1 •• N. Gel1nt1 Dr B. Akerren
'!'!ll.l"sdny. ~;)eral.
2,
Afternoon
sept_bel' Plenary Group A Group 13 Group C ;~a81ona
Rapporteur
Jr' H. Hetzel
rlr-oup Rupporteul'S
Dr F. Solon NiB. :iOl'lll8 Oabu
Dr J.O. Tuvi
- 42 -
Annex 5
F.' iday.
24
f1eptembe!' and MO"ldI\Y, 2'{
s"ptl'!mber
'"Ie lI'!,-al Rappot"T.eur
Plenary Sessions Dr H. Hern1rnan
',,"oup Rapporteurs
Group A O;"oup
Dr J. Brady Ms N. HaOa
B
Group C
Ms J.S. Kim
- 4.3 -
ANNEX
6
CONCEPT AND FUNCTIONS OF PRIMARY HEALTH CARE by Dr G. Emery* Until quite recently we uaed to define prt.ary health care aa that health care which ia provided by the health worker of firat contact. We liked thia definition, which ia atill followed by many authora becauae it was all embraciag. It covered care from a phyaician in a highly developed country to care from a village health worker in a leaa developed country. Now, however. the concept of primary health care and the primary health care approach have been given a different meaniag within WHO. The background of thia goea back a number of years. Examination of the health aervicea of moat developing countriea revealed that deapite the efforta of governmenta and international organizationa to provide relatively aophiaticated health aervicea ataffed by qualified peraonnel. there haa been faUure to cover up to 801 of the population namely. thoae living in rural areaa. In a number of countries succeaaful or potentially aucce.aful progr..... had been establiahed. WHO and UNICEF decided to carry out a study of some of these which waa commenced in December 1973. The final report of the .tudy "Alternative Approaches to Meeting Basic Health Servicea in Developing Countries" waa presented to the twenUeth aellion of the UNICEF/WHO Joint Co.aittee on Health Policy in February 1975. In May 1975, the atudy was endoraed by the UNICEF Executive Board. Later in the aame month the Tventy-EighthWorld Health Aasemb1y conaidered the study which had been placed before it as a background document to serve as the basis for a major worldwide action programme for primary health care; this programme waa approved by the World Health Aaaembly. The concept of a primary health care approach has a number of specific components. (1) Primary health care consiats of simple and effective measures in terma of cost techniquea and organization which include preventive. promotive. curative and rehabilitative activities. The emphasis given to any of these components will vary in individual countries and in time.
*Regi-;'nal Adviser. Strengthening of Health Servicea, WPR/WHO.
_ 44 -
Annex (
(2) Primary health should be based on feasible modern scientific knowledge and health technologies as well as accepted and effective traditional healing practices. (~) Primary health care is carried out at the periphery of the health services. For its effective functioning other echelons must be developed and adapted to support the need at the primary level especially in terms of technical supervision, referral, logistic support snd training.
(4) From an organizational point of view primary health care implie~ An intersectoral government approach at all levela relating national health services to other government development activities. This approach is needed to promote the improvement of living conditions in the community. (5) The effective functioning of primary health care depends upon community acceptability which impliea recruitment of the health worker from the community and selection by the community. (6) Primary health care ahould use available local resources including manpower, materiala and funds generated from within the community itself aa well aa atrictly neceasary reaources received from the government. (7) Primary health care should be mutually supportive of community development. In situationa where a community development framework exists primary health care should be implemented within this framework. In r,ituations where such a framework is weak or lacking, primary health care activities could be utilized as a means for ita development and strengthenin~ . . (8) For the initiation of primary health care in a country, external technical and financial assistance may be required in accordance with the ~trategy .pecifically designed by the country. However, this should be limited aa primary health care eventually needa to be self-supporting in the country itaelf. The primary health care worker is a man or woman selected by the loe'l: community authoritiea or with their agreement to deal with the health problema of individuala and the community. The worker will be responsible ~~th to the local authoritiea and technically to the supervisor who is a member of the government health service of the country. The worker will be paid in ca.h or in kind by the local community and his work may be full-time or part-time. The worker will follow the instructions given by his ,upervisor and will work in a team with him. The worker will receive an initial period of training from the health service of the country which is practical and given near hia home. Periods of further training will follow. His work will cover both health care and community development but will be restricted to what he has learned. He will know his l1mitatior" and refer as necessary to the nearest health centre or hospital. The functions of the primary health care worker will vary according to the priority needs of the community or country in which he is working and the training he has been given to meet these needs. There are certain core activitiea which are common in moat if not all community
••• I
Annex 6 settings. They include activitie. in the field of MCR including family planning. The delivery of .ervice. withiD the NCB i. of particular intere.t to the participants of this .eminar. Since mothers of childbearina age and children amount to over half the population of many developing countrlel. the primary health care worker ha. an important duty to fulfill in relation to them. Nutrition is another important field. also the treatment of simple infection. and non-serious accident. by fir.t ald. Health education and environmental lanitation are i.,artant area. which are clo.ely related to community develo~nt. In the latter he will work clo.ely with .ectors other than health. for ex..ple. aariculture and education. In the field of health he will refer ~o and be .uparvi.ed by the next echelon of the health .ervice. It ..y be nece •• ary because of local customa to train two typ•• of primary worker with only certain functionl In c~. For example. a .. Ie worker who will b. active in enVironmental .anitation. firlt aid h.alth education and developmental activitie. In aariculture and ... 11 ani. . l husbandry and a f.male worker who.e activitie. will b. in MCR and f ..ily planning. the treatment of simpl. condition•• health education for perlonal .nd community hygiene. sanitation and iaaunization. ca.e findina and firlt aid. In .ummary. primary health care i. an intearal part of the national health care .ystem which at.. to meet the balic h.. lth needs of the population for securing relief from illnes. and obtainina auidance in leadina a healthy life. In the primary health care approach all elements nec ••••ry to make a po.itiv. input in the health statu. of the population are integrated at the community level. WHO is launching its promotion on a global basis among member countries to attain fuller coverage of the population especially in rural areas.
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ANNEX 7
CORstJMElS OF REAL'l'H CARE AND APPROACHES 'l'O STRERGTREN SERVICES IN RESPONSE TO THEIR REEDS Soc101o81ca1 rea.arch and developaent of baa1c h.a1th aerv1c.. 1n Lao. 1973-1976 by
Mr R. Pottier WHO Soc:io1ogilt
- 48 -
Annex 7
1.
INTRODUCTION
In view of the imperative need to achieve the IIIOst comprehensive health service coverage of the population as possible, WHO reco. .ended the establishaent of public health zones in Laos from 1970. Some pilot projects were implemented, following which the programme organizers had to modify the initial design of the zones for improved operation. This paper seeks to analyse the problems encountered and to show the extent to which SOCiological field studies on health demand in rural areas were of value in working out solutions. 2. STUDY ON THE OPERATION OF HEALTH ZONES
In the health system (currently being reorganized) in the area controlled by the former Vientiane governaent, each public health zon~ had a health centre with an assistant medical officer and coverage for 20 000 to SO 000 people, plua a variable nu.ber of sub-centres under a nurse, each covering 5000 to 10 000 people. The establiahaent of health centres and sub-centres in rural areas was a first step in deconcentration of the health systea, which had previously been confined to urban areas. This measure brought a . .rke~ improvement in the lot of the populations concerned; but studies showed that there was some under-utilization of the new faCilities, particularly the health sub-centres. It was therefore concluded that the type of service provided in the rural areas did not altogether meet health demand, i.e. to the health needs perceived by the users themselves. In fact, this type of problem always arises in any deliberate action relating to socio-economic processes. It is clear, in fact, that ~pontaneous social evolution leads only to types of services which meet the demand of at least part of the population. Traditional aedicine, for instance, precisely because it is the expression of a particular culture, necessarily meets the deaand of the people since it is determined by the same cultural mechanisms. Similarly the e.ersence of modern medicine as a profession exercised in a private profit-motivated capacity is linked with the development of deaand backed by the ability to pay, in some sectors of the popUlation. But a decision to establish health services for the public stems precisely from the observation that the spontaneous aechanisas of supply and demand are incapable of meeting the health needs of the popUlation satisfactorily, and also from the determination to correct the undesirable effects of these mechanisms. It seems that under these circumstances the purpose of health policy should not be to meet the existing health demand, i.e. with the ability to pay and corresponding
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Annex
7
to felt need., but to . .et the!!!! need. of the entire population, i.e. including tho.e which are not felt (particularly in the vay of disease prevention) and those for care vhich cannot be paid for. That ia why health education as a . .ans of stlllUlating d-.nd which 18 lacking when the health needs are not perceived by the population, and the partial or co.plete exa.ption f~ pa,.eat of health .ervice. as a . .ans of sati.fying d...nd in the ab.ence of ability to pay, are important features of a health policy. Hovever, even if we adait that the basic purpo.e of health .ervices is not to meet the pre.ent deaand of the population as deterained by socio-cu1tura1 and socio-econoaic factors but rather the real health needs as defined a pri~ri and externe11y by tho.e re.poD.Ibie for the health progr.... (a propo.ition which can incidentally be challenled but which cannot be di.cu •• ed in this paper), it i. neverthe1e •• true that mov1eqe of the _chai.s which lovern d__ d 18 e ••ential in.ofar as utilization of the health .ervice. i. a1.0 lovemed by those .echani. . . Surveys carried out on this point in Lao • •hoved that cultural factors vere of only ainor t.portace in the under-utilization of health .ervices that va. ob.erved. In particular it appeared that there vas virtually no ~.tit1on betveen traditional and ~d.rn . .dicine. Insofar as the.. two fo~ of .edicine vere on co.pletely different levels (the fir.t being appreciated more for p.ychololica1 reasona and the latter ~re for ita efficiency or convenience), at.ultaneoua recourae to both for.a vas often regarded aa the ideal and, when a preference vas expreased, ~dern .edicine vaa lenera1ly favoured. What did ..erge, hovever, vas that competition to governaent health services vaa due larlely to the exiatence of an entire parallel medical ayat . . . .de up of people living in the vill..ea theaaelves or paying regular visits to th .. who, privately and in return for .oney, vere providing "~dern" medicine of very poor quality. The parallel ayatea included health profeaaionals and non-profesaiona1a, particularly: nurses giving treat.ent (a~at
exclusively injectiona) privately;
pseudo-nurses vithout any nursinl qualifications who had nevertheless learned aoae techniquea (particularly that of injections); shopkeepers se11inl druga without any or licence. pha~cy
qualifications
Through the perallel syat .. the rural population vas exploited econoaically, at leaat in certain parts of the country. Surveys ahoved that before the change of aoveftllleDt in Lao., expenditure on health in the Vi_tiane Plain vas taking 51. to 101. of houaehold inCDae. Such an outlay vas certainly burdenaoae for a poor and largely peasant population. Furtheraore~ the unsupervi.ed .edical practice by persons vithout any proper traininl had obvioua iatrolenic consequences: aequelae of unsound treataent; developaent of resistance to antibiotics because of use of out-of-date stocks or inadequate dose.; hae.orrhagic disorders following the uae of chlor.-ph_ico1 or corticoida, etc.
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Annex 7 Analysis of the survey relultl showed that the succe.1 of the parallel systea as compared with the lovernment system was due to two main factors: The Accessibility factor. The great advantage of the parallel systea from the point of view of the users was that it was immediately accessible, t're !;"!t""Ij.ces ~'ei'~ .~'.lIllah-.E: 'm thf' epot "1' at home. The imoorlance of dist.ance in the utilization of health services :.y \.tH. .;·I"'I!l:V.l .. l.Oll t.•' ~t •. ,.. ell use vas made of the centres lind sub-centres in the Villages '~"~r:' ~.hcy "'::1'e situated and progrelsively less as distance from thea increased. ,.• ' ~ .1:.111.. t •.,(:·J
The drug factor. There is nn doubt that the lack of drugs which was a feature of the lovernment he".lth s ..... viccs discouraged people from using thea because after visiting a h~nlth c~ntre or .ub-centre they often had to purchase the drugs pre$cribed, in an urban phar.acy or from a village drug seller. Consequently there vas a .trong temptation, for people with little education and appreciation of the need for vi.its to .. linics and medical ex_inations, tn go direct;-7 to the place where the drug was on sale, omitting the visit to the health centre or sub-centre. Insofar a. the parallel syatem had the double advantaae of offering services on the spot and making drugs immediately available, its .ucceS8 can easily be explained; and this success aggravated the under-utilization of the government health services. j.
POSS IBILITIES FOR DEVELOPMENT 07 IRE REAL'nI SYSTEM
The obvious solution in this situation was to continue to decentralize the ~ealth system, extending it to the Village level. The very existence of a parallel system showed clearly that a health system that did not go down to this level was providing inadequate coveraae of the popUlation: in a way the parallel systea was filling a vacuu. caused by the lack of a village health .ervice. Neverthelel. one difficulty was taDediately apparent in ~leaentin~ such a programme, i.e. the limited resources available to the authorities. How could a village health service be establilhed when staff, dru.s and equipaent were already lackina for health centres and even .ub-centre.? With regard to the problem of lack of drugs, the firlt .olution which .eeaed appropriate was to use the re.ources of traditional medicin •• Care which can be given in a village health service constitutes what i. now conventionally called "primary health care". However, the avaUab 1. data show that in about two thirds of cases a purely s,.,tomatic treat.eat aufficea to solve problems encountered at the village lev.l. Thul in.ofar a. traditional Laotian remedies ar. always harmle.s and .... fairly effective in dealing with 'ymptoms, they appeared very .uitable for u.e at this level. Moreover .urvey. on the subject showed that their ule would be well accepted by the popul~tion.
-
.J.
c:.
-
_._---;~~~·nex
i
Traditional medicine cou ld, however. on ly be used for c 1;lIIi ted part of the care provided; and it could not solve what was considered the priority problem of disease prevent inn. For that reason in Laos, as in all countries at the same historical juncture, it appeared indispensable to enlist public partici~ation in extending the health services. Apart from being essential for economic reasons, public participation seemed a d~termining factor in the success of all disease prevention ~ctivities, in that: environmental sanitation activities in rural areas require work of such a continuous nature, with such extensive manpower, that they are hard to implement without active participation by the villagers themselves; with regard to health education, it seems difficult to change a population's behaviour (for instance in hygiene and nutrition) when the initiative comes from the outside: effective results can only be ~chieved by persons belonging to the community concerned, living like the others, enjoying their confidence and familiar with their customs, and able to work patiently and repeatedly, day by day. Nevertheless, in enlisting public participation a number of obstacles were encountered, which are well known elsewhere in the world, namely: Health was not a priority need for the community; surveys showed that priority was given the school, the pagoda and communications. Health was not regarded as a community need but as a private matter. Preventive needs were wholly unrecognized by the population. There was, however, a favourable factor, i.e. a tradition in Laos of community decision-making and investment in the village~. Village communities were able - through a traditional system of village government which was democratic, efficient and largely independent of the State system - to work out schemes of value to the community and in various ways to mobilize the resources in kind, money or labour that were necessary for their execution. It seemed advisable to try and use these traditional processes to make the people recognize the need for a village health system and ensure that they would assume at least partial responsibility for it. The underlying idea in the strategy selected was that the passive attitude of the people towards the health programme could be attributed largely to the lack of interest they had always shown in any measure initiated by the government and kept under its exclusive responsibility.
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Annex '( It was felt that if public participation involved not only a sharing of costs by the government and the community but also a genuine sharing of responsibilities making health a matter for the villagers themselves, the new system - associated with the villagers' capacity for selfgovernment - had a real chance of success. The village health service it was proposed to set up would have been semi-governmental and semi-community - "semi-governaental" in that the service would technically have been part of the government system (with the village health workers being trained at the health centres and working under the technical supervision of the public zone staff) and "semi-co~nity" in that the entire health progr_e at this level would have been under the responsibility of health co..ittees elected by the population. The village health workers it was proposed to train would not have been professionals but members of the community providing part-time services in return for payment in kind or ~ney. as decided by the village health committee. and assisted by voluntary health motivators working on a purely disinterested basis. The village health co..ittees would not only have been responsible for aa-inistrative supervision of the village health staff but would also have been able. either directly or through the canton and district health co__ittees. to exercise some control over the lovernment health system and staff. The success of such a prolr .... probably depended on the possibility of setting up effective health committees. able to aske people aware of the importance and essentially community nature of health probl~B. It should not be overlooked that at the outset the villagers would probably have preferred a purely governmental health service, over which they would have had no control but which would have been entirely free. A long task of public information would have been necessary; however the economic exploitation of the population that took place through the parallel medical system would certainly have facilitated this task, a~ it would have furnished arguments in favour of setting a system more consistent with village community interests. What was needed in fact "'as to show the villagers that they would have been well advised to place on a community basis the outlay on health that they were already making privately. At the .ame time the Government would have had to be resolved on taking over control of the drug trade and to accept a democratization of the health system. supporting the establishment of popular representative bodies - for which the need was being felt. All these conditions were met in Laos when the new government came to power; since the founding of the Lao People's Democratic Repuglic, it has in fact applied throughout the country. in accordance with the pattern in the previously liberated sectors. a health policy ve::y ~i.milar to the one advocated by WHO
- 53/54 Annex 7
4.
CONCLUSION
The experience in Lao. deaon.trate. the i~ortance of taking into account the views of user. of health service •• Before de.ilDing a health .ervice, the hee1th d...nd of the population .hou1d be deterained to en.ure that the propo.ed .ervice will not be under-utilized. The people should a1.0 have a role in the aana, ...nt and operation of h.a1th ••rvice., at 1.a.t at vi11..e l ..el and perhap. al.o at hilher level.. The appropriate fora of thi. public participation can be deterain.d by empirical field .tudie••
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ANNEX 8
COMMUNITY INVOLVEMENT IN PRIMARY HEALTH CARE Western Samoa by
Dr Sale Ieremia1
lChief, Public Health Division, Health Department, Apia.
- 56 Annex 8
INTRODUCTION Western Samoa is an independent tropical Polynesian State divided into two main islands: Savaii with a population of 40 581 in 1971 census and Upolu with a population of 106 046 according to the same census. The estimated population at the end of 1974 was 151 251, a figure based on birth and death projections and known migration. HEALTH SERVICES AND PERSONNEL The government health personnel are employed in the national hospital of Apia, the capital, 14 district hospitals/health centres, 11 subcentres and some special areas (tuberculosis and leprosy, filariasis, emigration, public health clinic, etc.). In the districts, the health team, consisting of a district medical officer, staff nurses, nurse aides, laboratory technicians and a dental officer, provide curative and preventive care. The district nurses provide basic health services to the villages through monthly visits including the holding of MCH clinics, home visiting, school health technical support and guidance to women's committees. Assistant llealth inspectors attached to the health districts also visit the villages for environmental sanitation activities. rraditional birth attendants are responsible for the majority of the deliveries particularly in the rural areas. A programme of training for these attendants started in 1975. So far only 30 of them (selected members of women ',s committees) have been trained in the pilot area. The following health personnel are employed by the Government: Medical officers Total 55 of whom 27 are in the national hospital and 9 are in the district hospitals and health centres. 14
Dental officers Dental assistants/hygienists Nurses/technicians Pharmacists Assistant pharmacists District nurses Hospital staff nurses (Apia and districts) Nurse educators
19 2
4
54
171
5
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Annex 8 Health inspectors Assistant health inspectors Laboratory technologists Laboratory technicians Radiographers Occupational therapists Assistant therapists 3
16 2
28 4
2
1
THE PRIMARY HEALTH CARE PROGRAMME The primary health care programme in Western Samoa is adapted to the social and cultural p,attern of the country and is aimed at meeting the basic health needs of the community. The village women's committees take initiative and actively participate in the development of primary neal th care. The women's committee is an organized voluntary group at the village level which serves as a mechanism to pool individual opinion in identifying llealth problems and generating group effort in trying to solve these problems. Tile women I s committee organization is based on the "matai" system of decision-making in the community. The leaders of the women's committees are usually wives of the prominent matais which make their organization function well. The committees work hand in hand with tbe staff of the district health teams under the supervision of the district medical officer based in a district hospital or health centre. This team is responsible for carrying out the following health activities: maternal and child health including family planning. communicable disease control. environmental sanitation. health education and simple health care. FUNCTIONS OF THE WOMEN'S COMMITTEES The committee functions are as follows: (1) in relation to the mother and child health activities. helping the district nurses to inform and gather together mothers and their babies for weight registration, immunizations and health education on nutrition. and encouraging pregnant mothers to use ante-natal facilities; (2) assisting district nurses and health inspectors to clean up the environment and inspect domestic facilities;
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Annex 8 (3) assisting the health personnel to carry out mass campaigns sponsored by international agencies, e. g. agains t yaws, filariasis, tuberculosis and leprosy, etc.; (4) improving the protein intake of the people by ra1s1ng cows, engaging in poultry and farming and cultivating vegetable garden; (5) building "fales" which serve as meeting places for daily activities in primary health care and, where the district nurses carry out mother and child health, for health education and health activities; (6) seeking funds to build hospitals, health centres, health sub centres , school houses and churches; (7) purchasing simple drugs and instruments for first aid;
(8) contributing labour for cleaning and maintenance of the compounds of district hospitals, health centres and subcentres; (9) providing funds for plants to supply electricity to distriG:t· hospitals; (10) contributing local materials for the construction of water-seal latrines. DISCUSSION The formation of women's committees started in the 1920s. The move was initiated to cope with the growing health needs of the people. Perhaps it was viewed at that time as a temporary measure to help solve the health problems then. But as time progressed the organizations grew and are still growing. Now the women's committees have become the backbone of the health services in Western Samoa. Despite obstacles which weaken the organizations from time to time - the work has nevertheless been carried through. Non-women's committee members despite their nonparticipation in women's committees activities are given all the help they need by the rural health teams. The district nurses are the front-line personnel in delivery of the primary he.alth care. Along with other health personnel they play a very important role. The district medical officer, being the team leader, is the key person on whom the successful achievement of primary health care in the community depends.
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Annex i.l
CONCLUSION Recently a joint study by the WHO and UNICEF was made in Western Samoa to study community participation in primary health care. At the same time the Princess of Tonga and her party were there to study the scheme with the hope of trying it in her own country. The team under the leadership of Dr J. Stromberg gained the impression that the village women's committee activities are built upon a particular model and social system (the matai system) that can hardly be considered a viable model to be reproduced in the same form in many other areas. In the case of replicability, these activities may only be replicable in the same form in areas where a similar social system exists. In another sense, there is much about the activities of the Government especially the Health Department, in relating its present programme, staff and training to the viable local traditional structure and in developing plans to further strengthen the programme which is replicable in a general rather than specific sense. This is especially true as governments are gaining a better understanding of the implications of community involvement and self-help. In conclusion, the writer fully agrees with the team's impression gained during their study. What applies to Western Samoa based on its social and cultural system may not be applicable to other areas.
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ANW~
9
OPERATIatS RlSEAIOI S'l'UDIIS IN '11tB Wl8TERN P~l1'IC: sam BXPERIINCBS IN WHo-ASSIS'l'ID PROJP.C'lB 11
Mr M. Subr-.n1an
11_ M.
SubrMul1an, Teohn1oal orr1oer (Operationa Researoh). Health Plann1q Unit, l1li0 Redonal otnoe tor the We.tem hoU'io.
MUl1la.
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Annex 9 1. INTROOOCTION
In the Western Pacific Region, one of the significant activities of the World Health Organization since 1909 has been the co-operation with Member governments in carrying out operations research (OR) studies that contribute to the development of national self-reliance in solving problema related to organization and delivery of health services. In these efforts, operations research as a problem-solving and actionoriented approach has been used making the necessary adapatation to tackle the types of problems posed, with the existing re.ourc~s and time constraints. Of the three are.. - of application of OR in'health care delivery, viz. short-term solutions in the utilization of existing resources, development of alternative strategies for provision of servioes to existing population and long-range deCisions in planning and evaluating programmes for future population, it is considered necessary to demonstrate success in the first area before working on the other two. However, there have been few demonstrated successes in studies in the first area, mainly because of failure of the studies -to' acihieve their real potential in contributing to development. of strategies in the secClnd area. In the Region, the emphasis on studies carried out with WHO co-operation baa been on development of alternative strategic designs for the delivery of service to an existing population, while using the existing resources effectively (in terms of means and results), with built-1n dynamism in the service delivery system to respond to chllng1ng requ1rements. Also in some of the countries, one of the felt needs in prOViding adequate and equitable health care to the population is that the health care delivery syatem should be replicable for nationwide implementation, with a mechanism for necessary modification to suit local needs. To satisty this reqUirement, a few studies have been undertaken in which OR has been effectively applied to development of innovative designs. These designs have stimulated health services development in the countries concerned. 2. STRATEGY FOR OPERATIONS RESEARCH STUDIES
In carrying out the OR studies, efforts are directed to develOPing an effective multid1sc1pl1naq team able to: define problema with different recognized manifestations; _identify areas of further improvement by studying the character of inputs, moni toring and evaluating service delivery, assessing the quality of service asSOCiated with the output and hence contributing to the effectiveness of service delivery (basic system discriptors); isolate alternative strategies under the given constraints with regard to resources, physical or administrative oonditions and policy; and evolve relevant criteria. For the studies to be productive and contribute to better delivery of services and thus to the well-being of the population, they will not be service-based but relate to actual effectiveness of the services rendered
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Annex 9 and will thus involve a change in orientation to health problems, paUents or the population. Finally, the studies will be carrled out to deal with problems considered as being of serious concern for the organization ,~d management of health services, that will affect e 1erge proport1nn of population and/or will trigger off improvements in dIfferent components of the health services delivery system.
3.
PROBLEM OF HEALTH SERVICES DEVEUlPMENT
In all of the countries in the Region. there is some sort of health services system and, generally, the basic service delivery design appears to be reasonable. Over a period of time. health services reach an equilibrium state. functioning much below their capacity due partly to structural deficiencies and partly to demand on the services. In adapting to the pattern of denaand. the services delivery system becomes less efficient and less effective due to "negative goal discrepancy". Usually this manifests itself in the form of scarei ty of resources. be they human or monetary; and generally this is stated as a reason for failure of the system to provide effective coverage to all the population through generalized basic health services or specialized disease control programmes. and particularly to the rural popUlation. 4. OBJECTIVE OF OPERATIONS RESEARCH S'ruDIES
The overall objective is to develop ways by which effectiveness in the utilization of health services resources can be further increased and to develope alternative strategies for provision of health services to an existing population. The immediate objectives are to carry out studies in the operations, training and management sectors of the health services system, to innovate ways for improved performance in these three sectors and through the studies to develop national capability for optimal utilization of resources.
5.
APPROACH TO THE OPERATIONS RESEARCH STUDIES
There are several approaches to studying a complex. functioning system like that of health services and the choice depends on a number of factors like the purpose of the analysis. degree of access to the system. ability of the analyst. and strengths and limitations of the techniques themselves. In health services development research one can use an approach that is analytical (analysis of one component in isolation) or systematic (analysis of interrelated components of a system and synthesis of findings). In the case of the studies carried out with WHO collaboration, the latter approach is being adopted; OR methods are adapted and used to study problems involving the operations of the health .ervices system so as to provide those in charge with optimal solutions.
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Annex 9 In undertaking these studies a two-pronged attack is made, compris1np;: (i) initial concentration of efforts in developing a service delivery design and then provision of a compatible service support (logistics, supervision, infonnation) design which together form a service design package and (ii) design of a service management information system compatible with the managerial style of the ministry or department responsible for organization and management of the health services. It is assumed that large-scale contributions in operations and management will involve radical modifications in training in these two areas and hence development of effective designs for the purpose. The follOWing ateJ)8 are involved in using the (1) (2) observation: O~
approach:
symptoms of felt problem and real problem;
definition of real problem;
(3) development of a framework to describe the situation, baaed on the contributing factors; (4) through field studies and analysis of data, identification of possible areas for intervention;
(5) improvement;
identification of critical factors that may contribute to an
(6) determination of technically acceptable solutions to improve the effectiveness of the system;
(7) testing of the solutions for operational feasibility, population acceptance, and applicability under field conditions; (8) application of the solutions: implementation.
A number of studies effectlvely using the above approach have been undertaken in the areas of generalized health services delivery, apecialized disease control programmes and of health management information. In the case of generalized health services delivery, emphasis in the studies has been given to the provision of services at the primary care level and, to a lesser extent, at the secondary care level. Tertiary care is beyond the. scope of this approach since a number of intangible factors determine performance at that level. Also to achieve the desired impact, it would almost always be necessary that an effective service support system compatible with the improved delivery design be developed to stimulate performance.
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Annex 9
6.
ACTIVITIES AND RESULTS
In the Region. the Organization has been co-operating in carrying out OR studies as a part of WHO-assisted general health services development projects. Because of its pioneering nature. the Organization itself has been developing and perfecting the methods following their application in real-life situations. So far. studies have been undertaken in Malaysia. Philippines. Japan and the Republic of Korea. The areas studied comprise general health services. health management information. tuberculosis and hospital care services. In all these cases emphasis is on utilizing existing resources effectively; and the outcome of studies completed so far has demonstrated successes in this area. The findings have formed the basis of a new orientation to the development of health services. Below is a short summary of different studies: 6.1 General health services development
Studies in this area were carried out in Malaysia and Philippines on the proVision of health services to population in the rural areas. A stUdy is due to be undertaken in the Republic of Korea. 6.1.1
Malaysia
Scarcity of manpower resources has prevented rapid expansion of heal th services to provide full coverage of the rural population. The objective of the OR study was to develop ways by which higher coverage could be obtained by further improving the effectiveness of existing rural health service resources. ~ study ~ougbt out the fact that, for strategic intervention to achieve much higher coverage of POPUlation in the proviSion of effective health care by the available personnel. a new rural health services design based on a two-tier system should be developed. with minimal modification of the existing rural health unit structure but some changes in the functions. activities and ~ of the staff of rural health units. The study, started in January 1970. was completed in January 1972; and the report is available for reference. Findings formed the basis of a new orientation to the development of health services and the design is being implemented on a national scale. A national OR team was trained in the process. The Ministry of Health established a permanent operations research unit as the research and development arm of the Division of Planning and Development. and this unit has since carried out a number of stUdies. 6.1.2 Philippines
A major constraint to rapid progress in providing the best possible health services to the population. particularly in rural areas, has been scarcity of resources (mainly financial) and also ineffective utilization of available resources.
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Annex 9 The objective of this OR study was to identify ways of ensuring more effective utilization of the resources, both human and material, available to the rural health services, to test the chosen design for operational feasibility and population acceptance and to provide the Government with a duly evaluated design for possible implementation on a national scale. The study was divided into Phase I dealing with service delivery design to further improve the effectiveness of the rural health services, and Phase II dealing with service support design to develop supportive systems in terms of supervision, supplies and information monitoring that are necessary for sound operation of the services under the restructured design of Phase 1. Phases I and II were interrelated and mutually dependent and their outputa formed a "technology package". Both phases were completed and the reports are available for reference. Findings of the study form the baais of a new orientation to health services developnent in the country and the proposed design ie being implemented on a national Bcale. National OR teame were trained during the study and SQllltl of the me..bere are presently with the a.ar.au of Planning and Development of the Department of H.alth. Th. _bers are also assisting the Project Managelllent Staff of the Department in nationwide impl.....ntation of the design. 6.1.' Republic of Korea
Through the WHO-assisted general health services development project, the Gov.rnment has been deyeloping a delivery syste. for provision of basic health services to the rural population which, wh.n found technically valid and operationally feasible, can be considered for national implementation. The purpose of the OR study is thus to review the structure and content of the system so far developed, further improve its effectiveness and provide a field-tested and evaluated service design with supportive instruments for possible nationwide implementation. In the process, national capability in the Ministry of Health and Social Affairs to carry out studies on other aspects of health services using the OR approach will be developed. The study is expected to commence in late 1976 and will be completed by mid 1977.
6.2
Health management information syatem
The OR studies in the general health services developnent field have brought out the gap between the information required for organization and management of health services and that presently available and drawn attention to the significant proportion of time being spent b1 persoMel in data generation and handling at the expense of service delivery. The Governments of Malaysia and Philippines in collaboration with WHO are currently developing a comprehensive and dynamic national health informa~ion system; for this purpose they are using the same OR approach, al though adapted to the speci fic problema and environments. Both these studies are oontinuing.
- 67/68 Annex 9
6.3
Disea se contr ol prog r_es:
tuber culos is
Sever al studi es have been under taken by the Resea rch Insti tute of Tuber culos is of the Japan Anti- TUbe rculos is Assoc iation and the findin gs are being publi cized throu gh the WHO/Japan Tuber culos is cours es condu cted in Japan every year. The prese nt effor ts are aimed at linkin g the findin gs of the studi es, fillin g the recog nized gaps in knowl edge and ident ifyin g ways to ensur e bette r and broad er utiliz ation of resou rces avail able to the tuber culos is programmes. FOur studi es are being carrie d out on: treatm ent effec tiven ess (effec tiven ess of short -term chemo therap y); fatal ity reduc tion (iden tifica tion of facto rs respo nsible for tuber culos is morta lity among known tuber culos is cases ); selec tive scree ning (improved effec tiven ess of routin e passi ve radio logic al exami nation s of symptomatic cases ); and development of a tuberc uloSi S problem surve illanc e and perfor mance monit oring system . The study findin gs are expec ted to bene fit diffe rent count ries in the Region in devel oping new or impro ving the perfor mance of ongoing tuber culos is contr ol programme.
7.
CONCWSIONS
It is clear from the above review that the findin gs and solut ions emana ting from the opera tions reaea rch studi es have formed the basis for streng theni ng healt h servi ces deliv ery and for furth er devel oping healt h care in rural areas . The fact that the study findin gs have enabl ed a reori entat ion of healt h servi ces development and that the propo sed desig ns are being implemented on • natio nal scale is in itsel f a demo nstrat ion of the succe ss of studi es of this type insof ar as their contr ibutio n to gener al healt h servi ces develo pment at prima ry care level is conce rned. So far the studi es have ~ the activ e inter est, involv ement and suppo rt of top management in the minis terial hiera rchy, and thus their progr ess and succe ss can be attrib uted, in no small measu re, to activ e colla borat ion in devel oping ratio nal solut ions to proble ms in the count ry conte xt. The existe nce of an OR team traine d in the proce ss will contr ibute to development of self-r elian ce in impro ving perfor mance where there is slack ness. It is envis aged that studi es using this methodology will be under taken to improve the produ of instit ution al care servi ces parti cular ly in emergency and ctivit y provi ncial hosp itals and to stren gthen manpower train ing programmes. In the proce ss, the methodology itsel f would be modif ied and impro ved for appli catio n to diffe rent proble ms. In this respe ct, behav ioura l aspec ts will have to be consi dered and relev ant param eters incor porat ed in the models devel oped for the studi es.
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ANNEX 10
APPROACHES TO PLANNING. IMPLEMENTATION AND EVALUATION OF BASIC HEALTH SERVICES PROGRAMMES by
. G.L. Dorros
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Annex 10 1. INTRODUCTION
In many developing countries, the basic strategy which has been used for providing basic health services to the rural population has been the establishment of health centre networks staffed by physicians. nurses, midwives and sanitarians. Although conceptually sound. these networks have not effectively responded to the health needs of the population. The problems underlyinl their effectiveness lies. in part. in the approaches used for planning. implementinl and evaluating the.e services. The purpose of this paper i. to outline an approach which could respond to the problems encountered and identify soae methods which ha.e been successfully applied in a number of countries. 2. PLARNlIIG APPROACHS
The empirical and no~tive are two approaches to planning ba.ic health services which have been used in the pa.t with . .rainal .uee•••• The basic reason for their limited .ucces. i. that they do not con.id.r most of the important related factor. such as .ocio-econo.ic conditioa. health resource liaitation. progr.-.e prioritie •• etc. whieb aff.ct the type and amount of .ervice. rendered to the con.u.er. The systems approach to plannina attempts to fill this VOid. !hla approach is in fact not ~letely new. It siaply tries to identify end systematically analyze all tmportant related factors of a particular problem regardless of its scope and size. Since various descriptions and experiences are required to do this it naturally a ••umes that the process is a participative one including people froa different specialitl••• field operations and administration including the consumer. The systems approach is currently being used by -.ny countries In their national health planning proce.s. The method. and technique. u.ed in this approach to analyzing national healtb probl... and outlining alternative solution. have been developed durina the past fifteen year. and continue to be developed by each country accordlna to its need. and individual situations. Although the sy.t ... approach has been u.ed .uccessfully in tbe preparation of national bealth plan•• the need which has been widely experienced by lII&Ily countries ba. been the developlMnt of _tbod. and techniques to translate national bea1tb priorities, objective. and targets into specific action plans which could be carried out and monitored by lover act.inistrative and operational levels of the health services. Again tbe .yst... approach ba. been used to develop three . .thod. each with its specific purpo.e. Tbe fir.t i. a prolr...tng _thod which has as its goal tbe specific translation of a national health plan into a regional or provincial .ediua-term plan (5 years). The tr.nalaCion i.
- 71 AnMx 10
ba.ically a modification of health progr..... and target. and h.. lth service design to suit the specific problea. and condition. of the region, province or .tate. In addition to this, the progr...ing effort endeavours to detail the types of activities to be performed by each category of health service staff for each programme area. Since a programme planning process is primarily au-ed at detailing activities for ongoing services, it identifies areas for d~elopaent where chanses or innovations in existing health services are required. These areas for development are identified as projects. The second is the project planning method which has also been developed and widely tested in a number of countries. Its specific purpose is to prepare a detailed alternative de.ign of the chanlesl innovations required in a health service and to specify plans and schedule the activities and resource. required for their ~l-..ntation. The project planning process 11 not neceasarily dependent on a prosr_ plan but would alao be carried out at the national level a. a re.ult of development priorities indicated in a national h .. lth pl.a. Finally the third method which utilize. the I,.t ... approach for planning health service. is operations re.earch. Thi. . .thod il u.ually used to deteraine the most effective and efficient way of operatins health .ervices within the limitations of existing reaources. Operation. re.earch (oa) method. are .pecifically geared to study the perforaance of various categories of staff in a given service in relation to the d...nd or need for these services. The product of such studies ulually provide. detailed re~endations for modifying the functions and activities of staff and resources to optimize the services provided. The systems approach to planning health services is ca..on to the three methods described above. Basically this approach endeavours to study the related factors regarding the situation relevant to a particular area of concern. Based on the findings of this analysis, it identifies specific problema and establishes objectives ai.ad at eliminating or reducing these problema. Alternative approaches or designs are prepared which will implement activities related to the attainaent of the objectives and provide a solution to the problems identified. The differences among the methods described lie primarily in the scope of the study or analysis undertaken and on the techniques applied. For instance OR is usually considered a mi~TO approach to planning because it tends to analyze in detail the specific activity of individuals within a given service. Its analytical approach relieR ceavily on .adels or simple facsimiles of real situations to t·s~ its ~yPnthes~s and arrive at solutions to problems. National health planning and progr...tng aethods are considered to be macro approaches to planning. They rely heavily on available information and the knowledge of experienced individuals. These techniques are usually limited to statistical analysis and construction of matrices which illustrates relationships among various interrelated factors.
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Annex 10
Which of these methods should be used to plan basic health services? In fact all of these can and have been used for this purpose. The decision on which one to apply rests primarily on what plans have already been developed and what type of plan is required by the public health administrator responsible for basic health services. Examples: If a national health plan exists which identifies policies, priorities and objectives of programme related to basic health services and the decision maker wishes to translate them into interrelated activities at the peripheral level, a programming method undertaken at the provincial or state level would be appropriate. If decision makers wish to optimize available resource. in the basic health services in order to make them more effective and efficient, then the use of OR studies would be appropriate. Finally, if a PHA wants to make specific changes or innovations in the basic health services such as the development of primary health care services, the use of project planning as a method would be most effective. In summary, the systems approach to planning is perhaps the most effective approach for identifying and solving probleas related to the basic health services. Since there are several methods which use this approach it is important that the method selected is appropriate to the planning needs of the decision makers and will provide them with the answers they require. 3.
IMPLEMENTATION
Assuming that the plans for basic health services contain specific objectives and targets for each programme undertaken, the approach to implementation should be the management of those objectives. This approach to implementation has several important assumptions and implications. First, the achievement of any programme objective cannot be done by anyone staff member working in the basic health services. Because of the complexity and different levels of skills and experience required to attain even one objective, the assumption is that a coordinated set of activities must be assigned to individual members of a service. Second. administrators need to evaluate the achievement of objectives from time to time for purposes of replanning or making decisions regarding changes in the objectives. The management by objective approach provides the administrators with a basis to evaluate the effectiveness and efficiency of the service in relation to the objective. It also provides a good basis for evaluating individual performance of basic health services staff. Third. management by objectives implies a team or group approach to implementation. This applies not only to the planning of activities but also to the problems experienced in the course of implementation. The underlying assumption here is that a group is best equipped to discuss and find solutions to individual problems they have encountered. Fourth. since the attainment
- 73 Annex iU
of objectives is essentially a team effort, the responsibility for achievement or fallure should helong to the group(s) responsible for each objective and not one individual. In applying this approach to implementation, objective••hould be classified into two basic groups. The first can be classfied as functional performance objectives. The objectives reflect the routine tasks or activities of any service. Example: To maintain the nu.ber of BOG vaccination at the same level as in previous years. The second group of objectives can be identified a. change objectives. For example, to increase the number of home visits by lOt for every midwife. Each of these objectives require the active partiCipation and contribution of several individuals in a basic health services system. The change objective is a little more complex because the individuals responsible have to determine how they are going to achieve the objective taking into consideration other activities which they may have to sacrifice and what may be the implication of additional resources and service requirements resulting froa increased contact with the population. In order to identify who is involved with each objective a simple matrix can be used. The matrix would list separately the functional performance objectives and the change objectives. Next to each objective the function, e.g. medical care, health education training, etc. needed to carry out activities related to that objective should be identified. The names of each staff member responsible could then be identified by his/her function for each objective. Hanagement by objectives is an approach which provides direction, facilitates control and combines the relevant resources to implement the planned activities of the service. 4. EVALUATION I
Evaluation is defined as a process for making judgments about certain activities by comparing them with standards for the purpose of making decisions on action. Evaluation can be applied to any process in the health services and can be used at sny administrative level. Evaluation is basically a decision-making tool for the public health administrator who must determine what must be evaluated, why it must be evaluated and how he will undertake this evaluation and use its results. To simplify this process it is possible to identify at least three types of evaluation which would be undertaken. First is the asses ••ent of needs. This type of evaluation is carried out on a .hort-term b.sis
IExcerpts from Guidelines for the Evaluation of MCB/FP Programme Regional Seminar, WHOIwPRO, 28 October 1975, Manila, Philippines.
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Annex 10
in order to assess a particular health problem. It is used to establish the need for and priorities in programmes. Second, is the assessment of plans and designs. This approach involves an analysis of whether they effectively and efficiently relate to the problem at hand. This is also a short-term process which involves an interdisciplinary spproach. OR is one method which has been used for this type of evaluation. The result can be used both for the replanning and redesigning of programmes as well as modification of implementation plans and approaches. Third, is the assessment of performance and effects. This type of evaluation is the most frequently used by the PHA and is normally done on a routine basis. It encompasses the operational aspects of the programme or service, i.e. the resources used, the processes employed and the services rendered as ",e 11 as the immediate effect of these services on the patients. Th~ systems approach can be used for all three types of evaluation. The assessment of a particular health problem would consider not only morbidity or mortality but would also take into account related factors such as malnutrition, poor sanitation, etc. In all cases the evaluation would be undertaken against certain standards to determine the level of concern for the public health sector.
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ANNEX 11
THE USE OF
~IIEMIOLOGY
IN BASIC HEAL'l'H CARE
by
Basil S. Hetzel Member of Council, International Epidemiolosical Aaaociation
J
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Annex 11
THE USE OF EPIDEMIOLOGY IN BASIC HEAL'ffi CARE
Epidemiology is concerned with the distribution and determinants of health and disease in population groups. It contrasts with the clinical medical disciplines which are concerned with disease in individuals. Epidemiology is also the relevant discipline for the study of health services - including both preventive and curative services and Basic Health Care. Epidemiology provides the community's definition of its health problems. It is epidemiological data that provide the numerical basis for community awareness. planning and action for health. Examples of epidemiological data are the mortality profile for 1971-73 taken from Venezuela which is typical of a developing country (Tables 1 and 2). One qualification about epidemiological data is its reliability mortality data depend on notification of death usually by a doctor. In Venezuela. as in other developing countries. this is not always possible so data are provided on this point (Table 3). Notwithstanding theee limitations. the data shown in Tables 1 and 2 reveal the well-known mortality profile of developing countries with their predominant rural populations. High mortality under the age of five years, dominance of infectious disease (enteric and respiratory) clearly define 1.Ile major challenges that have to be taken up by basic health care. Basic health care is concerned with the whole community - a population group. It aims to meet the total health needs of the community and not simply the care of the individual patient. Basic health care should cover the whole health field. which includes human biology (e.g. nutrition and . infection). environment (housing and water), life style and health services. Important aspects of basic health care include (1) food supply as so vividly described in the Jamkhed project from India (good seed and fertil1ty) and the raising of goats in the Solo project from Indonesia (Newell 1975); (2) water supply as in the Jamkhed project by the digging of deep wells and the construction of a mini-dam in Klampok in Indonesia; (3) immunization requiring education and goOd co-operation to ensure levels of 8a,f; or more in the community - depending on a count being i.e an epidemiological study. :r.acJ~,
Such measures led to substantial health improvement as disclosed by epidemiological data in local communities.
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Annex 11
Health improvement through basic health care is essentially a social process dependent on the impact of information. discussion and then p~anning, agreement to the plan. and action follo..1 by evaluation. A VIvid example of this process is given by the Solo proJect follOWing the introduction of a prepaid medical care scheme in several neighbouring local community blocks (RT's) each comprising 50-100 families. One day the chairman of RT14 came to Dr Gunawan and said: "Doctor our scheme is suffering a loss during the last two months. We have too many patients. twice as many as the other RT's. What can we do about it?" Dr Gunawan suggested a survey be done before a possible answer could be found. A simple. quick survey was carried out covering primarily physical environment and health. The result illustrated with mapa were presented at a meeting attended by all heads of familie. in the RT. Suddenly the meeting saw that the stagnant water, the flooded latrines and the crowded houa~ng were relevant and it was the community's respon.ibility to clean up the environment. It started a week atter the meeting and wu completed one month later With appropriate benefits.
We can derive a model to describe the social proc..s involved using a wheel with a series of sections (Figure 1). Health improvement requires a continuous input of epidemiological data - which may be (depending on the problem) concerned with (1) demography population data. educational level. income; (2) mortality data with particular reference to the under five age groups who have high death rates in developing countries due to malnutrition and infection (Table 2); (3) morbidity data - concerning worm infection. nutritional status (height ill1d weight for age charts), spleen rates, eye and ear disease prevalence; (4) environmental data - water supply. food supply. housing. life style smoking and alcohol; (5) health service data based on utilization (attendances), consumer satisfaction, structural data including facilities and manpower. Health improvement also requires (1) (Uscuesion and dissemination of data in the local community in a suitable form - by word of mouth, through personal contact or by meetings. local newspaper or radio coverage; (2) planning a new initiative (general or educational) by a recognized group or committee; (3) political acceptanoe of the plan. locally or regiol1ally as the case may be; (4) action; (5) evaluation. Such a process requires a structure involving a local communitl health committee or council representative of the local leadership, local citizens as well as health workers. This oommitte. should preferably be elected by the local community and report back to it from time to time. The local communi ty 1 tself and not the health professional should be encouraged to take respons1bility.
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Annex 11 It will be apparent that epidemiological data are required for: (1) definition of health problems - as described by mortality or morbidity information, by use of health services, by mapping the environment; (2) change; evaluation of a new measure such as an educational programme, a change in environment, or a new health facility (see further Lowe and Kostrzewski 1973). Epidemiological data are concerned with groups. They should be collected with the authority of the group and community and then reported to the group and community for appropriate action. Such data form the necessary basis for health improvement but alone are inadequate. It 1s the community that has the responsibility for collection and implementation of findings from the data. monitoring progress over time in relation to environmental
(3)
LOWE. C.R. & KOSTRZEWSKI. J. (ed.) (1973) Epidemiology A Guide to Teaching Methods. International Epidemiological Association. Churchill Livingstone. London NEWELL. K. (ed.) (19"75) Geneva Health by the People.. World Health organization
I I
I ,
II
I ,
-
'(9 -
Annex 11
TABIE 1
PERCENT DISTRIBJTION OF DEA'IHS BY CAUSE
r-Pl"ea -<
Enteric D~seases
Other Infect10us D1seases
Cancer
Heart Vascular
Pneumonia Influenza
External Causes
Rest of Causes
I.e.D.
000-009 6.9 14.7
010-136 6.7 10·9
140-209 12.5 7.8
393-438 22.5 17.7 ..
470-486 8.5 11.9 "
800-999 11.2 9.2 31. 7 27 .8
Metropoli tan * Rural**
*
>100 000
** <1000
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Annex 11
TABIE 2
PERCENT DISTRIBl'l'ION OF DEA'lIIS BY AGE GROUP
Area Metropol1 tan * Rural**
0
1-4 J1'8
5-14 yra 2.7 5.2
15-44 yrs 14.3 12.4
45+ yrs 50.1 38.4
28.4 -
6.5 14.4
29.3
* **
> < 1000
100 000
•
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Annex 11
PERCENT OF DEATHS ASCRIBED TO "UNlQfCMf CAUSES"
Area
1951-5'
1961-6,
1971-7' 4., 45.9
Metropolitan *
11., 71.6
'.9 67.0
Rural·*
* **
> <
100 000 1000
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Annex 11
CAPTICW TO Flamm
Figure 1
Model for Use of Epidemiological Data in Buic Health Care Epidemiological data includes: (1) (2) (3)
Demographl - population, education, income; Mortality - age, sex, region; Morb1d! ty - nutritional statu, worm 1nfection i Environment - water supply, hous1ng, alcohol, tood supply; Health services - ut1l1zation, conaUMr response, outcome.
(4) (5)
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Annex 11
EVALUATION
ACTION
DISCUSSION AND DISSEM I NATION
POLITICAL ACCEPTANCE
PLAN