RETURN TO WHO LIBRARY, MANitA Y()RLD HEALTH ORG:\NIZATION RE GIONlJ. COI.fMITTEE
REGIONAL OFFICE FOR THE WESTERN PACIFIC
WP/RC5)rn/MJ.n .2 15 September 1954
Fifth Session Manila 10-16 September 1954 MINUTES OF THE SECOIID MEETING OF THE TECHNICAL DISCUSSIONS
ORIGINAL: ENGLISH
Institute of !Jygiene, Manila Wednesda,y, 15 September 1954 ,at 9:00 a.m. MODERATORa Dr. G. GRAHAM-CUl1MING CONTENTS
1
Remarks by tlie Mooerato·r Reports from Discussion Groups What is the basic unit in areas where limited or no health services exist? Obtaining suitable workers· for Health Departments The utilization of multi- and bilateral assistance for countries or. territorial health programmes 2 2
2
2.1
2.2
3 3 6
3 4
General Discussion Evaluation Session Group I Group II Group Group Group Group III IV V VI
13 13 14 14
14 14 14 ~
Group VII
WP/RC5/rD/Min.2 Page 2 1 REMARKS BY THE MCDERATOR
The MODERATOR stated that he proposed to divide the session into two parts1 (1) Consideration of the Group Discussion Reports and Recommendations; ani
(2) The evaluation of tre Technical Discussions. He informed the session that he would call on a representative from each group to comment on their 2 REPORTS FRO~!
~oup
report.
.DISCUSSICN . ·CJWUPS
Dr. lEE, Chairman of Group B, opened the discussions by stating that his group had considered t .00 question in accordance with the pattern suggested. 2.1 What is the basic unit in areas where
limited or no health
services exist? Following general discussion, it· had been agreed that this should be the smallest government unit which had a population of five to ten thousand persons. The minimwn services which the health unit· should supply were rnatemal and child health, including domiciliary midlt fery, medical care, environmental sanitation, health education and the prevention of coll'lllunicable diseases, including immunization. sanitaiY inspector. Consideration had been given to the question of staff, which it was felt should consist of a nurse, midwife and Considerable argw113nt had taken place on the need ~rk
for doctors in such units and it had been pointed out that inducements must be offered to staff to attract them to in. the rural areas.
These inducements might be classified as good salaries, satisfactory housing, some form of transportation in difficult areas and opportunities to
practice outside thei.r areas.
£\s far as community involvement was con-
cerned, the group was of the opinion that the ccntribution from the government matche'd by om fran the conmunity raised
tv
taxation would be a suitable /it was agreed
neans of involving the CO!TI'l1unity in the finances of the health unit, but
WP/RC5ftD/Min .2 Page it was agreed that this was not possible or advisable.
3
It was agreed that
the government should contribute to the health project in the first instance and that local taxation was not advisable until the value <f the health project had been firmly established in the community. The lines of administration to be followed should be fran the central government to the periphery"
2.2
Obtaining suitable workers for Health Departments The group had only considered the training of doctors and auxiliary
personnel.
As far as doctors were concerned, they were emphatic that docAuxiliary workers were defined The cpestion of assessing the
tors shouJd not be trained on two levels. for that particu~ar
as any type of health worker whose training was below the officiai standard category of health work. needs for auxiliar,r personnel was also discussed in relation to the various countries represented, and it was felt that emphasis should be placed on practical rather than on theoretical training. The dangers of auxiliary workers seeking full professional recognition, was also stressed,and it was felt that they should not be allowed to rise from the auxiliary grade unless they could fulfill the full educational re1uirements; special grades in tll3ir own category might also be created as a reward for their skill. The group was of the opinion that auxiliary personnel should only be used when there was an inadequate supply of higher gr.ade personnel. 2.3 The utilization of multi- and bilateral assistance for countries or territorial health programmes 4.s only a short time was available for discus.sing this question, no decisive answer had been agreed upon concerning the minimum stage of develoPment required for profitable utilization of outside assistance. The basic assessment of the capacity of a country to utilize outside aid was actual evidence of willingness to pass laws and make appropriations to ensure the p:lnnanence of· the programme. The value of short-tenn consultants depended upon the project and the person, but in general such
/visits served
WP/RC5/rD/Min.2 Page 4 visits served as a stimulus to bring together different groups in order to discuss the problem and at the same time contribute sp3 cialized lmowledge of' the local staff'. Dr. YEN, reporting for Group A, stated that during the discussions, the recruitment of' health wcrkers had been considered as there was difficulty in obtaining thea in remote areas. work. It had been suggested that if' the salary scale of' heal tl;l workers was raised, more people w:>uld be attracted to the This would, howev:er, be a difficult thing to do in view of the It had bean financial lim:i.tations of tre budgets in many countries.
pointed out that in sane areas in the Region, a system had been adopted whereby health workers were first ·assigned to the outlying areas from which they were gradualJ¥ moved into more central positions. conclusion was the group w~s rea~hed
No definite
on this point 1 although the group had benefited Another phase of' t~
from free discussion.
subject which had interested
public health nursing, and they had been fortunate to have
the benefit of Miss Sand in their discussions. The question of whether the nurses employed in public health units should be clinical or public health nurses had been considered. Some members of the group had conThere sidered that the public health nurse was too expensive 1 ltlile others felt that slB was most useful and would serve a multiple purpose. assistance. ficial. to had been frank expressions of opinion regarding multi- and bilateral There was no doubt that this type of' service hSd been b~ne although on sane occasions, the type of aid had The group_ strongly supported the view th..~ govonw:~nts,
bes on too high a level.
any
count:cy accepting assistance should see that a.ITangements had been made for continuation of the progranme after the withdrawal of international staff. Governments must feel free to express their opinion of interna... tional staff as occasionally they might feel that they did not fit into the- picture •
/Dr.
BLAND, introducing
WP/RC5/rD/Min .2 Page 5 Dr. BIJJID, introducing the report of Group
c,
stated that he wished
to offer sane comments on the question of obtaining suitable health workers. ]tv'ery person in the group had more or less the same line of thought that the career of the health officer was not sufficiently attractive to obtain recruits in the numbers needed. Medical Schools did not appear to be placing sufficient emphasis on the preventive aspects of health, and it was thought that vlHO might be able to help by calling the attention authorities to this need.
ot the university
Public health nurses were not so difficult to They should be able to
recruit as doctors, but public health nurses should not be specialized in preventive and health education aspects only. them from undertaking their other duties. carry out curative aspects of the work, provided this did not prevent Sanitary inspectors should be properly trained and qualified worlcers, and their duties should be more clearly defined so that their work was that of a health educator rather than a policeman. The group had also considered what the minimUm unit should be It was agreed that could be put into an area where no services. exj.sted. health who was the first essential of such a unit.
that the ·unit could not work efficiently without a medical officer of Additional members required were. considered to be a public health nurse arrl a public health inspector, both of whom would be sup:Jrvised by the medical officer. Some members believed that !3- midwife was more important than a public health inspector, but that had not been the general opinion. The members had expressed satisfaction with the international assistance received, but had felt that it was necessary to assess the country's ability to absorb the aid given. criter~a
The varying conditions ani problems existing in the dif-
ferent countries had made it impossible for the group to determine the on which such an assessment might be made. The importance of The group h.ad expressed establishing a co-ordinating committee to see that there was no duplication of international aid had been stressed. the opinion that the subject given h1.d been too broad to permit more than superficial examination, and that Technical Discussions at future meetings should be confined to a single problem canmon to all or many /of the countries
'rP fltC5jrn,/Mi.n .2
Page 6 of the countries in the Region. The French speaking representative be-
lieved that it would be preferable to have all French speaking members grouped together with soroo bilingual representatives, as they had experienced difficulty in following the discussions. The MODERi..TOR stated that the canments made showed a ma;-ked divergence of opinions amongst the members of the groups and between the groups, ani asked lhether there were any members ltlo wished to record any dissenting opinion with, the typed version of the reports. l;.s there
were no conunents, the ltJDERATOR stated that the reports were open for general discussion.
3
GENERAL DIS CUSSIOO Dr~
ANDERSON commented on the second paragraph of Group C•·e This conclusion was the opposite of that
report in which it appeared that the midwife was the least important meni>er of the health unit. most important. drawn by Group B who had oonsidered that the midwife was probably the Dr • .1.\NDERSON was of the opinion that midwife:ey was ani that in
the foundation stone of any rural health service in this Region, approach to the people was the most important one.
any area where western medicine was not yet accepted, this line of
In repzyi.ng, Dr. BIJOOl stated that his group had merely con•
sidered the minimum basic health unit and there was no suggestion that the midwife was the least important roomber. The public health nurse, by virtue of her qualifications, was herself a midwife and could assist in the training of the local midwives in better. methods and techniques. Colonel DEMANGE was of the opinion that following experience in French Overseas Territories, the midwife should be introduced earlier than the public health inspector, as she dealt with the basic needs of the population. /Dr. MACLEAN added
WP/RC5/rD/Min.2 Page 7
Dr. MACLEAN added that from the public health point of view, children were exposed to more risks in their earlier life thm. at tba time they were born. .£-.s it had been the basic requirements his group had discussed, they had felt that however desirable the services of a midwife were, the requirement could be easily covered by the presence in the unit of a nurse and a health insp3ctor Under the supervision of a medical officer. Referring to tba report of Group
c,
Dr. LEE stated that the medical
officer of health represented the basic personnel for a health unit.
In
many areas covered by the members of the group, however, it was difficult to obtain enough medical men to head these basic units, and therefore the staff reqUirements of the unit had been limited to personnel easily obtainable • The MODERATOR asked Group A. to speak on the canposition of the basic . health unit, as they appeared to have quite a different scale of staff in their recommendations. Dr. EJERCTIO referred to the difficulty of obtaining sufficient physicir.llls to head the health unit, but said that it was the opinion of his group th1.t it ~uld
not bo a very good basic health unit if it were not
headed by a medical officer. Dr. YEN drew attention to the fact that Group A had recommended
a bigger staff than the other two groups, as they had felt that the basic health unit was a no:nnal unit. If the area is big and sparsely populated, it might be necessary to establish sub-stations where doctors might not be necessary, but the midwife and the nurse important. sub-units.
Many of his group
had agreed that a midwife was essential in any health unit, including If the area was circumscribed but highly populated, it might Health education work should be done by be necessary for the sub-units to have doctors, who were not merely public health doctors or clinicians.
/all workers
WP/RC5/rD/Min.2 Page 8
all workers in the unit.
It might also be useful in certain circumstances
to attach specialists to the unit, e.g., malariologists. The MODER.:cr'OR stated that the divergence of opinion appeared to be in the exact rileaning of a basic health unit. mentioned; where was one to draw the base line. Dr. DO\tiES was of the opinion that the inclusion of a nurse ani a midwife was too much. The post . of midwife was important and·. should To obtain the cooperation of the be included in every health unit. Sub-units had now been
people in a communit-y, it was. necessary to stress the curati:ve side, and
to look after the health of the new born baby and to give innoculation.s was of value. Dr. DeLIEN considered that there was no reason for stressing ei~her
one. or the other aspect whiCh could not be separated in a field He felt that. the family, the community and the profession . should
unit.
be treated as a whole. Dr. EJERCITO ste.ted that in his group, there had been no argument regarding preventive and curative medicine. It was, however, his opinion that curative medicine was -more attractive to the population; medicine and drugs attracted people to the health centre and in this way, they could
be educated to the idea of preventive medicine. Dr. De LIEN was of the opinion that where there was a plethora of doctors, the unit would differ · fran that required in a country where there was a shortage of doctors • . In the latter case, it would probably be necessary to organize sub-units. Dr •. ELICaNO was of the opinion that the needs of the country should be considered. In areas where there was a high birth rate and many places beyond the reach of licensed doctors, it was necessary to have micbt ves /in the health unit
WP/RC5Jrn/Min.2 Page 9 in the health unit, first~ because they were needed and secondly 1 because
they were cheaper than doctors or nurses. Dr. LEE asked the group whether they were satisfied with the definition of a basic health unit as so much seemed to depend on the area, population, economic situation, geography, etc. reached. Dr. EJERCITO felt th:xt it was important to decide on what a basic health unit was,as otherwise countries in the Western Pacific Region would have different health units and it would not be. possible to com~e
It seemed difficult to
argue about the personnel and services required until a definition was
s,ystems.
In view of the stress laid on midwi vas, he suggested that one midwife be added to the team of medical officer, public health nurse and sanitar,y inspector. Dr. YEN informed the group thllt the sub-unit was not meant to be a minimum heat. th unit. It was not 31'1.
independent unit but a branch of the
main health unit, so that nurses and doctors could be sent out to the subunits from the basic health unit. Doctors need not be attached to subunits, but there would be trained nurses to ca:rry out the functions of the unit under the supervision of medical officers. Dr. iJIDERSON was of the opinion that· the sub-unit was essentially the midwife who could handle about 2 ,ooo people. Group B had . mentioned 10,000 people, so there should in actual fact be five midwives attached to this unit, one working at the centre and the other four in outlyiDg districts. Dr. SODA stated that the basic health unit should be tre smallest unit which could render the minimum scope of well-balanced health services. 'fhe sub-unit might be established for the purpose of rendering special services according to the area, in which case it might sanetimes cmsist of /a midwife
WP/RC5/rD/Min.2 Page 10
a midwife
o~,
while in others the malariologist might be the most
important person. Dr. a~tend M:~CLE1lli
felt that there might be sane danger of falling into ;.\.midwife with 2,000 h~alth
contusion in the matter of nomenclature.
b~rths
to
to could do much more than just attend to women in child birth nurse as
and would, therefore, be acting vezy much lik;e a public considered by Group
c.
It appeared that
~here
might be sane confusion in
regard to the activities and functions of health workers in relatioq to the na.rres given to them. Dr. liNDERSON was not willing to anend the tern flmidw.ife" to J>Ublic health nurse. He felt that the midwife was tb3 foundation stone of rural health services and came int.o closer contact with the people so that; she was able .to report back to .the centre aey conditions relating to housing or health which required attention. access to a house, whereas it might health nurs~ someti~s
The midwife had prima.:cy
be difficult for the public
or sanitarian to go there without a valid excuse.
Dr. 1-K>Rr•\RA stated that he had como across throe different types of midwives: {~)
the public health nurse who had received training in mid-
wifery; {2) the second class midwives found in certain countri:l s who had been trained in the ancient practice of midwiferY; and
(3) the indigenous {llidwives who have had no training cf any sort but could assist women in delivezy. Dr. ANDERSON replied that his concept of a midwife was a wanan who had been trained in midwifery for a period of 18 months to 2 rears. In Malaya, there were two types a (1)
the nurse midwife and the bidan who was not a nurse but who had had experience
{2)
in midwifery.
/Dr. BLAND was
Wf/RO 5JrDftf;i.n •2 Page 11
Dr. BIJ;ND was of the opinion that the difference of the midwife.
1~
in the status proper
He maintained that there was no point in
givin~
attention to the mother and child during child-birth if three years afterwards the child died of 3llother disease. The public health nurse who was midwi~e
trained in health education and the ' sanitarian who had been trained in health and environmental sanitation were .just as important as ._ the
in a place
where there was no health education or -environmental sanitation going on. The MODER:aoR stated that some people considered the subject in _ terms of the rural health centre, others in terms of individual functions; as it
wa.s not necessary to reach a definition, he suggested that they pass to "Consideration of the RecoJTDllendations". Dr. STRAHiiN asked the group how they wished the report, .w hich would be referred to the main colTDilittee, to be arranged. and recommendations. The group adjourned for a few minutes to consider this matter. The ~MODERb.TOR then asked for a definition of a basic health unit. Dr. LEE suggested that 11 the basic health unit shall be that administrative health urii.t capable of providing the basic health services for a community under the direct supervision of a physician". This appeared to be sufficiently flexible for any cou.ntr,y. It had already bee~ generally agreed that the basic health services should be MCH, communicable disease control, environmental sanitation, health education, medical care and tre maintenance of minim~~
.i.t previous meetings,
it had been customar,y to base the ·report an the group discussion reports
statistical records.
As there were no further comments, the HODER..&TOR suggested that tre
final discussion reports of the throe groups and tre document to be prepared /on the day's
WP/RC5/rD/Min.2 Page 12
on the day's discussions be adopted as part of the documentation· and proceedings·. group. Dr. DEMliNGE asked whether it might not be possible to have more translators so that the .French speaking representatives could stay with the general group. The suggestion of a. separate group had onzy been made following the experience of the day before 'When it had been difficult to follow the discussions arid express views. Dr. SAYCOCIE felt that it wotlld not be good to divide the groups by language, as the French speaking countries of Ca."nbodia., Laos and Vietnam had the saJOO problems, and it would be preferable to join groups with other experiences. Dr. GE.;Ut informed the committee that the basic point was that the technical discussions were completely informal and were established by the Executive Board in order to provide an outlet for purely technical conversations,as it had been felt that due to misunderstandings, some delegations were leaving the assembly with a. feeling of frustration. Although these discussions had been in operation for three years, they were still in the experimental stage, and it was still debatable whether they were serving a good purpose. into account ~
He then asked ·tor conments on the suggestion that French
speaking representatives should in future fonn a separate discussion
There was no need to take
official considerations as far as WHO was concerned. ~
The participants were meeting as individuals and not as government representatives. technical discussion group could make aqy rule of procedure it wished. Dr. BLAND stated that if it were possible to find sufficient interpreters, then the French spe ak~g people would probably prefer to remain in the mam group. If this was impossible, then they could have a more interesting discussion in French in a. single group.
/Dr. STR.tili&i informed
WP/RC5)rD/l-fin .2 Page 13 Dr. STR.::.....tt•.N informed the conunittee that the staffing situation was not sufficiently strong to carr,y out arrange~ents as efficiently as was desired. It was agreed that the recommendation should be included anong the official recommendations o£ the group. 4 EVi'J.U.i..TION SESSION The MODERATOR explained the method to be used and then asked the session to move themselves into small groups in order to answer the evaluation questions. A reporter from each of those small groups was elected and the folloli ng reports were made a Group I. Miss Sand reported 1
The best sub;P ct was "The Fupctions and Composition of a Basic Rural Health .Unit". The best technique was the invitation to observers and other experts to join the discussion. 1J.l the subjects ware of equal importance. The least interesting technique was the panel discussion method as the subject was presentGd too fast and sometimes people spoke together. The environmental conditions of the room were unsuitable. Recommendations: It would be more beneficial if before
technical discussions are considered, a glossar.Y of definition of terms was included in the basic documents. Everyone should be encouraged to speak or participate in the discussions. /Group!!.
WP/RC5irD/Min.2 Page 14 Group II. Dr. Hennessey
This group liked the best the opportunity of meeting other representatives and observers for informal discussions and of obtaining information in regard to other countries in the Region. The panel discussion did not contribute sufficient stimulation for group discussion. The basic subject was too wide and a more particular subject matter would have provided better discussion. Group III. Group IV. No report. Dr. Soda
The conclusions of this group were: already mentioned by Groups I and Ils The informal nature and impartial attitude of ti,~\e
participants in the technical discussions was outstan4ing.. The subject was too broad for the available.
Group V.
Dr. You Chhin
Que stions one and two pgrmitted the exchange of views between representatives fram different countries. The Subject was too vast and a more limited subject matter would be prefer~ble.
Parti cipants should be divided into a bilingual -and French speaking group and English speaking group. Group VI.
Dr. Regala
Agrees with other groups apart f:ran the statement on panel discussions which they found useful. /Group VII.
WP/RC5Jrn/Min .2 Page 15 Group VII. Dr. Clapham
The size of the group was adequate and the provision of background material was appreciated, although this should be sent out earlior to participants. Suggested topics for tho following year: (a) (b) Domicialia.ry midl,dfery as a means of approach to people. Health Education.
The 1-IODERia'OR then stated that the meeting was now open to discussion oft he points raised. If no further coJIIi11ents were raised, then the remarks would be included in the official recommendations from the meeting. Dr. LEE suggested that a vote of thanks should be extended to the panel members for the part they had played in the discussions. seconded by Dr. Dr. rt~CIEltN
This was
and carried unanimousl.y.
MACLE~\N
also stated that as the groups did not have sufficient
time to make recommendations regarding subjects for future technical discussions, he hoped that the Secretariat would not be confined to the subjects suggested, but that countries might feel free to send in suggestions later on.
Colonel AUCERE thanked Dr. GRii.H1u,I-ctJMMING for acting as Moderator. His conciliating attitude and wise direction made him acceptable to them all. The rooeting adjourned at 12:10 p.m.