WPRO-128
FIFl'H R'EnIONAL SEKI:NAR ON PUBLIC BEAIlI.'H ADMINISTRATION: nm:aRATION OF BEAIIm SERVICES
Sponsored by the
WORlD BEAIIm ORGANIZATION REGIONAL OFFICE FOR THE WESTERN PACIFIC
MANILA, PHILIPPllIES
15 to 28 February 1966
• FINAL REPORT
by the
I •• I
R'EnIONAL OFFICE FOR THE WESTERN PACIFIC of the Wor1d Health Organization Manila, Philippines
May 1966
NOTE
/'
The views expressed in this report are those of the advisers and participants at the seminar and do not necessarily reflect the policy of the World Health Organization
This report has been prepared by the Regional Office for the Western Pacific of the World Health Organization for governments of Member countries in the Region and for those who participated in the Seminar on Integration of Health Servicc.s which was held in Manila. Philippines. from 15 to 28 February 1966. A limited number of copies are available on request to persons officially or professionally concerned in this field of study.
TABLE OF CONTENTS
1•
INTRODUCTION .......................................................................... . CONCEPT OF INTEGRATED HEAL'lH SERVICES ••••••••••••• COUNTRY REPOR'IS ••••••••••••••••••••••••••••••••••• INTEGRATION OF BASIC HEALTH SERVICES •••••••••••••• INTEGRATION OF MASS CAMPAIGNS IN 'lHE GENERAL HEALnI SERV'ICE ...................................................................... ..
1
2.
2
3.
4
4. 5.
8 10
6.
PllBLIC ADMINISTRA'rrON ASPECTS IN THE INTEGRA TION OF HEAL'lH SERVICES ................... . COILABORA TION BE'IWEEN 'lHE HOSPI'rAL AND THE
11
7.
GENERAL HEALTH SERVICE •........................... 8.
15
COLLABORATION BE'IWEEN PRIVA'IE MEDICAL AND ALLIED PROFESSIONS AND 'lHE GENERAL HEALTH SERVICE •••••••• COLLABORATION BE'IWEEN VOLUN~RY
17 18 20 21
9.
AND OFFICIAL
HEAL'I'fI AGENCIES .................................................................... ..
•
10.
COMMUNITY :CEVELOPMENT AND THE GENERAL lIEALm SERVICE ...................................................... ................ .. INTER-COUNTRY COLLABORATION ON HEALTH PROGRAMMES THE ROLE OF IN'IERNATIONAL ORGAN:;:zATIONS IN THE
11. 12.
PROMOTION OF INTEGRATION OF HEALTH SERVICES ••••••• 13 .. CONcr.USIONS ............................................................................ ..
22
25 II
ANNEX: 1 - LIST OF CONSULTANTS, PARTICIPANTS, OBSERVERS, SECRETARIAT AND RESOURCE PEffiONS ............................................................... .. ANNEX 2 - AGENDA OF THE SEMINAR •••••••••••••••••••
27
31 3r
ANNEX: 3 - SUMMARY OF COUNTRY REPORTS ••••••••••••••
..
1.
INTRODUCTION
The Fifth Regional Seminar on Public Health Administration on the subject, "Integration of Health Services", was convened by the 'WHO Regional. Office in Manila, philippines, from 15 to 28 February 1966. There were seventeen participants frOm sixteen countries and territories in the Region. UNICEF. tl..e South Pacific Commission and the Department of Health of the Rel'ublic of the Philippines were each represented by an observer. Four 'WHO field staff members assigned to public health administration projects within the Region attended as resource persons. One of the three consultants was international1~ recruited; the other two were detailed by WHO rleadquarters and EChFE. respectively. The list of participants, observers, consultants and resource persons appears in Annex 1 of this report. The objectives of the Seminar (1) wer~:
to exchange country experiences and to consider current problems and approaches to the integration of health services under national. health administrations; to review current trends and problems of co-ordinating programmes within the health agency and with related programes of other agencies j to stimulate inter-country co-operation in tackling health problems of mutual interest and to explore the roles of international. bilateral and other organizations in its promotion.
(2) •
(3)
The Seminar was forma.J.ly opened by Dr. I.C. Fang, Regional. Director, who observed that "while integration is the cOI!ll!lOn aim of national. health administrations, it has, for a number of reasons, not been easily realized". He not.ed the assets which the Seminar could mobilize for its task, namely, the eJq)erience of Member countries in integration measures and technigues, the attendance of national officers who had been engaged in integration efforts back home and the presence of consultants who possessed knowledge ot and experience in the subject matter. The programme of the Seminar (see Annex 2) involved consideration of eleven topics. Each topic was taken up in three meetings: a first plenary, whe.r.e a consultant introduced the subject with the assistance sometimes of one or more regional advisers and, in one instance, of a resource person from the Office of the Presi1ential Assistant on COJIIDUIlity Development, Republic of the Phil.i.ppines; separate discussions by the two working groups constitut.ed by the participants, observers and attendin<:': WHO staff members j and a second plenary, where the reports of the working groups were discussed and reconciled. In the presentation of the country reports, copies of which had been distributed beforehand, each participant
.
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ws allowed fifteen minutes to summa.rize and repl.\v to questions frOm the fJ.oor. The t-Opic on the roJ.e of international. organizations in the promotion of heaJ.th services integration 'Was presented in pJ.enary by a paneJ. made up of the WHO Operational. Officer and the Representatives of the South Pacific Commission and UNICEF. The seminar group eJ.ected a chairman and two vice-chairmen who presided al.ternatel.\v by t-Opic. A rapporteur and two co-rapporteurs were aJ.so chosen. The rapporteur prepared a summa.ry of each topic introduced and consoJ.idated all the group reports for each topic. One co-rapporteur ws given responsibillty for summarizing the country reports which were cJ.eared ind1vidually by the participants concerned before being incorporated in the seminar report; the other co-rapporteur assisted general.l.\v in the consolldation of the group reports on the discussion topics. Each working group seJ.ected a chairman and a rapporteur for each topic discussion. As much as possibJ.e, the consuJ.tants aJ.so rotated among the discussion groups. One workiDg day 'WaS set aside for a fieJ.d visit. With the assistance of the PhiJ.ippine Department of Heal.th, visits were made to two provinces near Manila (RizaJ. and Bul.acan) where heal.th centre and hospital. operations were observed.
The cJ.osing ceremony 'WaS heJ.d on 28 February. The seminar Chairman, Dr. G. BaJ.bin, speak1 Dg on behaJ.f of the participants and observers, expressed their appreciation to WHO for haviDg organized the seminar which had provided them 'With the opportunity of exchanging views and experiences 'With coJ.J.eagues frOm other countries and territories and of acquiring new insights into the concept and methodol.ogy of heal.th services integration. The consul.tants expressed their gratification for the free and friendl.\v exchaDge of views 8.IJIOIlg the group and the benefit they had gained from the two-way fl.ow of bowJ.edge and experience between them and their national. coJ.J.eagues. In cJ.osing the Seminar, the RegiOnal. Director expressed the hope that the participants wouJ.d adopt the concJ.usions of the Seminar, in respect of the concept and practice of heaJ.th services iutegration in their country environment, as it 'WaS onl.\v through this means that the objectives of the Seminar woul.d be realized.
•
2.
CONCEPr OF INTEGRA'l!Em HEAIIl'H SERVICES
2. J.
General.
With the advances in medical. science, mortaJ.ity and morbidity in all countries have been greatl.\v reduced. In many countries, however, measures to controJ. disease have not kept pace 'With clinical. medicine owing to the J.ack of funds and the difficuJ.ties in overcoming apathy and ignorance. It is therefore important to integrate preventive and curative services as cJ.osel.\v as possibJ.e.
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2.2
'rerms used 1
It is appropriate at this stage to adopt definitions concerniDg basic matt ... -rs, which 'Will be discussed 1ater, and it is of the highest importance that the terms and definitions used in this context be universaJ.l;y understood by and common to a.11 countries. (a) Mass caupaign _ a scheme for the contro1 or eradication of a particular communicab1e disease on a community-wide basiS, carried out by machinery operating 'With this precise objective. (b) GenersJ. hea.1th service - a country-wide system of established institutions 'With mu1ti-purpose objectives, having a definite organ1zat1oll8.l. structure at a.11 leve1s - local, intermediate and central - w:Uch would provide services for the promotion of health, as well as for the prevention and cure of disease and disab1lity • (c) Integration - a series of operations concerned in essence with the bringing together of otherwise independent administrative structures, tunctLons and mental attitudes in such a way as to combine these into a whole. 2 It is appropriate to mention a.1s0 an ea.r!.1.er definition in whicll the eJ!;pression "integrated hea.1th service" was defined as lithe service necessary for the hea.1th protection of a given area and provided either under a single administration, or under several agenCies, 'With proper provision fOr the co-oreination of these services". 'rhis visua.l1~r.d a situation in which integrated services rm.y be entirely satisfactory under more than one administration, provided there is adequate provision for their complete co-ordination. 2.3 Purpose
•
It is important to remember that integra.tion per se is not an eM in itself but rather a means to an end, with the broad objectives of efficiency combined with economy. Economy results from the central ordering of supplies, organization of training and common utilization of premises and facilities. Efficiency should result from centra.l plannjng and direction and the realistic deployment of manpower. However, efficiency nay be ha.!qpered by the mental attitudes of personnel, the adaptability and flexib1lity of whose minds cannot a.1ways be relied on. Integration of health services is unlikely to succeed without the goodwill and enthusiasm of staff at a.11 1evels. 'rhere is, nevertheless, overwhelming evidence of the value of integration in developing countries whose health services are in incomplete stages of evo;J.ution. As Sir Eric Eddie has said about tuberculosis control,
~ 2wld Hlth Org. techno Rep. Ser., 1954, ~, 4 lvild Hlth Org. techno Rep. Ser., 1965,
•
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the integration of anti-tubercuJ.osis campaigns with the general. health Services, where such services exist, is essential. l In spite of this it must be emphaSized that IIIB.SS campaigns, however val.ua.ble, are tempo~ expedients although they may well contribui:e to the development of a continUOus whole-t:lJne integrated general health service. F1naJ.J.y , it shouJ.d be remembered that the pattern of disease is cbaDging and that the problem of an increasing world population overshadows all planning. One must be flexible and open-minded and what is suggested as a gOOd idea today may be inadequate or inappropriate for tomorrow. 2.4 Implications on personnel
..
As a resuJ.t of this changing pattern, certain medical personnel may become su,perUuous and the problem of their disposal remains unsolved. Some may be retained to serve in other disciplines but some may wish to cling to their former spec1al1ties. This is the consequence of an attitude of mind and education. If reasonable, compensation and the opening of new channels of promotion are necessary to prevent this situation arising.
3.
COUNTRY REPORTS
3.1
General .'
The country reports were compiled on the basis of a. suggested format which was sent in the form of a guide outline to participants in advance of the Seminar (see Annex 3). This provided for such basic information as physical characteristics, population, vital and health statistics, administrative organization and manpower resources for health, together with other significant information on the administration of health services to provide a background for the subsequent discussions· on integration. In the following summary of the reports, an attempt is made to present briefly the salient pOints in broad and general terms. 3.2 ¥?pulation and vital statistics
As one would expect, there are represented wide variations of total population ranging :from 71 thousand to 97 mill10n with equally wide variations in density and urban/rural situations. It is of interest to note that birth rates are commonly high and death rates decreaSing, while infant mortality rates and maternal deaths are still high in many countries. The proportionate mortalities at fifty years and over and
ii II II
lworld Health Organization (1965), Report on St~ of Progress of Integration of Schistosomiasis, Leprosy and TubercuJ.osis Services with ProgratmllElS of HeaJ.th Services, Geneva (doc. PA/10l/65 Rev.l)
• •
- 5under five years show wide differences. It is clear too from some reports tbat too much reliance shou1d not be placed on some of the essential health indices.
3.3
Political organizations
These ranged from legislative councils to the most sophisticated federal, presidential and state parliamentary systems.
3.4
Manpower resources for health
Here again are found extremes in numbers and ratios of medical and paramedical manpower in relation to population and it is appreciated tbat c~ar1son between territories with small self-limited p~~ulations, such as those found in SJDall islands, and large countries or densely populated areas is nothing more than a broad index of availability of basic staff for health requirements. A significant feature of many reports is the expanding facilities for medical and paramedical training. Educational systems in many countries appear to be adequate. However, this situation is apparently by no means uniform and in several instances concern ~s expressed that schools and instituticns to provide education and training in health disciplines were insufficient to meet the increasing need for the extension and development of the health services. Adminj.stration of health services National organization (a) The organization of healt1. services differs considerably. Geners.lly speaking, the more economically developed countries operate their health services at three levels (national, provincial, and local) and sometimes decentralization reaches town or village levels. Contrary-wise, the countries which are highly urbanized and cover a small territorial area do not feel it necessary to deconcentrate so far. In all cases, the pattern of health adm1ni stration follows the pattern of public administration and in no case are there special health regions in which bou."daries do not coincide with the public ailm1 xU stration regions. However, in certain countries the regional or local level does not correspond with an administrative or political authority. This may resu1t in difficulties where part of the health expenditure should be covered by local taxation. (b) as a separate of welfare or of health but In most countries, the health administration is organized ministry, but in some cases it is merged within a ministry "')cial affairs. In the territories there are no ministries only executive agencies and services.
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• (c) The financing of heal.th services follows ve.r1ous patterns. Many possibilities exist bet-ween a COlII.Pletely centralized service, -which covers expenditure (for heaJ.th activ1.ties) from national funds, and a largely decentralized organization -where local. funds coming from provincial. and/or municipal. taxation are used for financing the corresponding heal.th serv1.ces. The degree of decentralization of financial. sources varies also according to the type of services performed. commonly, mass campaigns are covered by the national governments and J.ocal. health services and hospitals may receive part of their funds from local sources. Heal.th insurance or social. security schemes have been created in the develOped countries of the Region. However, some interesting developments can be observed in a few of the developing countries -where health ins·.xrance is l1mit.ed to certain groups, such as government officials, salaried -workers in industries or to some professional groups. (d) Some countries are contemplating, or even illl.Ple..nenting, long-range national health plans. The dra:t'ting of the plan is, in most cases, the responsibiltty of the health administration itself. With a few exceptions, there are committees for socio-ecor.omic planning at national level and in some countries the targets for the extension of health services are closely integrated -with rural develOpment pl a nn1 ng.
3.5.2
Local. health services
(a) As a ru1e, the basic heaJ.th services are available to the pOpulation and integrated at the local level. Their level of efficiency obv1.ously depends on the qualifications of the personnel attached to the J.ocal heaJ.th services. In the most favourable conditions there are quaJ.ified physicians and public health nurses; in others, there are medical assistants or auxiliary personnel. (b) The curative and prevent!ve aspects are integrated and the local service practises referraJ.s -when distance, COmmunication and the availability of hospitals make this possible. (c) In many cases, the local services are paid by the central government but the local authorities may also contribute. Sometimes, voluntary organizatiOns participate and the people help by providing the land. and building the premises. (d) In most countries, there is a trend towards encouraging local authorities to participate in health planning by expressing their problems and their needs to the local health officer. The degree of 1III.Plementation of the plan depends on financial possibilities and available personnel. (e) The IlB1n current problems seem to be: of qualified personnel, and diversity of dialects. lack of funds, lack
,
3.5.3
Mass campaigns
(a) The type of mass campaign depends on the prevaJ.ence of specific diseases and priority is given to the fight against diseases -which are most prevaJ.ent and economically 1III.Portant.
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beg~nning
(b) Mass campa.:igns are undertaken by special. teams at the of the campaign and there is a marked tendency to transfer operations to the general heaJ.th service as soon as the consolidation phase is in view. Thus, integration seems to be a natural. trend. However, the spec1al1zed services, such as mal.aria eradication, remain separated longer than more current campaigns such as iIDlDUnization against smallpox. (c) The extent of collaboration depends on the stage reached by the mass campaign and no particular problems seem to be raised.
3.6 Voluntary organizations, who~ or part4' engaged in coIDlDUn1ty heaJ.th work, are operating in almost all the countries of the Region, their. activities depending on the degree of social consciousness of the people and the level of national economic development. While religious missions, women 1 s organizations, the Red Cross and St. John 1 s Ambulance Association are the principal organizations undertaking cOIDlDUnity health measures, a few countries have established naticnaJ. organizations for food sanitation, improvement of nutnt:!on and parasite eradication. There are also voluntary organizations for the care of the old, the infirm and menta~ retarded, for prevention of tuberculosis and cancer, and for the care of the physicall.y handicapped. Voluntary organizations of a pure4' local cbaracter appear to function best where local government administration is running the local health services efficientl¥. Co-ordination with the government I s heaJ.th department exists where these organizations receive subvention frOm national revenues, but in other cases it is conspicuous by its absence. Duplication and overlapp:i.':g are common but it is encouraging to find that earnest efforts are being made by governments to co-ordi:late the work of these organizations with the heaJ.th department. 3.7 The coIDlDUn1ty development movement, which has made noticeable headway in many countries, is still new to some. The personnel of the health services are generall.y oriented to the community development philosophy and have made good use of techniques to initiate and implement health programmes successfully. There has been little or no coordination between coIDlDUn1ty development workers and heaJ.th personnel in some countries due t<J lack of appreciation of the inter-dependent nature of community development and health work, especiall.y in the rural. areas • ..\nother reason is that community development programmes may not have been well conceived. The countries concerned, however, are now making efforts to remedy these defects.
3.8 Inter-country collaboration is limited except for projects like maJ.aria eradication or surveys for yaws. One project worthy of special mentirm is the collaborative study of cholera El Tor by Japan and the Philippines. Facilities for training of health personnel fro!'; countries in the Region are provided by some countries.
.8 -
JOOst, i f not all, of the international.l¥ assisted projects for 'Which technical assistance has been provided by WHO and UNICEF are helping to promote the integration of health services.
3.9
4. 4.1 General
lM'EGRATION OF BASIC HEAI1.rH SERVICES
All countries have at some time in their development reaJ.ized the importance and value of having an integrated health service. This health service requires to be organized at three levels central, intermediate and local. No strict rule can be set for the organizational structure for all health services but, as a general principle, the more developed a country becomes, the more speCialized is the type of health service required. 4.2 Central level
The central or ministerial level is responsible for such :functions as communication up and down the chain of comma.nd, formulation of policy, planning of programmes, determination of standards, operational research, finance and co-ordination of all parts of the health service and, in most developing countries, for the establishment of hospitals and provision of drugs and supplies. The ministry must also promote close and harmonious relations 'With other government departments.
4.3
Intermediate level
At the intermediate level are such services as hospitals, mental health, air pollution ('Where this is not included in routine environmental sanitation), laboratory services, ambulances and transportation. These should be under the overall responsibility of a medical officer trained in public health and to him some duties and :functions of the central authority may be delegated. 4.4 Local level
At the periphery are health centres under the care of a medical officer(s) or medical assistants 'With a team of nurses and sanitarians. In deveJ.oping countries 'With limited resources a health service 'With multi-puxpose personnel is required at this level. These multi-puxpose personnel 'Will, in time, as the level of national development improves, be replaced by professional personnel performing more specific duties. Health centres may be urban or rural or mixed and for their success the active participation of the local people, together 'With adequate finance, are essential.
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At each level, officers are required to supervise those subordinate to them and this duty is usually specially applicabl.e to thOse at the regional. or intermediate l.evel..
4.5
c~onents
of the basic services
The following are the seven basic servicesl. provided by such heal.th centres: maternal. and chil.d heal.th communicable disease control environmental. sanit;ation preparation and maintenance of statistical records health education public health nursing medical. care (to an extent varying 'With the needs of the area and the accessibility of l.arger hospital centres) In general, all the services are bound so intimately with one another that they are inter-dependent. Nevertheless, emphasis at this level. must be on l..ealth promotion and the local heal.th officer must be health conscious and preferably trained in public heal.th. However, mul.ti_purpose personnel. may profitably be empl.oyed and staff should al.so assist in the formulation and impl.ementation of community devel.opment projects, promote close liaison with voluntary organizations p~d private practitioners and establish goodwill with the local. admi~stra tors and leaders of the community.
•
•
Health education is one factor common to the seven items of a basic health service and its importance cannot be over-emphasized. All health workers are involved in heal.th education. It is emphaSized too that child heal.th does not cease after infancy but must be continued through school life.
4.6
Factors which hel.p integration
Integration of these basic heal.th services at local level is tacili tated by the training of personnel to work together and by teaching them the essentials of one another's diSCiplines, by supervision of their activities with advice and assistance where required, by adequate planning and evaluation, by provision of suitable transport facilitiea and by a fajr and equitable distribution of available funds. Regular staff meetings 'With an agenda and the power to influence departmental policy are also of value. Post-basic training of personnel also maintains interest and the necessary spirit of co-operation. The stimulation of universities and medical schools in the deve10pment of community health consciousness was noted. Urbanization and mass movements of population, with resultant overcrowding and poor hygiene, are problems to be overcome.
•
lwld HUh Org. techno Rep. Ser., 1954, 83, 4
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Co-operation with non-health agencies In some countries the health services are administered by ministries other than that of health and this is not considered a bar to their efficient management. Integration does not mean fusion and by maintaining good relations with other departments the public health services can be successfully co-ordinated.
c
5.
IN'l'llX:mATION OF MASS CAMPAIGNS
m
THE GENERAL
HEAmH SERVICE
5.1
Mean1Dg
of mass campaigns
A mass cam,paign may be defined as a scheme for the control or eradication of a particular communicab~e disease cn a community-wide 1 basis, carried out by machinery operating with that precise objective. They are specific projects having a definite time-table and requiring special mobilization of workers, resources and supervisors. They are not to be confused 'With special disease control programmes which may be carried out by the general health service with existing personnel and therefore cause little or no difficuJ.ty in integration. 5.2 Requirements
Mass campaigns are of particular concern to developing countries since they are directed against certain specific diseases which are common in such areas. They are attractive to governments with limited resources as they are undertaken for only a specified time, the resuJ.ta are quicJt4r demonstrable and may often be spectacular as a remlt of modern drugs, vaccines and insecticides, and they are usually popular with communities. No mass campaign, however, should be undertaken without operational research or a pilot study to decide whether or not it is essential. However, such campaigns cannot provide the solutions to all. problems and the basic health services must still be provided. Nevertheless, they are not contrary to the concept of badc health services but are complementary to them and must be integrated with them. Mass campaigns require, particuJ.ar~ at the ear~ stages, personnel who can carry out their duties free from the other routine duties of the general health service staff. Tbese personnel shouJ.d, howe~', work in close co-operation with the existing healtb services staff. otber duties sbouJ.d not be assigned to such personnel at too ear~ a stage or the project is liable to be retarded. Mass campaigns require firm leadership and adequate finance, equipment, transport and motivation, particular~ at their early stages.
lwld Hlth
arg.
techno Rep. Ser., 1965, ~
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As the programme progresses, the early gains require to be consolidated and wherever possible this should be done by the permanent local health staff. As the campaign nears completion it becomes necessary to prepare for the· time 'When its personnel 'Will no longer be required and they should, 'Where possible, be retrained and directed into other duties. Campaigns directed against different diseases may require to be conducted in varying manners. However, it is generally desirable that the medical officer in charge of aDy project should be responsible to the director of the general health service, that existing facilities and staff should be used to the utmost, that local health staff be kept informed of what is planned and that, 'Where no such staff exists, the campaign be used as a spearhead for its eventual establishment. When an acute epidemic disease such as smallpox or cholera breaks out, special emergency teams may have to be organized but even here close liaison 'With the local health services is vital.
5.3
Relation to general health service
Integration of the staff involved in a mass campaign should be started as early as possible and it should then continue and intensify as the campaign proceeds. There is an optimum time for declaring campaigns completed which should be carefully assessed and all personnel should, as much as pOSSible, have been integrated by this date.
•
•
Integration is facilitated by several. factors, the chief of which is adequate financial resources for the general health service 'With 'Which to absorb the extra staff. This, in turn, is made more likely if the budget of the campaign is part of that of the general health service. Special training and re-orientation of the 'WOrkers is also vital so that they may have the correct mental attitude to-wards learning new skills. Careful planning of. the process by both the chief office of the service and that of the mass campaign is essential to the smooth integration of the operation.
6.
PUBLIC ADMINISTRATION ASPECTS IN THE mrEGRATION OF HEAIlffi SERVICES
6.1
General
All emerging nations have embarked on planned development as they are no l~nger satisfied 'With traditional conditions of poverty. In order to improve the lot of their people, governments must have a policy 'Which can be implemented 'With economy and efficient a.dJninistration. Sound public aC'!Iinistration obviates wastage, overlapping and duplication and in the text 'Which follows several aspects of administration related to the public health service are considered.
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6.2
National health pl.ann1Dg
It is essential to present a well-1'ormulated plan to the financial authorities in order to obtain a share of the us~ l.1m1ted national resources. Health, education and social welfare are still considered by many economists as "consumer services", although some are now realizing that money spent on these is trul;y prodUctive. Any plan must show priorities and the demands of economic and social development must be balanced. There is no clear index for doing this as it must be ba.sed partly on vital and health statistical information and other methods as well as consideration of the felt needs of the population. The final decision on expenditure on each service must be political. The field of puelic health is so large that it is difficult to quantify the value of every aspect of it. It is easy to show economists the monetary value of a malaria campaign or a hospital for acute illness but the value of a cancer clinic or of a geriatric unit is not so obvious. The deciSion as to which services are required should not be left entirely to the economists who ~ be unable to make a proper scientific judgement. A criterion bas not yet been developed to decide between the claims of economic and social development plans and in the field of' public health such a rigid determination could be dangerous.
6.3
Decentralization
Too much centralization impedes the development of health services. Decentralization can be performed by devolution or deconccntration. The principle of decentralization of health sel"vices should be pursued to the extent compatible with the availability of competent personnel, especially supervisory personnel. Where a capable local government organization exists, decentralization should be by devolution a progressive pa.ssing of powers and fUnctions in health matters to the local government body. However, many countries in the Western Pacific Region lack strong local government organizations and in such cases deeentralization should be by deconcentration, which is delegation of central authOrity to regional or aree. units. It is possible by deconcentrat10n to decentralize effectively even if there is no local government aOmini stration at the provincial or lower level. wcal health boards or councils bave a valuable role in ensuring public partiCipation in health services. However, it is most important that they should bave clearly defined functions and terms Qf reference. At the outset, functions are probably best limited to those of an advisory nature, but where adequate Official medical and technical representation is assured these bodies may take over certain adm:I.n1strati ve functions. There are three types of bodies which contribute to public participation in health and medical programmes. These are: (a) Voluntary organizations, usuaJ.l.y with a fund-raising programme and a narrowly defined objective. Efforts must be made to have voluntary agencies understand the health department I s total prograJllDe and not only their own limited field.
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(b) EJ.ected bodies - These. are usually beneficial. in putting forward public views and needs, though they may disrupt planned health activities by over-emphasis of unessential. points. (c) Appointed bodies - Carefully seJ.ected members represent. ing aJ.J. sections of the popul.ation, including the professional and technical skills, can be effective. Separate counci::..s for public health and medical care are not favoured. Local hecJ.th boards or counciJ.s should be strongly encouraged to take a balanced view of the total community health problem. There shoul.d be close liaison betveen the chief of the health programme or service and the council as they are mutually complementary. Financial powers should be delegated to appropriate leveJ.s in decentralized organizations. Without fiscal power, such decentralized units can have little real authority. There is aJ.so need for greater financial delegaUon to hospitals in most countries of the western Pacific Region. Not only does increased financial delegation simplify management, but it makes a greater number of senior hospital staff conscious of the need for economy.
6.4 • t
~ t and
accounting
In aJ.J. countries represented, it was considered that existi.ng methods of government audit and accounting tended to be oppressive, timeconsuming and uneconomical. All staff of a health department should be educated in cost on methods to avoid stock deterioration and on the necessity to avoid inflation of requests. Standard supply lists should be frequently reviewed to avoid the continued listing of redundant items. It is essential tm t the most direct supply routes to aJ.J. field points be kept open, and that bottlenecks in transit be avoided. a~ness,
6.5
Transport Adequate transport facilities are essential to any programme
and lack of them leads to wastage of health manpower and resources and
are a physical handicap to integration of hea.l.th services at the local level. The provision of an adequate transport system requires sufficient vehicles and vessels, close co-ordination of the activities of aJ.J. health personnel, and co-operation with those responsible for repairs and maintenance. When transport and equipment are inadequate, the assistance cf international agencies may be of value.
- 14 6.6 Vital and health statistics
Both short- and long-term health plans for incorporation in the nationru. develOpment plan shouJ.d involve the participation by intermediate or regional level and fiel.d units of the health department. A pre-requisite for all health plann1ng is a survey of local problems, including an exam:l.nation of available statistics and the allocation of priorities on the problems uncovered. In this connection, all countries represented considered their system of collecting vital and health statistics could be improved. It ws felt that improvements couJ.d be achieved in a variety of 'WB¥S, incJuding the following: training of greater numbers of health vorkers in the collection of statistics, education of health staff in the value and uses of health statistics, co-operation of the public and other governmental agencies with the health department in obtaining improved coverage, possibly with some form of inducement to register births and deaths, regular review of current data, and standardized record forms.
6.1
Personnel
Civil. cervants must be adequately remunerated, promoted o~ on merit, and ~iven satisfactory conditions of service and security so that they have confidence in the service. There 1DB¥ be a case for pB\Ying higher salaries to members of the health service in view of their responsibilities and longer training. Personal factors - such as families having children of school-ege- often prevent the depl~nt of staff to the best advantage of the country. Incentives are necessary to help ensure that the right staff could be sent where they are most needed.
6.8
Training
Be-training of personnel becomes necessary when integration is carried out as peOple ~ be required to undertake new and unfamiliar duties. Such training shouJ.d include orientation and training in administrative procedures and control of finance. Assistance to carry out this training is obtainable :from many international bodies. content courses remains left to Most medical schools are graduall:y increasing the preventive of their courses but so far as is known the idea of designing aimed at achieving a balance between preventive and curative aspects to be realized. Specialized consideration of preventive vorit is post-graduate courses.
•
- 15 -
• 7.1
7.
COLIABORATION :smrwEEN THE HOSPITAL .AND THE GENERAL HEAmH SERVICE
General.
Throughout the h:l..story of' the world the hospital has been accepted as the sanctuary of curative medicine. From the time of' Hippocrates to the present day however, there have been those who considered the existence of' hospitals to be an admission of failure on the part of' the preventive services and, during the French Revolution, their financial resources were for a time abolished. Nevertheless, the need for hospital remains acute and at the present time their growth and the cost of' their ailrr.i ni stration is out-3tr1pping the gross Dational. income of most countries. Though it ~ seem a paradox, th:l..s growth of' hospital services is largeJ.y due to the activities of thof!e concerned witil preventive medicine. Th:l..s has come about in four 'W8¥s: (1) OWing to the improvement of the public health services patients who need treatment are being discovered at an earlier and more eas1ly curable stage of' disease. The result is that these patients expect treatment and hospi'tals must be available to receive them.
•
(2) Preventive medicine is increasing the average expectaticn of life and so there is a greater frequency of the malignant and d~~nera tive diseases of the older age groups. Th:l..s has been lOOst str1ld.ng in the develOped countries.
(3) The improvement of communicati.ons, press and radio and their use to promote health education has made peOple more aware of what hospitals can do f'()r them. Suffering is no longer fatalistica1J.¥ accepted. (4) The concept of free or subsidized medical attention and the introduction of social insurance schemes have accelerated and increased the demand for medical attention in many countries. In some highly develcped countries a fifth of the population is admitted to hospital every year. All these have necessitated an increase in the number of hospital beds required wh:l..ch, in some developed countries, 1s now over 10 per 1000 of' the pOpulation. However, the solution does not rely only on the prOvisions of lOOre beds for patients. Ambulatory care schemes are now develOping in many countries, includiDg day hosp1 tals and rehabilitation f'or convalescents, to k~ep the bed pOpulation ratio at the lowest possible level. Hosp1 tals should therefore be co-ordiDated 1n the broad scheme of' public health to ensure that the services are unifOrmly spread out in the cure of' disease and in promoting positive health at an economical cost.
- l6 -
7.2
Evolution of relationship 'With the general health service
,
In some emerging countries 'What hospitals there are, are us~ run by philanthropic bodies such as religious missions. In intermediate countries hospitals are commonly managed by the local authority 'With the income cOming from the local people and the central government playing little or no part. As development proceeds, government supervision increases. At the outset, certain minimum standards of hospital design and staffing are required. As soon as the government commences paying for the treatment of indigent patients, stricter supervision is imposed. Then comes the exercise of inspectorial functions, particularly of maternity hospitals. Eventually, the government may institute regulations requiring hospitals to provide certain preventive services in their out-patient departments. At a later stage still, legislation is enacted covering all aspects of hospital construction and management. The budget is required to be balanced and approved by the central. government which makes good the annual. deficit. Hospitals are then required to play their part in the public health field by providing maternal. and child health clinics, cancer detection services and so on. In socialist countries the hospital is part of the govermnent organization. All medical care services (specialist, general practitioner, dOmiciliary and preventive) are centred on the hos:pital.
7.3
Collaboration between different types of hospitals
•
Hospitals in all countries can be local. or rural, intermediate, and regional. or central. Rural. hospitals are sometimes staffed by local private practitioners. This type of hospital provides simple services and seriOUS cases have to be referred to institutions with better facilities. The intermediate hospital provides certain specialist services and can perform much preventive work. Surveil.l.a.nce of patients after completion of treatment, for instance, is an important facet of their activities. Central or regional. hospitals are concerned with specialist services and not infrequently serve as teaching hospitals. Although preventive medicine practice would be limited in such an environment, consideration of the preventive aspects should find a place at best in the teaching content.
7.4
Budgetary aspects
The total cost of health services varies from three per cent. of the gross national. income in less developed countries to seven or eight per cent. in fully developed ones. The 'Way this allocation is divided, however, remains remarkably constant with the medical care services consuming more than eighty per cent. of the money and the preventive services less than twenty per cent. Of the medical care services budget, about fifty per cent. is spent on hospitals, thirty per cent. on salaries
•
- l7 of medical staff and tventy per cent. on drugs. The cost per patient per day also remains very stable in respect of its ratio to the gross per capita income. This cost is borne entire~ by the state in a few countries and most~ by the patient in others. In most instances, however, various schemes of health insurance split the cost between the patient and pa;yi~ agencies.
7.5
Public health activ:tties in the hospital
In the larger interests of community health protection, more emphasis must be placed on preventive medicine by the hospitals. This can be accomplished by including this aspect of medical care in the curriculum of medical students, by health education of in-patients, and by using the out-patients' department for a variety of services. These v->uld include such matters as maternal and child health services, physical examination of foodhandlers, screening for ear~ signs of chronic diseases, detection of carriers of communicable diseases, mental health services and child guidance clinics and IIBJly others. Surveillance of the discharged patient to prevent recurrence of his illness is not the least of such services. On the otl"er hand, although as much collaboration and integration as possible should be encouraged, complete fusion is not considered deSirable. The private sector plays a valuable part in the medical field and public health officers can carry out their duties more efficient~ if they are not too close~ tied to a hospital.
8.
COLLABORATION BETWEEN PRIVATE MEmICAL AND ALI..IE:D PROFEgSIONS AND THE GENERAL HEAIlL'H SERVICE
8.1
General
In almost all countries there is a dichoto~ of interest between the private sector of medicine, 'Which is largel¥ concerned 'With curative services, and the public health service. In the interest of efficiency, alt~ough complete integration may not be possible, it is desirable to have close collaboration between the tv-> sectors. 8.2 Initiative for collaboration
This collaboration cannot be imposed by political influence or by legislation and an advance is required by both sides. Private doctors shOuld not be totall¥ concerned 'With the profit motive and they should be encouraged to take more interest in the preventive aspects of medicine. This is encouraged by greater emphasis being pJaced on the latter during undergraduate training, by post-graduate orientation courses and by recasting textbooks to cover both disciplines. The establishment of medical associations and colleges of general practitioners oft~n results in their members beCOming more a-ware of their public health responsibilities.
-1.8.
Collaboration can al.so be enhanced by the more rational. application of laws which require general. practitioners to divulge information, on a confidential basis, about their patients, and by making them feel that good use is being made of the epidemiological information they are required to submit. I t is also of importance that the income differential between government medical officers and pri vate practitioners be reduced so that the former are not tempt-ed to compete with the latter in order to augment their salaries. Public health departments can assist by issuing publications to show what services are available to private practitioners and by increasing facilities such as laboratory and radiological services. It is of assistance in some cases to appoint general practitioners to part-time public health posts.
8.3
Areas for collaboration in the public heal.th field
Collaboration can profitabl¥ take place in IIIBllY fields such as the giv1Dg of iJmDunizations and maintenance of immunization records, collection of morbidity and mortality statistics and their notification to the local health authority, cancer prevention services, maternal and child health services, reporting of adverse side-effects of drugs, et-c. Collaboration should also involve other paramedical professions such as dentists, private midwives, opticians, pharmacists and veterinary surgeons. All must be brought into the broad picture so that their services may be utilized in the promotion of health. Special mention may be made of the necessity for the collaboration of traditional. midwives. Close supervision of their activities is essential and this may be achieved by monetary encouragements for attendance at training courses.
8.4
Role of private doctor in the hospital
In hospitals the role of the private doctor requires sympathetic consideration. 'rhe general. practitioner should be kept informed as to the progress of his patients and be made to feel a part of the medical team. Whenever feasible, he should be permitted to participate in the care of his patients and in the me.nagement of the hospital.
9•
COI..IAroRA'rION BE'l'WEEN VOI1JN'rARY AND OFFICIAL lIEAIlrH AGENCIES
9.1
General
'rhe private institutional sector is made up of both philanthropic and commercial institutions and of these the latter category restricts its activity to curative medicine. Although they plq a certain
•
- 19 • role in the protection of health through curative measures given to paying patients, their participation in general health schemes is very small. There are more possibilities for collaboration between the voluntary or philanthropic institutions and the general health service. Private institutions consist of various types and include national voluntary institutions (such as the Red Cross Society, welfare institutims, associations for abandoned children, blind, mentally or physica.1ly deficient, the infirm and crippled, etc.), general hospitals with inpatient and out-patient departments which are functional.l.y similar to the public hospitals, specialized hospitals (such as institutions for tuberculosis, mental, or t:lderly patients and the chronic sick), t-eaching hospitals owned and operated by privat~ medical schools, local dispensaries for simple medical care, hospitals run by industrial organizations, and convalescent and nursing homes. The degree of collaboration varies largely according to circumstances. 9.2 Voluntary associations
•
In most cases, voluntary associations at national level work closely with the government. F..anking officials of health ministries are often members of the executive boards or governing bodies of voluntary organizations. These organizations are commonly subsidized by the government, directly or indirectly, through reimbursement of the services rendered. They contribute largely to emergency measures, to the training of personnel and to special activities such as the blood ba.nk service.
9.3
Prfvate hospitals
Voluntary general hospitala admit many :indigent patients and also those covered by health insurance or social security schemes. It is customnry for the cost per patient-day to be approved by the government agencies and social security responsible for p~nts and reimbursement. The participation of the voluntary general hospitals in the preventive fielu is perfectly possible. In most countries, private specialized hospitals for tuberculosis, cancer, mental disorders, the chronic sick and the elderly work in closp collaboration with the public health authority, which pays for patients who cannot afford the cost .of prolonged stay and treatment.
Teaching hospitals owned by private medical schools raise a special problem but it is advisable that they provide a department of preventive and socia.l medicine as a training area for the medical students and nurses training under them. The medical se-hools should also be encouraged to send advanced students to the health centres operat~d by the public health authorities.
•
_ 20 _
9.4
Private dispensaries
Weal. private dispensaries gE:le~ restrict their activities to curative care. They shouJ.d, however, be encouraged to participate in public heal.th campaigns and to keep records of their cases. These records shouJ.d be available to the heal.th authority in order to ensure continuity of care and to avoid duplication of work.
9.5
Industrial. clinics
Permanent liaison should be established between the general heal.th service and the ho~itals and clinics run by industrial. organizations.
9.6
Welfare services The importance of the welfare service cannot be over-emphasized
in promoting the coll.a.boration between private institutions and the general.
health service.
10. 10.1
COMMUNITY DEVELOPMmNT AND THE GENERAL HEAIJrH SERVICE
General Any improvement of the heal.th of an individual community
•
contributes to the heal.th protection of the people of a country. However, improvement of the heal.th of a community cannot be accomplished without its parallel socio-economic development. Community development is therefore a multi-facet€d process in which diverse aspects of development are dealt with under the basic principle of self-help. COmmunity development is not mere4r a method of effecting economic development cheapl¥, and success is gauged. not by adding up the material projects completed but by the achievement of a stable and selfreliant community. . 10.2
Heal.th aspects of community development
To change a Community, it is essential to change the individuals of 'Which it is composed in both their attitudes and their outlook in life. This change 'IIB:y, to a certain extent, be introduced through the assistance of a worker 'Who has a working knOWledge of various disciplines and 'Who is prepared to d'Well in the community and become accepted by it as a friend and adviser. In the establishment of heal.th and sanitation services in under-developed communities, one has to contend with superstition and tradition and these cannot be overcome by lec~uresj only demonstrations will be effective.
-21-
...
Programmes should be geared to the needs and capabili1.ies of the people and although a subsidy from government may be required to get a project started, it should, thereafter, be conducted and financed by the people themselves assisted where necessary by government. The correlation of basic needs is therefore important and acceptance of changes in health and sanitation habits is best achieved when these are related to other community-felt needs such as increased income and production, education, public improvements and local self-government. The public health programme should not be planned as a separate compartment but as part of a total community pro.;ramme. Any effort to gain undue advantage in time or resources for health projects can only be done at the expense of limiting other sectors of a planned community development programme. Community development requires an emergence of social conscience on the part particularly of young people who are prepared to go and work in backward areas and medical practitioners, nurses and sanitarians are also needed who wili do this. It is encouraged by the development of "grass-roots" government in the form of village councils and, above all, it depends on education without which no progress can be made. Education, however, can only be effective if communication is complete and this means that the community development worker must be accepted by the people and be versed in the technique of mass education. 10.3
The health worker as a community development worker
!
The health worker as a front-line commUnity development worker should assist by acting as technical adviser to the local development committee and co-operate with it in endeavouring to interest the community in recognizing its health problems, in taking elementary steps to deal 'With them, and in teaching the people to use properly, thereafter, the health facilities that they themselves have provided.
li. li.l
INTER-COUNTRY COLLABORATION ON HEAIlrH PROGRAMMES
Review of current programmes
International collaboration in the field of preventive and curative medicine has already received consideration in a number of countries. The following list shows some activities now successfully being uniertaken: (a) Medical examinations performed in the home countries of workers seeking employment in others. (b) Bilateral or multi-lateral agreements between countries on social security schemes covering the medical and health care of workers •
•
- 22 -
(c) Reciprocity in recognizing the qualifications of doctors, nurses, mid~ives, dentists and social workers. (d) Access to the use of special medical facilities in another country, such as tuberculosis sanatoria, heart surgery facilities and reference laboratories. (e) Standardization of medical and hospital records.
(f) Exchange of research workers, of fello~s and of teachers in the health field. The international agencies play an important role in this field. (g) countries. (h) Inter-country collaboration in the field of malaria eradication. In order to discuss common problems in malarial countries and to co-ordinate joint anti-malarial activities a series of conferences have been convened in the Region. Some of these are regional in character ~hile others covered much ~ider territorial interests. (i) The InternatLonal Sanitary Regulations require lJIliversal case reporting of the six internatioll9.J.4r quarantinable diseases cholera, plague, relapsing fever, typhus, smallpox and yell~ fever - and this has been universally adopted. (j) In accordance ~th the Brussels Agreement of 1 December 1924, those countries ~hich have ratified or adhered to the Agreement are required to provide adequate facilities for the treatment of venereal and other diseases among seafarers. Multi-lateral assistance between developed and developing
12.
THE ROLE OF INTERNATIONAL ORGANIZATIONS IN THE PROmTION OF INTEGRATION OF HEAIlIll SERVICES
12.1
General
Many organizations are involved directly or indirectly in programmes of technical assistance to developing countries. These organizations may be international, inter-governmental, bilateral, multi-lateral and non-governmental, the latter including the group of professional organizations.
In these programmes, an important segment may comprise assistance to the national health services. This assistance may not be necessarily related to the integration aspects but may result in an understanding of the need and pave the w:y for integration in the health services.
•
- 23 -
.
12.2
Rol.e of WO
The term "international. organization" norma.1.l.y refers to the United Nations and its fam1~ of specialized agencies. As the specia1.ized agency for health, WO is vested under Art1cle 2 of its Constitution with functions such as serving as "the directing and co-ordinating authority in international. health work ••• duty to establish and maintain effective collaboration with the United Nations, specialized agencies, government health adlllinistrations, professional groups and such other organizations as may be deemed a~propriate ••• assist governments upon request in strengthening their health services •.. promote co-operation among scientific and professiOnal. groups which contribute to the advancement of health ••• (and) ••• promote conventions, agreements and regulations and make recommendations with respect to internationel. heal.th matters ... " WHO collaborates with the other specialized agencies in activities with health implications, for example, in community development programmes with the United Nations, nutrition and zoonoaes with FAO, the health of seafarers with 110, health aspects in re1.ation to fundamental education with UNESCO, disinsecting and disinfectiTg of aircraft with ICAO, application of the medical uses of atomic energy with IAEA. In gene't'8.l., WHO assistance to governments includes advisory services to strengthen national. heal.th services, the sponsoring of intercountry meetings to consider health problems of common interest, the provision of facilities for disease intelligence and health information, the organization of study groups and expert committees to stw.y and recommend guidelines concerning prevailing heal.th probl.ems and needs, the coordination of research in the medical and hea1.th fiel.ds, and heal.th manpower education and training. 12.3 Role of UNICEF
UNICEF, a semi-autonomous instrument of the United Nations, collaborates with WHO in many health programmes. It provides material aid to national. hea1th services and thus helps materially in the strengthening, and consequent~ the integrati. on, of health services. UNICEF assistance, apart from its primary interest in the health of the mother and chil.d, includes activities concerned with the basic health services, the control c:" eradication of important communicable diseases, the provision of water supplies and support of hospitals in so far as these contribute to maternal and chil.d health. 12.4 The South Pacific Commission
Inter-governmental organizations may be set up by the governments having interest in or comprising a particular area. An example is the South Pacific Commissicn which was established in 1947 by metropolitan governments administering territories in the South Pacific. The Member countries are Australia, France, New zea1.and, the United Kingdom, the United States of America, and western Samoa. Organized primarily to promote the peopl.e· s we1.fare in the South Pacific territories, the Commission has
- 24 given its attention, amo~ others, to improved methods of nutrition, improved village hygiene (including housing), general surveys of diseases and disease carriers (including tuberculosis, leprosy, male.r1a, treponematoses, tilariasis, intestinal parasites, etc.), maternal and child health, quarantine procedures and epidemiological information. The COmmission has a medical division which e~loys full-time technical staff. It has conducted research, produced technical papers, organized seminars and traini~ courses, offered fellOWShips to local doctors and co-operated with WHO and FAO on matters of mutual. interest. In 1961, the Commission, in association with WHO, conducted a month-long seminar for locally qualified doctors on the subject of integration of health services in the rural areas. 12.5 United States Agency for International Development
A bilateral assistance programme refers to the assistance of a donor government to a reCipient, usually a developing, country. The United states Agency for International Development (USAID) is a notable example of an agency engaged in bilateral assistance. This agency coordinates technical and tina.ncial assistance from governmental and private sources in the Un!t-ed States to countries willing and able to develop themselves economically and socially. USAID ass~stance in the health field is influenced by such factors as the degree to which preventable diseases adversely affect socio-economic development, the stage or degree of economic and human resources development, the priority given to health by the recipient go'rernment, the extent of resources that can be invested in health, and the availability of assistance from other external sources. The programmes on which USAID has made the greatest 1Ii!pact have been malaria eradication, the reduction of mortality and morbidity from waterborne enteric infections, and health manpower development through the provision of fellowships and assistance to teaching institutions. 12.6 Colombo Plan
The Colombo Plan is an inter-country programme which is bilateral in operation although multi-lateral in approach. It envisages technical co-operation in the economic development of independent countries in south and south-east Asia. It provides as&istance in the form of capital aid, the &u,pply of experts, facilities to enable students and trainees to learn new skills and the grant of necessary equipment as may be needed. A number of projects involving assistance in the health field have since been generated. The Colombo Plan has no secretariat. It has, however, a bureau in Colombo which serves as a record office and a centre for disseminating infOrmation on the Colombo Plan as a whole. The Colombo Plan countries include: Australia, Bhutan, Burma, CambOdia, Canada, Ceylon, India, IndoneSia, Japan, Korea, Laos, Malaysia, Nepal, New Zealand, Pak:lstan, the Philippines, Thailand, the United Kingdom, the United states, and Viet-Nam.
- 25 -
..
Non-governmental organizations Certain non-governmentaJ. organizations, which are un:1. versa.J.J.;y recognized, e.g., Rockefeller Foundation, China Medical. Board, Kellogg Foundation, Ford Foundation, Population Council, have made contributions to heaJ.th services development. 12.8 Professional organizations
The role of professional organizations has been less tangible. However I there is a gr')'Wing bond of mutual. interest which is bringing into closer co-operation related national professional. organizations. Such a trend promotes the rapid application of new knowledge which is of benefit to mankind.
13.
CONCLUSIONS
In the western Pacific Region the pattern of heal.th services varies widely from one country to another.
..
The degree of structural complexity does not al.w~s correspond to the economic development of the country concerned. However, in general, it seems that the countries enjoying a high level of economic development are precise4r those offering the larger range of heaJ.th services with the result that integration of heaJ.th services is far frOm being realized. On the other hand, countries suffering frOm a lack of resources in money and in manpower have often achieved a practical. integration of basic health services at the lowest level. It has been stressed that integration is a constructive process with the object of achieving economy and improved efficiency. As mtegration is in most cases achieved step by step and does not necessari4r imp4r a complete4r centralized command but relies rather on co-ordination of' activities, there is no risk of jeopardizing existing patterns and of drying up present sources of finance. The methods of improving integration are many. Sometimes, it can be achieved through s\.mplif'ication of procedures, strengthening of administrative and financial. powers and the obviating of' duplication and overlapping. Converse4r, integration ~ be realized through apparent4r more complicated machinery involving decentralization and health insurance or social. security schemes. Experience however has &hown that these organizations ~ contribute to an actual simplific~ tion of heaJ.th services through standardization, implementation of' technical requirements, balanced financing and performance control. In developing countries where mass campaigns are of' particular concern, they act as spearheads from which local heaJ.th services ~ be developed on a permanent basis.
- 26 • In pa.raJ.le~, in countries where collllD\.Ulity development is taking place, the heaJ.th worker plays his part in the programme, acting as a catalyst and as a member of the frOnt-line community deve~opment team. In this general. process of integration the object woul.d be to form links between the gene~ heaJ.th and medic~care services provided at ~oc~, intermediate and regio~ ~eve~s. The desirability of :re.gionalization becomes apparent and can be progressively 1m,p~emented.
The integration of public he~th services with medic~ care services by reason of the variety of their disciplines will require variOUS methods of approach. Different sectors such as general. hospi~s, public or private, regio~, intermediate or locu, specialized institutions for specific diseases, general. practice and 1ndustri~ medicine will be integrated with public he~th st:rvices. A variety of methods of co~boration, especi~ designed to meet particul.ar relationships, will need to be considered. A sound public administration 1s an essentiaJ. prerequisite of a.n;y system of integrated heaJ.th services. Such administration will be closely linked with nati~ socio-economic deve~opment planni.ng as heal.th and weUare of the community cannot be considered in isolation. Considering the increasing com,p~exi ty of the medic~ sciences which favours specialization and the multiplication of the system of administration, integration will ensure co-ordination and, as such, will be the inev1tab~e soJ.ution for the future.
1
Wld Hlth Drg. techno Rep. Ser.,
~951,
J22, 11
•
- 27 .ANNEX 1
.. LIST OF CONSUILMNTS J PARl'ICIPANrS J OBSERVERS, RESOURCE PERSONS AND SECBm'ARIAT
1.
CONSUIJrANTS
Seminar Director and Public Health Administration Consultant
Dr. C.W. Kidd (presently Deputy Chief' Medical Of'ficer Ministry of HeaUh ana Social SC.L'vices Northern Ireland) Dr. R.F. Bridgman (presently Chief', Organization of' Medical Care Section, WHO Head.quarters, Geneva) U Khin Maung Gyi
Consultant on Medical Administration
care
Consultant on Public Administration-
(presently Regional Adviser on Public Administration f'or Asia and the Far East, ECAFE, Bangkok)
• 2. PARTICIPAMS
AUSTRALIA
Dr. G.M. Redshaw Deputy Director-Genezal of Health CODDDOnwealth Department Of Health Canberra, A.C.T. Dr. C.C. Lin Assistant Director Taipei Public Health Training and. Demonstration Centre Taipei, Taiwan Dr. D.W. Beckett Assistant Director of' Med.ical Services (Health) Medical Department Government Buildings Suva
CHINA (Taiwan)
FIJI
•
- 28 JAPAN
Dr. J1ro Yamamoto Assistant Chief and Senior Medical Officer l Health centre Section Public Health :Bureau Ministry of Health and Welfare Kasumigaseki 1 Chiyoda-ku Tokyo Mr:. Yasuo Matsuyoshi Assistant Chief Drug Manufacturing Section Pharmaceutical and Supp~ :Bureau M:l.nistry of Health and Welfare Kasum~asekil Chiyoda-ku Tokyo
~
KOREA
Dr. Hong Kyu Park Chief, Section of Medical Services Ministry of Health and Social Affairs 354 Bon-Dong 1 Young Dung Po-Ku Seoul
IAOS
Dr. Phouy Phouttbasak AdjOint au Directeur general de 18 Sante publ1que Direction geMrale de 18 Sante publ1que Vientiane Dr. Tow Siang Yeow Acting Senior Medical Officer of Health Government Health Office General Hospital Malacca
MALAYSIA
(Malaya )
(Sabah)
Dr. c.o. Innis Acting Deputy Director of Medical Services Medical Department The Secretariat Jesselton Dr. Guy Ie Henaff Medecin chef du Condominium Nord. et de l'H8pital Francais de Santo Nouvelles-H@br1des
NEW HEBRIDES
PHIILll'PINEs
Dr. Gabino V. Balbin Regional Health Director II Regional Health Office No. 3 Department of Heal.th Manila
•
- 29 • Dr. Tsuneo Ina.DJj. Chief, Medical Affairs Section WeUare Department 2-17 Wakasa-Cho Naha City Dr. Tan Hiew Kang Health Officer (South) c/o Ministry of Health Singapore 2 TERRITORY OF PAPUA AND NEW GUINEA
Mr. L. Tomlinson Assistant Director of Public Health (Administration) Department of PUblic Health Port Moresby Dr. 'Alo 'Eva ~tcal Officer in-charge Vaiola Hospital Nuku'alofa
TRUST TERRITORY OF THE PACIFIC ISLANDS
Dr. Luke Amos Howe ActiDg Director of Public Health Saipan, Mariana Islands Dr. Truong Minh Cac Adjoint au Directeur general de la Sante et des OOpitaux Sa.!gon
3. UNITED NATIONS CHILDREN'S FUND (UNICEF)
OBSERVERS
Mr. I.H. Markuson UNICEF Resident Representative P.O. Box 883 Manila, Philippines Dr. A. Mangay-Angara (Alternate) Programme Officer UNICEF Country Office P.O. Box 883 Manila, Philippines
- 30 -
soum (SPC)
PACIFIC COM-mlSION
Dr. D.W. Beckett Assistant Director o~ Medical Services (Health) Medical Department Government Buildings Suva, Fiji
PHILIPPINE GOVERNMENT
Dr.
Me~chor Jacinto !nstitute of Hygiene Uni versity of the PtUlippines Herran Street MAnila, PtUlippines
4. WHO PROJE~
RESOURCE PERSONS
STAFF
Dr. E. Christiansen WHO Medical Officer Laos-~O Project Vientiane, Laos Miss E. CatUll WHO Public Health Nurse/Midwife Cambodia-9 Project Phnom-Penh, Cambodia Miss D. Goodwin WHO Public Health Nurse/Midwife ~sia-35 Project Kua~ Lumpur, Ma.1.a.ysia Mt-s. M. Huang
,
WHO Public Hea~th Nurse/Midwife Korea-25 Project Seo~, Korea PRESIDENTIAL ASSISTANT ON COMMUNITY DEVEIDPMElNT (PACD)
Mr-. A~varo L. Martinez Executive Assistant Presidential Assistant on COmmunity Deve~opment United Nations Avenue Philippines
5. OPERATIONAL OFFICER
SECRETARIAT Dr. A.A. Angara Regional Adviser on Public Health Administration WHO Regional. Office for the western Pacific ManUa, Philippines
other Regional. Office Technical Statf who may be co-opted from time to time during the seminar deliberations.
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• AGENDA OF THE SEKrNAR
Discussion topics (including discussants and references)
TOPIC 1
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CONCEFT OF INTEGRATED HEAIlffi SERVICES (Dr. C. W. Kidd) References: Concept and Practice of Integrated Health Services by Dr. C.W. Kidd (document WPR/PHA/7) Methodology of planning an Integrated Health PJoogra.mme for Rural Areas (TRS No. 83) wcal Health Services (TRS No. 194) Integration of Mass campaigns Against Specific Diseases into General Health Services (TRS No. 294) Mass campaigns and General Health Services by Dr. C.L. Gonzalez (pap No. 29)
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TOPIC 2
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COUNTRY REVIEW OF INTmRATION OF HEAIlffi SERVICES IN CotJllTlUES AND 'l'ERR!TORIES m THE WESTERN PACIFIC REGION Summaries by Participants of Country Reports on: Australia ChiDa (Tai"Wan) Philippines Ryukyu Islands Singapore Territory of Papua. and New Guinea Tonga Trust Territory of the Pacific Islands Viet-Nam
Fiji Japan Korea Ieos Mal.a.ysia (~)
(Sabah)
TOPIC 3
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mTEGRATION OF BASIC HEAIlffi SERVICES (Dr. C. W. Kidd) Comments or remarks
:rrom WHO Regional Advisers:
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Mr. A. Aldama - on vital and health statistics Mr. J. Arbuthnot - on environmental health Dr. J .H. Hirshme.n- on medical care Mr. D.C. Johnson - on health education Dr. H.M.C. Poortman - on maternal and child health Miss M. de L. Verderese - on public health nursing Dr. C.H. Yen - on communicable diseases
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References:
Concept and Practice of Integrated Health Services by Dr. C.W. Kidd (document WPR/PHA/7) Method01ogy of Planning an Integrated Health Programme for Rural. Areas (TRS No. 83) Loca.1 Health Services (TRS No. 194) Integration of Mass Csmpaigns .Against Specific Diseases into Genera.1 Hea.1th Services (TRS No. 294) Basic Health Services (document JC14/UNICEF-WHO/2.65) Mass Campa.1gns and Genera.1 Hea.1th Services by Dr. C.L. Gonza.1ez (PHP No. 29)
TOPIC 4
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IN'l'EGRATION OF MASS CAMPAIGNS IN THE GENERAL HEAIlrH SERVICE
Dr. C.W. Kidd Dr. C.T. Ch'en Dr. C.H. Yen References: Integration of Mass Ca.mpa.1gns Against Specific Diseases into Genera.1 Health Services (TRS No. 294) Mass Cam,pa.1gns and Genera.1 Hea.1th Services by Dr. C.L. Gonza.1ez (PHP No. 29) A Review of the Present-Day Concepts of Leprosy Contro1 'With Specia.1 Reference to the R01e of the Loca.1 Hea.1th Services by Dr. L.M. Bechelli (WPR/LeprosY/33) Report on Study of Progress of Integration of SchistOSOmiasis, Leprosy and Tubercu10sis Services into Programmes of HeJ.I.1th Services by Sir Eric Prid1e Experience in the Consolidation and Integration Phases of Ya'WS Contro1 in ThaiJand by Dr. Somboon Va.cbrotai Intes:na.tiona.1 Work in Endemic Treponematoses and Venereal Infections (1948-1963)
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TOPIC 5
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PUBLIC ADMINISTRATION ASPECTS IN THE lmEGRATION OF HEAIlrH SERVICES U Khin Maung Gyi References: Public Administration Aspects of the Hea.1th Services by U Kh1n Maung Gyi (document WPR/PHA/6) Seminar on Centra.1 Services to Loca.1 Authorities, New De1hi, 1963 Decentra.llzation for Nationa.1 and Loca.1 Deve10pment, New York (ST/TAO/M/19) Organization and Staffing for Full-Time Loca.1 Hea.1th Services (PHS Publication No. 510) A Handbook of Public Administration - Current concepts and Practice with Specia.1 Reference to Deve10ping Countries, United Nations, 1961 Report of Seminar on Organization and Administration of Public Hea.1th Services (ADM/SC/2)
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TOPIC 6 -
COLIllOORATION BETWEEN THE GENERAL HEAIJrH SERVICE Am> THE HOOPITAL (Dr. R. F. Bridgman) References: Medical. Care Services in the Integration of Heal.th Services by Dr. R.F. Bridgman (document WPR/PHA/5) Rol.e of Hospital.s in Ambul.atory and Domiciliary Medical. Care, (TRS No. l.76) Rol.e of Hospital.s in Programmes of Community Health Protection (TRS No. 122) The Rural. Hospital. (Its Structure and Organization) (WHO Monograph Series No. 2l.)
TOPIC
7 - COLIABORATION BETWEEN THE GENERAL HE.AIfrH SERVICE AND THE PRIVATE MEDICAL Am> ALLIED PROFESSIONS References:
(Dr. J .H. Hirshman)
General. Practice (TRS No. 267) Promotion of Medical Practitioners' Interest in Preventive Medicine (TRS No. 269) Conference on Publ.1c Health Training of General. Practitioners (TRS No. l.40)
TOPIC 8 (a) -
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COLLABORATION BmWEEN OFFICIAL Am> VOWNTARY HE.AmH AGENCmS (Dr. R.F. Bridgman) Rol.e of Hospitals in Programmes of Community Heal.th Protection (TRS No. 122) Rol.e of Hospital.s in Ambulatory and Domicil.1ary Medical. Care (TRS No. l.76)
References:
(b) -
COMKlNITY DEVEWPMENT AND THE GENERAL HEAIfrH SERVICE Mr. Al.varo Martinez, Executive Assistant, Presidential. Assistant on Community Devel.opment of the Philippines (PACD) Role of Community Deve10pment in the Devel.opment of Rural. Heal.th Services by H.B. Minocher Homji (Discussion Notes Topic 8)
References:
TOPIC 9 -
INTER-COUNTRY COLIABORATION ON HEAIfrH PROGRAMMES Dr. R.F. Bridgman Dr. C.T. ChIen Dr. C.H. Yen THE ROm OF INTERNATIONAL ORGANIZATIONS IN THE PROlmION OF INTEGRATED HEAIfrH SERVICES Dr. A.A. Angara Dr. D.W. Beckett Dr. R. F. Bridgman Mt-. I.H. Markuson
TOPIC 1.0 -
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SCHEDUlE OF WORK
SUNDAY 13 February A.M.
MONDAY 14 February
TUESDAY 15 February 8:30 a.m. REGISTRATION
WEDNESDAY 16 February
THURSDAY 17 February 'roPIC 3 Group Discussion
FRIDAY 18 February 'roPIC 4 Group Discussion
SATURDAY 19 February 'roPIC 5 Group Discussion
9:45 a.m. OPENING
10:15 - 10:30 a,m,
CEREMONIES i COFFEE !
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'roPIC 2 Plenary I (cont. ) BREAK 'roPIC 2 P1enar~
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ELECTICN OF OFFJpERS
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OR~ATION
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(cent.)
'roPIC 3 Group Discussion (cont.)
'roPIC 4 Group Discussion (cent.)
'roPIC 5 Group Discussion (cont.)
P.M.
!
I:#'roPIC 2 P1enar~
2:00 p.m. 'roPIC 1 Plenary I
I I I
I
(cont.)
'roPIC 3 Group Discussion (cont. )
'roPIC 4 Group Discussion (cont. ) FREE
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3:15 - 3:30 p.m.
COFFEE 'roPIC 2 Plenary I
BREAK 'roPIC 3 Plenary I 'roPIC 4 P1ena~
'roPIC 5 I Plenar~
I FREE
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• MONDAY 21 February TOPICS 3 4 5 Plenary II TUESDAY 22 February TOPIC 6 Plenary I
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SUNDAY 20 February A.M.
WEDNESDAY 23 February
THURSDAY
24 February TOPIC 7
FRIDAY 25 February 'roPIC 8 (a) and (b)
SA'roRDAY 26 February 'roPICS 6 7 8 9 Plenary II (cont.)
FREE
FIELD TRIP
Plenary I
Group Discussion
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10:15 - 10:30 a.m. 'roPICS 3 4 5 Plenary II (cont. )
COFFEE 'roPIC 6 Group Discussion I·
BREAK
I FIELD
FREE
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'roPIC 7 Group Discussion
'f~jI~n~
(b)
BIf~«Sti~n con • 11:00 _ 12:oorxn TOPIC 9 Plenary I
TRIP
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~ FREE
'roPICS 6 7 8 9 Plenary II (cont.)
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'roPICS 3 4 5 Plenary II (con";.)
'roPIC 6 Group Discussion {cont.}
FIELD
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'roPIC 8(a) Plenary I
TRIP
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'roPIC 9 Group Discussion
FREE
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3:15 - 3:30 p.m. 'roPICS 3 4 5 Plenary II (cont. ) '------------
COFFEE TOPIC 6 Group Discussion (cont. )
BREAK TOPIC 8 (b) 'roPICS 6 7 8 9 Plenary II
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FIELD
PleIlal'l I
FREE
TRIP
FREE
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SUNDAY
27 F1!bruary A.M.
KlNDAY 28 February T~PIC
10
,
FREE
Plenary I
~ , • 10:15 - 10:30 a.m. • •
COFFEE
BREAK
FREE
FREE ~
P.M. FREE
Adoption of Seminar Report and
Conclusions
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3:15 - 3:30 p.m.
COFFEE
BREAK I I ,
CIDSING FREE CEREMONY
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ANNEx: 3
SUMMARY OF COUNTRY REPDR'l'S
1. as follows:
Australia ~he
health services in Australia. are organized in three tiers, Commonweal.th Ministry of Heuth State M:l.nistr:Les of H~th Municipal. Heuth Services gener~
(~)
(2)
(3)
Each tier plays a part in the provision of in generU they do not overlap.
health service
and
~he COlllDOnweeJ.th Government is concerned 'With international hea1th obligations, the quarantine service and the planning and ailm1 ni stration of the national heuth scheme. ~he State is :-esponsib~ for the provision of hospitab and fOr medicu and paramedical education and registration, vhile the mun1ci~ties are responsib~e fOr ~cU heuth services.
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hea~th
Problems arising f'rOm the three-tiered contro~ of the generU service are tackled by a medic~ council and the frequent conferences held to thresh out these problems.
Integration of the curative ard preventive aspects of haUth occurs at the ~cu health services ~evel. ~he problems affecting this ~evel are mainly insufficient staff to carry out the various activities. ~here. is uso a geographic problem in that Australia is composed of an urbanized sea-board area 'With good generU health facilities and a sparsely populated rurU interior vhich does not get sufficient med1cu care. A RoyU Flying Doctor Service has been organized to meet this need. It is financed partly by voluntary contributions and partly by government funds. ~here is, in addition, a comprehensive 'Wireless service for diagnosis and treatment in these areas.
2.
China (~a1van)
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~aiwan, considering its Size, is a highly populated country. It is in the midst of' a change from a largely rural econ~ to an industrialized one. ~here is uso a noticeable change f'rOm large family groupings 'With absolute authority vested in the head of' the household to smUler family units where young married couples manage their own affairs •
.
The administrative organization of the country is unique in that it fOllows the five-power system enunciated by the late President of the Republic of' China, Dr. Sun Yat Sen.
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• The organization of the health services rmy be divided into four levels, name~, national, provincial, county and municipal, and viJ.lage and township levels. The highest authority is vested in the Department of Health Administration in the Ministry of Interior at the national level, but the Tai'WBO Provincial Health Department is ma.i~ responsible for the various health programmes. Health services at the local level are provided by government health stations, hospital.s, private practitioners and herbalists. Preventive medicine is ma.i~ the responsibility of the health stations where a certain amount of curative service is also provided. A pilot projec·... "WaS undertaken abo·,rt three years ago to integrate the provincial hospitals with the heal.th bureaux by means of rotating the staff of the hospitals with those posted to health stations. This was dflne to encourage doctors to join the public health se.rvice, as most doctors prefer to work in hospitals. However, the scheme bas met with litUe success as moving staff about was laboriOUS and expensive. Furthermore, there was fregneuUy insufficient work for the hospital dOctors at the health stations and they considered their time was being wasted. One the other hand, the health station doctor may bave built up a clientele of private patients and he is frequent~ reluctant to leave them to go on rotation to hospital work. The Provincial Health Department has drafted a ten-year health plan co-ordinated with the overall socio-economic ten-year plan. Whether this plan will be successful or not o~ the future can tell.
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Fiji consists of an archipelago of over 300 islands of which about 100 are inhabited. The population is roug~ one-half million and multi-racial, with Fijians and Indians l?redominating. o~ Admin1strative~, Fiji is a British Crown Colony but with a considerable measure of internal autonomy. A Legislative Council with a majority of elected members is now coming into being, thus giving a further measure of autonomy.
With regard to vital and health statistics, there is certai~ room for improvement. The registration of births is, however, compulsory, and the infant mortality rate of 30.49 per 1000 live births in 1964 is thought to be fair~ accurate. The high incidence of "influenza" during the same year is probab~ due to a group of viral diseases and not just influenza virus alone. There are 199 physicians in Fiji, some of whom are in private practice. This gives a comparative~ favourable ratio of 1 physician to 2293 of the population. These phySicians are most~ graduates of the Fiji School. of Medicine which also trains l?ersonnel for the other health disciplines.
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Integration of the health services is co~lete all the way down f'rom the central l.evel. At the local level, area medical officers, besides carrying out curative work, are also fully responsible for all aspects of public health on their respective areas. other bigbl1ghts (1) Birth control. measures have been active~ propagated by the Fa.m1~ Planning .i\ssociation, with subSidies, technical advice, and clinical services being provided by the Medical Department, in order to bring the high birth rate down to reasonable levels. The birth rate is now showing an encouraging downward trend and it is hoped event~ to reduce it to 30 per 1000 p~pulation. (2) COmmunity development planning has, for some time, been carr1ed out by the planners without prior consultation with tht: Medical Department. This has resulted in the neglect of the health aspects and the mushrooming of "shanty-towns". This state of affairs is presen~ being rectified.
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Japan
Japan is a populous country with 97 million people, the majOrity of whom live in urban areas. Fair~ accurate vital and health statistics are available on a country-wide basis and there are adequate facilities for training health and medical personnel • The organization of the health services is at three levels. At the national level, the M1n1stry of Health and Welfare comprises a number of bureaux that share responsibilities in planning national health pOlicies and prc>graIDllles. At prefectural level, ou:t of 46 prefectures, 25 have autonomous health departments, the other 21 having an autonomous department of health and welfare. At the local level, all prefectures and municipallties are divided into "health centre districts" each with its own health centre. The composition of the staff of these health centres varies, but on the average there are forty staff, including doctors, dentists, nurses, etc. Local and community health services are ~ integrated at health centre level, but the stress is more on prevention. Mass c~a1gns against tuberculosis, for the improvement of nutrition, and maternal and child welfare are curren~ being undertaken. They are ~ integrated into the general health service. Japan is taking an active P&t in international health collaboration, pa.rticular~ in the provis10n of health and medical technical aid for developing countries. Japan is also current~ carrying out collaborative studies on chol.era El. Tor in conjunction with the Philippines.
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, population.
other highlights (1) Japan has a social insurance scheme covering l~ of the
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however
(2) Some families have their own fam1ly doctor. Many, make use of the facilities of govermuent hospital out_patient dep~nts without being screened by their fami1.y doctor, thus causing congestion at the out-patient departments. This situation will have to be rectified.
(3) To cope 'With the e:x;pand;lng population after the second Worl.d War, induced abortion ~egislation was enacted. However, the stress is now on fami1.y pl.anning and contraceptives are free1.y ava~b~e and subsidized by the Government.
5.
Korea
Korea has a population of 28 mi~on, JOOre than ~ of whom live in the rural. areas. Korea has ethnic~ a hoJOOgeneous population comprising three main religious groups, na:me1.y, Confucionists, Buddhists and Christians. The collection of vital and h~th statistics is not comp~ete. Manpower resources for heal.th and training facilities in the he~th discip~es
are fair1.y adequate.
The adm;lnistration of he~th and medic~ services is the responsibility of the Ministry of He~th and Soci~ Affairs. At the provinci~ ~eve~, the Bureau of He~th and Soc~ Affairs is responsib~e for the h~th of the province, and at the district ~eve~ a h~th centre is provided for every 200 000 people. There are 189 he~th centres and 630 public doctor I s clinics throughout the country. The loc~ he~th service is organized to provide the seven basic health services. It derives its budget part1.y from national and part1.y from prov1ncl~ fLulds. It ~so p~s and executes its own community health programmes. Problems include scarcity of funds, difficulties in retaining professional staff in the service, and lack of community participation in public h~th activities. Mass campaigns being carried out include a tuberculosis campaign, a malaria pre-eradication pilot project, a leprosy contro~ project, and a fami1.y planning project. The main pro1;lem with regard to these campaigns is the difficulty in recruiting enough sufficiently trained staff because of the unattractive salaries offered.
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6.
laos
laos is a land-locked country with a population of 2 635 000 which is 1.arge1.y rur~. The country has been plagued by internal conflict and because of the poor means of communication in existence, figures for vi~ and hea~th statistics collected. are at best unrellab~e. However, commun1cab~e and Other preventable diseases figure prominent1.y in haspi t~ morbidity and mo~ty statistics ref~ecting the general state of health in the country. Doctors are few in number and are concentrated in the urban areas. other categories of health personnel. are ~so in short supp1.y.
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- 41 The health services are UDder the adm1n:1stration Of the Ministry of Health, with a Director-General of Public Health who is the head. At the intermediate level, the provincial hospital and health service is run by a physician designated chief medical officer. At the local level are rural dispensaries run by multi-purpose senior nurses. Curative and preventive health services are hence fuJ.J¥ integrated at the local level. Mass campaigns against smallpox and cholera are currentl¥ being carried out with the collaboration of the general health service. The malaria eradication campaign, however, had to be discontinued in 1960 due to insecurity in the countryside. Being an unde~-developed country, ma.tly international and foreign organizations have assisted in carrying out various health activities throughout the country. A council for the CO-Ordination of these activities has been set up under the chairmanship of the Minister of Health with a view to the:lr integration. Special mel:.tion may be made of the rural development pilot project, which includes a :rural health scheme for promoting the health of the people in tbe project area. This will become a demonstration area for the whole country and it is hoped rural health and other services will eventua1.ly be ext~nded to all parts cf the country.
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7.
Malaysia
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Mal.aya covers an area of 51 000 square miles and has a good system of roads, rail'W8¥s and communications. Its population is about 7-1/2 million and three-quart~rs of the population live in the rural areas. It has a plural society in whica Malays and Chinese form the main groups. There is also a diversity of religion and culture arising mainly from the racial differences.
Vital and health statistics are available and fairl¥ accurat~, with the exception of the causes of mortality, seventy per cent. of which are being reported by pOlicemen and other non-medicall¥ trained persons. With regard to manpower resources for health, there is a relative shortage of health personnel, including doctors, dentists and pharmacists. Manpower resources for tra:lning in the health disciplines are adequate but training facilities are general.ly liDit~. The administration of the general health service is conducted at three levels, namel¥, national level, state level, and district or local level. This does not include the municipalities of Kuala Lumpur, Penang and Malacca which are responsible for their own health services and are financiall¥ autonomous.
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long-range national heal.th planning has been carried out as part of national development plans to raise the standard of living of the people. To correct the imbalance between the health facilities in the urban and rural areas, the national health administration plans to establish a network of 100 rural. health units to serve the hitherto neglected rural population. Curative and preventive health services will be 1'ul.1y integrated in these rural health units. Mass campaigns presently operating under the national. health administration include those against malaria, yaws, tuberculosis and filariasis. Plans are afoot for the initiation of a leprosy control campaign. Existing campaigns are in variOUS stages of integration into the general health service. The main problems encount~red by the health administration are shortage of staff and lack of funds as a result of increased defense commitments. A rapidly increasing population is also a cause for concern.
7.2
Sabah
The general health service in Sabah 'WaS developed in the post-second World War period. Of necessity the emphasis was on the curative services, although a start was al.so made with regard to maternal and child heal.th services, malaria and tuberculosis control.. The development of these services has been hampered by poor communications, lack of suitable candidates for training in health disciplines and, until recently, lack of training facilities. There is also lack of continuity in the higher echelons of the health service as it is manned largely by expatriate officers recru1t~d from Britain and el.sewhere on a temporary basis. Despite the above-mentioned drawbacks, the Health Department in Sabah has been able to provide a fairly adequate and integrated health service with general hospitals in the larger towns, twelve-bed hospitals/ dispensaries in the districts, and sub-centres in the periphery. The medical. Officer in charge of the area health unit provides both curative and preventive services with emphasis on one or the other, depending on his orientation, and on public demand. The large measure of success achieved in providing a good general health service may be attributed to the relatively small papulation (520 000) and also the well-knit health orga.nization with close liaison between the various members of the staff. Mass campaigns against yaws, malaria and tuberculosis have been launched with international assistance, and with a good measure of success. Yaws has now been eradicated, malaria control is entering the consolidation phase, and tuberculosis control is also well underway. The malaria eradication and tuberculosis control programmes are gradually being integrated into the general health service as each district passes into the consolidation phase of the programme.
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.. 8. New Hebrides The first contact of the local population vith modern medicine was through a British Protestant Mission and, after the Franco-British Protocol in 1904, the French authorities set up governmental health units in the Territory-. As a result, there are now the i'ollowing services: (1) French governmental units i'inanced vith French funds _ i'our hospitals, two with surgical equipment, and several dispensaries. (2) British Protestant Missionary units, still entirely independent - six hospitals of various kinds and Sizes, several dispensaries and a leprosarium.
(3)
Some condominial dispensaries buiU and sll:Pplied with
funds :from the budget of the COndOminillD1.
For the units in the first category-, the financial responsibility rests with the French metropOlitan budget. Those in the second category depend on funds provided by cbarities and by the mission headquarters in Australia and New zealand. However, in both cases assistance is given :from the cOndominial budget for the procurement of drugs reguired to control, endemic diseases.
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Altogether, fOr a population of 65 000 inhabitants disseminated over some f~j i6landS, the New Hebrides have available fifteen doctors and ten hospitals of various standards, six witll surgical wards • There is no service to deal vith mass campaigns, but WO has sent a team under a medical officer to ass:i.st the Adm1n1strat:i.on to carry out a tuberculos:i.s control campaign. Co-ordination is ensured by the French D:i.rector of Health, who is Medical Officer of the CondOminium, with the help of a British asssl. tanto The Director and his assistant are both hospital doctors. They central:l.ze the statist:i.cal data and issue the drugs for the Condominium. In the three districts, the intermediate level is under the responsibil:l. ty of a c.ll1ef medical officer of the Condominium 'Who is also chief medical oi'i'icer of the French hospital and often in charge of the Town Sanitation Service. Moreover, he s:i.ts in the Urban Planning Committee. Integration: As a result of the situation mentioned above, integration is already partly achieved, at least theoretice.l.4, as the chief medical officers of the Condominium are also chief medical officers of the hospitala and even of the Sanitation Service. There are, however, still many difficulties to overcome:
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(1) Collaboration between French and British doctors is not always sufficient, although recently the situation has improved considerably • (2) The Missions, desirous of mainta:i.ning their independence, are not always conscious of the role of public health and submit reluctantly to a measure of sll:Pervision.
- 44 (3) The mission hospital.s are not always very .rell distributed as their location was often determined ~or religious purposes.
(4) Insula:r:tty and lack. of means of communication hinder travel in the islands. (5) The very existence of a Condominium creates di~ficult1es as ~ar as finances and personnel are concerned. The sources of ~s are multiple in the various units. Conclusion: The Territory has good medical coverage but the present situation is such that complete integration is likely t() be di~ficult to achieve. Philippines The health services are he&.ded by the Secretary of Health with two under-secretaries assisting him, each in control o~ a number of bureaux. These bureaux as a result of decentralization, exercise onlY s~~ functions over the peripheral units. Regional Offices with regional directors responsible for administrative direction and supervision over both preventive and curative services .rere introduced in 1959 in line with the new governmental. policy of decentralization of the health services. Regional directors, thus, exercise control over the provincial and city health officers. Provincial health officers, in turn, supervise the rural. health units and provincial hospitalS. Decentralization o~ the health services, however, has been a painful process as central headquarters are reluctant to delegate adeguate authority to the regional directors, thus, to a certain extent defeating its purpose. There are more than 1300 rural. health units throughout the country, each being staffed by a physician, public health nurse, midwi~e, sanitary inspector and at times, a clerk-cum-driver. The curative and preventive services are hence largely integrated at the peripheral level. Apart from the designated training hospital.s in some provinces, the rest are now under the direct administrative supervision of the provincial or city health office concerned. Hence, both health sarvices are, in general, also integrated at the prOvincial level. The of the central the provincial programmes ~ planning of health programmes is largely in the hands headguarters. The local health authorities, including and city health officers, are not consulted and hence hit unseen snags or may not fully serve their purpose.
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A number of mass campaigns are currently underway, including malaria, tUberculosis, leprosy, schistosomiasis, filariasis, cancer and mental health. Of these, onlY tuberculosis and leprosy have been fully integrated into the general health service. There is, however, active collaboration between the special teams o~ the mass campaigns and the personnel in the general health service.
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~O.
Byukyu Islands
The Ryukyu Islands consist of three groups of islands scattered bet'Ween Japan and China (Tai'Wan) out of 'Which thirty-six are inhabited. The total population is nearly one million, consisting mainly of native Okina'Wans 'With a small number of Chinese, Filipinos, Indians and others. Buddhism and Christianity are the main religions practise4-. CuUura~, the Ryukyus 'Were strongly influenced by the Chinese up to the nineteenth century and then by the Japanese. The Ryukyus have their 0'Wn government 'Which is advised by the United states Ci vi~ Administration of the Ryukyu Islands, but there is a movement among theRyukyuan peop~e for unification 'With Japan. The United States Civi~ Administration of the Ryukyu Islands has its 0'Wn Department of Public Health and Welfare and the Government of the Ryukyu Islands has a separate Bureau of Welfare 'Which incorporates the three functions of health, 'Welfare and insurance. There is a shortage of health administrators, there being only tvo full-time administrators 'With technical background 'Who have to dea~ 'With a 'Wide range of problems. A 'Wide variety of hea~th services is available at the loca~ level but there is an unfortunate lack of co-ordination, and very little int.egration. The most acute problem facing the public administration is probably the shortage of qualified and experienced health officers to man the service.
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Mass campaigns against specific diseases being currently carried out include those against filariasis, tuberculOSiS and leprosy . It is, ho'Wever, felt that a definite long-term health programme should be established before further mass campaigns are und~rtaken. ll. Singapore
Singapore is mainly a city-state 'With over 1.8 mi~on population. It deals 'With a large volume of entrepot trade and is nOll also being rapidly industrialized. COmmunications within the state are good and it is linked 'With !&ilaya by a causeway. Singapore has a high population density (8880 per square mile), a multi-racial society, each ethnic group having its 0'Wn distinct culture, and many religions are practised. It has an elected government 'With the Prime Minister as head of the cabinet and various ministers as members, including the Minister of Health. The collection of vital and health statistics is fairly complete and accurate. Manpower resources for health are genera~ adequate and so also are training facilities. The health administration is centralized, the health services beiIg run directly from the Ministry of Health. There are no local authorities and no intermediate level running any of the health services. Finance for the general health service comes entirely from the State.
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Mass campaigns being undertaken incJ.ude the tubercul.osis com:.ro~ campaign and leprosy eradication campaign. Mass campaigns -work in close co~boration with the general health service. Current health problems being tackled indude industrialization and its health illl.Plications, the high birth rate, the replacement of the night-soil bucket system in some parts of the city with a sewerage system, and the hawker problem. 12 • Territory of Papua and New Guinea
The terrain of Papua and New Guinea is gene~ difficul.t, comprising a mountainous i:.lterior with a ~ coastal strip. Many of the rural communities can on4r be reached by foot. The population numbers about t-wo million, is largely of Melanesian stock, and rural. Reliable vital and health statistics are not obtainable on a national basis although morbidity and mortality figures are gene~ kept by the hospitals. There are 136 doctors and a fair number of other professional and auxiliary health staff distributed fairly even4r between town and
rural areas.
The a.dministration of the health services is based on a relatively simple pattern. There is no M1n1stry of Health, but a Department of Public Health which is one of fifteen functional departments within the Administration. The Department of PubLic Health in turn is sub-divided into a number of divisiOns of the various health disciplines. The health services at village level consist of medical aid posts staffed by indigenous aid-post orderlies with t-wo years of basic public health training and maternal and child health clinics. Above the aid posts are rural health centres (looked after by assistant medical Officers), sub-district hospitals, district hospitals and regional base hospitals in the hierarchial order. The curative and preventive aspects of health services are closely integrated and referrals practised. Mass campaigns include those against malaria, tubercul.osis and lepro.sy.· A fairly high degree of integration into the general. health service has been achieved in the tuberculosis and leprosy campaigns. The problems met with in the attempt to provide an adeguate, and integrated, health service include language and cul.tural difi'icul.ties, recruitment of specialized manpower, and provision of transport.
13.
Tonga
The Kingdom of Tonga cOlII.Prises some 150 islands and has a population of 56 838. The population density in 1964 was 265.6 persons per sguare mile.
- 47 Tongans are Po~esians and they l.ead an easy-going and main4r rural. life. Theirs is an independent kingdom with constitutional. IDOnarchy but under British protection. The col.l.ection of vital. and health statistics is not co~l.ex. However, it wil.l. be notict.d that the three main causes of morbidity for 1964 were influenza, mumps and whooping cough. These high incidences were in :fact due to the epidemic nature of these diseases in l.964. Peptic ulcers rank number two as a kil.l.er disease and the possibl.e expJ.anation for that is perhaps the irregularity of meal.s of the village peopl.e, some of whom take on4r one proper meal. a day. There is a :fair number of doctors, dentists and other health personnel, and the schools provide ~l.e candidates for training in the health disciplines. However, there are no universities and profesSional. workers have to be trained in Fiji and el.sewhere. No l.ong-term national. heal.th plan has been envisaged and ~ pl.a.ns in the past have been short-term ones due to l.ilI1itation in financial. resources. The local. heal.th services are fully integrated in that curative and preventive services are performed side by side. These services are financed f'rom the general revenue, except in respect of water supplies to villagers where the Government subsidizes a pound-for-pound raised by the village water supply committee. l.4. '!'rust Territory of the Pacific Islands
•
The Trust Territory of the Pacific Islands consists of a group of 2000 sllBll islands in the western PacifiC, of which about loo are inhabited. These islands are spread over a large area and transport and communications thereby pose a great problem. Int.er-island travel is by means of boats or larger ships. The total. population is 88 000 and the people ru-e mostly concentrated at district centres on the larger islands. About one_third lives in urban areas, the remaining two-thirds in the rural areas. The administration of the '!'rust Territory is carried out by a central. government l.ocated at Saipan and six district governments which take orders from headquarters at Sa1pan. The vital. statistics col.l.ected are probably l.ower than the true rates because of incomplete registration and reporting.
6 clJnical. supervisors and l.00 graduate nurses.
resources for heal.th incl.ude 35 medical. practitioners, There is presently a shortage of practitioners, and an acute shortage of nurses and l.aboratory technicians.
~~power
A mass immunization programme began in l.963 with its goal. for compl.etion in l.966, is nearing the end, but there are no territory-wide preventive medicine programmes as such for leprosy, tubercul.osis control. and fil.ar1asis.
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Outmoded facilities, lack Of well.qualii'1ed personnel, and insufficient funds are some CIt' the reasons. Current problems are tuberculosis, leprosy, filariasi s, lack of safe ~ter supplies and proper sewerage systems. 15. Viet.Nam
The organization of the health services in Viet.Nam may be divided into We levels, namely, central and local. At the central or national level, the Ministry of Health is responsible for public health, hospitals and health programmes such as maternal and child health, tuberculosis control, leprosy control, etc. At the local level, each province has a health serVice, and each district has a dispensary or dispens8-~-cum-maternal and child health. The health organization follows closely the adIDinistrative areas of province, district aDd vil.lBge. The health services are most complete at the provincial level 'Where there are provincial hospitals. At district level, there are only maternal and child health services, sanitary agents and visiting nurses. Finall:y, at vil.lBge level, there a-e the first-aid posts and rural mid'Wives. There is integration of health services at the local level. Midvives, for instance, are trained to ca:rry out BCG vaccination and they also assist in mass campaigns such as those against cholera, plague and smallpox. Probl.ems in integration of the health services include shortage of staff and lack of means. Too much is generally expected of the staff at local level, 'With the danger that efficiency may be lowered. It is thus felt that integration should also be achieved at central level if 'We are to expect a good co-ordination of various health activities at the local level. The Hospital Re-organization Programme, however, is achieving a degree of success through the Board of Directors established for each hospital. Problems are discussed and threshed out by the Board 'Which consists of local personalities as 'Well as hospital staff. Other problems concerning health integration are the large numbers of mental cases that require attention, but for 'Whom only an embryOnic mental health service is available. Also, due to the political and military situation, health programmes for certain areas, particularly rural ones, have to be abandone:i and the 'WOrkers remain idle. This is particularly true of the malaria control programme. • !